Ep. 262 Ozempic: Exploring the Benefits and Uses – A Comprehensive Review with Dr. Tracy Gapin

I am honored to reconnect with Dr. Tracy Gapin today. He is a board-certified urologist and men’s health expert. 

The current state of metabolic health in the United States and most westernized countries has sparked a great interest in a GLP1 agonist, AKA Semaglutide Ozempic. So I wanted to talk to a clinician actively utilizing this medication.

Dr. Gapin and I discuss what this drug class represents. (These are synthetic peptides.) We speak about Semaglutide, Ozempic, Wegovy, and oral Rybelsus. We get into current research, side effects, who should not take these medications, and the mechanisms of action specific to the pancreas and beta cells, reductions, gastric emptying, and the upregulation of satiety. We discuss changes in the brain regarding leptin and how these drugs work. We also talk about weight loss resistance, and I answer questions from listeners. 

From my perspective, it all comes back to basics. I believe that if we are to prescribe these medications, we must help our patients understand how lifestyle impacts weight-loss resistance and metabolic health. I loved that Dr. Tracy spent some time talking about the specific ways he works with his patients, even before prescribing medications. He also explains how important he has felt this drug has been for his patients.

I approached today’s conversation with an open mind, and I hope you will do the same.

“Dehydration inhibits your ability to lose weight.”

– Dr. Tracy Gapin

IN THIS EPISODE YOU WILL LEARN

• How the GLP1 agonists help Dr. Tracy motivate his patients to lose weight.
• What are GLP1 agonists, and how do they work?
• The physical benefits of GLP1 agonists.
• Who is Semaglutide not appropriate for?
• Some of the common side-effects of GLP1 agonists.
• How those who fail to implement lifestyle changes when they stop using Semaglutide may regain all the weight they lost.
• Why it is essential to stay hydrated when using Semaglutide.
• Why you need to eat enough food- protein in particular when taking Semaglutide.
• How to follow the metrics that matter.
• Some factors that could hinder successful weight loss.
• What Dr. Tracy does to ensure his patients do not regain the weight they lost after they stop using Semaglutide.

Listener questions:

• Why is a diabetic drug being used for non-diabetics?
• Does this drug target muscle versus fat in terms of weight loss?
• For how long do most patients take it?
• Are there unique characteristics in perimenopausal and menopausal women that must be accounted for differently?

Bio:

Dr. Tracy Gapin is a board-certified urologist, a world-renowned men’s health & performance expert, and the founder of the Gapin Institute, the global leader in High-Performance Health. 

He has over 20 years of experience focused on men’s health optimization, human performance, and longevity, providing executives & entrepreneurs a personalized path to fulfill their highest potential. He’s been featured in Entrepreneur, Dave Asprey’s Biohacking Conference, and as a TEDx speaker.

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Text “Health” to 26786 to receive 10 Secrets to High-Performance Health and a free copy of Dr. Gapin’s book.

Transcript

Cynthia Thurlow: Welcome to Everyday Wellness Podcast. I’m your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent, is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.

Today, I had the honor of reconnecting with Dr. Tracy Gapin. He is a board-certified urologist and men’s health expert. With the current state of metabolic health in the United States and actually in most westernized countries, there’s been great interest in a GLP-1 agonist aka semaglutide, Ozempic. And I wanted to bring a clinician on that is actively utilizing this medication. We spoke about what this drug class represents. These are synthetic peptides. We spoke at great length about semaglutide in particular as well as Ozempic and Wegovy as well as oral Rybelus.

We discussed current research, side effects, who should not take these medications, and spent quite a bit of time talking about mechanisms of action specific to the pancreas and beta cells, reductions in gastric emptying and satiety being upregulated, as well as specific changes in the brain with regard to leptin and how these drugs work and manifest. We spoke about weight loss resistance. I answered many listener questions. Thank you for submitting those. From my perspective, it really comes back to basics.

If we are going to be prescribing these medications and let me be clear, I’m not currently doing so, but if we are going to be prescribing these medications, we owe our patients the opportunity to really understand how lifestyle impacts weight loss resistance as well as metabolic health. And I love that Dr. Tracy spent quite a bit of time talking about specific ways that he works with his patients, even prior to prescribing medications, but how important he has felt that this drug has been to his given patient population. I think I went into this conversation with a very open mind and I hope you will as well.

Tracy, so good to have you back. Thank you for carving time out of your busy schedule to talk about a topic that is getting a lot of attention. Ozempic, semaglutide, Wegovy all these drugs. Tell me from your perspective, I mean, obviously, you’ve been a urologist for a long time. When did they kind of fall onto your radar in terms of your given patient population? Full disclosure, you work with men, but still when did you start utilizing these drugs, and what has been kind of the progression of using them? Are you using them with greater frequency now? I’m sure people are probably coming directly to you and asking for them.

Tracy Gapin: Yeah, absolutely. First of all, thanks so much for having me on your show again today. [Cynthia laughs] I love you, I love all your content. You’re amazing human being, and so I’m glad to be with you tonight first of all. Yeah, so at the Gapin Institute, my focus is men’s health. I have a nurse practitioner who does all the women’s health work. But when I work with high-performing executives they come to me really Cynthia for four reasons and they come to me for almost only four reasons. “I want more energy, I want to lose weight, I want better sex and I want to live longer.”

And I’ve doubled down on really just those four things and so when guys come to me for something else that’s not really what I do. I help you have more energy, lose weight, have better sex, and live longer. Those are the biggest complaints that I hear men talk about. And so when it comes to the weight loss issue and specifically we’re talking about burning fat, building muscle, improving body composition is how I define it, they just say lose weight.

