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The Get Healthy Tampa Bay Podcast
Bringing all things health and wellness to Tampa Bay, FL from your very own family and obesity medicine physician, Dr. Kerry Reller, MD, MS. We will discuss general medical topics, weight management, and local spots and events focusing on health, wellness, and nutrition in an interview and solo-cast format. Published weekly.
The Get Healthy Tampa Bay Podcast
E95: The GLP Medications Advantage Explained with Dr. Sarah Stombaugh
Welcome to the Get Healthy Tampa Bay Podcast with Dr. Kerry Reller! This week, I am excited to welcome back Dr. Sarah Stombaugh, a medical weight loss physician with a passion for helping patients achieve their weight loss goals. In this episode, we dive into the role of GLP medications in weight management and how they can support long-term health. Dr. Stombaugh shares her expertise on the importance of a comprehensive lifestyle approach, including nutrition, movement, and behavioral changes, to maximize the benefits of these medications. We discuss recommended protein intake, managing common side effects, and the surprising non-scale victories that patients experience on their weight loss journeys. Tune in to discover valuable insights and practical tips for navigating weight loss with GLP medications!
Dr. Sarah Stombaugh is a family medicine and obesity medicine physician in Charlottesville, Virginia. Dr. Stombaugh grew up in central Illinois. She attended undergraduate and medical school at Creighton University in Omaha, Nebraska. She and her husband couples matched at the University of Chicago for their residencies in family medicine and anesthesiology, respectively.
During residency training, Dr. Stombaugh pursued an Obesity Medicine Track and completed the requirements to sit for the American Board of Obesity Medicine.
After residency, Dr. Stombaugh practiced outpatient family medicine with NorthShore University Health System for three years. In 2021, Dr. Stombaugh moved with her family to Charlottesville, Virginia for her husband’s job at the University of Virginia, where he practices in cardiothoracic and critical care anesthesiology. Dr. Sarah Stombaugh took the opportunity to open a private practice weight loss clinic. She has a clinic in downtown Charlottesville, Virginia, but primarily sees patients by telemedicine, which allows her to see patients both in Illinois and Virginia. Outside of clinic, you will find her enjoying time with her three young children Jack (6), Max (4), and Eddy (2).
0:28 - Introduction to the Episode
1:42 - Transitioning from Obesity Medicine to Medical Weight Loss
2:15 - The Role of GLP Medications in Weight Loss
3:28 - Importance of a Comprehensive Lifestyle Approach
6:04 - Recommended Protein Intake
11:07 - Understanding Hunger Cues
17:27 - Movement and Exercise Recommendations
31:34 - Success Stories with GLP Medications
39:49 - Myths About GLP Medications
42:05 - Tips for Managing Side Effects
45:25 - Conclusion and Resources
Connect with Dr. Stombaugh
Podcast: https://www.sarahstombaughmd.com/conq...
Website: https://www.sarahstombaughmd.com/
TikTok: @ConquerYourWeight
Connect with Dr. Kerry Reller
Podcast website: https://gethealthytbpodcast.buzzsprou...
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LinkedIn: https://www.linkedin.com/in/kerryrellermd/
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Instagram: https://www.instagram.com/clearwaterfamilymedicine/
Tiktok: https://www.tiktok.com/@kerryrellermd
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Hi, everybody. Welcome back to the Get Healthy Tampa Bay podcast. I'm your host, Dr. Kerry Reller. And today we have a returning guest, Dr. Sarah Stombaugh welcome to the podcast again.
Sarah:Yes. Thank you so much for having me. I'm really excited to be back and sharing with your audience about the GLP medications and how we can support people in their weight loss journey.
Kerry:Yeah. So you have your own podcast, but why don't you tell us in case other people didn't hear your previous episode, just a little bit of what you do. And you know, here you are.
Sarah:Yeah, absolutely. So I am a medical weight loss physician. I've recently transitioned from using the phrase obesity medicine to medical weight loss to be more inclusive for my patients. My background is in family medicine, and I worked in primary care for a while in the Chicagoland area, where Doing medical weight loss as part of my work there. And then when my family relocated to Virginia a couple of years ago, I'd really had a passion for supporting people with their weight and their weight loss goals. And so I decided to open a medical weight loss practice. And that is what I've been doing for the last couple of years here. And I love sharing that with people locally as their physician, but then also more broadly in my podcast, as well as on social media, try to be a good voice of evidence based medicine amongst all the crazy things we sometimes hear.
Kerry:Yeah. Your podcast is wonderful. I've recommended it to my patients as well, because you really do speak with the evidence based approach. And I appreciate that. And I think that's, that's great. Definitely something everybody needs to hear. So they're definitely going to be checking you out again, if they
Sarah:Thank you.
Kerry:you know, so you are kind of like our GLP one expert, and I think you wanted to kind of come back on the podcast to talk about, you know, how can lifestyle, a comprehensive lifestyle approach can support usage of the GLP one. So where would you like to start with all of that?
