← unPAUSED with Dr. Mary Claire Haver
unPAUSED with Dr. Mary Claire Haver
GLP-1s and Midlife Metabolism: Dr. Rocio Salas-Whalen Breaks Down the Science of Weight Loss and Menopause: Part 1
01:03:25
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- [00:00]
A
This episode is presented by MIDI Health. Be sure to stick around for a MIDI pause. Presented by Midi Health. This is where I'll take a moment to discuss some of the hottest topics in women's health as I partner with MIDI to bring women the care they deserve. You know, when you throw on the simplest outfit, your favorite jeans, a tee, maybe a blazer, and somehow one piece of jewelry just pulls it all together? That's exactly what Ginny Bird does. I just ordered my first piece of jewelry and I'm excited to wear it. There's Their pieces have this effortless way of standing out. You may even start getting compliments. People will notice and ask about them. They just have a way of pulling a look together without even trying. From bold hoops that step up a casual outfit to sleek bracelets and bangles that are perfect for stacking, there's something for every mood and style. And with the holidays coming up, gifting couldn't be easier. The pieces ship fast. They're comfortable enough to wear all day. Get 20% off your first order by going to jenny-bird.com and using the code unpaused at checkout.
- [01:03]
B
You've heard of Ozempic face, but have you heard of Ozempic liver and showing an improvement in the liver function test or the Ozempic pancreas? Less insulin resistance, right? Because there's more good than bad with these medications. And whenever a drug is FDA approved or whenever I prescribe a drug, it's because I know the benefits outweigh the risks. If it's in the right hands, we're gonna have very minimal side effects. Okay? If it's in the wrong hands, somebody who doesn't know how this drug work, they don't know how to guide the patient, right? Then that's where we see this crazy side effects that we're hearing in the headlines.
- [01:48]
A
The views and opinions expressed on Unpause are those of the talent and guest alone. They are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis or treatment. Menopause weight gain is so incredibly common. 80% of my patients come in with unexplained body composition changes as they're going through perimenopause and menopause. It can be so difficult to lose that weight and keep it off with diet and exercise alone. Quite frankly, when I first heard the hype around GLP1s, I was skeptical. Everything I saw on social media described it as the easy way out and that it was cheating. I hadn't realized that GLP1 medications had been used safely in diabetes care for more than 20 years before they suddenly became part of the public conversation around weight and metabolic health. Then I came across our guest, Dr. Rosil Saliswelan on social media and she explained these medications in such a compassionate, clear and evidence based way that I Learned more in 3 minutes that I had in months of reading headlines. I was so struck by her ability to translate complex science and real patient stories. I shared her video with my own audience and the response went viral. I reached out to her, curious to learn more and that message started a friendship that has changed my life. Since then, she's continued to educate me, challenge me and inspire me and I'm so excited to share her voice with you today. She filled the gaps in my knowledge. She taught me how to prescribe these drugs, the science behind them and why they work. She also gave me the confidence to start suggesting them in my clinic. The difference this treatment makes is night and day for my patients and that's why I'm here now, talking with my colleague and friend, Dr. Rocio Salas Whelan, because she's not only changed my perspective, but the lives and the health of my patients. I'm Dr. Mary Claire Haver, a board certified obstetrician and gynecologist and certified menopause practitioner. I'm also an adjunct professor of Obstetrics and Gynecology at the University of Texas Medical Branch. Welcome to Unpaused, the podcast where we cut through the silence and talk about what it really takes for women to thrive in the second half of life. Joining me today is my friend, Dr. Rocio Salis Whelan, a triple board certified internist, endocrinologist and obesity medicine specialist. She's also the founder of New York Endocrinology who's leading the conversation on GLP1 medications and how they can transform women's health. She's not only an expert in obesity medicine, but also a powerful advocate for women in midlife, challenging the stigma around weight, hormones and menopause. Her upcoming book, A doctor's guide to GLP1 medications, sustainable weight loss and the health you deserve is going to change the way we think about GLP1s and sustainable health. Today, she's here to help us cut through the hype and share what women really need to know. For those of you who've managed to tune out all of the talk about GLP1's let me give you a quick 101 depending on who you talk to, GLP1s are either a crutch or a cure, a lifesaver or a drug that wreaks havoc on your life. These injectable drugs, which we all know by the brand names Ozempic, Mounjaro, are technically called glucagon, like peptide 1 receptor agonists, and were originally developed to treat type 2 diabetes. Here's how they work. They mimic a gut hormone that tells your brain you're full, slows the emptying of the stomach, and improves how your body handles insulin and blood sugar. In just a few years, they've gone from niche prescriptions to cultural touchstones as breakthrough tools for addressing obesity. There is no doubt they are effective, but this has fueled both excitement and scrutiny, with some saying they're life changing interventions that finally validate obesity as a treatable, biologically driven disease. Welcome to Unpaused.
- [06:02]
B
Thank you. Thank you.
- [06:03]
A
Glad to have you here. I am so excited about this. When I sent a question out to my followers on social media, this was one of the top topics that they wanted to discuss and I could not think of a better expert to have on the show.
- [06:18]
B
Well, thank you so much.
- [06:19]
A
You and I met after you shared a few social media posts discussing GLP1s and I had never seen anyone do it in such an understandable, digestible way that was also led with compassion. What I'd been seeing were a lot of the people in the wellness section or personal trainers who were really skeptical about GLP1s and it made me skeptical as well until. Until I heard you talk and I think I sent you a DM or shared one of your posts and it went viral and I sent you a DM and we started chatting and then I was in New York for business and you texted and said, hey, let's meet for dinner. And I think we were out for about three hours talking that night.
- [07:04]
B
Yes, we were in a Greek restaurant.
- [07:06]
A
So I feel like I know you so well. But let's catch our listeners up. You were not born in the United States.
- [07:12]
B
No, I am born and raised in Mexico. I'm from the north. I'm from a border town in Mexico and I completed my medical training in Mexico. And. And then I decided to venture to New York specifically to continue with my medical training, my residency, my fellowship for our listeners.
- [07:31]
A
You went to medical school in Mexico?