The GLP-1 agonist had been a great way to really help augment that process. The way I look at our human operating system is complex and there’re a lot of inputs too. We have to look at hormones, we have to look at micronutrients, we have to look at the gut, we have to look at stress and sleep and all these other factors that come into play. The GLP-1 agonist, damn, they’re a great way to kind of give guys a kickstart, get them some momentum, get some weight loss to where now they’re starting to see some progress, and we’re simple creatures, Cynthia, you know this. [Cynthia laughs] We got to see results. We got to see results quickly or else we’re not going to continue.

It’s all about how do I show guys a big win to start that will get them motivated to make more changes. Do I think these peptides are the be all end all and all you need is this and you can eat like shit, not sleep and not do all the other things you need to be doing? Definitely not. But it’s a great addition to everything else we do.

Cynthia Thurlow: It’s such a good point and I think it is a very Americanized kind of focus that we want everything instantaneously. We don’t want to wait 3, 6, 10, 9 months. We don’t want to wait. I think there’s been tremendous interest in these drugs. I think that as soon as the social media stars and influencers and celebrities started using them and talking about them, I think it’s brought greater awareness. And I think a really good place to start is to talk about what exactly are they. I think it’s important just to note that these glucagon-like peptide 1 is a hormone released by the small intestine in the presence of food that has important metabolic benefits. So, it’s really that simple, but it’s also helpful to talk about how they work mechanistically. We know that these incretin hormones actually help increase insulin sensitivity and decrease glucagon.

So, insulin and glucagon work in opposition of one another and they actually exert stress on pancreatic beta cells. For people that have some familiarization with pancreatic function, that’s where a lot of these drugs are doing their work. Now, for you, when you’re looking at there’s so many options now, obviously, these are synthetic, but Ozempic and Wegovy and I guess in the UK, they actually have an oral drug now called Rybelsus. I’m not even sure if that’s available here in the United States.

Tracy Gapin: [crosstalk] Yeah.

Cynthia Thurlow: Yeah. How do you make sense of which drug you’re going to start and how you approach discussing this with patients to help them understand how it works mechanistically?

Tracy Gapin: Yeah, so just a little bit of brief background because you and I throw around a lot of these names and trade names and semaglutide. A lot of people like what is in this, there’s tirzepatide, the new one. It just kind of gives clarity for the listeners. This all started actually 15 years ago when research started showing this GLP-1 receptor on the pancreas and how stimulating, it can really improve insulin sensitivity. Ozempic got FDA approved for type 2 diabetes in 2017. Ozempic is a branded version of semaglutide. And they’re actually all made by the same company just to be clear. There’s one single manufacturer of all semaglutide. Then ty realized, holy cow, this is a great product for losing weight. The FDA actually did approve it for weight loss under the trade name Wegovy 2021, still semaglutide. But now it’s specifically indicated for weight loss for people with a BMI of 27 or greater. And at least one health condition or those with a BMI of 30 or greater.

Since then, other GLP-1 agonists have come along. Rybelsus is a semaglutide as well. It’s more commonly used internationally. We have liraglutide, which we can talk about as well, and then Mounjaro, which is tirzepatide as well, which is a little even more powerful than semaglutide. The key here is what these are all doing is focusing on improving glucose homeostasis, blood sugar regulation for a layperson, it improves insulin sensitivity by affecting, as you mentioned, the beta cell of the pancreas, two mechanisms, that’s the main one. It improves blood sugar regulation without any risk for hypoglycemia. That’s the key thing is that when taking these medications, you’re not going to really encounter hypoglycemia unless you mix it with another diabetes medication, then you increase that risk.

So, improves insulin secretion from the pancreas, it improves blood sugar regulation, it suppresses glucagon, which as you mentioned the opposite of insulin and that’s a hormone that increases blood sugar. That’s why it works so well for that. It also works by delaying gastric emptying. What I think is probably most powerful is it actually works at the brain level, at the ghrelin receptor level in the brain to regulate hunger and satiety. By all these different mechanisms, the ultimate outcome is weight loss through blood sugar regulation and through really better appetite control. They’re pretty powerful drugs for that purpose.

Cynthia Thurlow: It’s really interesting because I’m seeing in the biohacking community that people are using it in subtherapeutic doses, people who are thin, who want to take the edge off their appetite, who maybe they’re going away on vacation, they don’t want to overeat. People are telling me privately and these are licensed healthcare providers telling me that they themselves are taking subtherapeutic doses just to kind of take the edge off. Are you seeing clinically that people who are already thin are asking for the drug to utilize it in that mechanism or that way?

Tracy Gapin: Yeah, 100%. It’s the Wild West, and I hate to say the word abuse because it’s a relatively safe drug, but it is at your [unintelligible [00:09:20]. It’s being used by individuals. I mentioned the indication for it previously on how it’s FDA indicated, but it’s being used off-label absolutely for people who have a little bit of belly fat they are trying to burn, to decrease appetite and so, yes, it is being used a lot. There are a few contraindications we can talk about for sure, but it is perhaps being overused. I want to just emphasize where we started that it’s not the magic pill. It’s a great addition to what else we do. There are studies showing that as soon as you stop semaglutide, if you don’t have other things in place and you’re taking care of what you need to be doing with hormones and nutrition and sleep, then you’re going to gain the weight right back. And that’s very clear that semaglutide is not a long-term solution in that regard.

