Comprehensive Weight Loss Symptom Management Protocols
Managing Acid Reflux
GLP-1 RA medications such as Semaglutide,Tirzepatide, etc. have some common side effects (>10%) including but not limited to;Nausea, constipation, or diarrhea, loss of appetite/feeling of fullness and acid reflux.Over time this, like other side effects associated with GLP-1 RA medications will improve in time (usually 2-4 weeks after a dose increase). If some of these side effects are left untreated and become severe, serious health consequences can occur, including renal failure and even death. We have compiled some specific recommendations that we hope you find helpful in managing some of these side effects should you suffer from any of them.
Eat small amounts of food at more frequent intervals rather than 3 meals a day.
When you go to bed, start by lying on your left side to help make it less likely that you will have reflux or sleep with your head elevated.
Wait at least two to three hours after eating before lying down or going to bed.
Eat food slowly and chew thoroughly. Put down your fork after every bite and pick it up again once you have chewed and swallowed that bite.
Avoid foods and drinks that trigger reflux. Common triggers include alcohol, chocolate, caffeine, fatty foods or peppermint.
Avoid tight-fitting clothing. Clothes that fit tightly around your waist put pressure on your abdomen and the lower esophageal sphincter.
Antacids neutralize stomach acid. Antacids containing calcium carbonate, such as Mylanta, Rolaids and Tums, may provide quick relief. Chronic use of these medications is not recommended.
Medications to reduce acid production. Histamine (H-2) blockers : cimetidine (Tagamet HB), famotidine (Pepcid AC) and nizatidine (Axid AR). H-2 blockers don't act as quickly as antacids, but they provide longer relief and may decrease acid production from the stomach for up to 12 hours.
Medications that block acid production and heal the esophagus (from the inflammation caused from the gastric reflux). Proton pump inhibitors: stronger acid blockers than H-2 blockers and allow time for damaged esophageal tissue to heal. Nonprescription proton pump inhibitors include lansoprazole (Prevacid 24 HR), omeprazole (Prilosec OTC) and esomeprazole (Nexium 24 HR).
Managing Constipation
GLP-1 RA medications such as Semaglutide (Ozempic/Wegovy), Tirzepatide (Mounjaro), etc. have some common side effects (>10%) including but not limited to;Nausea, constipation, or diarrhea, loss of appetite/feeling of fullness and acid reflux.Over time this, like other side effects associated with GLP-1 RA medications will improve in time (usually 2-4 weeks after a dose increase). If some of these side effects are left untreated and become severe, serious health consequences can occur, including renal failure and even death. We have compiled some specific recommendations that we hope you find helpful in managing some of these side effects should you suffer from any of them.
What should you eat and drink if you are constipated?
Fiber: depending on your age and gender, adults should get between 22-34gm of fiber per day.
Drink plenty of water and other liquids, avoid letting yourself get dehydrated and avoid processed foods.
Good sources of fiber
Whole grains like oatmeal, whole wheat bread or bran flakes.
Legumes: black beans, lentils and soybeans are a few examples
Fruits: berries, apples with the skin on, oranges and pears
Nuts: almonds, peanuts and pecans.
Nutraceuticals offered by Nervana Medical to optimize gastrointestinal health
Fiber Plus
Motility Pro
Ortho-Biotic/probiotic
Reacted Magnesium (also beneficial for gut and cardiovascular health)
Types of laxatives/Softeners available over the counter
Bulk forming laxatives: Metamucil (Psyllium): is a bulk forming laxative: may take up to 1 tablespoon 3 times a day, this may take 12-72 hours for onset of action to occur.
Osmotic agents: Miralax: is an osmotic agent, meaning this medication helps pull water back into your colon, softening your stool. May take 1 capful dissolved in 8 ounces of liquid once to twice daily. This may take 1-2 days to produce a bowel movement. Magnesium citrate.
Stool softener: Docusate sodium: is a stool softener. May take 100mg 1 to 2 times per day. This may take 24-48 hours to produce results.
Stimulant laxatives: Senna: is a stimulant laxative; it affects electrolyte transport across the intestinal mucosa and enhances colonic transport and motility. Stimulants have the potential to cause some abdominal discomfort/cramping.
Amino Acids: L-Glutamine: is an amino acid. Amino acids are molecules that play many roles in the body.Their main purpose is to serve as building blocks for proteins. Proteins are crucial to the organs. They also serve other functions, such as transporting substances in the blood and fighting off harmful viruses and bacteria .Glutamine’s immune system benefits are related to its role in intestinal health.Your intestines are a major part of your immune system. Glutamine is an energy source for intestinal and immune cells. It also helps maintain the barrier between the intestines and the rest of your body and aids with proper growth of intestinal cells. You can take L-Glutamine orally or we also offer it as an intramuscular injection.
