In this episode, Dr. Rena Malik, MD is with Dr. Alexandra Sowa to explore the transformative nature of GLP-1 receptor agonist ...

understanding-glp-1-medications-benefits-amp-risks-ft-dr-alexandra-sowa

Understanding GLP-1 Medications Benefits &amp; Risks ft. Dr. Alexandra Sowa

let's talk about the gp1 medications because they are transformative and I think there's a lot of questions out there about what they are how they work so let's just start there how do they work so glp1 receptor Agonist medications they mimic natural hormones in the body now they are analoges so they are synthetic hormones so they mimic they are not the same as and what makes them so powerful is that they have a very long halflife they last a very long time in the body much longer than the natural native versions in our body so glp1 is the most famous and we see that in OIC and wovi and then the next most famous is Gip receptor Agonist medication we see that in combination with glp1 and that is tepati manaro or Zep bound and how do they work so they work on all over the body actually I think this is something that people don't realize that there are glp1 receptors all over the body the biggest way that makes them the most effective is not actually the stomach which everyone talks about it does work on the stomach and it does decrease stomach emptying time and and make you feel Fuller it's actually the brain MH and that's where we see the biggest impact of this drug is that it it directly influences the way that the brain is feeling the way that it's experiencing hunger and fullness and thinking about food and thinking about sex and thinking about shopping it it has a very big impact in in terms of its primary FDA approved indications it does work on the brain the stomach and then it's very effective on working on the level of the pancreas so it really helps with any insulin resistance we see but also what it does is it make fine-tunes your body's insulin response to to carbohydrates and blood sugar and it just becomes very effective at sweeping up that blood sugar and and and processing it effectively rather than storing it as fat and those three things are the biggest way that we see its effect in terms of weight loss and blood sugar regulation I mean I think they're they're phenomenal there's been a lot of talk on how they reduce uh cardiovascular disease risk renal failure very recently I saw some papers on that in fact I'll share some data here reduces the risk of renal failure by 16% % cardiovascular death Mi or stroke by 133% and all cause death by 12% yes that is insane I mean these medications are extremely powerful so you talked about how they affect the brain so how does it and what I've been told from like a friend of mine who started taking it she said you know what the brain chatter is gone like all this thought about what I'm going to eat now what I'm going to do next what I'm going to have for dinner like it's just not there anymore yep they call it food noise yeah that's like a that is a a term coined by the users it's like I don't have any more food noise I don't think about it yeah I had a patient tell me that I gave her 4 hours of her day back I was like what do you mean and she said I just am not constantly thinking about what I'm going to eat next yeah like how freeing is that so yes it really works on the level of the brain and it just quiets our our desire are for food you know it probably takes us back to more how our brain was before we were introduced to all of the junk food out there these hyper palatable things that have changed our brain and made it very hard to regulate a normal relationship with with hunger and food and it's what my patients tell me is the the best gift so how does it exactly what's happening in those glp1 receptors in the brain that's changing that we're still learning about this but what we do know is it influences the release of dopamine in a particular part of the brain called the nucleus accumbens and it decreases reward so food and alcohol and drugs and other addictive behaviors all probably work on the same level of the brain and so we find that when you have a decreased desire for food especially when it was like food that was all controlling we'll see the same thing for decreased desire for alcohol if alcohol was all consuming for you or cigarettes or even drugs lots of reports pornography or pornography I mean I have not actually seen that studied yet but I'm sure it's it's out well I would say you know probably one is that pornography addiction is not a is not recognized as terms of a thing there's problematic porn use and based on the you know most up- toate literature they say like 4% of the population has it but it's very difficult to study because there's no clear definition and then you know who like cuz someone could watch porn for one time a year and feel like they have an addiction cuz to's lot of like what and what is good in terms there's no like oh I use it every so it's and I use it once a week and it's bad like it's really about how you perceive it yeah but I feel like that you could easily study same same can be said for shopping addiction which is actually something I've heard a lot about this like I don't feel the desire to just like go buy things to to give myself a dopamine hit yeah I bet it could be pretty easy to subjectively study this and just ask people if they feel like there's improv they have a problem has there been Improvement like is this something you think about less if you if you identified that it was too much sometimes we do things that we don't even think are problems but then you notice after on this drug people say like I think I was like spending a lot of time you know scrolling on Instagram and it's not giving me the same amount of pleasure or you know I was really truthfully drinking too much at night it wasn't alcoholism and I could stop and it wasn't binge drinking but it just wasn't something that I needed and now I realize how much I don't need it so it's this disregulated dopamine response and it's tempered with these drugs and you know that can have a trickle down effect in other