This week, we address a hot and controversial topic in medicine: weight loss pharmaceuticals.
Glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptides (GIP) agonists are gaining popularity for their use in treating type 2 diabetes and, in some cases, obesity. These medications stimulate insulin secretion and are shown to increase weight loss and improve blood pressure.
However, significant gastrointestinal and other rare but concerning side effects make these medications controversial. Patients often also gain back much of the lost weight when these medications are stopped.
Our guest this episode is Christina Robins, MD, who has a successful clinic called RevitaLife, which blends family medicine, women’s health care, antiaging medicine and medical weight loss, among other services. Dr. Robins has long been using GLP-1 agonists with her patients, and she joined James to share her strategies for supporting patients using those medications in combination with nutraceutical support.
Listen to the full conversation to learn about the following:
- Lifestyle and nutraceutical support before, during and after the use of weight-loss medications
- How to prevent connective tissue and muscle loss during weight loss
- FDA approval for weight loss and type 2 diabetes drugs
- Appropriate uses for these medications and potential off-label uses
- And much, much more!
James Maskell: Obviously, this is a hot topic now, but you felt like this is getting hotter.
Dr. Christina Robins: It’s getting hotter. Yeah, so it’s going to get hotter. What’s so interesting is Ozempic came out in 2017. Ozempic has been out five, almost six years. It’s been out a really long time, but just in the last year, six months to a year, have people heard of it. Because of Hollywood and all these, you’re kind of seeing people talk about it more. And then even Wegovy, which is the exact same thing for weight loss, Wegovy’s been out two years. So, it’s just interesting. Even that has made kind of a big splash. But Mounjaro the newest game in town, which came out last June, I believe, that is officially still a diabetes-indicated drug, but that will be become a weight loss drug, we think later this year. The FDA has approved it in a fast-track way.
James Maskell: Welcome to the Evolution of Medicine podcast, the place health professionals come to hear from innovators and agitators leading the charge. We cover the latest clinical breakthroughs and health technology, as well as practical tools to help you transform your practice and the health of your community.
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Hello and welcome to the podcast. This week, we interview Dr. Christie Robins. She is a family practice specialist in the St. Louis area. She has a very successful practice combining family medicine, women’s health, hormone therapy, and also medical weight loss. And we brought her in because we wanted someone to talk to us about how to support the GLP-1 agonists and this new exciting brand of medication that’s been really becoming super popular in the last few months. I mean, I’m sure you’ve been hearing about it, whether it’s Wegovy or semaglutide. I’m sure patients are coming your way and asking you about it.
I know that there’s been all kinds of controversy about it, and we tried to get into some of that today, talking about the downsides, talking about some of the side effects and how to support those side effects with functional medicine. We also got into what is the future of weight loss and how can medication play a role and what role should it play? So, hopefully, this is a good primer for anyone who’s just starting to use it in their practice or thinking about using it, and great to have someone with so much experience come and share their wisdom. Really powerful half an hour, enjoy.
James Maskell: So, a warm welcome to the podcast, Dr. Robins. Thanks for joining us.
Dr. Christina Robins: Great, thank you. Thank you for having me.
James Maskell: Well, I’m really excited to talk about what is such a hot topic in medicine right now: the GLP-1 agonists. I know that whether you are in private practice or whether you’re working in the system or however your practice is running, this is something that I’m sure you’re being connected with. And so, I just wanted to bring someone in to the podcast who has experience using these drugs and can actually give a bit more of a functional medicine-style approach to it because obviously one way or another practitioners are going to come into contact with this. So, before we get into it, obviously every doctor that ends up in some sort of functional integrative medicine has some strange and wonderful story about how they ended up here. So, tell us a little bit about your journey and your practice right now.
Dr. Christina Robins: Sure. So, I’m in St. Louis, Missouri and started a practice called RevitaLife about 10 years ago. Went into traditional family practice after residency about 20 years ago, and then, after many years of just more of a traditional approach, we see very quickly that a lot of the things we’re treating all day, such as diabetes and hypertension, really have a lifestyle based to them. And just as my own aging experience and lifestyle, I quickly figured out we really need to look at how we’re aging and intervene in that a lot sooner with lifestyle and different things and an approach that’s very different versus the traditional approach, which is wait till you have the disease state.
