Episode 197: When Weight Loss Stalls: What Now?

[00:00:00] Welcome back to the Back on Track Achieving Healthy Weight Loss, where I help you get on track and stay on track with your weight loss journey. I'm your host, Dr. Alicia Shelly. So let's get started.

[00:00:28] Welcome to the Back on Track Achieving Healthy Weight Loss podcast. I'm your host, Dr. Alicia Shelly. I'm an obesity medicine specialist, TEDx speaker and advocate for helping you live your healthiest life one step at a time. So have you ever felt like you were doing everything right, taking your weight loss medications, eating well, staying active, but then suddenly the scale just stops moving?

[00:00:57] That's happened to me many, many times. Or maybe it's even worse. It creeps back up a few pounds. Also me. Well, you're not alone. This happens all the time. Today, we're diving into a powerful episode all about what happens when obesity medications stop working.

[00:01:19] We'll talk about why this happens, what metabolic adaptation is, what lifestyle tweaks can help, and when to switch medications, and even when it may be time to consider bariatric surgery. So let's get started.

[00:01:35] Now, why does obesity medication stop working? So one big reason is something called metabolic adaptation. As you lose weight, your body becomes more efficient. That means it burns fewer calories than it used to.

[00:01:50] Think of it like your body. Think of it like your body switching to an energy saving mode. This can make continued weight loss more difficult. So in the body, the hormones start to shift. The leptin hormone, which actually causes you to feel full, actually starts to decrease. So you feel more hungry.

[00:02:07] And then on top of that, the ghrelin hormone, which is your hunger hormone that tells you when you're hungry, goes up. So in conclusion, leptin goes down, ghrelin goes up, and you're hungry. And it's basically your body's natural way of fighting against perceived starvation.

[00:02:24] Because our body wants to be able to fight against your body. And so if it sees us losing weight, it's like, oh no, we need to switch things into a different gear. And that's when you start to see that shift in hormones.

[00:02:38] Also, it can start to reduce your metabolism. So your metabolism gets a little bit slower as you lose weight. And the Biggest Loser study, which looked at the contestants who were on that Biggest Loser show, what they noted was that their metabolisms were lower as they lost weight.

[00:02:58] And when they regained some of that weight back, their metabolism stayed the same. So we do see that your metabolism starts to decrease as you lose weight, which makes it that you're basically burning calories, but you're burning less fewer calories than you used to. And that's why that weight starts to stall or plateau.

[00:03:15] Another factor is tolerance. Over time, your brain might become less responsive to the same dose of medication that you're on. It doesn't mean that the medication has failed. It just means your plan needs to adjust. And so we're going to talk about some ways that we can adjust in our plan, whether it's lifestyle intervention, medications, and so forth, to kind of help break through this plateau and overcome when the medications don't seem to be working.

[00:03:43] But first, let's start with lifestyle. Now, even with the best medications, lifestyle habits are essential. You can't outrun a bad diet or a lack of exercise. Let me say this again. You cannot outrun a bad diet or a lack of exercise. You need both. You need all of this. And we'll talk about some other strategies too.

[00:04:09] And I do find that some of my patients, yes, they're stalling, but they haven't tweaked their lifestyle habits. They haven't changed. They haven't found ways to get it in. And what they're finding when we look at the studies with these medications is that it included lifestyle habits, change, a reduction in calorie intake, an increase in physical activity. So in order to get the max dose or kind of get the max impact from you taking medications is you have to change your lifestyle habits.

[00:04:37] Now, here are some ways to troubleshoot when your weight loss stalls. First thing, nutrition check-in. Are your portions creeping up? Are you eating a little bit more than you think? Or are you eating more ultra-processed snacks or foods that are coming back into your diet?

[00:04:55] And when I mean ultra-processed foods, I'm talking about candy, packaged desserts, margarine, sugary drinks, packaged snacks, processed meats like hot dogs that we may be eating more of and not realizing that this is also stalling. They did a study looking at ultra-processed foods, and it showed that when people are eating more ultra-processed foods, their weight starts to increase just gradually. And when these same people were switched to less processed foods, their weight started to decrease.

