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

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 can not 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. 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 Unpost, we began a conversation with Dr. Rosio Salis-Walen 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. Salis-Walen 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, Weightless, 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-Walen 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 GLP1s, 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 Unpost, 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 homerun therapy. A woman cannot get a break. She has to justify her need for anything and everything. Do you feel the same way? Yes, and I tell my patients you don't have to earn the right 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 pregnant or possible 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, 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 to drama? We see on social media? 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 this medications and it's a little bit more controversial because people tend to attribute whatever weight gain or symptoms that we have 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. 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? I say it's not true, right? Because I have women that have a good muscle mass, that their metabolism is working and they're going to 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, 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, I see the shaman 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 are age, like 98% of what I see is centered around that. So I am a bit of a bubble. But do you see, because you treat both sexes, the shaman stigma for both genders? Well, I think the issue that you are talking about is women are held at higher standards in regards to appearance. 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 is going to try to use a medication to look a certain way. But again, we have to retrain the way that we think about waking and these medications. And the moment that we see it as a medical problem, then we can remove that stigma from it. That's not just about looking a certain way. It's about feeling a certain way, because what I love of what I do in my patients is they come thinking they want to look a certain way. And halfway is how they feel. 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 debilitating hot flushes and night sweats, joint pain, brain fog, all the things. And the first thing we do is put out the fire of menopause. That's what I do. We get them on hormone therapy if they're a good candidate and most women are. And we make them feel like they're human again. 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 the 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? What helps a lot is when you show the patient their body composition. I think that's when they 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 going to look muscle-y and I don't want to get so big. But when they see it, 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 get any muscle? Their muscle takes over and I love it. The other day I had 76-year-old patient with us to process. And I've been working really hard on her to build muscle in she's of that concept of skinny no matter what. Right? So finally, she started working out gain muscle and she came to me in her next visit and she said, Dr. I was going to fall the other day. But I felt my core held me from falling. So she felt it. She felt it grounded because of her muscle mass. Want somebody feels that? It's your work there is done really because once you feel strong and you feel protected in your own body, you don't want to get them out. And you realize you avoided injury. So I was in Australia and we spoke at I mean, 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, you know, 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 then 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. Yeah. 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 in the bed and tried not to wake up my husband and tell him what had happened. 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. Yeah. Let's talk about Serena Williams. She's all over the internet, all over the news right now. You know, here is in arguably the best athlete. Maybe her sister is right up there with her in the world. In the world, you cannot tell her workout more eat less. And she was struggling with postpartum weight loss. Get some of GOP one, lose us 30 pounds, tells the world about it, takes a picture in a bikini. She's got muscle. She is still as you know, she's healthier than she's ever been. But why do you think the uneducated are wanting to get into this discussion and so much judgment? Definitely. And I think she, I think what she did, it was a very positive and 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 one several championships in what she does in her sport. If there's somebody who knows how to exercise, how to eat, it's going to be an 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 as some people died in their 20s and their 30s, they 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 hurt. 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 GLP one medication. And this is a perfect example on how a GLP one medication can be very beneficial. Right? And how a GLP one 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 GLP one. 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 lose the weight with a GLP one, they continue to promote this erroneous idea that exercise and eating less, that's what the weight loss. So people say, well, if 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? Yeah. 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 some Italian health service for the GLP one, right? So she's a business woman and she's never shied away from from owning it. Shaming women for being business women is a whole nother podcast. We can get into. And but you know what? Thank 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, it's another podcast, but talking about telehealth, telehealth can be very successful for GLP one medications. I've had patients that I've never met in person that they've lost 80 pounds, a hundred pounds. It's just through telehealth in your office. Yes. Okay. And what is telehealth? Just in case. Telehealth is not in person visits is virtual visits. Right. I have a lot of patients who come in and weight is now an issue, visceral fats and issue. Their muscle mass is fine. We have no, I have no worries about starting them on a GLP one. 