November 18, 2025 • 56 mins
Why does your body start “shape shifting” in midlife, even if you’re doing everything “right”? And what’s really behind all the GLP-1 buzz? Endocrinologist and weight-management specialist Dr. Beverly Tchang explains the science behind midlife metabolism, why BMI alone doesn’t tell the full story, what GLP-1s actually do in the body, and what women should know before considering these treatments.
Links to resources mentioned in this episode:
Dr. Beverly Tchang’s Professional Disclosures
SWAN Study (Study of Women’s Health Across the Nation)
HOMA-IR Calculator (for assessing insulin resistance)
STEP 1 Trial – Semaglutide for weight management
SURMOUNT-1 Trial – Tirzepatide for weight management
Note: In this show, we use “women” as shorthand for people with XX chromosomes. We understand sex and gender are more complex, and acknowledge the experiences we describe reach beyond that word.
See omnystudio.com/listener for privacy information.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:17):
Pushkin. Hi everyone, Doctor Poyter here, I'm popping in to
let you know that we're working on a special episode
of Decoding Women's Health. We're i'll be answering your questions
about one of my favorite topics, hormone therapy. If you've
been wondering about the different types of therapy, when it
(00:39):
might make sense to start possible side effects, are really
anything else? This is your chance to ask. You can
leave us a voicemail at four FI five two one
three three eight five, or send an email to Decodingwomen's
Health at Pushkin dot fm and let us know if
you'd like to stay anonymous, or if you're up for
(00:59):
having your voice featured on the show. I'm so excited
for this one. Hormone support is such a misunderstood area
of medicine, and there's a ton of new and fascinating
research to talk about together. I can't wait to hear
what you're curious about. This show is not a substitute
for professional medical advice, diagnosis, or treatment. It is for
(01:21):
informational purposes. Please consult your healthcare professional with any medical questions.
This episode includes discussion of weight and health. We know
these conversations can be sensitive, please listen in a way
that feels right for you.
Speaker 2 (01:38):
In the past few decades, we've only been pushing this
narrative of eating less and moving more, which is oversimplified
and not the right message. And we've never had a
tool that was potent enough, effective enough to address the biology.
So when women come to me and they say that
they are working on their weight, we talk about both
(02:00):
in tandem. We talk about the lifestyle changes that we
can make, and at the same time we talk about
what are the biological factors that might make that challenging.
And for those biological factors, we offer medications.
Speaker 1 (02:18):
Welcome to Decoding Women's Health. I'm doctor Elizabeth Pointer. Today
on the show, we're talking about metabolism and GLP ones.
When it comes to perimenopause. One of the most common
early complaints I hear from my patients is what I
like to call midlife shape shifting. Suddenly, seemingly out of nowhere,
your waistline starts to get thicker. I remember getting together
(02:42):
with my college friends when we were all in our
late forties and early fifties. One of them, a former
athlete who'd always taken great care of her health, brought
up her frustration with stubborn fat around her stomach that
just wouldn't go away. Everyone else immediately started commiserating. They
were all struggling with the same thing. It's a frustrating
(03:04):
problem for many women because even if you're exercising, eating well,
getting enough sleep, and managed in your stress, you may
still gain what's called visceral fat, the type of fat
that accumulates around your organs and changes the shape of
your midsection. Many physicians write this off as a normal
part of aging, and until recently, there wasn't much we
(03:26):
could do about it. We could suggest lifestyle changes, and
I would occasionally prescribe met formant to my patients who
are really struggling with insulin resistance, but it didn't move
the needle for everyone. That is, until GLP ones came
on the market. There's been a lot of excitement around
these drugs. Some see them as a new way to
(03:46):
potentially hack midlife women's biology. But there's still some trepidation
around these medications and a lot of questions that we
can't yet answer. But today on the show, I wanted
to begin a conversation around GLP ones, to talk through
the basics and break down the science and we've got
someone terrific helping me unpack all of this. She's an
(04:08):
expert in both weight management and midlife women's well Triple
Board certified endocrinologist and obesity medicine specialist, Doctor Beverly Chang.
How did you get drawn to this area? Because it
(04:28):
really is the intersection of two areas that people aren't
well trained in, obesity and menopause. So how did you
get involved in this? What drew you to it?
Speaker 2 (04:38):
I think what's crucial here is looking at the overlap
between what the medical community is responsible for versus what
I think the wellness industry is trying to do. And
that's the difference between sick care and healthcare. I think,
as a doctor in the traditional education system, we are
(05:00):
trained to treat people who are sick, right we wait
for someone to develop symptoms, we diagnose the disease, and
then we offer treatment. And yet many many people are
not sick, and they still want to do things to
preserve their health or to optimize their health. And yet
when they come to see a doctor, we don't have
(05:22):
the right language or tools to help them. And that's
really where the wellness industry comes in. I think obesity
and menopause intersect these two very well because obesity, for
the longest time, has never been seen as a disease.
It's been thought of as a lifestyle choice, which is incorrect.
(05:42):
We know this from the science, and only recently I
think there's greater acceptance of obesity as a medical problem,
so that now it's being addressed both from the wellness
industry side as well as by the medical community. And
then menopause is one of these issues where it's natural
(06:02):
and yet it can be such a struggle and a
challenge for our quality of life. However, because it's natural,
people think we should just let it happen as it does,
and that it doesn't need intervention. It shouldn't need any
sort of intervention. But my position is, really, well, even
if it's natural, why should we suffer through it? I
(06:25):
think it really opens up the conversation more to what
does healthy living, optimize living look like.
Speaker 1 (06:33):
So when we go through when we start to go
through perimenopause and into that perimenopausal transition, you know, we
tend to change our body composition, putting on visceral fat
and have to pay more attention to wellness. A lot
of this is signaled by or has a foundation in metabolism.
Can we just like unpack metabolism a little bit here?
(06:55):
What is metabolism and how does it become disrupted for
the midlife woman so that she now enters into this
like less than healthy state for her.
Speaker 2 (07:04):
Absolutely, I think most people think of metabolism as you know,
the burning of calories, and we feel this way as
we age that our metabolism slows down. We do have
a lower energy expenditure, which is our scientific term for metabolism.
All of that happens just from general aging. The challenge
(07:28):
around metopause, interestingly enough, is that when we look at
weight trajectories and changes in metabolism, we see some pieces
in the research that absolutely validate what a woman's experience
is in the sense of, I feel like I'm doing
the same exact things. I'm exercising, watching my nutrition, all
(07:51):
of those things, and yet my body is changing. And
when we look at the literature, we find that the
rate of weight gain we see actually is about the
same rate as we would see just from general aging.
And the way we examine this is through large prospective,
longitunal studies. There's one called the Swan study. They followed
(08:13):
women over the course of decades and they just tracked
what their weight was from age forty over to age
fifty five about and they saw that on average, people
gained weight. But when you look at that weight curve,
it doesn't become suddenly steeper around perimenopause. But what's more
(08:37):
crucial is that the body composition changes, and that body
composition was seen as a faster accumulation of fat mass
and a faster loss of lean muscle mass around that
perimenopausal time period. And I think that is exactly what
women experience. The distribution of their weight changes, and of
(09:01):
course the excess fat that they feel is really sitting
around their trunkle area. This also tracks with a reduction
in energy expense, so we do see that metabolism reduce,
we do see that lean muscle mass go down, and
we see that fat mass accumulate faster during perimenopause.
Speaker 1 (09:23):
So when we go to the doctor and we do
our vital signs, we still do our height and weight
and look at our BMI and obesity or being overweight
is defined by BMI. Right, do you think it's time
to change that? Because if a perimenopausele or menopausal woman
really isn't necessarily gaining weight at a rapid rate, but
she is what I call shape shifting. Right, how do
we measure that?
Speaker 2 (09:44):
The short answer to that is yes, one hundred percent, yes, yes, yes.
If you look at our BMI scales right now, they
are not adjusted for men versus women. Even though we
know that there are vastly different distributions of body composition
of fat mass and lean mass, they are not adjusted
for ethnicity either, at least not in our clinical practices.
(10:08):
In the research, it is very very well support in
that we should be using adjusted BMIs for specific ethnicities,
for example, in those of Asian East Asian, South Asian
Southeast Asian ethnicities. We find that the metabolic consequences of
excess fat excess weight occur earlier, so we should be
(10:32):
using those different thresholds if we were still committed to
using BMI now, the more important question is what do
we use instead? And I think there is greater acceptance
now for the waste to height ratio. So you're looking
at your waste circumference, comparing that by your overall height,
(10:53):
and that should be less than zero point five. If
you're greater than zero point five or greater than zero
point six. It's a graded level of increased risk level
for cardio metabolic diseases.
Speaker 1 (11:05):
Yeah, so a woman may have what I call shape
shifting her waist, it gets a little thicker, and she
goes into her doctor and her do so your BMI
is fine, It's totally fine. So you're totally fine. Right,
So a woman go in to ask for a healthcare provider,
you know, can you look at my waiste to height ratio.
Speaker 2 (11:20):
A more accurate way of assessing adapacity nowadays may actually
be to do a body composition analysis. We can do
what we call dexas scans or bioelectrical impotence analyzers to
look for body composition. A dexas scan is effectively a
whole body X ray, really focusing on bones for people
(11:42):
who are worried about bone health or in the case
of weight management, looking at the body composition so specifically
what percentage is fat mass, what percentage is bone, and
what percentage is muscle mass.
Speaker 1 (11:56):
So this is something that we have to be proactive
on our own as healthcare consumers. Right, our healthcare providers
aren't necessarily going to go over our body comp with
us they're going to go for that old fashioned BMI
that's not going to be totally reflective. So we need
to be knowledgeable of this. That body comp is important,
and that's going to segue me into my next question.
Why is it so important? Why do we really care
(12:18):
about visceral fat.
Speaker 2 (12:20):
One of our central theories behind the perimenopausal transition has
to do with insulin resistance. Insulin is a hormone. It's
a normal natural hormone that our pancreas produces, particularly in
times of when we eat, because the role of insulin
is to take the glucose, the sugar that we eat
from our food and either store it or help it
(12:45):
be converted into energy. And the thing with insulin is
that it's what we call an anabolic hormone, meaning it
encourages storage versus breakdown. So if we have more insulin around,
then we are going to be prone to storing more
and more of the calories that we take in. During perimenopause,
(13:08):
women can develop an increasing level of insulin resistance, so
you're more likely to store calories, and you're storing those
calories in, particularly in that adipose tissue around your abdomen,
around your organs the stomach. That's what we call that
visceral fat.
