The Uneducated PT Podcast - #34 Summer The Dietitian - GLP-1

Episode Date: June 13, 2024

In this episode of the Uneducated PT Podcast we speak to Registered dietitian Summer Kessel. We talk about GLP-1 the benefits, side effects and the misconceptions around the weight loss drug. We also speak about food noise and summers journey on the drugs and what she has experienced. 

I read that you lost 145 pounds over the course of 17 years, correct? Yeah, lifelong journey for sure. Tell me a little bit about that. What are some of the lessons you've learned over them 17 years in terms of weight loss? I mean, where do we start? I struggled with my weight since I can remember since I was a child. I was luckily an athlete, but always like the biggest gal in the room. I played basketball.

I danced. I did all the things and I always struggled with being hungry. I had this big appetite, loved food, came from a family of people who loved food. And so I was just really struggling with my weight, I think, since I can remember. And I always had an interest in nutrition and trying to control my weight. And I was pretty successful with diet and exercise in my early 20s. I'd lost about 100 pounds over three. years just with counting the macros and doing the diets and reading all the books and watching

all the, you know, at the time there weren't podcasts, all of the, you know, specials. And I said, you know what? I've made nutrition my whole life, if nutrition and working out and losing this weight my whole life, I'm going to go back to school to be a registered dietitian. And so that kind of is what inspired becoming a dietitian. And while I was in school to be a dietitian, I got married, had a baby, gained back most of that weight, really struggled postpartum, gained back most of what I had lost. So I did it all again, right? I dieted. I counted the macros. I got no gym. I, you know, really had to work at it to lose weight. So at my heaviest, I was about 300 pounds.

And I was always pretty successful at losing down to 200 pounds. Yeah. I could kind of do that. I could do that 100. But man, getting below that 200 was just so hard. It was like I would hit this wall and I'd still struggle and I was hungry all the time. And, you know, when you're when you're dieting, when you're restricting, when you're trying to control your weight, you get hungrier.

When you love to work out, you love to lift weight. you're hungrier. And so I just really struggled in that space around 200 pounds for quite a while, working as a dietitian, working with people to achieve their weight loss, posting about it on social media. And I would always like maybe be able to get down to like 190. You know, like I'm going to do a cut. I'm going to do it.

I'm going to lose to 190. And I'd always gain it back. And I'd always. And then I'd creep up to 210. And it'd be like, oh, you know, time to get my shit together. and get it back together. And I just really always struggled in that space. The overreaching theme the whole time,

she was freaking hungry. Like, I was just never satisfied. And everybody would say, like, are you eating enough? Are you getting enough protein? Are you getting enough vegetables? I was like, I know what I'm doing. Like, yes, I'm doing all of the things that should have worked to lose weight

and just couldn't get into a healthy body weight. Like I just always was living at that, BMI over 30, you know, in that 200, low 200s, and just not really happy, you know, with where I was at. So about two years ago now, I, my friend, Dr. Spencer Nodelski, was posting on Twitter about these GLP1 medications. And I said, you know, that kind of sounds like me, hungry all the time, never satisfied. These people are starting these medicines. And finally able to adhere to their nutrition plans consistently enough to actually lose weight to meet their goals.

And he was describing this one thing called food noise. I don't know if you've heard me. I've talked about it a lot of my pages, but just patients talk about where even when they're eating enough, even when you're like physically full, always thinking about food and just seeking food or if somebody brought cookies into the office, like you felt. like you couldn't resist or you had to white knuckle it to not overeat. That was me. I was like, oh, he's talking about me. So then I started GLP1 medicines through telehealth platform with Dr. Spencer and it changed my whole world. Part of why I'm here with you, it's just become my whole mission

to work with people who are on these medicines, to advocate for these medicines, you know, for the people that they're appropriate for. And to do that. just dispel myths and answer questions and really help people get the care that they need and to understand like what their options are. There's loads of things that I wanted to touch on there. One, I love Dr. Spencer. I love is the content that he puts out. Number two, like I think that's a really important point that a lot of people just don't recognize or notice or understand that like people's biological drives to eat can be completely different and everyone's not on a on an even playing field in terms of that yeah and i have a friend that likes to say that these medicines bring us to a more equitable place with our appetite

so then we can do the stuff that's supposed to work a question i wanted to ask you i think it's it's the fTO gene isn't it the one that's for um you you can have a deficiency and that and a and a that I think your leptin increases. Is there any way to check whether someone has a higher drive teeth than someone else? Is there any tests for that?

