Friday Q&A: managing blood sugar and cholesterol; heart health for women; when to get a DEXA scan; & fueling adequately on a vegetarian diet

Great questions this week!

Jun 20, 2025

ICYMI 👉

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In this week’s reader-submitted Q&A, we’re tackling these questions:

How do you balance medication concerns while treating prediabetes and high cholesterol?
What heart symptoms do women often miss?
When should postmenopausal women get DEXA scans?
How can vegetarians get enough iron and B12?

📣 Send me your questions for future Q&As! Click here to write me. ✍️

a couple of lollipops sitting on top of a pink surface — Photo by Towfiqu barbhuiya on Unsplash

The following subscriber questions have been lightly edited for length and clarity.

QUESTION #1: MANAGING BLOOD SUGAR AND CHOLESTEROL

My A1c is in the prediabetic range and I have hereditary high cholesterol, but I've had bad reactions to multiple medications in the past. I have a GLP-1 prescription sitting at home that I'm afraid to start because of my demanding job - I can't afford to feel sick. Some people say my numbers aren't "bad enough" for medication yet, but I'm also scared of doing nothing. How do you help patients who feel stuck between fear of medication side effects and fear of letting these conditions progress?
-DN

Dear DN,

I can hear the frustration and fear in your situation, and honestly, there's no perfect answer here. You're caught in an understandable cycle of worry that's making it difficult to move forward with any decision, and that paralysis can be its own kind of burden.

Let's start with the facts about your GLP-1 medication. Not everyone experiences side effects, and many that do occur can be managed effectively. For example, if you develop heartburn or reflux, a low-acid diet and eating on a regular schedule often helps significantly. Constipation, another common concern, usually responds well to increased hydration and fiber. The key is that you can always stop the medication if it's not working for you.

Think of improving your metabolic health as having multiple levers you can pull— exercise, healthy eating, sleep optimization, stress management, and yes, medications like GLP-1s when appropriate. It's not a set of rigid rules or a one-size-fits-all strategy. Sometimes the hardest part is simply getting started rather than trying to figure out the perfect approach.

Your A1c numbers aren't just abstract data points—they represent real cardiovascular risk that compounds over time. The same goes for your hereditary cholesterol issues. While I understand your medication sensitivities make this more complex, doing nothing carries its own significant risks that deserve equal consideration in your decision-making.

Consider this: you could start the GLP-1 on a Friday so you have the weekend to assess how you feel. Begin with the lowest dose and have a plan for managing potential side effects before they occur. Keep easy-to-digest foods on hand, stay well-hydrated, and remember that initial side effects often improve as your body adjusts.

Your fear about not being able to function at work is valid, but remember that poorly controlled diabetes and elevated cardiovascular risk also affect your energy, cognition, and long-term ability to work effectively. Sometimes taking a calculated risk with a new treatment is actually the safer long-term choice.

The goal isn't perfection—it's progress!

QUESTION #2: HEART HEALTH FOR WOMEN

I’ve read that women’s heart symptoms can be different than men’s, and it worries me that something might get missed. What do you want your female patients to know about heart disease that’s often overlooked or misunderstood?
-Jenny

Hi Jenny,

You're absolutely right to be concerned about this. The gender gap in heart disease recognition and treatment remains a real and dangerous problem, despite decades of awareness efforts. Women are more likely to have their heart symptoms dismissed, experience diagnostic delays, and receive less aggressive treatment than men with identical presentations.

The classic "Hollywood heart attack"—sudden crushing chest pain with a man clutching his left arm—represents only one way heart disease manifests. Women are more likely to experience what we call "atypical" symptoms (although I wish we'd stop calling them atypical since they're quite typical for women!) These can include fatigue that feels different from your usual tiredness, shortness of breath during routine activities, nausea, back or jaw pain, or a general sense that something is "off" without obvious chest discomfort.

The most insidious scenario is when women's symptoms get attributed to anxiety, stress, or being "emotional." I've seen too many cases where women were told their chest tightness was just anxiety, only to have a heart attack weeks later. This doesn't mean every symptom you have is cardiac-related, but it does mean your symptoms deserve the same serious evaluation regardless of your gender.

Here's what I want you to know: trust your body and advocate for yourself. If you're experiencing new or concerning symptoms—especially if they limit your normal activities or feel different from anything you've experienced before—insist on proper evaluation. This might include an EKG, cardiac enzymes, or stress testing depending on your symptoms and risk factors.

