Understanding Weight Loss Medications and Heart Health
Episode overview
Struggling to lose weight often feels like a losing battle, but the latest medical research suggests the challenge is often biological, not just a matter of willpower. For those managing obesity, metabolic adaptation—where the body actively works to regain lost weight—can make sustainable change feel impossible.
In this deep dive, we sit down with board-certified cardiologist Dr. Pamela Rama to pull back the curtain on the science behind modern weight loss medicines. From explaining how GLP-1 and GIP receptor agonists work to signal satiety and extend the half-life of natural hormones, to navigating insurance coverage and managing side effects, Dr. Rama provides a comprehensive look at the treatment landscape. She explains why viewing obesity as a chronic medical condition—rather than a character flaw—is the critical first step toward reclaiming health. Discover how these interventions are doing more than just helping patients lose weight; they are reducing inflammation, protecting heart health, and offering a legitimate path to long-term vitality.
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Episode Transcript
I have Dr. Rama, who is a board-certified cardiologist who also helps run a weight loss clinic, but it's more complex than that. I am excited to have you here. We're going to talk all about weight loss and some weight loss medications, but I thought first we'd touch a little bit about your background as a cardiologist and why you decided to start a clinic that helps with weight loss, too.
Thanks so much. I'm so excited to be here to talk to you because I have a passion for treating obesity. I am a board-certified general cardiologist. I like prevention. Several years ago, I started noticing that most of my patients have obesity as their primary problem. They may have coronary artery disease, hypertension, or diabetes, but 70% of the patients that we see in our cardiology practice have obesity.
I started going to lectures about obesity, and we figured out that there's a big effect if we deal with our obese patients in a different way. That's how I got started with it. Here at Baptist Heart, we started the Cardiometabolic Clinic. It's not just seeing patients who are being consulted for patients who have obesity, but we deal with complex patients. These are patients who have obesity and diabetes. They have all the risk factors, such as CKD, liver problems, and coronary artery disease.
From a heart health perspective, why is weight loss so important?
It is so important because we know, first of all, that obesity has been associated with so many other diseases. Coronary artery disease is one of them. It causes a lot of inflammation, so because of that, you end up with coronary artery disease and hypertension. That's the first thing that you see when you treat obesity. Dyslipidemia is affected by that.
A lot of these things are intertwined. It's time to look at the patient as a whole and not treat them as silos. A lot of times, when we have complex cardiac patients who have all of these metabolic risk factors and the endocrinologist takes care of the diabetes part and the obesity part. The internal medicine takes care of one other part, and then we get to take care of coronary artery disease. We're trying to shift looking at these patients as a whole and targeting all of these risk factors to give them better outcomes.
I love that. What do you think is one of the most common misconceptions about weight loss?
Years ago, people were considering patients who have obesity as not having willpower. They always say, “You tell them to stop eating, and they should lose weight.” That's not the case. We know a lot about obesity in the pathophysiology of obesity. It's not a matter of people not having willpower. A very important study that I think a lot of people who study obesity should know about is Sumithran’s article that came out in the New England Journal of Medicine in 2011. It highlighted that obesity is not just because you want to eat all the time, and you don't have willpower.
They took 50 patients and put them on a strict diet. You're talking about 500 kilocalories a day. These patients lost a remarkable amount of weight, like 30 pounds, which is very good for their lifestyle. They followed these patients, and they took hormone levels. They took the hormone levels of the ghrelin, which is the hormone that makes you feel hungry all the time. They took the hormone levels of the hormones that make you feel full, such as leptin, CCK, and all that.
After eight weeks of intensive diet, they told the patients, “You can eat whatever you want. Let's follow you through the year.” They stopped the intervention after eight weeks. What they found out was that all of these patients started regaining their weight. What happens is that your body thinks, “I need to get you back to your original weight.” All of this metabolic adaptation was sustained for years. The ghrelin levels were still elevated, and the hormones that make you feel full, those levels were down for at least one year.
It points to the fact that for people who are obese, this is a constant battle for them. This is not something that's fixed with a three-month diet or, “Let's go on a keto diet and lose the weight. They will eventually gain it back because of this metabolic adaptation. Thinking of it as a disease has changed our approach to obese obesity as a whole.
That makes sense. People are understanding that it’s so much more complex. The whole eat less and moving more is not exactly a true concept for people who struggle with obesity. It's wild how all those hormones have such a huge effect. For somebody who has been trying to lose weight, when should they stop trying to do it all on their own and talk to a doctor?
Even for overweight patients, if you have a BMI of 27 and you have risk factors like hypertension and obstructive sleep apnea, you should be seeing a doctor and talking to them about obesity. As medical professionals, we should look at the BMI as the fourth vital sign. We deal with their hypertension and their heart rate, and we ignore BMI. Every step of the way, once you see patients starting to gain weight, you need to be talking to them about a healthy diet. Not everyone needs to go on medication, but if you want to interrupt this and start them with this healthy lifestyle, starting it early on is the best way to go about it.
Who do you think would do best in a medically supervised weight loss program? Who would be a good candidate for your clinic?
For our clinic, ours is a little bit unique because we take care of patients with underlying coronary artery disease. A lot of our patients have had strokes and heart attacks. They have congestive heart failure and obstructive sleep apnea. We address obesity as a whole. When we see our patients who have obesity and have all of these other risk factors, we do try to address the weight at that point.
