The Weekly Vlog - Susan Peirce Thompson, PhD
March 15, 2023
Hey there, it's Susan Peirce Thompson and welcome to The Weekly Vlog. I have been asked, I have been asked and asked and asked to shoot a vlog on semaglutide drugs for weight loss. So, here we go. So let's talk about the pros and cons of drugs like Ozempic, Wegovy, and tirzepatide for weight loss. Now tirzepatide (Mounjaro) is not technically a semaglutide drug, but it's very, very similar. It just has an additional hormone, in addition to GLP-1, that is active. But for the purposes of this video, it works essentially the same way, produces essentially the same results, and I'm just gonna lump them all together.
Now, as of the shooting of this video, only Wegovy is approved in the United States by the FDA for weight loss. However, doctors are prescribing tirzepatide and Ozempic for weight loss, sort of off-label. They're just doing it because people are asking for it. And all of these drugs are diabetes drugs. Well, Wegovy is a weight-loss drug, Ozempic is a diabetes drug, tirzepatide is a diabetes drug, and something that people are grumpy about is that diabetics are having a hard time getting their medication because so many doctors are prescribing it for weight loss.
Now, the pros of these drugs are really, really clear. Massive weight loss, really significant weight loss, which is very exciting because people need to lose weight and they're having a hard time doing it. And doctors feel helpless in the face of all these patients they have that need to lose weight, that want to lose weight, and doctors have been saying, "Hey, go do behavioral interventions"—meaning eat less, exercise more—and patients aren't getting results from that.
And so the biggest upside of these drugs is that they work for weight loss. Now, additional upsides is reduction in hunger and cravings. Now, if you've heard me talk ever, you know that these are separate systems in the brain. And I just have to give a big caveat here, which is I am not a doctor. I do not prescribe these drugs. I have no pharmaceutical conflicts of interest. I'm not a doctor.
I'm not here to give you medical advice. I am a brain scientist, though, and I'm a weight-loss expert and an expert in the psychology of eating. And so people have asked me to weigh in on what I think about these drugs. And so the trifecta of massive weight loss, decreases in hunger, decreases in cravings—it's a very powerful thing, because people are suffering from food cravings and runaway hunger, which I call insatiable hunger, this weird new kind of hunger that doesn't seem to be satisfied by eating, which regular hunger is. Right? And these drugs curb that insatiable appetite, making it relatively easy to lose weight. So the weight loss that people are seeing is way beyond what people see with typical behavioral interventions. So typical behavioral interventions like Noom, like Weight Watchers, like any of the typical apps or diet programs that people go to—Jenny Craig, Nutrisystem, all of them—what you see is that people lose 5-7% of their body weight and that happens in the first six months to a year, and then weight regain begins. And then people regain much of that lost weight, on average.
Some people, of course, regain it all and then gain more. So what people are losing on these drugs is like three times that much. They're losing 15-18% of their starting body weight. And so that's really exciting to doctors and to patients. It's a lot of weight loss and people are also seeing some of the benefits that go along with weight loss, like better cardiovascular outcomes and things like that. So that's one of the biggest upsides of these drugs.
Now, how are these drugs working to produce these effects? So GLP-1 is a hormone. It's also a neurotransmitter. And what's happening from a diabetes perspective is it's helping to regulate blood sugar and it does that in two ways. It does that by working in the pancreas to increase insulin production and in the liver to decrease glucagon production, having the effect of balancing out blood sugar.
Now, if you've heard me talk, you might be concerned that the increase in insulin would then block leptin, which would make you hungrier. But actually, this GLP-1 goes right to the brainstem, right to the center of action of satiety and suppresses hunger, suppress it—like increases satiety, suppresses hunger. So it works directly on those circuits to produce a powerful anti-hunger effect, a suppression of hunger. So that's helpful and it's powerful.
And people notice, "Hey, I just don't feel hungry. I don't feel like eating on these drugs." So it's not that people are eating healthier. It's just that they're eating less. They're just less interested in eating. Now, what people have noticed—what doctors, researchers, patients have noticed when people are taking these drugs—is they're also smoking fewer cigarettes, drinking less alcohol, one-clicking less on Amazon.
