Join Dr. Lindsay Ogle, a board certified family medicine and obesity medicine physician, as she explores evidence-based strategies and practical tips to prevent and treat weight and metabolic conditions. Dr. Ogle provides insights on managing diabetes, PMOS, metabolic syndrome, obesity and related conditions through lifestyle optimization, safe medications and personalized care.
Obesity Phenotypes & Why Ozempic May Not Be Right For You
•Lindsay Ogle, MD
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We break down why Ozempic and other GLP-1 medications can lead to wildly different weight loss outcomes from person to person. We explain the four obesity phenotypes and how matching treatment to your biology can make lifestyle changes, medications, and even surgery far more effective. • why “hyper responders” and “hypo responders” exist with semaglutide and similar medications • what an obesity phenotype is and why many people are a blend • hungry brain signs and why high-volume high-fiber meals help • hungry brain options including phentermine, Qsymia, and sleeve gastrectomy • hungry gut signs, gastric emptying studies, and strategies like protein starters • why GLP-1 agonists and Roux-en-Y gastric bypass fit hungry gut physiology • emotional hunger patterns, the role of CBT and therapy, and why surgery is not the solution • Contrave as a medication option for reward-driven eating • slow burn metabolism, resting metabolic rate, and lessons from intense weight loss • resistance training, protein, and NEAT as the best slow burn tools If you found this information helpful, please share with a friend, family member, or colleague. We need to do all we can to combat the dangerous misinformation that is out there. Please subscribe and write a review.
Welcome to the Modern Metabolic Health Podcast with your host, Dr. Lindsay Olgill, Ford Certified Family Medicine and Obesity Medicine Physician. Here we learn how we can treat and prevent modern metabolic conditions such as diabetes, PCOS, fatty liver disease, metabolic syndrome, sleep apnea, and more. We focus on optimizing lifestyle while utilizing safe and effective medical treatments. Please remember that while I am a physician, I am not your physician. Everything discussed here is provided as general medical knowledge and not direct medical advice. Please talk to your doctor about what is best for you. You've
probably heard that the average body weight loss on Ozempic is about 15%. But you may not know that there are a subset of people who lose much more than that, and there's a set of people who lose much less than that. Today we're gonna talk about why that might be. We're gonna talk about something called obesity phenotypes. And a phenotype is a set of characteristics that is observable that comes about based on a combination of somebody's genetics and their environment. So there are four distinct obesity phenotypes. With each phenotype, I'm gonna talk about a lifestyle approach, whether that's diet or something else that can help optimize somebody who has that phenotype. We're also gonna talk about medical interventions, whether that is medication andor surgical options. Some people fit very nicely into one phenotype, others are a combination of two or three. Other people may not fit neatly in one category. This is why working with a specialist is so important so that they can identify which phenotype you are and tailor the appropriate treatment for you. Obesity
phenotype number one is hungry brain. Somebody with hungry brain, even though they've consumed the amount of calories that they would need to fuel their body, their brain is going to tell them that they need more. It's gonna signal that hunger even after a full meal. So it's very difficult to be satiated, to be satisfied and full after a meal. The best nutrition intervention for hungry brain is a high-volume diet. So we are thinking about things that are high in fiber that take up a lot of space in the stomach to help increase the sensation of fullness. That's we're gonna activate the stretch receptors on the stomach because we're gonna put a lot of food in there, but we're gonna be choosing foods that have less calories. So we're going to trigger that stretch receptor in the stomach to signal to the brain that we are full because the signal based on calorie intake is not effective in patients with hungry brain. And so we're gonna utilize a different mechanism to trigger that fullness. The two medications that seem to be most effective for hungry brain are fentramine and cucimia. And cucimia, if you remember, is pentamine and topiramate. Both of these medications work at the brain level and help with hunger signals. So it helps suppress hunger and it allows people who have hungry brain to have some relief from that constant feeling of hunger, and it allows them to stick to that nutrition plan of large volume, less calories. I did a whole video about medications. I will include that here so you can take a look at that and review the specifics about pentamine and keusimia and other medications that I talk about today because we don't have time to get into all of that. But if you identify as hungry brain, then ventramine or keucimia would be the medications that may be best for you. For hungry brain, the best surgery option is sleeve gastrectomy or gastric sleeve. And I talked about the surgical treatments in last week's video, but in case you missed it, I will include the link here.
