GLP‑1 medications have transformed the way we approach weight loss and metabolic health. But how do they actually work? And who are they right for?
In this episode of HEALTH Yeah!, our experts break down the science behind GLP‑1s, who might benefit most, common side effects and what patients can do to maximize success. They also explore the impact GLP-1s can have on quality of life, as well as the promising future of these medications.
The Experts
What You’ll Hear in This Episode
- 00:00 Opening and Introductions
- 1:40 What are the different types of GLP-1 medications?
- 3:26 How do these medications work for weight loss?
- 4:58 How have GLP-1 medications changed the way clinicians think about obesity and metabolic disease?
- 5:47 Who is a good candidate for using GLP-1 medications for weight loss? And what conversations should happen between patient and healthcare provider before starting the medication?
- 7:45 What makes somebody not a strong candidate for GLP-1s?
- 8:50 Do GLP-1s work for all patients?
- 9:28 Do GLP-1s work differently for men and women?
- 10:07 Quality of life improvements for patients using GLP-1s
- 10:53 What other conditions can be treated or improved with GLP-1 medications?
- 14:00 How do these GLP-1 medications compare to older medications or even lifestyle-only approaches to treat obesity or health conditions associated with obesity?
- 15:05 What side effects are most often reported by patients on GLP-1 medications?
- 15:57 What can patients do to reduce side effects?
- 17:05 How can patients maximize chances of success in using GLP-1 medications?
- 18:08 How can GLP-1 medications affect muscle mass?
- 19:25 Access to GLP-1 medications
- 20:48 The future of GLP-1 medications
- 21:31 Closing Remarks
Full Podcast Transcript
00:00 Opening and Introductions
Announcer
Welcome to HEALTH Yeah!, where experts from Stony Brook Medicine come together to discuss topics ranging from the complex inner workings of an infectious disease to tips and tricks for staying safe and healthy all year long.
Konstantinos (Dino) Spaniolas, MD
Welcome to our podcast. I’m Dino Spaniolas, Director of the Bariatric and Metabolic Weight Loss Center at Stony Brook Medicine. For the past few years, GLP-1, glucagon-like peptide one, medications have become a frequent topic of conversation around weight loss and weight management.
By definition, GLP-1 is a hormone released by the intestines after eating, signaling fullness to the brain, slowing digestion and helping the pancreas release insulin to regulate blood sugar.
The GLP-1 receptor agonists are medications designed to mimic this hormone to help you feel full longer, reduce appetite and food cravings, and regulate blood sugar. My colleagues and I are here today to discuss the various types of GLP-1 medications, their uses, whom they benefit and the outlook of medication assisted weight loss in general.
Before we get started, I’d like to ask my colleagues to introduce themselves. Dr. Panagiotou?
Pollytia Panagiotou, MD
Hi, I’m Dr. Pollytia Panagiotou. I am an internal medicine and obesity medicine specialist, and I’m practicing here in Setauket.
Farzad Forohar, MD
I’m Farzad Forohar. I’m a gastroenterologist. I practice in Smithtown.
Konstantinos (Dino) Spaniolas, MD
Great. Let’s get started.
So what are the different types of GLP-1 medications?
1:40 What are the Different Types of GLP-1 Medications?
Pollytia Panagiotou, MD
So there’s two different categories, and I’ll go into detail with both. There are the GLP-1s like you discussed earlier. There are ones that are strictly for weight loss and then for diabetics. So the ones that are for the diabetics are Ozempic, which you have heard. And then also for weight loss that includes Wegovy.
The other class that I wanted to branch on was the GLPs plus an additional hormone, GIP hormone, that is an additional hormone that we have found that helps more with staying full. The two different medications there include the one for diabetics, including Manjaro, and then there’s Zepbound.
Those medications also, some of them have found there have been indications for both. For the GLPs, there has been an indication for diabetes, like I said, for Ozempic, and also for cardiovascular disease, for both Ozempic and Wegovy. For Zepbound and its counterpart, Manjaro, Zepbound has been found to be approved and indicated for obstructive sleep apnea and Manjaro for diabetes.
There’s also been out in the market some compounded versions of these GLPs and GIP hormones. However, it’s not widely studied. Their efficacy and safety is not really there and published. So those are medications that we have not really been experienced with, and don’t really know what are the side effects at this time.
3:26 How Do These Medications Work for Weight Loss?
Konstantinos (Dino) Spaniolas, MD
Thank you. So Dr. Forohar, how do these medications work for weight loss?
Farzad Forohar, MD
The most important thing is at the central nervous system in the brain, we have a hunger center there, it sets the temperature lower, meaning that we believe that every human body may have a thermostat-like setting, like your home, you have a temperature at 72 degrees, and your heater and air conditioning work in order to maintain that temperature.
