Semaglutide is a relatively new medicine that was initially used for diabetes but it is now receiving increasing attention for use for weight loss. In fact, many patients who have used this medication for diabetes have experienced significant weight loss. Consequently, further studies have been performed to address the weight loss potential of this medication. In recent trial data released just last year, this medicine was associated with significantly reduced body weight compared to placebo (-15.2% versus -2.6%) that was maintained over 1 year when used in conjunction with diet and exercise.
The weight loss potential of this medication has also been demonstrated in my own clinic with many patients losing significant weight since starting it. Most patients have had minimal to mild side effects.
In regards to weight loss, semaglutide appears to act to reduce appetite and food intake by acting on the nervous system. It also works to delay gastric emptying which aids the feeling of satiety. The majority of weight loss is due to decreased caloric intake.
Some common side effects of the medication include nausea and vomiting, constipation, diarrhea, and stomach discomfort. These side effects are not thought to be a significant cause of weight loss with this medication.
What are some other benefits of semaglutide? In some patients like those with diabetes and a high risk of heart disease, semaglutide was associated with decreased rate of cardiovascular death, non-fatal heart attack, and non-fatal stroke.
Some potential concerns with the medication include an increased chance of pancreatitis, possible thyroid cancer, gallstones, and retinal changes. It should not be given in patients with a family or personal history of multiple endocrine neoplasia type 2, impaired renal function, or medullary thyroid cancer.
The injection is a once weekly mildly painful subcutaneous injection often given in the abdominal area. In order to ensure tolerability and efficacy the dosage starts at 0.25 mg and can increase to 2.4 mg which was the most effect dose. Even lower dosages were found to be effective but the higher dosages were associated with more weight loss.
The goal with each patient is to use lowest effective dosage for the shortest duration of time and to focus on creating good eating and exercise habits which can be continued after the medication has been stopped.
If you have questions about this medication or are interesting in trying it please give us a call.
See below for further resources:
1. Wegovy (semaglutide): a new weight loss drug for chronic weight management
You are not alone!
As a physician I have the privilege to speak to people about their innermost struggles. I am often struck by the amazing bravery and forthrightness of some of my patients. On occasion, after barely an introduction has been made, eyes become quickly moistened, tears are expressed, and the most personal of information is shared. Some of it can be shocking and terrifying. I hear stories of abuse, trauma, betrayal, regret, and self-destruction. Some of it is self-inflicted, much of it is not. Some of it is inherent in the human condition.
People are struck with catastrophic illness or face eminent death. There is a lot of loneliness, despair, and disconnection. There is great fear. There is bitterness and resentment against the world. Far too many people ask themselves if life is worth living. They want to become extinct. They don’t want to remember any more.
Out of a pit of nihilism some seek to take revenge against the world and God by punishing His creations, by inflicting pain, suffering, and death. They would rather destroy than create. They want to be remembered for going out in a ball of flame and a hail of bullets.
Many people feel that they are drowning in a stormy sea without hope of rescue. They are constantly overwhelmed and anxious. They tell a story of powerlessness, fear, loss of control, self-loathing, and desperation. They are crying for help but don’t know where to turn or how to express it. They are looking for an outstretched hand.
These people are all around us, but we just don’t know it. We all have egos that cover over our innermost selves from others and even ourselves. We want others to know but at the same time we don’t. We fear peer rejection and vulnerability above almost anything else. We keep others at a safe distance from our true selves so that we can’t possibly be hurt or helped. We fear frailty and death.
My interactions with people have taught me that we are not alone and that someone’s apparent outward composure does not always correlate with their level of inner composure. All of us have things about ourselves that we despise and feel powerless to change. We push up against a wall that will not budge. We may have lost hope and given up trying. We may feel a lack of purpose or meaning. We may be bored with life.
Many try to cope with these negative feelings by seeking immediate relief, immediate gratification. The substitutes or stand ins for negative feelings can come in the form of substances, behaviors, or food. We can also try to hide from these feelings by retreating or withdrawing out of society. We can sleep too much, work too much, or exercise too much. These are all attempts at avoidance and distraction. They are attempts to avoid self-responsibility. They are ultimately self-focused and selfish. They are a refusal to bear our own cross and carry it up the hill. They are focused on losing or having less of.