Cynthia Thurlow: Yeah, and it’s interesting because as I was doing research and prep for this podcast, that was definitely evident that there are celebrities and laypeople that are saying, “You need to understand that if you go back to your old ways. If you’re still going to eat the same foods, you’re not going to lean into those lifestyle changes that you have the ability to gain all that weight back.” We know yo-to dieting, in particular, is a really important indicator of people that are dealing with some degree of significant metabolic dysfunction, because usually when people gain the weight back, they don’t just gain that weight, they gain more back.

Tracy Gapin: Yeah, absolutely. I think it’s important to point out that there are incredible benefits with this drug when you look at physiology. We’re seeing improvement in lipid parameters, hemoglobin A1c is better, blood pressure is even better, inflammatory biomarkers are improved. We’re seeing definite improvement in endothelial function. What’s really amazing, Cynthia is the studies that are showing a reduction in cardiovascular events. We’re talking about improvement in cardiovascular survival with semaglutide, which is incredible and even more so with some of the newer ones as well.

Cynthia Thurlow: Yeah, and I think that’s certainly exciting. I think initially when these drugs kind of came on my radar, I didn’t feel like I had enough information to really, as a clinician, be able to speak confidently about the pros and cons. I think it’s important for people that are listening to touch on the people that this drug is not appropriate for, because I found an extensive list. It’s not just a couple of different concerns that people have about certain individuals utilizing the drug or the drugs that class of drugs if you will. For you, what are some of the low-lying fruits, the things that you will say to your patients? If you have X, it is absolutely not appropriate to take this drug.

Tracy Gapin: Number one, any diabetic for the simple reason that diabetics, if you’re on any blood sugar medication already, you do encounter the risk of hypoglycemia with a combination of semaglutide with other medications. If you’re pregnant, you should not be taking semaglutide, that’s a big one. Any history of pancreatitis, you want to avoid semaglutide because of its effect on that beta cell. There’re some rare things where any personal or family history of thyroid carcinoma called medullary thyroid carcinoma, it can potentially provoke that as well. There’s a super rare condition called MEN, multiple endocrine neoplastic syndrome. MEN type 2 is the one that we want to avoid. Again, incredibly rare situations there. Talk to your doctor and again, I’m not here to give medical advice on the show, but those are the reasons why when patients work with me why I might not prescribe it.

I also make it very clear. I have guys reaching out on an almost daily basis, “Hey, can I just get semaglutide?” The answer is no, you cannot just get semaglutide. What I’m going to do is I’m going to optimize your whole system. I’m going to fix your hormones, I’m going to get you eating the right foods, I’m going to get you sleep, and we’re going to control stress, clean up the gut. And yes, semaglutide is great on top of all that, yes.

Cynthia Thurlow: Well, I think those foundational principles always apply and I love you know, it gives you a sense of how much research I did going into this. In addition to what you’ve talked about, active gallbladder disease came up as a concern. Tumors of the thyroid gland, parathyroid, pituitary gland, pancreas, or adrenal, so those are all included. You mentioned people who are pregnant, but also people trying to conceive or those that are breastfeeding. I always say breastfeeding is, you know, all bets are off when you’re trying to feed another human.

The other thing that I thought was interesting, I also saw some reports talking about people that are alcoholics or drink excessively that that may not be the ideal drug for them. Certainly, I know when you’re doing an intake on your patients, you’re doing a very, very extensive kind of overview of their habits, not just the ones that we’ve already identified.

Tracy Gapin: For sure.

Cynthia Thurlow: Now, when we talk about semaglutide and for purposes of this podcast, we’ll just say semaglutide and that applies to all the GLP-1 agonist just to make things simpler, there are some common side effects. There are definitely some side effects that the layperson may be hearing about. Let’s run the gamut from more benign all the way up to more serious because I think the concern and it’s interesting on Twitter, there’s a very anti-semaglutide kind of focus. On Instagram, it seems to be very pro semaglutide. It’s interesting on different social media platforms because I was asking all across different platforms what people’s thoughts were. Some people think of it as a cheat and I’m using someone else’s words and I’m putting that in sir quotes. Other people called it a miracle. What are some of the common side effects, starting with the more benign ones that your patients will complain about or will discuss with you?

Tracy Gapin: Yeah, the biggest one without question is nausea, burping, occasional vomiting. Those are really by far the most common side effects. They’re mild and the fact that they’re not life threatening, cause any major threat as long as you’re able to still keep fluids down and still eat and have some semblance of nutrition. I have had patients in the past who overdosed, not through our lack of purpose but they actually just didn’t read the instructions and took what they thought they were supposed to be taking the wrong amount.

Anyway, she was sick for three weeks and so that can happen. And so, dosing is really important. You want to really titrate up the dose slowly. Semaglutide is one of these drugs where you don’t need to go, we can go through dosing schedules, but we don’t need to get to that top dosing to reach the peak effect. I have a lot of patients who actually get great results with the starting dose and don’t ever need to be titrated up. What I tell patients is if they’re having those side effects from the dosing that they’re on, I would hold it until they’re feeling better and then I would drop that dose in half. What they’ll often find is they’ll get the same weight loss benefit, blood sugar regulation, insulin sensitivity benefit without the side effect.

Cynthia Thurlow: Yeah, I think that’s really important for people to understand that bio-individuality goes a long way. There’s kind of a prescriber’s recommended starting dose and you and your practitioner may start at a lower dose, you may start at a higher dose. Some of the things that I thought were interesting, and I had nurses that were reaching out to me saying, “Oh, we’ve got patients coming into the emergency room that have irretractable vomiting. They have a lot of vomiting and a lot of nausea.” Obviously, that’s an extreme reaction. That’s not the average person.