Speaker 1 (13:28):
So what comes first? Is it the insulin resistance that
comes first that gives us the central adipacity or visceral fat,
or is it the visceral fat that gives us insulin resistance.
Speaker 2 (13:37):
We don't have a good answer to that. Unvirtually, yeah,
right now, where we see it as a snowball effect,
Absolutely one thing leads to another. But I think the
positive spin to that is that once we start treating one,
the other one also gets better. And to be completely transparent,
it's not the whole story, certainly, because we find that
we develop obesity even without insulin resistance or any measure
(13:58):
of that. So I think this story is more complex
than the narrative that I'm presenting sometimes, But I think
that's just speaks to how complicated we are as human beings.
Speaker 1 (14:08):
And it's probably a combination too of like esther and
fluctuations leading to metabolic disruptions, but also sleep disruptions that
occur at midlife stressors and cortisol. Right, It's like a
number of other hormones probably that impact the insulin resistance
and visceral fat.
Speaker 2 (14:23):
Absolutely, we do know from circadian dysrhythmia studies that they
can affect insulin resistance. If you cause sleep deprivation in individuals,
they actually wake up the next morning with a higher
level of grellin, which is the hunger hormone that increases
our appetite. In a very interesting other study where they
(14:45):
jet lagged participants and had them eat the same meals,
collected their microbiome, and transplanted their microbiome in mice, they
found that the jet lagged microbiome transplanted mice actually had
higher levels of insulin resistance. So absolutely it is all connected,
and the story around estrogen is so much more complex
(15:06):
than we know. There's some interesting preclinical mouse studies demonstrating
that estrogen suppresses appetite. Now we don't have this fully
translated into humans, but estrogen actually acts on specific neurons
in our brains that control appetite, and so you can imagine.
I think sometimes when we work with patients who have
(15:29):
premenstrual dysphoric disorder, or they might report increased cravings right
before their periods hit, there probably is a cyclical control
of appetite when it comes to estrogen fluctuations and progesterone
as well.
Speaker 1 (15:46):
So how do we measure insulin resistance? What test should
women ask their doctors for to assess their level of
insulin resistance and where they are.
Speaker 2 (15:53):
There's a couple of different ways, and certainly many more
in the research world, but I think in clinical practice
what patients can ask for simply is a fasting insulin
level with a fasting glucose level. What this allows us
is to calculate something called in homa IR calculation. You
can do online as well and effectively just looks at, well,
(16:16):
if your insulin level is high, is it appropriately high
because your glucose also happens to be high at that time,
or is it too high for what we would expect
it to need to be given a very normal and
low level of glucose. So we kind of need those
two data points. I will say that if you do
(16:40):
find that you have the diagnosis of pre diabetes or
type two diabetes, those intrinsically come with this insulin resistance problem.
So if that is already a part of the diagnosis,
then you don't need to be asking about actual insulin levels.
Speaker 1 (16:57):
So what's a target range for a fasting insulin for
a midlife woman or a fasting glucose. For a midlife woman,
what's a good number for her?
Speaker 2 (17:04):
Generally the normal range is less than ten for an
insulin level, less than one hundred or less than ninety
for glucose level. But I don't want to give too
many absolute numbers because I think it's also important to
recognize that any relative changes is good too. Right, just
because your number isn't completely normal doesn't mean that you're
(17:27):
not getting health benefits from even reducing that level from say,
you know, a fasting glucose of one hundred and fifty
down to one hundred twenty, that's still a good health benefit.
Speaker 1 (17:38):
So let's talk about hormone therapy. So what is the
role of hormone therapy in maintaining a body composition during
perimenopausal menopausal transition?
Speaker 2 (17:47):
Yeah? I think the research around hormone replacement therapy is
always evolving. There's a Cochrane review of randomized control trials
looking at the weight changes in women on hormone replacement
therapy versus those who were not on hormone replacement therapy,
and that systematic review of meta analysis found that there
(18:08):
was no significant difference. Weight change was not significantly different
whether you took hormone replacement therapy or not. And we
don't yet have the level of evidence to say that
it reduces fat mass or it reduces the rate of
fat mass gained. But there's some interesting observational studies and
(18:33):
what we find is maybe a difference of a pound
of fat that in women who were on hormone replacement
therapy versus those who are not on hormone replacement therapy
gained one less pound of fat mass over time. I
think whether one pound of fat mass is meaningful to
(18:55):
my patients, I'm not sure, so I think the data
still needs to be sorted out there.
Speaker 1 (19:02):
I think we're moving more into thinking of this as
more of supportive care and not waiting until a year
after the final minstrual period or the final menstrual period,
kind of nabbing this physiology early on as it changes
any thoughts on that at all.
Speaker 2 (19:17):
Absolutely, we should be having these conversations earlier on, to
not wait until a patient comes in and says, oh,
my last period was last year to talk about what
menopausal support is. We should be talking asking explicitly about
hot flashes, because that is the on label indication for
hormone replacement therapy and examining what other parts of a
(19:40):
woman's quality of life is being affected. Now, I think
it's important to know that hormone replacement therapy is not
FD approved for body composition changes. It's not FT approved
for overall quality of life. It's really FDA approved for
bone density improvement and hot flashes. However, the menopausal transition
(20:01):
is fraught with so many physiologic changes that it's important
to ask about all of these pieces, whether it's sleep,
body composition, mood, irritability, to see what is interacting with what.
For example, one in two women during perimenopause have a
(20:24):
sleep disorder, and that maybe insomnia. Maybe that's undiagnosed sleep apnea.
It could run the gamut, But I think that means
it's crucial for us to be asking these questions and
having these discussions earlier rather than later.
Speaker 1 (20:38):
Coming up after the break, doctor Chang and I discuss
how GOLP wants might be helpful and managing symptoms associated
with menopause and perimenopause will be right back. There's a
lot of women, especially a lot of the women that
(20:58):
I've taken care of in the past, who do everything right,
they eat right, they exercise, they sleep, they banage their stress,
and they still have a body composition that is not healthy.
You are the newer weight loss medications, such as the
golp ones, Are they appropriate?
Speaker 2 (21:16):
Yeah, I think that's what we're seeing the most from
the population now of people who are doing everything right,
as you say, and I put right in quotes, wondering
what else could they do? And I like to frame
it this way that you know, weight is just like
any other characteristic of yourself, any other human characteristic. My
(21:40):
hair is black and straight because of my genetics, but
maybe your hair is black and straight because you colored
it and you strain it during the day, And so
who we are all of our traits, the combination of
genetics and the environment. It's a combination of external internal
factors of the choices we make in life or the
(22:04):
factors that we may have control over, plus our own biology.
And I think what has transformed the landscape of weight
management is that now we have tools to really address
the biology. Typically these medications nowadays are one of the
golp ones, like some magnetide in ters appetite, but there
(22:25):
are a number of other medications that have predated the
gop ones that we have been using for many years
now to treat that biology of weight regulation. And I
do think that people should be discussing both. We shouldn't
necessarily have to wait until we're at a certain level
of excess weight or have tried and failed so many
(22:48):
other lifestyle changes just to really have a discussion about
what it means to fix that biology.
Speaker 1 (22:56):
So when do you begin to speak to women or
speak with women about gop ones or other weight loss medications.
What factors go into that decision with maybe you as
a physician bringing that up to a patient that you're
currently counseling.
Speaker 2 (23:11):
By on large wait, I have to understand what is
their overall quality of life and what are their goals?
On a very simple basis, we of course want to
know what is their current weight, what have their weights
been in the past, What are they struggling with? Is
it cravings? Is it excess appetite. Many people come to
me saying that they've never felt full in their lives,
(23:33):
and so examining their food relationships I think is part
of the comprehensive approach as well. We want to know
what the potential benefits and risks are if we were
to start a medication, for example, if the starting weight
isn't that high to begin with, then we might actually
(23:53):
be at risk of overtreatment and maybe more side effects
if we were to start a medication that's too strong
for them. Or are we looking at a medical history
that would increase the risk of other side effects from
some of these medications, for example, if you have a
history of pancreatitis or this other very uncommon medical history
(24:18):
called medullary thyroid cancer. These are typically conditions where we
would not be offering a gop one medication.
Speaker 1 (24:27):
You know, these are such big blockbuster drugs just across
health in general. Can you talk to us a little
bit about the science? How do they work? Sure?
Speaker 2 (24:36):
So, I think most people know of them under this
umbrella term of GLP ones to be more precise, there's
some magnetide which is a GLP one receptor agonist, and
then there's terzepetide, which is a GLP one and GIP
receptor agonists. So there's a little bit of nuance there.
(24:59):
I know I may sound like an alphabet soup here,
but in effect, what we're looking at our gut hormones,
hormones that your gut your small intestine produces when you eat,
and by and large, the role of those hormones are
to signal to your brain that you are in the
middle of eating and that at some point you should
(25:21):
feel full and eventually stop eating. So it's really a
way to tell our brain what our short term energy
status is. Are we in the fed or fasted state?
Did we just eat? Are we in the middle of eating,
and are we about to get full? What these medications
do is increase the activity of these hormones. That we're
(25:46):
really helping people feel full. And for many people who
have been raised in a food centric environment, having this
tool with them to help them respond to just plain
hunger cues, hunger and fullness cues is a level of relief.
(26:07):
It simplifies their food relationships to a degree where they
literally just have to eat when they're hungry, and you
don't eat if you're not hungry, and that's what these
medications do.
Speaker 1 (26:19):
So if a woman opts to use one of these
GLP one medications, what kind of results can she expect?
What can she expect in terms of her weight loss,
but also importantly her body comp I mean, it's my
understanding that you also lose some muscle mass.
Speaker 2 (26:32):
Right when we look at the studies for some maglatide,
for example, in a step one trial, they saw an
average weight loss of about fifteen percent over a course
of a year with semaglatide, and for truzeppetite in its
landmark surmount one trial, we saw about twenty three percent
weight loss again over the course of a year at
(26:54):
its maximum dose. And so two points there, number one
over a year is crucial. I don't want people thinking
that this is something that they start and immediately they
see thirty pounds weigh loss in just a few months.
This is really a comment that's medication and to the
lifestyle changes, because both of these trials were done on
(27:17):
a background of a reduced calorie diet and increasing exercise.
But the body composition changes is also a good question
because we do see a loss of muscle mass with
any type of weight loss. So whether it's through medication,
through diet and exercise, through any commercial diet program, through
(27:41):
baratric surgery, whenever we lose weight, we lose both fat
and muscle, and so this is just something we're seeing
time and time again. Even with the medications in general,
what we see with samagnetide is that if you lose
three pounds, let's say one pound of it will be
(28:01):
muscle loss, two pounds will be fat loss. Turzepetide seems
to have a slightly better ratio. If you lose four pounds,
one pound is muscle, three pounds is fat.
