Weight loss, GLP1s and Sarcopenia: A Podcast with John Batsis, Shen Dewar, Aruna Josyula

Eric 00:13

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:18

This is Alex Smith.

Eric 00:19

Alex, we got a great episode today. We’re going to be talking about GLP-1s, sarcopenia, and obesity in older adults. Who do we have on the podcast with us?

Alex 00:27

We are delighted to welcome John Batsis, who’s a geriatrician researcher at the University of North Carolina. John, welcome to the GeriPal Podcast.

John 00:37

Thanks, Alex. Thanks, Eric. Really excited to be here.

Alex 00:41

And we’re delighted to welcome Shen Dewar, who is a geriatrician and board certified in obesity medicine, and she’s at the University of Michigan.

Shen 00:49

Thank you, Alex and Eric. Happy to be here.

Alex 00:53

And we’re delighted to welcome Aruna Josyula, who is a geriatrician and directs the geriatrics fellowship at Texas A&M and is chair of the American Geriatric Society Ethics Committee. Aruna, welcome to the GeriPal podcast.

Aruna 01:07

Thank you, Alex. Thanks, Eric. So great to be here.

Eric 01:10

All right. We’ve got a lot to cover, a lot to talk about. GLP-1s, weight loss, strength loss, muscle loss, all these potential things. But before we do, who has a song request? Is it Shen?

Shen 01:25

Yes. So, Alex, would you play The Weight by The Band?

Eric 01:30

Why did you choose this song?

Shen 01:33

So in this song, a guy walks into the town, and everybody wants him to carry something different. Now, that’s geriatric obesity in one song. 10 medications, 5 specialists, and one patient asking, what matters to me? Back to you, Alex.

Alex 01:50

Take a load off, Fanny.

John 01:53

Yeah.

Alex 01:53

The Weight. Great, great choice. If you ever see me at a sing-along, um, at one of these national meetings, this is one I love to do because we try and do the harmonies. Today you just got me, but dear listeners, hopefully we can harmonize to this one someday.

Alex 02:25

(singing)

Eric 03:24

Oh, it’s a great song.

John 03:26

Awesome. Love it.

Eric 03:27

Yeah, I love it. Good decision-making. Oh, I love that, those lyrics.

Alex 03:33

Fun fact, Bob Dylan’s backing band when he first went electric, for those of you who saw that Bob Dylan movie, that was The Wait. Yeah, mostly Canadian. Thank you. Great choice, Chad.

Eric 03:45

So, uh, we got a lot to talk about today. On GLP-1, sarcopenia, and obesity. I want to just highlight that we have 2 articles in JAGS that cover this. One is just published now a month ago. We’re actually recording this in July, but I think this is coming out in August. One Size Fits None: Developing a Person-Centered Approach to Weight Management in Older Adults. Aruna, that was your article. Wonderful. And another combo article, Incretin-Based Therapeutics in Older Adults: Information for Clinicians and Tip Sheets for Practice.

I love this article. Because it has great cases in it. John, you were an author in this article, just absolutely adored it. So well done. We’ll have links to both of those. We’re going to be talking about some of those topics during our talk today. I’m going to start us off with just big picture. What are some of the age-related changes that we see in weight and muscle? John, can you kind of give us a picture? Others feel free to chime in.

John 04:45

You got it. You know, this, this comes up all the time. You know, think about when we age, we actually gain weight over the course of lifespan. I’ve noticed that. Yep. And, you know, I always like to say, forget about being your college weight, you know, but let’s think about beyond that. We’ve gained fat as we age, usually peaks around the 7th, 8th decade of life. And then subsequent to that, you know, it kind of, it falls off a little bit, but here’s where it gets really interesting.

Great. You build muscle mass and muscle strength with age up until about the 3rd to 4th decade of life. I always like to say it’s all downhill from there, but guess what? You can actually fix that. We’ll get to that, I’m sure, at some point in the podcast.

Eric 05:35

And why is that? Why does fat increase and muscle mass decrease with age? Do we have an idea?

John 05:41

There’s a lot of like interactions. interactions with the environment, your metabolism, you know, dietary and physical activity factors. I would love to give you a simple, like, one-liner.

Alex 05:51

Yeah.

John 05:52

As with everything, it’s complicated. So you lose muscle mass and muscle strength really like peaks and it’s all downhill, but you can, you can, you can hopefully adjust for that. When you think about it, I love this anecdote. Think about the weightlifting champion at each decade of life. If you look at who has a weightlift, what the maximum amount of weight they can bench press at each decade of life, it actually diminishes. So, you know, you have like really objective data to say it reduces with the, with age.

Eric 06:23

Yeah.

Aruna 06:24

So there’s also changes in bone density, right? With aging. So that’s the other piece that we should mention along with the muscle and the fat changes that are happening with aging.