I think nausea and constipation were the two things that appeared to be– so imagine you trade the ability to have cravings and desire to eat. You trade that for nausea, which is not going to make you want to eat, and then constipation where you feel like you can’t move your bowels. One of the reports that I was reading was interesting. Again, there were a lot of healthcare providers who reached out to me with their own experiences with it, and one of them said, I went from having a lot of cravings and wanting to eat two to three meals a day to not wanting to eat anything and then being constipated for a week.

Acknowledging that each one of us are individuals and we may react very differently. There were people who had injection site reactions, headaches. There was also some nasopharyngeal irritation, which I didn’t fully understand and appreciate why that was happening. But it’s interesting, I was reading a study from the Diabetes, Obesity, and Metabolism Study that said, as an example and we kind of touched on this earlier, weight regain. People that have taken the drug and then they stop the drug, the weight regain and cardiometabolic effects after cessation. There were 327 participants in the study, 12 months after stopping. So, this is a considerable amount of time.

So, 12 months later, two-thirds had regained the weight with changes in cardiometabolic effects, which I’m assuming are some of the parameters you talked about, blood pressure, glucose, cholesterol, etc., participants with a BMI greater than 30 with at least one risk factor. Very interesting to show that even the research is demonstrating that when people stop, and I do think of this as not per se a side effect, but understanding that if you don’t clean up what you’re doing, you have the potentiality of actually regaining the weight that you’ve originally lost. In your patient population, how much of that are you seeing that men that are coming to you are perhaps they use it for six months, use it for a year, they go off, and then all of a sudden, they’re boomeranging back into the office saying that they’ve regained what they originally had lost.

Tracy Gapin: Yeah, I hear a lot of stories about that. Most of the men who come to see me, they’d never tried it before, they’d heard about it, and it’s fairly new. It’s just trying to really gain traction in the media and the public. Hadn’t had a lot of guys on it previously. You see studies of patients who regain all that weight, like you’re talking about. What I’ll see commonly is nausea, the occasional vomiting. I do see probably as much diarrhea as the constipation. So, like you said, bio-individuality, all bets are off, everyone’s going to respond slightly differently. Abdominal pain, cramping is pretty common as well.

But among all of that, I think that a common finding is dehydration and I want to really emphasize dehydration inhibits your ability to lose weight. You have to really be sure if you’re on semaglutide, that you’re staying incredibly well hydrated because like you said you just don’t want to eat or drink. People can get profoundly dehydrated from the diarrhea, from the nausea, vomiting, not eating, and not drinking.

Cynthia Thurlow: Again, this is not medical advice, but just speaking in generalities, what is a common starting dose for your patients? Or I know that your nurse practitioner also sees women, but is there any gender difference in terms of starting doses or is it based on weight? How do you come to that decision?

Tracy Gapin: Yeah, great question. The dosing schedule is not based on weight although I could argue that perhaps it should be. In general, the starting dose is the same among men and women, although I will be super careful if someone is petite, if they’re small, just for the sheer concern in my mind that they’re going to be more likely to have side effects. That dosing typically is 0.25 milligrams to start. That’s a once-a-week dose. It’s a sub-Q injection 0.25 milligrams once a week is the starting dose. I’ll tell you, Cynthia, a lot of people will get great results at that dose and we never ever go up from there. It’s incredible. So, that alone can be fine. If anyone gets nausea, vomiting with that again I’ll hold it for a week. When they start to feel better and all that’s completely back to normal, they have no side effects. Then I’ll restart it at half that dose of 0.125. You don’t need a lot of this.

The dosing schedules we have that are out there, you go from 0.25 milligrams once a week for 4 weeks. For the next 4 weeks, you go to 0.5 milligrams once a week for 4 weeks. Then you go to 1.0, 1.25 milligrams once a week. And then it goes up to like 1.7, 2.4. I’ll be honest with you I’ve never had to go above 1 milligram per week. I think it’s dosed as high as 2.4. But I’m telling you just don’t need that high of a dose. Most people stopping a point, I think I’ve had one patient where I’ve had to go above 0.5. No symptoms, no nausea, no vomiting, but no benefit hit the 1 milligram and we saw something, most people are going to get the benefits at 0.5 or less.

Cynthia Thurlow: It’s interesting. I guess, in my mind, I’m thinking if someone’s going from standard American diet, eating all day long, there’s really a lot of benefit to cut back on the frequency of consumption. Do you have people where they start losing muscle mass because they’re not able to maintain what they have because they’re not eating enough food? Because I see a lot of that in the fasting space. It’s always a concern I have for OMAD. Like if you’re just eating one meal a day, how are you going to eat enough protein to be able to maintain lean muscle mass? I would imagine for susceptible individuals that could be a great concern.

Tracy Gapin: Yeah, absolutely Cynthia. So, this goes into the concept of starvation and malnutrition. A lot of men and women will try to just simply reduce caloric intake with the purpose of losing weight. And you know as well as I do that when you do that, you’re going to lose both muscle and fat. And so that’s not really the point. What you want to do is you want to build muscle, you want to be burning visceral fat, and so to do that, you still have to have fuel for the engine. The engine needs to be running. You have to be strength training and strength training and strength training, building muscle, and that’s going to help you burn fat while you’re sleeping. But you got to feed it, you have to give it the micronutrients, you have to give it the macronutrients, and specifically protein. I tell that if you’re not getting 40 grams of protein per meal, then you’re not going to have sustainable energy to build that muscle. And so, the answer is yes. The risk with semaglutide is, again, that you just don’t eat at all, don’t drink water at all. Yes, you can get into that situation where either you don’t lose weight because metabolism shuts down or you’re burning muscle and fat at the same time.

