I am delighted to have Dr. Alexandra Sowa joining me for our second conversation today. Dr. Sowa is a pioneer in obesity medicine, known for combining scientific expertise with compassionate patient advocacy. She is also the author of the new Ozempic Revolution book.
In our discussion, Dr. Sowa shares her insights on GLP-1 medications and their role in metabolic health and weight management, and we tackle some of the biggest misconceptions about these drugs, exploring the differences between Metformin and GLP-1s and examining the damaging effects of ultra-processed foods have on our brains. We discuss the impact of the body positivity movement, yo-yo dieting, and microdosing, and Dr. Sowa offers her perspective on metabolic adaptation. We dive into the science behind how GLP-1s work in the body and some specific concerns about their side effects, and we also provide practical guidance on insurance coverage and answer a broad range of listener questions.
I know you will love this invaluable discussion with Dr. Alexandra Sowa.
IN THIS EPISODE YOU WILL LEARN:
Dr. Sowa shares her experience with GLP-1 medications
Why you must understand your metabolic health before starting with GLP-1s
Some of the broader benefits of GLP-1 medications
Dr. Sowa explains what food noise is and clarifies how GLP-1 medications can help reduce it
Why healthy-at-any-size and GLP-1 medications are not mutually exclusive
Why is Dr. Sowa opposed to microdosing?
The importance of using GLP-1s for health benefits rather than thinness
How yo-yo dieting impacts metabolic health
The mechanism of action and side effects of GLP-1s
Some tips for navigating insurance coverage and accessing GLP-1s
The importance of protein and the benefits of low-carbohydrate diets for individuals with insulin resistance
“What is the point of being on this amazing GLP-1 medication if you don't even know where you started in your metabolic health?”
-Dr. Alexandra Sowa
Connect with Cynthia Thurlow
Follow on Twitter
Check out Cynthia’s website
Submit your questions to support@cynthiathurlow.com
Connect with Dr. Alexandra Sowa
On her website
On all social media: @alexandrasowamd
Purchase a copy of Dr. Sowa’s book, The Ozempic Revolution: A Doctor's Proven Plan for Success to Help You Reverse Obesity, End Yo-Yo Dieting, and Protect Yourself from Disease
Transcript:
Cynthia Thurlow: [00:00:02] Welcome to Everyday Wellness Podcast. I'm your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.
[00:00:29] This is my second conversation with Dr. Alexandra Sowa. She's a trailblazer in obesity medicine, known for her unique blend of scientific rigor and thoughtful patient advocacy. She is also the author of the new Ozempic Revolution book.
[00:00:45] Today, we spoke about common misconceptions specific to this class of drug therapy, the advent of GLP1s as well as their importance for not only metabolic health but also weight loss, key differences between metformin and GLP1s as drug classes, the role of food noise and bliss points as well as damage that ultra-processed foods do to our brains. The impact of the body positivity movement and health at any size, the impact of microdosing and her personal thoughts on this philosophy, the impact of yo-yo dieting and metabolic adaptation, key ways that GLPs work mechanistically in the body, specific concerns around side effects including gallstones, hair loss and gastroparesis, how to get your drugs covered by insurance and specific FDA indications for them and last but not least, listeners questions that run the gamut from do we have to be on meds forever? And how to view carbohydrate intake as you are losing weight. This is a truly invaluable conversation and one that I know you will enjoy thoroughly.
[00:01:55] So good to have you back on the podcast. We were laughing before we started recording. Since we last connected, you've had a couple babies. You now birthed this book. Really excited to dive into GLP1s. As you and I both know, very hot topic right now. And as a provider, what are some of the most common misconceptions that patients will come to you about? Where you as you're navigating social media, you're probably not doing a lot of that with little people at home. But if you're on social media and you see something that kind of piques your interest, what are the more common misconceptions about this drug class?
Dr. Alexandra Sowa: [00:02:29] Oh, there are so many, but I think the biggest one, and the one that motivated me to write the book The Ozempic Revolution, was the misconception that this medication is just a magic wand and it is from the patient side, just a shot and you don't have to do anything else. And from the outside viewer side, “Oh, you're just taking a shot and it's the easy way out.” And it just couldn't be further from the truth. And in order to use this medication to its fullest capability, which is for health, and even if that is for weight loss, that weight loss is leading to added health benefit, we really need to take a very holistic approach. And I just don't see that around me with the rise of this medication that people are really getting more with their prescription. They're just getting a prescription, walking out. And so, in the book, I walk people through the foundations that I think are crucial for health. So, I'd say that's the biggest misconception I see.
Cynthia Thurlow: [00:03:25] Yeah. And it's interesting for me, being an outsider kind of looking in at as a clinician, but also as someone that's in this metabolic health, perimenopause, menopause space. I think there's a lot of well-meaning providers that are starting their patients appropriately so on GLP1s, but then not having the lifestyle conversation and hopefully that's more of a minority than a majority, but I think that when we're looking at kind of a traditional lens for allopathic medicine. In many instances, we've conditioned our patients to take the pill and then they tune us out about the lifestyle. And what you're really speaking to is that this is a very powerful, very impactful, very important class of drugs, but they have to be used judiciously and they have to be used with the understanding, like when you're having a conversation with your patients, you are talking about the lifestyle because it is equally as important. That's what creates the sustainable long-term benefits, not just, “We'll take this drug for a couple months and then we go back to our old habits.” It really needs to be this kind of evolution of how we look at lifestyle vis-à-vis, this new lens of GLP1s, which I think are really exciting. And I'll be the first person to say the more I learn about the way they work mechanistically, the more interesting I find them to be.
[00:04:42] And you bring up in the book that they've been around since 2005. Maybe we weren't aware of them, but my mom was prescribed by ADA in 2005 for prediabetes. So typical menopausal female, a little bit insulin resistant and very appropriately her doctor at University of Pennsylvania prescribed it for her and she would dutifully take her little injections and it really helped her metabolic health. So, these are not new drugs. When did you start using them in your practice clinically? When did they come on your radar? Probably way before most of us.
Dr. Alexandra Sowa: [00:05:14] Yes. So, I was using them as far back as my internal medicine residency at NYU because they have been around since 2005. But we were not using them just quite yet for weight management. We were using them in the metabolic health and type 2 diabetes space. As soon as I entered the obesity medicine field right after residency, we had GLP1 medications for weight loss. So Saxenda had come out as the first FDA-approved GLP1 for weight loss and I was using that. Now it was a little different. It was a daily injection. So much like the other iterations, early iterations of GLP1 medications for type 2 diabetes, it was daily.
