Midlife Metabolism with Dr. Gillian Goddard [Ep. 160]

0:00 This is the Eat Well Think Well Live Well podcast. I am Lisa Salisbury and this is episode 160 Midlife Metabolism with Dr. Jillian Goddard. Welcome to eat well. Well, the podcast for busy women who want to lose weight without constantly counting, tracking, or stressing over every bite. I'm Lisa Salsbury, a certified health weight loss and life coach, and most importantly, a recovered chronic dieter here. You'll learn to listen to your body and uncover the reasons you're reaching for food. When you're not truly hungry, freeing you to focus on a healthier, more fulfilling approach to eating. welcome back to the Eat Well Think Well Live Well podcast.

0:42 I am so excited to be talking to Dr. Jillian Goddard. She's an endocrinologist and an adjunct assistant professor at Grossman School of Medicine. Did I get all that right? Mostly, yeah, Mostly. Okay. You correct me. Let's, let's hear from you. Introduce yourself a little bit. Tell us about who you are and what you do. Sure. Absolutely. So as you said, I'm an endocrinologist and a professor at NYU. uh, write a newsletter called Hot Flash, which is all about women's hormonal health, not just about menopause and perimenopause, but sort of everything from puberty through menopause, and I'm so excited to be here.

1:24 Great. Okay. Well, as a lot of my listeners are in midlife, less of us in puberty, it's like, what do people call it? Like second puberty or, Something like that. And sometimes if you yourself are in midlife, you live with someone in puberty, so there's lots of crossover there. Yes, I'm familiar with that. I have two, two girls, so, um, 17 and 20. So yeah, we are definitely in that crossover time. So obviously the main feature of perimenopause going into menopause is the hormonal changes. That's what causes all of the, problems.

2:04 So, let's just talk about that, like a little bit of education on how those hormonal changes of perimenopause, like what happens. generally, and then specifically we wanna talk about how those affect our metabolism since that's, you know, a lot of what we talk about on this podcast is weight loss and, things that affect it. Absolutely. So. I think the best way to think about perimenopause is from the point of view of your ovaries. Women and girls are born with all the eggs that they will ever have, and from your first period onward, you are maturing eggs and ovulating approximately once a month, barring.

2:49 You know, events like pregnancy, and as we get into our, typically into our late forties and early fifties, the numbers of eggs that are left in our ovaries are starting to dwindle. In addition to that, the way our hormonal system works is the, the, the young healthy, like best quality eggs get ovulated. First, and so again, by the time we're in our late forties and early fifties, not only are there fewer eggs, but the quality is lower. And the reason that's Sorry, I'm gonna interrupt you. The body just naturally chooses those. kind of. It's more that they kind of raise their hand, That's fascinating.

3:32 I did not know that. Which is why we're more fertile when we're younger because of the quality of the egg. Fascinating. Okay. Carry on. So those old low quality last kids picked for the team, eggs that are left in our ovaries in our forties and fifties need a lot more. Hormonal drive to get them to mature and prepare for ovulation. Um, and the hormone that does that is called follicle stimulating hormone, FSH. And so you need much, much more FS, H to drive those eggs to. And FSH also tells the ovaries to make estrogen.

4:16 And so what happens in perimenopause is you get these big spikes in estrogen and these big drops in estrogen. And that is a lot of what drives the symptoms that we are having, during perimenopause and early menopause. And then As the eggs get even fewer by the time you're down to, you know, under a thousand eggs at that point, sometimes it takes so long to get an egg ready to go that the wires get crossed and you have a period without ovulating. That's called an anovulatory cycle and sometimes you might go many months. Without a period because you're not ovulating. 'cause the eggs just can't get ready quickly enough and be ready to ovulate.

5:01 and then finally you run out of eggs essentially, and you have your last menstrual period. And the ovaries kind of start to say they're done and start to shut down, but. Our estrogen levels can still occasionally like spike up and drop even after our last menstrual period. And it is actually not the rising estrogen, but really the dropping estrogen that tends to create a lot of the symptoms that we have in perimenopause. The classic ones that people think of, like hot flushes, night sweats, and sleep disruption. But the other thing that happens is our estrogen levels drop and our androgen levels, those are hormones that we typically associate with men like testosterone.

5:46 Our androgen levels oftentimes stay about the same, and so estrogen levels drop, but androgen levels stay the same. So the balance, the ratio between androgen levels and estrogen shifts toward androgens. And androgens promote weight gain in our midsection around our organs. Estrogen promotes weight gain around our hips, thighs, and in our breasts. and so we get this shift from a sort of weight gain more in the hips and thighs to this weight gain in the midsection.