We may have a set point in our brain that sets a certain weight for our body. So part of this is the hunger center. When these medications act on the central nervous system, they actually tell the brain to eat less, that constant food noise that many patients feel gets alleviated. That’s really the central mechanism of action.
It has other properties as well, as you alluded to by the digestive system, making you feel full, and with that comes the sensation of nausea and slow gastric emptying. So this is the other mechanism of action. The other one, metabolism may also increase. So these are the three different ways.
4:58 How Have GLP-1 Medications Changed the Way Clinicians Think About Obesity and Metabolic Disease?
Konstantinos (Dino) Spaniolas, MD
So how have GLP-1 medications changed the way clinicians think about obesity and metabolic disease in general?
Farzad Forohar, MD
Very good question. This is no longer considered willpower. This is a biologic disease. This is not a matter of not having discipline. So by a clinician understanding this concept, this is like diabetes, like certain other diseases that have multiple sources, we don’t put blame on the patient any longer, and that is really alleviating a lot of guilt that many patients may have felt before.
5:47 Who is a Good Candidate for Using GLP-1 Medications for Weight Loss? And What Conversations Should Happen Between the Patient and Healthcare Provider Before Starting the Medication?
Konstantinos (Dino) Spaniolas, MD
That’s very insightful. Thank you. Dr. Panagiotou, who is a good candidate for using GLP-1 medications for weight loss, and then what conversations should happen between the
patient and the healthcare provider before starting them?
Pollytia Panagiotou, MD
Very good question. So as far as criteria and indications, criteria meaning anyone who has a body mass index greater than 30 that’s basically calculated off of height and weight for that individual. 30 or over, typically, most insurances will cover these medications, and also anyone with a body mass index of 27, plus one comorbid condition relating to weight. And those conditions can be diabetes, prediabetes, obstructive sleep apnea, fatty liver, heart disease, such as a history of stroke and history of myocardial infarction, or heart attack as well.
The discussion I typically have with my patients is that these medications are a tool. They help jump start your weight loss journey in conjunction with what you have already or should have already been doing from the get go, such as diet and exercise.
I always tell my patients that these are not a band aid, that these medications really, like I said, are a tool that you have to be on a high protein diet. Also, if you haven’t already seen someone for diet counseling, that is also advisable. And moderate intensity activity is also highly advisable with these medications.
Also sleep is very important with these medications, because the more sleep you get, such as seven to eight hours, that will help boost your own GLP hormone that we already make in our body. If we don’t get enough sleep, we make a hormone such as ghrelin, which is the hunger hormone that will kind of sabotage these medications that we’re taking to help lose weight.
7:45 What Makes Somebody Not a Strong Candidate for GLP-1s?
Konstantinos (Dino) Spaniolas, MD
That’s great, great explanation. Now, in a similar way, who is not a good candidate for these medications?
Pollytia Panagiotou, MD
Patients that are not good candidates, obviously, initially, are patients who are already kind of in the normal weight range. We think that is, you know, inappropriate. Patients who are not good candidates are patients with contraindications to these medications.
Patients who have a history of obstructive gallstones, history of pancreatitis in the past, history of also medullary thyroid cancer, which is a rare thyroid cancer, but it was found in rodents that these medications did cause that cancer to come more about, and also multiple endocrine neoplasia syndrome that runs in the family as well.
Also, we don’t like to add these medications to anyone’s regimen if they are currently pregnant or also breastfeeding as well.
Konstantinos (Dino) Spaniolas, MD
Very good. That’s a great explanation.
8:50 Do GLP-1s Work for All Patients?
We often hear from patients that they see stories and they hear from their friends who have had great successes, and sometimes that puts a lot of pressure on them. From your experience, do these medications work for all patients?
Pollytia Panagiotou, MD
They do, however, it is variable across the board. Again, some patients do everything that’s advisable along with these medications, diet and exercise, they get up to the maximum dose, and sometimes it doesn’t quite help them. You know, that happened a few times in my practice, but other patients, we do see quite a bit of benefit, and especially those who have chronic obesity. We found that these medications are very helpful to them with keeping the weight off long term as well.
9:28 Do GLP-1s Work Differently for Men and Women?
Konstantinos (Dino) Spaniolas, MD
Very good. And then, similarly, do they work differently between men or women?
Pollytia Panagiotou, MD
I have not witnessed that. In fact, I found that females are coming more to me because they’re hearing their friends are losing weight with medications, particularly those who are perimenopausal or postmenopausal. It helps very much with getting that weight off that they were unable to lose, they were just in a standstill during menopause. And they look to these medications as a kind of like a savior for them, to help them go back to their initial weight where they were pre-menopause.