John 06:35

And, and I think that’s one thing that we always forget is like, when you think about it’s muscle, fat, and bone are all intertwined. They’re not, they’re not independent of each other. So there’s a lot of like, you know, crosstalk.

Eric 06:50

Okay. And then, so we have this idea of fat increases, muscle decreases. There’s this idea in geriatrics about sarcopenia. Anybody want to define that for me?

John 07:05

Yeah. Let me, let me jump into that and I’ll have the others weigh in. So you rewind like 15 years ago and over the last 15 years, I would say you could probably count equal number of definitions of sarcopenia. Traditionally, we’ve been thinking about sarcopenia as loss of muscle. Well, there are international consensus right now that really define loss of muscle mass and strength is what defines sarcopenia and performance measures, which are thought to be an outcome of sarcopenia rather than part of the definition.

Europeans and Americans, we tend to kind of butt heads a little bit on that, but generally the consensus right now is really loss of muscle mass and strength is what we define as having a patient having sarcopenia.

Eric 07:52

Well, I guess, John, that goes to your point earlier is with increasing age, you’re losing muscle mass and strength. Aren’t they like perfectly aligned? Or is there some, if you lose muscle mass, are you not always losing strength?

John 08:08

You think, you know, loss of muscle mass, you lose muscle strength, but guess what? They’re not one-to-one related. So, and this is where it gets interesting. And we’ll talk about the effect of weight loss on muscle quality, which is really hard to define and measure. But you can lose muscle mass, but not lose muscle strength. You can, your strength can actually improve or vice versa. We’re trying to still try to figure that out.

Eric 08:36

And then Arun, I’m going to turn to you. Like, how do we think about weight and obesity in older adults? And am I using the right word? Obesity? Is that—

Aruna 08:48

That’s a great question. I love that curiosity because I think Obesity is a clinically accepted term, like in medicine, in the literature, we use that term all the time and we know exactly what that means. But I think thinking about what the impact of that word on the receiving end is for our patients, we need to pay attention there. And that, that word can be jarring for many of our patients. And so there’s actually a movement, you know, one of the things we talk about in the article is Really think about what is the way in which you’re ­ the person in front of you, your patient wants to talk about weight.

Is it, are they comfortable with a term like obesity? Some people are reclaiming the term fat. Some people want to use the term larger body or higher weight. And so I think thinking about the term before you use it with your patients or how you’re documenting about it in your notes is really important. But I think obesity is the clinically accepted terminology, at least from the medical standpoint.

Eric 09:49

And how are you defining obesity? Like, are you using BMI or are we shifting away from BMI?

Aruna 09:54

I mean, that is, yeah, that again, BMI is not the best standard single measure to assess, you know, the adiposity of an individual. However, that is sort of still the practice of using the BMI status as a definition for classification for obesity. So, um, 30 and above kind of is in the obesity realm. And then there’s gradations within that.

Shen 10:21

Because at the population level, you want to have a standard easy measure. So height and weight becomes an easy measure, even extending it to the waist circumference, which reflects adiposity, has not everybody’s doing it. So that’s why we still stick to the BMI. And I want to add on to the obesity terminology. So I developed a clinic at University of Michigan called Optimal Health Weight and Lifestyle Clinic.

I purposely wanted to avoid the word obesity there, and I call it an alternative weight management clinic. So just to add that we want to avoid the term obesity to the patients. So the patient checks in, I’m coming to the obesity clinic, and they’re so— there’s a stigma attached to it. So we need to be very thoughtful about how we term calls.

Eric 11:03

Yeah, and it’s an interesting question as we Talk more about what we can do about it. I also wonder how much, like in your own clinical practices, how much do you focus on weight as a goal versus other goals like strength, function, or just bigger picture, decreasing adiposity, increasing muscle mass? How do you think about that?

Aruna 11:24

Yeah.

Shen 11:24

So when a patient walks into the clinic, so most often I don’t ask, what do you want to achieve in terms of weight? And I always ask, what matters to you most? What are your top priorities coming to this clinic? And what I hear is, I want to be with reduced pain.

I want to walk to the parking lot with less shortness of breath. I want to see my daughter’s graduation and walking up, and I want to play with my grandkids. It’s more function. And underlying this is a weight loss, which gets to them, but they want to achieve improvement in function and quality of life. So that’s what I target, not a particular number or a weight loss.

Aruna 12:02

I absolutely agree with that. I think, you know, obviously coming to Dr. DiVar’s clinic, there’s an idea about weight, but let’s take a step back further. Let’s say you’re sitting in the primary care physician office, a referral is going to be made. I don’t think you walk in assuming that weight is the thing the patient wants to talk about that day. Or they come in for something else.

My finger’s hurting. Let’s not kind of— let’s not assume that weight is the problem. That’s causing all the issues. And so we really have to talk about what matters most, as Dr. DuBois said, from a holistic perspective before honing down to the weight piece.

