The Liz Moody Podcast - GLP-1s: The New Science Transforming Hormones, Weight Loss, Brain Health, and Beyond

Starting point is 00:00:00 There's been this interesting evolving conversation about using GLP1 medications for things that are way outside of weight loss. And I'm really, really interested in this research. I see this clinically. I have patients that have addictions to drugs that they express that the want is less and also with alcohol. And it has to do with the reward system. The patients with PCOS do great on a GLP1 medication. And I'm going to tell you why. A breakthrough moment for me as a doctor in my profession was too.

Starting point is 00:00:30 to discuss how obesity can be passed from generations, liberating that girl from guilt. Hi, I'm Dr. Rosio Salas Whalen, and I'm an endocrinologist and obesity board certified physician. And I have more than 15 years of clinical experience of using GLP1 on my patients with type 2 diabetes and obesity. And I just wrote a book about all of this experience that I've gathered through the years.

Starting point is 00:00:57 Dr. Salas Whelan, I am so excited to have you here. We're going to get into all of the weight loss and the more commonly talked about things with GLP-1s in a second. But I wanted to start with there's been this interesting evolving conversation about using GLP-1 medications for things that are way outside of weight loss. And I'm really, really interested in this research. I find it fascinating, really compelling. So we're going to start with that. We're going to go down the list and kind of talk about what is the research actually show about using GLP-1s for these different conditions. What have you seen in your practice?

Starting point is 00:01:27 what have you seen an anecdotal experience? And also, like, do you have any speculation from a mechanism of action perspective of if GLP-1s would work for these things? So let's start with addictive behavior. I've heard, obviously, that GLP-1s work to help with food addiction. But I've also heard people say that when they're taking GLP-1s, they are reaching for their phones less. They're scrolling online less.

Starting point is 00:01:50 They're also not drinking as much. So outside of food, how are GLP-1s impacting addictive behavior? I see this clinically. I have patients that have addictions to drugs that they express that the want is less and also with alcohol, right? And it has to do with the reward system. So just to give you, I'll do an alcohol example. So if you have somebody who is reaching for a glass of wine at night because you're anticipating certain relief or certain reward, right, I'm going to get relaxed with a glass of wine. I want to get home at night. You're anticipating something from that glass of wine. of wine. If you are on a GLP1, that will change. So we have receptors in our brain for GLP1 medications or for the GLP1 hormone because it's a hormone in the reward system in the amygdala. So it blocks any reward either from food or beverages, but as you mentioned, we're seeing for other things too. And in regards to the alcohol, so for this person that is anticipating, once you're on this medication, you see that glass of wine and the behavior

Starting point is 00:02:57 at the beginning is still there to reach for that glass of wine. You reach for it, but then you don't get that response. You don't get that reward. So then the next day, you're not thinking about it. You're not anticipating anymore because you know you're not going to get the reward, right? But let's say somebody who drinks alcohol, not because they're anticipating a reward. That's not going to change with a GOP one. So who's drinking alcohol because they're not anticipating a reward? If you are socially, if you're going on a restaurant with a friend and you're talking and then you want to have a When you're anticipating reward even then, you know, we're like, oh, I had a hard day at work. I want to feel a little bit less stressed.

Starting point is 00:03:34 I feel like any time. That's a reward. Yeah. That is a reward, right? But not everybody drinks for that. Okay. Not everybody drinks for that reason, right? Somebody may just like a glass of alcohol if you're in a social setting and it's there,

Starting point is 00:03:48 but you're not anticipating. You're not building. You're going up. Well, some people may, right? But that's not the majority of the recent people drink. Have you seen it with social media? Because I feel like so many of us are scrolling so much more than we want to. And it's really interesting to me if a side effect of these medications is that we'll pick up our phones less.

Starting point is 00:04:09 I haven't seen that in the thousands of patients that I see, right? But let's say, I don't see that as a direct effect. As an indirect effect, there's many reasons that this could be happening. right so if you and you have to understand all the studies that we have on these medications and the reason that we're using is some people with obesity or type 2 diabetes so as an example a patient with obesity and they go on this medication you start losing weight your behavior starts to change in your lifestyle overall right you may be more prone to exercise you may be more prone to eat healthy it would just lead all the scenarios to less being sitting and scrolling right or being

Starting point is 00:04:50 sedentary. So I think it's more of an indirect effect that just leads to better and healthy lifestyle habits. And it sounds like we're breaking habit loops essentially. We're getting in the middle of anticipating the reward, then experiencing the reward and then that making us anticipate the reward more in the future. Would that sort of rewiring of our brains hold even if we go off of these medications? It depends on how long you've been. So normally it takes six months for you two. year to a new behavior, right? So I think the longer somebody is on these medications, the more likelihood that they're going to stick with those new behaviors. Okay. PCOS. I've heard from so many people who have had huge improvements in their PCOS symptoms with GLP ones. What is happening

Starting point is 00:05:39 there? 100%. And the patients with PCOS do great on a GLP1 medication. And I'm going to tell you why. The main problem with polycystic ovarian syndrome is not having cysts or follicles in the ovaries, right? You can have PCOS without even having cyst in your ovaries. The main driver of PCOS is insulin resistance and hyperinsulinemia. And GLP1 medications were designed for this. That's their main goal is that's the main effect in our body is to improve insulin production. So it decreases hyperinsulinemia. And this way also increases insulin sensitivity.

Starting point is 00:06:14 So those are the two main drivers of PCOS and GLP-1s treat both hyperinsulinemia and insulin resistance. Do you think that GLP-1s are going to become a go-to treatment for PCOS? They should be the go-to treatment for PCOS because we never saw, and I can tell you of my more over a decade of clinical experience and endocrinologists, never saw this results with metformin, which is one of the most common drugs that is prescribed for PCOS, as we do with a JLP1. I like to differentiate. I say metformin is like the rotary phone, right? And GLP-1s are the iPhone 17. Are there any other ways that GLP-1s interact with our hormones or impact

Starting point is 00:06:58 our hormones outside of PCOS? Like would we see, have you seen in your practice improvements with thyroid or adrenal or anything like that? Well, I can tell you for fertility for sure, right? So So, GLP 1 medications can increase fertility in somebody who's using the medication for the main direct effect from decreasing your body weight. So we know obesity can cause infertility. Also, in obesity, there's a lot of inflammation. And GLP1's medications help. They have some indirect and indirect anti-inflammatory effect.

Starting point is 00:07:33 So that also helps with fertility. So we do see rates of fertility increase when somebody is. on a GLP1 medication. In fact, I've had patients that end up pregnant while they're on a GLP1. So we always have to consult patients that even though some patients, they say, I've tried IBF, I've died in IUI, and I'm not going to get pregnant once they go on this medication, there is a chance that they can actually get pregnant. And I've seen it clinically. Is it okay to be on GLP1 while you're pregnant? Well, it's not recommended. We're not going to say somebody who's actively pursuing conception

Starting point is 00:08:07 to be on a GLP1. This is more like, oops, you're on it and you were not using birth control, even though it was recommended. Then we stop the medication as soon as the patient finds out they're pregnant. And so far, no complications on the babies that have been born while the mom was on a GLP1 in conception. Is there any research on GLP1s in breastfeeding? Because I imagine that people are going to be looking at this for postpartum.

Starting point is 00:08:32 Very little. So far, what we have is that subcuting. gulpatechineous gulp-1, meaning through the injection, the particles are too large to go through the mammary duct. So also, if it's subcutaneous, the baby is not going to swallow it right through the breast milk. It's a different effect. So let's say there is some absorption through the mammary ducts and the baby swallows a gLP1 that is injectable in the mother. it's going to be broken down by the acids in the stomach. So that's why this medication is injectable because it doesn't work oral.

Starting point is 00:09:11 Now, for the oral gLP ones that are coming out, then that's going to be a little bit different. In the future, it's going to be approved for pregnancy, for gestational diabetes and obesity. Oh, interesting, because gestational diabetes is a real concern during pregnancy. Yes, and obesity and pregnancy is a real concern, right? And I think for many women who struggle with obesity, lose the weight, then we stop the medication, the GLP 1 in pregnancy. I don't think that will be fair for the patient that has worked so hard to lose the weight and then go into pregnancy, gain weight.

Starting point is 00:09:47 I think in the future, we will find a use of a GLP 1 during pregnancy. Of course, the studies will have to be done and to be done in pregnant women. it may be more retrospective than designing a study in pregnant women because we don't study pregnant women for many reasons, right? But I think it's going to be more retrospective in seeing if there were any complications. But also we're going to have to take into account the growth of the baby, right, and not suppressing the appetite too much on the woman. So a lot still to design, but they are safe enough that in the future we may be able to use a microdose there in pregnancy. So I had a UCLA professor on, and his specialty is the brain and the microbiome, but he said that he thinks we're moving towards a future where people before they get pregnant, if they are struggling with metabolic issues, would want to spend a few months on GLP ones to have better pregnancy outcomes.

