Today, I am privileged to speak with Dr. Rocio Salas-Whalen. She is a triple board-certified physician with extensive expertise in all aspects of endocrinology, focusing on women's health and obesity.
Dr. Salas-Whalen believes that effective care should be tailored to the specific needs of each individual, as every patient is unique. In our discussion today, we explore the obesity epidemic, challenging the notion that obesity is simply a lifestyle-driven disease. We examine various factors contributing to obesity, clarifying why BMI is ineffective for assessing body composition and discussing the implications of sarcopenic obesity and visceral fat. Dr. Salas-Whalen offers valuable insights into the specific issues faced by perimenopausal and menopausal women, including the role of hormone replacement therapy and the increasing use of medications like GLP-1s. She emphasizes the complexity of weight loss, advocating for responsible prescribing and recognizing that obesity is controllable yet not curable.
I trust that you will love this conversation with Dr. Rocio Salas-Whalen and find it both enlightening and informative. Stay tuned for more.
IN THIS EPISODE YOU WILL LEARN:
The five causes of obesity
How portion sizes are distorted in the US, leading to overeating and obesity
Why BMI is an outdated tool and not the gold standard for body composition
Why education on reading labels and making healthier choices is essential
What is sarcopenic obesity?
Why visceral fat is more problematic than subcutaneous fat
How HRT can improve body composition
Why it is essential to find a practitioner who aligns with your goals and values
How so many women struggle with self-care and advocating for themselves
Why strength training and increasing protein intake are essential for middle-aged women struggling with weight loss resistance
How obesity medications have evolved over time
How GLP-1 medication can help those struggling with binge eating and weight management
“I tell my patients to stop counting calories.
The only thing to count is your grams of protein.”
-Dr. Rocio Salas-Whalen
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Submit your questions to support@cynthiathurlow.com
Connect with Dr. Rocio Salas-Whalen
Transcript:
Cynthia Thurlow: [00:00:02] 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.
[00:00:29] Today, I had the honor of connecting with Dr. Rocio Salas-Whalen. I've been an admirer of hers for quite some time. She is a triple board-certified physician with broad experience across all facets of endocrinology with an emphasis on women's health and obesity, and she believes that every patient is different and that effective care must be customized according to individual needs.
[00:00:53] Today, we spoke at great length about the obesity epidemic, why obesity is multifactorial and not just a lifestyle-mediated disease, contributing factors to obesity, why BMI is not an effective way of assessing body composition, the impact of sarcopenic obesity and visceral fat, the unique challenges she sees in her perimenopausal and menopausal females, and the role of hormone replacement therapy, the rise of medications, including GLP-1s, and why she feels that weight loss is complex and necessitates prescribing responsibly and understanding that obesity can be controlled but not cured. I know you will love this conversation as much as I did recording it.
[00:01:41] Welcome. It is such a pleasure to have you on the podcast. I've been so looking to this conversation.
Dr. Rocio Salas-Whalen: [00:01:46] Thank you for having me.
Cynthia Thurlow: [00:01:48] Yeah, I would really love to start the conversation today around the existing obesity epidemic because I think in many ways, it provides some perspective about some of the things that contribute to this and your unique perspective because you are a triple board certified, which for anyone that's listening, endocrinology deals with hormones. But I think you have a very unique perspective. I think that you are incredibly judicious, kind, compassionate, and very research focused. And I've enjoyed following you on social media and your content because it just provides a different perspective instead of being very rigidly dogmatic, I think you are incredibly open minded and encourage others to be the same way. And I think that is a byproduct of who you are as an individual but also a clinician.
[00:02:40] Help us have some perspective about the direction things are going right now in terms of looking at risks and morbidity and mortality related to obesity, and why this has become such a huge focus of your work, is helping people turn the course, maintain metabolic health and feel like they're more in control of their health and wellness.
Dr. Rocio Salas-Whalen: [00:03:02] Fortunately, the trajectory in regards to weight, and this is not just in the US, this is worldwide. It's an uphill projection. What happened is that it really focused or brought attention to obesity and comorbidities. Before COVID we always used to tell our patients, you will develop chronic diseases if you continue with this in 10 years, 20 years, 30 years, you might develop type 2 diabetes, you might develop this, osteoarthritis, exposure to cancer. And came COVID and it was quick. Patients didn't have to wait. Patients with obesity were the ones with higher mortality, higher or longer ICU stays. So, I feel like it brought the message very rapidly with COVID, the pandemic.
[00:03:54] And I think people suffering with obesity or having obesity got the message. Got the message that a virus out of nowhere came and you are at high risk of mortality just because of your weight. And the WHO predicts that in 2030, in six years, half of the population will have obesity. So, you're talking about the next pandemic. It is an epidemic right now. And it's not just having the obesity, it’s the comorbidities. The decrease in function, the shorter lifespan, being productive at work and fertility. There's many other connotations that brings and carries half of the population having obesity will be sick population.
Cynthia Thurlow: [00:04:41] I can just imagine, as a clinician, as a mom, what was it like living in ground zero, really being at the crux of where the pandemic seemed to be magnified in New York City, what was that like for you? I'm sure it was probably every emotion you can imagine.