John 12:39

And, and I want to jump in and we really, I want to echo, we really need to get away from the number. It like that has been a detriment because it also worsens bias and it, you know, folks get fixated on numbers. We’re fixated on our blood pressure. We’re fixated on our cholesterol. Folks are fixated about their weight, but it’s really about what can they do?

What’s important to them? So, you know, I’ve used the term, we need to move from a weight-centric approach to more a function-centric approach. And particularly, I think it’s even more important, you know, for older adults, because that’s often is what they’re— they want to remain independent. They want to remain functional. They want to have better quality of life.

Eric 13:21

Yeah.

Alex 13:22

And then, and you also, what about appearance? Does that come into this as well?

Aruna 13:27

So the stigma piece, right? So, you know, I, I am passionate about ageism and I kind of explored that concept of weight stigma when actually was not in geriatrics, but actually at a university health services medical director. And you were, they were talking about the concept of weight stigma as it relates to disordered eating in younger adults, but that actually exists even for older adults that, that we, you know, just like I say, ageism is sort of in our air and water.

I feel like weight stigma is in our air and water, and it’s very natural for us to sort of assume, um, that people who look a certain way in a larger body, we associate automatically to them that they’re lazy, slovenly, whatever the things are. And this is in popular media. This is, and this is inherent inside us as well, internally.

Shen 14:15

Yeah.

Aruna 14:15

And we internalize that. And so when people start talking to you about weight loss, because now they’re excited, there’s new programs making things cheaper to lose weight. for some of these newer drugs, which I’m sure we’ll get into, then it’s like, how much of that is coming from what you yourself have internalized from what society’s telling you how you need to look?

Shen 14:34

Yeah.

John 14:35

So you got both ageism and a bias about obesity. You have 2 isms that are kind of merging.

Aruna 14:44

But if you think about the age of our patients, right, they’re in their 70s, 80s. They’ve lived with that sort of perception for 50 to 60 years already. And so it’s really hard to tease that out.

Eric 14:55

But can I ­ because it’s also potentially like, I just think for myself, it’s a motivating factor too. Like, I noticed like, oh, like my belly is starting to get a little big. Maybe I shouldn’t be eating like ice cream every night. Like, maybe I should be exercising more. It is a potential motivator for people to do more healthy behaviors. I mean, I could just say this personally too. How do you think about that?

Aruna 15:22

I think that’s reasonable as long as we’re not making assumptions in how the patient, what we’re saying to our patient.

Alex 15:29

Great.

Aruna 15:29

I, you know, everybody thinks about it differently. What might be motivating for you may not be the motivator for somebody else. And so really, as a clinician talking to a patient, it’s really important that I remain neutral and curious and not assume why they want to lose weight and ask about what might Gently ask about, can we talk about how your weight might be contributing to your health conditions? Right? That may not be their automatic assumption, but it’s contributing.

Eric 15:57

I love that, Aruna. Thank you. And John, what I— oh, go ahead, Jen.

Shen 16:02

And what I do in the clinic, as they come for a referral to my clinic, so I start with the conditions, the medical conditions, and start connecting the dots and making it clear to them that these conditions are related to the weight. high blood pressure, high cholesterol, sleep apnea. Once they kind of realize the weight is the underlying problem for the connection, the adherence and towards all the next steps becomes easier. So associating, instead of telling the weight, if you tell the conditions and then say that is interrelated, the patient starts to accept and take care of the next steps in terms of intervention. I found that very helpful.

Eric 16:40

Yeah, because it’s really interesting. We’ll talk shortly about GLP-1s, but we use GLP-1s primarily also to treat other conditions. And a good side effect is weight, or sometimes we use it for weight, and it helps with these other conditions. So I imagine, Shen, in your practice, that that’s also helpful, is when you’re thinking about these meds, like, what’s our primary target?

Shen 17:01

Yes. As John mentioned earlier, in our clinic, I don’t go as a weight number as a target, but percentage of weight loss. Can we achieve 5 to 10% weight loss as a first approach to take care of the medical problems. So I kind of try to teach the patient, it’s not the number we are going to drive, it’s the medical issue we are going to target by percentage of weight loss.

Aruna 17:24

Okay.

Eric 17:26

And then, John, I’m going to turn to you because there’s this idea of sarcopenia. We’re talking about obesity. They can co-occur, right?

John 17:35

Absolutely. You got it. And this actually increases With age, we know that. So, you know, you’re gaining fat, you’re losing muscle mass and muscle strength. And so really it’s kind of like the synergy of 2 really bad diseases/syndromes. And we know that it’s worse, you know, it increases risk of, you know, nursing home placement, death, more comorbidities, functional decline. So you kind of name it. And a lot of that has to do with, you know, trying to identify that in clinical practice though is really, really difficult unless you have body composition, because that’s the only way you can really assess fat and muscle surrogate, so to speak.

