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Social media outlets are full of stories about celebrities who have lost weight with the new generation of incretin medications like semaglutide (Ozempic and Wegovy) and tirzepatide (Mounjaro).


Jaime P. Almandoz, MD, MBA

Some of these medicines are approved for treating obesity (Wegovy), whereas others are approved for type 2 diabetes (Ozempic and Mounjaro). Tirzepatide (Mounjaro) has been fast-tracked for approval for weight loss by the US Food and Drug Administration this year, and in the first of the series of studies looking at its effect on obesity, the SURMOUNT-1 trial, tirzepatide demonstrated a mean weight loss of around 22% in people without diabetes, spurring significant off-label use.

Our offices are full of patients who have taken these medications, with unprecedented improvements in their weight, cardiometabolic health, and quality of life. What happens when patients stop taking these medications? Or more importantly, why stop them?

Although these drugs are very effective for weight loss and treating diabetes, there can be adverse effects, primarily gastrointestinal, that limit treatment continuation. Nausea is the most common side effect and usually diminishes over time. Slow dose titration and dietary modification can minimize unwanted gastrointestinal side effects.

Drug-induced acute pancreatitis, a rare adverse event requiring patients to stop therapy, was seen in approximately 0.2% of people in clinical trials.

Medications Effective but Cost Prohibitive?
Beyond adverse effects, patients may be forced to stop treatment because of medication cost, changes in insurance coverage, or issues with drug availability.

Two incretin therapies currently approved for treating obesity — liraglutide (Saxenda) and semaglutide (Wegovy) — cost around $1400 per month. Insurance coverage and manufacturer discounts can make treatment affordable, but anti-obesity medicines aren't covered by Medicare nor by many employer-sponsored commercial plans.

Changes in employment or insurance coverage, or expiration of manufacturer copay cards, may require patients to stop or change therapies. The increased prescribing and overall expense of these drugs have prompted insurance plans and self-insured groups to consider whether providing coverage for these medications is sustainable.

Limited coverage has led to significant off-label prescribing of incretin therapies that aren't approved for treating obesity (eg, Ozempic and Mounjaro) and compounding pharmacies selling peptides that allegedly contain the active pharmaceutical ingredients. High demand for these medications has created significant supply shortages over the past year, causing many people to be without treatment for significant periods of time, as reported in Medscape.
Recently, I saw a patient who lost over 30 lb with semaglutide (Wegovy). She then changed employers and the medication was no longer covered. She gained back almost 10 lb over 3 months and was prescribed tirzepatide (Mounjaro) off-label for weight loss by another provider, using a manufacturer discount card to make the medication affordable. The patient did well with the new regimen and lost about 20 lb, but the pharmacy stopped filling the prescription when changes were made to the discount card. Afraid of regaining the weight, she came to see us as a new patient to discuss her options with her lack of coverage for anti-obesity medications.

Stopping Equals Weight Regain
Obesity is a chronic disease like hypertension. It responds to treatment and when people stop taking these anti-obesity medications, this is generally associated with increased appetite and less satiety, and there is subsequent weight regain and a recurrence in excess weight-related complications.

The STEP-1 trial extension showed an initial mean body weight reduction of 17.3% with weekly semaglutide 2.4 mg over 1 year. On average, two thirds of the weight lost was regained by participants within 1 year of stopping semaglutide and the study's lifestyle intervention. Many of the improvements seen in cardiometabolic variables, like blood glucose and blood pressure, similarly reverted to baseline.

There are also 2-year data from the STEP-5 trial with semaglutide; 3-year data from the SCALE trial with liraglutide; and 5-year nonrandomized data with multiple agents that show durable, clinically significant weight loss from medical therapies for obesity.

These data together demonstrate that medications are effective for durable weight loss if they are continued. However, this is not how obesity is currently treated. Anti-obesity medications are prescribed to less than 3% of eligible people in the US, and the average duration of therapy is less than 90 days. This treatment length isn't sufficient to see the full benefits most medications offer and certainly doesn't support long-term weight maintenance.

In addition to maintaining weight loss from medical therapies, a recent study showed that incretin-containing anti-obesity medication regimens were effective for treating weight regain and facilitating healthier weight after bariatric surgery.