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, maybe this time it'll work. What would you say to a patient like that? And do you hear the same thing? I do. I would say a lot of my patients come knowing that they will need a GLP one medication because of my specialty, right? That I'm an obesity physician. So many patients come to that. Right. I see guilt and sharing that they're on a GLP one medication, right? Even within their spouse or their children, their spouse, their shame, their embarrassed that they think they're taking the easy way out. It's not an easy way out. No, because building muscle, eating protein a day, it's hard work. So when you're educating them that and make them part of the treatment, it changes the concept of the medication. There's no more cheating. You're actually have to 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. What I find with our patients is it is work because your hunker cues are different. You're not as hungry. And they really have to work at getting enough protein. And now, I know we're going to get a ton of questions about this. How much protein do they really need? What the USDA is recommended is like point eight, the necessary for life, right? Right. The bare minimum, two of a wide course, your core, which is severe protein malnutrition. Great. Very different than something to support muscle mass. 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. Okay. 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 one is around 100 grams of protein a day. Does the minimal to not lose muscle or to lose less than 10% of the muscle? Is that dependent on how tall she is or how tall she is? I would say bullpark for the majority of patients when we're just talking about not muscle loss. Okay. Hence also if it's a male that is 62 and their ideal body weight is still 200 pounds, right? Then that's it's more the amount. So what's recommended with literature tells us is should be one gram of protein per pound for your ideal body weight. Okay. So if somebody who is 250 pounds comes to see me, but they need to lose 80 pounds, I may base on the, I'm tired. Yeah. I'm tired. 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 their appetite. Okay. It will go back to the restrictive full-time job. Okay. 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. Okay. So we have to, it's a fine line between having the patient not go to the restrictive in the opposite way or obsessive with exercise, obsessive with the protein, right? So you have to have some room there for no, not for perfection, we're not reaching for perfection. I've really been leaning into the idea that fewer better pieces just make life easier. I don't want to cause it full of noise. I want pieces that work. That's why I've been loving quints. 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Go to q-u-i-n-c-e.com slash unpause for free shipping and 365 day returns. Quints.com slash unpause. Perry Menopause is not early menopause. It is its own distinct biological phase. And it has been largely ignored. My new book, The New Perry Menopause, is about the seven to ten years before your period stop. A transition that is anything but gentle. Hormones fluctuate wildly. And for many women, this is when the anxiety, brain fog, sleep disruption, weight changes, mood shifts, joint pain, and that unsettling feeling of, I don't feel like myself anymore, begin. Long before anyone says the word menopause. Perry Menopause often starts quietly. It shows up in the brain first, then the body, then everywhere else. And too often, women are told, nothing is wrong. I wrote The New Perry Menopause because you deserve answers before things spiral. You deserve care before burnout. And you deserve a clear roadmap for a transition that medicine has ignored for far too long. The New Perry Menopause is now available for pre-order everywhere books are sold. Learn more and pre-order your copy at thepaslife.com. I have seen on the internet that GOP ones can cause a needing disorder. Oh, no. I have patients with eating disorders that they get relief from the eating disorder, 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 mental disorder, eating disorder. So it helps them a lot. Let's move towards the emotional impact of GOP ones 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 through Perry Menopause 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? This is one of my protest 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're not educating on the after, right? Because for the first time in history, we're going to have masses of people reaching weight that was unreachable before, right? Right. So many patients for their first time in their life, they are in their ideal body weight. Because I follow my patients long term, right? And what I see is patients get to their goal weight, especially with an uneducated, you know, someone just giving out the medication, they get to their goal weight and they're done. They never see that doctor 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? Michael 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 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, they've lost significant amount of body fat. Some patients that had ex excessive amount of fat, then they have ex exes amount of skin that some patients may need surgical treatment for relief because you can have infections, right? Is bothersome physically, not just psychological or aesthetically, but it can also have medical consequences, 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 in those patients to beautifully with abdominal plastic, moving 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? 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 to, it can affect them mentally, right? Okay. So it's reassuring them. It's seeing them after their reach their goal to maintain also that they don't become anxious about weight wreaking. Some patients, the physical adaptation takes it's quicker than the psychological adaptation. So many patients, even though they've lost 100 pounds, they don't see themselves is still in that way, right? 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? 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 gel P1, but I decided not to use it. I decided to go to therapy. First before going on a gel P1. 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 that 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 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. Do you think that massive weight loss those patients deserve therapy? 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. 