When I work with my clients, I’m all that data and we use body composition tracking on a daily basis, whether it’s a home digital scale, or InBody, or DEXA. We follow that data and all I care about is body muscle, lean muscle mass and visceral fat, body fat percent. Those are the numbers that matter, true weight overall isn’t really important because as we know body composition can vary so much.

Cynthia Thurlow: Now, it definitely can. Of those metrics that you mentioned, when you’re looking at body composition, I know BOD POD is out there. I don’t know in the crux of the pandemic, I’m sure a lot of those businesses closed. But is DEXA the most cost effective to get, the most information, biggest bang for your buck? Is that your preference?

Tracy Gapin: So, DEXA is the gold standard. I want to clarify that I love DEXA and I wish everybody can get a DEXA, but the problem is you can’t get to it first of all, they’re not everywhere first of all, you got to get it scheduled and it’s not necessarily convenient, is it the most accurate? 100%. What I will do is I will have guys use a bioimpedance digital scale at home on a daily basis and we’re tracking all those data points, we’re tracking lean muscle mass, we’re tracking visceral fat, body fat percent, and we will recognize and appreciate the fact that on a daily basis, you’re going to have changes in your water balance and you’re going to changes in what you’ve eaten and when you’ve had a bowel movement, etc. There’s going to be a lot of variation. But I tell you, when you track week to week to week and look at the average over a week, you can get a lot of really valuable data that really is able to broaden or flatten that curve of all the variability you might have from day to day.

And so, we look at two things. We look at in body in the office, understanding again there’s going to be some fluctuation. But I’ll tell you what, when you do enough data points on that map, you can account for variability and start to really see that trend in that curve. And that’s what we’re focused on. The absolute number is not as important as, are we seeing the trend in the right direction, are we seeing a delta that’s in our favor.

Cynthia Thurlow: I think that’s really important for people to understand. Not only are we wanting to make sure that we are eating enough food while we’re taking this medication and we’re lifting weights, and then we have appropriate measurement and this is not an excuse to be obsessive about the scale. I think that’s a very, very important point I want to make that many of the women that I work with, I would say it’s a small percentage that are obsessive about the scale and the number and that guides their entire way they look at themselves all day long. That’s not what we’re talking about. We’re looking at very specific metrics. You specifically are looking at, over time, what’s the trends that we’re seeing. And I think that’s the big picture. That’s where I think a lot of people sometimes can get lost in understanding why it’s so important to track information, but to do it in a way where we’re looking at the big picture and we’re not getting caught up in minutiae of information.

Tracy Gapin: Yeah, for sure. I think it’s important to really have metrics. What are the numbers you’re tracking? What are the key metrics that you care about? So, for my clients it’s body composition. The metrics we just talked about is body fat, lean muscle mass, and body percent fat. And then lab numbers as well. We track fasting insulin numbers, hemoglobin A1c, insulin resistance scores, things like that. The matter when it comes to blood sugar regulation and then looking at markers of inflammation, cardiovascular health, and micronutrient, all these key metrics that matter rather than things like your weight, which is really not what we care about.

Cynthia Thurlow: Yeah, and I’m so glad that you said that. When you’re working with your patients and your clients and you mentioned hydration as being one of these key things that people sometimes don’t think about that can contribute to weight loss resistance. What are some of the other things that you commonly see that people think are not really important? Like hydration, that has a huge net impact on whether or not we can successfully lose weight.

Tracy Gapin: I’m going to give you an example. This is a classic guy that comes in. He’s an executive, he’s an entrepreneur running his own business and he is grinder. He stays up till 12:00, 12:30 every night, and wakes up at 4:00. He has a couple of drinks after dinner and a couple of whiskeys and then he’s up on his computer till late at night and then he crashes. He will get up a couple of times at night and then he’ll wake up early in the morning and he will be at it again. He’s eating fast food on the go. He has no time for exercise, no time to himself and he’s let himself go. He’s stressed out and worried about finances because he’s trying to do this startup business and he’s still trying to support his family. His kids are in college, he’s trying to pay for the kids to go to the nicest school. And he’s being pulled in 10 directions and he’s incredibly stressed and he’s taking some supplements as his buddy told him online he should be taking and he is 35 pounds overweight. He comes to me and he’s like, “Hey, doc, I just need semaglutide so I can lose my belly fat because my wife is starting to comment on it and I feel like she doesn’t find me attractive.” That’s we’re all here, come and asking for semaglutide for that. To back up and recognize all those issues that are wrong with that picture.

First of all, alcohol. I see so many men who suffer with the consequence of alcohol and you don’t have to be an alcoholic for this to be a problem. Two drinks a night guys think they are nothing, but what that’s doing is promoting inflammation, it’s promoting insulin resistance, it is promoting the storage of visceral fat, it’s raising your internal cortisol stress level and it’s crushing your sleep. So, alcohol is a big one. Not appreciating the value of sleep. We know that going to bed at the exact same time every night is critical for a circadian rhythm. And so, when you don’t pay homage to that and when you don’t really honor the value of sleep, now what you’re doing is you’re raising your stress level even more. When I say stress, I don’t mean psychological, I mean like our internal physiologic stress, cortisol stress hormone, I know you’ve talked about this so many times before.