Sarah:absolutely. Well, I think one of the things I've been seeing a lot in social media is this narrative of like, what does it mean to take the GLP medications? And when you're taking them, what else do you need to be doing? Do you need to be doing anything else? Are you just eating less? Is it cheating? Is it okay to use these things? And so thinking about how I like to support my patients and then how I would recommend for anybody to best utilize these to support their long term health goals. And so it's really interesting because we have studies where we look at patients who take these medications as part of a weight loss program or part people who take these medications without really much additional guidance and people who are part of an intensive lifestyle intervention program do better in terms of having less side effects. And in terms of losing more weight compared to people who were prescribed these medications, and then maybe just given like a handout about, you know, like go eat healthier, for example. And so we'd know that being really intentional about all of the other pieces. You know, what does our nutrition look like? What does our movement look like? Are we doing things to address our stress or other aspects of our health. When we can build a really comprehensive program we support patients in losing weight, but really improving their health, which is the most important part.
Kerry:Yeah, I totally agree. And it is important to have that comprehensive approach. And I even try to counsel patients when I have to fill out a prior auth or something I'm like, we're saying you need to be part of this program. They are expecting you to do that because all the clinical trials and everything say it's not just here's the medicine see you later. I don't know about in your area, but we're definitely flooded with, you know, the kind of things that you had mentioned, but like people get on social media where they just get the medication and maybe a handout and then that's it. So I really appreciate that you're doing things in the right way with a very mindful approach. So where do you kind of, Start, I guess, with everything to support the patient and how does that look from your end?
Sarah:Well, it's interesting. I think the way these medications are being prescribed or sometimes people are getting the medication without a lot of additional information. I think a lot of people want that, right? They want to have more support and they just don't know where, what to do or where to turn for that information. And so when we think about each of the components, I really like to think about from a dietary standpoint, you know, are we eating foods that properly fuel our body and are going to support our weight loss goals? So that can look like foods that create satiety naturally. So the GLP medications are going to increase satiety as part of them. But are there things that we're doing in terms of the foods that we're eating, whether that's really fiber rich foods, protein rich foods, even a little bit of fat, that those things can help to create satiety and create this more long lasting effect of food in our body. You couple that with a GLP medication that's almost synergistic when you get these two things working together, but also thinking about that protein component and making sure, you know, I think. the message of protein, protein, protein, we're hearing a lot. And so what does that, you know, what does that really mean and how much protein do we need? And it's interesting because there are patients for whom they're eating a huge amount of protein. And there's patients who I talked to who are eating like, No protein. You know, they have a very carbohydrate heavy breakfast, a carbohydrate heavy lunch with minimum protein in it. And then maybe they're getting a serving of protein at dinner. And so taking a look at what it is that I'm doing right now and how can I make sure that I'm getting adequate protein? Because as we lose weight, you know, we talk about losing weight, but the reality is you don't want to lose weight. You want to lose fat mass. And when I say that to somebody, they're like, Oh yeah, of course. And in order to make sure we lose fat mass, that means we're emphasizing protein in the diet to protect our muscle mass. And we're doing things like resistance training to support the muscle mass that we do have and potentially even build it during our weight loss journey.
Kerry:So, how much protein do you normally recommend for your patients?
Sarah:Yeah. So I like to start with the RDA, the recommended dietary allowance, which is a really good minimum for starting. So we look at that guidance. It says 0. 8 grams of protein per kilogram of body weight. So I like to use easy math. So we'll look at someone who weighs like 220 pounds, for example. That person, we divide 220 pounds by 2.2. It's a hundred kilograms. And so a person who weighs 120 or a hundred kilograms rather at 0.8 grams of protein per kilogram of body weight per day, that person would need 80 grams of protein per day. So that's a really good starting point. And then you can take your weight, divide it by 2.2 to get kilograms, multiply it by the 0.8 to get your grams per day. That's a really good minimum. So you might take a look, you know, generally I don't do calorie and macro counting with my patients, but it's sometimes helpful for a day or two to estimate what the protein content looks like to say, okay, am I getting this or am I falling short? And if you realize like, yikes, I really don't have much protein in my diet as well. What are the things that you can do to start building that up? So for some people, they hear that RDA number and it's like, Whoa, you know, It's 80. It's 100. It's 120. And they're like, okay, I really need to be ramping up my protein here. And so if that's the case, that's a really good starting place. If you're already there, you may look at bumping it up even more. I'll often have patients get even up to 1. 2 grams per kilogram of body weight. And that's a pretty good number for a person who is like moderately active, not someone who's doing like intense resistance training and trying to do powerlifting or Olympic weightlifting or anything like that. Those, those men and ladies try to get quite a bit more protein than that. But for the average person, 1. 2 grams per kilogram of body weight tends to be a pretty sufficient amount. Now, I'm sure there's people who are listening who are like, That's a lot of math. I don't want to sit and calculate and do math. So another way to estimate it, a lot of times is about a third of our calories coming from protein. And so looking down at your plate to say, okay, is at least a third of my plate here, protein. And if not, what could I do to adjust that? And then learning too, about where, where protein lives in foods. You know, a lot of times we think about. Meat sources. We think about fish, but we can of course find it in dairy products. We can find it in plant sources like legumes, like tofu like other nuts and seeds. For example, we even have protein and some vegetables even have a little bit of protein in them. So making sure that we're learning about how we're getting that in and then incorporating it in our day.
Kerry:Do you ever do calculations based on ideal body weight or mostly just just body weight in general?