Speaker 1 (28:13):
How do you counterbalance this? Is it strength training? Is
it hormone support? How do you counterbalance this muscle loss
that occurs with any weight loss.
Speaker 2 (28:22):
We don't have the best evidence that we would want
yet because we don't yet have published data on these
medications in the setting of let's say resistance training versus
nor resistance training, etc. But when we look at the
broader literature of weight loss interventions without medications, we do
find that if you adopt a higher protein diet plus
(28:45):
resistance training, then you're more likely to preserve muscle mass
as well as functionality. So it's not just about quantity,
it's also about the strength and the balance and the
functional measures that we care about.
Speaker 1 (29:00):
And what else do women need to look out for? Nauseousness, constipation, diarrhea,
gallbladder issues.
Speaker 2 (29:08):
Yes, so I would say the most common side effects
these medications tend to be gut related, so gastrointestinal side
effects nausea, vomiting, diarrhea, or constipation, reflux, or heartburn. Some
women are experiencing some fatigue as well, which may be
related to hydration status because we tend to be drinking
(29:29):
less water when we're not eating as much as well.
But those are the primary kind of more and more
common side effects that are typically present during dose escalation phases.
So if we're increasing the dose for you, that's really
where most of those side effects come in. Once you're
on a stable dose and your body has built up tolerance,
(29:50):
most of those side effects abate. The one side effect
that does seem to be persisting a little bit longer
is constipation, and that's something to definitely talk to your
doctor about to see what other avenues should we be
doing to mitigate that, and that could be increasing hydration,
more fiber, maybe over the counter agents, what have you
(30:11):
to help make that quality of life better. Now, some
of the rarer side effects that we want to pay
attention to our pancreatitis, which I mentioned earlier. This is
inflammation of the pancreas that can happen spontaneously in some
cases or be related to alcohol intake, or gallstones if
you've had a gallstone issue in the past, gallbladder issues
(30:35):
as well, so that could be gallstones themselves, or inflammation
of your gallbladder, another condition called coalsistitis.
Speaker 1 (30:43):
So what percentage of women actually stop these medications due
to side effects.
Speaker 2 (30:48):
From the clinical trials? It's about ten percent. So I
actually think that the clinical trials in particular capture a
highly motivated and committed population where they are really willing
to do whatever needs to be done. So I think
the discontinuation rates in the clinical trials of about ten
percent is probably an underestimate than what we might see
(31:11):
in clinical practice. I also think that practically speaking, many
people face other challenges in the real world of just
accessing the medication, accessing providers such as myself, to actually
prescribe that medication, or the whole gamut of lifestyle support
that they need to really feel comfortable in the weight
(31:34):
loss journey that they're on right now.
Speaker 1 (31:36):
These medications are only FDA approved for women who are
significantly basing challenges. Any comments on the off label use
for midlife women of the GLP ones.
Speaker 2 (31:48):
Initially based on American Heart Association guidelines American College of
Cardiology guidelines and the Obesity Society guidelines back from twenty thirteen,
so more than a decade ago we really thought about
these obesity medications for a population with a BMI of
thirty or greater or those with a BMI of twenty
(32:11):
seven or greater with a weight related comorbidity. That thinking
has shifted significantly over the past decade, and international societies
like European Association for the Study of Obesity have supported this.
They have come out with new landmark guidance around how
(32:32):
obesity should be a clinical diagnosis, a combination of these
anthropometric measures that we mentioned waste bouty five percentage, et cetera,
plus a clinical component which is in recognition of how
is that excess weight affecting our lives? How is it
affecting us medically, psychosocially, functionally, And using those two components,
(32:59):
can we make that diagnosis of obesity? And so I
think right now the medications, yes, absolutely, we're studied in
these clinical trials with those specific criteria, be my thirty
or greater, twenty seven or greater. But because the conversation
around obesity is shifting, we are becoming more mindful of
how obesity manifests differently in different people. So current guidelines
(33:24):
that package insert for these medications, what the FDA agreed
upon says that these medications should be used for people
with obesity or overweight with an obesity related comorbidity.
Speaker 1 (33:38):
So we know that some doctors are prescribing GLP ones
off label. How are the insurance companies responding?
Speaker 2 (33:44):
They are not on board, Absolutely not on board. I
think insurance companies have a different priority, right Their priority
is not necessarily health outcomes, it's health affordability. And for them,
asking what does it cost to treat one hundred million
people with obesity is overwhelming, and so I think nowadays
(34:10):
the conversations are all about trying to find a place
where we can compromise. We have to find a way
to increase access without incurring bankruptcy inducing costs, but still
providing a level of value to our population, to our
(34:32):
healthcare system, to the individual patient.
Speaker 1 (34:35):
So how do you choose when you're choosing a weight
loss medication for a midlife woman. How much is based
on her biology and how much is based on accessibility
and what you basically can get for her under insurance coverage.
Speaker 2 (34:47):
It's definitely a challenge. I think pragmatically speaking, we have
to think about what is accessible to them. So we
certainly talk about what I might recommend in the ideal
world where everything is covered or accessible for them rather
and what might be the best option for them given
(35:08):
their comorbidities. So we talk about other issues whereby we
can address multiple things at once while keeping in mind
what the potential side effects are and what can we
do to mitigate those risks as well. But when I
think about what regimen to build for a patient, and
(35:33):
this as I teach to my fellows as well, this's
heuristic of the four sees which I list as contraindications, comorbidities, cost,
and then choice. And from a clinician's perspective, we are
very adept at helping patients sort through the risk benefit
ratio between contraindication, side effect tolerability and the comorbidities and
(35:57):
other potential benefits of these medications. I think cost is
an increasingly important part of our conversations just because of
that accessibility piece, and patient choice is paramount. They have
their right to decide themselves if they want to budget
(36:18):
x amount of dollars per month to pay out of
pocket for this medication. Then that's something that I will
stand by and of course support them to do, but
I want to be able to give them that option
to discuss that, and on the flip side of a
patient says, that's certainly not something that I can handle,
or I have a needle phobia, there's no chance I
(36:40):
can take one of these weekly injections. Then we talk
about alternatives as well, so it's really about needing the
patient where they.
Speaker 1 (36:47):
Are coming up. Doctor Chang gets into some of those
alternatives she's mentioned, the ones that pre date the glp ones.
She also explains how different weight loss medications stack up.
We explore what golp ones might do beyond weight management,
and we unpack the growing trend of microdosing these drugs.
(37:09):
We'll be right back. So what is a little bit
of a lightning round with you with the different medications
that are available. Just give me your thoughts that come
you know, the one liners about these medications, just so
(37:31):
our audience can understand a little bit about the differences
or when you would prescribe them. Will gov or semaglatide.
Speaker 2 (37:37):
Excellent medication, really one of our most transformative agents that
have started, I think, and opened the conversation for obesity.
Speaker 1 (37:46):
Care z that bounder to zeppatide.
Speaker 2 (37:48):
Really pushing the envelope forward in terms of the degree
of weight loss that we can achieve.
Speaker 1 (37:54):
Sexenda one of the ogs.
Speaker 2 (37:56):
I think one of the OG's a daily injection still excellent,
great evidence based rebelsus. The oral form of some magnetide
I think really helps with individuals who are needlephobic. But
I think that somemaglatide oral shows us the very beginnings
(38:17):
of what we as a scientific community and biotech community
can do when it comes to getting these types of
medications in a pill form.
Speaker 1 (38:27):
To simia one of.
Speaker 2 (38:28):
Our forgotten medications, I think that really have quite good efficacy.
I think when people rank the obesity medications, it's some
version of GLP one as one, two, and three. But
actually when we look at the level of weight loss efficacy,
this combination pill of fen remine plus to pyramid is
(38:50):
probably number three.
Speaker 1 (38:51):
Contrive also really good medication.
Speaker 2 (38:54):
I think that it helps very specific people who have
that rewarding relationship with food, and my experience, the degree
of weight loss isn't as impressive of what we're seeing today,
which is why we're talking about a whole new generation
with the GLP one medications, but may still play a
(39:16):
role in some people where they have that particular emotional
connection orlistat wow orlistat oh. That came out in nineteen
ninety nine and it was gosh, we did like fifteen
studies around oralistad. We really thought it would change the landscape.
And I think it's just because it was our very
(39:37):
first medication that's still available now for long term weight
management to really show one of the safest long term profiles.
Because prior to that, medications were concerning for high blood
pressure or valvular disease, heart issues, but Oralistat showed us
(39:59):
that weight management through medication could be safe.
Speaker 1 (40:04):
So are there any medications that a midlife woman should avoid,
any interactions with hormone support or anything that a woman
should avoid.
Speaker 2 (40:12):
I would say that just in the way that exercise
might worsen the experience of hot flashes, Anything that increases
your synthetic nervous system, anything that increases adrenaline in your
body can worsen hot flashes. Certain medications that are what
we call some pado mimetics can do that. So phentromine
(40:34):
as part of veetrominetal pyramid can potentially worsen that as
well as buproprion, which is part of buproprion outrec zone
and contrary may also worsen hot flashes. I think everyone's
experience is different because beuproprin is also as a monotherapy
i FDA approved to treat depression, and perhaps some women
(40:57):
are having mood changes in the setting of perimenopause and
would welcome something like an antidepressant to help them as well.
So I think these are important pieces to tease out,
and we're looking at precision prescribing, but shouldn't be considered contraindications.
Speaker 1 (41:17):
Let's talk about supplements. There's a lot of supplements being
marketed on social media right now as similar to GLP
ones or mimic GLP ones. Can you comment on any
supplement support that women may find beneficial or useful.
Speaker 2 (41:32):
The supplement industry, as I'm sure many people know, is
less regulated than the pharmacotherapy industry. The supplement industry is
typically what we call post market regulated, meaning these supplements
can enter the market, anyone can buy them, and it's
only after the fact that we find out that oh
it had a contaminant or something. So I think the
(41:57):
quality control in that industry is harder to discern, and
that means intrinsically, when someone buys a supplement, you're taking
on a higher risk. So I would caution a little
bit about the supplement industry. The one space that I
do think is crucial for perimenopausal women is bone health.
