You Are Not Broken Podcast

Host: Dr. Kelly Casperson, MD
Episode 329: GLP-1s with Dr. Salas-Whalen
Date: August 3, 2025

Episode Overview

This episode dives deep into GLP-1 agonists (GLP-1s)—their history, science, use in weight management, the shifting cultural perceptions on obesity, and how hormones and body composition play critical roles in women’s metabolic and overall health. Dr. Kelly Casperson is joined by Dr. Rocio Salas-Whalen, a Manhattan-based endocrinologist and obesity specialist, for a highly informative and candid conversation about the future of obesity care, misconceptions, the societal and psychological aspects of rapid weight loss, and practical advice for both patients and physicians.

Key Discussion Points & Insights

1. The History and Medical Boom of GLP-1s

• Origins and Early Drugs: GLP-1s first FDA approved in 2005 (Byetta) for type 2 diabetes; progression to once-daily and weekly injectables; expansion to weight loss indications.
  • "Back then, also an injection, they're all subcutaneous injection...It was first indicated for the treatment of type 2 diabetes." —Dr. Salas-Whalen [01:25]
• Why the Massive Surge?
  • COVID-19 starkly highlighted obesity as an immediate health risk, dramatically increasing demand for weight loss solutions.
  • "Covid made it big...people with obesity were having the highest mortality...So patients with obesity got like a quick memo that...your body is not in a healthy state." —Dr. Salas-Whalen [02:25]
• Cultural Shift in the View of Obesity: Shift from treating complications far downstream to focusing on obesity as a disease and addressing it as preventive medicine.
  • "Before, we used to tell patients, if you don't lose weight in 20 years, you'll develop diabetes...but came Covid...and people with obesity got the message pretty quickly." —Dr. Salas-Whalen [03:10]

2. GLP-1s: Mechanism and Science

• What are GLP-1s?

  • “They're peptides—small protein molecules, made in the gut, acting as a hormone.” —Dr. Casperson [04:20]

• Mechanism of Action:

  • Rapid degradation in the body necessitated synthetic, long-lasting forms (inspired by a lizard’s peptide, the Gila monster).
  • GLP-1s have receptors in the pancreas, gut, brain, heart, and kidneys, with multiple systemic effects.

• How They Work:

  • Boost satiety, lower hunger, affect reward centers in the brain, and optimize glucose response.
  • "It increases our satiety hormones...and it suppresses your hunger hormones in between meals." —Dr. Salas-Whalen [28:15]
  • "In the amygdala...it blocks the reward response. So there's no feedback of that reward anymore when you reach for that food or drink." —Dr. Salas-Whalen [29:10]

3. Body Composition: More Than the Number on the Scale

• Muscle vs. Fat:
  • With GLP-1s, focus should shift from simply 'weight loss' to body recomposition—preserving muscle while decreasing visceral fat.
  • "With GLP1, we can fine tune it that you don't lose muscle mass and the only thing you lose is body fat." —Dr. Salas-Whalen [08:39]
  • "Low muscle mass increases all-cause mortality...Muscle is as, if not more important, than asphyxiating on fat tissue." [09:32]
• Concrete Strategies:
  • Baseline and ongoing body composition analysis is crucial.
  • Protein intake (1 g per lb of ideal body weight) and progressive strength training are key interventions.
  • “Every patient should have a body composition...and to not lose muscle, we need to increase your protein intake.” —Dr. Salas-Whalen [10:38]
  • “If there was no muscle loss, then we're good. If they lost muscle mass, I know they're not consuming enough protein.” [12:08]

4. The Role of Sex Hormones in Weight Loss & Body Composition

• Synergy with Hormones:
  • Estrogen/testosterone combined with GLP-1s—greater muscle preservation, better weight loss outcomes, improved sleep and recovery.
  • "They can build more muscle...can see the difference in their body composition once they start on testosterone or estrogen." —Dr. Salas-Whalen [16:41]
• Under-treatment of Hormones:
  • Only 5% of eligible women use hormone replacement therapy—driven by outdated fear, poor marketing, and provider uncertainty.
  • “It's shocking that still 5% of women are only on hormones.” [18:47]
  • “Men are under-treated as well...Testosterone is associated with depression, low bone mass, dementia, diabetes.” —Dr. Casperson [19:08]

5. Access, Cost, and the Future of GLP-1s

• Access Barriers:

  • High cost and manufacturer monopolies persist; insurance coverage lagging.
  • “There's a monopoly right now between Novo Nordisk and Eli Lilly...once other pharmaceuticals come with their own versions...we’ll start seeing more decrease in price.” —Dr. Salas-Whalen [26:37]
  • Newer vial formulation from Eli Lilly is less expensive ($300/mo vs. $1100/mo for pens), but still out of reach for many.

