GLP-1 Medications: Separating Science from Social Media

Podcast Transcript

Dr. Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end. Hi again, everyone, and welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the president of main campus and colorectal surgeon here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today I am very pleased to welcome our expert, Kristen Louden, a nurse practitioner for the medical weight loss program within the Bariatric and Metabolic Institute here at the Cleveland Clinic, talking about a very hot topic, and that's GLP-1 medications. Separating science from social media. Kristen, welcome to Butts and Guts.

Kristin Louden: Thank you for having me.

Dr. Scott Steele: So we always like to start off first with just a little bit more about you, where you're from, where'd you train, and how to come to the point that you're here at the Cleveland Clinic?

Kristin Louden: Well, I was born and raised in Cleveland, Ohio. I got my undergrad at The Ohio State University and my bachelor's and master's in nursing from Kent State. I started in med-surg nursing, then I became an operating room nurse. And then I landed at my current position at the BMI. And I love specializing in obesity medicine. I help patients with nutrition, lifestyle, and of course, obesity medications when appropriate.

Dr. Scott Steele: Well, we are super glad to have you here. And so let's jump right into it. Maybe an obvious question, but I'd like to hear your perspective. Why is early treatment of obesity important?

Kristin Louden: Well, early treatment is important because obesity is linked to over 200 different health conditions. And it's kind of like smoking in which it's dose dependent and time dependent. Our risk for these other conditions increase based on how much excess weight someone carries and how long they carry it. So obesity is much the same as smoking.

Dr. Scott Steele: So today we're going to talk a little bit about these GLP-1 medications. And so in your eyes, what's the biggest misconception you would like to clear up about GLP-1 medications?

Kristin Louden: That they're not safe or that they're a shortcut. Actually, GLP-1 medications aren't as new as people think. They've been FDA approved since 2005, so that's over 20 years. We have extensive long-term safety data from millions of patients using them for diabetes. What is new is using them in higher doses for weight loss in patients without diabetes. But that stigma that they're not safe is, they have a great safety profile and they're not a shortcut. That's another misconception. They're a treatment for a disease.

Dr. Scott Steele: So Kristen, it seems like I can't turn on any media without seeing some advertisement for GLP-1 medication. So can we start first with what are they and how do they work in your body to help with weight loss?

Kristin Louden: Well, GLP-1 stands for glucagon-like peptide hormone receptor agonist. That's a mouthful, but it naturally mimics the natural hormone that exists in our bodies. Usually it would only last 20 to 30 minutes, but scientists found a way to make it last over a week. In patients with obesity or diabetes, we produce lower levels of GLP-1 or our bodies become less responsive to it. GLP-1 receptors are in our brain and in our gut, and they help to control appetite, cravings. They also slow gastric emptying so that you feel fuller longer, and they help to keep blood sugar stable. So our hunger is also more stable. They also work on the brain's reward pathways and they quiet food noise and reduce the urge to eat even when we're not physically hungry.

Dr. Scott Steele: So Kristen, we don't have to go to the individual medications themselves, but in broad terms, can you talk about the different GLP-1 options available right now? And as a clinician, how do you decide which one is right for each patient?

Kristin Louden: Well, today there are several GLP-1 medications available. They come in different forms. There's weekly injections, daily injections, and now even a pill. The once-weekly injections are some of the newest out on the market. They're definitely the heavy hitters. Tirzepatide and semaglutide are these options. Tirzepatide actually works on two hormones instead of one, which is why it tends to produce slightly more weight loss. They first came out with a medication that was twice daily dosing, and then they reduced that to once daily dosing, and now we are once a week. And now we're going back to the pill options that are the new oral form of semaglutide for people who don't want injections. The catch is you have to take it first thing in the morning on an empty stomach with water and then wait before eating or taking other medications. And we decide which one is right for a specific patient looking at other health conditions like, does my patient have heart disease or kidney problems, diabetes?

