Skinny Shot Update: What TikTok Doesn’t Tell You About GLP-1s

Announcer (00:00):
You're listening to The La Jolla Cosmetic Podcast with Monique Ramsey.

Monique Ramsey (00:05):
A while back we had Dr. Jerry Haas on the podcast to introduce our signature skinny shot weight management program. And since then the program has continued to grow and evolve and so we can think it's time to have a proper update so he's back to share how the program has developed over time, what we've learned from patient experiences and how it's helping other people reach and maintain their goals. So welcome Dr. Haas.

Dr. Haas (00:31):
Thank you Monique. Good to see you again.

Monique Ramsey (00:33):
Good to see you too. So if you could just take a moment to remind listeners what you do here at La Jolla Cosmetic Surgery Center and how your background in weight management plays into it.

Dr. Haas (00:44):
Well, I am the director of the weight management program here. As you said, I'm also an anesthesiologist, but originally I started out in internal medicine and I was also a ship's doctor in the Navy and during that time of being sort of a general practitioner, I did work in weight loss clinics out of Norfolk, Virginia. So that was many years ago. The drugs are much better now and much more successful. So happy to be here doing this now and helping people.

Monique Ramsey (01:18):
Great. Well now we've been doing the weight management program in the office now for not quite two years, but a little over a year and a half. And so from then till now we've learned a whole lot. And if you could just kind of give everybody a refresher on what we call our signature skinny shot and how this weight management program works.

Dr. Haas (01:39):
So the signature skinny shot is a GLP-1 medication and we offer two different medications, semaglutide or tirzepatide, and those are the two different medications that we offer, but it's not just the medications, we check patients' lab work beforehand. There's a medical evaluation that occurs and then there's follow up on a monthly basis where we have people weigh in, we're getting feedback from them, we're checking for side effects, and that really helps us in dosing the medication and customizing it for the patient.

Monique Ramsey (02:21):
From that very first patient that was in our program to now. What kinds of things have you really been able to learn? Is it mostly having to do with side effects and dosing, or is it also maybe once they hit their goal how they can maintain?

Dr. Haas (02:38):
It's all of those things. So I think there is a learning curve with how to dose these medications and I think this is occurring all over the country, these medications being used for weight loss and what is the best way to dose them. Some of that is individual to the patient, but I think in general there's been a move towards less is more cautious is better, and that helps lessen side effects. And then also the part of helping educate patients on diet and exercise and adjusting their metabolic rate and for long-term effects.

Monique Ramsey (03:25):
So I'm assuming there's going to be a little bit of a difference between that initial weight loss phase ramping up and getting to where you're happy with how much weight you're losing per week and like you say, not too fast, and then as they sort of taper off maybe. And so how are those two parts of the journey different?

Dr. Haas (03:47):
We usually start at a standard dose and then depending on weight loss plateaus that may occur or side effects that may occur, we find a customized dose for the patient and use that for the program. And then once they get to their goal weight, we go through a maintenance phase. That's very important for long-term success. If we just stop these medications abruptly, patients will just gain the weight back. But the patients have to be engaged. They have to know this is the right diet. I want to eat clean, I want to eat healthy, and I can do that more easily when I'm on the medication. And then slowly weaning them off in that maintenance phase has to be long enough so it really sets in and it becomes part of their normal diet and their normal habits.

Monique Ramsey (04:42):
Part of what makes us unique is that there is that handholding throughout and that you being able to talk to them and help customize like you said, so we're really personalizing that dose to how they're doing or not doing. Maybe things have slowed down and what do we need to do and whether it's not, are you able to sort of, let's pretend it's going between, I don't know the right doses, but one and 2.5, and are you able to sort of help bridge a gap if they're not ready to go to the next dose?

Dr. Haas (05:21):
Yeah, that's a great question because the manufacturers, their medication comes in an auto-injector and so it's a set dose. Let's just use tirzepatide, it's 2.5, it's 5, it's 7.5, it's 10. So you're sort of locked into those doses. We have a lot of patients that they're doing great on 2.5 and then 2.5 is not working as well, let's say after six weeks. But they're having a little bit of side effects and then they're nervous about going all the way to five. We can jump to four and see how they do there and use that. Or we have some patients that don't even want to start at 2.5. They're very sensitive, they're very nausea prone and they might just want to start at two. There's no way to do that with an autoinjector pen that comes from the manufacturer. So our process here is we can drop customizable doses for the patient in that set time.