(42:21):
And I speak on this from the perspective of an
endocrinologist who treats osteoporosis, who counsels women on osteopenia. I
think it is important that women in this age range
also meet their daily recommended intake of calcium, ideally from diet,
but may also get that from supplements. So in that
(42:44):
space of supplementation, I think it is crucial to get
at least a thousand milligrams of calcium per day.
Speaker 1 (42:51):
Microdosing let's talk about microdosing. Everybody's talking about microdosing. What
is microdosing of the golp ones? Why would one do this?
And what are the benefits of microdosing.
Speaker 2 (43:02):
So micro dosing I don't think we have an industry
acceptant definition for this, but effectively it's looking at off
label doses that are administered or whatever help benefits at
doses that are lower than those studied. And typically when
people talk about microdosing, they're referring to the GLP ones
semaglatide or trzeppetide. The lowest dose of semaglatide that has
(43:25):
been studied for weight losses zero point twenty five milligrams.
The lowest dose of turzepetite available is two point five milligrams.
So doses lower than those numbers would be considered microdoses
by some. And I think people are doing this because
they're thinking that they're going to have less side effects
with the dose titration if they go up by smaller increments.
(43:48):
And actually a study was just recently published demonstrating exactly that.
Speaker 1 (43:53):
So let's talk briefly about some of the other benefits
of the GLP ones. People are talking about anti inflammatory effects.
We noticed in our endming triosis patients that were using
GLP ones that far before they lost any weight, their
pelvic pain got better. It was pretty impressive. So can
you just speak to the anti inflammatory effects of these
medications and maybe how they impact brain and cardiac health.
Speaker 2 (44:15):
We know from the studies that HSCRP so high sensitivity
see reactive protein, one of our biggest inflammatory markers, is
significantly reduced with these medications, and we do see reductions
in HSCRP even before significant weight loss, and i'lsoy clinically
we're seeing that too in our patients with osteoorthritis, rheumatoid arthritis,
(44:37):
some of the autoimmune diseases like psoriasis. So it is
definitely a fascinating area of research, and I do know
that there are a number of clinical trials exploring that
in the autoimmune space, for example in Croh's disease the
combination of samagotype plus a disease modifying agent, or even
(44:58):
in Alzheimer's where we think perhaps inflammation is playing a
role in dementia too.
Speaker 1 (45:03):
So stay tuned for more research on this right totally. Yeah,
in terms of just cardiac and brain health effects with
the GLP one medications, have we really teased out how
much of that is due to direct anti inflammatory effects
maybe on immune modulators, and how much is due to
white loss. Has that been teased out?
Speaker 2 (45:24):
It's a great question. There's an interesting secondary analysis that
came out at the European Congress for Obesity earlier this
year on the Select trial, which was a cardiovascular trial
conducted in people with obesity randomized to placeibo versus some magnetide,
and the headline for that was a twenty percent reduction
(45:45):
in cardiovascular problems, and those cardiovascular problems were non fatal
myocardalin friction, cardiovascular death, or non fatal stroke. What they
were looking for was what was the earliest point in
time that we started to see proof of that cardiovascular benefit,
(46:06):
and that earliest point in time was around ninety days,
so as early as three months before people are even
on the maximum dose of some magnetide, before you're even
getting five percent weight loss, we're seeing proven cardiovascular benefit.
Cholesterol improved, yes, blood pressure improved hscrp are, inflammatory market
(46:29):
improved as well as urinary albumen so some proachin in
the urine. So we think there's a number of different
physiologic changes when we're administering these GLP ones, and these
are happening very early on before significant weight loss.
Speaker 1 (46:45):
Yeah, that's so consistent with our endometrios as patients. It was.
It was fascinating wind waste. It was. It was within
maybe three weeks actually very quick. I mean people would
come back and say you know, I don't have pain anymore,
and it was unbelievable. Actually, you know heralding that it
had to be because endmetrios is a disease of inflammation, right,
(47:06):
so it had to be something anti inflammatory.
Speaker 2 (47:09):
That's amazing.
Speaker 1 (47:10):
What do you think about medspas and some of these
other groups offering GLP ones for more cosmetic weight loss.
Speaker 2 (47:18):
I'm happy that everyone is trying to learn more about
these medications because in the past, I think weight management
was really this fringe specialty of medical care. But I
do think it requires a level of ethical responsibility to
understand what is the evidence based for these medications, who
(47:40):
were they intended for, and if I am offering these
medications to individuals in which they were not studied, I
need to be transparent about that these medications have not
been studied in individuals with a BMI of twenty two. Now,
whether it should be used or not, it is not
(48:02):
my judgment call, because it's not my role to place
my value on whether you, as a patient values your
cosmetic appearance anymore than you value your health parameters that
are measured in the blood. Really, it's the job of
the medical community. Whether you're medical directors, medical professionals working
(48:26):
in medspas or clinics to transparently present what the evidence
is or the lack thereof, for these agents. And in
the population you're offering them to.
Speaker 1 (48:40):
So disordered eating starts to come out again in the
perimenopausal transition, and we know that a significant number of
perimenopausal women will experience disordered eating. Any potential for abuse
of these medications, how do you watch out for that
as a provider.
Speaker 2 (48:55):
I don't think we know yet, but it's certainly something
that we're paying attention to. We see if they have
any history of eating disorders, any propensity for binge eating,
overly restricting, history of purging, any kind of red flags
that we can capture we want to And it may
not necessarily mean that they are ineligible for these medications,
(49:16):
depending on other health issues and anyone else on their
healthcare team, but it does mean that we want to
pay very close attention to them.
Speaker 1 (49:26):
What pearls could you offer to women in terms of
lifestyle approaches to counterbalance some of these body comp challenges
that occur at the menopausal perimenopausal transition.
Speaker 2 (49:38):
Very simply based on the evidence, I would say, increase
your protein intake by twenty grams. So whatever you're eating
baseline right now, try to add twenty grams of protein
that's like four ounces of chicken or protein shake or
some version of that every day, extra twenty grams every day,
and then do resistance exercise. So at least two days
(50:01):
a week of resistance training. That could be a pilates class,
that could be bodyweight exercises at home, free weights, machines,
any verse of that that you can enjoy. I think
that will go a long way towards a longer health span.
Speaker 1 (50:17):
How are you prioritizing your health? What are you doing
for yourself right now?
Speaker 2 (50:21):
I think for me, actually it comes back to that
resistance training. So I have a two year old child,
and so I still feel like I'm in that post
pregnancy body where things have shifted. I have chronic back pain,
all of these things, and so I actually think that
focusing on strength and functional strength, being able to lift
(50:46):
the car seat, those types of things is my priority
right now. And I think if we all focus on
being stronger in our bodies, whether those bodies are larger
than what we'd like, or we're fitting in these clips
or those clothes, as long as we feel strong in
our bodies. I think that should be the goal.
Speaker 1 (51:07):
If women could take away one point from our conversation today,
or remember one point from our conversation today, what would
it be.
Speaker 2 (51:16):
Don't be afraid to bring up your issue with your doctors,
even it feels like everyone else is telling you that
your experience is normal, whether it's menopause weight gain, menopausal
weight gain, It's not an experience that you have to
suffer through.
Speaker 1 (51:33):
So don't take it's all normal and aging as an answer.
Make sure that you proactively tell your healthcare provider about
your issues and concerns and try to get answers.
Speaker 2 (51:44):
Absolutely. I think that you know it's challenging when we're
in this space like we started out with weight management
and menopause, because it exists both in the wellness industry
and the medical community. And that means when you present
yourself as a patient, it's hard to say it's like,
am I sick? Do I have a problem? Or am
(52:05):
I healthy? And I'm just looking to be healthier. And
I think sometimes we can run into just resistance if
we're healthy people trying to be healthier in the medical community.
So I think we all just need to have a
more open mind. Otherwise we're going to continue to have
(52:25):
clashes between the wellness industry and the medical community when
really we all have the same priority, which is to
improve a person's health.
Speaker 1 (52:33):
Yeah, I mean, I think the healthcare community needs to
focus on healthcare and prevention, right, I mean, we have
to evolve from sick care and move more into prevention.
We'll always have some illness that we need to treat,
but to prevent it and to decrease it would be
I think we need both.
Speaker 2 (52:48):
I think we definitely. I think we still need people
who treat disease, of course, but I also think that
the wellness industry and the treatment of healthy people and
prevention should be held to the same standards, or even
higher standards than what we have for sick care, because
the risk of harm in treating someone who's already healthy
is actually higher, right because you're already working with someone
(53:11):
who is healthy. So I think we just need to
have the same standards.
Speaker 1 (53:16):
There's lots of buzz around these drugs, but of course
there's also a lot to think about before you start
any new drug. Let's be honest. Gop Ones might not
be right for everyone, but they are a tool in
your doctor's toolkit. Talk to your clinician about your options,
your concerns, and of course your goals, and if you
want to make a change, don't settle for it's a
(53:38):
normal part of aging or it's natural as an answer,
the changes that come with the menopausal transition are indeed normal,
but that doesn't mean that you can't take steps to
feel better. If you're noticing symptoms of perimenopause like hot flashes,
mood changes, brain fog, or sleep disruptions, you can also
consider starting hormone therapy to help manage these changes before
(54:00):
they escalate. We'll have another episode completely dedicated to the
latest science about hormone support during perimenopause and menopause later
in this season, and this certainly won't be the only
time we discuss GLP ones on the show. So much
research around these drugs is still ongoing, and as we discussed,
(54:21):
there's been some early work looking into how these drugs
might actually be beneficial for other areas such as cognition,
cardiovascular health, and maybe even for autoimmune conditions. So stay
tuned for more on all of this. I'm excited about
the possibilities coming up on the next episode of Decoding
(54:43):
Women's Health will be speaking with the country's first preventative
neurologist about why two thirds of Alzheimer's patients are women
and why he believes that many of those cases are
actually preventable.
Speaker 2 (54:57):
Genes are not our destiny.
Speaker 1 (54:59):
The field of Alzheimer's disease is changing so rapidly.
Speaker 2 (55:02):
The things that I can talk about now like I
couldn't even dream about ten years ago.
Speaker 1 (55:07):
And if you like this podcast, please consider leaving us
a re wherever you're listening now. It helps new people
find the show. Thanks so much. Decoding Women's Health is
a production of Pushkin Industries and the Atria Health and
Research Institute. This episode was produced by Rebecca Lee Douglas.
It was edited by Amy Gaines McQuaid, mastering by Sarah Burguier.
(55:32):
Our associate producer is Sonia Gerwit. Our executive producer is
Alexandra Garreton. Our theme song was composed by HANNS. Brown.
