GLP-1s and Midlife Metabolism Part 2: Dr. Rocio Salas Whalen Breaks Down the Science of Weight Loss and Menopause

23:58Dr. 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. 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. This is what you feel like is the most important part. 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?

24:34My 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 there are 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 X excess amount of skin that some patients may need surgical treatment for relief because you can have infections.

25:20It's bothersome physically, not just psychological or aesthetically, but it can also have medical consequences. Right.

25:27Dr. Mary Claire Haver: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. 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?

26:07Now they have an anxiety of weight regaining. Now that they know what it is to be in their weight, they're terrified of regaining the weight. They're really, it can 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-reaking. Some patients, the physical adaptation it takes is quicker than the psychological adaptation. So many patients, even though they've lost 100 pounds, they don't see themselves still in that way. Right.

26:44Dr. 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 then all of a sudden they have this new body. How are you counseling them about that? I had a new patient that I saw in her late 20s, early 30s. And she told me one year ago, I went to a doctor and he gave me a GLP-1.

27:20But I decided not to use it. I decided to go to therapy first before going on a GLP-1. 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 a 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 and and I applaud her and I was so proud of her do you think that massive weight loss those patients deserve therapy? A hundred percent.

28:10A hundred percent. And right now we are doing everything ourselves. And this is why what I'm learning. And this is why I wrote my book because I'm seeing more day by day than anybody else can see. I see them together. That's all you do. 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's 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 going to come out.

28:47So if somebody who's in healthcare and mental health stop 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. Yeah. Even with those changes, patients would not choose to go back to where they were. So for the majority, it's always something positive.

29:16Dr. Mary Claire Haver:So in my clinic, I only treat females. You're treating both. And I'm sure you treat couples. 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 part of the couple is on a GLP-1 and the other is not, there are so many micro changes in their relationship, going out to dinner, staying at parties, drinking alcohol, you know, that things that they built their relationship on, their fun time, their social interactions have changed where one person is left behind and the other person is changing.

29:58Dr. Mary Claire Haver:And it's not that one part is obese. She's loved this person for 25 years, 30, whatever it is, you know, even though his body hasn't changed, but she's changed. Do you see that in your practice as well? Yes, I do. And I've actually seen divorces. Yeah, I was going to ask, have you heard of the Ozempic divorce? Yes. And I've had several patients that actually I saw them as coupled individually, but that the wife came, the husband came and that they got divorced, right? So So again, there's going to be a lot of biopsychosocial environmental changes. This is even before GLP-1 medication, when I used to talk to my patients about diabetes, nutrition, care.

30:38I 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 an 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 and not doing that with them. 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.

31:20And I think I see that a lot.

31:23Dr. Mary Claire Haver:Talk to me about addiction and changes in behavior we're seeing with unintentional, you know, GOP-1 changes we're seeing that might be positive. 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 GLP-1s block that reward system. If alcohol was a sort of a reward, 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.

32:06I rarely see an effect on alcohol or smoking at the lowest doses. We actually have to reach higher doses.

32:15Dr. 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 GLP-1 versus patients on GLP-1 and menopause hormone therapy. The menopause hormone therapy GLP-1 group lost more weight than semaglutide alone. Why do you think that is? 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 3 a.m. 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-1, well, they're going to have better results, right?

33:10If 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? Right, never. Hormones are not weight loss for that. We have GLP-1 medications, but it's going to help your body recomposition.

33:33Dr. Mary Claire Haver:Synergistically, they'll 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. That's so sad. 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 prediabetes.

34:20Dr. Mary Claire Haver: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? I do think right now there's some monopoly of this medication. 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 see in Europe, the Monjaro pen gives you four doses.

35:02So 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 in 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're 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, tersepatide in vials. Yes.

35:36Dr. 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. 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. Yeah.

36:14Removing the manufacturing process of the pens or they can become multiple use pens. I think that's also going to decrease. But also once there's more competition that is coming from different pharmaceuticals and more drugs and more options, then the cost needs to come down.