Monique Ramsey (06:25):
When you are doing that dosage, are they, let's say they're going from 2.5 to five and you say maybe five is too much, we're going to do four. Do they have to do a whole month of four or do they just do a couple weeks of four and then they could move again? Or how does that work?

Dr. Haas (06:42):
I think in general, we like to see people on a dose for a month at a time, but if we're experimenting with going to a next phase or a next tier, sometimes we do okay, try this dose for two weeks and then we'll jump all the way the third and fourth week. But generally we're set up for 28 days at a time on a given dose.

Monique Ramsey (07:09):
So part of our process is like a monthly follow-up, whether it's in person or online. So how does that regular check-in help patients stay on track and feel supported?

Dr. Haas (07:21):
Our follow-up occurs it's either a phone call or an e follow-up where it's a questionnaire and there's also a Bluetooth scale where people weigh in at least weekly and consistent time of day. So we have an accurate read on how they're really doing. And then when those follow-up questionnaires come in, Lauren scans those, and then if someone wants to be contacted by phone or they need to talk to me, then that can be arranged. And a lot of this is just education and reinforcement about clean diet, protein intake supplementation that needs to occur depending on what side effects might be happening. So it's not like we're just giving you a prescription. If you went to your regular doctor and got a prescription, you might see them in three to six months. Here we're checking in with you on a regular basis and making little adjustments along the way.

Monique Ramsey (08:25):
Yeah, I think that's nice because it's not one of those things where you want to feel like you're all alone on an island with your little syringe every week. It's like what's happening? Is this normal? And a lot of times things are normal. You just have to talk to somebody and say, Hey, this is what I'm feeling, this is what's happening. What do you suggest? Because you guys have seen now hundreds of patients, so you know what, maybe the logical next step if they're having a certain side effect or they're seeing something like you now have this whole population of patients that you've treated to be able to help them move through that problem.

Dr. Haas (09:06):
And I think we've learned along the way, we're 18 months in now and I'm constantly reviewing the medical literature and what's coming out on a daily basis about GLP-1s and staying current and up to date with that, and also listening to social media and what's out there and what people are saying and what's true and what's not. And we really try to sort through what people are hearing on TikTok versus what's in the New England Journal of Medicine.

Monique Ramsey (09:39):
Have there been any things that people are asking you consistently now where you're like, where are they hearing that?

Dr. Haas (09:45):
Something that came up in the last 18 months was about eye disease and whether that was a real issue in our type of patient taking a GLP-1 and a lot of the sort of headline news that comes out about some of these things, we have to remember that that's a different subset of patients. Those are diabetic patients that already are prone to eye disease and a very rare subset of even that type of patient might have an issue related to GLP-1 use. And we have to remember that our patient population is different than that and that it's been shown whether we're looking at cancer rates, thyroid cancer rates, the risk of all that is very negligible, but we have to remember the health benefits of being on these medications and lowering your circulating blood sugar. So you're inflammation is less, your cardiovascular risk is less, your risk of dementia is less. There's a huge improvement in people's health from being on these medications. So we have to factor that in and remember that a lot of these things are sort of meant to scare people almost.

Monique Ramsey (11:06):
Right. We don't want people to be fearful. And I think when there's a lot of input, it's easy to become overwhelmed and to be scared. And I actually talked to a patient or a prospective patient, a friend of a friend last week, and we had about an hour conversation and she was asking me all about the skinny shop program and just my opinions about it, and I've been on GLP-1s. And so she wanted to know my personal experience. And a lot of the things, she was just really scared and she was sort of overwhelmed from just all this information and she's like, I am like, you're a healthy person who's not needing to lose a lot of weight and think about the benefits.

(11:52):
And I really just encouraged her to get in touch with Lauren and set up a visit with you and do her lab work and see, and then you can help address some of those things from the medical point of view. But I feel like that is one of those things, you see these headlines or you hear these different stories and you don't know what to believe. And how do you separate fact from fiction, from what you've seen firsthand in terms of how our patients have been benefiting, not just physically losing weight, but emotionally and socially. What do you see from maybe the first time you talk to somebody to they're finished with maintenance and that transformation?

