What is the best diet while taking GLP-1 medications?

Dr. Mike: Hey, Dr. Mike here. If you're on a weight loss medication and you're eating less, you [have to] make sure every meal counts. Stick around to learn how with our guest, Dr. Su-Nui Escobar.

Live Foreverish Introduction: You're listening to Live Foreverish, a show dedicated to helping you live just a little longer. Here [are] your hosts, Dr. Mike Smith and Dr. Crystal Gossard.

Dr. Mike: All right. Welcome to Live Foreverish.

Dr. Crystal, probably seven times a day—and I don't watch a lot of TV other than one channel, the Food Channel—I see commercials for these weight loss medications. What about you? They're all over the place.

Dr. Crystal: I haven't seen any commercials.

Dr. Mike: What are you talking about?

Dr. Crystal: It's on my timeline, so I see it on my social media timeline. So yes, people are talking about these different medications. People want the medications.

There [are] mixed reviews out there where people or practitioners are just sharing their thoughts on why you shouldn't be on these medications. It's a little controversial, but we know that they are everywhere.

Dr. Mike: I guess it's a sign of the times. People say my generation, Dr. Crystal, is the last generation to watch TV because I talk about it in terms of commercials [and] you talk about it in terms of your feed. It's kind of funny.

We have a guest that's going to help us today [and] walk through all of this: What are these medications? How are they really working? How do we stay healthy on these medications? Does it have to be long-term? A lot of questions to cover.

Our guest is Dr. Su-Nui Escobar. She's a Doctor in Clinical Nutrition and a Registered Dietitian/Nutritionist with a passion for helping individuals on GLP-1 medications—those are the big ones—optimize their weight loss journey. She recognizes the unique nutritional needs and challenges faced by those taking these weight loss medications. Dr. Escobar combines her extensive experience counseling patients with her expertise as a dietitian.

She's also taught at Nova Southeastern University, that's right here in South Florida at the Patel College of Osteopathic Medicine and is a former spokesperson for the Academy of Nutrition and Dietetics.

Dr. Escobar, welcome to the show.

Dr. Escobar: Thank you. It's a pleasure being with you.

Dr. Mike: So, good press [and] bad press, there's a bunch of it out there about these weight loss medications—Ozempic® [and] Wegovy®…there [are] so many now.

What are your personal thoughts about these drugs? Because there's a lot of people are going on them now.

Effectiveness of Weight Loss Medications 00:02:54

Dr. Escobar: Yes, everybody wants to have a hand on these medications. I was really skeptical when I started working with these medications. But let me tell you, they work.

Do they have side effects? Absolutely. Are they for everybody? No.

But you cannot deny that these weight-loss medications have revolutionized the tools that we have to lose weight. It's a tool, and that's something that I feel is really important for us to get as providers.

And also, if you're thinking about using these medications, it's a tool. It's not a magic solution, but [it’s] definitely something that we have in our little toolbox to help individuals with excess body weight.

Dr. Mike: I'm glad you mentioned they do work because I have family members and friends [who] have taken these medications, and they’ve lost a lot of weight. There's no doubt about that. But you're right; they're not magic pills.

Because we also know—and we're already starting to see this—that when you stop them, people often gain that weight right back. Which is the same old story: the ups and the downs, the yo-yo dieting.

So really, it's how do we use this tool, as you say, to manage that weight [loss and keep] us at that healthy, good weight. I think [this is] another conversation for us to have.

Dr. Escobar: Oh, absolutely. I also do research studies [on these] medications. And the beauty about that is you see everyone going through [it] at the same time.

Right now, we're at the phase where people [have] stopped the medication two months ago and the way you saw everybody losing weight at the beginning of the study, now everybody is—I'm not gonna say every single person—[gaining that weight back]. Those who used the medications to eat less, but they didn't make any changes, are gaining weight back [at] an alarming rate.

It's crazy. But you see those who have been very diligent [about] exercising, changing their eating habits, [and] doing the right things that we always advise as health care providers. Those help maintain the body weight or maybe [they] gain one or two pounds [back], which is honestly not a big deal after they lost 60 or 70.