That makes sense. You touch on it a little bit, but are there certain conditions where you say for this person, “It is especially important that you lose weight?”
Yes. Patients who've had prior heart attacks. If you have peripheral artery disease or prior strokes. People with congestive heart failure, particularly the HFpEF population. Those are the patients with heart failure because their heart is very stiff, and it doesn't relax well. People with obstructive sleep apnea and diabetes, and patients with CKD. Those are the patients that we probably deal with in our practice.
It is wild. The body is so complex, and it's all related to each other. These diseases that we see, for a lot of them, inflammation is such a driving factor. With the weight gain, all that inflammation goes up. A lot of people probably don't realize how much it is linked to and how much it can help with some of these diseases. Before taking medications, what lifestyle changes would you say matter the most?
Diet is the thing that causes you to lose the most weight. It is easier to reduce your energy intake by 500 kilocalories a day rather than burn 500 kilocalories a day. Diet is the mainstay for losing weight. There are people who can do different kinds of diets. There are people who do very well on a low-carb diet and a high-protein diet, and there are people who don't tolerate the low-carb diet. It needs to be tailored to our patients.
What we normally recommend is that you have at least 70 grams of protein a day and that you eat the protein before eating the carbohydrates so that your satiety is reached earlier on. You have healthier food in you rather than concentrated sweets or processed sweets. We tailor the diet depending on our patients. Being cardiologists, the diet that we recommend the most, because it has the most data, is the Mediterranean diet. It incorporates grains and healthy vegetables.
People don't realize this, but the Mediterranean diet did allow meat. They allowed their patients to have maybe 1 or 4 helpings of meat a month. The most important thing is incorporating healthy fats like avocado, olive oil, and nuts. As cardiologists, that's the one that we adhere to. If you can be plant-based, there's a lot of data there. Plant-based is probably better than not being plant-based. However, for the Mediterranean diet, if you stick to the principles of that, that's a good diet to start with.
There's so much data on that, and even in terms of dementia prevention. It makes sense because a lot of the same factors that cause cardiovascular risk also increase your risk for dementia. There's so much there. That touches a little bit on the nutrition aspect. Is there anything else that you wish people understood more about calories, protein, and food quality for weight loss?
You want to stick with the high-quality food, the food that gives you the most energy. Sticking around 1 to 1.5 grams of protein per kilogram is what we recommend. It can be anywhere between 70 grams of protein and 110 grams of protein. Half of the plate has your healthy vegetables. You don't want the starchy vegetables. You have some protein in 1/4 of the plate. The other 1/4 of the plate is your healthy fats. There are so many diets out there. It’s getting away with the sweetened drinks and getting away with the concentrated sugars are the things that we would recommend.
People don't realize all the sweet teas and sodas add up quickly. How important would you say exercise is for weight loss versus for overall health?
It is very important for overall health. It contributes around 20% of the weight loss. The thing with exercise is that it helps you maintain weight loss. We want that to be a combination, so we recommend 150 minutes of exercise a week. We recommend that you do some cardio and strength training, particularly with our patients who are on GLP-1s, because you do lose some 30% of muscle mass and around 70% of fat mass. You'd want to maintain that muscle mass. Strength training is important in this case as well. We recommend they exercise 150 minutes a week. We exercise a heart-healthy diet. We also emphasize sleep. Sleep is also very important.
It leads me into the next question. How much does sleep affect weight loss in terms of appetite, cravings, and people's metabolism?
It's very important. When people have the graveyard shift, the first thing that happens to them is that they start gaining weight. Sleep is so important. It regulates everything. You want 7 to 8 hours of sleep. If you have less than that, it increases your risk of obesity, diabetes, and weight gain. It all affects that. What we know is that the lack of sleep increases your ghrelin. Remember, your ghrelin is a bad hormone. It makes you feel hungry all the time. When you're awake at that time, you tend to eat more. It increases your ghrelin and your calorie intake by 300 to 500 kilocalories by working at night and staying up late.
I believe it, though. I remember in residency, those overnight shifts were always when I would grab the junk food and the chips. You're tired. Your willpower is not there. You have all of these other background things, like your ghrelin increasing.
When you're stressed out, the reward center of your brain is telling you, “Give me something that makes me happy.” What is that? That's usually carbohydrates. You have bad choices at night when you're not sleeping well.
How would you say stress makes it harder in terms of weight loss?
Stress is also a very important thing. You've heard about people who are stress-eating. You have increased cortisol levels when you have a lot of stress. What it does is you're constantly in that fright mode. When you're in flight mode, you want to conserve energy. What happens is you have a lot of visceral fat, which is not healthy fat. This is the inflamed fat that people tend to store when they're under a lot of stress.
Stress also leads to poor sleeping habits. It's a vicious cycle. You have people who become obese because they're not sleeping well, and they're eating more of the bad calories at night. The body is used to the circadian rhythm. The body knows that you should be sleeping, and you shouldn't be eating. It doesn't know how to process all of these carbohydrates that you're eating late at night. Telling our patients, “You need to have at least 7 to 8 hours of sleep a day,” is very important.
The next topic would be weight loss medications. They're all the rage. I feel like everybody has heard of Ozempic or Wegovy, but maybe start with the main categories of medication that people should know about.
