Dr. Alexandra Sowa on Weight Loss, GLP-1's, and the Ozempic Revolution

Hi y'all, hey y'all, it's me, Dr. Smeenaraman Gyno Girl. I'm excited to bring you guys a new episode of Gyno Girl Presents Sex, Drugs, and Hormones. I'm Dr. Smeenaraman. As you heard in the intro, I have an amazing guest who's on fire right now. Oh my God. I was telling my last guest that I'm gonna start introducing people like Oprah, so I'm gonna say, it's Dr. Alexandra Sohwa. Anyway.

Alexandra Sowa (: 00:21

Yeah.

Alexandra Sowa (: 00:26

it.

Dr Sameena Rahman (: 00:29

So I'm super excited. We just met because I was like, gotta get her to talk to her about everything that she knows about ozemic because I've talked about ozemic on the podcast a couple of times with other people, it is one of these things that I sort of discovered because, and I'll say it again, I'm South Asian and so we have a lot of diabetes in our family. I'm not diabetic, but I learned about ozemic because it came out years ago and I had a family member that was going on it.

So I wanted to be up to date on what was happening with it. And then that's when I started going down the like obesity medicine, like, you know, Cornell stuff where I was learning the lectures. But what was interesting is that, you know, there was a time where I used Ozembic, like when people with PCOS failed metformin and it was getting covered by insurances. It was crazy. But now of course you have to be diabetic or you have to use it. So you obviously know.

Alexandra Sowa (: 01:15

I know.

I know, that was a sweet spot in time.

Dr Sameena Rahman (: 01:23

because you've been doing it forever. So I want to hear everything you know about Ozembe. I'm just joking. Tell me, Alexander, first, how much, whatever you feel comfortable talking about in terms of like your journey into like the obesity medicine field, and then like what inspired you to write Ozemic Revolution, which I will say I ordered and it was delivered to my neighbor who won't give it up now.

Alexandra Sowa (: 01:25

Mm-hmm.

Alexandra Sowa (: 01:37

Yeah.

Alexandra Sowa (: 01:50

We're gonna get you one, I promise.

Dr Sameena Rahman (: 01:52

Yeah, but I did a lot of back reading about what, you know, what. Yeah.

Alexandra Sowa (: 01:55

Yeah, and I'll tell you all about it. So my journey, I have always been interested in public health and actually my undergraduate degree was from Johns Hopkins in public health and I wanted to affect change on a large scale. But when push came to shove, I really had the calling to be a doctor and work with people one on one. I think that that desire to really

be a preventative health force and think about large systemic change led me to the field of obesity medicine. It was a totally new, totally nascent and really unknown to most people fields when I entered it over 10 years ago. I did my internal medicine residency at NYU and it was outstanding training, but it was the majority of my education was end of disease management and even end of life care I would consider.

The majority of people that I was taking care of in our clinic, I would say 19 out of 20 people needed to, the advice was counseled on losing weight. we would say counseled on losing weight, but then when you go to the preceptor and like, what did we learn? And there wasn't much to do because yeah, exactly. And everyone knew that they should lose weight, but they're like, well, I tried and it didn't work. So I'm just going to keep existing. then

Dr Sameena Rahman (: 03:04

Yeah. Go out and lose weight.

Alexandra Sowa (: 03:15

Meanwhile, the weight would keep coming on and the diseases would keep piling on. And then we were writing more and more medications. Just never sat right with me. And when I found the field of obesity medicine, I was like, okay, this is it. This is what I meant to do. And there was no turning back. So for the past 10 years, I've been exclusively practicing in obesity medicine. And I'll tell you where I differed from my field early on. At the beginning, it was very much focused and still some of the conferences are this way, are just very much focused on the medicines.

Dr Sameena Rahman (: 03:27

you

Dr Sameena Rahman (: 03:45

Yeah.

Alexandra Sowa (: 03:45

and what can the medicines can do. And it was, I do believe it was important for the conversation of realizing that obesity is a disease and we should treat it like any other chronic disease management and medication can and should be part of it. But I did not think that there was enough education on nutrition and behavior and cognition and lifestyle. And so when I set off to build my practice, it was...

And very intentionally, I designed it to be a holistic practice with a majority of the time, lots of education. I know this is you practice too. Lots of time educating and really walking people through what they need to do, how they need to behave, like the habits they need to build, how they need to eat, how they need to think. And with the larger evolution of GLP-1 medications and how effective they become and how powerful they've become, I think it's become even more important

Dr Sameena Rahman (: 04:31

No.

Alexandra Sowa (: 04:40

to bring in these foundational holistic elements, whole body elements, whole lifestyle elements as part of this and not just giving people a prescription and shuttling them out the door. Because one, you're not gonna have the health success that you really can achieve. You might not feel great. And you'll probably feel pretty out of control and disconnected from the process. So when I just realized it was time that the world was ready to embrace

kind of what I've been doing in my practice for a while. I thought, okay, I'm gonna bundle up my So Well method. I'm gonna take everything that I teach my patients, everything I know, I'm going to put it into this book. And that's how it came to be.