[00:05:54] And we didn't see the pronounced, profound weight loss percentages that we do with the weekly injectable. And that's probably why this medication really kind of come into the cultural ethos where people are talking about it, because one, it's not something you have to do every day, and two, we really are seeing these great strides in total weight loss and metabolic health. But I was using them way back from the beginning of my career in this field. And we had gone a little bit offline about this. The thing that was so different then is that I would tell people, “I'm a board-certified obesity medicine doctor, we have tools to help with weight management. And one of them is an injection.” And they would look at me like I had three heads and then I was trying to sell them snake oil or kill them.
[00:06:39] Really, truly, it was an uphill battle to even get patients to consider some of these medications. And then they would go on them and they said, “Oh my gosh, I can do the things that I haven't been able to do for 15 years.” And that's when I started to realize how transformative they could be for overall health too. Because these medications don't just treat metabolic health and help with weight loss. They truly transform our ability to embrace the things that we've been thinking about for a long time or we've heard about or we knew. They help us make the right food choices. They help us to get up and want to go to the gym now, but you still have to do those things, but it's so different than anything else I've ever used in clinical practice for any other disease.
Cynthia Thurlow: [00:07:26] One of the things that I find interesting, I have a family member who reached out to me who very clearly menopausal female, not on hormone replacement therapy. And that's a whole separate conversation. This individual has become incredibly insulin resistant. Her fasting blood glucose was in the 160s, her hemoglobin A1c was close to 8, which, that's-- I said, “You have diabetes. This is not insulin resistance. You have diabetes.” And I said to her, “Did your provider talk to you about GLP1s?” And then I kind of gave her some resources and she said, “No, I'm going to take metformin.”
[00:07:59] So, what I would love for you to talk about as an obesity medicine specialist, help listeners understand, yes, Metformin, Glucophage is an oral diabetes medication, but is not nearly as powerful and works very different mechanistically, is not nearly as well tolerated for me that I've been able to see clinically. So, when she mentioned that to me, I was like, “oh, that's disappointing because I think you could certainly get more bang for your buck, not just literally and figuratively, but much more benefits from this class of medications as opposed to this kind of old school oral diabetes medication.”
Dr. Alexandra Sowa: [00:08:37] Well, I think we need to-- Let's clock how many times I'm going to say holistic in this podcast. But the thing is, it's true. I think we actually need to take a whole centered approach when you answer this question. One of the things that I talk about in the book is that a lot of people are getting prescriptions without full metabolic workup. And I actually think that that's the bigger question that we need to address. So, you're coming to me with-- In this specific case, we know what the metabolic situation is. Hemoglobin A1c of 8 is type 2 diabetes and pretty progressed actually. And so, what I would say at that point is that we need to stop the progression of disease and use the medication that is best in class. And at this point in time, that is a GLP1 medication.
[00:09:22] On the flipside to that, sometimes I think that potentially we might be jumping to GLP1s without understanding where we're starting metabolically. So, because these medications are so safe and well tolerated, there aren't labs that we necessarily need to check to make sure that everything's operating optimally. But that is just because we don't have to check them doesn't mean we should. And I lay out in the book what you should be talking to the person giving you the prescription about and in terms of understanding what we're starting, because what's the point of being on this amazing medication if you don't even know where you started in your metabolic health.
[00:10:00] When I first came on this podcast, we were talking all about insulin resistance, which I still think is-- It is not what I think, it is truly the main driver of the majority of weight gain and inability to lose weight in this country. It's a big problem we have and we're still not talking about it. And I think in a lot of traditional medical spaces, we are just bypassing the insulin resistance what got us there, what we need to check, and just throwing a medication at it, and we shouldn't do that.
[00:10:28] But in the case of what you brought forth, yes, I think that we need to balance everything. So, metformin is a wonderful tool. It is a medication that makes our body more sensitive to the insulin it already secretes, and it has longevity benefits and it has powerful blood sugar stabilizing benefits. I use it a lot. I just saw patients this morning and I think two out of five of them were still on Metformin. But what we see with GLP1 medications is, again, it is not just acting on one part of the body. It is affecting our brain, it is affecting our gut, and is affecting our pancreas. So, where metformin works, it works too, but even more powerfully. And we have GLP1 receptors all over our body. So, you see this downstream, very quick effect of cardiac protection, kidney protection, brain protection, total body decreased mortality when on these medications.
[00:11:29] And so, especially if we get to a place of full metabolic dysfunction, it makes sense to me to use the medication we know that has all of these benefits and will help us really change our lifestyle. I have not seen that effect with metformin alone where someone says to me, “You know, for the first time in my life, I'd rather eat broccoli rather than eat chips,” and that's because GLP1 receptors are in our taste buds, and this medication actually works at the level of our brain, at the level of our hormones, at the level of our taste buds, and it's telling us to do things in a much more healthy way and that's profound.
Cynthia Thurlow: [00:12:14] No, it absolutely is. And you make such a beautiful argument. And I would be the first person to say that what I have seen in terms of patients reporting to me, the noise in their head is quieted. And you and I both or I'm obviously older than you, but we both trained in a time when we would tell our patients, exercise more, eat less.
Dr. Alexandra Sowa: [00:12:36] Yeah.
Cynthia Thurlow: [00:12:37] And that was what I was conditioned to share with my patients in cardiology. And I recall I was always thoughtful about the conversations I would have, but I think we now understand at a much deeper, more profound level that it is much more than just willpower. And when you're working with your patients in particular, what are some of the common behaviors that they will share with you that lead to a disordered relationship with food? Whether it's overeating, binge eating, undereating because I'm sure we see the extremes of every-- And certainly, in the fasting community, I see the extremes of undereating, overeating, binge eating, and everything in between.
Dr. Alexandra Sowa: [00:13:17] I think I see all of it. I think the thing that's so dramatic is just what you touched on is this food noise idea. I give case studies throughout the book, and one of them is a patient who super high functioning in all parts of her life, because weight has nothing to do with your ability to execute in your life and to be a high performer. And she told me after going on this medication that I gave her four hours of her day back. What do you mean? And she said, “I truly was always thinking about what next? What do I eat next? What do I eat for health? What do I eat to not gain weight?”
