Weight Loss Drugs & Metabolic Health in Midlife
Dr. Rocio Salas-Whalen 0:03
And we're looking for rapid and quick and too much weight loss, which we can be blinded by that idea of, oh, we have this drug, the patient was to lose 30 pounds, let me do everything I can so the patient can lose. We're missing the point, the point of weight loss is to improve their metabolic health. Right. And what happens to many patients, the majority of patients with obesity or overweight is that they have higher percentage body fat and lower muscle mass. Right. So if they're just losing weight, they're losing fat and losing muscle. They're losing fat, they're losing muscle. So yeah, maybe they lost 30 pounds, but they still have more higher visceral fat percentage body fat and low muscle mass. They're still not metabolically healthy.
Sarah Milken 0:44
Hi peeps. Before we get into my chat with Dr. Rocio Salas Whelan, I wanted to let you know that I am not personally endorsing the drugs discussed in this episode. This is merely a conversation between me and a triple board certified doctor talking about her experience in her medical practice, based on real medical research and FDA approvals. So please consult your doctor before taking any of the drugs recommended. Remember that everybody's body is different and what might work for one person's medical profile may not work for another everybody has a different path. Once again, please do your research and consult with your doctor. Hey, peeps, welcome to the flexible neurotic podcast. I'm your host Dr. Sarah Milken. Yeah, you heard that right. I'm a real PhD doctor. Long, long ago, like last fucking year. I was sitting in the midlife funk wondering, was this it for me? That day, I realized I needed to get off my ass and start my midlife remix. I dusted off my PhD wipe the menopause, sweat off my forehead, grabbed my golden shit shovel and started digging deep to all my midlife bitches. It's not just love coffee and hormones that get you through your midlife remix. It's action steps. Let's do this. Hi, good peeps. This is the next episode of The flexible neurotic Podcast. I'm Dr. Sarah Milken, the flexible neurotic. Today I have an awesome guest. She is a mother of two, a physician who is triple board certified with vast experience across all areas of Endocrinology with an emphasis on obesity, diabetes, metabolism, thyroid disorders and osteoporosis. I bet I piqued your interest already. She did her internal residency at Albert Einstein College of Medicine endocrinology residency at University of Maryland, and research fellowship at Johns Hopkins in internal medicine, endocrinology, diabetes, metabolism and obesity medicine. Her private practice is based on evidence based medicine and is called New York endocrinology on Park Avenue in New York City. Her name is Rocio Salas, Whelan, Dr. Whelan wants her patients to have one to one extra time and care in her practice. She wants people to take ownership of their health and wellness, through information and less way from the media and sensationalism. And working with patients facing metabolic and obesity issues for over a decade, she has learned that people have tried so many things by the time they get to her that we're all just looking to feel good in our own skin. Hi, Doctor, I make this work. I know me too. For a reason. I know we're both on vacation. We're both with our kids. We're not in our normal places. We don't have the regular setup the whole thing. So I'm so happy you're here. I think as you know, my podcast is a midlife self reinvention podcast. We talk about all sorts of things from menopause to creativity, all the things that we are kind of dealing with in midlife, so for you and having an endocrinologist and obesity special Assan. The intention of this episode is to take a deep dive with you. And I really want to get into some metabolic and obesity drugs that are getting a lot of media coverage right now. And they're basically sold out in many pharmacies across the country. And some of these same drugs are now being approved under new names for obesity and weight loss. The drugs are helping many people achieve the health they want in need for Optimal Living and longevity. listeners have probably heard of some of these ozempic will go V and so many more. We're going to get into it for my midlife self and all of my midlife listeners. We're looking to get some answers on weight hormones, muscle and fat composition and the mid Life's do as I sometimes call it, and I know Wait, are you 47? Or 4847? Okay, so my I'm turning 48 in February. So the beauty of that is that you can relate to all of this personally, and as
Dr. Rocio Salas-Whalen 5:14
a doctor, and as a woman.
Sarah Milken 5:17
Yes. I mean, it's beautiful. We talk about what happens to our bodies after 40 ish. And there are things we can do, but at what physical, mental and financial cost. So we're gonna get our golden shovels out. We're gonna make sure our kids aren't screaming, right? Yeah, hopefully, Mike, my teenagers are probably still sleeping. So this episode is going to be about female metabolic health research evidence and personal experience and rosiest practice and drugs that are being used for obesity and metabolic health. So what are you seeing in your practice?
Dr. Rocio Salas-Whalen 5:56
Well, I mean, as we're seeing in the media and the news, where there's shortages of the medications that we will talk about, I'm seeing the same in my practice, I would say in the last year, my practice group, probably 200%. Wow. So significant, you know, I think it's not just to dance, definitely the drugs that we have available. Now. It's what it's part of it, but also COVID, the pandemic brought a lot of attention to obesity, right? I think before as physicians before the pandemic, we used to warn patients in regards to their weight and long term complications, right, we were talking about and 20 years, you're gonna develop type two diabetes, and the future you might develop hypertension, cardiovascular disease. But what happened with COVID, COVID came in out of nowhere, it started affecting or having more severe cases in the patients or in the people that had obesity or were overweight, the majority of the people in the ICU, worldwide internationally was people with higher BMI, right. And those studies are there there's publish. So I feel like the pandemic brought a lot of attention and light to what obesity can cause. Right. And it's not something I said in the future. It was something in the moment. And I feel I had many patients come in, during the pandemic, being afraid of their weight and saying I don't want to end up in the ICU. I don't want to die from COVID. So I feel like people got the message very quickly with the pandemic and regards complications with obesity. Added to that, that we now we actually have treatment that we have drugs that can help with obesity and weight loss long term for weight loss and weight loss maintainence. I think it was just like the perfect combination, right? Because this drug, they're not new, those drugs. The first incretin, which are the ones with drugs that we're going to talk about, are since are available since 2005. And I've been using them and patients since 2005. The first one was called by Jabra or extended 10 was the generic name. And we've been using them initially for diabetes, and then weight loss, right? So it's not that the drugs are new. And that's what's causing this. I think it was just that COVID really made it played a number in obesity.
Sarah Milken 8:22
Now the women and the men, but for the purpose of this podcast, the women who are coming to you, when would the word obesity, you know, we have this image in our heads of of obesity. But what really is it because like we think of a 300 pound person or somebody who has to lose 75 pounds? How do we define that?
Dr. Rocio Salas-Whalen 8:45
I mean, there's there, unfortunately, the diagnostic tool that we use the most is the BMI, right? But I mean, that's a very outdated tool, diagnostic tool. So body mass index, body mass index, right? That's what unfortunately insurances uses as guidelines for
Sarah Milken 9:04
prescriber you so are you required to use that in your office and additional to other?
Dr. Rocio Salas-Whalen 9:09
You know what I mean, I'm independent provider, I don't take insurance, I might have metallisation. And I feel like that gives me a lot of the freedom to practice medicine, not so much by insurance standards. And that's the reason that I decided to opt off insurances, we have better tools to diagnose and really say, Who needs this medication or not, not the BMI. I use an impedance body composition machine. And it's incredible, but so many times I see a normal BMI with high visceral fat, high percentage body fat and low muscle mass. So the BMI is just a calculation between your body weight and your height right? So that calculation is not really giving us your body composition so we can have a normal BMI. Am I a BMI of 2021? With high visceral fat and low muscle mass?
Sarah Milken 10:05
Will you define visceral fat for everyone?
Dr. Rocio Salas-Whalen 10:07
Yes, I do. For every single patient that comes into me, I do a visceral mass percentage body fat, and a skeletal muscle mass. Those are my three metabolic components.
Sarah Milken 10:19
So what is visceral fat?
Dr. Rocio Salas-Whalen 10:21
So visceral fat is the upcoming accumulation of fat intraabdominal, right? It's not what we're pinching outside with the pitch with our hand that's more subcutaneous is intra abdominal fat is the, what we call the bad fat is the fat that attaches or ideas to your internal organs, including your liver, your pancreas, your gut, right and as that liver accumulation of fat that can take you to have insulin resistance and hyperinsulinemia. There's a miscommunication and the insulin signup, when there's accumulation of fat in the liver and the internal organs, that leads to hyperinsulinemia insulin resistance, and that can lead to diabetes or type two diabetes.
Sarah Milken 11:08
So why are so many women in midlife in this menopausal like perimenopausal to postmenopausal zone? Why is this insulin resistance becoming such a hot topic right now? Is it sort of just that we're focusing more attention on it, but it's always been there? We have more tools like what's the deal
Dr. Rocio Salas-Whalen 11:27
is the drop of estrogen, right? A drop of estrogen promotes visceral fat. visceral fat, promotes insulin resistance, insulin resistance, promotes visceral fat, and then it goes into that vicious cycle.
Sarah Milken 11:46
Right? So if you take someone like me, I haven't tested my visceral fat, but I have I have insulin resistance. But I do, but I take birth control pills. So my estrogen is sort of probably in the range of where it's supposed to be. So Does that just mean that's like my hereditary makeup?
