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unPAUSED with Dr. Mary Claire Haver
GLP-1s and Midlife Metabolism Part 2: Dr. Rocio Salas Whalen Breaks Down the Science of Weight Loss and Menopause
00:54:21
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- [00:01]
Dr. Mary Claire Haver
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- [02:22]
Dr. Rocio Salis Whalen
If they're looking beyond the scale okay if they're talking about muscle, if they're talking to you about protein from the get go from your first visit, you cannot leave the office without having knowledge about muscle, about the possibility of muscle loss, about on how to avoid the muscle loss and why it's important not to lose muscle. Right? That's a green flag.
- [02:52]
Dr. Mary Claire Haver
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. In our last episode of Unpaused, we began a conversation with Dr. Rocio Salis Whalen about GLP1 medications, the science, the stigma, and why these drugs are changing the conversation around weight and metabolic health. Because we had so much to talk about, we decided to make this a two part episode, so today we will continue our conversation. Dr. Salas Whalen is a triple board certified internist, endocrinologist and obesity medicine specialist. She's the founder of New York Endocrinology and is one of the leading voices helping clinicians and patients understand GLP1s and how they can transform women's health. She's been a key voice in challenging the stigma around weight, menopause and hormones and next month her new book, A doctor's guide to GLP1 medications, sustainable weight loss and the health you Deserve will be released and is going to change the way we think about GLP1s. In this episode, we're talking about what happens after weight loss, the physical and emotional changes that no one prepares you for. We'll discuss compounding pharmacies, the future of oral medications, how to find the right provider, and what makes someone a good candidate for these drugs. Dr. Salis Willen also shares why body composition matters more than the number on the scale, how to support a loved one in this journey, and what the standard of care should look like. If we're doing this right, if you haven't listened to part one, go back and start there. But if you're ready to go deeper into GLP1's muscle preservation and what women really need to know, let's continue the conversation. I'm Dr. Mary Claire Haver, a board certified obstetrician and gynecologist and certified menopause practitioner. I am 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. The conversation around GLP1s seems really familiar to me. I'm seeing as much controversy and drama and guilt and shame and speculation and judgment in this conversation as I do with menopause hormone therapy. A woman Cannot get a break.
- [05:24]
Dr. Rocio Salis Whalen
Yeah.
- [05:25]
Dr. Mary Claire Haver
She has to justify her need for anything and everything. Do you feel the same way?
- [05:34]
Dr. Rocio Salis Whalen
Yes. And I tell my patients, you don't have to earn their rights to feel better. You don't have to prove to us anymore. In fact, I tell some patients, you don't have to convince me. When talking to my perimenopausal patients, I feel like they're trying to convince me to get them hormones. And I'm like, you don't have to convince me now.
- [05:56]
Dr. Mary Claire Haver
What do you think about this? If obesity was simply a man's issue and women just genetically would never become obese, do you think this would be a debate? Do you think we'd have the drama we see on social media?
- [06:10]
Dr. Rocio Salis Whalen
No. And yes. I think obesity affects both sexes equally. But definitely for women in midlife, it does become more difficult to get access to these medications. And it's a little bit more controversial because people tend to attribute whatever weight gain or symptoms are we having to part of aging. Right. To part of this is where you are. This is how it works now. It's just making it more difficult for us to have access to feeling better.
- [06:41]
Dr. Mary Claire Haver
So specifically to women in midlife. And this is centered around perimenopause and menopause. I see in the literature now, especially in the older guidelines, women gain weight with age. This is an age related issue. This has nothing to do with menopause. What do you say to that?
- [06:57]
Dr. Rocio Salis Whalen
I say it's not true. Right. Because I have women that have good muscle mass, that their metabolism is working and they're going through perimenopause, menopause, and they're still struggling. Definitely as we age, yes. We tend to accumulate problems physical, mentally, socially. That makes it harder for us to lose weight or easier for us to gain weight. Right. But not necessarily a concept of age. It's more our hormonal status, our parents getting sick, kids growing up professionally. There's just so many variables to it in the debate.
- [07:38]
Dr. Mary Claire Haver
I see the shame and stigma though, really focusing on women, like, oh, you're taking this to look a certain way. And maybe my social media is very biased. It only shows me menopause content and women our age, like 98% of what I see is. So I am in a bit of a bubble. But do you see because you treat both sexes, you know, the shame and stigma for both genders?
- [08:02]
Dr. Rocio Salis Whalen
Well, I think the issue that you are talking about that is women are held at higher standards in regards to appearance. Right. We have to look a certain way. We have to keep our husband. We have to be slim, be thin. There's just more pressure in women to look a certain way than it is with men. I think because of that, there is more stigma that somebody's going to try to use a medication to look a certain way. But again, we have to retrain the way that we think about weight gain and these medications, and the moment that we see it as a medical problem, then we can remove the. That stigma from it. It's not just about looking a certain way, it's about feeling a certain way. Because what I love of. Of what I do in my patients is they come thinking they want to look a certain way and halfway is how they feel.
