Weight Loss Medications and Beyond

We're in a new era of obesity medicine, where innovative medications are transforming weight management.

Dr. Bass shares the latest updates since our last weight loss episode, including new brands, ongoing shortages, and insights into their long-term effects, like whether people regain weight after stopping these medications.

This wave of weight loss is also reshaping the aesthetics industry. Surgical procedures like liposuction and skin removal, along with non-surgical options like RF microneedling, are becoming increasingly popular as people refine their bodies after shedding pounds.

Find out:

• Are compounded medications safe?

• How can you ensure your prescriptions come from a reliable pharmacy?

• Why does losing muscle instead of fat pose serious risks?

• How do these advancements impact bariatric surgery's role?

• Do studies confirm rebound weight gain after stopping medication?

• What are Dr. Bass' predictions for the future of weight loss medicine?

Links

• Learn more about tummy tuck and liposuction
• Learn more about Ultherapy and SculpSure

About Dr. Lawrence Bass

Innovator. Industry veteran. In-demand Park Avenue board certified plastic surgeon, Dr. Lawrence Bass is a true master of his craft, not only in the OR but as an industry pioneer in the development and evaluation of new aesthetic technologies. With locations in both Manhattan (on Park Avenue between 62nd and 63rd Streets) and in Great Neck, Long Island, Dr. Bass has earned his reputation as the plastic surgeon for the most discerning patients in NYC and beyond.

To learn more, visit the Bass Plastic Surgery website or follow the team on Instagram @drbassnyc

Subscribe to the Park Avenue Plastic Surgery Class newsletter to be notified of new episodes & receive exclusive invitations, offers, and information from Dr. Bass. 

Transcript

Summer Hardy (00:01):
Welcome to Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host, Summer Hardy, a clinical assistant at Bass Plastic Surgery in New York City. I'm excited to be here with Dr. Lawrence Bass Park Avenue plastic surgeon, educator, and technology innovator. Today's episode is Weight Loss Medications and Beyond. You've talked about this topic before on the podcast, haven't you, Dr. Bass?

Dr. Lawrence Bass (00:31):
That's right, Summer. I have.

Summer Hardy (00:33):
But here we are again. So there must be some new information. What are the updates?

Dr. Lawrence Bass (00:38):
Our last episode on this topic released in November of 2023, right at the point where FDA approved Zepbound. Today, I'd like to update on new medications that may be coming, medication shortages, and what we've learned about how these medications performed since our last episode.

Summer Hardy (01:03):
Okay, let's take those one at a time. First, what have we learned about the amount of weight loss and the stability after the medication?

Dr. Lawrence Bass (01:11):
So just to back up for a second, these are a group of medications which stimulate different receptors. The main group stimulate glucagon-like peptide one receptors and Mounjaro or Zepbound also stimulates a second receptor, glucose-dependent insulinotropic polypeptide So GLP-1 and GIP for short. So those medications, and these are the main ones. And we talked in previous episodes about some of the others. That main one is semaglutide. That's the generic name, which goes by the brand name, Ozempic for diabetes treatment and Wegovy for weight loss treatment. And it has specific FDA approvals for each of those things in certain circumstances. And the second main medication nowadays is tirzepatide, which goes by the brand name Mounjaro for diabetes treatment and Zepbound for weight loss. And on average, 15% of your weight can be lost on Wegovy and 20% on Zepbound in a typical six month course of medication.

(02:41):
So a 15% weight loss if you weigh 200 pounds, puts you down to 170 pound and a 20% weight loss would put you to 160 pounds. That's quite a lot of weight loss. That's very difficult to do with diet alone. But we've learned some things about these medications, as I said, since we last ran an episode, and this isn't the final answer, but this is an update on where things stand now. So as I said, you can lose up to 15% body weight on a course of Wegovy, Ozempic, but sometimes it's less than that. And not only that, but about 15% of patients can be non-responders. So they take the medication and they don't lose weight. So that's the bad news. The good news is people who are taking medications for weight loss seem to do better at losing weight than people who are taking them for diabetes.

