The Gut Health Podcast
The Gut Health Podcast explores the scientific connection between the gut, food, mood, microbes and well-being. Kate Scarlata is a world-renowned GI dietitian and Dr. Megan Riehl is a prominent GI psychologist at the University of Michigan and both are the co-authors of Mind Your Gut: The Science-based, Whole-body Guide to Living Well with IBS. Their unique lens with which they approach holistic conversations with leading experts in the field of gastroenterology will appeal to the millions of individuals impacted by gut health.
As leaders in their field, Kate and Megan dynamically plow through the common myths surrounding gut health and share evidence-backed information on navigating medical management, nutrition, behavioral interventions and more for those living with or without a GI condition.
The Gut Health Podcast is where science, expertise, and two enthusiastic advocates for wellness come together to help you live your best life.
Learn more about Kate and Megan at www.katescarlata.com and www.drriehl.com
Instagram: @Theguthealthpodcast
The Gut Health Podcast
Miracle or Misused? Benefits, Risks, and Responsible Use of GLP-1s
Glucagon-like peptide-1 (GLP-1) can transform metabolic health, but only with smart dosing, adequate dietary protein, regular strength training, and mental health support.
In this episode, we explore how GLP-1 medications work in the brain and gut, why metabolic health is more than BMI or a weight on the scale, and how to use these drugs safely. Our expert guest, gastroenterologist, Dr Supriya Rao shares practical dosing, side effect strategies, and what makes results stick.
• Defining metabolic health beyond BMI and weight
• How GLP-1s reduce appetite and slow gastric emptying
• Healthy weight loss pace and preserving lean muscle
• Practical + science-backed dosing and individualized titration
• The unknown risks of compounding and microdosing
• Managing nausea, reflux, and constipation
• Diet shifts: smaller meals, more fiber, adequate protein
• Mental health, body image, and stigma in care
• Durability of results and maintenance dosing
• New indications: MASH (metabolic dysfunction-associated steatohepatitis), sleep apnea, cardiovascular protection
• Building an educated care team
References/Resources:
Integrated Gastroenterology Consultants (Dr. Supriya Rao's practice site)
Book: The GLP-1 Kitchen: A Cookbook for Living Well on Weight Loss Medications Escobar S-N et al. (contains affiliate marketing link)
Learn more about Kate and Dr. Riehl:
Website: www.katescarlata.com and www.drriehl.com
Instagram: @katescarlata @drriehl and @theguthealthpodcast
Order Kate and Dr. Riehl's book, Mind Your Gut: The Science-Based, Whole-body Guide to Living Well with IBS.
The information included in this podcast is not a substitute for professional medical advice, examination, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider before starting any new treatment or making changes to existing treatment.
Maintaining a healthy gut is key for overall physical and mental well-being. Whether you're a health conscious advocate, an individual navigating the complexities of living with GI issues, or a healthcare provider, you are in the right place. The Gut Health Podcast will empower you with a fascinating scientific connection between your brain, food, and the gut. Come join us. We welcome you. Hello, friends, and welcome to The Gut Health Podcast. We are your hosts, I'm Kate Scarlata, a GI dietitian.
Dr. Megan Riehl:And I'm Dr. Megan Riehl, a GI psychologist. Today's topic: GLP1s, otherwise known as glucagon-like peptide one, a hormone that helps regulate blood sugar by boosting insulin release, slowing digestion, and reducing appetite.
Kate Scarlata, MPH, RDN:Yeah, so there's a little backstory on these medications or the discovery of this tiny hormone with huge potential. As Dr. Real mentioned, it's glucagon-like peptide one or GLP1s. It lasted only minutes in the body, but scientists found it could control your blood sugar, slow digestion, and even quiet that appetite. So fast forward to today, and more and more discovery has sparked a medical revolution from the first GLP1 drug in 2005 to high-impact treatments like semaglutide and today's powerful combination therapies. How did this fragile hormone become one of the most talked-about drugs on the planet? Well, we're going to get into it today.
Speaker 1:Yes, but first we're going to introduce our incredible guest. Dr. Supriya Rao is a quadruple, that's four, a board certified physician in internal medicine, gastroenterology, metabolic and lifestyle medicine, who focuses on digestive disorders, gut health, obesity medicine, and women's health and wellness. She is the director of the Metabolic and Lifestyle Medicine Program at Integrative Gastroenterology Consultants, located in the Greater Boston area. She's one of your neighbors, Kate. She runs a lifestyle medicine program that teaches patients how to improve their health through sustainable changes in their lifestyle, which is what is so important to us. She also runs the motility program, which focuses on disorders of the esophagus, IBS, and anal rectal disorders. Fun fact, she is one of three U.S. gastroenterologists that is board certified in both obesity and lifestyle medicine. So she is a true gem and is going to share so much information with us. She's also a real human that enjoys cooking, traveling, running yoga, and spending time with family and friends. Please follow her on Instagram to learn so much @ GutsyGirlMD. So we like to kick things off with a myth buster. What myth, Dr. Rao, do you want to bust regarding the use of GLP1s?