I have experienced many of these same feelings around many areas of my life. One of these areas that I have been pretty open about is my struggle with compulsive eating. I have personally lost several hundred pounds over my life. In two stints I have lost more than 80 lbs. And like nearly everyone else who has tried to lose weight I have gained the weight back on many occasions.
I was 155 pounds when I got married right before medical school. I was pretty physically active and played a lot of sports. During medical school I exercised less and ate poorly. I experienced more stress due to the rigors of school. I unconsciously resorted to eating as a way to cope with negative emotions and stress after a long day. When I got to residency and started having children the stress only got worse. During my medical training my wife and I dealt with some pretty trying circumstances like surviving hurricane Katrina. Eventually, during a particularly harrowing portion of my residency I ballooned up to 240 lbs. I experienced a lot of self-doubt and became depressed about my weight which began to have a significant impact on my health. I developed sleep apnea and significant anxiety. I worried a lot and felt overwhelmed.
Somehow, I came to a place where I had had enough. I was tired of feeling crummy and I resolved to make a change. It was around this time that I had begun to research the Ketogenic diet which is now popular but at the time was not well known. Over a whole year I lost about 80 pounds with this diet. I tracked my carbs, fats, and calories diligently. I tried to stay at about 1000 calories and for the most part I stayed committed and consistently lost weight. I felt great and my physical symptoms disappeared. I did feel better about myself, but I still had negative feelings that arose due to life circumstances. This, of course, is unavoidable.
Then, I made a mistake. I subconsciously wished, like many people do, that I could just go back to eating like a “normal” person, that I could eat naturally only to satisfy hunger. I thought that I could in a sense return to a point in the past where eating did not fulfill other wants, needs, or desires. It is almost like I wished that I could once again return to a state of innocence and to have never partaken of the forbidden fruit. But just like an alcoholic who can never expect to go back to drinking like a regular drinker so a compulsive eater cannot expect to do so either. Once the apple has been eaten it cannot be uneaten.
Eventually, the memory of the pain of what it felt like to be significantly overweight faded and it became easier to rationalize going back to eating like I had previously. I had become focused on loss, the loss of food choice and the loss of pleasure of eating.
In a way, I longed for weight to not be a challenge anymore. I suffered weight loss mental fatigue and got tired of fighting. I just wanted to be able to relax. As a result, I began to seek food more as a source of comfort and a relief from inner distress. I would binge eat frequently. I relaxed, took it easy. I indulged. I was focused on self.
The result of this is that in relatively short order I lost control of eating and regained all the weight that I had lost. I was right back to 240 pounds within about 1 year or so. Like the proverb says I was “as a dog” that “returns to his vomit” or like a pig, that is washed, that returns to wallowing in the mud.
It wasn’t until I started my own medical practice in 2015 that I started working on losing weight again. Since my previous weight loss, I had since gathered hundreds of peer reviewed articles about weight loss and various diets. I was and continue to be very fascinated with helping people become stronger physically rather than enabling their compulsions with medicines. I wanted to help patients by sharing my research about diet and weight loss, but I couldn’t effectively convey how to lose weight from a practical standpoint when I was still very overweight.
Once again, through sheer determination and will power over the period of about 1 year I lost about the same amount of weight in about the same amount of time and using the same diet. I also incorporated intermittent fasting and long fasts into my routine.
I have since continued to struggle with weight. I have gone up and down 10-20 pounds and still binge eat on occasion. This is largely due to the fact that I have at times let my guard down and indulged in my previous habits. I have found that inertia is incredibly powerful. It is much easier to continue eating healthy once you get in a groove and vice versa for satisfying unhealthy compulsions.
Because of my struggle losing and maintaining weight loss I have also invested a lot of time researching “weight loss maintenance” which is the least successful part of weight loss programs. The evidence that I discovered was not only not encouraging, it was bleak. Only about 2-3 percent of people that lose a significant amount of weight manage to keep the weight off over a 5-10 year period. Most of the others gain it all back or more.
Many people have repeated the cycle I had repeated over and over again. They despair and may eventually give up as I have been tempted to do on many occasions. They may take long weight loss sabbaticals until the physical and emotional consequences becomes too much to bear. They may then find the will power to make yet another attempt to lose weight out of a reaction to this suffering and pain.