(03:49):
But I pointed out very clearly on the previous episode, and we now have more study data that we didn't know how much rebound we were going to get when you go off the medication. But we now have some study data that answers that question. And that's a big deal because think about it, when you go on a diet, sometimes it's really hard to lose the weight, but even if you succeed in losing weight, you often rebound back to where you started when you go off the diet. That doesn't happen overnight, but over a few months it certainly does. And so in one study that looked at this issue with semaglutide, the medication in Ozempic, in patients who were trying to lose weight, because that's a different study group than patients who have diabetes who stay on the medication to manage their diabetes. So this group, on average lost the predicted amount of weight on average in that 15% range. It was actually 17% in this particular study, but about two thirds of that weight came back within a year after stopping the medication. So that tells us that we may need to stay on it or we may need some kind of a maintenance dose and where we need more studies to confirm this kind of result. But it's been clear that there's some rebound when going off the medication.

Summer Hardy (05:25):
So given the shortage of the pharmaceutical manufactured product, what are the alternatives?

Dr. Lawrence Bass (05:32):
As I mentioned in terms of things I wanted to put in this update, I did want to discuss shortage because a lot of people in the United States of America and around the world have non-insulin dependent diabetes, and a lot of them are now being treated with Ozempic or Mounjaro. And there are some other medications being used as well, but have become very popular. And that alone has created a shortage. And then added to that is the need for more of the medication for treatment of obesity. And on top of that, some people who are not obese but are having trouble losing weight are taking the medication as well. So there is a shortage and it can be difficult to get a supply of the medication. The medication is also quite expensive. A thousand dollars a month is a typical number can be as high as $1500. And even if your insurance is covering it, you may be paying several hundred dollars a month, three to five hundred, to be on these medications. And that's a big deal if you think about that cost at the end of the year. So one of the alternatives is to obtain the same kind of medications, not from the main manufacturers, Eli Lilly and Novo Nordisk, but from compounding pharmacies that make the same medication, but not through the FDA-approved, FDA clinical trial studied process.

Summer Hardy (07:15):
Is compounding safe?

Dr. Lawrence Bass (07:17):
So that's the key question because I just said it's not that FDA process in terms of everything about the medication. And the FDA approved medication goes through typically half a dozen to a dozen clinical trials before it's FDA approved and has all kinds of studies done. And the FDA looks at every phase of the production of that medication, the distribution, the plants that it's made in or inspected by FDA and so forth. So that's our best assurance of quality compounding pharmacies or pharmacies that make medications. And in particular, this is used in circumstances like this where there's a shortage. So they make essentially a generic equivalent. But again, they're not even a generic pharmaceutical manufacturer. They're a pharmacy and that simplifies who they are because they're bigger than your neighborhood pharmacy. But they're preparing a medication for use by prescription just like other prescription medications where there's a shortage and you can't readily get it from a regular pharmacy.

(08:49):
Now it's kind of a little more complicated than that because if you are getting a medication by mail order, that may not even be coming from a compounding pharmacy. It's not clear where it's coming from. If you're getting a medication without a prescription, you should be highly suspicious that this may not be a legitimate pharmacy. So there are all kinds of medications because of the popularity of Ozempic and Mounjaro that purport to be generic equivalents but are really counterfeit. If you're being treated by a physician in a weight loss program in the physician's practice, then it's their job to do the due diligence if they're treating you with the medication of getting it from an appropriate pharmacy. And there are different categories of compounding pharmacies. So there are 503A pharmacies and 503B, 503B pharmacies are actually inspected by FDA and FDA holds them to good manufacturing practices the same way it holds pharmaceutical companies. And so there's more oversight of 503B pharmacies. But given the shortage of these medications, the compounding route offers a greater supply to help us meet the clinical needs of patients until it's more readily available or more price approachable.

Summer Hardy (10:23):
Okay. So what do you see for the future of weight loss?