Dr. Haas (12:32):
We've had all kinds of patients and we've had patients that have a hundred pounds to lose and they're well on their way, and you just see their whole health improve before your eyes and their confidence, their energy level, they're able to exercise and they hadn't been able to exercise for years. So we have patients that have a deadline and we've had a couple of patients that are getting married or their relative is getting married and getting them to their goal and a certain timeframe. But I would say, to answer your question, it's really people's feeling more confident, feeling more energized so they can do more and get out in society and live their life

Monique Ramsey (13:20):
Well and I would think also for some of our patients want to lose 10 pounds and some want to lose significantly more, and some patients are trying to lose some weight to get to be able to have a surgery that is on their wishlist. For example, a mommy makeover, but there's still maybe 20, 25 pounds overweight. And the ideal thing from the surgical point of view would be to be that healthier weight and something that they can keep long-term. And how many times do you see, or how many patients have you seen where that's kind of the main driver? Maybe it's not a wedding, but it's a surgical intervention.

Dr. Haas (14:00):
I think there's a large group of our patients that are perimenopausal postmenopausal, they're interested in having a surgery, they eat great, they exercise, but they're just stuck with that 25 pounds and they just need something to help get them going in the right direction. This medicine's been great for that.

Monique Ramsey (14:23):
Yeah, I can attest to how the metabolism seems to come to a screeching halt when you hit a certain age. And it's frustrating too, and it's like you feel like I'm doing everything and I'm still failing. And where I think these medications help, first of all, you're not failing. Your body's just doing its thing. Yeah. And so how do we get to the next spot so that you can be more healthy and enjoy your life? And I'll put in the show notes, but we have some links to patients who've talked about it and talked about their journey, and it's a huge transformation for people, whether it's 10 pounds or it's 50 pounds, it's a lot. It means, I think just as much to that individual as it doesn't matter the number I think that you're trying to lose. So the biggest thing I think that people worry about is, okay, and you alluded to this earlier, when you stop the medication, what happens? So how does customizing that dose so that maybe hunger isn't completely gone, help them transition more smoothly and build long-term and healthy habits?

Dr. Haas (15:32):
So it's really a combination of slowly decreasing the dose and increasing the interval between doses. And we work with the patient to sort of gently land the plane. So say they're on the dose that got them to their desired weight, we really need to go through probably a minimum of a three month period where we're coming off that dose. I think a high percentage of our patients do stay on a very low maintenance dose. There are a lot of health benefits to these medications. So for me, I'm always going to take this medication. It's going to help decrease my risk of a heart attack. It's helped me with my arthritis. And we hear that from a lot of patients that they just feel better on the medication. And even though they're at their desired weight, they want to stay on a small dose. Maybe that's every two weeks, every three weeks, maybe it's once a month, just to help keep them at their desired weight.

(16:42):
It does require that engagement from the patient of, okay, this is my opportunity. The wind's at my back, that food noise has been decreased. Let's really learn how to eat. So it's lean protein, it's fruits and vegetables. It's avoiding all the processed food that's out there and just really using this opportunity to get healthy. So when you do come down off the medication, you have these habits that were easier to form, you were on the medication, but then as you come down to either a very minimal dose, a microdose, or maybe you come completely off the medication, you've really established these firm habits that can stay with you the rest of your life.

Monique Ramsey (17:32):
So you said that that word microdose, and I've heard that out there and I don't really know what it means. I mean, I assume micro means small, but what does that mean in the context of this conversation?

Dr. Haas (17:46):
I think a lot of people want to use GLP-1s as, and this is a newer thing as anti-inflammatories or just to improve their health. And there's so many disease processes in Western society that are really related to and over consumption of calories. And also the only thing that's ever been shown to prolong life is caloric restriction. So these medications help with that, and if they're used in the right way in a microdose, so the lowest starting dose of tirzepatide is normally 2.5 milligrams, but what if we're just taking two milligrams or one milligram or one and a half milligrams and taking that maybe twice a month long-term to just help get the health benefits? Is there a lot of hard science behind all of that? Not yet, but there's definitely preliminary results that are showing the health benefits of these are still attained with those smaller doses in that micro dose that gives you the health benefit, but you don't have the side effect profile that comes with the higher doses.