Unfortunately, by this time weight loss has often become simply a means of escape. There is often a lack of sufficient vision or purpose. It is like an inmate being let out of prison only to find that out they are much more comfortable with the familiar controlled circumstances of prison life than the uncertain and unrelenting challenge of making their own way toward a higher life. In the short term it is sometimes easier to stick with the pain you know rather than the pain you don't. But the paths are not equal in their sum total of pain and joy.
So if you struggle with weight what can you do?
To escape this revolving door in regards to our compulsive behaviors requires a shift in our vocabulary and our approach. For example, I don’t like the term “weight loss.” It implies a deficit and that something is missing. Nobody likes to lose anything. We like to gain. I like to focus on what someone is gaining when they make a significant change in their life.
The proper vision of “weight loss” in my view is the increased physical, emotions, and spiritual capacity someone gains from proper health choices that helps them serve themselves, their families, and the community to the highest degree possible. It is a commitment to love rather than fear. It is a commitment to serve the highest meaning and purpose, to walk the road less traveled, and to help others along the same road.
The change in vision also starts by acknowledging with honesty that you have been powerless to control your eating and all the efforts you have made have been unsuccessful. It means acknowledging that you need help and that will-power is not enough. It means that thinking about how to lose weight or reading more self-help books is not enough otherwise you would have figured it out by now. It means when it comes to weight loss you are figuratively lost and will not find the way out by yourself.
Ask yourself. If you were the CEO of your own weight loss company would you fire yourself? Ask yourself. Who is my higher power? Is it food or some other substance or behavior? You can know who your higher power is by what you think about or what indulgence in when you are stressed or have negative emotions. Your God is what you believe will give you comfort and relief. It is where you put you trust. It is safe and secure and reliable. It is your deliverer. For an alcoholic it is the bottle. For a compulsive eater it is binge eating. It is Don Corleone. It is a deal with the devil and the road to unhappiness and regret. It is a shortcut.
To get the necessary strength means to have the correct lens to look through. It starts not by focusing on how to lighten your burden but on how to strengthen your back. It starts by writing down with real commitment and purpose what the ultimate vision for yourself is. Ask yourself if you could visualize the ultimate version of your self what would it be and how would you go about transforming yourself into such a person? If you still cannot come up with a vision of your future potential self then think about a potential future version of yourself that if you met in person you would be in awe of or you would be strongly tempted to worship. That is the person you should be but are avoiding.
Focus on your future self. The God of compulsive behavior is to desire immediate relief and to avoid responsibility for the future potential of yourself and that of others. It is a lack of faith in your future potential. It is a life ruled by fear rather than love. It is self-rejection, self-hatred. It is a self-condemnation of your value. Will you sell your birthright and your soul for a mess of pottage? I certainly have at times and you may have done so as well.
The true God represents the highest way. The way that sacrifices the short-term fix of today for the transcendent future for you and humanity. It means letting go of earthy pleasures, the search for power and prestige, and the desire to remove the hard realities of life such as pain and death. It means letting go of resentment and bitterness about the reality of the situation you are in. It means letting go of blaming others. It means being honest with yourself and that you need help beyond yourself. It means letting go of your ego and being vulnerable and acknowledging your weakness.
Once you have realized this then there is potential for real magic to happen. The key for me has been to realize that out of the greatest suffering comes the opportunity to help others will similar suffering. Be a true hero. Transcend your greatest weakness and you can help others transcend theirs. Walk the path of strength and you can strengthen others. Have sufficient love to stick out your hand to all those that are suffering who you could help. Offer them hope and a way out.
Rely on a greater power and greater vision than yourself because you will set your sights to low. Love yourself and others. Make a covenant with your vision of a higher power and to your future self and to others that you will do everything it takes to accomplish this vision and that you will leave yourself no outs. As Yoda from Star Wars famously said: “Do or do not, there is no try.” Ask for courage. Say the serenity prayer.
Don’t focus on hunger as a loss. It is a friend, not a foe. It is future strength. Don’t focus on the loss of not being able to eat junk food. Focus on the strength that will be gained from eating the right foods. Be thankful for the blessings you have received as a result of other’s contribution to alleviating your suffering and making your life easier. Choose to live in abundance and not in depravity.
Trade your expectation for a “normal” life for an appreciation of the potential and opportunity of a “celestial” life, one that is hard won.