Starting point is 00:10:40 Would you agree with that? 100%. And every woman or even men, because it's not just the woman's weight that affects the baby's health and baby's future weight, like men, father and mother. I always recommend them that. But preconception, they start in a healthy metabolic weight. Why? Because it reduces the risk for the woman in pregnancy, right? Complications of pregnancy, complications in delivery if you have obesity or overweight. And also for the development of the baby. We have a lot of research of transgenerational obesity.

Starting point is 00:11:15 So we know that epigenetics are a big driver for obesity. So your parents' weight at preconception can determine your weight up to 50 to 60 percent. And both of them, the father and the mother. Yes, both of them. Whenever I see a patient in my clinic for obesity, I always do a very detailed family history. I like to go three generations behind if possible. How was your parents' weight and dig? Because many times somebody may say, oh, no, my mom is very lean, my mom.

Starting point is 00:11:47 but is that naturally or is that consciously? Oh, no, my mom is restrictive. She had a eating disorder, blah, blah, blah. Or her parents have obesity, and that's why she works really hard to not have obesity, but she didn't work that hard. She will have obesity. So it always tracks two generations behind my patient.

Starting point is 00:12:07 And in those patients that are thinking conception, I tell them, your parents didn't know this information that we have now, that their weight was going to impact your weight and that may be the reason that you're here with me in council today. Your grandparents didn't know that, but you know, I'm giving you this information that we know that your weight will impact your future children's weight. So we have the opportunity to break that transgenerational obesity epigenetics that we, that we have.

Starting point is 00:12:35 Even also past trauma of generations can impact and can promote obesity. It's really interesting. So going back to your question, definitely. If anybody is thinking of conception, the best thing they can do for themselves and for their future child to not struggle with obesity is to start conception in a healthy weight. And is one generation enough to break that cycle? Because you said it goes back two generations. Well, one generation, yes, because now what I'm saying is like the two generations back is the grandparents started with obesity in preconception. They had the child obesity. That person. also didn't know that their weight, that's what I'm talking about.

Starting point is 00:13:17 Forward, it can take one generation. If your weight, you start in a healthy weight, you're changing already, your epigenetics and the baby epigenetics and also what the mother does during the pregnancy, right? So we can break that into two. Father and mother preconception in a healthy weight and then mother during pregnancy to maintain a very healthy weight and be cautious of what she eats, drinks, chemicals, endocrine disrupting chemicals. Would this is maybe a little bit in the weeds, but would this extend to egg freezing and embryo freezing?

Starting point is 00:13:50 Would we want to be in a metabolically best state before we engage in that type of thing? Yes, because already your genes are going in that egg or in that even if it's an embryo, frozen embryo also. And then the next step is implantation, maintain a healthy way in the pregnancy. Yeah, that's so interesting. Okay. Any other hormone things that we should be aware of? I would say not directly, but as an example, thyroid hormone. So when somebody, we base the thyroid hormone dose on the patient's weight.

Starting point is 00:14:22 So higher weight, higher dose, lower weight, lower dose. So if a patient has obesity and they have hypothyroidism and they are on thyroid hormone when we begin treatment, usually after a 15 pound weight loss, your dose of your thyroid hormone may change. So every 15 pound weight loss, your dose needs to be probably adjusted or your levels definitely need to be checked, your thyroid function test, right? So for many patients, that are the indirect changes that may happen. There's a lot of chatter on TikTok and Reddit about people who are seeing their autoimmune conditions like Hashimoto's, which is a thyroid autoimmune condition, going into remission when they get on GLP-1s. What's that about?

Starting point is 00:15:07 Inflammation. Muscle is your strongest. anti-inflammatory organ. So if you don't have muscle, you are already in chronic inflammation. But if you don't have muscle and have obesity or high visceral fat, then it's a double wamy in inflammation. So if you relieve that inflammation from decreasing visceral fat, which is what GLP1s will do, then you're relieving your immune system to actually do what is supposed to do and it's protective. So autoimmune diseases is an auto attack to our body. So if you liberate your immune system to do its job, then all autoimmune disorders will improve. Not only that, we consume pro-inflammatory food. So when somebody goes on a GLP1, they're going to decrease their

Starting point is 00:15:58 food consumption by half almost immediately, even before we see any weight loss or visceral fat loss. So this is just by decreasing that half or whatever percentage of less consumption of pro-inflammatory food, also we're going to see a lot of improvement and autoimmune disorders. And that's one of the first things that people say when they go in a GLP1, oh, I feel like it has an anti-inflammatory effect. I feel less swollen. My joints feel better. And that just shows you that really what we consume in food is so pro-inflammatory, salt,

Starting point is 00:16:36 sugar, saturated fats are all pro-inflammatory. So just by decreasing that in half, even before we see significant weight loss, patients already feel better. And that's being decreased in half because people are just craving less food? Well, two ways. One, because you're getting fuller

Starting point is 00:16:53 with smaller portions of food, and because most pro-inflammatory food are reward drivers, fats, fried food, sweets, simple carbs, starches. Because that for many people is a reward, that you have a reward effect from those food. So if you're targeting both things in a person, shutting down that reward system of those pro-inflammatory foods and then making you consume only half of it, that's what we see such a significant improvement. Outside of decreasing visceral fat and decreasing inflammatory inputs, is there any mechanism of action wherein the GLP1 would directly do?

Starting point is 00:17:36 decrease inflammation? Like, let's say you're eating the exact same diet and then you take a GLP1, would your inflammation still decrease? Yes, it also has some direct anti-inflammatory effect, GLP-1 medications, but it's not as significant as the indirect effects that I mentioned. And is that different? We're going to get much more into like GLP-1s versus GLP-1s with GIPs and then try acting, triple-acting one. Is the inflammation effects, are those different for different drugs? That's a great question. Not directly, but more indirectly because they cause more weight loss. They're stronger in regards to appetite suppression and weight loss. Okay, we'll get more into that later. But heart health, if we have cardiovascular markers that aren't ideal, let's say ones that are related

Starting point is 00:18:23 to our metabolic health, related to weight, and then also maybe ones that feel like they're not related to weight, would those change when we get on a GLP1? So the studies that we have now is all in patients with obesity. So this medication has not been studied in people that may have cardiovascular disease without obesity or without type two diabetes, which both type two diabetes and obesity are big drivers for cardiovascular disease. So we cannot say that it's going to have the same effect in somebody who doesn't have obesity. So most of the beneficial effects that we're seeing in sleep apnea, in dementia, in Alzheimer's, is in patients that had obesity or have type two diabetes. Because improving the glucose, because improving the weight, we're going to have direct positive effects

Starting point is 00:19:11 in the heart and your blood pressure, in less dementia, less inflammation in the brain. So because of that, we're seeing all of those improvements in sleep apnea. When somebody starts to lose weight, then we're going to see improvement in the sleep apnea. So all the studies that we have is people that have this complication's cardiovascular disease, sleep apnea, because of obesity or because of type 2 diabetes. I think there's a lot of people who are curious if they are at a healthy weight. But let's say they have dementia in their family or they have heart disease in their family. Is this a path that's worth exploring?

Starting point is 00:19:48 I love this. I love discussing this subject because I think it's a lot in social media in the microdosing universe. If somebody thinks or believes that they're in a healthy weight and that they will just want to get the good benefits, the other benefits besides weight loss of this medication, I will return the question and say, okay, to say that you don't need to lose weight, first we need a body composition. If your body composition shows me you're metabolically healthy. If I see your body composition, you have significant amount of muscle that you have more muscle in your weight than body fat. And I see your percentage body fat is below 28 in a woman or below 20 in a men and your visceral fat is.

Starting point is 00:20:31 slow or you don't have excess visceral fat, then that's a good weight that you don't need medication to lose weight. In those cases, you already have all the benefits that you may think you may get from adding a gLP one. Why? Because you have more muscle than body fat in your weight. So you have already your own anti-inflammatory organ working for you. You don't have visceral fat, then you don't have to worry about that inflammatory process from visceral fat. If you truly have a good body composition, as I just mentioned, you're not going to get anything extra from using a GLP1. And this isn't something that you can necessarily tell just by looking at somebody because you can appear to be the societal standard of thin but still have visceral fat.

Starting point is 00:21:15 I've worked 15 years with patients with obesity or overweight and I cannot say what's the percentage body fat of somebody just by walking into my office. So I think we need as a society, as healthcare workers, really, redefine what is a healthy weight and that's not a BMI. We know the BMI is a very outdated tool from the late 1800s that was based on white European men. It's an average between height and your weight. That's it.

