Bill Klaproth (Host): This is The Healing Podcast, brought to you by MarinHealth. I'm Bill Klaproth. And with me is Pamela Riggs, a registered dietician nutritionist at MarinHealth Integrative Wellness Center, as we talk about staying healthy and maintaining muscle while taking a GLP-1. Pamela, welcome.

Pamela Riggs: Thank you very much, Bill. It's great to be here again.

Host: Yes, always great to talk with you. So man, this is a big topic, GLP-1s. Oh my goodness. So happy to talk to you about this, because I know a lot of people have a lot of questions. So, let's start with this. Can you just first off explain in simple terms what GLP-1 medications are and how they work?

Pamela Riggs: Absolutely. And it's a great place to start. So, GLP-1 actually stands for glucagon-like peptide-1. And what GLP-1 is, it's actually a natural hormone that we produce in our gut to help kind of regulate our blood sugar to kind of slow the rate at which food leaves the stomach, and can help us increase our satiety or that feeling of fullness after eating.

So, these medications work by mimicking that natural hormone. And people know the meds as like Wegovy, Zepbound, Ozempic, Mounjaro, those are some of the brand names. So yeah, they mimic this natural hormone that we produce, helping us to decrease our appetite and lose weight.

Host: So, that's why they're effective then. They're basically mimicking what's in our body. But for some people, that hormone is lacking. So, these GLP-1s kind of get it working again.

Pamela Riggs: I think what it does is, basically, it mimics the action of that hormone, and it kind of lasts longer than our body's own production of that after we eat. So, we get that sustained feeling of fullness and disinterest kind of in food.

Host: And that is why it helps us lose weight. So, that's very understandable. So, thank you for that. So, can you share about your experience working with patients who are taking these medications and, you know, we see the ads on TV all the time, Pamela. And then, why might someone taking these want to work with a registered dietician nutritionist? Because we see ads on TV all the time where it seems like, "Hey, online, I can just go get these things."

Pamela Riggs: Yeah, it's been driving me crazy. You can't watch anything without seeing several commercials for those products these days. But yeah, you know, it's become really quite common now that I'm starting to see patients who are taking them. Wegovy's been out, I think, now for about five years, I think.

So in the very beginning, there was shortages. And people couldn't get them. And now, they're widely available. There's other options. There's just an introduction recently of the Wegovy pill. So, that's going to even make it, I think, a bigger thing that'll start to see more patients taking these medications.

And to be honest, I've seen a mix of things. I've seen people who have been very successful losing weight. I've seen people who've initially lost weight, and then they kind of stall out. And then, their doctors might change the medication to a different one. But I would say it's been a mixed bag of results for people.

And I would say really the important part, I think, of meeting with a registered dietician, you know, whether you're just starting the medication, been on it for a while, maybe hits your weight loss goal and want to try to taper off the medication, those are all really good reasons to meet with someone like me who has some expertise working with patients to help, one, in the very beginning set a realistic weight loss expectation, to certainly help mitigate any side effects from the drugs, to ensure that you're still eating a well-balanced and nutritionally complete diet. And also, you know, as I said, as you want to transition off the medication, it's really an important time to make sure that you're eating well. And I think sustaining that long-term weight loss after using the medication is certainly one of the most important things, and a registered dietician can help with that as well.

Host: Yeah, you just mentioned making sure that people have a complete diet. So many people taking a GLP-1 experience a drop in appetite. So, how should they then prioritize their meals to make sure that they're still getting enough nutrition, despite eating less?

Pamela Riggs: So, it comes down to nutrient quality versus quantity. So, really eating nutrient-dense foods that provide protein, healthy fats, fiber, fruits and vegetables, I think that's kind of one of the first things to go. And a lot of people don't even meet their needs for fruits and vegetables. But when you're just kind of not thinking about food as much, you might fall short on some of these important nutrients that we get from healthy foods, fruits and vegetables, whole grains, beans, legumes, and certainly protein and fiber.

Host: So, those nutrient-dense foods, as you call them. And then next to that, we're hearing so much about protein. It's such a buzzword today. Everything is protein, protein, protein, it seems like. So, how much protein do people typically need when taking a GLP-1? And what are some easy, realistic ways to meet those needs?

