Episode 19: Rumors about Semaglutide and Lean Mass Loss

I want to talk about these new weight loss drugs, the so called GLP1 agonists, Wegovia, Zempic, Mangero and others. And the popular media or popular thought that they are causing not only fat loss, but causing substantial lean muscle mass loss. And this has been repeated over and over again to where I'm starting to hear from my patients saying, well, I heard that you mostly lose muscle. There's a famous podcaster who's an expert in many fields and he's very, very focused on preserving muscle mass. So he's claiming that he's found that 70% of the weight loss is from muscle mass. And I've heard other people say the same thing and this quite frankly just isn't true. So there's some realities that we have to have a fact check when we hear these claims. And really, would the FDA have approved a drug that mostly caused muscle mass loss? And the answer is no, that'd be, there'd be no commercial model for it. So I'm just going to dispel those rumors just with some facts. But first I want to briefly talk about this class of drugs. So the GLP1 agonist, it's glucagon, like peptide 1 agonist, meaning it activates this pathway that's FDA approved. It's called Wegovy W E G O V Y Now this is the generic form is Semaglutide and it's also the exact same medication that is called Ozempic, which is the diabetes form. Now why is there a diabetes form? Ozempic and a weight loss form will go vi well, they're slightly different dosages, but they're almost the same. And the reason they have two different names is that if some people do not have insurance coverage for weight loss, if your insurance plan such as Medicare and others don't cover weight loss, then you would use the Wegovy and pay out of pocket. The Ozempic is for diabetes. Some doctors might write for Ozempic for just weight loss, but there's potential problems with that. If the insurance company finds out that you're using this for weight loss, I don't know how they reconcile that, but that's the inherent reason there's two different names. Now there's other GLP1 agonists on the market, but this is the one that is FDA approved for weight loss. It works, clearly works. And we're hearing statements now that it causes muscle mass loss, so therefore that might be a problem. Now how do these drugs work? Well, they work in the brain, in the pancreas, which is where your insulin comes from, and the gastrointestinal tract. There's multiple, multiple pathways and they seem to work not just for weight loss, but also they seem to improve bone density and they seem to improve cardiovascular fitness or cardiovascular health. In fact, one paper showed that people who had risk for diabetes risk had diabetes and risk for heart attack, if they went on a GLP1 agonist medication such as Ozempic, they would add about 1.7 years to their healthy life. So that's really pretty substantial. Let's get back to the weight loss. So when somebody loses weight through diet, they're going to lose fat and they're going to lose some degree of muscle and bone mass. Our muscles and bone support the weight of our body. So somebody weighs 300 pounds, that's, let's say, not working out their sort of average activity versus somebody weighs a hundred pounds. There's obviously substantial differences in muscle mass because the smaller frame cannot carry all that weight. So our muscles adapt and they get thicker. So when we see people losing weight, they will lose some degree of muscle and bone density. What we call collectively lean body mass and lean body mass is very important for longevity. We also know that people with very low lean body mass don't survive as long as people with more normalized lean body mass. Now, there's no evidence that excessive lean body mass, like bodybuilding, causes longevity. It probably does not. But a higher level of lean body mass is preferable to a lower body, lower amount of lean body mass. But we look at this in terms of percentage of total mass. So somebody that's 6 foot 5 would obviously have more pounds of lean body mass than somebody five foot. So we look at lean body mass as a percentage of overall weight to determine fitness or health versus what we call sarcopenia, which is where the lean body mass is diminished. Let's get back to how do we measure that? There's a few ways to measure lean body mass. Some if you go to your gym, they might use calipers where they pinch different areas your fat. And that's, that's a good way to compare that you're losing fat or not. It's not the best measurement of lean body mass, but it's a good indicator that you're losing fat and doesn't give you a direct measurement of lean body mass. So that's. But that's how they determine body fat. In some cases, there's a water displacement. If you put something in water, how much water is displaced as a Calculation to figure out how much is from fat and how much is from muscle, just based on the various weights. So muscle weighs is much more dense than fat, so it weighs more per se quart. There's something called a DEXA scan that's a type of X ray. That's pretty much the gold standard for measuring lean body mass versus fat mass. And there's other ways, such as impedance, which is electrical current goes between your hands and your feet. And based on the speed of the current, it gives you a good estimate of your lean body mass versus your fat mass. And there's things such as ultrasounds and other methods to measure fat and lean body mass. But let's say the DEXA scan, the X ray scan is the most accurate. Impedance is probably the second most accurate. Okay, so going back to this concept, what do you lose if you're losing weight? So the long term study with Wegovy was 68 weeks long, so a little over a year. And people lost about 17% of their body weight. 