Chronic therapy is needed for weight maintenance because several neurohormonal changes occur owing to weight loss. Metabolic adaptation is the relative reduction in energy expenditure, below what would be expected, in people after weight loss. When this is combined with physiologic changes that increase appetite and decrease satiety, many people create a positive energy balance that results in weight regain. This has been observed in reality TV shows such as The Biggest Loser: It's biology, not willpower.

Unfortunately, many people — including healthcare providers — don't understand how these changes promote weight regain and patients are too often blamed when their weight goes back up after medications are stopped. This blame is greatly misinformed by weight-biased beliefs that people with obesity are lazy and lack self-control for weight loss or maintenance. Nobody would be surprised if someone's blood pressure went up if their antihypertensive medications were stopped. Why do we think so differently when treating obesity?

The prevalence of obesity in the US is over 40% and growing. We are fortunate to have new medications that on average lead to 15% or greater weight loss when combined with lifestyle modification.

However, these medications are expensive and the limited insurance coverage currently available may not improve. From a patient experience perspective, it's distressing to have to discontinue treatments that have helped to achieve a healthier weight and then experience regain.

People need better access to evidence-based treatments for obesity, which include lifestyle interventions, anti-obesity medications, and bariatric procedures. Successful treatment of obesity should include a personalized, patient-centered approach that may require a combination of therapies, such as medications and surgery, for lasting weight control.

Follow Dr Almandoz on Twitter: @JaimeAlmandoz


link;https://www.medscape.com/viewarticle/989988?src=FYE
 
Posts: 17718 | Location: Stuck at home | Registered: January 02, 2015Reply With QuoteReport This Post
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I have been taking Ozempic about a year for my Type 2 Diabetes. It is the only drug that I have tried with no side effects. My A1C is now normal & I am eating normal foods. I lost 20 lbs then my weight loss stabilized & I gained back 2 or 3 lbs. I have been constant now for 3 months.


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I don't have diabetes and have started the Tirzepatide and have lost 30 pounds since February. Yes it's spendy, about 90$ a week but for me it's worth it. Every person is different...just saying...


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Posts: 1478 | Location: Escaped from Kalifornia to Arizona February 2022! | Registered: March 02, 2006Reply With QuoteReport This Post
Nullus Anxietas
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quote:
Originally posted by ZSMICHAEL:
quote:

Obesity is a chronic disease like hypertension.
For some people: Perhaps. But, other than those suffering hormonal imbalances or certain diseases, obesity is simply a reflection of bad lifestyle choices. Specifically: A sedentary lifestyle coupled with poor eating habits.

For the vast majority of people it's a very simple equation: When calories in exceed calories out the excess calories are stored as fat.

quote:
Originally posted by ZSMICHAEL:
quote:
Chronic therapy is needed for weight maintenance because several neurohormonal changes occur owing to weight loss. Metabolic adaptation is the relative reduction in energy expenditure, below what would be expected, in people after weight loss.
This only happens when people try to lose too much weight, too fast. When they do that the body compensates by lowering its metabolism. (It's known as "panic mode" or "starvation mode.")

This does not happen when a reasonable calorie deficit of 500-1000 Calories/day is maintained.

Of course: Losing fat this way, the sane way, takes commitment. Persistence. Lifestyle changes.

quote:
Originally posted by ZSMICHAEL:
quote:
This blame is greatly misinformed by weight-biased beliefs that people with obesity are lazy and lack self-control for weight loss or maintenance.
That would be because, in the vast majority of cases, it's true.

People seek cheap fixes. (Not "cheap" in the sense of financial burden, but, "cheap" in terms of their own personal investment in their health.) The "health care" industry obliges by furnishing those cheap fixes and telling people "This is the way." Then, when the cheap fix is withdrawn: Surprise! The fat comes back.

I saw this happen, first-hand, with an ex-colleague. She got bariatric surgery. (A lap band.) In addition to hobbling her digestive system (that's what it does), she was obliged to go on a restrictive diet. She lost a ton of fat. Actually got down from morbidly obese to merely very overweight. Then the bariatric procedure was reversed. Next thing you know she's back to nearly constantly snacking on junk food at her desk job all day long. Yup: Back to obese in a fraction of the time it took her to get down to very overweight.

quote:
Originally posted by ZSMICHAEL:
quote:
People need better access to evidence-based treatments for obesity, ...
No, what people need is better advice and guidance from the government and their doctors.