[00:14:01] And she was not a person who overate, and she was generally eating healthily, but the ability for her brain to just quiet and for her to be able to sit down at a meal with her family and eat exactly what she had planned to make and eat it to fullness and not overeat and to feel great walking away from the table and not thinking about what her 9 P.M. snack was going to be was so transformative that she-- There's just no looking back. I think when we started, she said, “How long will I have to be on this medication,” which is a whole other topic. But she's like, “My brain is now functioning in the way that I think every other person around me, brain functioned and I was just different.”
[00:14:49] And that is actually what I see is that the way that our food system has been created is that a lot of the foods we are exposed to and a lot of the behaviors of eating we're exposed to from infancy damage our brain. And I think some brains are a lot more susceptible to this kind of constant thinking about food. And even if you're able to control it, it almost feels like it controls you. And even in this patient's circumstance, while her weight hadn't gotten to a place that was so categorically unhealthy, the consumption of constantly thinking about it was really interfering with her life. And I think in a previous decade, we would have said, that's an eating disorder, and we really need to work through this in therapy. And while we still need to do that and I'm not discounting that, I do think that there's some biology component here, and that these medications are really overriding, so I think constant thinking is almost like a new class that I want to see in [unintelligible 00:15:52]. It's not disordered, but it's just a constant preoccupation that this medication is freeing so many people from. This concept of food noise is not something that's clinical. This is something that the Internet has coined. And there's no better way to describe it that I can't even come up with a better term for it, so I think we see that a lot.
Cynthia Thurlow: [00:16:11] Yeah. And I just think about the food that I grew up with. And I grew up with a mom that was super crunchy before we even knew what that term was, but she made everything we rarely ate out. And so, as I was navigating college and being exposed to food I'd never seen before, tried before, experienced before. And I agree with you that a lot of the food or food-like substances that we have here in the United States are designed by food scientists to trick our brains into thinking we are not full. So, for the susceptible individuals who are more, even more, maybe the amplification of that information in their brains just gets echoed over and over and over again.
[00:16:53] We could talk about seed oils, or we could talk about high fructose corn syrup, or we could talk about again, the bliss point that we know that food scientists design these foods to be as delectable as possible, even though we all know that they're not delectable. It's just the science has gotten so sophisticated that it knows where that bliss point at. Whether it's salt or sugar or salt and sugar and fat combined, we know that our brains get overridden in terms of our ability to be able to say, “I've had half a bag of chips, I should be done.” Your brain is saying more and more and more. So, I think that you get a really insightful perspective because people that are coming to you are in a position where they're ready to make some significant changes and significant progress.
Dr. Alexandra Sowa: [00:17:44] Yes. And to go even a step beyond that bliss point of just our brain getting accustomed to it. Our brain is actually damaged by it. So, this is leptin resistance. Leptin is one of the hormones I talk about in the book. And our brain is without a doubt damaged by our exposure to hyperpalatable foods. And then we can't respond to hormones and we lose our regulation in our body. So that's where these medications are so profound in coming in and helping us reset relationship.
Cynthia Thurlow: [00:18:17] And where again, as a clinician, as a mom, as a wife, as a physician, what has been the impact on you and your perspectives for this health at any size? And I say this very respectfully, both as a clinician, both as a human being, the impact of the body positivity movement. Do you think it has made things easier or harder navigating these conversations with patients, people that are coming to you because they are looking for help very specifically with a problem with either disordered relationship with food, with obesity, with having these comorbidities, propensity for poor metabolic health.
Dr. Alexandra Sowa: [00:18:57] This is a great question and I do address this in the book because I can't not, I actually think healthy at every size and the rise of GLP1 should not be mutually exclusive. And in fact, I think they allow the conversation to come closer together. We can be healthy at many different sizes. And actually, that is something I talk about in the book is that we have to have realistic expectations of what this medication can and should do. And I get very worried that what we see on social media is a handful of influencers who had a very robust response to this medication, who have such dramatic transformations. That's not what we're going to see in the majority of people. And so, I set that out because I think it's a very important conversation for people to have. There are limits what we can do here. And again, we have to come at it from a place of health.
[00:19:51]I think that where I've seen this movement which should be rooted in positivity, be very negative, is that anyone now who is embracing these medications, and we have good examples of this in the celebrity media culture of someone who's lost significant weight, who might previously had identified as someone who was quite comfortable in a different body, lose weight and then that person experiences the wrath of the world, saying, “But you said you were comfortable.” Well, comfort and health can be very different things. I talk about a very specific example of a patient in the book who was very concerned actually about losing any weight. She really truly loved her body. And that's what I want for every patient. That's what I want. That's what I want for my daughter. That's what I want for my family. That's what I want for myself, just to love what this body has done for me.
[00:20:46] But sometimes, and in the majority of cases, significantly, excess weight will lead to disease. And in this particular patient scenario, we were dealing with high cholesterol, insulin resistance, a very strong family of progression to type 2 diabetes, high blood pressure. There were a list of things that we needed to lose weight to improve. And what we decided was we set a very specific percentage point of our goal for health benefit. And we can very clearly set these numbers out 5%, 10%, or 15%. We see what kind of response we'll have for cardiovascular health, for overall health, and so we set that. But her body was actually still losing quite easily, truthfully, on these medications and with all of the other good health things she'd already done, which was exercise and all the good habits, eating well. And we just had a check in about how she was physically feeling about being in her body at every 10 pounds down. And we actually had this agreement that she would come to me and she would email me and say, “Okay, I'm down another 10 pounds.” And really the script was, “How do you feel about it?” “I feel good.” “Do you want to keep going?” “Yes, I do.” And we actually haven't hit the point yet where she said, “I don't feel well.” And we've done it so slowly and she's been in such a controlled place, and we are still achieving added health benefits from continued weight loss.
[00:22:13] And so I think that that is a really important thing to understand that we are not with this medication, or at least I'm not. And I'm trying to spread the gospel that this is not about thinness, this should only be about health. And I do very much worry that for many people, this is a quick fix to thinness, and that is not inclusive of healthy at any size, every size of just health. We need to be very careful about that.
Cynthia Thurlow: [00:22:42] No, it can be a very slippery slope. I feel fortunate that I'm in the health and wellness space and I get to interact with so many different providers. And occasionally if I'm at events, someone will say to me, “Oh, I'm microdosing.” A lot of questions came in around this topic, which I know you'll be interested to answer, microdosing. “I use a GLP1 to microdose to take the edge off my appetite.” And this is already in a very thin person. I'm not talking about someone who has five or ten pounds. And when I say this with love, in perimenopause and menopause, it can get very confusing trying to figure out what your body is doing at any given time.