Sarah:Yeah, absolutely do. And I think, especially as we look at someone who has more significant obesity and may have a higher percentage of body fat, you know, someone who weighs 400 pounds, for example, you know, all of a sudden, if we're talking about, you know, like 200 kilograms, that become a really significant amount of protein. And if you look at what is their actual muscle mass, that a lot of times is more in line with someone's ideal body weight. Compared to their actual body weight. And so, especially as we're starting out using an ideal body weight calculation, you could easily search that, right? Go to the internet and just say, what's the ideal body weight for a female of this age of this height or male of this age of this height, and you can find someone's ideal body weight and then calculate it from there. So especially as patients are living in larger bodies, the ideal body weight calculation can be valuable.
Kerry:Yeah, no, absolutely. I think you know, the protein, we're all, you know, definitely pushing protein, protein, protein, and it's easy to break it down in that way. We've had some other guidelines, I guess, if you want to call it that, kind of breaking it down with like 30 at breakfast, 30 at lunch, and 30 grams at dinner, thinking of it that way, or obviously, like you said, meeting the patient where they are, and then working on increasing it over time, if they're clearly not getting enough. I had a a patient recently who is not using a GLP one, but he did have diabetes, but he's only eating fruits and vegetables. I'm like, I just met him. So I haven't got all the labs back or anything, but I was, I don't know how, where are you getting protein? How are you surviving? If you're only eating like fruits and vegetables, though, you did say, right? Some, Vegetables do have some protein, but I just find that incredibly difficult. I almost want to get a body composition on the person and see if there's any muscle mass there, but
Sarah:Yeah, no, I agree completely because there's plenty of plant sources of protein, so you don't have to eat animal flesh in order to get protein and vitamins are not vitamins. Protein coming from fruits and vegetables is really, really minimal. So you might find it in whole grain or you're going to find it in whole grains and legumes and things like that. But yeah, hopefully it's interesting, right? A lot of times. It's like fruits and vegetables are good for us, but they also need to be part of a more complex meal.
Kerry:yeah, absolutely. I agree. I don't know. We'll see what happens with this guy.
Sarah:Yeah Oh, that's interesting. I love your point about the 30, 30, 30 though, because our body doesn't store protein very well or at all. So when we are eating protein, it's important to make sure that it is distributed throughout the day. And so let's say, you know, you're supposed to be getting or you're trying to aim for 100 grams per day. It would be way better to do 30, 30, 30 breakfast, lunch, and dinner than it would be to sit down and have a hundred grams of protein in one serving. And so that's where sometimes even intermittent fasting may not be the right fit for someone because they're not able to hit those protein goals, just depending where they're at in their weight loss journey.
Kerry:And that's a good point too, because people may not be purposely doing intermittent fasting when they're using these medicines, but sometimes they're just not hungry for breakfast or whatever.
Sarah:Mm hmm.
Kerry:you know, If you can, you know, redirect and make sure that they are getting the protein goals. I think that's helpful. But like you said, you can't your body isn't going to absorb or, you know, manufacture all the take all the nutrients that needed from all the protein at one time. So it's best, like you said, distributed throughout the day. You also were talking about a carbohydrate heavy breakfast. How do you counsel patients nutritionally how to improve that and why is that important?
Sarah:Yeah. So with my patients, I will actually have all of them do a food log and then layer on a hunger scale where we're paying attention to what is my hunger, what is my satiety. And it's really interesting because we can start to see, you know, the day that someone has like a blueberry muffin for breakfast, they might find an hour or two hours later. They're just ravenous. They've had this very carbohydrate, like processed carbohydrate meal. They find that their blood sugar drops quickly and they're starving quickly afterwards. Versus the days where they have maybe a bit more of a protein rich and or fat rich breakfast. And they find that two, three, four or five, six hours later, they're still feeling really well satiated. So I like to first start with what are you already doing? What are your food preferences and things that you really enjoy that you can just build in more frequently. And if there's not those things, can we look at yogurts? Can we look at eggs? Can we look at avocado and smoked salmon? Can we look at cottage cheese? Are there other things that you can do? And I named like maybe traditional breakfast foods, but can you even eat like a lunch food or a dinner food? Like we can eat any food, any time per day. So if you don't like traditional, you're like, Oh, I hate eggs and sausage. Like you don't have to eat eggs and sausage. You can eat. You know, leftovers from dinner the night before, if you'd like to.
Kerry:Yeah, I really like that approach to I was, you know, you can always eat the leftovers. So that helps or some people who don't even like breakfast,
Sarah:Yeah.
Kerry:you were saying, the traditional breakfast foods are, you know, high in carbohydrate and not really best for anybody on a nutritional improvement journey.
Sarah:Yeah.
Kerry:talked a lot about nutrition. Is there anything else you wanted to add on to that before we talk more about the other lifestyle things? Sure.
Sarah:I think in terms of breakfast for the person, especially if they're on a GLP medication, but even just the person who wakes up and isn't hungry in the morning, it can be really hard. When you're on a weight loss journey, you're like, I don't want to force myself to eat. That seems kind of silly, but also am I getting protein? And would this be an opportunity that I could slip in a little bit of protein? And so I really do love protein beverages. In the morning time, if someone is not feeling hungry, I've been on a huge protein water kick with my patients, just because a lot of people find that protein shakes and stuff can be a little bit. And so if you're feeling nauseated and feeling like a little little the idea of having something thick and creamy may not be as appealing. And so some of the protein waters are pretty good options. That can be something you make your own with a dissolvable whey protein or collagen protein, but there's other ones out there that are pre bottled and flavored. And so those are pretty good options that may have like 15, 20 grams of protein.
