This year there has been a lot of buzz about weight loss medications. From headlines with celebrities endorsing these drugs, to diabetes medication shortages, and trending social media hashtags like “ozempicchallenge,” there is obviously A LOT to unpack here. This comprehensive article will cover the basics of what these medications are, how they work and the side effects. Then, in part two, we will review the research and some things to consider if you are interested in starting this type of medication. Buckle up! 

Note: This is one Health At Every Size® Registered Dietitian presenting evidence and also providing my clinical perspective. I so encourage you to continue your learning and from other folks. As you read this, please know Feed and Flourish Nutrition Therapy is an advocate for body autonomy. We believe folks have the right to make an informed decision regarding what supports their well-being. We recognize that these conversations are not black-and-white but complex, personal, and ever-evolving.

I will mostly focus on the two major players that are making the most headlines: Ozempic and Wegovy, which are both produced by Novo Nordisk. These are the same medication, semaglutide, which are in the category of GLP-1 (Glucagon-like Peptide 1) Receptor Agonists, the dosing is what differentiates the two. (Other GLP-1 medications include Victoza or Saxenda which are liraglutide.) Ozempic is the dosage used for diabetes blood sugar management, while Wegovy is the higher dosage form intended for weight loss. Rybelsus is also a semaglutide medication that is a daily tablet instead of a weekly injection. Similar to Ozempic this medication is intended for folks with type two diabetes.

 

·  Ozempic is started at 0.25mg weekly injections for four weeks, then is doubled for month two. From there, the provider can recommend staying at that dose, increasing to 1mg/week, or the maximum dose is 2mg/week.

·  Wegovy is also started at 0.25mg weekly injections for four weeks, it is doubled for month two, doubled again for month three, and increases until reaching the full dose of 2.4mg weekly. If the full dose is not tolerated, it is recommended to return to the 4-month dosage of 1.7mg.

 

While semaglutide drugs seemed to start making headlines this year, the first version was released in 2005. These medications have been in use for years for type two diabetes management. It is not surprising that when a side effect of these medications was noted to be weight loss, Novo Nordisk began developing the drug specifically for weight loss effects. 

 

What does semaglutide do?   

The primary mechanism for this medication is that it stimulates the release of insulin (the hormone needed to allow glucose to move from the blood into the cells to be used for energy) and suppresses the release of glucagon (the hormone that stimulates the liver to release glucose into the bloodstream) only when blood sugars are high. These events occur naturally in the body due to a hormone called GLP-1, so this medication essentially increases GLP-1’s activity. GLP-1, the hormone, and GLP-1 Receptor Agonists, the drug, both use these two different mechanisms to help the body manage blood sugars without the risk of bringing blood sugars too low. (Amazing, right?!) 

 

Secondary actions of this medication include: inhibiting the “inappropriate” post-meal glucagon release, improving insulin sensitivity, limiting stomach enzymes from breaking down carbohydrates, inhibiting glucose reabsorption in the kidneys, and slowing the movement of food from the stomach. GLP-1 also activates neurons in the brain to signal fullness and a reduction in hormones that signal hunger. These medications are also being studied for the reduction of cardiovascular events and improvements in Nonalcoholic Fatty Liver Disease.

 

As a Registered Dietitian, when I read through the secondary actions of semaglutide, it is no surprise to me that weight loss is a side effect. When the stomach's ability to break down carbohydrates is limited, and food stays in the stomach for longer, this is very likely to increase the feeling of fullness, nausea, and stomach discomfort, which would reduce food intake. When these symptoms occur outside of the use of these medications, it is a condition called gastroparesis, meaning slowed (or stopped) stomach motility. Gastroparesis is known for causing all of the above symptoms as well as weight loss and malnutrition.

 

From what we see in research and hear first-hand from our clients’ experiences, this is similar to the discomfort felt by many suffering from anorexia, where their body slows down the digestion of food to try to absorb every calorie it can, but this slowed digestion results in discomfort and a feeling of fullness, making it challenging for the person to increase calorie intake.

 

GLP-1 is naturally released by the body in response to food intake. The synthetic version also has a direct impact on the hypothalamus, impacting feelings of hunger and fullness- regardless of food intake. A side effect that is often talked about with these medications is “reduced food noise,” or essentially thinking about food less. On top of the physical effects of slowing down food digestion, the altering of neurons in the brain is responsible for the reduced appetite.

