Introduction to GLP-1 Medications

For this DrTalks, we are going to be discussing the new class of medications, the GLP-1s and GLP GIP receptor agonist. And I have a wonderful guest with us, Dr. Alicia Shelly.

Dr. Shelly is a board certified internal medicine and obesity medicine physician. She's a two time TEDx speaker and international speaker. She hosts Back on track: Achieving Healthy Weight loss Podcast, and she's been featured on CNN, CNN International, Fox 5 News, Upscale Magazine, and Shape.com.

Thank you so much for joining me and for sharing your expertise with us. Thank you so much for having me. I'm so glad to be here today. So let's start off with what are these GLP-1, GLP-1 GIP receptor agonist.

These new medications. Tell us just the basics of what they are. Yes. So these GLP-1 GIP injectable medications, they work by increasing the hormone GLP-1.

Now w one is in what we describe as an important hormone or a hormone that affects the pancreas digestive system, appetite system. And so these hormones are throughout our gut.

They're in our brain and they help with appetite and caloric intake. So when they're increased in our bloodstream we feel less hungry. We're not as full.

And then also sometimes we're not really thinking about food as well. And so GLP and GIP-1 one are hormones that were discovered or dip was actually first discovered in 1970.

And then GLP-1 came along in the 1980s. So they've been around for a while. But we recently when we first started, we started using them for diabetes because it helps with balancing out, insulin or insulin, insulin, more sensitivity also with balancing out glucose control.

But then we noticed just how well they worked with appetite where people were less hungry. We started seeing people losing weight. And so these injectables, were just recently, in the last several years, FDA approved for weight loss.

And so and now we are using it to help people with losing weight when we think about the percentages of of overall weight change, it's usually between 15%.

And 26% was what the studies have shown. So it's been around for a while, right? They're not they're not new. That's why I kind of put in reverse talking like these new medications, because they have been in development for a while.

They have been used for diabetes for quite some time. And then really the effects they had on appetite and just the effects they had on weight, became pretty clear.

How the Injections Work and Getting Prescribed

And so now they're also approved just for that use. You don't have to have diabetes to take these new medications. And we can use the names here. This is not a C of your presentation. So. Okay.

So when we talk about these meds, I think the most popular one that people have heard in the media is Ozempic. And putting that in quotes, because the Ozempic is technically for diabetes, it's same chemical.

It's same hormone. Semaglutide is called Wegovy when it is used for weight loss. And then our other big one is Zepbound that is also used for weight loss.

It's called Mounjaro and it's used for diabetes, but it's the same hormone either way. And so I think sometimes people get confused by the different names, but when we're talking about them for weight, we're talking about, Wegovy and Zepbound and then there's an older one that's a daily shot.

Those two new ones are weekly and it's called Saxenda. And so we have a couple different options of these, these medications. And again, they're not they're not brand new.

Okay. So we talked a little bit about how they work. But for people who maybe aren't familiar or only like seen them in the news or heard things, sort of distantly about them, what does it actually look like?

What is the process for getting this medication? You know, people get very, alarmed sometimes when they hear the word injection. What can people expect, for these medications?

Yes. So for these medications, just like you're saying, there are once weekly injection. So I have a lot of patients who hate needles. They hate it. And so a lot of times with these pens, they are one, just a one dose injector.

So you don't even see the needle. With the, with the Zepbound, you just press the button and you just hold it on to your skin, and it does all the work for you for Wegovy We just kind of push down and hold it for ten seconds until you hear that second click, and then it gives you the give you gives you the medication without you having to see the actual needle.

As far as the process of getting it. So because of how popular there are it, there has been some back orders and shortages, national shortages around.

So sometimes it may be a little bit difficult, but the first step is to talk with your doctor, make sure that you are the right candidate for this, and make sure that this is okay for you, and your health.

And then after that, your doctor will have to do a prior authorization, where they actually say, hey, this patient needs this medication because of this diagnosis.

