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November 5, 2023

Ozempic and Type 2 Diabetes: What Happens When You Stop?

Table of Contents

In this episode, Christa goes over the new “medication rage”: Ozempic. She shares the research, and her thoughts on weight loss, type 2 diabetes, and what to consider when thinking of taking the medication.

Key Topics: 

  • (0:40) Response to the New York Times Article “Ozempic Can Cause Major Weight Loss. What Happens if You Stop Taking It?”
  • (1:43) What is Ozempic? And how does it help someone living with Type 2 Diabetes? 
  • (4:24) What is causing the weight loss? 
  • (4:55) The major side effects of taking Ozempic. Are they good or bad?
  • (6:47) Advantages to taking Ozempic and what it does for your Type 2 Diabetes. 
  • (8:24) Let’s go to the research and see what happens when you come off Ozempic. 
  • (12:10) Lead researcher Domenica Rubino who conducted another study said in an interview that “…long-term treatment is needed to avoid weight regain. Weight regulation is incredibly complicated. It’s complicated physiology and there are all kinds of hormonal impacts that drive regain…”
  • (12:45) Christa’s response to why she disagrees and how researchers need to start analyzing other factors leading into treatment and post-treatment with Ozempic. Ozempic is also a medication used to help with blood sugar, the extra “perk” is weight loss. 
  • (14:07) Are we treating the person as a whole which includes an individuals lifestyle, stress factors, sleeping habits, eating patterns, and emotional state?

Ozempic Medication, Type 2 Diabetes, and Weight Loss: What You Need to Know

There has been quite a bit in the news between medication shortages and weight regain after taking this medication. The biggest question remains will the results stay the same AFTER taking the drug? What is actually true, what does the research say and what have been some professional observations in using the medication.

And if you didn’t know from the title of this podcast that medication is Ozempic.

The New York Times just wrote a piece in February of this year, 2023 talking about how one individual lost 20-pounds in 6 months of taking the medication [their primary reason was to manage their prediabetes and A1C levels] but they had to discontinue it due to not so fun side-effects of being nauseous all the time. But within two-months she gained the weight back. 

In my practice, I’ve seen major positives with this medication such as blood sugar control and weight loss. BUT I too am seeing and hearing the same results with surges in cravings and weight regain when coming off the medication. 

So in this episode, we will be discussing Ozempic, the research behind it, type 2 diabetes, blood sugar control, weight loss and weighing in the options for someone living with type 2 diabetes and what Ozempic means for you, if you and your doctor decide to go on it.

What is Ozempic 

Is a medication used to manage blood sugar levels in individuals with type 2 diabetes and it falls in a class of medications called a semaglutide or you will also see GTP-1RA which stands for this big fancy phrase. Recently, it’s been used off label for weight loss but it’s really meant for those living with type 2 diabetes to manage their blood sugar and have a A1C, the 3-month average, above your recommended target. 

And just for a point of reference the American Diabetes Association classifies this that if your fasting blood sugar is above 126 mg/dL, with blood sugars 2-hours after a meal at 140-199 which translates as an A1C above 7 , to be considered an increased risk of type 2 diabetes. 

What this medication does is it helps people specifically with type 2 diabetes keep their blood sugar levels under control. And how it does it, is by making the body release more insulin, which helps to lower blood sugar, and by decreasing the production of a hormone called glucagon, which raises blood sugar. 

What makes Ozempic stand out from other diabetes medications is that it can also potentially help people lose weight. A study conducted by the New England Journal of Medicine placed people in two random groups and no one knew who was getting what [including the scientists administering the injections] a “water-pill” injection or a semaglutide. 

Participants received individual counseling sessions every 4 weeks to help them adhere to a reduced-calorie diet (500-kcal deficit per day relative to the energy expenditure estimated at the time they underwent randomization) and increased physical activity (with 150 minutes per week of physical activity, such as walking, encouraged)

Those who were on the medication after 68-weeks lost an average of 14.9% of their body weight versus the other group who took the “water-pill” with 2.4% of their body weight lost.

What I would’ve really liked to see here was a continuation of this very study to see what happens to these groups when they come off the medication. Unfortunately, that was not included in the study.

  1. Wilding JPH, Batterham RL, Calanna S, et al. Once-weekly semaglutide in adults with overweight and obesity. N Engl J Med. Published online February 10, 2021. doi:10.1056/NEJMoa2032183

What is causing the weight loss?

Weight loss with semaglutide stems from a reduction in energy intake owing to decreased appetite, which is thought to result from direct and indirect effects on the brain. Basically it’s telling you you’re not hungry. When you’re not hungry, you’re not eating and therefore you have a reduction in appetite, calories and now weight. Including more normalized blood sugar levels.

  1. Blundell J, Finlayson G, Axelsen M, et al. Effects of once-weekly semaglutide on appetite, energy intake, control of eating, food preference and body weight in subjects with obesity. Diabetes Obes Metab 2017;19:1242-1251.