Dr Sameena Rahman (: 05:18

I love it. I can't to read all of it. That's awesome. I think that's great. mean, you know, just from my experience of like,

how it's impacted patients with that real insulin resistance. So many of my PCOS patients now the midlife women who have that midsection weight gain, the visceral fat accumulation, the insulin resistance, it's really been, I think transformative. If used in the right way, like you're saying, right, we're not just gonna hand it out or give it to every Tom Dickener. Although it was funny, I don't know if you watch the award shows, I'm having a brain.

Alexandra Sowa (: 05:55

Yeah, the Golden Globes. It was a Zempix best night.

Dr Sameena Rahman (: 05:57

I then mixed in with money. Yeah. It's funny because I think obviously like, know, we see the movie stars that have, you know, probably been using it and you know, a lot of them have, you know, either they had obesity or they probably had insulin resistance and self-capacities work really well for them. And then there's this alternate field and people who think, you know, maybe I'll just use it to lose that last 10 pounds to micro dose or whatever. Tell me what you think about that.

Alexandra Sowa (: 06:01

Ha ha ha

Alexandra Sowa (: 06:24

Well, I think it's a nuanced conversation. I think we have to be very, careful of using this to go from thin to thinner. And I do worry about that. I really worry. We need to treat this with care. And when something works really well, it can be abused. And I am starting to see that, right? And this this.

Dr Sameena Rahman (: 06:36

Right.

Dr Sameena Rahman (: 06:45

Okay.

Alexandra Sowa (: 06:49

While it's gotten some attention from celebrities, really, I think the reason that it's become so popular is just because it actually works. Really, it works. And I think the average person who is on this medication is now willing to say that they're on a medication and they're letting go of the shame, which is huge. FDA says that there are BMI cutoffs for...

Dr Sameena Rahman (: 06:54

It's a great product.

Dr Sameena Rahman (: 07:05

Yeah.

Alexandra Sowa (: 07:12

using this medication, a BMI greater than 27 with a comorbidity or BMI greater than 30, which meets obesity criteria. The fact is, is that one, and I talk about this in the book, this is important, this only applies to the Caucasian population. So BMI is different per ethnicity. We don't know this widely in medicine and the EMRs don't track this and they don't ping it. And I feel like this is very overlooked.

And really bigger than BMI, BMI is an inexact measure. I mean, you could have a bodybuilder who has an elevated BMI, which like no muscle fat. Really, we need to be looking at body composition. And I think that is where we should be going to really determine whether someone is an appropriate candidate or not. And also, and I talk about this extensively in the book, we also need to be looking at metabolic function. And we overlook very basic labs in the primary care office. And generally,

Dr Sameena Rahman (: 07:47

Right.

Alexandra Sowa (: 08:10

And we need to know the level of metabolic dysfunction to consider going on this medication. Now, weight is its own independent entity, but sometimes we'll have significant insulin resistance, pre-diabetes, or creeping up to type 2 diabetes. And if you don't quite meet those BMI criteria, should we be keeping this from you? No. This is all about health. And so you really have to look at the whole big picture. the book, I wrote it.

as a clinician for patients, but it really is also for clinicians to understand, well, what do I wanna do? I wanna start bringing this into my practice and I really wanna like go through the right, I wanna have the toolkit so I can help my patients. And I also want patients to advocate for themselves saying, know, great that you're offering this to me, but like, have you checked, you know, my insulin resistance? Have you looked at my metabolic function? Are we looking at blood sugar? Do we understand where I'm starting so I can see where I'm going, you know?

Dr Sameena Rahman (: 09:06

No, absolutely. And I think that's very critical. mean, I'm obviously a little biased. I'm South Asian and like my parents are from, they immigrated from Pakistan, which is number one in the world for diabetes. So like, it's true. I found out recently out there. yay.

Alexandra Sowa (: 09:17

True? I didn't know that.

Dr Sameena Rahman (: 09:22

But like South Asians carry a heavy burden of diabetes and their metrics should be different in terms of even cardiovascular disease. I would say 25 % of the world population, 67 % of the world heart disease. My mother just passed away from a massive MI first and like it was her only thing, first cardiac event and it was her last, unfortunately. so this...

protection, whether or not it's cardio projection or brain protection is very important for me personally, but also I feel like our listeners should really be acutely aware of the benefits of this medication with other lifestyle modifications. We're not saying nothing is a magic bullet. I say this about hormones all the time. Your estrogen patch isn't your magic bullet, but it is one of the tool kits. It's one of the tools.

Alexandra Sowa (: 10:10

Right, exactly. Yeah, I mean, we have to take a multifaceted approach to this. Health benefits are outstanding. And I think this is the thing that pop culture-wise gets overlooked. And this is another reason why I wrote the book. It's like, let's get past the misconceptions and the myths about this and then actually look about what we're doing. So we now have gone beyond the FDA of saying that this is approved for type 2 diabetes and for...

Dr Sameena Rahman (: 10:29

Right. Yeah.

Alexandra Sowa (: 10:39

weight management. We now have with existing heart disease, it's being covered for secondary prevention, sleep apnea, just gained approval. We are seeing this for kidney disease protection. I do believe in about within 10 years, we will start to see for specific risk, family history of dementia, we might start to see use of this. We're seeing, what's that?