Dr. Rocio Salas-Whalen: [00:04:58] It was very strange to see New York how it was during COVID. And this is a very busy city at any time of the day, any day of the week, there's always people around. You're overcrowded. I remember pre-COVID in restaurants, you're literally touching elbows with the person next in the table. And it was a very strange feeling during COVID. But as New York always comes together in moments like that. So, it was really reassuring being in the city during that time, talking, going a little bit back to what you mentioned of my approach with patients. I really have to give credit to my patients themselves, because everything I've learned about obesity, not in the pathophysiological way, it's been with my patients.
[00:05:49] I've learned. They've taught me so much, my patients that struggle with obesity, that as a physician, we are not exposed to the patient’s side living with obesity. We're trained to see the inside, the physiological, how can we help? How can we fix, but not what the person is actually going through? And what I learned and realized through talking to thousands of patients is that idea of the couch potato patient that is not listening to us, that goes out the door in the clinic and is just not exercising, not eating healthy, eating junk food doesn't exist. I'm courageous to say that I haven't met a single patient that fits that criteria.
[00:06:33] Any patient that struggled with obesity at one point in their life, or every day in their life, they've done a diet that was recommended by a doctor or celebrity, they exercise, they join programs, they've done different classes of exercise, they exercise the juror. And the results were not happening. It wasn't a lack of the patient's trying. It was that obesity is caused by way more than just lifestyle. Obesity is a multifactorial disease. It's a chronic disease. And I like to break it down in five causes for patients to make it more simple. One cause to be lifestyle. I mean, definitely sedentarism or certain eating habits, but it's just one fifth of the equation. Other one are genetics, hereditary. If your mom, if your dad have obesity then you're pretty supposed to or run the risk of developing obesity.
[00:07:28] We know now that the mothers and the fathers’ weight preconception is going to impact the offspring's weight. So, their patient has no control of what their parents’ weight was prior to conception. But that's one part of the cause of obesity. Then hormonal changes through lifetime. Simple examples in women PCOS, polycystic ovarian syndrome, perimenopause, menopause, all those hormonal fluctuations can predispose to weight gain or make it hard for weight loss. Then we go with aging. Aging, we know it decreases our metabolism. So, here are many times what patients used to do in their 20s and their 30s is not happening in their 50s and their 60s, even if they're working out harder.
[00:08:13] And then the fifth part of the equation is environmental factors. And in environmental factors, you have the food industry, you have the plastics, the BPA, the forever chemicals and all those things that can disrupt our endocrine system. Stress, frequent traveling, jet lag, not sleepin,g all those things are environmental in our day to day also produce obesity. So, if you think about it, patient really has control, basically on one part, but all the other ones at certain point, not necessarily. Not to the point that will impact their weight.
Cynthia Thurlow: [00:08:48] Well, I think you really speak to the human experience. I think when you define it as these are the things that put us at risk for developing this multifactorial disease. It's helping people understand we have control over some, but not all of it. And I know that you have been quite outspoken about the processed food industry, identifying that you are hopeful, much like the tobacco industry, was called out and held accountable that the processed food industry, which is over $400 billion a year industry, calling them out on it because they are contributing to the problem. They're thinking more about profits as opposed to the health of our constituents. And I think the other issue that I see as a clinician myself is that so many of my obese, overweight patients had so much shame and guilt around their inability to follow recommendations.
[00:09:42] And we would sometimes label, and I say we collectively, as healthcare practitioners, we can actually label patients as noncompliant. But the human experience trumps that, because if we're telling our patients to eat more and exercise less, which we know doesn't work, we're setting our patients up for some degree of failure. And yet I feel like so much of our training, our traditional allopathic training, doesn't per se encompass acknowledging all of these contributory factors. And I think that, we have to look at it from that perspective, understanding that our current system is not working as it is designed to be. And in many ways we were not serving the needs of our patients, who as you rightfully said, so many of them really want the help.
[00:10:28] They don’t want to be dealing with these chronic unrelenting issues. And so, when we talk about cheap, addictive food and we talk about how the tobacco industry was ultimately held accountable, and that changed the tide of smoking overall. I think a lot about restaurants. And when I go to portion distortion, my family and I were just in Portugal, and the food was absolutely amazing and delicious. And the portions are half of what they are here in the United States. And we always walked away from the table completely full, completely satiated, different level of ingredients.
[00:11:04] And I think a lot of the contributory issues here is that our portion distortion, our idea of what, a portion of pasta or rice or teeny tiny portions of protein, more often than not. I have teenage boys, and oftentimes I've taught them, “Ask for a second portion of protein, or, ask for more of this.” I think in many ways, our perspectives on macronutrients and portions of these are heavily skewed by what we see, not only in the processed food industry, but also in our restaurant industry, I mean, it is absolutely the norm that portions are easily two to three times what we should be eating.
Dr. Rocio Salas-Whalen: [00:11:40] And in Europe, another example is that after your meal, there's a lot of walking. The people walk pretty much everywhere or take public transportation versus here is more being in a car, going to the restaurant and driving and then driving back home and then being sedentary. There aren’t any portion control. And the physical activity that you see out of the United States when you travel somewhere else.