Dr. Rocio Salas-Whalen 12:06
I mean, definitely. obesity as a broad umbrella term or waking or overweight. it's multifactorial, right? It's not just one thing. It's not one cause it's not lifestyle only is there's genetic factors. There's hormonal factors, right in women. We can talk about PCOS, we can talk about menopause, menopause. There's aging factors, though those are irreversible. And then we talked them about environmental factors, right? What plastic EPA, endocrine disrupting chemicals, sleep stress, industrialization, food industry, that's considered like an environmental factor. So yes, we cannot say only one source causing the visceral fat, especially in a woman in midlife is going to be multifactorial is when the genetic starts to kick in is when you change it, you're starting to have fluctuations in estrogen that that can promote. What happens in menopause perimenopause with a drop of estrogen. There's redistribution of fat. So in our fertile years where we have our fat for fertility, which is our hips, our breast, Wednesday, one day, estrogen starts to fluctuate down or to drop, that body fat that redistributes centrally, viscerally. So then we're more risk of insulin resistant and sort of resistant causes weight gain. So then we get into that cycle. So that's why we're seeing that in midlife and perimenopause and menopause in women, specifically, we're talking about the changes in estrogen is promoting visceral fat added to that all the other factors that I mentioned. So it's, again, it's not one source is different manufacturers contributing to that.
Sarah Milken 13:46
So the typical midlife woman who comes into your office, let's do like a quick overview. Did you start with estrogen? Like, where do you start? And what are you seeing? And how does it go like for the typical woman,
Dr. Rocio Salas-Whalen 14:01
so let's say that my typical patient that I seek in my practice is going to be it could be a midlife, right, mid 40s, right? It late 40s, early 50s, that they are doing everything that they possibly can, right in regards to exercise diet. I mean, they they've done it, I mean that they're doing it, it's not like they're not trying, you know, and a very common thing that patients mentioned is what I'm doing now. And I used to do that in my 30s or in my early 40s, where my choice is not happening. It's not working, right. I'm doing exactly the same thing. I'm eating the same thing. I'm eating even less, I'm exercising more, and the weight loss is not happening, right. So that's what what I see mostly coming in my office and yes, we're not talking about 100 pounds. I mean, we're talking maybe 15 pounds 20 pounds, right. So then we do a body composition then I want to see where their body fat is a muscle mass is then it's more a complete journey also if and also if they're symptomatic with perimenopause symptoms, or menopause symptoms, right, then I have to stratify a patient is at low risk, intermediate risk or high risk to to receive estrogen for breast cancer and blood clots. So it's a very thorough, thorough visit. But if it's done properly, then we can really offer the patient the right tools to improve their quality of life of the app, once they're going to their second phase of their life, right? I always tell to my patients, yes, we all gonna go through menopause, we all gonna go, our restaurant is gonna drop, but we don't have to just take it like lying down, right? We have, we have helped for that. And that's what I tried to offer to my patients. So we'd go from exercise, resistance training, diet, medications for weight loss, and estrogen replacement therapy. And now we call it menopause hormone treatment. Definitely putting some body on estrogen. We don't promote it as weight loss that is going to help redistribute the fat from this early to different areas, right? That is not the dangerous fat.
Sarah Milken 16:21
And how long does that take? So if you have a woman, like for me, I've been on birth control pills my whole life. So I you know, except for obviously, when I was pregnant, but if you have a woman who's coming to you, and she hasn't taken estrogen before, how long would it take her to sort of shift her body fat around?
Dr. Rocio Salas-Whalen 16:41
Well, for symptoms, let's say the patient is having some Peri menopausal symptoms that we can talk about those to the whoremonger menopause hormone treatment takes about I start seeing changes in three to four weeks, right. And many times I tell my patients with we're not seeing the improvement that we want is more of a matter of the dose and not that it didn't work for you. Right? Correct. I personally am very conservative with hormones. I respect hormones dearly. So I always tried to start very on the lowest dose possible and then gradually go up, right? So yes, there's a chance that in four weeks, you're not going to feel improvement, but then it's more of a matter than just going up on your dose. So it can take four in regards to weight redistribution or fat redistribution. It could take about three to six months for us to see that right?
Sarah Milken 17:29
Yeah. Do you find that women get frustrated and are just like, Wait, I don't I don't, I'm not seeing the results I want I'm still having hot flashes?
Dr. Rocio Salas-Whalen 17:37
Well, if we're talking about weight, and depending on the amount of weight that the patient has to lose, I'm not again, I'm not gonna do estrogen for weight loss, then I add a weight loss medication for her in regards to the weight, right?
Sarah Milken 17:51
Okay. Yeah, surgeon does help with the osteoporosis and all
Dr. Rocio Salas-Whalen 17:55
estrogen. How if I mean independent of weight, I mean, estrogen can improve the quality of life of women asleep. sex, sexual function, cognition, energy, decreases chances of dementia, cardiovascular disease, bone mass muscle mass. So I mean, there are many other benefits of estrogen versus weight, right? Again, we don't give it for weight loss. It does register your fat, it decreases your risk for insulin resistance and type two diabetes in the future. But it's not a weight loss medication for weight loss. And I will do what independent weight loss drug for the patient.
Sarah Milken 18:35
But you do look at the metabolic health markers before deciding about the weight loss medications that we're going to talk about. Yeah. And in terms of like inflammation and Alzheimer's, I mean, those are obviously huge topics in the midlife space. What is the research showing about these weight loss drugs, what we're going to get to called incretins, in helping to reduce insulin and reduce inflammation and help with cognitive decline.
Dr. Rocio Salas-Whalen 19:06
So visceral fat, it's an inflammatory organ, right? And it releases cytokines and that's what promotes inflammation, right? So that's why we know that in OBC, it's a chronic inflammatory process. And that's why that explain COVID Right, when COVID enters your body, if your body is already occupied or preoccupied in a chronic inflammatory process, using all your cytokines and inflammatory things that can protect you from when something comes in your antibodies. They're already preoccupied with the inflammation from obesity or visceral fat, then comes a virus and can have a party right because there's no antibodies to protect you. So that's what's happening with inflammation in obesity. And we know that dementia is can be an inflammatory process cardiovascular disease, type two day Be nice. I mean, there's inflammation is pretty much the basis of many of our chronic diseases that we have. And there's a lot of research being done currently in regards to estrogen and dimension woman, right. I mean, unfortunately, many of the studies that done about dementia has been based on men, right? And we know that our bodies are different, our hormonal composition is different. So now the studies in woman in regards to estrogen and menopause and perimenopause and dementia are being done.
Sarah Milken 20:35
So we'll have more now, thank God because there's so much information out there. Okay, let's get into the pharmaceutical drugs. They're in a class called incretins. And I'm sure many listeners have seen it all over the news and Instagram and social media everywhere. Can you tell us what they are and what categories they are.
Dr. Rocio Salas-Whalen 20:57
So there are a class of medications called incretins. And their hormones are synthetic hormones, we make this hormones in our gut, in the small intestine, there is GLP, one glucagon like peptide one, and gi P, glucose inhibitory peptide. So those are the two ingredients that we humans we make. But the problem with our endogenous incretins is that they have a very short life from from an enzyme called DPP four. And this enzyme breaks down this hormone within three minutes that is released. Right? So we do make them but unfortunately, they don't live long enough to give us all these benefits that we're seeing with the synthetic forms of this of this drugs. And what they do, we have receptors all over our body for this type of hormones. They're more studies are the ones in the gut, and brain and heart and you know, even in kidney, so again, we have in different organs, receptors for this, and so we don't know even what other potential benefits multi organ they could they can have, right. But in regards to weight, the way that they work, it's in our gut, in our stomach with our hunger and satiety hormones. This, this incretins what they do, they increase your satiety hormones, when you start eating their release, and they're started working to release your fullness hormone, so you start eating, and you feel fuller, with smaller portions of food. And in between meals, a decreased your hunger hormones. So you really have more control way of it almost I like to say that it gives you a similar effect as cardiac surgery that is restricted way of eating that you don't, you cannot eat more than what you can put in. And that's more like a mechanical restriction. But in the amygdala, and the hedonistic eating area, we have receptors for this hormones, too. And what they do is they dissociate any positive feedback, or positive reinforcement from food in regards to comfort, emotion, anxiety, right? So many, many people that are emotional eaters, anxiety eaters, it takes it away, you're not getting the response back from food anymore. So it really changed your behavior with food. You enjoy your food when you're hungry, but then you get satisfied with smaller amounts. And then that's it, you're not thinking of food or anticipating food for certain size, type of relief, or comfort.
Sarah Milken 23:36
But I know a lot of people are probably thinking like me, but what about, like, when you're looking forward to going to that Italian dinner date night with your husband? Like, are you going to lose your kind of interest in food? Or are you still going to have it but maybe it's less?