17%, but they didn't say that they lose fat or muscle. They just said, well, they lost 17% of their body weight. And therefore in a safe and very little drug interaction, and it worked pretty good. They went to the FDA and got an approval for weight loss. And then in some cases, some insurers cover it, some, some don't, but it became a blockbuster drug so much that they ran out of the little pens they use for injecting and they ran out for about a year. So people couldn't get their, their wegovy. I think they're back caught up with that now. So does WeGovy or Ozempic cause loss of lean mass? Well, yeah, it does, but is it important? So let's talk about that. How much weight loss are they losing and what percentage that is fat? So first time we review, they had 178 participants. These were diabetics and they did DEXA scanning. This is the X ray scan. And they were already on metformin and they added in some semaglutide, which is Wegovia, another similar medication or placebo, for a year. And what they found is that they lost weight and they lost muscle mass and they lost fat mass. However, they lost muscle mass, not very much compared to fat mass. In fact, at the end of the study, their percentage of lean body mass went up relative to their overall weight, meaning that they would be more musculoskeletally fit after losing weight, even though they lost some degree of muscle mass because they lost so much more body fat. And this is what we would typically see during weight loss. Again, this was without exercise. If they exercise, they probably would preserve their muscle mass. There's been studies demonstrating that. So in this study was kind of small, 178 people, but we generally consider that big enough because this is enough to be randomized. And they did lose some muscle mass, but their percentage of lean muscle mass went up relative to their weight because they lost so much weight overall. So this is I think important to understand this. Another study, 1961, adults without diabetes and they started out with a BMI over 27. Now BMI body mass index is a rough indicator of lean, overweight, obese or extremely obese. But it doesn't count for different degrees of muscle mass. But it's a crude index of which you're, you know where you are relative to other people. But in this study they took at people with BMI over 27 with 1 comorbidity. Comorbidity means some weight related disease such as hypertension or BMI over 30. And that's the FDA indication for WeGovy. So this was people that were overweight, without diabetes and they followed the FDA indication. The study was 68 weeks. They took a subgroup of them and did DEXA scanning before and after and they saw same thing. Weight went down, fat went down significantly, lean muscle mass went down, lean body mass went down a little bit. But their fat free mass, their lean mass went up as a percentage of their overall weight. Also they lost no strength. They did studies on strength, lost no strength. They were, they had a higher percentage of lean body mass relative to their overall weight. This again dispelled this notion that you're mostly losing lean body mass, which again is nonsense. But people are claiming this third study measured strength, fat mass, waist circumference and lean body mass. Same thing. They found that the waist circumference declined, strength remained the same, percentage of fat free mass improved even though they lost some fat free mass. So they lost some fat free mass, but their percentage of fat, fat free mass improve. So why are people saying that you lose muscle mass? Well, it's sexy. It sounds really cool to knock down something that really works. Now this, I've been in this industry and interested in weight loss for about 20 years and we've tried many things that work and some things that didn't work so good because it was a lack of compliance on the patient's part. So if we say in general, if we have a really compliant patient, we don't need Any drugs just, you know, eat really healthy and exercise, and people are saying they're doing everything they can. There's probably stuff we can do that is additional to lose weight. But we got to face the fact that some people are still struggling in spite of doing their best efforts. And these drugs work without being stimulants, without having significant side effects. It does have the side effect of gastrointestinal distress, such as nausea and, and heartburn and ingestion. But most people can tolerate it or it goes away in time. And this drug has worked better than anything we've seen now. In an FDA trial done by published last year, they saw, or they saw a 17% reduction in body weight at 68 weeks. So, you know, well over a year seeing much faster weight loss than that. But when our patients are getting this, they know they're not getting placebo because in the studies they give people either the active drug or placebo. And the study that was published in New England Journal of Medicine, that was really the linchpin for the approval. They were instructed to do 150 minutes a week of exercise. That'd be like 30 minutes, three times, three minutes, five times a week. And they're instructed to decrease their calories by 500 calories per day. And the placebo group lost about 2% of their body weight, and the people on The