Know your personal risk factors beyond just family history. These include high blood pressure, diabetes, high cholesterol, smoking, and autoimmune conditions like rheumatoid arthritis or lupus. Pregnancy complications like preeclampsia or gestational diabetes also increase future heart disease risk - something many women don't realize.

Don't let anyone dismiss your concerns as "just stress" without a thorough evaluation first. Stress can certainly affect your heart, but it shouldn't be the default explanation for every woman's cardiac symptoms. You deserve the same diagnostic rigor as anyone else.

I’m postmenopausal and just starting to hear about bone loss from friends. My doctor hasn’t mentioned doing a DEXA yet. When do you typically recommend getting screened if there’s no obvious issue?
-Angela

Thanks for your question, Angela,

You're being smart to start thinking about this proactively. The current guidelines recommend DEXA scans for all postmenopausal women by age 65, but many of us start earlier depending on risk factors. If you're younger than 65, we typically consider scanning if you have early menopause, family history of osteoporosis, history of fractures, or certain medical conditions or medications that affect bone health.

Here's what many women don't realize: bone loss accelerates after menopause due to declining estrogen levels. The first few years post-menopause are when we lose bone density most rapidly, which is why catching this early matters. A baseline DEXA scan can help establish where you stand and guide our prevention strategy.

The conversation around bone health has evolved significantly. We used to focus primarily on calcium supplements, but now we understand that bone health is much more comprehensive. Weight-bearing exercise and resistance training are actually more effective at building and maintaining bone density than calcium alone. I've had patients improve their DEXA scores significantly through strength training, even without medication.

Your bones respond to mechanical stress by becoming stronger—it's the old "use it or lose it" principle. Activities like walking, hiking, dancing, and especially resistance training with weights or resistance bands signal your bones to keep building new tissue. This is why I often recommend strength training even before starting bone medications.

Don't wait for your doctor to bring this up. Ask about getting a baseline DEXA scan, especially if you have any risk factors. Even if your results are normal, having that baseline gives us something to compare future scans against. We can also check your vitamin D levels, since deficiency is incredibly common and affects bone health.

The goal isn't just preventing fractures years from now, but maintaining your strength, balance, and independence as you age.

QUESTION #4: FUELING ADEQUATELY ON A VEGETARIAN DIET

I’ve been a vegetarian for 20 years and recently started to feel more fatigued and foggy. My labs showed low iron and B12. I don’t want to go back to eating meat, but I’m not sure supplements are cutting it. How do you help people stay true to their values without compromising health?
-James

Hey James,

I completely understand your dilemma, and this is actually more common than many people realize. Your commitment to vegetarianism for 20 years represents important personal values, and you absolutely can work within that framework to optimize your health.

The fatigue and brain fog you're experiencing are real consequences of these deficiencies, not something you should just push through. Iron and B12 are particularly challenging nutrients for vegetarians because the most bioavailable forms come from animal sources. But that doesn't mean you're stuck choosing between your health and your values.

Let's start with iron. Plant-based iron is less easily absorbed than iron from meat, but we can significantly improve absorption by pairing iron-rich foods with vitamin C sources. Think lentils with tomatoes, spinach with citrus, or fortified cereals with orange juice. Cooking in cast iron pans actually adds iron to your food, and avoiding tea or coffee with iron-rich meals helps since these can inhibit absorption.

For B12, this is trickier because it's primarily found in animal products. Many vegetarians do need supplementation here, but the form and timing matter. Sublingual B12 or liquid forms are often better absorbed than pills, and taking it with food can help. Some nutritional yeasts are fortified with B12 and can be a tasty addition to meals.

The key is getting your levels retested in three to six months to see if your approach is working. If standard oral supplements aren't cutting it, you might consider B12 injections, which bypass absorption issues entirely. Some people simply have genetic variations that make absorbing these nutrients more challenging, regardless of diet.

Remember that your vegetarian diet likely provides many health benefits—higher fiber, antioxidants, and phytonutrients that omnivores often miss. We're not trying to fix a "bad" diet; we're optimizing a healthy one that happens to need some targeted attention in specific areas. Many of my healthiest patients are thoughtful vegetarians who've learned to navigate these nutritional nuances!5

Disclaimer: The views expressed here are entirely my own. They are not a substitute for advice from your personal physician.

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