It's an interesting question. There's definitely genetic disorders that can be tested for but not everybody who struggles with obesity has this very clear genetic marker that predisposes them, right? Obesity is this multifactorial disease where

our environment, our education, our lifestyle, our biology, our privilege, our access to healthy food, like just our work schedules, you know, all of that play a role in weight management. We know that, right? And we can only control so much that's within our control. Like, you and I coach people all the time, right, about you can control what you can control and you make the best choices when you can and you set your environment up so that you have the best chance of success. But I think we miss the point that a lot of people don't have as much control over their choices as they might think they do. You know, you see people on the internet wagging their finger will just eat healthier. I like, I would love to. But, you know,

I live in a very food rich environment. I'm driving down the street and there are 20, fast food restaurants. Yeah, you're not, you're not on a deserted island where you've, there's something about my biology where these foods call to me and I'm hungry enough that I could always eat them and they're tasty and they're designed to be tasty to appeal to me. And so navigating that world that we live in and being somebody who maybe is biologically predisposed to being in a heavier body is just a recipe for difficulty. Like truly just like, really just like, makes life hard. You know, even if you have all the motivations and all the skills and all the knowledge and all the

tools available to you, um, sometimes our biology is just that powerful. Yeah. I, I, I remember seeing someone online do a really, uh, talk about a really good analogy. And it was like, um, you know, if I had a lighter and I lit the lighter and I put my finger there, like all the willpower in the world wouldn't stop me from pulling my finger away essentially. And it's kind of the same. It's like, you like you have a. physiological joy of tea, regardless of, you know, people who say, oh, just try hard or just,

you know, willpower your way into doing it. And it's just, it's just not the case. But people who aren't in them circumstances or them situations can't understand it because it's not their reality. Yeah, I truly don't think that everyone understands, like, what it feels like to have that food noise. And a lot of people will say, well, just go to go to therapy and work on your issues with food. And it's like, exactly, I would love to be able to, prior to taking my medicines, I wanted so badly to be able to be that person that could bake cookies with my kids, have one, and enjoy it and love it and think it was amazing. Mentally, I know that that one cookie, I can count it towards my macros, like the carbs are going to be great for my workout. Like, the cookie's not

the problem, right? But my, I knew that if I brought those things into my home and I had the cookies available, I would have to will myself to not eat them all, to not be thinking about them constantly, to not know, like I know they're there, they're calling to me. And then you do the mental gymnastics. Well, maybe I can make two cookies fit into my macros. Maybe I can make three cookies fit into my macros. And it's just torture. to not be satisfied by one great cookie. What's so cool about these GLP1 medicines is like, now I can do that. Now I can say like, oh, I have a little bit of a craving for chocolate.

Go and buy a bag of chocolate. Bring it into my home. And then like really, truly just enjoy that one piece of chocolate and move on. And it's, and then you sit there and you go, is this how all like normal people feel with food? is this what all these like skinny girls that talk about intuitive eating mean when they say like unconditional permission to eat like all foods fit you know you told me to eat intuitively like my intuition was to eat the whole pizza right and I used to roll my eyes and be like oh these intuitive eating people they're so full of shit like they're just they're just naturally skinny and it's like well

know, I think they just have that regulation in their brain where cravings are more easily satisfied. They have a better like internal thermostat when it comes to their calorie needs. And so they're not tempted to overeat in the same way that I am. So those strategies now, the intuitive eating kind of practices are so cool to me now because I can actually do them and they work because I have this medicine on board that makes it possible. I don't count macros anymore. I don't count calories. I just kind of move throughout my day and eat well.

I'm like, okay, I'm lifting weights. I know I need protein. You know, I'm a grown up. I should probably eat my vegetables. And like just make like responsible, nutritious choices most of the time. But I can still go out and have whatever I want. I'm actually just able to stop now when I'm full. and I never knew what that felt like before.

That's a really good point. It isn't that like, you know, the problem when movements like that are techniques or strategies or tools or any way that you want to call them, they tried to have a blanket statement that like this is supposed to work for everyone even though everyone's completely different. And like you said, even upbringing's biological drivers,

all that is going to be completely different to each person. So even a tool that didn't work for you before can work for you now and not to kind of have that kind of even all or nothing mindset around them different strategies. 100%. And I've always coached people in that way through nutrition. It's like these are your options. These are the things that we could do.

What's going to work for you in your real life? Right? Like not everybody has to, there is no one perfect way of eating. There is no like one perfect strategy. There's no like manual that we can write. That's going to work for everybody because everybody's life is totally different. Everybody's body and biology is totally different.

And so I've always loved your content too because it's so just like realistic. Like, hey, this is what your life is like. How can we make incremental changes that are going to help? You know, we don't have to jump all the way to all of the solutions all at once. We can kind of figure out what's going to work for you. Another thing that I really like, even of you kind of being that example and being very transparent about your journey, like is the fact that a lot of people will probably have the misconception that, oh, because you're a professional, you didn't struggle with these tigs.

And I think that kind of, it closes the gap between, you know, them and us in terms of like the general public struggle with this, you know, professional struggle with this. Anyone can kind of struggle with these issues. It's very interesting because I'll have clients who say, you know, I'm so glad that you have been so open with your struggles and that you get it and that you've lived it and you know what it's like to be big

and you know what it's like to struggle to lose weight. And then at the same time, I'll get some folks who are, especially online, who are not so nice. And they're like, how can you be a dietitian and not, you know, and eat that cookie? Like, how dare you? And I'm like, well, I'm still like a real person. I'm a mom. I got kids. I got a job.