Dr. Supriya Rao:I think one of the major myths associated with GLP1s is that they're the easy way out. I think that a lot of people think that, oh, I'm going to take the fat jab or the obesity jab, or and we see a lot of patients who are on these medications, and maybe some of these patients aren't using it the way that it's meant to be used. But I do think that this is not the easy way out. Being on a medication long term is hard. I look at obesity as something like a chronic medical condition. And so just like high blood pressure or diabetes, we're treating it with a long-term medication. And those medications have side effects. Those medications, you know, need to be taken, and there are contraindications, and you know, it's all part and parcel of being on a medicine. It's not the easy way out. It helps support weight loss, it helps support improvements in insulin regulation, but it's really hard to be on these medications and it takes lifestyle change and just you know, changes in diet, like it takes a lot of habit changing as well. And so I think that thinking about GLP1s as a medication as being an easy way to lose weight is a myth. And so I like to bust that.
Kate Scarlata, MPH, RDN:That's a good one. Yeah, that's a really good one because I definitely think that that's the thought out there, right? And I know you are certified in lifestyle medicine and really embrace the full picture of changing habits, exercise lifestyle, diet. You live that, you know, you you show that through your Instagram, which is awesome. So let's get into, you know, sort of an intro here, just defining what is metabolic health? Like, how do you define it? And why is it more important or more broad than a weight on a scale or a BMI?
Dr. Supriya Rao:Sure. So BMI is basically a ratio of height and weight. It came about specifically for Caucasian males. And so it's not really generalizable to the public. Metabolic health, I look at many different factors. So we're looking at optimal levels of blood pressure, we're looking at optimal levels of cholesterol, triglycerides, waste circumference, blood sugar. So those parameters give me much more information than just a number of BMI. BMI, you know, patients can have a normal BMI but actually be metabolically unhealthy. You may have heard the terms of like thin outside, fat inside, or skinny fat, and those are the patients who have visceral adiposity or increased fat around the midsection, around your liver, which is actually a marker for significant metabolic dysfunction, but still have a normal BMI. So I think thinking about muscle mass percentage, fat mass percentage, true body composition, and those parameters I mentioned earlier are actually a much better predictor of metabolic health.
Kate Scarlata, MPH, RDN:Can I just interject here? So I totally agree. And it is you need more comprehensive markers than just weight for sure. Do you check insulin levels? Are you measuring for insulin resistance? Like I'm just wondering how mainstream that is.
Dr. Supriya Rao:Right. So, I mean, we definitely look at hemoglobin A1C, fasting glucose levels. Insulin levels take it another level. And I think, you know, for some patients, we definitely do check it, but it's not something that I'm doing routinely. I do oftentimes team up with endocrinologists and we do check insulin levels in certain patient populations, but it's not something I'm doing routinely, but I'm actually looking into doing it more frequently. But for me, as a gastroenterologist, looking at the fatty liver and we have fibro scan in our office. And so being able to follow fibrosis and steatosis scores is actually really telling as well.
Kate Scarlata, MPH, RDN:Excellent.
Dr. Supriya Rao:And we also check, like I mentioned, waist circumference. So any patient who comes in who's part of our metabolic clinic, we get waist and neck circumferences each time.
Dr. Megan Riehl:So I think, you know, when we're thinking about metabolic health, it is comprehensive in that yes, we're doing far more assessment. You're talking more with your patient, though. They are. They're more than a number on the scale. Their motivations for even seeking out medical care are going to be different. But today we're going to talk a little bit more about kind of honing in on ways to address our metabolic health. And just, you know, as the psychologist in the room, I have to say, like our mental health plays a picture into all of this too, and and needs to be a part of these conversations as we're deciding treatment plans and how that fits into the treatment plan. But at this point, most people have heard of a GLP1 as a medication. But as we peel this back a little bit and learn more, what do you think is actually happening in the body, specifically in the gut? Because there's so much in kind of the GI world around this medication and what it's doing. So we've got an expert here. Let's start to kind of dive into the facts of this.
Dr. Supriya Rao:Sure. So really quickly in the brain, we know that GLP1 glucagon-like peptide. One, it is secreted in the small bowel. And in the brain, it acts in the arc root nucleus in the hypothalamus to basically go down that satiety pathway so you feel full. In the gut specifically, which is my focus, it kind of helps slow down gastric emptying. And so the food is hanging out longer in your stomach. It's almost like an induced gastroparesis type situation. And so that physical sensation of fullness, you're kind of stretching the receptors in the stomach, that signals it also to the brain in terms of the satiety signals and helps blunt blood sugar spikes after a meal. So that's kind of what's happening from a gut perspective.
Dr. Megan Riehl:Okay. So we'll get into this for our patients living with GI conditions and all of our gastroenterologists that are listening to and primary care of patients that are managing these gut symptoms with also maybe a gut diagnosis. But what is the reason some people go on, generally speaking, that metabolic health? But also many, many people, especially in the new year here, are thinking about a reduction in weight. And so how quickly do we see this weight loss generally occurring? And is there a standardized target to reduce muscle loss too?