6:26 And the, that's super important for everything that happens to us metabolically after that, because it's weight gain in the midsection that changes how we metabolize carbohydrates. That changes, you know, How well our body is able to use carbohydrates and how much insulin we need to use carbohydrates. it also has some effects on muscle mass. So, on average women lose about a pound to two pounds of muscle mass during the perimenopausal transition. And if you gain fat in your midsection and you lose muscle mass, you pick up some insulin resistance and you lose some basal metabolic rate, so your metabolism slows, you're burning less calories at rest.

7:16 and when you consume carbohydrates, you're needing a lot of insulin to utilize them, and so they preferentially get stored in your midsection, which causes more weight gain in your midsection, and then you just end up on this vicious cycle where you become more insulin resistant, you gain more weight in your midsection. On and on and on. Un until you break the cycle. Doesn't it sound fun? Okay. Yeah. Oh, dear. Okay. so I have questions. Sure. First of all, and this is actually just like a curiosity question, not really even on this topic. You said when you get down to under a thousand eggs, I used to think, and I I might be like, I was today years old when I learned this.

7:58 I used to think that you had the exact, like the number of eggs and you released one per cycle. But I learned recently that that's not exactly true. 'cause I'm thinking a thousand eggs, that's, you still got plenty, like that's a lot of cycles. But That's three years or something, right? More than, more, yeah. Way. So how, how many eggs do you typically release? Because a thousand eggs seems like still a lot left. So you start, most women start life with something in the neighborhood of. 600,000 eggs, which sounds like you should be able to ovulate for like a millennium. But what actually happens is a whole group of eggs, start down the process of maturation.

8:44 So at the beginning, you might have 50 or a hundred eggs starting down this process. But over the course of the maturation process, many of them will die off and there's a chemical process that occurs within the ovary so that some of those eggs spontaneously, like they stop growing and they, they kind of just. Involute and get taken care of by the, the body's system for cleaning up old cells so that you get to, you end up with a dominant follicle, and that dominant follicle is the follicle that ovulates, so you only ovulate typically one egg a month.

9:26 There are exceptions to that. Sometimes some women ovulate two eggs per month, and that's, you know. get twins. Outside of IVF? Yes, that, that's one of the natural ways we get twins. but most of the time you ovulate only one egg, but many more eggs are starting down that process. So a thousand eggs is, you know, enough to get you through three to five years probably. Okay. Okay. That makes, that makes a lot more sense because I was like, but how can you release more than one egg? We would have way more multiple births. But it's not that you release more than one, it's just that, more than that there's a big Okay. Ghost, you, you heard her?

10:07 I won't restate. So that's, that's really just, that's just interesting. I just like learning about the women's body. So, Okay, so my next question about this, like estrogen versus testosterone balance is that we have seen a lot in, You know, I'm sure a lot of my listeners are on Instagram and with a lot of menopause influencers. So there's a, a lot of push with hormonal replacement therapy, which I am on, and I really, I'm thriving on, especially progesterone at night. I love that she's nodding. If you're not watching video, she's nodding along so we can talk about. therapy is fantastic. Okay, but why then is testosterone?

10:48 One of the things that I've been recommend, I, I've been on and off of it. I am, I'm like, I mostly because I'm not sure I'm seeing the results for the cost and because my estrogen and progesterone are like basically covered a hundred percent by my insurance. But testosterone, my doctor won't prescribe the, the mail version because that's an by her insurance, even if she did. Well, it's just a lot cheaper than the compounding version that I have to choose anyway, point being. It's a little bit of a, of a cost for me. And so I have been kind of on and off about it and, but what I'm kind of paranoid about, now that you've said this and I, I just think people that might be on testosterone might think, well, why would I want to be on testosterone if that's gonna cause weight gain around the middle?

11:34 So how would that play into it? Why would we be, you know, recommended to be on a testosterone replacement? I think this confuses a lot of people. So I'll say a couple of things about this. Not everyone's testosterone stays the same in perimenopause. Some people's testosterone actually rises during the perimenopause. In early menopause, some women stays approximately the same and some women's testosterone actually falls. And so if your testosterone levels are very low and you're symptomatic because of that. then adding testosterone may be helpful. That said, the only thing testosterone has really been studied for in women is, hypoactive sexual desire disorder, which put much more simply is low desire for sex and difficulty getting aroused.