- [07:33]
B
I did medical school in Mexico. Then when you come as a foreign medical graduate, you do your usmle, your American boards. Once you pass them and you get certified, then you can Apply for training, for residency, and then fellowship.
- [07:46]
A
So how long did that take you?
- [07:48]
B
A good 14 years.
- [07:50]
A
Wow. To go through all of the training. So walk me through. I mean, were you originally like, I'm going to get three board certifications. Like, explain to our listeners what a board certification is.
- [08:01]
B
So board certification is when you pass the exam, but you need to complete the training. Right. So in medical school, I fell in love with endocrinology. I fell in love with diabetes, metabolism, weight. Diabetes is the third cause of death in Mexico. So it was a disease that I was exposed to since very little with family members. So in decided endocrinology. So when I came to my training here, I knew I had to complete internal medicine first and then apply to endocrinology. During my endocrinology fellowship, these new medications that we're gonna talk about came out. And so I decided to become even more specialized in this and became obesity board certified, too.
- [08:41]
A
So basically, you did three residencies.
- [08:42]
B
Yes.
- [08:43]
A
I've only done one to give you.
- [08:44]
B
And one is enough.
- [08:46]
A
I was really honored to be asked to write the forward for Waitlist and so, so impressed with everything that you had to say and how you laid it out. But this is such an explosive topic, and today we're here to make sure that we get it right, that our, you know, listeners and everybody watching the podcast truly understands pros and cons, the good and the bad, and what, realistically, what a GLP one can do for patients. Tell me why you picked the title wait list. And I think you got pushback from the publisher a little bit, maybe.
- [09:20]
B
So the publisher wanted the GLP one word on my title. But I felt. And I know, and the vision of my book was beyond the GLP1, right? Yeah. GLP1. It's a big part of it. It's the end is the treatment. But my book is more about understanding why we're using a GLP1, right? Understanding obesity, understanding remov, removing the bias, removing the headlines, the negative headlines. In fact, I start my book with an apology, right? Because I feel like we owe an apology to patients with obesity because we were underestimating, we were doubting them, and they were actually following our recommendations. It was just not working because that was not the solution. And what I see in my patients as they're losing weight is they're losing not just the physical weight, but they're losing emotional weight. They're losing years of guilt, years of trauma, of shame. So they become lighter, not just physically, but mentally, mentally, emotionally. So that's Why I chose the word or the title weightless, because this is what I see my patients to become. And it's not just the physical weight is they're releasing, letting go of everything that was weighing them down.
- [10:50]
A
In your book, you write about a story, and you're talking about a patient, a man that you saw and you said. I explained to him what we now understand about obesity, that it's not just about what you eat or how much you move. It's about hormones, genetics, the brain, the gut, and many factors outside of willpower. And then something unexpected happened. There was a visual shift. I watched the tension in his shoulders ease as this emotional burden was lifted. He started to cry. For the first time, he heard that he hadn't failed. He felt the validation that what he was up against wasn't a personal flaw, but a medical condition. And I hadn't even told him the best part yet. There was something we could do about it. Why did you write wait lists?
- [11:44]
B
It makes me emotional because I remember exactly that moment with the patient, and it was not an isolated event. It was not an isolated visit. I saw this with many patients, and that's why the idea of wait list came for many patients, which. This patient was in his mid-50s, has struggled with weight since childhood. He spent most of his life feeling guilty, right? He had never heard that. It was not his fault. And me being an endocrinologist, exposed to metabolism, obesity, for me was an eye opening. When I started seeing patients with obesity, after one after the other were telling me that they were actually doing what we were recommending them, right? I would ask the questions, and they knew the answers. And they told me about diets that I've never heard. I'm learning about diets from my patients. Some can have personal trainers, chefs, they've been to camps, they have life coaches, nutrition coaches, you can name it, and they've done it. And they were not losing weight. And I learned this by listening to my patients. And I think as doctors, we always have to take the time to listen, but especially when you're talking about obesity, about somebody's weight, it's such a vulnerable conversation that they've been let down by family members, by doctors they don't trust. Right? And rightfully so. They have given up. So for many patients, their visit to me is like their last stop, right? I'm like their last opportunity for that to happen. And as I was learning this, I said to myself, people have to know this. Doctors have to know this. The general population have. If we doctors don't understand that people were actually listening to us. Let less people that are not in the medical field. Right. That we assume because even we as doctors, we would think they're lying to us.
- [13:43]
A
Yeah.
- [13:43]
B
Oh, you're telling me you're eating healthy? Oh, I'm sure if I go to your house, I will find out that it's not. Or you're exercising. I don't think you're exercising that right. We were questioning what they were doing.
- [13:53]
A
I 100% agree. The only thing I understood about obesity in four years of medical school and the little bit we touched on it in obgyn, not much, mostly around pregnancy, was this was a willpower issue. This was simply a caloric imbalance that nothing else, not hormones, not environment, not anything had anything to do with it other than it was a failure of the patient to not restrict calories enough or not move their body enough to burn the calories that they were consuming. Since really the revolution around the talk around GLP1s, I've come to understand a lot more. And in our in depth conversations and of course with medical articles now coming out and reading in Waitlist, you talk about obesity not being a matter of willpower, but of hormone genetics, brain and gut. How do GLP1s fit into that broader definition now of treating obesity as a medical condition?
- [14:49]
B
Well, once we can classify obesity as a disease, then we can think of treatment. Right. Beyond lifestyle changes. GLP1 medications is what we have actually at the moment for treatment of the disease of obesity. So it should be our first, but it should not be our last resource. Right. We should not exhaust all the other possibilities before a patient can earn a GLP1.
- [15:21]
A
So walk me through this as if I'm a patient. I'm coming in. We do a body composition scan and I have excess visceral fat. You are telling me the first thing in the treatment plan is going to be a GLP1?