There are oral medications that we're not using as much. You were looking at the GLP-1s. There are only two GLP-1 formulations that are approved. One is the GLP-1 agonist, which is semaglutide. The other one is a GLP-1 GIP combination, which has two incretin hormones. That's your Tirzepatide. Those are the two major categories of the injectables that we're using. Everything else is not FDA-approved. If you're getting something else besides these two medications, you're probably getting it compounded. Which has a lot of different issues that we can talk about later on. Those are the main categories of the newer injectables that we're using. We get very good results when patients start taking these medications.
With every commercial that comes on, there’s at least one for these new medicines, so I feel like people have heard of them. A lot of people don't understand how they work. I know it's complex. There are multiple ways, but what are the main ways that it works?
When you eat, what happens is that once the food touches your intestine, particularly the lower intestine, the L-cells of your intestine release GLP-1. The GLP-1 gets released. The GLP-1 has a lot of beneficial effects, but the main effect of the GLP-1 is to send a signal to your brain and say, “You've got to stop eating. Otherwise, you're going to be eating all day.” However, that naturally occurring GLP-1 stays in your bloodstream only for 1 to 2 minutes because it's degraded by DPP4. It degraded right away.
What these companies have done is they figured out a way to extend the half-life of the GLP-1. We know that it signals satiety. It tells your brain, “You have to stop eating,” and it has other effects. The companies replace around three proteins in that GLP-1 molecule. What it has done is extended the half-life of the medication to 1 week instead of 1 to 2 minutes. That's why it's very effective. The effect of signaling your brain telling you to stop eating lasts that whole week instead of for a few minutes.
That makes sense. For people who are on these, what weight loss do they usually see?
There’s the difference between that and Tirzepatide. Tirzepatide has two incretin hormones. It has the GLP-1 and the GIP. With semaglutide, you would expect a mean of around 15% weight loss. With Tirzepatide, which has two components to it, which is a GLP-1 agonist and GIP. There's a little bit more robust weight loss, around 20% of weight loss.
Is it very common that you would start with the GLP-1?
Since the FDA has approved one over the other for certain conditions, we base it on what the comorbidity is. Semaglutide, which goes by Wegovy, has been approved to reduce MACE. MACE means Major Adverse Cardiovascular Events for patients who've had heart attacks, strokes, and peripheral artery disease. When we have a patient who has these conditions, we tend to give them Wegovy. The Wegovy semaglutide has been approved for MASH, or metabolic dysfunction-associated liver disease, which a lot of people know as fatty disease. It has the indication for that. That would be our first go-to medication.
If you have a patient with obesity who has sleep apnea, because Tirzepatide has been approved for sleep apnea. We would go with Tirzepatide for those patients. We look at the indications. Also, for HFpEF, there's some data. Although, Tirzepatide has not been approved for HFpEF or congestive heart failure, we would go with Tirzepatide for those types of patients. We look at the type of patients and determine which medication would go well for them.
It's exciting that it's getting approved for so much more.
There's a lot more in the pipeline. This is a good time to be board-certified in obesity medicine because you're talking about maybe five more. Some are even more powerful in causing weight loss. In the indications, they're looking at Alzheimer's and so many different things. It’s a good time for treating these patients, and it's about time. Patients have been suffering from obesity for such a long time that it's about time we have treatment for them.
Would you say that these medicines are more for overweight people or obese people? We talked about it. This is very helpful, especially with these health issues. For people who are overweight and not just in the obese category, but have health issues, are they also helpful for them?
The indications for anti-obesity medications are if you have a BMI of 27. That's not the obese category. Twenty-seven with at least one risk factor, which is hypertension, dyslipidemia, obstructive sleep apnea, or diabetes. If you have that, then you will qualify for these medications. If you're in the obese category, if you have a BMI of 30, you don't have to have any comorbidities to qualify for these medications.
I'm curious. Since that's qualifying, how often are insurance companies paying for it?
That has been an issue because if you think about the cost of these medications, they cost around $1,300 a month. What we found out is that it's not so much the insurance as it is the employer. If in your benefit plan, obesity medications are covered, it can go down. For insured people, it can go down to as low as $25 a month, or $0.
For example, Baptist Health covers anti-obesity medications. It would cost $0 to $25 for patients with that. If you don't have any coverage, then you're stuck with the $1,300 a month. However, we recognize that these medications are life-saving for a lot of people, so there are ways to pay for them as self-pay. Novo Nordisk, which produces or manufactures semaglutide, has the NovaCare, which drops the cost of the injectable to around $199 for the 1st dose, and then $349 to $399 for the higher doses.
It's the same thing for Tirzepatide, which is Zepbound. If you do self-pay and go directly to the company, it still needs a prescription from a doctor. You can get the first dose at $150, and then it goes up to around $450 max for the maximum doses. It's not cheap by any means, but still better than having to pay $1,300 for the medications.
I didn't look this up to verify it, but I think I saw something that Costco was going to have a discounted program where, if it was prescribed by a physician, I want to say it was under $300.
Also, we have to remember, too. Wegovy came out with a tablet. The tablet is an oral tablet that you have to take every day. It has the same indications as the injectable Wegovy. Those are cheaper. The starting dose of that is $150, and then it goes up to $399 for the higher doses. They're doing a lot of things. Medicare is different. I've been surprised because Medicare will pay for these medications if you have the comorbidity. We're talking about Medicare with Part D.
SELECT was the trial that showed CB outcome improvements. If you had a heart attack, a stroke, or peripheral artery disease, they will approve you to have Wegovy, and it goes into the Part D. Part D means that you pay $2,500 as your deductible. After that, the medication is free for the rest of the year. It also goes with the Zepbound. For Zepbound, you have obstructive sleep apnea, and you can prove that you have moderate to severe obstructive sleep apnea, Medicare will pay for the medication as a Part D.