WeGovy lost 17% of their body weight. In a sub arm of that same study, they told the people to stop the medication, be it placebo or the wegovy, stop the exercise and stop the dieting, which seems nonsense, but that's what they told them to do. And what they found was that the people on placebo, they gained all the weight right back, which is expected if you went back to your old lifestyle. The people on the active drug, the amount of weight came back dependent was really subject to how much weight they lost in the first place. So the people that lost more than 20% of their body weight kept most of the weight off for a year after they stopped the drug. The people that lost about 5% of their body weight, the ones that we would say those are the minimal responders, gained it all back. Not in then some they just gained it all back. The people that were the average responders gained about half or a little bit more than half the weight back, even though they went back to their old lifestyle and even though it was a year later. So this statement that you gain all the weight back and then some after discontinuing the drug, that can happen, but in General, it does not. In general, it does not. And this statement that you lose mostly muscle mass now, you lose some muscle mass, but your percentage of muscle mass goes up as a percentage of your weight. So these things are statements that people are making. Now, why do people make false statements like that? Well, there's sometimes a matter of following the money. There's a new drug that's being tested that appears to cause weight loss, fat loss, and preserves or increases the amount of pounds of lean muscle mass. Now if that happens, they'll have a drug that not only reduces your fat, increases your muscle mass. They'll be more popular. Again, it's not out yet, but sometimes these kind of drugs come out and it seeds disinformation so that they have a good opportunity to market their drug as the drug that increases your muscle mass. So that's, that's one possible reason. The other reason is bias. So if you're an expert in weight loss and for years you've been working with people on their lifestyle and you know that works and it definitely works, and you've been successful at it, and out comes a drug that upends your world. It's a drug that somebody can take once a week as a shot and they'll lose more weight than your clients ever did with your method. Well, that's concerning to people, so they want to shoot it down. And I understand that. I'm very empathetic towards it. We have to accept the fact that it's just not real. This idea that you're mostly losing muscle mass is not real. And I've heard very famous podcaster state that in his experience, the patients are mostly losing muscle mass. 70% is muscle mass. I don't know. There's no evidence to support that. There's no study that proves that. And that particular person's bias is so much towards muscle mass preservation, it might be that he can't sit that the literature is showing the opposite. We haven't been measuring muscle mass in our practice. So I'm not going to talk about personal experience. I base it on, we call evidence based medicine. And evidence based medicine is a connection between the literature, what we see scientifically, what the community wants or expects, and the individual practitioner's experience. And that combination is, I'm seeing this literature that states that you increase your percentage of lean body mass and you lose mostly fat. I've seen this in my own employees who are taking the medication. They have the same strength and they're losing fat and clearly look thinner. They don't look Less muscular, they just look thinner, less fat and the customers are seeing the same thing. So when you hear that you have have to take it with a grain of salt that it might not be true. Why would we have a drug that mostly loses muscle mass? It just wouldn't, it wouldn't really work. So I want to put that to bed that you're losing mostly muscle mass. You're not, you are losing some. But if you exercise during, you probably would gain muscle mass. It doesn't stop that from happening. And I didn't talk about those studies. I talked about studies where they did no exercise. There was no exercise in the studies and they showed their percentage of lean body mass improves because of the fat loss. And this is typical of what we see with any other method of non strength training weight loss. So if we look at studies that looked at intermittent fasting, going on a calorie restriction diet, doing bariatric surgery in our own practice, we do something called a intragastric balloon or an endoscopic gastric sleeve. Those patients lose mostly fat and they lose some muscle mass that's in proportion to the fat loss. Now, one exception to that is with a the Rowan Y procedure, the surgery that is a bariatric surgery, they take out some of the organs. They will occasionally lose a disproportionate amount of muscle mass. So they're encouraged during to consume a lot of protein and do some muscle building. But accepting that extreme weight loss situation, typical weight loss, lean body mass improves a percentage of your weight. So body composition improves again. These semaglutide does appear to extend life or has a potential to. That's very beneficial. It does cause diabetes parameters to improve. In some cases. Patients may no longer be diabetics if they're on this and they do some lifestyle changes. People that are overweight, obese will come back about 11 level of weight. If they're