Monique Ramsey (19:00):
Yeah. I have a friend who a couple of years ago, she started to do this medication. I think I had started it before her maybe, I don't know, six months before. And she was super frustrated because it was like three weeks in or almost a month in, and she really hadn't lost anything and she was just ready to give up. Whereas I had lost maybe five pounds the first week because it was a big change for my body. But she's a big tall person. I'm a short person, and maybe that had to do with it. So how do you help patients? Just because something might be normal, maybe normal is two pounds the first week or four pounds the first week. I don't know what it's, but if the person isn't getting there, how do you help them kind of stick with it?

Dr. Haas (19:48):
You're right. The normal amount of weight loss is about seven pounds the first month. But not everybody loses that. I mean, some people lose more, but we have some people that maybe only lose two pounds the first month, and some of that can be hormonal. We do check for thyroid function and make sure your thyroid is functioning normally, but other types of hormone imbalances can be at issue. Alcohol consumption can be a component, and we have to really focus on decreasing alcohol consumption during this time period, and then also just meeting people where they are. So for instance, I recently had a patient who really had a special needs child, really did not have much time in the day for herself. So we have to find someplace for her to start exercise wise. And in her mind, she needed to do an hour walk. Well, there's not time in her day for that.

(20:51):
So she had a bicycle in her house and maybe it's a 12 minute bike ride. That's where we're starting just doing something to get that metabolic rate to increase and to build a little muscle so her body's starting to burn a little more calories during the day. So all of those conversations happen with just trying to get people going in the right direction. And I think the people that can get really frustrated is they think, I'm taking this medicine, it should be really easy. And it is for a lot of people, and that can be sort of misinformation in a way because it still requires active engagement from the patient to structure their diet, structure their exercise in a way and get their head wrapped around that. The medication's going to help with all that. But we do have some people that just assume, oh, I took the shot. The weight should come off, and I don't have to change anything that I'm doing. And that can be frustrating for some people.

Monique Ramsey (22:00):
Yeah, they're almost magic shots.

Dr. Haas (22:02):
They're almost magic.

Monique Ramsey (22:05):
But they really do, I think what's interesting about them is that they work on these gut hormones, right? But they seem to work on your brain too. How does that technically work?

Dr. Haas (22:16):
In our bodies, naturally, these GLP-1 hormones are released inside our gut after we eat food. Those hormones have receptors in the hypothalamus, in the satiety center to let us know we've been fed. They stimulate the pancreas to secrete insulin. They slow the emptying of food from our stomachs. But I think we're learning more every day about these GLP-1 receptors and all the different benefits that can occur by augmenting those peptide hormones in our body.

Monique Ramsey (22:55):
Besides the idea of coming off of a maintenance, that's probably a big question I would think. Another big question people have before they go into this is what are the side effects that are typical and how do you work with patients to help manage or minimize those?

Dr. Haas (23:14):
Usually we have to remember after each injection, if you're going to have side effects, they're going to be worse for the first 18 to 36 hours, and then they're going to dissipate during the remaining week, and they're also related to what and how much you're eating and drinking. So it's really about eating smaller volumes of food and eating clean food. But the side effect of belching or nausea can really be improved with just what you're eating, how much you're eating. If you're going out to eat and eating a large fatty meal and you're having two cocktails, that's just not going to agree with you.

Monique Ramsey (24:01):
No.

Dr. Haas (24:01):
So

Monique Ramsey (24:03):
Once you do that the first time and it backfires on you, you're like, oh, I don't ever want to do that again.

Dr. Haas (24:09):
Do that again.

Monique Ramsey (24:09):
Because you can not feel very good.

Dr. Haas (24:12):
Yeah.

Monique Ramsey (24:12):
And I think I noticed I just don't even really care about alcohol at all, and I didn't go crazy for it before, but I could take it or leave it. I'm sure the alcohol industry has been impacted somewhat by this, right?

Dr. Haas (24:25):
Yeah, no, it has. And a lot of people do find it's much easier to decrease their alcohol consumption and maybe not even drink at all. Also, I think taking your shot in the evening versus first thing in the morning when you have to perform at work or you have to deal with the kids in the morning, I find taking it in the evening gives you a period of time for your body to sort of work through some of those side effects while you're sleeping, before you have to perform yes, while you're sleeping. So things like headaches or pancreatitis, these things are very rare, but they can occur. But again, I think with lower customized dosing and taking things slowly, the risk of serious side effects has been greatly reduced.