- [15:34]
B
Yes, and I'm gonna tell you why. Why? Because this patient that is coming to me that whatever age they are, I'm not gonna be the first doctor that has told them eat less and exercise more. They've heard it way before I came into the picture. In their lives, they've heard it. And they not only have heard it, they've done it. Right. So we cannot assume that somebody with obesity doesn't know they have obesity. Right. We cannot assume that they haven't done more than you can imagine in order to lose weight. And if we think of somebody who has struggled with this, and let me tell you this takes over their life. For somebody who's trying to lose weight, and not necessarily obesity, but even somebody who's trying to maintain their weight, right, who may have tendency to gain weight, it takes over their life. It becomes a full time job. And what I was seeing it was in my patients in their 60s and their 70s, still, still concern. Every meal, every plate in front of them. How is this going to impact my weight? How am I going to feel after this? Am I going to feel guilty? Did I ruin my weight? Do I have to work harder even after five decades of struggling? Right? So when you have a teenage patient and you can have the opportunity to bypass that on them, imagine how much freeing it is mentally for that person. You're avoiding decades of struggle.
- [17:06]
A
I am seeing that in our clinic with our patients who we start on GLP1, suddenly they are clearing up headspace that they never had before, just taking what we're now calling food noise and out of the equation. And it's just giving them back such a huge chunk of time in their lives. And they're becoming more creative and picking up new hobbies because they're not always sitting there ruminating over how much is on this plate, when am I gonna eat my next meal, how many calories is in that? How am I gonna do this? When women come to you? And of course my patients are all female, so I'm, you know, I'm a little biased and say that they're doing everything that they used to do that used to work, but they're still gaining weight. How do you explain what is happening to them?
- [17:52]
B
It's a very frustrating thing for a woman in midlife to go through because many of them, they're exercising more, they're even eating more healthy, they're being more conscious, and the weight either is not coming down as they used to or they keep gaining weight. In a situation like that, we have to explain to the woman, the female patient, that her current environment, physiologically, hormonally, socially, is not allowing her and will not allow her to reach to the weight goal that she needs to be to be in a healthy weight.
- [18:34]
A
Right?
- [18:35]
B
Because our hormones, and you are an expert on hormones, in this period of a woman's life, which I've learned a lot from you too, their hormones are putting them against their own success or moving forward in their weight. Right. We know that the drop of estrogen can, can impact the body composition of a woman in midlife. We have more tendency of storing fat in areas where in our fertile years, our reproductive years, we did so more if in our reproductive years it's more hip breast due to the changes of estrogen, we start storing it centrally intra abdominally. Right. It's not just subcutaneous, but it goes surrounding our internal organs. And we know that that's. But that's visceral fat. And that's what we call the bad fat. Right. That's the pro inflammatory fat that leads to hyperinsulinemia, insulin resistant metabolic syndrome. That's why women in menopause have more risk of developing type 2 diabetes than in premenopause. Right. Because of these changes in body composition. And not only that, but we have more easy to lose muscle or harder to put muscle mass. So we have those two things that we're fighting against. So we whatever you were doing before that it was working. Now it's not because of that.
- [19:53]
A
So you're saying to our listeners that the estrogen declining in perimenopause and menopause is directly driving fat deposition to new areas.
- [20:05]
B
Storage of visceral fat which we had in subcutaneous areas. Right.
- [20:10]
A
Okay. So subcutaneous meaning under the skin.
- [20:12]
B
Under the skin where we can pinch. Right.
- [20:19]
A
You've heard me talk about the care gap in menopause. How women's symptoms are often dismissed or left untreated. I see it all the time in my practice. There are many women struggling for answers, unsure where to turn and too often not getting the support they need. That's why I'm so excited to tell you about MIDI Health. MIDI Health is a telehealth clinic focused exclusively on women in midlife. Led by trusted medical leaders and clinicians, the team is committed to evidence based whole person care. They're also the only national women's health teleclinic covered by major insurance. Making expert care accessible and affordable. When you work with Mitti, you get a personalized plan that can include hormone therapy, nutrition guidance, weight management and lifestyle support. It's care designed not just to help you feel better today, but to protect your heart, bone and brain health for the future. This is such an exciting moment. Menopause care is finally evolving into what it should be. Accessible and centered on women's real needs. It's inspiring to see the progress MIDI is making, helping women feel truly heard and supported. You deserve care that supports you now and protects your long term health. Visit join midi.com to meet with a MIDI clinician and start feeling your best for the years ahead. You know when you throw on the simplest outfit, your favorite jeans, a tee, maybe a blazer and Somehow, one piece of jewelry just pulls it all together. That's exactly what Ginny Bird does. I just ordered my first piece of jewelry, and I'm excited to wear it. Their pieces have this effortless way of standing out. You may even start getting compliments. People will notice and ask about them. They just have a way of pulling a look together without even trying. From bold hoops that step up a casual outfit to sleek bracelets and bangles that are perfect for stacking, there's something for every mood and style. And with the holidays coming up, gifting couldn't be easier. The pieces ship fast. They're comfortable enough to wear all day. Get 20% off your first order by going to jenny-bird.com and using the code unpaused at checkout. I just read a study that came out probably last week that talked about heart disease risk and where fat is deposited in males and females. In males, all fat deposition was harmful and led to increasing risk of cardiovascular disease. But in premenopausal females, fat deposited around the hips and thighs was actually protective of the heart. Postmenopausal, we lose that protection and we start shunting fat deposits to the abdomen. You actually tend to lose a little bit of subcutaneous fat of the fat under the skin over time. And that was the biggest driver of the risk of cardiovascular disease. It's so fascinating.
- [23:07]
B
This is something that I see clinically, the woman in midlife that is saying, this is not my body. I never used to put weight in my center. Now it's everything's going to my middle. My patients all the time during a.
- [23:19]
A
Well woman exam used to sit and grab their bellies in their little paper gowns and shake them at me and say, Dr. Haver, you know, what is this? Where did this come from? You know, I was always taught calories in, calories out. And I would give them the same tired advice and just think, this has to work. But I knew these women. These were my friends. I ran marathons with them. We hung out. Our kids went to school together. Like, I knew their lifestyles and their patterns, and I knew that all of a sudden they weren't, like, eating bonbons every night and had stopped exercising. And it really was. That was the inflection point for me as a clinician to be like, wait a minute, maybe there's something else going on outside of just lack of willpower leading to this. And then when I just focused on menopause care and was tracking the numbers, 80 to 85% of my patients are coming in with these body composition changes. So let's take it back to the basics for a second. What is body composition?
