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Welcome to “Should I Call a Doctor?” The podcast where we dive into trending health topics to separate fact from fiction. We bring in experts to talk about all things health, to empower you with knowledge and answer your questions hosted by Inova Health.
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Welcome to should I Call a
Doctor, the podcast where we
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dive into the questions you have
about your health and today's
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trending health topic to
separate fact from fiction.
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I'm one of your hosts, Doctor
Samuel Gauley, an internal
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medicine physician at Inova.
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I'm Tracy Schroeder, I lead
communications for Inova.
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Doctor Sam will give you the
clinical perspective while I ask
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the questions that keep patients
up at night.
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Today we have doctor Lily
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Dastmalchi, who is a
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cardiologist, board certified in
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cardiovascular disease,
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echocardiography, and internal
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medicine.
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She is committed to delivering a
holistic, patient centered
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approach to cardiovascular care.
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Today, we're going to focus on,
um, a specific area that she,
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that she works on, which is
obesity medicine or more fancily
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termed cardio obstetrics.
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Um, and we would love to talk to
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her about that along with GLP
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one and its relationship to
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heart health.
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Um, I'm going to let Lily.
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Doctor Dastmalchi, very nice to
meet you today.
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Um, tell us a little bit more
about, uh, what she does.
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So Lily go ahead.
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Yeah.
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Thank you so much for having me.
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I'm so excited to be here.
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Um, so what do I do as a
preventive cardiologist?
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I really focus on
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cardiometabolic health, which
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means all of the risk factors,
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including obesity, that are
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related to cardiovascular
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disease.
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In addition to that, I do also
look at menopause.
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As we know, the menopausal
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transition is a time frame where
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cardiovascular risk or your risk
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for developing heart disease can
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increase.
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There are some changes that
occur.
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You end up having some, as we
say, cardiometabolic
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dysfunction, which if we talk
about today or another time.
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Um, they're all somewhat
intertwined.
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So I focus on cardiometabolic
health.
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And as part of that, I do use
GLP and weight loss therapy,
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including lifestyle, kind of
focus on what patients can do to
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help reduce their risk of having
another heart attack or stroke,
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or reducing the risk of having
one in the first place.
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The, um, the first kind of high
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level question I think I'll ask
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is obviously GLP ones are a very
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hot topic.
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Have been for a while.
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More recently becoming a hot
topic specifically in the
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cardiovascular health world.
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High level.
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If you had to summarize what is
kind of over the last year or
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two, the biggest impact you see,
um, and what is the role of GLP
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ones as it relates specifically
to the heart?
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Yeah, I'll try to be brief.
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I can't make any promises, but I
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think this what overall, what
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we've seen, and this started
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with the select trial that
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showed there was a twenty
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percent reduction in patients
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who had, there was a twenty
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percent reduction in recurrent
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heart attack, stroke and
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peripheral artery disease in
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patients who already had
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established those diseases
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before.
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Um, they this is in adults
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greater than eighteen years of
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age and with a BMI greater than
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twenty seven.
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So it didn't have to be thirty,
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which is typically our cutoff
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for obesity.
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It was twenty seven, which means
you're over overweight, which
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twenty seven is actually also
the number for obesity.
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For those who are South Asian.
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So there is ethnic differences
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in the cutoffs for the markers
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for obesity.
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Now what we've seen is that with
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weight loss you have reduction
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of cardiovascular disease, which
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no other real trial has really
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shown us that the G, P or G and
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g I p therapies, whether it's
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tirzepatide or semaglutide, they
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have shown profound impact in
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not just reducing cardiovascular
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disease and weight loss, but
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also normalizing these
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cardiometabolic parameters.
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So, for example, firsthand, I've
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had patients who've had
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reduction in their blood
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pressure medications.
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We've scaled back to like about
lowest dose.
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And then eventually we get off
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of the blood pressure
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medications.
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I've seen cholesterol panels
normalized.
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I've seen waist circumference
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decrease because we know waist
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circumference, a marker for
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visceral adiposity, which is the
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fat that lines our internal
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organs and is also very
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inflammatory, hormonal.
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It leads to insulin resistance.
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I've seen people have reduction
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in their A one C, which is one
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of the markers to check for
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diabetes.
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Um, also just overall, I've seen
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patients who no longer want to
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drink alcohol if they had a
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little bit of an addiction to
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it.
