Introduction
Let me start by saying that I am not a medical doctor, and I don't have the qualifications to “treat” obesity. However, as a chiropractor and portal of entry physician, I frequently get questions about weight loss. Recently, I’ve been asked about two newer classes of weight loss medications, Semaglutide (Ozempic, Wegovy) and Tirzepatide (Mounjaro).
To better assist those seeking information, I decided to educate myself about these medications so I could provide an informed perspective, and in turn share with you what I’ve learned. But first, let’s start from the beginning…
What is obesity?
Obesity is a medical condition characterized by an excessive accumulation of body fat that presents a risk to health. It is commonly assessed using the Body Mass Index (BMI), which is a measure of body weight relative to height.
According to the World Health Organization (WHO):
- A BMI of 30 or higher is classified as obese.
- A BMI of 25-29.9 is considered overweight.
While BMI is widely used, it does not directly measure body fat or its distribution, and other methods (e.g., waist circumference, body composition analysis) are sometimes used to assess health risks associated with obesity more accurately.
Who treats obesity?
Obesity is a complex and multifactorial condition influenced by various factors, including genetics, environment, diet, physical activity, and socioeconomic factors. It is associated with an increased risk of many chronic health conditions, such as heart disease, Type 2 diabetes, certain cancers, hypertension, and osteoarthritis.
The medical specialty that primarily treats obesity is Bariatric Medicine (sometimes referred to as Obesity Medicine). Physicians in this field focus on the prevention, evaluation, and treatment of obesity and its related conditions.
Other specialties involved in treating obesity may include endocrinologists, registered dietitians and nutritionists, gastroenterologists, bariatric surgeons, psychologists, and primary care physicians. A multidisciplinary approach is often used to address obesity comprehensively.
How is obesity normally treated in a medical setting?
Obesity is typically treated in a medical setting using a multi-layered approach that may include lifestyle modifications, behavioral interventions, medical treatments, and, in some cases, surgical options.
Patients are often encouraged to adopt a balanced, calorie-controlled diet focusing on whole foods, including fruits, vegetables, whole grains, lean proteins, and healthy fats. Specialized diets (e.g., Mediterranean, low-carb) may be recommended based on individual preferences and health needs. Regular physical activity is encouraged and is important as well.
Behavioral therapy may involve counseling sessions to help patients understand their eating habits, triggers for overeating, and strategies for making healthier choices. Support groups can also provide motivation and accountability.
In some cases, weight-loss medications may be prescribed for individuals who have not been successful with lifestyle changes alone. These medications can help promote weight loss, but they should be used alongside lifestyle changes and under the supervision of a healthcare provider.
For individuals with severe obesity (often defined as a BMI of 40 or higher, or 35 or higher with obesity-related health conditions), bariatric surgery may be considered.
The old-school medications.
Some of the more commonly prescribed medications for weight loss include but are not limited to: Phentermine, Orlistat, Phentermine/Topiramate, Naltrexone/Buproprion, and Liraglutide. These medications are usually recommended for individuals with a BMI of 30 or greater, or a BMI of 27 or greater with related health conditions, such as type 2 diabetes or high blood pressure.
You can find out more information about these drugs, how they work, and possible side effects here….
New kids on the block.
Semaglutide is a medication that belongs to a class of drugs known as GLP-1 receptor agonists (glucagon-like peptide-1 receptor agonists). It is used primarily to manage type 2 diabetes and more recently has been approved for treating obesity under the brand names Wegovy (for weight management) and Ozempic (for diabetes management, which also promotes weight loss).
Semaglutide mimics the actions of the natural hormone GLP-1, which is released after eating and helps regulate blood sugar levels and appetite. The medication works in several ways:
Semaglutide activates GLP-1 receptors in the brain, specifically in areas responsible for appetite regulation, leading to increased feelings of fullness and reduced hunger. This reduces overall caloric intake.
It slows the rate at which food leaves the stomach, prolonging the sensation of satiety after meals.
Semaglutide enhances insulin secretion in response to meals, while also reducing the release of glucagon, a hormone that raises blood sugar levels. This helps stabilize blood glucose in individuals with diabetes.