- [24:18]
B
Whenever we see a number in the scale, we're looking at sum of the weight of water, muscle, bone, organs. Not everything makes you sick in your weight. Right. It's specifically body fat or visceral fat, as we were just mentioning this. And also an other important metabolic marker is muscle mass. Right. So whenever we're looking at somebody's weight and we want to recommend weight loss, we need to see visceral fat, we need to see percentage body fat, and we need to see muscle mass. If somebody gets on a scale and gives us a total number, we cannot make the right recommendations. Right.
- [24:54]
A
So when I was training again that 25 years ago, we define health risks by weight and BMI, but that's changed recently. Can you talk about that?
- [25:04]
B
Definitely. I mean, BMI is a very outdated.
- [25:06]
A
And what is bmi?
- [25:07]
B
It's your body mass index, but it's a simple calculation between your height and your total body weight.
- [25:14]
A
I still use the term obesity.
- [25:16]
B
Yeah. And for many people it's easy to understand in that language. Right. But it's a simple calculation that it was designed for the white European in the 1800s. But if we cannot use it as a parameter of health, I think we can use it in a very broad population. Right. But it cannot be specifically for somebody when they're a single person, when they're trying to improve their health. We should look at other parameters. Look, GLP1 medications are sophisticated drugs. So for sophisticated drugs, we should have sophisticated ways of diagnosing somebody with obesity. Right. We know better now. This is not 20 years ago when we didn't know what we were looking at. Now we know. We know what matters in somebody's health. For longevity, for quality of life, for independence, movement to decrease your risk of mortality. Right. To decrease the risk of more than 50 cancers related with obesity, increase fertility.
- [26:20]
A
So how do you measure body composition?
- [26:23]
B
So there's several ways. The gold standard for body composition is an mri. Right. But mri, well, it's expensive. Expensive, expensive. You need to be in a radiology center to have all the logistics to have an MRI machine. The second best is a DEXA scan, but also expensive machine to have a doctor in their office. The third best is an impedance machine which uses electric current to separate fat, muscle and water. And that's what we use. What I have in my office, I have the same.
- [26:55]
A
So do you think these drugs are a game changer for midlife weight gain?
- [26:59]
B
They're a game changer for overall health. We will live longer because of the development of these medications. Okay, but which I have to say that GLP1 was discovered by a woman, which I think is important to mention because we don't hear their names. Right, right. It's Dr. Svetlana Mokschev and she was in Harbo Rockefeller center here, also in New York. And she's the one that discovered GLP1 in the human body.
- [27:27]
A
So how should we think about GLP1s in perimenopause and menopause?
- [27:32]
B
I think it's a great option, right, that we have. I think it's a great time to be a woman in midlife right now because of the availability of hormone therapy and GLP1 medication. Meaning no more accepting the less than 100% feeling good or having a good quality of health.
- [27:56]
A
Right.
- [27:56]
B
There's no excuses. Right. We can talk about cost, accessibility, but they are available. Right.
- [28:03]
A
What about in adolescents or younger patients? Do we have enough data?
- [28:06]
B
Yes. So they're actually approved. So liraglutide, which is Pictosa, that's a medication. A GLP1 that has a daily injection approved for type 2 diabetes, is approved for 10 years and older with type 22 diabetes. Saxenda, which is liraglutide for weight loss, branded for weight loss, is approved for 12 years and above. Wegovy, which is Semaglutide, also approved for 12 years and above.
- [28:32]
A
So rapid weight loss, if we know if someone undergoes a gastric bypass or, you know, severe caloric restriction, the studies done on those patients show a lot of muscle loss. And this has become really a hot topic on social media. How do you counsel your patients to protect their lean mass or their muscle mass while they're being treated with the GLP1?
- [28:54]
B
And this is something that even me, at the beginning when I started prescribing these medications, I wasn't aware of this. So it makes me think all those patients that lost after bariatric surgery or that we were recommending eat less, restrict yourself, and then coming and losing ten pounds. And we were so proud and reassuring to the patient, great, you lost the weight. It was probably a lot of muscle. Right? So we were doing more harm than better. But why?
- [29:23]
A
Why is losing muscle harmful?
- [29:25]
B
Muscle is our most important metabolic organ. It's actually an endocrine organ. It produces hormones called myokines. So muscle is anti inflammatory muscle, prevents insulin resistance, hyperinsulinemia. Right. Metabolic syndrome. Muscle, when it contracts, it subtracts glucose or takes glucose from the Blood and converts it to energy. Muscle burns fat for energy. So the more muscle you have, the more it's like you're burning calorie machine, you're burning fat machine. Right. The more muscle you have, the higher your metabolism is. The less muscle you have, the lower your metabolism is. Right. So muscle is a vital organ that we cannot talk about weight loss without talking about muscle.
- [30:16]
A
So in our clinic, we have an hour counseling visit before, you know, for a new start, GLP1. That's. We've already started them on hormone therapy. If they're a good candidate, they're coming back for this discussion and we take a whole hour to talk about ways to protect their lean mass while they're losing weight. What exact things do you counsel your patients about?
- [30:36]
B
Definitely.
- [30:37]
A
So is there a medication they can take to preserve muscle?
- [30:39]
B
Not yet. Not yet. We have to go back to the gym rack. So it's vital. And also I spend one hour with my patients in their initial visit because it's vital to explain to them that one part, one third of their treatment will be strength training and another third part of their treatment will be protein in their diet and the other third will be a GLP one.
- [31:04]
A
So that's your gps.
- [31:05]
B
That's my gps.
- [31:06]
A
So let the audience hear that again because I think it's so important.
- [31:09]
B
Yeah. So if I could write it in a prescription, I would. It's the gps. I call it like that because.
- [31:15]
A
Wait a minute. Do you think we should be able to write that as a prescription?
- [31:18]
B
Yes, we should. It is. It is health.
- [31:20]
A
Do you think that insurance should cover personal trainers?
- [31:23]
B
100%.
- [31:24]
A
All right, keep going.
- [31:25]
B
I like to call it the gps, like navigation system, because going on a GLP one, going into a weight loss journey is a journey. Right. So it's a roadmap. So the GPS consists of GLP1. Okay. The P is for protein in your diet.