Like their addictive tendencies, their reward-based tendencies are going down as well, which might make us think, well, it's probably acting somehow on the mesolimbic reward pathway, right? The ventral tegmental area and the nucleus accumbens, those dopaminergic systems. And it probably is, but we don't know how yet. So we don't know the mechanism of action there, but we're pretty sure that it's acting there because it's taking away food cravings. The craving system is separate from the hunger system, right? It's taking away food cravings. Those are produced by dopamine downregulation in the nucleus accumbens.
So it's taking away cravings, but not just for food, also for these other substances of abuse, these dopamine-producing, reward-based behaviors and substances. So either there's some sort of separate action that's working somehow on the mesolimbic reward pathway or somehow downstream from the GLP-1 impacting the satiety centers in the brainstem, somehow downstream from that, the reward pathways are being affected. But one way or another we really think the reward pathways are being affected. It's just people's experience on these drugs.
So as you know, for me as a former drug addict and food addict, who was living with clinical obesity by my mid-20s, having some of the most powerful food cravings I can picture anyone having—food practically ruined my life and fighting food cravings has been one of the dominant things I've done in my adult life—I can really see the attraction to a drug that would take that away, right?
And I especially see the attraction because I experienced it myself when I was 16 and I found methamphetamine. When I started snorting crystal meth, all of a sudden my food cravings were gone, my appetite was gone, and it felt like a miracle. It felt like a friggin' miracle. I was so relieved to not have that hunger and that craving plaguing me. Already by the age of 16, those cravings were dominating my life. So I can see why people are attracted to these drugs, because it just quiets all that down.
So those are the pros, right? And let me just say, these semaglutide drugs are not stimulants. They're not acting in that same way as speed does, right? This is not Adderall. This is, these are operating in different ways, but with that same effect. Okay.
So, let's talk about the cons now. Well, at the moment, these drugs are outrageously, ridiculously expensive. We're talking on the order of about $15,000 a year, like over $1,000 a month. Hard to get covered by insurance, good luck with that. And they're hard to get, right? So super expensive. Let's say you have the money. Let's say that that's not an issue.
There are also side effects of these drugs. Now the way the drugs work is they're an injectable. That's a downside for some people, is a needle injection once a week. Some people are like, no thanks to that. At the moment, these drugs are injectables. And so once a week, you get this injection and they're gonna ramp you up. So they're gonna start slow, light, on a small dose, and then increase it slowly. During that introduction phase, some people have side effects, gastrointestinal side effects that are so bad that they can't continue the drug. It's actually a fairly sizable percentage of people. I'm talking about nausea, vomiting, constipation, diarrhea. So these drugs are doing something to the small intestine and it's not good. Now in some percentage of people that calms down after the ramp up phase and they're able to tolerate the drug.
Now the FDA has just put a black box warning on these drugs for thyroid cancer. That's the highest level of warning. It's like, warning, warning, may cause thyroid cancer. So there's another downside. Now we don't have any long-term data on these drugs, right? The clinical trials, like the big one for weight loss was 1.3 years. The longest it's been studied for diabetes is two years. And so we don't know what happens longer term with taking these drugs, right? So side effects are a potential downside for sure.
And I just gotta say I have a bias here, which is, in general, I'm not a fan of pharmaceutical solutions to problems. I prefer addressing the root cause of the issue. Really going down and saying, "Okay, what's the underlying issue here, and can we heal that without drugs? Can we actually heal?" I'm a bigger fan of that in general. Not to say that I'm not also understanding of Western medicine drugs to take away symptoms and sometimes to treat things. I had twin babies who were born weighing one pound, and I was very grateful for the Western medicine interventions that saved their lives. So Western medicine has its place, and when you're suffering from something, getting a doctor to give you a pill sometimes feels really, really good. So, I get that.
But here's the third and final downside—and I think this is a huge one—which is, the minute you stop taking the drug, the weight comes rushing back. Now, that's not shocking. If you are on a cholesterol medicine and it's lowering your cholesterol, one might assume that when you stop taking the drug, your cholesterol's going to go back up. But it is a little disappointing, because if the weight's already off, why can't you just maintain that weight loss? And that is not what the research shows.
