13: Listener Q&A: Medical Tourism, Hair Loss and “Slow” Progress

Today, I’m diving into some of the most common questions I get asked from you, my community.

My rule of thumb is that if one person is asking it, there are likely many more of you thinking it or struggling with a similar issue. 

As always, I am not providing any medical advice in my responses, this is purely informational and educational. While I cannot give specific recommendations, there are some general points and takeaways that I want to share with you.

I’m covering a wide range of topics, including:

• Concerns about slow progress on anti-obesity medications
• Bariatric surgery vs. anti-obesity medications
• Issues around medical tourism
• Suggestions for hair loss on GLP-1 medications.

Don’t forget, if you have a topic you’d like to hear covered in a future episode, you can sign up to my weekly email that lets you know what's coming out on the podcast. Simply hit reply to those emails with your suggestion and we'll look at incorporating it into a future episode!

• “I have been on Ozempic (0.25mg dose) for 3 weeks. I have lost 3 pounds. Is it normal for it to be that slow?”

Ozempic is one of the anti-obesity medications which is injectable once a week. Ozempic is specifically branded for diabetes. The other name for weight management is Wegovy. Semaglutide is the generic name, and 0.25mg is the starting dose. 

First of all, one to two pounds a week is the maximum amount of weight loss that we'd want on a medication like this. If it's higher than that, we're at risk of you losing your lean muscle mass (the muscle that you have in your body).

It’s clear that there is an issue here with comparing weight loss to other people that are losing weight at a super rapid pace. That is not normal, not expected, and not what we're wanting. Therefore, comparison like this is really not helpful for us. It's much more productive for you to look at what you’re doing as sustainable. If you lose weight super quick without the correct guidance in terms of protein intake and resistance training, we are potentially seeing up to 40% muscle loss, which is hugely significant. You're also increasing the chance of getting gallstones and losing your gallbladder.

Losing one to two pounds a week is absolutely amazing for the average person. If you find yourself in the camp where you have less weight to lose, you might be only losing half a pound a week, but it does not matter. You're still making forward progress.

What is more important to look at is the weight loss percentage that you're losing. To find out more about how to calculate the percentage of body weight that you've lost, head over to my recent podcast episode: Anti-Obesity Medications Part 2. That is a much more revealing number compared to just pounds in general.

This kind of progress is not slow at all and seems to be right on target.  

• “What is your opinion on VSG (vertical sleeve gastrectomy) versus medications?”

When it comes to my thoughts on bariatric surgery versus weight loss medications, it's really not an “either/or” situation. If we really look at the data, bariatric surgery is extremely effective for long-term weight loss. But what I really look at is what's the right tool right now.

You might be someone where surgery might not be covered at the moment, or you might not feel comfortable with the thought of surgery. If medication is covered, that could be a good starting place. If you have a significant amount of weight to lose, you may then consult with a bariatric surgeon who shows you the data and how surgery is actually the most effective tool right now to bring down the weight.

If you don’t get all the way to your goal after you have surgery, medications can then be used, which is actually quite common with my patients. I have many patients that have had bariatric surgery in the past and they lost weight and kept it off, but they didn't get all the way to their goal. So for health reasons, they want to keep going, which is when we bring in medications. 

This is really not a black and white scenario. The challenge people often face with this is finding someone who can walk them through the logic of all of this. Ultimately, I think an obesity medicine specialist can help you with the best route to take.

• “I lost 30 pounds on Mounjaro, but it wasn't covered anymore, so I switched over to Ozempic. I have only lost five more pounds, I’m eating one meal a day and I don't know what else to do.”

Firstly, there is no universe where eating once a day when you're on these medications will mean you are getting enough nutrition.

If the medications are working properly, part of what’s happening with these injection weight loss medications, is that we're slowing down the gut motility. This means that you will usually get full with less food. If you're only eating once a day, you typically cannot get enough protein and the other macronutrients that you need in that one meal.

Not only that, but when you are undereating, you actually stop losing weight. When people find themselves so frustrated because they feel they've done all they can, it can help to stop focusing so much on the medication that you're on because in doing that, you give it too much power.

It's definitely there to help you along, but it seems like it could be time to switch gears and see, for example, if you could meet with a registered dietician or someone that can help you to optimize your nutrition. I suspect if you're eating once a day, there could be other issues such as overeating, undereating, drink consumption etc. which is affecting progress. Eating one meal a day will never be helpful for you.  

• “I’m in my thirties, over 300 pounds and am trying to decide between medication or going to a clinic in Mexico to have bariatric surgery. My insurance doesn't cover bariatric surgery here in the States and I don't know if the medications are covered.”

Medical tourism, unfortunately, is very much a reality both outside of the States and in terms of people coming to the States to receive treatment. What's unfortunate here is that insurance can up lots of exclusions and so people are faced with these incredibly difficult decisions.

Even before I went into the weight management space with obesity medicine, I had a lot of  patients in primary care that had gone to Mexico to get the bariatric surgery done. They would then follow up with me or other weight specialists afterward.

The biggest challenge that I see with this is that, firstly, I have no idea about the medical care that you're getting there. Additionally, I did not see these patients receiving as much follow up afterward as they would've had if they were at a US center getting this done. 

Centers that do bariatric surgery in the U.S. are usually centers of excellence. They need to be doing a certain amount of cases to even qualify to be able to do this. This stems back to when the mortality rate used to be quite high. Typically, there is a lot of follow up and this is very beneficial in the sense that a bariatric surgeon knows what you should be projected to be losing and if you're on track or not. If you are not on track, then they know other interventions that can be done right away. 

The challenge when you go to a place like Mexico is that that follow up does not exist. Previous patients have told me they do a video call, but I suspect that a bariatric surgeon in Mexico would do a video conference with them before they would come for surgery, and tell them the percentage of weight loss they can expect with this surgery. But if no one's following you afterward, it's a very tough road. 

If someone chooses to go down this road, I would definitely encourage them to think about what their follow up plan is going to be. That could look like ensuring to have a weight specialist that you're following up closely with afterward.

5. What are your suggestions for hair loss on GLP-1 medications?   

First of all, always go and talk to your doctor. That should be the first step.  Hair loss patterns can be very complicated and quite often a dermatologist will be a great step for you if your primary care doctor is not helpful.

I would also recommend revisiting my interview with dermatologist Cris Berlingeri MD to find out more about telogen effluvium, which is rapid hair loss caused by stress or a change to your body.

Hair has several different phases to its cycle. The first three phases — anagen, catagen, and telogen — cover the growth and maturation of hair and the activity of the hair follicles that produce individual hairs. During the final, or exogen, phase, “old” hair sheds, though usually, a new hair is getting ready to take its place. Each phase has its own timeline, which can be affected by age, nutrition, and overall health. 

Whenever there is a massive stress on the body, which can be anything from having a baby to having surgery, the body knows cortisol is up and it abruptly goes into telogen (the falling off phase). It can be up to 50% of your hair that gets lost, but this happens months after the stressor. Usually around three months after the stressor, you start to lose hair, it can last three months and then it comes back (think 3, 3, 3). 

Unfortunately I can’t say that if you take a certain supplement, the hair will come back. A lot of it is just the fact you've had a stress on your body and so talking to your doctor is an important first step.