Dr Sameena Rahman (: 11:02

Vascular specifically you think? Vascular dementia specifically? Yeah. Wait can you tell me about the kidney one? I didn't know about that one. Okay.

Alexandra Sowa (: 11:08

And it, know, kidney, yeah. So kidney benefit and type two diabetes, we're seeing significant improvement in kidney function and delay of disease. We are studying this for addiction. I mean, the early trial data on this is outstanding, decreased. It helps in alcoholism and opioid addiction. And the list at this point is just like, what else, what else? Keep it coming.

Dr Sameena Rahman (: 11:18

Dr Sameena Rahman (11:36.545)

Yep.

Alexandra Sowa (: 11:37

So why this is, is because the majority of chronic disease that we deal with is rooted in inflammation and blood sugar dysregulation. And as a society, we've become very metabolically deranged because we are animals who are built to survive in feast and famine. We now are in a constant state of feast, even if you try your absolute hardest and

We just really weren't built for this modern world and the foods that come at us. And that is why we're seeing such improvement because these medications work at the level of the brain, the gut, and I think most importantly, at the level of the pancreas and blood sugar and insulin. And a really rebalancing was kind of gone so awry.

Dr Sameena Rahman (: 12:29

Yeah, I'm very interested in the brain function and the cognition and all the things around addiction. let's get into a little bit about sex med. But let's talk about how it impacts your brain specifically. Like how does these...

Alexandra Sowa (: 12:42

Yeah, so I would say that a lot of, this is complicated, but I would say a lot of obesity and excess weight is actually the biggest thing to blame is brain dysfunction. Yeah, well, it's even deeper than that. I'd say, yeah, so people call it the food noise, but the same parts of the brain that light up with alcohol or opioid addiction, drug addiction, are the same parts of the brain that light up.

Dr Sameena Rahman (: 12:55

The food noise we talk about, right?

Right.

Alexandra Sowa (: 13:13

when we see hyperpalatable food. And that hyperpalatable food will actually destroy parts of our brain so that we become less responsive to our hunger and satiety hormones. And so it's a hormonal imbalance, but actually it's one that's really becomes distorted at the level of the brain.

That's a hard concept for people to understand because they're like, we'll just stop eating. Well, you can't tell a brain to just stop breathing, right? Our brain overrides and it's the same thing that's happening. And that is where this medication is just so amazing. It acts on the level of the brain and to rewire these hormones, but then to tell the brain to stop constantly thinking about food. And it becomes a lot more sensitive to

the normal hormonal pathway, just to take it a step back, GLP-1 medications, what are they? They are mimicking a hormone that naturally occurs in the body. They're very similar to the hormone that occurs in the body. What makes them even more effective, what we naturally produce is that the newer iterations of the drugs that are being created, they're very, very long-acting.

and they last a long time. And so instead of a quick pulse of a GLP-1 that hits right after eating a certain food, we get this sitting in our brain, talking to our brain, sitting in our blood and our body for a very long time, a week. And that's why these drugs are weakly injectable. And so the power on the brain is remarkable. And we start to see...

healing of the parts of the brain that have become so distorted. We actually see that on functional MRIs. So it's a really big superpower of this drug. These drugs are not just appetite suppressants.

Dr Sameena Rahman (: 15:05

Yeah, and I think that was one of the first things that I kind of came to understand with some of my patients was that I have a lot of patients who are, they are very like glamorous. like to dress very well and they would come to me like, I stopped shopping. Like this whole like drive to do online shopping like stopped and they're like, yes, like don't feel like it anymore.

Alexandra Sowa (: 15:28

It's totally, mean, because it's just like another addictive behavior. So it lets your brain sit with life rather than trying to fill it. And I talk about this in the book because I go through three foundations. We talk about the habit foundations, the food foundations, and then the thought and mental foundations. This actually affects people where they're like, but what do I do now? And I'm like, we need to work on finding a hobby. Honestly, like my patients will take up

I have a little anecdote, like a patient who like was like, can I do Legos again? He's like, I love that as a kid. was like, sure, there are adult Legos, go. He didn't know what to do with his hands at night. know, cross stitching, going for hikes again, like getting back to basics of what you did as a kid. You actually have like time and space for it and don't want to fill it up with things that have, can potentially have been toxic in your adult life. It's really interesting.

Dr Sameena Rahman (: 16:01

Yeah.

Dr Sameena Rahman (: 16:21

And that's probably why it helps so much in the cognition field, right? Because all of those things as we age, like that's part of cognitive fitness is trying new things or doing new things. that's wonderful. Well, as we talked about a few minutes ago, I treat a lot, I'm a sex med specialist. It's something I treat in and out of my office every day. so I find it, and this is where some of our research, I'm part of the board of the International Society for the Study of Women's Sexual Health. And we have this group of students that do a lot of research. And so one of the things

Alexandra Sowa (: 16:29

Exactly, exactly.