[00:23:23] And this individual shared this with me and I listened out of interest. And then I thought to myself, but how many other people are already at a healthy weight and they've just gotten maybe it's a little bit of body dysmorphia, but in their minds they need to be thinner. And that's not just unique to other experts. That can be anyone, anywhere, not just on social media, not just an influencer, not just a celebrity where I feel like the poor people's photos get photoshopped. They probably don't look as thin and gaunt as they do in a magazine, but they're designed to kind of-- Well, there's a degree of shaming that I think that goes on, but I also think a lot of people are microdosing with a specific purpose of eating less, like they're not interested in nourishing, they just want to eat less, take the edge off their appetite. What are your thoughts around this concept of microdosing?
Dr. Alexandra Sowa: [00:24:18] I think a lot of it is rooted in weight bias. So, it's rooted in weight bias. And it's this concept of I don't really need the medication, but I want to jump on this bandwagon. And so generally I'm very against this concept. Now I'm not against the concept of treating everyone as an individual, but where I have seen this rise is stemming from wellness influencers who as of 18 months ago were so anti Ozempic, but now they've figured out some sort of hack to make this accessible to you and they're putting a new spin on it.
[00:24:54] We study these medications at every dose. So, we've studied the microdosing and the FDA-approved dosages were set because that's where the threshold of benefits far outweighed risk. And when we start looking at smaller doses just for the purpose specifically of weight loss or very vague things like anti-inflammation, which I am not saying is not happening, I do think that there is a profound anti-inflammatory benefit of these medications, but we have to be careful to use something kind of as a catch all and cure all because there are still risks. This is still a medication. This is a synthetic hormone that once you start, if you achieve results on it, you will likely, in the vast majority of cases, about 95% of people will need to continue with that medication to maintain. So, I worry if people using this as a short-term fix and they're like, “No, not me, I won't need to stay on this forever. I'll be one of those 5%.” We can all have the best of intentions of that, but we don't know how you're going to respond.
[00:26:02] And then are we setting you up for a firestorm of constant yo-yo dieting? Like, are we just doing the same exact thing we did in the 1990s with low fat? And are we ruining you for the next 40 years of your life because your basal metabolic rate is now lowered? You're constantly going to be fighting against this. And we've set off something in your brain that says you are better at five to ten pounds down. The best thing I could ever give to my daughter is to work with the weight that she has and to maintain it and to be strong at any given size. And I wish someone would have said that to me when I was 15 years old and said, “Be strong, hold on to this weight and do not constantly try and restrict and diet,” because it does set us up for just a life that is more complicated and I see this all the time with my patients. Very, very few of my patients have come to me saying, “I have never once tried to lose weight in my life.”
Cynthia Thurlow: [00:26:58] Yeah. And I think for a lot of people, they probably don't appreciate the significance of yo-yo dieting.
Dr. Alexandra Sowa: [00:27:05] Yeah.
Cynthia Thurlow: [00:27:06] Can we speak to this? Because this concept is so important, because in programs or across social media, people will send us emails, messages, and it's so clear they have gained and lost the same 10, 20, 30 plus pounds throughout their lifetime and not been able to manage, and I'm using their words, “Not been able to manage or maintain,” whatever that ideal number is. And we can probably have a whole tangential conversation about that number in our heads that we get fixated on. Maybe it's the number you weigh when you're 18 or 17 or what have you, but yo-yo dieting, what is the significance of it to you as a clinician when someone tells you I have been gaining and losing the same 10, 20, 30 plus pounds throughout my lifetime?
Dr. Alexandra Sowa: [00:27:52] There is a reason that the word yo-yo dieting is in the subtitle of The Ozempic Revolution. The Ozempic Revolution will help you end yo-yo dieting. Because yo-yo dieting on a clinical level is very unhealthy and we are better off to just stay at a higher weight than to constantly lose the same 10, 15, 20 pounds. Because what happens, and anyone listening who's done this knows that this is the case. If you restrict and you lose 10, 15 pounds, generally speaking, it is very, very hard to keep that weight off and you will regain that weight and then some. And why that happens is because of metabolic adaptation.
[00:28:33] So as animals, we are built to thrive and stay alive in terms of famine and weight loss. And then our body says, “Well, maybe we have less access to food now. So, I need to figure out how to operate at a lower energy need. And I'm also at the same time going to fire up all of your hunger hormones and I'm going to tell you to eat. And it's going to be impossible to not eat when you have access to food.” And thankfully in the modern society we don't exist in a famine state and we always have access to food and our body isn't really built for that. So, then you eat and then your hunger hormones say “We're not satiated, keep eating. I want to put back on that weight to get back up to our set point.” And this is the cruel fact of it, in that weight loss period, we lowered our basal metabolic rate and we always take off muscle when we lose weight. We don't just take off fat. So, your body composition has changed, unless you're working very hard to keep up the muscle mass. So, then we gain weight and the majority of it tends to be fat weight. And then we're at a worse body composition state and our basal metabolic rate is lower at the same higher weight than where we started. And so, then you set off the same thing again, and you're like, “This time I'm going to do it.”
[00:29:54] And no one told us this. We just lived in a world for a long period of time when we did all this cardio exercise and restrict and people didn't really understand this and it was really only in the early aughts. And one of the best papers to come out on this was actually out of the show, The Biggest Loser, where we showed that metabolic adaptation was real and that basal metabolic rate really took a hit every time we did these extreme versions of weight loss.
[00:30:21] So, we know that yo-yo dieting makes it harder on your body, your body composition, your basal metabolic rate. But with every big loss, it gets harder on our cardiometabolic profile. So, it's harder on our heart, it's harder on our pancreas, our insulin resistance will increase because again, it has to do with that-- Likely it really all stems back to that muscle-fat ratio. And so, then we end up being sicker for it. And that's the remarkable things about these medications is that because we've had them at our disposal now for over 20 years and we have a very large body of evidence, we see that when you maintain on these medications, you are not regaining and we are ending the yo-yo dieting and the cardio metabolic benefit that we see for them does maintain. And so, it's pretty dramatic on our ability now to say, “Okay, I recommend weight loss, but I'm actually going to recommend it in a way that will stay off.”
Cynthia Thurlow: [00:31:21] Yeah, it's such an interesting thought process because I certainly grew up in the age of fat bastardization and snack wells, which any of my community that remembers snack wells and cheese that didn't melt because it had no fat in it. And we thought that if we just abstained from eating fat and did a lot of cardio that we could lose weight, maintain weight. And of course, now the pendulum is swinging the opposite direction and we'll realize how important fat intake is and how important it is to maintain muscle mass and all these concepts that maybe we're kind of swinging back to a degree of reasonableness in terms of our approaches to nutrition and exercise.
