The link below is to a lay article to explain why plateaus occur while on any diet program—whether it be without meds, on the GLP-1 meds, or after weight loss surgery. The article does not go into much detail, so I added some information below that will help you in explaining things to patients when they hit plateaus:
https://www.health.com/ozempic-wegovy-weight-loss-plateau-7975174
The problem is that we don’t know whether a particular plateau is temporary, semipermanent, or permanent for any particular patient. This can only be determined retrospectively, after a patient gets “stuck.”
For some, these plateaus may occur early. For others, they lose a lot of weight before it happens.
The significance of these plateaus is that they represent a battle or tug-of-war between the genetically-encoded appetite centers of your brain in the hypothalamus and the GLP-1 agonists. This center, prior to any weight loss medication, strives to maintain the weight that that patients come to us with. On the GLP-1 agonist, that setpoint is reduced to an equilibrium point below where their natural setpoint is. It is this battle that creates the obstacles patients face, despite going up on the dosage. The appetite centers do this by regulating appetite and energy expenditure.
How does the appetite centers in the hypothalamus maintain a patient’s weight at a certain number? Well, it is not actually the patient’s weight that is being regulated; it is the patient’s energy or fat stores. What the brain does is exert its effect on both the appetite and the caloric expenditure of the patient. On our medications, the appetite side of the equation is reduced considerably, at least at first. As the patient loses some of their fat, however, the brain interprets this as a threat, since the appetite centers evolved thousands of years ago. The message the appetite center gets is that there is a threat to the food supply, which ultimately is a threat to life. The hormones that regulate this effect are ghrelin from the stomach and leptin from fat tissue. Ghrelin increases appetite; leptin reduces appetite. When a patient loses weight, ghrelin levels go up, and leptin levels go down, resulting in an increase in appetite. The GLP-1 agonists mitigate this effect during weight loss. However, at some point, the patient’s hormonal milieu wins. That is when a plateau is reached. Some plateaus are temporary, while others are more resilient, providing significant obstacles to weight loss that cannot be overcome even at the highest doses of the agonists.
However, this does not mean that, under ideal circumstances, the patient should stop their medication. The medication actually maintains this lower setpoint. If the medication is stopped, the setpoint resets higher, and the patient regains their weight. That is why I stress to the patient that these meds should be taken for life—if cost were not a consideration. You will find, sadly, that most patients will regain weight after stopping the medication. While that may be good for your business, it is ultimately bad for the patient. Research conducted thus far has confirmed that the weight is maintained nicely if the patient continues with the medication, but that the weight is regained for most patients after they discontinue the medication.
The other side of the equation that your body’s hormones affect is the energy expenditure—i.e., the calories burned. With weight loss, the aforementioned hormones make your body more efficient. Ghrelin increases efficiency, while leptin decreases it. This is one area where efficiency is a bad thing. The more efficient your body is, the fewer calories are burned both at rest and with activity. The encouraging thing here is that this part of the equation can be fixed to a degree, and that is through exercise. Aerobic exercise, in addition to burning calories during the exercise, actually raises your metabolism for the rest of the day, such that you burn more calories throughout the day. In addition, if patients do resistance exercises twice a week—e.g., weight lifting—they will add to their muscle mass. Adding to their muscle mass also increases the metabolism and energy expenditure of the body. This is the reason that I stress to the patients that they should shoot for 2.5 hours per week of aerobic exercise at the very start, starting “low and slow.” After better conditioning, they should add the resistance days.
Which brings me to a corollary topic: Using weight loss as a measure of success. While it is easy to measure, it is not a good correlate for fat loss. A better gauge is following the patient’s fat percentage during their clinic visits. For those that do not have it yet, the scales that can do this cost less than $100. They measure fat percentage using bioelectrical impedance. Bioelectric impedance analysis (BIA) is a relatively accurate way to determine the percentage of fat in a patient’s body. It uses a harmless, low electric current, conducted through the patient’s feet, to distinguish this percentage based on the fact that fat tissue has more impedance (resistance) than nonfat tissue. Just make sure that you follow the directions carefully to get an accurate reading, particularly regarding the patient’s fluid and food status. These need to be comparable for each reading to get an accurate depiction. Importantly, do not use these scales to measure BIA in patients who have implanted electrical devices, like pacemakers or defibrillators, since it may be unsafe and inaccurate.
In any event, I hope the above helps you and the patients understand why weight loss is very dynamic, with constantly changing messaging going on from the patient’s brain. This creates a challenge for the patient, who may get discouraged. I am working on a pamphlet to cover this issue that can be given to the patient, written in lay terms. If the patient can understand what is happening, they will be more motivated to do the things that will ensure greater fat loss.
Sincerely,
Arie Blitz, MD, MBA, FACC
CEO, Arie Blitz MD MBA PLLC