And then after that, that's where it gets a little bit tricky. They'll send it to, you know, send the medication to the pharmacy. But then the question is which pharmacy has it and it's just trying to find out which one.

Yeah. Yeah. So sometimes it can be a little bit of a challenging process because of the cost of the medication. Insurance definitely likes to make sure that the right people are getting it, which are essentially people with a BMI over 27 usually.

But, there can be some wiggle room there. And then, the shortages also, sometimes there can be a delay in getting it, or you might have to check with multiple pharmacies.

And sometimes I think one thing I like to prepare my patients for is they may have to switch between the type of medication, based on which one is is currently available.

And that's not uncommon in general, in medicine, we often have to switch people's insulins around or their blood pressure around based on on what is covered or what's available.

And that is just something that, it is sort of like the nature of, of taking a medication. And sometimes we do have to switch that based on, on which one is the easiest for you to get.

Absolutely, absolutely. And the couple of things I didn't mention. There are some, like you said, the indications of BMI of 27 plus a weight related comorbidity like high blood pressure, diabetes, sleep apnea, but then also you have a BMI of 30 with no weight related comorbidities as indicated.

But there are a couple of contra indications, such as if you're a family or or you have a personal history of medullary thyroid cancer. So it was important to talk to your family about what's out there, because sometimes we don't know different cancers that people have.

And that can make a big difference with these medications. Or if your family has, multiple endocrine neoplasia type two history. So that's important to maybe, reach out and to ask just to make sure that you don't have any of these particular conditions in the family or personally.

Yeah. Those are those are like the two big ones. Right? Those are ones we we think those people might possibly theoretically be at risk for thyroid cancer if they took this medication.

Who Can Take Them and Who Should Avoid Them

And so those are the group of people who really we do not prescribe this medication to thyroid disease is really common. So it's definitely possible that you or someone in your family has hypothyroidism or graves disease or a different type of thyroid cancer.

So it is important to see what details you can find out. Most of the time, a thyroid problem is not medullary thyroid cancer. But if it happens to be that specific thing, this medicine is really off the table for you.

Exactly, exactly. So you mentioned in the beginning how effective these medications are. Can you go into that a little more? What can people expect in terms of how much weight they'll lose and how quickly they can expect to lose that?

Yes. Now, the one thing I'll have to say is that when they did the studies to get this approved, it was people who were actually having a good diet. They had a caloric deficit in their diet.

They were exercising. So they had that the lifestyle change too. So it's important that we make sure that at baseline we are doing that. We're making sure that we're eating healthy, exercising, getting a good night's rest, decreasing our stress.

All the things that help with weight loss. And then what we found is that when they were taking these medications at the highest dose of Wegovy at 2.4mg, they, lost around 15%.

And then with the Zepbound at the 15mg dose, the average was 24. But then another study also. So 26. So 24 to 26%. And usually you don't lose weight right away.

So nothing is like you're not losing 20 pounds in a week. Okay. Even though people on TikTok may make you believe that normally what I see is that you see people gradually losing weight.

That was 1 to 2 pounds per week, but it's consistent and there will be some weeks where you may gain a pound and then lose 2 pounds, but you're seeing it consistently coming off.

And then over time when you look back, you can see what, you know, such a large amount that 20% that you've lost. So I do have patients that sometimes get discouraged because they are expecting to lose 20 pounds in a month, but honestly, it's the slow and steady that wins the race and you usually will see that the weight lose.

You lose weight gradually. Yes. So that's a good point, that it is gradual. And most of the studies, it's kind of over the course of a year, you know.

And so and then people do stop losing weight usually at some point. And I think that can always be a little hard to is, you know, when to accept that, that new weight, is that the right weight.

How do you counsel your patients on that when they, you know, our sort of have been on the medicine for maybe a year or so. And they have have stopped losing weight.

How do you have that discussion. Yeah.

Expected Weight Loss and Realistic Goals

So if they haven't stopped losing weight, we actually try to do an assessment, make sure there's not anything in their lifestyle that we can maybe tweak or improve on or optimize this to kind of help with losing weight.