[00:32:07] Now I want to pivot and talk a little bit about GLP1 specifically. You mentioned they have three main effects when we're looking at their mechanism of action and where they work in the body. I think this is important because there's so much emphasis on GLP1s. If you take too much, you're going to have gastroparesis or you're going to have a gut infarct, or you're going to have some significant untoward side effect. And this is where working with someone that is conscientious about low and slow, monitoring for symptoms is so important. Let's talk about where they work mechanistically in the body because I think this is really interesting and it goes back to the food noise conversation that we just had.
Dr. Alexandra Sowa: [00:32:49] Yeah. So, we went through the brain, effects on the brain, which is dramatic, and then the effect on the gut, so it does slow stomach emptying. So, food sits in our stomach longer. And because of that a lot of the side effects, and really it's just a byproduct of how the drugs work is what you're experiencing is what gets a lot of attention. So, the biggest side effects are nausea. They are constipation and diarrhea. And this makes sense because of its effect on the gut.
[00:33:23] Now, the nausea, I found is something that happens when you eat too much or too little. And that's hard to navigate sometimes on these medications, because, one, for many years, you weren't really blocking hunger, and then you don't feel it on this medication either. And it's hard to know when to eat or when to stop. And so actually, in the book, I lay out my program, which actually starts before you start the drug. I actually want you to do an inventory about what you're eating, how you feel, why you're eating it, and what your hunger level is, because it's really important to try to tap into it and then use that same template once you go on these medications. And a lot of the side effects that people experience can be managed honestly through some small behavior tweaks. But you need to kind of understand how you respond to specific foods or, “Hey, I didn't eat until 2 P.M. that wasn't great for my acid reflux. I should definitely make sure that I eat something small and that I'm getting my hydration in.”
[00:34:26] Same thing for nausea. I find a lot of the nausea comes because not only does this medication work on the brain to tell us not to eat, it's tied up with thirst. And so, a lot of times people just won't drink. And if we're not eating and we're not drinking, that's like a double whammy for dehydration and feeling unwell. And I'm a big proponent of electrolytes and starting your day with electrolytes when you're on this medication, because we need a solute or a salt to get water into the right parts of our body. So just knowing small little acts like that truthfully can help us manage a lot of the side effects. And thank you so much for not saying the word stomach paralysis and using the right term, which is gastroparesis. [Cynthia laughs]
[00:35:10] But those things that we hear about, those are very clickbaity headlines, and they're very, very, very rare. I mean, so rare, and they're generally tied up with another disease state. So, gastroparesis is something that does occur, actually, in advanced type 2 diabetes when our nerves are damaged. And of course, we are seeing a crossover of populations and we can see that. But my big thing is that you need to be working with somebody who you can just honestly shoot an email or call the office or get in touch up with these symptoms or know what to look out for. And one of my problems with how a lot of these medications are being written right now is they're asynchronous, they're very large programs, people don't know what they don't know. And then it comes time to some side effects. There's no one to reach out to and no one warned them. And so, they're just living with pain, which you should never, ever, ever do. And if you're experiencing something, we just need to acknowledge it and then and work it up.
[00:36:08] Generally, usually if someone has some stomach pain on this, it's some gas and they need Gas-X. But we need to be looking for the other things, a gallstone getting inflamed and getting stuck or in the very rare extreme scenarios of a bowel obstruction. It's so rare, but we don't want to overlook it, so you need to be comfortable knowing what to look out for. And I lay this all out in the book because there isn't enough time in a doctor's visit to go through all of this, especially if it's an online platform where you don't even talk to anybody.
Cynthia Thurlow: [00:36:39] Well, and this is where I think the concept of buyer beware. This is why it's important to work with a clinician or clinicians that are experienced and are going to be accessible. You bring up the point that sometimes these programs are so large that there's no one to connect with. And you bring up the topic around gallstones. And I think gallstones are an interesting topic for a variety of reasons, more common in women. We know that to be the case. They're more often associated with weight loss. And I think sometimes, again, because weight loss is equated with GLP1s, the thought process is, “Oh, it's the GLP1s that are mitigating that.” And unfortunately, they kind of get dragged into the whole conversation when you're helping let's use women as an example for right now. When you're working with your female patients. We know that the concept of weight loss, we don't want it to be too fast. It's sometimes when we have these very dramatic weight loss situations that they become more common. What are some of the signs that you like to educate your female patients in particular about? Because let's be honest, the genetics of it were just more prone to them.
Dr. Alexandra Sowa: [00:37:50] Yep. So, you hit the nail on the head. Gallstones are not caused by GLP1s, but gallstones are caused by significant weight loss and so we see them in bariatric surgery. We see them in large weight loss. We see them in yo-yo’ing up and down. And we just see them specifically women in midlife. I mean, that's where they develop generally. And so, I always counsel people on what biliary colic, that's the official term for the little pain that happens with early gallstone formation. And so, it tends to be something that happens after meals and is right under your right rib cage. And it kind of comes and goes and is worse after fatty meals or alcohol.
[00:38:32] And usually that people ignore it. Like, they'll be like, “You told me that and then I forgot,-
Cynthia Thurlow: [00:38:39] But it's not convenient.
Dr. Alexandra Sowa: [00:38:42] -it just got over, it’s not convenient, so I didn't let you know.” It's very rare that something does happen. But if we have gallstones and you have this pain, then what you do is you just ask for a right upper quadrant ultrasound and you take a peek. It's very easy, it's a very straightforward, easy exam. And then if you have gallstones that are over a particular size or even if they're there and causing you any pain, we have to talk actually about having your gallbladder removed, because these at a certain place, we know that they can get stuck, and that's when it causes some problems. Even when that happens, we still have great interventions to just go in and get the stone out, but it's a bigger process than just going in and getting your gallbladder out.
[00:39:19] I get a lot of questions on social media about, “Oh, I don't have a gallbladder, so I can't go on these medications.” I'm not really sure where that started either. You most definitely can go on GLP1 medications after having your gallbladder removed. You might have to take a little extra care with some foods and knowing how you respond to them, but people do very well. I've had a handful of patients, very few who have needed to have their gallbladder out. Actually, they've been younger patients more than the typical midlife. They've been women in their 20s and early 30s, and they can go back on the medication after the gallbladder comes out, and they want to generally, and they feel fine. So, it's a fortunate/unfortunate thing that these medications just cause a lot of weight loss and sometimes gallstones are formed.
