Subscribe to The Podcast by KevinMD. Watch on YouTube. Catch up on old episodes!
Obesity medicine physician Jessica Duncan discusses the article “GLP-1 weight regain: Why stopping medication leads to weight return.” Jessica explains that expecting to maintain weight loss after abruptly stopping GLP-1 therapy is unrealistic because it ignores the physiological forces that defend a person’s prior weight. She critiques a marketplace that often treats these powerful medications as consumer products rather than chronic disease therapies, noting the risks of obtaining prescriptions through brief online questionnaires without ongoing medical oversight. The conversation highlights the complexity of appetite regulation and metabolism, emphasizing that obesity must be managed as a chronic condition rather than a short term problem to be solved. Jessica advocates for longitudinal care relationships and individualized plans that address hunger cues, sleep, and food environment to prevent weight return. Discover why mistaking predictable biology for personal failure is the greatest hurdle in modern obesity care.
Partner with me on the KevinMD platform. With over three million monthly readers and half a million social media followers, I give you direct access to the doctors and patients who matter most. Whether you need a sponsored article, email campaign, video interview, or a spot right here on the podcast, I offer the trusted space your brand deserves to be heard. Let’s work together to tell your story.
PARTNER WITH KEVINMD → https://kevinmd.com/influencer
SUBSCRIBE TO THE PODCAST → https://www.kevinmd.com/podcast
RECOMMENDED BY KEVINMD → https://www.kevinmd.com/recommended
Transcript
Kevin Pho: Hi and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Jessica Duncan. She is an obesity medicine physician. Today’s KevinMD article is “GLP-1 weight regain: why stopping medication leads to weight return.” Jessica, welcome to the show.
Jessica Duncan: Great to be here.
Kevin Pho: All right, so you are an obesity medicine physician. Just tell us briefly a little bit about yourself and your practice.
Jessica Duncan: Yes, absolutely. I actually started out my career as an anesthesiologist. I became obesity board-certified a couple of years ago. I started noticing in my anesthesia practice an increased prevalence of patients with overweight and obesity. I got really interested in learning more about the disease process and wondering what we are doing wrong as a health care system that this is becoming such a big problem. So I decided to shift out of anesthesia completely once I got board-certified in obesity medicine and decided I was going to see if we could do it a better way. I joined the company IVY Health a couple of years back, became the medical director, and now I am the chief medical officer. We are a telehealth practice. We provide individualized integrative care, focusing on weight loss, hormone health, and some wellness as well.
Kevin Pho: All right, your KevinMD article is about GLP-1 weight regain, and that is a potential scenario that patients may have to experience when I talk to them about GLP-1s. What led you to write this article on KevinMD in the first place? And then you could talk about the article itself for those that didn’t get a chance to read it.
Jessica Duncan: Absolutely. Lots of studies were coming out really talking about weight regain after GLP-1 therapy. I started diving in, and when I started looking, I realized that in a lot of the trials and studies being done, patients were on GLP-1s with a very pre-prescribed standard reduced-calorie exercise plan. Then they were coming off medications and trying to continue that very pre-prescribed reduced-calorie diet. Seeing these studies and seeing weight regain was kind of a “no duh” moment for me. This is what is going to happen if we don’t have a full spectrum of support.
Obesity is a disease; it requires a long-term solution. So I really wanted to talk about the nuances of prescribing the medication. Who should come off medication? These are things we need to start thinking about before we even start prescribing. Then, when we do think about who should and can come off medications, how do we treat them? What is their plan going to be? This is a lifelong therapy for some, but for some, they just need a lifelong lifestyle plan, and we have to support all of those things too. It is not our fault as a health care system that we don’t have the ability to do this, as a lot of it is built into the way the system works. It was just my way of advocating for looking at it from a different angle.
Kevin Pho: So what actually does the data say about weight regain after a patient stops a GLP-1?
Jessica Duncan: When a patient abruptly stops a GLP-1, the vast majority do regain weight. There is some variability on how much they regain based on what medication they are on and the ways we are treating them afterwards. But for the vast majority of patients who just abruptly stop and have no real structured individualized lifestyle support, they do regain weight. Some are able to maintain their weight loss, and I do have patients all the time who are able to maintain their weight loss, but it requires a very structured and individualized plan for them.
Kevin Pho: So what exactly does that look like in terms of that structured plan? If a patient chooses to stop a GLP-1, whether by choice or because of cost, which is another reason why a lot of patients stop, what would such a plan look like when you say that some patients do well after stopping because of this structured plan?
Jessica Duncan: Well, first of all, it starts while they are on therapy. It can’t start after, so you have to start making those changes pretty much as soon as you start medication. GLP-1s are one tool in the toolbox, so you can’t wait until you are ready to take a patient off medication to start thinking about everything else. It is very comprehensive. It is a nutrition plan. It is a movement plan that works best for that individual patient’s body and that they can keep up with so it fits within the constraints of their lifestyle. It is a sleep plan. It is a stress management plan.