- [31:39]
A
Protein. So GLP1 protein.
- [31:42]
B
And the S is strength training.
- [31:43]
A
Strength training.
- [31:44]
B
Right. So that has to go. I tell my patients the other two is as important as the GLP one.
- [31:50]
A
Okay.
- [31:51]
B
It's re educating the patient. We as physicians, as healthcare, we are re educating ourselves, but also we have to re educate our patients of the concept of weight loss. Right.
- [32:02]
A
So does it work?
- [32:04]
B
100%. So that idea or that headlines that you read, you're going to lose 30% of muscle? Yes, you can lose 30% of muscle. And it will definitely happen if you don't do your gps. Right. So once a person decreases their caloric intake, we're Decreasing our protein consumption. Right. So that's why there is muscle loss.
- [32:26]
A
Right.
- [32:27]
B
Rapid or significant weight loss is not free without muscle loss. Right.
- [32:33]
A
What's an acceptable amount then? So what you're saying is, let me make sure I get this right. You with any weight loss, you are going to lose muscle, right?
- [32:41]
B
Yes.
- [32:42]
A
How much is too much and what is your goal?
- [32:44]
B
So I recommend of what I've seen, because I perform body compositions on every single patient, on every single visit. So I know what the changes and what the changes that we're making in the patient's diet and the strength training, what changes we're seeing in the body composition. Let's say a patient comes to me after eight weeks, they lost 10 pounds. If they lose one pound of muscle, meaning 10% or less, it doesn't impact their fat loss. Right. Their percentage body fat loss and their visceral fat. If they're losing more than that, I have patients that maybe they lost 3 pounds out of the 10 pounds or that's 30%. Right. So that impacts or slows down the body fat loss.
- [33:26]
A
And why is that? Why would that be?
- [33:28]
B
Because you're losing your burning basal metabolic rate machine. Right. Your basal metabolic rate is becoming even slower. So whenever they said, oh, when you lose a lot of weight, your metabolism becomes slower. Well, it's because of all the muscle loss that happen with it.
- [33:42]
A
So what I think most of our listeners don't understand is what is the basal metabolic rate?
- [33:48]
B
It's how many calories you burn at rest just by what is one organ.
- [33:52]
A
That determines that amount. Right. So if I take all the muscle out of your leg, you know, 25% of your muscle mass, then you are not going to burn as many calories at rest. We know from studies that patients who stop GLP1s will regain about 70% of the weight. So there's a big debate about that. Well, and I have patients frightened, am I gonna be on this for the rest of my life?
- [34:19]
B
So we have to take, take a step back on this. Because the problem that we as a society, general society, and even healthcare, we need to stop viewing weight loss as something aesthetic, as something external. So if somebody's going into these medications thinking of something external, it does seem completely crazy to be on a drug long term for it. Right?
- [34:50]
A
Right.
- [34:50]
B
You got there, you got to your size, you got where you look good, then why continue with this medication? The problem is how we are viewing weight loss. And how should we be viewing weight loss? That's a medical problem. Obesity is a chronic disease. That weight loss is a treatment. GLP1s are a treatment for a chronic condition. And why do we understand by chronic conditions that they're not curable? Right. They're chronic. They will require long term treatment. Let's say somebody goes on blood pressure medication, they improve their blood pressure. What do we say? Oh, stop your blood pressure medication because now it's normal.
- [35:26]
A
Now there are people who can stop their blood pressure medication.
- [35:29]
B
It will depend on the individual personal story that took them to the place of needing a medication. Right. So if I have a 60 year old patient that started struggling with their weight at 8 years old, 9 years old, that it's been a lifelong struggle, then most likely they will require the medication long term. Right. And I always like to flip it and say it is not a bad thing because for the first time in history we have something that is going to help not just with the weight loss, but maintaining the weight loss. Right. Because any diet, yeah, you will lose it, but to stay there is what becomes impossible. But now using a drug with the correct supervision, it can be used long term, it is safe to be used long term and it's designed to be used long term. I can give you the example, my example, I never struggled with weight. I got pregnant in my late 30s, had my first kids. In my early 40s, I hit perimenopause, I gained 30 pounds. My A1C went up. Right. I had two toddlers, I used semaglutide for six months and I was able to stay off of it. But I strength training all my life and I didn't struggle with weight. Right. So in those situations there's a possibility. Right. I always tell my patients, your biggest bet on not depending on this drug long term is what happens to your muscle mass.
- [36:59]
A
What about patients who come in wanting to use them for short term reasons, say for an event, for a wedding, they're using them for cosmetic reasons.
- [37:07]
B
Well, again, they should not be used in that scenario. Right. But I've learned to not to assume anything. Right. And I don't know if this person is restrictive to maintaining weight and cannot get to a lower weight.
- [37:25]
A
So walk me through that. I've heard you talk about this before and I think it's so important for our listeners. Someone comes in with a relatively healthy weight and they are asking about this medication. It's not an automatic.
- [37:38]
B
No, it is not an automatic. No, it's not an automatic.
- [37:41]
A
Because the Internet will argue with you here.
- [37:43]
B
Yeah, even me that I've treated thousands of patients. When I see somebody externally, when they walk in my office, I cannot say what's their visceral fat, what's their percentage body fat, what's their muscle mass? They may look slim, but maybe it's because they have very low amount of muscle and high percentage body fat. And high visceral fat, right. Is what we call skinny fat or sarcopenic obesity.
- [38:08]
A
Okay. So but they come in, you do the body scan and everything kind of looks okay.
- [38:12]
B
Yeah.
- [38:13]
A
You're still saying no, no.
- [38:14]
B
And then I go, walk me through your day to day, right? Like what is it that you eat, what is it that you exercise? And for many patients it's a restrictive lifestyle to maintain that weight.
- [38:26]
A
What does restrictive lifestyle mean?
- [38:28]
B
Something that is not sustainable, Right. Something that is removing you from your daily life. Right? So somebody who is counting calories, who is weighing their food, somebody who is exercising seven days a week, right. That they cannot enjoy the process, that it's a full time job to maintain that weight.
- [38:49]
A
What do you see with those patients?