Monique Ramsey (25:18):
Yeah, I think one of the things that people that I consistently hear is, one is that they're not eating enough protein. And I know for me it's a struggle. You might think, oh, I'm going to get 50 grams of protein that's not even close to how much you need. And that's probably where you guys help you and Lauren help, okay, we want you at this much protein per day.

Dr. Haas (25:41):
Yeah, I think to help prevent muscle wasting, I mean, we're all going to lose some muscle if we have a lot of weight to lose, but we want to cheat things, so you're losing the fat and less muscle, and that involves taking in a hundred, 120 grams of protein a day at a minimum, and front loading that protein to help with satiety. So really getting in some good protein early in the day, and then also at least twice a week, studies have shown 15-20 minutes of resistance training really makes a difference in minimizing muscle wasting. And then we can help people with types of food supplementation. There's different supplements that are out there that really help get your protein up early in the day or a good way to start the day and then go from there. But it is a challenge to get a lot of protein in, but this isn't about yourself. So we do want people to really focus on getting your nutrients. Maybe you're only taking in 1200 calories while you're on the shot. Those need to be really good calories.

Monique Ramsey (26:56):
That's a good point. Yeah. If you're feeling super nauseous, then you don't want to really eat, and then there's a bad circle that can happen. And so I think having that partnership with the patients so they can text Lauren and she can help, here's where let's try this and help get them over whatever's going on. So one other thing that as we've started this program a year and a half ago or so, and something that people are concerned about sometimes is sourcing. So where does this medicine come from? That's a big topic, and people want to make sure that the medication that they're getting is from a safe place. And so we hear about compounding pharmacies and what does all that mean and where do we get our medication from?

Dr. Haas (27:50):
That's such a great question, and I think it's one of the things that really distinguishes us from so many places out there. I mean, you can find GLP-1s cheaper than what we provide them at on the internet, but we are getting our medication from a manufacturing facility that is certified by the FDA, inspected by the FDA, had to go through a whole approval process with the FDA. Compounding pharmacies are not regulated in the same way. They're regulated by boards of pharmacy and individual states, and there can be a high degree of variability in the product with a compounding pharmacy that you won't see in a manufacturing facility. A manufacturing facility is making drugs for hospital infusions and those kinds of things. And the place we get ours from is all robotically made. A human hand doesn't touch it. It's all inspected and approved by the FDA. Ours comes from a pharmaceutical company, they're licensed in the state of California. It's good stuff. So I feel good about that.

Monique Ramsey (29:07):
So in terms of misconceptions that are floating around, whether this is just a quick fix, I mean, what kind of misconceptions do you hear from people or maybe how do the compounded versions or how do these other off-label maybe versions compare to the name brand versions and what would you say to clear up maybe some misconceptions that people have?

Dr. Haas (29:32):
Yeah, I think, and we hear some of our people on the TV saying, oh, people should just lose weight with diet and exercise, but that just doesn't work for everybody. And we all have different internal systems. We process food and energy differently in our bodies. We have different needs and using something that is naturally in our system, but just augmenting it to help decrease food noise and help get you on the right path. I don't find it to be a quick fix. Gosh, I feel like this is so beneficial to so many people and helping 'em fix their metabolisms and making better habits in their diet, I think is so rewarding and so necessary really. And in western culture where we have so many processed foods around us just constantly, we have to find a way to sort of fix our systems, our bodies, and this medication can help you do that.

Monique Ramsey (30:46):
Now, one of the questions we hear from people is, why would I get it from a cosmetic surgery practice? Can you explain maybe the value of going through a program like this with La Jolla Cosmetic Surgery?

Dr. Haas (31:01):
I think La Jolla Cosmetic, I know when I come here, it's going to be done right. We have always done things the right way here, and we've projected that onto the Skinny Shot program. So we're going to draw your labs, you're going to have a medical evaluation. We're going to get into the details of your health, and we're going to discuss what we need to do to help you succeed. We really try to take this seriously and do this the right way, the way it should be done. I hope that that comes across to people.

Monique Ramsey (31:40):
Yeah, I think in our 37 plus years, safety has always been a huge thing

Dr. Haas (31:46):
Absolutely.