Dr. Lawrence Bass (10:27):
So likely, this is me looking in the crystal ball. And so we can never say what FDA is going to do. They're going to base that on the clinical data that they receive, and we can't say for sure how clinical studies are going to work out, but it's pretty clear that a few things are likely and likely very soon. And when I say soon, I mean sometime in the next year, not talking about something that's five or 10 years down the line, but in the next year or next two years at the most, we'll almost certainly have instead of injectable medications, because currently Ozempic and Mounjaro are injected once a week, we will likely have oral versions of the GLP-1 receptors. We will likely have medications that target other receptors besides GLP-1. And the biggest thing that I think is going to be the focus of obesity treatment in the future is it's going to be about fat loss more than weight loss.

(11:46):
Currently, these medications are demonstrating in their clinical studies that when someone stands on the scale, the number goes from a higher number to a lower number, you've lost weight, and that's a good thing. We always feel happy when we lose weight, but what we really want to lose is fat. And there's a lot of reasons why we don't like fat. We don't like fat because we don't like how we look in clothing. We can't get into the clothing that we used to get into maybe if we've gained weight. Fat also, metabolically drives illnesses like hypertension and diabetes, which are two massively common chronic illnesses in the United States. So there are a lot of reasons why we don't like fat, but we'd like to keep our muscle. And in reality, when we go on a diet, for example, and lose weight, we lose some fat and some muscle, and we're hoping it's mostly fat, but muscle is hard to get back, and as you age, we naturally lose some muscle anyway. This is a condition called sarcopenia, which just means a low amount of muscle because we're losing it with aging and we don't want to amplify that as part of weight loss programs. So likely in the future there'll be a focus on figuring out how to help people lose fat and preserve muscle.

Summer Hardy (13:26):
Where does all this progress with pharmaceuticals leave bariatric surgery?

Dr. Lawrence Bass (13:30):
So we discussed on the last podcast that a few years ago, the indications for bariatric surgery were greatly expanded and there was a refinement and how bariatric surgery was done many years ago when this was mostly converted about 20 years ago, a little more to being done laparoscopically instead of with open surgery. So that was a big growth and expansion for bariatric surgery and to finally redefine definitions of who was appropriate for bariatric surgery. That hadn't changed since sometime in the 1990s, but at this time, these non-invasive pharmacologic options really despite some side effects, and we talked about those on the last podcast, still don't have the major life impact of having a surgery like bariatric surgery. And so these seemingly, despite any disadvantages, are much more popular both with physicians and with patients. So there's likely to be a reduced role for bariatric surgery, although certainly not eliminated. And currently the amount of weight loss typically with bariatric surgery remains greater than the amount of weight loss that could be expected on average with these medications. Despite that there's a rebound rate with bariatric surgery, just like with these medications. So you don't keep a hundred percent of the weight loss off, but we don't tend to see as many non-responders as you see with something like Ozempic where we said there was that 15% non-responder rate.

Summer Hardy (15:44):
Now that you've explained bariatric surgery, where does that leave plastic surgery options like liposuction?

Dr. Lawrence Bass (15:51):
So okay, now we get to go back to my field where we're talking about beauty and plastic surgery because it's important to realize that weight loss is about health. It's not about body contouring. Of course, if we lose a lot of weight or smaller thinner, we like that shape better. It contributes to our beauty, but it's really a health issue in these medications or our proof for treatment of obesity where the amount of excess weight is at a level where it impacts health and wellbeing. So there's a lot of lessons in body contouring that have grown out of the bariatric surgery past 20 years. So we treat people who've lost a lot of weight with a range of plastic surgery treatments because there are unfinished business, so to speak, even after you've lost a massive amount of weight. And all of the plastic surgery options are still appropriate, preferable for certain body shaping applications.

(17:19):
If you're already at a normal weight, if you're at a normal or maybe even an ideal body weight, you don't want to lose a lot of weight because now you're losing muscle and not much fat with it. So that hurts you more than it helps you. And there are certain areas of the body that just tend to have bulges that are formed by fat that don't respond well to diet and exercise. Love handles, the outer thigh area or saddle bags are two typical areas that just don't diet and exercise off very well. So even despite being at ideal weight, there are many people with fatty contours there that they don't like and that don't show well in clothing. So that's ideally what liposuction is for. And to a lesser extent, the nonsurgical options. If the area is small, things like CoolSculpting and SculpSure can knock down those areas a little bit.