Starting point is 00:21:44 We need body compositions. We need to know what's the percentage body fat. We need to know what's your muscle mass. We need to know if you have visceral fat. And then work from there. I can tell you as an example, somebody who comes to me and they said, oh, I only have to lose 10 pounds sure I use the medication. once we do a body composition, you felt you needed to lose only 10 pounds or maybe your BMI

Starting point is 00:22:05 was normal. It's because you have very low muscle mass and you still have high body fat. So the number on the scale is not going to change that much because the muscle weighs more than fat and they're gaining the muscle. Exactly. Oh, that's so interesting. So would you say before anybody goes on these medications, they should be getting a Dexa scan? 100%. Or a body composition with the impedance machine, which is what gyms have. A lot of doctors. I have one in my office, the impedance machines. So our goal standard is by electric currents that go from your soles of your feet up.

Starting point is 00:22:38 And what they do, they separate tissue. They can differentiate the tissue where they're going through. So they can differentiate water, fat, and lean muscle mass. Can you feel it? No. Okay. You're not going to get electric shock. So our goal standard for body composition is an MRI.

Starting point is 00:22:56 But are we not going to do MRI? They're expensive, expensive machines. Their second best is a Texas scan, which is also a big machine. A lot of radiology centers would have, but you don't find that in the gym or in many doctor's offices. And then their third best are impedance machines. That's the most widely used in doctors' offices and gyms. But you have home versions of impedance machines that you hold with your hands, the electrodes, and then you step on the scale and it can give you this information.

Starting point is 00:23:25 And many people tell me, but are they true? Are they good enough? They will be better than the regular scale. Right. Because, again, the regular scale is not differentiating between muscle mass and fat. It's just an average of your bones, of your organs, of your water. Can the impedance machine tell you about visceral fat? Some do.

Starting point is 00:23:44 Okay. Some do. So get one that does that. And I think even if you're not a JLP one, we want to know what's your health. Get a body composition. Can you just say in a nutshell for anybody who's not familiar with why visceral fat is so dangerous, why we're really paying attention to that? Visceral fat is the fat that's the internal fat, not what you can grab with your hands. Not the role that you can grab in your abdomen is the internal fat.

Starting point is 00:24:11 You cannot touch it. You cannot feel it. This fat surrounds your organs. And this fat is pro-inflammatory. It's an active, it's an active tissue. So fat is an active tissue. And it's just producing inflammation, chronic inflammation interleukin 2, all these chemicals that cause inflammation. And this visceral fat with time and with chronic inflammation can increase your risk for many health problems or many diseases, including type 2 diabetes, insulin resistance.

Starting point is 00:24:45 There's 13 cancers associated with inflammation from visceral fat or from obesity, breast, process. Custate, colon, thyroid, pancreas, esophageal cancer, stomach cancer. This is what we call the bad fat. There's research that shows the GLP-1s can help with cancer risk reduction. Why is that? Is that because of the visceral fat? It's because of decrease of inflammation and also decreased consumption of pro-inflammatory food. So what are we seeing in terms of the research on GLP-1s and cancer?

Starting point is 00:25:15 It's too soon, right? It's too soon to say that it is going to change the course of an individual type of. of cancer, I do think in the next generations and the next two generations, we will see decrease in the incidence of certain types of cancers that were related to obesity. But we know that for cancer cells to survive, they need the nutrition, they need the glucose. They need your immune system to be preoccupied with another thing, right, visceral fat, inflammation. that's how they thrive. So by cutting that out, by decreasing inflammation,

Starting point is 00:25:57 by decreasing glucose in the cells with the GLP1, then we can only anticipate that this will decrease the multiplication of cancer cells. I've had patients that come to me in, they said that their oncologists mentioned to them that when they found the cancer, it was found in the stage that it was, most likely from a GLP1, that it didn't spread as fast from a GLP1. Because it was like starved essentially.

Starting point is 00:26:24 Exactly. Many oncologists are now sending me patients to be started on a GLP1, the patients that have our own cancer treatment, because they'll probably, most likely, we can anticipate that they will have better prognosis. Wow, that's so interesting. The number one rule of habits is to make the things that you want easier and the things that you don't want harder.

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Starting point is 00:33:16 with those tuberculosis. I think a lot of things there are happening due to the effects of the weight loads, due to the effects of your diet changing, due to the effects that people now feel more inclined to exercise and to build muscle because muscle and protein are having a moment. And I think it's due to GLP1 medications because we've know that lifting weights is healthy. We've known that to build muscle, you need a high protein diet. This is not something new. People that lift weights, bodybuilders, and not only bodybuilders, I've been lifting weights for 30 years. I know that you need to eat protein, lean protein. I know you need to lift weights. So the fact that we're hearing so much about it right now is not because we're just finding out that lifting weights is healthy and eating protein is healthy.

Starting point is 00:34:01 is because the GLP1 brought a lot of attention to muscle and muscle loss and how to rebuild muscle. So I think that's actually I'm giving a talk tomorrow in a fitness conference. And the name of my talk is from the clinic to the gym, how GLP1 brought us together, right? Because now we're working together for patients that are on GLP1, losing weight, losing muscle. Now we're referring to personal trainers. where teaching patients, you need to lift weights. You need to increase your protein in your diet. And that's because essentially if you're on a GLP1

Starting point is 00:34:36 and you're losing all of this weight, you're going to be losing muscle mass if you're not intentionally strength training. It depends. That's what in my book, people that read it will find, is like how to take a GLP1 the right way to achieve the results that we want. And the results that we want at the end of your journey

Starting point is 00:34:56 is that you have less body fat and more muscle mass. If you take a GLP1 and not have a conversation about lifting weights, about increasing the protein in your diet with your provider, your prescriber, you will lose muscle mass. And that's not directly because of the GLP 1. That is just a natural consequence of the weight loss. It's a natural consequence of your decreased caloric intake, right? So there's no direct effect of GLP1 to your muscle fibers. Okay. That's like a big myth.

Starting point is 00:35:27 That's something that's going around. on the internet. Huge. So there's no direct effect in muscle from a GLP1. It's an indirect effect from the decreased caloric intake that you're going to have from this drug that will cause you to lose muscle. So whenever we're talking about adequate weight loss, it's usually around half a pound to a pound per week. If that's happening, I can almost guarantee you that you're not losing significant amount of muscle. Anything about one pound per week, you're losing. You're losing some muscle mass. And going back to body composition, any patient going on a GLP1 or on a GLP1, we need to do consistent body compositions. I do one on every visit. But I encourage my patients

Starting point is 00:36:13 to invest in a home scale that can range from $50 to $300. And that way, they, in between appointments, they can track their muscle mass. They can track their percentage body. What is it that you're losing? Are you really losing percentage body fat or you're just losing muscle mass? If you lose muscle mass, you're losing your burning fat machine, right? Because muscle consumes body fat as energy or transforms body fat as energy and also glucose from your bloodstream. So you're slowing down your metabolism. That's why when somebody says, oh, you lost a significant amount of weight, you're slowing your metabolism. It's because you're losing your metabolic organ, which is muscle mass.

Starting point is 00:36:55 And again, the whole goal of being on something like a GLP1 is to increase our muscle mass, decrease our inflammation, and have these positive health effects overall. It's not just to get a certain number on the scale that doesn't even mean anything. Or a number in a size number for your dress of your pants, right? And this is like constant work. And I can tell you as an example in my office, a patient may come thinking of weight loss in an external way. They have wedding or they want to fit in that jeans that they used to fit 10 years ago. and they want to go back and they're trying so hard. Halfway of the journey, it switches because from day one,

Starting point is 00:37:31 and these are like red flats and green flags, and I talk this about my book on how to choose a provider for a JLP1 medication, right? If day one, you're not being talked about protein in your diet, about how to increase the protein in your diet, when they're giving you a medication to decrease your appetite, if they're not giving you ideas and ways to increase your protein while they're suppressing your appetite. If you're not having an initial discussion about your body composition and setting goals,

Starting point is 00:37:59 okay, then you will not have those results. But when you educate a patient and what matters of their weight, something changes. And when patients halfway, they start feeling strong, lean, the external idea of way lost goes out the window. It becomes more about how they feel and not how they look. Because you can look skinny, you can be size zero, but you're not going to feel strong, right? It's no way you're going to feel strong because you don't have muscle because you lost your muscle. So it's not sizes. It's your muscle mass. It's how you feel also, right? I want my patients to feel strong. And it's about the ratio of the muscle mass to the fat, if you had a lot of muscle mass and you had a lot of fat, would you be,

Starting point is 00:38:52 could you be healthy in that state? I tell my patients, if you didn't have this amount of muscle, you would have more body fat, right? But that doesn't mean that they wouldn't need a GLP1 medication to decrease their body fat because I can tell you by that amount of muscle mass, this patient is working out, is eating what they're supposed to be eating, but it's just not happening because that's not what causes obesity, right? So I cannot ask them to lift more weights and eat more protein because they're already doing that.

Starting point is 00:39:19 They have significant amount of muscle. They need help. They need medical treatment with a GLP-1 medication. Now, there's a lot of studies that show in patients with obesity that have significant amount of muscle that is not necessarily healthy muscle. There's a lot of studies showing that that muscle mass is infiltrated with fat. So it's not going to be the same healthy, lean muscle. Wait, I've never heard of this. the muscle is infiltrated with fat?