Cynthia Thurlow: [00:40:10] Yeah. The other thing that people ask a lot about is, do they cause hair loss? Again, it goes back to the same, if you lose weight, you may also lose hair. Now because middle-aged women seem to be more prone to hair fluctuations, not just postpartum women that have just had a baby, but also women that are making this perimenopause to menopause transition. How do you help tease that out for them?
Dr. Alexandra Sowa: [00:40:35] So everyone's going to experience hair loss. I found that it generally happens at about 30 to 40 pounds down or 20% of your weight loss, which generally if you have 20% of your weight loss to lose, you'll be seeing it around that 30-to-40-pound mark. It's called telogen effluvium. It's the same phenomena I'm dealing with. My baby is 10 months old and I've got like these short little hairs that can't stand. It has to do with a hormonal change state and your body won't release as much hair as it's losing weight at the beginning. And then all of a sudden, I'll say, “Well, I guess this is the new normal,” just like post pregnancy and we'll release a lot of hair at once and in the same fashion.
[00:41:21] You are so right though that we feel this more at particular stages and especially in this midlife perimenopausal state. And so there are a few things that we can do. One, just know it's happening, don't panic, it will grow back and it will. And I think anyone who's made it to the other side will tell you that protein really matters. I mean, my nutritional foundations in the book are protein, protein, protein, because it matters for muscle, it matters for hair, it matters for metabolic health, it matters for so much, but really it does help with hair. And collagen has been proven to have a benefit here with regrowth. And I also do encourage a multivitamin. I don't think we need to do super fancy hair regrowth, but I do think that there are some multi micronutrients that you become deficient in and will help.
[00:42:14] The other thing is to not lose too much weight too fast. But in that same breath I'm saying this will happen to everyone, but I do find that the nutritional deficiencies are greater when there is such rapid weight loss without control. And that's rare that happens, but you want to kind of control the rate of loss. I send a lot of patients now to the dermatologist for treatment to help regrow, especially if they're in midlife and estrogen is dropping and it's just that double whammy of what they were going to see anyway, using Rogaine can help, and it can help with the regrowth, but it should be a conversation you have with the dermatologist because often that's another conversation of, “Hey, if we start this, you might need this.” And I do find that sometimes people just need added support to regrow the hair and then they're good. But, why not go to the experts? So, I'm always sending my patients to the derm.
Cynthia Thurlow: [00:43:08] Yeah, no, it's interesting. We actually have, an expert, a dermatologist who's kind of a hair guru is coming on the podcast and I was explaining to him in his DMs. I get asked so many questions and I just get to a point where I'm like, “I don't know all the tricks, I just know the couple of things that we need to do,” and then someone gets a referral. Now a lot of questions came in around how do I get-- And this is something I see echoed across every platform I'm on, sometimes I get tagged in things, so I try to avoid answering because I'm like, I don't have a patient provider relationship. These are some resources, maybe check these out. But when patients are hopeful that these GLP1 drugs can be covered by their insurance, what are the technical indications right now, again, kind of broadly for where these drugs can be covered? And then how do patients navigate milieu of their insurance providers? Because we all know it is sticky business right now.
Dr. Alexandra Sowa: [00:44:08] It's very tough. I have a whole chapter dedicated to this and I provide prompts to ask your insurance company and they come straight out of my practice because it is actually that hard. So, the FDA indications right now, they're growing. And these drug companies are being very smart about what they're going after because coming back to weight bias, a lot of insurance companies are not mandated yet. Hopefully this is changing soon on a government level. They're not mandated to consider obesity as a disease, so they can exclude coverage, but they can't deny sleep apnea, they can't deny cardiovascular disease, they can't deny kidney disease, they can't deny osteoporosis. So, these drug companies are going after FDA approval for these other medications.
[00:44:51] So but as it stands right now, we have approval for the management of type 2 diabetes, and they are sticklers for having a hemoglobin A1c that meets that criteria right now. And so that's pretty straightforward. And then on the weight loss front, there generally are two buckets for the FDA if your BMI is greater than 30 or if your BMI is greater than 27 with a health-related condition that would be improved with weight loss. I can always find one of those truly at a BMI of 27 because the list is very long. Insurance companies are being jerks right now though and changing those requirements. And I'm starting to see wild things like we will only cover this with a BMI greater than 40 and they're just rewriting medicine here and they're rewriting what the FDA says.
[00:45:40] So it's a frustrating time right now because insurance companies that were covering potentially aren't. It's January when we record this and I've had a lot of patients who had coverage for years and as of January 1st their insurance company decided to stop covering it. In my opinion that is absolute malpractice and you can come after clinicians for malpractice. And yet we can't go after insurance companies report. If this is you and you're listening to this report, this to your state insurance commissioner to be given a medication that we know is approved for lifelong use than to be taken away and to set you up for yo-yo dieting is malpractice in my opinion. So, complain, it really does make a difference.
[00:46:21] We also have a new proposed rule sitting in Congress right now that the new administration is going to rule on in the coming months that would allow for coverage of these drugs in Medicare and Medicaid and for the government to get involved in coverage if that happens, costs going to come down for everyone. So, I am hoping and praying that we are able to see obesity as a disease that deserves treatment across the board. Talk to your HR. If you're somebody who's like, “I have a great insurance plan, like what happened?” Go talk to them, tell them how important this is to you and how obesity is a disease and it shouldn't be a plan exclusion. I have definitely had patients able to move the needle there.
[00:47:01] I also think it's really important and in the book I give you the script to do this. I think it's really important to actually not trust the back end of your doctor's office unless they are hyper specialized in this. It's very hard work to get through to your insurance company and you should know from them, hear it from them, get it in writing that either you have a plan exclusion or you have a specific BMI criteria, and even with a plan exclusion, you are able to appeal and you should do that.
[00:47:30] So many times, patients are coming to me, they do have coverage, but their doctor's office previously or the telehealth platform they worked with was like, “No, we just don't do prior auths.” They are a ton of work. They are so much work. But don't just take it at face value that you don't have coverage. Really call your own insurance company and understand. And listen, I've got four kids. I deal with so many doctors and so many stupid insurance issues on a personal level, it's so annoying. So, I know hearing this you're like, “Sure, yeah,” but like, just take the time, set aside one hour because that's probably how long it will take. Call them and understand your plan so that you can advocate for yourself at your doctor's visit.