Eric 18:21

So what do you do in any of you? What do you do in your, your practice to assess for sarcopenia and obesity?

Shen 18:29

Yeah.

John 18:30

Yeah. The obesity component, I think as Aruna was mentioning, you used to be, and Shannon were mentioning. You use BMI. That’s what you have, you know, in primary, like I do when I, as a primary care geriatrician, we’re not measuring waist circumference because we don’t have time in the clinical practice to do so. So often you try to do from a screening standpoint, you know, if you have an ability to do a questionnaire to kind of screen for sarcopenia, great. Otherwise you use performance measures as a surrogate, you know, chair stand is the easy one that I generally do in clinical practice. Otherwise, if you can measure strength with a dynamometer, sometimes—

Shen 19:07

Which I do in my clinic.

John 19:08

Which is great.

Eric 19:09

You know, grip strength for everyone.

Shen 19:11

Grip strength for everyone who walks into the clinic for my obesity and then follow up every 6 months. I was doing before, but with the new burst of obesity medications being prescribed, I just switched to every 2 months just yesterday when I was at clinic.

Eric 19:26

And how generalizable? Oh, go ahead, Alex.

Alex 19:28

Shen, is your clinic an obesity-specific clinic, or is this a primary care geriatric clinic?

Shen 19:35

Obesity-specific clinic. Geriatric obesity-specific clinic, 65+.

John 19:40

Yeah.

Alex 19:40

And, and so there you’re regularly using a dynamometer. Am I saying it correctly? Are you also measuring waist circumference?

Shen 19:48

Yes.

Alex 19:49

Yeah. Are there any other measures that you’re doing or scans?

Shen 19:53

I do timed up-and-go, timed up-and-go test, and some questionnaires. They get questionnaires before, through the portal, like PROMIS questionnaires for physical function, mental health, and pain questionnaires to kind of assess where this obesity is affecting their physical function, mental health, and pain, and monitor them serially.

Eric 20:14

And you talked about the connection between muscle, fat, and bone. Are you also doing like DEXAs?

Shen 20:20

I wish DEXA is covered. DEXA is covered only once in 2 years, just for the primary care. But I think John, definitely me and John had multiple conversations about doing DEXAs, but not yet. That’s not in practice. TANK is the only one we— pan-group is the only one we have now.

John 20:37

Yeah, that’s going to be, that’s a huge policy issue, you know, should you be doing DEXA scans? And again, I want to be really clear though, for our clinician audience. DEXA does not measure muscle. It measures what we call fat-free mass or lean soft tissue. So there’s a big distinction. That’s like a whole different podcast, but you know, it’s a surrogate. I think that’s, you know, it’a —

Eric 21:01

So you’re using DEXA not just for bone, but potentially lean soft tissue?

John 21:06

So yeah, so in my research, for instance, like we’re measuring, you know, fat-free mass and lean soft tissue in addition to bone. in our, in our research participants, but no one is going to get it covered for body composition.

Aruna 21:21

And I think there’s some interesting bone density related kind of discrepancies in terms of what happens with bone density for people who are diabetic and losing weight versus who are not diabetic and losing weight there, that those with diabetes, it may not impact as much the bone density. So there’s some interesting things that we can do.

Eric 21:38

Why would that be?

Aruna 21:40

You know, I don’t know. And I’m going to defer if John might know that. I just read that and I was like, huh, that’s interesting.

John 21:46

Yeah, I think they just like, it has to do really with biology. You know, the biology of, of patients with diabetes is completely different. You know, they, they’re at higher risk for sarcopenia. They affect, you know, the cells, the mesenchymal stem cells, which really kind of differentiate, you know, get a little technical here, into bone cells, muscle cells.

Alex 22:07

Yeah.

John 22:08

And fat cells. It, it, it can affect that, but that’s above my pay grade as well.

Eric 22:14

So I also got to ask, so pretty revolutionary GLP-1s. Like there are a few drugs that I think actually deserve that, that title. I think GLP-1s do. They help in a lot of different conditions from cardiovascular disease to diabetes. People claim they help with a lot of other stuff based on observational studies, which I question. But let’s talk about GLP-1s. And fat and muscle, what happens with GLP-1s with fat and muscle?

John 22:48

So I want to, can I flip that question a little bit? Just to be like provocative. I think it’s the question is really what happens with weight loss on fat and muscle rather than GLP-1 specific.

Eric 23:02

Is there a difference? Like, do we think?

John 23:05

Yeah. Yes. Okay. So So shameless self-promotion, you know, we published an article earlier this year that really demonstrated even in patients who in clinical trials, behavioral weight loss, lifestyle, lifestyle-based weight loss still leads to loss of fat and muscle-related indices. GLP-1s, what they do, we don’t know its direct effect on muscle and fat yet. But what you know is it increases the amount of weight loss. We know that weight loss itself has a negative, has an effect on muscle, fat, and bone. So it’s the degree of weight loss.