So, body fatness is regulated by a homeostatic process in the hypothalamus in the brain, and one might have hoped or expected that taking these drugs might lower the adiposity set point so that the brain would allow you to maintain that lower weight when you stop taking the drug. But it doesn't. The brain remembers what you used to weigh, and it forces you right back up there fast. In a New York minute you're right back up there.
And so what that means is if you start taking these drugs, you need to be prepared to take them for life, potentially. Now I'm going to wrap up this video proposing an alternate solution there, but there is another way to think about it, potentially. But that is a big downside, is the way it's going to come back when you stop taking the drug. And so, if you're like me, that gives you pause. I don't know if I want to be on this drug for life, especially if it causes thyroid cancer. Who knows what it's doing to the gastrointestinal system. The fact that the minute you start taking it, these terrible effects of the small intestine kick in. And yeah, so side effects are a big problem, and weight regain after you stop taking the drug.
Okay. So that's kind of the lay of the land. Now, what I want to mention here is I do have a conflict of interest. I do have a horse in this race. I do have a dog in this fight, which is that I'm the founder of Bright Line Eating®. And while it is true that most behavioral interventions produce only 5-7% body weight loss, fat loss, and then that weight gets regained starting at six months to one year, let me show you a graph here that is a compilation of all of the published studies that I could find in the peer-reviewed scientific literature on weight-loss programs. These are behavioral weight-loss programs. Programs that teach people how to eat differently and/or exercise so that they can lose weight. And what you see here is that Bright Line Eating produces the same massive weight loss, in that 15-17% of your body weight range, as these semaglutide drugs. So, you can get the same effect from Bright Line Eating.
And if you look at that dark blue bar, you can see that people are not regaining the weight after a year. They're maintaining that weight loss. So that's really powerful. You can get these results in a different way. And other published findings have shown that doing Bright Line Eating, which is a behavioral intervention that also connects you with up with a community of people; gives you social support; it improves your feeling of being loved, connected, and supported in the world; decreases loneliness; decreases depression; decreases days of poor mental health. These are all published findings. Increases energy, increases happiness. And so, you're learning habits and behaviors in Bright Line Eating that support overall wellbeing, while eating an amazingly healthy diet. So you're not just eating less crappy food, like less of your junk food. You're actually eating really good food with better nutrition, which has all kinds of other benefits. On Bright Line Eating we see people having all kinds of positive effects.
And so, also with Bright Line Eating, published results show that hunger and cravings go down to negligible levels after just eight weeks. So with Bright Line Eating also, we heal those parts of the brain that generate that insatiable hunger, that generate that intense feeling of craving, reduce the mental food chatter so you're not obsessed with food anymore and give you the same benefits without having to take a drug.
Now, some people who have a very pernicious form of food addiction may struggle to get their bearings with Bright Line Eating, or with other approaches like a 12-step program for food addiction. And I can see a world in which it might be beneficial to take a semaglutide drug for weight loss for a temporary period of time to give you some relief so that you have some breathing room to set up the habits and practices of Bright Line Eating, and then wean off the drug. Some people just need a little bit more support to make that work.
And in that world, you aren't signing yourself up for a lifetime of taking the drug, because you're going to be doing Bright Line Eating for life, which by the way, you got to keep doing that too. Otherwise, the weight's going to come back as well. But in the case of doing Bright Line Eating, we're talking about eating healthfully, meditating, staying connected with people who are loving and supporting you. These are all the things that you should be doing anyway. So really what Bright Line Eating is doing is setting you up to lead the kind of healthy lifestyle that is part and parcel of living a flourishing life. So that is one world in which, or one approach to these drugs that I can see could make sense in some cases.
Now, just to say, most people who start Bright Line Eating don't need a drug to do it. If they surrender to the program and they really work it in, our average results—average results—show the same kinds of phenomenal results that people are getting with these semaglutide drugs, without taking a pill.
Now, just saying these drugs are here to stay for sure. We know the pharmaceutical companies right now are working on a form that can be put into a pill, so it's easier to administer probably at some point then it'll become cheaper and so forth. So these drugs are here to stay, and they have their pros and cons. Like I said, I really sympathize with someone who's looking to just have the cravings and the hunger stop, and there are other ways to achieve those results other than pharmaceutical drugs.
So those are my thoughts. Thanks for requesting that I shoot this vlog. It's been high time. That's the Weekly Vlog. I'll see you next week.