I've got hobbies. I've got, you know, like I'm living in this world too. And frankly, like nutrition and fitness, while very important, obviously, it's what we do for a living. It's a hobby at this point. It's something I enjoy. it's not everything right it's not it's not the most important thing that i do and so if i am doing pretty good most of the time like that's fantastic for me doesn't have to be perfect um good enough is good enough yeah and we're gonna we'll transition into gLP ones and talk a little bit about that

and i have a couple of questions um from clients and and people on social media i wanted to ask you a couple the questions. But before we go into that, I just wanted to ask you, what is your role with Weight Watchers? What, what's, how long have you been working with them? What do you do? How, what does your day to day look like with them? Yeah. So I am a registered dietitian nutritionist with Weight Watchers Clinic. We work directly with people who are patients within, members within our clinic, who are either on the GLP1 medications or we offer some other non-GLP1 weight management medication, some of the traditional oral medications. I'm part of their multidisciplinary teams.

They get a clinician, a fitness professional, and a registered dietitian to support them along their journey. And I have virtual visits and sessions, you know, just like this with folks who are living their lives and have questions or need some support. And then I also do a lot of their social media and marketing. So I get to make videos and content and recipes and that sort of. of stuff for their social media pages. It seems like you have a really nice community there as well in there.

I see in the picture you put up with all the registered dietitians that are weak. Yeah, we're expanding. We're growing. We are offering more medical nutrition therapy, in-depth nutrition coaching and care to our members. So currently only available within the clinic. But coming soon, we're. opening up registered dietitian access to all of the United States Weight Watchers members,

which is a big undertaking, big project. But I think it's going to be really unique to combine that community and then the app and all of the tools that are there within Weight Watchers with that one-on-one support that you can get with a registered dietitian for the folks that need it. Yeah, that's unbelievable. Okay, so we'll go into GLP ones. and, you know, just starting out for anyone who might not know if you could even kind of give a little bit insight into, like, what they do, how they work, all that stuff. Yeah. So the GLP1 agonist medications are a peptide injectable. So we're not injecting GLP1. That's not really how it works. It's an agonist that works in the body to stimulate the receptors that are traditionally, stimulated by your natural GLP1.

And I know that's a little complicated, a little biology, but it's really important to recognize that because there are a lot of products right now in the market that are claiming to increase your GLP1, like probiotics and supplements and a lot of bullshit out there. That's just not a thing. So your natural GLP1 metabolizes within minutes. So you can eat a high fiber, high protein diet. It stimulates GLP1. you fill that sense of fullness, it goes away.

Okay, these medicines are peptides that are injected that then have a half-life of like six to seven days. So it's stimulating that feeling of fullness that comes from the GLP-1 hormone in the body. It helps you feel fuller, longer between meals. These medicines reduce cravings and food-seeking behavior where, like, we're thinking about food all the time, it quiets that food noise. So it works in the brain. It also works in the gut to slightly slow down the gut emptying. So you know how in nutrition coaching we may tell somebody to eat more fiber and more vegetables. And like if they're really hungry to eat like a really big salad is going to slow down their digestion, take longer to digest

and keep them fuller longer. So these medicines kind of mimic that. that kind of process of keeping the person feeling physically full or longer. So you're mentally more satisfied. You're physically more satisfied. And then the cool thing that a lot of people don't talk about is it's working on the process of insulin resistance in the person's body with obesity. So we know that most folks who struggle with obesity have some degree of insulin resistance where no matter what they're eating,

they're more likely to store those extra calories as fat because they don't have the insulin to pull it into their muscles into their body to be used for energy. So obesity becomes this like vicious cycle, like insulin resistance is this vicious cycle where it makes you hungrier, right? And even if you're not overeating, you're not even utilizing your energy intake appropriately. you're more likely to store it as fat. And so overeating is even more likely to make you hold on to even more weight if you have insulin resistance.

So these medications work on that glucose uptake into the muscles and reduce insulin resistance. That's why they were initially developed for people with type 2 diabetes. They're so effective in lowering blood sugar, bringing the extra carbohydrates into the muscles for energy, and making that person. just feel more satisfied when they do eat. So they work in those three main ways to help the person then eat normally. Like, you know, it's a common misconception that you're never hungry or that you shouldn't be hungry or that you're starving or that you can't eat.