Starting point is 00:39:45 Yes. There's a lot of papers published that show the MRI images of a lean muscle versus muscle in somebody with obesity. And would that muscle not have the same positive metabolic effects or anti-inflammatory effects? Exactly. Oh, yikes. Is there a way to tell if our muscle is infiltrated with fat? That would be with an MRI only.

Starting point is 00:40:08 But if you have somebody with a percentage body fat that puts them in the obesity category, and they have significant amount of muscle, most likely that muscle may probably will be infiltrated. We don't need to do an image to confirm that it may be infiltrated with body fat. The next thing that I hear about on TikTok and read it all of the time that I don't understand how GLPs could be impacting it, but people say it really does is anxiety. I struggle with anxiety myself quite a bit, and I went and looked this up. And the warnings you get when you take GLP ones is that might increase your anxiety. But then all over TikTok and Reddit, people are saying that it significantly decreased their anxiety,

Starting point is 00:40:46 especially anxiety that was related to OCD-type thoughts, which is what I struggle with. Have you seen that in your patients at all? I think we have to mention this every single time that we talk about other effects of GLP-1s is that the studies in patients with type 2 diabetes and obesity and people that are using this medication, most likely is because they're trying to lose weight. So what I can tell you what happens in somebody with obesity or somebody who has struggled with their weight, or somebody who's trying to lose weight or gains weight easily is that there's always anxiety around meals. There's always anxiety about your body. There's always anxiety about exercise or not exercising,

Starting point is 00:41:24 about if you ate the right food or didn't eat the right food or if this food or this alcohol drink is going to impact your weight and then how you're going to overcome it by adding more exercising or by eating less the next day. It's a constant 20. four, seven thinking, that I didn't know that as a medical student, that I didn't know that in my internship, in my fellowship, in my obesity board certification until I heard this from patients, patient after patient telling me what, how their life looked, and for many, for decades, struggling with this since they're eight, since they're nine, since they're 10, and they're 50, they're 60, they're 70 years old. The toll, the mental toll, the mental toll, that is,

Starting point is 00:42:11 obesity or waking or not losing weight ticks in somebody, it's something that I never imagined until I heard it from my patients. This is the reason, this is the main reason that I wrote my book, because I had the privilege to having that conversation with patients because I run my practice, I run a private practice. So I spend one hour with my patients. But many doctors don't have that luxury. Many patients don't have that luxury to going to an out-of-network provider that you're going to be able to open yourself to your most vulnerable place. So I said, people need to hear this. People need to know what people are struggling, that that idea and that recommendation of

Starting point is 00:42:56 eat less, exercise more, that every visit we were like saying, just eat less, exercise more than the other time. People were doing it. Patients were actually doing it. And we were chuckling to lazy, not intelligent. They're lying to me. They're not compliant. And we created a lot of anxiety.

Starting point is 00:43:16 And no wonder why some patients say they don't want to go to doctors. They don't trust doctors. They weren't help us. We should have helped them. So that creates a lot of anxiety. And once they go on this medication and they don't have to worry about if the exercise or the eating is going to impact their weight 24-7, it leaves open space, for other things.

Starting point is 00:43:43 I also wonder if there's maybe a decreased anxiety or an increased productivity. I don't know, something to the idea of turning down the food noise and the food thoughts in our brain. It just almost feels like a, if my brain was absent of that, it would feel quieter.

Starting point is 00:44:00 Yeah, definitely, and I mentioned this in the book, I said, if people with obesity, even with their mental struggle about their weight, because I have not met a single patient with obesity that wants to have obesity. Right. Let's get that clear. If they achieve so much, how much more would they be able to achieve if they didn't have that mental space preoccupied with their weight, right? And that's one reason that I'm very strong proponent of childhood and adolescent treatment of GLP1.

Starting point is 00:44:32 Because I see the patients three decades later, four decades later, five decades later that they were impacted. Talk to me about that because there's a lot of concerns. around GLP-1s in kids. There's a lot of people who are like, we don't know the impact this is going to have on a developing body. We don't know what this is going to look like 30, 40 years down the line. How would you suggest parents approach the debate of whether to have their kids take GLP ones? It's not easy. It's not going to be an answer.

Starting point is 00:45:00 It's a complex one. We have studies that showed, and they were recently published in serious journals, that they've looked at early childhood intervention from the parents and the outcome in weight. If early intervention in lifestyle is going to change the course of the weight in children with obesity. And the lifestyle modifications were diet, physical activity, screen time, and sleep, right? Because those are like the main pillars that we attribute obesity in childhood. If they're not done right. And what the study shows, that in the majority of patients, it didn't change the course of obesity in them.

Starting point is 00:45:45 Right. Why? And we mentioned this early in our conversation because epigenetics. Because a child may already be predisposed to obesity just even before he was born. I think using GLP-1s in patients is going to be beneficial, but it's not going to be as straight as an adult, right, that you go with. with your specialist, you get your GLP1, you're being, there's going to be more of a multidisciplinary effort in children with obesity from the pediatrician, from the obesity specialized physician or pediatrician, maybe even psychotherapy, to really cement the knowledge and the idea that

Starting point is 00:46:30 this is for health and this is not because of looking a certain way or being a certain size or looking like their friends. There's a lot of like thin lines there that it has to be done very properly. Also, it's very important to know that in puberty or adolescence, a GLP1, if it's not used the right way, it may stunt growth. And I've seen this clinically. So if you push the pedal too much in appetite suppression and somebody who's growing, you're going to stunt growth. So in certain age, the doses need to be minimal that you're getting some weight loss, but not so much appetite suppression that you're going to stand their growth. So again, I do see the use of GLP1 medication in children and adolescents, but it's not a straight line as with adults. Is there any concern

Starting point is 00:47:25 that in 10, 20, 30 years, we're going to be like, oh, no, there's all these negative side effects, either for adults, but especially for children that we just didn't know about. And now we're like, oh, shoot, we shouldn't have done that. I think at this point, because the first FDA-approved was 2005, so we have 20 years of FDA-approved GLP-1, but for a medication to get approved, it's been studied for seven to 10 years, right? So we have more than 10 years of clinical data

Starting point is 00:47:50 of safety long-term of these medications. What's going to happen in 50 years, I cannot tell you that we don't know that. But we do know what's going to happen in 10 years, in five years. and 20 years and 30 years of somebody having obesity. We can almost predict what the future may look on a child who is severely obese or has severe obesity. They'll have type 2 diabetes when they're 14, right, when they're 18.

Starting point is 00:48:23 And also I want to say that Wigobi, which is a maglutide, is FDA-approved for obesity 12 years and above. Victosa, which is lyraglutide, is FDA approved for 10 years, 10 years and older for type 2 diabetes. Coisemia, which is an oral weight loss drug, there's not a GLP1, but it's also approved for 12 years and above. And currently, Monjaro is being studied in 10 years and above for type 2 diabetes. And semaglite is currently on a phase 3 study for children 6 and 2. 10 with obesity. So it is approved for 10 years and above a GLP1, but now the studies are being done as early as six years.

Starting point is 00:49:14 What would you say to the parent who's beating themselves up a little bit and they're like, well, I control what my kid eats, I control my kids exercise. Like, is it cheating to go to these drugs? Definitely not cheating. I mean, this is a medical treatment for a medical condition. This is not a gateway for bad lifestyle. choices. I think that's another big misconception that we can talk about. I want to talk about a really

Starting point is 00:49:38 nice patient experience that I had. It was a 12-year-old girl that their parents brought to me for initial consultation for obesity. To possibly start a GLP1 medication, the father, both parents were there in the office room and the father struggled with obesity all his life. He actually wasn't a GLP one medication. It was at such a breakthrough moment for me as a doctor in my profession. To be able to discuss how obesity can be passed from generations, liberating that girl from guilt. And also the father liberating himself because his parents also struggle with obesity. Liberating the mother that was there that I was like going, didn't know what else to do in regards to healthy, bringing healthy food at home, encouraging her daughter to do physical activity, putting her on camps.