Managing Diarrhea
GLP-1 RA medications such as Semaglutide (Ozempic/Wegovy), Tirzepatide (Mounjaro), etc. have some common side effects (>10%) including but not limited to;Nausea, constipation, or diarrhea, loss of appetite/feeling of fullness and acid reflux.Over time this, like other side effects associated with GLP-1 RA medications will improve in time (usually 2-4 weeks after a dose increase). If some of these side effects are left untreated and become severe, serious health consequences can occur, including renal failure and even death. We have compiled some specific recommendations that we hope you find helpful in managing some of these side effects should you suffer from any of them.
What to avoid in your diet if you are having diarrhea:
Excessive sugar or products with sugar substitutes
Fast food
Excessive caffeine
Some raw vegetables like broccoli and cauliflower
Avoid dairy, if possible, during this time
What foods to eat during episodes of diarrhea:
Eat small, frequent meals.
Follow the BRAT diet: include Bananas, Rice, Applesauce, Toast
DO stay hydrated, drink plenty of water, sports drinks are a good option too but too much sugar can worsen diarrhea by causing an osmotic effect. Pedialyte is always a win.
What medication can help with diarrhea:
You may benefit from taking a Probiotic, these are known to improve our naturally occurring gut flora that helps keep our digestive tract healthy;
-We offer Ortho-Biotic/Probiotic
Fiber is also a great way to bulk up stool.
-We offer Fiber Plus
Imodium is an over-the-counter medication that can be used SHORT TERM for acute diarrhea. Normal dosing is 1-2 tablets after a loose stool, but you should never take more than 4 tablets in a 24-hour period. Since this medication slows down gut motility, you are more prone to develop constipation if misused. Additionally, it can cause some drowsiness so do not take it if you are driving or working with heavy equipment.
Prior to starting this medication we advise you to discuss this with your pharmacist as this may interact with other medications you are taking.
If you have too severe of diarrhea, you can become dehydrated. Severe dehydration can lead to very serious problems. Do not let yourself become too dry. Some signs of dehydration include dry skin/poor skin turgor, dry lips, dry gums/mouth, increased heart rate and dizziness/faint upon going from laying to sitting or standing too fast. We do offer IV therapy should you begin to not be able to keep up with your “output”. Remember, intake must at least equal output; meaning if you are having lots of diarrhea, you need to be drinking lots of fluids!
Managing Nausea/Malnutrition/Dehydration
GLP1-RA medications such as Semaglutide (Ozempic/Wegovy), Tirzepatide (Mounjaro), etc. have some common side effects (>10%) including but not limited to;Nausea, constipation, or diarrhea, loss of appetite/feeling of fullness and acid reflux.Over time this, like other side effects associated with GLP1-RA medications will improve in time (usually 2-4 weeks after a dose increase). If some of these side effects are left untreated and become severe, serious health consequences can occur, including renal failure and even death. We have compiled some specific recommendations that we hope you find helpful in managing some of these side effects should you suffer from any of them.
Treatment goals for nausea management are directed to prevent serious complications of persistent vomiting that could lead to hypovolemia and vitamin deficiencies that could lead to more serious conditions including but not limited to renal failure, cardiac abnormalities and electrolyte imbalances that could be fatal. Early intervention and treatment of patients with mild and moderate symptoms may prevent progression to severe disease and overall a better outcome for both patient safety as well as medication compliance.
Risk Reduction:
Avoid Triggers. Examples of some triggers include stuffy rooms, odors, heat, humidity, noise, visual or physical motion, and gastric irritants (eg, coffee, iron supplements).
Eat small amounts of food every one to two hours to avoid an empty or full stomach. It can be helpful to eliminate spicy, odorous, high-fat, acidic, and very sweet foods, and substitute protein-dominant, salty, low-fat, bland, and/or dry foods. Fluids should be consumed at least 30 minutes before or after solid food to minimize the effect of a full stomach. Fluids are better tolerated if cold, clear, and carbonated or sour. Avoid lying down after eating.
Dietary: When reintroducing food, start with a diet consisting of bananas, rice, applesauce, and toast (BRAT diet) and then advance as tolerated.
Dehydration:
If you have issues keeping fluids or food down, early detection/ recognizing symptoms of dehydration is imperative to prevent further complications such as renal failure. Persistent vomiting/inability to tolerate oral fluids or nutrition can lead to dehydration.
Symptoms of dehydration include:
Urinating less often than usual,dark yellow urine,dry skin/poor skin turgor, dry lips, dry gums/mouth, increased heart rate and dizziness/faint upon going from laying to sitting or standing too fast.