Concept creative development and fact checking by Shavon O'Connor. A
special thanks to Alan Tish, David Saltzman, Sarah Nix, Eric Sandler,
(55:53):
Morgan Rattner, Amy hagdorn Owen Miller, Jordan McMillan, and Greta Cohne.
If you have a question about women's health in midlife,
leave us a voicemail at four FO five two O
one three three eight five, or send us a message
at Decoding Women's Health at pushkin dot FM. I'm doctor
(56:14):
Elizabeth Poiner, and thanks for listening. Until next time.
Pushkin. Hi everyone, Doctor Poyter here, I'm popping in to
let you know that we're working on a special episode
of Decoding Women's Health. We're i'll be answering your questions
about one of my favorite topics, hormone therapy. If you've
been wondering about the different types of therapy, when it
(00:39):
might make sense to start possible side effects, are really
anything else? This is your chance to ask. You can
leave us a voicemail at four FI five two one
three three eight five, or send an email to Decodingwomen's
Health at Pushkin dot fm and let us know if
you'd like to stay anonymous, or if you're up for
(00:59):
having your voice featured on the show. I'm so excited
for this one. Hormone support is such a misunderstood area
of medicine, and there's a ton of new and fascinating
research to talk about together. I can't wait to hear
what you're curious about. This show is not a substitute
for professional medical advice, diagnosis, or treatment. It is for
(01:21):
informational purposes. Please consult your healthcare professional with any medical questions.
This episode includes discussion of weight and health. We know
these conversations can be sensitive, please listen in a way
that feels right for you.
Speaker 2 (01:38):
In the past few decades, we've only been pushing this
narrative of eating less and moving more, which is oversimplified
and not the right message. And we've never had a
tool that was potent enough, effective enough to address the biology.
So when women come to me and they say that
they are working on their weight, we talk about both
(02:00):
in tandem. We talk about the lifestyle changes that we
can make, and at the same time we talk about
what are the biological factors that might make that challenging.
And for those biological factors, we offer medications.
Speaker 1 (02:18):
Welcome to Decoding Women's Health. I'm doctor Elizabeth Pointer. Today
on the show, we're talking about metabolism and GLP ones.
When it comes to perimenopause. One of the most common
early complaints I hear from my patients is what I
like to call midlife shape shifting. Suddenly, seemingly out of nowhere,
your waistline starts to get thicker. I remember getting together
(02:42):
with my college friends when we were all in our
late forties and early fifties. One of them, a former
athlete who'd always taken great care of her health, brought
up her frustration with stubborn fat around her stomach that
just wouldn't go away. Everyone else immediately started commiserating. They
were all struggling with the same thing. It's a frustrating
(03:04):
problem for many women because even if you're exercising, eating well,
getting enough sleep, and managed in your stress, you may
still gain what's called visceral fat, the type of fat
that accumulates around your organs and changes the shape of
your midsection. Many physicians write this off as a normal
part of aging, and until recently, there wasn't much we
(03:26):
could do about it. We could suggest lifestyle changes, and
I would occasionally prescribe met formant to my patients who
are really struggling with insulin resistance, but it didn't move
the needle for everyone. That is, until GLP ones came
on the market. There's been a lot of excitement around
these drugs. Some see them as a new way to
(03:46):
potentially hack midlife women's biology. But there's still some trepidation
around these medications and a lot of questions that we
can't yet answer. But today on the show, I wanted
to begin a conversation around GLP ones, to talk through
the basics and break down the science and we've got
someone terrific helping me unpack all of this. She's an
(04:08):
expert in both weight management and midlife women's well Triple
Board certified endocrinologist and obesity medicine specialist, Doctor Beverly Chang.
How did you get drawn to this area? Because it
(04:28):
really is the intersection of two areas that people aren't
well trained in, obesity and menopause. So how did you
get involved in this? What drew you to it?
Speaker 2 (04:38):
I think what's crucial here is looking at the overlap
between what the medical community is responsible for versus what
I think the wellness industry is trying to do. And
that's the difference between sick care and healthcare. I think,
as a doctor in the traditional education system, we are
(05:00):
trained to treat people who are sick, right we wait
for someone to develop symptoms, we diagnose the disease, and
then we offer treatment. And yet many many people are
not sick, and they still want to do things to
preserve their health or to optimize their health. And yet
when they come to see a doctor, we don't have
(05:22):
the right language or tools to help them. And that's
really where the wellness industry comes in. I think obesity
and menopause intersect these two very well because obesity, for
the longest time, has never been seen as a disease.
It's been thought of as a lifestyle choice, which is incorrect.
(05:42):
We know this from the science, and only recently I
think there's greater acceptance of obesity as a medical problem,
so that now it's being addressed both from the wellness
industry side as well as by the medical community. And
then menopause is one of these issues where it's natural
(06:02):
and yet it can be such a struggle and a
challenge for our quality of life. However, because it's natural,
people think we should just let it happen as it does,
and that it doesn't need intervention. It shouldn't need any
sort of intervention. But my position is, really, well, even
if it's natural, why should we suffer through it? I
(06:25):
think it really opens up the conversation more to what
does healthy living, optimize living look like.
Speaker 1 (06:33):
So when we go through when we start to go
through perimenopause and into that perimenopausal transition, you know, we
tend to change our body composition, putting on visceral fat
and have to pay more attention to wellness. A lot
of this is signaled by or has a foundation in metabolism.
Can we just like unpack metabolism a little bit here?
(06:55):
What is metabolism and how does it become disrupted for
the midlife woman so that she now enters into this
like less than healthy state for her.
Speaker 2 (07:04):
Absolutely, I think most people think of metabolism as you know,
the burning of calories, and we feel this way as
we age that our metabolism slows down. We do have
a lower energy expenditure, which is our scientific term for metabolism.
All of that happens just from general aging. The challenge
(07:28):
around metopause, interestingly enough, is that when we look at
weight trajectories and changes in metabolism, we see some pieces
in the research that absolutely validate what a woman's experience
is in the sense of, I feel like I'm doing
the same exact things. I'm exercising, watching my nutrition, all
(07:51):
of those things, and yet my body is changing. And
when we look at the literature, we find that the
rate of weight gain we see actually is about the
same rate as we would see just from general aging.
And the way we examine this is through large prospective,
longitunal studies. There's one called the Swan study. They followed
(08:13):
women over the course of decades and they just tracked
what their weight was from age forty over to age
fifty five about and they saw that on average, people
gained weight. But when you look at that weight curve,
it doesn't become suddenly steeper around perimenopause. But what's more
(08:37):
crucial is that the body composition changes, and that body
composition was seen as a faster accumulation of fat mass
and a faster loss of lean muscle mass around that
perimenopausal time period. And I think that is exactly what
women experience. The distribution of their weight changes, and of
(09:01):
course the excess fat that they feel is really sitting
around their trunkle area. This also tracks with a reduction
in energy expense, so we do see that metabolism reduce,
we do see that lean muscle mass go down, and
we see that fat mass accumulate faster during perimenopause.
Speaker 1 (09:23):
So when we go to the doctor and we do
our vital signs, we still do our height and weight
and look at our BMI and obesity or being overweight
is defined by BMI. Right, do you think it's time
to change that? Because if a perimenopausele or menopausal woman
really isn't necessarily gaining weight at a rapid rate, but
she is what I call shape shifting. Right, how do
we measure that?
Speaker 2 (09:44):
The short answer to that is yes, one hundred percent, yes, yes, yes.
If you look at our BMI scales right now, they
are not adjusted for men versus women. Even though we
know that there are vastly different distributions of body composition
of fat mass and lean mass, they are not adjusted
for ethnicity either, at least not in our clinical practices.
(10:08):
In the research, it is very very well support in
that we should be using adjusted BMIs for specific ethnicities,
for example, in those of Asian East Asian, South Asian
Southeast Asian ethnicities. We find that the metabolic consequences of
excess fat excess weight occur earlier, so we should be
(10:32):
using those different thresholds if we were still committed to
using BMI now, the more important question is what do
we use instead? And I think there is greater acceptance
now for the waste to height ratio. So you're looking
at your waste circumference, comparing that by your overall height,
(10:53):
and that should be less than zero point five. If
you're greater than zero point five or greater than zero
point six. It's a graded level of increased risk level
for cardio metabolic diseases.
Speaker 1 (11:05):
Yeah, so a woman may have what I call shape
shifting her waist, it gets a little thicker, and she
goes into her doctor and her do so your BMI
is fine, It's totally fine. So you're totally fine. Right,
So a woman go in to ask for a healthcare provider,
you know, can you look at my waiste to height ratio.
Speaker 2 (11:20):
A more accurate way of assessing adapacity nowadays may actually
be to do a body composition analysis. We can do
what we call dexas scans or bioelectrical impotence analyzers to
look for body composition. A dexas scan is effectively a
whole body X ray, really focusing on bones for people
(11:42):
who are worried about bone health or in the case
of weight management, looking at the body composition so specifically
what percentage is fat mass, what percentage is bone, and
what percentage is muscle mass.
Speaker 1 (11:56):
So this is something that we have to be proactive
on our own as healthcare consumers. Right, our healthcare providers
aren't necessarily going to go over our body comp with
us they're going to go for that old fashioned BMI
that's not going to be totally reflective. So we need
to be knowledgeable of this. That body comp is important,
and that's going to segue me into my next question.
Why is it so important? Why do we really care
(12:18):
about visceral fat.
Speaker 2 (12:20):
One of our central theories behind the perimenopausal transition has
to do with insulin resistance. Insulin is a hormone. It's
a normal natural hormone that our pancreas produces, particularly in
times of when we eat, because the role of insulin
is to take the glucose, the sugar that we eat
from our food and either store it or help it
(12:45):
be converted into energy. And the thing with insulin is
that it's what we call an anabolic hormone, meaning it
encourages storage versus breakdown. So if we have more insulin around,
then we are going to be prone to storing more
and more of the calories that we take in. During perimenopause,
(13:08):
women can develop an increasing level of insulin resistance, so
you're more likely to store calories, and you're storing those
calories in, particularly in that adipose tissue around your abdomen,
around your organs the stomach. That's what we call that
visceral fat.
Speaker 1 (13:28):
So what comes first? Is it the insulin resistance that
comes first that gives us the central adipacity or visceral fat,
or is it the visceral fat that gives us insulin resistance.
Speaker 2 (13:37):
We don't have a good answer to that. Unvirtually, yeah,
right now, where we see it as a snowball effect,
Absolutely one thing leads to another. But I think the
positive spin to that is that once we start treating one,
the other one also gets better. And to be completely transparent,
it's not the whole story, certainly, because we find that
we develop obesity even without insulin resistance or any measure
(13:58):
of that. So I think this story is more complex
than the narrative that I'm presenting sometimes, But I think
that's just speaks to how complicated we are as human beings.