  • Eat a healthy, balanced, nutrient-rich diet.
  • Calories in less than calories out to lose weight. Calories in equal calories out to maintain weight
  • Regular exercise
  • Drink plenty of water
  • Get a minimum of seven hours of quality sleep each night.



"America is at that awkward stage. It's too late to work within the system,,,, but too early to shoot the bastards." -- Claire Wolfe
"If we let things terrify us, life will not be worth living." -- Seneca the Younger, Roman Stoic philosopher
 
Posts: 26059 | Location: S.E. Michigan | Registered: January 06, 2008Reply With QuoteReport This Post
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Proper long term exercise- as in regular and routine- is the right path to healthy weight loss and avoiding gaining it back. It’s a commitment that eats up time, but nothing worth doing is a breeze. The key is looking in the mirror, seeing what is happening over time and doing something about it before it gets out of hand. Once it does that, it is far harder to get out and reverse it.




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Posts: 16011 | Location: Martinsburg WV | Registered: April 02, 2011Reply With QuoteReport This Post
The Unknown
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quote:
Obesity is a chronic disease like hypertension.


Aaaaaand I'm done reading this bullshit.

Yeah, that must be it. It's not the constant stream of HFCS we shove in. It's not the mega-sized McDs "value meal" we just ate. It's not the 2 liter of coke or pepsi we smash every day. It's not the way we act like the elevator is the only method for going up one flight. It's not the way we sit on the couch all weekend.

It's a disease, you see. And we can solve it all with just a little pill. No need to change habits or lifestyle. Just take the pill.

I find it interesting that these "diseases" never seem to affect the very poor, those who take accountability, or the highly motivated. Isn't that odd?

ETA: This isn't meant as a dig toward people who are overweight. This is a dig toward addiction. No different than my addiction to nicotine that I've had for over 30 years. We all have our vices, but pretending it's a medical problem and not an addiction issue only allows us to continue the fantasy. That's why when the pills run out the beast always comes back. Always.
 
Posts: 10833 | Location: missouri | Registered: October 18, 2009Reply With QuoteReport This Post
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Weight loss is a complicated issue involving psychological and biological issues. Currently bariatric surgery is the deal. One of the first patients had bariatric surgery in the 70s and then killed herself. Bariatric surgery is overdone and does not address the underlying issues which are genetic,environmental and psychological. Clearly your average American does not exercise nor have a proper diet. Losing weight is much more than willpower. It is not a disease by any means.
 
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Nullus Anxietas
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quote:
Originally posted by bionic218:
ETA: This isn't meant as a dig toward people who are overweight. This is a dig toward addiction. No different than my addiction to nicotine that I've had for over 30 years.
Indeed. (It was forty years for me, btw.)

There was a short blurb in the local "news" the other day. Somebody did a study that determined eating junk food resulted in metabolic changes that caused one to crave more junk food.

You don't say Roll Eyes

One can be cured of those addictions, and it doesn't require medical intervention. Just wean yourself off the crap. If you're like most people you'll find a funny thing happens: Once you successfully wean yourself off that stuff: After a time you'll find that, not only do you no longer crave it, but, if you eat some you'll find it really doesn't taste all that good anymore.

E.g.: A couple months back somebody started a thread (in another forum) that reminded me of Little Debbie Oatmeal Cream Pies. Those things used to be like crack to me. As luck would have it: I accompanied my wife grocery shopping soon thereafter, where I spotted them on a store shelf. Bought a box on a whim.

That was a month, month-and-a-half ago. Most of the box is still sitting there.

quote:
Originally posted by ZSMICHAEL:
Weight loss is a complicated issue ...
At its heart, for the vast majority of people, it is not. It's actually very simple. The science says so.

But, telling people it's complicated, addressing symptoms, rather than causes, is very profitable for the "health care" industry.

quote:
Originally posted by ZSMICHAEL:
Losing weight is much more than willpower.
For the vast majority of people that's all it is.