If there are times you feel less nauseated, we encourage trying to at least drinking the amount of fluid lost from vomiting (if amount of fluid intake is not at least equivalent to the amount of output (i.e. vomiting, diarrhea, etc), then you will be at a higher risk of developing dehydration.
Loss of appetite/ risk for dehydration
You will lose your appetite, please choose highly dense/ nutritious foods to consume and take a daily multivitamin. If you feel as if you are not getting adequate vitamins and minerals in your daily oral intake, we do offer nutrient injections for an additional cost. Patients typically do well with a nutrient dense smoothie in the morning. We also recommend adding electrolytes to fluids such as pedialyte to maintain electrolytes.
Nutraceuticals offered by Nervana Medical to assist with optimal nutrition
Essential Amino Acids - Mitocore (also beneficial for energy/atp + immune support)
Vitamin/Mineral Support - Alpha Base with Iron
Essential Nutrition Support - Indigo Greens
Nausea Medications
Your provider may decide to prescribe you an anti-emetic medication to help you with nausea and vomiting. They will discuss this individually with you to help ensure the best option for you based on your medical history.
Is there anything I can do on my own to feel better?
Yes. To feel better, you can try the following:
●Eat as soon as you feel hungry, or even before you feel hungry
●Snack often and eat small meals. The best foods to eat are high in protein or carbohydrates, and low in fat. These include crackers, bread, pretzels, nuts, and low-fat yogurt.
●Avoid foods that are spicy, greasy, or acidic (such as oranges)
●Drink cold, clear beverages, such as sports drinks and ginger ale. Avoid coffee. Also, try to drink between meals, rather than with a meal.
●Suck on popsicles or ginger-flavored lollipops
●Brush your teeth right after you eat
●Avoid lying down right after you eat
●Take your vitamins at bedtime with a snack, not in the morning
●Avoid things in your environment that upset your stomach, such as stuffy rooms, strong smells, hot places, or loud noises
Nutritional + Physical Activity Recommendations
Significance: Why is it important to achieve a healthy weight? The medical rationale for weight loss in people with obesity is that obesity is a disease associated with a significant increase in mortality and many health risks, including type 2 diabetes mellitus, hypertension, dyslipidemia, and coronary heart disease. The higher the body mass index (BMI), the greater the risk of morbidity and mortality. Several studies/trials have reported a beneficial effect of weight loss on additional cardiovascular disease risk factors, including blood pressure, diabetes, and plasma lipid levels as well as a reduction in cardiovascular events. Additional benefits of weight loss include improvements in urinary incontinence, sleep apnea, depression, quality of life, physical functioning, and mobility. Evidence from observational and cohort studies demonstrate that weight loss in people with overweight and obesity is associated with a reduction in mortality.
At Nervana Medical, we are committed to helping you achieve weight loss success; while we believe pharmaceuticals can be utilized as a catalyst to your endeavor, we stand by the approach of comprehensive lifestyle interventions for best sustained results.
Nutritional: We recommend increasing your protein intake (unless instructed otherwise by your provider) ;aim for a daily protein intake between 1.6 and 2.2 grams of protein per kilogram of body weight (0.73 and 1 grams per pound). Athletes and heavy exercisers should consume 2.2-3.4 grams of protein per kilogram (1-1.5 grams per pound) if aiming for weight loss. By replacing carbs and fat with protein, you reduce the hunger hormone and boost several satiety hormones. This leads to a major reduction in hunger and is the main reason protein helps you lose weight. It can make you eat fewer calories automatically.
If you are interested in a nutritionist/nutritional coach; we are happy to refer you to some of our favorites!
Nutraceuticals offered by Nervana Medical to assist with optimal nutrition
Essential Amino Acids - Mitocore (also beneficial for energy/atp + immune support)
Vitamin/Mineral Support - Alpha Base with Iron
Essential Nutrition Support - Indigo Greens
Physical Activity: Exercise — Although less potent than dietary restriction in promoting weight loss, increasing energy expenditure through physical activity is a strong predictor of weight loss maintenance. In addition, physical activity can attenuate the loss of lean mass (eg, muscle) during active weight loss. Physical activity should be performed for approximately 30 minutes or more, five to seven days a week, to prevent weight gain and to improve cardiovascular health. There appears to be a dose effect for physical activity and weight loss, and much greater amounts of exercise are necessary to produce significant weight loss in the absence of a calorically restricted diet. Therefore, when weight loss is the desired goal, a calorie-restricted diet should be combined with less sedentary time and increased physical activity; the activity should be gradually increased over time as tolerated. A multicomponent program that includes aerobic and resistance training is preferred. Existing medical conditions, age, and preferences for types of exercise should all be considered in the decisions.