Pamela Riggs: Yeah. And it is really important when people are trying to lose weight, whether it's traditionally through diet and exercise or with the help of these medications, which I see them as just another tool in the toolbox. They're not a magic bullet by any means, and you still do need to eat well. And so, protein's really critically important because what we find with especially these medications and the type of weight loss that people experiences, they also lose lean muscle mass. Yeah, you lose some body fat, but the body is super smart. And when it perceives kind of starvation, it wants to hold onto our body fat for that survival fuel. And we'll begin looking elsewhere for the energy that it needs just to function every day. So, lean muscle mass gets broken down. And as a result, when we lose muscle, we slow our metabolism because muscle burns calories. And so, we can slow our metabolism, making it more difficult to transition off those medications back to a normal diet without regaining the weight. And we can talk about weight regain, because that is a big issue. But protein is important, so it's going to help preserve that muscle mass. It also makes us feel full and satisfied, but the medications do that as well.

And certainly, it's important to get protein and to focus on that at each meal and snack that you consume. How much protein people need, it kind of varies. When I work with someone, I usually base it on what their calorie needs are for weight loss and to make sure that about a quarter of their calories are coming from protein. For example, if you were eating 1500 calories a day, that would come out to about 90 grams of protein.

Another way that people sometimes calculate it is based on body weight. So using a calculation of 1.2 grams per kilogram body weight or about 0.55 grams per pound of body weight is where that recommendation falls in. And so, just to give an example that if you weigh 200 pounds, that would be about 110 grams of protein a day. And that's a lot, you know, you really have to be mindful and you have to kind of spread it evenly throughout the day so that your body can kind of utilize the protein on breakdown to amino acids and get that into your system.

Host: Yeah, for sure. I do want to touch on concerns and side effects. So, I'm going to just stay on diet for a quick minute. So for listeners who feel full very quickly or forget to eat, can you give us some examples maybe of small nutrient-dense meals or snacks? I know you've mentioned a few things, but maybe you can kind of wrap this up for us as far as diet, some examples of things people can eat to help meet their vitamin, mineral, and calorie needs.

Pamela Riggs: It takes a variety of foods to kind of meet all of our needs, but I can throw out some quick ideas. So, for example, at breakfast might be like a Greek yogurt with some berries and chia seeds and walnut pieces or almond slices. At lunch, you might have some tuna, maybe combine it with some white kidney beans or navy beans; throw whatever, a bed of lettuce, have some whole grain crackers to go with that. Dinner could simply be just stir fry some grilled chicken breast with some vegetables and serve it over brown rice.

In terms of some like easy portable snack ideas, maybe a piece of fruit, some apple slices and roasted almonds, maybe some hummus and vegetables. I really love just doing a mix of like carrots and celery and snap peas, and dipping that in some hummus or tzatziki, which is like a yogurt cucumber dip. Just a hard boiled egg or some cottage cheese and fruit. Those are all protein-rich good sources of nutrients and easy things to do that don't take a lot of effort.

Host: All of that sounds great. So, let's talk about concerns and side effects a little bit. So, one major concern we hear about is muscle loss. And the longer we have these things out there, the more things we learn. What strategies do you use with your patients to help them maintain or even build muscle while on these medications?

Pamela Riggs: Really important. So as I mentioned before, like our bodies are smart. And we tend to lose some muscle mass if we're not paying attention to what we're doing with getting adequate protein. So if I meet with somebody, we'll sit down, we'll figure out what your meal pattern's going to look like. We'll come up with a protein recommendation. Give you some ways to do that through some sample meal plans and snack ideas.

And the other crucial part is to do some kind of weight-bearing, weight training exercise. And I would say that it's important to get started on that, because the only way to build muscle is to use your muscles. So yes, we can get protein in and that might help you hold onto the muscle that you have. But if you really want to change your body composition, which is the ideal way to approach it, is we want to lose that extra body fat, but we want to be lean, strong, and fit. So, certainly incorporating weight training two to three times a week.