Kerry:You mentioned the hunger scale and. you know, these, the satiety effects of the medication, would you say that patients have to eat like when they're not physically hungry? How do you manage that?
Sarah:Yeah, so it's such an interesting question and when we look at like, do I need to force myself to eat, right? Because this question comes up. I'm not hungry at all. So looking at the dose of medication that a patient's on, it's interesting. I'm sure you see this in your practice all the time. There's patients for whom even at the lowest dose, they are just hyper responders. They respond well to the medication. They may have side effects from the medication, but they may find like, wow, like this really works even at like this weenie dose of medication. And so I utilize that to decide about adjusting their dose for one. So some of the prescribing guidelines where it's like, you know, every month they're going up to the next dose. It really. Yeah. When you're looking one on one with an individual, that doesn't always make sense to just be consistently titrating up. So I make sure that I'm titrating the dose based on how that person is feeling, based on their weight loss, based on the way it feels in their body. And so there are a lot of patients for whom we're able to keep them on really low doses. So I think that piece is really important that we're not sort of over treating because you can have. Medication induced, I'll say anorexia, and when I say anorexia, I don't mean like psychological anorexia nervosa, but anorexia in like no appetite, right? The word anorexia itself technically just means like, I don't have an appetite for food. And if we've created a situation where a person's like, yeah, I could literally eat nothing all day every day. Is that really ideal for their weight loss goals, for their long term health, for their metabolism? Like totally not. And so how can we support them with enough medication that they're losing You know, like one to two pounds per week, maybe slightly more depending on the person. But if I have someone who's just rapidly dropping weight or feels like I can't eat at all in these medications, it's often a sign that we can use a lower dose. And so and sometimes there is that sort of like forcing myself when it comes to the protein component and that's where I'll sometimes slip in things like protein drinks, for example.
Kerry:Yeah. I hadn't been familiar with protein water, so I'll have to look into this, but yeah, I completely agree. Yeah. I want patients to actually have some hunger, right? It's just supposed to be suppressed. I want them to be hungry enough for a meal. So we don't move up on the titration. I think that's Same page on that. So I think that's really good. Okay. So what else is the, I guess, a part of a comprehensive lifestyle?
Sarah:So thinking about the movement piece, and this can be really twofold in terms of what is your movement in general. So just daily movement throughout the day, are you doing things that are supporting your cardio and respiratory system, cardiopulmonary exercises like walking, running, biking, things that get your heart rate flowing are really important. And are you doing things that will support your body in terms of your muscle mass, your bone density? Are you doing resistance training? And so I really like to emphasize both of those two pieces with patients, the movement piece in general. A lot of times we're able to just lean into what are the things that you really enjoy? You know, whether it's a walk with a friend, going for a bike ride, whether it's a dancing or paddle boating or like whatever it is that you want to do, you can absolutely build that in the resistance training piece is so, so important though, for protecting muscle mass and even that, I think a lot of times people think about going to a gym and lifting traditional dumbbells or barbells or, you know, doing machines that are weight resistance machines, but the reality is there's a lot of things we can do like Pilates, Classes that are using bands, for example, a lot of aqua aerobics, for example, uses water weight resistance in order to increase resistance. So there's a lot of things beyond just traditional, like throwing weights around that are resistance exercises. And that piece is so, so important.
Kerry:Yeah, I totally agree. I think that they can find activities that they like, right. And even in done in community, like you mentioned Pilates, sometimes those are classes, yoga and things like that, where it's not just. You don't have to be pushing the way, but your own body weight could be that. And then you mentioned bands, which is really good too. And I think that's helpful for some patients who are just not used to any of these activities, but slowly increasing and doing that. And I know you recently brought on like a health coach. That's also a personal trainer. Is that correct?
Sarah:Yes, that's exactly right.
Kerry:So how do you incorporate her into your, practice and recommendations?
Sarah:So all of our patients are working with me once a month and with her once a month. And primarily when they're working with her, they're working on a health coaching goals to work on their behavior. And is there a certain behavior, whether it's exercise, whether it's planning food ahead of time, getting to bed early, whatever behavior it is, that's sort of keeping them from being able to be most in line with their goals or working on that behavior with them. But she does, she's a personal trainer as well. And so for patients who It's really intimidating. If you're like, I've never lifted weights before, it's really intimidating to just go to a gym and like, okay, I'll just try out this machine or I'll lift these, you know, am I doing it properly? I'm going to injure myself. We have these questions. And so she could work with patients one on one in person, if they're local to us in Charlottesville, Virginia, or even by zoom to help patients. In doing some of the like body weight resistance exercises. And so we do that as an add on package if they're doing some of the personal training, but it's a really great resource to be able to offer someone like, Hey, I know this person. I trust this person. Cause there's also a lot, like there's so much out there when it comes to movement and you want to make sure you're supporting your patients in something that feels safe and then in line with their goals.
Kerry:I didn't mean to jump the gun to the behavioral things, but yeah,
Sarah:Yeah
Kerry:those are really good, important things. One thing you mentioned with improving your cardio respiratory fitness is with, you know, getting the heart rate up. You can do that with, you know, weights and moving your body weight as well, but obviously incorporating walking or just moving more in general during the day is important too. How do you get your, you know, clients or patients to just do more movement in general?