- [38:51]
B
That they may benefit from the medication, right? It's a, they can relieve them from that. And it's not just, here's the drug, you don't have to wait. But then it becomes a re education. Then you talk about muscle building, muscle strength training. See, these patients may be cardio queens, right? They're doing spinning every day, they're running, they're doing all the cardio. Then you re educate them on how to exercise. But once you remove that, that weight noise, then they can concentrate on exercising for health. So when you remove the pressure of weight loss to somebody or maintaining your weight, or maintaining your weight, it becomes enjoyable for many patients, right? It becomes more adaptable and easy to maintain long term. Because that's not the solution, right? That is not the solution for the weight loss. So to answer your question, it depends on the story, it depends how it's consuming their life. It depends on their body composition.
- [39:58]
A
So it is not FDA approved for outside of obesity. Right? It's approved for weight loss and obesity. But in this situation we don't have an FDA approval for this. But in your clinical experience you feel.
- [40:13]
B
Yeah, so patients, when we're talking about the indications, currently it's indicated for a BMI greater than 27, so that even on overweight patients. Right, but see, we're treating numbers, right? Right. We're treating numbers. We are not treating the patient. And we have to meet patients where they are. And I've heard you said this before, we have to see where they are in their life, in their age. We ask too much from patients sometimes without getting their results. It's not. I don't think it's fair for us to gatekeep a medication that can be beneficial not just physically, but mentally, also on a patient. Now, I do say no to some patients. So if a patient comes to me and they tell me, I wanna lose weight, but their muscle mass is great, their percentage body fat is great, then I say, no, you don't need the medication. So it's more of a reassuring, continue doing what you're doing. Because if somebody comes to me and their percentage body fat is low and their muscle mass is high, I already know that their lifestyle is healthy. I already know what the nutrition is. Right. I already know that they're working out. I can see their blood work is gonna be good. Right. Their blood pressure is good. So the parameters go with the body composition.
- [41:30]
A
That's my favorite visit, is someone who's felt she was overweight or even obese her whole life and she's never had a body scan. And we get her on the scanner and I'm look at this gorgeous muscle that you have. You have such little body fat. You have no visceral fat. You just have a curves that your genetics and God gave you. Her labs look great, her blood pressure's perfect. And she is so reassured because she has felt, because of this BMI ridiculousness that she has had a weight problem her whole life.
- [42:01]
B
Yeah. And it's also teaching patients, and this is going to take time, few generations is to understand that their weight doesn't equal their health. The number and the scale is not telling us all the picture in there. Right. It's your body composition.
- [42:17]
A
They're still hearing this from their clinicians and their doctors that your weight is too high, your BMI is too high. Even though the guidelines have changed, how long do you think it's gonna take before everyone gets on board?
- [42:30]
B
I think it's gonna take probably the new incoming generation of medical school students. Right. So probably in the next five years, 10 years, I think it's going to be more broadly accepted.
- [42:49]
A
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- [46:46]
B
So microdosing is when you use a micro amount, a smaller amount than the therapeutic doses. Microdosing is when somebody wants to use a smaller dose than the therapeutic dose to get benefits outside of weight loss. Right? Because we know that to reach weight loss you need the therapeutic doses. Now the concept of microdosing is by people and this is what I've seen the most. Is that for the anti inflammatory properties or am I missing out? Am I missing on the all healthy GLP1 that people that are losing weight are getting?
- [47:23]
A
I see it all over the Internet. Every wellness influencer talks about microdosing and.
- [47:27]
B
But so there's two things in those scenarios. One, it could be somebody who has a perfect body composition, right? Who low percentage body fat, high muscle mass, low visceral fat that I reassure them. You already are getting all the positive benefits that somebody's going to get from a GLP1, right? You have muscle mass, you are burning calories with your muscle, you're strong, you have a low percentage body fat, you don't have visceral fat. So you have a very low risk of disease. There's nothing extra that you're gonna get from a GLP1. Now that's one side of it. The other side is somebody who thinks who doesn't need to lose weight, right? I don't need to lose weight and I just want to use the medication. But surprise surprise, when we put them on the machine of truth, I like to call that the body composition. Then you realize they're under muscle, they have high visceral fat, they have high percentage body fat. So you don't need the micro dose, you need the regular dose. So what is that causes inflammation in our body? Visceral fat is pro inflammatory Right. And visceral fat increases insulin resistance, hyperinsulinemia, which also in itself is pro inflammatory. And then many patients with obesity may have low muscle mass, so it's a triple whammy in inflammation. Right. So when somebody goes on a GLP1 and they start losing visceral fat, their inflammatory markers go down. And if they start building muscle, then their inflammatory markers go even lower. Right. That's why we see improvement in autoimmune diseases. Right? Because now the immune system can do its job, can protect the body. Less infections, less getting sick because of that effect. But what is it in the medication? One, that you're gonna decrease eating, right? Your caloric intake is lower and how.
- [49:20]
A
Would that lower inflammation?
- [49:21]
B
Because you're dropping visceral fat. Second is because the effect of this medication that it decreases suppresses your hunger hormones and increases your satiety hormones. Satiety is when you're full, so these drugs increase your fullness hormones so you feel fuller with half of what you normally would eat. And then it suppresses your hunger hormones in between meals. Ok. Patients eat half of what they would normally eat without feeling hungry or craving in between meals. So by cutting us already immediately to 1/3 to 2/3 or half of what you normally would consume, your also decreases pro inflammatory food. This medication also suppresses their reward or blocks their reward from food. So what is the reward of food for many patients? Either starches, sweets, salt, those are high reward foods. They can be high reward foods. Right. And that's pro inflammatory food.
- [50:18]
A
Do you feel that part of the obesity epidemic and do you feel like it's an epidemic?
- [50:24]
B
Yes.
- [50:25]
A
Yeah, we know it is. Okay. Is due to the food industry in big part, yes.
- [50:30]
B
The way that our food is made in this country is not the best for our health. Right. We, we concentrate on quantity and not quality when it comes to food. I do feel like the food industry at one point, hopefully in the not too far away future will be held accountable for the obesity epidemic that we have. Right? Food accessibility, the good healthy food tends to be more expensive than the nun. Right. And you cannot argue with a family of six that they're making it month by month on their paycheck to buy grass fed meat or organic fruit. Right?