Cortisol is going to crush your testosterone, it’s going to prevent any chance of losing weight, it’s going to make you store visceral fat and it’s going to put you in a catabolic state breaking down muscle, not anabolic building muscle. Now you’re in this catabolic state because you have high cortisol, you’re not sleeping, you’re eating like crabs, you’re giving your body the wrong fuel, and you think you’re going to be able to turn all this around and lose weight? And have sex? And have energy? It’s all tied together. That’s what we’re talking about, we’ve to fix all these systems.

Now, by the way, everything we just talked about has crushed your gut health and so your gut’s a mess, which then perpetuates this vicious ugly cycle that I see in every man I work with. When guys are having issues with performance in the bedroom, when they’re having energy problems late in the day, when they can’t burn belly fat, it’s all of these things that we have to pay attention to. There’s not one single magic fix like semaglutide.

Cynthia Thurlow: Yeah, and it’s interesting because I think many of these same principles apply to women except that you add in the net impact of perimenopause and menopause and the shifts in sex hormones. I think for a lot of women, it’s the shifts in testosterone that have the largest net impact on body composition changes. Women will say, “I don’t understand why I used to have a waist or I’ve noticed that I’ve got all visceral fat that I never had before.” I have to remind them, it’s a combination of the loss of estradiol, but it’s also the contributing factor of this gradual decline of testosterone.

I know in past conversations you’ve mentioned that many individuals just don’t even realize the net impact of estrogen-mimicking chemicals that we’re exposed to. I know we’ve had a lot of conversations about water. I was like what can screen estrogen-mimicking chemicals out of our water? Because it was something I’d never really even thought of. But imagining that individuals that are out there, if you’re on synthetic hormones like oral contraceptives as a woman and you urinate into the water supply, guess what? Those things don’t get screened out.

So, we are constantly bathed and exposed to all these endocrine-mimicking chemicals. And so, for you, is that also part of the work that you’re doing with these men, counseling them on the net impact? Because I think for a lot of guys, I’ve got a pretty masculine husband and when I talk to him, sometimes his eyes will glaze over. Like he just doesn’t want to hear that there’s a degree of cognitive dissonance. I can’t imagine that what’s in the environment, my food, or my personal care products could potentially be contributing to why I’m dealing with some weight loss resistance or why my hormones aren’t as optimized as I would like them to be.

Tracy Gapin: Yeah, it’s so common. Again, we’re simple creatures. Guys want the easy button, magic pill, quick fix, give me the testosterone, give me the semaglutide and get out of my way. The problem is the endocrine disruptors you talked about. They are little things, but they’re big things because they add up and they create layer upon, layer upon, layer upon of endocrine disruption. It’s not just lowering testosterone, but it’s promoting obesity. It’s promoting issues with fertility, and promoting cancer, cardiovascular disease, diabetes. It’s amazing the physiologic consequence of these toxins.

We can make small decisions on a daily basis that can really have profound effect on our exposure to this. Things like water, like, I have a stainless-steel water bottle everywhere I go, you won’t find me without one and I filter my water because I know that’s such a big deal. There are little decisions, but they make such a big impact.

Cynthia Thurlow: Absolutely. And is there a filter that exists that actually filters out these estrogen-mimicking chemicals?

Tracy Gapin: Yes, there are. So, you want to specifically go for a carbon block filter. Okay, carbon block filters, they do exist. They are out there. Reverse osmosis is great for a lot of things, but it’s not really good for clearing endocrine disruptors. So, RO alone will not suffice. I can tell you that. In our house, we built our house two years ago, and we put in a Kinetico system built into the house. So, that our ice maker and we have a separate water tap at our kitchen sink specifically for drinking water that runs through there. I have no personal gain from Kinetico, but I found that that was one that had a good system. There are some that you can put under the sink as well on your existing faucet but you want carbon block for sure.

Cynthia Thurlow: Yeah. I think for a lot of people, they go down the rabbit hole of understanding. They want to test your water first, to find out what’s in it, and then determine what type of system that you need. I know this is going down a whole tangent, but we’re in a new house, we did a new construction as well, and we actually had our water tested. What we actually had high levels of was cadmium of all things. I was surprised it wasn’t actually other things that were problematic, but we have gone down many different avenues trying to figure it out. If you do reverse osmosis, you have to add minerals back in. It just becomes so much more complicated than it needs to be. Let’s loop this conversation back in. Getting back to listener questions all across social media, I got a lot of interest.

The first question I received and this was from a nurse and I thought this was funny, and so I wanted to keep this. “I’m a nurse. Why are we using a diabetic drug for nondiabetics?” That’s kind of the common misconception from a lot of healthcare providers. I don’t understand why we’re using this off-label, but really it isn’t because it sounds like in 2021 there was another indication provided by the FDA.

Tracy Gapin: That’s right, yeah. It is specifically FDA approved for weight loss alone in nondiabetics. It does qualify, again, BMI parameters, which I got to point out here. BMI is nonsense because based on your height, your body composition can so much affect that. And so, BMI to me is an irrelevant number, honestly. It says that I’m morbidly obese where I am right now because I’m a short guy.

Cynthia Thurlow: [laughs] [crosstalk].