Dr. Crystal: Wow. I'm curious to go back to describing how they work.

Why are they working so well? How are these medications different than other weight loss medications? Because the world of weight loss medications is not new.

How GLP-1 Medications Work 00:05:54

Dr. Crystal: I'm sure you know this as a registered dietitian. We’ve always helped individuals with managing their eating patterns, diet [and] exercise. There's a point when we're working with our clients or patients where we realize maybe a medication can be beneficial—appetite suppressants or many other types of medications.

Why are these working so well?

Dr. Escobar: Dr. Crystal, you're right. We've been using medications for decades, but [the way GLP-1 works now]—this new generation—is new. And they're much more effective than anything we had before.

We're talking [about] some of these medications—especially tirzepatide, which is like a double agent, so a little more potent, but people [on] these medications have almost the same amount of weight loss [as] people [undergoing a type] of bariatric surgery. [It’s] that effective.

Like 25 percent of weight loss for tirzepatide…which is the Mounjaro® and Zepbound® because right now those are the only FDA-approved medications. And then with semaglutide, [weight loss] is closer to 17 percent, which is very significant.

So, how they work is—and the media describes this beautifully—they decrease the food noise. People are not thinking about food. So it's much easier to eat healthy and follow a more balanced diet that is adequate in portion sizes when you're not constantly thinking about food.

They also decrease cravings for sugar, and surprisingly, we're noticing [it with] alcohol. Combined, you're eating a lot less, [and] you're not thinking about food. So you can really do what you need to do.

You're not feeling like eating sugar. And I see that they're not really feeling like drinking alcohol. More studies [need to be] done on the last one, but it's much easier to lose weight.

Impact on Food Cravings 00:08:27

Dr. Mike: Yeah. When you try to lose weight simply by calorie restriction, that takes a lot of willpower because you are hungry often [and] you are thinking about the food. These drugs—what you're saying—[help with] calorie restriction. Because you feel full, you're not thinking about it.

It's taking that out of the equation. You're focusing on your everyday [life]. And then you realize, “Oh wow, I haven't had anything to eat for four hours.”

Dr. Escobar: Yes…What they have to be thinking about [is] did I eat enough today?

Dr. Mike: That’s a good idea. Well, let's talk about that.

When people first start taking these GLP-1 drugs, these agonists, they start losing weight. I think it's fairly quick. But what are some of the negative parts of this that they [have to think] about and know early on?

Dr. Escobar: Could you rephrase the question like [what] not to eat…

Dr. Mike: Well, meaning if they start taking these drugs and they start losing weight early, that's great. For instance, you just said, are they eating enough? That's a side thing they need to be asking themselves.

What about side effects that may occur early? I'm talking like…maybe it's the first month that they've been on this drug. What are some of their experiences—not necessarily on the positive weight loss side—they've noted that [have] been tough about these drugs?

Do Healthy Fats Help With GLP-1? 00:10:11

Dr. Escobar: First, let's talk about how these medications are given in escalating doses. Meaning they start with [a] small dose, and then if they do well on that dose, they move [to] the next one and the next one. [It] usually takes about four months to get the highest dose.

When they first start, maybe they don't have a lot of side effects. But as they progress with the dose, they do start having a lot of GI issues, like vomiting and constipation—constipation is a big one. They're not really hungry [or] they feel tired because fatigue is a side effect of these medications.

I noticed that a lot of the time, two or three days after the injection is when they feel the side effects the most, and then they feel better after. So, what they need to be thinking about is, as you said, at the beginning of the show, are they making every meal count? Because now the meals are so precious, and they cannot eat [as] much, [so] they need to have high protein—that's essential—and fiber.

Those are the two things that you have to do. But now think about this: They [have to] eat fiber, but they cannot have a lot of volume. Dr. Crystal, what would you do in that case?

Dr. Mike: This is Dr. Crystal’s…well, yes.

What Should I Eat While On GLP-1 Medications? 00:11:39

Dr. Escobar: No big salads. A lot of [fiber sources] give us volume. So, what would you tell a patient?