Monique Ramsey (31:47):
For us, and there's no point in doing these things that are there not medically required. It's not medically required to have a tummy tuck or have a facelift. But if you're going to have that and you're going to choose to have it, you want to have it in a place where it's safe and the people around you in that operating room or during your whole experience are of the highest level, and you don't have a person running in and being in or being the circulating nurse and then running around the corner to go check on the patient in recovery and running over here to go. It's so important to know sort of who's with you throughout the process. And you've been with La Jolla Cosmetic Surgery Center now. How long do you know?

Dr. Haas (32:35):
I think I first started working here in 97. A long time.

Monique Ramsey (32:41):
26 years, 25 years. Yeah. Wow. All right. So yeah, you know us pretty well, and we know you pretty well, and that's why we were so happy when you wanted to do this for us. And you already had some background in it too. Last question has to do with price. Cost is always part of the conversation for people. What does pricing look like and why is there a difference between different options?

Dr. Haas (33:06):
Semaglutide which is a GLP-1 agonist, they both are, but tirzepatide, so their semaglutide and tirzepatide. Tirzepatide works at two different receptors. It's the newer medication. It is a bit more effective and does have less side effects. So it does cost us more. There's about a $200 a month difference between the two for given tiers of dosing. And so we're sensitive to that. We understand some patients are more price sensitive, and semaglutide works great, especially if it's dosed the right way and we give the right education. A lot of people can use the less expensive medication and have success with it. But the pricing, we really try, and I know we've had a couple times where we've been able to gently lower the dose when we do find that there's some savings on our end, we try to pass that onto the patient.

Monique Ramsey (34:13):
And I would assume, as you, and I don't know if this is true, so correct me if I'm wrong, if you move up a dose, is it more expensive?

Dr. Haas (34:22):
It can, yes, but not every dose. So there's a bit of moving up that we can do where it's at a similar price and with the customized dosing, we can play that game where we're giving you a little bit more, but it's not such a different price. Whereas when we first started the program, we weren't really doing that. The pricing structure was different, where if you went all the way to this dose that was going to cost you a significant amount more. We've tried to come up with those in-between numbers, so the jumps aren't so big, but we can still get you the results that you need.

Monique Ramsey (35:03):
What would you say for, I guess it depends on how much you want to lose, but I was going to say, on average, how long does it take people to get to their goal? But I guess it depends on what their goal is.

Dr. Haas (35:15):
Yeah, no, I think we have a lot of people that are just open to it taking whatever it needs to take. And that's probably the ideal, right? You're not in a rush. You're looking to do this the right way. And if you have 35 pounds to lose, if it takes six months or nine months or a year, that's okay.

Monique Ramsey (35:39):
Well, this has been really interesting to kind of, you and I talked a year and a half ago, and when we were first getting this started, and we've now seen hundreds of patients and have a lot of happy patients who've made it to their goal and have made it through maintenance or maybe are, like you say, doing kind of a low dose or microdose and just to keep the health benefits. It's exciting to see how much the program has evolved over time and how much you've been able to really grow and refine the program too.

Dr. Haas (36:15):
Yeah, I think, and it will continue to change over time as we learn more about GLP-1s and there will be new products that come along the line and new techniques and new information about what diseases or that it may improve. So all of that is a learning process going forward.

Monique Ramsey (36:38):
Yeah. Well, thank you Dr. Haas. I appreciate your time today.

Dr. Haas (36:42):
Thank you, Monique.

Monique Ramsey (36:42):
And if you're listening, thanks. And if you're listening, if you have any questions, we'll have all the links in the show notes so you can shoot us a text or we will have links to some of the patients that we've spoken with who have been on the skinny shot over different periods in the last couple years. And so anyway, if you have any questions, give us a shout. We're always here, and we appreciate you listening today, and we'll see you on the next one. Bye.

Announcer (37:14):
Take a screenshot of this podcast episode with your phone and show it at your consultation or appointment, or mention the promo code PODCAST to receive $25 off any service or product of $50 or more at La Jolla Cosmetic. La Jolla Cosmetic is located just off the I-5 San Diego Freeway in the Ximed building on the Scripps Memorial Hospital campus. To learn more, go to ljcsc.com or follow the team on Instagram @ljcsc. The La Jolla Cosmetic Podcast is a production of The Axis, theaxis.io.