Semaglutide has been studied for its effects on both weight loss and glucose control. A key study published in the New England Journal of Medicine demonstrated its efficacy in managing obesity.
In this large, randomized, double-blind, placebo-controlled trial, 1,961 adults with a body mass index (BMI) of 30 or greater (or 27 with related health conditions) were given 2.4 mg of semaglutide weekly or a placebo, in combination with lifestyle interventions. The trial showed that participants on semaglutide lost an average of 14.9% of their body weight compared to 2.4% in the placebo group over 68 weeks .
Another study in the Journal of the American Medical Association (JAMA) demonstrated that semaglutide not only led to substantial weight loss but also improved cardiovascular risk factors, such as blood pressure and cholesterol levels, further supporting its use in treating obesity-related complications
These results highlight semaglutide's effectiveness in promoting sustained weight loss, making it a promising therapy for obesity management.
Tirzepatide is a medication used primarily for the treatment of type 2 diabetes and obesity. It belongs to a new class of medications known as dual incretin receptor agonists (DIRAs). Tirzepatide mimics two naturally occurring hormones: glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP), both of which are involved in regulating blood sugar levels and metabolism.
Tirzepatide works by activating the GLP-1 and GIP receptors. These hormones play a role in glucose regulation:
GLP-1 receptor agonism:
- Stimulates insulin secretion when blood sugar is high.
- Suppresses glucagon secretion, which decreases glucose production by the liver.
- Delays gastric emptying, leading to slower absorption of food and increased satiety, which can result in weight loss.
GIP receptor agonism:
- Enhances the effects of insulin secretion in response to food intake.
- Potentially contributes to improved insulin sensitivity and has complementary effects on metabolism beyond those of GLP-1.
Several studies have demonstrated tirzepatide’s effectiveness in managing type 2 diabetes and promoting weight loss. A notable clinical showed that tirzepatide significantly reduced hemoglobin A1c (a measure of blood sugar control) and led to substantial weight loss in patients with type 2 diabetes. In one study, patients on tirzepatide lost up to 20% of their body weight.
One key study published in the Journal of the American Medical Association found that tirzepatide outperformed semaglutide (a GLP-1 receptor agonist) in reducing blood glucose levels and promoting weight loss in people with type 2 diabetes.
By stimulating both receptors, tirzepatide may lead to more comprehensive blood sugar control and greater weight loss compared to single-hormone therapies (GLP-1 agonists alone).
Side Effects (Direct).
So, the medications appear to work, but at what cost? Medications can produce a variety of side effects in the body, and can be classified as direct and indirect.
Direct side effects are the immediate consequences of a medication's pharmacological action. They are often predictable and occur as a result of the intended effects of the drug. Direct side effects of medications are well-documented and can typically be found on the medication's label. You can also discuss these side effects with your prescribing doctor or utilize online resources like Drugs.com to gain further insights.
Direct Side Effects
Semaglutide:
- Gastrointestinal symptoms:
- Nausea
- Vomiting
- Diarrhea
- Constipation
- Hypoglycemia (when combined with other diabetes drugs, such as insulin).
- Injection site reactions.
- Acute pancreatitis (though rare).
- Gallbladder issues (risk of gallstones, especially with rapid weight loss).
Tirzepatide:
Has a similar side effect profile to semaglutide, though it tends to result in greater weight loss due to the dual action:
- Gastrointestinal symptoms:
- Nausea
- Vomiting
- Diarrhea
- Constipation
- Hypoglycemia (more likely if taken with insulin or sulfonylureas).
- Pancreatitis.
- Gallbladder issues due to rapid weight loss.
- Thyroid tumors: observed in animal studies but unclear in humans.
Side Effects (Indirect).
My concern, which I believe is not discussed enough, is the indirect side effects of these medications. Indirect side effects are not the result of the primary action of the drug but rather occur due to the broader implications of medication use. They can be harder to predict and may depend on individual factors, including the person’s overall health, concurrent medications, or lifestyle choices
Concern Number One – Muscle Loss.