There's something exciting going on with Medicare. The government had partnered with the manufacturer. Come July 1st, 2026, the Medicare Bridge GLP-1 is going to start. This is for Medicare patients. From my understanding, it doesn't matter if you're on plain Medicare or if you're on Medicare Advantage. For these patients, all the GLP-1s and the GLP-1 GIPs are going to cost $50 a month.
That's awesome.
For six months. What they're trying to do is they're going to do this and get this patient started on this medication for $50 a month. What they're hoping is that the insurance companies will continue this. That is iffy. We don't know if insurance companies are going to start it off, but the cost is going to be even lower at that point. We'll see what happens, but it's good news for people who have Medicare.
It makes sense, too. If you think about it, people on Medicare are probably going to stay on Medicare. These decrease so many other medical issues. Cost-wise, it would make sense for Medicare to cover it because you're going to decrease all the comorbidities that go along with this.
You can't imagine how many patients have had to stop their blood pressure medications. The first thing that we see when they have even 5% or 10% of the weight loss is that their blood pressure starts going down. I have patients for whom the only medication they're taking is the GLP-1. They're off their blood pressure medications and diabetes medications.
That is so huge. A lot of people don't realize that it can have that effect. The next question is, what are the biggest benefits apart from the number on the scale? Those are real benefits. That's huge.
It's very interesting. When they did the SELECT trial in Wegovy, they enrolled 17,000 patients. This is a very robust trial. There were 17,000 patients during COVID. People stuck to the medication because they were losing weight. It is almost an average of a three-year follow-up. The reduction in mortality, strokes, and recurrent MI's was 20%. This was on patients who were already on aspirin, statins, and antiplatelet medications. These were on top of the standard of care. We haven't seen this in a long time.
They saw the effect or beneficial effect within three months before any significant weight loss occurred. If you look at the graph of the people who are taking the GLP-1s and the ones who are taking a placebo, it splits up into three months. People weren't losing that much weight in three months. There is another effect of the medication. We still don't know what it is. Do you remember the JUPITER trial that looked at a super statin in patients who are high risk but have never had cardiac events?
They had a 40% reduction in cardiac events. It was also beyond the lipids. The lipids went down a little bit, but the important thing is that the C-reactive protein dropped by 34%. The SELECT trial did show that Wegovy dropped the C-reactive protein in these patients. Do you know how much? Thirty-four percent, same as the Zep. It's in the trial. If you look at the trial, it's right there. It's not just the weight loss. The inflammation has a lot to do with it as well.
In so many disease processes that what we're realizing is that inflammation is such a driving factor of that.
All the chronic diseases that we think about. Even cancers are all inflammation.
From a cardiology perspective, what would you say this helps specifically for heart health? It seems like it helps so much with the heart.
It is. The first thing that we see is a reduction in their blood pressure medications. The most important thing, though, is that they start moving. They’re so surprised. They’re like, “I’m starting to exercise. Overall, I feel so good.” They're walking. That promotes a lot of weight loss. It's not just the calories that are going down. It’s exercising and moving more. That's one of the biggest benefits of the medication. We take them off their blood pressure and blood sugar medications. Diabetes is remarkable as well.
These medications are marketed as diabetic medications as well. We take away their sulfonylureas, which I hate anyway because they have no cardiac benefit. They're bad for the heart. We stop those medications. The insulin requirements go down. In the long run, there's going to be a cost-benefit overall for this medication, especially when the cost of the medication goes down over time. It's going to be a matter of time.
There's the mortality benefit, but then there's also the whole comorbidity effect. If you're able to stop this at an earlier process where people aren't getting all the heart attacks and strokes, then you're going to have happier, more active, and healthier people. That's huge. We have to get into risks and side effects. Every medication has something that's a side effect, too. What would you say are the most common side effects that you see?
The GI, by far, is the most common side effect. The most common reason for people to stop the medications is GI. You're talking about nausea, vomiting, diarrhea, or constipation. Those are the most common, and that happens probably in 5% of the patients.
That little? I expected it to be way more than that.
When you look at the studies, it's anywhere from 5%, maybe 10%, but it's not that much. I tell my patients, “Nausea and vomiting are something that you would expect.” Some people don't feel it, but there are some people who are going to have those problems. It usually is while you're titrating the medication. If you have a doctor who gives you the highest dose possible, that’s wrong. You have to go to another doctor.
To mitigate the GI side effects, you need to start slow. Everyone starts at the lowest dose possible. A lot of times, you feel the nausea. Most patients feel a wave of nausea. It's usually between the first two days after the injection. As time goes by, you're not going to feel nauseous anymore. As you titrate it higher, you have fewer side effects as well. We have patients who can't tolerate it.
We tell these patients, “If you can't tolerate it, you have to watch out. If you're not eating, you have to make sure that you're able to drink water.” If not, we've seen renal failure in patients, not because of the direct effect of the medication on the kidney, but because of dehydration. You have to be careful with these patients. That's why we watch them closely and maybe get them back in the office in 1 to 2 months, especially if they're having side effects, making sure they're well-dehydrated.
I tell my patients, “Nausea or vomiting is common, but abdominal pain isn't common. If you do have abdominal pain, you have to watch out for gallstones and pancreatitis.” Remember, in med school, that regardless of how you lose weight, if you're losing weight, the gallstones are affected, and there's an increased risk of cholelithiasis in these patients.
