Welcome everyone to another edition of the Doctor’s Note where we talk about what’s on our minds when it comes to your health. As you know, the main focus of my practice for the last 18 years has been the fight against obesity. In fact, that’s why I hung my own shingle and got out of “corporate” traditional medicine.
This week’s Note will be along those lines. There is a new class of drugs on the market that is rocking the weight loss world, the newest being Mounjaro (Tirzepetide) and it’s worth all the hype!
Let’s get started.
The Obesity Epidemic
I’ve said many times that our country’s main medical problem is obesity. Being overweight, (BMI of 25-29.9) or affected by obesity (BMI of 30-39.9) or morbid obesity (BMI of 40 or greater) greatly increases your risks of heart disease, cancer, general debility, and diabetes. Insulin resistance being at the root of them all. Note: BMI = Body Mass Index. A normal weight would have a BMI of 18.5 to 24.9.
Fortunately, mainstream medicine is starting to accept the fact that obesity is a chronic metabolic disease and needs chronic treatment. Granted, the conditions we live in today are not the same as they were many years ago: the foods that we eat, the constant stress we live under, toxins we live in, etc. But in my opinion, the main cause of the obesity epidemic (and heart disease) in this country was: (a) the introduction of high fructose corn syrup (everybody started eating more sugar), and (b) the FDA telling us that fats make us fat. Fats do NOT cause heart disease or obesity. Sugars and refined carbohydrates DO.
The result is an epidemic of obesity. By 2030, the prediction is 1 in 2 people will be obese (globalwellnessinstitute.org). According to the 2022 CDC National Diabetes Statistics Report, cases of diabetes have risen to an estimated 37.3 million. I feel the impact of these statistics. Half of my day is spent treating diabetes and obesity, the other half figuring out people’s hormones. Thankfully, we have a breakthrough.
A New Class of Drugs
The evolution of a new class of medications (i.e., Ozempic), changed the way mainstream medicine thought about weight loss. This was a good thing. People now have hope! Even a company like Weight Watchers realized that they were going to go out of business unless they admitted that they were going about weight loss the wrong way. They are now in the telemedicine business helping people obtain these new drugs for weight loss. Isn’t that interesting? They’re betting their whole company on this!
Everyone knows people need to eat better (the common denominator being less sugar and refined carbohydrates). But remember, every diet works and fails to some extent. It’s more a way of life. Most people that are chronically obese have a metabolism problem. Very complex. Even Weight Watchers admits that it’s difficult for most obese people to maintain weight loss. Then comes Ozempic (Semaglutide). The game changer! It’s FDA approved for weight loss under the brand name Wegovy. Note: Ozempic is approved for diabetes.
In my opinion, this class of drugs is the most significant new drug of this century (maybe even of the last 50 years). The newest on the block is called Mounjaro (Tirzepatide), the same class of medications, with an added benefit. It will be the biggest selling drug of all time. Right now it’s just approved for diabetes, but I predict it will be approved for weight loss soon. I’d be shocked if it doesn’t, especially with the new studies that have come out on it. It’s been astounding!
What is Mounjaro?
Mounjaro is a dual GLP-1 Agonist AND it has a GIP Agonist (glucose dependent insulinotropic polypeptide). We are always talking about peptides. I love peptides. Mounjaro is an acylated peptide. The GIP added to the GLP-1 is what makes Mounjaro different from Ozempic (Semaglutide). They are both what we call incretins. Incretins are hormones secreted by the gut, after food intake, to stimulate insulin secretion. The GIP is secreted from the upper gut, whereas the GLP-1 is secreted from the lower gut. It gets real complex. It involves other factors such as DPP-4 and Peptide YY that I’ve talked about in the past.
The incretin hormones (GLP-1 and GIP) are impaired in obese patients. It’s not the same as someone who is lean. They are impaired. In one aspect, that’s why bariatric surgery works. Bariatric surgery does bypass part of your stomach, but it affects the incretin hormones. Note: That’s why, the day after your bariatric surgery, your sugars are normal. The surgery has not changed the way you eat. They’re finally coming around to the fact that after bariatric surgery, you’re probably going to need one of these medicines (the GLP-1, and maybe the GIP) to maintain the weight loss, because you can easily regain the weight after surgery. I’ve seen it many times.
Incretins have additional effects on adipose cells (fat cells), as well as bone and the cardiovascular system. Their therapeutic effects are protective for heart, kidneys, brain, and even for fatty liver. Other specialists like cardiologists, gastroenterologists, and nephrologists are using these medicines for those purposes.
These drugs are for a lot more than just weight loss and diabetes.
They work by stimulating the release of insulin to control your blood sugars.
They slow down the release of glucose from your liver.