When someone loses weight, the percentage of weight lost from fat versus lean body mass (LBM) can vary widely depending on several factors. On average, 75% to 90% of weight lost during a caloric deficit is from fat stores while the remaining 10% to 25% of weight lost can come from lean body mass, which includes muscle, bone, water, and other non-fat tissues. Several factors can influence the proportion of fat versus lean body mass lost during weight loss, including the speed at which bodyweight is lost.
Rapid weight loss often results in a higher percentage of lean mass loss compared to gradual weight loss. Slower, more sustainable weight loss tends to preserve lean body mass better. While semaglutide and tirzepatide are effective for glycemic control and weight reduction, there is growing concern regarding the potential for muscle loss associated with the rapid weight loss these medications can induce.
There is emerging evidence suggesting that rapid weight loss induced by semaglutide may lead to more than desirable loss of lean muscle mass alongside fat loss. In a study by Wilding et al. (2021), significant weight loss was observed with semaglutide, but the composition of the weight loss included reductions in both fat and lean body mass, including muscle.
As with semaglutide, muscle loss is a concern with tirzepatide, especially in the context of significant weight reduction. SURMOUNT-1, a key clinical trial for obesity treatment, found that while tirzepatide led to impressive weight loss, there was a reduction in lean body mass, which includes both fat-free mass and muscle tissue.
Weighing the risk.
When considering the quantity (lifespan) and quality (healthspan) of life, both fat loss and muscle preservation are important, but muscle preservation is increasingly recognized as a critical factor for overall health, especially as people age.
On one hand, we know that reducing excess body fat is essential for improving metabolic health, reducing the risk of chronic diseases like heart disease, diabetes, and certain cancers, and improving overall cardiovascular health. Excess fat tissue secretes pro-inflammatory cytokines that contribute to chronic inflammation and insulin resistance, further impacting healthspan. Studies show that modest fat loss (5-10% of body weight) can lead to significant improvements in markers like blood sugar, cholesterol, and blood pressure, thus improving life expectancy and reducing disease burden .
On the other hand, we know that maintaining or increasing muscle mass is crucial for metabolic function, physical strength, mobility, and maintaining independence as we age. It also plays a role in reducing frailty and the risk of falls and fractures. The loss of muscle mass and strength is a predictor of physical disability, loss of independence, and reduced quality of life. Moreover, muscle tissue is metabolically active, and greater muscle mass is associated with improved insulin sensitivity and better control of blood sugar levels. This can reduce the risk of metabolic disorders, even in people with obesity.
While fat loss improves metabolic health and decreases disease risk, muscle preservation is arguably more important for maintaining both quantity and quality of life, especially in older populations. As muscle mass and strength may be better predictors of long-term health and longevity than body fat alone.
Strategies to Mitigate Muscle Loss.
Engaging in regular resistance exercises helps maintain muscle mass. The American College of Sports Medicine (ACSM) provides guidelines for strength training that emphasize its importance for overall health and fitness.
Adults should perform strength training exercises for all major muscle groups 2-3 days per week. Include exercises for all major muscle groups: legs, hips, back, abdomen, chest, shoulders, and arms. You can use a variety of equipment (e.g., free weights, resistance bands, machines) or incorporate bodyweight exercises.
For novice and intermediate exercisers, a resistance level of 60-70% of 1RM (one-repetition maximum) is recommended for improving strength. 8-12 repetitions are recommended for each exercise, with 2-4 sets of each exercise are ideal for strength gains A session should last between 20-60 minutes, depending on the number of exercises performed and rest intervals. Gradually increase the resistance or volume of training over time to continue making gains in strength and muscle mass.
Consider consulting a fitness professional, especially for beginners or those with health concerns.
Older adults, individuals with chronic diseases, or those with physical disabilities may need tailored strength training programs that consider their unique needs and limitations.
Apart from exercise, ensuring sufficient dietary protein helps preserve lean body mass as well. Adequate amount of protein intake can vary based on factors such as age, activity level, and the specific goals of the individual. In general, 1g/lb. of bodyweight or 1g/lb of lean body mass is sufficient for almost everyone.