- [51:16]
A
Right.
- [51:16]
B
So food accessibility has to also change, but also our environment, right. Where we live, we live in cities where walking is not promoted, is not encouraged anymore. Then work from the car.
- [51:29]
A
We take the car everywhere.
- [51:30]
B
So also now we can work from our living room. We live in an environment that exposes us or makes Us be sedentary.
- [51:38]
A
I've heard it called an obesogenic environment.
- [51:41]
B
Environment Also we can talk about endocrine disrupting chemicals in the obesogenic environment. Right. Plastics, bpa, the forever chemicals. What's in our water, what's in our, the paint in our walls. Right. So that also can promote obesity now. And when we talk about obesity, we can go even generations before us and this is where we talk about removing the guilt for someone. Right. And I can give you the example of an appointment that I had with a new patient. It was a 14 year old girl that was brought by her mom and her dad and they were bringing her for obesity. And I had both parents there. And I always want to know what's the family history. I go two generations behind. The European parents struggle with obesity. In this case she was a 14 year old, her parents were there. So I was able to talk directly to both parents. The father also struggled with obesity. The mother had pcos. The father, his mother struggled with obesity and his maternal aunts also struggled with obesity. His brother struggled with obesity. So you can see three generations to my patient with obesity. So obesity is transgenerational.
- [52:57]
A
Yeah.
- [52:57]
B
There's even data, it's so interesting, there's even research showing that transgenerational trauma is a cause of obesity also.
- [53:09]
A
So there is a study I remember reading about in residency in obgyn and it was talking about imprinting, of changing our genetics. And this was specifically on women who were in Germany had, this is World War II and they had occupied maybe Belgium or you know, one of the European countries. And women who were pregnant during the occupation, they were severely calorically restricted because they didn't have access to food during the occupation. So they were just eating a few potatoes a day or whatever they could get their hands on. But malnutrition and starvation was huge during this occupation. They then go on to deliver their babies. Those babies were all born underweight. Okay. Which is normal. When you don't feed it a fetus, it doesn't grow. An overwhelming majority of those children who had non obese parents grew up to be obese. And the thought process was we had changed their genetics while they were, you know, embryos and forming in the uterus from this severely restricted environment.
- [54:10]
B
Yeah. So transgenerational trauma is a cause of obesity. Right. There's so many studies that, that children that go through trauma, even without having family history of obesity tend to have obesity more than those that were not exposed to trauma in early childhood. Right. So there's so Many factors that if you put them all together, how many does a person with obesity actually have control of?
- [54:38]
A
And being told your whole life this is your fault and you don't have willpower, I think that that's traumatic for patients as well.
- [54:43]
B
Very traumatic, very traumatic. And, and that's the reason that also they don't trust. Right? And they stop talking about it. But when I tell patients, even before you were born, you might already have the risk of having obesity. Because we know that genetics, and I'm talking about epigenetics, right, that there's multiple genes affecting that one single gene. So we know that both parents weight at preconception will impact the weight of their offspring of offspring. Amazing, even. And 50 to 70% going back to my patient, the patient, the 14 year old says to the dad, oh, so see, it's your fault that I develop obesity. And it was not to blame because his mom had obesity too, right? She didn't know, the father didn't know. But now we know, right? So this 14 year old that we can treat now will break that cycle of transgenerational obesity. And this is something that I always have when I have my reproductive age patients that they tell me, oh, I want to get pregnant in six months and they have obesity or overweight, I explain to them, look what your weight is and the father's weight. This is not just the mother, both parents weight is going to impact the weight of your children and your grandchildren. So with this information that we have, we can break that transgenerational obesity pattern.
- [56:16]
A
Now for a Medi pause sponsored by MIDI Health. One of the simplest, most powerful nutrients for women's health is vitamin D. Vitamin D is actually a hormone that affects nearly every system in the body, from our immune function, our mood, metabolism and even muscle strength. Yet over 42% of Americans are deficient in vitamin D and this number can approach 85% for women in medical. Here's why that matters. During perimenopause and menopause, our risk for osteoporosis, muscle loss and even low mood increases as estrogen declines. Vitamin D helps our bodies absorb calcium and phosphorus, two minerals essential for keeping bones strong and preventing fractures. But it also supports immune health, reduces inflammation, and has been linked to better mood regulation and cognitive function. The challenge? It's hard to get enough vitamin D from food alone. Fatty fish egg yolks and fortified dairy help. But sunlight is our biggest source. And depending on where you live, your skin tone and how much time you spend indoors, that might not be enough. Most women benefit from supplementing with 1,000 to 2,000 international units per day of vitamin D3, which is the form your body absorbs best. I recommend getting your levels checked with a simple blood test and adjusting your dose under your clinician's guidance.
- [57:37]
B
Guidance.
- [57:38]
A
Because when your vitamin D is optimized, your bones, muscles, immune system, and even your mood may thank you. And remember always to consult a clinician before introducing any new nutritional supplement. You say in waitlists that some patients who are given GLP1s are being set up to fail by being offered these medications.
- [58:05]
B
Well, unfortunately, everybody's prescribing these medications, right?
- [58:08]
A
Everybody.
- [58:11]
B
I can prescribe chemo drugs. I don't. Because I'm gonna create harm, right? But I could, but I don't. So GLP1 medication should be seen as the same thing, right? It's a medical treatment for a chronic condition. They're not something superficial, external to make the patient happy. I mean, I've had neurologists, ophthalmologists asking me, how do I prescribe this? And I'm like, you just shouldn't for now. I do think that every specialty gets a patient with obesity for whatever reason or that they're seeing the patient form a complication from obesity. But before we do more harm than good by prescribing these medications, we have to educate ourselves and obesity. And every doctor who's going to prescribe or anybody who's gonna prescribe this medication should have a body composition in their office. You need to do it responsibly because otherwise we are creating more damage than health. You're making the patient, maybe, yes, they lost 40 pounds, but they lost 20 of muscle, right. And their percentage body fat didn't drop that much. So, yeah, outside they look like they improved, but you might have made them less healthy than they came in.