That's not the goal at all for these medicines. And that's kind of my big mission is like, are you eating enough? Like that's our biggest challenge actually is to make sure that people are eating enough. But ideally what these medicines should be doing is taking folks who have a really big appetite and making it just more manageable. So they can eat a normal breakfast and then not feel like they need a second breakfast. And then they can eat a normal lunch and then they can make it to dinner and they can eat a normal dinner. And then they're not snacking all night long because they can eat just like three balanced,

nutritious meals a day. They're full. They're satisfied. And then maybe when it's getting close to the next meal time, they're like, oh, yeah, I could eat. I'm a little bit hungry. So that's the goal. Not everybody uses them correctly, right? Not everybody understands that that's the goal. A lot of people are really excited by the fact that like they're never hungry. And so that's why I think it's so important to work with a nutrition coach or dietitian for folks that are on these medicines to make sure that they're eating enough because it's really easy to lose too much weight too quickly. And so I think it's important to recognize. I know that, you know, I'm the United States. I'm in Florida. So we have kind of, I think, a few more options than y'all may have there.

But when we say these GLP-1 medications, what we're talking about are the Ozempic and the Lagoe, so the Simoglutide. And then the Zepound in the Monjaro, which is the Trezapitai. Yeah, this was going to be my following question. What's the kind of difference between them? Yeah, and it's an interesting question. So the OZMPIC was initially approved for diabetes. Wagovi is exactly the same medication as OZMPIC, just with a different name, approved for weight management in the United States. So they're both simaglutide. Simaglutide works by the same ways that we just talked about in the brain and the gut.

It is powerful for weight loss, brings about 15% body weight. weight loss over a year is kind of what people can expect on those. And that's from one manufacturer. A different manufacturer made Trezepatite, which was originally produced for diabetes as Monjaro. And in the United States, it's had a name change to Zepbound for weight loss. But Monjaro and Zepbound are exactly the same medication and exactly the same pen. It's just different branding and marketing.

Those medications and people without diabetes get us closer to 20 to 25% weight loss. So the trucepetide is like that next more powerful version of the simoglutide. The sum of glutide's been around a little longer. It's easier to source. It's less than shortage. And it's more likely because it's been around a little bit, it's been approved longer. It's more likely to be covered by people's insurance. So the tricepetide, because it's newer, is not on as many.

people's insurance plans, which here in the United States is a whole hot mess. And even though you say newer, I think a lot of people have the misconception that, oh, this is just, you know, brand new and that there's no research done on it. But this has been actually out a long time, hasn't I? Yeah. I mean, OZMPIC's been used for people with diabetes, I think, since 2017. And then we have previous generations of these medications, a trulicity. Sechenda, those have been around since 2009.

So they're not brand new, right? I've been on mine for two years and it had already been out for a while before I started. And we did actually just get a recent research that showed the four-year mark for people in a study of the Wagovi, the summit glutei, were maintaining their weight at four years out after continuing on their medication. And now we're starting to see these medications be approved for more than just weight loss and diabetes. The Wagobe has a indication now for heart disease in the United States. And we're seeing also studies that show that it could be helpful with sleep apnea, fatty liver disease, and alcohol dependence. So, you know, I know that there's some skepticism around the safety of these medicines. but I'm always so encouraged that every new publication we get just shows how health

promoting these medicines really are for so many different conditions. Sometimes I make a joke that one day it might just be in the water supply. I really do feel like it's just they're just so beneficial for people, especially when you think in comparison to living a life with obesity, that the risk there is clear, you know, over time. And so the benefits to maintaining a healthy weight and then the anti-inflammatory impact that these medicines have. It's just really cool. The science around it is really promising and really exciting.

And we're going to continue to get more medications in this class of medications that are more affordable. Hopefully oral version, so it's not always an injectable. I think the future is really bright for these medicines. So I want to talk about the positive impact that the medication can have on people's lives and then obviously kind of break down the misconceptions or skepticism that the general public might have on it. So I suppose first and foremost, okay, so we know this helps people to lose weight and to increase their level of fullness and not to be having this field noise. but from you obviously speaking with people on a regular basis who are on these medications

and have seen the results of these medications, what are some of the kind of life-changing experiences that they've had from being on the medication? Yeah, I mean, people really do report that it's life-changing, that it's like all of a sudden they have a new brain. Like they just feel like they're in a mind. much different place. I think back to when I first started working with people with nutrition more than 10 years ago.

And I know I've seen you talk about this a lot in your content too, about how to promote motivation. Right. Like one of the big things in fitness and nutrition coaching is getting people to a point where they're ready to make changes. Right? And it's such overcoming those like belief systems where I can't do it or I don't have time or I don't know like that. You know, people have people will do all the research and all the reading and all the to figure out what's the best diet for me instead of like taking action to do it. Right.

Like moving people from contemplating change to actually doing the thing used to be all of the work that I would do. Right. like really coaching people through, you know, are you sure you don't have time? Like, let's figure out where we can find the time. Like, how do we make the time, right? These medicines do in the brain all of that work for me. So people are showing up to sessions ready to go. And they're like, what do I eat?