So, about 10 years ago went and opened my own practice called RevitaLife. We’ve added many practitioners since then. We’re just based here in St. Louis, but we’re very large now at this point and do a traditional, we do some family practice. Then we also kind of mix to more of truly an integrative approach with patients from hormone therapy to more of even IV therapies to peptide, to medical weight loss. Basically, what that patient needs at that point, so.
James Maskell: Amazing. So, I guess let’s just dive into how you first came across the GLP-1 agonists and what you were hoping for and your first forays into it. I mean, if you’ve been this experienced doing it up until this point, you must’ve been among the first to be using it in practice.
Dr. Christina Robins: Yes. I feel like I experimented with them very early in the game as we look back. So, the first GLP-1 that really came out was Byetta in 2005. So, it’s interesting to see all the current hype because these have been out since 2005. So, that was the first one out. It was a twice a day injection, so it was very rigorous on people. It was officially for diabetes. That one I used in diabetic patients at that time started to see a little bit more weight loss than we would have with other medications and then quickly moved over because of Victoza. The other name is liraglutide, that came out in 2010. So, that’s when I really started using Victoza more in diabetics and in some pre-diabetics. So, even a little bit more off label for a pre-diabetic to try to prevent diabetes.
And there I noticed even a better approach to a weight loss. And then that of course was followed many years after that in 2000, what is that? Well, I guess just about three or four years after that they turned Victoza into a weight-loss drug called Saxenda. Then we used a lot in non-diabetics for weight loss and was able to really use that to a much better level at that point. However, that was still a once-a-day injection, so it had its limitations there. But yes, I saw very quickly back probably 2009, 2010, that these medications were the wave of the future and did things that we could not do with what we had already such as metformin and things like that.
James Maskell: So, I guess what is your general thesis on the combination of pharmaceutical interventions, lifestyle and functional approaches? What’s your general thesis on that before we get into the specifics?
Dr. Christina Robins: So, I’m a very big blender of pharmaceutical and nutraceuticals. So, I like to use pharmaceuticals where I need to use them. And many times, that’s on label, many times that’s off level. And then using the nutraceuticals either by themselves or with that to really get someone more dialed down on their metabolic process or gut health or whatever, liver health, whatever we need to do. So, because these GLP-1s and GIP, they’re peptides, so an amino acid chain that basically works on your body at receptor sites. So, they’re very specific, which is nice, but they also go to a lot of places. And so, we then have to make sure we’re doing the correct things through our diet, through coaching, through interventions of tracking, body composition tracking, supplement nutraceuticals that are basically supporting liver breakdown. Basically, what you’re doing on the protein source and your collagen sources and the gut motility, these are all things that are affected by these medications.
James Maskell: Yeah, that’s great actually. So, as an example, let’s say there’s a doctor listening who doesn’t use pharmaceuticals that much and is focused more on de-prescribing but is now intrigued by these medications because maybe all their patients are coming in and asking about it and they’re feeling called to start to get in the game. What are some things that you saw in the side effect profile that you look to support? You mentioned some of those there, but just I guess to name them out, what is some of them and what are the things to look out for the negative side effects that can occur from the ongoing use of these medications?
Dr. Christina Robins: Sure. Okay, so real quick, I’m going to do a quick little primer on the two main classes that are out there of these medications. So, you’ve got the GLP-1. Glucagon, like peptide agonist, that is your Ozempic and Wegovy, which is the exact same drug but indicated for weight loss, and then the Victoza in that crowd too. So, that is what we’ve had for years and years and years. And then just one year ago, out came Mounjaro. Mounjaro is a different beast here that is two receptor activity. So, it’s got GLP-1, but it has a new receptor to the game called the GIP, which is the glucose insulinotropic peptide receptor. And that one is very, very different than we’ve seen before and that’s why Mounjaro is a little different. So, in these medications though, especially the GLP-1s, you have GLP-1 receptors at your stomach, small intestine, pancreas, liver.
So, they’re kind of told to work on these receptors of all these places. So, the most common thing we would see is some nausea, is some change in gut motility. So, you could have even diarrhea or a constipation. We would see definitely some more reflux type things if the gastric motility would change. So, a lot of gastrointestinal and also nutritional, some in there too. So, if someone’s going GLP-1, that person, we need to make sure they have the support, especially gastrointestinal support for that. The newer one out called Mounjaro because of its less GLP-1, it’s only 33% GLP-1 and 67% GIP. The GIP receptor has a lot less side effects for gut. So, the incidence of side effects on that medication is less than for Ozempic or Wegovy, but you still got to make every patient aware that you go low and you go slow on these meds, they’re a once a week shot. So, you start very low, you move up slowly and you support all the possible side effects and detoxification and nutritional support that you can.