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 not 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 it's the next specialty that is going to come on to somebody who's a health care and mental health, subspecializing 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 majorities, it's always something positive. 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-up, some 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 microchanges 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 and it's not that one part 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? I do and I've actually seen divorces. Yeah, I was going to ask, have you heard of the ozampic 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 again, there's going to be a lot of biopsychosocial environmental changes. This is even before GLP one 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 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 in that doing that with them exactly. But if you have a couple that both of them struggle with their weight is struggled with eating poorly or alcohol, then eventually the other spouse comes to. And I think I see that a lot. Talk to me about addiction and changes in behavior we're seeing with unintentional, you know, GLP one 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 one's block that reward system, if alcohol was a sort of a reward, the drive will be less. They behavioral changes. Also, it makes you fuller, so you may have one, two drinks 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 lower doses. We have to actually have to reach higher doses. As a menopause specialist, I was really excited. I know you were to last year to see what research had really confirmed that we were seeing in our own practices that versus, and it was simiglutide, it's maglutide. Patients on the GLP one versus patients on GLP one and menopause hormone therapy. The menopause hormone therapy GLP one group lost more weight than simiglutide alone. Why do you think that is? Well, it can go from the physiological to the socially part too. 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 one, well, they're going to have better results. If we talk about the external things, but then hormonal also. As we talk initially, the drop of estrogen can change your body composition. By giving somebody what they're not making, we never promote them as weight loss. Never are not weight loss or that. We have GLP one medications, but it's going to help your body recomposition. Synergistically, that work together. 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. 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 unopily of this medications. Let's talk about that. No, but nor this and Eli Lee. 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 Monjaro pen gives you four doses. So it's a monthly pen versus here we have every week you use 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 Lee now, they have their drug to serpitate in vials. Yes. That is now where most of our patients are getting the medication is direct from Eli Lee. And the cost is roughly half of what we had to tell them last year. So if they're paying out a pocket for the 2.5 milligram dose, it could be 1100 dollars for the the vial itself. It's $300 a month. So it's almost a one fourth of what they cost, 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 novel nor the scanela, 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, but also once there's more competition that is coming from different pharmaceuticals and more drugs and more options, then the cost needs to to come down. I want to go back to you know, semi-glutide and terzoepatide, 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 compounding 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 campaigning or nothing as far as their budget. So the safety should not have a price, right? You should not put your health at risk because it's cheaper. You feel these drugs are putting people at risk? Yeah, so actually there's studies, this is specifically the compounded compounded. There are studies that have shown that most of the calls for toxicology for overdose of GLP1 is with compounded medication. Okay. Because you've run the risk of overdosing yourself. The problem with compounded medication, there's several. One is that is not FDA regulator. 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. That doesn't happen with compounded medication, right? Second, right now, when there was a shortage of the drugs, it was legal to compounded medication. Okay. But now there's no shortages and actually both illegally and over nor does 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 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 a reality. I see patients who come in on a compounded medication who would never have used anything compounded. Absolutely. We go to Walgreens and pick up whatever they need it would never occur to them to go that route except for this. That's so desperate. I don't recommend that 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. There are the highest standards of 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 it's the non-inducrinologist. They're not going to be more sort of phytobicity medicine. So it's not just that they're giving you the compound that is what guidance are you getting with the compounded medication. Let's go back to the future. The exciting part. What is the drug pipeline look like? So right now we have GLP ones and then we have the the TERS appetite. What is TERS appetite versus semically tied? So I like to describe the the medications like the iPhone, right? So we have the iPhone 10, the iPhone 12. Every time they they improve it, their work better, they have less bugs. Same thing with the GLP one medication, right? So right now we have the iPhone 16, which is TERS appetite, Muncharo, Sebbown, but the iPhone 17 is coming this year, next year, right? So the drugs are becoming more sophisticated, safer with let side effects every time that a new one comes out. So we went from mono GLP one, right? That is what does that mean? That it only has one hormone. There's GLP one. All right. And now we have semagglutide and lyrgglutide. Okay. Now exactly semagglutide. Now we have twin critins. So we have two increitins because this class of class of treatment, we have a drug that helps the pancreas produce more insulin for glucose control. Okay. So that's a type of hormone. This is their main function. So that's a GLP one is an it's an ingredient. Okay. So we have the GLP one, which is lyrgglutide, semagglutide, but now we have twin critins, which is two ingritins in one drug, which is GLP one in GIP. Now that's a combination that has two different pathways. So we're seeing more weight loss. But and less side effects. And less nausea. That's what our patients see. We almost don't