Okay, I'll do it. No problem. I got it, you know? And they're so powerful for weight loss that there is so, motivating because they're seeing progress on the scale. And so it's working and they feel good. And it's anti-inflammatory. So they've got more energy. They're not hungry all the time. Food tastes good. You know, they can stop. Like it's working. And it's working like immediately within the first couple of weeks or most people. And so I'm not doing any of that like pulling you. Like I can't

make you want it, right? It's something I used to say to my clients. I'm so glad you're here for this session, but I can't do it for you. How are we going to get you to come over here to this side and start eating more vegetables? We don't have to do any of that work anymore. It's like they show up to session and they're like, okay, so I'm getting tired of chicken. How can I eat more protein? Like we're problem solving and we're actually taking that next step to like improve their dietary quality. And then we're seeing folks that are like they're feeling good, right? They've lost those first few pounds. They want to get moving more. And they're like, I want to get to the gym. I want to go walking. I have more energy, which is so cool. I know I keep saying so cool. The medicines, we talked

about how the insulin resistance issue, right? So if you're a person struggling with obesity, your whole life probably didn't have great energy, right? Because you're not pulling that glucose into your muscles to use the food that you're eating for energy because you're your insulin resistance. So now the medicines are pulling all of that energy that you're eating into your brain and into your muscles. You feel freaking great. So people are like, I have so much energy. I need to do something with it. I'm going to go for a walk. I'm going to start jogging. I'm going to join a gym because they feel better. And they actually have the energy to do it. which is really neat to watch.

Like people just decide, you know, I'm going to start moving more. And I think that's a big misconception online because people will be like, oh, they should exercise first. I was like, the medicine is going to help. Yeah, the medicine is going to help you to exercise. And I always love using like an analogy with someone that says, okay, hold on.

Let's just grab a weighted vest of about 30 kilos and stick it on you and see how motivated you're going to be to walk down to the end of the road or to go for a runner to go to the gym. That's so important because it's not motivating to do stuff that sucks. Right. Very few people actually enjoy the torture of a long run or a really hard workout, right? Like there are some unicorns out there, but it's like they love it for whatever reasons they love it for, right? It's really hard to get people to do things that they hate.

Yeah. Just flat out. So if you're a person who feels uncomfortable in your body, doesn't have a ton of energy, doesn't have a ton of confidence, you know, how hard it is to pull those people into the gym, right? And it's like, well, you should just join a gym. They would love to, right? But getting through all of those barriers is pretty tricky. and it's really hard to motivate people to do things that they don't enjoy. So if we can get people walking, we love that.

If we can get people doing a little workout video on their computer on their phone, we love that. Like we got to meet people where they are and move them. But then also to what you said is like people should try to diet and exercise first. I don't know a single person living with obesity. who hasn't been trying all of the things. They bought the packages. They had a personal trainer at one point. They've seen a dietitian.

They've joined all the apps. Like most people living with obesity know more about nutrition than the average Joe because they've tried all of it. I was about personal trainers online that I see. And I'm like that person probably knows more about weight loss and about nutrition and about diet and then you have ever experienced. Because most personal trainer, got into personal training because they love fitness anyway.

It was always easy to them. And so, you know, it's kind of a, it's just, it's stigma, really. It's like, it's a stigma and it's a stereotype and it's a bias that people have about people in larger bodies. They must not be eating, right? They must not be moving. Do you think that most, do you think that most people, because obviously you'll see all the, all the worst of the comments as well as obviously seeing the, the, the, the, the,

life change and results of people, but you'll see the worst of people as well. Do you think that a lot of people don't even realize that they have that way bias or that weight stigma? Oh, absolutely. I have a theory that it's actually sometimes the people who have lost weight, sometimes that hold the most judgment towards other people who have been unable to lose the weight. There's very much just like, well, I did it and it was hard. So why can't you? They think that they were cheated out of. Yeah, it's very interesting. Sometimes folks have to go on. their own journey to realize that like people hold internalized bias against themselves even like I've

had members that say you know I really thought I had to do it on my own first before I you know and then I tried and it didn't work out and then I finally gave these medicines a chance because they feel like they're they don't deserve it or they're not good enough or you know there's a lot of big heavy stuff around that that people have to work through for themselves we grow up in a world where we're told that people in larger bodies must be have something wrong with them or it's a character problem not a biology problem and it's just couldn't be further from the truth i have people at the time they're like i'm smart i'm successful i have degrees i'm a great mom i run a business why can't i lose weight and it's because your biology is getting in the way

It's not your fault. You didn't do anything wrong. You know, sometimes we just need a little extra help, and I think that's totally okay. So going on to the flip side of that, obviously we know that the medicine can be like unbelievable life change and circumstances for some people. When would it not be appropriate for someone to be going on these medicines, do you think?

That's a really good question. So first we want to recognize. recognize that we really want to promote these medicines for people who struggle with the disease of obesity. Yeah. Right. And who have the insulin resistance, who really have that really big appetite. I don't necessarily think that these medicines are always appropriate for everyone who struggles with obesity. If you're not overeating, then these medicines may not be for you.