Obesity phenotype number two is hungry gut. Individuals with hungry gut can feel full at an appropriate amount of calories, but very quickly after the meal, they're hungry again. And so food is not staying in the stomach as long as it's supposed to. You feel full and then food moves quickly out of the stomach, and then you're hungry again. And so you're it's difficult to maintain that fullness in between meals. The way that this was tested in the lab was with gastric emptying studies. So this is when somebody takes a food that has a radioactive tracer in it, and it's watched how that passes through the GI tract over time. In people with hungry gut, the food go was going through the system faster than other people, which then caused that hunger fairly soon after meals. There's a couple things that somebody with hungry gut can do from a nutrition standpoint to work with their physiology to maintain their weight or to aid in weight loss. Things that you can do would be to set three to five meals a day that are lower in calories and then to actually before the meal have protein. So having a protein starter or even a protein shake up to an hour before your meal can help trigger the sensation of fullness after the meal. The best medication for hungry gut are GLP1 agonists. The reason these are great for hungry gut is that it slows the gastric emptying, it slows the stomach, and so food stays in the stomach longer, which helps with fullness in between meals, which is offsetting what we saw in the gastric emptying studies. For hungry gut, the optimal bariatric surgery is ruin-wide gastric bypass. The
third obesity phenotype is emotional hunger. Now we all emotionally eat for better or for worse. We eat when we are stressed or when we're procrastinating or when we're celebrating something positive like a birthday or a promotion. It's in our culture and it's not a bad thing. What can be hurtful for our health is when we are constantly doing this or overly indulgent. And people who have emotional hunger, they have emotional eating like the rest of us, but it goes to an extreme, it goes to a level beyond that can be difficult to control. Individuals with emotional hunger, their brains are very sensitive to that reward, and so they're getting even more reward, even more pleasure during those circumstances when we are eating for something other than you know our nutritional needs. The best way to address this through lifestyle is through cognitive behavioral therapy, working with a licensed clinical therapist. Also, there are coaches who may be very helpful in this space. I will include some links below for websites to find a therapist or a coach that I think could be very helpful in these circumstances. But working with somebody who is trained with emotional eating can be really, really powerful here. As far as medication, the best medicine for emotional hunger is Contrave. And again, I talked about these medications in a prior video, so check out the link below to learn more about Contrave. For people who have emotional hunger, this is a great option to consider. There is not a recommended bariatric surgery for emotional hunger, and that is specifically because we need to treat the underlying cause through therapy, and if we don't do that, then the surgery is not going to be effective.
And the fourth obesity phenotype is slow burn. This is when somebody's resting metabolic rate is lower than we would expect. There are some advanced techniques that can directly measure how many calories somebody's body is burning when they when it is at absolute rest, when they are doing nothing. And what they found was that there are definitely a subset of people who have lower energy expenditure than we would expect for somebody at that same body size and age and sex. And there can be different factors for this. Genetics definitely play a role, medication somebody is taking, and also history of you know gaining and losing weight, and and especially in how that was done. We know from the biggest loser study that was completed that those individuals who went through that intense dietary restriction and physical activity, while they lost a significant amount of weight during that time, that later on they had their resting energy expenditure taken and it was much lower than they would expect. Um, I think it was about 500 calories a day lower. So these individuals were required to consume lower than 500 calories compared to their you know counterparts at the same body weight. So it just highlights how difficult it can be to maintain weight once it is lost. We don't have a great way to treat this through medication or surgery at this point. Neither of those are going to help. There's some signal that ventramine or kusemia may increase resting energy expenditure, but if it does, it's pretty minimal, and so it's not you know ideal or considered first line for this. What is really best for slow burn is exercise, and really in two flavors, I would say resistance training is so important here. We want to build up muscle mass. So really resistance training plus protein. And the reason this is important is because if we are able to build up muscle mass, muscle burns more calories than the rest of our body tissues, and so the more muscle we have, the more calories we're gonna burn at rest. So this is a way to you know increase your resting metabolism is to increase your muscle mass. And then the other way is through neat non-exercise activity thermogenesis. So this is little movements throughout the day. So maybe even if you're sitting down, you know, um bopping your knee up and down, or if you have a pedal at your desk, or walking back and forth when you're on a phone call, or parking further away in the parking lot and taking the stairs, playing games, playing with your kids, um, dancing, doing movement throughout the day, moving your body as much as possible is going to help add little calories here and there throughout the day to increase your caloric burn throughout the day. Since people who have slow burn, their calories that are spent each day are so low that this is a way to help offset that.
So you may clearly identify with one of these four obesity phenotypes, and that's great, and I would take that to your provider, whoever is helping you with your health journey. But if you're not sure, I would recommend two things. One is to make sure that you are working with an obesity medicine physician, and I will include a link to search for one in your area. And then two, there is a genetic test now for this. I will admit that this is something that I have not ordered yet for a patient, but it is available and something I would definitely consider. And if you're interested in, I will include the link below on how to get that ordered if you want to have more information about tailoring and creating an individualized treatment plan for your weight management. So,
to get back to our original question, why are there hyper responders and why are there hyporesponders to medications like Ozempic or Vigov? It's because the hyper responders probably have hungry gut. And the hyporesponders probably have another obesity phenotype like hungry brain or emotional hunger or slow burn, and they would be better suited with a different treatment plan. I think this example really speaks to this. This is back with lyriglutide, which is a GLP1, it's a daily injectable, and lyriclutide is not as effective as semaglutide. But the patients who have hungry gut and were treated with lyric glutide lost on average 6.7% of their body weight after 16 weeks. And those that were hungry gut negative, meaning they did not test positive for hungry gut, they do not have hungry gut, they only lost 3.4% of their body weight at the same 16 weeks. So the individuals who did have hungry gut and were treated appropriately with a GLP 1 lost in this study twice as much as those who did not have hungry gut.
So I hope this helps you in your metabolic and health journey. Thank you for listening and learning how you can improve your metabolic health in this modern world. If you found this information helpful, please share with a friend, family member, or colleague. We need to do all we can to combat the dangerous misinformation that is out there. Please subscribe and write a review. This will help others find the podcast and they may also improve their metabolic health. I look forward to our conversation next week.