Unfortunately, insurance coverage is a huge factor in what I get to prescribe. And there are new FDA indications such as for cardiovascular risk reduction, sleep apnea. So sometimes if I treat those indications, I have better luck with getting cost and coverage down. I also look at the patient's preference, how much weight loss they need, and any side effects that they might be prone to.

Dr. Scott Steele: Yeah. Let's delve in there, that last point. Every medication may have some side effects. So can you talk a little bit about the most common side effects that patients may experience with GLP-1s and should these side effects worry patients?

Kristin Louden: I think that these are blown out of proportion some on social media. The most common side effects that people experience are nausea, diarrhea, constipation, rarely vomiting. But the good news is that these effects are usually mild to moderate and they typically get better over time. They're most likely to happen the first couple days after your injection or when we're doing dose increases. And I feel like I do a good job of educating my patients so that we can avoid a lot of those side effects. Should you be worried? No. In clinical trials, only about 6% to 10% of patients actually stop the medication because of side effects. And I usually help to educate patients to minimize these side effects by eating smaller, more frequent meals, eating slowly, staying hydrated, watching high fat or high fiber meals, especially right after you do your injection. So there's a lot that we can do to manage the side effects.

Dr. Scott Steele: So how much weight loss should patients realistically expect from these GLP-1s?

Kristin Louden: They can definitely range depending on the person and the medication. Liraglutide, the daily injection, usually about 5% to 8% weight loss. Semaglutide or tirzepatide, usually that can range anywhere between 12% to 21% weight loss. And those results can vary depending on the person. And we're all individuals, so try not to get too tied to a number. And I also like to set very realistic expectations with my patients. Some of them think they're going to lose 30%, 40% on these medications, and that's typically not very realistic.

Dr. Scott Steele: So there's been a lot of discussion out there about muscle loss with GLP-1 medications. Is that a real concern? And what should patients know?

Kristin Louden: I also think that this has been blown out of proportions some. Yes, you will have some muscle when you lose weight on these medications, but that can happen with any form of significant weight loss. Now, these medications, while we do lose weight and we lose muscle, what's important to understand is that the muscle itself becomes healthier. It functions better, it contains less fat, it's more insulin sensitive, and our overall cardiovascular fitness actually improves. And we can do things to offset muscle loss with weight loss, even though it is very minimal by getting enough protein and incorporating resistance training or strength exercise.

Dr. Scott Steele: So I'm always amazed by some of these trends that occur on social media. And some of the trends regarding the GLP-1s are microdosing, off-label use. How do you address these trends and make sure the information out there is correct?

Kristin Louden: Well, recently, the FDA issued warnings about compounded GLP-1 manufacturers. And I know that some of the pharmaceutical companies are going after some of these companies that offer compounded GLP-1s, but there are concerns about the quality of the medication, the accuracy of the dosing. There's higher risk for medication errors. So overall, they're not as safe. These medications are complex biological drugs and small formulation differences can affect how they work. So the safest approach is going to use the FDA-approved medications in the presence of someone that specializes in these types of medications.

Dr. Scott Steele: So Kristen, not everybody has the same response, as you said, to these. And so when someone takes a GLP-1 medication but doesn't lose either enough weight or maybe they can't even tolerate them, what are the next steps? Are there alternatives?

Kristin Louden: Well, we first troubleshoot, can we go a little lower and slower with the dosing, repeat a dose, go backwards a dose? We look at their diet. Are they staying hydrated? Can we manage the side effects maybe with over-the-counter medications? But unfortunately, no matter what we do, some people are not going to tolerate the medications. So we may try a different agent, we may combine therapies, or also consider bariatric surgery if they're a candidate.

Dr. Scott Steele: So let's talk a little bit about that. How does the GLP-1 medications compare to bariatric surgery when it compares to weight loss? Is one better in the long run and the patients have to choose between one or the other?