Dr. Supriya Rao:Sure. I think healthy weight loss on these medications is about one to two pounds a week, especially in the initial couple of months as you're on the medication. And the clinical trials have shown, you know, with both semaglutide tirzepatide even more so, about 15, anywhere from 15 to 25% total body reduction after about a year or so. And so there's no true standardized target when you're thinking about muscle mass retention or how much you think you should be losing to retain lean mass. But my clinical number, I mean, in those patients who they did the studies on, they lost about a quarter of their lean muscle mass while they were also losing from their total weight loss. So my goal is to try and get below that number as much as I can while promoting fat loss but retaining muscle loss. And so we want these patients to go through resistance training and making sure that their diet is high in protein. Those are kind of non-negotiables for me because I don't want my patients to end up becoming frail and losing a lot of weight. There are patients I've seen who have been given these medications and don't have great follow-up and end up losing 50 pounds within a couple months and are dehydrated, you know, not doing well and look really ill and end up coming off the medications and gaining back a lot of the weight and end up being metabolically more unhealthy, actually, from where they started. And so the lifestyle piece, like I mentioned, being on these medications is not easy. So changing around those lifestyle, the in terms of what you're eating and how you're exercising and everything is really important to ensure that you're not losing much muscle mass.
Kate Scarlata, MPH, RDN:Yeah. So don't be watching Instagram and seeing all this, like, I dropped 50 pounds in one month. I mean, you see it all the time. And it's it is frightening because I I do think like your gut's a muscle, your heart's a muscle. We need to be strong as we get older. And I think it in some ways it's not really being managed. And I think the fact that in your practice you're really addressing, and it's important for you to address the lifestyle pieces is so important.
Dr. Megan Riehl:Or I think what it is is right now, at least from my perspective and vantage point, it can be the wild, wild west. You've got doctors like Dr. Rao, who are quadruple board certified, but not every patient is has access to that. And the access to these types of medications is ever evolving. The concepts of microdosing and that there are no necessarily, not to my knowledge, guidelines that are real informative or helpful for patients that are doing that on their own can be dangerous. So I'm very excited to be having this conversation today to, you know, really help our listeners understand that there are some safe ways to go about this and some really meaningful ways to improve your health. But again, you don't want to get caught up in the wild wild lust. No, and lose 50 pounds a month.
Dr. Supriya Rao:Yeah, it is a wild wild lust out there, honestly, because between compounded medications you get at MedSpa's and, you know, self-diagnosis or, you know, GLP1 supplements, you know, GLP one has become this very loaded catchphrase. And I think unless you are undergoing supervised medical weight loss, you it can be very dangerous for you.
Kate Scarlata, MPH, RDN:Yeah, it's scary. Scary, but like it's nice to see something revolutionary or changing the landscape of dealing with this vast problem of chronic diseases that we're seeing escalate.
Dr. Supriya Rao:I totally agree. I believe that these medications are perhaps like the most important medication that has come out in decades. You know, after statins, probably I would say these meds are it.
Kate Scarlata, MPH, RDN:So there's certain patient characteristics that probably make the drug more effective or less effective. You know, I see a patient with a low FODMAP diet, for instance, that has, you know, horrific IBS, and I'm like, they've got bloating and a lot of pain. And I'm like, you're gonna be a good, probably a good candidate if they're a good candidate. You must see the same. You see certain patients, and you're like, oh, this is a really good candidate for this medication, or maybe not. So is there such a thing?
Dr. Supriya Rao:That can be a little tricky. I would actually say the patient who is adherent to the medication is the biggest factor, honestly, because early in the, you know, 2021, 2022, when these medications were first coming out, the medication was plentiful. But then when it started gathering steam, it was impossible. The supply was hardly there. So people who had done very well over a few months then were all of a sudden out of luck because they were calling around to 10 CVS or Walgreens trying to find the medication and couldn't. So they were off of it for a time. Or insurance decides to stop coverage of the medication. You know, the patients who can tolerate going up on the medication to therapeutic dosages without severe GI side effects, I would say, are the ones that tend to do the best. And also those who actually have the worst metabolic profile. So if they have significant visceral adiposity and insulin resistance, they oftentimes saw really dramatic improvements in their metabolic health early on because you're addressing that kind of initial metabolic dysfunction with the medication. And that early response is actually a great predictor of being able to hit that 20 to 25% of body of weight loss over time, over the following year or so. So I would say those patients, so the ones that can stick to it, manage the side effects, and the ones who are actually metabolically worse off do best.
Kate Scarlata, MPH, RDN:I've seen that where, like, you know, even friends, relatives, not my relatives, but relatives of my friends, where they've gone on medication, they know GLP1 and they're off their diabetes medication, they're off their cholesterol, they're off their hypertension, they've dropped five medications. Also, you got to keep that in mind. It is taking a medication for life, but it's one medication replacing maybe you know, five that you are taking because of just this metabolic dysfunction.
Dr. Supriya Rao:So yeah, for sure. We've had patients come off insulin, we've had patients come off their blood pressure meds, like you've mentioned, and you know, having their cholesterol medication. And it's not even just the medications, also other non-scale victories, being able to move. And, you know, I've had a patient actually, she used a GLP 1 up until the time she got pregnant, but she was dealing with significant infertility, but a combination of GLP1 medication and lifestyle. She got down to a weight that was appropriate, stopped the medicine, was able to get pregnant. So these medications are actually quite life-altering and really helpful for all the metabolic disease that we see in the US.