This is where real meaning and purpose arises. Want to know how to help others and to not feel alone? Make amends for those things that you have done to hurt others. Seek out those that are suffering as you have suffered and give them hope. Help show them the way. Strengthen their feeble knees. Let them know that they are not alone. Be the light in the darkness. Draw people closer to you with your own outstretched hand and lighten their burdens. Love first and love will be returned. Be and do what is seemingly impossible and you will inspire others to do the same. Don't seek for a finish line, rather seek for a new starting line to a land of greater possibility and capacity. Invest in yourself everyday because you are worth it and others need your help.
Start today by taking these action steps. First ask yourself what your ultimate meaning, purpose, and mission is. Then ask yourself that if you could become the person you dreamed of and that you were meant to be what would that person be doing now. Feel it, breath it, and visualize it. Write it down. Then post it on your bathroom mirror and fridge. Begin every day by focusing on the abundance this vision holds for you, your family, and to humanity. Finally, create one action step that you can and will repeat every day that will take you a little closer to becoming this person. Post it next to your vision. Forget perfection and focus on progression.
For me losing weight and keeping it off once seemed impossible. I have now become the impossible in my own mind and in reality. I am as healthy as I have ever been not by accident but because I purposefully invest in my health every day. You can do the same. Be the impossible in your own life and health!
A common refrain I hear from patients when they discuss their weight loss challenges is that they have hit a weight loss plateau. By this they mean that they have been working on losing weight but have stalled out and got stuck at a certain weight. They often tell me that they are eating just as carefully as when they started losing weight and have even been working out and still cannot lose weight. Obviously, this can be really frustrating and perplexing for patients and clinicians. But there are answers and potential solutions to this predicament.
So why do we get stuck?
Before we get into some potential solutions it is key to understand the factors that might be at play that can lead to a weight loss plateau.
First and foremost our bodies are very smart and some of the strongest regulatory processes we possess are designed to prevent us from starving to death. Orexigenic hormones (hormones that stimulate appetite) such as Ghrelin increase in response to purposeful weight loss. Conversely, anorexigenic hormones (hormones that suppress appetite) such as Insulin and Leptin down-regulate in response to purposeful weight loss. These changes lead to differences in many metabolic processes that may influence our responses to food cues and our ability to experience satiety. The changes in these hormones may also make us hungrier. In addition, our resting metabolic rate or the amount of calories we burn at rest goes down and the efficiency of our skeletal muscle increases. This means that overall our energy expenditure will go down more than would be normally expected from loss of body weight and lean muscle mass. All of this translates into needing to further reduce calorie intake and to be more vigilant about monitoring hunger cues as we lose weight.
However, the most important factor related to an early weight loss plateau is how precise people are about there diet and exercise regimen. In an interesting paper in the American Journal of Clinical Nutrition it was noted that "intermittent lack of dietary adherence, not metabolic adaptation, is a major contributor to the frequently observed early weight-loss plateau." The study also observed that this plateau happens at about 6 months. In my experience it often happens much sooner.
This paper highlighted the importance of strict adherence to a diet and weight loss program as a potential key to breaking through a weight loss barrier.
With that in mind here are my top 10 ways to break through a weight loss barrier.
1. No cheating: As evidenced in the paper I cited above intermittent or occasional loss of diet control can seriously impact successful weight loss. An alcoholic knows how significantly one drink can set him or her back. Intermittent dietary cheating can have the same impact.
2. Tracking: Along with no cheating I have often found that people assume that they are eating a certain number of calories when in fact they are eating a lot more. Many studies show that people significantly underestimate the calories that they consume. If you are stuck at a plateau start tracking what you eat religiously for 1 week with a calorie tracker such as Cronometer. You may be surprised.
3. Increase your protein: Protein has been shown in many studies to aid in weight loss and prevention of weight regain. Protein takes significantly more energy to digest and there is no significant storage form for protein as there is for fat and sugar.
4. Decrease your calories further: As you lose weight your energy expenditure will go down. This means that inevitably you will run into a weight loss plateau if your calorie intake is too high. Try lowering calories further. Please keep in the mind that significant decreases in your caloric intake (below 1500 calories/day) should only be done under supervision of your physician.
5. Increase your exercise: Exercise is an obvious way to burn calories. Exercise may also help preserve a higher proportion of lean muscle mass. Becoming more consistent with an exercise and overall activity regimen is essential.
6. Strength Training: While it is often touted as a way to increase your metabolic rate it is probably not as significant as a contributor to increasing your basal metabolic rate as many people assume. That being said you can clearly burn some calories with strength training and as you increase the size of your lean muscle mass your resting metabolic rate will increase.