Cynthia Thurlow: [00:12:06] Absolutely. Well, I remember our guide in Portugal was like 67 years old, and he was keeping pace with the teenagers. We were hiking and doing all these things, and he said, “Well, what's the alternative?” He was so open to talking about how-- sometimes when he travels with certain tourists, he has to augment what he's doing because so many people are not accustomed to being that physically active. And yet he was vibrant and healthy and spoke very openly about all the hikes that he was doing. And I was like, “This is fantastic.” I can only hope to be that way when I'm 67. But some of the other things that I think about that contribute. I trained inner city, Baltimore, and the things that my patients would share with me. I know that you trained in Baltimore as well, the socioeconomics.
[00:12:51] So, we know that people who grow up in poverty or grow up with public assistance can be at higher risk for developing some of these chronic diseases. And when you're working with your patient population, what are some of the workarounds you do? If people are having trouble accessing fresh fruits and vegetables? They talk about these deserts. How many of my patients literally had a “Corner grocery store.” And most, if not all of everything that was in there was in a package. It wasn't actually fresh fruits and vegetables. It was very challenging and quite expensive for them to get access to healthy food.
Dr. Rocio Salas-Whalen: [00:13:29] I think one of how we can help patients and people in general is to really individualize care and options. Whenever we talk about healthy eating and organic, we're generalizing, but we know that's not feasible for the majority of people. And I don't like to say healthy and unhealthy food, but better quality food tends to be very expensive and hard to find. So, I think the best what we can do for people of a different socioeconomic status that don't have the accessibility is teaching, is education. To teach them how to read labels. There always is going to be a better option than other. And I think education is going to be their biggest weapon in regards to options of care and how to make better food choices, even if the best of the best is not an option. But it's still to give them that education to know what to bake and what to order.
Cynthia Thurlow: [00:14:32] I think that's really important in that concept of good, better, best. If you're in a situation and let's say you're in Chick-fil-A or McDonald's asking for a hamburger without a bun, or asking for the salad. Yeah, exactly. And helping them navigate, irrespective of where they are, we can always pick a healthier option. I love that. Now, when we're talking about obesity and assessing obesity, I know that body mass index is not a particularly helpful way of assessing body composition. And I know that MRIs are becoming very popular. I just interviewed another physician, Sean O'Mara, who was talking about, “Everyone needs an MRI. Well, it's great, but it may not be financially feasible for everyone to get an MRI.
[00:15:18] What are some of the modalities you like to use in your practice to help yourself and your patients find ways to effectively assess body composition?
Dr. Rocio Salas-Whalen: Definitely, the BMI is a very outdated tool, and it's very surprising and impressive in medicine that we are very advanced in certain things. We're always progressing in certain things and other aspects we take them for granted and we stick with them without questioning them. And I think the BMI is one of those tools that we've just adopted it to our care and take it for 100% tool, which it's not. The gold standard for body composition is an MRI, which is expensive and gets radiation. So, we're not going to have a patient do one every visit or every so often. The second from MRI is a DEXA scan. Again, it's a big machine, it's expensive and also has some radiation.
[00:16:12] And then the third best is an impedance machine, and there's several brands out there, and that's the one that I use in my office. And I do a body composition on every patient in the first visit, and as they're progressing through their journey, whatever their journey is. But what I find, there's so much data that I found by giving body compositions on every patient. It is that those patients that we would categorize as a normal BMI, more often than not, they still will benefit from weight loss, because a BMI is just a calculation between height and total body weight.
[00:16:48] So, many times take into account the total body weight in the height may give you a good average of a normal BMI, but once you do the body composition, you see that is due because they have either higher body fat mass and very low muscle mass. So, an average is going to give you some normal weight. But most patients with a normal BMI most likely have more body fat than muscle mass. And not that so much where we hear the BMI is not good because if somebody's too muscular, their BMI is going to be high. Well, I don't see that often. [chuckles] I see more the opposite. Normal BMI that they still require weight loss.
Cynthia Thurlow: [00:17:25] Yeah. And it's interesting to me because I think about just the role of muscle mass. It's not a question of if, but, when and how that really accelerates, especially for women, as they're navigating perimenopause and a menopause. I know that for me, I jokingly told my provider recently, it is not a question of not enough protein, not enough strength training, it is just exquisitely harder at this stage than it would have been 15 years ago. And admittedly, I don't even think I was aware of how profound sarcopenia can be. And I think for anyone that's listening, this is not just about body composition. This is understanding that our muscle is metabolic currency. It helps with insulin sensitivity. It is so important. And you speak about this underdiagnosing of sometimes called TOFI. So, its thin on the outside, fat on the inside, that's an acronym. But help us understand what sarcopenic obesity is, because I think that's really what we're dancing around, is helping individuals understand that muscle loss and increase in fat mass can be potentially metabolically catastrophic.