And then, it is really important too to refuel yourself after that type of physical activity. There's about a two-hour window after a good workout where your muscles are most receptive to receiving protein, the amino acids. Some carbohydrate which we have to restore in our muscles that helps us do those quick, fast activities like weightlifting. So, we need to eat something pretty much right after we're done with a workout. It doesn't have to be a big meal, but something that has some protein and carbs so that you can refuel your muscles properly so the next time you go to workout, you have the full strength that you need to do a good workout.

So, really important to get that protein intake in and to do some weight-bearing type of physical activity as part of your approach to successful weight management on these GLPs.

Host: Lean, strong and fit. That's what we're after.

Pamela Riggs: That's what we're all after.

Host: I like it. I like it a lot. Okay. So, let's talk about side effects. Many patients report nausea, constipation, or reflux. What are some of the most effective diet tweaks you recommend to reduce these common issues?

Pamela Riggs: Yep. And I do see people come in with some of those complaints. Usually, in the beginning when someone starts a medication, the most common thing that I hear is kind of that, "I feel a little nauseated," or "I get too full too quickly." So for nausea, it really helps to eat frequent smaller meals, things that aren't really high in fat because some fat kind of stays in our stomach longer, and the medication already worked to kind of slow that gastric emptying. So, that can contribute to that feeling of nausea or early satiety. Not sometimes drinking liquids and solids at the same meal. So, sometimes we'll just say, "Okay, drink your glass of water or something else, like, 30 minutes to an hour." And then, when you're eating your meal, just eat the solid food." Sometimes the combination of liquids and solids at the same time, the stomach can add to that queasiness.

And just to note too that, when you're starting out on these medications, to start on the lowest dose possible and stay on that if you can, and still get the results that you want to see. If you taper up on the dosage, just do it in a slow fashion so that your body gets used to it. But I would say with nausea, it's usually temporary, unless people are really overdoing it and ate too much accidentally at a meal. And then, they don't feel so good.

In terms of constipation, again, sometimes when we're focusing on that high-protein diet and we're not getting enough dietary fiber, because we've cut carbs and we're not really getting our fruits and vegetables in there, we can get constipated. So, it's really important to get that fiber in, drink plenty of fluids. We have to sometimes make appointments with ourselves to make sure we get those extra glasses of water in throughout the day. And that physical activity, if we're moving around, we're out walking, doing some kind of physical activity, that helps kind of get the digestive system moving. And if you need to, occasional use of something like a MiraLax, which helps get the bowels moving or even magnesium dietary supplement can help ease constipation or a fiber supplement if you can't get it through your diet.

Host: So, you mentioned drinking fluids, getting enough water in in that answer. So, hydration, it sounds like, is something people often overlook. So, can you go a little bit more in depth on that? Why is it so important to stay hydrated on a GLP-1? And do you have a couple of tips for boosting fluids without, you know, overwhelming this stomach?

Pamela Riggs: Yeah. Hydration's important whether you're taking the medication or not. And I think sometimes we just neglect that. And also, as people age, our thirst mechanisms are not as sharp. And so, we can not feel thirsty in the same way maybe we did when we were in our younger years. And so, we kind of have to schedule the time to get those extra fluids in. And it's just important because, I mean, water is, like, key to all metabolic reactions in our system. So, we want to be working our best and stay hydrated. It really helps with that mitigation of constipation, if that's a problem for you.

Some easy things to think about just to think about how do I get those liquids in? You know, it can be water, it can be herbal tea, milk, coconut water. Even if we're having soups or broths or even fruits and vegetables tend to be pretty high water content. So, citrus fruits or cucumbers or celery or a salad meal with lettuce. So, we do get some fluids from eating those foods as well. And I think, to help do that, we just need to, you know, add maybe a half an hour before each meal, just setting a little reminder on our phone to drink a glass of water, having water with you in a water bottle when you go to work at your desk, maybe you have a liter bottle sitting on your kitchen counter. And the goal is to kind of get through that, at least, throughout the day. So, we need some kind of visual reminders.

And in terms of kind of knowing if you're well hydrated, I think the best way to do that is you should be urinating often, and the color of your urine should be this nice light lemonadey color. So if you're not going to the bathroom very often and it's dark in color, you know you're certainly not meeting your hydration needs.