7. Be Patient: Short weight plateaus are very common during weight loss in part due to changes in fluid balance, stress, bowel habits, sleep, and other factors. It can sometimes take a week or two to break through some apparent plateau. The rate of weight loss also slows down as we loss more and more weight. So just be patient!
8. Weigh yourself weekly, not daily: This goes along with being patient. From a day to day standpoint weight will fluctuate. Have faith in the process. The weight will come off. Over a week or two period you should generally see some weight loss if you are sticking to the process religiously.
9. Thyroid problems/Health issues: If you have followed all the other steps outlined above and are still not having any progress then you could have a hormone or other metabolic disturbance. I would follow-up with your doctor for further evaluation.
10. Poorly designed program for weight loss: The final issue that I often see is that people may have misunderstandings of how to eat, structure a diet, and exercise. When I talk to these people it is often easy to find a few quick things that can be changed that are causing the issue.
So there it is. My top ten list for ways to break through a weight loss barrier. For more information about my weight loss programs feel free to email or give me a call.
Before starting any weight loss or diet program please consult with your physician.
It has been a little while since I last wrote. I apologize for this absence. Thanks to those that have encouraged me to keep writing. I plan to write much more over the next few months.
As you may or may not know I have a few weight loss programs at my practice. I love working with patients on diet and weight loss. I would also say that there seems to be few things more satisfying for patients than when they lose a lot of weight and start feeling great. It doesn't take long for patients to notice increased energy, vigor, and improved stamina. This process is soon accompanied by an increase in confidence and hope for the future. The long term transformations can be simply life altering.
I have been occasionally blown away by what dedicated patients are able to accomplish. I have had some patients who have been on multiple diabetes medications for years who have been able to get off all their medicines in periods as short as a month. Truly radical changes are possible. In my experience we often underestimate what is possible especially with sustained and consistent effort.
When I was heavier I used to suffer from sleep apnea, low energy, depression, lethargy, poor cognitive performance, decreased impulse control, joint pain, inability to take care of household tasks, and much more. I could go on and on. After losing weight these symptoms disappeared. Unfortunately, despite the great benefit I observed I slowly gained all the weight back and had to struggle to lose it all again. This story is not uncommon.
Interestingly, one of the reasons that obese people tend to struggle with weight may be in part related to a propensity to seek immediate gratification (at least in terms of food) at the expense of long term benefit. Why people do this can be for many reasons including emotional eating, responses to stress, accessibility, and many other reasons. To some degree it is also biological because our hunter-gatherer ancestors didn't have much reason to focus on the long-term effects of weight or diet as they were mostly concerned with eating as much as possible of the food they encountered as soon as possible. They also preferred foods that provided as much caloric density as possible such as foods high in sugar and fat. This explains to a large degree why our brains are hard wired to prefer foods like ice cream or pizza which are high in calories, fat, and sugar. Basically, when we eat these foods we are following the pattern of our ancient ancestors to take advantage of the availability of calorie dense foods.
The problem is that in modern society our biological preference to favor high calorie dense foods with high amounts of sugar and fat can now become detrimental to our health especially as we generally lack periods of scarcity and have an abundance of these foods available to us at all times. This contributes to obesity.
So how do we combat this natural and biological tendency?
The answer lies in part due to something called "time preferences."
In theory, our modern stable society-where we can expect to have a reasonably long life expectancy and some semblance of stability-should permit us to make decisions that favor our long term success or the success of our future selves.
However, most of us still prefer to do things that have short time preferences meaning that they provide more immediate rewards and consequently favor our present selves at expense of our future selves. This explains why illicit drugs and fast food are so prevalent as they favor this time preference. It also explains why people people eat pizza and ice cream so readily.
However, is this time preference really what will provide us with more meaning, satisfaction, personal pride, dignity, and the ability to love and serve others?
When most of think of the drug addict we can easily see how favoring the short term drug high is seriously detrimental. But when we overeat or indulge in any other unhealthy habitual behavior we are doing the same thing. It is just not as socially stigmatizing.