- [09:01]
Dr. Mary Claire Haver
So my patients come in and same, same reason. A lot of them are super symptomatic from their menopause. Outside of the body composition changes. They're coming in with, like, debilitating hot flashes, night sweats, joint pain, you know, brain fog, all the things. And the first thing we do is put out the fire of menopause. That's what I do. You know, we get them on hormone therapy. If they're a good candidate and most women are, and we make them feel like they. They're human again, you know, then we address the body composition changes because of social conditioning, because that's all they know. They want that number on the scale. They want to look a certain way, they want to get back in that dress. They're showing me pictures of them in a wedding dress and what they used to look like as proof and could I ever get back to that? But what they leave with is talking about their mothers and their grandmothers who fell and broke their hip and who got dementia. And what are the steps we need to take so that you can live in this body as healthy as possible, and it may not be at this weight. How do you explain that to a patient?
- [10:09]
Dr. Rocio Salis Whalen
What helps a lot is when you show the patient their body composition. I think that's when the patients really understand what we're talking about, because it's very easy for that to go over your head if you're talking about their muscle and they're thinking, oh, I'm gonna look all muscly and I don't wanna get so big. But when they see it, right. Also when a patient loses muscle on a GLP1 and they see it, then they get it. And then the conversation becomes, how much muscle did I gain or did I not lose any muscle? They're like, muscle takes over. And I, the other day I had a 76 year old patient with osteoporosis. And I've been working really hard on her to build muscle and she's of that concept of skinny no matter what, right? So finally she started working out, gained muscle and she came to me in her next visit and she said, doctor, I was going to fold the other day, but I felt my core help me from falling. So she felt it, she felt it grounded because of her muscle mass. Once somebody feels that it's your, your work there is done really, because once you feel strong and you feel protected in your own body, you don't want.
- [11:30]
Dr. Mary Claire Haver
To get that out and you realize you avoided injury. So I was in Australia and I, we spoke at, I mean I, I was at a conference at the opera house, which was amazing. My husband and I traveled for, you know, 10 days after to go see parts of the country. And we were staying at a hotel like on a hillside. So our room had different levels. And I got out of bed to go pee in the middle of the night and as per usual and I stepped forward and I was confused. I had been in a different hotel every night and there were stairs and I didn't see them, it was pitch black. And so I kind of stumbled down the stairs, but I didn't fall. And I caught myself and quickly was like, I could have lost teeth, I could have broken massive bones. But all of this exercise I've been doing for strength training, when I was a cardio queen, I was that girl because thin was the only way to be healthy. And I realized at that moment, I saved myself in that moment because my balance and my strength were on point that I stumbled downstairs in the pitch black of night and avoided a horrible injury. And once my pulse went back down, I went and peed and then got back into bed and tried not to wake up my husband to tell him what had happened.
- [12:39]
Dr. Rocio Salis Whalen
It's a real thing how you work out, you build a muscle, but when you use it in the day to day life, then it gets really like it settles in your brain.
- [12:50]
Dr. Mary Claire Haver
Then, yeah, let's talk about Serena Williams. She's all over the Internet, all over the news right now. You know, here is inarguably the best athlete, maybe her sister is right up there with her in the world.
- [13:07]
Dr. Rocio Salis Whalen
In the world.
- [13:07]
Dr. Mary Claire Haver
You cannot tell her, work out more, eat less. And she was struggling with postpartum weight loss. Gets on a GLP1, loses 30 pounds, tells the world about it, takes a picture in a bikini, she's got muscle. She is still, as you know, she is healthier than she's ever been. But why do you think the uneducated are wanting to get into this discussion? And so much judgment.
- [13:37]
Dr. Rocio Salis Whalen
Definitely. And I think what she did, it was very positive in many different ways that I'll mention them. But I think that she being an example of being an athlete, right? She is an athlete. She has won several championships in what she does in her sport. If there's somebody who knows how to exercise, how to eat, is going to be a athlete at her level. But she's in midlife too. She's in her 40s. She had kids late. There may be some family history there, some tendency. And when I see many times is some people that are in their 20s and their 30s that were physically active and they were able to maintain the weight if they were not as active, if they didn't have that lifestyle, probably they've had obesity. Right. So the moment that that stops or changes. Right. You know, having kids, having toddlers, many times you don't have the time to exercise as much. And then midlife. So all of that had her with the difficulty of losing the extra weight from pregnancy. Right. So if there was somebody who knew what to do about this, she was her. And we cannot assume that she didn't do it and she just went to get a GLP one. I'm sure without knowing I'm not her doctor, but her trajectory as an athlete, that she must have tried first with what worked before being active and eating healthy. But when that didn't happen, then she used a GLP1 medication. And this is a perfect example on how a GLP1 medication can be very beneficial. Right. And how a GLP1 medication is not the only way. Right. In her case, she's continues to exercise, continues to do her tennis and eat healthy, but also using a GLP1. So this is like a beautiful example. And I also think it's really important that she shared because what happens when people don't share that they lost the weight with a GLP1? They continue to promote this erroneous idea.
- [15:46]
Dr. Mary Claire Haver
Yeah.
- [15:47]
Dr. Rocio Salis Whalen
That exercise and eating, eating less, that's with the weight loss. So people say, well, if she did, she did it with that, then I should be able to do it. Right. But when you say, no, I didn't do it like that. I actually needed a medication that helps. Other people say, well, okay, then I should benefit from a medication too. Right. You don't propagate that idea that eating less and exercising more was what they needed to lose the weight. Right. So we're seeing a lot of celebrities and people that struggle with weight most of their life and suddenly they're losing weight. So when they share, they normalize this as a medical treatment. Right. Otherwise they keep giving the false idea that by eating less and exercising more is the way to do it. Now, she also promoted a telehealth service for the GLP1. Right. So she's a businesswoman and she's never shied away from owning it.