Sarah:It can look like a lot of different things. So it can look like parking further away in the parking lot, taking the steps at work, you know, some of those really seemingly simple things add up in a pretty meaningful way over time. For those of us who work from home, you know, even as a physician, I work from home a couple of days a week, which is wild. But like when your commute is from your office to your bedroom, It's like, wow, I've only gotten a few hundred steps per day is that feels like. And so what can I do to start building that back into my routine? And so that can look like a five or 10 minute walk after meals. You know, a lot of times we think about, oh, I have to go to the gym. I have to get sweaty. And then I will have to shower and I won't be able to go to work afterwards. And so is there something that you can incorporate that would be super easy. And so one of my favorite things to recommend is can you just walk out your door set a timer for five minutes and just walk in one direction and the timer goes off turn around and walk back. And now you've built in 10 minutes of walking. Could you do that a couple of times per day as movement as stress relief can be really helpful and glucose metabolism, you know, something like that can make a huge difference in our day. And, you know, so many of us easily waste 10, 20, 30, 30 minutes per day on social media or in checking emails and, you know, reading something that, you know, like your dad forwarded you an email about like, Hey, see this funny joke. Could you use that time in a way that you enjoy more and would help support you in your weight loss goals? Most people find that probably yes.
Kerry:Yeah, very true. I know with it hot in the Florida area, sometimes people are, you know, not wanting to go walk in the middle of the day because it's,
Sarah:Mm hmm.
Kerry:you're going to come back sweaty. So sometimes I'll be like, all right, we'll go keep inside maybe get a walking pad or stand more or do some calf raises or squats or something like that to do some alternative things when you don't want to get full of sweat in the middle of the day.
Sarah:Yeah. I actually moved it out of my office, but I, and it's just across our basement now, but I have an exercise bike that used to just get up and like walk five feet to my exercise bike, just get my blood flowing. Cause you know, it's embarrassing to sit all day long when I'm preaching movement. So I need to like get my blood flowing and you know, practice what I preach.
Kerry:Yeah, we all got to do that. I am standing, I will say, right now.
Sarah:Oh, good for you. Yeah.
Kerry:Yeah. So, okay, so we talked about the nutrition movement. Is there anything else you wanted to say about those before you tell us what you want to talk about next?
Sarah:No,
Kerry:So
Sarah:I don't think so.
Kerry:what is your next component to that you want to bring up?
Sarah:I think the behavioral stuff is really important as well. And this, you know, so many of my patients say to me, as I'm sure they say to you, now I could write a book on nutrition, right? Like I sort of know all of the things that I need to do, but when the rubber meets the road, it's really hard for me actually to implement these into my life. And so whether that is planning, because life is just hectic, you know, you've got kids, you've got work, whatever it is, life can be crazy. And so is it a planning thing or Is it a motivation thing? How can you explore some of that? And so we do a lot of that with our patients, but leaning into to like, what is it that your body is asking for rather than always turning externally? So a lot of times diet culture, for example, is like, Hey, follow this very regimented specific dietary plan. And while there are going to be certain dietary principles that are going to be more in line with health behaviors compared to others. A lot of times there's these diets that are. Really restrictive cutting out whole, you know, whole entire groups of food, entire, you know, macronutrient groups, or it's a six week plan or a 12 week plan or something like that. And it was never really designed for long term use. And so instead of turning to something like that, can we use something like food logging, for example, to pay attention to, okay, what are the foods that I actually like that also meet my health goals? Because most people. Even if they're not eating those every single day, we're like, man, if I could eat, you know, this specific food, or if I could find a way to prepare that more often, or if I could just keep this stocked in my house, we oftentimes have foods that are totally in line with our goals that we also really enjoy. And so that piece is so, so important.
Kerry:So how do you, you said previously you use food logging, but you don't use macro counting, right? So explain that a little bit.
Sarah:Yeah. So in my food logging with patients, I have patients write down the date. I have them write down the time and I have them write down what they ate with enough detail that they'll remember it. So, for example, it might be 8 a. m. two hard boiled eggs, a slice of toast. Like that could be the extent of it. Lunch, Cobb salad with dressing on the side, 2 p. m. a handful of cashews, dinner, chicken breast, and brussels sprouts, 9 p. m. fudgesicle. Like it could be that level of detail that we know what happened, but we're not weighing it, we're not, Estimating what that looks like. And the reason why I do that is because a lot of times, for one, we know that people are really bad at estimating their calories. We know that if you, unless you are weighing something or measuring something that our estimations tend to be wildly off as much as 30%, but sometimes even more. Like, I, you know, My husband weighs all of his food as part of his weightlifting and powerlifting work, and it's interesting to see, I always help him, like, measure some of his stuff in the weekends for meal prep, and like, nuts, for example, get me every single time, where it's like, one serving of nuts, and it's like, It's like this tiny little, you know, it's a handful, but it's like it barely fills my hand and my hands aren't huge, right? It's so few nuts. And so when we think about what is a portion size, a lot of times we have no idea anyway. And so can we instead start to pay attention to as I'm eating, what is my body telling me in terms of satiety? You know, as I'm eating a chicken breast, a lot of times we see a portion and we eat it because it sounds like a logical portion, but maybe you need half of a chicken breast. Maybe you need three quarters of a chicken breast. Can you start to check in with your satiety to end your meal based on what your body is feeling rather than based on an external signal, whether that is calories, whether that is macros or whether that's just a portion size, for example. And so we can start to pay attention to that, we may check in with calories from time to time. If I'm worried that a patient's like not eating anything, if we're trying to estimate protein goals, we may take a day where I'll do a calculation and help them decide, you know, approximately how many calories are they getting or approximately how many grams of protein does that look like, but general, how can we make it easy so that it just becomes part of the routine and you can spend 30 seconds doing it rather than like five to ten minutes logging your food, which is truly how long it can take for some of the apps if you're weighing and everything like that,
Kerry:Yeah, I, I know it can take a while. I find it very interesting with having patients kind of relate back to, you know, youth, right? You look at your kids and they oh, I'm full and they left tons all bites on the plate. And I'd be like, you know, it's terrible, but just really, like you said, listening to your body cues is really important. And that's why these medications are helping you feel full and making those decisions a little bit easier. Like you'll realize, oh man, I felt so uncomfortable last time because. I'm, you know, I over ate and, you know, my body was telling me stop and I didn't listen or, you know, the medication definitely helped with that too. But, you know, I think those are really good points of really dialing in on what you're feeling.