Starting point is 00:50:35 And also teaching this little girl about what's health, about talking about their percentage body fat, about encourage them to start working out, lifting weights. So to ensure a future for her different from what the father did. And also not putting guilt or anybody because we just didn't have this information, even before. The father didn't have this information that we have now. So it was a really beautiful family moment and talking it about in a very scientific way, too, that liberates willpower as a guilt. If a parent is debating whether or not it's a good choice to put their kid on GOP1s and they don't have access to a doctor like you, obviously read your book, but are there questions that

Starting point is 00:51:24 they could be asking themselves to know if their kid is a good candidate? Looking at their own history, if they also struggle with weight, then most likely is there's some genetic contribution there. And that already, again, takes over 50 to 60 percent of the cost of the obesity or the child being overweight. It's an important consideration, but more important is who they will choose to get this treatment for the child because it can go bad also. So I think in children and adolescents, there's even a second tier of a filter of finding the doctor with experience in this matter, both in obesity and experience on GLP1 and experience on GLP1 in children or adolescents. Do you have any recommendations for finding those people? Ideally, it will be a pediatrician that is obesity board certified or a physician like myself that is also obesity board certified. They can go to the American Board of Obesity Medicine website, and then they can look by the

Starting point is 00:52:30 zip code what doctors are board certified in obesity. And the website is www.abom, abom, abom, dot org. Perrymenopause and menopause. Your forward for your book is by Dr. Mary Claire Haver, who is an incredible menopause expert. How do GLP-1s impact us when we are in perimenopause or menopause? I think it's just another tool that we women have to achieve our best health. So during perimenopause, which is the period before entering menopause, menopause is 12 months without a period, but most of the symptoms that we hear from,

Starting point is 00:53:09 that we think is in menopause actually happen in perimenopause. And pari menopause can happen up to 10 years before you're stopping your period. So this is usually early, mid, and late 40s. And in this period of time, as Dr. Haver baptized this period in a woman's life as the son of chaos, like hormonal chaos, is where we see changes in body composition or from that hormonal fluctuation. So the body fat that we used to have or how we store body fat in our premenopausal years or in our fertile years, which is more like your hip, your breast, doing perimenopause, it transitions more intraudominally. So it becomes more visceral fat. So that's why many women say, this is not how I used to gain weight before. I used to gain it in my hips.

Starting point is 00:53:56 And now everything's going to the middle. So it's because of the change of hormones. Also in midlife, we tend to lose lean muscle mass more easy and it's harder to build muscle. So during midlife, we tend to collect more intrepdominal fat and then lose our lean muscle mass. Is a physical belly pooch, which I know is something that a lot of people complain about in paramed, menopies or menopause. Is that a sign that we have more visceral fat that's actually like pro-inflammatory? No. Subcutaneous body fat is what you can pinch, right? That tells me more your amount of subcutaneous fat, but it doesn't tell me a lot of your internal fat. And that's why it's dangerous because we cannot see it.

Starting point is 00:54:41 We cannot feel it. We cannot proactively work for it. Is there any indication that women in perimenopause or menopause accumulate more visceral fat? Yes, and that's why women in menopause are at a higher risk of developing type to diabetes because we tend to store visceral fat in perimenopause and menopause from the drop of estrogen. So would taking GLP-1's help with a number of different diseases that become more likely in perimenopause? 100%.

Starting point is 00:55:12 Also hormone replacement therapy. We never say that hormone replacement therapy is going to cause weight loss. We don't promote it as a weight loss hormone. But it will change again. It helped change your body composition to build a little bit more lean mass and decrease your visceral fat. But many patients that didn't struggle were weight or were maintaining their weight because they were exercising and eating healthy in their 20s and their 30s comes perimenopause. And that doesn't happen anymore. Also because of the change of hormones or because of aging.

Starting point is 00:55:42 In those cases, GLP1 medications will definitely be very helpful. Will GLP1 medications help with perimenopause symptoms? Very good questions. Many times when a patient comes and they're saying I'm having trouble sleeping or I'm feeling hotter than normal or I don't feel like having sex with my spouse, I don't feel comfortable. Many times they overlap the symptoms and many times by improving the weight loss, a lot of those symptoms that we could have thought that could be from perimenopause, they were from the excess body fat. But many times a person can have both things, right?

Starting point is 00:56:18 Many times some of the symptoms may be from paramedopause and some of the symptoms may be from overweight or having obesity. Okay. So it's going to be about figuring out exactly what your unique situation is. It's about a good clinical questionnaire by your physician. I know. But so many people don't get that. That's what it frustrates me so much.

Starting point is 00:56:36 And it's one of the reasons I try to make is much information available, actionable. Yeah, it's frustrating. But it's good for people to even have the awareness that perhaps it's, the GLP1 could help with these symptoms, et cetera. You know why? Because then they become advocates and they take no, they don't take a note for an answer and they find the doctor that they will listen to them. Let's get into the weight loss of it all.

Starting point is 00:57:00 What are the top reasons that somebody could be eating in a calorie deficit, working out, doing all of the right things, but still not losing weight? Genetics is one, right? There may be some hereditary of obesity or overweight that is pushing you to gain weight, so not everything you do will help to combat that. Hormone changes, hypothyroidism, paramedopause, menopause, certain medications that you may be taking. So many antidepressant, many psychiatric medications can promote waking or blood pressure medications, glucose control medications.

Starting point is 00:57:38 so some of your medications may be pushing you to gain weight. Endocrine disrupting chemicals. So things that we have in our environment, plastics, right, the forever chemicals, those are real things, right? They do impact your hormonal system. What they do, they mimic the function of your hormones and they block the receptors where the hormones should go. This causes significant changes.

Starting point is 00:58:07 we know infertility, right? Obesity. So the things that we are exposed now that we were exposed in utero can impact and promote obesity. And then we have also some monogenetic diseases, right, that are different from epigenetics. Epigenetics mean that your parents struggle with obesity, their diet, their environment, and then you inherited that. But then there's some gene mutations. single you mutations that we can see severe genetic diseases of obesity. Usually those are diagnosed early in childhood because they're so severe that you don't go into adult life with nobody suspecting something or taking you to the doctor, right? But there are some mild versions that can go into adulthood and we are diagnosing them later in life.

Starting point is 00:59:02 What do you think is the reason for the obesity epidemic? Definitely. we have to talk about the food industry and the obesity epidemic that we have now because most of our food is genetically modified or engineer. It's the more, the cheaper, the bigger, the better. We are not so much looking into quality food. Also, we don't have good access to healthy food for all socioeconomic status because of that. And also, sedent tourism we live in cities that don't promote walking that don't promote mobility that you have to be in the car most of the day and now working from home then that also promotes more

Starting point is 00:59:49 sedent tourism then all the chemicals that's affecting our climate our environment it's affecting our health too they promote obesity all the all the things that I mentioned so because of that we almost have like a no winning chance by you just trying to eat less and exercise more. You say that there's a secret reason that many of us gain weight as we get older. What is it? Sarcopenia, so loss of muscle mass. We focus so much on fat that we forgot to focus in muscle. I like to say that sarcopenia or having low muscle mass is even more dangerous than having high body fat. Because having low muscle mass not only puts you a risk for metabolic disorders also for mobility, for stability to prevent injury and as well,

Starting point is 01:00:35 we grow older to really be independent, to get out of the chair, to go to the bathroom by yourself. So I like to tell to patients, concentrating on muscle gets you more than concentrating on body fat. Well, and also, didn't you say that muscle is anti-inflammatory? So muscle produces hormones. It's actually an endocrine gland. And it produces myokines, which are anti-inflammatory hormones. And it also, the more muscle you have, the less insulin resistance you have, the more you metabolize glucose, 80% of your glucose in your blood is metabolized in muscle. 80%. So I see this also in patients with type 2 diabetes, the ones that have low muscle mass, they require higher doses of the medications because that's the only thing that is controlling

Starting point is 01:01:24 their glucose. But patients that build muscle, they require less diabetes medications, right? Because then you have your glucose burning machine. Muscle utilizes body fat as energy. So the more muscle you have, the more you're burning fat for energy. When you think about strength and resilience, like your ability to feel energized, to recover well, to stay strong as you get older, what do you think that actually comes from?

Starting point is 01:01:52 Most people say working out are good nutrition, and yes, of course that matters. But there is a biological foundation underneath all of that that most people are completely overlooking. I have been diving deep into this lately with the team at timeline and what I've learned has genuinely shifted how I think about my own health. Every single movement that your body makes, every step, every workout, every muscle contraction depends on energy produced at the cellular level. And at the center of that is your mitochondria. Here's the thing that nobody tells you, certainly nobody told me. Starting around age 30,

Starting point is 01:02:25 our mitochondria naturally become less efficient. More get damaged, more become slender. More become and over time that impacts your energy, your strength, your recovery, and your resilience. Most of us respond by pushing more. We're like noticing these things and we're adding in more protein. We're trying to fix it with more supplements. We're trying to do harder workouts. And those things do help. But timelines research suggests that we also need to be supporting the cellular machinery underneath. And that is exactly what their supplement mitopure does. It contains Eurolithin A, which helps your body clear out damage mitochondria and support healthier ones so that your cells can produce energy more efficiently. Because this is happening to your cells, it's going to

Starting point is 01:03:08 impact your entire body, your immune system, your muscles. One study found that taking mitochondria increased muscle strength by 12% in four months with no change in exercise routine, it's going to impact your energy, your sleep, your skin, your cell health impacts all of this, and urolithin A keeps your cells healthy. Timeline has done over 15 years of research and testing on this one product, urolithin A, which, by the way, most of us lack the gut bacteria to synthesize naturally. That's why many of us need to supplement it to get the benefits. This has become a staple supplement for me.