- [16:39]
Dr. Mary Claire Haver
Shaming women for being business women is a whole nother podcast we can get into.
- [16:44]
Dr. Rocio Salis Whalen
But you know what? Thanks to those women that we can also be entrepreneurs. Right. So they're opening doors for us for a woman to own a business. And yes, that's another podcast. But talking about telehealth. Telehealth can be very successful for GLP1 medications. I've had patients that I've never met in person that they've lost £80, £100.
- [17:06]
Dr. Mary Claire Haver
It's just through telehealth in her office.
- [17:08]
Dr. Rocio Salis Whalen
Yes. Okay.
- [17:09]
Dr. Mary Claire Haver
And what is telehealth? Just in case.
- [17:10]
Dr. Rocio Salis Whalen
Telehealth is not in person visits, it's virtual visits.
- [17:15]
Dr. Mary Claire Haver
I have a lot of patients who come in and weight is now an issue. Visceral fat's an issue. Their muscle mass is fine. We have no. I have no worries about starting them on a GLP1. I think they're a great candidate. And they say to me, they. They feel guilty for, you know, that they're cheating somehow. They always say, let me give diet and exercise a try. And I say, well, haven't you already done that? And they say, yes, but, you know, may maybe this time it'll work. What would you say to a patient like that? And do you hear the same thing I do?
- [17:43]
Dr. Rocio Salis Whalen
I would say a lot of my patients come knowing that they will need a GLP1 medication because of my specialty. Right. That I'm an obesity physician. So many patients come to that.
- [17:53]
Dr. Mary Claire Haver
Right.
- [17:54]
Dr. Rocio Salis Whalen
I see guilt in sharing that they're on a GLP1 medication. Right. Even within their spouse or their children, they're shame. They're embarrassed that they think they're taking the easy way out. It's not an easy way out.
- [18:06]
Dr. Mary Claire Haver
No.
- [18:06]
Dr. Rocio Salis Whalen
Because building muscle, eating protein a day, it's hard work. So when you educate them that and make them part of the treatment, it changes the concept of the medication. There's no more cheating. You're actually work out. You have to go to the gym, lift the weights, and I'm going to be looking for your muscle in your next visit. Right. And Eating protein, the amount that is recommended for not to lose muscle, lifting weights is work. It's not cheating. Actually, patients have to work a little bit harder.
- [18:39]
Dr. Mary Claire Haver
What I find with our patients is it is work because your hunger cues are different, you're not as hungry and they really have to work at getting enough protein in. And now I know we're going to get a ton of questions about this. How much protein do they really need?
- [18:58]
Dr. Rocio Salis Whalen
What the USDA is recommended is like point 8, the necessary for life. Right, Right.
- [19:06]
Dr. Mary Claire Haver
The bare minimum. The bare minimum to avoid kashioricor, which is severe protein malnutrition. Exactly. Very different than something to support muscle mass.
- [19:15]
Dr. Rocio Salis Whalen
Exactly. You need to build muscle, you need to feed the muscle. To not lose muscle, you need to eat the protein. There's no way around it. Right. So what I found for the majority of patients, the sweet spot, and I can say this by doing thousands of body composition and seeing different amount of protein in somebody's diet. What's the minimum necessary to not lose muscle while you take a GLP? 1 is around 100 grams of protein a day. Just the minimal to not lose muscle or to lose less than 10% of muscle.
- [19:50]
Dr. Mary Claire Haver
Okay. Is that dependent on how tall she is or her starting muscle mass?
- [19:53]
Dr. Rocio Salis Whalen
Ballpark for the majority of patients, when we're just talking about not muscle loss, I mean, hence also if it's a male that is six two and and their ideal body weight is still 200 pounds. Right. Then it's more the amount. So what's recommended, what literature tells us is should be 1 gram of protein per pound for your ideal body weight. So if somebody who is 250 pounds comes to see me, but they need to lose 80 pounds, I may base on the ideal targeted weight target. It's a lot. So I cannot ask a patient to eat 180 grams of protein when I'm giving them a medication that is suppressing it will go back to the restrictive full time job event. And we're moving away from that. That's the last thing I want. Right. I wanted to make it something that is sustainable and that the patients can still do without taking over their life.
- [20:48]
Dr. Mary Claire Haver
Okay.
- [20:49]
Dr. Rocio Salis Whalen
So we have to. It's a fine line between having the patient not go to the restrictive in an opposite way or obsessive with exercise, obsessive with the protein. Right. So you have to have some room there for not for perfection. We're not reaching for perfection.
- [21:12]
Dr. Mary Claire Haver
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- [24:01]
Dr. Rocio Salis Whalen
Oh, no. I have patients with eating disorders that they get relieved from the eating disorder. Right. Especially binge eating bulimia patients with anorexia. It's a different conversation. I wouldn't say no, but it will be per case basis. But somebody with binge eating disorder, bulimia, it does help. It minimizes the anxiety and the mental disorder. Right. Eating disorder. So it helps them a lot.
- [24:35]
Dr. Mary Claire Haver
Let's move towards the emotional impact of GLP1s and weight loss. So how can people manage this mental shift of rapid weight loss? They've been living in this body at this size, usually for a minute, and it's been a slow kind of progressive. Most women gain three to five pounds a year at perimenopause, through perimenopause and menopause. So they feel like they, you know, some women will gain 30 pounds in a very short period of time. But most women, it's a very slow progressive. All of a sudden, you know, in our clinic, within six months, we're taking them back down. It's an emotional shift for the patients. And so how do you help them navigate this?