My one junk food addiction is chocolate. I'm a chocoholic. I can easily dispose of an entire 5½ oz. chocolate bar (850 Calories!) in one sitting. But I'm on a fat loss program, right now. There's a crap-ton of chocolate bars sitting in our "junk food" bin in the pantry downstairs. And there they'll stay until I've hit my body fat percentage goal.

I love McDonalds' sausage, egg, and cheese biscuits. One of those and a couple orders of their hash browns are heavenly to me. 760 Calories--and that's not incl. the OJ. I ain't eatin' that stuff right now. At all.

Sit-down restaurant down the street makes pancakes to die for. A stack of those, saturated in butter and maple syrup, and a side of sausage links. Mmmmm... Nope.

I could come up with many more examples. One of my inspirations, my motivations, for forgoing that stuff right now? WalMart electric scooter people. I don't want to ever be one of those people.

Same as the guy that used to walk around one of my gyms tethered to an oxygen tank was one of my inspirations for quitting smoking. I quit smoking nearly thirteen years ago. My weekly pulse oximeter check says my blood oxy is running around 98%, on average, for the last eighteen weeks.



"America is at that awkward stage. It's too late to work within the system,,,, but too early to shoot the bastards." -- Claire Wolfe
"If we let things terrify us, life will not be worth living." -- Seneca the Younger, Roman Stoic philosopher
 
Posts: 26059 | Location: S.E. Michigan | Registered: January 06, 2008Reply With QuoteReport This Post
quarter MOA visionary
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quote:
Originally posted by ensigmatic:
what people need is better advice and guidance from the government and their doctors.

  • Eat a healthy, balanced, nutrient-rich diet.
  • Calories in less than calories out to lose weight. Calories in equal calories out to maintain weight
  • Regular exercise
  • Drink plenty of water
  • Get a minimum of seven hours of quality sleep each night.


All good at a basic level.
All working together are a good start.

However, simply focusing on calories is inaccurate.
Soooo many say just controlling cals-in vs cals-out will solve all your problems.
It will not.

More important is what you eat... period.
Case and point is to ask anyone who deploys a low carbohydrate diet.
Control your carbs is vastly more important than controlling your calories.

Bottom line is all of the points above work together and one can affect the others.
Look at the problem in total not from an over simplified talking point.

We have other threads on diet so I don't need to elaborate here.
 
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Nullus Anxietas
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quote:
Originally posted by smschulz:
More important is what you eat... period.
Case and point is to ask anyone who deploys a low carbohydrate diet.
Control your carbs is vastly more important than controlling your calories.
I would argue as important, rather than more important. Even if you're eating Keto or carnivore: If your calories in exceed your calories out you're going to put on fat.

E.g.: About six weeks ago I transitioned from break-in exercising (getting my body used to doing it again) to progressive overload training. At that point I bumped my protein intake by about 50%/day.

Next week I'll undergoing umbilical hernia surgery. I'll be on a 20-lb. max lifting restriction for 2-6 weeks. When that happens that additional protein supplementation will cease and I may eliminate my morning protein bar. That will be necessary to maintain a 500-1000 kcal/day calorie in deficit.



"America is at that awkward stage. It's too late to work within the system,,,, but too early to shoot the bastards." -- Claire Wolfe
"If we let things terrify us, life will not be worth living." -- Seneca the Younger, Roman Stoic philosopher
 
Posts: 26059 | Location: S.E. Michigan | Registered: January 06, 2008Reply With QuoteReport This Post
quarter MOA visionary
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quote:
Originally posted by ensigmatic:
I would argue as important, rather than more important. Even if you're eating Keto or carnivore: If your calories in exceed your calories out you're going to put on fat.

E.g.: About six weeks ago I transitioned from break-in exercising (getting my body used to doing it again) to progressive overload training. At that point I bumped my protein intake by about 50%/day.

Next week I'll undergoing umbilical hernia surgery. I'll be on a 20-lb. max lifting restriction for 2-6 weeks. When that happens that additional protein supplementation will cease and I may eliminate my morning protein bar. That will be necessary to maintain a 500-1000 kcal/day calorie in deficit.