Side Effects to GLP-1’s 

One of the most common side effects that I hear at the start is the major reduction in hunger. The reason is because the medication is slowing down the way your body is absorbing the food. This is where you’ll see your blood sugars starting to normalize because it’s acting as a release regulator, sort of speaking. 

It prevents a flood gate of sugar to rise into the body and “spike your blood sugar.” That sugar spike is loosely coined as a hormonal imbalance because it can disrupt energy levels,  sleeping patterns and even your bodies ability to utilize and store this energy appropriately. 

Another side effect I see is that when individuals experience favorable results like blood sugar decrease, weight loss and feeling good. They actually stop seeking the help and working with the professionals. Which is a big mistake. Look, I get it and this may sound controversial but I encourage you to continue seeking your endocrinologist, dietitian, physical therapist, psychologist, and any other health care practitioner necessary because taking the medication alone will get you to the initial weight loss BUT what about the maintenance piece? We’ll talk more on this a little later! 

Now on a more medical side note,  mild acute pancreatitis  was reported in three participants in the semaglutide group (one participant had a history of acute pancreatitis, and the other two participants had both gallstones and pancreatitis), Gallbladder-related disorders, mostly gallstones were reported in 2.6% and 1.2% of participants in the semaglutide and placebo groups . 

What are the Advantages to Ozempic and Type 2 Diabetes

Number one is that this drug is glucose dependent. That means when there is glucose or sugar present in the blood Ozempic acts on it to signal our pancreas to release more insulin. 

This also means that if there is not enough glucose present, it does not signal the pancreas to release insulin which means hypoglycemia or very low blood sugar events won’t take place. Unless you’re taking other medications like insulin this medication does not cause hypoglycemia.

The second is it promotes weight loss. However, the mechanism of action is not completely understood other then it works with the satiety hormones that make you not want to eat within our central nervous system – and just want to mention this mechanism of action has been studied in mice mostly where they used exenatide, another form of semaglutide  – so it would be nice to see what happens with humans here (1) 

Finally, it delays gastric emptying. Rather, it literally slows down how the food leaves your stomach. That is what causes you to also be full and may contribute to some nausea. 

  1. Drucker DJ. Mechanisms of Action and Therapeutic Application of Glucagon-like Peptide-1. Cell Metab. 2018 Apr 3;27(4):740-756. doi: 10.1016/j.cmet.2018.03.001. PMID: 29617641.

What Happens When You Come Off Ozempic?

This one is big, and it has been a HUGE question because it has been in the news!

And what I’ve been seeing is that these individuals are gaining weight back.

I’m going to go into the research of this and just as a disclaimer Novo Nordisk who does make this medication funded this study but think the results are worth mentioning. 

They took 1,961 adults with BMI greater than 30 and with at least one weight related comorbidity such as hypertension, dyslipidemia, obstructive sleep apnea, cardiovascular disease and a history of one self-reported unsuccessful dietary effort to lose weight. 

Those who were diagnosed with type 1 or type 2 diabetes were excluded. But did include those living with prediabetes.

These individuals were randomized into two groups for once a week injections of semaglutide or the placebo with a lifestyle intervention consisting of counseling every 4-weeks on a 500 calorie deficit, and 150 minutes of exercise per week for 68-weeks.

Then they came off the injections and placebo with an observational extension phase at 75, 80, 104 and 120 weeks -mimicking a true real-life setting.

Those in the semaglutide group had an average weight loss of 17.3%. So if you had a 240 pound individual they lost 42 pounds. With improvements in A1C, cholesterol, HDL, LDL and triglycerides. 

The placebo group lost 2% of their weight which would be a 5 pound weight loss for a 240 pound individual. But still had some improvements in cardiometabolic profiles. Clearly, we see here that the medication works.

However, after one-year of semaglutide 2.4 mg and lifestyle interventions ⅔ of their prior weight loss was gained back. 

So do I have to accept this? 

I really think we need to accept that there are a variety of factors to consider here. And it all stems from taking an individual approach to diabetes management.

Living with type 2 diabetes and having your weight reduced by a minimum of 10% certainly helps risks associated with heart disease and with blood sugar management. And quite frankly medical practitioners want to see even 15% weight loss to just simply reduce the likelihood of those comorbidity outcomes.

You may be wondering if you need to stay on the medication forever to keep the weight off. Therefore there was another set of research done where everyone received semaglutide for 20-weeks, then they were all randomized into the water pill or semaglutide for an additional 48-weeks. All subjects at 20 weeks lost about 10.6% pounds, those who continued for the 48 weeks lost an additional 7.9%, those who stopped regained 6.9% of their weight. Therefore at the end of the total 68 weeks 18.5% weight was lost in the semaglutide group and 3.7% in the placebo group.

