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A
This is a real good story about Bronx and his dad, Ryan. Real United Airlines customers. We were returning home and one of.
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The flight attendants asked Bronx if he wanted to see the flight deck and meet Kath and Andrew.
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I got to sit in the driver's seat.
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I grew up in an aviation family.
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And seeing Bronx kind of reminded me.
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Of myself when I was that age. That's Andrew, a real United pilot.
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These small interactions can shape a kid's future. It felt like I was the captain.
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Allowing my son to see the flight deck will stick with us forever. That's how good leads the way.
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A
Welcome to the you are Not Broken podcast. I'm your host, Dr. Kelly Casperson, a board certified urologist, thought leader, and conversation starter on midlife living, hormones and sexuality. Enjoy the show. Hey, everybody. Welcome back to the youe're Not Broken podcast. GLP1s. What are they? Are they for everybody? Will the price ever go down and is there a best practice to take them? Thank you so much for my friend Joining me today, Dr. Rocio Salas Whelan. Thank you for coming.
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B
Hi. Hi, everybody. Thank you for having me.
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A
And you are an endocrinologist in Manhattan? In New York, Yes.
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B
I'm endocrinologist and obesity board certified in the city.
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A
And I feel like, you know, when GLP1 started to get big, what, last year, you're like, yeah, we've been doing these forever. They came out of nowhere, but they've actually been around for a while. Can you give us a history of them?
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B
Yeah. So the first FDA to approve GLP1 back in 2005, and it was named Bayera. And this was for type 2 diabetes. Now back then, also an injection, they're all subcutaneous injection. We have an oral one, but the body absorbs it better if it's subcutaneous. And it was first indicated for the treatment of type 2 diabetes. And then in 2010, that was a twice a day injection every day. Then in 2010 came Victoza Saxenda in 2012, and this was one a day injection also for diabetes. Then 2012 for weight loss independent of diabetes. Then 2017, the poster child of them Ozempic came out. And then 2022, WeGovy. 2023 was Mounjaro. And then last year, Sepa.
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A
And what made it big? Did Oprah make it big? Did the Kardashians make it big? Like, was it media that made it big? Why did it explode all of a sudden?
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B
I saw it with my own eyes. Covid. Covid made it big. And I'm going to tell you why. Because for the first time, people with obesity, and we as a medical society got it, that obesity puts you in a risk mode. Right. Before we used to tell patients, if you don't lose weight in 20 years, you're going to develop diabetes, you're going to have complications, osteoarthritis, sleep apnea. But came Covid a virus out of nowhere. And people with obesity were having the highest mortality, the more critical care visits. So patients with obesity got like a quick memo that the way that your body is right now is not in a healthy state.
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A
So being obese isn't a problem down the road, it's a problem now. And that's a total culture change. Like we had the whole, like, don't use it as a biometric. Like we. The pendulum really swung and then it was like overnight. And obesity is a health problem.
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B
Exactly. Because obesity, the fat tissue puts the body in a chronic pro inflammatory state. So if your autoimmune system is busy with the chronic inflammation of obesity came a virus. You didn't have the protection to protect you against this virus. So people with obesity got the message pretty quickly that you needed to change something. And I remember in my office having patients that would come to me and say, I need to lose weight, I don't want to die from COVID So people were actually. So the demand or change in perspective of obesity was there. And then we had the drug that will help the patient lose weight. So I call it the Perfect storm. It was a perfect combination. The demand was there and the good work and the goods were there. That's what made this huge acknowledgment of GLP1s and the benefits of them very interesting.
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A
So how so GLP1s are peptides. Peptides are. They're small. Correct me where I'm wrong, but I'm like, they're peptides. Which means it's like a small protein molecule.
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B
Yeah. So the. We make GLP1 in our gut, right. And it's considered a hormone. So GLP1 is truly.
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A
It's a hormone hormone because it travels from one cell to another cell to communicate.
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B
It takes messages, right. To. To the organ that is going to have any activity. It sends a message of what it should do. And we have receptors, as we do for hormones all over our body, in our gut, in our brain, in our heart, in our kidney. Our own Gl once it's released into the bloodstream, it's broken down within two to four minutes by an enzyme. So that's our own one. Right. So our own one was isolated for the first time in the 1980s by a physician in Harvard. Because our own one lasts only two to four minutes, they couldn't use it as anything for medication. But in 1992, a researcher in the VA hospital here in the Bronx, Dr. John Eng, isolated the first GLP1 outside the human body. And this was in the lizard in the Gila monster. And that GLP1 was not broken down by an enzyme. So it was long acting and that's the boom. That's what happened. Then it became patent. And actually the story is really interesting. He, Dr. John Anning, who was an endocrinologist, brought it to Mount Sinai at the BA Hospital in the Bronx to help him patent the drug. They said, no, we're not interested. He mortgage his house to patent the drug on his own and then took it to an Endocrine society meeting, presented an abstract in there, Amlin, the pharmaceutical, was there and purchased the patent.