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I've seen patients want to eat
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more of a Mediterranean like
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lifestyle.
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They can't tolerate the fatty
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foods because of the slower
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gastric emptying, which means
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your stomach can't digest fats
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as much.
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Um, and I saw this through my
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training over at Temple in North
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Philly, where very different
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demographic that we see at
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Inova.
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And I saw such profound impact
and benefit there where patients
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in North Philly who suffer from
a lot of social determinants of
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health, were also seeing these
benefits in cardiometabolic
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markers and different outlook in
life as well.
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And I'm seeing the same thing
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here at the Anova population,
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Northern Virginia.
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So what's the profile of a
typical patient that's going to
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come to see you, that you're
going to kind of take down this
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path that you're talking about.
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Yeah, that's a great question.
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So typically I'll have someone
who's referred to me, since I do
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a lot of women's health and I'm
menopause certified, I do get a
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lot of menopausal aged women,
but I also see males as well.
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And some of them have had a
history of heart disease, and
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some of them have not, to be
honest with you.
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They'll come see me just for
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evaluation, referral for weight
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loss therapy.
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They'll have a lot of risk
factors.
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They'll meet the criteria for
obesity based off the new
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definition that was published in
The Lancet last January of
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twenty twenty five.
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And with that, I'll do a
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prevention screening, which
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means, okay, we look at your
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lipid profile.
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One of the basics.
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I'll get an LP, a level which is
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an inherited marker for heart
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disease, and then I'll also do a
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calcium score.
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Now with the calcium score, some
we it's a out of pocket test.
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Insurance doesn't cover it.
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But one of the great things
about it is that, well, it's not
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thousands of dollars.
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Thankfully, it's between like
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fifty to one hundred and fifty
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dollars.
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And I give people a list of
places they could go to, but
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with it, it's a quick ten minute
test, and they take a photo of
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your coronary arteries and see
if there's any calcification,
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and that lights up as bone, and
they calculate how much coronary
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disease you have.
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And that's if someone does have
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that, that's considered
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subclinical atherosclerosis,
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which is a very fancy term to
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say you have some heart disease
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without symptoms.
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That's really what that means.
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And with that being said, I say,
okay, well, this person does
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have established heart disease,
so we should get them on a GLP
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because now it's more imminent
to actually reduce the risk of
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having an actual heart attack or
stroke or peripheral artery
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artery disease event.
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So now we now we see something
that could cause that.
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Exactly.
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Now we want to try to address
exactly as it reversed that.
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Or does it just stop it in its
tracks so it stops it in the
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tracks in the sense of it
reduces all of the other
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cardiometabolic parameters that
I discussed earlier, right?
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So all the risk factors that we
talked about, and even the
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obesity itself is a risk factor.
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And metabolic syndrome is a risk
enhancer.
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Um, it reduces all of those
parameters.
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So people the risk for
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developing further
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cardiovascular disease
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decreases.
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And are you seeing like in terms
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of timeline, is it pretty
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consistent?
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You know, some of the examples
you gave of how the GLP ones
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affect parameters beyond
obviously just weight?
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Mhm.
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Um, do they tend to correlate,
you know, in terms of timeline?
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So someone's on a GLP one for
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one month, two months, three
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months.
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Is it pretty consistent that you
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see the lipid profile, the blood
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pressure, any other, uh, you
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know, cardiometabolic parameters
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that you're talking about sort
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of move in consistency with the
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weight?
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Or is there sort of a lag
between the two?
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How associated are they and
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what's the timeline you
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generally find?
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Yeah, that's a great question.
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And with everything in medicine,
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everything's very
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individualized.
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So I asked all patients, don't
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compare yourself to your friends
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who are also on these
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medications Just because people
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respond differently, they may
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have sudden drop in weight
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within the first month of
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starting the drug, or they may
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not lose much weight until the
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end.
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Some are considered
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non-responders if they don't
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lose a certain percentage of
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weight while they're on the
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medication.
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I typically see a reduction in
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the traditional risk factors of
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heart disease while the patient
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is losing the weight, which
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shows more that how important
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weight is in cardiovascular
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risk.
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What's the timeline when they're
going to start to see all these
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factors that you were talking
about sort of be affected?
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You know, is it a month?
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Is it two months?
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How long are you are you keeping
them on this drug indefinitely?
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It just becomes some way of
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managing, you know, their their
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overall health and their overall
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metabolic profile.