- [59:28]
A
73% of Americans over the age of 20 have obesity or are overweight. That's 180 million people. Why?
- [59:36]
B
Again, because our knowledge of what caused obesity was not completely understood, right. As we know now. And even with the information that we have now, it's going to take several generations to make the changes. So even if today the food industry stop and changes the way that they produce food, food, it's gonna take two generations, right, three generations for us to see the impact. So that's why where we are, because food industry, industrialization, environment, right, because of all of that, is why we are in an epidemic as we are Weight Watchers.
- [60:14]
A
Noom telemedicine companies developed originally for hormone therapy are now shifting platforms and adding these medications, and now I've even seen new telemedicine platforms being develop. Now, this is a prescription. You must be a licensed practitioner in a state in order to prescribe these. So you can't go to Walmart and pick it up for yourself. So these are all licensed clinicians, but how do you feel about this kind of wave of new options available to patients?
- [60:46]
B
Well, I think weight loss has always been a very lucrative market.
- [60:51]
A
It's a big business, always.
- [60:52]
B
Even before we had GLP1 medication, right? So everybody's gonna want a piece of the pie. My problem with that is if they're not doing the right supervision, if they're not doing the gps, we know that they're gonna lose muscle. We know that that increases the risk for metabolic disease. So it's. Again, we cannot just concentrate on the number in the scale, on making the patient happy, on seeing a number drop or a bmi. So if they're doing body recomposition, explaining the patients have a body composition, doing DEXA scan, the more the merrier, right? Because I'm only one. People that are experienced, that have expertise are very few. And that's the reason that I wrote my book, because this is growing so fast. It's faster than what doctors are being trained of. So with my book, I want to have more people educated in the subject, right? Even maybe faster than what doctors are being educated.
- [61:49]
A
We've all heard horror stories of side effects, especially the viral ones, on social media. But let's break it down. What are the big side effects? How do you counsel your patients? And how common are they?
- [62:00]
B
We like to talk about the bad things, and we never talk about the good things. Right? I even made a video where it says, oh, you've heard of ozempic phase, but have you heard of ozempic liver and showing an improvement in the liver function test? Or the ozempic pancreas, less insulin resistance, right? Because there's more good than bad with these medications. And whenever a drug is FDA approved or whenever I prescribe a drug, it's because I know the benefits outweigh the risks Now. Now, if it's in the right hands, we're gonna have very minimal side effects, okay? If it's in the wrong hands, somebody who doesn't know how this drug work, they don't know how to guide the patient, right? Then that's where we see this crazy side effects that we're hearing in the headlines, right?
- [62:45]
A
So what are the side effects?
- [62:46]
B
So these medications work by slowing your Gastric emptying, that's how you stay fluor, that's your stomach. So normally when we eat, it goes through the stomach, it gets digested with the enzymes and then it goes through your bow, and then it's like a 24 hour process from when it comes in, absorb the nutrients and then dispose of what's not needed. This medication is going to be a slower process. Right. And that's how you stay fuller, also for longer periods of time. So what I've seen that I've had patients come, that they develop some abdominal obstruction or bowel obstruction.
- [63:23]
A
What is abdominal obstruction or bowel obstruction?
- [63:25]
B
So a bowel obstruction is when there's no passage of the nutrients not needed or of stool. Right. And it gets impacted and you can start vomiting, having pain. So it's very serious.
- [63:39]
A
So how often should these patients be seeing a clinician while they're on these medications?
- [63:45]
B
Ideally every six to eight weeks at the beginning. Right. Once you understand, once the patient understands the importance of protein in their diet, once you see they're not losing muscle, once you see they're tolerating the medication without side effects. You should see them every six to eight weeks. Once they're like halfway in the treatment, you can see them every three months. Right. But always available to answer any questions and teach your patients what things to look for. But in reality, you don't have to change the dose before every three months. Okay, so that's another thing. Right. So going up every month on the medication is not the recommended management of these medications. Right. Especially with our newer drugs like Tirzepatide. I have patients have lost 30 pounds even on the 2.5 or the initial dose.
- [64:33]
A
So they never. Some of the patients never go dose.
- [64:35]
B
Some of the patients never go to higher doses.
- [64:37]
A
So we talked about the gastrointestinal side effects. I've seen reports on the Internet of, you know, thyroid cancers. And Mark Hyman was discussing like a laundry list of, you know, potential complications, pancreatitis and all this stuff. How, how frequent are these? Or are these just case reports?
- [64:53]
B
I can tell you I've been prescribing GLP1s for close to 10, 12 years, okay. And I've never had, had any of those complications on my patient.
- [65:04]
A
What is the most common complication?
- [65:06]
B
Nausea especially, but more with semaglutide, which is Ozempic and Wegoli. I don't even mention it anymore with Mounjara and Seban, which is tersepatite diarrhea. But diarrhea can happen with any of the drugs of any of the generation of GLP1s usually. And this happens with any fatty food or fried food. They don't break the fat as easy and they may have diarrhea dehydration because normally our thirst is connected with hu. They need to proactively be hydrating themselves.
- [65:36]
A
How much water? What are we looking at?
- [65:38]
B
So I like to say one and a half to two liters. They should be peeing every three hours a day.
- [65:43]
A
Yeah, what about our menopausal mama who's getting up at pee, you know, at night?
- [65:47]
B
Well, the whole day I tell them three hours before you go to sleep you stop drinking water. So load your water during that first half day, the 2/3 of the day and then wind down and this is for everybody so they wake up where.
- [66:03]
A
To find Dr. Rocio Salis Whelan As a reminder to our audience, your book Wait List is out in December and available for pre order right now. Listeners can also find you on Instagram Rsalis Whelan I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram rmaryclaire and get the honest, accurate information on health, fitness and navigating midlife at the Paws Lab. If you're loving this podcast, be sure to click Follow on your favorite podcast app so you never miss an episode. While you're there, leave us a review and be sure to share the show with the women you love. We would be so grateful. You can also find full episodes on YouTube. Unpaused is presented by Odyse in collaboration with pod people. I'm your host, Dr. Mary Claire Haverto. The views and opinions expressed on Unpause are those of the talent and guests alone. They are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis or treatment.