Articles by Dr. Giese

WHAT IS NEW AND TRUE

It works!  Natural appetite suppression is helping people eat less calories, without feeling deprived, and lose weight.  Eating less over an extended period of time results in slow, steady, REAL weigh toss, NOT RAPID weight loss.

It is re-setting people’s weight “set point”, which drifted upwards over the years.  Most people are returning close to their low weight as an adult.

WE ARE HEALTHIER

I interpret recent research from the NIH (CALERIE study, 2019), that adults should not gain much weight as we age.  Staying closer to one’s low weight as an adult keeps an individual’s cardiometabolic risk profile lower as well.  That means minimizing risk of developing hypertension, atherosclerotic disease, cardiovascular disease and insulin insensitivity.  The good news is that you can reset or return to that lower risk by staying close to your low weight.

The CALERIE study is the first to observe the effects of moderate weight loss in a non-obese population, with the realization of ongoing health benefits.  Their study group was similar to many of my Elective Weight Loss (EWL™) patients, who are “overweight relative to themselves”.  For example, that may be someone who has gained 15 pounds, whose normal weight is 135 pounds.  Losing 10% of their starting weight will yield health benefits.

The difference between the CALERIE study group is that attained weight loss with controlled meals and intensive behavioral modification.  In my group similar effects are found with the aid of semaglutide.  Similarly, they do eat less, lose weight and interestingly adopt behavioral modifications.  This is verbalized and realized by their maintaining weight loss following attaining target weight and being off of medication.

A CALORIE RESTRICTED DIET IS A LONGEVITY DIET

Many of us eat more than we need to.  Multiple studies in animals and humans have shown that a calorie restricted diet is a longevity diet.  Calorie restriction does not equate to lack of nutrition.  I noticed that many of my patients adopted a more nutritious diet while taking semaglutide.  Filling up on junk food was not as satisfying or filling.  However, because they were not given any food restrictions, they were able to stay on a lower calorie diet without the feeling of deprivation which often comes with quick fix options, which fail in the long run.

PEOPLE ARE EMPOWERED BY THE SUCCESS OF THEIR WEIGHT LOSS

Seeing is believing.  Achieving their target weight, virtually seeing the result (getting back into a wardrobe), knowing that they did it by finding the right amount of food they needed, modifying their behavior and thoughts around food is incredibly powerful.

All of the above fuels the positive psychology of weight loss.  We have learned weight loss is about biology, not willpower.  It turns out the body’s brain it powerful in regulating appetite and making it difficult for many people to lose weight.  Semaglutide, the active ingredient of Ozempic® and Wegovy®, and another, Mounjaro®, act on the brain to decrease the appetite, make a person feel full sooner, satiated.  People then, naturally realize they need, and can be satisfied, with less food.

I also believe people feel empowered by not overeating because there is a world-wide deficiency of food.  They feel good monitoring their consumption, to help do their part.

WHAT ELSE I SEE AND HEAR FROM MY PATIENTS

“Food noise” is diminished.  Many people would obsess about food or plan their next meal while consuming the current one.  This was a surprising but positive side effect.  This freed their mind to be more productive, to accomplish more in other areas of their lives.   Reduction of “food noise” is a reason some of my patients have continued on a low dose of semaglutide, even through they have achieved target weight.

Getting back in their old wardrobes was a common goal of men and women in my practice.  Some were on the verge of throwing them out.  I said, “Wait and see”, and boy were they grateful.  Many expressed better quality of older pieces and fabrics, others were motivated by sustainability.  Shopping your own, older closet, is similar to a sustainability calculator on popular clothing resale websites.  There are positive environmental savings.

Most of my patients are saving money on food and alcohol consumption.  They are buying less in the food markets and eating less in restaurants (or bringing home more left-overs for another meal).

SOME ECONOMICS OF SEMAGLUTIDE

Ozempic® and similar weight loss drugs may radically reshape the food industry.  Earlier this year the US CEO of Walmart, commented that customers taking Ozempic® buy less food.  In an 82 page report this summer, a team of Morgan Stanley analysts, strategists and associates laid out how the new weight loss medication could dampen the demand for food.   Since the use of these new weight loss drugs is expected to increase to 7% of the US population over the next 10 years, changes in consumption will follow.  They predict that people on the drug will likely consume 20% fewer calories.  Increased use of these weight-loss drugs could also hurt demand for high-calorie and sugary foods.

I think these are all positive changes in the face of the growing obesity epidemic in American.  The health risk and cost associated with the disease of obesity are very real.  However, I believe the prevention of reaching the threshold of falling into that diseased and inflammatory class is also very dire.  Very few, if any effective preventative programs exist or are supported by health insurance.  This is why am closely following all of my Elective Weight Loss (EWL™) patients for the improvement of their health, in addition, to weight loss.

I will also share that weight loss programs and medications are covered by FSH and HAS programs, making them a bit more accessible to non-obese patients, in addition, to those with obesity whose health insurance does not cover them.