Dr Sameena Rahman (: 16:51

that we're always trying to figure out some of the research I think is going to go into like how does it affect your sexual function, right? Because you definitely have patients who come and it's because libido is so complicated, you know, there's so much, there's a bio portion, there's a psycho portion, there's a social portion. So it's very complicated for women especially. But what I've found is like, well you definitely have the patients who don't feel good about themselves and feel really like they don't, they have body image issues or whatever and they take GLPs and all of a sudden, all of sudden their libido's

improved and their sexual functions improved right and so we see that but I've also seen the opposite happen too where it's like their desire has kind of like plummeted down you know for you know I think for how it works on the brain can you speak to that a little bit what's your experience when it comes to sexual function

Alexandra Sowa (: 17:37

Well, it's complex. Again, it's nuanced. What I have found generally, and I'm so interested to hear what you have to tell me about this. What I've actually found is that the libido in this journey is more affected by how their relationship is affected. So I think...

This is not talked about enough at all. Like I really never heard anyone else talk about this, but we enter into relationships with a social contract, whether it's romantic, as we're talking about in this case, or in friendship. And it can be very hard to, from one day to the next on this medication. And it can be that dramatic, being a different, having different interests. So you don't like my

25 year old patient really struggled when she no longer wanted to go to the bars and just hang out for hours and eat chicken wings and drink beer because one, she had no desire to and two, she really didn't feel well if she did. And we had to work, we had her working with a therapist because she really needed to figure out how to evolve into the next stage of her adulthood and what that looked like and didn't mean leaving friends behind, but figuring out I'm gonna host a game night at my house.

rather than during kind of the same old. But no one's counseling people that when they're giving this prescription, right? And then I see the same thing in romantic relationships. And a lot of times people will say, my husband is not liking this because his idea of romance and sex is drinking too much, just going out, having a nice dinner, getting a little tipsy, and then coming home.

and having sex. And I don't want to do that anymore. So where does that leave us? So you have to start rewriting patterns. Yeah.

Dr Sameena Rahman (: 19:39

what sex is

I totally agree with that. I think that's what I see with some of my patients as well. And I think it's sort of the nature of, you know, how we treat sexual dysfunction, because there is, you know, there's like the whole responsive desire versus spontaneous desire. You know, what brings a couple together? What's going to like really cause distress in their relationships? Because, you know, for the most part, sex is between, you know, partners, right? It's, know, obviously, you can masturbate and do all that stuff. But still, when it comes to these relationships,

and continue to make them fulfilling, I do find that this has been an issue with a lot of patients. also, as to your point, you definitely have the patients who would like to go out to eat and they have these great dinners and all the different types of wine and the different types of food and all of a sudden they don't want to do that. Or if they try to do that, they're in so much pain, Like stomach-wise, they don't feel well. And we can talk about that. You can tell us a little bit about how GOP affects the other intestines and the system as well. But it is a rewatch.

Alexandra Sowa (: 20:30

Yeah. Yeah.

Dr Sameena Rahman (: 20:41

And so a lot of those patients, I do have them either meet with sex therapists and couples therapists, but also, like you said, you have to find new ways to keep it spicy for them that the partner will agree with as well. I think that's the other issue with the...

Alexandra Sowa (: 20:58

I think it often just starts with awareness of knowing that, it's not you. Because often we take this on ourselves, right? And something's wrong. But really, it's probably the other person. And we talk about that a lot in the book, kind of rewriting cognitive scripts. And how do we not internalize things that we're feeling into a negative place and how we own them again? And I think even just the awareness of saying, hey, this might change. And maybe you should think about this. I actually, on my intake,

Dr Sameena Rahman (: 21:04

Okay.

Alexandra Sowa (: 21:28

ask if someone is partnered and how their partner approaches health and do they want to lose weight or, and if someone tells me, gosh, no. And if that's an on the intake, like, you know, my fiance keeps like so much junk food in the house and loves it so much. Well, that we need to talk about that. I don't think it's something that necessarily needs to be a problem, but the patient is going to need to understand how they're going to kind of understand this dynamic.

Dr Sameena Rahman (: 21:34

Yeah. Yeah.

Alexandra Sowa (: 21:58

I will also say the other thing I've seen is that sometimes people feel really threatened by significant weight loss of the partner. it feels like a mirror back on them of all the things they are not doing and want to do. And when someone's finally feeling like they're for the first time in 10 years, they're like, I feel good enough to go to the gym now. And your partner's like, I've never known you once to go to the gym. Who are you? We have to work on that.

Dr Sameena Rahman (: 22:24

Yeah. Right. And then automatically there's this concern like, is she seeing someone else? there something else happening here? Is there another layer?

Alexandra Sowa (: 22:32

Exactly, exactly.

Dr Sameena Rahman (: 22:34

So all of that has to be discussed. And I always talk to my patients when I'm dealing with sexual dysfunction about the brain being our biggest sexual organ, right? And then things that'll put us into excitation mode and things that put us into inhibition mode that make us not wanna have sex. we call that the dual tipping point. But just so they have an understanding that there are neurotransmitters like dopamine and norepinephrine and hormones like testosterone and oxytocin that are the biologic reason we wanna have sex. And some of these can be altered by the use of

from the GLP lunch, right? Like I think.