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A
That's cool. They didn't see the like medical reason for having this drug at that moment.
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B
The only benefit that was seen was for glucose control. So is that another diabetes drug?
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A
No, like we already have Metformin. It's the best.
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B
Look what they missed out. No, I mean, this is the drug that has changed, will change everything. How we practice medicine and how we live.
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A
Yeah. There's so many big topics, I think with GLP1. One of them that is exciting as far as midlife and hormones and should we take things for prevention is the data that, you know, we've been screaming from the rooftops of, Hormones help keep the body healthy. Hormones help keep the body healthy. And now we're like, GLP1 is also a hormone. And it's looking like it has data long term for dementia, Alzheimer's, maybe prevention of diabetes. It's an exciting time because medicine's really being forced to consider how many women are told, come back when you're more sick, for sure.
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B
And this is as a medical society, that's what, unfortunately, that's what we learned because that's what we knew. Right. To treat all the complications either from menopause or in this case, for obesity. Right. We had all the tools to treat type 2 diabetes, hypertension, high cholesterol, osteoarthritis, sleep apnea. We had everything else because we didn't have anything to treat obesity, because we didn't think of obesity as a disease to begin with. Right. We thought it was a willpower issue the patient has to resolve on their own. But we find out decades later that actually obesity is a disease that is not the patient's responsibility or solely the patient responsibility of losing or gaining weight. And then now we can treat that. We have medications to treat the actual disease and then we're going to prevent all the complications. So I really foresee that in the next two generations we're going to have less type 2 diabetes. Probably in the future we won't have type 2 diabetes, hypertension, high cholesterol, we build specialties in the complications of obesity. So really the way that we practice medicine is going to change. And finally we can do some preventative medicine and not just treat the acute problem.
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A
It's so exciting. Do you know, are the weight loss bypass surgeons, are the jobs hard to find now? Because people, I would think people are getting less surgery for weight loss now that these medications have come out.
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B
Look, I've had patients. The most that I have a patient has lost with me is 160 pounds, right? And this is with medication, no surgery. And I have many patients that lost over 100 pounds or in high numbers of 80, 90 pounds that before we only used to see in surgery. And the beauty of it is that with bariatric surgery, you lose it within three to six months. You lose significant amount of muscle and there's no way to control that. Right. Because you go in a very small caloric intake from restriction. But with GLP1, we can fine tune it that you don't lose muscle mass and the only thing you lose is body fat. With GLP1s, what we can do is body recomposition, which is the whole goal whenever we say weight loss, right. We really, we want to do body recomposition, increasing your muscle mass and decreasing your visceral fat. Because we know that that low muscle mass increases all cause mortality. So if we don't talk about muscle, we're missing the big picture. We don't say that about obesity or having high body fat. We don't say it increases your risk for all mortality. But we do have the research and the data that low muscle mass does increase all risk for mortality. So whenever we're talking about body composition, muscle is as if not more important than talking so specifically about asphyxiating on fat tissue.
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A
Yeah, I love that. I think that's what a lot of the, I would say cautious, not SK skeptics, but cautious people about GLP1s is the saying that you will lose muscle mass. And Lord knows, I just, I just got a half a pound of muscle in the Last half a month. And I'm like, that was the hardest, hardest gained half a pound. Right? It's like. And so when you think about like, oh my God, something's going to make me lose your muscle, like you kind of want to stay away. So what are you people like you, what are the doctors doing to say let's use GLP1s and let's maintain the muscle mass? What do people have to be thinking about?
- [10:38]
B
So first of all, every patient should have a body composition, right? Any patient that is thinking of doing a GLP1, they need a body composition to really see what's wanting your weight. What is it that you really need to lose? What's your muscle mass? And once you go on a body and GLP1 to not lose muscle, we need to increase your protein intake. So in reality it's about 1 gram of protein per pound for ideal body weight. And through a body composition we can kind of calculate what's your ideal body weight. And then also strength training. I think I like to take baby steps with my patients and the first thing that I want them to get a handle off is getting enough protein in their diet. Because really to preserve muscle, the bare minimum is protein to gain muscle. Then we can add the strength training or the resistance training. But for many patients it's already a change. Being on a GLP1, you want to let them adapt. And at the bare minimum, the first, first homework that I give them is to really measure and follow their grams of protein.
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A
Good. Yeah. I've come into this recently where I think it's a mindset, let me know. But people or women are like, that's just what I eat. That's just what I'm used to eating. It's kind of this like it's partly cloudy today. Instead of like you actually have to think about food in a different way and not be like, oh well, you know, I just, I only eat blah, blah, blah. A day of like, you have to think about it differently. How do you help people realize like food's not accidental?