While the big pharmaceutical companies are reaping fortunes from this new class of weight loss medications, shortages of the medication still abound in pharmacies.  The FDA indications, in addition to diabetic ones, are for weight loss for people with a BMI > 30, or a BMI >27 with another medical condition.  Medical doctors can have their license censored for writing them off label for those weighing less, even if they are overweight relative to themselves.

Ozempic® and Wegovy® remain on the short list, which has allowed compounding pharmacies to manufacture and distribute the active ingredient semaglutide, alone or mixed with other ingredients, such as vitamin B12 and L-carnitine.  The use of these compounding pharmacies helps not to diminish the supply to people with obesity and diabetes to attain medication from their primary care doctor and traditional commercial pharmacies.

However, this has created a buyer beware market.  A quick look on tik tok reveals “self-proclaimed experts” selling counterfeit semaglutide, in self labeled vials.  It is recommended to only attain medication and direction of use from a board-certified medical doctor, with experience in the weight management.  Additionally, only use medication from an American Accredited Compounding Pharmacy.

I am intentionally NOT recommending ’a diet’.  A ‘no-diet diet’ has been found to be equally if not more effective than any specific restrictive diet plan.  Everyone’s lifestyle and relationship with food is different and changes over time.  You are all adults.  I am not going to tell you what to eat and be the food police.

You will find that you will become more efficient in your eating.  You will likely spend less money and lessen overall food waste.  Take this time to observe and reflect and make small changes to you r nutrition intake.  If you desire more assistance, our nutritional health coach, Kate Stempl, who will be checking in with you weekly, will be happy to help.

Eating less is generally consistent with longevity.  Particularly with supply chain issue, possible food source scarcity and inflation, there are many reasons to incorporate a lifestyle less dependent on large amounts of food for satisfaction.

Early in my career in plastic surgery I was a fat researcher.  I did the first research to show large volume liposuction could successfully be incorporated into a weight loss program with health benefits.  I collaborated with the NIH and supported a fat research lab at Yale University.  When the semaglutide (active ingredient of Ozempic® and Wegovy®) craze for weight loss went wild, with everyone wanting to know about it, I went back to the scientific literature and started a clinical trial with my patients.

Wegovy® is FDA approved for weight loss for people with obesity.  I wanted to see how the active ingredient, semaglutide, worked for non-obese people trying lose 10-15 pounds (or more) that they were over their normal weight.  I consider those types of people to be “overweight” relative to themselves.  To minimize cardiovascular and atherosclerotic disease risk factors, one should not gain weight as you age.

Most medical doctors will NOT address 10- or 15-pound weight gains in men or women they view as normal weight or overweight.  They do not view them as having a problem, even though the person has grown out of their clothes, is depressed and just feel miserable.  I think this is a shame and can see how  successful weight loss really empowers people and makes them more effective at everything.

It made me recall a conversation I had with a prominent, female cardiologist in Manhattan.  I was telling her I working on losing 10 pounds I had gained around menopause and she replied, “You can’t lose 10 pounds, your metabolism slowed during menopause”.  I was shocked and knew my metabolism had not changed significantly since my late 30’s when I had an accurate measurement of it.  What a discouraging, dis-service to women.  I hear stories like this all the time, patient’s doctors refusing to listen or help their patient with weight loss, even obese ones.

The classically used body mass index (BMI) chart was never meant to be used clinically.  It does not account for bone structure, muscle mass, or even sex.  A healthy, normal weight for any given individual can easily be set by setting a target a little above their lowest weight as an adult.  If someone is 10% above that weight, I consider them “overweight” relative to themselves and that likely confers a higher cardiometabolic risk and they should lose weight.  My Elective Weight Loss™ is very effective for this.

Food noise is not a scientific term but is diminished with the use of GLP-1 agonists, such as Ozempic®, by many accounts. It represents internal chatter and intrusive thoughts about food which can become excessive and harmful. Some people become almost dysfunctional because they think about food all day, disrupting their productivity. Thoughts about food can be triggered by internal cues, such as hormones involved in hunger and appetite OR eternal cues, such as a pizza ad during Superbowl or the smell of theater popcorn. GLP-1 agonist slow stomach emptying. A person feels full faster and longer.

This feeling is fed back to the brain and is the gut-brain connection. Willpower against food noise simply does not cut it. In a recent WSJ article (8-14-23) several weight loss researchers support that the brain helps to maintain the bodies set point by regulating how much to eat. They hypothesize that GLP-1 agonists lower the set point by sending feedback to the brain. Food noise is diminished; the volume is turned down.

However, this reduction may be temporary. When the medication is stopped, the food noise may return. This is where behavior modification is critical, must be realized and practiced. I have a handful of patients who have been so profoundly and positively affected by this reduction alone, they have opted to stay on a very low maintenance dose, to keep the food noise at bay, while not further reducing their weight. This is a very interesting side effect of GLP-1 agonists, which no doubt, will be the topic on ongoing research.

If someone is not able to access semaglutide or Ozempic®, food noise reduction can be improved without medications, by decreasing stress and improving sleep. Identifying triggers to binge, taking your time to eat, lowering distractions while eating, not skipping meals and eating meals with good nutritional composition will aid this effort.