- [25:15]
Dr. Rocio Salis Whalen
This is one of my proudest thing in my book that I wrote is the part three is the what happens after. Because we are barely educating in the before and the during. We are not educating on the after. Right. Because for the first time in history, we're gonna have masses of people reaching weight that was unreachable before. Right, Right. So many patients, for the first time in their life, they are in their ideal body weight. Because I follow my patients long term. Right.
- [25:50]
Dr. Mary Claire Haver
And what I see is patients get to their goal weight, especially with the uneducated, you know, someone just giving out the medication, they get to their goal weight and they're done. They never see that doctor again.
- [26:01]
Dr. Rocio Salis Whalen
Because I like to separate the treatment. One is the getting there and the other one is the maintaining the weight loss. Right. Because that's the hardest thing is maintaining the weight loss.
- [26:11]
Dr. Mary Claire Haver
This is what you feel like is the most important part.
- [26:13]
Dr. Rocio Salis Whalen
Yes. Because it's where the work that you've done in this process starts to give fruits. Right. Any diet, crazy diet, can take you to your goal to maintain the habits. Right. My goal for my patients is not necessarily stopping the drug, but always the lowest dose possible long term. So that's the goal. But when we're talking about the after the weight loss, and I've seen this in my patients, by following them after they reach their goal weight, let's talk about the physical changes because they're physical changes, right. Many patients start experiencing painful cold intolerance. They start feeling cold and it's something so foreign for them that it's actually painful. It's because they've lost insulation, right. They've lost significant amount of body fat. Some patients that had X excessive amount of fat, then they have excess amount of skin that some patients may need surgical treatment for relief because they. You can have infections. It's bothersome physically, not just psychological or aesthetically, but it can also have medical consequences.
- [27:20]
Dr. Mary Claire Haver
Right. We see that after pregnancy, occasionally someone with a very large, you know, especially with multiples distended abdomen, suddenly they're not pregnant, they go back to their normal weight and they have this massive amount of skin hanging. And those patients do beautifully with abdominoplasty removing that skin because they are getting fungal infections and bacterial infections underneath that flap.
- [27:41]
Dr. Rocio Salis Whalen
Exactly. And it's a problem for them. It's not something banal. It is a true problem. So those are the physical. Then we go to the emotional or psychological changes. Many patients that were never on their ideal body weight until now, a new type of anxiety comes in. Right now they have an anxiety of weight wreaking. Now that they know what it is to be in their weight, they're terrified of regaining the weight. They're really affect them mentally, Right. So it's reassuring them. It's seeing them after they reach their goal to maintain also that they don't become anxious about weight wreaking. Some patients the physical adaptation takes is quicker than the psychological adaptation. So many patients, even though they've lost a hundred pounds, they don't see themselves still in that way. Right.
- [28:36]
Dr. Mary Claire Haver
What another thing that I see with our patients, especially if it was a large amount, you know, 50 plus pounds is the world is looking at them differently and treating them differently. And they don't have the social skills to deal with all of this new attention. They were invisible before. Especially women become more invisible in midlife and beyond. We always value youth and vanity and being thin and all of a sudden they have this new body. How are you counseling them about that?
- [29:05]
Dr. Rocio Salis Whalen
I had a new patient that I saw in her late twent and she told me one year ago I went to a doctor and he gave me a GLP one but I decided not to use it. I decided to go to therapy first before going on a GLP1. And she said I wanted to be prepared when people would act differently to me when I lose the weight. She said I needed to feel secure about myself and not question when people start being nicer to me just because I lost weight, which I like. It was for me, it was like mental orgasm almost. Right. Like the thing that you want is like, oh my God, yes. You know, this is what we're seeing now. And I applaud her and I was so proud of her.
- [29:57]
Dr. Mary Claire Haver
Do you think that massive weight loss, those patients deserve therapy?
- [30:01]
Dr. Rocio Salis Whalen
100%. 100%. And right now we are doing everything ourselves. And this is what I'm learning and this is what I wrote my book. Because I'm seeing more day by day than anybody else can see. I see them together.
- [30:16]
Dr. Mary Claire Haver
That's all you do?
- [30:16]
Dr. Rocio Salis Whalen
That's all I do every day, five days a week. So that's why it's important for my book to get it out there for those that don't have access to doctors like me or mental health. Right. It doesn't replace any of that. But in the meantime, we all get educated and we have more mental health professionals specialized in obesity and weight loss, I think is the next specialty that is gonna come out to you. Somebody who's healthcare and mental health sub specializing in weight loss. It's going to be very important because we need to give therapy to give them the mental tools for patients to approach our new life. And let me stop and say, for the majority of patients, it's happy changes.
- [31:00]
Dr. Mary Claire Haver
Yeah.
- [31:00]
Dr. Rocio Salis Whalen
Even with those changes, patients would not choose to go back to where they were. So for the majority, it's always something positive.
- [31:08]
Dr. Mary Claire Haver
So in my clinic, I only treat females, you're treating both. And I'm sure you treat couples that it's probably inevitable. I don't. We only see women so occasionally, you know, in follow ups and we're talking about how's it going? What I'm seeing is if there's a mismatch, if one. One part of the couple is on a glp, one and the other is not. There are so many micro changes in their relationship. Going out to dinner, staying late at parties, drinking alcohol, you know, that things that they built their relationship on, their fun time, their, their social interactions have changed. Where one person is left behind and the other person is changing. And it's not that one per. One part is obese. She's loved this person for 25 years, 30, whatever it is, you know, his body hasn't changed, but she's changed. Do you see that in your practice as well?