Kristin Louden: Well, surgery typically produces more weight loss and more enduring weight loss, about 25% to 35%. While GLP-1 medications usually lead to about 10% to 22% weight loss. Patients don't have to choose. It's much like how we treat cancer where you can have adjuvant, pre-adjuvant, post-adjuvant therapy. We can consider medications before bariatric surgery to make the surgery safer for the patient or after if the patient experiences any weight recurrence, or even as a complete alternative for some patients. They're both effective tools and the best approach depends on the individual, but it doesn't have to be either or.

Dr. Scott Steele: So we talked a little bit about the types or classes of medications within GLP-1 pipeline. Is there anything that's new in this pipeline? And are there any new medications coming out soon or any exciting research happening right now?

Kristin Louden: We're entering into a very exciting time in obesity medicine. Over the next several years, we're going to see more combination therapies, including dual and triple agonist hormone medications, including new biologic targets, and they include amylin, glucagon, GIP pathways. These therapies will improve effectiveness, last longer, and be more tolerable for patients. And we're seeing this class expand far beyond weight. There's going to be more treatment in the comorbidities of obesity, such as heart disease, fatty liver disease, kidney disease, sleep apnea, and other obesity related conditions from substance use to cancer.

Dr. Scott Steele: You mentioned some hormones there. So how do these hormones affect our body and what do they do, and especially as it deals with weight loss?

Kristin Louden: Well, the newer medications combine GLP-1 with other hormones involved in metabolism. Amylin helps to regulate fullness and portion control. Glucagon actually increases blood sugar, but when you combine it with a GLP-1, it can actually increase energy use and fat burning. GIP influences how the body manages energy and insulin. So it makes GLP-1 more tolerable and more effective. So by targeting these multiple pathways in combination, we can better mimic our own systems and better regulate appetite, metabolism, and energy balance.

Dr. Scott Steele: Okay. So I have to ask you the question. I'm sure you've been asked multiple times. What happens when you stop taking these medications? Do you gain the weight back? Do you gain it all back? Do you go overweight? What happens when you stop? And once you start, do you got to keep on going?

Kristin Louden: Well, when you stop your blood pressure medicine, does your blood pressure go up? Obesity is a chronic relapsing progressive disease. And yes, sadly when you stop these medications, you're going to be hungrier, you're going to feel less full. And unfortunately, that can lead to weight recurrence in the vast majority of patients. And this relates to something called set point theory, meaning that our body is biologically wired to defend a higher weight. So that is why patients benefit from long-term management, not because of a lack of willpower, but because of our biology.

Dr. Scott Steele: So now it's time for our quick hitters, a chance to get to know our guests just a little bit better. First of all, are you salt or sweet?

Kristin Louden: Salt.

Dr. Scott Steele: What was your first car?

Kristin Louden: This is so embarrassing. It was a Geo Metro.

Dr. Scott Steele: Fantastic. And so if you could have one superpower, what would it be?

Kristin Louden: To be invisible.

Dr. Scott Steele: Now go back and take me finally to maybe just graduating from college. If you could go back to yourself at that stage and give yourself a piece of advice, what would that piece of advice be?

Kristin Louden: Don't be so critical of yourself. Have fun and don't take life too seriously.

Dr. Scott Steele: Fantastic. And so can you give us a final take-home message to our listeners regarding GLP-1 medications?

Kristin Louden: A lot of what people see on social media is designed to get attention. These headlines amplify rare side effects, the worst case scenarios, because that's what drives clicks. It's important to look at who's posting the content, what their credentials are, and whether the information they're using is coming from evidence-based sources. I would encourage you as patients to bring these questions to your healthcare providers rather than making your decisions about these medications based on what you hear online. And individual responses vary. Some patients may lose a lot, some might have a minimal response, and this doesn't reflect effort or willpower.

Dr. Scott Steele: That's fantastic. And so to learn more about medical weight loss through Cleveland Clinic's Bariatric and Metabolic Disease program, or to schedule an appointment, please call 216.445.3136. That's 216.445.3136. You can also visit clevelandclinic.org/firststep. For more information, that's clevelandclinic.org/firststep. Kristen, thanks so much for joining Butts and Guts.

Kristin Louden: Thank you. It's my pleasure.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.