(18:19):
But the weight loss patients likewise are still going to need some shape adjustment. There may be residual shapes even if they lose weight going on Ozempic or Ozempic-like medications. So there's still a role for liposuction, and in fact, if people have gotten goods, they often want to finish the job. And so in fact, on some level, it amplifies the volume of those procedures going forward. The other issue that arises when we start to think about significant weight loss is loose skin and the skin will tailor to an extent when you diet and when you have liposuction. But if you lose enough weight, there is substantial extra skin. And again, this is a lesson that was known, but that a great deal of experience was gained after bariatric surgery became more mainstream. And many patients who have had massive weight loss need skin excision procedures, skin removed from arms, tummy area, chest, waist, thighs, and sometimes again with more modest weight loss, that can be dealt with without actual surgical skin excision.

(19:51):
But with energy devices like RF microneedling, Ultherapy, TempSure, things that sculpt, things that put energy into the skin and stimulate some smoothing, tightening, remodeling of that skin. And there are even injectable techniques like Hyperdiluted Radiesse where a very diluted filler that is what's called an active dermal matrix filler, one that stimulates collagen production in the skin, can help stimulate a little smoothing of skin that's modestly loose. So all of those things are also part of what's needed after weight loss and also as a part of aging, and that is going to have a growing role as these medications become more popular.

Summer Hardy (20:50):
Before we wrap up this episode, can you share any important takeaways with our listeners, Dr. Bass?

Dr. Lawrence Bass (20:56):
We're at the dawn of a new era where pharmacologic approaches are at the forefront of obesity medicine as well as the forefront of weight management. Even for non-obese individuals, diet and exercise are not done. They're still an important part of health and wellbeing. And bariatric surgery likewise, is not done. However, every time there's a paradigm shift or a major new innovation, all of the options most of the time stay on the table, but the pie gets sliced up a little differently. The role for each option shifts and adjusts. So all of these things are still important. A multimodality approach probably gets you there best. That's very clear with these GLP-1 medications that using the medication in combination with some dietary management and an active lifestyle greatly improves the chances that you're going to achieve your goals. So body contouring and skin treatments, the plastic surgery side of it are not really weight loss themselves.

(22:18):
They're part of the beauty or appearance side of it, but they're going to play an increase, not a decreased role to finalize and perfect the changes that are started by the weight loss, whatever modality you're pursuing, and that's the same as it ever was. We've already seen this in the massive weight loss patients after bariatric surgery. And the same will be true with the more moderate weight loss that's seen with these new GLP-1 medications. The biggest unknown is the mix of surgical and nonsurgical treatments for chasing these residual unwanted shapes. The bulges of fat and the love handles, the saddle bags and the looser crepey skin that remain after weight loss. So this was the original role of liposuction, contouring unwanted shapes made of fat in people at ideal body weight, but it's in recent years played a growing role in people after weight loss as well.

(23:28):
And both categories, the surgical and nonsurgical are going to have a role in these post weight loss patients again, however they managed to lose the weight. So selecting the best option requires that relationship with an experienced plastic surgeon who's up to date on the latest capabilities and technologies and can put together a program for you to get to your best appearance after weight loss. As you can see, this area is undergoing rapid change. We're learning a lot in a short amount of time, and this will continue to evolve as we look increasingly at muscle maintenance and restoration, both in aging patients and in patients who have lost a lot of weight. The future is going to be focused on fat loss with muscle maintenance.

Summer Hardy (24:30):
Wow, those are really interesting points that I didn't think about when looking at the number on my scale. Thank you, Dr. Bass, for sharing your expertise and updating us on this rapidly changing subject. Thank you for listening to the Park Avenue Plastic Surgery Class podcast. Follow us on Apple Podcasts, write a review and share the show with your friends. Be sure to join us next time to avoid missing all the great content that is coming your way. If you want to contact us with comments or questions, we'd love to hear from you, send us an email at [email protected] or DM us on Instagram @drbassnyc.