- [32:02]
Dr. Rocio Salis Whalen
Yes, I do. And I've actually seen divorces.
- [32:04]
Dr. Mary Claire Haver
Yeah. I was gonna ask, have you heard of the Ozempic divorce.
- [32:08]
Dr. Rocio Salis Whalen
Yes. And I've had several patients that actually I saw them as couple individually, but that the wife came, the husband came, and that they got divorced. Right. So again, there's gonna be a lot of biopsychosocial environmental changes. This is even before GLP1 medication. When I used to talk to my patients about diabetes, nutrition care, I always used to tell them it will work better if the other people in the house will also eat this way or start exercising or eat healthy. Right. It's easier to maintain. So what I see many times is if the spouse comes first, eventually the other spouse would come. Right. If they were also struggling with weight or food was and enjoyment. Because if you have a spouse that is working out weight training, then that's not an issue. Right. They're happy that their spouse is now.
- [33:00]
Dr. Mary Claire Haver
In that, doing that with them.
- [33:01]
Dr. Rocio Salis Whalen
Exactly. But if you have a couple that both of them struggle with their weight, struggle with eating poorly or alcohol, then eventually the other spouse comes too. And I think I see that a lot.
- [33:15]
Dr. Mary Claire Haver
Talk to me about addiction and changes in behavior we're seeing with unintentional, you know, GLP1 changes we're seeing that might be positive.
- [33:24]
Dr. Rocio Salis Whalen
So with alcohol. Right. There are studies with tobacco also. Because for some who have addictions. Let's talk about alcohol. It may be a reward. It's an anticipation, because GLP1s block that reward system. If alcohol was a sort of a reward, it's the drive will be less, the behavioral changes also, it makes you fuller. So you may have one, two drinks and that's it, and you're done. What I do see is for those effects to happen, it has to be on higher doses of the medication. I rarely see an effect on alcohol or smoking at the lowest doses. We have to actually have to reach higher doses.
- [34:08]
Dr. Mary Claire Haver
As a menopause specialist, I was really excited. I know you were too, last year to see what research had really confirmed that we were seeing in our own practices that versus and it was semaglutide. Semaglutide. So patients on the GLP1 versus patients on GLP1 and menopause hormone therapy. The menopause hormone therapy. GLP1 group lost more weight than semaglutide alone. Why do you think that is?
- [34:36]
Dr. Rocio Salis Whalen
Well, it can go from the physiological to the socially part too. Right. So if you have a woman in midlife who's having insomnia, not sleeping, waking up at 3am in the morning, versus you have somebody who's on hormone replacement therapy, they're sleeping they're feeling energized, they have more drive to exercise, and you give them a GLP one, well, they're gonna have better result. Right. If we talk about the external things, but then hormonally also. Right. So as we talk, initially, the drop of estrogen can change your body composition. Right. By giving somebody what they're not making, then you're helping. We never promote them as weight loss. Right. Hormones are not weight loss. For that we have GLP1 medications, but it's going to help your body recomposition.
- [35:25]
Dr. Mary Claire Haver
Synergistically to work together. So there's no question that these medications are very expensive and out of the ability right now for probably half of Americans or more than half to afford. My daughters were showing me these memes that were basically celebrities before and after plastic surgery. And the title was, you're not ugly, comma, you're just poor. And now it's, you're not fat, comma, you're just poor.
- [35:57]
Dr. Rocio Salis Whalen
That's so sad.
- [35:58]
Dr. Mary Claire Haver
It is something that I struggle with as a provider because the only patients I can offer these medications to who don't have overt diabetes and get insurance to cover, or some policies will cover pre diabetes. But if she's coming in with elevated visceral fat, but she's not morbidly obese or she doesn't meet whatever the gatekeeping of the insurance companies is deciding, some of these patients cannot afford this medication. Do you see the cost coming down?
- [36:28]
Dr. Rocio Salis Whalen
I do think right now there's a monopoly of these medications. Let's talk about that. Novo Nordisk and Eli Lilly, they control. They're the only sole producers of this medication. So they can charge whatever they want, because they can. Also the production of the individual single pens is very expensive. So if you have. If you see in Europe, the Mounjaro pen gives you four doses. So it's a monthly pen versus here we have every week you use a new pen, which, believe me, that hurts me to prescribe so many. And what's doing to our environment, because I investigated what to do with the pens. You cannot recycle them. They cannot be burned. They go to landfill. So to start with that, it's already we are fixing one problem, but are we creating another problem environmentally? Right. So that's what's driving the cost. So Eli Lilly now they have their drug Tirzepatide in vials.
- [37:28]
Dr. Mary Claire Haver
Yes.
- [37:28]
Dr. Rocio Salis Whalen
Right.
- [37:29]
Dr. Mary Claire Haver
That is now where most of our patients are getting the medication is direct from Eli Lilly. And the cost is roughly half of what we had to Tell them last year.