Tracy Gapin: But that’s why I don’t believe in BMI. Nonetheless, it is FDA-approved for that reason. Now, it is technically off-label if you don’t qualify from a BMI standpoint, but it’s still nonetheless FDA approved for that reason in nondiabetics. Those who want it, they want it and they see the benefits. As a clinician, as a physician, I see amazing results with the guys I work with. Again, as long as it’s part of a more comprehensive approach as well.

Cynthia Thurlow: Yeah. I think that’s really key is that if you’re working with someone and I’m seeing just like I see pellet clinics that pop up, I’m noticing even in my area that people are jumping on the semaglutide bandwagon. I don’t know how much additional support these individuals are getting. If you are looking to find someone in your area, make sure they’re doing a very comprehensive assessment.

Next question, does this drug target muscle versus fat in terms of weight loss? We kind of have touched on that, but maybe specifically, if you’re using it appropriately, you’re eating enough food, you’re lifting weight. I would imagine the statement would be you can maintain the muscle and lose the fat with this drug.

Tracy Gapin: 100%. Yeah. The mechanism of action here is really think of it threefold. Number 1 is working at the pancreas beta cell level to improve insulin sensitivity and reduce glucagon secretion, which is going to help just better controlled blood sugar. Number 2, it reduces or slows gastric emptying. That’s going to add to the sensation of satiety or feeling full. And then Number 3, it works at the brain level to reduce central appetite as well. And so, the comments about loss of muscle mass are reasonable. But if you are aware of that and you be sure that you’re still maintaining the proper macronutrient ratios and that you’re not in a massive caloric deficit, then you’re okay.

Cynthia Thurlow: I think that’s important. It’s interesting when I was doing research for a conversation, I found it really interesting that when you look at macros as an example, if you look at carbohydrates versus fat versus protein. And this is if you are just consuming food, this is not if you were per se taking a GLP-1 agonist. If you consume carbohydrates, your GLP-1 levels go up and down very fast which makes sense. If you consume fat, you’ll have this lower progression but longer. With protein, your GLP-1 will go up and stay elevated for up to 3 hours. So, really kind of identifying that protein is going to be the most satiating macronutrient which I talk about a lot. The other thing that was interesting, there was another study that talked about different types of fat and the impact on GLP-1 in the body. And it was looking at lard, olive oil, and safflower oil.

The last is seed oil and we know that lard and olive oil actually activated GLP-1 and safflower oil did not. The reason why I’m mentioning this in our conversation is that I talk a lot about the dangers of seed oils and so safflower oil is one of these seed oils highly inflammatory. Dr. Cate Shanahan who’s been a podcast guest on this podcast before, she talks a lot about how seed oils will oftentimes lead to overeating carbohydrates, will drive inflammation, and have the potential for leading to insulin resistance. This really speaks to the fact that endogenously in the body our GLP-1 is largely impacted by food choices that we make both macros and then the types of fats we’re eating. Understanding that lard and olive oil had a positive impact on GLP-1 versus safflower oil did not, it did not drive these key satiety mechanisms that you were mentioning. There’s this kind of three-step process. And I would imagine really impacts brain and leptin levels.

Tracy Gapin: Yeah, for sure. I’ve heard that also with foods like avocado and nuts, it’s probably because it’s against the healthy fats that are helping their eggs as well. I think this comes down to again, it’s a great drug, peptide. It’s one of the few FDA-approved peptides we have. Most of the peptides we use are not FDA approved. And so, it’s an amazing drug in that sense but you just got to pay attention to these key aspects of nutrition that are important. And that they don’t go away just because you’re on this magic drug.

Cynthia Thurlow: Exactly. How long do most patients take it?

Tracy Gapin: Good question. It depends on the goals on how much fat you have to lose. My goal when I talk to patients when they first start semaglutide, we’ll talk about what’s our expectations and my goal is typically no longer than six months. My goal is to use it as a short term, three to a six-month window, get some weight loss going, get the momentum going that you need so that we can get you off of it. I want to be clear that I do not expect to keep anyone on semaglutide as a long-term treatment option. It’s really in my mind to get the momentum going, get the weight loss, and then get going from there.

Cynthia Thurlow: No, do you have a kind of a step-down approach when whether I don’t know if you need to wean it or you just stop it abruptly? But when they are coming off of it, is there a step-wise approach? Are there things that you encourage them to do to ensure that they don’t gain the weight back?

Tracy Gapin: So, guys who work with me, we’re fixing their hormones, we’re cleaning up their gut. I have amazing functional medicine coaches who work with me as part of my team, who work with them on nutrition. We use genetics to guide all nutrition recommendations. What should you eat? What should you not eat? Macro ratios, all that kind of stuff. I feel like we’re doing a great job of setting them up for success. So, once we take that away, they don’t even notice the difference.  So, yes, it is a cold turkey, one day you literally just shut it off.

Cynthia Thurlow: I think that’s awesome. Now, it’s interesting, I was reading about ways to increase GLP-1 naturally, because, of course, listeners of this podcast are curious, what are the things I can do in my normal day-to-day that are going to positively impact these hormones in the body? It was interesting, I was reading that exercise actually increases these hormones and impacts the gut microbiome in a positive way. Again, we’ve talked a lot about adequate protein intake. For me, I say no less than 100 grams of protein a day minimum, so 40 to 50 grams of protein in each meal and that’s conservative. I would say if you’re a bigger person, if you’re a 250-pound guy, you need way more than that. Have you read any other information that has suggested there’re other ways to kind of modulate your incretin hormones, especially the GLP-1.