For a lot of patients, one of the most difficult things about coming off medication is the return of food noise and cravings when the appetite suppression has gone away. Really working on coping skills is important, and sometimes that requires advising them to seek cognitive behavioral therapy. There are lots of different ways of managing that, but it is a full spectrum, full plan. Typically, if I have made a decision with a patient to discontinue therapy, we do it slowly. We are not going to abruptly stop a GLP-1 medication. It is usually about four weeks before the hormonal and metabolic effects wear off, and so does the effect on food noise and appetite suppression. We are not going to wait; we are going to start slowly decreasing the dose, slowly stepping up the lifestyle modifications, checking in on how it is working for them, and determining what we need to change and modify. It is an ongoing deceleration of the dose. Then we come off the medication and see how it goes.
Kevin Pho: And from your experience, what are some of the common reasons why people eventually stop GLP-1s?
Jessica Duncan: A couple of reasons, and you hit a big one. A lot of it is cost. I think patients also want to try and see what will happen when they come off the medications. I think there are a lot of patients who don’t like the idea of being on lifelong therapy and want to see if there are things they can do to maintain their weight. I will say those are probably the biggest reasons that I find patients want to come off.
Kevin Pho: And from the data, do we have an approximate number of patients who would regain some or all of their weight back? It doesn’t have to be an exact number, but what kind of ballpark number are we talking about?
Jessica Duncan: Just to be broad about it, the majority of patients do regain their weight back based on the data. In clinical practice, depending on how it is done, your deceleration plan, and your comprehensive plan, that number could be a little bit more variable.
Kevin Pho: When you initially talk to patients about the potential of starting them on GLP-1s, how does that conversation go? How do you let patients know that this is a long-term medicine and there is a potential for weight regain? How do you approach that topic?
Jessica Duncan: That has to start with visit one. I will tell you, a lot of my patients ask me right out of the gate if this is something they are going to need to stay on or if it is something they can eventually come off of. So we talk about who I typically find are patients that need to stay on the medication long-term. Those are patients who have risk factors, known cardiac disease, or certain risk factors where they would benefit from staying on medication. That is one category of patients that would stay on.
Then I talk to them about their obesity trajectory and any genetic or risk factors. We start to make that decision almost before we even start the medication. I give them an estimate of whether I think they are someone who may need to stay on this long-term. I want them to know that going in. For some patients, I think it is reasonable for them to come off medication and try, but it is a conversation that you need to start on day one. It is part of that risk-benefit assessment that we all learn in medical school, and it is really part of that primary visit. Then we can reassess as time goes on during follow-up visits, discussing how they are doing, their progress, and how their metabolic markers are looking. Even if on day one we think it is reasonable for them to come off therapy at some point, maybe something changes along the way. So it is an ongoing conversation that you need to have with patients.
Kevin Pho: You mentioned earlier that you don’t abruptly stop GLP-1s on patients. Give us an example of what a typical tapering protocol would look like.
Jessica Duncan: Yes, it depends on the patient, right? But I certainly don’t think it is in the patient’s best interest to be at the highest dose of tirzepatide, say around 15 milligrams, and just abruptly stop. I think it is always a smoother transition to slowly decrease the dose month over month, in a similar way that you titrate and accelerate up to the max dose if patients need it. I like to do the same thing backwards and get them to a dose where they are not feeling such strong appetite suppression anymore, where they are not feeling such strong suppression of food noise, and they feel like they are almost doing this on their own. They feel they are kind of ready to come off. For some, that is titrating back down to the starting dose; for some, that is a slightly higher dose. But again, it is really all about individualizing and seeing where the patient is at every stage along the way.
Kevin Pho: So it sounds like a fair amount of counseling needs to happen before patients start GLP-1s. I am seeing on television that there are a lot of compounding pharmacies and a lot of different ways where patients can obtain GLP-1s outside of a physician’s office. As far as you know, do they receive the requisite amount of counseling when they see an ad on the Super Bowl, for instance, or online and get GLP-1s that way?
Jessica Duncan: Physician-led care and provider-led care are essential. If you are using a company or a medical institution and you don’t have access to seeing somebody like me, you are probably not getting the support that you need. You need to be able to access your provider when you have questions and have access to a support team when you have questions. It can’t just be a prescription and wishing you the best. It has to be that ongoing support. My practice is a telehealth practice as well, but we provide structured support and unlimited video visits. You can come in and talk to me or someone on my team anytime to get more information, and we customize and guide your plan. If you are not able to do that, or there is not a provider that you are able to see before you get that initial prescription, that is probably not the way that you want to go about your GLP-1 journey.
Kevin Pho: How about in a primary care setting? I am not an obesity-certified physician, but primary care doctors like myself prescribe a lot of GLP-1s. In these counseling visits and follow-up visits, tell us some of the main points that we need to hit when we are managing GLP-1s in our patients.
Jessica Duncan: It is such a great question. I think you always want to go through the risks and benefits of the medication to make sure it is the right choice for the right patient with the right long-term plan. I think it is always important to give patients general guidelines on nutrition. I find that patients are not always ready to hear a very individualized meal plan on day one, but that is something I would always invite them to come back to get more information on.