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One of the things you mentioned
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there that I really want to harp
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on that you asked was, is it
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life long?
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And yes, so, so that's the short
answer.
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Yes.
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It's a lifelong drug.
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Um, patients ask me that all the
time.
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And actually some of them don't
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realize that when they come to
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see me, when they refer to me
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for cardiometabolic risk
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assessment and management and
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everything, and I tell them, I
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just before we start anything
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and get into the whole, you
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know, my long spiel of this
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drug.
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This is a lifelong medication.
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And they look at me and they're
like, I don't want to be on
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medication the rest of my life.
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And I was like, understandable.
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But patients aren't ready to be
on this.
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Like, no problem.
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Here's the information.
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Go home.
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Think about it.
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If you don't want to be on it,
I'm happy to continue with
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lifestyle because lifestyle
nutrition is actually what drove
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me to be a cardiologist.
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And I tell them, like with any
diet you choose or dietary
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pattern, I should say you
choose, it's going to have to be
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a lifelong transition to get you
to optimal health.
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So I say, all right, let's say
you decide to go on one site
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type of dietary pattern.
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You exercise, you lose the
weight, and all of a sudden you
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decide, I'm going to go back to
the way I was eating before.
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You're going to regain that
weight.
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Maybe back in the same spot.
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One hundred percent.
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So I tell him being on the
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medication is essentially the
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same thing.
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And I also explain to them being
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on a medication is not a band
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aid.
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I know we have a lot of people,
celebrities who are like, I'm on
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GLP and I look great, or some
people, you know, they are like,
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I want to get ready for
graduation or wedding.
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I'm like, this is not what this
is.
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This is this is not what I do
still look great, right?
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And I'm like, you look great.
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Like that is something that
that's a different thing.
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It's not what I'm doing here.
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Um, but I tell them, I was like,
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okay, you're going to start this
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medication.
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If you decide you also have to
think about lifestyle, it has to
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go hand in hand.
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One hundred percent.
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Nutrition is still so important.
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Your microbiome is still so
important.
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You need to feed your body with
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rich nutrients, the
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antioxidants, the fiber, the
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lean proteins.
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Eating that plant forward
Mediterranean pattern, I think,
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is what I usually recommend
people just because it's a
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little bit easier and malleable
for everyday life.
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Um, and with culturally, you
know, I'm not saying, you know,
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have hummus every day or the
fish all the time, obviously
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adhere it to your culture.
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Um, and then exercise is really
important while you're on these
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medications and we can get into
that later, but really you have
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to be active.
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And we know for reducing
cardiovascular health, you want
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to do about one hundred and
fifty, which is about thirty
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minutes a day, five days a week
of moderate intensity exercise,
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or seventy five minutes a week
of high intensity exercise.
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That's for cardiovascular
benefit.
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And we also see that with these
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drugs, in addition to weight
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training is, you know, it's
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interesting this year what you
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just said, and I like the
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analogy, you know, with the
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medication.
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And if you just do lifestyle
always is the idea.
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I mean, let's say you have
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someone who, you know, was
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actually never really pursued
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lifestyle modification.
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Or if they did and Okay.
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They weren't very successful.
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So they're like, forget it, I
need to get on a on a GLP one.
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But as you said, they get on the
GLP one.
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And really as part of its
success and as part of the
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regimen, they really need to
adopt the exercise and diet
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approach as well.
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And let's say that gets adopted
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and they're doing very well with
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it.
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Would you still say or let me
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ask it this way, is the reason
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that you say it's life long just
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because statistically it's
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unlikely that someone is going
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to maintain the diet exercise
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approach.
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Or is it?
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No. Even if they did, we still
think they would need it, right?
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So just imagine someone's like,
you know what?
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You changed my life.
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I'm a big fan of exercise now.
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I love this Mediterranean diet.
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I'm going to be doing this till
the day I die.
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Like the dream would they still
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need to stay on a GLP one or is
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the idea.
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No, they wouldn't.
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But the reality is most people
aren't like that, Sam.
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So we keep them on the GLP one.
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Yeah, that's almost like phasing
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out of medication into permanent
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lifestyle.
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That would that would be amazing
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because honestly, I mean, yeah,
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it's it's not that I think
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everyone has to be on
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medications.
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It's not exactly my goal.
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But unfortunately, we've seen
seen in trials.