Abdominal pain and pancreatitis occur only in 0.2% of patients, so it's not even a common thing. If you start having the classic thing, we tell them to stop the medication and make sure that they talk to us about it. We may have to run some tests to make sure they're not having any of those 2 complications or 2 side effects.
Are there any other serious side effects?
Those are the major ones. When they looked at the SELECT trial, they enrolled patients over the age of 70. There were some people who were over 70, 60, and 80. They had a slight increase in hip fractures. Part of it is because of the loss of muscle mass, but we don't know. There's a slight increase in that. Wegovy is approved for children who have obesity. If they're 95% out of their weight, they can have it.
They had a slightly higher incidence of cholelithiasis compared to their adult counterparts. That’s something to think about. There are two contraindications to the medication. One contraindication is if you have a history of medullary thyroid carcinoma. The other one is if you've had anaphylaxis with any of the ingredients. Those are the only two contraindications or black box warnings for that.
The MCT is a very interesting thing, though. The MCT, or Medullary Thyroid Carcinoma, is one of those generic, weird thyroid cancers. We're not talking about papillary thyroid carcinoma. They are very deadly carcinomas. It comes with endocrine tumors as well. Sometimes, it's familial. If you have a patient who has a history of that or a family history of that, you don't want to do that.
The reason why is that the rat thyroid glands apparently have a lot of C cells in them. The GLP-1s attach to the C cells in their thyroid glands. When you over-stimulate it with GLP-1 agonists, there's an over-stimulation of the C cells, which causes the Medullary Thyroid Carcinoma. The interesting thing is that in humans and in primates, you don't have that many C cells. The effect on humans is very different. I've been doing this for years. The GLP-1 agonists have been around for twenty years, and I see very little of that MCT, but now, it is in the black box warning.
I feel like there are a lot of people talking about all the muscle loss with this. Is that a real concern? How do you help patients prevent it?
You have to remember that in any type of weight loss, when you lose weight, you're going to lose muscle mass and fat mass. Muscle mass is around 30%. Fat mass is around 70%. You are still losing more fat than that. We tell our patients that strength training is crucial. You have to be doing your squats. If you're walking, you want to make sure you walk with weights or the weighted desks and things like that. That's very important. It's also important for older individuals because they’re the ones who have a tendency to fall. The fracture rate in individuals is a little bit higher. It's important to incorporate that. Incorporating protein in their diet as well is important in protecting them from that.
I was reading something. They were advocating for a lot of the patients who are on this for people to get a bone density scan. It was to monitor their muscle and how much muscle they're losing, and to help in terms of titration. I thought it was a good thought because it’s measurable.
We have the SECA scan, too, that looks at your fat mass versus your muscle mass. If they exercise, you tell them, “Here is the comparison of your fat mass to your muscle mass. You're having a lot of fat mass.” When you start exercising, you see that change. Sometimes, people like that, but it's not readily available for everyone.
When people start these, and we talk a little bit about the GI effects, is there anything that they can do to try to decrease the side effects from the medication if somebody's going to start this?
Remember, it causes early satiety, so you have to eat slowly. The problem is that if you eat too fast, you don't know until you're sick that you're overeating. We tell our patients, “Make sure that you eat small meals rather than big meals. Make sure that you eat slowly so that it has time for the signals for your brain to tell you, ‘You're full already. Stop eating.’” I always talk to my grandchildren and my children about what’s called hara hachi bu. Have you ever heard of that term?
No.
It's a Japanese term. It’s hara hachi bu. The Japanese have a way of saying that you should eat until you're 80% full, which is very different from the American way of thinking. When we were growing up, what did they tell you? “You finish your food.”
You have to be a part of the clean plate club.
The Japanese are hara hachi bu. When you're 80% full, you stop. That's what I tell my grandkids to do. Those are the things, and avoiding fat. People get sick when they have a fatty meal on GLP-1s. What’s interesting, too, is alcohol. A lot of people don't want to drink alcohol when they're on GLP-1s. All of those reward centers, they don't feel it. Avoiding alcohol when you're on GLP-1s is also one of the things that we advise patients.
It's cool. It's off-label, but they are finding that it helps with different things with addiction, like alcohol addiction, but also other drugs and things like that.
We tell our patients to drink lots of water as well.
How closely should people be monitored when they're on these medications? People can sign up online. There are his and hers. There are all these sites where you could go and get it prescribed. What would you say for the average person? If they're going to do this, how closely should they be monitored?
We follow our patients, especially during the titration period. We see them in our office every 2 or 3 months. That's the follow-up that we usually do. We get them in here for a weigh-in and titration of the dose over the three months. They should be followed. One of the important things, too, is that you have to think about the medications.
The GLP-1s don't interact with any medications. For example, somebody who's hypothyroid. You remember that levothyroxine is weight-based. There's been an article in JAMA that saw a patient who started GLP-1 and lost a lot of weight, but the thyroid hormone or the TSH level was not followed, and ended up with hyperthyroidism. There are things like that that you have to think about.
Adjusting their medications for high blood pressure is one of the biggest things within two months. Some people lose an incredible amount of weight even just starting it. They can lose 10 to 20 pounds, which is unheard of before. The first thing that they complain about is, “I feel so dizzy when I stand up.” It's a matter of adjusting their antihypertensive medication. That's why we get them early, because a lot of our patients have these comorbidities.