36:31Dr. Mary Claire Haver:I want to go back to, you know, semaglutide and terzapatide, 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. Yep. So the safety should not have a price, right? You should not put your health at risk because it's cheaper.

37:09Dr. Mary Claire Haver:You feel these drugs are putting people at risk? Yeah. So actually there's studies. This is specifically the compounded version. There are studies that have shown that most of the calls for toxicology for overdose of GLP-1 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. So for a drug to get approved, you know, it can take 10 years of studies and showing the studies of safety. But that doesn't happen with compounded medication.

37:51Second, 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 Nordis have active lawsuits to compounded 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 adding vitamin B12. They're adding folate. They're adding other things. So it's already manipulation of the drug, of the compounds or another risk of side effects.

38:27Right. 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.

38:38Dr. Mary Claire Haver: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 needed. It would never occur to them to go that route, except for this. They're so desperate. 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 of which are the compounding pharmacies that are at the highest standards of the higher quality. Also, what red flags and green flags from who's giving you the compounded medication, right? Because if somebody is giving you compounded medication, I can almost know that they're not an endocrinologist.

39:20They're not going to be board certified obesity medicine. So it's not just that they're giving you the compounded. It's what guidance are you getting with the compounded medication?

39:28Dr. Mary Claire Haver:Let's go back to the future, the exciting part. What is the drug pipeline look like? So right now we have GLP-1s and then we have the terzepatide. What is terzepatide versus semaglutide? So I like to describe the medications like the iPhone, right? So we have the iPhone 10, the iPhone 12. Every time they improve it, they work better, they have less bugs. Same thing with the GLP-1 medication, right? So right now we have the iPhone 16, which is terzepatide, Monjaro, SEP-bound. But the iPhone 17 is coming this year, next year, right? So the drugs are becoming more sophisticated, safer with lead side effects every time that a new one comes out.

40:10So we went from mono GLP-1, right? What does that mean? That it only has one hormone, that's just GLP-1. All right. And that's semaglutide and liraglutide. Okay. Now, exactly, semaglutide, liraglutide. Now we have twincretins. So it has two incretins because this classic... What's an incretin?

40:29Dr. Mary Claire Haver:We haven't talked about that. Incretins are drugs that help the pancreas produce more insulin for glucose control. That's a type of hormone. This is their main function. So that's a GLP-1 is an... It's an incretin. Okay. So we have the GLP-1, which is liraglutide, semaglutide, but now we have twincretins, which is two incretins in one drug, which is GLP-1 and GIP. Now that's a combination that has two different... That's trisopatide. So it has two different pathways. So we're seeing more weight loss. And less side effects. And less nausea. Less nausea. 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.

41:04Dr. Mary Claire Haver:We tend to lean towards trisopatide because of the lower side effect profile. Now, retatrutide is another coming next year that's three incretins in one. So GLP-1, GIP, and glucagon, which is another hormone that is made in the liver. So all of this are working different pathways to provide us greater weight loss. And what are the studies on this newer medication showing? Weight loss that we've never seen before. Significant up to even 30, 40 % of body weight loss. Are they monitoring body composition? Are they just doing weight and BMI? Now they're starting to do body composition, right? Because all of the studies were done with using BMI.

41:46Then we have other pharmaceuticals coming with their own type of incretin. We have a monthly one coming in the next few years. What about oral options? So oral options, we have semilutide orals since 2019. It's called Rebelsis. And it was like a huge expectation. Oh, now we have the first oral GLP-1. 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 going to see the same as Osimpec for diabetes. And then we saw the results. People were losing weight. Now it has the indication for weight loss.

42:25But that didn't happen with the oral somaglutide. Again, since 2019, it's available. Why? Because we did see glucose control similar to Osempec at that time, but not weight loss. Not the weight loss. So just to give you an idea, the doses there is 3 milligrams, 7 milligrams, 14 milligrams when it's available. Right now, Novo Nordisk, who has this drug, they're studying at 50 milligrams for weight loss. 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, Elilili has Orphoglipurone, which is another oral.