One of the greatest insights I have come across is how many of our ancient stories such as those contained in the Bible focus on the idea of sacrifice or time preference. One of the lessons of the stories of Cain and Abel and Abraham and Isaac is the idea of how the willingness to produce a correct and worthy sacrifice of the most prized immediate possessions will provide long term success, meaning, and prosperity. When you think about it this a truly astounding insight and not shared by any other animal species. Many of the bible stories reveal how much better our lives can become over the long term if we sacrifice short term gratification, pleasure, and evil. The ultimate example of this came in the form of Jesus who willingly sacrificed his life for the long term benefit of humanity.
This bring me to a technique that some researchers call "Episodic future thinking". This technique relies on our innate human ability to vividly imagine the future and has been shown in many studies to help people lose weight and make better food choices in the moment. This is a technique that I practice. At a basic level it means that prior to eating any food you take a few moments to imagine positive future events that you like to have happen. These events don't necessarily have to involve eating. They could involve imagining running on a beach or attending your children's wedding. Focusing on future potential positive events that you would like to have happen can help overcome the urge to satisfy short term urges and put you in a future favoring position.
I personally find it even more powerful to vividly imagine the worst possible results of making the wrong decision repeatedly and contrast that with outcome of making the right decision repeatedly. I tell patients to run away from their own nightmare scenario and toward their own ideal future. I do this practice immediately before I go to eat food. I generally can be fairly certain that I am making the right decision if I can be proud about that decision one hour, one day, one month, one year, and even ten years from now. Both the present and future have to be prioritized.
One other visualization strategy that I picked up in a podcast from health guru Ben Greenfield is to imagine that you are the protagonist in a movie and that the crowd in the theater is watching your behavior and rooting for your success. It can be useful to visualize how they will react to a potential good choice versus a bad choice. I have also found it useful to visualize taking advice from my future self who is the person that faces the ultimate consequence of my current actions.
I encourage you to try these techniques as much as possible when you are tempted to satisfy any unhealthy habit including eating behaviors. As I mentioned earlier I have many weight loss programs and would be happy to help you in your weight loss journey. Stayed tuned for future posts on weight loss and weight loss strategies.
After years of discussing weight loss, depression, anxiety, and addictive patterns with patients I have noticed that we are all full of excuses when it comes to making changes in our lives. When I have contemplated changing things in my own life the first thing that often comes into my mind is some sort of excuse. We all have created many internal excuses for why we cannot improve our lives. These excuses are designed to discourage us from tackling the unknown. We feel powerless.
If you are honest with yourself about the difficulties you are having with some aspect of your life you will realize that you are holding onto a lot of useless suffering. So why not opt for some useful suffering? There is also no absolute evidence that what you will do will be in fact difficult. It is just as likely to be easy as it is to be difficult.
That brings me to the most common excuse that I hear from others. This excuse is simply that change will be too difficult or hard. When it comes to weight loss, people often say that it will be too difficult because of how much they have to lose, or because their wife only makes certain kinds of foods, or because they have too many sugar cravings. The list of reasons why it will be too difficult for them to make the changes are dizzying and endless. The funny thing is that they know that they are just making excuses and I think that they know that I know that they are just making excuses.
So is it really harder to change a habit? A little perspective can help.
Start by just thinking about all the things that you have to do to maintain the habit that you would like to change. A smoker, for example, has to have packs of cigarettes with them, dispose of ashes, earn extra money to support the habit, go to the store to buy them, have access to an ash tray, have a lighter, stand outside, worry about others getting exposed, the smell, social connotations, stained teeth, chronic cough, and an endless list of physical ailments. On the other hand, the useful suffering that is needed to change this habit is to simply choose in the moment not to smoke. Now, I ask which choice is actually harder in the long run!
The same holds true for weight loss. All it takes is to obtain correct dietary information from someone who has expertise in the area (such as myself) followed by making the daily choices to follow the process. The alternative often entails poor sleep, heartburn, joint pain, poor energy, deconditioning, feeling terrible, social stigma, poor self-confidence, earning extra money to support the extra food, heart disease, diabetes, high blood pressure, buying medications, and much more.
The key is to love yourself enough to make every decision in your life consciously and then count the benefits and the cost. Over the long run we suffer much more and encounter many more difficulties by maintaining a habit than by changing one.
You can decide today to cast out all the mountains of useless suffering you are experiencing and substitute a little useful suffering.
For those that need support through this process I am happy to help.
WEIGHT LOSS $55
HCG DIET $399
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BLOOD WORK $50
STEM CELL $999
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