prescribe semagglutide unless they've been on it and they're happy with it and it's going well. We tend to lean towards the stereotype because of the lower side effect profile. Now red dot true tide is another coming red dot true tide. That's okay. Three increitins. So GLP one, GIP and glucose one, 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. Then we have other pharmaceuticals coming with their own type of inkritin, right? We have a monthly one coming in the next few years. What about oral options? So oral options. We have semagglutide oral since 2019. It's called rebelsis. And it was like a huge expectation. Oh, now we have the or the first oral GLP one 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 same as the same thing for 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 semagglutide. Again, since 2019 is available. Why? Because we did see glucose control similar to ossempic at that time, but not weight loss. Not the weight loss. So just to give you an idea, the doses there is three milligrams, seven milligrams, 14 milligrams, what's available? Right now, over nordisk, who has this has this drug, they're studying at 50 milligrams. Wow, for weight loss. Oral. Okay. So significant much higher now. Oral gives more side effects. Yeah, actually. So it's going to be interesting to see if patients actually tolerate it. Now, Ilalili has orphoclyperone, which is another oral GLP one, it's not tersepatide oral. It's just GLP one, 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 an oral pill, which in theory should be less expensive. But oral semagglutide 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. 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 you get in to see you is probably very difficult. Who do they talk to? Is this their family medicine doctors, is this their OBGYN? Who do you go to? 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 one, what to do, what to look for, and then during a GLP one, how to guide them to a safe journey, and then after a GLP one. So my book is my protocol is like having me at their home. Moving to that, ideally, an obesity-bore certified physician will be more expert on these drugs. And there is the American Board of Obesity Medicine website, which is a bum, that org. There is a list of obesity-bore certified that you put your zip code. And we'll put this in the show notes. And it can tell you who is close to you that is obesity-bore certified. How do we know we're getting the 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. Okay, what about the red flags? I always tell my patients, even for hormones, don't assume that just because they're some under chronologist, gynecologist, you're going to 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 one, 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. 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, nutrition, more focus and lean protein in a GLP one. How can we as love the one? So we're physicians, we know how to do this and thank you for being the main source of my information on the 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 one? I think it's really important from family members, right, to understand that your friend, your son, your husband, whoever's on this GLP one medication will not eat as they used to eat. Not to question what are you saying? What 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 appetite, sir, and then learning. I always talk to patients, especially if they're in a mismatch, meaning one person in the relationship is on a GLP one and one is not, that their hunger cues are going to change and you don't have to mention constantly all day because you might irritate your partner. 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. There 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 GLP ones and we in medicine, we call it contrary indications, 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 medallary thyracarcinoma, okay, even family history. It's not recommended because in mice, it was shown to promote medallary thyracarcinoma, which is a very severe aggressive type of thyracancer. So unfortunately for patients with personal or first degree family history of medallary thyracarcinoma, it's not it's contraindicated. Any other type of thyracancer, papillary, follicular, hurdle, thyranodules is not a contraindication. Okay. Somebody who has developed pancreatitis from the medication. Okay, and that it's also a little bit open to per case basis. If somebody was started on the medication and move 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 who to lose weight, maintaining weight, it feels like a full-time job. They can be candidates. They may be candidates for this medication. This has been an amazing conversation and I'm sure our listeners have learned so much before we finish completely. I'm going to ask what I ask all my guests a few questions on on pause. 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 first-hand 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's a possibility. There's 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. 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, cat slushes, night sweats, depressed, vaginal dryness, UTIs, and they still managed to do things. 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. 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 stronger. Leaving my home, leaving my country. Do you miss it? I do. You go back every three to four months. I'm like I have to go to Mexico. I have to touch Mexico. I have to eat Mexican food. Just like to feel like okay, 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. 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. 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. 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 GLP1 or they are on a GLP1. I wish everybody had access to experienced doctors but unfortunately there's not enough doctors strained. So with my book I want enough people educated in the subject. Where to find Dr. Rosio Salis-Walen? As a reminder to our audience your book Waitless is out in December and available for pre-order right now. Listeners can also find you on Instagram at Dr. Salis-Walen. I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram at Dr. Mary Clare and get the honest accurate information on health, fitness and navigating midlife at thepaslife.com. If you're loving this podcast be sure to click follow on your favorite podcast apps 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. Unpawged is presented by Odyssey in collaboration with Pod People. I'm your host Dr. Mary Clare Haver. The views and opinions expressed on unpaws 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.