Sometimes I find, what's interesting with these medications, they make you not to feel as hungry. And so sometimes people restrict too much in their calories.

And so we like to make sure we go through their, caloric, their dietary habits to make sure there's not anywhere where we can improve on that. But then also, I sometimes remind them that we can change some things up, whether we're changing something in their physical activity, changing something up in their diet to kind of help with moving forward.

Also, sometimes just actually being realistic and seeing how happy are you are with your body. Like, are you in a good place or are you chasing a number?

Because a lot of times, and myself included, we have this number fixated in our brain that we want to be this number, but we're actually happy at 10 pounds heavier, or we're actually happier this way.

We feel good. We're able to do the things our medical conditions are improve, but because we have this number in our mind, we're like, oh, I need to be it.

I've it's interestingly enough, sometimes we look back to when we were kids, when we were adolescents, and we expect to be that weight that we that our weight when we were went to the prom in high school.

And not everyone can be that way. And sometimes that weight may not be as healthy for you at this point than it was there. I had one lady, she had a BMI of 23, and she's like, you know, I'd like to lose ten more pounds, but I'm like.

But where you're like, what? And why write like that BMI right. You're exactly where you need to be, you know. So so definitely we we we sit down, we see where they are.

We make sure that we have that conversation and make sure we have realistic goals to. Yeah, I think that that's really key is like those realistic goals which I always try to bring back to health.

Right. Like, are you able to do the physical activity that you need or want to do what is your blood work look like? How do you feel? What's your energy level?

Because people absolutely can be healthy at different weights. And you know, a BMI of 23 is going to be a really healthy BMI for most people. So in terms of the lifestyle, I think that's really important to talk about because I think sometimes the impression people get from maybe social media is that they just take this medicine and that's all they have to do.

And the meds are pretty powerful. So people will have weight loss even if they don't do anything else. But I know for those of us who work more intensely with our patients, I know I see really much more amazing results for my patients when they are also doing specific nutrition things and being really intentional about their movement.

What sort of general guidance do you give about, you know, lifestyle when someone is on these medications? Oh, definitely. So, you know, when it comes to diet, some diets are better for some people.

And for example, if you, have heart disease, then maybe the keto diet is not best for you because it's higher in more saturated fat, higher in protein, low and carbohydrates.

But it can cause your cholesterol to increase. And if you're trying to improve that, that would not be great. If you were having diabetes, sometimes a low carbohydrate would be better for you.

And so it's just trying to make sure, number one, where you are with your medical conditions and what diet would be best. And then also what are your preferences?

You know, if you hate vegetable oils, maybe plant based diet is not for you. We can try something else. So just trying to work where you are have that individualized approach is important.

But when I think about general health, health habits, the one thing I would say, regardless of which that you do decide, is to make sure that you are reducing the processed foods in your diet, make sure you're having time not only with meal prepping, but making sure that you're able to cook more healthy and fresh foods for you and your family just because studies have shown and that makes a difference with weight loss as well.

Also making sure that you're getting more complex carbohydrates, you know, higher fiber to help with having more regularity. As far as valve movements are concerned, making sure you're drinking water, and you're hydrating your body, staying hydrated.

And that is so important with these medications we haven't got there yet. But one of the higher the, the highest ed side effect is nausea. And so sometimes people don't feel like drinking water.

So just like doctor think of is drinking water. We need to drink water to important. It's important to get that in because, we need to be able not only flush our body, but to flush our bowels and to flesh our kidneys.

And then also it's zero calories, so we're not giving our body extra calories as well. And so, it's important to, I know, to, to get away from those sodas, especially those diet sodas that has the aspartame and the artificial sweeteners.

So making sure that we're focusing on more healthier, options. And I love it. That's great. So let's talk about some of those side effects on the medication.

So we've talked about how well it works. And sort of what people can expect. What are some of the side effects that people are likely to see. And if you have any tips for handling those.