43:03GLP-1 is not tersepatide oral. It's just GLP-1, one single hormone. But the weight loss is not comparable to 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 an oral pill, which in theory should be less expensive. But oral semilatide 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.

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44:29So you can spend less time worrying about insurance and more time enjoying the ride. Download the State Farm app or go online at statefarm.com. Like a good neighbor, State Farm is there.

44:40Dr. Mary Claire Haver:To kids, summer isn't just time off. It's time building confidence and curiosity. But when school meals pause, millions of children lose the food they count on. Your support helps the Feeding America Network nourish every child's potential. Give now at feedingamerica.org slash summerhungry. What can my listeners do? They've heard all this information. They're like, okay, I want to go and talk to someone about this medication and what it might do for me. I know that to get in to see you is probably very difficult. Who do they talk to? Is this their family medicine doctor? Is this their OBGYN? Is this their, you know, who do you go to?

45:19Dr. Mary Claire Haver:How do you know? Is there a list somewhere? 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 GLP-1, what to do, what to look for. And then during a GLP-1, how to guide them to a safe journey. and then after a GLP-1, 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 abum.org. There is a list of obesity board certified that you put your zip code.

46:05And we'll put this in the show notes. And it can tell you who is close to you that is obesity board certified.

46:11Dr. Mary Claire Haver:How do we know we're getting the best care? 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, on how to avoid the muscle loss and why it's important not to lose muscle, right? That's a green flag. Okay. What about the red flags? I always tell my patients, even for hormones, don't assume that just because they're an endocrinologist, gynecologist, you're going to leave with a prescription of hormones.

46:46You have to do your due diligence. Call and ask, does the doctor prescribe hormone replacement therapy? Same with GLP-1. Does the doctor have experience? How long has this doctor been prescribing a GLP-1? 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.

47:11Dr. 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? Body composition, strength training. Yep. Nutrition, more focused in lean protein and a GLP-1. How can we as loved ones, so, you know, we're physicians, we know how to do this. And thank you 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 supportive of someone going through this journey and perhaps starting a GLP-1?

47:51I think it's really important from family members, right, to understand that your friend, your son, your husband, whoever's on this GLP-1 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.

48:33Right. 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 learning.

48:46Dr. Mary Claire Haver:I always talk to patients, especially if they're in a mismatch, meaning one person in the relationship is on a GLP-1 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 your hunger cues or things are going to be different. And remember, your partner is not feeling the same way. So your life has changed, theirs 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.

49:28Dr. Mary Claire Haver:Who's a good candidate for GLP-1s? And we in medicine, we call it contraindications. Who should not be taking it? There's more who can take it that not. So I'm going to go with the who cannot. Anybody who 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.

50:11Okay. Somebody who has developed 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 developed 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 who to lose weight, maintaining weight feels like a full-time job, they can be candidates. They may be candidates for this medication.

50:52Dr. 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. Yeah. Divorce, single mom, started your own practice, bought an apartment in New York City. 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.

51:40Type 2 diabetes. Can you imagine that? That's a possibility. There are going to 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, it's truly defining what our health is going to be in the next generations. And I think that is great. But 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.

52:36And they still managed to do things like I'm grateful 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.

52:50Dr. 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. Yeah. 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 stronger? Leaving my home, leaving my country. Yeah. Do you miss it? I do. And I 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, OK, then I can go back. You know, as a doctor, and I'm sure this is you experience the same, you start getting used to missing birthdays.

53:29You 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 I 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.

53:51Dr. Mary Claire Haver:So thank you for being with us today. And anything else you want to say to our listeners? I'm very happy to be here and to have this conversation and definitely look for my book. I wrote it for everybody who doesn't understand obesity, for anybody who's thinking of being on a GLP-1 or they are on a GLP-1. 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.

54:46Dr. Mary Claire Haver:health, fitness, and navigating midlife at thepawslife.com. If you're loving this podcast, be sure to click follow on your favorite podcast app so you never miss an episode. While you're there, leave us a review and be sure to share the show with the women you love. We would be so grateful. You can also find full episodes on YouTube. Unpaused is presented by 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 or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment.

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