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Starting point is 01:07:36 Masterclass.com slash Liz Moody. Okay, we talked a little bit about this at the beginning, but I want to get into the difference between GLP-1s, which is like Ozempeg, GLP ones with GIPs, which is like Zep bound. And then there's ones with three pathways like Reda-Trutai. who would benefit from taking each one and how should we know what to go for? As expected in science and in everything, right? Things get better as they're made new.

Starting point is 01:08:03 They get more sophisticated and this is what we're seeing in GLP1 medications or in weight loss medications. And I like to do the iPhone analogy. I want you to think of Ossempec as the iPhone 12, Monjar or Saban as the iPhone 16 and the iPhone 17 is here, which will be retro trutide. That's not out yet, right? It's not out yet. That's still in studies.

Starting point is 01:08:26 There's a compounded version running around in social media, but it's not the real drug. And it's usually combined with other things that it's not safe. I have a question about the compound. But first, just like to wrap that, that is like the newest one you can get is better. Every generation of this drug is made safer and less side effects and more effective. So stronger and stronger and safer. But when somebody tells me, what's the best drug that I can get? It's the one that either your insurance covers, the one that you can afford, the one that you're going to be able to stay consistently on it.

Starting point is 01:09:03 But if you were a king and you could afford all of them, get the newest one. At the moment, Sebon Munjarro is the best. Good to know. Okay. Compounded versus not compounded. What does that mean? So I'm going to come and say it here. I don't recommend prescribe any compounded medication, including hormones.

Starting point is 01:09:22 Okay. And the reason is because for me, safety above price. What does it mean? Like when you go to like a compounding pharmacy, doesn't that just mean they like make the drugs in house and that's cool? Exactly. But you have to understand something. The patents for these drugs are not out yet.

Starting point is 01:09:40 Okay. So to say that they're making the exact formula is a stretch because the patents are own currently by the pharmaceuticals. So if you get compounded, That is like a pharmacy making their own version of a OZempeg, of a Zetbound. And currently it's not legal to compound them because there's no shortages. At one point, they were allowed to mimic the drug when there were shortages, but there's no shortages anymore. So to make it legal, what they're doing compounding pharmacies is adding additives like vitamin B or folate or they're combining it with something else.

Starting point is 01:10:19 But this makes it even more unsafe because that hasn't been studied in combination. And most of the toxicology calls of overdosing of GLP1 is from compound medication. Okay. So you're like just don't do compounded. I understand the price issue, right? I understand. But I don't want the safety of your health to have a price stack. Yeah.

Starting point is 01:10:43 I've also seen a lot of companies offering GLP1 pills and like sublingual. I didn't think that existed. It's compounded, right? So we have a semi-glutide oral FDA-approved drug. It's called revilsis, and that's for the treatment of tuberantibitis. Next year is coming up much higher dose in that pill form that we are seeing comparable weight loss with the injectable injectable versions. So that is available, right? So those you can have. But sublingual, that becomes more like of a compounded drug. Or the gommies is also compounded. There's gommies? There's everything. What do you think about taking a pill of semi-glutide versus an injectable? So the first oral GLP-1 approved was 2019. So we've had it for six years. I never saw the same weight loss as the injectable version.

Starting point is 01:11:33 Again, they're coming with higher doses that are more comparable, but also what I found clinically and what's been shown in the studies, it has more gastric side effects. Which makes sense. So more nausea, more vomiting, less adherence. of the medication because of the side effects. And also we don't see as significant weight loss as we see with the injectables. I think the pill form will going to have a use more in children or adolescents that having an injection seems a little bit scary and that we don't want the severe or the significant weight

Starting point is 01:12:05 loss that we may want in adulthood, which reach their normal height, which in children, we're trying to not stand to growth. So I think there will be have a use or also for. maintenance once a patient has achieved the desire weight loss and we don't need an injection anymore or they don't want to do an injection anymore than the pill form at a lower dose where there's less side effects but not significant weight loss because now we're in maintenance may be useful there but one thing that I I want to clear is that the oral gLP one is as expensive as the injectable it's not because it's oral it's going to be cheaper than the than

Starting point is 01:12:45 the injectable. It's just like a little less scary. It's a little bit less scary, easy to travel. You've done the injectable, right? Myself. Yeah, have you? Yes. And twice. Is it scary? It's not. Does it hurt? It does not hurt. Really? Even though you're sticking a needle into your body? I mean, you have to take it for me that I'm a doctor and I'm not afraid of needles, right? So injecting myself with it. But you don't think it's like even from your patients. Do people have a hard time with that part? Not at all. Some people say, I don't want to do the pill. This is so much easier, the injection. And it's once a week. It's once a week.

Starting point is 01:13:17 Oh, and next year we're having once a month. Oh, wow. Maritime Tide, it's called. And this is also in phase three, I believe. So hopefully approved by end of 2026. And this is going to be a monthly injection. I think that's going to be great for maintenance too. You just said you've done it twice.

Starting point is 01:13:34 I think a lot of people, one of the reasons that they're reticent to utilize these drugs is because they're like, if I take a GLP1, I'm going to have to be on it forever. you have clearly cycled on and off of it. What do you think about that perception? So I'll tell you my experiences and the reason that I went on it. So the first time was back in 2010 when Victosa was approved, which is the daily injection. And I started practicing out of my training. And I said, okay, if I'm going to be prescribing this drug so much and it works as good as they say, I need to know what my patients are going to feel to.

Starting point is 01:14:12 guide them. Ginipeg did yourself. I guinea pig myself. I injected it myself. I knew it doesn't cause hypoglycemia. It's not like I was injecting myself insulin, right? This drug does not cause hypoglycemia. It only works as a diabetes drug if you actually have diabetes. But if your sugar is normal, you're not, it's not going to bottom it down. It's not going to drop it. So I felt safe of doing that, right? It was more of feeling like the nausea, the side effects that they were mentioned. And what was the effect on your appetite? So I tried it. I felt, um, I felt, the nausea, I did it for a couple of weeks because I wasn't looking for weight loss either. So I knew what to tell my patients the first few times that they would use it. So that was my

Starting point is 01:14:51 first experience with the GLP1. Fast forward 12 years later, I had my first pregnancy at age 38. I gained 70 pounds in that pregnancy because I was very restricted most of my life in regards to exercising and eating healthy. It was like for me, it was like, whoa, if it's a moment, it's going to be now and I gain 70 pounds and then I got pregnant again five months after delivery. Oh my god. And then I ended up with two under two. Oh my god. Early 40s and hitting perimenopause. Then I was in that spot and I couldn't lose the weight as I was able to maintain my healthy weight prior to my kids and I couldn't dedicate six days in the gym with having two under two and being my my early 40s going through paring menopause. So being a doctor, I know this is a treatment. I had done what I could. I know that

Starting point is 01:15:48 it wasn't going to happen. So I used to Sempec at that time. It's the one that we had. And I used it for six months. I lost the weight that I needed to lose and I've never needed to go back and I'm 49 years old now. So because my family didn't struggle with obesity because I lifted weight since I'm 20, it was easy for me to not needed it to maintain my weight loss. Do you think there's a significant amount of patients who could use it to establish healthy habits to get over a hump and then go off of it? Or do you think most people are going to be signing up for being on this forever? We just need to look at statistics, right?

Starting point is 01:16:28 There's more people with obesity and overweight. And because of that, then many people will need to be on it long term. but somebody like me as an example that didn't struggle with weight. And for whatever life event, life circumstances, you're in this situation that you cannot go back, even doing the same things you were doing before, which happens to a lot of women in midlife, right? Then it is a great medication or a great way to achieve that healthy weight again and reincorporate in your healthy habits. Yeah, you wrote in the book that GLP1s make sense for people with smaller amounts of

Starting point is 01:17:05 weight to lose if weight management is taking over your life, if it feels like a full-time job, and you've already been following lifestyle recommendations and healthy habits without seeing results, I think a lot of people resonate with the idea of feeling tired and overwhelmed and just wanting the time and energy and brain space they are spending on this back. Yeah. If losing weight or maintaining your weight feels like a full-time job, then most likely you're predisposed to gaining weight, right? Because, Because if you didn't do that, if you weren't trying to overcome all your genetics, your hormonal changes, aging, environmental factors with your lifestyle, it wouldn't feel like a full-time job. So if you didn't do that, most likely you would gain weight.

