Semaglutide Injections (Ozempic and Wegovy)

Back at the beginning of the month I told everyone that I'd soon be writing all about Ozempic. And after taking a few weeks to collect all my thoughts, research, and clinical knowledge, I'm ready to share with you all what I know and what I've learned up to this point.

​*** warning for those who do not want to read about BMI, weight loss treatments, and medical descriptions such as overweight and obesity. A talk about these medications necessitates that I talk about all of this in-depth, so if this does not feel like a good topic for you, please skip this, delete this message now, and I'll catch you next time***
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First up, what exactly am I talking about?

Due to pharmaceutical commercial success in this country, many of my patients have seen the, "Oh, Oh, Oh, Ozempic" commercial advertising this category of weekly injectable medication.

Ozempic is the brand name for the generic medication Semaglutide. The other brand name is Wegovy. The medication category is Glucagon-Like Peptide-1 (GLP-1) Receptor Agonist. There is one oral option approved for use in Type 2 diabetics, but most in this medication class are injectable medications.
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A brief history and why all the buzz nowadays?

Semaglutide and other GLP-1 Receptor Agonist class medications have been used for decades for Type 2 Diabetes, so they are not anything new.

The FDA's recent change in approving them for use as a weight loss medication (in those who do not have elevated blood sugar) has been the big change over the last two years.

Whereas previously these medications were only approved as second-line medications for blood sugar management (so only a portion of those with Type 2 diabetes), starting in 2021 the FDA approved their use in those with a BMI of 27 or greater.

We're talking a change of before perhaps tens of thousands of people in the US being approved to use them to now over half of the adults in the US. This massive change now means that hundreds of millions in the US are now approved to use this medication for weight loss.
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A real quick aside on BMI, overweight and obesity classifications and the "epidemic of obesity"

So, this whole topic is fraught. Very, very fraught. It is impossible to disentangle our society's historic and current discrimination towards those with larger bodies, the decades and centuries of biased "research," and our entire culture's general aversion to larger bodies when we discuss this topic.

To say someone with a larger body can be healthy is still considered a radical statement in many social and medical circles.

But it shouldn't be. And science backs it up.

If you would like to learn more about the racist origins of the BMI, how the BMI is not a measure of health, and how our medical system perpetuates anti-fat discrimination to the detriment of us all, I will stop here before I really get rolling and just include a few resources at the bottom of this message for those who would like to learn more.
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"Pharmacist Holding a Box of Ozempic" by chemist4u is licensed under CC BY 2.0.

Alright, so back to the weight loss shots

I have been sticking my ostrich head in the sand these last two years since Ozempic and Wegovy have been approved. I admit that. I rebel against the weight-loss paradigm and dogma (I enthusiastically support a Health at Every Size medical model - ask me more about this the next time you see me).

I also saw how the earlier generation of weight loss drugs (such as phentermine or Phen-fen) were basically speed and pulled from the market due to heart-harming effects.

I was figuring like everything else, that this is a trend that would soon burn itself out.

But I was wrong. This category of medication has continued to gain momentum and use over the last few years. I have had more patients discuss it with me in the last few months than all the previous years put together.

So let's get into the science behind them.

The GLP-1 Receptor Agonist class medications (let's just bundle them all under the generic name Semaglutide from here on out) work on the pancreas. The pancreas is one of your digestive organs that regulates a lot of functions. Our focus here is on insulin production and release. Insulin is a hormone that works all over your body, directing the glucose (sugar in your bloodstream) where to go - basically where to be used as energy.

Semaglutide stimulates cells in the pancreas called islet cells, which release the insulin.

The effects of this medication are many and wide-spread, including:

• Slows gastric (stomach) emptying, thus slows absorption of dietary carbohydrates (sugars)
• Increases satiety (feeling full) via appetite suppression, which also leads to decreased carbohydrate intake overall
• Decreasing blood glucose levels (which also decreases Hemoglobin A1C numbers on labs)
• Decreases oxidative inflammation (which can have cardiovascular benefits)

Over time all of these effects lead to a sustained weight loss as seen in research. One- and two-year trials show that weekly injections of these medications lead to an average 15.2% loss of body weight (again, slowly and over time). The average starting weight of research participants in some of the longer-term trials was 233 lbs, and on average they lost 35 lbs (so ending weight of 197.5 lbs on average).

A weight loss medication that has been studied for decades and shows a pretty decent and sustained weight loss. Must be magic, right?!

Well, contrary to Ozempic's use of the 70s song Magic in their commercials, no it's not magic. It's tinkering with the pancreas in order to trigger biochemical and hormonal changes that lead those taking it to feel full, longer, eat less, and lose weight. Yes, that much is certain.

But they are not without a cost.

Two-year trials show that over 82% of those on Semaglutide report digestive side effects. Gastrointestinal symptoms of upset stomach, nausea, diarrhea, vomiting, and constipation are common. Very, very common.

And there is some concern about thyroid cancer (this comes from early animal trials) and a potential for pancreatitis, but in looking at the larger picture, those are not the dangerous side effects I'm most concerned about.

I am most concerned about the drugs working, but at an unhealthy cost. Most of medicine seems overly fixated on weight loss, no matter the potential negative mental health ramifications (or metabolic, or hormonal...).

Research shows that dieting increases anxiety, depression, and disordered eating patterns. Whether that is dieting that someone is doing on their own (often due to societal pressures) or from a disparaging medical provider, the potentially-catastrophic effects are the same.

The last thing I want to do is harass my patients about weight loss and scale readings, all the while wreaking harm in the process.

And yet, I'm not against this medication on principle. In fact, I have started managing the medication for a very small number of my patients.
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So where does that leave us?

If you can't tell by now, I feel very conflicted on this whole topic.

I want to support all my patients the best I possibly can. I want to address and remove any harmful stigmas that are rooted in bias rather than actual medical knowledge.

And at the same time, I have the (perhaps naive) view that if any provider can use Semaglutide in the most harm-reducing way, maybe it's me.

And lastly, since I believe that I can skillfully help patients (who are candidates) through the process of using this medication, it's really not up to me and my beliefs to put up barriers to their access.
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So, here's what I want you to know if you want to chat with me about this

No medication is magic, every intervention has potential side effects.

The current FDA indications are as follows:

• BMI of 27-30 if someone has additional risk factors for cardiovascular disease (such as hypertension or high cholesterol)
• BMI of 30 or greater
• These medications have not been studied for safety (nor efficacy) in anyone with a BMI less than 27

I am formulating a handout for each patient to use as a guide through this process. I will be working closely with each of my patients, so that they can receive the outcomes they are looking for in the safest way possible.

I am not a proponent of any diet. Those who have known me for a while may know my background and knowledge in some of the low-carb and ketogenic diets, and while I still can use that information in those for whom it's the right fit, I have left the "one diet fits all" dogma in my past.

I personally follow and support an Intuitive Eating approach. This approach may naturally trend towards certain types of food intake for certain people (such as vegetarian, or low-carb), but only because it is the right fit for that person.
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Next step? reach out

If you would like to discuss this further with me, please make an appointment (in-person or virtual). There is a lot of information I need to obtain, and a lot of information I want to share with each patient before we get started.

This is a type of treatment that must be monitored closely, to minimize negative side effects and maximize safety.

This is definitely not the right route for everyone, even those who technically meet the criteria above. But for some it may be the right treatment plan that they would like to choose to explore, so I will be here with you every step of the way.

Adding to my upcoming rotation of topics will be more discussion on diets and Intuitive Eating, as I see this as a crucial subject and more timely than ever before.

In health,
Dr. Angela Cortal