Dr. Rocio Salas-Whalen: [00:18:33] Yeah. So, one of the things that I want to change the perspective, and I think people are understanding more, is removing the external with weight loss and health. Removing how one should look or what our idea of healthy is, skinny or thin and really more focusing on body composition. Because if we just concentrate on something superficial or external, that's the point we run the risk of patients having psychopathic obesity, of being skinny fat. We go back to that concept of the BMI that is just an average. But once we look in body composition and we see a skinny fat. So, meaning you can have a normal BMI, but still be predisposed to having type 2 diabetes, or still have prediabetes, or have insulin-resistant metabolic syndrome, having a risk of osteoarthritis and many comorbidities. Even if you're thin because of that sarcopenic obesity or skinny fat that we call. So, just because you may look thin doesn't mean that you are healthy.
Cynthia Thurlow: [00:19:38] No, I think that's an important distinction. It's interesting. I do weight train, but I do Pilates a couple days a week. And when I look around the room at the women, many of whom are thin, but they've lost so much muscle mass in that perimenopause into menopause transition, I think that there is still this outward validation of being a certain weight or a certain size without understanding that there is a slippery slope. I have a parent who recently passed, and part of many reasons why I talk about sarcopenic obesity and body composition is that my father was always thin his entire life. But what comes with this loss of muscle is frailty, failure to thrive, all of these things, and then they get to a point where they start falling.
[00:20:29] And that was one of the conversations I had with my dad, was, “Why are you falling?” And he said, “I don't know why.” And that was the saddest thing of all, trying to get looped in with his internist to help figure out what was going on. But having said that, helping to navigate awareness and education around these things so that people can avoid becoming frail, because that's ultimately, we don't want to fall and break a hip or hit our head or have a head bleed. So, there's sarcopenic obesity, which can be where you're under-muscled and too much body fat, and then there's another type of fat that is much more problematic and can be much more pathogenic.
[00:21:14] So, when we talk about visceral fat, helping individuals distinguish subcutaneous fat, which sometimes we don't like, but does serve a role, versus visceral fat, which is what becomes more common as we get older, but something that we definitely want to avoid or limit as much as possible.
Dr. Rocio Salas-Whalen: [00:21:31] Yes. Visceral fat is internal fat. It's the fat that is deep in your abdomen, that attaches and surrounds your internal organs. So, it can cover your liver, your pancreas, your gut and your heart. So, this type of fat is what we call the bad fat, the dangerous fat. This fat is the fat that promotes insulin-resistant hyperinsulinemia, and then insulin-resistant hyperinsulinemia themselves promote visceral fat, and then visceral fat promotes hyperinsulinemia. And then you get into this vicious cycle that it's feeding one into another. Visceral fat is proinflammatory. The danger of visceral fat is that fat tissue is so active with inflammatory markers that takes away the attention of anything else can happen in the body. And this is what we learned with COVID.
[00:22:27] Why were patients with obesity having more severe disease? Because their immune system was preoccupied in the proinflammatory process of the visceral fat. And when the virus came, the patient didn't have enough immunity that was free to protect them against the virus. It was busy and proinflammatory-- inflammation. So, visceral fat is really the most dangerous because of that proinflammatory effect we know agent we’re exposed to certain cancers because of that chronic condition.
Cynthia Thurlow: [00:23:00] Yeah, it's definitely one of those things when I think about body composition. So, women tend to be more of the pear shape, and then when we think about the apple shape. So, for anyone that's listening, that's trying to envision what this looks like, it's the people that are carrying a lot of fat in their bellies. I used to have patients that would joke about how they kept having to lower their inseam of their pants, and it had a lot to do with as their belly was getting bigger, they would have to buy a shorter inseam to accommodate their bigger belly. But it's not something to joke about. It's helping to, again, build that awareness so that patients understand there are things we can do to address these things.
Dr. Rocio Salas-Whalen: [00:23:40] One thing that I encounter very often is female patients in midlife. When we go over the body composition, and I say, “Look, you tend to store more body fat centrally, upper body, this is what we call the apple shape,” they're in shock because most of their life they were pear shape. But comes perimenopause and menopause, and with that drop of estrogen, it gets changed. Your body distribution changes.
Cynthia Thurlow: [00:24:06] Do you find that women that are in middle age, so perimenopause and menopause, the women that are on hormone replacement therapy, do you find-- at an appropriate dosage let me just shove that caveat in there, because there are extremes of things that people are doing. But your patients that are taking estrogen, if appropriate, progesterone or even testosterone, do you feel like their body composition tends to be more optimized? And by this, I'm not talking about vanity metrics, I'm just talking about from a metabolic perspective, they tend to be healthier.
Dr. Rocio Salas-Whalen: [00:24:41] I do see that patients that are currently on HRT, hormone replacement therapy, and for me testosterone, their body composition is more what we want to see, which is higher muscle mass and less body fat or more subcutaneous fat than visceral fat. So, it does impact your body composition, being on hormone replacement therapy.
Cynthia Thurlow: Yeah. So, your trajectory of your career as a clinician, you probably came into endocrinology post Women's Health Initiative. So, probably seeing the whole wave of “We were anti.” Well, when I say we collectively, yes the whole wave of fear around hormones and now I feel like there's growing awareness that HRT, if appropriate, can be very, very beneficial. What has that been like for you as a clinician and as a woman to be in the crux of all of that and also working with women that are at that stage of life as well?