The next section would be more about common questions people would ask. I feel like a lot of people know, “These medicines are a shortcut,” but as we've talked about, they're more of a legitimate medical tool. What would you say to the person who’s like, “These are a shortcut.”
Once we treat diabetes with insulin, we don't stop the insulin. People need to start thinking of obesity as a chronic illness. It's not something like once we get your heart blood pressure controlled, we don't stop your blood pressure medications. It's the same concept. As a matter of fact, there was a study, the STEP 4 study, that looked at patients on Wegovy.
One group of patients stopped the Wegovy and was given a placebo, and the other group was continued on Wegovy. The people on the Wegovy arm lost another 17% of their weight, and the people on the placebo arm started gaining their weight, around 7% of their weight. One thing that's very important is that if you stop the medication, you will probably start gaining the weight back. If it's having all of these beneficial effects and it's preventing you from having a second heart attack, a second stroke, or a cardiovascular death. Why would you stop the medication?
When they start looking at the medications for the cardiovascular benefit or the obstructive sleep apnea benefit, they're more likely to stay on the medications. A lot of patients still come to me, saying, “I want it for six months.” That's not the way it is. If you can't commit to the medications long-term, then you shouldn't start the medication.
That's something good for people to know that it is more long-term. Do you find that they have to stay on the same dose long-term, or are you able to go down on the dose?
When you look at Wegovy, which is semaglutide, since the studies looked at the benefit at 1.7 and 2.4 milligrams, which is the top dose, some of the insurance companies will not allow you to maintain people on the lower dose. They'll stop paying for the medication unless you get them to the maximum dose. It's different for Tirzepatide.
With Tirzepatide, you have the titration dose, which is 2.5, and then 5 is the maintenance dose. If they don't lose weight, then you go up to 7.5, and then 10 is their maintenance dose. With Tirzepatide, you titrate it to the dose that gives them the maximum benefit. If they reach their goal at 5 milligrams, then we stop at 5 milligrams. For Wegovy, what we've done with the patients is that we titrate them up to 1.7 or 2.4.
This is not what's in the package insert, but in some patients, if they're losing too much weight, I might tell them instead of doing it every 7 days, to do it every 10 days. It’s not in the package insert, but for some patients, it works well for them. It saves them money as well. Sometimes, I have patients on Tirzepatide 15. All of a sudden, I'm seeing that they're losing too much weight. I might drop the dose to 12.5, but keep them on the medications.
That makes sense. Would you say that somebody can take these medications and still have poor habits? I'm sure that they work best when they're paired with lifestyle changes.
In our practice, Baptist has a health coach. When I start the patients on medications, I send them to a health coach. The lifestyle is a cornerstone for treating. Although patients just want the medication and forget about the lifestyle, the lifestyle is an important part. As physicians, unfortunately, we don't have time to tell patients, “What are you supposed to eat? What are you eating right now?” You need somebody like that. Wegovy has a program. Once you prescribe Wegovy, you can go to the WeGoTogether program, where you're assigned a one-to-one coach who is responsible.
They look at what you are eating. They do that. That's a very good program. Many patients are on these medications, and we realize the need for the lifestyle portion of it. There are a lot of online programs that are coming up. One of them is Nourish. Nourish is a dietitian that you can talk to regardless of where you are in the country. It's an online program. It teaches you the lifestyle part of it.
That's awesome.
It's very important.
What would you say to somebody who feels ashamed or judged for even considering a weight loss medication?
The good thing about it is that, because the results are so good, that's out of the question.
The stigma is less now.
Before, they were ashamed of it. Now, they come to you and say, “Can you help me with this?” When you bring it up to patients who don't bring it up and tell them the benefits of it. That it's beyond weight loss, it’s beyond fitting into a size four dress, and it’s because you want to live longer. You don't want to get diabetes and you want your blood pressure controlled. They're more likely to accept it as a medication.
A lot of times, we've looked at weight loss medications as if we should take them so that we can fit into a dress and go to prom or whatever. You shift away from that and tell them, “We're doing this because it reduces your inflammation and risk for all of these chronic illnesses.” If you look at diabetes, it's been associated with 260 diseases, including 13 cancers. Why the effect the cancers, we don't know.
If the inflammation goes down, it can only be good. When you talk to them about that, they're more likely to accept that it is a medication to make you healthier because it affects a lot of your risk factors for these chronic illnesses, rather than the weight loss medication, so that you can lose weight and look good.
Many people don't realize that obesity increases their risk of so many cancers.
These thirteen cancers that it has been associated with, the prevalence of all cancers has gone down except for those thirteen cancers. It's because the obesity rate has been going up. You’re a public health specialist. When they were looking at the obesity rates in all of the 51 states here in the United States, the obesity prevalence has been going up. This is the fattest our country has been in all of these years. It would be interesting to look at it five years from now when a lot of these medications are being used. Did we stop that epidemic? I think there's going to be a significant reduction in the obesity rates in the States.
I think so, too. They have made a huge difference for so many people. That has then helped people take away the stigma of asking for the medications. People are talking about it. I feel like before, people were nervous to bring it up.
It's very interesting. The first patient that I treated with this cried and said, “My BMI has been going up every year, and all my doctor told me is, ‘You have to stop eating.’ That's all they said.” Now that they have it, they're tearful. They're so happy to have this available for them.