[00:05:25] So it makes a difference. So it's important to kind of get out of those ultra-processed foods, making your food meals at home, because you're not going to put all the sugar, salt, and fat into the same meal as maybe if you were to get it from the fast food restaurant or a processed TV dinner. Also, it may be helpful to start tracking your meals again, writing down what you're eating,

[00:05:49] seeing if you're eating or snacking a little bit more than you used to, and making sure that you're getting in the proper macros, making sure you're getting the proper protein, carbohydrates, fats, making sure you're getting a good balance with your meals. And it may be beneficial to start working with a dietician, have them look over your food and what you need to do and kind of giving you those recommendations. Next, it's going to be important to move your body. Okay.

[00:06:17] And even though you may be exercising, I have a patient like, I'm exercising five days a week, I'm doing all the things, I'm still not seeing that scale move. But it may be that you need to shake up your exercise routine. If you've been doing mostly cardio, add strength training. If you're doing mostly strength training, add cardio. So making sure you're kind of having that balance between both of them because they're both very important. Cardio helps with burning more calories, getting your heart rate up.

[00:06:43] Strength training helps with toning your muscles, which actually burns more calories as well. So it's important to have a combination of both. I've heard people that say, oh, you should lose weight first and then exercise. No, no, no. No, you should do it at the same time because remember, your lifestyle habits, these things that you're starting to incorporate, this becomes your new normal. And if you're trying to get your body to break through that plateau, you have to add cardio, exercise and strength training. All right.

[00:07:12] I do have patients who have a lot of medical conditions and limitations, like knee pain, back pain, or just kind of not able to move, just immobile. So the one thing I would say, if it's hard for you to kind of have that, or you may be too busy to have that intentional exercise, then maybe try increasing your daily movements instead. So taking the stairs, walking during your calls. You know, these small changes add up. Sometimes just documenting your steps.

[00:07:41] If you're getting 5,000 steps, shoot for 7,000. If you're getting 7,000 steps, shoot for 10. And if you're getting 10,000 steps, maybe shoot for 12. In this case, you want to kind of tweak your body or kind of change your exercise so that your body feels more comfortable burning fat and moving that dial. Also, I can stress the importance of having a proper night's rest and actually helping with improving your stress level.

[00:08:08] Poor sleep and chronic stress raises your cortisol levels, which can stall your progress. So aim for seven to eight hours of sleep per night. Whether that is you have to go to bed early or sleep in a little bit early just to kind of get those seven to eight hours in, your body will thank you. Also, it's going to be important to make space to unwind. Putting that balance or boundaries into your lifestyle so that you have time for you.

[00:08:35] I see a lot of women and men in my clinic who have like that work-life balance that is not balanced. That is more work than life. And first of all, they're unhappy. They are stressed out. And they don't have time for themselves. So they can't unwind and come back to work and be a good worker because they're working so much. And they feel this sense of chronic stress. And it's hard for them to get rid of. But you have to make yourself a priority. Say it with me. Make myself a priority.

[00:09:05] Because if you don't, you're spending all this time working for somebody else or maybe even working for yourself. But you're going to be so burnt out you can't help others. So it's important that you make yourself a priority. Having that space for you so that you can be able to unwind, to relax, recover, and then be able to get back into your daily grind. Also, the one thing I would recommend is focusing on that mindful eating.

[00:09:33] You know, sometimes we eat because we're bored. Eat because we're just emotional. And that could kind of creep in, especially when we're hitting those plateaus. We're getting a little discouraged. So we're eating and snacking more. We're like, oh, this is not working. So let me eat more. Which doesn't make sense. But it happens to us all. So I recommend reconnecting with why you're doing this. Why is it that you're getting on this journey? Is it because you want to be healthier? You want to live longer? You want to be there for your family?

[00:10:01] Reconnect to what your why is. And then try making sure to use different mindfulness tools to kind of help with focusing on reducing that emotional or boredom eating. Now, what if you've done all of that and you're still stuck? Well, if you've been plateaued for more than four to six weeks, then it may be time to reevaluate your anti-obesity medications. And there's a few things to consider. Number one, dose. Is this the optimal dose for my body?

[00:10:31] Do I need to go up on the dose? Is it time for us to increase the dose? I know for my patients, we sometimes kind of look at I'm kind of slow with tapering up because, first of all, I want to reduce any side effects that people have. But then secondly, I want to make sure that they're doing OK. And so if they're finding that they're plateauing, then it may be time for us to go up to that next dose. The next thing is sometimes looking at the class of medications. Do I need to switch from one medication to another?