Speaker 1 (14:08):
And it's probably a combination too of like esther and
fluctuations leading to metabolic disruptions, but also sleep disruptions that
occur at midlife stressors and cortisol. Right, It's like a
number of other hormones probably that impact the insulin resistance
and visceral fat.
Speaker 2 (14:23):
Absolutely, we do know from circadian dysrhythmia studies that they
can affect insulin resistance. If you cause sleep deprivation in individuals,
they actually wake up the next morning with a higher
level of grellin, which is the hunger hormone that increases
our appetite. In a very interesting other study where they
(14:45):
jet lagged participants and had them eat the same meals,
collected their microbiome, and transplanted their microbiome in mice, they
found that the jet lagged microbiome transplanted mice actually had
higher levels of insulin resistance. So absolutely it is all connected,
and the story around estrogen is so much more complex
(15:06):
than we know. There's some interesting preclinical mouse studies demonstrating
that estrogen suppresses appetite. Now we don't have this fully
translated into humans, but estrogen actually acts on specific neurons
in our brains that control appetite, and so you can imagine.
I think sometimes when we work with patients who have
(15:29):
premenstrual dysphoric disorder, or they might report increased cravings right
before their periods hit, there probably is a cyclical control
of appetite when it comes to estrogen fluctuations and progesterone
as well.
Speaker 1 (15:46):
So how do we measure insulin resistance? What test should
women ask their doctors for to assess their level of
insulin resistance and where they are.
Speaker 2 (15:53):
There's a couple of different ways, and certainly many more
in the research world, but I think in clinical practice
what patients can ask for simply is a fasting insulin
level with a fasting glucose level. What this allows us
is to calculate something called in homa IR calculation. You
can do online as well and effectively just looks at, well,
(16:16):
if your insulin level is high, is it appropriately high
because your glucose also happens to be high at that time,
or is it too high for what we would expect
it to need to be given a very normal and
low level of glucose. So we kind of need those
two data points. I will say that if you do
(16:40):
find that you have the diagnosis of pre diabetes or
type two diabetes, those intrinsically come with this insulin resistance problem.
So if that is already a part of the diagnosis,
then you don't need to be asking about actual insulin levels.
Speaker 1 (16:57):
So what's a target range for a fasting insulin for
a midlife woman or a fasting glucose. For a midlife woman,
what's a good number for her?
Speaker 2 (17:04):
Generally the normal range is less than ten for an
insulin level, less than one hundred or less than ninety
for glucose level. But I don't want to give too
many absolute numbers because I think it's also important to
recognize that any relative changes is good too. Right, just
because your number isn't completely normal doesn't mean that you're
(17:27):
not getting health benefits from even reducing that level from say,
you know, a fasting glucose of one hundred and fifty
down to one hundred twenty, that's still a good health benefit.
Speaker 1 (17:38):
So let's talk about hormone therapy. So what is the
role of hormone therapy in maintaining a body composition during
perimenopausal menopausal transition?
Speaker 2 (17:47):
Yeah? I think the research around hormone replacement therapy is
always evolving. There's a Cochrane review of randomized control trials
looking at the weight changes in women on hormone replacement
therapy versus those who were not on hormone replacement therapy,
and that systematic review of meta analysis found that there
(18:08):
was no significant difference. Weight change was not significantly different
whether you took hormone replacement therapy or not. And we
don't yet have the level of evidence to say that
it reduces fat mass or it reduces the rate of
fat mass gained. But there's some interesting observational studies and
(18:33):
what we find is maybe a difference of a pound
of fat that in women who were on hormone replacement
therapy versus those who are not on hormone replacement therapy
gained one less pound of fat mass over time. I
think whether one pound of fat mass is meaningful to
(18:55):
my patients, I'm not sure, so I think the data
still needs to be sorted out there.
Speaker 1 (19:02):
I think we're moving more into thinking of this as
more of supportive care and not waiting until a year
after the final minstrual period or the final menstrual period,
kind of nabbing this physiology early on as it changes
any thoughts on that at all.
Speaker 2 (19:17):
Absolutely, we should be having these conversations earlier on, to
not wait until a patient comes in and says, oh,
my last period was last year to talk about what
menopausal support is. We should be talking asking explicitly about
hot flashes, because that is the on label indication for
hormone replacement therapy and examining what other parts of a
(19:40):
woman's quality of life is being affected. Now, I think
it's important to know that hormone replacement therapy is not
FD approved for body composition changes. It's not FT approved
for overall quality of life. It's really FDA approved for
bone density improvement and hot flashes. However, the menopausal transition
(20:01):
is fraught with so many physiologic changes that it's important
to ask about all of these pieces, whether it's sleep,
body composition, mood, irritability, to see what is interacting with what.
For example, one in two women during perimenopause have a
(20:24):
sleep disorder, and that maybe insomnia. Maybe that's undiagnosed sleep apnea.
It could run the gamut, But I think that means
it's crucial for us to be asking these questions and
having these discussions earlier rather than later.
Speaker 1 (20:38):
Coming up after the break, doctor Chang and I discuss
how GOLP wants might be helpful and managing symptoms associated
with menopause and perimenopause will be right back. There's a
lot of women, especially a lot of the women that
(20:58):
I've taken care of in the past, who do everything right,
they eat right, they exercise, they sleep, they banage their stress,
and they still have a body composition that is not healthy.
You are the newer weight loss medications, such as the
golp ones, Are they appropriate?
Speaker 2 (21:16):
Yeah, I think that's what we're seeing the most from
the population now of people who are doing everything right,
as you say, and I put right in quotes, wondering
what else could they do? And I like to frame
it this way that you know, weight is just like
any other characteristic of yourself, any other human characteristic. My
(21:40):
hair is black and straight because of my genetics, but
maybe your hair is black and straight because you colored
it and you strain it during the day, And so
who we are all of our traits, the combination of
genetics and the environment. It's a combination of external internal
factors of the choices we make in life or the
(22:04):
factors that we may have control over, plus our own biology.
And I think what has transformed the landscape of weight
management is that now we have tools to really address
the biology. Typically these medications nowadays are one of the
golp ones, like some magnetide in ters appetite, but there
(22:25):
are a number of other medications that have predated the
gop ones that we have been using for many years
now to treat that biology of weight regulation. And I
do think that people should be discussing both. We shouldn't
necessarily have to wait until we're at a certain level
of excess weight or have tried and failed so many
(22:48):
other lifestyle changes just to really have a discussion about
what it means to fix that biology.
Speaker 1 (22:56):
So when do you begin to speak to women or
speak with women about gop ones or other weight loss medications.
What factors go into that decision with maybe you as
a physician bringing that up to a patient that you're
currently counseling.
Speaker 2 (23:11):
By on large wait, I have to understand what is
their overall quality of life and what are their goals?
On a very simple basis, we of course want to
know what is their current weight, what have their weights
been in the past, What are they struggling with? Is
it cravings? Is it excess appetite. Many people come to
me saying that they've never felt full in their lives,
(23:33):
and so examining their food relationships I think is part
of the comprehensive approach as well. We want to know
what the potential benefits and risks are if we were
to start a medication, for example, if the starting weight
isn't that high to begin with, then we might actually
(23:53):
be at risk of overtreatment and maybe more side effects
if we were to start a medication that's too strong
for them. Or are we looking at a medical history
that would increase the risk of other side effects from
some of these medications, for example, if you have a
history of pancreatitis or this other very uncommon medical history
(24:18):
called medullary thyroid cancer. These are typically conditions where we
would not be offering a gop one medication.
Speaker 1 (24:27):
You know, these are such big blockbuster drugs just across
health in general. Can you talk to us a little
bit about the science? How do they work? Sure?
Speaker 2 (24:36):
So, I think most people know of them under this
umbrella term of GLP ones to be more precise, there's
some magnetide which is a GLP one receptor agonist, and
then there's terzepetide, which is a GLP one and GIP
receptor agonists. So there's a little bit of nuance there.
(24:59):
I know I may sound like an alphabet soup here,
but in effect, what we're looking at our gut hormones,
hormones that your gut your small intestine produces when you eat,
and by and large, the role of those hormones are
to signal to your brain that you are in the
middle of eating and that at some point you should
(25:21):
feel full and eventually stop eating. So it's really a
way to tell our brain what our short term energy
status is. Are we in the fed or fasted state?
Did we just eat? Are we in the middle of eating,
and are we about to get full? What these medications
do is increase the activity of these hormones. That we're
(25:46):
really helping people feel full. And for many people who
have been raised in a food centric environment, having this
tool with them to help them respond to just plain
hunger cues, hunger and fullness cues is a level of relief.
(26:07):
It simplifies their food relationships to a degree where they
literally just have to eat when they're hungry, and you
don't eat if you're not hungry, and that's what these
medications do.
Speaker 1 (26:19):
So if a woman opts to use one of these
GLP one medications, what kind of results can she expect?
What can she expect in terms of her weight loss,
but also importantly her body comp I mean, it's my
understanding that you also lose some muscle mass.
Speaker 2 (26:32):
Right when we look at the studies for some maglatide,
for example, in a step one trial, they saw an
average weight loss of about fifteen percent over a course
of a year with semaglatide, and for truzeppetite in its
landmark surmount one trial, we saw about twenty three percent
weight loss again over the course of a year at
(26:54):
its maximum dose. And so two points there, number one
over a year is crucial. I don't want people thinking
that this is something that they start and immediately they
see thirty pounds weigh loss in just a few months.
This is really a comment that's medication and to the
lifestyle changes, because both of these trials were done on
(27:17):
a background of a reduced calorie diet and increasing exercise.
But the body composition changes is also a good question
because we do see a loss of muscle mass with
any type of weight loss. So whether it's through medication,
through diet and exercise, through any commercial diet program, through
(27:41):
baratric surgery, whenever we lose weight, we lose both fat
and muscle, and so this is just something we're seeing
time and time again. Even with the medications in general,
what we see with samagnetide is that if you lose
three pounds, let's say one pound of it will be
(28:01):
muscle loss, two pounds will be fat loss. Turzepetide seems
to have a slightly better ratio. If you lose four pounds,
one pound is muscle, three pounds is fat.
Speaker 1 (28:13):
How do you counterbalance this? Is it strength training? Is
it hormone support? How do you counterbalance this muscle loss
that occurs with any weight loss.