Starting point is 01:17:51 So most likely you will benefit from this medication. What are the top questions that we should ask ourselves if we're considering going on at JLP1? First is to do a body composition, to really know do you actually will benefit from it or not? if you feel like you've maxed your lifestyle changes and not seeing any result, if you struggle to maintain weight and you have a family history of obesity in your first degree family relatives, your parents, your siblings, or even your grandparents, and also if you have complications from your weight, right? If you're having trouble sleeping, if you're having mental health issues because of your

Starting point is 01:18:34 weight, then definitely you'll be a candidate for a JLP 1 medication. And if we do a body composition and our muscle mass is less than our fat mass, was that the ratio we're looking for? Okay. That would be a sign that we would want to consider potentially. That would be a sign that you need to pick those dumbbells and increase your protein in your diet. But if we're doing a body composition as part of our factoring in whether or not we should take a

Starting point is 01:18:57 GLP1, what we're looking for is the ratio of our fat to our muscle and we're also looking for our visceral fat mass. percentage body fat. So in men, healthy percentage body fat is 10 to 20 percent and in women is 18 to 28 percent. Right. So percentage body fat above 28 means that you are overweight above 32 percent in women. We consider that obesity. So in those cases, definitely that you can benefit from a GLP1 medication. I want to talk about some of the different things that people are scared of in terms of side effects. Thyroid cancer. Is there a link to thyroid cancer with GLP-1s? The thyroid cancer is exclusively medullary thyroid carcinoma, which is a very aggressive type of

Starting point is 01:19:41 cancer. And it was found this only in mice in lap, that they were more prone to develop medullary thyroid carcinoma. But it has not been seen in humans since the GLP-1 has been approved for 20 years now. And this is very confusing for people that have thyroid cancer, not all thyroid cancers. Again, it's just exclusively medallary thyracarcinoma, but if somebody has had history personal or family history of papillary thyracarcinoma, follicular thyracarcinoma, hurdle cell carcinoma, those are no contraindications of using a GLP1. But if you yourself or a first degree family member has history of diagnose medullary thyracarcinoma, that's pretty much our only absolute contraindication of using a GLP1 medication, unfortunately.

Starting point is 01:20:29 Gastroparesis. So these medications work by slowing your gastric movement, the emptying of your stomach. So it slows digestion. I personally never had a patient of mind-developed gastroparesis. It's not a normal complication or side effect that we should expect. It's poor management of this medication. Oh, do you do something different with your patients, like in terms of recommendations to make sure they avoid it? Yes.

Starting point is 01:21:01 Always start at the initial dose. Don't move the dose up just because we have other doses available. Move it when needed. The majority of the medications that we have in Ossempeg Wigobi-Mongaro-Zepbound, each dose has like a three-month effect in the majority of people. And then it would sort of turn into a maintenance dose? For three weeks, you stop losing. weight or patients feel hungry during the seven days, right? They start thinking, oh, maybe I should use it every five days instead of seven days. No, we need to go up on your dose. Or the day before your

Starting point is 01:21:36 next shot or the two days before your next shot, you're like, what is this that I'm feeling? I'm hungry. I'm, I'm overeating. I finish my whole plate. I'm thinking of the other foods that I wasn't thinking. That's the time that we need to go up. But going up too quickly, you are only setting your patient for having side effects, gastroparitis is one, right? You're not allowing the patient to get habitated on this new eating habit for many patients. It takes a few weeks to understand that their body tells them no more to eat, right? Because the behavior is still there. Mechanically, they may feel full, but the psyche hasn't catched up.

Starting point is 01:22:16 So if you move them to quicken the doses, you're not allowing the patient to really get accustomed to this new feeling of fullness and listen to their gut, right? That's what patient's going to start vomiting. If I tell patients you literally have to listen to your gut when you feel full, you have to stop. But if we don't allow the patient to understand this, you're setting them for failure. You've said you used to be against microdocene GLP ones and now you're not anymore. Talk to me about that. I'm against for pre-weight loss or for weight loss because the therapeutic doses are there.

Starting point is 01:22:53 for a reason because in the studies, the doses that we have available is where they saw the effect that we're looking for the drug, either for improving their glucose for type 2 diabetes or for weight loss. Microdosing happen from people prescribing this medication having no clue on how they work, right? No clue of the side effects that they were causing and most from compounded medications. So because the microdosing came from the compounding group, the thinking was, well, maybe if I give you a lower dose, I will cause less of a side effect. But it was not the dose. The problem is how they were prescribing this medication. So their idea is, let me give you a smaller dose to avoid the side effects that I was causing to begin with.

Starting point is 01:23:44 And that's where the microdosing idea came. Oh, let me use a smaller dose to get accustomed to the medication. But even at the regular doses, you shouldn't have side effects of those side effects that were in the headlines or they were mentioning. So they're safe if they're being given by somebody who knows what they're doing. So if we think of microdosing to get, oh, let me get this effect, even though I don't need to lose weight. We'll go back to the initial conversation. If you are in a healthy weight, truly you don't need the microdose or the dose. I feel underdosing.

Starting point is 01:24:17 I like to change the name of microdosing. out to underdosing, it's going to be helpful for maintenance. So let's say a patient that achieve their weight loss at the lowest dose, then for maintenance, they're not going to need that dose. They may need half of that dose or a third of that dose. So in those cases, underdosing, the therapeutic dose may have a use. And always basically just stick to the lowest dose that is working for us. At the moment, right?

Starting point is 01:24:47 But at the moment, once that dose starts to lose its effect, then you can go to the next dose. What about blindness? Is there any truth to the concerns around GLP1's causing blindness? There was a great study that look at millions of patients that show that patients on GLP1, there is no increase in the risk of blindness. And actually, a lot of patients on GLP1 had less risk of blindness, better outcomes in glaucoma because of the anti-inflammatory effect, because of the glucose control effect, right? What's happening with ozempic face or ozempic butt and how can we avoid those? You can avoid it and that's not an expected side effect that you think you're going to have because you are losing weight with a medication. If you're losing hair, if you're losing too much

Starting point is 01:25:36 laxity of your skin, you're also losing muscle because it's the same concept, not enough protein in your diet, right? Or you're losing weight too fast, meaning that you're losing muscle. muscle too if you are proactively increasing your protein intake in your diet and not losing too fast, too much. So ozambic face and ozemic butt are a sign that you're losing too quickly, you're losing your muscle. Yeah, and losing too fast, too much too quickly. There's a big debate online whether GLP1s directly cause hair loss or it's a side effect of losing weight.

Starting point is 01:26:10 It's a side effect of not enough protein in your diet. If you're losing hair, you're losing muscle. If you're losing muscle, you're losing hair. because you're not consuming enough protein in your diet to make it lasting, collagen, and build muscle. Okay. How much protein should we be aiming for? I found the sweet spot for the majority of women around 100 grams of protein a day on a GLP1. And for men, it's a little bit more like 120 to 140.

Starting point is 01:26:35 Do your patients have a hard time getting that much? At the beginning, but I found a way that it works for the majority of patients, and it's breaking it down in four portions of the, 25 grams of protein per day. They won't be able to get 100 grams of protein in food because I'm giving you a drug that is decreasing how much food you can consume. So even eating 100 grams of protein without a GLP1 is hard. But I add a GLP1, it becomes almost mission impossible.

Starting point is 01:27:03 So we have to rely on a supplement of protein while you're on a medical treatment. We have to remember you're taking a medication. You're in a medical treatment. So we need to use supplements to avoid muscle. loss, hair loss, collagen lost. 50% of your protein intake is going to come from food, and the other 50% is probably going to come from supplements, which is a protein shake, right? Also, protein shake are the most calorie condensed and high protein that we can get also, right?

Starting point is 01:27:35 Because a protein shake may have 120, 140, 150 calories. The key is that not to make it a meal, they'll make a smoothie of your protein shake. Don't add yogurt and fruit and fiber because then it becomes too bad. bulky and too feeling that you're going to replace a meal. They're not meal replacement. They're supplement to your meals. So getting four portions of protein of around 25 to 30 grams each is ideal and it's easy, right? Because you leave your house, you already have a protein shake, then lunch outside, dinner at home and then at bedtime another shake or breakfast, shake, dinner, shake. However, it works for the patient of their lifestyle to have two shakes and two meals

Starting point is 01:28:16 a day. There's a lot of concern that widespread access to these drugs is going to bring back a culture of disordered eating, of pedestalizing thinness. What do you think about that and how do you approach that? It's going to take time because we have to re-educate what the concept of a healthy weight is, right? Being skinny is not healthy. Actually, being skinny is the opposite of being healthy because they probably have very low muscle mass and who knows what's their body fat. Just because somebody's skinny doesn't mean that they're healthy. And I think that's the first thing that we need to change everybody, society culturally, right? That being skinny does not equal health.

Starting point is 01:28:56 And actually, I can tell you, actually it equals unhealth. Being skinny doesn't mean that you're strong. Doesn't mean that you have muscle mass. So we have to redefine what weight loss is. And weight loss is more body recomposition, right? So we have to re-educate ourselves that what it is to be healthy and what it is to look a certain way and to feel a certain way. Because again, the aim of this medication is not to make everybody skinny is to make everybody healthy. But healthy does not equal skinny, right?