Dr. Rocio Salas-Whalen: [00:25:41] Being an endocrinologist, I was always prohormones. I went into endocrinology for female hormones. I was always prochoice to the patient. I was always giving them the information and being there if a patient chose to go on it. But it was not so much more my reluctance to get it. It was more their acceptance from patients, to be honest. And it's very interesting what you see. Patients are in their late 60s or 70s that were on that prior to that 2001 studies of the WHI, that they were on hormone replacement or that they're still on hormone replacement. You can see them physically, the difference. They're more youthful. And I'm not talking just as an external thing, but yes, skin, hair, they have a full head of hair. It's also vitality. They're relatively healthy and strong mentally, sexually.
[00:26:44] They're happier versus those patients that are now in their late 50s that missed that window. Not necessarily. But they were not informed. Or was that period that everybody got scared of? I mean, we're seeing more comorbidities, shorter lifespan. So, it is very interesting to see the acceptance also more from the patient, because before, I always say, “Did anybody talk to you about HIV?” No, no, no, that produces cancer. No, no, no, my GYN answer, “No, definitely no.” So, it was a very reluctant acceptance from the patients. And I think patients are not being educated. Women are not being educated. And I think that New York Times article was coming from a nondoctor. I think it was very important for women to listen to somebody experience that was not a doctor promoting HRT.
Cynthia Thurlow: [00:27:36] Yeah, that's such a good point. And it's interesting because I finished up my nurse practitioner training in the 2000-2001 timeframe. And for me, navigating my whole background, other than the last eight years, was in clinical cardiology, so we did see a lot of women that were taken off their HRT, and you can imagine cardiology, we didn't want touch any of that with a 10-foot pole. We just referred people back to their GYNs or their internists we're like, “We're not the hormone people,” Appropriately so, but what was interesting to me is watching my aunts and my mom and my stepmother all be taken off of HRT and watching the sequelae.
[00:28:14] And I've been given permission to talk about these things publicly because they're hopeful that sharing their experiences will allow others to understand that their trajectory doesn't need to be someone else's. I have a family member who has end-stage Alzheimer's right now, and she was on HRT and then taken off of it. And I have a family member that is definitely very sarcopenic and becoming more frail. And it's hard to watch that and understanding that I'm hopeful that with all these physicians, nurse practitioners, coaches, and people that are speaking so openly about their perimenopause to menopausal transition and the things that they're seeing that are working well. I'm hoping this awareness allows every woman to make an educated decision for themselves. That's ultimately what we want it to be, making it in conjunction with your healthcare practitioner, the best decision for you.
[00:29:06] And even what I found interesting, and I know that you're familiar with Dr. Avrum Bluming and his book Why Estrogen Matters, even my friends who are breast cancer survivors, understanding that it's not a complete no for them. And I think that it's about finding the right practitioner that's going to be in alignment with your goals and the things that are important to you. So, for everyone listening, their own bio individuality, taking all that into account and just being an advocate for yourselves. And so, when we're thinking about things that contribute to weight loss resistance at this stage of life, we talked about some of the hormonal changes. What are some of the other things that you see as a clinician that are happening in middle age that are contributing to why women start to struggle?
[00:29:50] Maybe they didn’t in their 20s and 30s, struggle with weight loss resistance, but why does it become more problematic at this stage?
Dr. Rocio Salas-Whalen: [00:29:57] Entering your 40s for many women is a very stressful time. Just the idea of turning 40 or 50. The pressure that we have in women to be a certain age, and after a certain age, you're not important much or everything's going to change. So, I think that puts a lot of emotional stress and pressure during these years added to that, we are seeing our parents aging, our children growing up for some, some children going to college. So, it's a very shift transition time for a woman that it doesn't have to be like that. I mean, not everything is negative, but I do feel that they decrease their exercise routine. They sleep less, they have more stress. Maybe professionally they're at peak. They're traveling now. Women are traveling more, internationally, nationally, for work. Having children and working at the same time, it's a stress on its own. So, I think we're putting so many hats that it's hard to succumb to everything that's happening in our life.
Cynthia Thurlow: [00:31:08] Yeah. And it's interesting because I feel like a lot of women, some women do a good job with selfcare, but most feel guilty when they try to advocate for themselves. I have a good friend who wants to go to the gym and strength train, but she'll say, “Oh, well, you know, there's like five different things that came up.” And I just said, “It's like ripping a band aid off.” You just have to do it. It's like you have to create the time or have your spouse or significant other or get a babysitter. In fact, that's what I did when my kids were younger. I would get a sitter, even just to get my hair colored. I mean, just to do things that allowed me to disconnect as a mom and be an individual.
[00:31:44] And I think a lot of women struggle with advocating for themselves. They feel guilt, they feel shame. They feel like somehow, they're not being a good parent. And I would be the first person to say that I'm a better parent because for me personally, working as a nurse practitioner, even part time, allowed me to have that intellectual discourse at work. And then I could go home and be mom. This is what worked best for me, having the best of both worlds. And so, I think for a lot of women, they feel like they're pulled in so many different directions that it's hard for them to carve out time for themselves
Dr. Rocio Salas-Whalen: [00:32:20] Socially, religiously, I can tell you my experience. I'm divorced and I share custody with my ex-husband. So, I have my kids one week, and then the other week they go. So, every other week they're with me, and that week that they're with me, it's so hard for me to justify not being with my kids and I struggle to go to the gym and I struggle to weight train. I love weight training. And there's other things that I like that I'd actually like to do. It's a process. It's a very individual process to get to the point, to understand that if you're happy, it makes you a better parent [unintelligible 00:33:00] 1% your kids. That, “Oh, I'm giving everything to you and I'm expecting this from you.”