Speaker 2 (28:22):
We don't have the best evidence that we would want
yet because we don't yet have published data on these
medications in the setting of let's say resistance training versus
nor resistance training, etc. But when we look at the
broader literature of weight loss interventions without medications, we do
find that if you adopt a higher protein diet plus
(28:45):
resistance training, then you're more likely to preserve muscle mass
as well as functionality. So it's not just about quantity,
it's also about the strength and the balance and the
functional measures that we care about.
Speaker 1 (29:00):
And what else do women need to look out for? Nauseousness, constipation, diarrhea,
gallbladder issues.
Speaker 2 (29:08):
Yes, so I would say the most common side effects
these medications tend to be gut related, so gastrointestinal side
effects nausea, vomiting, diarrhea, or constipation, reflux, or heartburn. Some
women are experiencing some fatigue as well, which may be
related to hydration status because we tend to be drinking
(29:29):
less water when we're not eating as much as well.
But those are the primary kind of more and more
common side effects that are typically present during dose escalation phases.
So if we're increasing the dose for you, that's really
where most of those side effects come in. Once you're
on a stable dose and your body has built up tolerance,
(29:50):
most of those side effects abate. The one side effect
that does seem to be persisting a little bit longer
is constipation, and that's something to definitely talk to your
doctor about to see what other avenues should we be
doing to mitigate that, and that could be increasing hydration,
more fiber, maybe over the counter agents, what have you
(30:11):
to help make that quality of life better. Now, some
of the rarer side effects that we want to pay
attention to our pancreatitis, which I mentioned earlier. This is
inflammation of the pancreas that can happen spontaneously in some
cases or be related to alcohol intake, or gallstones if
you've had a gallstone issue in the past, gallbladder issues
(30:35):
as well, so that could be gallstones themselves, or inflammation
of your gallbladder, another condition called coalsistitis.
Speaker 1 (30:43):
So what percentage of women actually stop these medications due
to side effects.
Speaker 2 (30:48):
From the clinical trials? It's about ten percent. So I
actually think that the clinical trials in particular capture a
highly motivated and committed population where they are really willing
to do whatever needs to be done. So I think
the discontinuation rates in the clinical trials of about ten
percent is probably an underestimate than what we might see
(31:11):
in clinical practice. I also think that practically speaking, many
people face other challenges in the real world of just
accessing the medication, accessing providers such as myself, to actually
prescribe that medication, or the whole gamut of lifestyle support
that they need to really feel comfortable in the weight
(31:34):
loss journey that they're on right now.
Speaker 1 (31:36):
These medications are only FDA approved for women who are
significantly basing challenges. Any comments on the off label use
for midlife women of the GLP ones.
Speaker 2 (31:48):
Initially based on American Heart Association guidelines American College of
Cardiology guidelines and the Obesity Society guidelines back from twenty thirteen,
so more than a decade ago we really thought about
these obesity medications for a population with a BMI of
thirty or greater or those with a BMI of twenty
(32:11):
seven or greater with a weight related comorbidity. That thinking
has shifted significantly over the past decade, and international societies
like European Association for the Study of Obesity have supported this.
They have come out with new landmark guidance around how
(32:32):
obesity should be a clinical diagnosis, a combination of these
anthropometric measures that we mentioned waste bouty five percentage, et cetera,
plus a clinical component which is in recognition of how
is that excess weight affecting our lives? How is it
affecting us medically, psychosocially, functionally, And using those two components,
(32:59):
can we make that diagnosis of obesity? And so I
think right now the medications, yes, absolutely, we're studied in
these clinical trials with those specific criteria, be my thirty
or greater, twenty seven or greater. But because the conversation
around obesity is shifting, we are becoming more mindful of
how obesity manifests differently in different people. So current guidelines
(33:24):
that package insert for these medications, what the FDA agreed
upon says that these medications should be used for people
with obesity or overweight with an obesity related comorbidity.
Speaker 1 (33:38):
So we know that some doctors are prescribing GLP ones
off label. How are the insurance companies responding?
Speaker 2 (33:44):
They are not on board, Absolutely not on board. I
think insurance companies have a different priority, right Their priority
is not necessarily health outcomes, it's health affordability. And for them,
asking what does it cost to treat one hundred million
people with obesity is overwhelming, and so I think nowadays
(34:10):
the conversations are all about trying to find a place
where we can compromise. We have to find a way
to increase access without incurring bankruptcy inducing costs, but still
providing a level of value to our population, to our
(34:32):
healthcare system, to the individual patient.
Speaker 1 (34:35):
So how do you choose when you're choosing a weight
loss medication for a midlife woman. How much is based
on her biology and how much is based on accessibility
and what you basically can get for her under insurance coverage.
Speaker 2 (34:47):
It's definitely a challenge. I think pragmatically speaking, we have
to think about what is accessible to them. So we
certainly talk about what I might recommend in the ideal
world where everything is covered or accessible for them rather
and what might be the best option for them given
(35:08):
their comorbidities. So we talk about other issues whereby we
can address multiple things at once while keeping in mind
what the potential side effects are and what can we
do to mitigate those risks as well. But when I
think about what regimen to build for a patient, and
(35:33):
this as I teach to my fellows as well, this's
heuristic of the four sees which I list as contraindications, comorbidities, cost,
and then choice. And from a clinician's perspective, we are
very adept at helping patients sort through the risk benefit
ratio between contraindication, side effect tolerability and the comorbidities and
(35:57):
other potential benefits of these medications. I think cost is
an increasingly important part of our conversations just because of
that accessibility piece, and patient choice is paramount. They have
their right to decide themselves if they want to budget
(36:18):
x amount of dollars per month to pay out of
pocket for this medication. Then that's something that I will
stand by and of course support them to do, but
I want to be able to give them that option
to discuss that, and on the flip side of a
patient says, that's certainly not something that I can handle,
or I have a needle phobia, there's no chance I
(36:40):
can take one of these weekly injections. Then we talk
about alternatives as well, so it's really about needing the
patient where they.
Speaker 1 (36:47):
Are coming up. Doctor Chang gets into some of those
alternatives she's mentioned, the ones that pre date the glp ones.
She also explains how different weight loss medications stack up.
We explore what golp ones might do beyond weight management,
and we unpack the growing trend of microdosing these drugs.
(37:09):
We'll be right back. So what is a little bit
of a lightning round with you with the different medications
that are available. Just give me your thoughts that come
you know, the one liners about these medications, just so
(37:31):
our audience can understand a little bit about the differences
or when you would prescribe them. Will gov or semaglatide.
Speaker 2 (37:37):
Excellent medication, really one of our most transformative agents that
have started, I think, and opened the conversation for obesity.
Speaker 1 (37:46):
Care z that bounder to zeppatide.
Speaker 2 (37:48):
Really pushing the envelope forward in terms of the degree
of weight loss that we can achieve.
Speaker 1 (37:54):
Sexenda one of the ogs.
Speaker 2 (37:56):
I think one of the OG's a daily injection still excellent,
great evidence based rebelsus. The oral form of some magnetide
I think really helps with individuals who are needlephobic. But
I think that somemaglatide oral shows us the very beginnings
(38:17):
of what we as a scientific community and biotech community
can do when it comes to getting these types of
medications in a pill form.
Speaker 1 (38:27):
To simia one of.
Speaker 2 (38:28):
Our forgotten medications, I think that really have quite good efficacy.
I think when people rank the obesity medications, it's some
version of GLP one as one, two, and three. But
actually when we look at the level of weight loss efficacy,
this combination pill of fen remine plus to pyramid is
(38:50):
probably number three.
Speaker 1 (38:51):
Contrive also really good medication.
Speaker 2 (38:54):
I think that it helps very specific people who have
that rewarding relationship with food, and my experience, the degree
of weight loss isn't as impressive of what we're seeing today,
which is why we're talking about a whole new generation
with the GLP one medications, but may still play a
(39:16):
role in some people where they have that particular emotional
connection orlistat wow orlistat oh. That came out in nineteen
ninety nine and it was gosh, we did like fifteen
studies around oralistad. We really thought it would change the landscape.
And I think it's just because it was our very
(39:37):
first medication that's still available now for long term weight
management to really show one of the safest long term profiles.
Because prior to that, medications were concerning for high blood
pressure or valvular disease, heart issues, but Oralistat showed us
(39:59):
that weight management through medication could be safe.
Speaker 1 (40:04):
So are there any medications that a midlife woman should avoid,
any interactions with hormone support or anything that a woman
should avoid.
Speaker 2 (40:12):
I would say that just in the way that exercise
might worsen the experience of hot flashes, Anything that increases
your synthetic nervous system, anything that increases adrenaline in your
body can worsen hot flashes. Certain medications that are what
we call some pado mimetics can do that. So phentromine
(40:34):
as part of veetrominetal pyramid can potentially worsen that as
well as buproprion, which is part of buproprion outrec zone
and contrary may also worsen hot flashes. I think everyone's
experience is different because beuproprin is also as a monotherapy
i FDA approved to treat depression, and perhaps some women
(40:57):
are having mood changes in the setting of perimenopause and
would welcome something like an antidepressant to help them as well.
So I think these are important pieces to tease out,
and we're looking at precision prescribing, but shouldn't be considered contraindications.
Speaker 1 (41:17):
Let's talk about supplements. There's a lot of supplements being
marketed on social media right now as similar to GLP
ones or mimic GLP ones. Can you comment on any
supplement support that women may find beneficial or useful.
Speaker 2 (41:32):
The supplement industry, as I'm sure many people know, is
less regulated than the pharmacotherapy industry. The supplement industry is
typically what we call post market regulated, meaning these supplements
can enter the market, anyone can buy them, and it's
only after the fact that we find out that oh
it had a contaminant or something. So I think the
(41:57):
quality control in that industry is harder to discern, and
that means intrinsically, when someone buys a supplement, you're taking
on a higher risk. So I would caution a little
bit about the supplement industry. The one space that I
do think is crucial for perimenopausal women is bone health.
(42:21):
And I speak on this from the perspective of an
endocrinologist who treats osteoporosis, who counsels women on osteopenia. I
think it is important that women in this age range
also meet their daily recommended intake of calcium, ideally from diet,
but may also get that from supplements. So in that
(42:44):
space of supplementation, I think it is crucial to get
at least a thousand milligrams of calcium per day.
Speaker 1 (42:51):
Microdosing let's talk about microdosing. Everybody's talking about microdosing. What
is microdosing of the golp ones? Why would one do this?
And what are the benefits of microdosing.