Right. You know, we have folks who they really just don't overeat, but they're struggling with a little bit of extra weight. That's not what we're talking about here. We'd want to be really mindful that anyone and everyone who is taking any of these medications is being monitored by a prescriber who has a good understanding of how these medicines work and what side effects and issues to look out for. So there are side effects. usually they're mild usually they only occur in the beginning of treatment

when people are getting used to taking them What are someone of the side effects? Yeah, like nausea, upset stomach, acid reflux maybe some constipation Remember we talk these medicines slow down digestion So if we eat a high fat food

and then go to sleep that's sitting in our stomach for longer than it would have before we're probably going to have reflux If we overeat, we're going to feel overly full, and we might have some nausea. But this can be really managed through nutrition. It's kind of what I do, a lot of, like lower fat foods are usually the key. Even the healthy fats, I'll have people like, I don't know why I'm nauseous all the time.

And then you find out they're eating peanut butter in the morning, avocado with lunch, and then like salmon with dinner. And it's like, I know that those are all healthy fats, but those fats might be making you more nauseous. Yeah. And so they can be managed. Some folks, there are small percentage of folks that just are really sensitive to being nauseous, right, that just hate being nauseous and they can't stay in it so they stop the medicine.

Totally to each their own, right? We don't want people to feel unwell. Some folks do feel fatigue. Typically, I believe, usually because they're not eating or drinking enough. it's really important like I said in the beginning to make sure people are eating enough on these medicines because it really is just so easy to skip a meal is that the biggest is that the biggest obstacles that you face with clients is just essentially getting them to eat enough and to eat enough for the right nutrients yeah eat enough nutrient dense foods yeah so that they can still meet their

nutrition needs still get enough protein to maintain their muscle mass um making sure they're not losing weight too quickly is there a word of people kind of getting their nutrient deficiencies then from not? Yeah, they're not eating enough. So we typically will say like if you're not getting at least one or two servings of fruit and two or three servings of vegetables every day, you probably should take a multivitamin. Yeah.

You know, we do have folks who complain of some hair loss sometimes. But I think it's important to always bring this back to we see these things with just rapid weight loss from any method. Yeah. Right. So bariatric surgeries, people who go on very low calorie diet, people who go on cuts for way too long, right, with their macros. You'll hear people say, oh, I'm losing my hair.

I think that's just a result of the massive weight loss, not necessarily from the medicines. So the method, we see the same thing with muscle loss, actually. A lot of, you know, there's a lot of talk about the GLP1 medications being a increased risk for muscle laws. This is why we're really clear that people need to be eating enough protein and strength training.

That was actually one of the questions. Someone put in the chat box was, do you have any advice for someone who isn't getting enough protein in their diet on the medication who's struggling to eat enough protein? Yeah. If you're struggling to eat enough protein, work with a dietitian if you can, absolutely.

But I want to know what else are you eating, What does your day look like? Can we go lower in fat so that we have more room for protein? Can we go a little lower in raw vegetables? Because remember, those are really filling. So we may need to back off of that so that we have room for protein first. And this is where a protein supplement would be a great addition, a protein shake, a smoothie, some sort of protein drink to really make sure that you're

getting enough protein. It is important, though, to recognize that, like, we say eat a lot. of protein. We're really just targeting that like 1.2 grams per kilo. We're not saying that you need two grams per kilo. Like you're not a bodybuilder. We're just looking to like preserve your muscle mass. We're not trying to like build muscle. So we do a lot of people come to me like I'm trying to eat a gram of protein per pound that I weigh and I'm like no. Let's convert this to kilos. you know, as Americans are not good at that. And it's like one to one point two grams per kilo. And people are like, oh, so I don't need 300 grams of protein. I need 150. Yes, it's so much more doable.

Yeah. And like that, if you're trying to eat that much protein, it's just going to put you off thinking that, oh, this is impossible to do. Well, and then you're, you feel defeated. You feel like you're not achieving your goals. So we want to start with what's realistic? What are you currently doing? where can we make a shift in an adjustment, where can we add a drink? And maybe it's you need a bedtime Greek yogurt before you go to sleep every night. Maybe we need, you know, you're eating a bowl of cereal with milk. Let's use a protein shake over that cereal instead of regular milk. Like how can we take what you're already doing and sneak in some extra protein?

That's usually my strategy when I'm working with people. It's like, let's start with what you're doing and then make this really like an easy shift. What are some of the other misconceptions you see around these drugs that you hear online? Well, it's not so much a misconception, but a lot of people love to throw in my face, especially, like, what are you going to do when you come off of these medicines? And that's a good question, actually. What does maintenance look like? What's a long-term plan here?

I believe truly that I have struggled with obesity my entire life. It is a chronic disease for me. I know that if I discontinue my medication, that hunger is going to come back. Especially now since I'm in a smaller body, my body is going to defend that higher set point weight and try to bring me back there. I'm just going to be hungrier. The research shows that when you discontinue these medications, you have the perception of hunger again. And most people are not really good at resisting hunger. it creeps back in and the weight creeps back up.