Dr. Megan Riehl:Yeah, I was thinking of another, a similar patient where took a year to really focus on self and has a history of PCOS, been having difficulty with pregnancy. And again, we're not trying to like tout these as the end-all be all of health issues, but to just highlight that they're kind of in a renewed spirit around their fertility and pregnancy journey with making some changes.
Dr. Supriya Rao:100% agree. And like another part of like hormonal changes for women like perimenopause and menopause is another place where these medications have become really important because of our, you know, as we get older, the muscle loss that starts to happen and then the metabolic dysfunction that starts to happen with increased adiposity around the waist, these medications have been helpful for a lot of perimenopausal and menopausal women in terms of being able to ward off cardiovascular disease over time.
Dr. Megan Riehl:So much that we're learning so much. So a little bit about dosing. How do you determine whether to titrate more slowly or quickly for a given patient?
Dr. Supriya Rao:Right. So the companies have their dosing schedule. It's kind of a guideline. You start at the lowest dose, then after a month you titrate up. So I usually titrate to the amount that a patient is losing weight, continues to lose weight at a healthy clip, and balances it with the side effects. So each patient is individual. Some patients need that ramp up quickly, some patients are okay staying at certain levels a little bit longer. If someone's starting to have really significant GI symptoms, we think about dropping back down a dose. So it really is dependent on the patient, I would say. I usually titrate up when a patient has hit a plateau, no real GI symptoms, so then I'll go to the next level, but then also kind of encourage them in other aspects of their lifestyle to ensure that they're optimizing themselves as much as possible.
Kate Scarlata, MPH, RDN:Okay. Have you ever had to like titrate down because they're losing too quickly? And I would think that'd be a difficult conversation for someone that's anxious to lose weight.
Dr. Supriya Rao:Yeah, I have had patients who, you know, were losing, you know, three to four pounds, you know, very quickly. So then that's why I bring people back fairly often. I don't let people go off too long. Three months is usually the length of time. And we have touch points in between that as well. We have, you know, a chronic care management system in place to ensure, see how the patients are doing. One of my patients came in and was losing weight a little bit faster. So I said, you know what? Let's think about just dropping down. They were actually amenable to it because they also felt like this is a lot.
Dr. Megan Riehl:Yeah, I can imagine. And I hear this among friends in my clinic. You hit on some of the barriers of continuing the medication, whether it be insurance or access. And so I think that some patients are either forced to take things into their own hands. And this is where we then, you know, I've heard about patients that are like rationing their doses or the whole micro-dosing concept that we hear so much about. So I would love to hear just if you're in clinic with a patient or you're giving a talk or you're talking about this, what are your thoughts on these real world challenges and kind of this micro-dosing trend?
Dr. Supriya Rao:Yeah. So I'm not a fan of microdosing because there's really no, like you mentioned, no evidence to support microdosing of GLP1s in general, because that therapeutic window was established in the trials. There's a reason there is the lowest effective dose for patients. But obviously, like in the real world, like you're saying, patients are maybe trying to hoard the medication because January 1st, everything is gonna not be covered all of a sudden. And or maybe they're trying to manage side effects. And but my concerns with that are you probably might not be getting enough of the medication to truly benefit from the cardiovascular and metabolic benefits. Safety, like if you, for example, if it's a pen or a vial and you're trying to take a certain amount of it and you accidentally take more or less, or you know, there could be dosing errors, sterility errors. Again, compounding is just, you know, again, people have been accidentally taken 20 times the dose that they were supposed to. You know, the standard of care is set. That's how I operate. I understand the real world issue. Both Novo Nordisk and Eli Lilly have come out with their direct pharmacy, Lily Direct and Novo Nordisk Direct essentially. It's still pretty expensive. I believe they've dropped their prices to about $200 a month for the lower doses, and then I think about $350 or so for the higher doses. A significant investment for sure. However, if you're trying to get them from CVS, they would be about $1,000 to $1,200 a month. I think it really depends on how much of investment you're willing to put in. But obviously, thinking about access for all patients, you know, some, you know, patients are getting these medications currently for $25 a month, and especially those who are on a fixed income or in other financial situations, it's really difficult and they're not going to be able to do it. And so my hope is that, you know, either from through government policy or something come will happen. And there have been rumblings. I think the White House had talked about Medicare patients getting these medications at a lower dose, and new oral options are coming out with Eli Lilly and Triple G, I believe, is going to come out probably within another year, year and a half, one of the new triple action GLP1 medications. So I do believe that in the future, you know, 12 to 18 months, things will be better. But in the next immediate six months, I think it's gonna all hell will be breaking loose.
Kate Scarlata, MPH, RDN:Do you think the pill is gonna be less expensive? Yeah, just heard about that. They have a pill coming out maybe 2026. Yeah.