Alexandra Sowa (: 23:06

They can. This deserves a lot more research. I actually recently dug into this to see what was out there. there's probably no surprise to you. There's a dearth of actual literature on this, but I do think it's interesting. I have only really seen it played out when there was potentially an underlying sexual disturbance. I'm not even sure the right word, like,

Dr Sameena Rahman (: 23:11

Good.

Alexandra Sowa (: 23:33

maybe not having the same response to porn or it was something that was like a little, and it's almost like it was a behavior that maybe had a problem and then is quieted in the same way that we're talking about shopping addictions or these other addictions that maybe weren't benefiting you, but it feels almost threatening when that was something you relied on and now you don't have it. And so again, it's kind of coming to terms with what's new and in front of us.

Dr Sameena Rahman (: 23:42

Right.

Dr Sameena Rahman (: 23:56

Yes.

Alexandra Sowa (: 24:02

Generally speaking, I mean, I've never had anyone want to stop this medication for any sexual side effect. It's just something we have to navigate.

Dr Sameena Rahman (: 24:10

Alright.

And I'll tell you one other interesting story that you may find interesting as a specialist in GLP ones. I treat a condition in my office called persistent genital arousal disorder. So we think it's a multifaceted condition where people have this feeling of genital arousal without any psychological, you know, like they just spill it randomly in the car or they, and it's a distress. So we think of it as a genital pelvic dysesthesia, just an abnormal pain sensation of the pelvis, but it presents us this feeling of arousal and these patients

are so miserable and many of them are suicidal because and it's a multifaceted reason like we look at you know sort of like the end end and end organ like the clitoris and the vulva like how is it involved how the pelvic floor is involved how the spine is involved because those signals go through the spine and then the fifth region is the brain and so we look at like how that signal can get turned out from the brain and I had and I had a colleague tell me the same thing another sex med colleague but we there was a patient that I

that I think was all coming from region five, but of course, you the other regions kind of like get affected. So the brain was heavily involved. She was catastrophic size and had anxiety, but also it was perimenopausal having all this weight gain. So she was getting a little bit better and then she kind of got into the obesity range insulin resistance. we tried her myself and her primary care tried her on the GLP-1.

and her peak ad went away. Isn't that crazy? It's like, I did write it as a case report for like a presentation that we did at the World Sexual Medicine Conference, but it was so interesting to me that like this was, and you know, obviously there was an anxiety component and there was a hormonal component, you know, there's multifaceted, but it was that last thing, the JLP one that kind of closed it all down. It's so interesting. But.

Alexandra Sowa (: 25:41

Wow. Have we written this up? Let's.

Alexandra Sowa (: 26:03

Mm-hmm. I believe it. It makes a lot of sense.

Dr Sameena Rahman (: 26:08

Especially if you think about that, you know, dopaminergic or norepinephrine pathways that would be contributing to sort of like this hyper stimulus from the brain or something like that. But, you know, it's and I've talked to other sex med specialists who have also seen that. So it's it's I think we just need to get more research in this arena because it's so.

Alexandra Sowa (: 26:12

Mm-hmm.

Alexandra Sowa (: 26:27

Absolutely. You know, one other place that I see this that I really couldn't, this is great, because I can't really have this conversation with anyone else that I'm talking to because they wouldn't understand it. the other thing that I see in terms of sexual function is that a lot of women in my practice unintentionally throughout the years covered their body with excess food, used food, and

Dr Sameena Rahman (: 26:35

Thank

Alexandra Sowa (: 26:55

developed really a protective layer of fat. I that's really the only way to say it in response to trauma from childhood. And we see this, this has long been known to be true that adverse childhood events are linked to higher rates of obesity, but specifically we see this with sexual abuse. And I...

I have now started to screen in a very gentle way for this in my patient population because what I have started to see is that as people lose weight, they now have a body that they hadn't recognized in years that feels closer to a body that might have existed when they experienced a horrible sexual event.

they also now are getting attention in a way that they hadn't in years and it can feel like the world is falling out beneath them. And so it's such an interesting thing because again, this is not being widely reported on and people feel like maybe there's something wrong with them. But I would say that, no, if this resonates with you, we've got to get ahead of it with therapy. Even if for years and years and years you're like, no, I got this, I'm good, I dealt with it. It's something new that comes up.

Dr Sameena Rahman (: 28:16

No, I absolutely think that's so fascinating. Actually, I bet you would love to come to the Ishwish meeting sometimes at International Society for the Study of Homosexual Health. I got to get you on board. I'm going get you But you know, we have these annual meetings that we talk about the latest research. And I think there's going to be some people have done some, you know, look at some of the GOP ones. let you know if there's anything new that comes out of that. But I might pull you in next year.

Alexandra Sowa (: 28:25

I would love to. I would love to.

Alexandra Sowa (: 28:40

Yeah. Well, know, these meds let people live, they give a lot of space in the brain and in your world, and they free up a lot of the chaos that came along with dieting culture. And we talk about this a lot in the book, and you really have to do the mental work. So I lay the scripts out, like how to kind of tackle the way you're going to think on these medications. And I think we just need

to really help people be prepared for what comes up along the journey. And that's just a note, because people are like, all we're seeing in the media is the click-baity headlines, and like, yes, it's effective, and now everyone's going to be on it. Yeah, but we're not talking about some of the hiccups. And the part of the book that I'm actually proudest of, because it really hasn't been anywhere else, I talk about the patient journey on these medications, so what you can kind of expect.