I suggest small, incremental changes always in everything, including movement, nutrition, and the way you sleep. I think sleep hygiene is essential, and having a good, solid sleep routine is something that we should always talk about with patients seeking weight loss care, whether through GLP-1s or otherwise. I think it is always important to hit the basic side effect expectations and side effect management in primary care when you are seeing a patient for the first time. You don’t want somebody to be caught off guard when they start experiencing nausea. In general, patients like to understand the “whys” and what they should do about it, and what signals the need for them to come back in or seek emergency care. That is my general playbook when I am seeing a patient and I have a little bit of limited time.
Kevin Pho: You mentioned nausea is one of the more common side effects. Talk to us more about that. What can patients expect, and what are some other common side effects that patients typically experience when starting a GLP-1?
Jessica Duncan: The big ones that I see in practice are primarily gastrointestinal. It is usually two ends of the spectrum: nausea and constipation. I try to manage those before they even start. I give tips on preventing those from happening, like getting on a good, solid regimen with really solid fiber intake, supplementing if you need to, and ensuring lots of hydration to prevent constipation. For the nausea, we talk about listening to hunger signals, eating at small intervals, starting out with high protein intake, lots of good fiber, making sure to space out meals, and eating smaller meals. Of course, we see patients who experience some degree of fatigue. Sometimes patients will say they have headaches. Those are the common things that we tend to see in our practice that I always talk to patients about upfront so they know it is coming.
Kevin Pho: I know that there are both injectable forms and oral forms of GLP-1. Talk to us about the decision tree that you go through to determine which form is best for each specific patient.
Jessica Duncan: Yes, it is interesting because the oral GLP-1 pill, the Wegovy pill, has generated a lot of interest in our patient population. It actually signals to me that maybe the injections were a barrier to entry for some of our patients. Generally, I talk to patients about their daily routine. Taking the pill requires just a little bit of extra thought in how you are going to take it, as it requires an empty stomach and an additional daily routine. So I like to talk to patients about what fits best with their routine.
I think consistency when you are taking a GLP-1, whether that be an injection or oral, is very important. It is about whatever is going to work best with your lifestyle. If you are able to do a weekly injection, don’t mind the injectable form, and it is not difficult for you to remember every week, then that might be the one for you. Do you travel a lot? Is it going to be hard for you to travel with injections? That is one thing that we think about. Really, whatever fits into your lifestyle in a way that makes it consistent for you is the best choice for that patient.
Kevin Pho: Earlier on, you talked about what to do if a patient does regain weight after stopping a GLP-1. What are the options for patients then?
Jessica Duncan: Certainly, you always have to do a full assessment and try to dive into the reasons why that might be occurring. It is always possible to revisit the lifestyle modifications and other changes that you have made with the patient and see if there are things that need to be tweaked to fit better for them. Of course, it is always an option to go back on a GLP-1 or another medication. I have a mindset that it is OK to fail, so to speak. It is OK if we need to restart therapy as long as we know what the expectations are going in after coming off medication. In terms of weight loss, it tends to be a little bit different the second time around, and the way the medication feels might be a little bit different for some patients. As long as the expectations are there and a patient wants to do that, that is always an option. Remember, obesity is long-term and chronic. We have to be adaptable in the way we treat it, whether with medications or otherwise.
Kevin Pho: Talk to us about the role of exercise when patients are on GLP-1s. I understand that strength training certainly should be emphasized because there is a possibility of muscle loss on GLP-1s. Tell us about the role of exercise while patients are taking GLP-1s.
Jessica Duncan: I love for my patients to exercise. I want them to move every single day, and I do love strength training. I think it is really good not only for weight loss but for long-term weight maintenance and, of course, for maintaining lean muscle mass, like you mentioned. I love walking. I think walking is something that most of my patients can do, and it really needs to be a combination of both.
But again, it is really about what is available to you as an individual. Where do you live? What is your weather like? If you don’t have a treadmill and it is cold for the majority of the year, walking is not going to be possible. I love resistance bands, so I will always suggest them to my patients for strength and resistance training. Resistance bands can be found online pretty easily and at your local sporting goods store. That is a great way to do resistance training if you are limited to staying in your home. Most people can make modifications there. It is absolutely an essential component of any weight loss plan, not just on a GLP-1.
Kevin Pho: We are talking to Jessica Duncan. She is an obesity medicine physician. Today’s KevinMD article is “GLP-1 weight regain: why stopping medication leads to weight return.” Jessica, let’s end with some take-home messages that you want to leave with the KevinMD audience.
Jessica Duncan: A couple of things unrelated to GLP-1s. One thing I want to let all physicians know is that it is never too late to change your specialty. As I mentioned before, I was an anesthesiologist and now I practice obesity medicine. I think that a lot of us make our decision on what our specialty is very early on relatively in the scheme of our training. We might choose something that might not be right for us. If you are passionate about something and if you love something, it is always possible to make a change.
My second take-home message is when you think about your patients, always individualize your plan. Always think about obesity as a chronic disease, and understand that the way we manage it requires a long-term solution that fits that patient. That is not just a standard reduced-calorie diet. Really think about that individual and what is going to work best for them.
Kevin Pho: Jessica, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.
Jessica Duncan: Thanks for having me.