Oh yeah. The most common side effects that we see are going at the top four are going to be your nausea, vomiting, diarrhea, constipation. And the reason why that is, is that these medications delay.

The gut as far as the motility of the gut and is not emptied as fast. And so, you tend to sometimes people tend to have more knots and more, you know, they'll eat and they'll feel full and they'll and if they keep eating, they make it a little bit more nauseous.

So some tips and strategies to avoid nausea is number one, making sure you eat because if you're not eating you can get nauseous. And then avoiding overeating.

If you're feeling more nauseous, you can try, eating bland foods. You know, the, the what we describe as the brat diet bread, rice, and toast there. So at least that can be able to.

It's like more bland foods just to kind of help with that nausea. Also, like I said, make sure you're drinking lots of fluids so you stay hydrated. There have been reports of people having acute kidney injury due to the dehydration.

So it's important that we stay hydrated regardless. And drinking fluids, some other side effects that you can see with these medications. These aren't as, common, but can occur, you can have some, acid reflux, some, Gerd there that can occur or people describe it as sulfur burps is another way how they describe it.

Sometimes people can have some fatigue, some, reactions at the injection site. Also, some people have developed a small amount of people develop gallstones from it.

And even a smaller amount have developed some pancreatitis.

Lifestyle Habits and Managing Side Effects

So these are just different conditions that we have seen. If you do have a history of pancreatitis, then, you know it is not recommended to be on these medications as well just because it can trigger it.

As far as with gallstones, you can, you know, discuss that with your, your doctor as well. So great points. And I think if you have any symptoms, you should be able to discuss that with whoever's prescribing you the medication.

Because if they are familiar with this medication, they have seen the side effects before, and they're going to be able to tell you if it's a serious one or how to navigate it and reduce that.

And most people's, side effects decrease over time. So they usually tend to be the most intense. The first, when they're first taking the medicine or when they increase the dose and then they do tend to get better.

Yes, I have seen that too. One of the other exciting things we're starting to see with these medications is that they seem to treat other health conditions.

So it's not just that people lose weight, but their health improves in other ways. Tell us more about that doctor Shelly. So this is very exciting because there's so much research going into looking at how these medications can help other diseases.

So like we said, it helps with diabetes. It helps with weight. But just recently, semaglutide was approved for individuals who have coronary artery disease, heart failure, history of heart attack and stroke.

And what the study showed was that by those who had a history of stroke and heart attacks, and just cardiovascular disease, that it improved their risk for mortality by 20%, which is amazing, amazing.

And so now they are approved for that. Also, there is a recent press release from TRS appetizers that found a majority where they looked at sleep apnea and appetite, and they noted that regardless of the person was on, CPAp or BiPAP or not, they did see an improvement in their symptoms.

And so that's exciting. So hopefully, coming up, hopefully we'll be seeing more information coming out on that. Also their studies looking at addiction with, these medications that has been promising people anecdotally, people have noticed that, you know, they're not craving alcohol or opioids, with taking this medication.

Also, people have noted that have PCOS. The how that's been helpful for them as far as with that, becoming less, less insulin resistant. And so they're doing studies about that, and there's so many more studies that are coming down the pipeline, it's hard to keep up.

But it is it is. And I, I think it's like so great for us to go back to like that as like the the key here that weight loss is important to prevent problems for many people.

But it's also often treating problems that they have. So if you already have heart disease or sleep apnea, these medications may help reverse those processes or decrease your risk.

So it's not just, you know, when we're trying to figure out how much weight should you lose on these meds? It's not just about a number on a scale. It's like, how else is your health improving from this medication?

Exactly, exactly. And that's what we have to think about. Sometimes we have patients who are resistant to the medication, even though they've been doing everything in their lifestyle, but they just really haven't been able to see that push.

And so it's it is helpful that, you know, we realize that these medications are a way to kind of help us with living a more healthier lifestyle and being able to lose weight.