Your argument is only valid in the extreme ~ circa 1K+/-.
To eliminate protein because of calories is misguided, IMO.
You want to really control your metabolic state - eliminate (or reduce) sugar and carbs.
Make your body depend on fat-for-fuel rather than glycogen.
Calorie restriction rarely works well.
Of course a massive difference will add up over time.
Exercising while metabolically important to good health has a very minor role in weight control as opposed to diet. Just a fact.
FWIW, I've been down that route - calorie restriction, portion size control and extreme exercising.
Only to mild success.
For me, carb control was dramatically more effective as it is for most everyone who deploys it.
It isn't easy for some to maintain - I understand that but you cannot deny the effectiveness nonetheless.
But it is up to the each one of to determine our own path to success.
 
Posts: 23454 | Location: Houston, TX | Registered: June 11, 2006Reply With QuoteReport This Post
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Very little
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Not uncommon for a medication to find alternative uses once it's in the general population, Viagra is a prime example.

There have been a couple of posts with articles about Ozempic's transformation into a weight loss medication. Posts follow as if there is some problem with having a medication that enhances weight loss, specifically a bias against using these medications for weight loss, followed by the typical "they just need to change the way they live" commentary.

There is no reason that these medications couldn't transition from being a weight loss accelerant to a maintenance dose that helps these people keep weight loss down.

Just exercise and eat less isn't a valid solution for people with a problem of obesity. It's just not that simple, if it was, then we'd have zero obesity. If that kind of approach worked we could walk up to an alcoholic friend and just tell them to put the bottle down. Like Alcoholism, Obesity is a disease the product people ingest is just different.

For many it's an addiction, and in some cases any help that will get them on the path is welcomed, accompanied by some psychological eating assistance and eventually incorporating exercise along with a long term maintenance plan, perhaps part of that is staying on the medication with a low dose.

No different than how meds are used to treat drug addicts, alcoholics, those with bi-polar disorders.
 
Posts: 24725 | Location: Gunshine State | Registered: November 07, 2008Reply With QuoteReport This Post
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I have been on a clinical trial for the cardiovascular effects of semaglutide for the last four years. While I could have had the placebo, my weight loss of 89 lbs. suggest otherwise. I have no idea of what the dosage was is, assume it would have been between the Oziempic level for diabetes treatment and Wegovy for weight loss. My Dr. placed me in the trial for the potential for losing weight (I had the prerequisite cardiac history and factors).

The weight loss was significant, dramatic,etc. it was just taking the injection and everything is hunky dory. I did have to mind my calorie intake and in retirement have really committed to regular exercise. There were relapses into bad habits that required refocused efforts on my part.

In mid April, this trial will end. My doctor and the Clinical Trial Coordinator have mentioned other trials that my become available to me. I would have to wait 3 months after the current trial regime ends. I will be discussing with my doctor since I still am overweight enough that it would be helpful to continue on something like semaglutide. Medicare won’t cover Wegovy and I am leery of the off label copycat compounds used at the weight loss clinics popping up.

The next three months will be a good marker for me when I don’t have a pharmaceutical assist to losing and maintaining my weight.


Bill Gullette
 
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^^^^^^^^^^^^^^
Good post. Thank you.
 
Posts: 17718 | Location: Stuck at home | Registered: January 02, 2015Reply With QuoteReport This Post
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I have a good friend, a local gunsmith, who has been unable to get the Ozempic he needs for his type II diabetes due the the "fat women" prescribers handing out scripts for Ozempic and other semiglutides. I understand off-label usage, but this really pissed me off. So much so, I called an investigator for the State Board of Medicine and sikked him on one drug store that had the drug clearly in stock, but refused to fill my friend's script. Selling to "fat women" to make a higher profit is unethical in my view, but likely no one gives a shit.

RMD




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Posts: 20434 | Location: L.A. - Lower Alabama | Registered: April 06, 2008Reply With QuoteReport This Post
Nullus Anxietas
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quote:
Originally posted by smschulz:
Your argument is only valid in the extreme ~ circa 1K+/-.
Nope. On strength training days I burn an additional ±300 to ±400 kcals in active energy. Furthermore: Weight training, HIIT, and SIT increase RMR (Resting Metabolic Rate) for ±12 hours following exercise. If I stop weight training I'll no longer be expending that.

quote:
Originally posted by smschulz:
To eliminate protein because of calories is misguided, IMO.
In this respect calories are calories. If I'm consuming more calories than I'm expending I'll regain fat, regardless of whether those calories come from carbs, fat, or protein.

quote:
Originally posted by smschulz:
You want to really control your metabolic state - eliminate (or reduce) sugar and carbs.
I did that nearly five months ago.

quote:
Originally posted by smschulz:
Calorie restriction rarely works well.
Of course a massive difference will add up over time.