12:25 Loss of libido. Yeah. Yeah. Not really wanting to have sex and when you do not feeling all that satisfied by it. And that's actually the only thing that testosterone has really been proven in the literature to do. but you're right, there's no testosterone that has been approved in a formulation dosed for women. And so your two options are compounded testosterone, which you get at a compounding pharmacy. The big challenge, there's two big challenges there. One is cost, as you mentioned, and the other is that compounding pharmacies vary a great deal in their, quality control and reliability. They're not, the way they're licensed is very variable.

13:07 or you can use testosterone formulated for men and just use really tiny doses of it, which Yeah. It's messy and, and inelegant and not, but I have lots of patients who do it because it is quite a bit cheaper. there has been talk about getting a product for women on the market, but I think we're a long ways away from that, happening partly because a pharmaceutical would have to get behind it yeah. Yeah. And a lot more studies done because, so. studies. So if someone were like, okay, but I do have, you know, the loss of libido, it bothers me. I can't orgasm.

13:47 I'd really like to try it. Are they risking midsection weight gain by using it? Not if you're careful with the dosing. So Mm-hmm. one, so one thing that can happen when you take testosterone is you can get the, make the doses very high. So they're higher than like a typical woman's. testosterone would be, and there you may get into trouble with side effects, including some weight gain. if you're getting, taking the levels and you're moving them from sort of low to, you know, more middle of the road for a typical female level, you don't tend to see weight gain issues with that. And the question is sort of why, right?

14:29 some of this is because there's. Other factors at play that we're just starting to understand, around FSH and the role of FSH outside of the ovary. So I told you FSH tells the ovary to mature an egg and make estrogen. there's some. A growing body of literature, I think is the way I would put it. about FSH and FSH receptors outside of the ovary having potentially being related to metabolic changes we see. Women in perimenopause because what happens to FSH in perimenopause and menopause is that it can rise very high.

15:10 and so FSH may actually be acting in other parts of our body, including in this case, importantly the adrenal gland, to have impacts on. Our metabolism, our blood pressure, our cholesterol, that are mitigated by that hormone directly, and not by this mismatch between estrogen and testosterone. Okay, so it's my understanding that. Menopause hormone replacement therapy or HRT or however you want to call it, is not a metabolism or weight loss fix. We don't get prescribed these things because we've gained weight. How though, could they help in weight maintenance or are they a factor?

15:55 Because I've heard people say oh, well I'm gonna get on, HRT and try and lose some weight, and I'm like, those are two. Separate things, and yet our hormones are connected to our metabolism. So what role does that have? So that's actually why people got interested. It in, in FSH as a potential mitigating factor with all of this to begin with is people didn't understand. If you give women back, the reason we don't use estrogen to help women in menopause and perimenopause lose weight is because it doesn't work. there's lots of data to show that it doesn't work, And it works for a lot of other things, like it's great for hot licious, night sweats, great.

16:39 brain fog, muscle aches, joint pain, your hormone replacement will help you with all of that, but it does not help women lose weight. and so the question was, well, why doesn't it? And, and we think that this is where FSH comes into play because when you take hormone replacement therapy, you do not typically suppress. Your FSH, so you don't typically get a lower FSH from taking estrogen. and so that may be part of the issue. However, I do think women who are taking hormone replacement for other indications sometimes see that their metabolic changes are less dramatic.

17:22 and so They may not lose weight, but they also may not gain as much weight as the typical woman does in in perimenopause. Yeah. Possible though, that that could be a correlation factor because people that are pursuing HRT are also those that are living typically gonna be living a more healthy lifestyle. They're typically the ones that are gonna going to already be exercising and, and eating the things and, right. So it's, it's a confusing, it is, and we don't have nearly enough. You know, clinical trial data, like randomized clinical trial data, around any of these issues because for 20 years we didn't do clinical trials, in perimenopausal women with hormone replacement therapy, because of the women's health initiative.

18:12 And so we're just starting to see those types of clinical trials really get going again. And so all we really have are observational studies from the last 20 years or so, which. You cannot sort out causation versus correlation with an observational study. Unfortunately, So, I mean, percentage wise, really, except for from what I, I understand the last, you know, handful of years, the percentage of women on HRT has been so low. between 19 or between 20, 24, which was the year that the Women's Health Initiative study was paused, and.