James Maskell: If you have a situation where you don’t know which way the gut is going to go, is it going to go towards constipation or is it going to go towards diarrhea? What are some nutritional or lifestyle strategies or nutraceutical strategies that you’ve seen to maybe help to balance that out in a case where you don’t really know which way it’s going to go?
Dr. Christina Robins: So, I’ll typically use magnesium, is a nice one to add in there because not going to typically cause too much of a diarrhea problem. Most people typically are more constipated and have more reflux type stuff from the slowing down of the gastric empty. So, typically magnesium does a great job with that. The other thing I’ve used is aloe vera for more of a tougher constipation and then also some of the artichoke blends to help with motility and then the nutritional support. Basically, a very good multivitamin of some sort along with even some minerals sometimes. And then typically at least some sort of protein shake, even with some added collagen, even some lipo support. So, increased fat. So, lots of times, we kind of have a sheet where we have a lot of these options down. You never know side-effect wise what somebody’s going to have. So, you give them different options that way they know, okay, this would be a good one. Here, this is my symptoms, I could try this.
James Maskell: Is there ever a situation where someone comes in and they want it and you convince them not to take it because there’s some other less invasive tools that they have yet to try?
Dr. Christina Robins: Yes. I mean these typically are not made for that 10-pound person. They only need to lose 10 pounds. That’s not really what this is classically for. These are a little bit heavier duty medications. So, typically we need for the weight loss indication is a BMI above 30 or A B M I above 27 with at least one or two comorbid conditions. So, you’ve got someone with a little more serious weight to lose because sometimes you really need to stay on long enough to start getting the weight loss effect. And then there is also the whole how do we keep the weight off? That’s a whole nother kind of program and discussion that we have with patients. Yeah.
James Maskell: Well, I’d love to get into that because obviously what we’re trying to do is help humans be healthy and this can be a great accelerant to it, but ultimately it’s like where do you go in the medium term? And I would draw sort of an interesting parallel with psychedelic medicine where psychedelic medicine may give you a peak experience that could help you be a trigger towards stronger mental health, but ultimately, how do you then support a patient to create the kind of self-efficacy in their lives that would create that. So, I’d love to get into that, and we’ll get into that just in a minute. I guess one thing that’s come up and if you watch the big podcast and you see a lot of talk on this topic is the connective tissue and what percentage of the weight loss is coming from fat versus muscle and connective tissue. What are your thoughts on that? What have you seen and what have you found to help patients deal with those potential downsides?
Dr. Christina Robins: Yeah, so we do the body composition. Right now, we have an in-body machine, so we do that on patients when they come in and as they are losing, so we can really track that data. I would say that it’s kind of a little across the board. I do not see in the majority of patients a massive muscle loss. Now, a lot of that depends upon what age they are because the younger people that start with a little more muscle, like your 30, 40 year olds, they typically do not lose muscle hardly at all. They do a great job. If anything, especially the men, they can put muscle on, they can increase their protein intake enough. That is a key thing you’ve got to do, get that pound. Per pound, you’re supposed to do a gram of protein, so that’s unheard of for some people.
But you really have to stress that, that you’ve got to get this protein in or else your body will try to use muscle for its fuel source. So, because your diet is changing, you’re reducing your carbohydrate intake, you’re reducing your cravings, and so your total intake is down. So, you really have to get that protein up. Older women and men, especially postmenopausal females, that is where the problems sometimes lie a little bit for the muscle loss in that person because that’s definitely harder for them to build muscle. And it does kind of go sometimes. I will sometimes see, I mean they’ve talked about a two thirds, one third ratio. I can’t say I see that high of a ratio, but I would say that it is definitely more prevalent in older males and females and especially postmenopausal, but it can be helped. It’s just a lot of protein, a lot of coaching. Also, weight varying exercise of course is key as they’re going. And to not lose it super fast, you really have to be able to plug along at a slower pace to be able to keep the exercise and the protein up.
James Maskell: Absolutely. Yeah. Well, I guess that takes us nicely into that topic that you mentioned, which is the sustainability of it and obviously looking to build healthy behaviors that will maintain health in the medium term. So, what do you provide in your clinic and how have you worked out your provider team in such a way that you have the right people in the right seats to support people all the way through this journey?