parts of your life but generally we're just seeing positive positive positive across the board with its influence on the brain just so we're not um only being unbiased or unbalanced here what are some side effects of these drugs like what typ types of what people can't take them and then what kinds of side effects are people seeing okay so I maybe just even back up you know we really only have FDA approval for hand full of things we're talking about these positive effects and and what we're seeing on the brain but really it's for type 2 diabetes management obesity management and now it's garnering some other indications kind of in the cardiovascular space and more to come who can't take them very few people actually can't take them now access and cost is a different issue but we really avoid these drugs and people with a family history of something called Meen type 2 cancers endocrine Cancers and meary thyroid cancers this risk is actually theoretical more than something we see in actuality but we want to be extra careful that we're not inciting tumor growth in this very specific population other than that you it's not approved or it's not really studied so hence not approved for use in breastfeeding or pregnancy okay yeah that's pretty typical for most exactly like you can't do much exactly so generally a lot of people can take it I think the other big thing is like should the everyday person take it for for just like a couple pounds of weight loss well I can I can very clearly answer that just for a couple pounds of weight loss no but or or 10 or 15 like they're not over they're not maybe very overweight or they're slightly overweight or they're at the high level of normal and they just want to lose like 10 or 15 pounds let me give you the textbook answer and then I'll tell you where I think this whole conversation is going so the FDA says that for weight management you very clearly need to have BMI of 27 or greater with a comorbidity so some health issue related to excess weight and honestly in the majority of people that come to me with excess weight I can find something or just straight up you've got you're totally healthy we can't find a single thing wrong with you and you're just overweight then a BMI greater than 30 BMI is not a very great tool really to tell us about metabolic health and so body fat is actually a better IND indicator of health and need to potentially lose weight I also think that we are seeing such tremendous benefit that maybe in 10 years we will start bending the rules on this and when cost comes down and longer term studies for just prevention are there instead of treatment we might be using these medications in a different way and some people might say you know actually I know my family history and I know what 5 or 10 pounds is going to lead to and all of the the risks of taking these meds are less than the benefits for me and so we'll consider it but really right now no we're saying hey these meds are and or you know kind of going back to the idea of like how it's influencing our brain we might say this is going to get approval for alcohol use disorder and this is going to get approval for drug disorder and for other addictive behaviors I think we're a little far away from it but we see the benefits there and so especially in patients who have kind of these these comorbidities of both weight and another issue we're treating they're like a really good solution I think this conversation will I think what we have to be careful about is that we shouldn't be putting everybody in the population on this medication right and we do still need to be working very hard and I would like everyone to hear this that I do think these drugs are revolutionary but we need to fix the problem of what has led to this widespread obesity epidemic over the last 40 years we need to fix that yeah two things can happen at the same time you know I do not think we just have to throw these to the side and say we'll fix the food system and will fix our ecosystem of what got us here I don't also think we should just put everyone on this medication right we have we have to allow the world kind of like re-calibrate here and we can do that through improving our food sources and really educating and changing some of our recommendations because we've been a little upside down in some of our guidance years decades um yeah I think the other thing about this is um you know there are are certainly some concerns and I think some of them are founded and some of them are need a little work I've heard of like the OIC face the OIC butt and also the the fear of weight of muscle loss yeah so let's talk about that so whenever you lose weight you lose muscle in addition to fat and our goal always is to lose more fat than you do muscle and one of the ways well there are a few things you can do to help that is to keep up your protein that's really hard to do for a lot of patients really need to prioritize protein number one thing that my patients do number two probably turns into number one is strength training so we have to focus on building a muscle I know you know this I see you at the gym I love it uh it's so important and it's not something it that's one of the things that I think we need to change in our whole education system we were we grew up as children of like cardio cardio cardio how about let's teach everyone how to lift some weights you know and like really make that part of our physical education so we have to do things that hold on to our muscle I see a lot of headlines that say that these drugs lead to muscle wasting that's not true actually there's an improved ratio of uh fat to muscle loss on these medications versus a calorie restricted diet and actually there are drugs in the pipeline that are in this class of drugs but that will be muscle sparing that's going to be amazing exactly so that will really be the thing we're like well geez if we can if we can further kind of help this ratio and just muscle is more metabolically active than fat and it keeps you it's the longevity organ right right and so if we can keep that stronger through our weight loss we will be in a better position and potentially I mean in theory if we had a lot more muscle then those are the patients that are able to maintain their weight loss and potentially come off or down or titrate down on these medications or in the example of like significant weight loss where there's regain if youve build all like so much muscle it's going to be a lot easier to sit in that maintenance mode because you have a totally different body than you did before right not just physically but just like how it's operating the OIC face and the OIC butt that has to do with rapid weight loss and it's worse with age because our collagen doesn't rebound as much and we all know this and the thing I'll say also about fat and muscle loss we have to be very careful in patients over the age of 65 I'm always telling my patients no skinny is not what we're going for here it's Health but really in that population because they are at a higher risk for developing sarcopenia which is hey you got thin but you lost all your muscle right right so we don't want that either I was just talking to my at a 70-year-old couple this morning and I was just talking to them about how like I go what do you eat and I was like you guys are not getting enough protein like by far and in that age group it's even more important to get all your protein because you your muscles are a bit more resistant at that point yeah and to go to like I have my grandfather's 94 years old still does his exercises you know like it might not look like the exercises you did when you were in your 40s but you've got to you've got to lift some weights you've got to do something that has resistance and keeps you active so tell me the other thing about people worry about is that they're now not going to be able to enjoy food like they used to and there's such a emotional component to food right and going out with friends and having a meal and caring something that's like amazing or delicious or whatever yeah so what are you seeing in your patients and what's the data there's not great data on what we see in this but every Doctor Who's using this medication will tell you that this is a complaint and it only pops up in certain populations so let let me explain so most people are able to enjoy the food that they loved but in a different way right you just can't eat through your hunger you can't eat as much and potentially you might might actually lose interest in the things that you used to love but maybe that food doesn't serve you anymore so maybe like the fried food it's like kind of turns your stomach or some people lose a taste for coffee and that's actually a common it's not really a complaint it's just uh an awareness like I just don't crave my coffee as much or alcohol like the taste of certain things change and we actually know that the taste buds of glp1 users change on a genetic level very quickly and so they crave we do know that that they craze crave less salty less sweet um less calorically dense less ultr processed foods which we're seeing reflected in shopping behaviors at the grocery store right I mean like the big food Giants are kind of freaking out because people aren't buying as much of the snack foods and you know hyper palatable Foods as they were so things change I think the complaint of I can't enjoy food in the same way is a little different so in that case I think people find the ones that feel it were using food as an emotional crutch and it was more it was less about the taste of the food and more about how it made them feel mhm to eat this thing or eat this much of this thing and that can feel sad and I call it in my practice anhedonia like a like a lesson a dampening of pleasure kind of like a lack pleasure I find and it's not depression the when I identify it it's but it's like a longing it's almost like okay I'm going to mourn that and I have to figure out what else to do to make myself feel alive in that way again so I actually give this as homework to my patients I'm like what what did you do as a kid like what did you like to do to unwind as adults we unwind a lot with food and alcohol yeah and when you take the ability to enjoy those things in excess away there can be a temporary mourning period And so you have to fill it and a lot of people will be like okay I'm a person who works out now you know and I have people who turn to like Hobbies like I'm going to put together a Lego set with my kid you know I'm going to I'm going to paint again I'm going to Garden I'm going to have space to do the things that were crowded out by behaviors that probably in retrospect weren't certain me but in the short term as I'm figuring this out it can feel a little like a loss so I can imagine that this would also change your friend group and potentially your relationship I mean does it ever yes so I see changes in both a platonic and romantic relationship level so yeah if you're friends all just go out and drink and eat in excess and all of a sudden you don't actually want to do that that can be very confusing and it can be sad and it can be lonely so I actually do this on my intake I kind of ask people like what are you doing on the weekends like what are you doing like on wine to are your friends how does your spouse eat you know what does your boyfriend like to do and if it's all about food and alcohol I'll set them up like right away like okay we've got to we've got to troubleshoot this and can you have a conversation ahead of time with this person that like maybe let's go bowling like let's go do something else like have a game night instead you know let's go to the gym together EX exctly so I think people need to be aware that these relationships can change and um you know romantically I always do an intake about like you know what's your relationship like are you going to share that you're doing this you know you're starting on a New Journey on a health Journey are they in support because you it's going to shift it's going to change if you guys enjoyed that clip with Dr Alexandra SOA make sure to check out the fulllength episode on the Reena Malik MD podcast

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