The more weight you lose, even in behavioral trials, the more of an impact on muscle-related indices and fat and bone.

Aruna 23:52

So yeah, and I would agree with that. I mean, that’s kind of what we, we, in the article, the commentary that we wrote, it wasn’t, we weren’t trying to focus only on GLP-1s. This is true for all weight loss. And so I agree with that too. But of course, because there’s such an excitement around DLP-1s, that, that becomes the, the primary focus of conversation when we’re starting to talk about weight management.

Eric 24:14

Yeah. So I heard…

Shen 24:15

We also heard about it acting on the actin-myosin inhibitor pathway, like the muscle actin-myosin pathway.

Eric 24:22

The GLP-1s.

Shen 24:23

Particularly the GLP-1s. So I think it has an extra prong effect on the muscle and bone directly when Even lifestyle interventions also make you lose muscle and bone.

Eric 24:34

So it can have a direct effect on suppressing muscle protein synthesis, but also could be a side effect of just caloric deficit, decreased protein intake. Is that right?

Shen 24:47

Yes.

Eric 24:48

Well, I guess the question is if you’re also seeing it with just general weight loss, like if people are doing exercise and diet to lose weight, we’re also seeing those What I think I read in your article is like the weight loss is attributed to 30 to 40% of muscle loss. Is that right?

John 25:05

Yeah. So some of the new, the GLP-1 studies that have actually measured changes in muscle surrogates can be up to 40% of the weight that’s lost is a muscle-related indices, either fat-free mass or lean soft tissue. It all depends on a few other factors. And this is why it’s really important. We can probably get into the treatment soon that we need strategies, not only that lead to the weight loss, because that improves, that reduces fat.

We know reduction of fat improves cardiometabolic and kidney issues, but we need to mitigate that loss of muscle related losses and bone related losses. How do you do that? So I’m switching gears.

Eric 25:50

We’ll get to how to do that. I got a couple of other questions. So even in non-GLP-1 weight loss, are we seeing that similar? You’re seeing that similar reduction of—

John 25:59

Not that, not to that extent.

Eric 26:00

Not to that extent.

John 26:02

But there is like an old rule that came from caloric restriction studies that about 25% of weight loss is, is muscle, has to, it comes from muscle-related tissues. So that’s kind of like, it’s a heuristic benchmark.

Eric 26:17

Okay. And then I guess I, a smart person once told me Sarcopenia is not just muscle mass, but it’s also decrease in strength. Are you seeing decreases in strength too with GLP-1s or weight loss in general?

Aruna 26:31

I think the concern is there. So I’m not the expert on this. I think that concern is there, especially in older adults who are, you know, as they’re getting older, they’re automatically losing muscle strength. They’re not as active. They may not be engaged in as much activity as they used to be. So that concern is always there with regardless of whether they’re trying to lose weight or not, right? Like we have that for all of our patients.

Are we, we’re concerned about strength loss, but I think when one is actively trying to lose weight, whether it’s with a GLP-1 or not, we absolutely have to be doing things like we have to make sure that they’re capable of doing the things to regain some of the losses.

Shen 27:10

And last question. Yeah. Um, are you seeing that? I do see in patients where we start the GLP-1s. at a little older age when they’re already pretty frail, close to frail, and then their handgrip strength is a little bit on the lower range. And then they are less mobile. They are less able to engage in physical activity, but they need the GLP-1s for their heart failure or the cardiometabolic indications. And even though you start low, it goes slow, which is kind of the geriatric approach, you do see drop in handgrip. So we do see drop in strength.

And I do see patients coming from heart failure clinic who were started on GLP-1 by the heart failure specialist who really liked GLP-1, and they come to us, and then I’m like, so nervous. I’m like, you’re on such a big dose. Let’s go down on the dose. But then they end up with a fall, and then GLP-1s are being held. So we see these, you know, older or more frail, or even younger frail patients who GLP-1s are started. they are starting to demonstrate loose muscle strength, like hand grip.

Eric 28:15

Yeah.

John 28:16

And, and if I can just, you know, this is like a perfect example of a one-size-fits-all doesn’t work, and no pun intended there. But, you know, we are as geriatric care professionals and providers, right? We know this. Older adults are heterogeneous. Obesity is a heterogeneous disease. So part of the challenge here is we’re prescribing these medications But we need to identify who’s the right candidate. And right now it’s based on expert opinion, right? We’re all providing our input based on our clinical experience, but we need these studies to be able to tell us this subgroup would benefit, that subgroup won’t benefit. We’re not quite there yet.

Eric 28:56

All right. At the end, I’m going to ask you, are there wrong groups? Think about that, that kind of pop up in your head as, ah, I’m really nervous. But before we get into that, let’s, let’s talk about what we can do, because I think that that will lead us into maybe who these drugs aren’t the right people for. So I hear that GLP-1s can help decrease adiposity, but they also reduce potentially strength, muscle mass. We didn’t talk about bone, but what do they do on bone mass? Do we know?