Dr. Supriya Rao:So the hope is that it will be coming out 2026. I believe Eli Lilly, I forget the name of it, but it's essentially oral semaglutide, 25 milligrams. It will probably be less expensive than the injectable medications. Side effects-wise, I am a little nervous because it is oral, just about how people will be able to tolerate it. It'll be interesting to see. But in the early days, I actually had so there is an semaglutide. Currently, it's called Rybelsus. It goes up to 14 milligrams. And so for some patients, I actually had them on it, even if they weren't diabetic. It's only actually approved for diabetes. But kind of in like the 2021-2022 era, I had some patients on oral semaglutide for weight loss, and they actually did very well with it. So we'll see. I think time will tell.
Kate Scarlata, MPH, RDN:Yeah, definitely. I'm wondering what the clinical trial showed for adverse effects. I haven't looked at it. I know they just finished phase three. Obviously, they're maybe live. So they've done their due diligence.
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Kate Scarlata, MPH, RDN:So talking about sort of side effects, let's get into some GI side effects because I know we definitely hear there are some GI side effects with these medications. So what are the ones that are most common? And then maybe sort of the like, ah, these are a little bit more greater red flags to really address.
Dr. Supriya Rao:Right. So the ones I typically hear constantly are nausea, especially the day of injection and maybe the day after. And kind of this feeling of fullness or feeling bloated because you have slowed down gastric emptying, so the food is hanging around a little bit longer. So that makes sense. Sometimes acid reflux can flare up a little bit more, constipation just because overall motility has decreased. And so constipation is another one. So these, obviously, as a gastrologist, we're able to handle some of these side effects better through fiber supplements, water, increased hydration, even going so far as putting some patients on lenses or other medications to help with constipation. You know, I have some patients who take a zofran the day of their injection and they actually are able to tolerate it well. So we have tips and tricks to work with some of our patients who are experiencing these side effects, the common ones.
Kate Scarlata, MPH, RDN:And gastroparesis, if they really like get to the point where it's a little bit more significant, are you changing their diet to small particle size? Like, are you doing traditional gastroparesis diet interventions?
Dr. Supriya Rao:Yeah. So the lifestyle piece is important. So we have a nutritionist who works in our office and we'll work with a lot of these patients to kind of make sure that they're not eating these big meals. I mean, they patients can't anyway, even if they wanted to, it's impossible for them to. So making sure that they are and also the high fat diet makes them feel pretty terrible on these medications. So ensuring that they're high in fiber, protein, low in fat, and incorporating healthy fats is important. But small meals throughout the day tends to make things better as well.
Kate Scarlata, MPH, RDN:And what about vitamins? Should everyone be on a vitamin if they're eating less? Is that something that's routinely done? I was just curious, especially with these crazy amounts of weight loss, you know. So is there a general rule of thumb in your office?
Dr. Supriya Rao:Or we check certain vitamin levels before we get started. So for example, B12, folate, vitamin D, those are kind of like the main ones that we are checking. Hair loss happens quite often with significant weight loss. And a lot of the women, you know, are freaking call me freaking out. They're like, I'm losing my hair. And I'm like, it's not necessarily because of the medication, it's because of this telogen effluvium, significant fluctuation in weight. So beyond vitamin D supplementation and just making sure that your diet is well balanced, I don't recommend necessarily much more than that. Some people go on, you know, multivitamins or neutrophil or something like that, too, and or prenatal vitamins. Some people will do it. If they want to, it's fine. I don't really force one thing or another, whatever they're comfortable with.
Dr. Megan Riehl:Yeah. But I mean, ideally, right, that you have provided patients with access to a dietitian. If we're not having these kinds of conversations around, and again, if you're going off on your own and kind of procuring the medication and you're not changing outside of you don't feel great after eating foods and meals that you might have used to be okay eating, you've achieved a calorie deficit, you get these physical symptoms now because if you overeat or if if you're eating certain foods. So it's so important if you're making this shift in your health to think as holistically as possible, nutritiously as possible. Also checking in with yourself emotionally around these body image changes. Is it bringing up any feelings about your body image and sometimes this desire to just lose more, do more, do more? And especially women in terms of taking care of yourself. Men too. Men too. But you know, we tend to be the doers and the givers and the beers of all. And so as you're making this life change, you have to find the resources and supports to help you make this holistic change in how you're treating your body and your mind.
Dr. Supriya Rao:I think that's a really important thing that you talked about, especially with regards to mental health. A lot of patients, so I teach a lifestyle medicine curriculum where I have patients after hours, it's a group uh setting where we have about 20 people and we have several cohorts running at the same time, and we talk about different aspects of lifestyle, whether it's diet or exercise or sleep or stress. The body image comes up quite often. And so, you know, when patients deal with a lot of obesity stigma when they're at a higher weight, and then they start to lose the weight and they're feeling good about themselves, but then they start hearing negative comments from people around them saying, like, oh, now you're to this, now you're too that. There's always so many comments. So ensuring that patients are doing okay from a mental health perspective is very important. And if a patient has a history of an eating disorder or binge eating or anorexia or bulimia, I think it's, you know, I'm not a fan of putting them on medications like this because it can trigger some of those restrictive eating behaviors against. Exactly. Yeah. I really work with psychology. We have some psychologists that we can refer to to have discussions surrounding this because, you know, we don't want to get into that situation either.