Dr Sameena Rahman (: 29:20

Yeah. He's got a big face.

Alexandra Sowa (: 29:36

Everyone thinks that they are the outlier and that they're the only ones who are having a hard time or experiencing this or feeling this way. But because I've treated so many patients over the years, I kind of have come to understand exactly what's going to happen in your journey. So I have this one part of the book where I'm talking like, you'll probably hit a 10 pound panic. At 10 pounds down, the majority of patients come to me and say, this isn't working anymore.

And they're like, well, I've gotten here before and there's no way that this is going to get me to the next 10 pounds because I've never been able to get past this point. And they start to talk themselves out of success or it'll come as people start to notice the weight loss and then you take on, you activate your own negative thinking about this process or it brings up a trauma that trauma can come in the history of sexual trauma. can come in terms of...

Dr Sameena Rahman (: 30:08

Yeah.

Alexandra Sowa (: 30:27

family trauma, your grandmother poking at your belly telling you you were fat when you were five, or the school nurse weighing you when you were 13 in front of your whole class. mean, the things that we carry with us when it comes to our bodies are so dramatic. And we kind of need to know and be ready for them. I'll talk about what happens when people get close to within the 10 pounds of their final weight. They start to sabotage themselves because it feels very scary to finally get there, right? And like everything in between.

There's so much, just like your specialty, there's so much related between the brain and weight loss. And I'm not talking about willpower. I'm just talking about the relationship between the body that we live in and the brain that is with us.

Dr Sameena Rahman (: 31:06

Yeah.

Dr Sameena Rahman (: 31:12

That's so fast. You know what? I've spoken to a lot of people that are obesity-specific. I've never heard anyone really address the cognition as much as you have just now. And I'm really excited to read what you wrote about that, I see this, because I address cognition for know, perimenopause, menopause, sexual dysfunction. But understanding what you're saying makes so much sense when it comes to, it's the same, it's so nuanced. I really, I can't wait to read what you write. But why do you think it is that way?

It could probably obviously, like you've had so much experience with it that you've seen.

Alexandra Sowa (: 31:45

I think that medicine, I would like to think that this is how medicine used to be practiced. We're kind of like, let's take some time. This is how I romanticize the field. I was like, we're gonna sit and we're gonna talk and we're gonna get to understand. I think medicine has just become very broken in the way that the majority of care is delivered. And so we've stopped trusting our patient also, like we didn't give them enough credit.

Dr Sameena Rahman (: 31:59

Yes.

Dr Sameena Rahman (: 32:12

Yeah. Yeah.

Alexandra Sowa (: 32:13

And it's just kind of like, well, here, we'll just write you a prescription and we'll fix it. And I am not throwing doctors under the bus. It's the system. And so I think that we just haven't paid a lot of time. And I think all of my best mentors were always like, let's get to the root of why a patient is doing this. And I've always found that really fascinating. And I'm obsessed with my patient's success. And I just realized that you could not be successful at this if you didn't get over your roadblocks.

Dr Sameena Rahman (: 32:29

Right, right.

Alexandra Sowa (: 32:43

So I had to figure it out for them.

Dr Sameena Rahman (: 32:45

Do you usually connect them with someone for cognitive behavioral therapy like almost immediately or how do do it?

Alexandra Sowa (: 32:53

No. So in the book, I have kind of laid out how I walk people through. So I did something really unique in my practice. I actually started group medical education. So all the patients in my practice, when they enter, they have to go through an eight week program where we meet as a group online once a week and I teach and I give a lecture. people, I always felt like my patients needed to go through a mini med school to really get it. Education is so key because like

Dr Sameena Rahman (: 33:20

Okay.

Alexandra Sowa (: 33:20

Why are you going to do something I'm telling you to do it unless you understand why? So I really do teach and they have to go through that and still one-on-one medical care. So that's separate, but the most valuable thing that we did together was this, and I would create homework for them every week. And that is what I've put into this book. The So Well method is really what I've learned and I tweaked and I made, I just had the best outcomes for my patients. Our outcomes and our practice are far beyond what we see in clinical.

Dr Sameena Rahman (: 33:23

Yeah.

Alexandra Sowa (: 33:49

clinical literature, even with the outstanding weight loss numbers, we go much farther beyond that because people are doing this work. So with the cognitive behavioral therapy, I call it CBT light, where we take the tenants of evidence-based cognitive behavioral therapy and I give people the tools to do this on their own so that it becomes like a habit, like brushing your teeth. You're just doing certain things every day. That we know is what the consistency of a habit is what keeps weight off for the long term.

So I give people those tools and that's what I give in the book. Now, when we identify particular instances or triggers or events throughout the weight loss process where it is something that goes beyond your ability to help yourself and my ability to help you as a doctor, of course, then we are referring to therapy or psychiatry. It's you so unique that I'd actually say that the majority of times that I refer are not at the beginning. It comes up throughout the weight loss.