If you are interested in an exercise coach; we are happy to refer you to some of our favorites!
Behavior Modification — Behavior modification or behavior therapy is one cornerstone in the treatment for obesity. The goal of behavioral therapy is to help patients make long-term changes in their eating behavior by modifying and monitoring their food intake, modifying their physical activity, and controlling cues and stimuli in the environment that trigger eating. These concepts are usually included in programs conducted by psychologists or other trained personnel as well as many self-help groups.
If you are interested in additional information; we are happy to refer you to some of our favorites!
GLP1 RA Patient Expectations Education
At the point where a patient feels they have either met their goal weight or are not progressing in the way they had expected to, we ask that an appointment be made to discuss options moving forward.
What constitutes “unresponsive”: Clinically, per manufacture, a patient should not be considered as unresponsive to therapy until less than 5% weight loss over the course of 3 months of Semaglutide at 2.4 mg=100 units/wk has been established.
It is important to note that weight loss is more than just a number.
While reducing 5% of baseline weight is conventionally regarded as clinically significant, a greater amount of weight loss influences different organs to varying extents.
Moderate weight loss of 5 to 10% ameliorates cardiovascular risk factors such as hyperglycemia, hypertension, and dyslipidemia;
A greater weight loss of up to 10% is associated with improvements in obstructive sleep apnea or non-alcoholic steatohepatitis.
15% loss is associated with T2DM remission and mortality reduction.
According to the STEP + SURPASS studies 70% to 80% of patients treated with Semaglutide or Tirzepatide reached this goal (Semaglutide 2.4 mg/100 units and Tirzepatide 15 mg over the course of 60 weeks.
Approximately half of patients treated with Semaglutide 2.4 mg/100 units or Tirzepatide 15 mg experienced body weight losses of at least 10% and 15%, respectively. This is remarkable progress given the historical trends with previous anti-obesity medications used (i.e. Phentermine, Low Dose Naltrexone, Orlistat,etc.) were only noted to produce an average of 3-7% total percentage of body weight lost.
GLP-1 RA “Maintenance” Patient Education:
Risks vs benefits were laid out regarding “maintenance” therapy given at lower than manufacturer recommendations (manufacture recommendations recommend keeping the patient on at max dose (Semaglutide 2.4 mg/100 units per week or Tirzepatide 15 mg/week). The concern of keeping patients on “maintenance” therapy other than the manufacture recommendations of less than 100 units/wk has the potential to cause antibody formation; while rare (currently said to be less than 3%), I would hate to induce an antibody formation and essentially waste the chance of re-initiating a GLP-1 RA should they gain weight back. There are no issues in abruptly stopping the medication; it does not need to be weaned; however, should they need to be put back on it, they will need to start the titration process over again. Typically, patients who have already been on it previously tend to tolerate side effects better the second time around.
From our current clinical experience, the patients who typically require higher doses to respond, are typically the patients who have a higher insulin resistance profile. Maintenance dosing in patients who typically respond quite well to lower doses are those who seem to have less insulin resistance. Clinically, if any patient would like to be “maintained” on semaglutide; they should be titrated to the lowest effective dose possible (meaning not actively losing weight but not actively gaining weight either). We are happy to practice in a more customized approach that deviates from the manufacturer's protocol; but with the understanding that the potential development of antibodies against the medication may pose a threat to utilizing it in the future for active weight loss goals. We recommend at least one trial off the medication once hitting goal and we feel the best way to help maintain that success without utilizing a GLP 1 RA (ie. Semaglutide/Tirzepatide/etc.) is to provide assistance using one of the previously utilized anti-obesity medications in combination with nutraceuticals that promote healthy increased insulin sensitivity (more details can be found in the insulin resistance patient education handout) and/or our other weight loss options.
Nutraceutical Education:
We often recommend certain nutraceuticals that we feel could benefit your weight loss journey. If your provider talks about nutraceutical options to you, feel free to purchase them at any health food store, on our website online, our fullscripts supplement extension or in clinic.
Weight Loss/General Basic Wellness Labs:
GLP-1 RA medications such as Semaglutide or Tirzepatideis a medication used to treat type 2 diabetes, and it works by stimulating insulin release and reducing glucose production in the liver. As with any medication, it is important for healthcare providers to monitor patients taking semaglutide to ensure it is being used safely and effectively. We recommend that you have your labs checked at least annually while on GLP-1RA therapy. More information regarding our lab services can be found in your initial patient education packet which can also be found on your patient portal for future reference.
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