Concern Number Two – Consequences of Malnutrition.
Both semaglutide and tirzepatide work, in part, by suppressing appetite. This leads to reduced food intake and, consequently, a decrease in calorie consumption, resulting in weight loss. However, consuming less food can also reduce the supply of essential nutrients, which can lead to malnutrition, negatively impacting cognitive function, mood, and overall mental health.
Omega-3 deficiency, often resulting from poor dietary intake during caloric restriction, is linked to impaired cognitive function. A study published in The American Journal of Clinical Nutrition (2014) emphasizes the role of omega-3 fatty acids in preserving brain health and preventing cognitive decline .
Deficiencies B vitamins (B12, B6, folate) are linked to increased risks of depression and cognitive impairment. B vitamins are involved in neurotransmitter synthesis, and their deficiency can lead to poor mood regulation. A systematic review published in The Journal of Affective Disorders (2020) showed a significant relationship between low levels of B vitamins and the onset of depressive symptoms. The review highlighted that deficiencies, particularly in B12 and folate, are common in those undergoing calorie restriction or following restrictive diets .
Magnesium is crucial for neurotransmitter function and mood regulation. Low magnesium levels are linked to increased risks of anxiety, depression, and mental fatigue. Reduced calorie intake often leads to reduced magnesium intake, which negatively affects mental health. A 2018 study in Nutrients found that magnesium supplementation in people with low dietary intake improved symptoms of depression and anxiety, indicating how nutrient deficiencies linked to calorie restriction can exacerbate mental health conditions .
A deficiency in iron, especially in women, can lead to fatigue, brain fog, and decreased cognitive performance. Iron is vital for oxygen transport to the brain, and insufficient iron can result in mental fatigue and reduced focus. A 2016 study in PLOS One identified that iron-deficient women showed significant improvements in cognitive performance and emotional regulation when their iron levels were restored, emphasizing the role of iron in brain health and emotional stability .
Strategies to Mitigate Malnutrition.
Mitigating malnutrition while on a caloric deficit requires careful attention to food choices and nutrient balance. Although reducing calories is necessary for weight loss, it’s crucial to ensure that the body receives adequate macronutrients and micronutrients to maintain health and prevent deficiencies.
Prioritizing nutrient-dense foods such as lean proteins, whole grains, fruits, vegetables, and healthy fats helps provide essential vitamins, minerals, and antioxidants even when calories are restricted. Additionally, incorporating a variety of foods can prevent repetitive eating patterns that may lead to gaps in nutrition.
Supplementation may be necessary for some individuals, particularly for nutrients like vitamin D, omega-3 fatty acids, or iron (under the guidance of a medical professional), which can be challenging to obtain in sufficient amounts during a deficit. Regular monitoring, either through self-assessment or with a healthcare professional, can also help identify any signs of malnutrition early on. Balancing the goal of weight loss with the need for optimal nutrition ensures that the body’s energy requirements are met without sacrificing long-term health and wellness.
Conclusion.
Semaglutide and tirzepatide represent promising new options for individuals seeking effective weight loss strategies, as they have been shown to work as intended by significantly reducing body weight. Their mechanism of action, which targets appetite regulation and glucose metabolism, has made them a powerful tool in the fight against obesity.
However, like any medication, they come with potential side effects that should not be overlooked, including gastrointestinal issues and an increased risk of gallbladder disease. Furthermore, the indirect effects of rapid weight loss, such as muscle loss and malnutrition, must be considered. Ensuring that individuals on these medications maintain adequate protein intake and engage in resistance training can help mitigate these risks.
When used in conjunction with a balanced diet and healthy lifestyle habits, semaglutide and tirzepatide have the potential to revolutionize weight management by providing a new and effective solution for those struggling with obesity-related challenges.
If you would like more information, feel free to call (304-840-2820) or stop by the office. No appointments are necessary, and consultations are free. You can also email me at DocLeviChiropractic@yahoo.com.
Yours in Health,
Dr. Levi G. Merritt, D.C., NBC-HWC, CPT
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