Starting point is 01:29:34 Healthy is strong. Healthy is having lean muscle mass is being fit. So would the way to re-educate people in that be keeping an eye on this on our muscle mass versus our fat, like kind of really thinking about those numbers instead of the number on the scale, etc., etc.? 100%. And it's so beautiful when you see somebody being afraid of going to the gym or working out, incorporating this without the pressure for weight loss. when somebody starts exercising without the end result being weight loss, it changes completely how they look to exercise because now it's how they're feeling. You remove that pressure, it's different. People start exercising when they're not doing it just to achieve weight loss.

Starting point is 01:30:27 If we're interested in exploring this world, what should be our first step? Like, are we finding an obesity certified endocrinologist? What do you think about, like sites like Roe, which Serena Williams just came out all about. There's like L-E-M-D. How do we begin to get access to these things in a healthy way? I would say definitely read my book because my book is designed for somebody who's thinking of them or also for those that are already on it and to know that they're doing it the right way. I give red flags in what to look for red flags and who to go.

Starting point is 01:31:01 So red flag if they're not doing a body composition, red flag if they're selling you the medication themselves. Would that be like basically all of the online ones like LAMD and Rowe and all of those? Because it's compounded. All of those are compounded? I think that Rowe, they also have the FDA version with a prescription. So they give you, I think they do give you the option. But still may be a red flag because they're not doing. all the other stuff. But they're not doing your body composition. Most of this telehealth, you're just

Starting point is 01:31:35 filling out of form. Many of them, they don't even see you physically. You can be putting there that you're five feet and you are 300 pounds, right? That's a red flag. They don't care about your health. They just care for you to fill the form and get your medication and become a subscriber. You don't want to be under the care of somebody like that because they're not going to care when you are vomiting, when you have nausea, when you end up in the ER. Make your due diligence. Be an informed consumer. There's no more like I didn't know.

Starting point is 01:32:07 I didn't hear. I'm telling you, you need to investigate. Call, ask, does this doctor do a body composition? Yes. Okay, that's a green light. Do they sell their medication in their office? No, that's a green light. When you go in there, or you can even ask when you call to make the appointment,

Starting point is 01:32:27 are they going to give me a nutritional guidance? Is it going to tell me, is she going to tell me what I need to eat? What do I need to exercise? Is it cardio? Is it lifting weights? All of those can be green or red flags, right? So if they're talking to you about protein in your first appointment, if you're getting a body composition, if they're not trying to sell the medication there or supplements or stuff like that there,

Starting point is 01:32:50 that's a good place. They care about your health. I hear from a lot of people who feel really low energy when they take GLP-1s. Why is that? So this medication suppresses hunger, but it also suppresses. presses thirst. So you can be dehydrated and the thirst effect is not going to kick in. So for the majority of people that feel extreme fatigue, the day of the injection or the day after the injection is dehydration for the majority. So proactively, I tell patients you have to be drinking water without

Starting point is 01:33:19 feeling thirsty. About a liter and a half to two liters is enough. Or an easy way is you should be peeing every three hours. If you're peeing every six hours, every eight hours, you're dehydrated, you're going to feel tired, dizzy. So hydration and then also nutrition, right? If they're not consuming the protein, because you have to make what you're eating because it's going to be a smaller amount to count. So you want to get your nutrients in.

Starting point is 01:33:43 If you're eating something that is processed, fast food, and that's all you ate all day, you're not going to feel good. It's like because you're going to get full faster, every single thing you eat, you want to be as nutrient dense as possible, which is great for all the inflammation and all of that kind of stuff,

Starting point is 01:33:58 but can be tricky. if you're not used to eating that way. Exactly. Is there anything else that you feel like people need to know about these medications or myths that you want to bust? Definitely. So in today's world, nobody should be paying full price for this medication, even if you don't have insurance or even if your insurance didn't cover it.

Starting point is 01:34:16 So nobody should be paying those $1,200 anymore. Both pharmaceuticals who make the current medications that we have, which is Eli Lillian Novor Nordisk, have manufacturing coupons for each of their version of the drug that cost the price in half if you have a commercial insurance. So let's say you have your insurance, it didn't approve for the medication, you can use this pharmaceutical manufacturing coupon to decrease the price to half. Two, both pharmaceuticals have direct pharmacies that we doctors or your providers send a prescription there and they provide the medication, they mail it to you. And it's also around $500. So you ask your doctor to send it to their direct medical.

Starting point is 01:34:59 their direct pharmacy. The direct pharmacy. And then we send the prescription to the direct pharmacy. They send you, they send the patient a link. You open an account. You pay for your medication, which is no more than $500. And it gets shipped to your doorstep every three weeks. And where do we find the coupons?

Starting point is 01:35:16 The pharmacy would have it or your doctor would have it. Or easy, you go to the websites or both the Ossempeg, Wigobi, Monjarro, Seabbound individual's website, and there's the manufacturing coupon. And we can also now go even further that with the availability of a vial, because now Seabound, the direct pharmacy, they have the vials. So what we can do for some patients that are struggling to pay is to send the vial or send a higher dose and then do smaller doses in that vial. Because they can reuse the vial, essentially.

Starting point is 01:35:52 You can, like, put it back in the fridge. The pharmaceutical will sell no, right, because they don't want you. to do that, but it's safe. And I only do that with patients that feel comfortable with drawing the medication and inject them themselves because then we have the risk of overdosing cautiously when somebody with experience that can guide you and teach you how to other ways of being more accessible to the medication. This has been so incredibly helpful. I really appreciate you coming on and sharing all this info. And there's way more information, including exactly what to eat and how to work out and just very specific granular information about these drugs in your book

Starting point is 01:36:30 Weight List. Can you tell us a little bit about it in your own words? So my book is designed in three parts. It's the pre-GLP1. If you are somebody who's struggling with obesity and are thinking of going on a GLP1, the question is like you asked me like what to do, what to think, who to see, how to be proactive, how to choose the right doctor, or if you're somebody who is skeptical about a GLP1 or being on a GLP1 is cheating or you're feeling guilty about it. That's part one. Part two is once you make the decision, once you know this medication is for you, how to go through the GLP 1 is like myself going through every visit, holding your hand,

Starting point is 01:37:09 guiding you, what to eat, what to exercise, when to go up to the next dose, what things to ask your doctor. And the most proud part of the book that I am is the third part. And the third part of my book is what happens after you reach your goal. because we've been as a medical society and socially consume the last decades in getting to the goal, right? All our efforts has been, how do we get people to lose weight? For the first time in history, we're having masses of people reach weight goals that were not possible before. So this is the next horizon, the next era that we need to work on how to provide support to patients once they reach a weight that it was never possible for many of them.

Starting point is 01:38:00 And I'm not talking just about the physical changes where there will be physical changes like adapting to body temperature. Many patients when they lose fat, they start to feel extreme cold that it's almost uncomfortable, right? And we're just learning that because why they're losing that insulation panel. Now, there's physical changes, the extra skin, right? But there's also physiological changes, psychological changes. Patients now are having a different type of anxiety. The anxiety of weight regained. They're so afraid.

Starting point is 01:38:33 I don't want to go back to where I was before. It's like a different type of anxiety. Now it is from regaining weight. It's also so hard when we're trying to tell ourselves that are, appearance is not our worth or our value, but then the whole world treats you differently once you experience this type of thing? Exactly. We haven't prepared patience for that. Social scenarios, cultural scenarios, right? People don't know also how to approach you anymore or be in social settings that you are eating different than other people. That's the part that I'm the most proud of

Starting point is 01:39:06 my book because it's not talked about. And it's also telling somebody, what to look for or how to approach things once they lose the weight. Can I ask why you called it weightless? I chose this title and it took me a long time to choose the title that I wanted people to feel touched by the title. And the reason that I chose weightless is because what I've seen in my patients, when they come to me is for a physical load. It's a physical weight.

Starting point is 01:39:38 And what I see what happens in patients is that they start losing physical weight, that it's quantifiable, but they start to lose weight of trauma, weight of guilt. They start becoming lighter not only in body weight, but psychologically too, mentally. So I see patients, they become weightless. And that's the reason that I chose this title for my book. Thank you so much. This was such an incredible conversation. Thank you so much for having me. Thank you so much for tuning into this episode of the Liz Moody podcast.

Starting point is 01:40:20 If you enjoyed the episode, go ahead and follow on Apple or Spotify or subscribe on YouTube and hit that notification bell so you never miss a new episode. And if there's somebody in your life you think would benefit from this episode, send them a quick link. it is the best way to support the podcast, and it is so, so appreciated. And if you're watching this, drop me a comment. I would love to hear your thoughts and what resonated most with you. Thanks again for being here. I feel so lucky that I get to grow and learn and share with you, and I will see you on the next episode of the Liz Moody podcast. Oh, just one more thing. It's the legal language. This podcast is presented solely for educational and entertainment purposes. It is not intended as a substitute for the advice of a physician, a psychotherapist, or any other qualified

Starting point is 01:41:06 professional.

The Liz Moody Podcast - GLP-1s: The New Science Transforming Hormones, Weight Loss, Brain Health, and Beyond

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