18:54 Basically women throughout their HRT on, on mass, like in a single day, because of the media coverage of the study. between that, 20, 24 was just last year. 2004, sorry. Between 2004 and 2020. Sorry, I misspoke. okay. So in those, in, in those years between when the Women's Health Initiative study came out and 2020. Four to 5% of women were taking hormone replacement therapy. 80% of women have hot flushes and night sweats, and four to 5% of women were taking hormone replacement therapy. So when people talk about like, oh, we should be using it for this and that and the other, I'm like, how about we just start by treating the symptoms that women are having that we know it works for?

19:42 Yeah. Well, and another one I'm super passionate about, like all my friends know, I'm like, are, are you on vaginal estrogen though? Because everyone can be on vaginal estro. And this is kind of off topic from what we're, what you and I are trying to talk about with. you know, metabolism and, and these changes. But honestly, anytime I can plug that, like, it's so safe. It's a microdose and safe For women who have had estrogen receptor positive breast cancer, it does not affect breast cancer risk. yeah, like I just want you to say that again. Like, we have an endocrinologist here telling us it is safe. It Vaginal, estrogen is safe for everyone.

20:25 We even now think it's safe for the vast majority of women who had estrogen receptor positive breast cancer. Yeah. Okay. And why would a person want to use vaginal estrogen? because vaginal dryness is very common and can lead to a whole host of undesirable symptoms, when our vaginal va vaginal lining and our vulva and the muscles that support our vagina and vulva don't have estrogen, they dry out. When they dry out, they thin and they stick together.

21:05 One of my patients once said that her vagina felt like two pieces of Velcro being pulled apart when she moved. you, you can start to get atrophies. You can actually start to get breakdown of the tissues and not be able to. Insert anything in the vagina, a speculum, a finger, a penis, if that's something that you're interested in doing. So sex can become very uncomfortable. it disrupts the The flora, the bacteria that grow in the vagina so you can get yeast infections. And then my all time favorite is that the slumping down of the vagina actually pulls the anus and the urethra closer together.

21:48 So it's easier to get urinary tract infections too, because you get bacteria from the anus into your urethra. So. And then your, your, I mean, I could go on and on. Your Yeah, I know. I. press on your bladder and It's, it just, it affects the entire area down there. It's not just for vaginal dryness, although that is, I, I've gotten to be almost so sensitive that I'm, I, because it's just a twice a week. And so I can tell like when it's time, like my body will tell me it's time. Don't forget your dose today. but even, you know, if, especially. It's so cheap. So if you are having trouble like with in, with intercourse and you can't do testosterone, like start with vaginal estrogen, that will increase your comfort.

22:37 To the point that you, you might solve your problem there. I mean, I don't know. You know, it depends on what your problem is, but if it's just a comfort issue, start with vaginal estrogen because it's dirt cheap and, will really make such big difference. So anyway, I, I just love talking about HRT, like sometimes I think I should switch over to a menopause podcast, but I, it's just, it just makes such a difference and, big fan. So yes, we could talk a long time, but let's, let's get back to like the, the metabolic changes that we wanted to discuss. So we've got these metabolic changes and all of these hormones are kind of doing what they do in this midlife time, and we get that resulting change in body composition, so we get a little bit more fat.

23:21 A little bit less muscle, one to two pounds of muscle. Doesn't sound like a whole lot, but is this happening? Like every year we're losing one to two pounds of muscle or every decade. Like, and what can we do about that? So the best data that we have around around. Body composition changes in perimenopause really specifically looks at the five years before the last menstrual period and the five years after the last menstrual period. So a 10 year time with your period, your last period, is that the midpoint of that time. And so that one to two pounds of muscle is, over that 10 year period.

24:02 People do tend to lose muscle as they age too. So men lose muscle as they age. Also, not just women, it tends to be more gradual. but you, it, it only gets harder and harder to maintain muscle mass as we age because it becomes such a, again, like so many of these things, it becomes such a cycle because then. If it's hard to use your muscles, then you don't use them. And the less you use them, the less you will have. So this is where, and I know everyone's talking about this right now, but this is where strength training is so very important, for women in midlife because the best way to keep the muscle that you have and to.

24:46 Keep the metabolic benefit of that muscle is to actively do things, to use it and build it. the recommendation is at least two non-consecutive days a week, doing 30 to 60 minutes of strength training. that can look like a lot of different things. It does not have to look like you in the gym. Pumping iron, although if you enjoy that, like it, it definitely works. my, I, I use Pilates as my strength training and my instructor knows that my goal is. Is to use it as my strength training.