We talked a little bit about the cost. One thing I wanted to bring up was compounding. A lot of people hear about the compounded versions. What should people know about the compounded versions?
Better not to. The compounding came about because there was a shortage of the medication. When the FDA said, “There's a shortage of semaglutide and Tirzepatide,” it allowed compounded companies to compound the medication to fill that gap. In February 2025, they were taken off the shortage list. There are a lot of these medications available at this point. I understand the cause is still an issue. The compounded medications are still cheaper, but they have looked at the compounded medications.
They found out that it has a lot of impurities, including formaldehyde. Since they're not regulated by the FDA, the manufacturing method is not looked into. They found more impurities in the compounded formulations. What happens with a compounded one is that they give you a vial, and you keep reusing the vial. You’re drawing the perfect amount. Have you seen the instructions for that? If you're not a nurse, the overdose rates and the underdosing rates for compounded has been tremendous as well. We stay away from the compound.
What’s interesting, too, is that if you're a physician who prescribes it, look at your medical malpractice insurance. In Baptist, the medical practice doesn't cover any claims that involve compounded medications. If you have pancreatitis and it was because of the branded Wegovy, your insurance will cover that. If you have pancreatitis because of an unbranded or compounded medication, they're not going to cover you. If you are a doctor, look at your medical insurance and your fine print. If you get sued by somebody who got compounded medications, you don't have legs to stand on because your insurance is not going to back you up.
I have a feeling that probably a lot of people don't know. A lot of people won't read the fine print in their malpractice insurance. That's wild. If somebody can't afford their medications, what other options are there that could still help?
The pill formulation is a lot cheaper compared to the subcutaneous formulation. Talk to your physicians about that. The Wegovy tablet has the same indications as the injectable Wegovy. There’s a reduction in MACE for patients with heart attacks. They got the same indication because they’re the same medications. Eli Lilly came out with an oral, but it's not oral Tirzepatide. It's still oral GLP-1.
I don't know what the price point of that is going to be. It was approved not long ago. It has probably an 11% weight loss. It's not as good as Wegovy or Tirzepatide, although there hasn't been a head-to-head comparison, but that would be a good start if the price point is okay. The Medicare Bridge GLP-1 program will help a lot of our patients.
That's awesome. I didn't know about that. Have you noticed any differences between the oral Wegovy and the injectable in terms of patient benefit, side effects, or anything like that?
It has been good so far. It was approved a couple of months ago, so they're coming in. First of all, these are also patients who don't like injections. It's strict in the way you take the pill. You want to take it first thing in the morning on an empty stomach with no more than four ounces of water. You can't have coffee. You can't have anything. The way the pill is made is that it's not absorbed if you have food or other things in there. It's 30 minutes before breakfast. People comply with it. So far, the people that we've put on it have had significant weight loss, almost the same as the injectables.
That's awesome. You might not know this. Did they do the same studies in terms of CRP and the inflammatory markers on them?
They didn't have to because semaglutide was considered the same compound. It’s Wegovy. They got the indication for it based on the SELECT trial. It’s the same medication, but given in a different way.
In your clinic, who do you see tends to do well with this medication, versus they struggle with it?
Believe it or not, the people who have a lot of weight to lose are the ones who respond to it well. The percentage of weight loss in patients who start with 300 pounds or 250 pounds can lose up to 140 pounds, which is the most that I have. It's incredible. You have to remember, too, that 5% to 10% of the patients are going to be non-responders, unfortunately. They don't lose that 5% of the weight, and we can't continue the medications in those patients. There are going to be non-responders. As far as the side effects, you have to try the medications to know if there is going to be one of them that's not going to tolerate it.
For the non-responders, let’s say you started them on Wegovy, and then you switched. Does it make a difference or not?
Sometimes, it does. Switching from Wegovy-to-Wegovy table probably won't make that much of a difference. Switching from semaglutide to Tirzepatide and vice versa, sometimes, we see a difference.
What would you say are some early wins patients notice besides the weight loss?
Blood pressure. That's the first thing. With anti-obesity medications, regardless of how you lose the weight, you always have to think about depression in these patients. I've had two patients who had depression, for whom I had to stop the medication. It's a weird kind of depression. They don't know why they're so depressed. It's like, “I don't know what happened.” I’ve had two patients whom I had to stop it for. A lot of the patients have such a positive outlook after they start the medications because they can move, they have less pain, they sleep better, and the joint pain goes away. Those people are happy.
A lot of patients whom we start these medications on have been on tons of diets. A lot of them yo-yo. They've been to Weight Watchers. They've been to Noom. They go back to Weight Watchers and gain weight. It's a lot of that. Once they see a sustained weight loss, it's so good for them. Getting that first ten pounds out, they’re the happiest. For us, we're happy because we get them off blood pressure medication. We see it early on, too.
What would you say is a safe and sustainable weight loss amount?
We always say one pound a week is what we want, but frankly, with this type of medication, we've had significant weight loss. Two pounds to three pounds a week, especially starting off, is what we see. That tends to taper down along the way. It slows down like anything else. In the first 3 to 6 months, they have very strong or robust weight loss, and then it slows down.
That’s because the body is not going to make you dwindle away. It's going to stop at some point, and that's going to be your set point. You see that it slows down later on. What we've seen is as much as 3 to 5 pounds a week of weight loss, which is a little too much. You tell them, “You drink lots of water and continue exercising.” They overall do well on the medication if they don't have the side effects.
How do you help patients set realistic goals?