I personally hope to be on some sort of GLP1 medication therapy that works in this way for the rest of my life. Because I have this chronic disease of obesity and I think it deserves chronic treatment. Now, the issue there is that sometimes these medicines go in shortages. They can be very expensive. I'm very lucky I have an insurance coverage, but if I lost my job, and I lost my insurance coverage. I might lose access to my medicine and not be able to afford it. And so I, there's that caveat there knowing that like there's a chance that I might not be

able to be on this medicine forever. And I know that, but I hope to be. And but just like any other method for losing weight, you have to keep doing it to keep the weight off. Right. So I've had clients before, well before the GLP1 medicine. we would do a eight week nutrition program. They'd hit their goal.

Then I'd never see them again. And I'd find them on Instagram and they'd gain back the weight they lost in those eight weeks. And it's like, well, they didn't keep doing the stuff. Yeah. Right? People, we've got to remind people that nutrition and fitness and lifestyle is a lifelong endeavor. Like I hope to still be in the gym when I'm really old.

I hope to still want, you know, be eating, nutritionally forever. And unfortunately, a lot of people in the diet fulcher space, right, they want a 12-week fix. I'm going to lose this weight for a wedding. I'm going to lose this weight for summer vacation. I'm going to lose this weight to get to this certain size and then I'll be happy. And that's where you see people willing to do extreme things to lose weight, be miserable. like they're willing to be miserable for 12 weeks to get to a goal. But most people are not willing to be miserable for the rest of their lives, right? So they don't continue doing the thing.

And that's why I think it's so important to work with people in a way that they're putting into place nutrition and fitness and lifestyle habits. But they actually like to do. Like, are you eating food that you actually enjoy? Like, do you enjoy your gym? Like, do you like the people that are there? Do you have a good time while you're working out? These things are really important to make it livable and sustainable for the rest of your life. So if I had to eat in a certain way that was like so restrictive that I just hated everything I looked at on my plate,

probably wouldn't keep doing it forever. So I'm a big fan of flavor and taste and colors and exciting, you know, new recipes and playing with food and still really loving what I eat because that's what keeps me consistent. So if this is a medicine that potentially people might have to take for the rest of their lives, where do you see the future of this medicine? Like surely if it's working so effective and it's helping a lot of people to lose a lot of way, surely that will take a lot of strain and stress off healthcare systems and be more of an incentive for government to push it out even further and to make it cheaper.

And like you don't see it really going away, do you? Oh, no, I see it only growing. And I think that it's, you know, there are, it's different here, you know, in the U.S. It's very profit-driven. So there was an interesting paper that came out that showed that a single dose of semi-glutide cost the manufacturer like $5 to produce it. And here in the United States, four doses is about $1,200. So the profits of these manufacturers are just wild.

And here in the U.S., we have an insurance system, so we're playing premiums to our insurance, and it takes a little bit off, you know, it's a mess. It's a mess. And so there's definitely that component of supply and demand and access issues with health care in general in the United States. And so it's tricky when we start digging into the details of access to these medicines. It's not great. I mean, there are a lot of people who really could benefit from these medicines that just could never afford it. It sounds like with the obesity crisis that we have, it sounds like it's something that should be like free public health care almost.

Yeah. I mean, I agree with you. Yeah. But that's not the reality of the world. Politics as what they are here or, you know, that's just not reality. And so I do think, though, that the fact that it's an injectable and it's refrigerated is a barrier. I hope one day we have an oral pill that's just as effective. I think that will make it much more horrible and much more accessible. But like I said, I mean, they're working on it. That's for sure.

They're not going away. And in the same way, too, that you talked about, you know, people might be on these medicines for life, people are on hypertension medicines for life. People are on antidepressants for life. People are on, you know, cholesterol medication for life. Even if they do all the lifestyle stuff, they go to therapy, they've improved their life. They don't just stop their antidepressant if it's helping them, right? And so I see these obesity medicines in the same way. Yeah, yeah, that makes sense. Your opinion on resistance training while on these drugs. I know you touched on it there. What what what's the importance of

of trying to convince folks who maybe have never never done any weight training or maybe have been too anxious or self-conscious to to step into the gym but now starting to see a little bit of progress in terms of their weight journey. Yeah. I mean I'm a huge fan of strength training. Strength training independent of weight loss. Yeah. Is wildly promoting. Most Most people are under-muscled. Yeah. So I wish that people would view strength training as a health-promoting thing that has nothing to do with weight loss.

Far too often people are motivated to work out to lose more weight. And it's so frustrating because they're hungrier and they don't lose as much weight when they work out, right? and they're like, I'm putting in all this effort and it's not translating to this scale. Like, we know. Yeah, that's what happens. It's okay. It's not you.