Sarah:And allowing there to be this external support for that because we get so disconnected from our bodies over time. And so how can we reconnect with that both naturally by paying attention, but then do we have other factors that need to help support us and reconnecting there?
Kerry:What I kind of wanted to ask you some GLP one questions, but is there anything else you wanted to talk about first? I just a few. Yeah.
Sarah:No although I just have to say, my daughter just turned two. She ate half of a Ritz cracker the other day, and she was like, All done! And handed it back to me. You know, my kids have surprised me with examples of that in the past, but she ate half of a Ritz cracker. Like, when was the last time you ate half of a Ritz cracker? Like, never? I don't know.
Kerry:Yeah. Yeah. It's, it's interesting. We can learn from, you know, watching kids, right? until they lose those cues too, which happens, which is sad, but, you know, typically they're, you know, pushing away from the table until you bring like dessert around or something. And then that's all probably fell off the wagon as
Sarah:Mm hmm.
Kerry:When you're not actually hungry. So You're you're our GLP one expert today. So let's start with some positive things. So what is the most surprising success story you've heard from someone using GLP ones?
Sarah:it's really interesting when we look at the study data to say, you know, what is the average amount of weight loss for a patient on what Wegovy or patients on zepbound or, you know, taking these products. And it's really fascinating because we know with what Wegovy it's a little over 15 percent total body weight loss on average. With Zepbound it can be more up to 26 and a half percent total body weight loss when it's combined with an intensive lifestyle intervention program. And we'll often quote those numbers, but the thing that I find really fascinating is the number of patients of mine who've just blown those numbers away. I mean, patients who've achieved 20, 30, 40 percent of total body weight loss, and it's phenomenal to see. And that's where incorporating in the rest of the lifestyle intervention to make sure that you're choosing the foods that are fueling your body, to make sure you're building up your muscle mass, to make sure that you are working through some of these behaviors about how do you eat in certain functions and how do you plan ahead? And whatever that looks like. Sometimes we see the numbers totally blown away, and it's not just one or two patients. It's we're seeing over and over again. That's not the case for everybody, but many of our patients have had phenomenal success on these medications, and it's not a fluke, right? It's the combination of all this other stuff. And so I love I love that. And that's been really fun to see in the practice.
Kerry:Yeah, I have a patient. Oh, I guess I've been working with over two years now. And this person is down like 154 pounds. I don't remember exactly where they started, but that's definitely blowing away those percentages. It's it's amazing see, and I'm sure you're going to say some good non scale victories for me too. But how about what is your favorite? How about top three non scale victories from people who are using GLP 1s for their weight loss?
Sarah:So I live in Virginia and I had no idea how many people ride horses in this area. We live in horse country and at the number of patients of mine who have taken backup horseback riding, it's like, it's a handful of people and I'm like, I had no idea that this many people actually rode horses in this area. So the people for whom it was a childhood or young adult hobby of theirs. And then there are weight limits for riding a horse, which to be honest, before I worked in this area, like people in Chicago don't really ride horses in the same way. Like we lived and worked in the city. And so it's been really fun to see the number of patients for whom they've been able to get back on their horse and get back to horseback riding. So that's been a really surprising one. I think flying on an airplane, too. So, you know, we think about the way our body fits in space, and I have patients for whom previously during air travel, they would have purchased two plane tickets even so that they could sit, have two seats side by side and not worry about, you know, sort of invading the space of the person next to them. And people for whom they're sitting in one seat, they've no longer needed seatbelt extenders that they've maybe used in the past, which is such a huge victory and then oh gosh, I'm like struggling to come up with the next one because I feel like there's so many different ones. I think it's the, so I have a orthopedic surgeon who refers to me or a couple orthopedic surgeons rather that refer to me pretty often because there's patients for whom they are pre joint replacement surgery. They're looking to get their knee replaced, or their hip replaced, or maybe both, and they often, the surgeons will, or the hospital systems rather, will look to a BMI of less than 40 before you can pursue that joint replacement surgery, and there's a lot of reasons for that that I won't get into, but it's been really interesting, I'm like taking their business away, they've sent these patients to me to get their BMI less than 40 so that they can pursue their joint replacement surgery, And then the patients are coming to me and like, Oh, actually, I don't think I need that surgery right now. I feel so much better now that I've lost, you know, even early on sometimes 20, 30 pounds. It's a really meaningful amount of weight, but especially as they continue in their journey and they lose 50 pounds, a hundred pounds, it makes a huge difference in their joints. And so, you know, these are patients for whom they have a known history of osteoarthritis and I'm sure joint replacement may still be in their future at some point, but they've delayed it, which is really, really cool.