Dr. Christina Robins: So, Ozempic came out with a study recently where it showed that if people went off of these after a year that they did regain, not all of it, but about two thirds of the weight if they stayed off of the medication beyond that. So, we don’t get that patient to that goal and then say, oh yeah, you’re released. Bye-bye. You’re done. We do know after many weight loss studies that it takes your body anywhere from one to two years after you get to that weight to establish the new set point of that weight. So, it’s a journey. I mean, it definitely is not a quick fix with the medications and then the other nutraceuticals and diet support and accountability, that’s a huge thing. Every study shows that if you’re accountable to someone, something, you do a much better job with staying on track. So, with the medication side of things between the Ozempic, the Wegovy, the Mounjaro, we really allow patients to adjust what they’re taking to create their maintenance.
So, in other words, if you are at, let’s say, the highest dose of Wegovy to lose weight, you don’t necessarily have to stay on that every week to keep the weight off, but typically we need some component of that medication coming in for the next one year or so, at least to be able to maintain that. So, many times we’re able to lower the dose or stretch out what they’re taking to be able to do a maintenance. There’s no true studies on that. It’s just what we’ve seen clinically, what works for us and works for our patients. Because many times, especially with someone with PCOS or polycystic ovarian syndrome or more of a insulin resistance natural effect, you really have to keep that patient on track and be able to use the medication in a little bit more different way than what is standard to be able to create and sustain the weight loss.
James Maskell: Interesting. Yeah. Well, that’s very helpful. I think a lot of practitioners will benefit from your insights because I know a lot of them are just starting to be on the process of doing this. Let me ask you this. Obviously, I could imagine you may have to repeat yourself a thousand times to every question because you’ve got this information. Have you found ways in your practice to organize this into some sort of program where it’s not just you sharing it every time, but there’s some sort of like, this is how we do it here and this is what you need to learn along the way.
Dr. Christina Robins: A little bit. We try not to do too much of a classic protocol just because every patient is so different. So, we really like to get all their lab work done in the very beginning to look at the insulin level, look at the A1C, look at their uric acid, inflammatory markers, hormones. So, we take a pretty broad approach. But yes, many times I do repeat myself.
I mean, I do have two nurse practitioners and two PAs and a health coach, and so we are all kind of in it together. And yes, we do say a lot of stuff. We have a lot of handouts to try to explain, just to talk really about to start with how these medications work, how these receptors work. Then also how your body responds and how did we get to this point, this hyperinsulinemia that basically starts off where that insulin stays high throughout the day and therefore we’re getting this fat cell storage signals, and then how do we reverse this and how do we use these medicines to help you become more insulin sensitive and what’s the best diet? So, yeah, a lot of handouts, but in the scheme of things, I don’t really try to be just cookie cutter. I try to really adjust to each patient.
James Maskell: Yeah. Well, then let me ask you this. So, you mentioned earlier just before we came on that obviously this is a hot topic now, but you felt like this is getting hotter.
Dr. Christina Robins: It’s getting hotter. Yeah, so it’s going to get hotter. What’s so interesting is Ozempic came out in 2017. Ozempic has been out five, almost six years. It’s been out a really long time, but just in the last year, six months to a year, have people heard of it. Because of Hollywood and all these, you’re kind of seeing people talk about it more. And then even Wegovy, which is the exact same thing for weight loss. Wegovy’s been out two years. So, it’s just interesting. Even that has made kind of a big splash. But Mounjaro the newest game in town, which came out last June, I believe, that is officially still a diabetes-indicated drug, but that will be become a weight loss drug, we think later this year. The FDA has approved it in a fast-track way.
And so, Eli Lilly, they’ve done their trials on it. They’ve got multiple trials called Surmount. They’re on their fifth series of Surmount right now. So, we think at the end of the year, it will be a totally new name. It will not be called Mounjaro. It will still be a once a week shot, but basically the weight loss, and it was 21 to 22% of total body weight was the average. So, that is weight loss we have never seen before in a medication, whatever they’re going to call this. This will be the name everybody hears and everybody talks about.
James Maskell: Wow. Yeah, it’s interesting. Well look, as someone who’s in the functional medicine world and also in the family medicine world and also a medical weight loss specialty clinic, I mean, what are your thoughts about what the future of this world looks like? I mean, obviously we’ve been, I think hoping that a functional medicine solution could really get these kind of outcomes because we all want to see people empowered and self-efficacious and so forth. Ultimately, there’s a lot of potential here, but also it doesn’t have some of the beneficial side effects of a weight loss journey that is purely from empowerment, shall we say. I guess I’d just love to get your take on the future of the weight loss industry and the future of health creation around these key metabolic syndrome, diabetes, obesity areas.