Dr. Rocio Salas-Whalen 23:56
See it depends. If you I mean, if you're going if you're looking to enjoy, you're gonna go out with your husband, your significant other with a friend and enjoy and that's not going to take it away, right. But if you're are feeling if you're expecting your food that you're eating to give you certain type of comfort, or release, right? There's two different things right, then this is going to take that away, right? But you know what happens? something wonderful happens for those patients that do have that reach for food for that anticipation. Suddenly, they have so much more mental space to pursue and create other things and not consume food. Right? It's beautiful. Because when you have in this I see all the time, there's patients that are struggling decades, right and now we can talk more broadly about obesity and an overweight decades with their weight it consumes 90% of their brain, that meal in front of them Right, how is this going to impact my weight? Am I doing the right thing? Am I eating the wrong thing three times a day, four times a day, it runs into their head for decades, suddenly, they don't have to worry about that. It's like they let go of the control something wonderful really happens with those drugs. And it's very hard. Sometimes I tell my patients very hard to understand, once you're on them, and when I see you again, we're going to be having a completely different.
Sarah Milken 25:26
But you know, what's interesting is I also read that, and I think I listened to it on your Instagram that if somebody is a candidate for bariatric surgery, and they have that versus doing the drugs, what's interesting, what I read was, is that when you have bariatric surgery, there can be like relapses because it doesn't take away the dopamine connection, that you're getting that orgasm from eating that brownie. And let me
Dr. Rocio Salas-Whalen 25:55
tell you what, let me tell you why. And this is my research that I did in Colombia in John Hopkins. So we found that was by the hattrick surgery, especially the roux en y gastric bypass, we're talking about gastric bypass, not the seat, when we're talking about the gastric bypass, they take a part of your smoker, right, they take the part of your intestine. So there's a shorter journey or recall, like there's, the food gets closer to that area in this small guide with this, where this hormones are released. So it was found that with bariatric surgery, there's a higher release of this that hormones, right. So that's another way that it's not just a mechanical restriction, this effect that we're seeing with the, with the with the current medications that we have, we can see them in bariatric surgery, there's a higher release of this hormone, but the endogenous incretins, the ones that we make, don't cross the blood brain barrier. So that's why in bariatric surgery, we get the same mechanical effect, the satiety hormones go up that hunger hormones go up, but it doesn't change the pleasure eating part of the food or the or the emotional connection with food because they don't reach the amygdala. So that's why there's weight rigging, because that impulse, that effect is still there in their brain, they're still gonna reach for the food for that comfort and that relief that it was giving them that with time, they were gonna be waking, but we don't see them with the horn with the with the incretins with the synthetic hormones that we have. That's why they do better patients with the hormones. I have had patients have lost 140 pounds on them. So really, very few patients that I needed to refer for everybody that took surgery once we have this wonderful medications.
Sarah Milken 27:38
Okay, so let's talk about the medication, the actual mechanics of it like the there's there once a week injections that you kind of grab, you pinch a little fat on your tummy and poke it in and then there's a pill version two, what's the difference between the two.
Dr. Rocio Salas-Whalen 27:54
So they injectable is subcutaneous it goes to the subcutaneous fat and that's absorbed through the circulation, the oral will go through the stomach, right? I never I never saw the same effect in weight loss in the oral and the injectable. Send glucose control on both drugs, oral and injectable, but no weight loss on the oral medication. Oh, interesting. Yeah. So I personally don't use the euro for weight loss. I mean, again, for glucose control. It's either one or the other is the same effect but not for weight loss.
Sarah Milken 28:27
Okay, now, in terms of the injection, I mean, I have some friends who are taking it it's like the tiniest little prick. It's like you couldn't even feel it.
Dr. Rocio Salas-Whalen 28:38
Yeah, I have some patients that telling me I don't even know if the needle
Sarah Milken 28:45
so funny. Now, um, what in terms of I know there's different, like different I don't know what the medical term is, but there's different groupings, like there's one that's just GLP one, there's one that's GLP and now there's a new class that's been approved for that's always all of these drugs have been approved for diabetes in general. But now they're coming out with new names and rebranded the same drug but for quote weight loss. So I think that's like a little bit confusing for people because like ozempic is also called what like OB, okay, so is those so ozempic is the which is the one for weight loss and which is the one for diabetes or Sam
Dr. Rocio Salas-Whalen 29:29
because FDA approved for type two diabetes and WICO. V is FDA approved for weight loss, same drug, same molecule, same pharmaceutical, same thing. I always tell my patients imagine a bottle filled with semaglutide that drug and it has two openings and one is filling our bullpen and one is filling I know something is the same drug is just the FDA clearance right now we have prior to that we had Victoza which was liraglutide and that's a daily injection and then it was rebranded as SEC sender for weight loss. And now and now we have Manjaro, which is branded FDA approved for type two diabetes, but now they are on the fast track to get it approved for weight loss, which they will change the name of course, but it will be the same drug
Sarah Milken 30:17
and the trans appetite and tours How to know how to say that the trees up beside
Dr. Rocio Salas-Whalen 30:22
are two separate type. Yeah, that's Manjaro that's my
Sarah Milken 30:25
Okay, so that's Manjaro. And what is the difference between I know that that one is unique because it combines two hormones, the GLP and the GLP one, so is that kind of becoming like the hot one, or is it gonna become the hot one?
Dr. Rocio Salas-Whalen 30:43
I like to say that Manjaro is the iPhone 14 of Asana. It's, it's, it's, it's, they improve it, they fix the bugs, you know? Yeah, it works better. So yes, it's the same class of drugs they call inheritance. It's just different versions.
Sarah Milken 31:05
It has to it has both Yeah, hormones and not just one
Dr. Rocio Salas-Whalen 31:10
semaglutide which is a simple one. We go we it's just GLP one and two sympathise. It's a twin cretin. It has the two ingredients that we make, which is GLP. One and tip. So it's because of that, that we think that we see less side effects and more weight loss without it.
Sarah Milken 31:28
Now how is from what I read in your information is that one becoming easier to get approved by insurance, you know,
Dr. Rocio Salas-Whalen 31:37
is as I was saying pharmaceuticals, a bit a little bit more smarter than making this wonderful drugs and then in production and promotion, they will be as smart as when they make this drugs. But both Novo Nordisk, and Eli Lilly, when we go, we came out. And when Jarrell came out from Eli Lilly, they came out with a promotion. Right, they said, they need to be prior authorization, there's a coupon that the pharmacy was going to apply it for $25. So you were getting this medication without prior authorization for $25 a month. So it costs like
Sarah Milken 32:15
$1,500. Exactly. So
Dr. Rocio Salas-Whalen 32:18
then everybody started going crazy prescribing them off. I mean, just because of those, but then what happens that demand goes, I mean, Manjaro, the 1 million prescription was reached within a few months of being out. So I don't know if they didn't anticipate the demand. And would go we happen this the thing happened with with Kobe is that they couldn't keep up with it, the mind the production of the pen. Now the drug because the drug is semaglutide. And they were being able to make ozempic or sandpit can last you about five weeks with Goby pen is one week one. So what the what number daughter this run problem is with the production of the pen. So they couldn't make one pen a week as fast for the millions of people suffering with obesity, right? I mean, then, I mean, there was so much consequences. Remember those pens, then everybody wants it. And then we go, we said no more prescriptions. So we're gonna wait until we can make more sense than everybody that was in Waco, we fell back on something. So then we started having shortages of a septic because now we were using it for obesity and diabetes, right? Same thing is happening with Manjaro. Now, they cannot keep up with it than that. So yes, we're having shortages of all drugs, both pharmaceuticals, they're working 24/7 to improve that. They're guaranteeing that first trimester of 2023. We shouldn't run with shortages problems right.
Sarah Milken 33:45
Now, who are the doctors who are prescribing these? I mean, obviously, you're a very highly certified endocrinologist. So with every certification and degree in the world, but obviously, there are I mean, our regular internist prescribing this also and like, what are what are the downsides of that? Because these drugs, I do want to get into it do have side effects?
Dr. Rocio Salas-Whalen 34:10
Yes, any drug it has to say, even ibuprofen at the pharmacy has side effect, right. So there's drugs or side effects. I am a little bit conflicted in prescribing who's prescribing and not I feel like this drug should be offered more widely, right that they shouldn't have to come all the way to meet to be able to have a discussion about this drugs, right. I think there's many filters that can go before they get to me. Primary care, family medicine, for sure, right. But obesity is a very complex disease. Weight loss is a very complex weight loss is not just about the number in the scale going down. That's what we thought. That's what just by us 30 pounds that we improve your health. I I've seen that that is not as simple as it looks like as it is. with weight loss, there is muscle loss, right? And we're looking for rapid and quick and too much weight loss, which we can be blinded by that idea of the oh, we have this drug, the patient wants to lose 30 pounds, let me do everything I can so the patient can lose, we're missing the point, the point of weight loss is to improve their metabolic health, right. And what happens to many patients and majority of patients with obesity or overweight is that they have higher percentage body fat and lower muscle mass. Right? So if they're just losing weight, they're losing fat. They're losing muscle, they're losing fat, they're losing muscle. So yeah, maybe they lost 30 pounds, but they're still have more higher visceral fat percentage body fat and low muscle mass. They're still not metabolically healthy. We didn't do the right just
Sarah Milken 35:53
like being skinny, fat person.
Dr. Rocio Salas-Whalen 35:54
Exactly.
Sarah Milken 35:56
So for longer, we're better
Dr. Rocio Salas-Whalen 35:58
yeah, really, weight loss should be also taking care of muscle mass. And primary care may not have the capacity or the experience, and this time, and the time and the tools, right to have like an impairment, like a body a body composition analyzer that is gonna be looking at that, right. So again, we're missing the point if we're just looking at the scale. So unfortunately, if doctors are not obesity board certified, and yes, even as an endocrinologist, I didn't have as much expertise, I had to get board certified in obesity medicine, to really get a concept and a grasp of what's obesity and weight loss, not even as an endocrinologist as a general endocrinologist. So let alone a primary care or family physician are going to have the time to really dive in into what is obesity and weight loss. Right. So yes, I'm happy that more physicians are being inclined to prescribe it. But we should do it the right way. There's accountability, we should be responsible, and when we offering this drugs, right, and we don't, we don't necessarily need to have a body composition, but have a discussion about muscle, I asked patients to start my resistance training, because if they start resistance training, when they start this drugs, at least you know that they're not going to be losing muscle, that they're gonna be preserving muscle and the weight loss and not to go guided by big numbers in the skill of weight loss, because they will always and I've seen it and I have the numbers will equal to muscle mass loss, right. So I would say for primary care family care physicians that are prescribing these medications, great, but do it the right way, talk about resistance training, took about a muscle for service, talk about protein in their diet. With it, that's another reason that they're gonna lose muscle, and then continue with the medications and explain to the patients, we this is not a sprint, this is a marathon. Two pounds per week of weight loss is more than enough for five pounds a week of weight loss per week. There's muscle loss.
Sarah Milken 38:02
Now, obviously we read so much in midlife women about muscle, tell us in your expertise, why it's not optional, like a lot of us are walking outside walking on the treadmill and those are all amazing things, but tell us why muscle and resistance training is not
Dr. Rocio Salas-Whalen 38:21
optional. So there are a lot of studies showing lunge activity is directly proportional to muscle mass, right? Muscle mass decreases all cause mortality decreases ICU or severe disease. So it increases your your longevity in quality of life. And that's resistance training. It prevents injuring falls, increases your bone mass. Right. So it is as going in midlife gaining muscle and doing resistance training. That's the key exercise. There's even studies done which by Some neurologists, that shows that there's lower dementia, when there's higher muscle mass in the lower extremities because legs are the hardest
Sarah Milken 39:10
to do. It's so funny. I saw I actually saw that.
Dr. Rocio Salas-Whalen 39:14
Yeah. And I agree you know, when you do resistance training, once you're building muscle, but it takes it takes a lot of senses. You're doing a lot of things when you're doing resistance.
Sarah Milken 39:24
Finding when I work out with my husband's trainer, I call it mental fucking gymnastics. Stand over here, hold one leg movement.
Dr. Rocio Salas-Whalen 39:33
Exactly. And you're you're using your brain different ways, like protecting my back, I'm not gonna get injured lifting the weight. I'm like doing the proper movement, and you're feeling the concentration with feeling the contraction of the muscle, like the space reality is stability. Exactly. You're 100% focused on that. I mean, so I can see why it decreases dimensions because your brain is going 100 miles per hour to achieve a rep or a set. All right. So and especially legs, the squats, lunges, those are very complicated exercises. So I can see why the dementia is lower in people that have higher muscle mass in the lower extremities.
Sarah Milken 40:11
Now what about how much because like my version of doing Pilates twice a week and weights twice a week, compared to another woman who's like really going at it, like I call myself like the exercise light person, I do the sort of bare minimum to get by. But you know, I have friends who are doing heavy, heavy lifting. How do you know if you're doing enough? Do you have to do the bone density DEXA scan and look at the muscle mass? Do we have to do tasks? Like how do we know what we're doing is even enough because we could all just be going through the motions of Pilates and not really getting
Dr. Rocio Salas-Whalen 40:52
much. Okay. So the basis of muscle growth is muscle breaking, or rupture, right? Muscle actually has to break. And then when it gets back together, it becomes high petrified or becomes bigger, right? So to have some muscle breakage, you have to reach muscle failure. Right? So really, if you're lifting 15, if you're doing 15 reps, 20 reps, you're not reaching muscle failure, right? It's basically how much can you lift that you can do six or eight reps. And that's, that's going to reach muscle failure. And that's going to promote muscle growth. So that's one and then protein in your diet, right? You will never have muscle growth if there's not enough protein in your diet. So those two things, if we're talking about muscle growth, definitely a body composition always helps to see where many times as I was called the machine of the truth, because many times people think, Oh, I'm stronger in my legs, I'm stronger in my upper body. And it's completely the opposite. So you can really refocus where you need to train more and concentrate or more a little bit more heavy lifting. But in regards to how much I know, and even if it's, it's not how long is how smart, you're in the gym, right?
Sarah Milken 42:14
It's just so much so much easier to just do a treadmill or whatever. And I think that's why a lot of midlife women avoid weights because it requires more intention and intentionality. And what's the plan going to be? And what's the workout going to be? And how do I get myself to failure? And okay, I've been doing the same workout now for a month, what's my next move. And I think that that piece is hard. And I feel like, you know how we monitor a lot of people monitor their sleep with an aura ring. I almost wish there was a way to monitor this. So you actually knew what was going on.
Dr. Rocio Salas-Whalen 42:48
I look with two days a week, 45 minutes of resistance training is more than enough. I feel like many patients that what they expressed to me is that cardio, it's it helps more for mental health, right? That's right. But I think doing weights twice a week, and then doing cardio for your mental health, you have to find a sport or exercise that you'd like to write if it doesn't, but I really I would challenge women to stick with it for a month, or even three months. And I would almost assure them that they're going to fall in love with it. Because once you start feeling your body strong, there's no turning back. There's no turning back, you're gonna like how you feel you're gonna have like, a how you look? Right? You're gonna feel stronger. I really I doubt that once you stick with it for a few months, you don't want to keep going
Sarah Milken 43:47
it has to be weight bearing. I don't know if Pilates is exactly the same thing.
Dr. Rocio Salas-Whalen 43:53
Yeah, if you use it, you're using your body as weight bearing. So I would say you're not gonna have muscle growth with that, unless you use it. This is like the performer machine. And I mean, Pilates is great because it incorporates a lot of flexibility, core stability, strength. So I think overall is a great exercise. But really to build muscle you're going to need to do all school or not such an agar tumble.
Sarah Milken 44:21
Now, why which test in your office is the sort of gold standard to figure out where you are in muscle mass?
Dr. Rocio Salas-Whalen 44:33
The body composition, the gold standard is an MRI, but we're not going to send people for MRI the second the second is a DEXA scan. And then the third is a body composition and impedance machine, which there are many out there right? So
Sarah Milken 44:48
if you go and get a bone density test, they can tell you in addition to your bone density, what the muscle mass is,
Dr. Rocio Salas-Whalen 44:57
yeah, but specifically they have to ask for that right on I was just looking at your phone.
Sarah Milken 45:01
Well, it's funny that you say that because I went for a bone density test. I don't know, a couple years ago after I had this bike accident, because I was just curious. But then after researching for this podcast and listening to everything that you were saying, you were like, Yeah, but there's there is a calculation in there. So my mom just had a bone density test. And I was like, call them back and what your muscle is, and she says, Now, she's like bugging him to get that information. But why aren't they giving it to us?
Dr. Rocio Salas-Whalen 45:33
You know, insurance? I mean, it's just the problem with insurances that they view. And this is this gonna take a while for it to change, but they view weight loss medications, as lifestyle drugs, so they're still they're still not classifying or seeing obesity as a disease. Right? There's, I mean, there's still a lot of stigma in healthcare as a number one stigma and obesity, unfortunately. So those those things have to that has to change before it can start being incorporated more widely. And we're looking at different numbers besides just the BMI in the number and scale, right.
Sarah Milken 46:14
So in your office, when you're looking at metabolic markers, in the blood work of a patient, what are the main things? What are the main things that you're looking for? So let's just say a, let's say, the average person is going to their internist? What could they say? Like, Hey, will you tell me what my insulin resistance is? Or my a one C, like, what are the markers that we should really be looking at and focusing on right now at this time in life?
Dr. Rocio Salas-Whalen 46:43
Really, and I would say that that is the best marker that we have, that's, I would say almost our gold standard, otherwise miss measuring insulin levels in your blood, it's not as straightforward just to seeing a number there's many things that have to play part of it. And it doesn't really gives us an accurate, long longitudinal view of what's happening right. The a one C is a three month average of your blood glucose. And I think that's that's the that's the our best indicator right now for
Sarah Milken 47:15
you go in for bloodwork you get the do is a one c part of your annual exam. If you just go to a regular internist,
Dr. Rocio Salas-Whalen 47:22
it should and most likely isn't everywhere. Yeah. Okay.
Sarah Milken 47:27
Now, what range should that a one c be?
Dr. Rocio Salas-Whalen 47:30
So above, below 5.7. So 5.6 or below is what we consider normal. Okay. 5.7 to 6.4 is prediabetes. And then we know there's insulin resistant. Yeah, you haven't developed diabetes, right. But you're insulin resistant and hyperinsulinemic to the point that you are having some fluctuations, or hyperglycemia here and there that is giving us an average, which is elevated in the A one C and A one C of 6.5. And above. It's type two diabetes. Wow. So the damage was done, right? And those numbers keep going down before it was seven was diabetes. 6.5 was pre diabetes. But now we're trying to catch it earlier. And now 5.7 is pre diabetes, right? So we're getting more people, it's capturing more people than with higher agencies.
Sarah Milken 48:24
Got it. So the a one seed just for everyone listening is a one time test. You go in fasting, it's part of your blood work. It shows three months of your sugar levels, but you're not testing it for three months. It's just it can go back three months. Does that make sense?
Dr. Rocio Salas-Whalen 48:42
What happens is glucose attaches to the red blood cell and the red blood cell lives for 90 days. So that's why that's why we know what your sugar has been in the last 90 days because we're looking at your your red blood cells.
Sarah Milken 48:56
Just stop eating cupcakes the week before. It's gonna show the truth.
Dr. Rocio Salas-Whalen 49:03
Yes, exactly. I have patients tell me Oh, last night I need a cake. I said that's a matter this is pretty much your fasting glucose? Yes, they will show where you are or whatever. But now you're wondering,
Sarah Milken 49:16
oh my gosh. So if somebody if a woman goes in in her a onesie is 5.6 for example, which is like what you said is like the the one notch where it becomes pre diabetic. Does that qualify you for these drugs? No. What are the so what are all the other components that you're looking at in this like you're looking at mental health, childhood, you know, weight story? What are what are we looking at?
Dr. Rocio Salas-Whalen 49:44
So it would go by insurance guidelines for diabetes drugs to be approved. You have to be a diabetic so your agency has to be above or equal to 6.5. If we're talking about the weight loss version, let's say ozempic, you need to have six 6.5 A one C or above to get it approved by insurance. If we use talking about the Gobi, which is the same, same drug, but branded for weight loss, your BMI we use your BMI, your BMI has to be equal or greater to 27. And one comorbidity it could be pre diabetes, high blood pressure stroke, right? Is hypercholesterolemia or equal or above 30. With no comorbidities, right. But again, we're missing so many patients by going by the BMI. I've seen so many normal BMI with high visceral fat and low muscle mass, those patients require the medication, right. So I think why we have to look into the future is using other diagnostic tools besides the BMI. So in my case, that I mean, I don't take insurance. I look at other markers, right, I look at the percentage body fat, I look at the visceral fat, I look at the muscle mass, I do look at their agency, we're talking about diabetes, right. And we always can always explain to the patient this is going to be off label for FDA, right? In regards to weight loss if we're using one diabetes drug for weight loss,
Sarah Milken 51:14
right. So there are ways of getting around it if your body really needs it, and your healthcare provider thinks that you're a candidate for it.
Dr. Rocio Salas-Whalen 51:22
And if you think about it, I mean, we're preventing i This is a prediction and nice. And you
Sarah Milken 51:27
hear from me, that's funny, you're reading my mind, because I have this weight going
Dr. Rocio Salas-Whalen 51:31
to have less type two diabetes in the future, less, less obesity related cancers. I mean, we've we've built specialties from the obesity complications. Yeah. And we're so comfortable treating all the complications, but we actually now can treat the cause, which is obesity, right? So I think we're missing the point insurances are missing the point that we're actually going to prevent many other chronic diseases by being able to treat obesity, why wouldn't we offer that mental health? Right? I mean, mental health is so important, and it's so affected, and people that are struggling with obesity, right? So I feel like we have to change the way that we're seeing things.
Sarah Milken 52:18
Okay, so wait, remind me the name of the tool that you use to test body fat and muscle
Dr. Rocio Salas-Whalen 52:25
said an impedance machine. And what it does, it's like electrodes that go through your body and it separates. They can, it knows the difference between fat tissue, muscle tissue in water. So that's how it made machines work. And I don't know if I can say names. I'm not sponsored by any of them. But you are. Yeah, so the the most common one is called an embody. And there are different versions of it. They're like the professional that like the ones that I have in my office. But they have like a home version of it. And also multiple gyms have them. So in body embodied and you can go to online embody usa.com And it can give you locations that they have this machine so like local gyms around you may have them interesting.
Sarah Milken 53:16
No, I wanted I want to do that. And I think a lot of listeners will too, because it unless we have that information. We're just like floating in the atmosphere.
Dr. Rocio Salas-Whalen 53:26
Yeah, and I mean, definitely you can have access to any one numbers,
Sarah Milken 53:31
what numbers what's the range? You think that we should be like, Oh, that's an issue or oh, we're okay. Okay. What are we looking at so,
Dr. Rocio Salas-Whalen 53:40
the obesity Medical Association's we have a little bit of stricter guidelines, or a stricter, stricter cut offs numbers than the that like internal medicine, but because we, we want to target early right. So for percentage body fat in women, we want it around equal or below 28%. Ideally, around 23% in men is equal or, or, or less than 20%, or ideally around 15%. That's percentage body fat, visceral fat. In this machine, in particular, it's a scale and there's it goes from one to 20. We want it below 10 In visceral fat, and then muscle mass, you're going to look at, it's gonna give you three numbers or three lines, total body weight, muscle mass and total body fat. What you want to see is muscle mass greater than body fat.
Sarah Milken 54:43
And this is the same for men and women alike. The other thing
Dr. Rocio Salas-Whalen 54:46
that will be the same, that will be the same for men, and the same, the same, okay, the only thing that changes is the percentage body fat. But what you want to see is that the ratio in your total body weight is higher. Muscle them body fat. Got it.
Sarah Milken 55:04
And so when Doctor, so if I were to do this, and then I go to my doctor and I say bla bla bla bla bla, that just gives me more information for that person to work with. If yes, if they don't have that machine,
Dr. Rocio Salas-Whalen 55:18
I always, I am so happy you brought this up, because I always tell my patients, you have to be an advocate for yourself, right? And how you're going to be an advocate by by learning by knowledge, right? The patients that know more, do better. Oh,
Sarah Milken 55:35
my doctors crazy.
Dr. Rocio Salas-Whalen 55:37
And that way, you can advocate for yourself, right? I think many times we don't patients don't do that. And I mean, if you have the information, if you have the knowledge that that empowers you to be an advocate to yourself and find a doctor, that's actually gonna listen to you, there's some of us that we do listen, and we see beyond the box, right. But for that, you have to have the tools that you have to have the knowledge, right.
Sarah Milken 56:03
Yeah, no, and I think that that's part of the the journey in the midlife situation, too, is that we can't just accept everything that's given to us. It's like, our body's changing, our minds are changing, everything's changing. But we do have some control. And no doctor is a magician. No, and you don't get answers you want find someone else
Dr. Rocio Salas-Whalen 56:23
excited, you know, I mean, you know your body better than anybody, right? Better than, than any doctor. And it's so amazing. Like, whenever I have this interview with my patients for the first time, and we talk about their history of their weight, their heaviest weight, their, their better weight, where and where, what number or what weight, they felt the best in their skin, it always matches what the body composition recommends a weight loss. That's just to tell it based on a recommendation, your visceral fat, your percentage body fat and your muscle mass, right, it takes those two things into account. So it's so amazing that how patients know their body so well, that what the calculation recommends, it almost matches where they felt the best. Right? And that's just to tell you that how much one knows each other when they feel good?
Sarah Milken 57:17
No, I think it's such important information, especially in menopause, because it's kind of like hit or miss what works for one person may not work for another person, and it just goes on and on. So we have to be able to find doctors, which is not always easy, who are willing to be in the journey with us and not just go try this no, that didn't work by it's like it's a whole work in progress, like the body is a very complicated thing. And what works for her doesn't work for me
Dr. Rocio Salas-Whalen 57:47
is you know, just to show you I have two pair of identical twins, oh my gosh, patients, and each of them respond different. Each of them responds differently to the medication. I mean, it's just like, every patient is an individual, right? Every patient is different. And I tell patients, I have a lot of clusters of families of patients and treatment I said though, I try to always educate them not to compare themselves to either side effects or results to their mom, their daughter, their brother, because it's going to be it can be completely
Sarah Milken 58:20
different. That's amazing. Okay, so by going back to the drugs for the second for a second, let's talk about the potential side effects. So basically, there there can be side effects, what are the ones that you see the most.
Dr. Rocio Salas-Whalen 58:37
So with our older versions, which is a setback, and we go be an extender and Victoza there was a lot of nausea, for the majority of people will experience nausea at the beginning and it's a it's a self limited Nausea is not You're not all day, every day 24/7 Now she ate it. And it's usually at the initial doses while your body gets used to it. The one problem that I see for physicians that are prescribing this drug that don't have expertise on them is that they're moving too quickly on the doses. So the best or the best recommendation I can I can give is only move a patient up when they're symptom free, when they're not shuffling. Because it's not gonna go away, it's gonna get worse with higher doses and then we're gonna blow up our chances the patient's gonna one know nothing about the medication or them will start giving bad rep to the drug. It was not the drug, it was just the way that it was given. Right. So Nausea is the most common. Dehydration is the biggest one. Dehydration is what gets patient in a difficult spot. And you have and we can, we can see why it takes away your hunger. Right? So you're not thinking of food. You're eating less meaning you're drinking less. Your your thirst effect is suppressed too because it goes along with hunger. So you're not eating you're not drinking. And that can lead to dehydration and the symptoms of dehydration is going to be they feel extreme fatigue. It can be lightheadedness, dizziness and even loss of conscious from from the dehydration because it drops your blood pressure, right. So many times patients think there's a low sugar that they feel like they see lightheaded or tired from that they haven't eaten enough where there's a low glucose. Those medications don't cause hypoglycemia period. They don't cause hyperglycemia because their effect in glucose is glucose dependent, you have to have a high sugar to work as a diabetes drug. If your sugar is normal. There's nothing in your pancreas so it's not going to drop your sugar. So it's dehydration, what is the most complicated side effect for patients to tolerate? But the easiest to prevent right? And goes again, when having this proper conversation when you're starting up patient on this drug is to make an emphasis on water intake. Too much water, two to three liters of water per day, and electrolytes, right to retain some of the value.
Sarah Milken 1:00:58
Okay, and what electrolytes Do you like? Is there a brand that you like? I have many I have a million
Dr. Rocio Salas-Whalen 1:01:05
given that I have small kids I always say Pedialyte. Right.
Sarah Milken 1:01:10
But there's, there's Ultima. There's an element.
Dr. Rocio Salas-Whalen 1:01:13
I mean, there's a lot there's new yeah, there's a new talent have the talent. I always say the ones with the less sugar, right? That will be even eating some sell teams, or some pretzels, some salty stuff that can help you also with that, right, right. But I mean, there's electrolytes in every pharmacy store in the checkout area, there's electrolytes there. So whichever you find that you can tolerate the taste and keep up that those should be fine. The other side effects that I see, again, with the older versions, which was simply the one with all the reflux, symptoms of reflux. Vomiting is not a normal side effect, but it can happen if the patient's over eat their fullness. So, so there's medications delay, gastric emptying, right? They have an effect on the sphincter between the stomach and the small part. So your fuller for longer. So if you keep packing it up, not gonna go down, right when I come up, right. So I tell always, literally listen to your gut. If you feel full, you stop that right. Now, we go to other complications. pancreatitis is one of the most more serious, right and really, since I've been using this drug since 2005, I've only had two pieces of pancreatitis. And there were in diabetic patient patients with diabetes. And that makes sense, because if you don't have diabetes, it doesn't touch your pancreas. So I've never seen pancreatitis, and then non diabetic. Got it. But again, is very rare. And
Sarah Milken 1:02:57
I also saw you had you talk about vitamin D deficiency, protein deficiency and zinc, right?
Dr. Rocio Salas-Whalen 1:03:04
So I mean, Vitamin D deficiency. Most people are vitamin D deficient and vitamin D is absorbed per square meter in your body. So, higher body composition, so people that have obesity or overweight, they need even higher doses of vitamin D. So that's why we see a lot of vitamin D deficiency BCD. But they don't go anything with it has nothing to do with the ingredients or the drugs. It was just more of a matter of the obesity. Then in in lab and nice there was found that can have higher incidence of medullary thyroid carcinoma, which is a very rare aggressive type of cancer. But it hasn't been reported human cases of medullary thyroid carcinoma. So it's just more like a recent way to do a good family history. So anybody who has family history of medullary thyroid carcinoma is not recommended. Basic
Sarah Milken 1:04:06
got it? That's a very long word. What about what about a hair loss? I know that I was at a meeting in New York and an endocrinologist was talking about these types, the incretin drugs and she said a lot of people, a lot of patients don't understand that you still need to eat and have the nutrients because you're you're eating last and then three to six months later, your hair's falling out. Because yeah,
Dr. Rocio Salas-Whalen 1:04:33
that yeah, it's not a direct effect from the drug is not okay, drug itself doesn't cause hair loss. It's the rapid weight loss and that's another reason why I don't recommend rapid weight loss, rapid weight loss, you're gonna have hair loss because it means that you are not having enough rapid weight loss tells me something muscle loss, and fat loss. And it tells me that you're not eating enough protein because you're losing mass, muscle mass and that's why we're seeing so to rapid weight loss. So just to think that you're having rapid weight loss, and it's just only fat, it doesn't exist, I've never seen it. If you're having rapid weight loss, losing muscle, and you're losing muscle because there's no protein in your diet, and if there's not protein in your diet, your hair is you're gonna lose hair. But
Sarah Milken 1:05:16
if you're not hungry, how do you eat so much protein?
Dr. Rocio Salas-Whalen 1:05:20
So make the food that you eat, count, make sure that whenever and whatever you do eat counts, and it nourishes you, it should be higher protein, healthy fats, carbs in the bottom, that's my three my three year that tear that I have for my patients, right? producten is key in the diet when losing weight.
Sarah Milken 1:05:44
Now, would you say that protein, animal proteins are different than all these powders and everything. I know you're making a face, you don't want to say anything. I just I feel like all these powders in my mind just can't be the same and they make my stomach feel weird.
Dr. Rocio Salas-Whalen 1:06:02
Now in regards to protein, okay, so protein, I feel like in this case, because you're in a very restricted caloric intake, they do have a role they do play a role, right to supplement the protein that you can consume in real foods. Right. So I do I do recommend to my patients protein shakes. I just recommend like a high quality clean protein, right.
Sarah Milken 1:06:25
Especially favorite one.
Dr. Rocio Salas-Whalen 1:06:29
Yeah, it's called Vital sown and I usually get it at Whole Foods.
Sarah Milken 1:06:34
Okay. Is it may what kind of protein
Dr. Rocio Salas-Whalen 1:06:38
Wait, wait, okay. Yeah, whey protein. I know there's a lot of plant base. Groups and followers I I just feel like the protein that we get in plant basis high starchy from lentils, beans, soy, that have other things that that's a different conversation, right. But if whey protein I do recommend and then in diet, right, I mean, bison, I love bison meat, I recommend bison meat is very lean and high in protein. I mean, chicken fish, right. So I do prefer animal protein. But if there's, if they cannot consume enough, then definitely protein shakes can help.
Sarah Milken 1:07:24
Okay, well, I know you're on a time crunch. And there's a few more questions that I absolutely want to ask you. So a lot of you know, a lot of people have this question, which makes sense. Okay, so I go on this drug, I get my metabolic health and check. I, you know, if I, let's say I wasn't 100% in it to lose weight, but get my metabolic health in check. Maybe I lost a few pounds. And then there are some people who need to lose a lot of weight. When I stopped taking this drug, what's happening to the weight?
Dr. Rocio Salas-Whalen 1:07:58
So I mean, I know
Sarah Milken 1:08:00
this is your favorite question.
Dr. Rocio Salas-Whalen 1:08:04
You know what I like it, because it's part of the conversation. And we have to have a conversation, right? Different ways to see it. These trucks are designed for long term use, right? Remember, they were designed for type two diabetes, which is a chronic disease, we we don't cure diabetes, we control it. So let's think of the analogy of diabetes and glucose, right? We get your sugar is high, we give you this drug, your sugar comes down, we stop the drug, what's going to happen to your sugar? It's going to go back up back up. Right. So that's why we don't stop this drugs and diabetes. And I've and we can think about high blood pressure, we can talk about high cholesterol, what's gonna happen when we stop the statin, your cholesterol is gonna go up, go back up, right? Because it's not lifestyle. If we stop it, and we assume that lifestyle is gonna maintain a low sugar or low cholesterol, we're missing the point is not caused by lifestyle, right? I mean, you can argue that type two diabetes can be caused by lifestyle, right, but we don't say we improve your sugar. Now. It's on to you to keep your sugar low. Yeah,
Sarah Milken 1:09:08
I mean, I have a personal example. I mean, I have genetically really high cholesterol. And it's just it's in my family. I've done all these crazy lab tests, I could tell you down to the molecule, every single thing that's in my cholesterol, and I take a statin and now I might actually and I've taken a statin for years, but now my cholesterol as I get older isn't in check 100% anymore, so I might have to be adding Repatha or one of those injections to my monthly drugs. And it's not because I want to but it's because I want to keep it in check. But if I stopped taking the cholesterol drugs, I would have high cholesterol. So what you're saying makes complete sense. It's like you're in this for the long term or you're not this is not a quick thing of like Oh, my wedding is in two months, let me lose 10 pounds.
Dr. Rocio Salas-Whalen 1:10:03
And I think when when, when the Convert when the switch, the switch gets turned on or when the conversation when you explain to the patient, what's going to differentiate what we're doing medically, to all those crazy fad diets is the we can help you maintain the weight loss, right? That should be so liberating. Because that's the, that's the second question that I get from my patients, what's going to happen when I stop it. And Mike, when I regain the weight, we're actually they have they're scared because they've done diets through their life for decades, they've gotten to their goal, and then they bounce back up. So it's a valid concern, am I gonna regain the weight when when I stopped the drugs, we don't have to stop the drugs. You don't have to take it on your own. It's not on your own to maintain or to keep the weight loss, right. And we have to go all the way back to what obesity and weight gain is, is a multifactorial, we're talking genetics, hormonal agent, we're not fixing those things, aging, we cannot reverse, you're gonna continue to age, you're gonna go to perimenopause, you're gonna go to menopause. So those things we're not changing, there's gonna, there's still gonna be there was stuff that dropped. So all of those things are going to promote the weight gain again.
Sarah Milken 1:11:16
Now, what about if you, let's say, or you're in your 30s, and you want to get pregnant.
Dr. Rocio Salas-Whalen 1:11:24
So for patients that are in that stage, we stop it just prior to there's no washout period, right. And I am very important to my patients, I always tell them, I ideally, you have to be in your ideal healthy weight, before you try to get pregnant. One is going to improve your chances of fertility. That's that's already one thing, right. But second, there's so many studies showing that the mother's BMI, we're talking about BMI, because whether the mother's BMI in the first trimester impacts the weight of your offspring. So now, and also by entering pregnancy in a normal way, you're decreasing your chances of any complications of delivery, gestational diabetes. So it's not only that you're improving your chances to having a healthy pregnancy for yourself. But you're also improving your chances of your offspring not struggling with weight in the future. So it's always important to start in an ideal weight prior to conception. So for my patients, we want to do that we stop the medication, then there's the next cycle, they can start trying to get pregnant. Unfortunately, with this drugs are not approved for pregnancy. But there's some a little bit light in the tunnel. There's some studies done being done now that they're looking into using incretins for gestational diabetes. Oh, that's
Sarah Milken 1:12:42
interesting. I had to take Metformin at the end.
Dr. Rocio Salas-Whalen 1:12:45
So I think what's going to come really into is a fine tuning of this drugs in pregnancy, because we don't want to restrict colori restricts a really a woman that's during pregnancy because we want federal growth to be normal. Right. Right. So in regards to glucose control, and federal growth, I think it's gonna it's going to be a fine tune tuning then, but it's a little bit hopeful to see that could potentially be used in pregnancy, meaning that they can be safe in pregnancy, right. So many patients are concerned that they're going to regain a lot of the weight during pregnancy, but hopefully in the future, we can use them in pregnancy. Once they
Sarah Milken 1:13:24
deliver a net on what if you get pregnant and you're on it, and you don't know you're pregnant for three months?
Dr. Rocio Salas-Whalen 1:13:30
Well, we stopped them. We stopped them. And so far, we haven't had I mean, there's no data that but clinically, I've had patients that gotten pregnant. And so far, no complications. Right, right. Right. And I recommend that we use in pregnancy, but we know that it doesn't cause congenital malformations like
Sarah Milken 1:13:51
it's not like taking it's not like taking Accutane and I sadly don't
Dr. Rocio Salas-Whalen 1:13:55
have a general malformations that we have to wait for the patient to be off.
Sarah Milken 1:13:59
But you can also I mean, I guess there's other things like you could go maybe from these drugs to Metformin because you can take Metformin while you're pregnant.
Dr. Rocio Salas-Whalen 1:14:07
Exactly. Right. For me, it's a good bridge in between. Right.
Sarah Milken 1:14:11
And going back to the obesity, comment or conversation. I read from your information, you said that 72 million people in the US have obesity, 42 million have diabetes, and 10% of the 42 million have type one diabetes, and they can't take this drug anyway. So all of these newspaper articles that are coming out saying that people with hormonal issues who are taking this drug are taking it away from diabetics.
Dr. Rocio Salas-Whalen 1:14:41
Yeah, no, I mean, just just a percentage of the population with obesity. One of every two in 2030 will have obesity. So 50% of the population will have obesity, versus one out of every 10
Sarah Milken 1:14:55
This is just the United States, just the United States.
Dr. Rocio Salas-Whalen 1:14:58
Ah Yeah, states. But worldwide also there's more population with obesity than with type two diabetes, right? So it's really who needs this drug the most. And we're preventing type two diabetes by treating obesity. So those numbers will decrease, right. And another thing that we have to look at it as we have more than nine classes of family of drugs for diabetes, versus two classes, or three classes for obesity, right. So we have other options. And I'm not saying as I've always said, it's not mincing diabetics don't deserve this drug. And we should, but I'm saying they also need it people with obesity and weight loss, right? They need it also.
Sarah Milken 1:15:39
I think a lot of this comes from like, you see the articles with Kim Kardashian and Elon Musk? And did they take these and blah, blah, blah. And I think that these drugs are getting that sort of negative spin as like a fad diet rather than like, Hey, this is a medication that can really help our metabolic health.
Dr. Rocio Salas-Whalen 1:15:59
Yeah. And you're not let celebrity so I always say, I, I have close to 2000 patients, and I can still if somebody walks in my office, I cannot tell you who needs or who doesn't. Right? I don't know, their visceral fat. I don't know their percentage body fat. I don't know their struggles. I don't know what they're doing to maintain that weight. Right. So even celebrities can be struggling with their weight.
Sarah Milken 1:16:21
Yeah, no, that's a great point. Because I think that a lot of us do look at weight from an aesthetic perspective. Exactly. And it goes back to that like skinny fat thing. I mean, I remember, I don't know, a million years ago, I think I did a BMI or something. And they told me my percentage body fat, and I was like, What the fuck? Like, are you joking? I was like, wait, I'm like a size four. And they're like, but that's not what we're talking about. But I don't think we're talking about this enough. And we're talking about so much about scales and numbers. But we're talking about the wrong numbers.
Dr. Rocio Salas-Whalen 1:16:54
Exactly. Exactly. When we're talking with concentrated on the external on the on the cosmetic part of it right. And, and we're missing the point, right, we're missing the point.
Sarah Milken 1:17:04
Now, for your patients who start these drugs for either diabetes or weight loss and metabolic health. How often do you have to check in and do bloodwork to test with like, how much they've moved? Or what the improvement is? Like? What's the ongoing journey of this whole thing.
Dr. Rocio Salas-Whalen 1:17:24
So in the weight loss, I like to break it into two phases, the journey, weight loss, weight loss phase, and weight loss, maintaining space, right? So in the weight loss phase, we're concentrating on fat loss preserving muscle, so I see them every eight, eight weeks, it's a good it's a good time to make changes in the dose, or not, and assess what's happening and refocus if we need to, and then in the Maintain is once we reach the goal, then I start spreading it out a little bit more. So every three months to eventually every six months. Right? So patients, this is a new type two diabetes, because these are chronic patients, right? These are patients lifelong patients.
Sarah Milken 1:18:06
So when they're coming in, are they getting bloodwork done? And also the InBody tests? Like what are the the aim buddy
Dr. Rocio Salas-Whalen 1:18:13
isn't every visit and blood test unless I'm following certain number that I'm waiting to change from the baseline, but I get a baseline. But let's say somebody who's on thyroid hormone, when there's weight loss, the dose has to be adjusted gradually or eventually. So I will check their thyroid level, often as live weight loss is happening. But otherwise, I don't just check laughs every visit just for checking unless I'm following a certain value that I expect to change with the weight loss.
Sarah Milken 1:18:44
Got it? Now, do you have any patients who, let's say don't necessarily have to lose a ton of weight, but they're using it for the metabolic stuff? And they're just staying at the load the lowest dose for months? Like
Dr. Rocio Salas-Whalen 1:18:58
yes. And I have patients that I can even move them to every other week injection for photos.
Sarah Milken 1:19:06
And how does that mess with their minds? It's like, oh, the brownie tastes so good. Oh, no, the brownies not so great.
Dr. Rocio Salas-Whalen 1:19:14
To that point that we can go to every other week. Uh huh. Their brain wire is completely change. And no patient ever wants to go back to where they started. So there, you know, it's very, it's very interesting. I can we see it's very complex. The motivation happens after the weightless totally. The motivation happens after the weight loss or during the weight loss, right. So there's not better motivation that once they reach their goal, and they know how they feel there to keep them going.
Sarah Milken 1:19:46
So what's the what what's the reason for doing it every other week then?
Dr. Rocio Salas-Whalen 1:19:51
Because we're just looking for maintaining normal weight loss and if they reach a goal at the lowest dose, then every other weeks keeps that like at the end of For the month of like a balance that is maintaining the weight, so it
Sarah Milken 1:20:03
doesn't make you feel weird sight Exactly. Got it.
Dr. Rocio Salas-Whalen 1:20:07
And again, it's really interesting how our body is because this is not the type of drug that if you could just use keep using it, you just gonna waste the weight into thin air. Just like your body reaches a point, where is your normal body weight, and it just goes in maintenance mode.