[00:33:06] And it's not just a problem that is that you're molding your children to continue with that idea that as a parent, you have to sacrifice everything for the child. So, it's a process. But I do tell my girls always, like, “Who's the most important? Who's the person that you have to love the most?” And then they say, “Mommy.” And I said, “No, yourself.” Start teaching that. But to teach that kids are not just listening kids are seeing. So, you have to really live by example.
Cynthia Thurlow: [00:33:34] Yeah, that's so true. And I think it's interesting, since I've been an entrepreneur, I jokingly say I could work all the time, but I have to create really healthy boundaries. And as an example, saying to my teenager today, I need your help with the puppy, because I have three podcasts today. And when I'm podcasting, I'm focused on my guest and I'm focused on the questions I'm going to be asking. And I don't want to be chasing after a puppy and helping them understand. When that is all done, then we're going to do this, this, and this. And he's old enough. But I agree with you that we set the example, and it's like, I never want the example to be that work is more important than them.
[00:34:11] Although they understand that there are aspects of my work that are important for me intellectually and that is really important that I get that intellectual stimulation. Although, I always tell them, of course, I love being a mom. That's my favorite thing that I do. But it's also helpful to understand that finding balance is important as an entrepreneur, as a parent, as a human being. And I think a lot of people really struggle with that overall. Now, in terms of things that you have found to be most effective for your middle-aged patients that are struggling with weight loss resistance. I know that we're going to talk about medications, but in terms of lifestyle changes, what do you feel like are some of the most important things that women can be doing to help improve body composition, improve their metabolic health, etc.
Dr. Rocio Salas-Whalen: [00:35:01] First is switching the cardio for strength training, switching Peloton, switching SoulCycle, I mean, I think Pilates has a purpose for flexibility, get stability, muscle innovation. But really nothing replaces lifting weights. So, I feel like we have a generation that was hyper focused on cardio for weight loss purposes. Not so much for physical health, it was more to achieve weight loss or maintain weight loss, but really the exercise that everybody has to join as teenagers, because then you're banking, it's like you're 401 (k), you're putting money, you're putting muscle for your future. So, it's strength training and then the diet. If you increase your protein intake, then naturally you won't crave carbs, sweets, sugars. It just happens from the higher protein intake.
Cynthia Thurlow: [00:36:00] I think those are really important and certainly very consistent with things that listeners will hear on this podcast. But obviously hearing it from you is very validating about, these are two relatively simple things you can do that can really move the needle on changing body composition. Now, I definitely want to talk about medications because I know this is an area where you are an expert. And I think about back probably in the mid 2000s, my mom started taking Byetta. And what's interesting is at that time she was technically, I'm going to put that in “Technically not insulin resistant,” but she had a very thoughtful practitioner at University of Pennsylvania that said, “Hey, I think this would really be a good medication for you.” And she was pleasantly surprised to see a lot of benefits.
[00:36:47] And so these drugs have been around a while. Obviously, there's been an evolution. I know one of the things you talk a lot about is prescribing responsibly. So, these drugs are really having a moment. And I think there are practitioners that are practicing, as you said, responsibly. And then there are some that are not concurrently talking to patients about lifestyle, which I think they need to go together. It’s really important. Talk to us about some of the drugs that you utilize presently with your patients who are either insulin resistant, perhaps diabetic, or even people that are looking to change body composition because there is differing names for some of these drugs just based on the indication. So, for individuals that are not diabetic, there are certain drugs for that. And then there are drugs, different names, same drug may be clear, but some are covered by insurance, some are not. Talk to us about how these drugs are helping you with your patients to get them to a place where they are happier, healthier, as you say, strong, fit and lean.
Dr. Rocio Salas-Whalen: [00:37:48] The discovery of these medications are the biggest event in medicine that I think we will see in our lifetime because they're changing already the direction of that obviously. As you mentioned, the first one that was FDA approved was Byetta in 2005 for type 2 diabetes. And back then it was twice a day injection. It was 30 minutes before breakfast, 30 minutes before dinner, and then came Bydureon which was once per week that the patient had to mix the powder with the liquid and just [unintelligible [00:38:22] under the skin. So, they've been evolving everything in medicine that we have now, the weekly injection. I like to call them like the iPhones [unintelligible 00:38:35] iPhone 14, and now we have the iPhone 15, which is Mounjaro. It's the same concept, but improved, less bucks, and works better. And we're going to have newer and newer generations and medications will become even more sophisticated coming for the next years. This is the tip, basically, of what we're going to see in obesity medicine.
Cynthia Thurlow: [00:38:57] And for you, let's talk about when you're talking to your patients, how do the drugs work? And I think people will say, “Well, I lose weight.” Well, that's a side effect of how the drugs actually work mechanistically. But I think it would be helpful because we ourselves make endogenous GLP-1. So, glucagon like peptide, but these are exogenous. So, these are synthetic. So, helping people understand, how do they work their magic on patients?