- [37:37]
Dr. Rocio Salis Whalen
So if they're paying out of pocket for the 2.5 milligram dose, it could be $1,100. For the vial itself, it's $300 a month. So it's almost one fourth of what it costs. Right. If we go to higher doses, it becomes half of what it costs. There's more options. Right. There's a manufacturing coupon. There's the direct pharmacies from both Novo Nordisk and Eli Lilly. So that is good. Hopefully more they will become more available in a vial, removing the manufacturing process of the pens. Or they can become multiple use pens. I think that's also going to decrease. So once there's more competition that is coming from different pharmaceuticals and more drugs and more options, then the cost needs to, to, to, to come down.
- [38:24]
Dr. Mary Claire Haver
I want to go back to, you know, semaglutide and tirzepatide, which are the two most commonly prescribed medications now, and compounding. So some of these telemedicine platforms are only prescribing the compounded options. Some of these platforms are basically pharmacies and they're distributing a lot of compounded medications to the patients. How do you feel about compounding? It does tend to be cheaper. You know, a lot of patients, it's cost prohibitive. It's compounding or nothing as far as their budget.
- [38:53]
Dr. Rocio Salis Whalen
Yep. So the safety should not have a price. Right. You should not put your health at risk because it's cheaper.
- [39:02]
Dr. Mary Claire Haver
You feel these drugs are putting people at risk.
- [39:04]
Dr. Rocio Salis Whalen
Yeah. So actually there's studies.
- [39:07]
Dr. Mary Claire Haver
This is specifically the compound compounded.
- [39:09]
Dr. Rocio Salis Whalen
There are studies that have shown that most of the calls for toxicology for overdose of GLP1 is with compounded medication because you run the risk of overdosing yourself. The problem with compounded medication, there's several. One is that it's not FDA regulated. The standards of higher quality and safety that FDA drugs go through. Right. So for a drug to get approved, you know, it can take 10 years of studies and showing the studies of safety for that doesn't happen with compounded medication. Right. Second, right. Now, when there was a shortage of the drugs, it was legal to compound the medication. But now there's no shortages. And actually both Eli Lilly and Novo Nordisk have active lawsuits to compound in pharmacies because they cannot reproduce the drug anymore. So what's happening is a lot of the compounding pharmacies are mixing them with other things so they can get around that law. Right. So not exactly the same drug. So they're idiots. Adding vitamin B12, they're adding folate, they're adding other things. So that's already manipulation of the drug, of the compound. So another risk of side effects. Right. Or side effects that are not expected, that were not seen in the supervised studies with the FDA approved drug. I do talk in my book about compounded medications because it's a reality, as you mentioned.
- [40:30]
Dr. Mary Claire Haver
It's a reality. I see patients who come in on a compounded medication who would never have used anything compounded, absolutely would go to Walgreens and pick up whatever they need. It would never occur to them to go that route. Except for this. They're so desperate.
- [40:47]
Dr. Rocio Salis Whalen
I don't recommend it, I don't prescribe it. But I understand some people will still go on a compounded medication. So in my book, I give a guide which are the compounding pharmacies that are at the highest standards or higher quality. Also, what red flags and green flags from who's giving you the compounded medication. Right. Because if somebody's giving you compounded medication, I can almost know that they're not endocrinologists. They're not gonna be board certified obesity medicine. So it's not just that they're giving you the compound. That is, what guidance are you getting with the compounded medication?
- [41:20]
Dr. Mary Claire Haver
Let's go back to the future. The exciting part. What does the drug pipeline look like? So right now we have GLP1s and then we have the tirzepatide. What is tirzepatide versus semaglutide?
- [41:32]
Dr. Rocio Salis Whalen
So I like to describe the medications like the iPhone, right? So we have the iPhone X, the iPhone 12. Every time they improve it, they work better, they have less. Bu same thing with the GLP1 medication. Right. So right now we have the iPhone 16, which is tersepatide, mounjaro, SEP bound. But the iPhone 17 is coming this year, next year, Right. So the drugs are becoming more sophisticated, safer, with less side effects every time that a new one comes out. So we went from mono, GLP1, right.
- [42:06]
Dr. Mary Claire Haver
What does that mean?
- [42:07]
Dr. Rocio Salis Whalen
That it only has one hormone, GLP1.
- [42:10]
Dr. Mary Claire Haver
All right? And that's semaglutide.
- [42:12]
Dr. Rocio Salis Whalen
Semaglutide. Now we have.
- [42:13]
Dr. Mary Claire Haver
And liraglutide.
- [42:13]
Dr. Rocio Salis Whalen
Okay, okay, now exactly. Semaglutide, Liraglutide. Now we have two incretins. So it has two incretins. Because this classification.
- [42:20]
Dr. Mary Claire Haver
What's an incretin we haven't talked about.
- [42:22]
Dr. Rocio Salis Whalen
Incretin are drugs that help the pancreas produce more insulin for glucose control. That's a type of hormone. This is their main function.
- [42:28]
Dr. Mary Claire Haver
So that's a GLP one is an incretin.
- [42:30]
Dr. Rocio Salis Whalen
It's an incretin. Okay, so we have the GLP one, which is liraglutide, semaglutide. But now we have twinkritins, which is two incretins in one drug, which is GLP1, and GIP. Now that's a combination that has terceptotype and that's terseptepen. So it has two different pathways. So we're seeing more weight loss, but.
- [42:49]
Dr. Mary Claire Haver
Now and less side effects and less nausea.
- [42:51]
Dr. Rocio Salis Whalen
Less nausea.