Aruna 29:26

I think the understanding, that’s what we were saying. The understanding is that in some it does go down, bone density goes down, but I don’t think it’s clear in who or to what extent. Okay.

Eric 29:36

So there’s some heterogeneity in bone loss.

Alex 29:39

Okay.

Eric 29:40

What can we do if we start people on these drugs? What can we do to help prevent the bad side effects from these drugs, in particular, loss of strength, muscle, bone?

Shen 29:53

So I can talk with my experience at the clinic. Unless, John, you want to go?

John 29:57

No, go for it. Go for it. Yeah, yeah. That’s good.

Shen 29:59

So in my clinic, I mean, step 1, a patient comes in, severe arthritis, want to reduce weight. And coming for weight loss medications, I can see nowadays more and more than before, right? Step 1, what I do is, what matters to you? What, why are you asking? What matters, right? Number 1 question. What are your goals to achieve this weight loss? Next is a comprehensive assessment, which kind of involves what we talked about, functional assessment, the grip strength, the timed up and go, and whatever tests we can do in the clinic.

And then I look at the medications, the The medications usually are 10, an average of 10 medications. My initial cohort study mentioned there are 10 medications, and among 3 are weight-promoting medications. So look at those medications and start to kind of have a deprescribing plan if you can, right? Because with these medications, if you start weight loss medicines, actually the effect is not going to be great, and then you go up and up on the dose over time.

Eric 30:54

Can you give me an example of some of those meds that you, that pop up to your mind?

Shen 30:58

I mean, the basic, insulin could be a weight-promoting medication. Instead, switching to glucophage or the GLP-1 as a next step. That’s so common, and even physician providers are a little bit less aware. And the antipsychotics, and the neuropathic medications, because often these patients have pain, neuropathic pain, and so they are on gabapentin, Lyrica. So they’re all weight-promoting, and we have a host—

Eric 31:21

Gabapentin and Lyrica are weight-promoting?

Shen 31:23

Weight-promoting. And most often our patients are on it.

Eric 31:26

Yeah, 1 out of 10 older adults on gabapentin or Lyrica, pregabalin.

Shen 31:31

So, you know, interestingly, if we inform them and they actually tend to deprescribe it at a later stage, and you see the weight loss effect amplifying. So going back, step is looking at the medications, and then where’s the nutrition? What is the nutrition currently? And then come up with a plan of goals. Let’s set the goals. You know what, the first, they want a number, but we say 5 to 10% weight loss. So we go by that. And then do the lifestyle approach, you know, protein intake. What’s the required protein intake?

We mentioned it to them. I mentioned it to them, like 1.2 to 1.5 grams per kg body weight and resistance training at least 3 times a week. And also caloric restriction. Usually for older adults, we don’t go drastic, moderate, like minus 500 kilocalories of what they’re taking.

Eric 32:18

Can I ask some specifics there? So let’s talk about protein prescription. Like, I have no idea how to increase my, like, like what does 1.2 grams per kilogram actually mean to my diet? Like, what do you do? Or do you actually take, um, here’s some protein powder, here’s some, uh, like some other supplement.

Shen 32:39

So, oh, all right.

Alex 32:41

Yeah.

Eric 32:41

Eat some steak, go on the RFK diet.

Alex 32:45

Yeah.

Eric 32:45

What do you do, John? You were gonna say something?

John 32:46

Well, you know, this is where I’m going to take a step back and say, you know, the approach I think is a little different in a more specialty clinic versus primary care clinic. I would, you know, I would, I would say and argue. I generally have patients see a registered dietitian. This is about interprofessional team-based care. The physician or the advanced care practitioner is not the only person that should be managing the care. It needs to be multidisciplinary. So, you’re right. You know, I’m, as a physician, I know a lot about diet. This is what I, you know, what I study in my academic work, but I’m not a registered dietitian nutritionist.

Shen 33:28

Yeah.

John 33:28

That’s not, I have not had that training. I know just enough, probably enough to be dangerous, but not, but this is where, you know, you really need to rely on those with those, that expertise. Same thing from an exercise standpoint. Well, I’m sure we’ll get to But, you know, so working with a registered dietitian, they can develop meal plans that have elevated and increased the amount of protein spread throughout the day to yield that 1.2 to 1.5 grams per kilo per day.

Eric 33:57

Are you sending to physical therapists for exercise prescriptions?

Shen 34:00

Great question.

Aruna 34:01

Yeah.

John 34:02

Yeah. And, you know, we try to get that covered in various, various ways, but having a trainer physical therapist or an exercise physiologist.

Eric 34:11

Yeah.