And I actually give very specific examples in the book about this where it of catches you off guard and you're like, I thought I would be happy with weight loss. Turns out the weight loss does not change me on the inside. And that's shocking for people. And that's often when we have to address a lot of the underlying mental health issues.

Dr Sameena Rahman (: 35:07

Absolutely. Do you find a lot of your patients then end up having like go into plastic? Because I've talked to plastic surgeons and friends that are in there, they have this resurgence of people that have now lost all this weight. Where do you see that in this picture of like the weight loss?

Alexandra Sowa (: 35:24

I have never, for as much talk of there is of ozempic face and just like skin laxity, I have never had a patient say to me, I regret the weight loss or this has made my, I can't stand my ozempic face. No. The health benefits of real health, of weight loss for health are just so far beyond anything aesthetic.

Dr Sameena Rahman (: 35:42

Yeah.

Alexandra Sowa (: 35:53

I have a conversation with patients. If something's really bothering them, well, then that is the next step solution, especially for excess skin. When we're talking about losing 75, 100 pounds, 100 plus pounds, sometimes there is excess skin that is actually detrimental to health. And so I encourage people to just go have a consultation and learn what they might be able to do.

I talk in the book about how to avoid as much as possible, as much as non-genetically possible to reduce your risk of having excess skin. A lot of it is genetics, a lot of it is age, I'm not going to say, but there are certain things you can do. Prioritizing your protein, strength training, that is key. There are certain, we want complete proteins, but collagen has also shown to be effective.

We don't want to lose weight too quickly. People are often disappointed that they're like not 50 pounds down in the first month. And I'm being facetious, but really sometimes people are like, I lost eight pounds. I wanted more. And I'm like, you've just lost two pounds a week. We don't want to lose more than 1 % of our total body weight a week. So slow and steady weight loss is the name of the game and retaining your muscle.

Dr Sameena Rahman (: 37:10

And I think that's one of the misconceptions too around the GOP ones is that they cause muscle wasting. That's not the case. It's obviously, if you want to risk that.

Alexandra Sowa (: 37:18

No, no. When we lose weight, we lose muscle and fat. You cannot just lose fat. There are new drugs in development that potentially will have a much better profile than we currently have. But with GLP-1s, talk about this in the book, look at all the research, especially with the dual agonist trisepatide, so GLP-1 plus GIP, the ratio of muscle to fat loss is much better.

than with traditional dieting and exercise alone. And so we, no, it's not worse for you. It's better on these meds.

Dr Sameena Rahman (: 37:54

Right.

And so that just goes to your point of pushing the protein, making sure you're lifting, strength training and all this. And when it comes to this whole idea of ozumabic phase, I always joke with people that at some point as you age, you have to choose between your ass and your face. But I mean, seriously, think anytime you have dramatic weight loss, you can see it in any arena. So I think that again goes to your point about slowly losing the weight and hopefully

Alexandra Sowa (: 38:13

Yeah.

Dr Sameena Rahman (: 38:26

getting enough protein that you don't have these concerns. Are there any other misconceptions you want to make loud and clear to people that are listening that are on the verge of getting your book?

Alexandra Sowa (: 38:39

Yeah. Well, we talked about so many misconceptions. You know, I think the biggest one we've talked about it is these drugs are not a magic wand and getting a prescription does not equal success. So you really have to prepare yourself. And I think the book is the perfect way to kind of wrap your head around what's going to happen, how to... One of the things I love in this book and people are loving it too, is there's a downloadable list of things to buy at the pharmacy or the grocery store to prepare yourself because a lot of the side effects

can be mitigated and managed very well if you just know how to prepare your body. I actually have a company called So Well, the practice is So Well, and then I've launched a lot of products called So Well 2 that is a GLP-1 support system. And it's a three product, and I'll have to send you some for your patients to try, but it's a three product system that addresses the side effects because up to 66 % of people stop this drug by one year, which is

horrible because you are not seeing the benefit and for the majority of users it's because of side effects and side effects are probably inevitable but they're very very manageable and it means to me that the person who's having the side effects and is having to stop didn't quite know how to prepare themselves, how to eat and how to mitigate. So things like constipation and diarrhea, if we get the right fiber profile in and make it a regular part of our routine you can really manage that or nausea and fatigue.

We need to stay hydrated with the right amount of electrolytes and B6 can help. And there are these things, you only develop these tips and tricks when you've been in clinical practice for a long time. So most people writing the prescription just don't know. So we actually created a whole system for this, but in the book, things like, you might have to ask your doctor for Miralax or Zofran for nausea, advocating for yourself if you're just not feeling well on the medications, I think is a big one.

The side effects are just a byproduct of how the medications work and eventually they do go away and get a lot better with time and then they'll only occasionally come in one wave randomly and kind of affect you. So I think that's another big misconception that these drugs are horrible. People feel horrible on them. They don't. And there are ways to feel better if you don't feel great. we have, I have literally put everything I ever tell my patients and have learned in 10 years of clinical practice into this book.