Cynthia Thurlow: [00:48:11] Well, and it's so important to be able to amplify these messages. That's why, you know, this podcast is important, this conversation so important. I remember 20 plus years ago, as a new nurse practitioner, that it was still the heydays of gastric sleeves, gastric bypass. How many patients would sit in my office and cry and they would tell me, “My insurance will not pay for this gastric bypass surgery unless I weigh more.” So, they would then go try to gain 20 more pounds to be able to hit a BMI of 40 arbitrarily, whatever it was their insurance company was aiming for. And, what we're speaking to is we know these drugs are effective. We know these drugs have a profound impact on metabolic health, not just this generation, but every subsequent generation. So, it's important that we are amplifying the message.
[00:49:01] Now I got a lot of interesting questions, as I always do, a lot of the questions centered around if I start taking a GLP1-
Dr. Alexandra Sowa: [00:49:08] Mm-hmm.
Cynthia Thurlow: [00:49:09] -do I have to take these medications forever? What are your thoughts around this and how to kind of navigate, because for some people, maybe they're having to pay out of pocket, maybe they're still fighting with their insurance company. What are your typical, again, kind of broad generalizations? Your conversations around these?
Dr. Alexandra Sowa: [00:49:26] Broad generalizations are yes you need to be prepared that you will need to stay on this medication for the very long-term future and potentially life. This is what all of the clinical studies show, and this is what my clinical experience shows. Now there are people who are able to use this medication, really transform their lifestyle and are able to come off. But thinking that this medication just helps you change your life is not understanding that the pathophysiology of obesity is truly a disease. And we really become deficient, for lack of a better word, we become deficient in native GLP1. And when you respond well to this hormone, you need to continue this hormone. It is just like Synthroid for hypothyroidism. If we manage your numbers and we manage how you're feeling on synthetic hormone, we don't take it away when we get those things under control, same thing with this hormone.
Cynthia Thurlow: [00:50:23] That's a really important point.
Dr. Alexandra Sowa: [00:50:26] Yes. And it's a thought process. And people really do think it's willpower. Well, if I eat better, if I get to the gym, if I do all of these things that you tell me to do, I should be able to go off of it, but it's much bigger than that. Yes, you still need to do all those things, but also the medication is helping us achieve those things and stay here.
[00:50:46] The people that are able to come off, I found a few discrete buckets. One, they generally tend to be people who haven't lost and gained weight their entire life. It's something unique that happened and was weight put on in a short amount of time. Covid was a good example. People who were totally normal weight, their whole life changed and been very stressful and they put on 30 pounds. They came to me, we were able to take it off. And there are some of the few who have been able to come off, or you've gone on a medication for another treatment, steroid or something else that put on significant weight. Maybe you were working with a psychiatrist to put you on a medication and didn't warn you that weight could come on quickly. We see that you go off of the medication. We use a GLP1 to take the weight off. We use another medication for mental health and you can kind of go back to your synergistic baseline.
[00:51:35] Also, it is the people who are fully willing to embrace the healthiest of lifestyles. Strength training, whole foods, really learning how to count macronutrients, specifically protein. Those are the patients who do the absolute best and are able to potentially come off. But it's really important that you understand that that might be you. And likely if we're going to Vegas and we're betting it will be you, because only about 5%, maybe 10% of people can come off of these medications. I see a dangerous trend on social media of a lot of people selling the program that “I was able to get off. So, I'm going to teach you how to get off.” We just cannot guarantee that. And so, if you start this, you need to know you may need to stay on it. And that's really important.
Cynthia Thurlow: [00:52:23] Well, and I think it also acknowledges that much like hypothyroidism or quite frankly, women that are transitioning from perimenopause to menopause, we know our body no longer makes certain hormones at optimal levels. And being on hormone replacement therapy should be no different than if this is the conversation that you're having with your provider. A lot of women were asking about for menopause. “I'm on HRT, my lifestyle's dialed in, can I try a GLP1?” And I don't say this to laugh at the question. It's just the word fluff to me is so appropriate for those of us that have experienced that. “Can I try a GLP one for fluff?” Another person asked, “If I have 10 pounds or less to lose.” Again, we're going back to some of these conversations that we've had around these topics. When women are in menopause and they are struggling with body composition changes, they're doing all the right things. When is it appropriate to have that conversation with them, if it is appropriate for them?
Dr. Alexandra Sowa: [00:53:24] It's a complicated and nuanced question. I think it's always appropriate to have a conversation. I think what we need to be doing there is looking at body composition, which can tell us a lot. And we need to be looking also specifically at insulin resistance and advanced cholesterol panel testing. I would also throw in potentially a calcium coronary artery score in there. I would look at things like sleep apnea, which can rise in menopause and be very quiet but very detrimental to our overall health. And not thinking that a GLP1 is like the cure all. I think we really need to be looking at all of it.
[00:54:05] Now, if you say, “Hey, I actually found that I actually have some really plaque development and my insulin resistance, which I never, ever had, my hemoglobin A1c has jumped dramatically from the 4s up to 6. And I just can't control what's happening and I feel so unwell.” It's a very unique and different and scenario that maybe I wouldn't say it's different, but that's something that we have to look at the whole of the person rather than just looking at BMI cutoffs. So, I think it's a conversation worth having. But I would say everyone-- We have these life changes so right now I'm dealing with this postpartum with my fourth child. My body has changed. I'm 41. Like this is wild that I had a baby at the age of 40. And I have to understand that where my body was and what it is now, it's different. I'm looking at it from a lens of metabolic health and what, where I want to go. And I think that's how we need to frame this conversation when we experience weight change and body change throughout life.
Cynthia Thurlow: [00:55:06] I think that’s really important and I think because of all of my kind of cardiology background, I'm the one that's usually amplifying, looking at Apo Bs, looking at LP(a), looking at CACS or CT angios and helping women understand. There's a difference between, I'm frustrated because I've gained 10 pounds and I've lost muscle mass and this is purely adipose tissue, but I am still metabolically healthy versus the other scenario that you were talking about. So, the question is as you mentioned, complicated nuance but worth having and then doing a little bit of digging.
Dr. Alexandra Sowa: [00:55:38] And I think staying on top of those trends, and if you see the trends are getting worse, well then, okay, I think we have our answer about whether something might be appropriate for you.
Cynthia Thurlow: [00:55:46] Yeah. Conversations around gut health, reflux, those types of symptoms. When you're counseling patients about GLP1s, what are kind of your prevailing perspectives about if someone has existing reflux? Let's assume it's stable, there was no quantification, but like stable reflux on medication, is being on a GLP1 going to exacerbate underlying reflux? Because if they have slow gastric motility, I think that's the direction their question is probably going in.