Dr. Crystal: I would suggest for that individual to consider fiber add-ins. I know I'm a food-first individual, but fiber is so important. And there are new strategies to get fiber, even if it's just one to three grams of fiber.

For example, glucomannan fiber—just a little bit of that fiber—does bulk, but you don't have as much of the volume. I would suggest some of those glucomannan noodles—like the miracle noodles. Those are helpful to get some fiber.

Then sometimes you have to look at foods that may be fortified or where they have the fiber added in. And so, you do see that where you don't have to eat quite as much. Those are some strategies.

I would also suggest, personally, maybe pacing it out. [Dr. Mike and I] talk about this, we call [it] snacking throughout the day—smaller amounts more frequently. You may even have to set a timer because, again, you've turned off the food noise.

You're not going into the fridge or the pantry looking for a snack because you're like, “Oh, I'm so munchie.” You're not really munchie. So, then you have to use strategies to remind yourself, “Okay, I need to get a snack.”

So, nuts [or] seeds. Those will give you some protein [and] fiber. And space it out. So that's my take on it.

But I'm wondering [about] your experience because I've been in the Life Extension education [and] clinical field for a while now. I haven't really connected with patients as much as I used to in the past. I'm wondering, are we [still] finding those strategies still effective—like my little tricks that I just described? Are those tricks working?

Dr. Escobar: Yes, you actually said it perfectly. And of course, food first. I always see what my patients eat naturally, and I try to find sources of fiber there.

I have this patient [who] is Cuban—and we all live in South Florida. We know how Cubans love beans, and I love beans as well. And that's a staple in our cuisine. We [found] out that she loves eating beans with butternut squash or pumpkin.

Dr. Mike: Sounds good.

Dr. Escobar: Yeah, it’s really good. It’s a very traditional way of cooking the beans in that country. There you go: You have fiber through the beans and fiber through the pumpkin or whatever she’s adding there as a vegetable.

You work with them [on an] individual basis and see how they can add a little bit more fiber without a lot of volume. But yeah, by adding fiber-fortified foods and supplements. It's necessary most of the time as well.

Dr. Mike: This is a question for both of you guys—both of the experts. I'm just curious. If we're eating less [and] there's not that drive to eat so much as we've already mentioned, you [have to] make sure you're getting your protein [and] fiber.

People on these long-term [medications], you mentioned maybe it takes four months to get on the high dose—I think that's what you said. Are we seeing [nutritional issues] in those people that carry this out [for] five, six or seven months? Are we seeing protein deficiencies [and] vitamin and mineral issues in these patients?

Why Does Diet Matter With GLP-1 Meds? 00:16:18

Dr. Escobar: I don't think we have enough studies to know that, but definitely. I mean, we have to remember that there's a good amount of people [who] live with obesity that are deficient in many nutrients—like folic acid, iron and zinc. They already carry a lot of the deficiencies before they start these medications.

Now they start these medications, and they're eating less. If they're not very careful in what they put [on] their plate, you create even more deficiencies. I think we're going to start seeing studies that are going to prove this theory of mine and many other practitioners.

And yeah, definitely protein. People tend to eat enough protein because they prioritize it with the way our society values protein. But it is especially important because we have to remember they're losing a lot of weight [and] with that, they lose a lot of muscle mass. Working on maintaining as much muscle mass as possible is key.

Dr. Mike: Dr. Crystal and I love that. We talk about maintaining muscle mass a lot. It's very important for longevity.

One follow-up question for you guys…I know we don't have a lot of data, but I'm thinking of more long-term use. Are we thinking certain eating disorders could pop up and stuff like that? If they're eating less and they're avoiding food, is that an issue, or not?

Eating Disorders and Medication Use 00:18:07

Dr. Crystal: I can comment.

You can look at it in multiple ways. You can sometimes think that the person who has extreme food noise may need to address that through therapy. That's one perspective.

Maybe some individuals’ relationship with food is not a healthy relationship to start with. I do believe that needs to be addressed first and foremost. And I know the nutrition [and] dietetics community are pushing that; we can't ignore those concerns.

