And I know that getting in appropriate macro and micronutrients and getting in enough fiber and enough protein, how do we make sure that patients are getting that balance? And then also, how do we make sure they're getting enough protein and in various amounts? So one, that they're not getting an excessive amount of maybe just all animal protein that might put themselves at risk for cardiovascular disease and getting in a variety, but also getting in enough so that they won't get that associated muscle loss or muscle wasting that may come with chronic use of GLP-1s.

Yeah, I want to also mention that we are living in a very digital, technologically advancing world.

And most people are using AI these days, whether it's ChatGPT, Gemini, Claude, and so on.

And you have to be careful what you're really using it for.

But I actually see a world where the number of people getting these GLP-1-like medications desperately need guidance on what to eat.

And until those resources are more universally available, probably either through pharmaceutical companies or different societies having some general information, I would recommend you ask AI, hey, I'm on a GLP-1.

I was told I should be taking at least 1.2 grams a kilo, grams of protein per kilo, up to 1.4, 1.5.

So helping our patients know that when they're on these drugs, they need to be making sure they're getting an adequate amount of fiber, protein, protein and other vitamins and minerals just through a whole balanced healthy diet right and not over focus like you just said on protein so where does exercise come into play like how should we be counseling our patients on exercise

... side effects?

So, you know, these step trials, uh, were basically to test e-efficacy, tolerability, and safety, right? So now we're talking about what is the safety.

And we need to be aware of who should not take the medications, and if you do take the medications, what do you have to be concerned about? So we already know that someone with a family history or personal history of medullary thyroid carcinoma, it's not particularly common, but you need to ask for it.

Something called MEN2, uh, medull- uh, which is an endocrine neopl- multiple endocrine neoplasia, you should not be taking it.

So those are, those are contraindications.

When you take the medication, there were some early signals of pancreatitis.

That really has not borne out very much, and we don't really find that very much.

... beneficial?

Yeah.

Medication, a- as I said many times and I'll repeat, biologically does the heavy lifting by reducing appetite.

A- and, and it does guide you, by the way, to eating certain types of food because of the changes in the brain.

So things that are really s- salty or are really sweet, i- in, in general, not for everybody, greasy are not tolerated as well.

So it does shift people often to fruits and vegetables and healthier foods.

How do we know that? We know that, one, by patient care, but number two, even more importantly, if you look at what is going on in our society in the food industry.

So what are people sh- we have data on this.

What-- the all-or-nothing doer, how does that show up?

So what evidence is there about how best to combine diet and exercise with these incretin-based therapies?

You know, we're still learning a lot because the key evidence-based studies have not been done.

But one of the studies that was conducted that has questioned the importance of the intensity of intensive behavioral therapy were called the Step trials with semaglutide.

In Step one, for example, eighteen brief lifestyle visits were conducted over those sixty-eight weeks, which led to a fifteen percent weight loss, which we just said.

In another Step trial, we added thirty visits, which would be this intensive behavioral therapy.

And you know what? We only got a one percent greater weight loss despite adding all this intensive behavioral therapy.

And that really questioned, does the clinician really need to provide this intensive behavioral therapy to get that kind of weight loss? And finally, there was that one head-to-head trial of semaglutide and tirzepatide.

Can you talk a little bit about the recommendations you give if a patient's having adverse effects like nausea, for example, from the incretin-based therapy?

Can you give us a sense of what someone needs to know when it comes to things like timing with food, when to take these medications? Can you talk to us first about the injectable and then about the pill?

Sure.

Let's start with the injection.

It is taken once a week, a- any site in the body, like the thigh or the abdomen or the arm, and it's a, a self-injectable pen.

It's not reusable, so you discard it after the injection.

And the potential side effects of the medication is GI side effects, nausea, vomiting, diarrhea, potentially constipation, can occur with that and seem to be highlighted during the first one to two days after the injection, 'cause that's when the dose in the blood is the highest.

So I tell patients, "Pick the day of the week that you have the greatest control of your diet over the next one to two days," because we have learned by controlling your diet, you can control the, some of these gastrointestinal side effects more, more effectively.

Talk to us a little bit about how important those are as foundational to taking these medications.