Our patients are different. They're not coming to us just for weight loss. It's for cardiac events. I always let them know that there are people who are not going to be responders because I don't want them to be disappointed. This is one of those things. Some people don't respond to it. They realize all of the benefits when they start having to adjust their medications and get off the medications. It's different for different people. It's always going to be a bell-shaped curve where some people don't respond, and some people are going to be good responders, and you have the middle, which has a moderate response to the medications.
For someone who's overwhelmed, what would you say is the first step?
Some people, believe it or not, are not ready to start the medications. A lot of times, they hear things from social media. Every week, there's one thing that these medications cause, it looks like. They scare people out of taking the medication. For those patients who are not ready to take the leap and go into GLP-1s, we start with diet and exercise. I’m like, “Let's see how you do. I’ll give you three months. This is the diet that you have to do. This is the exercise you have to do. Come back in three months.” A lot of times, at that point, they're ready to do it.
The other thing that I also tell patients is that these medications have been around for a while. People are hearing of them because of all the weight loss and people using them for weight loss. That also helps reassure patients that this hasn't been around for the last few years. We have some long-term data on this.
They don't realize that it's similar to Saxenda. I tell them, “We have had these medications for twenty years, so we have data on them.” They feel better when they know that.
What questions do the patients ask their doctor before starting a weight loss medication?
Realistically, you need to know the side effects of the medications. You need to know if you're somebody who can qualify for it. I have patients with a BMI of 25. You have to tell them, “You don’t need this medication.” They're saying, “There are so many cardiac benefits.” I say, “It's cardiac benefits in patients who have obesity, not in patients who are thin to begin with.” Ask whether you qualify for it, and then find out from the physicians, “Do you think that my insurance will pay for it?”
That's a big deal for a lot of our patients. A lot of patients cannot pay $450 a month for this medication. Get that out of the way and say, “Do you think my insurance will cover it?” Then, ask them, “What do you think is the benefit for me? Do I have the underlying risk factors? Do you think that losing weight because of my hypertension is going to be good for me?” Those are the questions that you ask, especially about the side effects. Ask, “What side effects should I expect?”
Constipation is one of the big things with my patients. I always tell them that magnesium helps well if the patient has constipation. You'd be amazed. It's an over-the-counter medication. You take one at night, and it regularizes your bowel movements. It is things like that, such as side effects, if it's indicated in their case, and what the cost is going to be.
The other side effect that somebody told me, which is common, is that people have issues sleeping. Have you heard that one a lot?
It is mostly because of the GI side effects, you mean. Due to the delay in the gastric emptying time, there are tendencies for the food to stay in your chest. Some people have it worse than others. They're not able to sleep because of that. Not being able to sleep with the medication, I haven't heard that as a main complaint. One weird side effect that people don't know about is what we call formication. What it is you have this bug-like feeling in your hand, like it's crawling.
I've never heard of that one.
I don't know about the mechanism of action, but I have one patient who's like, “I don't know what to do. It feels like things are crawling on me.” With those patients, we give them some Claritin or Benadryl to go to bed. A lot of times, it does go away over time. If somebody tells you, “I have this thing that’s crawling in my skin.” It's probably your GLP-1s.
That's so interesting. I hadn't heard of that one. That's different. I heard that for some people, their heart rate increases a little bit.
There's a reason for that. There are GLP-1 receptors in the sinus node. When you stimulate the GLP1 receptors in the sinus node of your heart, it causes tachycardia. An increase of around 3 to 4 beats is the mean or the average increase in heart rate. However, there are patients for whom it can go up to twenty beats a minute.
We mitigate that by telling them to drink more water and avoid stimulants like caffeine. They shouldn’t be drinking sodas anyway if they're trying to lose weight. That's a true thing. You have to reassure them that it's not atrial fibrillation. The effect is on the sinus node, so it's not atrial fibrillation. As a matter of fact, what's going to be interesting is that a lot of my EP colleagues are sending me their patients who are overweight or obese, because the studies have shown that in atrial fibrillation.
If you lose your weight, it reduces your risk of having recurrent atrial fibrillation by 50%. That would be interesting to see. For patients with atrial fibrillation, the thing we tell them is, “If you lose weight, you're probably going to have less AFib.” It'd be interesting to see what the effect is on AFib, but we don't have studies looking at that yet.
It makes sense in terms of whether it's treating sleep apnea and decreasing the incidence of that. That's cool. If there were two things that the reader had to take away from this conversation, what would you say those would be?
If you've been battling with obesity all this time, there are neuro-hormonal reasons why that is. Your body is trying to get you back to your old weight. Don't think of that as a failure or you being lazy. The good thing, too, is that there are medications that are out there that don't just make you lose weight, but also reduce your risk for serious complications of obesity. Be open to it. The cornerstone of all this is still lifestyle. You can't just take the medication. You have to adjust your lifestyle as well. The medication helps you. It's easier to adhere to lifestyle changes when you start losing weight. Hopefully, a lot of these patients are walking more and eating more healthily.
One of the most encouraging takeaways from this, too, is that it helps people start losing weight. When they start losing weight, they want to go for walks. Their knees don't hurt as much. They feel a lot better. That's a huge positive.
That is true.
This was awesome. I learned a lot here, too, which was great. A lot of people have heard of these medications but don't fully understand everything about them, so this was great. I appreciate you taking the time to talk with us about this.
Anytime.
This was great. Thanks so much.
Thank you so much. Bye.