Kerry:Yeah, those are excellent. I have, you know, definitely similar ones. Definitely not the horse one. Don't
Sarah:Yeah, it's very regional, I think.
Kerry:Yeah, for sure. Okay. What about any weird or unexpected side effects, maybe in a good or a bad way that you heard from the, from the medications from your patients?
Sarah:Yeah, you know, in a good way, the first thing that comes to mind is alcohol use. And we know that these medications, because they work in the dopamine craving pathway within the brain, we think about that in terms of food craving, food urge, you know, here, food noise, food chatter, you'll hear those terms used a lot, but it's really the exact same pathways that regulate alcohol use, other substance use and addictive behaviors. And so many of my patients, even ones who are like, I'm not sure that I want to stay on these medications longterm, the way that they're feeling in terms of their cravings or desire for alcohol is just through the floor. I mean, patients for whom every night they would come home and have, you know, one, two, three glasses of wine, even are just like, eh, I could take it or leave it. And that. For them, just having the brain space of not having to think and resist that craving for alcohol. In addition to the food, they hadn't really been thinking about that. And it's been really profound. So it's been fun to see that you know, probably anticipated side effect, but also seeing how that's played out with patients. It makes a really big difference in their lives. I'm trying to think in terms of negative side effects. So there are side effects with these medications, right? You know, we think of nausea, we think of constipation. It's interesting because I find a lot of those with proper support early on with maybe supplements or just proper use of sort of staying on top of it, that we can really minimize those side effects as part of the person's life. In terms of severe side effects, We've been lucky. We haven't experienced any of those in our practice. So things like gastroparesis, things like bowel obstruction. I haven't seen any of those. The one thing I will say, I have seen more patients with sleep disturbance on this medication than is reported in the literature. I forget the reported literature rate, but it's pretty low. It's one of the, it is a reported side effect, but let's say like 5 percent and then I am making up that number, but it's not significant. I do sleep disturbance more frequently than I would expect in this medication. And so I actually, I do counsel patients that that is a potential thing to watch out for or I've been doing that more recently and it tends to present as like insomnia, restlessness, maybe weird dreams, but it tends to be something that is improving with time and with good sleep hygiene, which A lot of adults do not have good sleep hygiene. A lot of times we're able to really minimize that, and they find that within a couple of weeks that symptom really goes away, or that side effect really goes away.
Kerry:I haven't I haven't seen anybody or nobody said anything about sleep issues that would be new, right?
Sarah:You know,
Kerry:side effect for me.
Sarah:yeah, I'm probably I've had it in like, let's say five patients. And so I started sort of in my whole list of side effects that we talk about started mentioning it. So it may be like setting people up to look for it. So maybe there, maybe it's, you know, it's hard to say, but I've been noticing that. And so to say, if that's happening to anyone, it, it happens and it definitely improves over time.
Kerry:You alluded to this possibly, an answer to this, but do you have any unexpected tips for handling side effects like nausea or something that's unconventional that really helps? Like you mentioned supplements.
Sarah:So with, you know, we mentioned protein water earlier from the nausea standpoint there, when we think of nausea, sometimes there's that feeling of like, I'm so nauseated, I can't eat. And I'm not sure if eating would make it better or make it worse. And like eating sounds just if, but I know I probably should. And so, especially people who are waking up, having nausea in the morning, having trouble getting started. Those are the patients I sometimes find are turning to like ginger ale or saltines, or sometimes that like if you had a stomach bug, you might turn towards those type of foods, but it's certainly to be in that situation sort of day after day or week after week is maybe not most in line with your health goals. And so I really like supporting patients with a protein beverage in the morning particularly clear protein. So like a protein water, for example, that goes down a little bit easier. I'm, like I said, I've just done this huge protein water kick. And so mixing protein water with an electrolyte packet can be really nice as well. And making sure patients are getting, their sodium, potassium and magnesium. So I do like to look for supplements that include that magnesium component. Some of the rehydration solutions are just sodium and potassium. You of course want something that's sugar free. I really like the brand element. It's L M N T. I also like the brand so well S O W E L L. Those both include magnesium as part of their Electrolyte replacement. But yeah, protein water plus electrolyte replacement. You can mix it all into one drink even over ice because it makes you feel a lot better when it's ice cold is really, really helpful for nausea. So we do occasionally do prescription medications if nausea is significant, but that has cut down on patients use of like, so for, and for example, pretty significantly. And then from a constipation standpoint. Also, I have all my patients take a fiber supplement. I also am a huge fan of magnesium. So as I alluded to with the electrolyte replacement, you know, that magnesium component can be really helpful as you know, in reducing constipation. And so making sure that patients are getting magnesium as part of their electrolyte replacement is really helpful from a constipation standpoint. So magnesium and fiber, I really like from that standpoint. So we advise a lot of our patients on those that can be really helpful.
Kerry:Yeah, those are definitely good supplements to include. We use Element in our house, so I think I'd like that one for sure. So how about any weird myths about GLP 1s that you've heard on social media that should be, you know, dispelled or anything like that? Can you think of anything?