They slow down gastric emptying, which makes you feel full longer. This is why some people have a little nausea when they first take it. There have been very few people that couldn’t take this because of the nausea, but most of the time your body adapts to it.
Note: Mounjaro also inhibits the brain’s hunger signals. I’ve even had a few people tell me that they feel better mentally on Mounjaro. It does affect your neurotransmitters.
Mounjaro vs. Ozempic
The big news is a result of two recent trials of Mounjaro. The first showed a loss of 22% of your body weight after 72 weeks. The second trial showed a bit less, but overall major weight loss. What we call this is a twincretin. Instead of one incretin you have two! Really, it was more effective than Ozempic (which is a great drug)!
Clinically, I have a lot of experience with both of these drugs for weight loss and diabetes. Ozempic (or Wegovy) is an amazing drug, but Mounjaro seems to have the upper edge with a little better weight loss and probably less nausea. This is obviously not so for some people, but for most Mounjaro is probably a bit better. I have patients that prefer one or the other. They’re both great drugs, but there is a difference in the way they work. It seems that Mounjaro hits more pathways, maybe a little less side effects, and better weight loss.
Now we have two very powerful tools in our armamentarium for the chronic treatment of obesity and diabetes. Most obese patients will need to stay on these medicines. This is not something that you get on for a few weeks and then get off. Note: Some people can get off if they radically change their lifestyle (which we emphasize) and look into all of the other factors you need to look into.
If you have morbid obesity, you will need to stay on one of these medications chronically, just like you chronically need to stay on blood pressure for hypertension or cholesterol medicines for hyperlipidemia. Insulin resistance, prediabetes, and diabetes itself, is chronic in most cases. Not that there aren’t people who can’t reverse these totally. There are! There’s just not many people who can do that, in my opinion, without help. Note: Studies have shown that most people who use weight loss drugs for a year or two and then stop it, gain the weight back. Just like any other diet. Therefore, you need to learn HOW to eat. In my opinion, this means less sugar, less carbs, more good fats, and probably more protein. The old theory that you need to eat less fat is totally wrong.
This class of medications are a total game changer for weight loss. Mounjaro seems to have some advantages over Ozempic (Wegovy), which I love too, but for the most part it boils down to what you can get a hold of. Mounjaro is not yet approved for weight loss. It’s approved for diabetes only. About half of what us doctors do is off label anyway, so it’s perfectly legal. Note: You can’t take either of these drugs if you have a history of pancreatitis, medullary cancer of the thyroid (very rare), or something called MEN II (Multiple Endocrine Neoplasia, which is a series of endocrine cancers, or a family history of this).
How To Get It
The main problem I’ve seen with these drugs is that they’re expensive and insurance doesn’t want to cover them. Plus, with all of the Hollywood hype around Ozempic, it’s tough to find! They totally miscalculated how big this would be and how much was needed. There is a supply problem now, but that shouldn’t be a problem in the future. Believe me, Big Pharma wants to make money. They will figure it out.
The good news is that there are compounded versions of these medicines. When you do compounded medicine, it has to be somewhat different from the brand name. So they make a “like version” by adding something different or using different doses. It’s perfectly legal (as it should be) because they can make it a lot more affordable for the people who can’t get the brand name covered. Insurance is finicky about who gets the name brand.
Some weight loss clinics are charging people more to go in and get one subcutaneous shot per week, versus allowing you to give yourself the shots at home. I think most anyone can give this shot to themselves weekly, and it also makes it cheaper. My philosophy at Performance Medicine is to try and get your insurance to approve the brand name, one or the other. If there’s no way that they will approve it, then we order it as a prescription in your name as a compounded medication. We teach you how to use the medication, and you take it home, so it will be cheaper for you. Note: Be aware that the FDA is probably going to try to intervene and make it illegal for them to compound these medications. These drugs were originally for diabetes, but they are a lot better for weight loss. Remember, it’s not for losing 5-10 pounds (although it would work for that).
Final Thoughts
Obesity is not a character flaw or laziness, it’s a chronic metabolic disease. Metabolically speaking, we don’t live in a perfect world. This new class of drugs (Mounjaro, Ozempic/Wegovy) is just a part of the solution. There are lots of other important factors to consider, i.e., hormones, sleep, nutrition, exercise, stress reduction. Medication is just a tool.
As always, do your own research. It’s not just about losing the weight, it’s keeping the weight off that matters. Maintaining your weight loss leads to better overall health: reduction of arthritis, depression, anxiety, heart disease, cancer, fatty liver disease, and neurodegenerative processes (Alzheimer’s is also called Type 3 diabetes). Thankfully, we have some great tools to help!
Till next week.