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And there was one that came out
recently and I can't remember
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the exact numbers, I apologize.
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Um, but they've shown that you
regain two thirds of that weight
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within nine months.
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Mhm.
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And is that irrespective of, of,
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of, of the lifestyle
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modification, one hundred
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percent.
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People say that a normally they
call it food noise.
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They say it just like when I've
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had friends be on this and they
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say when when I'm not on it, the
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food noise comes back and I'm on
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it.
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It's just quiet.
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So I'm always thinking about
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where my where's my next snack
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coming from?
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Yeah.
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Yeah, absolutely.
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Um, I think the g o p g I p
therapies.
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We're trying to learn more about
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how they work, but they
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definitely impact chemistry in
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the brain.
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The, the dopamine drive, the
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addictive behaviors we see with
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like gambling addiction with
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drugs, alcohol, food is just a
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different sugar.
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Exactly.
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Um, but with the reducing the
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dose or coming off the
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medication, You know, I tell
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patients, we don't have to keep
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you on the drug once a week, all
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the time for the rest of your
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life.
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We could do like a quote unquote
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maintenance dose where maybe you
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tolerate it like once every two
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weeks and we kind of figure it
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out.
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But I say, let's get you to a
good, healthy weight.
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Let's make sure you're adhering
to the lifestyle.
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Let's go through the therapy and
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then we'll assess at that point,
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how do we maintain you on this
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drug?
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Mhm.
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And with the incidence now, you
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know, you were talking about the
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once a week and the, you know,
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in the injectable form now with
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oral semaglutide becoming
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available, I mean, it's pretty
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recent.
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Are you seeing any difference
now in engagement with this?
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Are more people interested
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because it's just a pill versus
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an injection.
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I mean, again, it's once weekly,
but I don't know how much that
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turns off or, or affects
people's decision to be on it.
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So that's kind of the first part
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of the question is, is there any
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change that you're seeing since
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there's now a pill form
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available?
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And then second, anything
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scientifically different that
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you've seen either in studies or
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otherwise with this oral version
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versus the traditionally
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injectable version.
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Yeah.
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I think your first answer, yes,
patients are more willing to
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start the medication because
it's a pill.
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Uh, there was a lot of hesitancy
given that it was an injection.
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And I explained to them, this is
not like an insulin injection.
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You know, people associate.
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Yeah.
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They think it's like a real
needle syringe.
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You're preparing everything and
you're injecting yourself.
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And I explain to them, it's
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actually like a really, really
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small needle.
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You don't even feel the
injection at all.
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But again, if people have a
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phobia and they can't do it,
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then you know, who am I to say
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you have to be on this
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medication, right?
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Like I'm not going to force
someone.
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Um, I didn't even realize it's
now available in a pill.
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Yeah.
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Yeah.
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So much more accessible for
people that have that aversion
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one hundred percent.
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The FDA approved it.
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Uh, the weight loss percentage,
I believe, is similar to.
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So it's semaglutide.
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Um, and the weight loss
percentage that they've seen is
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similar to Wegovy.
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So the average weight loss is
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about sixteen percent or so,
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whereas with Mounjaro or
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Zepbound.
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Tirzepatide.
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Um, the same exact thing, just
different names of the drug.
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Uh, that one is about twenty
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three percent, which
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interestingly, both trials, uh,
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across the board have shown that
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women tend to lose more weight
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on this drug, which is really
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exciting.
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Yeah.
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Across age profiles.
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I mean, in terms of comparison.
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Yeah.
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Interesting.
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Yeah.
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And if the profile of a typical
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patient that comes to you or
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gets referred to you is sort of
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a woman in a sort of menopause
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age range, are you seeing sort
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of ninety percent women
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patients?
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Like are you also seeing male
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patients and, and what, you
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know, are they presenting to you
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with similar sort of
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cardiovascular issues?
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And then you're sort of
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exploring like, you know, this
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could also be a path for you as
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well.
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Yeah, absolutely.
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So it's interesting.
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The I see both genders are all
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or however you identify
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yourself.
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I'm happy to see you.
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Interestingly, I think more
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women come to see me with risk
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factors that have not exactly
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been identified.
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Mhm.
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Men come to see me with clear
cut like risk factors.
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So. And by risk factors, I mean
these are chronic diseases that
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people have that elevate the
potential for you to develop
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heart disease, stroke and
peripheral artery disease.