Unknown Speaker 1:20:25
Got it? Wow.
Dr. Rocio Salas-Whalen 1:20:27
I mean, it's really beautiful to see like the progress and like things that you didn't expect with weight loss that you can see how our body is so intuitive and so amazing. And it does what is best for you if it's guided properly.
Sarah Milken 1:20:41
I think what I also think is amazing is like there's so many people screaming from the rooftops of like, oh my god, stealing these drugs from diabetics, oh my god, quick weight loss, the ozempic Hell, you're going to be nauseous and throwing up for just so you can be skinny. But then there's like the flip side of it of people who are having amazing health and metabolic reside, chain life changing
Dr. Rocio Salas-Whalen 1:21:07
lives. I've had grown men cry in my office, for the first time they feel in control, that for the first time, they don't have to worry about what they're putting in their mouth. This meet people struggle for decades. Since childhood. This is a low lifelong struggle battle. And I say what's the easy way out? They have to come and see me every eight weeks, they have to inject themselves once a week. I mean, it's not an easy way out. It's work. They have to put a lot of effort on this to work.
Sarah Milken 1:21:38
My last thing as we wrap up, you're being a midlife woman, you're being triple board certified, and all of these things and having a clinical practice with 2000 people. What's your bottom line advice for female midlife women for moving forward in health?
Dr. Rocio Salas-Whalen 1:21:56
You know, it's up. First we can we can go into feminism, but with First we can now let society tell us what role are we playing in what stage of our life right? Also to embrace the change at our better our best health state that we can and knowing that we have the tools to do that. I think it can make the transition so much easier, right? I mean, I'm 47. But I feel no different than when I was in my 20s. And physically, right, I mean, I do feel resistance training, healthy diet, hormone replacement therapy is going to improve our quality of life. Yes, we all have to go through menopause but we don't have to suck up, or just it doesn't have to. We don't have to suck it up this this this symptoms, right? We don't have to just lay over and take it right. There's things that we can do. There's look for the physician that is offering you and having this discussion with you. And not just saying well, this is part of your life. Now. This is what it is just right. I mean, no, there, there are physicians that we concentrate on a woman's health. And that we want to provide the best tools that we can for that next stage of your life to be easy, right and enjoyable. Because for me it's not the number of years is the quality of of those years. Sure, right. For sure. Quality of life. It's what matters.
Sarah Milken 1:23:34
No one wants to be sitting and not being able to move. I mean that it's just no way. And that that's part of the beauty of this podcast is I'm like, Okay, I'm going to try to dig up all this information from people like you, because I feel like women deserve I mean everyone deserves but women deserve the best information. And it's not easily accessible all the time, because there's so much bad information out there. Yeah.
Dr. Rocio Salas-Whalen 1:24:01
And that's one thing. That's one thing that I think positive for social media is that you get access to, to me, maybe not as my patient, right, and I'm posting.
Sarah Milken 1:24:15
You have an amazing Instagram, your Instagram is like an encyclopedia of metabolic health. I think I watched the whole thing.
Dr. Rocio Salas-Whalen 1:24:26
But there's other wonderful accounts there. Dr. Lisa Moscone. Yeah, the neuroscience. She's, she's she's investigating woman's health and not an estrogen in the men's I mean, there's great accounts there that we can follow and, and learn from them right and just just get the tools that you need when you go to the provider and say, Well, I think this could be helpful to it's teamwork between patients and doctors is teamwork. If it's just our side, then you know, you have to be part of it, too.
Sarah Milken 1:24:56
Dr. Rocio Whelan, triple board certified physician with fast experience across all areas of Endocrinology metabolism obesity, diabetes, thank you for saying yes. Thank you for chatting midlife metabolic health on your vacation. Thank you for being a guest on the flexible neurotic podcast. It was a pleasure having you. Thank you. And wait before we end where can we all find you?
Dr. Rocio Salas-Whalen 1:25:23
Oh, well Instagram handle is New York, endocrinology, the whole work word. And then I'm also on tic tac, same New York endocrinology and then my website is ny endocrinology.com. How do you have time for all of that? You know, I make it is my Oh,
Sarah Milken 1:25:43
and you have two kids. It's amazing. Wow, congratulations.
Dr. Rocio Salas-Whalen 1:25:47
Thank you is my you know is my creative outlet. Yeah, no, I
Sarah Milken 1:25:50
got it. Like I started this two years ago with my Instagram and my podcasts and unlike people are like, isn't it so hard? And like yeah, it is hard, but there's also like a creative expression to it that makes you can watch more
Dr. Rocio Salas-Whalen 1:26:02
people right? I can reach far more people than the people that walk in my office.
Sarah Milken 1:26:07
Right? Totally. Well, thank you so much for being here. So welcome. Hey, peeps, it's me again. I listen to this episode with Dr. Rocio Salas Whelan, triple board certified physician with vast experience across all areas of Endocrinology with an emphasis on obesity, diabetes, metabolism, thyroid disorders, and osteoporosis. So I could summarize the golden nuggets for you to have actionable items to start using today. I know that when I listen to a long episode, I'm like, oh my god, I love that. But then I can't even fucking remember the specifics. This is why come back and do a golden nugget summary. In this episode, we discuss metabolic and obesity issues and the drugs that are getting a lot of media coverage right now, for weight loss and diabetes. Golden Nugget number one, what is visceral fat? visceral fat is not the fat that we can see on the outside of our bodies. It is known as intra abdominal fat, meaning that it attaches to your internal organs, including your pancreas, gut and liver. Rocio refers to this as quote, bad fat. Understanding visceral fat is important because when it adheres the liver and internal organs, it can lead to hyperinsulinemia insulin resistance, and other metabolic issues including diabetes or type two diabetes in the future. Golden Nugget number two, speaking of insulin resistance, why is it such a hot topic? Insulin resistance simply put is when there is resistance to the hormone insulin resulting in increasing blood sugar. Rocio tells us why insulin resistance is gaining more attention, especially with midlife women. Because of this drop of estrogen. She explains that the drop of estrogen creates a vicious cycle of promoting visceral fat which promotes insulin resistance. Once the estrogen levels start to drop that body fat redistributes centrally. That's when it causes the higher risk of insulin resistance and then insulin resistance causes weight gain. So the reason insulin resistance I keep saying those words is being talked about with women. Midlife women is because of that drop of estrogen that occurs in the midlife years and the metabolic issues that can come from that golden nugget number three, how Rocio treats the typical midlife woman. Dr. Rocio says that her typical patient that comes in and midlife explains that she's trying to do all the things and she just can't lose the weight exercising, eating healthy, but those things that the patient has been doing since she was in her 30s are no longer working. Sometimes even when the patient has amped up their exercise routine eating less they still aren't seeing the results. Dr. Rocio takes the patient on a very thorough journey and background history she performs a body composition test to see the percentages of body fat versus muscle mass and rows you ask the patient if about perimenopause or menopausal symptoms to stratify and figure out if the patient is at low risk, intermediate risk or high risk in receiving estrogen on the journey with her patients. She works on exercise resistance training, diet and potential medications for weight loss and estrogen replacement therapy or menopause hormone treatment as it's called. Rocio doesn't promote it as quote just weight loss it's a redistribution of fat, Golden Nugget number five. What Rocio says is not quote optional for midlife women. Rocio says The key to exercise in midlife is gaining muscle and resistance training. She explains that studies have shown that longevity and quality of life is directly related to muscle mass resistance training increases bone mass, prevents injuries and falls and can decrease dementia. Rocio also explained that the basis of muscle growth is muscle breakage. So when that all comes together, it becomes bigger the muscle grows, we have to make sure we're doing the proper exercises and lifting the correct amount of weights to reach muscle failure, because that in turn is going to promote muscle growth. So for example, if you're lifting five pound weights, and you can do 30 of them, that is not going to get you anywhere you need to lift heavier weights, or you can't just do a million repetitions and you have to take your muscle to the point where it's fatigued, Golden Nugget number six, why should we test our a one C. The a one C test is a blood test that measures your average blood sugar levels over the past three months. It's not like you go in there and you're like, oh sorry, Doctor, I just ate a cupcake yesterday. It literally tests your blood from 90 days so your one cupcake isn't changing anything. It measures a percentage of your red blood cells that have sugar coated hemoglobin. It's used to diagnose pre diabetes and diabetes and manage current diabetic issues. It's important to check our Awan sea levels because higher levels are linked to diabetes. Rocio explains that our a one C levels can also determine if we're able to take certain weight loss drugs. The gold is dripping off these nuggets, rabbit use it. There are three things you can do. First, subscribe to the podcast. Second, share it with some midlife friends who might like midlife shit. And third, write in Apple review. writing reviews is kinda annoying, and it's an extra step. But guess what? It really helps the podcast grow. You think your little review won't matter? But it does. If you went to a show and everyone said my clap doesn't matter. I don't need to clap. Then there will be no clapping. You all matter. Please write a review. DM me, you know I always respond. I'm the only one on my Instagram. Oh and of course follow the Instagram at the flexible neurotic da love you talk soon