25:26 you, there's lots of different ways you can do it. You can use body weight, you can use exercise bands. You just have to be using those muscles. one of the things that's gotten very popular, is weighted vests. There's zero data for that. I wish, I wish it was so easy that you could just strap your weight and fast on and go for a walk. there's no data that it actually works and it actually misses a really important muscle group, which is like your upper core and your, and your arms. and. I can't tell you how many little old ladies I've seen who slip and fall on the ice on their outstretched hand and they break their wrist or they break their humerus or they break their shoulder, or, and awaited vest isn't gonna help you with that.

26:13 So, Because you're not using 'cause you're not using, you're right, you're not carrying the weight with your arms I, upper so if anybody in my own neighborhood listens to this podcast, they're gonna be like, but wait, we've seen you. I do use a weighted vest for a particular reason. And it is because I sometimes just wanna go for a long walk and be out in nature because I enjoy that and because, well, it's good for my dog and I can't get my heart rate up to the point that I want it to be at or the amount of time I'm spending. I don't wanna just go for a leisurely walk and then have to also work out later.

26:53 Like I want it to be my cardio for the day. And so I use a weighted vest to increase my, my heart rate. And so I just kind of wanna like for that, Like a post-it note. what, You're like, I'm don't think I'm strength training. yeah. I, I have done, like, there's an old episode on my podcast, about rocking, which is kind of like a little bit more like a, like a lot more weight. I, I feel like that's probably a little bit different category than a, you know, a five or eight Than what you usually see people out like on your Yes. So. trail? Right. So if you are using a weighted vest to increase your heart rate, go for it.

27:35 Do it, we know that increasing your heart rate is important, but it does not replace your strength training. Yeah. And also you don't wear your weighted vest to do deadlifts. Like it's not doing any good. Like, don't do that. It's not, there's no use for it. Just, just lift heavier if you need more of a challenge. Yep. Agreed. Okay. All right. So the other thing I think that's confusing about these guidelines, is when I am in the gym lifting, I take the rest periods, right? It's like my program, it's like, do these lifts and rest two minutes, but then I'm in there for, you know, 45 minutes. All of those 45 minutes count towards this 30 to 60 minute recommendation.

28:19 Even though some of those minutes I'm standing around. Yes, I know it feels really weird to be like. To be like I, it's a 45 minute workout and I didn't exercise for all of those 45 minutes. I think there's a certain like subset of us who are like rule followers and wanna like get the gold star that we're like, that doesn't feel quite right. It is, it is. The guideline does not say you don't get to rest. Okay. Yeah. Well, and I think too, a lot of us come from the, little bit, you know, cardio bunny, step aro. I mean, I started working out for like, my first experience with like regular working out was like step aerobics.

29:03 Right, And so, you know, it's like you're working out the whole time, and so strength training feels really strange when you've been doing that for a long, long, long time. Yeah. Yeah. And I think, I think some of that is generational. I think you and I are of the generation that was like cardio, cardio, cardio, cardio. And then like a year ago we were like, oh, maybe we should strength train. Yeah. Yes. So, okay, good. So yes, it feels like we know, we know everyone's talking about this, but it's, it's because it really is clear in the research, like it's really clear for, for midlife women strength training is key.

29:47 And, and what's sad is you can't like, not do your cardio though. Like, I'm still, like, I'm still doing those long walks. I'm still like in the pool, I sw still swim laps like. So we just need to balance our cardio with some strength training. That's correct. We need cardio because we, I mean, it's really important for your cardiovascular health, for your blood pressure, and you know, your heart. It's, it's really important. And so yes, we're asking everybody to fit in an extra Yeah. more stuff. Yeah. okay. So we're hoping that this sort of mitigates the weight, the weight gain, but it doesn't really work for everyone as far as some of us are still gonna see some weight gain around this time.

30:34 I can't tell you how many times I have seen a client who tells me like. Well, I guess I would say I'm about half and half. Some of my clients come to me and say they struggled with their weight their whole lives, and other clients come to me and say, I've never struggled with my weight until I turned 40, until I turned, you know, 38, 45, all of just right in this mid range. And so despite feeling like we're doing everything right, we're eating the fiber and we're, you know, counting the protein grams and all of that, sometimes. It feels like we're still gaining weight, so what are the options at that point? What are we doing wrong? And, you know, in the, like, what else can be done and, and what would you recommend?

31:19 Yeah, I mean, I think one of the things that's really tricky here is a lot of the patients that I see in my office, They're pretty well educated about their diet. There may be some, some changes that they can make, but There's not any low hanging fruit. They are really doing the work. And for a long time we were taught, this is literally a board question on the endocrine boards, that if a patient is not losing weight, if they create a caloric deficit. It means that they're miscalculating their calories or lying or eating more than they think they are.