I love that I'd actually like to ask you a little bit more about that, because in this summit, we are talking with all sorts of experts. We're talking about really trying to highlight all the different options for healthy weight loss.

And sometimes those are dietary strategies and exercise strategies and fasting. Plant-Based versus Low Carb. Right. All of these different strategies, and they all work for some people.

Some people anything works. For some people, nothing seems to work for. How does someone know if it's sort of time to consider a medication? I would say you wouldn't want to consider a medication if you've been trying with changing your diet, changing your lifestyle, physical activity, and you're not really seeing the results.

If you're finding that your body is kind of resistant to losing weight or you're not really seeing that change, then you may want to add on medication to that, to to that intervention, to kind of help with moving forward.

So a lot of people have tried multiple diets and exercise over their lifetime, and it just sometimes it's like the weight comes back and if you're kind of stuck, you're in a rut, then this may be an option to help with moving forward.

Yeah, that's what I see in my clinic. By the time someone has come to see me as an obesity expert, they have tried lots of different dietary strategies.

They are often moving or exercising frequently. A lot of them are coming in doing exactly what they're supposed to be doing, and maybe they've lost a small amount of weight.

Maybe, you know, they had lost it in the past and they've slowly regained it. And the things they were doing in the past aren't working anymore. And those are the people where I think, you know, working harder, like cutting more and more calories, cutting more and more types of food out of their diet, probably aren't going to lead to to that much change.

And, when they are able to try a medication, whether it be one of these or a different medication, it's often life changing. All of a sudden now, all the effort they're putting in adds up, and it's really powerful to to see how that can let everything come together.

Now, people can follow their healthy diet. They're able to actually eat less and feel satisfied. And then when they've lost, you know, 30 or 50 pounds, all of a sudden now they can run for the first time in a decade or two.

And so it just kind of lets it all kind of come together for a lot of people. Is that what you see? Oh, definitely. Definitely, definitely. And it's and it's actually really rewarding for me when my patient comes in, they're like, I feel so much better.

I have more energy. I'm able to, you know, work, play with my kids, my grandkids. Like, it's just it's just rewarding that this is what this is all about.

Beyond Weight Loss: Other Health Benefits

We're trying to give your life back. We're trying to get you to a place where you are happy and healthy. And, so I do see that. And these medications help. They help people get there.

Yeah. I, you know, I have, a couple patients that come to mind. One was, a guy maybe 50 ish, and we had really tried a lot of different things for him with a little bit of success.

And finally we decided to try, that bound for him. And he did so well on it. And he is doing pull ups for the first time in his life. And I thought that was so cool.

You know, that, like, that is such a success to see what he's able to do physically. And now, of course, exercise is like so much more rewarding to him because he can do so much more than he could before.

He lost another 50 or 60 pounds on the medication. And then I had another patient who was also in her 50s, and, she was on this medication for diabetes, and she lost quite a bit of weight.

I don't even know how much I think she's getting close to 100 pounds. And she's running for the first time in her life. You know, we had her working on getting her steps in, and she's now running a couple miles every day because she's like, well, doctor, think of all that. It turns out it was.

It's quicker to just run and get them. And by running I was like, what? Who starts running at like 50 years old, you know? So really, you know, let's everything come together for some people.

And I think that's been like the most exciting thing to see is how people it impacts their daily life and what they're able to do. With these medications.

Oh, yeah. I remember I have one patient, it was a couple of years ago. He we started him. He had type two diabetes. He was in his late 30s, early 40s, and he started on Monteiro for his diabetes.

We, and to help with weight. And over these last two years, he was. Oh, I forgot to tell you, you started off at 700 pounds. So he was he was he was walking with a cane.

And he's young. He's young. And then all of a sudden, I mean, over two years, we're working with him, changing his lifestyle. He would just like for exercise.

He would go swimming. He would just kind of keep moving. And then now he's lost 300, literally. I remember this number 365, 365 over two years with Mounjaro.

