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Very Low Calorie Ketogenic Diet / Incretin Mimetics: The Yin/Yang of Weight Management?

Many people are using Wegovy and now Zepbound for weight loss. They are incretin mimetics, puportedly treating the incretin defect that is the underlying cause of overweight and obesity. But, the prevalence of obesity is increasing, and it is getting worse, so that is not the whole story. They are actually FDA approved for chronic weight management, not short term weight loss. There are important reasons for that, and many people specifically say they do not want to take them forever but that is how they are intended. Weogvy was only FDA approved in 2021. Saxenda was approved in 2014 but never really took off (It was before Tik Tok). What is going to happen 5 or 10 years from now to people taking these medications? I don’t think we really know. People have been taking similar ones since 2005 to treat Type 2 Diabetes, but not everyone with excess weight has physiology like Type 2 Diabetes, and no one knows what has happened to people taking them for weight for very long. 

A Very Low Calorie Ketogenic Diet is fantastic for losing a lot of weight quickly, but not so great at keeping it off. The newest medications’ strengths are that they help keep weight off, but they can have some challenges as “weight loss” medications. Let’s look at what happens when they are combined! Is that the perfect combo?!

A Very Low Calorie Ketogenic Diet is the medical protocol that Rainier Medical has been using since 2015. It is well known to be a very powerful tool to drastically improve blood sugar, fatty liver, inflammation, and blood pressure while reducing specifically visceral fat and preserving lean body mass. It improves the “incretin defect” just like semaglutide and tirzepatide, and it does so within 1 to 4 weeks instead of 1 to 4 months. But, because of genetics and/or the horribly obesogenic society in which we live, the results do not always last and things can creep back towards where they started (although everyone is different and there are many variables and options along the way.)

Semaglutide and tirzepatide are FDA approved for “chronic weight management.” This is different than “weight loss.” The studies show 5 to 21% weight loss after taking them for 70 WEEKS! That is nearly a year and a half. And, while that is certainly a lot of weight loss, some people want to lose 30% of their body weight, and most people prefer to lose it faster than 70 weeks.  Additionally, with these medications, up to 30% of the weight lost is lean body mass, Lean body mass is good for you (usually)!  When a person loses lean body mass, their metabolic rate decreases a lot. Adequate lean body mass is crucial for normal insulin sensitivity and strong bones. Osteoporosis and fragility fractures are a known complication long term following gastric bypass, for example. If you lose a lot of muscle when you lose weight, you can end up with sarcopenic obesity, which means you have a deficiency of skeletal muscle at the same time as excess fat. That is a much tougher situation than extra muscle and extra fat. 

There are many important tools to use and levers to pull and factors to consider in the plan of care and treatment approach for an individual. Wegovy and Zepbound are powerful tools, such as a VLCKD, and there are others. Remember to have a comprehensive, individualized treatment plan that is reassessed and evolves over time, as you do. We do not yet have the “silver bullet” for treating these conditions. Not even bariatric surgery did that over time. Let us not be fooled by the short term newness and hype of these medications before over 32% of the population is dependent on them for the rest of their lives (% of Americans with a BMI of 30 or higher as of 2021).

In summary, if you want to lose weight quickly, or lose more weight, try a VLCKD. If you experience weight recurrence, incretin mimetics may be for you. No matter which tool you use, even surgery, remember lifestyle modification is crucial. Whether you choose a VLCKD, a medication, or surgery, their role is only that of filling the "missing link" between diet and exercise, not taking its place. All the while, society all around us is pushing foods and environmental changes that drive weight gain. Until we turn that ship around, we will not succeed in our quest for a healthier future.

Take Back Your Options,

Valerie Hope-Slocum Sutherland, MD

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