Dr. Rocio Salas-Whalen: [00:39:23] They're hormones. They're synthetic hormones. Like people that have hypothyroidism, they take synthetic levothyroxine. So, they are a synthetic copy of what we make. Now, the one that we make has a very short half-life in our body of two minutes before it's broken down. So, this synthetic version of them, they're long acting, not degraded by the enzyme that our natural hormones get degraded by. I like to explain it in very simple terms to my patients. They work, they target the two reasons humans eat. We eat for fuel, energy, survival, and then we eat for a reward. And this could be food and beverage for anticipation of vibrant work. For the energy part or the survival part, they increase your satiety hormones and they decrease your hunger hormones. So, they balance it out that one is not higher than the other one.
[00:40:22] So what happens? What this translates for the patient on the day-to-day life is feeling fuller with half or a third or what they would normally need to get full and satisfied. And then in between meals, not feeling hungry, so not snacking or grazing. You get hungry, but then you get satisfied with a small portion, and then it's out of your mind because you're physically content. Now, in the hedonistic eating and drinking area in our brain, in the amygdala, we have receptors for this hormone. And what they do is they remove the anticipation of our reward from food or beverage, as an example, alcohol. So, if you're anticipating-- I like to put the example of the glass of wine. You're anticipating getting home, feeling a certain way with the glass of wine.
[00:41:12] That's a reward for you with this medication, you won't get it anymore. You'll come home. You reach for the glass of wine, but then flat, you're not getting anything back emotional. This goes for stress eating, anxiety eating, binge eating. You're not getting that feedback of a reward. It just takes it away. So, you enjoy your food when you're hungry, but then you get satisfied and then you're not thinking of food in a reward manner.
Cynthia Thurlow: [00:41:39] I mean, that is a really impactful medication and more so than the satiety, I think decreasing the impulses from the amygdala, which is our reptilian lizard brain for a lot of individuals because we get lots of questions and I always ask my community a lot of questions came in around binge eating, stress eating, helping them understand that this drug used appropriately may be a good choice for an individual that's struggling with that.
Dr. Rocio Salas-Whalen: [00:42:12] Every plate in front of them, it's going to impact in a certain way in their head. How is this going to impact my weight? Am I going to feel guilty? Do I have to work out afterwards? And it's 24/7. So, here comes a drug that relieves them for the first time. I've had one man crying in my office because for the first time in their life, they were not thinking of food or how it was going to impact their weight. So, you have patients that struggled with obesity since teenage years, childhood for many, and they're in their 50s, 60s. So, you're talking decades of mental exhaustion, thinking about their weight and about food.
[00:42:55] For many patients, when I explain how the medications work, it's like a very foreign concept and I tell them, “We will be having a different discussion once you're on the medication” because it's hard to comprehend that for the first time you're not going to be thinking of food. And then they have so much mental space for anything else in their life going on.
Cynthia Thurlow: [00:43:16] Well, I can imagine. I mean, it would be life changing on every level for them. And I know that there is a lot of discussion press around side effects. I know that when I talk to clinicians that are prescribing these drugs, many of them say its dosage dependent or its being very clear about hydration and things like that. For you, how do you mitigate a lot of the side effects that are most commonly seen when using this class of drugs?
Dr. Rocio Salas-Whalen: [00:43:45] I think what we're learning now, and what hopefully doctors will catch on to, is that weight loss is complex. Weight loss is a complex journey that has individualized to every person according to their lifestyle, their goals, their body composition. It will simplify weight loss as just looking at the scale in every visit, and being that the game and the goal, then we run the risk of over treating patients too fast, too much, too soon in regards to weight loss, which before we could have thought of something positive, we know now that it's not positive.
[00:44:28] So, if a clinician, they're giving this medication without the proper hand holding off the patient through this journey, because it's a journey that you can embark with the patient, then you run the risk of those side effects that we hear you, but in a close, supervised scenario, we don't see that. Because you're always modifying why it's working and not for the patient. And then if something is not working, then you can guide them. Also, we should not be making patients skinny fat just by trying to get pat on the back, by making a patient lose too much weight too fast. We have to watch their body composition, otherwise we're making them metabolically unhealthy, but just thinner or skinnier.
[00:45:16] So I really think that when a physician or a clinician understands the complexity of weight loss, it's then that they will see less side effects, more effectiveness, and patients feeling better. Because there's a difference with patients or they look better or they fit in something, but when they tell you I feel strong, I feel healthier, it's completely different than just looking smaller.
Cynthia Thurlow: [00:45:44] Right. And so, walk us through it. We'll do like a high-level discussion. You're starting a patient on Wegovy, and how frequently are you monitoring someone? I know that you see patients in person. I also know you do a little bit of telemedicine. How often are you and your team monitoring them? Because it sounds like you're very hands on, which I love, very conscientious and very hands on with your patients. How often are you evaluating them or bringing them back when they start medication?