Dr. Megan Riehl:Yeah. So for so many reasons, you know, a GLP1 may be recommended to a person. And, you know, eating disorders can be very invisible. And so having those conversations around even asking, making sure that we're asking a patient about their history of eating disorder. And it doesn't mean that just because you had an eating disorder, you're totally off the table for this type of intervention. But we also want to make sure that similarly to when we have patients go through bariatric surgery or our endoscopic bariatric programs, that after the fact, some of these things around body image eating disorder history are creeping up and more prevalent. And it's so much more beneficial to have the mental health support in place before and as opposed to kind of catching up with it afterwards when you're already going through these changes with your body.
Dr. Supriya Rao:100%. We, you know, we have a medical weight management program, plus we do outlet reduction for gastric bypass. We do the sleeve gastroplasties. So, you know, we see a lot of these patients coming through. So we need to be sure that they are equipped to be able and A, have the support around them that they need, and B, are equipped for when things do change on them, like what that looks like for them and helping them manage that.
Kate Scarlata, MPH, RDN:Yeah, I think at the binge, eating or just people in larger bodies, and sometimes that just gets totally missed. I mean, you see someone super thin and you're like, oh, maybe they have an eating disorder, but you know, disordered eating doesn't have a look. And so it's really important that, you know, we're asking these questions prior to prescribing certain medications that might do that. And I think too, just being able like equipping people that are going on this, knowing that their body's gonna change, people are gonna perceive them differently, and having the right tools to sort of have the right sort of whatever phrase they want to say when people say they're too thin or start commenting on their body, which is none of anyone's business, quite frankly. So, you know, but just providing that kind of tool set for them so they can stick up for themselves, I guess.
Dr. Supriya Rao:Yeah, 100%. Like, you know, high blood pressure, high cholesterol is not cosmetically apparent. And so obesity is slowly being recognized as a chronic disease, but for a lot of people, it's still a cosmetic disease. So I think that is what we still need to work on to change that stigma and bias and treat obesity as a chronic medical condition.
Dr. Megan Riehl:Yeah, the stigma, it's kind of like you're damned if you do, you're damned if you don't, because I don't attend a conference or even like a get together anymore. And there's whisperings of like, oh, but they're on a GLP 1 or that, you know, like wow. And and like it's incredible. And and now I've also heard people that will interject that I'm not on a GLP 1, you know, like I did it this way.
Dr. Supriya Rao:Yeah.
Dr. Megan Riehl:And I think because this is, you know, really the societal shift, but also in a very medical advancement kind of way, I think our kind of societal stance right now is still one of a little bit of shock that people that have maybe taken years to lose weight for whatever reasons, you know, maybe they're like, ah, you get the easy way. And again, to your myth, right? That this is not an easy, there are clear side effects. And, you know, everybody is just trying to make the best decision for themselves.
Dr. Supriya Rao:Right. And so, like we talked about, the side effects can be managed pretty easily. But there are definitely when people are talking about certain things that kind of put my radar up a little bit in terms of maybe we need to stop this medication. So I haven't really had a patient like this, but there have been reports of patients developing pancreatitis on the medication, you know, with and so obviously if they've got very severe pain that's not improving at all. We get imaging and labs and everything like that to ensure about pancreatitis. I have had patients come in, like I mentioned, who were given the medication by either another physician or some other type of professional. And they come in having lost so much weight and then cannot even keep water down, super dehydrated, acute kidney injury, need to go to the emergency room kind of situation. So, you know, for those patients, we talk about what we have to figure out a way forward once they get better. I haven't seen this at all, but some patients get so constipated that they end up having a bowel obstruction. So, again, I've never seen that, but that's also a possibility. And then severe right upper quadrant pain, gallstones can happen, and we want to be sure that eventually that kind of goes along with the pancreatitis issue, gallstone pancreatitis could be a problem. So making sure that we're staying on top of the side effects, getting imaging in labs as needed, that will help ensure that patients are successful on these meds.
Dr. Megan Riehl:Okay. So I think this is a big point to talk about and how durable is the weight loss when medication is stopped? Do we stop it? What are the strategies for improving our long-term maintenance with this medication?
Dr. Supriya Rao:Sure. So there was actually trials done to look at this. And so the STEP trials were the ones that looked at how patients did on these meds. So there was an extension trial that showed that when patients stopped it, they regained almost 60 to 70% of the weight back, essentially. And so for me, these medications are long-term as long as you're able to tolerate the side effects. When patients reach whatever their goal is and they're doing well, I decreased the dose to kind of the most effective maintenance dose, whatever that would be. But I think patients, just like, you know, high blood pressure or diabetes, this is a lifelong condition, lifelong medication. If patients have made significant lifestyle changes with regards to what they're eating and how they're building muscle mass and other aspects of lifestyle that are very different compared to before they started the medication, again, I will bring them down to the lowest medication level that they need to be on. I've had one patient be able to come off successfully. So that's out of thousands of patients.