But then I think the flip side…I don't foresee this creating an unhealthy relationship with food long-term. I think the biggest thing here is—Dr. Mike, let's just take a step back and remember that the original [reason]—we realized that these medications work through their use as diabetes medication.

Dr. Mike: Right.

Dr. Crystal: People have been on them for a long time—the diabetics. They're not new in that realm, they just have [a] new indication. And so, we're not seeing that it's causing or leading to disordered eating in that population.

And we have the new form that's working in three different ways. The landscape has evolved outside of the typical GLP-1s that we see for diabetes. So, my thoughts are no.

But the question that I have for you, Dr. Escobar, is one: If we see that the side effects increase as you're increasing the dose, why increase [it]? Is it necessary to keep going higher? Are we finding that they plateau at some of those lower doses?

What Foods Should I Avoid? 00:20:36

Dr. Escobar: [That’s a] really interesting question because they do plateau at around month 11 or 12. The effects of the medications are not the same, but every person is different. So, some people take the smallest dose and they’re losing weight.

[For] some people [who] take the first dose, nothing happened with them. They might be less hungry, but not anything significant. So, they do increase the dose to increase the effects of the medication [and] the weight loss associated with that.

But also, I noticed that when people start feeling bad, many of them [are] like, “Oh, okay, this is a dose that I cannot handle. I want to go back to the lower dose.” That's something that they need to discuss with the practitioner.

I feel like practitioners should be very open and willing to work with the patient at a dose that works for them. Not every single person needs to go to a higher dose.

Dr. Crystal: Okay. I also had a follow-up question for you: something you mentioned about the medications. And now I’ve lost my question!

Dr. Mike: Oh no.

Dr. Crystal: It was about taking the medications [and] you increase the dose…Oh!

When we look at the side effects—going back to the side effects—are we finding that people are eating less? We know it's slowing gastric emptying. And so, one: Do we think that's the cause of the nausea, because they're slowing the gastric emptying?

I'm going back to [the] idea of me saying little snacks throughout the day. If you're already having slow gastric emptying, what would be the strategy for that? Is that where we would see the tiny, small snacks [be] better than a large meal?

Dr. Escobar: I honestly feel that mini meals—that's [what] I call [them]—throughout the day, like four, five or six a day, work better than large meals. Because digestion is a lot slower than usual, nausea [and constipation] is going to happen.

By spacing out the meals, [having meals with] fiber, drinking enough fluids and water, and moving is going to help [you] have a more regular bowel movement, which is going to help with all the side effects. I love giving probiotics because they also help with the GI [and] gut health. That could also improve the side effects at least a little bit.

Dr. Mike: Oh, we like that—probiotics. There’s still room for add-ins [with all of this], right, Dr. Crystal? Digestive enzymes, if necessary, or probiotics—that sounds fantastic.

A lot of people are on those supplements, anyway, so don't stop them. Keep using those add-ins.

So, what do you think looking ahead? Dr. Escobar, what are your thoughts on the future of GLP-1s in managing weight? Is this it, or is there something more on the horizon? Where do you think this is going?

Future of GLP-1 Medications 00:24:13

Dr. Escobar: They're here to stay; we're gonna see more and more. There [are] more potent medications coming up. There [are] different medications coming up.

They are in high demand. So, they will keep coming, and I [would] not be surprised if, within a year or two, we have more medications approved by the FDA. We may have some in oral form because, right now, they're injectables.

You have a little pen [and] you have to inject…Well, they are already researching this. The studies are there for oral forms.

Dr. Mike: A lot of insurance companies don't cover some of these drugs. We've already seen the compound pharmacy industry pick that up and they're also developing some oral forms as well. Any thoughts on the compounding pharmacies versus the main brands for these drugs?

FDA Approval and Safety Concerns 00:25:19

Dr. Escobar: Okay, I'm going to say it. The drugs that are approved by the FDA are just two companies, and that's it.

When [there's] a high demand and you don't have enough of that production, then compounding pharmacies have the right to [make] these medications. But we have to be very careful when we select a drug from [those] pharmacies because the FDA has warned [us] about the use of semaglutide salts [in making] these medications.