The researcher Domeinca Rubino who conducted this study stated herself, “weight regulation is incredibly complicated. It’s complicated physiology and there’s all kinds of hormonal impact that drives regain which is what most people experience when they go on a dietary intervention and cut back on their calories. So what the medication does is it actually signals back to the brain I’m not as hungry I don’t have these cravings and it actually allows you to get to a much lower weight and improve those comorbidities”    

My biggest takeaway from this study is are scientists  identifying or and recognizing WHY they had intense cravings in the first place? There are a ton of physiological and emotional reasons why there was weight regain. I keep hearing and seeing because the “cravings came back” the movement stopped, the stress of living has made them eat more.

Rubino D, Abrahamsson N, Davies M, et al. Effect of Continued Weekly Subcutaneous Semaglutide vs Placebo on Weight Loss Maintenance in Adults With Overweight or Obesity: The STEP 4 Randomized Clinical Trial. JAMA. 2021;325(14):1414–1425. doi:10.1001/jama.2021.3224

Wilding, JPH,  Batterham, RL,  Davies, M, et al.  Weight regain and cardiometabolic effects after withdrawal of semaglutide: The STEP 1 trial extension. Diabetes Obes Metab.  2022; 24( 8): 1553- 1564. doi:10.1111/dom.14725

Key Takeaways of Weight Loss, Diabetes and Ozempic by a Registered Dietitian 

My patients respond exceptionally well to these weight loss medications but the one thing I reinforce is you NEED to be working with a Registered Dietitian, and/or a Licensed Therapist and/or the appropriate doctor to ensure that if there is a history of disordered eating patterns, dieting, hormone replacement therapy, insulin resistance, and even just a stressful overwhelming lifestyle, seeking help and treatment in these areas can quite potentially help the other pieces 

Quite bluntly, Ozempic slows EVERYTHING down. This means a natural reduction in calorie intake, blood sugar stabilization and ultimately weight loss. Think of your body as a car. Cars need regular unleaded gas to run, some run even better with premium fuel. They get excellent gas mileage, less wear and tear on the pistons igniting it and actually helping to keep the crude off. 

What if you watered down regular gas. The pistons would not ignite properly, sludge will find its way in the joints and your car ultimately will “work” but you’ll need to replace quite a few parts more frequently. 

That’s our bodies. That premium unleaded is all our hormones working harmoniously with each other. That’s the complicated physiology part that is so individualized. And if we’re fueling and replacing the right parts to the best that we can [this include medication] wouldn’t we want the option for that? 

If at all possible, intervention needs to happen BEFORE going on the medication. If you’re someone who has high levels of stress, disordered eating patterns, poor sleeping habits, emotional barriers with eating, body image and lifestyle complications – let this be a clear sign that finding the health care team to help you is absolutely essential. Now, of course if your blood sugar is at dangerously high levels this is not me saying don’t take medication! What I’m saying is you can’t JUST take medication alone.

If you have more data leading into taking the medication, you may be able to stop or severely reduce the weight regain after coming off the medication. 

There does need to be more research isolating a person’s history and cross analyzing it with the medication in regards to their typical lifestyle which can include intake, physical activity, stress factors, eating habits. And I want to see more body composition tracking. 

Just because people are eating less and losing weight doesn’t mean it’s the right weight being lost. What about muscle preservation during these periods of calorie reduction due to the side effects of the medication? It was noted in one of the studies that visceral fat, the stuff we really want to get rid of was reduced but SO was also muscle. 

That is a red flag for me. Muscle is your metabolism, that is what helps keep the unwanted fat and weight OFF. If that is reduced, it just may be a wonder why the weight is coming back on top of removing the medication because they lost muscle. 

Another red flag is making a recommendation to stay on the medication when other factors have not been explored or investigated. Now, this may be because we simply don’t understand or have researched those factors and we just need people to lose more than 10% to improve their symptoms. What I’m challenging is if we exhausted all options for the patient emotionally, and physically?

My patients would definitely be chuckling here because I’m always telling them, “when you come off OR when the dose is lowered, expect cravings to come back, expect weight to plateau or jump up a little and if you are continuing to skip meals and not strengthening your muscles with some form of movement weather pilates, walking, bike riding, if your sleep patterns are still all over the place, stress plays an imminent part in your life – it is not going to help this trajectory.” 

My challenge to you is this, medication is not bad, and it certainly is life saving but what if you were able to manage your type 2 diabetes with a lower dose of the medication. What if you were given options? What if you didn’t need the medication after you fine-tuned your lifestyle to where your blood sugar and weight worked for you? 

That’s true freedom and certainly a Maverick way of living.  

I would love to hear your thoughts on the conversation and hope you found this podcast inspirational so that you can make decisions that help you to feel empowered. 

Please like, follow and share with someone you know who is on Ozempic or needs a little encouragement on their diabetes journey.

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