Dr. Christina Robins: Yeah, it’s going to change a lot, I believe, from what I see, but I don’t know. It’s hard to predict in which ways. I feel like the person who can diet and exercise and do it right and it works. I think that person will still be empowered by that and have success. I think some of us who have a little bit more underlying issues, whether it’s polycystic ovarian syndrome or even you see in menopause, or you see just some familial genetic hyperinsulinemia issues, that person is going to be able to reach out and do something like this where they’re able to basically do something different, which is going to be very effective, but also give them hope and empower them to really go down a journey that’s successful so they don’t end up a hundred, 200 pounds overweight and really just kind of hopeless at that point.
James Maskell: Absolutely. Yeah. No, that’s totally right. Well, look, I guess I want to just appreciate you for being ahead of the curve and bringing this knowledge to the rest of our community. Just being at some big conferences recently, I see that it’s such a hot topic. I also see that some big people in the functional medicine space are going to sort of tackle this with content and books and information coming up soon because of just what they feel like this is a significant breakthrough and that functional medicine can still be relevant, and it’s maybe even potentially more relevant than ever because ultimately you do want lifestyle change. You do want sustainable weight loss. You don’t want be reliant on the medication forever. And we do have a tool that we haven’t had, which gives people hope and can give people progress in there. I guess any last thoughts about recommendations that you have for doctors who are just starting to entertain this and what to look out for?
Dr. Christina Robins: Yeah, I would just say that I think I would be encouraging and empowering them to really understand what peptides are and to understand that this is something that’s been around a while now. I mean, we’ve started with this in 2005, so these are not all brand new. We’ve got lots of data on them. But really coming into this newer class, especially this combination of GLP GIP is going to really kind of change the landscape. So, not to be afraid of it, but to really kind of embrace it, empower it, and understand how we can all work with it, because it’s not going to go away. I mean, Amgen’s got another one coming out next year. Novo’s got. These companies are continuing to work these peptides, and there’s more research going on. So, I think as long as we can embrace it and say, okay, this is how we’re going to support it.
At our gyms, we’re going to keep our muscle mass and we’re going to encourage people, this is how you work with the medication, or if you’re not going to do the medication, that’s perfect too. Let’s try this first. But if that doesn’t work, then that’s maybe a medication person. Or even just on the medical side of things. I mean, we’re seeing people be able to go off their other hypertensive meds and their hyperlipidemia meds. So, really got to understand what that person’s doing medically, chemically, biochemically, nutritionally, because the nutritional support to this is huge. So, that’s where I think just the food industry could really help. And then of course, the supplement nutraceutical industry really to understand how to help these people detox, what helps their liver, what helps with gut motility and with protein and mineral support. So, it’s a very exciting time. I think you will see a lot of people in their businesses and in their medical practices really start to see how we can support these versus all be naysayers of them.
James Maskell: And then if you had your optimal situation, so a patient comes to you and they say, look, I want to go on this. I want to lose weight, but they trust you because they’ve worked with you for a long time, and they know you as someone who takes a root cause approach. Would you like to have a few months to work with them on some of the detox and gut building stuff before they went on the medication? Or can you do it concurrently to starting the medication?
Dr. Christina Robins: So, we love to be able to do at least… The perfect patient is the one who says, I am in from the get-go. We go through all their stuff and they say, okay, I’m going to do the seven-day detox plan now. And then when they come back from that, we’re able to really start the medication with all the support and nutrition that we’ve got set to go, because really that liver and that metabolic process works so much better when they’re in a better place, especially liver wise and as far as a mindset goes and cravings and everything really. So, yeah, that works wonderfully. We can’t always get people to that point from the very beginning, but we try to encourage that and of course, the accountability and the body composition as we go along as well.
James Maskell: Beautiful. Well, thanks so much for your time today. I really appreciate you jumping on. For people who are listening who want to find out more about your practice, what’s the best way to look it up on the web?
Dr. Christina Robins: Yeah, so we’re www.RevitaLifeWellness.com.
James Maskell: Perfect. Well, we’ll put the details in the show notes. Dr. Christie Robins, thank you for your time. I really appreciate you sharing your wisdom with our community. This is the Evolution of Medicine podcast. I’m your host, James Maskell. Thanks so much for tuning in, and we’ll see you next time.
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