Dr. Mike: That's how they stabilize them with the salts, and that's an issue.

Dr. Escobar: That has caused more hospital visits and other adverse effects. You have to do good research before you choose one from the compound pharmacy…so you select one that is good quality. And [another] thing is that they often come in a vial.

Now, the user has to draw the medication [and] measure it correctly, and that leads to errors. Think about it: There's someone without medical training [who tries] to get a vial. Instead of getting one dose, they get two doses [or] three doses.

And then they inject all of that at once. That can cause really severe side effects because they're taking more [than] what they need.

Dr. Mike: Or maybe they draw just enough to where they’re sure and they're like, “Well, let me just do a little more this time and see what happens.”

Dr. Escobar: Exactly. It's not working as much.

Dr. Mike: Let me try a little more right now and they took the whole thing.

Dr. Crystal: Oh goodness.

Dr. Escobar: So proper training, that's all I'm saying.

How Can I Make My GLP-1 Diet Easier to Follow? 00:27:04

Dr. Crystal: I'm thinking about some solutions because we've got you here; you're an expert. And again, I can come up with some thoughts on solutions. We do know the smaller meals you like—the small five, six, maybe even seven small meals—to overcome some of the nausea and the slow gastric emptying.

Focus on protein, focus on fiber. What are other practical, everyday strategies that you share with your patients that you can share with our listeners that they should incorporate if they are on these medications.

Maybe they need to see a nutrition professional. Maybe that's another one: Don't try to do it on your own. What are you telling your patients that they can do every day to make sure every meal counts?

Dr. Escobar: I will ask them actually to be mindful about what they eat. Because when you think about what you're going to eat, you can make better choices. And they should try to make sure that everything that they eat serves a purpose for their body, at least most of the time.

I'm very okay [with] if they're going out to celebrate someone's birthday and they may eat a small piece of cake or eat something that is not on the healthier side. But definitely be mindful to try to make every bite count.

Drinking water, high protein, high fiber and overall make sure that they eat enough. And we often develop strategies [for] what to do for those days when they have nausea and low appetite days. Because right after the medication, they tend to have very low appetite—for two or three days—and they may be too tired.

So, the solution for that might be: Before you inject, the day before, you go to the supermarket and have your refrigerator stocked with Greek yogurt, maybe cottage cheese or other things [that] are easy to eat but high in protein and nutrients.

Dr. Mike: I like that—plan ahead a little bit. And be ready for those days where you just don't feel quite like eating anything, I guess, which can happen.

Can I Eat Carbs While On GLP-1? 00:29:32

Dr. Crystal: I know this is a different thought, but what are your thoughts on adding in the protein shakes?

Dr. Escobar: I love them. I mean, honestly, they're easy to drink. [If] you're not hungry, they're very easy to go down. When they have nausea, usually higher protein meals are a little easier [to] tolerate and smaller.

So, protein shakes come into play. I love using both—like something where you add protein powder and make the shake, but also using foods to add protein. I mean, I completely jumped into the cottage cheese trend.

Dr. Crystal: I like it.

Dr. Escobar: I often suggest adding cottage cheese to your protein shakes because they're 25 grams of protein in one cup. Just play around with food and really learn about a healthy diet high in protein.

Dr. Mike: You're listening to Dr. Su-Nui Escobar, a nutritionist specialist. Thank you so much for joining us today. How can our listeners follow you [and] learn more about you? Do you have a website or something?

Nutrition Resources and Support 00:31:00

Dr. Escobar: Yes, I do have a website that I made because I [felt] like people taking these medications need more support. So, I have a website: NutritionForWeightLossMeds. It has a lot of resources for the listener.

Dr. Mike: Is that “.com”?

Dr. Escobar: Yes “.com.”

Dr. Mike: Awesome. Thank you so much for joining us today.

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And, of course, there’s LiveForeverish.com [with] tons more episodes you can download, like, share and subscribe, so you never miss a show. We post every Monday and Wednesday. That's LiveForeverish.com. I'm Dr. Mike. That's…

Dr. Crystal: Dr. Crystal.

Dr. Mike: Thanks for listening.