Dr. Megan Riehl:So I'm just gonna say, what is our N? I mean, that is really shocking and important. And that is a really important piece of this whole puzzle, right? Yeah. That when you're making this decision, this is not a I'm gonna do this for, you know, to get ready for my wedding or, you know, my bachelorette party or whatever it may be event, I'm gender stereotyping. So I know men are using these too. I love my ladies, but I'm just trying to kind of protect people out there that maybe don't get the full breadth of information that I think helps you make the most informed decision.
Dr. Supriya Rao:Yeah, this is not a jumpstart weight loss thing. You know, this is a long-term medication that you need to use, just like any other medication. And people need to accept that. And yeah, this is not something to use to get into a bathing suit for the summertime or anything like that. Though I know, you know, for some people it might be used that way, but I don't use it that way for patients.
Dr. Megan Riehl:What would be the risks of somebody that's doing that?
Dr. Supriya Rao:So the risks are that they end up losing a lot more weight than they were anticipating and are actually at an unhealthy lower weight. Again, you're just kind of throwing your system out of homeostasis. Yes. And so you're metabolically going up and down, starting, stopping, you know, it's just like yo-yo dieting, right?
Kate Scarlata, MPH, RDN:We know that's terrible for your body. Yeah, yeah.
Dr. Supriya Rao:So I would say those kind of metabolic changes and that yo-yo is really could be catastrophic over time.
Kate Scarlata, MPH, RDN:And some of these side effects, I just want to go back. So if they get constipated, that's just gonna be chronic for them. Like, is that also, or does that kind of work its way out?
Dr. Supriya Rao:For some patients, actually, it works out over time. It kind of adapts to it. Some patients need to be on something for constipation longer term.
Kate Scarlata, MPH, RDN:Yeah.
Dr. Supriya Rao:Yeah, it's individual.
Kate Scarlata, MPH, RDN:And as far as using them, you know, obviously we're seeing them for weight management, we're seeing them for diabetes. Is there anything else on the pipeline? And I just the reason why I'm asking is I did a series on mast cell activation syndrome, and we were talking there was a small case study using GLP1s for like refractory mast cell activation symptoms. It was just a case series. It wasn't, you know, saw an RCT or anything. Right. But I thought that was kind of interesting and just wondering if you know anything being looked at for these medications for other conditions.
Dr. Supriya Rao:Yeah, so I think in that case study, it was looking at how patients with MCAS, you know, actually had improvements in their inflammatory symptoms. And I think, you know, GLP1s, again, you know, they're helping you from a metabolic perspective. And so they're decreasing inflammation. And so I think, you know, they have the potential to have potent anti-inflammatory effects that stabilize your immune system. So, you know, I could understand, and I'd be interested to see if they end up doing a lot more, you know, true studies with GLP1s and MCAS, what that would look like. Wagovy was approved for NASH or fibrosis and inflammatory conditions in the liver. So we're seeing that. Zepbound was approved, which is tirzepatide, was uh approved for sleep apnea. And so the thought is that overall metabolic health, when your next circumference decreases over time, you know, actually sleep apnea ended up resolving in a huge percentage of patients in the sleep apnea study in Zepbound. And then cardiovascular protection as well. So in the inflammatory state of cardiovascular disease.
Kate Scarlata, MPH, RDN:I don't think people realize that most chronic health conditions have an inflammatory component.
Dr. Supriya Rao:Inflammation is a bedrock of most chronic medical conditions in this country, whether it's heart disease, arthritic type, musculoskeletal issues, cancer, inflammation is a huge part of it. So these medications almost have this whole anti-inflammatory part to them. So it'll be really interesting to see what other studies come out with regards to other disease processes that they would be treating.
Dr. Megan Riehl:I think the research opportunities are very vast. And, you know, probably also extending into incorporating aspects of mental health. How does one's mood, their quality of life, how does that change over time?
Dr. Supriya Rao:Yeah, actually, I believe there are studies going on with like addictive type behaviors with regards to alcohol and tobacco as well. I've had patients stop smoking and drinking on these medications. They just where that food noise goes away, also that addictive noise goes away too for them.
Dr. Megan Riehl:So yeah, I'm thinking about some of the medications that we use for psychiatric conditions where a side effect may be weight gain. And that medication is almost necessary for management. You know, and then patients that are dealing with mood issues are gaining weight. That doesn't help with many patients from a mood perspective. So it becomes this kind of double edged sword for some. For others, it totally matters in terms of their improvement in their psychiatric condition. But again, I think it's an avenue where potentially the option of pairing and Addressing that from a different angle could be beneficial.
Dr. Supriya Rao:Yeah, for sure. These medications are helpful. And also, metformin is really great for antidepressant, antipsychotic like medication weight gain. So I sometimes pair the two together because of that.
Dr. Megan Riehl:You're the perfect person to be having this conversation. It is so helpful. So it really is.
Kate Scarlata, MPH, RDN:You are the perfect person for this conversation.
Dr. Megan Riehl:So there is just as we've identified, there's a lot of hype. There's also misinformation surrounding these GLP 1s. What are the biggest misconceptions you find yourself correcting for patients? And what do you want listeners knowing as we enter into this very, very new year?