Sarah:yeah. Well, I don't know if it's weird, but I think it's pretty pervasive the myth of like short term use of GLP medications. So this idea of like, I'm gonna use it to jumpstart my weight loss journey. There are patients for whom that may work. And so it's not that that's not possible. We look at studies of patients who take these medications for long periods of time and then stop them and They're, you know, on average patients will regain weight, but there's patients who don't, there's patients who are able to effectively stop the medication and stay off of it for a long term. But the reality is when we look at what it takes to do that, it means a lot of things. It means sort of working and supporting your body in the other way. So working through food, making sure that you're choosing foods that are creating satiety for your body. Making sure that you're working on body recomposition. So decreasing fat mass, increasing muscle mass. For example I never recommend stopping these medications, cold turkey. It's safe to do that. So if you had like a major side effects, if you found out you're pregnant it's safe to stop the medications, cold turkey. But for someone who is interested in stopping the medication, I recommend slowly decreasing, you know, from whatever dose you're on. Can you space out the dose a little bit, you know, for weekly medications? Can you try it every eight days or nine days or 10 days? And then if that's going well, can we take a step back to the next lower dose of medication? And we can kind of take this stair step down approach. But it's really interesting because I find that most of my patients and recognizing, you know, I'm, I'm dealing with a patient population that has generally pretty clinically significant obesity. So either really high body weight or that BMI of greater than 27 with a weight related comorbidity, they may be a different patient population compared to someone who has 10 or 20 to lose, for example. But generally speaking, I think it should be considered that these are long term use medications and that the short term use. While possible, it's sort of a let's wait and see how your body responds. Make sure we're supporting you in this comprehensive way so that potentially that's an option, but we don't want this to be another field diet attempt. And I think that's one of the things I'm most worried about for people is like, Hey, let me take this for three months and then just stop. We might create a situation where it's really no different than any other diet attempts that they've had in the past.
Kerry:Yeah, I agree. I think it's pretty, I guess it could be a concerning thing if that's what's going to keep happening, right? People take it for a little bit, then they're going to kind of mess with their metabolism. It's just like yo yoing from any other diet trend.
Sarah:Yeah, exactly.
Kerry:So you mentioned not stopping at cold turkey, except for in other circumstances. And I just want to tell a story of not starting at cold turkey either. So I had a patient who had an unfortunate And I highly do not recommend this, but she took it and ended up in the hospital, of course for severe nausea and vomiting. And It was pretty bad. So clearly you definitely need to be under the guidance of a medical professional and be titrating up on the medicine. And you don't just take somebody else's and think that you're going to be fine either. It was pretty scary.
Sarah:Yeah, oh my gosh that that is terrifying and there's many stories of that happening for whether people don't understand their dose that they're supposed to be on It's there's a lot of common stories out there. So yeah, don't do that
Kerry:Yeah. Well, let me tell us what you've got in store and yeah, yeah. Share with us, you know, what you've got for us. What is the exciting thing that we're going to talk? About with the GLP ones for you.
Sarah:Yeah, absolutely. So recently I launched the GOP guide which is an online course that addresses the answers to to the most common questions for patients who are using GLP medications, and this will address any of them. Whether it's Cepamoncharo, Trisepatide, like, Texandelir, Glutide, you know, if you're taking a GLP, we've got you covered, but one of the things that we found is that the prescribing habits. You know, people get this medication online. Sometimes they get it at like, I don't know, like Joe's corner shop, like people are getting these medications and are not always getting adequate support with it. And so I feel very strongly that patients should have access to information about understanding the Their side effects, understanding some of their nutritional goals, making sure that they are building this as part of their comprehensive lifestyle management so that the medication can be both safe and effective for them. And so it is a series of online videos. It's on demand. So you can sit down and watch the ones that apply to you for people who buy the course. If they go through the course and they're like, Oh, my gosh. There's a question that I have that is not answered. I'm inviting people to email me and ask and we will create a video that will add to the library for them and for others who are interested in that topic. So if people are interested in the GLP guide, it's only 97 for a full year of access. We're We've got so, so much content and it is growing every day. And to buy that, you can go to www. sarahstombaugh. md. com slash GLP. And I'm just really excited about this resource because I think it will really help a lot of people to get that additional support that they may be lacking in their weight loss journey. Yeah,
Kerry:a wonderful thing that you've created. And, you know, I'm very excited for you and for it, because there are plenty of people who are getting, you know, medication without the guidance. And sometimes I forget that they can get it online and, you know, just get a quick script. And that's just not, Not appropriate. So this will be super helpful in answering any questions and making sure that patients can, you know, get the most benefit and be safe when using these medications, which is what we all want, you know, most of all,
Sarah:exactly.
Kerry:Yeah. Thank you for, for sharing that. And we will obviously include that in the show notes as well. And, you know, I thank you so much for coming back on the podcast. We did a really long one. Hopefully.
Sarah:Yeah.
Kerry:But it was, it was a lot of fun and thank you for your you know, fun answers to my crazy GLP one questions, which I kept tame a little bit.
Sarah:Yes. I so appreciate it. Thank you for having me on today. This has been really fun.
Kerry:Awesome. And if you need a primary care at obesity medicine, doctor in Clearwater or Palm Harbor, Florida, please reach out to us at 7274461097 Thank you.
