Urban Health Today Editors

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Obesity rates continue to rise, with Black adults experiencing the highest prevalence of obesity (50%) followed by Hispanic adults (46%), according to the CDC. Furthermore, obesity-related conditions include heart disease, stroke, type 2 diabetes, and certain types of cancer, which are all among the <a href="https://www.cdc.gov/obesity/data/adult.html">leading causes</a> of preventable, premature death.
Dr. Kris Wusterhausen, board-certified family practice physician and certified in age management medicine, demystifies GLP-1 medications, discusses their role and effectiveness in weight management plans, and debunks some commonly held myths about their use.
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Urban Health Today: We are hearing so much about GLP-1s right now, but before their popularity, what traditional therapies would you use with weight management patients?
DKW: How did we traditionally help patients lose weight?  Not very effectively. Past methods bring to mind the old joke, “I’m going to start my diet on Monday.” As doctors, we tried to educate our patients about eating less, eating better, and exercising more, but the unfortunate truth is that success was low, and we saw minimal results for most patients. People want instant gratification; when their efforts didn’t yield results within the first 30 days, patients got frustrated quickly and stopped trying.
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UHT: Can you tell us what exactly GLP-1s are and how they work?
DKW: GLP-1 stands for “glucagon-like peptide-1.” GLP-1s are peptides and nothing more than amino acids and a chain that cause actions in the body to either occur or shut off.
GLP-1s work by causing the hypothalamus of the brain to make us feel full after eating less, to make us feel full more rapidly, and to curb cravings for sweets and alcohol. Last but not least, they work on the body’s insulin response because hyperinsulinemia, or insulin resistance, is one of the main reasons that our patients become overweight.
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UHT: What percentage of your patients today request GLP-1s, and where do you stand on this medication?
Pretty much all of my patients coming in for weight management are asking for GLP-1s, so we have to look at each patient individually and figure out who would benefit from this medication.
My stance on this medication is that I love GLP-1s. One of the major factors that is overlooked about GLP-1s is that they help us long term. They have neuroprotective properties and enhance learning and memory, they improve gastrointestinal health, they lower the risk of heart disease, stroke, and kidney disease, and new studies are showing dramatic improvement in depression and anxiety. Furthermore, these peptides can be used long-term. Of course, a lot of patients’ budgets won&#8217;t allow for that because, unfortunately, GLP-1s can be quite expensive.
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UHT: Do you have concerns that patients may rely too much on GLP-1s instead of helpful behavior?
DKW: This is a good question, and this is where the provider comes into play. I’m very excited about the popularity of GLP-1s these days, but one pet peeve I have is that practically every clinic is prescribing them. However, in traditional insurance-based practice, you have at most a 15-minute visit scheduled with your patient. So, although the provider has the knowledge to talk about nutrition and how GLP-1s should be used properly in an overall plan, they often just don’t have the time.
At our office, every patient who comes in for a weight loss visit gets a body scan where we can actually see their body composition and where every pound is located. I can look at their muscle mass, the distribution of their body fat, visceral fat, water weight, etc. So, if a patient is using these GLP-1s improperly, such as cutting their appetite to a point where they just don’t eat or eating food with no nutritional value, you are going to see patients lose significant muscle mass. In my practice, we absolutely harp on our patients that we are trying not to lose muscle, and we stress proper nutrition. So, if I am monitoring a patient correctly through labs and scans and educating that patient, then my concern has been minimized.
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UHT: How do the efficacy and safety profiles of GLP-1s change for older adults?
DKW: Well, first, let’s think about our definition of an older person because I have some patients who are in their 70s and are in such great health that they can run laps around some 40-year-olds. I think that age is just a number, and we have to look not only at the patient’s chronological age but also consider their biological age.
For this purpose, however, let’s think of older patients as 60 and above. When we are developing weight management strategies, it&#8217;s important that we take a multifaceted approach and ask, what can they do exercise-wise? What are they capable of doing? Do they have joint issues that limit them? What kind of metabolic health issues do they have?
Generally, we need to take a more cautious approach for older patients. They are more likely to have unwanted side effects, and they may not be able to tolerate certain treatments like some of our younger patients can. Also, as we age, frailty is one of the most common conditions that develops. Older adults can lose muscle mass and become sarcopenic, which leads to frail bones and osteoporosis.
I always tell my patients that money is the currency of retirement, but muscle is the currency of aging. We must have protein; we must have muscle. If an older patient loses muscle mass when taking GLP-1s, then I won’t continue them on that treatment.
Basically, GLP-1s are a great tool but that’s really all they are. As healthcare providers we should constantly educate our patients on the roles of fasting, exercise, sleep, and hormone modification.
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UHT: How do you counsel pre-diabetic patients?
DKW: With insulin-resistant patients, their A1C may be 5.5 or 5.6, which is a normal range, but their fasting insulin level will be severely elevated—that’s where you first see insulin resistance. I have a saying that I tell my patients: if your insulin is up, your metabolism is down, and if your metabolism is down, that doesn’t help with weight loss.
The strategy to deal with insulin resistance is the same, but we are not going to see results as quickly as we do with another patient. We have to combine proper diet and fasting along with exercise and a GLP-1, and it’s going to be a little tougher going in the beginning to start losing weight. This can feel discouraging for a patient, particularly if he’s talking to other patients who do not have hyperinsulinemia and are losing weight fast, so it’s important to let them know why it’s tougher for them and to encourage them to continue.
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UHT: Why do some providers monitor the A1C, but wait until you get to the diabetes portion of their A1C before taking action?
DKW: Historically, providers gave their patients nutritional counselling and recommended exercise and a healthier lifestyle. They monitored their patients’ A1C levels, and eventually, when patients became diabetic, providers moved on to treatment and prescribed Metformin and Actos.