It's working for me. Since the beginning of November I've lost eleven pounds net weight and 4½% body fat. The numbers suggest all the weight loss has been fat.

quote:
Originally posted by smschulz:
Exercising while metabolically important to good health has a very minor role in weight control as opposed to diet. Just a fact.
There's a lot of disagreement on that point. But, I don't exercise for weight loss. I exercise for strength, mobility, and cardio-vascular health.

quote:
Originally posted by smschulz:
But it is up to the each one of to determine our own path to success.
I'm doing what's called "body recompostion" (aka: "body recomp"). That involves weight training with a very carefully measured calorie deficit. The goal is to have a calorie deficit just high enough to promote fat burn, but, not so high as to negatively impact weight training gains.

It means slower gains from weight training and slower (fat) loss from nutrition control, but, I'm okay with that.



"America is at that awkward stage. It's too late to work within the system,,,, but too early to shoot the bastards." -- Claire Wolfe
"If we let things terrify us, life will not be worth living." -- Seneca the Younger, Roman Stoic philosopher
 
Posts: 26059 | Location: S.E. Michigan | Registered: January 06, 2008Reply With QuoteReport This Post
Thank you
Very little
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quote:
Originally posted by BGULL:
I have been on a clinical trial for the cardiovascular effects of semaglutide for the last four years. While I could have had the placebo, my weight loss of 89 lbs. suggest otherwise. I have no idea of what the dosage was is, assume it would have been between the Oziempic level for diabetes treatment and Wegovy for weight loss. My Dr. placed me in the trial for the potential for losing weight (I had the prerequisite cardiac history and factors).

The weight loss was significant, dramatic,etc. it was just taking the injection and everything is hunky dory. I did have to mind my calorie intake and in retirement have really committed to regular exercise. There were relapses into bad habits that required refocused efforts on my part.

In mid April, this trial will end. My doctor and the Clinical Trial Coordinator have mentioned other trials that my become available to me. I would have to wait 3 months after the current trial regime ends. I will be discussing with my doctor since I still am overweight enough that it would be helpful to continue on something like semaglutide. Medicare won’t cover Wegovy and I am leery of the off label copycat compounds used at the weight loss clinics popping up.

The next three months will be a good marker for me when I don’t have a pharmaceutical assist to losing and maintaining my weight.


Great job Bill, glad to hear it's working for you, sounds like you know whats coming up and have a plan to work on addressing that situation.
 
Posts: 24725 | Location: Gunshine State | Registered: November 07, 2008Reply With QuoteReport This Post
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Not trying to beat a dead horse but I must share PERSONAL experience I have witnessed.

My ex-wife (married 10+ years) and her dad ate chips, candy, Pepsi, junk food, cakes-sweets, smoked, you name it if it was unhealthy they ate it. They did this. I witnessed it every day. They were both thin as rails. However, ex's mom and sister were obese. Genes? something at play there. I am no expert but I think some people are wired to drink wine and smoke everyday and live to be 100+ years old. Others, say, wasn't that Jim Fix, a Doctor? but a runner for sure..died at an early age.

And it seems the older we get, the more weight we put on.

I think we have all seen these types of examples.

Remember, they can put a man on the moon but they cant cure cancer or obesity. It's the governments why of controlling us. 'I'm as mad as hell and I'm not going to take it anymore'... Big Grin


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Posts: 1478 | Location: Escaped from Kalifornia to Arizona February 2022! | Registered: March 02, 2006Reply With QuoteReport This Post
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Posts: 23454 | Location: Houston, TX | Registered: June 11, 2006Reply With QuoteReport This Post
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"Ask your doctor if eating healthy and getting off your ass is right for you"
Sloth and lack of nutritional education is 99.999999% of this. The other .000001% is medical.
Learn how the human body works, get your heart rate up every day, and pick up heavy shit and put it down.
 
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