Dr. Alexandra Sowa: [00:56:19] Yeah. So yes, it can make it worse and it's something that we need to get. I have a little checklist of the things you need to do and talk to your doctor about before you start these meds. Because if you're someone who is taking occasional famotidine for symptoms or Tums, then you might need to start a short-term PPI as you start the medication and titrate up. It's also very important to chart your behaviors and your symptoms because you might realize, “Oh, I can't eat that thing or I ate too late.”
[00:56:51] I use PPIs a lot in the practice, but I don't use them long term because generally people's bodies understand what's happening over time. And as we get used to a dose or go up in the titration dose, we don't need it anymore. I think it's really important to stay hydrated too. A lot of times people just aren't eating or drinking and the stomach acid--
Cynthia Thurlow: [00:57:12] Backs up.
Dr. Alexandra Sowa: [00:57:13] Yeah, it's just the worst. I would also say we haven't talked about it in this call, but not all GLP1s are created equal. So, we have Wegovy and Ozempic which are the first generations of the weekly GLP1 injectables. And then we have Zepbound and Mounjaro. Zepbound and Mounjaro are better tolerated GI side effect wise. And so sometimes if you are the person whose reflux is getting worse and we have you on the full dose and you're known to have this for many years, then we have to consider whether we just jump ahead to the dual agonist GLP1 plus GIP with better side effect profile.
[00:57:45] You asked about gut health, which I think is so important. So, I am such a big fan of daily fiber supplementation. I will have people start getting into the routine of this before they even start the medication. I believe in this so much. I have a whole GLP1 support protocol that involves daily fiber with additional things, magnesium and probiotics. All of these things that we know that are good for health, but you tend to minimize when you don't have a craving for food. I like for my patients to get fiber in through whole foods. It becomes pretty impossible at the beginning of starting this medication when you just don't have an appetite and I need you to prioritize the protein first. So, fiber through insoluble and soluble fiber products is crucial. And just getting into a good habit of doing that will minimize constipation or diarrhea. People think fiber for constipation, but also fiber helps tremendously with preventing diarrhea. So that is key.
[00:58:41] I know you're really into the gut microbiome. One of the exciting things about GLP1s is they actually do improve our gut microbiome profile for cardiometabolic health. And we're learning more and more about this with long longitudinal studies. One of them is the way that the medication works and modulates GLP1 receptors, but the other is that over time, even at the beginning, if you don't think so, you really are eating a lot more whole foods and you are getting in better fiber sources and things that nourish our gut. So, kind of talking about the long-term benefits of this and the epigenetic potential for this drug, it comes in a population level, in our gut microbiome too. So got to take care of it, but it's exciting.
Cynthia Thurlow: [00:59:27] Yeah, it is very exciting. And just one last question, carbohydrates. We are so confused about carbohydrates. What can we eat? What should we not eat? Obviously, there's a difference between ultra-processed foods and processed carbs versus whole nutrient dense carbohydrate sources. When you're talking to your patient, if they're insulin resistant, how do you help them navigate making those choices?
Dr. Alexandra Sowa: [00:59:52] So, I am still a fan of lower carbohydrate diets for the right individual. This is not necessarily the trendiest thing to say right now, but it's what I believe and I found to be very efficacious for specific people. For the majority of people on GLP1 medications, the only macronutrient I really need you looking at is protein. If you can start your meal with a protein and you count that first, and that's the foundation of my food rules, you will do great. You will achieve everything you want to achieve. If you have pronounced insulin resistance at the level of approaching type 2 diabetes or type 2 diabetes, or have had long standing PCOS that's been very recalcitrant to weight loss, I find that coupling a GLP1 medication with a very low-carbohydrate diet is really efficacious at the beginning.
[01:00:46] I don't have any of my patients continuing on a very low-carbohydrate diet long term, but at the beginning it is almost like the signal, it's like a double whammy signal. We've known-- You know this too, therapeutic low-carb diets can really work when we have pronounced insulin resistance. If you couple them with GLP1 medications, I've seen even more pronounced weight loss. GLP1 medications, you do not see as much weight loss in the type 2 diabetes population. And that is because metabolically we've kind of become so deranged, the medication doesn't have the same effect. I have not found that to be true when I couple it with low-carbohydrate diets. So, carbs are not the enemy, get them through whole food sources, get lentils and get things that give you both carbs and fiber and eat your vegetables and have your fruit. But do look at how you're nourishing yourself. Protein first is key.
[01:01:44] I give an example in the book and I always come back to this. I had a patient who was such a healthy eater, such a healthy eater. She's the only patient of mine who's ever had to go to the ER for hydration because she could not stop vomiting. And it all came down to a kale salad. I kid you not, it was a kale salad. Her body, at the very beginning of going on these medications could just not take the high content fiber of some specific vegetables and she just had a hyper response against them. And we had to learn at the very beginning that she needed to focus on getting the chicken in and out of the salad first and then having a couple of bites and then ultimately her body learned how to work with it, but it's so funny because I'll sometimes tell people to watch their carb intake and it has nothing to do with the actual carb, but it has to do with what your body can process. And if you're filling it up with carbs, you're not getting your protein in. And even if it's the healthy carbs, the fibrous carbs, the low-glycemic carbs, still it's occupying space in your belly and we need to get the protein in first.
Cynthia Thurlow: [01:02:45] Such an important and vital conversation. Dr. Sowa. Please let listeners know how to connect with you, how to work with you if they would like to, and how to purchase your book, which I have sitting right next to me. And as I stated earlier, this conversation is so important, so necessary and obviously your book has kind of come out at the right time to help people navigate these conversations with their providers and actually find someone that is competent and good to work with.
Dr. Alexandra Sowa: [01:03:12] Yeah. So, thank you so much for this great conversation. You can find me across all socials @alexandrasowamd. You can find me on my website at getsowell.com. We are the go-to resource for GLP1 users. We've created products that are popping up in stores nationwide to help people on their journeys. And our book is you can get wherever books are sold, including on Amazon and the big retailers. I love supporting local bookstores. So even if they don't have it, request to get it in. And yes, I do have a private practice. We have been on a little bit of a hiatus of accepting new patients but will be again soon. So, you can find that over at getsowell.com also.
Cynthia Thurlow: [01:03:56] Well, thank you again for your time today.
[01:03:59] If you love this podcast episode, please leave a rating in review, subscribe and tell a friend.
Comments