GLP-1s Beyond Weight Loss – The Future of Women’s Health, Fertility, Hormones, and Longevity

Hello everyone, welcome. I am very excited about this topic today because we are here to talk about GLP-1s and their impact on women's health. And GLP-1s are all over. We probably all know someone or multiple people on a GLP-1 at this point in our lives, and they are being prescribed a lot of times for weight loss. But there are many, many indications beyond weight loss, especially when it comes to women's health. So I'm very excited to learn from these amazing panelists today who are brilliant. They are prescribing these medications. They understand the indications inside and out. And so we are going to discuss GLP-1s for things like fertility and menopause and hormonal conditions. And this is not about promoting them or telling you to take them or not to take them. It's just to open up the conversation so that the public is informed and educated. About what they do, who they're for, who they're not for, the true risks, if there are myths around these things, and how to support your body if you do choose to take a GLP-1, because there are lifestyle factors that are incredibly important when you're on this medication. So the plan today is we will talk about microdosing, risks, myths, thyroid and autoimmune conditions and hormonal conditions, fertility, menopause, Lifestyle factors that matter the most when you are on a GLP-1. And then we'll open it up at the end for some Q&A, hopefully in the last 15, 10 minutes. So we have a lot to cover today. I'm very excited to be joined by these amazing panelists, and I'm going to quickly introduce them one by one, but please know that their information is on the screen behind us. So if you want to follow up with them, they all have amazing social media presence. They all have podcasts. They all have books. McCall McPherson's in the process. Hers is out soon. So please follow up with them if you would like to work with them further after this discussion. So first, we'll start with McCall McPherson to my left. She is a physician associate. She specializes in thyroid and hormones. She's the founder of Modern Thyroid and Modern Weight Loss, and her book is coming in 2027. So stay tuned for that. Thank you for coming. Thank you for being here.

Thanks for having me.

Next, we have Natalie Crawford, Dr. Natalie Crawford, to my right. She is a double board-certified fertility physician. She's the author of The Fertility Formula, which you can preorder now. Yes, she's very busy. And so having her here is a true gift. Uh, and she's also the founder of Fora Fertility right here in Austin, Texas. And to my far right, we have Dr. Jessica Shepherd. She is a board-certified OB-GYN. She focuses on longevity, perimenopause, and menopause. She is the author of Generation M, and she's also the chief medical officer of hers. Again, very, very, uh, grateful to have these three amazing women around me to facilitate this discussion. So thank you all for being here, and thank you audience for being here as well. And I am, I guess I should introduce myself, shouldn't I? I am Shannon Ritchie. I am a physical therapist. I'm the founder of Evlo Fitness, which is an online strength training app designed to help women build muscle without wearing down their bodies. And as I'm sure we'll talk about today, muscle is a crucial part of the process of being on a GLP-1. I have to talk to each of these women individually about the importance of muscle, so I may be weighing in on that, um, as well as we go. So let's start with Dr. Shepherd as I slip off the chair. All right. Can you give us just a quick 30-second description of the mechanism of action of a GLP-1 so we're all kind of on the same page of how these medications work inside our bodies?

Yeah, absolutely. Thank you for being here, everyone. I love talking about GLPs because I believe they're fascinating and the new frontier of what we're seeing, not only for weight loss but our health. But in general, we all— it's a peptide, it's a glucagon-like peptide which we actually make naturally by ourselves. Everyone in this room makes GLP. But the thing about GLP, of how we make it, has a very short half-life in the sense that when it's secreted, it's secreted and then it goes away. What we've been able to do now from a pharmaceutical perspective is make a GLP similar to the one that's in your body, but making it last longer. And when it lasts longer, then it has the capability to do things, namely we've been using it for decades for diabetes control because it has a really good way of controlling your glucose intake and also your insulin secretion. But what we did realize over the years is that there was a weight loss component to it. And from there, that's when it was FDA approved for weight loss. But what we are seeing in the use of a GLP-1 now is just how much benefit we have when it comes to, uh, weight loss, but also for brain health, also for our bone health, and we're starting to see even for cognitive decline that it may have some potential for that as well. So we'll start to see more throughout the next few years as we start to research it more, but that's where it started. But it really is fundamentally based on a peptide that we already make in our body.

Beautiful.

McCall McPherson McCall, I would love for you to add on, what is one thing that you think that people misunderstand about these medications?

You know, I think the general public sees these medications as simply weight loss medications by way of reducing the amount of food that people eat, and that couldn't be farther from the truth. In fact, we'll talk a lot about the other purposes of them, but often I tell our patients, look, if you actually don't change what you eat at all, which is not what I'm recommending, but to prove a point, you could still lose weight. And the reason is because it changes your body's physiological response to food short-term, but it does the same thing long-term. As we age, especially with people with thyroid conditions, we lose our metabolic potency. It begins to degrade. And even if we're doing the same thing we've always done, we'll gain weight, we won't be able to lose weight. GLPs begin to reverse that metabolic dysfunction and resensitize our metabolism in and of itself, which is incredibly, incredibly powerful. So definitely I want to start the conversation with the mindset of these are not making people lose weight because they're eating less food. Nothing could be farther from the truth.

I did not know that. And so I'm so glad that you explained that so eloquently. Dr. Crawford, do you have anything to add to that?

I think from the standpoint of fertility and hormones, it's important to set the stage that a lot of people have heard the term Ozempic baby. And they might think that GLP-1s are a magic fertility medication, or that they are safe to take if you're trying to conceive. Now, it's not that they're unsafe. There's definitely uses beyond just weight loss for fertility that we're going to dive into. There's actually receptors inside the ovary on some of the cells that surround each egg, but the medication's not proven safe in pregnancy. So I think we have to reframe the fertility discussion to say that if you are wanting to get pregnant, we want you to stop a GLP at least 2 months before you conceive. And this is due to the risk of potential birth defect or changing the metabolism of a baby inside your womb. I also think it's important to say that many people have gotten pregnant while on the medication because especially for conditions like PCOS, where you may not ovulate, the benefit to helping with insulin resistance and losing weight can restore ovulation. There's a registry. There have been no reported birth defects from it. So if you are on a GLP and you do get pregnant, we want you to stop the medication. It's not proven to be harmful. But as you know, when it comes to pregnancy, we're extremely conservative when it comes to recommending medication. So when I talk some about fertility and hormones, if you are in the audience or you know somebody and they want to get pregnant, we wanna make sure we're not recommending this while you're actively trying. It's almost a precursor to when you're trying to get pregnant or doing treatment.

And we're gonna dive into all of that in more detail because I think it's such a fascinating part of this discussion. But before we do, I wanna go back to McCall McPherson McCall and talk a little bit about microdosing hormonal conditions, thyroid conditions, because we've spoken before about how you often give a microdose. So can you tell us a little bit about the difference between microdosing these medications and who is that indicated for in, in your population that you see?