 

Thinking about food can be a signal of biological hunger. It is unsurprising to me that folks on these medications report having reduced “food noise.” Most likely before starting these medications, folks would have been trying to suppress their appetite and lose weight. The body typically responds to weight loss efforts by increasing our hunger hormones and thus increasing food thoughts. When feeling full and nauseated, food is probably the last thing you want to be thinking about. A combination of the slowed digestion process and the impact on hormones likely results in the reported reduced “food noise.” Once stopping this medication the “food noise” is likely to come back, with a vengeance. 

Blood sugar management:

There is a major difference between using a medication for the purpose of managing blood sugars vs. intentional weight loss. In its lesser dose, semaglutide is not dissimilar to Metformin, a common type two diabetes medication, also known for having some gastrointestinal side effects. These medications manage blood sugars through different mechanisms. Managing blood sugar helps prevent serious health problems like heart disease, kidney disease, and vision loss. Even though the intention of this class of medication was to aid in blood sugar management, that has been completely overshadowed by its effect on body weight. 

Side Effects:

The dosage of these medications is slowly increased due to the side effects. On the Wegovy website, it reads: “the most common side effects include nausea, diarrhea, vomiting, constipation, stomach (abdomen) pain, headache, tiredness (fatigue), upset stomach, dizziness, feeling bloated, belching, gas, stomach flu, heartburn, and runny nose or sore throat.” It seems for some people taking the medications that these type of side effects occur at the start of the medication and at dosage increases, but eventually subside. For others, the side effects are unmanageable and do not reduce with time. Wegovy’s clinical trials report 44% of people taking the medication experience nausea, and 24% experience vomiting. 

 

I believe this is challenging for folks who are taking this medication with the goal of weight loss, as they may expect some of these side effects, and they do contribute to weight loss, but at what cost? There is no clear definition that I can find of what is considered “appropriate” nausea, diarrhea, vomiting, lack of appetite, etc., when taking this medication and when it is indicative of the body not tolerating and should be discontinued. These are essentially eating disorder behaviors that are being recommended and praised by providers for the purpose of weight loss, and for other people, these same symptoms are being treated as life-threatening mental health disorders. 

 

Additionally, there is a boxed warning (the highest safety-related warning a medication can have from the FDA) due to the risk of Thyroid C-cell tumors. Wegovy is contraindicated for those with a “personal or family history of medullary thyroid carcinoma (MTC), or in patients with Multiple Endocrine Neoplasia syndrome type 2 and/or with prior serious hypersensitivity reaction to semaglutide or to any of the inactive ingredients in Wegovy. Serious hypersensitivity reactions, including anaphylaxis and angioedema, have been reported.”

 

“Wegovy can cause fetal harm, and so it’s recommended that it be discontinued when a pregnancy is recognized,” and warns, “you should stop using Wegovy  two months before you plan to become pregnant because of the long half-life of semaglutide.” Wegovy also lists it has “serious side effects including acute pancreatitis, acute gallbladder disease, hypoglycemia, acute kidney injury, hypersensitivity, diabetic retinopathy complications, heart rate increase, suicidal ideation and behaviors.”

“On my third month, I became very sick. I started feeling tired, nauseous, throwing up. I went to the hospital because I started having heart palpitations,” Diaz told The Post. While in the hospital doctors discovered she had a hyperactive thyroid – something, she said, had never been an issue prior to taking the diabetes drugs for weight loss.

“In my case it [Wegovy] worked but, I had a lot of health issues afterwards. It wasn’t the best experience,” Diaz said.

 

If you are like me, you tend to nod off during medication commercials when the long list of possible side effects plays. It is important to note that these types of medications (like many others) do come with risks. Clients have shared with me that providers, including gynecologists (please stick to reproductive health- I beg you!), recommend them to try semaglutide medications for weight loss effects. Even folks with a documented history of an eating disorder. I have heard from clients that their doctor assured them of the drug’s safety and often downplayed the side effects. Typically, this is a medication that you are required to stay on for the rest of your life, and the longest study on its effects is two years. Why would providers not be giving the required, ethical informed consent that they are trained to give their patients? Weight stigma. Their own personal belief is that the supposed benefit of these medications outweighs any potential side effects. Reminder- this is not your provider's decision but your own. 

 

Now that you know how these medications work and what the side effects are, join us for Part 2, where we look at the research and offer some considerations to help you make an informed decision regarding these medications. 

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