[00:11:00] Do I need to be on a GOP-1 receptor agonist and then switch to a dual to a receptor agonist, like going from Wagovi to Zepan or Zepan to Wagovi? Just trying to figure out, is it time for me to switch? Or if I'm taking Fiptermine, do I need to go to something else? So, you know, making sure that you're working with your doctor, your obesity medicine specialist, your primary care,

[00:11:22] or whoever is prescribing your weight loss medications and deciding whether it's time for us to go from one medication to another. One of my patients worried about the fact that they were concerned that the medication that were at the max dose, that the medication wasn't going to work or would stop working. And then what should she do? And I told her, I said, well, besides changing up your lifestyle, and we kind of went through what I talked about just a few minutes ago and to see where she can make those tweaks,

[00:11:52] we may need to discuss adding on a different medication. And so I recommend talking with your doctor about whether you need to combine medications, not taking two GOP-1s, but whether you need to combine Fiptermine or Contrave with the GOP-1 or so forth. But I recommend to always work with your trained obesity medicine specialist because they will look at your history and look at what you're doing and then to tailor a program straight for you.

[00:12:19] Sometimes the one thing about these online programs is that it's more of an algorithm sometimes, so it's not quite tailored to where you are. Now, let's talk about when to consider bariatric surgery. I would say sometimes bariatric surgery is an underutilized tool. And for those individuals who have a BMI over 40 or over 35 with conditions like diabetes or sleep apnea, and you've tried lifestyle changes, medications, and you may have lost some weight, but not enough,

[00:12:49] or maybe you hadn't lost weight, then bariatric surgery would be the next step. So modern bariatric surgery is usually the gastric sleeve, gastric bypass, and it's safer than what most people realize. In fact, it's safer than getting your appendix taken out. However, people get nervous about just the permanent nature of the medication. And so I just want to just remind those people that bariatric surgery is not the last resort or a sign of failure.

[00:13:16] It is a medically proven life-changing option. Many patients continue with the medications after surgery just to support their long-term maintenance. This is not an either-or, but it's a team effort. When we look at the strategies and the tools for our toolbox for treatment of obesity, it is lifestyle interventions, obesity medications, and bariatric surgery. They all work together to kind of help you maintain your weight. And why is that?

[00:13:45] Because obesity is a chronic disease. And there are many different factors that drive it. For some factors like genetics or medical conditions, you can't change that. So you need these tools to help with maintaining your weight, helping you lose weight and maintaining your weight for a long period of time. Because you can't change genetics. I can't change that I have PCOS or I have hypothyroidism. I can't change that. Although I don't have those conditions, but I'm just saying I can't change those conditions.

[00:14:15] But I can treat them as best as I can. And that's how these tools work. So as we wrap up, I want you to remember that plateaus happen. When your weight is stalling, you're in a weight plateau. It occurs. You're not alone. And they're not signs of failure. They're not signs that you're not doing what you need to do. It's just the fact that your body is adjusting to your current habit. And now we got to change it up. So don't get discouraged when you're in your plateau.

[00:14:45] Just think of it as an opportunity to change things up, to kind of trick the body a little bit, to kind of burning more fat. Because the body, like I said before, your body wants to prevent starvation and wants to stay alive. And so it wants to hold on to as much weight as possible. But we got to trick it so that we can get down to a healthier weight for us. Now, if your medication isn't working like it used to, it doesn't mean you hit the end of the road.

[00:15:11] Just focus on a multifaceted plan like lifestyle changes, medication adjustment, and possible surgery so that you can get back on track. The most important thing, though, is do not, do not, do not, do not give up. You deserve to feel your best. And there are always options to explore. If this episode has encouraged you, share it with a friend who may be feeling stuck in their weight loss journey. Also, please feel free to leave a review so we can keep reaching more people on their journey.

[00:15:40] And if you have any questions or want to hear about specific topics, reach out to me on Instagram or Facebook or LinkedIn at DrShellamd or visit my website at drshellamd.com. Until next time, stay strong, stay committed, and stay consistent, and we'll see you next time.