And now we're in like the 400 getting close. No, we're in the 300 pound range. And this is the lightest he's been. He's like doc, my knees feel like they're they're now like I mean you know.

And to get him into that place it is so rewarding. It is so rewarding to be able to have that opportunity to to travel this journey with him. And, and realistically, someone, in his situation was really unlikely to lose that amount of weight, without something like a medication or surgery, right?

I mean, it's possible that the lifestyle alone would would do that, but very, very unlikely. Maybe you know, 1 in 100 people in that situation, lifestyle alone would, would let them have that success.

Absolutely. Absolutely correct. Yeah. I mean he he definitely needed extra, extra assistance. Yeah. So tell me the one of the biggest questions I get from everyone is about how long they need to take this medication.

And I just know that we have all that information actually 100% yet. But what how do you explain that in terms of how long does someone need to be on this medicine?

And this is a very common question. A lot of patients before we're done. Any questions? Well, how long do I need to be on it? My answer is as long as you need it.

So when we look at what the data shows we have a certain trial has come out, that looked at Mounjaro or, Zepbound and they looked over.

How Long to Stay on Medication and Final Advice

They had the patients take it for good. I forget how many weeks, but I would say close to about a year. And then they stopped it for some people, and then they continue it for the other people.

And what they noted in those people who stopped it, they regained their weight. And it wasn't the full amount of weight back, but it was a good portion of it.

And so what we're finding for some people, obesity is a chronic disease. And so the medications are dis assisting and facilitating, you know, the different factors that are out there and there's multiple factors why people gain weight.

It can be biologic, can be genetic, could be environmental. It could be, psychosocial, cultural, multiple factors out there. And every event is different for everyone.

And so what we find is, is that for some people they need something. So even when they get to their goal weight, they may need to have something to kind of help them with maintaining their weight.

But, you know, definitely does depend on the person. Yeah. And I think, you know, in that study, people didn't know if they were getting the medicine or not, right?

They were getting a placebo. Still, in the real world, if you and your doctor decide to stop the medicine, you would know you're going off of it. And so you might be doing some different things to compensate.

You might switch to a different medicine, maybe a supplement that takes the edge off. You might you have to be more intentional about your eating. You might need more appointments with your doctor or a health coach or a dietician to, you know, really get more support.

And so, I think it's important to, you know, the real world sometimes can look different from studies. There may be hope that some people will not need the medicine forever, especially in a more controlled setting where they can do other things.

But I think it's important that we make sure people know if you do need to stay on the medicine forever, that's probably pretty normal. And you're not a failure like that's what we would expect.

And if you go off of it and you're struggling, come back to your doctor, so we can help you troubleshoot that. And say, do we need to restart it? Do we need to try a different medicine?

Is it time to consider surgery? Do we need to try a different way of eating? Like what can we do to help troubleshoot your situation right now? Absolutely, absolutely.

100% follow up with your doctor. Well, Dr. Shelly, I think you and I could talk about these medications all day because we're so passionate about it, but any other, last thoughts or things you feel like we didn't cover?

You know, I would just say, number one, as you all are considering, I'm so glad to be a part of this summit where we talk about all aspects of health and weight loss and, and as you are listening, the one thing I would say, you know, if you're in that process where you're contemplating getting started with your wellness journey, just start.

Just take one step at a time, regardless if it's, continue starting with lifestyle interventions or medications. But just take that one step and don't delay it because you will not be disappointed with having not only a healthier lifestyle, but feeling better and, and being in better health.

Dr. Shelly, if someone wants to connect with you, where can they find you? They can find me at drshellymd.com, at your on your social media, Instagram, TikTok, Facebook, LinkedIn, all the above.

But then also, if you want to hear, you can join me every week at the Back on track: Achieving Healthy Weight loss Podcast wherever you listen to podcasts.

Awesome. Thank you so much, Dr. Shelly.

Alicia Shelly, MD

Discover 5 Key Facts About GLP-1 Weight Loss Meds