10:07 Quality of Life Improvements for Patients Using GLP-1s
Konstantinos (Dino) Spaniolas, MD
Now, as patients use these medications, have you seen improvements in their quality of life that maybe are not reflected on their scale?
Pollytia Panagiotou, MD
Absolutely. The first thing I always hear from patients is that they always say that they have more energy. They also just feel less achy in general, and overall, those who have chronic osteoarthritis, we find that, you know, that is much more relieved with these medications.
Also we see it in blood work. We see as far as like, improvement in metabolic panels, such as their sugar levels and also their cholesterol levels. And also over time, blood pressure comes down as well.
10:53 What Other Conditions Can Be Treated or Improved With GLP-1 Medications?
Konstantinos (Dino) Spaniolas, MD
Very good. Dr. Forohar, we touched on this a bit up to now. But what other conditions can be improved or treated with GLP-1 medications? We already mentioned heart disease and sleep apnea.
Farzad Forohar, MD
One thing that is dear to me is liver disease. And fatty liver is a very common problem nowadays in society, particularly in women, I should say, though it’s really not exclusive to women.
Currently, fatty liver is the number one reason women get liver cirrhosis, alcohol is number two. In men, alcohol is number one and fatty liver is number two. So Wegovy, with semaglutide, just got approved for this indication.
So by prescribing this medication, we actually hit multiple targets, the weight loss, obviously, liver fibrosis also decreases. Hoping by that process, the development of liver cirrhosis will be, if not abated, but maybe even delayed. We don’t have the long term evidence. It’s been only studied for, I believe, around 72 weeks.
But the expectation is that it will reverse liver fibrosis, and by that, liver cirrhosis. Other conditions that are exclusive to women are human polycystic ovarian syndrome and these patients, unfortunately, do gain weight, not because of, again, willpower, but because of the hormonal insulin level, etc, and these GLP-1 medications may help in that regard as well.
I believe we touched upon osteoarthritis, we touched upon sleep apnea, and one of the reasons that patients immediately may feel less tired is by improving their sleep apnea.
Konstantinos (Dino) Spaniolas, MD
Yeah, these are really remarkable benefits. Dr. Panagiotou, for which conditions are GLP-1s now more and more being considered earlier, rather than leaving them as a last resort?
Pollytia Panagiotou, MD
First I’ll say that for diabetes management, now these medications have totally replaced the other prerequisites, such as Metformin and other class drugs that we use for diabetes, and we jump straight to that, and we see better control right from the get go with diabetes.
Also, as Dr. Forohar said, throughout start to sleep apnea, we see when we add this to that, it helps with minimizing that. And with cardiovascular disease, I even see cardiologists starting to prescribe these medications as well, on their own to help more with their cardiovascular benefit.
14:00 How Do These GLP-1 Medications Compare to Older Medications or Even Lifestyle-only Approaches to Treat Obesity or Health Conditions associated with Obesity?
Konstantinos (Dino) Spaniolas, MD
Very good.
Dr. Forohar, how do these GLP-1 medications compare to older medications or even lifestyle only approaches to treatment of obesity or health conditions associated with obesity, like fatty liver disease that you just mentioned, right?
Farzad Forohar, MD
I would describe the older medications being in the minor league versus this is the major league. So it’s really those older medications anywhere between three to five to seven percent weight loss that was under ideal conditions. So they are really not comparable.
We have another medication that is approved for fatty liver, but that medication is really only indicated for fatty liver. It doesn’t have the other benefits that GLP-1 have, which we already covered.
So again, it’s really what I describe as major league versus minor league.
15:05 What Side Effects are Most Often Reported by Patients on GLP-1 Medications?
Konstantinos (Dino) Spaniolas, MD
Similarly, as you mentioned earlier, about some of the nausea or other impacts of the medications, what side effects are most often reported by patients on GLP-1 medications, and what’s the connection between side effects and dosing, perhaps?
So the most important side effect, probably early on, is nausea. And we expect that because it causes delayed gastric emptying, when the stomach is extended and is not emptying well, it causes nausea. So that’s why we start at the lowest dose and gradually increase, hoping that the patient will assimilate to the new condition.
Constipation, vomiting, even diarrhea are the other common side effects of these medications.
15:57 What Can Patients Do to Reduce Side Effects?
Konstantinos (Dino) Spaniolas, MD
Dr. Panagiotou, what can patients do to reduce those side effects?
Pollytia Panagiotou, MD
I always like to address first the timing of the medication and how they’re taking it. I always say, either one hour before their first meal of the day, or if they’d like to take it at nighttime, if that’s what their schedule allows, it’s better for them. They’re for their convenience, three hours to four hours after their last meal of the day, closer to bedtime.
Also, I always ask them to circle back to their diet. Are they eating larger portions and trying to push through the meal? I always like to tell them that they should really listen to their body and slow down eating when they start to feel full, so they don’t feel that nauseousness.