Shen 34:11

But what I also, I refer all the patients to the nutritionist as part of the protocol. But an education from a physician about the protein, especially when they really are going to the next step of the GLP-1, I try to see them because of fact nutrition appointments sometimes take long and they want to get started before on the plan. So the advice on the nutrition and the resistance exercise is part of my initial visit and a referral to the dietitian, as John mentioned, is really, really crucial because they see them once a week where we are going to see them once in 2 months. So we cannot see them adhering to a nutrition plan.

Eric 34:49

What does resistance training look like?

Shen 34:52

So the way we, I explain to the patient is like dumbbells, free weights, colored bands, and going to the gym and, you know, doing all those 8 stations. And slowly they get it. They can either buy it or some obese patients due to the weight stigma are kind of refraining from going to the gym just because of the appearance.

And what I see is after weight loss, they start engaging in the program, the gym.So I give them examples of resistance machines, starting with the dumbbells, if that is low cost and easy to get, both upper body and lower body. Okay.

Aruna 35:26

And I think the other kind of unique, and this, John mentioned this earlier about not knowing which is the right population exactly. yet, cuz there’s, you know, scenarios that are not ambulatory. Cuz when you think about like weight training and resistance and going to physical therapy and going to dietitians and making all these appointments and running around, then you’re thinking about the patients that are in a skilled nursing facility or in a home-based setting where they’re motivated to lose weight, but because they don’t quite have the access or the ability to get around in the same way, they can’t necessarily do everything that you want.

And I mean, literally yesterday we were talking about a patient who has a BMI would qualify him just on weight alone to lose weight. But the thing is, are we able to ensure that we can get protein appropriate? Are we able to ensure that even if he can’t get off the bed, can he sit up and do some resistance training and physical activity? Is that good enough to be able to keep up with what a GLP-1 would do? So there’s some unique things around How we might have to think about nutrition, supplementation, and activity for other kinds of populations that can’t, can’t do things in a typical way.

Eric 36:36

Well, let me ask you that. Let’s say they, they can’t do that. Would you still prescribe a GLP-1 if they can’t keep up with protein, they can’t do weight and resistance exercise, or, or do you think at that point that those risks are outweighed, the multiple potential benefits in somebody with, let’s say, diabetes, obesity.

Shen 36:59

Yeah.

Aruna 37:00

That’s a complicated question. And I love it because we’re geriatricians and we are complexivists, right? We love this. And so I think this is where there’s evidence gaps that we don’t have enough information for our older adults fully in all things, right? No studies really incorporate tons and tons of older adults in the way we need them to, to really have a good—

Eric 37:21

What do you do in your clinic?

Aruna 37:22

So exactly. So then it’s, it’s, it’s absolutely risk benefit conversations over and over and really detailed. And it’s not, it’s, there’s a reason why the title of the article is One Size Fits None. It is every individual. You sit down and you have that conversation and you say, you know, these are the things we don’t know. These are the potential risks. What can we do in this? I don’t think there’s an answer that says, if you can’t do these things, you do not qualify. I don’t know that we have that evidence yet to back that up.

Shen 37:50

Yeah.

John 37:50

Okay.

Shen 37:51

I agree with the same. After 4 to 6 months, we see this patient cannot do anything meaningful, lifestyle change, both in terms of diet and exercise. And so it’s a risk-benefit equation we try to balance in our head and do a shared decision-making with the patient, inform them this is the data. This is the current data we have on the weight loss. As John said, 24% to 39% fat-free mass loss. So one-third of your body weight which comes off could be important stuff like muscle, and then Start low and go. Start at the lowest dose and monitor them more frequently. Bring them into the clinic every 2 months. Do that hand grip. Do this get up and go tug and stuff. More monitoring.

Eric 38:30

When would you deprescribe these drugs? I know it’s not one size fits all.

John 38:36

So I will, yeah, no, I had a, actually I had someone who presented to me as a new patient. for unintentional weight loss. Although it was a patient with diabetes, it was, it was in his mid-80s and he was playing golf early in the year. And then 6 to 8 months later was walking with a walker. No hospitalizations, just had lost a tremendous amount of weight. Family was concerned. Of course, what do we do as geriatricians? We look at the med list.

Shen 39:08

Oh.

John 39:09

When did tirzepatide, when was that started? Why are we on 15 milligrams?

Eric 39:14

We occasionally get palliative care consults for weight loss, unintentional weight loss. So like, well, we’re not going to see them until you actually stop their GLP-1.

John 39:22

Yeah. So it’s, we see it, it can lead to functional decline. These are patients with, you know, some patients with diabetes, some patients without, you know, and this is what, again, the comes full circle to the problem. We don’t know who are the right candidates for this, but that, that would be a case. Time to deprescribe, maybe try one of the earlier generation GLP-1s. Liraglutide, for instance, can lead to about a 5 to 7% weight loss on average. So maybe they need a little bit of weight loss, but not that precipitous. You know, I think this patient had lost like 50 pounds, you know, 20-plus percent. of their body weight.