- [42:52]
Dr. Mary Claire Haver
That's what our patients see. We almost don't prescribe semaglutide unless they've been on it and they're happy with it and it's going well. We tend to lean towards tirzepatide because of the lower side effect profile.
- [43:03]
Dr. Rocio Salis Whalen
Now, retatrutide is another coming. Retatrutide, that's three incretins in one glp, one glp, one gip, and glucagon, which is another hormone that is made in.
- [43:14]
Dr. Mary Claire Haver
The body, and glucagon.
- [43:15]
Dr. Rocio Salis Whalen
So all of them are working different pathways to provide us greater weight loss.
- [43:20]
Dr. Mary Claire Haver
And what are the studies on this newer medication showing weight loss that we've never seen before.
- [43:25]
Dr. Rocio Salis Whalen
Significant up to even 30, 40% of body weight loss.
- [43:29]
Dr. Mary Claire Haver
Are they monitoring body composition? Are they just doing weight and BMI now?
- [43:33]
Dr. Rocio Salis Whalen
They're starting to do body composition. Right. Because all of the studies were done with using bmi. Then we have other pharmaceuticals coming with their own type of incretin. Right. We have a monthly one coming in the next few years.
- [43:49]
Dr. Mary Claire Haver
What about oral options?
- [43:50]
Dr. Rocio Salis Whalen
So oral options? We have semaglutide orals since 2019. It's called rivelsis. And it was like a huge expectation. Oh, now we have the first oral GLP1. And what we found clinically, and it was approved and came out for type 2 diabetes, it was never tested for weight loss. Right. But we assume it's the same drug. We're gonna same as ozempicain for diabetes. And then we saw the results. People were losing weight. Now it has the indication for weight loss, but that didn't happen with the oral semaglutide since 2019 is available. Why? Because we did see glucose control similar to ozempic at that time. But not weight loss.
- [44:27]
Dr. Mary Claire Haver
Not the weight loss.
- [44:27]
Dr. Rocio Salis Whalen
So just to give you an idea, the doses there is 3mg, 7mg, 14mg when it's available right now, Novo Nordisk who has this drug they're studying at 50 milligram. Wow. For weight loss. Oral, Oral. Okay, so significant. Much higher now. Oral gives more side effects actually, so it's going to be interesting to see if patients actually tolerate it. Now Eli Lilly has Orfogliparone, which is another oral GLP1. It's not tirzepatide oral, it's just GLP1, one single hormone. But the weight loss is not comparable to the injectables. What they can have a use is for maintenance. Right. I think oral medications will have great use for maintaining the weight loss when you need a lower dose. And maybe patients just can take a oral pill, which in theory should be less expensive. But oral Cemalutide is equally expensive as the injection. So just because it's oral doesn't mean that it's going to be more accessible to everybody.
- [45:36]
Dr. Mary Claire Haver
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Dr. Mary Claire Haver
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- [49:37]
Dr. Rocio Salis Whalen
Yes. And for all of them is who I wrote my book for because my book is my own personal guidance is that before you go on a GLP1 what to do, what to look for and then during a GLP1, how to guide them to a safe journey and then after a GLP1 right. So my book is, my protocol is like having me at their home. Moving to that. Ideally, an obesity board certified physician will be more expert on these drugs. Right. And there is the American Board of Obesity Medicine website, which is a bum, that there is a list of obesity board certified that you put your zip.
- [50:21]
Dr. Mary Claire Haver
Code and we'll put this in the.
- [50:22]
Dr. Rocio Salis Whalen
Show notes and it can tell you who is close to you that is obesity board certified.
- [50:27]
Dr. Mary Claire Haver
How do we know we're getting the.
- [50:29]
Dr. Rocio Salis Whalen
Best care if they're looking beyond the scale, if they're talking about muscle, if they're talking to you about protein from the get go, from your first visit, you cannot leave the office without having knowledge about muscle, about the possibility of muscle loss, on how to avoid the muscle loss and why it's important not to lose muscle. Right. That's a green flag.
- [50:53]
Dr. Mary Claire Haver
Okay, what about the red flags?
- [50:54]
Dr. Rocio Salis Whalen
I always tell my patients, even for hormones, don't assume that just because there's an endocrinologist, gynecologist, you're gonna leave with a prescription of hormones. You have to do your due diligence. Call and ask, does the doctor prescribe hormone replacement therapy? Same with glp. Does the doctor have experience? How long has this doctor been prescribing a GLP one have the doctor has severe complications or side effects in patients. Right. You can make that choice. You can call and ask if they're not doing body composition, that's a red flag.
- [51:28]
Dr. Mary Claire Haver
So if you could make the world perfect and rewrite the standard of care for obesity care, what would that look like?
- [51:36]
Dr. Rocio Salis Whalen
Body composition, strength training.
- [51:38]
Dr. Mary Claire Haver
Yep.
- [51:39]
Dr. Rocio Salis Whalen
Nutrition, more focus and lean protein and a GLP1.
- [51:44]
Dr. Mary Claire Haver
How can we as loved ones, so you know, we're physicians, we, we know how to do this. And thank you for, for being the main source of my information on this subject or at least getting me started. But for our listeners out there who don't have a weight problem, but probably because 73% of Americans do, how can they be more support of someone going through this journey and perhaps starting a.