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Um, or cardiovascular disease is
the broad term.
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And it's interesting because
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yeah, men come in, they have
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known high cholesterol,
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hypertension, um, they have high
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triglycerides.
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So all these parameters and the
women come to see me like
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evaluate for high cholesterol.
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And I was like, well, this, this
poor woman's had high
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cholesterol for six years.
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Like, what are we doing?
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So, and then I find them like,
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wait, do you have hypertension
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as well?
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Are you going through menopause?
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You know, I asked them the
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questions of their final
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menstrual period, their
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obstetric history, you know, ask
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them about what symptoms are
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having right now menopause, if
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any.
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And then we do our basic, um,
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you know, I do a more
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comprehensive prevention
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screening like I do with all my
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patients.
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Is it moving towards becoming
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almost like a first line
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medication for cardiovascular
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health prevention?
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So right now, the FDA approval
or indication to start these
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drugs is BMI of twenty seven
with a cardiovascular disease
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risk factor or established
cardiac cardiovascular disease,
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or a BMI over thirty and no
other risk factors, right?
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Period.
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So it depends on the situation
and where the patient is.
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Again, the approach I take is
very individualized.
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I sometimes have patients I see
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in the hospital who had a recent
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heart attack.
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They have you know, they have
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established heart disease at
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that point.
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They just had a heart attack.
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Um, they may have abnormal
lipids and so on, and they may
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meet the criteria of a BMI
greater than twenty seven.
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I unfortunately can't prescribe
it in the hospital, but I will
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put it in my note that this
needs to be started right away.
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Mhm.
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Um, to just quickly dampen the
risk Again, the most important
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drugs to be on after a event
like that are your dual.
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If you're.
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If you have a stent, which most
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likely people do, you're on your
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aspirin and your other
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anti-platelet therapy, you're on
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your statin, you're on your beta
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blocker, and then the GLP and
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other medications that need to
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be started.
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We, I definitely document that.
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So whoever's seeing the person
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next understands that's really
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important to start these right
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away.
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Um, for people who have, let's
say when I do the coronary
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artery calcium scoring, they
have really high calcification.
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And I would probably want to be
more not a, I'm not aggressive.
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Maybe, maybe some patients will
say I'm aggressive, but I would
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want to be a little bit more
forward about how I would like
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them to start this medication
sooner than later.
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Just because their risk of
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having an event is so much
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higher, right?
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So again, it's very a one
hundred percent.
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So again, the approach is very
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individualized for me and my
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practice.
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But overall I would like to use
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it sooner than later, Especially
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if I feel as though the patient
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needs that support system a
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little bit where they're like,
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yeah, I've tried diet, but I
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don't really want, you know, I
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didn't really work for me or
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they've had a history of yo yo
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dieting.
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They're interested in the gym,
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but they're a little bit
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reluctant.
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And you know, that's something I
really tell patients.
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I'm like, I really need you to
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go exercise while you're on this
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medication.
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Because I tell them the science
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of weight loss is when you do
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caloric restriction, just the
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basics of it, your body without
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exercise, your body actually
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burns lean muscle mass first,
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not adipose, which is the
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opposite of what people want,
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right?
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Like I'd rather lose the adipose
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tissue, not the lean muscle
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mass.
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But unfortunately, our body will
actually burn the lean muscle
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mass than the adipose tissue.
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So that's why when you're trying
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to lose weight in general, it's
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important to do some sort of
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weight training exercise and eat
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the protein.
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And I don't want to sound like a
social media person who's like
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protein, protein, protein, but
like, there's so much
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information on protein right
now, but no one's talking about
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the importance of eating protein
with the movement.
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You have got to exert some have
to work out.
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Otherwise protein is just more
calories per gram than carbs.
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So you're just eating more
calories, right?
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And so you can't just approach
it and be like, oh yeah, like,
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I'm gonna lose so much weight.
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No, that's not how this works.
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You have to exercise people.
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Um, so with these drugs, I tell
them, you know, I give them the
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basic science of weight loss.
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And then I say, when you're on a
rapid weight loss regimen, like
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with bariatric surgery or with
GLP, you tend to lose more lean
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muscle faster because you're
burning more calories and you're
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not eating as much.
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So I tell them, I really need
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you guys to start doing weight
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training.
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Granted, we would love strength
training with a heavier weight,
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but some people are very new and
they're novice to exercise.