obese, they might become overweight. Overweight may become normal weight. Our own experience, we did a trial in our South Carolina offices and it was our employees who were overweight and they wanted to lose weight. Not all were the ones that were enrolled in the trial. And her starting weights were 149 to 219 pounds. And we put them on the semaglutide the company paid for. We did it for three months. After the three months, we put them on metformin, which is a drug that is not a GLP1 agonist but actually improves or increases the level of GLP1 in your body. And that that seems to keep the weight off after you stop or discontinue the semaglutide. So in our experience, that was done months after discontinuing. The Wegovia is the. They lost about 14% of their body weight, plus or minus 2%, and the average weight loss was 24 pounds, plus or minus 4 pounds. In my experience with our company treating thousands of individuals, we're seeing that older individuals, say over 50, will lose less weight than people say under 35. Men may lose more weight than women, and heavier people will lose slightly more weight than people that are not as heavy. So somebody that's overweight might lose a smaller percentage of their weight than somebody that is obese, but they'll still both lose weight. We have had treatment failures, that is, patients that lost no weight, but it's been very few, less than 1/10 of 1%. We've had some minimum responders that would be people that lost only five or ten pounds in three months, but that happens less than losing over ten pounds. So the pattern that we're using is to use this as a way to lose weight and give you some help to keep it off. The drug is a little too expensive to take for the rest of your life for most people. Some people might have insurance coverage. Well, that's great. But it's about $20,000 a year for the commercial version. The compounded version is less than that. But we're seeing if you want it for three months, which is where most of the weight loss occurs, then switch over to metformin. You tend to keep the weight off. And this little story and how the drug works, it has a rapid tolerance, so the initial dose is 110 as much as the maintenance dose, and it's a dose escalation. So you start out with 0.25 milligrams and 0.25 milligrams, and then you increase it after four weeks to 0.5 and. Or to. I think it's 0.5. And it keeps. The dose keeps going up until you get to ultimately to 2.4, 2.5 milligrams a week. That's weekly shot. And then you stay there. Well, in the study that was done over 68 weeks, most. The most rapid weight loss occurred in the first three months. And then the weight loss kind of slowed down and pretty much tapered off around 40 weeks or so. What that's telling us is there's a tolerance to the drug, but there's also an extinction of the tolerance that occurs pretty rapidly. So if you take the drug for three months. And let's say you lose 15 or 20 pounds and you want to lose more weight. Well, the studies show that you're going to pretty much lose a little more weight, but if you take it for another year, you're not going to lose much more than that, maybe another ten pounds or so. However, if you stop the drug for six or eight weeks, go on metformin, that improves the pathway the drug is treating in the first place, then start it up again. You won't lose weight as fast as you did the first time, but you lose it about half as fast and you may get that extra 10 pounds or 15 or 20 pounds off that you need to get off. So again, this is without deliberately dieting or exercising. The range of weight I've seen over three or four months has been pretty much none, which is very, very rare. But typically about 10 to 40 pounds is the range we're averaging in right around 20 or so. And then we put people on metformin for six or eight weeks and at that time their tolerance to the drug extinguishes. And then we get started up again at the lower dose, which is again lower dose. So it's much less expensive. So it saves a substantial amount of money. And a drug that costs 20,000 a year for the commercial version. The. There's, you know, it's really not attainable for a lot of people. Either their insurance doesn't cover it or they don't qualify based on the parameters. And you can do this much less expensive by using this in a, in a stepped fashion where you go on the weight loss dose, take a pause, let your body become less tolerant to the drug and start it over again. And that in combination with lifestyle changes, we're going to see a better result. So we're seeing the best results and people that make some deliberate effort, particularly with their diet. So when you're taking the medication, people are less hungry and they crave crappy food less. And this is an opportunity to change your taste over to a Mediterranean diet. I've done separate videos on a Mediterranean diet that would be, let's say, almost the opposite of the American diet, the processed food, high fat, high sugar, high salt, American diet. So a Mediterranean diet and then adding in some activity or exercise is also going to hasten weight loss and also even preserve more lean body mass or potentially build lean body mass. So that being said, I want to dispel the rumors that this mostly causes muscle loss. It does not. The lean body mass improves fat mass, improves characteristics of cardiovascular disease, of pre diabetes of health all improve. And again, one study shows an expected extended healthy lifespan of 1.7 years over conventional treatments. So thank you very much.