Yeah. So I know microdosing is now like part of the conversation, which is really, really cool. Microdosing, what it means, because I get this question a lot, is a smaller amount of medication that generally is readily available in a pre-loaded injectable pen. Right? It could be a quarter of the lowest dose that people start with. It could be a tenth of the lowest dose. There is no defined amount, so it varies. And the key that's really interesting, it's variable. Like, we can tailor it to each individual person. We can reduce the dose, we can increase it. And there are some benefits in this. When I first started our weight loss program at Modern Thyroid Clinic, I started with standard dosing. Right out of the gate, really early on, I was a pretty early adopter on the weight loss front because thyroid people, y'all, they struggle with weight loss. Even if you perfect their thyroid, their metabolism is so incredibly damaged. And what we had was a lot of women who felt horrible, who were really nauseous, who weren't eating enough food to fuel their bodies, much less exercise, build muscle, eat enough protein during the process, build muscle mass to improve their metabolic function, right? And so early on, we adopted microdosing, and we noticed, hey, we quit prescribing anti-nausea medications. I haven't written a Zofran script in 2 years. I used to write 10 a day. We noticed people could nourish and fuel their body— bodies, get enough macronutrients, get enough micronutrients, and they were still getting the benefits that they previously were getting on the standard doses. Things like massive inflammatory reduction, things that I've never seen in my practice of functional medicine happening in lab data one week after they take a microdose that were also happening on standard dosing. And so, you know, I think the benefits are far-reaching. In studies, this is the next frontier, right? Like, I truly believe that companies like Eli Lilly will invest in the concept of microdosing and hopefully tailored dosing. I think we can't put everyone on the same darn protocol of medication, unendingly increasing them and expect to have positive benefits without negative consequences.

What are— people think about the negative consequences all the time, I think, with this medication, and they're afraid of it. Dependency, cancer risk, sarcopenia, maybe some others I'm forgetting. What is actually supported by the evidence as far as risks of the medication, and does it differ if it's a microdose versus a more standard dose?

Great question. So it blows my mind that in the media we are constantly cycling these fear-based conversations. Like, you know, for the longest time it was, oh, you're gonna get thyroid cancer immediately if you start a GLP, right? I'm very invested in that conversation because I am exclusively treating people for years with thyroid conditions with GLPs. Those were my people that I started using these meds with. So at Modern Thyroid Clinic, we did ultrasounds every 3 months with everyone on our weight loss program until one, we realized nothing's happening here. These people are not developing nodules. They're not developing markers that we think are significant for cancer. But during those years, more and more data was coming out. And what the data showed was pretty clear. There was an international study done looking at true risk in humans for thyroid cancer, and it came back that, hey, there really isn't one. In fact, insulin carries more of a risk for thyroid cancer than GLPs. And guess what? Insulin does not have a black box warning for thyroid cancer, nor do I think it carries a risk at all. But really where that came from is in studies on rats they got medullary thyroid carcinoma. Why? Because rats have incredibly dense GLP receptors on their thyroid glands, and they were given 20 to 100 times the human equivalent dose of medication. So honestly, not really a shock that they ended up with medullary thyroid carcinoma, which is one of the most rare forms of thyroid cancer. Humans don't, in fact, have incredibly dense GLP receptors on their thyroid. So it has not translated to human risk in the literature. But again, we cycle this fear-based narrative perpetually. I think the muscle loss thing is a really important part of this conversation though, right? Because a lot of people are losing muscle mass. That's the reality. A lot of people are on doses of medication that do not allow them to eat food. They will eat 200, 300, 400 calories a day. They're nauseous, so they just want to eat carbohydrates. Why would they want to eat protein, right? Those people are in fact losing muscle, but it's lack of fueling. It's starvation. Our body is searching for fuel and it's pulling it from anywhere it can, whether that's muscle, whether it's fat, whether it's hair, whatever it is. If you control the dose, if you pull it back, if you're not looking to not eat food, there are muscle protective compounds in GLPs themselves. So inherently, they don't simply go and pull all of your muscle. And in fact, you can build a lot of muscle while you're on GLP if you do the work, right? You have to lift heavy, you have to lift to failure, as Shannon always says. You have to fuel your body with enough protein and nutrients to be able to develop that. But it's very, very possible. The other thing I did wanna bring up too, circling back to cancer, is we have all these conversations about cancer, about pancreatic cancer, about thyroid cancer. GLPs have been proven in research to reduce a lot of cancer. Breast cancer by 13%, prostate cancer by 17%, pancreatic cancer by 6%. So while everyone's talking about these increased risks, no one is actually reading the data that you all deserve to know. And in fact, too, in people with a history of cancer, if they're on a GLP, they show a statistically significant reduction in their mortality. So huge deal. And that's not even bringing into the conversation heart disease, which is, you know, kills more of us every year than all cancer combined. And you have a 12 to 18% less likelihood of dying for any reason. But 20 to 25% less likely to die of heart disease if you're on a GLP, which is huge. Like, but why aren't we talking about it? Like, why isn't this the thing that's on in the headlines?

Why do you think it— I would love to hear from both of you as well on everything that she just said. Why do you think we aren't hearing about those things in the headlines, in the media?

You know, when we, we talk about headlines, it really is a form to gather someone's attention to listen. And one of the ways that we've done that in media is what is the most sensational thing that we can bring to everyone's attention that they will then listen to that and draw their attention. What I would say for anything when we think about health is anyone who walks into a hospital, a doctor's office, and is there for a condition and wants to address that condition Every person in here has risk and benefit, and everyone in here has the wherewithal to decide how that risk and benefit pertains to them individually. So when we as healthcare providers do the due diligence of reading the studies and understanding the statistics and bringing that to your attention, it still requires you to sit and say, for what I'm going through or what I would like to do and how I would like to address that, there's risk and benefit, and everyone out in this room would walk out with a different understanding for themselves of what that risk and benefit means to them. So when we hear the statistics of, yes, maybe there is an increase in a study in a rat, right? So it's like digging down into the narrative and saying, okay, for that risk of which I thought was a big factor, what is my risk of dying of heart disease? Number one killer of men and women. In the world. So that's a risk, and a benefit would be, what do I do to decrease my risk of that death of cardiovascular disease? You get to choose. And I think that that's where, if we fashioned healthcare around that and stopped kind of maximizing what the worst-case scenario is— this is what I see in the world of hormones, of, you know, the real fear was breast cancer, when, when we really look at the numbers It really wasn't that significant. It wasn't even significant in the study, but that's what we led with because of kind of sensationalizing information. I feel that the public— we're doing a disservice to the public of allowing what we project into the media for people to hear and then sit with like the worst-case scenario of 4 in 1,000 people of having something when where they're sitting at that point in their life that there's something that needs to change. And when we look at one of the best countries in the world with the best research and healthcare resources, but yet we have poor health outcomes than many industrialized countries when we stack it, then there's an issue. And so I would say that we have to start taking more autonomy in how we listen to information, who we're getting information from, and every individual gets to assign risk and benefit.

Yeah, I'll just add, medicine by definition constantly changes. There's a lot of nuance to apply what is new research to the patient who sits in front of you. And unfortunately, there's a lot of good practitioners in bad systems, and you need to be on a journey, especially when research is evolving or something new is introduced to market, where you sit across from somebody who's willing to walk that road with you, explaining the nuance, how it might benefit you, what risk you should be able to be worried about, and have your questions answered. And if you're not getting that type of a relationship, I really encourage you to try to find it somewhere else, especially when it comes to something like GLP-1s.

This is a very important conversation. Thank you for adding that.

I—

before we move on to fertility, I would love for you to close with anyone in the audience, anyone listening, that maybe has some symptoms that they have ignored, or their doctor has maybe, uh, not helped them with in whatever way. What symptoms have you found to be resolved or improved when you prescribed your patients GLPs?

So the consistent story that I get from my patients is they start GLPs for weight loss, right? Of course, naturally. Very quickly, the benefits turn from that to a slew of other things. It could be joint pain. It could be less flares in their psoriatic arthritis, reductions in their Hashimoto's antibodies, which I haven't found yet in the literature, but it is undeniable. We certainly have the data to show that. But I think the most powerful thing that GLPs do is massive and significant reductions in inflammation. That I have not been able to replicate with lifestyle change. So, and I'm in the business of functional medicine. I'm not in the business of, here's your Lipitor, good luck, go on your merry way. No, my patients are really dedicated. They eat well, they exercise far more than they— they're more diligent than we should expect them to be. But not everyone can influence their inflammation that way. It's a byproduct of our natural physiology. Being able to turn the faucet down in a mere 48 hours. We have documentation after a week of one microdose, uh, with data on their hs-CRP, which is an inflammatory marker, significant huge reductions that would take years to reduce with lifestyle modifications in one injection. To me, that is the most powerful thing because that inflammatory reduction then elicits so many other impactful changes for healthspan, for lifespan, for cardiovascular disease, for cancer, for fertility, for all these other aspects of our physiology that I think are on the next frontier of what we can expect for indications for these meds. I think we'll soon see them indicated for so much more than weight loss because the data is everywhere and clinicians around the country are seeing this just simply transform lives. And it's been one of the most sacred journeys I've taken in my practice of medicine, and one I certainly didn't expect so many years ago. So excited to share a little bit with you about it. Excited to be here.

When I think about who we're working with, their goal is to build muscle. And we know that muscle is an important part of this conversation, not even if you're on a GLP, but just for everyone. We all need to be building muscle. We are under-muscled, and it's a big problem, and it is our metabolic tissue And so when I think about GLPs decreasing inflammation, I immediately go to, they're gonna recover better, they're gonna be able to load their muscles with more efficacy, build muscle easier and faster. That's immediately where my mind goes. So when you say the downstream effects of this, I find that to be a really interesting piece.

Oh, absolutely. And joint breakdown, it has been shown to reduce and significantly reduce the breakdown in OA and osteoarthritis, rheumatoid arthritis. Really, truly, the effects of inflammation reduction are far more reaching than we could even talk about today because it impacts everything.

This is fascinating. Thank you. I feel like we could probably take a whole hour talking to each one of these panelists, but we'll, for the sake of today, we'll move along to fertility. Dr. Crawford, when we are thinking about fertility metabolic dysfunction during reproductive years, when are GLPs appropriate and when are they not appropriate? We talked about not appropriate during pregnancy or in the months up to trying to conceive. So when does someone think about, should I consider this? What are your thoughts?

I think it's really important to zoom out on fertility. Many people think fertility equals having a baby, but really fertility is a health marker and it's a state of appropriate hormonal health and that your body is in the right state to get pregnant. It's highly influenced by chronic inflammation and insulin resistance. Regardless of the disease state that you may or may not carry. Things like autoimmune disease, endometriosis, significantly impact your ability to get pregnant, but also your ability to make hormones. So we want to think about what the ovary does. The ovary responds to signals from the brain. An egg has to grow to make estrogen. You will then ovulate, and then it has to make progesterone. And this requires communication between the brain and the ovary. As I said earlier, there are receptors inside the granulosa cells in the ovary, the ones that make your hormones, and also in the hypothalamus of the brain, meaning that part of the way we can see some of this profound reduction in inflammation is also at the level of the ovary and at the brain. Research has shown immense benefit for patients with PCOS. PCOS, in definition, is a metabolic disorder where patients essentially have insulin resistance. Their bodies don't respond to to the same insulin signal. They need greater levels of insulin, which cause more visceral fat, higher levels of inflammation, and it actually changes how the ovaries respond and produce hormones. You see a different response to the gonadotropin signal. So even if you're doing fertility treatments, if you have insulin resistance, you're not going to have the same response. So when you ask, when do we use GLPs? One, if we know we have insulin resistance, it can be a powerful tool. That's a multifaceted approach based on how old you are, where you are in trying to conceive, if you're doing fertility treatments. There's other options to help with reducing insulin resistance, myo-inositol, metformin, weight training, lifestyle changes. But as McCall McPherson said, GLP-1s can make the biggest difference the fastest, especially if there's also weight to lose in addition. So often I will say in a PCOS patient, let's try this before we do ovulation induction or medication to get pregnant. The other place that I'm most excited about that research is not there— I always think we've got proven and promising. Proven to help with PCOS. Promising is going to be recurrent unexplained pregnancy loss, unexplained infertility, places where we know we have autoimmune disease, the Hashimoto's, endometriosis patients who are struggling despite going through IVF. Some of these patients have a high HSCRP, those inflammatory markers. GLPs can lower them. And sometimes we take what I call a purposeful pause. Hey, we're not gonna try in these 3 months. We're going to really try to target this hard, see if we can drop our inflammation, and then come back to the table. And I've seen immense differences in ovarian response to stimulation, embryo quality in the lab, ability to get pregnant and stay pregnant. And this is in my own clinic, so there's no randomized controlled trial. This is where we're using what one patient's going through and their clinical state to try to make a difference. So again, it really does go back to that discussion with your own doctor. We don't want to just put everybody on one, but I think the greater discussion that inflammation impacts a lot of infertility— so many people who are struggling to get pregnant have undiagnosed insulin resistance or chronic inflammatory disease. There's a big failure in women's health to diagnose patients in some of these conditions. And so asking the right questions is part of what's really important here.

We know that when there is rapid weight loss, 25% of that weight loss can come from lean mass. So it's interesting to me because we know the importance, the metabolic importance of muscle and building muscle, especially in pop— all of these populations that we're speaking about today. But if someone is on a GLP and they are losing weight and losing muscle, they're not properly strength training, what effect does the medication have then on improving the outcomes that you're looking for?