32:00 And in my experience, that answer should be wrong. It's not. That's the, that's supposedly the correct answer, but. There's so much more going on that we don't understand about weight that isn't calories in and calories out. and, genetics are a huge component. and, and metabolic syndrome. And you know, we used to say, well, weight gain causes metabolic syndrome. It's becoming more and more clear that weight gain and metabolic syndrome are caused by the same thing. That is probably an interaction of our genes with our environment. and so I think. You know, sure.

32:41 If, if you're eating poorly, then, then changing your diet can be really helpful. And I do think sometimes people are eating a lot more starch and carbs than they realize they are. And a lot less protein and fiber than they realize they are. and so making that shift can be helpful. And starting a food, I mean a food journal. This is like, I preach on this all the time, like just start writing it down. Like you don't even have to have an app. You don't have to be entering and, and calculate, like weighing and measuring everything. Just write down what you're eating. It'll give you a really clear picture of like. Oh yeah. I really didn't eat a vegetable today. You don't need to weigh and measure all of your bread to notice that there wasn't anything green.

33:25 Yeah, I, I agree with you. I actually track my intake daily in a very casual way. It's just, you know, I had. I don't know. I can't even think I had a salad with chicken for lunch with the, that's it. Like, that's the whole entry salad with chicken. Mm-hmm. Mm-hmm. complex than that. but it does, you look back on it and it makes you think like, oh gosh, like I am really missing protein today. I should really focus on getting some protein in on my next, my snack or my dinner or what have you. it does raise your awareness It's not judging, like it's just information.

34:06 It's not, I think sometimes people feel like that you're being very like punitive about it. It's really, it's just data to help you make good decisions. Yeah, we can't, we can't make any changes until we see what's happening currently. We can't possibly know what to do if we don't know what's currently going on. So, yeah. So that's for starters, but carry on with some of your other ideas. so there's a couple of different things that people have done over the years. I think that, Medications in general have been underutilized, although I think that pendulum has really swung in the last few years.

34:46 Now, I would argue medications are probably overutilized, but if you are someone who is following a healthy diet. And a, what is a healthy diet? A diet that is low in refined carbohydrates and simple sugars, high in fruit, vegetables, fiber, and lean proteins and healthy fats. It, it doesn't have to be more complicated than that either. there's no like right diet, it's more of a concept. but if you're doing that and you're exercising and nothing is happening, or perhaps you're even gaining weight and you're getting told that you have high blood pressure or you're pre-diabetic, or your cholesterol is rising, or you have fatty liver, which are, I mean, all of these metabolic changes that can come with midlife.

35:40 This is really where I start to think about medications. and until fairly recently, we didn't have a lot of great options, but in the last 10 years we've had GLP one receptor agonists. So, I mean these are, this is Ozempic and Wegovy and Mojarro and UND are slightly different, but kind of fall under the same umbrella. and the newer ones, the Ozempic, wegovy, mounjaro, Zep Bound are much more effective than the older ones. But the concept of using these medicines for weight loss is, is actually not new.

36:25 it really didn't start with Kim Kardashian. Right. have been using, have been using these medicines for weight loss. for more than a decade and off-label for probably close to two decades. Yeah. Well, GLP ones as a class were invented, I think 20 some years ago. first GLP one was approved in 2005. It was called Byta. It didn't do much for weight loss. it was a diabetes medicine and the reason you don't hear a lot about it is'cause it was a twice a day injection, so it was hard to even get diabetics to use it. Yeah. Goodness. But not long after that. In 2010, liraglutide was approved.

37:07 That's Victoza and Saxenda. It was approved for diabetes in 2010. People were using it for weight loss basically from the minute it was approved, and it actually got a weight loss indication in 2014. So this idea is, is not new. it's just been very widely adopted. Yes. Which leads us to yes, they are excellent. Very useful in midlife. lot of combinations that we're seeing, like you're on hormone replacement therapy and you're on a GLP one can be very helpful for midlife weight gain. As opposed to someone who, suffers with a disease of obesity who will likely be on a GLP one for their entire life.

37:50 It's my understanding that those that struggle with just some midlife, like just in the last couple years, might be able to use it more short term. Yeah, that's my experience too. I find that. You know, the, the people who really got some midlife weight gain and maybe it crept on and they kind of, I feel like I, I see this woman a lot. She comes in, she's maybe early fifties, and she almost didn't notice at first that because it was, it's so insidious. It's like a couple pounds, a couple pounds, a couple pounds until you've gained 20 pounds. and.