Also, water is their best friend. They need to be drinking up to 64 ounces to a gallon of water a day to help mitigate the other side effects that Dr. Forohar mentioned, such as constipation.
And also, you know, they would need to possibly take stool softeners if need be to help with the constipation. Very rarely do I have any patients say that they have diarrhea, but on those rare occasions, they could use, you know, symptomatic relief medications over the counter for that as well.
17:05 How Can Patients Maximize Chances of Success in Using GLP-1 Medications?
Konstantinos (Dino) Spaniolas, MD
And we mentioned earlier that there’s a lot of variability in the effect of those medications. Who is really successful using GLP-1 medications?
Pollytia Panagiotou, MD
So those who are successful, really again are those who are adhering to the lifestyle changes that we discussed.
Also, I also like to mention that those who are, you know, exercising again and long term use tends to show more success if someone is stopping, restarting or just non-compliant. In general, they will not be successful.
Those who have chronic obesity, I have noted that they will be more successful long term if they remain on these medications. Who have been basically battling obesity since childhood. Those are the patients that need to be on these long term and they will see greater success.
18:08 How Can GLP-1 Medications Affect Muscle Mass?
Konstantinos (Dino) Spaniolas, MD
And that’s something that I’ve noticed in our practice too, and oftentimes, within three months, you can already see who’s a responder and who’s not, and who’s going to benefit from long term use.
Dr. Forohar, how do GLP-1medications affect muscle mass? And what can patients do, really, to protect their own muscle?
Farzad Forohar, MD
Thank you for that question. That’s really, really very important. Patients may lose 20 to 40 percent of lean body mass, so it’s very important to have a high intake of protein, between 1.2 to 1.5 grams per kilogram of body weight. So they say if you are 100 kilo, which is 220 pounds, you probably need to get 150 grams of protein a day.
And ideally you should start your meal with taking the protein first before you become full and stop eating. So start the protein, then move on to a carb. And then the other important thing is weight bearing exercises, not cardiovascular, not being on treadmill, but lifting weights. You don’t have to become Arnold Schwarzenegger, but you need to increase muscular exercises, toning your muscles.
19:25 Access to GLP-1 Medications
Konstantinos (Dino) Spaniolas, MD
Dr. Panagiotou, who currently has access to GLP-1 medications and who doesn’t. I know that’s always a moving target when we counsel patients, but tell us a bit about that.
Pollytia Panagiotou, MD
Yes, and it, like you said, it is a constantly changing landscape, but it basically depends on the insurance that the patient has, also if they meet those criteria that I discussed earlier, but particularly usually the commercial insurances mostly cover these if you meet the BMI 30 or over or 27 BMI plus comorbidity, or if you have those indications that we discussed, obstructive sleep apnea, cardiovascular disease and also diabetes is a big one that’s usually always covered for most GLPs.
Again, there are the rare exceptions for certain insurances. But now there have been more options now that if the patient is unable to get these medications covered through insurance, they are offering them out of pocket. And because these medications are such life changing medications, a lot of patients are opting to invest in taking these medications in the hopes of minimizing the other comorbid conditions. So you know, each pharmaceutical company has formed crash options to get the oral options versus the injectables as well.
20:48 The Future of GLP-1 Medications
Konstantinos (Dino) Spaniolas, MD
How about the future of GLP-1 medications?
Pollytia Panagiotou, MD
The future is endless for these medications. They are here to stay, and if not, they’re going to keep getting better and better. And there’s going to be more and more hormones being added to the GLP combination.
Like I said, there’s the GLP and then there’s the GLP plus the GIP. And now there’s studies that they’re going to be combining another hormone to make a three hormone medication, basically. So it’s on the horizon.
Now they’re coming out with even oral options to these injectables as well, one of which has already been out the last two, three weeks now. So it’s endless.
21:31 Closing Remarks
Konstantinos (Dino) Spaniolas, MD
It really is. Well, thank you for a thoughtful discussion that’s all the time we have today. I want to thank Dr. Panagiotou and Dr. Forohar for your time and expertise, and thank you to our viewers and listeners. For more information, please call 631-440-4274.
If you found this conversation interesting, don’t forget to like and subscribe for more informative health related content.
Announcer
Stony Brook Medicine is Long Island’s premier academic medical center. We transform lives through scientific discovery, education and care, and we bring together innovative research, advanced education and extraordinary healthcare expertise to set the standard for how healthy communities thrive. For more information, visit stonybrookmedicine.edu or follow us on social media.
*DISCLAIMER: The information provided in this podcast is for educational and informational purposes only and is not intended as a substitute for professional medical advice, diagnosis or treatment. If you think you may have a medical emergency, call your doctor or emergency services immediately.