Speaker 2 (43:02):
So micro dosing I don't think we have an industry
acceptant definition for this, but effectively it's looking at off
label doses that are administered or whatever help benefits at
doses that are lower than those studied. And typically when
people talk about microdosing, they're referring to the GLP ones
semaglatide or trzeppetide. The lowest dose of semaglatide that has
(43:25):
been studied for weight losses zero point twenty five milligrams.
The lowest dose of turzepetite available is two point five milligrams.
So doses lower than those numbers would be considered microdoses
by some. And I think people are doing this because
they're thinking that they're going to have less side effects
with the dose titration if they go up by smaller increments.
(43:48):
And actually a study was just recently published demonstrating exactly that.
Speaker 1 (43:53):
So let's talk briefly about some of the other benefits
of the GLP ones. People are talking about anti inflammatory effects.
We noticed in our endming triosis patients that were using
GLP ones that far before they lost any weight, their
pelvic pain got better. It was pretty impressive. So can
you just speak to the anti inflammatory effects of these
medications and maybe how they impact brain and cardiac health.
Speaker 2 (44:15):
We know from the studies that HSCRP so high sensitivity
see reactive protein, one of our biggest inflammatory markers, is
significantly reduced with these medications, and we do see reductions
in HSCRP even before significant weight loss, and i'lsoy clinically
we're seeing that too in our patients with osteoorthritis, rheumatoid arthritis,
(44:37):
some of the autoimmune diseases like psoriasis. So it is
definitely a fascinating area of research, and I do know
that there are a number of clinical trials exploring that
in the autoimmune space, for example in Croh's disease the
combination of samagotype plus a disease modifying agent, or even
(44:58):
in Alzheimer's where we think perhaps inflammation is playing a
role in dementia too.
Speaker 1 (45:03):
So stay tuned for more research on this right totally. Yeah,
in terms of just cardiac and brain health effects with
the GLP one medications, have we really teased out how
much of that is due to direct anti inflammatory effects
maybe on immune modulators, and how much is due to
white loss. Has that been teased out?
Speaker 2 (45:24):
It's a great question. There's an interesting secondary analysis that
came out at the European Congress for Obesity earlier this
year on the Select trial, which was a cardiovascular trial
conducted in people with obesity randomized to placeibo versus some magnetide,
and the headline for that was a twenty percent reduction
(45:45):
in cardiovascular problems, and those cardiovascular problems were non fatal
myocardalin friction, cardiovascular death, or non fatal stroke. What they
were looking for was what was the earliest point in
time that we started to see proof of that cardiovascular benefit,
(46:06):
and that earliest point in time was around ninety days,
so as early as three months before people are even
on the maximum dose of some magnetide, before you're even
getting five percent weight loss, we're seeing proven cardiovascular benefit.
Cholesterol improved, yes, blood pressure improved hscrp are, inflammatory market
(46:29):
improved as well as urinary albumen so some proachin in
the urine. So we think there's a number of different
physiologic changes when we're administering these GLP ones, and these
are happening very early on before significant weight loss.
Speaker 1 (46:45):
Yeah, that's so consistent with our endometrios as patients. It was.
It was fascinating wind waste. It was. It was within
maybe three weeks actually very quick. I mean people would
come back and say you know, I don't have pain anymore,
and it was unbelievable. Actually, you know heralding that it
had to be because endmetrios is a disease of inflammation, right,
(47:06):
so it had to be something anti inflammatory.
Speaker 2 (47:09):
That's amazing.
Speaker 1 (47:10):
What do you think about medspas and some of these
other groups offering GLP ones for more cosmetic weight loss.
Speaker 2 (47:18):
I'm happy that everyone is trying to learn more about
these medications because in the past, I think weight management
was really this fringe specialty of medical care. But I
do think it requires a level of ethical responsibility to
understand what is the evidence based for these medications, who
(47:40):
were they intended for, and if I am offering these
medications to individuals in which they were not studied, I
need to be transparent about that these medications have not
been studied in individuals with a BMI of twenty two. Now,
whether it should be used or not, it is not
(48:02):
my judgment call, because it's not my role to place
my value on whether you, as a patient values your
cosmetic appearance anymore than you value your health parameters that
are measured in the blood. Really, it's the job of
the medical community. Whether you're medical directors, medical professionals working
(48:26):
in medspas or clinics to transparently present what the evidence
is or the lack thereof, for these agents. And in
the population you're offering them to.
Speaker 1 (48:40):
So disordered eating starts to come out again in the
perimenopausal transition, and we know that a significant number of
perimenopausal women will experience disordered eating. Any potential for abuse
of these medications, how do you watch out for that
as a provider.
Speaker 2 (48:55):
I don't think we know yet, but it's certainly something
that we're paying attention to. We see if they have
any history of eating disorders, any propensity for binge eating,
overly restricting, history of purging, any kind of red flags
that we can capture we want to And it may
not necessarily mean that they are ineligible for these medications,
(49:16):
depending on other health issues and anyone else on their
healthcare team, but it does mean that we want to
pay very close attention to them.
Speaker 1 (49:26):
What pearls could you offer to women in terms of
lifestyle approaches to counterbalance some of these body comp challenges
that occur at the menopausal perimenopausal transition.
Speaker 2 (49:38):
Very simply based on the evidence, I would say, increase
your protein intake by twenty grams. So whatever you're eating
baseline right now, try to add twenty grams of protein
that's like four ounces of chicken or protein shake or
some version of that every day, extra twenty grams every day,
and then do resistance exercise. So at least two days
(50:01):
a week of resistance training. That could be a pilates class,
that could be bodyweight exercises at home, free weights, machines,
any verse of that that you can enjoy. I think
that will go a long way towards a longer health span.
Speaker 1 (50:17):
How are you prioritizing your health? What are you doing
for yourself right now?
Speaker 2 (50:21):
I think for me, actually it comes back to that
resistance training. So I have a two year old child,
and so I still feel like I'm in that post
pregnancy body where things have shifted. I have chronic back pain,
all of these things, and so I actually think that
focusing on strength and functional strength, being able to lift
(50:46):
the car seat, those types of things is my priority
right now. And I think if we all focus on
being stronger in our bodies, whether those bodies are larger
than what we'd like, or we're fitting in these clips
or those clothes, as long as we feel strong in
our bodies. I think that should be the goal.
Speaker 1 (51:07):
If women could take away one point from our conversation today,
or remember one point from our conversation today, what would
it be.
Speaker 2 (51:16):
Don't be afraid to bring up your issue with your doctors,
even it feels like everyone else is telling you that
your experience is normal, whether it's menopause weight gain, menopausal
weight gain, It's not an experience that you have to
suffer through.
Speaker 1 (51:33):
So don't take it's all normal and aging as an answer.
Make sure that you proactively tell your healthcare provider about
your issues and concerns and try to get answers.
Speaker 2 (51:44):
Absolutely. I think that you know it's challenging when we're
in this space like we started out with weight management
and menopause, because it exists both in the wellness industry
and the medical community. And that means when you present
yourself as a patient, it's hard to say it's like,
am I sick? Do I have a problem? Or am
(52:05):
I healthy? And I'm just looking to be healthier. And
I think sometimes we can run into just resistance if
we're healthy people trying to be healthier in the medical community.
So I think we all just need to have a
more open mind. Otherwise we're going to continue to have
(52:25):
clashes between the wellness industry and the medical community when
really we all have the same priority, which is to
improve a person's health.
Speaker 1 (52:33):
Yeah, I mean, I think the healthcare community needs to
focus on healthcare and prevention, right, I mean, we have
to evolve from sick care and move more into prevention.
We'll always have some illness that we need to treat,
but to prevent it and to decrease it would be
I think we need both.
Speaker 2 (52:48):
I think we definitely. I think we still need people
who treat disease, of course, but I also think that
the wellness industry and the treatment of healthy people and
prevention should be held to the same standards, or even
higher standards than what we have for sick care, because
the risk of harm in treating someone who's already healthy
is actually higher, right because you're already working with someone
(53:11):
who is healthy. So I think we just need to
have the same standards.
Speaker 1 (53:16):
There's lots of buzz around these drugs, but of course
there's also a lot to think about before you start
any new drug. Let's be honest. Gop Ones might not
be right for everyone, but they are a tool in
your doctor's toolkit. Talk to your clinician about your options,
your concerns, and of course your goals, and if you
want to make a change, don't settle for it's a
(53:38):
normal part of aging or it's natural as an answer,
the changes that come with the menopausal transition are indeed normal,
but that doesn't mean that you can't take steps to
feel better. If you're noticing symptoms of perimenopause like hot flashes,
mood changes, brain fog, or sleep disruptions, you can also
consider starting hormone therapy to help manage these changes before
(54:00):
they escalate. We'll have another episode completely dedicated to the
latest science about hormone support during perimenopause and menopause later
in this season, and this certainly won't be the only
time we discuss GLP ones on the show. So much
research around these drugs is still ongoing, and as we discussed,
(54:21):
there's been some early work looking into how these drugs
might actually be beneficial for other areas such as cognition,
cardiovascular health, and maybe even for autoimmune conditions. So stay
tuned for more on all of this. I'm excited about
the possibilities coming up on the next episode of Decoding
(54:43):
Women's Health will be speaking with the country's first preventative
neurologist about why two thirds of Alzheimer's patients are women
and why he believes that many of those cases are
actually preventable.
Speaker 2 (54:57):
Genes are not our destiny.
Speaker 1 (54:59):
The field of Alzheimer's disease is changing so rapidly.
Speaker 2 (55:02):
The things that I can talk about now like I
couldn't even dream about ten years ago.
Speaker 1 (55:07):
And if you like this podcast, please consider leaving us
a re wherever you're listening now. It helps new people
find the show. Thanks so much. Decoding Women's Health is
a production of Pushkin Industries and the Atria Health and
Research Institute. This episode was produced by Rebecca Lee Douglas.
It was edited by Amy Gaines McQuaid, mastering by Sarah Burguier.
(55:32):
Our associate producer is Sonia Gerwit. Our executive producer is
Alexandra Garreton. Our theme song was composed by HANNS. Brown.
Concept creative development and fact checking by Shavon O'Connor. A
special thanks to Alan Tish, David Saltzman, Sarah Nix, Eric Sandler,
(55:53):
Morgan Rattner, Amy hagdorn Owen Miller, Jordan McMillan, and Greta Cohne.
If you have a question about women's health in midlife,
leave us a voicemail at four FO five two O
one three three eight five, or send us a message
at Decoding Women's Health at pushkin dot FM. I'm doctor
(56:14):
Elizabeth Poiner, and thanks for listening. Until next time.
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