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B
Well, it becomes almost with constant reinforcement. Right. And also when my patient comes for their first follow up after being on a GLP1 is really eye opening visit because we do the body composition again and they're there, we can see if they truly are consuming enough protein as they think they are. If there was no muscle loss, then we're good. If they lost muscle mass, I know they know that they're not consuming enough protein. So it really clicks at that moment that they were all and many times they overestimate. They were overestimate the amount of protein. So if they tell me, but I'm consuming so much protein and they still lose muscle, I said, okay, walk me through a day of your meals of your protein. And you can always see that they were overestimating another 30 or 40 grams of protein a day. In reality, they were consuming halves or what they should have consumed. And then that settles really well. When they see it, they freak out a little bit like, oh my God, I did lose muscle. It can happen. And then just a shift happens. And then every visit becomes, how did I do with my muscle? Did I save my muscle? It shifts the focus from weight loss to how am I doing with muscle? Which is great.
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A
Yeah, that's so fun. Really. I mean, we have to get away from the number on the scale, like you said, is absolutely meaningless. And muscle actually weighs a lot.
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B
This episode is brought to you by Progressive Insurance. Do you ever find yourself playing the budgeting game? Well, with the name your price tool from Progressive, you can find options that fit your budget and potentially lower your bills. Try it@progressive.com Progressive Casualty Insurance Company and.
- [13:50]
A
Affiliates Price and coverage match limited by state law.
- [13:53]
B
Not available in all states. States. Yeah, yeah, I, I mean yesterday I, in a podcast that I also did, they told me, what's the one test that you would tell women to have if they can only do one? And I said a body composition, because so much can stem for that from that result and from what it comes out. Right. And we can improve so many things just by looking at a body composition that are going to spill into other aspects of your health.
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A
Oh, I think the flip side, just to go off on the flip side of the GLP1, people who wanna lose the body fat is the really thin woman. Thinness is associated with wealth, with status, with beauty, with, you know, all of these things. And you're looking at like a sarcopenic person who's gonna trip on the curb and break a hip. They've got osteoporosis, Right. And so it's kind of this opposite but similar metabolic problem of like, you don't have muscle, you don't have strong bones. We actually need you to put on the pounds to be healthier.
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B
Yeah, definitely. And many times they have, they still have high body fat, but they look thin or small because of no muscle mass. Right. So they have, they're metabolically unhealthy because they have high body fat and metabolically unhealthy because they have low muscle mass. So that's even worse than a patient with obesity and high muscle mass because.
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A
They'Re strong underneath all that. I flew to Dallas, like two weeks ago, and on the plane, you know, the people who need the extra help, and they have the people in the wheelchairs, right? And it was three frail women in a row. It was just like, boom, boom, boom. And I was like, oh, my God, we're staring at our future. If we just think that we should just take the natural approach of, like, living however many days the good lord has given us is like, it's assistance down the jetway, like, very frail. Is there published data saying GLP1s/1 gram of protein per pound body weight will maintain muscle? Do we have that published data?
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B
Not yet. And I have thousands of body compositions from thousands of patients. And that's what I'm writing my book. I'm giving everything that has worked for my patients. And you need the students, the residents. If anybody there listening, you want to publish data, come reach out to me.
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A
I love it. Talk about doing GLP1s without sex. Hormones versus people who take. So there's a couple published papers saying being on hormone. What I mean by hormones is estrogen, testosterone. Being on sex hormones plus GLP1s is sometimes more weight loss, but better lean body preservation because their hormones are replete. What's your experience with that?
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B
Yeah, definitely in my patients that are specifically with testosterone, my. My midlife patients or postmenopausal patients on testosterone, they can build. They can build muscle. Right? They definitely build more muscle. I can see the difference in their body composition. Once they. They start on testosterone, sometimes they gain one or two pounds of muscle without strength training. Right. And the protein and the. And the nutrition needs to be there too. Right. But also with estrogen and progesterone. I mean, it's just, if you think about it, the patient will be sleeping better. When you weight train, when you sleep is when you build muscle, not when you're in the gym lifting the weights. But if you have a woman that is not sleeping through the night because of menopause perimenopause, they're not resting, they're not recovering, and that will translate into not gaining muscle mass. So definitely being on hormones just makes the environment for you to succeed more likely.
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A
Yeah, I mean, it's crazy. The adoption of GLP at this point. One in five Americans have been on a GLP one something crazy high. You're like, the adoption of that. I know they've been around since 05, but, like, since COVID right. The adoption of that compared to the adoption of estrogen and Testosterone, which is 5% of Americans and 100% of women have low sex hormones at some point in their life. But we jumped on GLP1s. They're just like so much sexier.
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B
Well, because at the beginning, everybody jump in hormones too, right. In the 70s and the 60s, everybody, I mean everybody was on hormones. Old woman, you can see the transgenerational damage from the wh because anybody who's not on hormones or is thinking, but not doing it is because cancer, because cardiovascular. So it's because of bad headlines back then that it became very ingrained in our mothers, in the doctors that, that we've trained with. So it's going to take another generation probably for that to increase because it's shocking that still 5% of women are only in hormones.
- [18:48]
A
Yeah, it's crazy. And men are under treated as well. I mean, I think that men should have a screening testosterone Maybe at age 50, I don't know. I haven't settled on a number yet. But the data we have for men and testosterone, it's associated with depression, low bone mass dementia, diabetes. Like we have all that data. Why is it not a screening test? I think we're under treating that gender as well.
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B
Yeah. And we don't do bone densities in men. Right. That's like the, that's the reverse of in research in healthcare, all the research is in osteoporosis. Is the majority in women and not in men. So we say, yeah, there's osteoporosis more frequently in women. But because we don't study the men. Right. That's like the flip point of what we experience as women.
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A
Yeah, totally. Let's talk about endocrinology. Endocrinologists and their inability to treat sex hormones.
- [19:38]
B
Endocrinology. And I would say like GYN and OB is so best. Right. For an endocrinologist to like really focus on every hormone that we make in our body. So even in endocrinology, which is a specialty, people tend to of hormones is a specialty of hormones. Many people tend to lean to specific hormones. So their endocrinologists that all they do is thyroid. Right. There's endocrinologists that all they do is type 2 diabetes and endocrinologists that they fixate in type 1 diabetes. And once in narrow endocrine prolactinomas, all the, all the brain hormones. Right. But sex hormones is like a gray area because we share it with gyn, we share this with urologists. So it's. It's not as. We don't tend to fixate as much as that because we assume that there's other specialties also checking them out for the patient. Right. But the other hormones, it's really. Everybody gives it to us.
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A
I think you're being kind.
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B
Very kind. Of course, I'm very kind with my people.
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A
But I mean, the endocrinologist, the endocrinologists who do the sex hormones are like, these are hormones. We should know this. So my question is, like, in your endocrinology fellowship, did you get trained in the sex hormones? Do they even train you with them?
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B
Yeah, I got training in menopause, and I would say I was very early adopter. I mean, as soon as I got out of my fellowship, I was prescribing hormones. I was like, this is. I mean, because the data was already being questioned back then. Right. And seeing women suffer. And also my training in Mexico, we use hormones in women for perimenopause and menopause. So I really carried that with me. And in medicine, like, everything, there's going to be doctors that can look outside the box and doctors that won't, doctors that are a little bit more, I don't want to say, risk takers that we are willing to see outside the box and see. Okay. It's not necessarily as dangerous as they can see, and it can benefit people. Right. So I think also being in academic medicine, if while doing academic training, that also limits you of thinking outside the box.
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A
Yeah, yeah. I just, I think from. From what I hear on social media, women feel so dismissed because they're like, I went to a hormone doctor, and the hormone doctor doesn't do these hormones. And so they're kind of like, it's a. Maybe it's a marketing problem. Like, don't call yourself a hormone doctor. But you're. But you're right. Like, not all urologists take out prostates.
- [22:08]
B
Yeah. And not all GYN prescribe hormones. I always tell women that, tell me, how can I get somebody? How do I know? I said, okay, don't assume to begin with. Right. Don't assume that it's an endocrinologist. They're gonna give you hormone replacement therapy. Don't assume that you go to a GYN and they're gonna give you hormone replacement therapy. The best thing you can ask when you call to make an appointment, does the doctor prescribe hormone replacement therapy? And that will be like, the first indication of if you should go there or not.
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A
That's what I tell women Same thing. I'm like, don't waste your time. You don't want to find out once you're in the room you've already paid for parking. Don't do that.
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B
Yeah. And your time, I mean, and set up your time apart and all of that. Right. Just don't ask. Don't make any assumptions. Call and ask. Ask.
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A
So I'm hearing more about microdosing GLP1s. Is there more published data on this? Is this just more that we should get more personalization in dose titrations? Because not everybody should take the same dose. And where do you think the data is going is just as far as metabolic health and really low doses of GLP1s.
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B
So this is what my answer to somebody who tells me I don't need to lose weight, but I want to get the benefit from GLP1. That's what I microdose. First of all, I want to have a body composition of that person and see if in reality you are metabolically fit and don't need to lose weight. I want to see that you have more muscle mass, that your percentage body fat is anywhere between 18 to 28, and that your visceral fat is low. I would say 9 out of 10 of people that say that they actually have high percentage body fat, high visceral fat and low muscle mass. Right. But let's assume somebody is metabolically healthy. More muscle mass, less percentage fat fat. That's body fat. That tells me immediately that that person is doing everything the right way. They're strength training, they're doing resistance training, they're eating a lean protein diet, meaning low in sugar, low in carbs and starches. So my comeback is you don't need the extra protection. You're already there where we're aiming to get with a GLP1. But it's very different if you say I don't need to lose weight, I just want the benefits. But then your percentage body fat is 35%. Then you will benefit from a GLP1 at the first regular dose. Where I see the use of microdosing is going to be at the end of the road of a patient with a GLP1. Right. If somebody lost all the weight that they needed, all the fat that they needed, needed to lose at the lowest dose for maintenance, we can do half. We can do one third of the dose of what you use to lose weight. Right. So I see more the use of micro dosing as maintenance, but not to get to the goal.
- [25:05]
A
Got it. So the main, the lower doses won't get you to the goal. Say, say you've got somebody who's like 32% body fat. They're like, I'm at the gym, I struggle a little bit with protein, but like I do my best little bit just to kind of get their body fat optimized.
- [25:21]
B
Yeah. But you can do 0.25 of semaglutide or which is wegovia and Ozempic that is not as strong as the first dose as tirzepatite. So we can play around with what we currently have in the first doses. Also, microdosing came out of compounding GLP1. Right. Because the branded GLP1 come in pre dose form. Right. So that's another issue with microdosing is the com is that you need the compounding version. But now Eli Lilly has a vial that we can manipulate in regards of the dosing. But again, for really weight loss, we need the therapeutic doses for maintenance. We can do lower than the therapeutic doses. That's where the use comes.
- [26:13]
A
Got it, Got it. Where do you think we're going as far as cost on this? I recently saw something that seven out of eight people who qualify for this drug can't afford this drug. Do you think with time and more people in the market it's going to come down? Do you think insurance companies are going to be like, hey, this is actually cost effective because we're preventing disease long term. What do we say to the people who are like a thousand bucks a month is out of reach?
- [26:37]
B
Yeah. So I mean there's a monopoly right now between Novo Nordisk and Elini. Right. Pretty much. They are pulling all the strings right now and they can do what they do because they can get away with it because they're the only ones. I think once other pharmaceuticals come with their own versions of GLP1, then we will start seeing more decrease in the price. Right. I think also what I'm starting to see and Eli Lilly did this instead of a pen, they came out with a vial. So that decreased the cost from 1100 in a pen to 300 in a vial for a month's worth. Right. So I think that also will decrease the pricing. The other thing is that both pharmaceuticals have manufacturing coupons. That brings the cost down to half if your insurance is not covering for it. Right. So you will pay $500 for a month's worth. The other part of the equation is educating people. We need to educate people that this is an investment in their health out of everything. They spend thousands of dollars through the years in crazy diets, crazy books, crazy detox, crazy exercise program. This is money well invested, that for the first time, it's going to give you long lasting results.
- [28:02]
A
I love it. Let's talk again real quick about how it actually works. Our GLP1 that only lasts two minutes is produced in the gut. It sends a signal to the brain to say we're full. Is that how GLP1s work?
- [28:15]
B
Yeah. So we have receptors, right? Like receptors in the pancreas for it. And when your sugar goes above normal, for somebody who has type 2 diabetes, this hormone sends a message to the pancreas to produce more insulin. Right. So that was the first discovery or the first effect that was found of GLP1. But we also have receptors in our gut. And with this hormone, what the GLP one does, it increases our satiety hormones once we start eating. So you get fuller with smaller portions and then it suppresses your hunger hormones in between meals. So for most patient, it looks like two small meals, physically content and satisfied through the day. Then in the amygdala, in the hedonistic eating and drinking area of the brain, we have receptors too where we eat for a reward. The hedonistic area is you anticipate a reward either from food or for some beverages for some people. Right. It blocks the reward response. So there's no feedback of that reward anymore when you reach for that food in particular or that drink in particular. So it's out of your mind, the behavior changes. And then when you're hungry, you enjoy your food, but then you get satisfied with half a portion of what you normally would.
- [29:32]
A
And that portion better be protein.
- [29:34]
B
100%.
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A
Got it.
- [29:39]
B
Yeah.
- [29:39]
A
I mean, there's promising data on GLP1s and addiction. Like people are wanting to gamble less, they're wanting to drink alcohol less. I haven't seen much in the sex med world, but there is some rumor that number one sex life goes up because body image is better. Also, especially in men, as they lose the body fat, their testosterone goes up naturally, so there's a higher sex drive that could happen. But then also losing the reward of the orgasm and the sex. And so desire might actually be affected by these drugs because you're like, yeah, I could take it or leave it. I'm kind of, I'm kind of happy over here with my protein.
- [30:13]
B
I have to say. I have not seen that. I have not seen that. I have not seen that. Actually, the opposite. There's increase in sex drive. I mean, if somebody's in perimenopause, or menopause, then the answer could be different. Right. It could be estradiol, it could be testosterone. The reward of the weight loss is so high that I don't think either patients don't complain about sex drive because they haven't not expressed that. That that's actually they express the opposite. That their sex drive improve.
- [30:41]
A
Yeah, very cool. So what's. If you can think, what's the most surprising result you've seen in your own patients using GLP1s beyond the scale because you had 160 pound weight loss happen? Like, that's, that's incredible. But any other, like, surprising results?
- [30:57]
B
The majority of the patients want to get fit if they could. That the majority of patients take, really take to heart training, being strong. They do marathons, they climb mountains, they climb volcanoes. Their weight, for many people, it was something unreachable, something that they only dream of, something that was not a possibility, maybe halfway in between, but not to the point of having a normal, healthy weight. So when a patient achieves that, it's like, what else can I achieve? My mind is not consumed with my weight. Then you have room. There's room for creativity, room. I mean, I've had patients get promoted. Other flip is divorces. I have several patients that they become that they get divorced during the treatment.
- [31:55]
A
Do they say, I was staying in this relationship because of my weight? I didn't think I was otherwise lovable. I didn't. So that was kind of.
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B
I could reach for more. I mean, I guess I think that's mostly the explanation. Right. I don't think it's the cause of the divorce. I think it was just something that it was uncovered. And interesting enough, the patients that get divorced, then they keep coming to me, and then they bring me their significant others as patients. And then sometimes I have like, okay, let's make sure we not have every four of them at the same time.
- [32:29]
A
Well, that's good. That's good proof that you provide good care. As you're bringing in the exes and the new people, what do you think one of the biggest misconceptions with GLP1s is as far as safety. You know, people will throw up. Thyroid cancer, pancreatic cancer, bowel obstruction was the big thing. It was starting to get big. And for like, the surgeons were worried about that. Anesthesiologists were like, you have to be off GLP1s for like a whole week before you can have general anesthesia because of the gut slowing down. What are the biggest misconceptions and can you kind of share day to day risks with these medications?
- [33:06]
B
Yeah, definitely. So I think one of the biggest misconceptions is that they're new medicines and we're not going to know what's going to happen in five years and 10 years. You're going to grow an ear from your cheek. I mean, it's things like that. Right. We have the data for 30 years now. The other misconception is that anybody can prescribe it, that it's just a skinny shot. So anybody can prescribe it. Right. A med spa, an ophthalmologist, a neurologist. I mean, anybody can prescribe it just because they can still can prescribe chemo drugs. And I don't do it because I can. I don't have a clue. I'm going to create more damage than benefit. So I think there's a misconception that these drugs are easy and anybody can prescribe them because everybody wants a piece of the pie right now. Right. Economically. Well.
- [33:53]
A
And if you look at how many people there are to help, if you look at just, you know, 80% of the nation's overweight.
- [33:58]
B
Yeah. And there's only 9,000 obesity physicians and we need all the help we can. I cannot see everybody, nor, nor, I want to say everybody. Right. But do it responsibly. If you're going to be prescribing this medication, do it responsibly. Take some courses, get a body composition machine for your office. There's ways to do it the right way. I think that's one of the misconcept. I mean, a lot of the other headlines that we see in the news, definitely I've never seen in my clinical practice bolus obstruction. So this tends to be from taking overdosing from constipation. I mean, the way of the medication, it slows down digestion, so it also causes dehydration. So if those are not proactively prevented individually, then you're going to have this. Right. But again, again, this depends, the safety depends on the expertise on who's prescribing you this medication.
- [34:54]
A
Love that. For a doctor who's listening, who's like, no, my patients are asking me, I want to do it. Best of practice. Is there a great place to go get a course that you can do online? What would you recommend?
- [35:06]
B
Definitely. So I would recommend the Obesity Medical Association. They have great courses, virtual courses, live courses, books, everything. Also the Obesity Society. Go to one of the conferences. Either the Obesity Society, which is once a year, or the Obesity Medical association, which is two or three times a year depending. And it has the bicoastal. So there are resources for them to get informed without having to go two years into fellowship with obesity.
- [35:37]
A
Right? Yeah. Oh, I love that. Do you think they're going to be sweet formulating these to be able to be swallowed or subcutaneous buccal to get absorbed that way, vaginal route. Right. Like for your needle phobes or to get the cost down. Where do you think the future of drug development? From what I'm reading, they're very interested in oral, but it takes a much higher dose of the drug to get it in because it's processed orally. So that's why it exists the way it exists.
- [36:06]
B
And you'll be surprised. The oral version is extremely expensive, almost as the injectable. So we do have an oral version of Ozempic, it's called Rivelsis and it's for the use of type 2 diabetes. And this was approved in 2019. So we have six years of an oral version of it. The reason that you don't hear it as much is because we never saw anything similar in regards to weight loss as the injectable. Right. We saw with glucose control comparable to the injectable is still as expensive as the injectable. And to reach the higher doses for us to see significant head to head weight loss as the injectable patients don't tolerate it, they're struggling to tolerate the current doses. So it's interesting to see what's going to be the tolerance on the higher doses. Just to give you perspective, the current oral doses is 3 milligrams, 7 milligrams and 14 milligram. What just got accepted the application by the FDA last week is a 25 milligram dose. And two years ago the 50 milligram dose was studied but patients were not tolerating it. Right. So it's going to take time to get somebody to that point to tolerate the 25 and the 50 milligram dose if we ever can. And cost is not. That's going to be cheaper unfortunately. Like.
- [37:31]
A
Got it. Yeah. Interesting. So metabolic markers, you think every woman should check yearly? A1C. Yep.
- [37:40]
B
A1C. Lipid panel, lipoprotein A, APOB. Right. I think those thyroid hormones definitely once a year that's, that should be done regularly.
- [37:51]
A
If you see a woman who's got high cholesterol, say she's starting on estrogen and the hormones, what are, what are you recommending like diet wise for these? Because I think the old School of like low fat is falling out. But it's like we don't want to put.
- [38:07]
B
We.
- [38:08]
A
I. My understanding is we don't have primary prevention data for statins. A lot of women don't want to be on statins. What advice would you just give a woman who's like all of a sudden their cholesterol's up besides get on hormones? Because I can lower it by 20%.
- [38:22]
B
Definitely wait and see once we start hormones. Right. That'll be like the chemically part that. But let's let the hormones do what they can do and then we'll recheck before starting any statin. I mean, I rarely start anybody on a statin. And then also, what changes can we do in your diet? Right? I mean, definitely increasing lean animal protein is going to help. And exercising, definitely. We do have data that exercises decreases LDL and then, then Omega 3. Right. I mean the good fatty acids. But then that can go into the lean pro lean animal protein. Right? Salmon, white fish. And then wait and see. And then repeat your lipid panel. Not, not earlier than three months and then see what really happens. For the majority, it comes down nice.
- [39:11]
A
And I know triglycerides are associated more with carbohydrates high sugar diet. So when you see triglycerides, you should be thinking, let's cut the carbs down, down, get rid of the processed food. Does the same hold true for cholesterol or is that more triglycerides?
- [39:25]
B
Triglycerides definitely is telling me about insulin resistance. It's telling me that you run the risk of prediabetes. Of course, if they were fasting, Triglycerides is the only one that really we need patients to be fasting to really see it as a true value. And many times it's familial hypertriglyceridemia. Right. So many times the patients still need medication, but triglycerides is more diet controlled. That meaning changes in your diet can have the most effect in your triglyceride level than any other of your cholesterol markers.
- [39:58]
A
Love it. Tell us about your book. December 30th.
- [40:01]
B
So my book is pretty much my care that I give my patients. I know that I'm not accessible for everybody and I cannot see everybody even if I was. So this is my. I'm doing this for the people that don't have access, not just only to me, but to good medical care with a GLP1 to help them even from choosing the right doctor. Where are the green flags, the red flags to look for when you go to a doctor, when you call to make the appointment. So the moment that you reach your goal. And I divided my book in three parts. The part three is something that is my favorite part of the book because it's something that we are just learning. For the first time ever in history, we are having masses of a population lose weight and reach their goal. We're finding that once they reach the goal, there's a lot of adjustments to do. Not only physical, psychological, socially, culturally, that we are not prepared to guide the patient with once they get there, because, again, for the first time, they're able to get there. So for the majority of patients, it's something. It's happiness, it's something successful, it's something that is celebrated. But even in that celebration, there is anxiety. Many patients get so scared and anxious that they're going to regain the weight, that they're going to run out of the medication, that there's going to be a shortage of the medication, that don't. Their rug is going to be pulled out under their feet. Right. Many patients tell me, I see my body, I see myself in the mirror. I don't recognize myself with the physical part. The physical part happens. We can palpate it. But the cycle, I mean, you're having patients that struggled with their weight for decades. Some patient told me, oh, people are nicer to me now. It makes me question, was I not worth before for people to be nice to me? Right. Many times people assume that the close relatives or the loved ones are going to be happy for them. But sometimes that brings their own projections of somebody who's trying to lose weight, and they're seeing this person now lose weight and eat healthier and exercise. Right? So it's really interesting, the post that's.
- [42:18]
A
Going to be so good and I think so necessary and I think so missing from the toolbox of this is what everybody wants, right? And to realize there's a book called When Sex Hurts. And at the end of that book, there's a chapter of what do you do when the pain's gone? Your whole world was set up because of something, and that something's gone now. And how do you. And so I thought that was brilliant. And that sounds like what you're trying to do with your book is like, how do you keep moving, you know, or what's the new goal post? Or how do you reorient?
- [42:53]
B
And that it's okay to have those emotions. Right? I mean, it's okay to not feel 100% happy. It's okay to say okay, now that I got here, now, now what? Right? It's okay. And the purpose of that book is just to, to walk you through that. And I've seen and I've learned all of this through my patients. Right. And through the close follow up. Because when you lose follow up and that's what happens with bariatric surgery many times, right? You have the surgery, you lost the weight, you're lost to follow up. Nobody's following you. But what I'm doing with my patients is what I'm able to do is really build this that I see my patients continually after they lose the weight for maintenance. And that's where I'm hearing all this feedback. Right. And we're learning as we're going. So that's what I wanted to show in my book is like the experiences that I'm seeing after years of following patients.
- [43:41]
A
I love that. So everybody follow her on Instagram until her book comes out. What's your Instagram, Dr. Salas?
- [43:48]
B
Whalen. D R S A L A S W H L W H A L E N Perfect.
- [43:54]
A
I'll put it in the show notes too so we don't have to, so we don't have to struggle. So 2026, that means I'll have read the book and then come on again and we'll talk about it and we'll talk more. We'll update to you know, todays of like is the cost still crazy? Are people still having access? What's new after a half a year's gone by?
- [44:10]
B
So yeah, well no, my book coming this year 2025. 20.
- [44:13]
A
Right. But, but the end of December. Right?
- [44:15]
B
End of December, yeah. So.
- [44:17]
A
So we'll get a turn of the year. We'll get you back back on any, any final thoughts for, for people and GLP1s and seeking care that you want to leave them with.
- [44:26]
B
I would say don't leave a GLP1 as your last resource. Right. Don't, don't, don't spend mental. If, if you're, if you losing weight, maintaining your weight feels like a full time job, you definitely will benefit from a GLP1.
- [44:45]
A
I love that. And bonus points if you can be with somebody that can be there with you to. I see a lot of people in my practice because my practice is a year long membership because I believe in the same relationship, doctor patient relationship that you believe in. And I see a lot of them from like the medispas or the IV infusion place is like they buy like a 6 week, 8 week 12 week ozempic thing and then it's done. And then they're kind of like, like realize like this is a lifestyle, this might be longer and then there's other things to to deal with afterwards. And the body composition too.
- [45:20]
B
They don't even do body compositions of the med spot. They come. They have them come every week to weight themselves, but nobody knows if they're losing muscle, if they're losing fat, why are they losing. Right, yeah.
- [45:31]
A
Body composition. I. I get that on every single patient of mine. It's a game changer. It's so insightful.
- [45:37]
B
And I think we're gonna change the weight loss. It's going to become body recomposition.
- [45:42]
A
I love that.
- [45:43]
B
That's the goal. Body recomposition. I love that.
- [45:46]
A
Muscles are sexy as hell too, by the way, people. By the way, they're very sexy. All right, thank you so much for joining us today. Until next time, thanks for coming on.
- [45:58]
B
Thank you.
- [46:00]
A
Thank you for listening to this week's episode of youf Are Not Broken. If you want to dig deeper with me, sign up for my Adult Sex Education Masterclass where you learn adult things like communication skills, anatomy lessons and desire types and how to talk to your doctor about sexual health concerns. If you want the Adult Sex Education Masterclass for free, join my monthly membership for more in depth exclusive content, more time with yours truly. A private podcast, coaching and educational empowerment and you can watch my interviews live and get them immediately without advertising. Head over to www.kellycaspersonmd.com for the membership and adult sex ed masterclass members. Get the master class for free. This podcast is presented solely for educational, entertainment and informational purposes only. I am a doctor, but not your doctor in this format and all of my platforms and guests including on this podcast are not giving individual medical advice or practicing medicine medicine. See in Consult with your own care team for your individual needs and concerns. This podcast is not intended as a substitute for the care and advice of a physician, therapist or other qualified professional. This podcast does not constitute the practice of medicine, in case you were curious about that and no doctor patient relationship is formed. But I still love you. Using the information on this podcast or any of my platforms is at your own risk. Until next time, remember, you are not broken.