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And I asked them, I'm like, are
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you realistically going to start
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exercising?
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And they seem hesitant.
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And no, I'm like, how about we
take a break, go home.
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Think about it.
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See what you want to do.
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Because I'm worried that if they
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go take this drug, don't
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exercise.
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They're going to have reduced
functional capacity, which means
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that eventually these people
won't be able to, like, get up
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from a chair.
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They won't be able to like, go
to the grocery store and live
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their everyday life.
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And, you know, I'm saying
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mobility is going to be impacted
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one hundred percent their
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mobility.
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Exactly.
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And I don't want people to have
a poor quality of life because
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what kind of.
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Right, right.
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Yeah.
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Right.
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Skinny.
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But you can't move.
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Like that's not better.
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Yeah.
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That's not better at all.
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Um, especially my women who are
like peri post-menopausal, the
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bone health component is really
important as well.
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So I tell them like, you're
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supposed to exercise and do
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weight training for osteoporosis
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prevention.
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Now you really need to do it for
your G L, T and weight loss.
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But overall, you know, I
recommend patients to do some
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element of strength training
maybe about three times a week.
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Some patients have been really
amazing.
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Gotten personal trainers if they
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if it's within their financial
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means.
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Um, I tell them honestly, like,
go online.
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And I'm sure like YouTube has a
lot of resources.
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Even the Inova Well has classes,
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the Obesity Management Group at
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Inova.
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They have resistance training
programs you can follow online.
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I just tell them you don't have
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to go and lift like thirty
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pounds.
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Like I personally don't do that.
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Like you can start low, like
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maybe Pilates two, two pounds,
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five pounds and build up from
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there safely because I don't
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want people to go get injured
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too.
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If this is like a new thing for
them.
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I think this is one of the most
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important points that you've
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made, both from a just a health
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standpoint that I think is how
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important it is for everybody to
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adopt that kind of lifestyle,
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but also dispel the myth that
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GLP one is just a, an easy fix,
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right?
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Because if to be honest, if
you're a responsible physician
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prescribing it the way that you
just said, it's not an easy fix.
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You're not getting a GLP one
without doing the work, right.
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It's not like, hey, I'm going to
stop going to the gym.
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I'm going to eat whatever I
want.
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It's actually from hearing what
you're saying, it's actually
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quite the opposite.
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But for those who feel like it's
a quick fix or they hear
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someone's at GLP one, well, of
course you're in a GLP one.
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That's what an easy way for you
to lose the fat.
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You haven't really worked for
it, which is, you know how some
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people think about this.
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Um, that is clearly not the
case.
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Right?
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Right.
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If you're going to get on a GLP
one, you do need to exercise.
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You do need to do weight
training.
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You do need to adopt a healthy
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diet or else it's simply will
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fail.
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Um, for all the variety of
reasons that you said, right?
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Yeah.
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Right.
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And like, I want patients to be
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on these medications and feel
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empowered, strong.
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Yeah.
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Strong and healthy and have a
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completely different outlook on
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life.
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I think that's so important.
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We are just about out of time.
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So I would just ask, what would
you leave us with?
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You know, what is what would you
like patients to know if they're
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listening to this?
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I think the big takeaway,
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though, is that even though we
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love our GLP, they've shown
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cardiovascular benefit lifestyle
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still matters.
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Your nutrition still matters.
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Not magic.
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It's not magic.
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It's not a bandaid.
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I say that to people who are in
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their thirties, who are my best
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friends and like family up to
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people who are in their
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eighties.
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You know, the ability to do
exercise and diet is so
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empowering and just changes your
overall outlook on life.
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And then when you see the
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results, if you're someone who's
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had trouble losing weight and
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has that elevated BMI, then
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yeah, seeing the results of
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weight loss with everything else
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you're doing feels really good
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because, you know, not only are
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you aesthetically losing weight,
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but you're also changing your
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risk for heart disease and
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cardiovascular disease, which is
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so huge because we know that's
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the number one killer of women
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worldwide.
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And, you know, and of course
men, I care about you too, but
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I'm just saying for women's
health, two purposes.
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It's really important.
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Thank you so much for being with
us today.
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You're so welcome.
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Thank you for this.
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Oh, thank you guys so much for
having me.
Speaker:
It was so much fun to talk to
you guys.
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Thanks for tuning in.
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We hope you enjoyed this
episode.
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