• Insurance and Value Proposition:

  • Encouragement to see GLP-1s as a health investment compared to years of failed diets/programs.

6. Safety, Myths, and Misconceptions

• Long-Term Data:
  • “We have the data for 30 years now.” [33:05]
• Prescribing Responsibility:
  • “Anybody can prescribe it...but if you're going to prescribe, do it responsibly...take some courses, get a body composition machine for your office.” [33:05, 33:58]
• Side Effects:
  • GI slowdown can lead to bowel obstruction only with overdosing; proactive management prevents most side effects.
  • “Safety depends on the expertise of who's prescribing this medication.” —Dr. Salas-Whalen [34:54]

7. Societal & Psychological Impacts of Massive Weight Loss

• Changing Social Landscape:
  • Dr. Salas-Whalen notes many patients blossom—marathons, mountain climbing, new careers. Some experience major life changes, including divorce.
  • “When a patient achieves that [healthy weight], it's like, what else can I achieve?” —Dr. Salas-Whalen [30:57]
• Adjustment After Success:
  • Her upcoming book will address the psychological and social issues post-weight loss—identity, relationships, anxiety about regain.
  • “For the first time ever in history, we are having masses of a population lose weight and reach their goal. We’re finding...there’s a lot of adjustments to do: physical, psychological, socially, culturally...” —Dr. Salas-Whalen [40:01]

8. Notable Practical Tips and Takeaways

• Microdosing vs. Full Dosing:
  • Microdosing GLP-1s better used for maintenance, not initial weight loss.
  • “For really weight loss, we need the therapeutic doses. For maintenance, we can do lower.” —Dr. Salas-Whalen [25:05]
• Yearly Health Markers:
  • A1C, lipid panel, lipoprotein A, ApoB, and thyroid hormones recommended for all women.
  • “That should be done regularly.” —Dr. Salas-Whalen [37:50]
• Navigating the Medical System:
  • Don’t assume any endocrinologist, gynecologist, or urologist prescribes hormones—call and ask before booking.
  • “Don’t make any assumptions. Call and ask: does the doctor prescribe hormone replacement therapy?” —Dr. Salas-Whalen [22:08]

Notable Quotes & Memorable Moments

• "Obesity is a health problem now, not a problem down the road. That's a total culture change." —Dr. Casperson [03:10]
• “The drug that has changed, will change everything—how we practice medicine and how we live.” —Dr. Salas-Whalen [06:27]
• “With GLP1s, what we can do is body recomposition...muscle is as if not more important than...fat tissue.” —Dr. Salas-Whalen [08:39]
• “If you're losing weight feels like a full-time job, you definitely will benefit from a GLP1.” —Dr. Salas-Whalen [44:26]
• "Muscles are sexy as hell too, by the way. They're very sexy." —Dr. Casperson [45:46]

Important Timestamps

• History of GLP-1s: 01:25–02:17
• COVID's Role in GLP-1 Popularity: 02:25–04:20
• How GLP-1s Work: 04:20–06:09, 28:01–29:32
• Body Composition & Muscle Preservation: 08:39–13:20
• Hormones and GLP-1 Synergy: 16:41–18:47
• Access, Pricing, and Future of GLP-1s: 26:37–28:01, 35:06–37:31
• Safety and Prescribing Myths: 33:05–34:54
• Societal Impact of Weight Loss: 30:57–32:28, 40:01–43:41
• Practical Patient/Physician Advice: 22:08, 44:26–45:46

Closing Thoughts

Drs. Casperson and Salas-Whalen paint a holistic, hopeful, yet realistic picture of the current and future landscape in metabolic health—GLP-1s as not just "skinny shots," but as powerful, disease-modifying agents with physical, emotional, and social ramifications. Listeners are encouraged to seek individualized, responsible care—never “leaving GLP-1 as your last resource”—and to reframe “weight loss” as “body recomposition,” highlighting muscle preservation as foundational to long-term health.

Follow Dr. Salas-Whalen on Instagram: @drsalaswhalen
Look out for her upcoming book in December 2025.