- [52:07]
Dr. Rocio Salis Whalen
GLP one I think it's really important from family members, right, to understand that your friend, your son, your husband, Whoever's on this GLP1 medication will not eat as they used to eat. Not to question, why are you sick? Why are you not eating? Don't take it personally. If they're not eating, they're on a medication that is suppressing their appetite. And that's what we want the drug to do. It's to respect the way that they're eating. Understand that There is supervision whoever's giving them that medication, right. That there were some steps taken for that person to be on this medication and to let the patient guide them in how much they want to share. Right. I think it's something very personal that people share when they feel it's time for them to share. I always say share an entry, right. Share the appetizer and then learn.
- [53:02]
Dr. Mary Claire Haver
I always talk to patients especially if they're in a mismatch, meaning one, one person in the relationship is on a GLP one and one is not that you know, their hunger cues are going to change. And you don't have to mention constantly all day because you might irritate your partner, you know, oh, I'm not hungry. Oh I just, oh, you know, like, like your hunger cues or things are going to be different and, and remember if your partner is not feeling the same way way so your life has changed, their hasn't yet. So like, you know, keep the conversation open and honest. But constantly mentioning that you're not hungry and you're so full may not be the best way to share that information, you know, with your loved ones. Who's a good candidate for GOP 1s and we in medicine we call it contraindications. Who should not be taking it.
- [53:52]
Dr. Rocio Salis Whalen
There's more who can take it that not so I'm going to go with the who cannot. Anybody who has has personal history of medullary thyroid carcinoma, even family history, it's not recommended because in mice it was shown to promote medullary thyroid carcinoma which is a very severe aggressive type of thyroid cancer. So unfortunately for patients with personal or first degree family history of medullary thyroid carcinoma, it's not, it's contraindicated. Any other type of thyroid cancer, papillary follicular hurdle thyroid nodules is not a contraindication.
- [54:27]
Dr. Mary Claire Haver
Okay.
- [54:28]
Dr. Rocio Salis Whalen
Somebody who has develop pancreatitis from the medication. Okay. And that is also a little bit open to per case basis. If somebody was started on the medication and moved the doses too quick and develop pancreatitis then maybe there's the possibility with always the risk. Right. So those are the patients that should that it's absolute contraindication on the medication. From there I think it's a very open book on who can benefit from this medication. I would say for anybody to lose weight, maintaining weight is feels like a full time job. They can be candidates. They may be candidates for this medication.
- [55:08]
Dr. Mary Claire Haver
This has been an amazing conversation and I'm sure our listeners have learned so much. Before we finish completely, I want to ask what I ask all my guests a few questions on unpaused. So what's the best part of this stage of your life? So you've had a pretty big transformation in the last few years. Divorce, single mom, started your own practice, bought an apartment in New York City.
- [55:37]
Dr. Rocio Salis Whalen
I think the best part of my life right now is being an early adopter and seeing firsthand how health is going to change for people. This is the beginning of less type 2 diabetes. This is the beginning. It may become obsolete. At one point, type 2 diabetes. Can you imagine that that's a possibility? They're gonna be. Be less type of cancer that are related with obesity. Breast, colon cancer, prostate cancer, stomach cancer, thyroid cancer. That related with obesity. So this moment in time is truly defining what our health is going to be in the next generations. And I think that is great in a personal moment is I think of my mom and I think of other women that went through everything that I went or other women go and didn't have the tools that we have now that they had to go through it. That they went through a divorce, that they went through single motherhood, feeling terrible, not sleeping, forgetting things, hot flushes, night sweats, depressed vaginal dryness, UTIs. And they still managed to do things like, I'm grateful that, that at this period of my life, I have the knowledge and the access to things that can help me get through things better, because that's how it should be.
- [57:06]
Dr. Mary Claire Haver
These conversations of putting women's health first, of really understanding that we can change the trajectory of our health span for the rest of our lives. And it's these conversations that are going to make it happen. What is a challenge you thought once that might break you, but actually made you feel?
- [57:25]
Dr. Rocio Salis Whalen
Leaving my home, leaving my country. Yeah.
- [57:28]
Dr. Mary Claire Haver
Do you miss it?
- [57:29]
Dr. Rocio Salis Whalen
I do. And I. You go back every three to four months. I'm like, I have to go to Mexico. I have to touch Mexican ground. I have to eat Mexican food. Just like, to feel like, okay, then I can go back, you know, as. As a. As a. As a doctor. And I'm sure this is. You experience the same. You start getting used to missing birthdays, you start getting used to missing holidays. But also my divorce. Choosing a divorce instead of the other option, which is staying in an unhappy marriage. Right. I thought that was going to be very hard, not seeing my kids every day, which I still struggle, but I'm still here and I'm thriving and my kids are happy.
- [58:07]
Dr. Mary Claire Haver
So thank you for being with us. Today and anything else you want to say to our listeners.
- [58:13]
Dr. Rocio Salis Whalen
I'm very happy to be here and to have this conversation and then definitely look for my book. I wrote it for everybody who doesn't understand obesity, for anybody who's thinking of being on a GLP1 or they are on a GLP1. I wish everybody had access to experienced doctors, but unfortunately there's not enough doctors trained. So with my book, I want enough people educated in the subject.
- [58:41]
Dr. Mary Claire Haver
Where 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 @ Dr. Salis 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 @Doctor Maryclair and get the honest, accurate information on health, fitness and navigating midlife@thepawslife.com if you're loving this pot, 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 Odyssey in collaboration with pod people. I'm your host, Dr. Mary Claire Haver. 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, podcast, or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment.