Semaglutide, Ozempic, and Mounjaro - Are these the Magic Obesity Solution? With Dr. Rocio Salas

Today on Midlife conversations, I've got Dr. Salis Whalen, who I've been following on social media. She's triple board certified internal medicine, endocrinology and obesity medicine. And what got my attention about horror, her social media was talking about the trendy drug right now, Ozempic. The thing that everyone's accusing people that have lost weight of being on. The thing that's also been helping a lot of people. I have so many questions. I am completely clueless when it comes to this medication. So thank you so much for being here today.

Thank you for inviting me.

Okay, so first and foremost, we know this is a trendy topic right now, but how did this even become part of your practice? When did you make this shift to going, I need to include this in my practice? I know you've been dealing with obesity for years and years and years.

So when I finished my fellowship in endocrinology, a new drug got approved, was named Bayetta in 2005. And it was the first in this class of drugs that were so popular. Right now there are GLP ones like the class, the drugs that are called incretins. And in 2005, when the first one was approved, it was with the indication for type 2 diabetes. And being an endocrinologist, that was. That's my bread and butter in endocrinology is type 2 diabetes. And I started using that drug then, and then eventually a newer one, which was Victoza in 2010. And while I was using it in my patients for diabetes, it was really interesting. Patients were coming back not just with better glucose control, but with weight loss. And that is something very rare that we didn't see in any diabetes medications either. We got the glucose control, but we never saw weight loss with it.

Right.

We had to tackle the two things differently and separately. And for the first time, we had a drug that we. That it was tackling both things in one drug. So eventually I started using it off label in my patients for weight loss. And then the indication came for weight loss in 2012, and then the rest is history.

Right.

But really, I've been using these drugs for. Since the beginning that they started.

Got it. Okay. So you've seen this whole, like, evolution of this now. Where did it become when you see somebody that's obesity dealing with this, how do you go from let's, let's try you on, you know, let's just change your habits with nutrition, with workouts, with all of these things. Let's try supplements to these, to these drugs and then to the extreme where some people actually have weight loss surgery. How do you decide like who's ready for something like that? And because, and I know there's a huge stigma around obesity, especially in the United States, my gosh. Of people just saying, oh, it's because they're not doing these things or they're not working hard enough. So how do you know, like how do you navigate that and know when it's time for those things?

So we have guidelines on when and who to use these drugs, right? So the current guidelines, the current clinical guidelines by the Obesity Society, the Obesity Medical association, the Endocrine society is a BMI of 27 + one comorbidity, which could be high blood pressure, high cholesterol, pre diabetes, osteoarthritis, sleep apnea, then they meet the qualification for being prescribed weight loss medication or a BMI equal or greater to 30 without any comorbidity, then their there meet the criteria for weight loss medications. Now definitely what I practice in my office, I stick with the guidelines for sure. But I also do the BMI is not the best tool or the tool that we should be using to classify somebody using, needing or not this medication. The BMI is a very antiquated, simple.

I was going to ask you about that because sometimes like, like I know with people that have less than £20 lose, I'm like, this isn't even an indicator because you could have more muscle, you could have this. So I can ask you about that.

So I really don't go by the bmi. I go more. I do body composition in my office, right. I measure visceral fat, I measure percentage body fat, I measure muscle mass. And according to that, I make my recommendations. And it's not just to start the medication, but also to guide me in the goals of the patient.

Right.

I tailor their goals according to, according to their, their metabolic internal numbers, not the BMI or the number in the scale.

Got it. And then do you take lifestyle habits into consideration? Like, like I would assume, I mean, I'm guessing you're the doctor, not me. But if somebody comes in and if it's very different, if they've been working really hard on what they're eating and moving and they've been doing all these things and they're not moving the needle because they've got these, this genetic markers or whatever it is. And then there's the somebody that really hasn't even attempted to do that. Do you start them first on a healthy eating plan? What do you do?

Well, I have to Say that unfortunately for many of my patients, I'm their last stop, right? When they come to me, they've done everything. I hear of diets that I've never heard in my life from patients that they've done. I mean, some patients have struggled with weight for decades, since childhood. So I have patients that told me I had my first trainer at age 12, I went into my first diet at 9, I went to a fat camp at 12. So the patients have done the legwork, right? I mean, I haven't met, I haven't had a patient cross my door of my office that is not exercising, that is not knows what should be eating, that has not tried the trainer, the extreme caloric restriction, the extreme workouts, right. The fasting, the cleanses. I have not met a patient with obesity that hasn't done some sort of work.

When you, when you look at obesity, when you say obesity is there, do you have, do you define a certain amount as being that? Because I think that like there's such a range, right? There's, there's the women that have a few hundred pounds, like extra, and then there's a few that, that they're calling themselves obese that have 20 pounds to lose. So how do you even decide what is and what isn't again?

From, from their internal numbers, right? I, I mean the general, I think view or the general consensus is using the B, the bmi, right. But thank, thankfully the American Medical association came last year saying that the BMI should not be the tool to diagnose somebody with overweight or obesity.

Right.

So I base more my numbers in their percentage body fat, in their visceral fat and in their muscle mass. And then from there I categorize the patient, right. And where do they fit?

Now when I would work with people that have an excessive amount to lose, I have experience with some of them that came to me that did surgeries. You know, they had the sleeve, they had their, they had us an actual surgery. And when that happened, they would lose their teeth, you would see their hair change. Like they had a lot of horrible side effects from that and they, it's like they were presenting as malnourished after. Is that similar stuff happen when somebody jumps to a medication? And why does that happen with weight loss surgery?

So I think unfortunately it is a risk. But I say this so many times and I will never get tired of saying it, the efficacy and the safety of the drug is going to depend on the expertise on who's giving this medication, period.

Right.

If you're Going to somebody who's not an obesity board certified or an endocrinologist, they may just concentrate on the number on the scale.

Right.

And you come back a month later, you lost 20 pounds. That's fabulous. But you lost six of six pounds of muscle and your percentage body fat might have gone up.

Right.

So if we base our success in the scale or in the bmi, we will be missing many things, including the possibility of causing or making the patient skinny fat.

Right.

So many times. And I now that I have way much more information on what is weight loss and how a complicated process it is. And it's not just dropping the number on the scale. I wonder how many people we made skinny fat.

Right.

Just by concentrating on the number on the on the scale and being happy with. Because somebody lost 30 pounds in one month.

Sure.

When probably they lost muscle and their basic metabolic rate went even lower, their metabolism got worse. So we haven't been doing the proper things.

Right.

That the weight loss drugs may be not new, but the way that we are evaluating how people, people is losing weight, that is new. And when you go with an obesity specialist, they're not just going to be happy that you're losing weight. They're going to make you strong fit. Having more muscle than body fat at the end of the journey because that's health, that's longevity.

Yes.

Having more muscle mass than body fat.

So there's a lot of risks that I hear and I'm going to, I'm going to ask you in a few minutes about just the people are doing this for cosmetic reasons like that last five pounds. I actually know people doing that. So I want to talk to you about that. But what about the, the risk like when you go off of this medication, is that also based on provider? Because it's my understanding and it helped me understand this because I might be explaining it totally wrong that like Ozempic manipulates your insulin, it changes how your body and it changes your gastric emptying like so it slows down the process. So if one does it do those things and two, what happens when you stop it? Or do people have to be on it for the rest of their life?

So to answer that question, we have to go way back to the basic and what's obesity and what's overweight?

Right.

Obesity and overweight are not a lifestyle problem. It's not the lack of exercise, it's not the lack of nutrition. It's part of it.

Right.

But obesity and overweight is multifactorial. There are more. There's about five if I put them broadly, factors that can contribute to weight gain and obesity. One is lifestyle as we mentioned.

Right.

The other one, which is probably two thirds of the cost is some genetic background, some hereditary, some family history without an necessarily being a genetic mutation. There's other cases of obesity that are more severe that they're detected in childhood. But just the person, the regular person that doesn't have that. About 40% of their weight or obesity or weight determination is already genetically predisposed by your family history. Then we go to aging, it's another factor.

Right.

As we age, our metabolism slows down. Then we go with hormonal changes as a cause of obesity awaking like in women, classical pre menopause, menopause, the drop of estrogen. And then we go to environmental factors where we live. Is it promote walking, is it sedentaries? And do we work from home, the food industry.

Right.

So do we sleep? Do we not sleep? And we live in an industrialized world that promotes obesity and weight gain. So it's multifactorial. So if we concentrate on the patient maintaining their weight loss only back to the basics, we're missing the whole point. All of this, all the other factors are going to promote the patient to regain the weight.

Right.

It's not the lifestyle that is going to maintain the weight loss. So that's why the medication are designed for chronic long term use. Because obesity is a chronic.

Got it.

Multifactorial disease. We don't cure it, we control it.

That all makes sense to me. So now what doesn't make sense to me is the people using it to lose those five pounds, they'll lose the ten pounds to microdose it to do. Help me understand that because. And I actually have some friends that did this and it's interesting because they got like they dialed it in and they looked and then they stopped it and they gained it all back and they're, it's just to me, I was like what's, what's the point of this? So can you speak into that?

So there's two points to make there that are really important. One is what are we basing that estimation on?

Right?

Are we basing that estimation of those £5£10 on a BMI on, on what?

Right.

Because I've seen many patients that they may have a normal BMI and they have high percentage body fat, they high visceral fat that they will benefit from the medication.

Right.

That's one that by the simple eye we cannot say who does and who doesn't. Need the medication because they may look slim or thin or skinny because they don't have muscle mass, but not because they don't have body fat to lose. That's number one. And the second, the question that I always, that I can base that decision is, okay, you have ten pounds to lose. What in your life is it costing you to be this weight and to try to achieve those 10 pound weight, pounds extra?

Right.

So does it become a full time job for you? Is it taking most of your, of your daytime thinking, planning, exercising, what extremes are you having to do to do £10 or £5 more? Those patients may benefit from the medication.

Right.

What about side effects for those people though? Because like I definitely heard of like some gastric things and then they're insulin.

So the side effects are going to be the same for somebody who has to lose £100 to somebody who has to lose £5 and it's going to be muscle loss, dehydration.

Right.

Wow.

And depending on the class of drug, there may be nausea, like with the older drugs. Okay. Now we're going to say it's almost older because there we have newer drugs. But with the newer drugs, which I have to mention tirepatide, which is mounjaro sep bound, we don't see nausea, we don't see constipation. So really. And this is, and this is the future of the weight loss medications.

Right.

They're going to become more sophisticated, more effective and safer.

Wow. So what is your prediction here? Because like we always, you know, say in fat loss and weight loss, there's no such thing as a magic pill. Like there's no such thing as a magic pill. And I teach it.

There's not. It's a magic injection.

Yeah. So that's what I want to ask you. Like, is this the magic injection? Like, do you really, do you think when you think of the future, do you think obesity will be gone? Like, what do you think?

I'm going to tell you, I think that what we are witnessing right now is the biggest event in medicine that we've had probably, I don't know, in the history of medicine. Because I would say this is even bigger than insulin.

Right.

Because insulin was only for the patients that had type 1 diabetes.

Yeah.

This is for people that have obesity and overweight. And I mean it's predicted that in 2030, almost 50% of the population is going to have obesity.

Right.

Yeah.

So I think that this is really going to change the way that we live. I think we're going to Live longer and healthier lives. I think there's going to be less cancer because there's many cancer produced and associated with obesity and the visceral fat.

Right.

That it's an inflammatory tissue. I think the way that we practice medicine is going to change because of these medications. If you think about it, we've created specialty subspecialties from obesity for the complications of obesity. I think we've been very comfortable because that's what we knew and that's what we only had to work with, was treating the complications of obesity because we didn't have anything to treat the causing.

Right.

So now we, we have what to prevent all those complications from.

So when I've heard that these are originally created for type 2 diabetes, is that, I mean, is this kind of go together or what is it about the insulin that this helps with that? That's why that was originally created with that.

So this medications, they target, they target in regards to weight loss. They target two reasons that we humans eat.

Right?

Okay.

In regards to diabetes, what it does, this, this medication, this, it's a hormone. It's a synthetic hormone. GLP and creatins are hormones. What they do in the pancreas. When your sugar goes up in your blood after eating, as an example, they work in your pancreas to produce more insulin. That's how it works for diabetes.

Right.

So you're making more insulin, you're making your pancreas work better when your sugar is high. But if your sugar is normal, it's not high, it doesn't stimulate the pancreas. That's why we don't see hypoglycemia on these medications. That's why we can use them in non diabetics.

How is this different than like metformin? Because, like metformin would reduce your blood sugar. So is it. Do they operate sort of similar metformin?

No, Metformin, what it does, it increases insulin sensitivity in the tissue. Oh, so it helps your insulin that you're making work a little bit better, but it doesn't help your pancreas make more insulin. Otherwise we would use it for type one diabetics and we don't.

Right.

We use it only for type 2, so it doesn't affect the pancreas. You don't make more insulin with metformin. It just makes the one that you're making work a little bit better in the tissue issues that is going to have an effect like the muscle, the brain, the heart.

Right.

But in regards to weight loss, these drugs, because I think it's important that we explain how they work and how they differentiate from bariatric surgery. So what they do, these drugs at your gut level, they increase your satiety hormones when you start eating, and they decrease your hunger hormones in between meals. So what it looks like is you get full with maybe half of what you normally would need to get full, and then you'll be full for six, eight hours, and then you'll get hungry again, but then you'll feel full again. So you're content with a half of what you normally will.

So it ends up being like somebody that actually doesn't have a weight issue. Like how that person is typically eating or hungry. Is that.

Exactly. It changes the behavior. It helps you know how to feel full again and eat when you're hungry and not eat for. Just for eating. Then in the brain, in the amygdala, in the hedonistic eating and drinking area, it takes away the anticipation of our real reward towards certain food or alcohol.

Right?

Yeah.

So one thing is you feel hungry, you eat and you're satisfied. But another thing is that you're thinking, oh, I want to have this pasta, I want to have a glass of wine when I get home. You are anticipating a reward of that. So this medication takes it away. So you eat when you're hungry, you enjoy it, but then it's out of your mind.

It sounds like too good to be true. You know, like, it almost sounds like, so help me with that, because there's got to. There's a ying and a yang to everything. So, like, I think about, well, first of all, I have actually seen people that didn't have a lot to lose do this and then go off it and have rebound effects. Like, now they've got high blood sugar, they've got things going on. So what, what is the danger of this?

Well, the danger of this is that the people that are prescribing this drug, or whoever you're getting the prescription for, are not educating you about the drug.

Okay.

Right.

This drug does not replace a healthy lifestyle, does not replace healthy eating as healthy eating. And a healthy lifestyle doesn't replace the effects of the medication.

Right.

So they work good, they work better together. So you need somebody who's going to guide you, your lifestyle around this drug. It's not like, here you go, I'll see you in three months, and good luck. You have to tailor their nutrition, tailor their physical activity, their exercise, their hydration.

It's not to take this and eat everything. You're still doing all the things helps you eat it.

By the way, the few patients that don't lose weight with this drug is because of that. Because the caloric density, even if it's half a portion, you may have lost in calories, will that we never catch up.

So here's my, here's my struggle. I'm just being honest with you. I'm just going to be honest. So I am. I've been fat loss expert for years. Fitness, nutrition and I teach this and I've helped people lose £100 plus. I'm not, I'm not you, I'm not a doctor. I don't do it that way. But in my mind and I, and I believe me, I get. Obesity is a very real genetic. There's a lot going on there. I don't think people are lazy and that's why it's happened. I don't believe that at all. But I'm having a hard time with the quick fix mentality because I've always taught let's do it, let's change our relationship with food, let's change our mindset, let's, let's do our movement, let's use supplements. And so I'm struggling with that. And I'm also not naive. And if there's something that really could help people, because here's what I also look at. Even if there's side effects, if this is going to also reduce your chances of cancer or type 2 diabetes complications or like all these, these other things that go with obesity, then what's the payoff like? To me I'm like, well, yes, there's a slight risk, but if this is really going to help with all those things, I'm torn. I'm just being honest with you. Like, that's why I'm trying to understand this.

Yeah. And I think it's, it's a great question and I think it's really important to clarify that this is not a quick fix.

Right.

Again, when you go to the. Went to the. It's just, I cannot like emphasize it so many times because my goal and I'm going to talk about how I practice medicine and how we should see this medications is not a quick fix. It's not you losing £10 and in two weeks.

Right.

It's not getting you into that Met Gala dress. It takes time.

You don't take that. You don't take those. If somebody comes to you with that, you see through that.

So let me tell you what my goal and this is what body composition is so important.

Right.

Because I Always tell patients the healthy weight loss is one to two pounds per week. Anything more than I say you're losing muscle.

Water muscle.

Yeah. You're so a person that has. And I have a patient that lost 170 pounds, that's the one that's lost the most. It's going to be a year and a half. Right. If you think about per week with ups and downs through. So it's not a quick fix. And, and that patient right now is 170 pounds less with and her body composition is higher muscle mass and lower percentage body fat. So it takes time and you know that it takes time to get the patient totally to do that.

Right.

The problem is, is when you go into this med or you're getting it online and you're losing that concerning in two weeks, then you're losing muscle and you're dehydrated.

And that's why we're having the problem.

Yeah, that's a problem. And those are the people that are going to have those side effects that were that we're listening. Why? Because this medications were tested in control settings with supervision. So we mimic that in our office. I see patients every six, eight, ten weeks.

Right.

Just to make sure that they're tolerating, that they're safe, that they're losing what they need to lose and not muscle.

Right.

But if, if you're seeing somebody telemedicine, they're not doing body compositions, they're not taking your history. When did you started struggling with weight? What is your relationship with food then that that's wrong. That I do not support that and I cannot promote that.

And then in the biohacking space, I definitely see people microdosing this now have you heard much about that? Where they're taking like somebody that's already fit doing these microdoses of it.

I mean I'm sure you know this is. Unfortunately there's going to be people that want to take advantage of. Of what's happening.

Right.

I do feel that it might have use in certain situations where patients are athletes, they're exercising six hours a day, they're eating super healthy. But maybe their metabolism, maybe their genetic background is not allowing them. Can we use this to help them achieve that but under the right supervision?

Sure.

Maybe. Maybe again it's per case basis, it's per patient, per lifestyle basis.

Not that anyone's asking, but here's my opinion on it now based on talking to you, I think if you've got like that five or ten pounds and you're just trying to do this to fit in and be trendy or whatever. Like, forget it. I feel like you're risking. I think you're messing with the wrong things. But if you really are struggling, like you're saying with obesity and you've truly gone through all of this, I can't relate to what that's like personally. So I can't blame people for wanting to correct their health there, because it does. We know that obesity shortens your life, but even with.

And I respect your, your opinion and we all entitled of our opinion, but it's not like, oh, you're gonna lose five pounds, but you can, you can maybe end up dead. No, that's right. Okay, don't, don't. They're. They're very safe again when they're used by somebody who use them often.

And would you, Would you do it on yourself? Like, would you do it on yourself? You would because you see it actually.

First time I'm saying this, but I did it when, after my second child. I gained, you know, in my first pregnancy. I've always been exercise fit.

Yeah.

But after I had my kids late, I had my first one at 38 and the second at 39 in my. And I. Look, this is my story. I was very restricted growing up in my 20s and in my 30s, exercising two hours a day, six hours, six days of the week. I had. I ate Paleo, I didn't eat any carbs. I. I made my own flour with almond flour. Yeah. I was like a nut and I loved it and I felt great. But when I got pregnant with my first kid, it was like a switch. I was like, oh, I'm allowed to do this. I can do this if I'm pregnant. I can have a cupcake. I can do this. And I gained 70 pounds.

Yeah.

Right.

So then I got pregnant within five months of that, of having my second baby. And then in that one, I was more controlled, but I was already carrying so many. And then I had my second one, so I ended up with 30 pounds that I couldn't lose. And I was a fit person. I knew what to do. But I was struggling. You know, I was in my early 40s now. Yeah. Use the medication. And I got to where I, where I went back, and now I found a balance because I cannot spend seven days, six days in the gym, two hours a day.

Right.

Yeah.

It's just finding that balance. Having a very restrictive life is also. It's not good.

Yeah, no, I hear it all. This is just all so interesting to me and so new and I, and I. The reason I wanted to interview you is I don't want to withhold information. Like I want to share this. I want, if this could help somebody.

You know, I think, and I think it goes for a lot of, of the personal trainers and the, the, the, the physical, the training business.

Right.

I think it's not. I don't want them to be afraid. We're not going to take patience and I think, think we need you more than ever.

Oh, I think it works together. It works like you said, they'd have to learn the lifestyle. Yeah.

I've never referred so many patients to physical trainers, personal trainers, as I do now with the weight loss medications because I want to prevent the muscle loss. I need a personal trainer, a lifestyle coach to help them maintain their muscle, their nutrition habits. It's like I feel like we need each other more than ever for the goal of the patient.

I'm with you on this. No, this is fascinating to me. So what I'm hearing through all this too is a big red flag warning about where you're getting this done and who is doing this. Because I do see the med spas and all the random like, like that's what scares me too.

And then you get the compounded medication that we, I mean the, all the obesity societies, the endocrine society, the bariatric society, they came with a statement probably like two months ago of all advising against compounded medications because they're the side effects and bad things that we're seeing is from not regulated.

Right.

The compounded medication and usually those compounds are sell in the med spas and they sell it for syringe. So then we go into that not properly supervised regulated service.

Got it. Okay. Makes sense. Yeah. I'm. And I use compounded bioidentical hormones, so I hope they don't shut down compounding. But, but I hear you on the. On.

No, for semaglutide. It was for semaglutide.

Specifically for semaglutide. Yeah, for semag. Semi. So. Cause there's so many names. So semi, glutide, Zenpak. Are they all, they just all different versions of this or how do you know?

So semaglutide is a drug, Right. Semaglutide is a molecule. Ozempic is the branded semaglutide for type 2 diabetes. But Golby is branded semaglutide for weight loss. And then we have tirzepatide, which is our newer of the bunch, I like to say is the iPhone 15 of the class of the drugs and at Mounjaro and Sepam, which is the same drug, same pharmacy.

Got it. Okay. No, this is fascinating. Thank you so much. This was super helpful. If people are going to. Can people work with you from all over the country or how does that work?

Yes, I do. I do telemedicine. I have international patients. I'm based in New York City. My office is in. On Park Avenue in New York City, but I do telemedicine.

Amazing. I'm going to link all of your information. Thank you so much.