38:31 And oftentimes those women. Have healthy habits or by the time they get to me, they have healthy habits. They've already seen, someone to help them with their diet. those people tend, those women in particular tend to do quite well with GLP ones and I often have my patients come off of them. the one exception to that is women who. had gestational diabetes and then have started to develop some blood sugar changes in midlife. a lot of those women tend to need to stay on GLP one's longer term, not for weight, but for blood sugar management to avoid getting diabetes.

39:12 And they have been proven to significantly reduce your risk of getting diabetes if you're pre-diabetic. So, and that's an interesting feature about GLP ones. It's not just, they don't just work by suppressing your appetite. There's, there's other o other things as, as the layman and me, it's going to, she'll tell us what the other things are, but there's other things that they do to help with the metabolism. Is that correct? Absolutely. So I actually think that the appetite suppressant effects are some of the least important things that they do, especially for people who are already following a fairly, a fairly healthy diet.

39:53 They, they will reduce intake, particularly at first because you just feel full faster and you stay feeling full longer. but they also, they. They make your body more sensitive to insulin. And insulin as a hormone doesn't just so it's main thing that everybody thinks of it for is that it helps your cells take up sugar from your blood, so it helps keep your blood sugar normal and it helps your fat cells and muscle cells take up sugar. And your lip. but insulin has signaling in your brain, in your satiety centers, insulin tells your body, tells your brain that you're hungry and that you want carbohydrates. And so if you can reduce insulin resistance, you actually see.

40:39 Your central drive for hunger and cravings reduced. It also changes what you do with sugar when you do consume it. So when your insulin levels are high, you preferentially take up sugar and store it in your midsection is fat, which we've already talked about is particularly bad for us from an overall health perspective. and instead you're able to utilize that carbohydrate for, for, ener like physical activity for your brain. and so you're not needing to consume carbohydrates. You're not on this roller coaster of eat carbohydrates.

41:21 They all get taken up by my midsection and turned into fat, and my blood sugar drops, and then I feel. Hungry and I crave carbs and then I get back on the rollercoaster. So it really helps you even out those blood sugars so that you're not constantly feeling the need to consume those carbs just to kind of maintain, to keep yourself feeling okay. and the rollercoaster feels crummy. So a lot of times people say they feel so much better when they're on these medicines'cause they didn't even realize that they were on that sort of. Rollercoaster ride from the, you know, the minute they started eating when they got up in the morning. So, it also slows gut transit times, not just out of your stomach, but into your gut and how carbohydrates get absorbed from your gut into your bloodstream.

42:11 And all of those things have significant impacts on why they work. They've actually done some studies. I actually think these are, nobody ever talks about these studies, but I really like them. So anytime you make a drug that blocks a receptor or, or turns on a receptor, so in this case these drugs turn on a receptor. They act like the hormone GLP one, which is a hormone we all have in our bodies. they act like that hormone and they bind to these receptors. Anytime you make a drug that works that way, one of the potential downsides is that the cells just start making more of those receptors. And so they've actually looked at the body and looked at different tissue types to see how they respond to GLP ones.

42:55 And our gut does upregulate our receptors. So when you start taking a GLP one, you might feel really nauseated. You might get really constipate constipated. then the receptors upregulate, so there's more GLP one receptors and those side effects go away. That's also why sometimes people. Panic because they aren't getting that real big sense of fullness anymore. but the other thing, but then when they look at the brain and our brains, the receptors don't change. And so all the effects around satiety in the brain and cravings in the brain are not changing, and the food noise Yeah, the food noise is amazing. Yeah.

43:35 Yeah. So that's why, the protocol is to continue to go up in dose because the receptors increase. protocol is to continue to go up in dose because when you do, I'm not a big fan of the protocol. when you do a clinical trial, your goal is to show that the medication is as effective as you possibly can in the shortest possible time, because your goal is to have the data that you need to go to the FDA and say. Look, our drug works approve us so that we can start selling it and making back our money. pharmaceutical companies are. businesses, there's no doubt about that. and so when they did these trials for, with both wiggle Ovy and Zeep, they had very strict protocols around, up, up, titrating the dose.

44:24 And if you couldn't tolerate the up titration, they, you were out of the trial essentially. and it was because they wanted to get the biggest effect possible in a reasonable amount of time. I actually think. People. Can titrate up the dose much more slowly, and we would see a lot fewer complications with these medications if people did. I usually only increase the dose if people aren't losing about a pound a week. Depending on patient's side effects profile. So if someone's losing more slowly than a pound a week or they're having a lot of side effects, we may decide to increase or, or not increase the dose based on that.