Dr. Supriya Rao:Yep. So I think the misinformation, like I mentioned earlier, the easy way out. I think that's definitely a misconception. These drugs require work. You have to change your lifestyle, otherwise, you will become frail. I think, you know, compounded meds are just as good as the real thing. And I don't believe that. The medication in the compounded drug is not the exact same one. It's like instead of semaglutide or tirzepatide, it's the salt version of it, which is different and was not studied. So I don't mess around with compounded medications. Another misconception is if you take these drugs, you're just going to lose all your muscle mass and become frail. I think again, if you really are doing it in a supervised way and making the necessary changes, you can lose weight in a really healthy way and take care of yourself with these. So going into the new year, I want patients to and listeners to think about moving their mindset from just weight loss or trying to get into a bathing suit to really gaining health and improving not just your lifespan, but your health span. I want patients to think about, you know, the next several decades of my life. How do I want them to be? Do I want to be on several medications? Do I want to be going in and out of doctor's appointments and hospitals for all different things? The goal is not to be skinny, the goal is to be, you know, strong and metabolically robust. And so, you know, there's a lot of talk around precision medicine and precision obesity medicine and looking at your microbiome and all this kind of stuff. I think the jury's still out on a lot of that. But these medications are one tool in a whole toolkit that you can use to help yourself be your healthiest. And so that's what I want patients to think about how you can be your most optimal health and whatever that takes, whether it's bariatric surgery, endoscopic, and endobariatrics, the medications, the lifestyle, the dietitian being at the gym, ensuring you're getting eight hours of you know restful sleep, all those things matter. So thinking about what works for you to be strong and not just to be skinny.
Kate Scarlata, MPH, RDN:Love that. And I think with that, I love that too. You know, you do need to realize that, you know, weight loss requires or is gonna lead to some muscle loss. So you gotta be building muscle, you've got to be getting enough protein in your diet, and you really need that guidance up front. You can't just you can take the medication and you'll lose the weight, but it's gonna probably not set you up to be strong.
Dr. Supriya Rao:Sure.
Kate Scarlata, MPH, RDN:You know, right? So just that reminder that all of those things have to be in place for the best results.
Dr. Megan Riehl:And that might be where you consider working with a lifestyle medicine specialist, much like yourself. You hit on some of those pillars of health that include exercise, nutrition, stress management, staying away from risky substances, medication management. So if what we're talking about is something today that you're like, huh, like a key person to kind of consider and look up in your area would be a lifestyle medicine specialist.
Dr. Supriya Rao:Yeah, I highly recommend that if you are going to go on these medications, I'm obesity medicine certified, lifestyle medicine certified. I think it's very important to see someone, at least for these medications, who is obesity certified, and someone who has good access to ancillary services like diet headaches and other services to help you.
Kate Scarlata, MPH, RDN:Totally agree. So, what do you say? Let's transition to our speed round. We'll get to know you a little bit. Let our audience get to know you a little bit. So these are just quick, fast answers, and let's take a look into your world. Okay. So is it coffee or tea?
Dr. Supriya Rao:Uh, it's tea for me. I actually never drank coffee throughout residency or anything like that. It's green tea for me.
Dr. Megan Riehl:Green tea. I love that. And what's more important, fiber or protein?
Dr. Supriya Rao:As a GI doctor, I have to say fiber.
Kate Scarlata, MPH, RDN:All right. Yeah, I'm with you on that one. But both. We'll say both.
Dr. Supriya Rao:Both are important, but fiber is what I because we have a fiber deficiency in this country, we don't have a protein deficiency.
Kate Scarlata, MPH, RDN:So all right. So what's one thing you think everyone should adapt for their gut health?
Dr. Supriya Rao:I think trying to increase the number of plants in their diet, aiming for both increase in the number of plants as as well as the diversity, and trying to aim for 30 different plants in a week.
Dr. Megan Riehl:There's a goal. There's a goal. Go-to hydration drinks besides water.
Dr. Supriya Rao:I would say actually probably coconut water. It's got a lot of electrolytes in it and you know, potassium and whatnot. So coconut water is what I would drink.
Kate Scarlata, MPH, RDN:Yum. Okay. What's your favorite way to unwind after clinic?
Dr. Supriya Rao:My favorite way is to, you know, just come home and hang out with my kids and like cook a really nice meal because it kind of puts me in a zen mode and I cook a lot. And actually did like a cooking class last night for my patients. And so it's just really fun to talk about food and why certain foods are healthy and what why certain ingredients are, you know, are healthy for you. And so I love getting meals together and hanging out with family.
Dr. Megan Riehl:Well, you are an inspiration, working mom, again, quadruple certified physician, but also walking the walk. So that's a wrap for this fantastic episode. Thank you so much for joining us and for sharing your expertise. Perfect way to kick off 2026.
Kate Scarlata, MPH, RDN:Absolutely. And so to our listeners, thanks for joining us. Please like and share the gut health podcast. Your support means the world, friends.
Dr. Megan Riehl:Thank you for joining us as we grow this gut health community. We hope you enjoyed this episode and don't forget to subscribe, rate, and leave us a comment. You can also follow us on social media @The GutHealth Podcast, where we'd love for you to share your thoughts, questions, and experiences. Thanks for tuning in, friends.