Dr. Rocio Salas-Whalen: [00:46:17] For their second visit, after their first consultation, when we decide to start medication or [unintelligible [00:46:21] it's in six weeks, because I think sooner than that, I also want to set expectations to the patient. We're not going to see significant weight loss in four weeks and three weeks, and I'm not going to go up in the dose in a month because basically the patient's just starting to get used to the medication. Six weeks is enough to get a glimpse of what the patient's journey is going to be. And then after that, it's every eight to maximum ten weeks until we reach a goal. Once we reach a goal, then I can space it up to more like every three to four months, and then once during maintenance, every six months.
Cynthia Thurlow: [00:47:04] Okay. And it's my understanding and based on my milieu of preparing for this podcast, that you believe these drugs are lifelong, it's not we use it for six months, lose the weight and we stop it. It's been your clinical experience that patients do best if they continue on the medication long term,
Dr. Rocio Salas-Whalen: [00:47:25] It's going to depend on the individual. For somebody who has struggled with weight in early childhood, it’s more unlikely that they will be able to get off the medication. I'll give you my example, I always get asked, “Do you use the medication?” My experience was in my 20s, 30s, I weightlifted. I love weightlifting. I enjoy it. Then I had my kids, so I never struggled with weight because in my family there's no obesity. And again, I started weight training and very cautiously high protein, being an endocrinologist. And then when I got pregnant in my late 30s, it was a switch in my pregnancy, it was, “Oh, I can eat whatever I want” [Cynthia laughs] [unintelligible [00:48:12] of protein, I do work out. I was so restricted in my 20s and 30s that with pregnancy, I thought I had a free pass for those.
[00:48:22] I said, if it's not now, it's not going to be after, well, I gained 70 pounds with my first pregnancy and I got pregnant four months after I had given birth, so I just kept adding the weight. So, I used the medication after my second child and then I was able, I've been off of it since. I just used it for about six months. So, I've been able to stay off of it. So that's one example of how somebody will not be on it chronically, but then you have a patient that has struggled with weight or that they're doing everything in there possibly that they can control, that is not happening. Then those patients will benefit in a long-term manner with this medication. And we have to remember, these drugs are designed for long-term use. They're not designed for a short-term use. But every patient is different. So, depending on the patient's journey and their weight is really what's going to determine the length of their treatment.
Cynthia Thurlow: [00:49:26] Thank you for sharing your personal story. I think that's very helpful to know that there very much is this bio-individual perspective. It's really assessing where a patient is at-- what their entire medical history really looks like. What are your thoughts on misuse and abuse of GLP-1s? And the reason why I'm asking this is that there are a lot of, I believe, well-meaning individuals in the health and wellness space. And I'll go to events and I'll listen to what people are talking about. And there's a lot of very thin people that are using GLP-1s to, “Take the edge off their appetite,” but they're already very thin. And so, I think about it from the perspective more as a clinician, I'm just curious, what are your thoughts on misuse or abuse of these drugs?
[00:50:11] I mean, I've met nurse practitioners who've told me that they haven't pooped in a week and they don't care because they are the thinnest, they have been in 20 years. And I always just go, “Hey, I guess you have to decide what's most important,” but what are your thoughts on this? I can imagine that you probably have a lot of thoughts, but given the fact that we have a culture that is very focused on outward appearance and thinness and a lot of these body composition changes that are not always healthy per se, what are your thoughts on use and abuse of GLP-1s?
Dr. Rocio Salas-Whalen: [00:50:45] Because we think of weight loss as something physical, I think until we don't change that, that will continue to happen. But I've learned to be very open minded by what I see in my patients and what I have learned from my patients. So, you may have a female midlife that seems very slim and fit and may want to go on this medication. The question is, should you go on this medication? So, in those cases, first, a body composition many times shows that actually that person could benefit from weight loss. I always say when somebody's thinking that they can lose 10 pounds is making around 20 with the body composition. [Cynthia laughs] So, the concept is different.
[00:51:33] But I like to hear what's the story of the patient, because if it's a full-time job maintaining that weight. If it's consuming you and it can from any person then there may be use of this medication. So, it's a very individual story. And I cannot say by looking at somebody that they don't need the medication.
Cynthia Thurlow: [00:51:59] Such a good answer.
Dr. Rocio Salas-Whalen: [00:52:01] And hearing the patient stories, I cannot say, even me as an obesity specialist, if I look at somebody saying, “No, that patient would not need this medication.” I don't know.
Cynthia Thurlow: [00:52:11] You need more information.
Dr. Rocio Salas-Whalen: [00:52:12] I need their story. I need their lifestyle. I need their body composition.
Cynthia Thurlow: [00:52:17] I love that. Well, I can't thank you enough for your time today. I've really been looking forward to this interview. Please let listeners know how to connect with you if they want to work with you and they live in New York City or can access your offices there.
Dr. Rocio Salas-Whalen: [00:52:31] You can find me on Instagram as @drsalaswhalen. My website is nyendocrinology. My office is on Park Avenue in New York City. And I do personal visits and I also do telemedicine. And I have patients nationally and internationally.
Cynthia Thurlow: [00:52:54] Wonderful. Thank you again.
Dr. Rocio Salas-Whalen: [00:52:57] Thank you for having me.
Cynthia Thurlow: [00:53:00] If you love this podcast episode, please leave a rating and review, subscribe and tell a friend.
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