Dr Sameena Rahman (: 41:07

amazing. Everyone needs to go and we're gonna link it in the in the show notes how to get it but it was number one on Amazon right? think someone. That's awesome. I'm sure it's gonna hit the New York Times soon so fingers crossed. Everyone get out there buy the book you know what I'm saying? I'm gonna try to get mine back from my name. I'll show you the picture that Amazon sent me. I didn't even deliver it to my house.

Alexandra Sowa (: 41:15

It was, we were at number one new release. Yes, very exciting.

Alexandra Sowa (: 41:28

I don't know why!

Alexandra Sowa (: 41:35

I'm so sorry.

Dr Sameena Rahman (: 41:36

That's okay. Anyway, but I look forward to getting into all your tips too. I think it's great that you were able to do this. And I do think this is a medication that's really gonna change the trajectory for healthcare. I mean, in the right context.

Alexandra Sowa (: 41:51

Yeah, I do too. And we just have to continue to treat it with respect and embrace it. And yes, I do think this is a modern medical miracle. I do.

Dr Sameena Rahman (: 42:01

There you go, guys. And if you're not finding, I guess I should ask you what your thoughts are on some of these weight loss clinics that are popping up left and right and a lot of compounding and the FDA across, are warning on compounding some of these medications. What are your thoughts on that?

Alexandra Sowa (: 42:25

Mm-hmm.

Well, you probably have understood this by listening to me for the last 40 minutes, but I really, my biggest concern with a lot of these clinics that are popping up is that there is a deep lack of understanding of these medications, how they work, how we should use them, and they're totally lacking in any holistic support. That is my biggest concern. The compounding pharmacies provide a whole other level of concern, which is

you really can't guarantee what's in these medications when they're not coming through an FDA approved mechanism. The drugs are under patent. So yes, you can get the molecules from China that kind of mimic, but the way that it's all put together, that is under lock and key. I've had a lot of patients come to me after trying compounds and it didn't work for them or they didn't feel well. And that makes me question what exactly is going on.

I think it feels like a real threat to people when I say that though, because they might not have insurance coverage and it feels like a more affordable option. I will say if you work with an obesity medicine specialist, most obesity medicine specialists can figure out a way not to necessarily get insurance coverage, but to get you a more cost-effective way to take the FDA approved medication. So that's something to consider. I did have a program

Dr Sameena Rahman (: 43:43

Even if it's just you.

Alexandra Sowa (: 43:55

Something pop up in my Facebook feed. was a advertising, compounding pharmacy advertising GLP ones for vanity. It's literally was their tagline. No BMI screening required.

That is horrible. This is still a medication. We still need to have an informed discussion of risk and benefits. And what I do not think is happening in these clinics is people do not realize that once you start this medication, you may and may likely need to stay on this medication for life to continue to see the reward. And in the title of my book, I say that GLP-1 medications will end yo-yo dieting.

Dr Sameena Rahman (: 44:27

Right? Right.

Alexandra Sowa (: 44:36

And if we start to use compounds or medications just on and off, it's going to further exacerbate all the health issues that come with yo-yo dieting, are big. So you should not start something unless we see it as a path to something you might have to maintain and are really willing to put in the work. So that's me on my soapbox. I'll get off now.

Dr Sameena Rahman (: 44:58

No, totally agree. mean, I think similarly it happened with, you know, menopausal hormone therapy where like, you know, this negative press came about, compounding became a thing, the bioidentical thing came to be, you know, fruition. And now it's, you know, pushing to get back on FDA approved products because of the same reason, the safety and efficacy is sometimes unknown. So I think I don't and I think it's the same for like when you talk about testosterone replacement. I mean, I don't.

I tell the patients, I get why the thing exists because people weren't getting the medication that deserved it, which is similarly like there's so many patients that maybe aren't getting the GLP ones they deserve because they haven't been able to find the right person to help navigate the system for them so they can get it. But there's still other ways to do it and more safe ways. So I agree.

Alexandra Sowa (: 45:32

Mm-hmm.

Alexandra Sowa (: 45:47

Yeah, and really we just need to put a lot of pressure on industry. Everything from government to pharmaceutical companies to the PBMs that manage all of the in-between, we need massive reform. These drugs are far too expensive. They are $100 to $200 in Europe and other parts of the world per month, not $1,000.

Dr Sameena Rahman (: 45:53

in the straight line.

Dr Sameena Rahman (: 46:08

Right, absolutely.

Well, Alexandra, I really appreciate you coming on, especially like last minute, I was able to snag you for now. I appreciate it. And I can't wait to delve into the book a little bit more and for myself and try to understand everything that you've learned over the last 10 years. think it's great. But you guys can find her on Instagram. I'm going to link everything, how to get her, if you want to be her patient, how to get to her. If you want to get her supplements, that will help your journey as well.

Alexandra Sowa (: 46:18

I loved it, I loved it. Thank you so much.

Dr Sameena Rahman (: 46:41

It's all going to be in the show notes and and check out the book. I think it's going to be life transformative for so many people But thank you again for coming. I'm dr. Smeen Arman. Thanks for coming to my Thanks for participating in my episode today everyone. I'm here to educate so you can advocate for yourself Please join me again for another episode next week

Alexandra Sowa (: 46:48

Thank you.