Tracy Gapin: Yeah, good question. I honestly have never measured anyone’s GLP-1 level. [Cynthia laughs] But I think this comes back to a bigger picture. How do we improve insulin sensitivity? Because that’s the goal here, right? Weight loss is the end result, but the mechanism of action we’re trying to do is improve insulin sensitivity. And so, a lot of that, in my mind, is nutrition, eating the proper macros that improve reducing cortisol. Most of the guys I work with have chronically elevated cortisol levels, and so it’s focusing on that, reducing inflammation. When you do that, I would imagine doing all those right things, your GLP-1 level goes up. But honestly, Cynthia, I’ve never tested, I didn’t even know there’s actually a lab test available to measure your GLP-1 levels. So, I got to admit that’s not a test I’ve ever done.

Cynthia Thurlow: Yeah, I would imagine it’s probably in a research environment because inevitably we’ll get a question, how do I measure that? Because everyone wants to measure autophagy and all these other things. I’m like, no, we can’t measure them outside. Because your partner is seeing women, are there situations where you feel like women maybe have to be on a different schedule in your clinical experience? I know the nurse practitioner handles those patients, but in conversations with her, are their unique characteristics to and I’m just going to speak to perimenopausal, menopausal women because that’s the bulk of who listens to this podcast. Are the unique characteristics at that time in a woman’s life that we have to account for a little bit differently?

Tracy Gapin: I haven’t seen a massive difference other than, I’ll tell you, most women stay at the 0.25 dosing don’t ever go up. My nurse practitioner who sees all the women tells me that she rarely ever goes above 0.25 and she seems to get great results with that. As I mentioned, I will more often than that bump the men up because they seem to tolerate it well and they’re looking for more fat loss. That’s about it though, Cynthia. I don’t think there’s any other major difference other than that.

Cynthia Thurlow: Well, this has been such an interesting conversation. I can’t thank you enough. For listeners you have to understand this has been such a hot topic. My team and I have been filling so many questions, that I really just have to thank you, Tracy, for coming on to help kind of facilitate the conversation, because I’m not prescribing it, and I’m getting so much feedback from also healthcare practitioners who aren’t per se prescribing it, but they’re seeing patients in their ER or they’re seeing patients in their offices, and everyone’s asking for this drug. I think it really speaks to the fact that our current kind of model about calories in, calories out, and counting your calories just isn’t sufficient for helping people facilitate the kind of weight loss that they’re really looking for.

I think there’s a lot of interesting aspects to this GLP-1 agonist. I think it also speaks to the fact that it’s really about having a healthy relationship with your patient and your provider and making sure that they are accounting for your degree of bio-individuality. Anything that you want to add to the conversation that I haven’t already asked you or we haven’t already discussed that you think would be really relevant for listeners?

Tracy Gapin: Yeah, I think maybe one thing else I’ll mention is that semaglutide is a great peptide for weight loss, specifically if there’s mechanisms of action. We have a lot of other peptides that we use for weight loss, for energy, whatever we’re looking for. I like to think of it as often a very personalized cocktail, if you will, for the individual, knowing that everyone’s a little different. There are peptides that will help with appetite, peptides that will help with burning fat, help with sleep, help with all the other aspects of reducing inflammation. That may be a nice adjunct in addition to semaglutide as well, so if you are having issues where you can’t take semaglutide for those side effects, we have a lot of other options as well.

Cynthia Thurlow: I guess the question that will come from this is “How do I go about finding a practitioner in my area?” Because you’re obviously based in Florida if people are outside your area and they’re not in a position where they can get on a plane and maybe come to you, do you have things that you will recommend that people need to look for to find a qualified provider that actually is savvy with all of these peptide therapies and hormones, because let’s be clear, hormones are a complicated business. We’d like to think of them as not being complicated, but they are very complicated.

Tracy Gapin: So, I’ll tell you, Cynthia, as part of our G1 Program, we actually will fly patients to Sarasota on our dime.

Cynthia Thurlow: Amazing.

Tracy Gapin: [crosstalk] we can see them and establish medical care. We work with a lot of patients from around the country who come to us for one of those four things, I want more energy, I want to lose weight

[Cynthia laughs] We do work with a lot of folks around the country. We do consults via Zoom telehealth all the time as well. But you bring up a good point, it’s become the Wild West. There are a lot of shady characters out there who are just out to make a buck on semaglutide without understanding there’re a lot of nuances involved. Again, it’s not to be considered a magic pill. And so, reach out to Gapin Institute, we would be happy to speak with anyone if they have questions. My nurse practitioner works with all the women and I work with all the men and we’re happy to help.

Cynthia Thurlow: Well, thank you for all the great work that you’re doing. I can personally attest to the fact that you are very well-versed in this. You’re one of the first people I thought of when I wanted to bring on an expert to talk about these drugs because there’s a lot of misinformation that’s out there. This has been incredibly helpful and insightful conversation. Please let listeners know how to connect with you. You mentioned the Gapin Institute, but how else can they connect with you? You are active on Instagram, even maybe your team is active on Instagram? But how can they connect with you? And obviously, we’ll link up all of your information and the podcast we did together last year.

Tracy Gapin: Thanks so much. Yeah. If anyone wants to get some more information, they can text the word HEALTH to 26786 and they’ll get my 10 secrets to high-performance health as well as a copy of my book. Again, that’s the word HEALTH to 26786, website is gapininstitute.com as well and you can reach out there.

Cynthia Thurlow: Thank you, my friend.

Tracy Gapin: Thank you.

Cynthia Thurlow: If you love this podcast episode, please leave a rating and review, subscribe, and tell a friend.