Especially with my patients, when we're at this state, we're trying to throw everything we can. And the way I frame it is we can't control everything, but we should control what we can. Building and using your skeletal muscle is one of the top tools you have for hormonal health. Decreasing inflammation, utilizing glucose without needing insulin, therefore improving your insulin sensitivity. Regardless if you wanna be pregnant one day, you're trying right now, going through fertility treatments, pregnant, postpartum, lifting weights, resistance training, building and using your skeletal muscle is the key. And I stress that even more in my patients who are on GLP-1s. We tend to start low, right? We don't wanna see a rapid drop in weight most of the time. That's also going to negatively inhibit the hypothalamus because if it thinks you're starving, it's going to say, not a good time to be pregnant, right? So it's really a nuanced discussion with that one as well. But lifting weights, building skeletal muscle, that's key no matter what. And I think that discussion gets lost a lot. I know Shannon, when you are on my podcast, this is still the most popular episode because women are still told, don't try to work out, don't lift weights if you're trying to get pregnant. And that's really not the truth and not what data and literature supports. So I think when you're rapidly losing weight, it's problematic. That's never the road we want to go down. We really want to start very low. We're trying to build muscle as you're losing the fat, and that's where the sweet spot is.

Absolutely. And if someone is on this medication, what is a— and it probably is highly dependent, but what is a realistic weight loss if they're losing weight? How much, how often, or how much weight loss should they be looking for on a week-to-week basis?

That is a hard question because it is going to depend somewhat on starting weight and goals. Meaning, if you are extremely obese and I'm trying to get you to a weight appropriate to do an IVF cycle and undergo anesthesia, we might accept more weight loss because your body can tolerate it. Most people honestly who benefit the most are in this 15 to 20 pounds overweight. It's not severe, it's just a little over ideal body weight. I always say the perfect zone, 2 pounds a week, which is— can be really hard to achieve, and that's slow. But we're not really shooting for a weight loss goal with how we're utilizing them. We're shooting for the inflammatory decrease, and so we don't want that rapid drop all at once.

Sure. So what is a, a weight that would be too much that you'd be like, okay, we need to adjust?

I get nervous when we're losing like 5 pounds a week, which you see tons of patients who are on GLP-1 losing 5 pounds a week. And I always think there's the scale. If we're hindering more towards 5 pounds, we need to pull it back. It's hard. Patients who are overweight are thrilled.

I lost 5 pounds, that's so great.

But it makes us really nervous because we know that they're underfueling, they're probably not eating, their dose is too high, and we need to pull it back.

Is that— weigh in here. What do you think?

I absolutely agree. So I think the expectation of people is not healthy. And in fact, people come back and they're like, look, I'm completely stalled, I need to increase my dose. Well, we don't define a stall until you've lost less than a half a pound a week for 3 to 4 weeks in a row, because that's reasonable. Like, the slower you lose this weight, the healthier you are being in the process, and the more likely you'll be able to maintain and carry on in a healthy way. I couldn't agree more. I mean, we deal with a different patient population, but if my people are losing 5 pounds week over week, it makes me really nervous. With the exception of the first week or two because people drop so much inflammatory weight, right?

And tell us what the inflammatory weight— what is that? It's just water retention. Tell us what that is.

Yeah, so think about if you get stung by a bee, you swell where you get stung by a bee, right? Like, that is your body sending inflammatory responses to that area. When people struggle with significant inflammation, that's happening systemically. It's their whole body. So their whole body is swollen. I'm sure— I mean, I imagine many of you have woken up in the morning and been really puffy. I deal with that. I'm an inflamed person compared to my husband, who has never been inflamed a day in his entire life. So if you get it, you get it. If you're inflamed, you know. But it's— you're walking around like a marshmallow man, just feeling really puffy in your own skin.

Thank you. I would love to shift to peri and post-menopause. This is an area of discussion that is getting so much more press and recognition and education, but it is still under— misunderstood very much so. How do you see GLPs fitting into this conversation when it comes to perimenopause, postmenopause?

I think when we think of our bodies, we have to understand that they are beautiful machines. And the way that they're designed to function is kind of like a, I guess, an auto factory, like a car factory. So everyone's there, everyone's doing their job, they know what they should be making, how many they should be making, who's on the time clock, who's not. And when we pull someone out of that assembly, which is typically what we see happen with hormones, functionality of the body from an organ system, from a whole body perspective, is shifted completely. And so when we can look at our bodies as that, it makes perfect sense that when our hormones start to shift, whether it's thyroid, whether it is your estrogen and progesterone, and those ratios are shifting, that's when your body is unable to respond in the way that it has before, which kind of now goes into the disease or a conditioned state. So the goal ultimately is to— how do I, in the best way possible through lifestyle, which I think that lifestyle is the best way to do it categorically, and then also with the help of whether that's hormonal support or medications. And I kind of pull hormones out of a medication because a lot of my patients come to me and say, oh, I don't want to be on hormones in perimenopause and menopause because those are medications. And I'm like, well, you were kind of born with them. What I'm trying to do is allow your body to kind of fuel that gas tank again because it's been depleted. And when it's depleted, all of your organ systems can't respond the way that they want to. Menopause and perimenopause is a whole body experience. We have typecast it to the pelvis and think that it just has to do with pregnancy or it just has to do with cycles. But when you realize that there are estrogen, progesterone, and testosterone receptors all over your body— your brain, your heart, your muscle, your bone, everywhere— it now makes sense for women when I explain it to them that when you're going through that shift of those hormones in your 40s and your 50s, your body organs can't respond to the messages that were being sent to it daily from the ovaries emitting estrogen, progesterone, and testosterone. So what my job is to make sure that everyone understands how their body works, how to optimize it, and then find out what their experience is. Because like I said before, risk and benefit, it's an N of 1. Everyone should have a different objective or goal that they're trying to, to reach. But also, how do you feel? What is your experience with perimenopause and menopause? And so when we look at GLPs, there's a study that was done 2 years ago. Now that we're trying to recoup this topic of hormones and menopause, because for so long, 20 years since the WHI study, we really have been trying to allow people to understand that hormones are actually a natural part of their body system and functioning. And how do we get that back for them so that they can live a thriving life as they go into their 60s, 70s, 80s, and 90s. Now, adding on a GLP, when we think of hormones, it would make sense if we know that glucose and insulin is the engine of our body. It really deals with inflammation, it deals with fertility. Glucose and insulin are the machine of our body, and when that's not regulated, that's why you have a whole system kind of like out of shift and out of sorts. So when hormones, estrogen and progesterone, are starting to decline throughout your 40s, and then when you get to menopause, it declines significantly, it's almost like flatline. Then when you recoup those through hormone replacement therapy and added GLP, the study showed that they're synergistic, and the outcome that you'll get is better glucose control. And estrogen and progesterone are facilitators of glucose control. And so when you lose the estrogen, the glucose is like, well, now I don't have all the help that I had before. So now it's kind of like you're rising all tides so that they can work together in the most synergistic way so that your body can now start that engine and function in the capacity that you want it to and reach those goals and objectives, which goes back to what are you walking in with? And that's when I say advocating for yourself is knowing what am I going through personally that I can allow for someone to understand so that they can help me in that path to get to where I need to be.

What are some of the symptoms that you see are resolved or improved in this population when you prescribe a GLP?

Yeah, GLPs have— obviously we see the weight loss component when they're on the dose for weight loss, and even when they're on the dose for weight loss and then maybe shift to microdosing, or they just came in for a microdose dosage at the time, is a lot of joint pain. Resolution, a lot of patients have kind of a, a change in, and it's, and it's hard to describe, kind of that just when you wake up and you, you just feel not great in your body. And a lot of that has to do with inflammation, and a lot of that also has to do with the shift of estrogen as well. So again, we're kind of creating this assembly line back to where it was. But joint pain is probably the number one thing that I hear from. So that's an external feature, like that's a symptom. But the other part of a GLP is when we think of visceral fat. So that's not the subcutaneous fat that we have, like, that we can see in our bellies. I'm not saying everyone has fat belly. I'm not saying that. But when you can see that, right, that's the external fat that's subcutaneous. But fat that surrounds your organ is the leading cause of disease and conditions, but you don't see that fat. And we start to see a decrease in visceral fat on microdosing of GLPs as well. And that is vital as well to decreasing cardiovascular disease and also diabetes.

And I would love to ask all three of you this question. Do we see GLPs as a long-term lifetime? I, I know it's different for fertility because if you're getting pregnant, then you're getting off of it. Aside from that, do we see this as a lifetime medication or do we see this as we microdose or do the dose for the certain amount of time, get some lifestyle habits changed, and then eventually taper off?

I will always fundamentally say first, lifestyle is key. You can take a GLP all day, but if you don't correct your lifestyle, when you come off the GLP, you're going right back to baseline of what you started with. But I always say it's choose your own adventure. Microdosing of a GLP, there are some people who use it for longevity benefit of metabolic function. And can decide, I'm going to stay on this until maybe I don't want to come off of it, or I do. And I think that should be a guided conversation as someone is going through it, that they should kind of like an annual, every year you're addressing, I'm on a microdose of a GLP. Are we staying on it? Are we not? Making sure that you're also looking at what it's doing for you internally at your labs. I'm very big on your hemoglobin A1C, your ApoB, your lipoprotein A, your lipid panel. And seeing what those are to make sure that you're also like looking at it cumulatively and not just, I'm on a microdose for a GLP, but I have people who are like, I'm just gonna stay on it. I think with a guided kind of approach, it can be done.

I'll just add, I know we're coming off it if we're getting pregnant, but I deal with a lot of patients with reproductive disease who maybe are not looking for fertility, notably endometriosis. I see it making the biggest difference in disease. We have a really hard time with treatment opportunities and long-term options because so many of them traditionally have just made you hormonally plateau into that low estrogen state. Estrogen feeds endometriosis. So if I can damper the inflammation and make you feel better and resume your quality of life with long-term use of a GLP with endo, that I think is going to be, again, one of those new frontiers for this autoimmune population. That has for so long struggled. And McCall, you can speak— I know how you feel about this, but for your patients.

Yeah, absolutely. I mean, I echo what both Dr. Shepherd and Dr. Crawford said, and I'm not interested personally in giving people GLPs that don't want to invest in their lifestyle. Like, that's just not it for me because I think that is a path to destruction, a path to muscle loss. But I will say in the thyroid community specifically, There are kind of several subsets of people, and again, it, it's a bit like choose your own adventure. There are people who are just metabolically disadvantaged. They do everything that they possibly need to do to lose weight, and they can't, and they need to for long-term health outcomes. So a lot of times those people get on it, they lose weight. We look for very specific markers in their blood that show and manifest, hey, we've made significant metabolic improvement, and it's likely safe that they can come off of these meds and maintain their weight with appropriate efforts— not over-exercising, not overly calorically restricted. And a lot of people want to do that, right? They don't want to be on this forever. The other subset of people are people who are really inflamed, people who have a lot of heart disease in their family, who are genetically predisposed to heart disease. And those people probably want to stay on a small amount forever. The key is finding the lowest possible dose that these people can be on that doesn't trigger weight loss, that allows them to maintain in a healthy way. And I think there's benefits to that too. Much like Dr. Crawford said, there are subsets of people whose lives are completely changed with these meds that are not yet indicated. Like, they are not meant to get these medications for treatment. They're simply for obesity at this point, or, you know, diabetes. Um, but it's such a profound change that they deserve the option to. And so the biggest thing I'd like to highlight in this conversation is you don't always have to be on these forever, right? Like, I certainly have patients who aren't. I'm sure you both can echo the same. And so it's not like just because you take it, you're stuck on it forever. There are lots of people who successfully maintain weight loss after discontinuing.

Anything in this discussion that we've missed that you three would like to add before we open it up to Q&A? Any patient populations that we didn't touch on, or any— anything that you think would be important? Any misunderstandings about GLPs that you would like to add?

It's not necessarily about the GLP, but that factors into it, is, you know, especially in women's health. I think that what we have missed for decades is that women's health was not very important, and so it wasn't on the forefront when we think of research or how to manage. But women women really have this kind of timeframe where there is an opportunity to change the trajectory of what we see in women in their 70s, 80s, and 90s, and that's midlife. So that can be anywhere from 40 through 55. And so when I see the utility of GLPs and what they can offer women at that timeframe as they're struggling, as their hormones are being depleted, which starts this kind of domino effect of how the body organ shows up, right? So diabetes, obesity, joint pain. All of these things typically start to happen in midlife because of the shift in hormones. And so what I would say is, I call it the magic of midlife, is we have this opportunity to really take a different avenue so that the investment on our health at that time frame can really catapult our end result if we just take the time to pay attention to what's going on in our bodies and give ourselves that opportunity to invest in our health.

Well, we'd love to open it up for Q&A. Do we do Q&A in the mic in the center here? Is that typically— OK. Feel free to line up, and y'all ask any of these panelists anything you'd like. Hi. Thank you very much for the panel. I think 3 questions very quick. I think the first one is, could GLP-1s be silently creating a metabolic disorder crisis in the near term? And secondly, is there evidence that GLP-1s could influence negative healthcare outcomes in postpartum women?

Did you say in postpartum women?

So he said yes, given that they used it before that for fertility purposes.

We don't have any evidence of that. If anything, in the population that is overweight and using them to lose weight, being a more normal body size is going to be advantageous for postpartum postpartum recovery. It's such a hard thing to ask your body to grow a child and birth it and recover. It is hard to even put it into words, but being more metabolically healthy, having better muscle, and normal body weight are 3 of the top signs that you're going to recover better.

The one thing I would just say in general, which we could use maybe as some framework for GLPs, which kind of comes under the safety is that we have actually used this for decades, and for diabetics, which it was solely used for, for years, the outcomes that we saw when we see a diabetic potentially lose weight— that's what they weren't using it for— but the ability to then get pregnant and then decreasing their mortality outcomes after pregnancy, because we've now taken diabetes and weight off of the kind of, uh, I guess, menu. That's where we start to see decrease in mortality outcomes. So although I agree with Dr. Crawford, we don't have data on it, but sometimes when you have substantial data points from when we've used it in the past from a safety feature and outcomes, that's where we can fundamentally look at it and say it probably won't bring harm. But I think in the future when we start to see research, we can confirm that.

Thanks.

And lastly, is there any evidence that men on GLP-1s actually increase uh, the probability of, uh, getting their wives or their partners pregnant?

There is emerging research that sperm parameters are improved on GLP-1s. So we don't have definitive data, but there was a small study done showing that that is improving sperm counts, which of course, theoretically better sperm, higher likelihood of getting female partners pregnant. So I think we know even more so than women, sperm production happens in the body over a 90-day period. Sperm are very sensitive. That's why men make 1,500 a second. Inflammation is very toxic to sperm, so decreasing inflammation alone can drastically improve sperm counts. So I think we'll have the research come showing that men on GLP-1s, especially of a certain population, will have improved fecundability in their partners.

Yeah, and the study came out literally just in the last few weeks.

McCall sent it to me.

Quality, quantity, motility of sperm on GLPs. And I think To your first question, I think there's different subsets of people on these meds. There's people who are on really high doses that are underfueling themselves, that aren't partnered with a great clinician who isn't invested in their outcomes. And I think metabolically in the future, they could be worse, right? If they're truly losing all this muscle mass. There's a whole other set of people, a whole other population who are improving their metabolism vastly. Undeniably, these meds do that, and those people will come out much, much better on, you know, in the, in the long term. Those are my people. That's the data that I see every day.

And what an incredible double whammy, building muscle while you're on a GLP, because you're getting the metabolic benefits from the muscle and from the GLP. I mean, amazing.

Love it. Hi, I'm Bridget Garrett.

I'm with Hot Flashes and Cold Topics podcast, and I think my question is probably going to be more toward Dr. Shepherd, but all of you can weigh in.

So the liver function, fatty liver, and also the decrease in the use of alcohol. I've also heard even like shopping addiction. Have you seen studies that show an improvement with that?

Yeah, there is. I'll start with the last one first, addiction. There are data coming out that shows that they are likely to start using this with addictive behaviors, for one. When we look at fatty liver, fatty liver actually is because there is a backup of cholesterol, triglycerides, namely in the liver. A lot of that has to do with estrogen. So you start to see these liver malfunctions or dysfunctions occur when estrogen starts to decline, but also with diet as well, or lack of exercise. They all contribute to how the liver is able to function. And so what we do see with the use of GLP is that you're going to have a decreased amount going back to the glucose and insulin. And so when the glucose is utilized better, it does not have to be stored in the liver, which was already responsible for making and storing glucose. So that it's, it's kind of like a storage overload. And that's why you see fatty liver. So when you are able to equilibrate the ability to being like, this should be storage, this should be fuel, that's when you'll start to see the decrease in fatty liver. I actually have had a few patients in my own practice who were denied going on a GLP because they had fatty liver, but when you trace back the fundamental beginnings of why they had fatty liver, I was like, if you will allow me, between patient and physician, to put you on a GLP. Let's see what we can get. Risk-benefit, right? So that's the patient assessing, I want to take the risk of what I was denied to see if I can get the benefit. She was able to clear her fatty liver. Not only that, she had PCOS, which makes sense because it's a metabolic issue, and she got pregnant.

Thank you very much. Thanks.

Hi, my mom has been overweight for over like 30 years and nothing motivated her until my brother's wedding. So she went into the medications and she lost 40 pounds, but now the wedding is over and she won't exercise. Will she win all the weight back?

That— I think McCall McPherson and I can, can contribute to that. We've kind of fundamentally said lifestyle is key. And so typically this can be with any— it's not just GLP-1, any drug that was used for weight loss, right? The goal was if you go on this but you continue what you were doing before, more than likely your body through habit will gain the weight back. And so I think that, that those are discussions, personal discussions on what someone's willing to do. What someone's willing to do on the other end of a medication solely resides in that individual to adhere to that. So we do see that with a lot of GLP-1 use, that because it works so well that people will take it, and that's where we see misuse and abuse. I mean, it's with any medication, there will always be misuse and abuse. And so I think that it's important to make sure that we understand every individual has the ability to do what they have the capacity to want to do. And I say that with no judgment because not everyone is going to do things the way we would expect them, want them, the way that we would do it. And sometimes we have to be okay with that, with the right information, knowing that they know that.

I just agree with everything Dr. Shepherd just said, so nothing to add. Okay, there we go. Uh, I don't know if it's because you're all podcast hosts, but I want to just start saying This was the best panel I've been to. This was really, really good.

So thank you all.

The question, it was building on kind of where you were ending, Dr. Shepherd, in the main session, because most of this has been about treating illness and how we can get back to ordinary, maybe. But you started to touch on the potential for longevity or optimization in a healthy population. And I just didn't know if you'll look at that and you had any advice on that front.

I would say when you look at like the function of longevity, right, and longevity doesn't have to mean living longer. It means for the life expectancy that you're going to have, how can I do that in the best way with optimization? And so that's why I would kind of classify microdosing as with the GLP is more of an optimization opportunity for someone to keep in check and in balance. It's like a check and balance system of their internal insulin-glucose levels and how they're functioning. Because we've heard at every level, at thyroid, at fertility, the fundamental part is inflammation, which is usually caused by a surplus of glucose. And if you look at just how we live in day-to-day, we are so evolved here in North America that we do less, right? So the goal is, how do I do more and not have to do it? But what that has done to our bodies is not make it move, We eat on, you know, convenience. So all of those contribute to glucose, which then causes inflammation and sends our organ systems in disarray. So when you look at it from a longevity perspective, I think that this will again be on the frontier of how do we keep longevity, decrease inflammation. So that could come in diet and exercise, but clearly we live in an ecosystem, whether it's toxins, stressors, foods that we eat. That are still kind of creating this upward tick of inflammation. So I do see it as kind of like a mediator of all that. That's my personal opinion. And a lot of the doctors who I, you know, serve with in the longevity function, but I'd be interested to hear from McCall's perspective of in your own practice and how you use it as a longevity or microdosing fashion. What are your opinions on that?

Yeah, I'd be lying if I said I didn't already use it in my practice for longevity. I think to echo what Dr. Shepherd said, you know, two key things that are tied to our healthspan/lifespan— number one is our insulin sensitivity, and number two is inflammation, right? These meds directly influence both of those in a more powerful way than I've seen, specifically the inflammation, anything else. No other medication, no other biohacking tool, no other diet, no other lifestyle change, period. Full stop. In my mind, it's non-negotiable. And if we can intervene at those two points, we can improve our healthspan, we can improve our lifespan. But I think the data backs it up, right? Like, our chance of dying on a GLP is 12 to 18% less. That's pretty remarkable. Our chance of dying or having a cardiovascular event, like a heart attack or stroke, is 25 to 39% less likely to happen. Depending on the study, depending on what the mechanism of cardiovascular event is. So if that's the number one cause that most of us are going to die from in this room, how could it not impact longevity?

I'll just add, since the panel's on women's health, that chronic inflammation is one of the top drivers of low ovarian reserve, which would equal into going into menopause earlier. The ovaries are the key to longevity for women. The longer we can get them to make estrogen and respond, the better a woman's health is going to be. And chronic inflammation drives ovarian fibrosis. So eventually the ovary is just going to stop responding. So we don't have full data showing it's going to improve the ovarian lifespan, but if we follow the chain, it's exciting that potentially it could aid in trying to extend that.

Might be able to get one more question in. We've got about 3 minutes.

Okay, I'll make it quick and maybe somebody else can get one in.

So I'm certainly sold.

This is like really, really fabulous information.

And so the next question is, okay, so GLP-1s are awesome, especially microdosing for women, but there's so many of them out there.

Uh, so which ones are we choosing?

And if we don't have the luxury of getting them covered by insurance, is compounded options a good idea or not?

Compound. So the question of compounded meds is, you know, unequivocally for me, it's a hell yes. So I think it opens up— that might really not make people super happy here from whoever, but no, it's, it's an absolute yes. I think no one should be buying GLPs from the black market, period, full stop. Not the gray market. They need to be prescribed by a licensed medical provider that is ready to partner with you, tailor the dose, work with you, not write you a script and be like, "Bye, see you in like 6 months. Wish you the best of luck." Right? In my opinion, both work on inflammation, both impact long-term health outcomes. There's a little nuance in my experience. I'm curious to hear what you all think. I know tirzepatide is like the most amazing thing, and it is, but I think— and we use it in our patients— I think sometimes it has the propensity to bomb out people's appetite a little too harshly. And so a lot of times we start people on semaglutide, and I do say semaglutide because that is the proper way to say this, just so we're all clear. Um, but you can say semaglutide, that's fine too. I start people on that because it doesn't have the same propensity to really erratically and seriously reduce appetite to the point of malnutrition and improper fueling. And then we transition them to tirzepatide if they have side effects or if they stall on semaglutide. So that's how we approach it. But again, this is unique. This is per patient. It should be tailored to each individual person.

Do we do one more? And what's our hard stop? Someone tell me. They didn't answer.

No one knows.

We'll just keep going till we get kicked out.

We're the last panel, so they said I think we could run a little bit over and she would come in.

Okay, we'll run a few minutes late then.

All right, thank you. I have two questions. I'm a personal trainer and I I work with women in perimenopause, and I've seen a lot of lean body mass loss in the last 6 months from a lot of my clients who are on these medications. What percentage is too much? That's a great question. So typically what you'll see— and I'm not sure, you know, of your clients and where you've seen this— so it comes with where they came in. So what is their loss per week? I think that's important. And also looking at their macros and seeing where they're looking at that depletion versus restoration of their protein in order to substantiate that muscle build. Another good way of detecting what that muscle loss is, is to do a DEXA scan. Yeah, I usually start with DEXA scans and I follow them up every 4 to 6 weeks. Yes, and you're seeing still the loss there. Yeah. So this is where the body's adaptability has the ability to then push them a little bit more on the weight, and some women are a little bit hesitant to do that. But I think once you are able to really kind of push them up in the weight category, because we're kind of fighting a sarcopenia effect based on age, but then also based on the use of the GLP. So the other part of that, which is a good part, is depending on how long they're on and the dosage that they're on the GLP, it doesn't mean that they're just going to continually lose that muscle mass. So it's kind of having the foresight to being like, okay, for management of each particular patient, where do they start, where do they come in with, and where can I get them to maybe decreasing their GLP dosage in where they're not having substantial muscle loss. And also on the other end of that is using like supplements like creatine to help build the muscle, and then making sure that you're really trying to get them to adapt to more of that kind of a muscle fiber twitching and building with increasing their weight substantially. The body will adapt, but in, you know, in a slow and safe way. But I always say lift heavy shit.

I would like to add in on that, and most people are not building muscle because they're not training close enough to failure. They might be lifting weights, they might be going on a weighted walk, weighted vest walk. That is not enough to build muscle. You have to train either to failure or 1 to 3 reps shy of failure in every single set in under 30 reps. If someone could physically do more than 30 reps of an exercise, the weight is too light. Rep ranges we see even in perimenopause and postmenopause can range from 4 reps all the way up to 30 or anywhere in between. I like to stick around, you know, that moderate rep range that tends to be really comfortable for a lot of people. So like 10 to 15 reps. But I think that is one of the things that women are just not educated on how to do properly. So failure-based training, and, and this is for everyone in this room, this isn't just for perimenopausal women. Failure-based training means you are physically unable to do another rep. You don't have to get all the way there, but you do have to get close. How you know you're close is your velocity slows down. So if you can physically do your rep quickly, as quick as you could do your first rep, you're not close enough to failure. So keep going. So that's one of the things that we've seen and we've taught people how to do, and it makes an immense difference in their ability to retain muscle and even to maintain muscle. You have to be strength training close to failure. So it's not even— you can't maintain muscle by just going to your favorite group fitness class or walking with your weighted vest. It has to be close to failure.

Thank you. And my second question, can exogenous GLP over time affect endogenous GLP production? Well, it's not so much that it's affecting endogenous GLP, it's the fact that the GLP that we make in our bodies are such short-lived. And so it's the sustainability of a GLP use over time that it's able to kind of change the mechanism of the short-term one, which is the ones that we make. And so because they're close in how they're made, they're not the same thing, which is similar to estrogen. When we give estrogen in hormone replacement therapy, it's very close to what we make endogenously, but it will never cancel it out, I guess, if that's what you're asking. Yeah.

Hi ladies, this has been amazing.

Thank you. I have PCOS.

I range on the pre-diabetic range, and I basically—

oh, I also have hypothyroidism. I basically check all the lifestyle boxes. I'm a former collegiate athlete. I lift heavy shit all the time.

I eat well, I sleep, but I've been really curious about GLP-1s for myself lately.

So I have a question about, have you been able to see your hypothyroid patients come down in their dosage or having been able to stop their medications? And also, you briefly touched on the ability, like, once you know you can stop taking the GLP-1, so how do I know if I were to start, like, what those markers would be and that I know I don't need to to keep taking this for forever?

Yeah, so a couple things. When people are initially on a GLP, we often see a dose increase with their thyroid medication because of changes in the excretion of their thyroid hormone. Sex hormone binding globulin increases and their thyroid hormone levels tend to decrease. So initially we actually increase their medication a small amount. As you lose weight naturally, you need less thyroid medication, so you can ultimately have a reduction. But what we truly see is reversal of Hashimoto's, reduction in antibody levels consistently, which doesn't mean you don't need thyroid medication, but it means you'll need less in the future. And additionally, if you have one autoimmune disease, you're at an increased risk of over 30% of developing another autoimmune disease. Well, if we can reduce those antibodies measurably in lab data, I think we could infer that you're— you have a risk reduction for developing another autoimmune disease, which is incredibly powerful. So I know that was a long-winded answer. And lastly, we want to see really sensitive insulin, we want to see sensitive leptin, and we want to see a low hemoglobin A1c. If you guys know me from outside of this, I basically share absolutely everything freely— our thyroid ranges, everything. The only thing I don't publicly share is the numbers we found that allow people to come off of GLP medications. Maybe I will one day, but right now I can't do that. I'm sorry.

I just want to say, for PCOS, I find fasting insulin to be a much more sensitive marker of your current state of insulin resistance than hemoglobin A1c is. So if that's not something that's been checked, that might help you decide if you want to try medication or not.

Where are we at with timing? We need to leave? I don't think there's anyone in the room that is— Okay, who's in charge here? I guess it's me. I have. Okay, we'll take the last two then.

Okay, cool.

I'm Amanda.

I work on our women's health team at Oura. And so I'm curious, one, what information can wearables provide women to see if their GLP-1 is working and working both well and safely? And then two, what kind of clinical research would you like to see done in this space?

Oh, thank you for being here from Oura. Thanks for— you guys launched your women's health initiative about 2 weeks ago, so that's a great intersect to what is important. So there are a few things that are important. The reason why I like wearables is because it really validates an N of 1, like what is your personal data, so that you can attune it to what we come up with clinical guidelines and management, and it helps us manage you better.

One—

two things I would say: sleep. Sleep should improve when you use a GLP because you're decreasing inflammation, you're helping restoration of thyroid, you're also helping restoration if someone's at depletion of hormones. And they're on hormone therapy. And then the other thing is HRV. You know, HRV tends to change as we age, so that's the aging component. But then also for women, as they go through changes in hormones, you see HRV change. So those things that you can look for improvements through wearables that I find are critical, overlooked often, uh, when we look at like cardiovascular risk with HRV and then also with sleep. We know with sleep studies and sleep medicine, the decrease in quality and quantity that you get of sleep substantially increases your risk of diseases such as obesity, heart disease, and then also diabetes.

I would also say one of the most common side effects that I see with GLPs on regular or microdosing is dehydration. So as we lose our appetite, our thirst cues are also suppressed. And so people's heart rate increases, their blood pressure drops, they get dizzy when they stand. This is obviously especially an issue in Texas in the summer. So it might be interesting if you were to track, hey, one, is this person on a GLP? Two, is their heart rate increasing, which presumably means their blood pressure is dropping? And could you maybe cue, are you a little dehydrated? Perhaps you might need to, you know, hydrate more, consider electrolytes, etc. Thanks for being here.

Thank you.

Hi, thank you all so much for being here. It's been really informative and super helpful. I'm Sally. I'm a personal trainer. I've been—

I've had my own business. I've been a coach for about 2 decades, and I work a lot with people in improving their relationship with movement and food.

And something that I've been a little bit concerned with is people's relationship with their bodies after taking medication.

Specifically, I guess my, my very specific question is, how common practice is it to talk to patients about their maybe history disordered eating or body dysmorphia before prescribed or even just counseling to go along with medication?

So I definitely have something to say here, and this is going to be the opposite of what you all think I'm going to say. I never would have expected this. This is— put a pin in it— the most surprising thing I've found with GLPs. Mark my words, I think they are the future treatment of disordered eating at least I've found in the thyroid community, the most fascinating thing is what happens when people are metabolically disadvantaged. They begin restricting more. They begin beating themselves up about eating every time they don't eat well, every time they eat too much. It begins a negative cycle with food in their mind until they're a failure simply for eating because the effort that they are putting in does not equal the outcome that's happening. Okay. What GLPs do, what I've seen them do, is allow these women to rewire the relationship that they have with food. And I'm not kidding and I'm not exaggerating because now every time they cheat on a weekend, they go out for happy hour, they don't gain 5 pounds. They're like, okay, I'm not a failure. I'm actually going to be okay. And that is reaffirmed over and over and over for months, years. Until they don't look at food as the enemy, they don't look at themselves as a failure, they look at food as fuel. It removes the power from food in so many cases. And I will tell you guys this, this is a safe environment. I have used it in about 5 patients with an eating disorder, with therapists involved, with family involved, and the, the results were profound, y'all. It's It's, it's pretty incredible.

I will just echo that with exercise. Again, you were the one prescribing it, so I would be interested to hear what you think about this, but many people over-exercise because they're trying to make themselves smaller, they're trying to lose weight. And when they find, I don't have to do that anymore to lose weight, they could change their relationship with exercise as well and start exercising to build muscle and for metabolic health and for overall health, since exercise really doesn't make that big of a difference for weight loss anyway. So I think I could see how it could potentially improve your relationship with exercise as well, but that's just theory.

So insightful.

My, uh, take on this is the educational part of it. We have a poor relationship with food in general, uh, in the westernized world, and we are constantly flooded with images and food that's convenient but not healthy for us. So the educational part of it, for my patients specifically, when they want to go to a GLP, I have them see my functional nutritionist first. Because once someone has the ability to make better choice through education, then they actually will usually do that. But most people didn't know. And so whether that comes with food logging and seeing, oh, with— it's not always removal of food or restriction of food, it's sometimes addition of better choice of food. And then understanding macros and how to shift that narrative between lower glycemic foods and increasing your protein. We also make sure that we run vitamin and micronutrient deficiencies to make sure that those are not depleted as well. So once you kind of put in there an educational background, then people actually will say, I get to make choice because I know better. And I think that that's important as well, because what routines and habits that we've built over the last 30 years is usually fueling this bad relationship with food, as well as specifically for women, this diet culture of what we're supposed to look like. So body image is very important. The BMI is not even a good tool of what's healthy. So I think the more we move away from that and we give people more educational value into what choice they can make, then they can make choices for themselves.

I'll really quickly just say there's definitely people prescribing them for patients who don't need them, and we are completely seeing a shift towards, you know, skinny culture coming back. What we're talking about on stage is using them in medically appropriate patients, which might be in a micro way, but patients who are going through hormonal shifts, who have unexplained infertility, who have inflammation, autoimmune disease, and those patients have had a disordered view of their body failing them most of their life. And to echo what McCall McPherson said and what Dr. Shepherd said, when suddenly you're helping them be more metabolically healthy, they view their body in a loving, healthy way where it has always been the enemy. So I think when utilized appropriately, they're a tool to a better more positive body image and love of your body and less disordered eating. But yes, we see celebrities on the red carpet last night who look very unhealthy. And so there's overuse in the wrong patient population. We have to acknowledge how it's influencing younger girls and making sure that we're talking about this in the appropriate medical context.

Just one last thing that all of us have said, it is all of this that kind of goes to the narrative of, you know, body image and what you were speaking to in your question. Is that there was so much we were managing in, "I have to do this, I can't do this." So it's like taking over your mind. And I feel that the GLP and the quieting of the noise, the food noise, and the ability to metabolically restore, it actually takes more off your plate that you have to manage and allows you to focus more on the things that are actually helping you and aiding you rather than pushing against you. So I do find that it creates somewhat of a I'm going to take that off your plate so you don't have to worry about it, so you can focus on the things that are actually helpful for you.

Yes, I, I want to wrap this up, but also just, this is such an important conversation, this last question, and I just want to make sure we're saying all the things. But if you're working with a good provider, they would screen that and they would take you off of it, or— and all of you are great providers, and you would see red flags if you were coming— if your patient was coming to you with too much weight loss. So I think that's a huge part of the conversation as well. But thank you so much for that. That amazing question. And thank you all so much for coming. I know we went over. Appreciate you, panelists. Thank you, audience. Appreciate you. Please follow up with all of our panelists on the screen.

See you all next time.