Shen 40:01

And did you say tirzepatide 15 milligrams or something?

John 40:04

Yeah. That the previous provider had titrated it up all the way up.

Aruna 40:09

And I think the, even before, you know, deprescribing, as with anything else, like thinking more before you actually start is really helpful, I think.

Alex 40:17

Yeah.

Aruna 40:18

Sometimes it’s hard to stop something later, like, right? Like, and so one of the things that we kind of know, but not enough know, is that there is a little bit of a difference in what BMI means If we go back to the BMI measure, even though it’s an imperfect one for an older adult of where the, you know, is it classically that older adults will do better if they’re under 25? I don’t think we, I think we actually see that a BMI that’s a little bit higher, maybe protective, may have a mortality benefit somewhere between 25 and 29.

And the reason I bring this up is that the new Medicare program for the GLP-1 bridging. Actually allows people to get medication, treatment for weight loss alone without any coexisting comorbid condition at a BMI of greater than 27. And so then you’re like, and that’s for anybody 18 and older. And so then you’re like, okay, so then we have to really be cautious and thinking like, is a BMI under 27 good for my older adult patient? I think there’s some things that we have to think about there too.

Alex 41:22

Yeah.

Eric 41:22

It’s a great point. Let me ask you this, Aruna. When we think about what’s success, when we think about weight loss with or without GLP-1s, again, it doesn’t sound like pounds lost is the right thing. It sounds more like, how do we opt to, like, what is the best body composition for you? And how do we measure that over time? Or is that not it?

Aruna 41:44

Yeah.

Eric 41:44

And I don’t think it’s function.

Shen 41:47

Yeah.

Aruna 41:48

It goes back to what matters most, right? Like, this is the fundamental for everything. It’s never going to be this body composition mix is the right thing. That can’t be right. Nobody can really answer that. I think it is, you know, John mentioned the case of his patient who was golfing and now is on a GLP-1 and is using a walker. I mean, clearly that is not successful, right? Like that kind of a scenario, especially if the patient’s goal was, I’m going to be able to maintain golfing.

John 42:15

Yeah.

Alex 42:15

Yeah.

Eric 42:16

So let me ask you this, John. I’m just, uh, last question for me. Um, is like that patient, if you deprescribe the GLP-1, right? Uh, they may regain their adiposity, but are they going to regain their strength?

John 42:32

So they actually did. So this is the challenge. You, when you stop these medications, we know you will gain, regain weight. Unfortunately, the limited, and I’m going to use the word that deliberately. The limited data that we have is based on lifestyle interventions, and the majority of the weight that’s gained is that of fat rather than muscle or fat-free mass or whatever term you want to use. In this patient, he graduated from a walker, graduated from a cane. He’s not playing golf, but at least he’s able to walk in and around, you know, the community. That said, his glucose control is not ideal.

Alex 43:10

Yeah. Yeah.

Eric 43:11

Yeah.

John 43:12

So, you know, it’s complex.

Aruna 43:13

There are, and, and, you know, patient priorities, right? What is the patient’s priority? That’s going to really help determine which way you go. Do you, how do you prioritize diabetes management in that setting? Yeah, absolutely.

Eric 43:25

Yeah, this is a fabulous topic. I want to appreciate all of you, but before we end, we’re going to play a little bit more of The Weight by The Band. And again, for all of our listeners, we’re going to have links to some of these great articles because It really was fabulous. And a big thanks to John too, because this podcast was inspired by me listening to his talk at American College of Physicians. He gave a great presentation in San Francisco at their annual meeting. So shout out to that. Okay, Alex, a little bit of the wait.

Alex 44:10

Go down, Miss Moses. There’s nothing you can say. It’s just old Luke, and Luke’s waiting on Judgment Day. Well, Luke, my friend, what about young Anna? He said, do me a favor, son, won’t you stay and keep Fannie Lee company? Take a load off Fannie. Take a load free. Take a load off Fannie.

Shen 44:50

Fannie.

Alex 44:52

You put the load, put the load right on me.

Eric 45:09

John, Shen, Aruna, thank you for joining us on the Cherry Pal— I can’t even talk anymore on this Cherry Pal Podcast.

Aruna 45:17

It really was a lot of fun to talk with you all. Thank you.

Shen 45:20

Yes. Thank you so much.

Eric 45:21

And again, for all our listeners, check out that article. We didn’t even talk about some of the subjects like pre-surgical, like how do you deal with that? I know that’s a big topic, but check out some of these articles. We’ll have links to it. And this, right? Yeah.

Alex 45:34

More.

Aruna 45:35

Yeah.

Eric 45:35

There’s more out there. And again, big thanks to our listeners for your continued support.

This episode is not CME eligible.

For more info on the CME credit, go to https://geripal.org/cme/