Many years ago, the American Diabetes Association&#8217;s protocol for the onset of type two diabetes changed to medication – it’s no longer nutritional counseling. That step is simply gone. I think the ADA and providers alike had given up on counseling their patients to eat better because it simply wasn’t effective.
Today, with GLP-1s, we can now see insulin levels are elevated and head that off at the pass. Insulin resistance, which comes before type 2 diabetes, is treatable, and it’s a whole lot easier to fix the problem when we find it at that stage.
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UHT: What are your thoughts on fasting?
DKW: I’m a huge advocate of fasting – it’s one of the best ways to keep weight off. But first, let’s define fasting: I want my patients to go at least five days a week, 16 hours a day, without consuming any type of calories. So, for example, you start eating at noon up until 8:00 pm that day, and then you do not eat anything again until the next day at noon. You can and should consume water and can also drink black coffee or sweet tea.
It&#8217;s a medically proven fact that if you fast routinely, you are going to find yourself with more energy. You are going to be able to jump higher and run faster; you are going to get sick less because your immune system is going to improve. And, perhaps most importantly, especially if you are not insulin resistant, your insulin levels are going to fall very, very low, and if insulin is low, then your metabolism is up. This forces your body to start using fat for fuel. A lot of patients don&#8217;t understand that as we age, our bodies don&#8217;t want to use fat for fuel. Our body wants to save this fat for a rainy day. I always joke that our body doesn&#8217;t know we&#8217;re in 2024 – it still thinks we are cavemen, and unless I&#8217;m able to club something over the head and cook it today or find a bush that grows something that I can eat, then I may go a long period of time without eating. So, our body wants to hold on to that fat until we force it, through fasting, to use that fat for fuel. This is why intermittent fasting is so effective and it’s easy for most patients to do.
I do want to point out, however, that patients who have diabetes and use insulin, for example, may be contraindicated from fasting. It’s always important to evaluate each patient thoroughly before prescribing a fast.
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UHT: How do weight management approaches and GLP-1 therapy impact patients with chronic conditions? 
DKW: As people age, they are more likely to have chronic conditions, so it’s similar to treating older patients in that you have to monitor the population more closely. The biggest issue I see is titration or dosage. Many providers use GLP-1s, and their patients complain about headaches, fatigue, nausea, vomiting, or constipation. It’s important to start the dosage low and go up slowly. GLP-1s are weekly injections, so if you give a dosage that is too high and the patient feels sick, they are going to feel sick all week.
There’s a wide range of dosing and each person is unique. I may have a 300-pound patient who responds to a low dose, but a 180-pound patient may need a higher dose. Again, it comes down to having a provider who is educated and well-versed in this medication.
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UHT: What about the patient who needs to lose 10 pounds and is not obese?
DKW: As an age management physician, I might be more aggressive in this case than the average provider. If I look at a body scan and it’s perfect, we won’t proceed. However, an overweight patient can be just 10-15 pounds overweight, but there is visceral fat around their organs, and over the long term, they can become diabetic. If you have excess fat, you are at increased risk for all conditions, including cancer, stroke, and high blood pressure. My job is to prevent and avoid chronic conditions, not to wait for them to happen.
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UHT: What happens when a patient on a GLP-1 plateaus? How do you adjust that patient’s weight loss plan once they’ve met their health and weight loss goals?
DKW: We hear a lot about plateauing, but let’s break this into two categories. The first is reaching a plateau when the patient is not yet at the goal. With these patients, you have to have an honest conversation and find out what’s going on.  Are they eating properly? Not exercising? Is the dose correct? Has there been a tolerance buildup?
The second case is if the patient is at a plateau because we have reached our goal. In this case, we can hopefully use all the weight loss techniques that we’ve learned – smaller portions, timing of food, fasting, exercising – and take them off GLP-1s and continue monitoring.
An alternate route, if they can afford to do so, might be to lower the dose to reduce cravings and help prevent them from gaining weight back.
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UHT: What educational strategies do you find most effective in communicating the benefits of GLP-1 therapies to older patients?
DKW: Undoubtedly, the most effective is face-to-face education. All my new patients who start on GLP-1s begin with a one-hour visit where we set realistic expectations and discuss how we are going to achieve our goals. Subsequent visits build upon this foundation, and we continue to educate during every visit. If a patient understands the plan and feels part of the treatment process, they will have a much better chance of success.
Even though GLP-1s make weight loss easier, it’s still not easy. Patients can still eat through the GLP-1s, just as a patient could have gastric bypass surgery and not lose weight.
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UHT: What is “Ozempic face,” and can it be prevented?
DKW: When a patient loses a significant amount of weight, such as a morbidly obese person who loses 150 pounds, their skin is not going to look as tight. This is especially true if that patient is losing muscle mass at the same time. Their skin will get drapey because fat and muscles have filler. However, for the most part, I find that patients who lose a moderate amount of weight and do not lose muscle mass do not have this issue.
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UHT: Looking forward, what advancements in weight management and GLP-1 therapy are you most excited about, particularly for improving care for older adults?
DKW:  I’m excited about where medicine is headed now. We are focusing on root cause medicine and prevention, which I have always preached. Peptide therapy enables the body to heal itself and to reverse and cure conditions. Hormone therapy and education provided by companies like <a href="https://biote.com/">Biote</a> are likewise enabling great strides in functional medicine, where balanced hormones impact a host of conditions such as osteoporosis, arthritis, diabetes, and cardiovascular disease. We are finally focusing on increasing our patients’ health span and helping people to age as themselves for longer periods of time.

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Dr. Kris Wusterhausen, a board-certified family practice physician certified in age management medicine, discusses GLP-1s, and their role and effectiveness in weight management.