45:06 and so I have patients who are on very middling doses who have done incredibly well without going on a very high dose. I think it. another feature of pharmaceuticals, which is to use the lowest possible dose to get the effect that you want, which really, although that doesn't make the money. And get it to the DA very quickly. It, it is the safest route. Yeah. Yeah, I mean, I just think that there's, if you are getting the desired effect, Mm-hmm. why would you increase the dose? It just doesn't make any sense to me. You're all you're gonna do is get more side effects. You're not necessarily going to get a bigger effect. And in, in real life, we are not limited to the 72 weeks or whatever it was that most of these trials were.

45:56 You can be on these medicines for an unlimited period of time for as long as you need'em. And so, you know, I always. You read about all the horrible side effects that people are having, especially vomiting. I always tell my patients, if you're vomiting, I wanna know about it. You should not. You can be nauseated. You should not be vomiting because that is a sign that you're increasing the dose too quickly. I, I had a client that w finally quit because of the vomiting. And I was, I just felt so bad because there I couldn't do anything'cause I'm not the doctor, you know? And I'm like, okay, but you shouldn't be vomiting. Like, don't do that. We gotta do, and finally they just quit the I know. I mean, that's what I worry about.

46:38 Yeah. I feel like the patients who are really sensitive to these medicines honestly often do really, really well because they're very sensitive to them and we don't need to ratchet up the dose for them to get the desire result, so So as with any medication, there are people that these are not right for, and so. to popular belief. Yeah, there, I've seen some videos of some people that are like, I think in 10 years everyone will be on these'cause they're good for everything. Like, probably not, probably not good for everything. but who should not be considered a candidate?

47:19 I mean, I really think these medications are for people who are struggling with weight gain, struggling with overweight and obesity. Who and. I would even add and are starting to see the, have metabolic effects that are associated with obesity. Those are the people who, who these medicines are intended for, and those are the people who have been studied in clinical trials with these medicines. people who should not be on these medicines are people who are looking to lose a modest amount of weight, for. Sort of more van vanity purposes.

48:02 Look, I mean, I think there's, there's lots of us out there who, you know, grew up in diet culture and feel like we, you know, we could always lose another five pounds. These are not for that. I also think that one of the things that. It really concerns me about people who are using these medications inappropriately. Women in midlife who are using these medications appro inappropriately. Is that it really? Being too thin leads to problems later in life too. and so people who are thin and frail also have health problems.

48:43 They may have different health problems. and so I worry that people are, you know, gonna be trading one. Like one thing for another, and we need to recognize that there's a point at which being thinner is not better. Yeah. Yeah. Perfect. Okay. This has been so good. So good. I've been delightful talking to you. I love, well, I just love talking to medical professionals that really just know what they're doing. So thank you so much for sharing your wisdom. So why don't you tell us more about, I know you have a substack, we wanna, we'll put the link, but tell us a little bit about that, where people can find you online.

49:28 Yeah, absolutely. So, I have a substack called Hot Flash. it is not just about perimenopause and menopause, it's about all women's hormonal health. we talk about all different kinds of things there. And that is@savvypatient.substack.com and we'll make sure to get you that link. And if you like what you read there, stay tuned because I do have a book coming out in spring of 2026 where we will talk about all things related to women's hormonal health and not just estrogen and progesterone, but like all the hormones. So I think it's gonna be really great. Awesome. Thank you so much. And yes, we'll put those links in the show notes have so thanks again.

50:10 Oh, thanks so much for having me. It's been really fun. If this episode hit home for you and you want support working through your perimenopause or menopause symptoms and weight gain, I'd love to talk with you. I have two free resources right now that I know will help you download the What to Do When You Overeat Course. If you find yourself overeating too many times in a week to see lasting weight loss, you'll get the reset and recover guide and figure out how to reduce your over eats and not beat yourself up about it. Or you can grab my brand new GLP one Success Starter Kit. This is for anyone already on GLP ones, or maybe you're just GLP one Curious, but you don't have any support or structure around what to do. Your doctor knows how to write the prescription, but she isn't equipped to support you day to day, and that's what a coach does.

50:52 You can also schedule a free consult session to see if my one-on-one coaching programs are right for you. All the links are in the show notes. Remember, it's not just about the food, it's about empowering yourself with choices that truly serve you. Have a great week and as always, thanks for listening and sharing the Eat Well Think Well Live Well podcast.