Host: That's a good tip. Dark yellow, not good. Drink some water. Absolutely. Well, Pamela, thank you so much. This has been great. Before we wrap up, as people move toward long-term maintenance, can you give us some eating habits that you encourage so people don't just lose weight, but keep it off in a healthy, sustainable way?

Pamela Riggs: That is the million-dollar question of how do—

Host: That is. Ding ding. I got it.

Pamela Riggs: How do we sustain these positive outcomes from medications. I don't want to be a party pooper, but there has been some recent studies now that these drugs have been out long enough to kind of follow people, is that a large proportion of people regain the weight when they stop these medications, and pretty rapidly over a year's period of time. Some of that data suggested it comes back on faster than traditional ways of losing weight.

So, I just want people to have realistic expectations from the get go. And that's why I really want to work with people because our eating decisions are influenced by a lot of things. Yes, hunger is key and stopping when we're comfortable, but we're influenced by emotions, situations, habits, so many things that influence us, you know, getting through the holidays, if something happens in our life and throws us off our routine. And so, that's when things get difficult and people kind of go back to their old ways. So, certainly trying to help people identify, "Okay, you might not be feeling very hungry on this medication," and all of a sudden we talk about this like food noise. Like, it's quiet in our head, we're not thinking about the next meal coming, and it helps us eat like a normal human being. But that stuff comes back when people stop these medications. So, trying to help identify what got you here in the first place before you decided to go on the medication, what was challenging? And try to help people work on some of those issues so that when they taper off the medication and they get back to like where they were, that everything doesn't just go backwards. And we can start making some sustainable changes on some of those habits.

So, I would say things that are really important is really trying to understand our body's natural feelings for hunger and satiety and trying to weed out eating for other external reasons. So if your stomach is quiet and you want that chocolate bar, it is probably being triggered by something else, an emotion or something else. So, we need to be able to learn to deal with cravings and emotions and stress and all the things that might be triggering us to want to eat things.

And then, the other part is really being committed to some physical activity plan, because exercise isn't really always the best way to try to lose weight, but it's important for preserving our muscle mass while we're trying to lose weight. But it's really important for weight maintenance. Because as we age, we just naturally lose muscle. So if you can stay active and work out, you're going to keep your metabolism up and more likely to keep the weight off, if you have a good fitness plan. So, that's certainly a very important part. And eating mindfully, paying attention, slowing down, tasting every bite, like stopping and thinking, "Do I really need to eat this, is it going to help me? Is it going to hurt me?" The same things you do to lose weight are the same things you need to do to maintain the weight that you lost. It's just the truth.

Host: Yeah. Really, really good advice there. So, kind of a one-two punch. The diet is number one, but exercise is important to maintain that weight once you reach it, and to build that muscle. You want to keep the weight off in a healthy, sustainable way. So, that's the goal. Once you do lose it, you've done all that work, you've gone through all of this, you want to do what you can to keep it off.

Pamela Riggs: Absolutely. You know, so people just need to keep that in mind. These drugs help certainly. They've been highly effective. It's still early to know what the long-term success is. And I will just throw out there, I'm sure drug companies would love to have people on these for lifetimes. But my hope is that that's not going to be the case and that we can figure out a way to taper people off and to sustain healthy eating, and physical activity and stress management and all those good things.

Host: That would be the goal. And you make a great point about working with a registered dietician nutritionist such as yourself. Always a good idea. And you can go to the MarinHealth Integrative Wellness Center and work with Pamela. You're awesome. Who wouldn't want to work with you?

Pamela Riggs: Well, thank you for saying that. And this has been an area of my interest for many, many years. And these medications have certainly changed the landscape a little bit for me.

Host: Yeah, absolutely. For sure. Pamela, thank you so much for your time today. This is very informative. We really appreciate it. Thank you again.

Pamela Riggs: You're welcome, Bill. It's great to be here.

Host: Yep. And once again, that is Pamela Riggs. And for more information, just go to mymarinhealth.org. And if you enjoyed this podcast, please share it on your social channels. Turn people on to the great MarinHealth Podcast. And you can check out our entire podcast library for other topics of interest to you. I'm Bill Klaproth. This is The Healing Podcast, brought to you by MarinHealth. Thanks for listening.