My goal, as well as my patient’s goal, is to eventually get off semaglutide. I view this as a three-part journey: 1) achieve target weight, 2) solidly maintain the target weight, and 3) wean off medication. To date, approximately 50% of my patients who have reached their target weight are successfully off medication and maintaining their weight loss. Depending on the amount of weight a patient has lost and if they have a yo-yo weight loss-gain history, I will vary the time I lower the medication dose during the maintenance phase. Additionally, the medication has a long half-life, meaning that once stopped it gradually clears from the body over 5 weeks. Therefore, it has its own internal wean once it is stopped.

For patients who are anxious, I have them keep a small amount of medication on hand, so they can easily and quickly take a small dose.

Since the weight loss is real, no rapid, I see naturally changing their habits. I also believe that the dopamine reward system also adapts and resets during the slow weight loss period. This reward system is activated when one experiences something good, such as eating something tasty, satisfying a craving, having sex or using an additive drug. The dopamine reward system reinforces beneficial behavior (like eating when hungry), but it can also lead to bad behavior, such as abusing drug, addiction, or presumably overeating.

I have recently started offering EWL™, elective weight loss, appetite suppressant gummy to help people, get off medication, power through any weight loss plateaus and maintain weight loss. They have Tetrahydrocannabivarin (THCV), which is a non-psychoactive, hemp extract shown to exhibit appetite suppression and glycemic control combined with apple cider vinegar. I also have another one formulated to aid sleep. They both taste great.

As much as I do not like body mass index (BMI) charts and think they are unethical and non-ethnically sensitive (refer to my article on What is Your Ideal Body Weight), you may be able to use it to your advantage.  If you have a sensitive primary care doctor and are obese (BMI > 30) OR are overweight (BMI>27) with one other medical problem you may be able to get Ozempic® or Wegovy® covered by your insurance.  If you are looking to lose more than 35 pounds, this will be the less expensive route to go.  However, you will need your primary care doctor to:

1. write the script (unfortunately many will not)
2. then the insurance company must agree to cover the medication and,
3. you will have to find a pharmacy that has a supply of the lower, starting dose pens

Most primary care doctors are not trained to manage weight loss and many see up to 80 patients a day.  This is also likely true for most gynecologist.  If you do not meet the FDA indications listed above, in many states your doctor may get their medical licensed sanctioned by their state medical board.  This is an attempt by the FDA and Novo Nordisk (manufacturer of Ozempic® and Wegovy®) to keep the pharmacy supply to those most in need of the medication.  They are simply not being mean.  It is very serious to have a license sanctioned.  Currently, both medications are on the short supply list with the FDA.  This is important to understand because it allows compounding pharmacies (see my article for more on this topic) to cover the short fall here.  This is common for many medical medications and supplies that are on backorder.

This also allows medical doctors to prescribe a medication “off-label” use.  That is prescribing something that is not stated in the FDA indications, in this case, for people with a BMI < 30 or non-obese individuals.  “Off-label” prescribing and use is a very commonly accepted practice.  The more responsible way to do this is utilizing an accredited, American, compounding pharmacy, thereby avoiding depletion of the supply in traditional pharmacies (i.e. CVS or Walgreens for example).

My Elective Weight Loss program specifically covers the gap for non-obese individuals who otherwise have not been able to lose weight on their own, are “overweight” relative to themselves, and will derive health benefits from the loss AND people with obesity and no other medical problems who are unable to obtain medication through their primary doctor, insurance, or commercial pharmacies.

Also, please be aware of counterfeit or “home-made” substitutes of semaglutide.  There are many pop ups on Tick-tock, with social influencers call themselves experts, with a flash ad to receive $50 off a first order.  This is a buyer beware market.  A medical doctor or in some states a nurse practitioner,  who has experience managing weight loss should dictate your program and reliable follow-up until you have reached your target or ideal weight.

HSA or health saving account is a tax-advantaged way to save for qualified medical expenses.  It is an account you can save pre-tax dollars.  Your contribution reduces your taxable income.

The HSAstore.com site states,
“Weight loss programs or drugs are eligible for reimbursement with flexible spending accounts (FSA), health savings accounts (HSA), and health reimbursement accounts (HRA) with a Letter of Medical Necessity. They are not eligible for reimbursement with dependent care flexible spending accounts and limited-purpose flexible spending accounts (LPFSA).”

The same is true for weight loss counseling and surgery.

There is a possible triple tax advantage for HSA’s.  You can receive tax-free distributions from your HSA to pay or be reimbursed for qualified medical expenses you incur after you establish the HSA. If you receive distributions for other reasons, the amount you withdraw will be subject to income tax and may be subject to an additional 20% tax. Any interest or earnings on the assets in the account are tax-free. You may be able to claim a tax deduction for contributions you, or someone other than your employer, make to your HSA. I recommend you contact qualified tax or legal counsel before establishing an HSA.

Contributions amount vary typically from $2000 a year to up to $8750 for a family plan.  Some must be spent at the end of the year and some rollover.  It is nice to know this is a option for paying for weight loss programs.