It's just that's what happens. So I like to help people frame strength training to disconnect it from the weight. Yeah. View it as just all the wonderful health promoting things that strength training can do. And then I personally love to bring to light the. role of strength and mobility as we age. And like what kind of old person do you want to be? Do you want to be able to get up and go to, you know, and walk and take care of yourself

and have mobility later in life is so strongly related to how much muscle you have on board and how you use it in your mobility and your strength, you know, throughout your life. And so we're working towards not an aesthetic, not a strength goal, which are all great, by the way, very motivating to have strength goals and aesthetic goals. That's all fantastic. But really to help people who are like reluctant, think about the question I ask, what kind of old person do you want to be? Do you want to have enough muscle to tie your own shoes, get yourself dressed, live independently for as long as possible with like good quality of life? You need muscle to do that. and so and we lose muscle as we age so we really need to get ahead of it so that we can make sure that we have this muscle we take care of it we protect it because it's going to serve you well for the rest of your life what about the psychological impact of losing not of losing a lot of weight on this drug of not having an appetite to eat the same amount of food that you might have before because obviously a lot of people will use food as a coping mechanism for trauma in their

life or stress and when they go on these drugs they might not be able to use that as a coping mechanism to the same degree that they they used to before. Is that something that you see come up with clients? Sometimes. Yeah, I'll have people who instead of eating now they're shopping too much or instead of eating they are an emotional wreck. Right. And that's a reality that some people do have to confront um big fan of you know mental health counseling and therapy and support on that front um it's a good question some people some people will have the like some people will have the misconception that okay once i lose all this weight then i'll finally be happy i'll finally have reached my weight goal that i struggle to my whole life and then sometimes the reality can hit that you hit that weight goal

and you're still not happy and then you're like huh why don't i feel the way i should feel it's like the gold medal syndrome, you know, when like, you know, athletes work their whole life to go to the Olympics and win gold and then they get this wave of depression after they've achieved everything that they ever wanted to. And I was just curious to see is that something that could be a potential, you know, obstacle in the road for people to deal with, not just the physiological drive for hunger, but then the psychological journey that you have to go on. on with weight loss. Yeah.

I mean, I love the way you frame that question too because it is a journey and we should probably start working on those psychological aspects of just our life. You know, wow, we're losing weight, not wait until we get to goal to deal with things. I do see sometimes folks will focus on their weight to avoid focusing on other things that maybe should be addressed. And it's really important to take a holistic view of like your journey towards health and your journey towards self-improvement should have like maybe multiple facets to it, multiple measurable things, like not just the number on the scale, but how are you feeling?

How are you sleeping? How are you managing your stress? How are you performing at work? How are your relationships with your friends and family? how, you know, what does life look like? Because if we're sacrificing life to achieve this weight loss, like that's not healthy either. So we have a lot of those kind of conversations. And we always comes back to this.

I love sharing with people. There's an interesting paper I read that said the degree to which you have self-compassion, how nice you are to yourself while you're on a health journey and trying to lose weight is a great predictor of how well you'll maintain it after you lose it. Yeah, makes complete sense. A lot of the time, our goal is just to, you know, feed back what they're saying to themselves and be like, well, you're definitely being too hard on yourselves,

but it's hard for you to see when you're in that bubble of yourself. And it's, you know, as a coach, it's really tricky because you don't want to, like, kill somebody's motivation either, right? Like, you're like, so excited that you're so motivated and so dedicated. but you don't have to show up to the gym seven days. Yeah, yeah. You don't need to make it more difficult than it has to be. You don't need to punish yourself or feel like you have to make it hard for it to be successful.

And I see it's a lot with like athletes and former athletes especially where like they're so used to like, well, if I don't win, right? Like I got to be the best or I got to do it all in or I've got to be like fully committed. but if you can't stay fully committed consistently, then that's really not serving you in the long run. I'd rather people be like 80% in all the time than 100% in for two weeks and then you don't see them again for a month. Yeah. Right?

So being good enough, doing the easy stuff, the like low-hanging fruit, like let's, how much alcohol are we drinking? How many like sweet treats can we cut back? are we getting enough protein you know do you cook at home at all or are you just always ordering takeout like let's start with the easy stuff and you know are you even walking like let's just start walking forget the gym like give it for like let's walk for four weeks is that doable absolutely and then we move on and sometimes it's sometimes it's the easy stuff that is actually the hard stuff for people because they're like oh well that's too i need to do more than that that sounds too

simple it's like that's that's the whole point they're the actual difficult things for people to have the mindset and the perception that or it's them little small compound and actions and behaviors that are going to build up to get the result that you want yeah 100% people overcomplicate nutrition and fitness all the time um and i think it's this like this human behavior where like if it's not worth it like it needs to be interesting and novel and difficult and complicated that must mean it's going to work more. It's going to be more effective if it's harder. Yeah, it needs to be complicated because it's hard.

But it's it's just hard even though. And again, it's the hard things are the are the simple things that you have to do every every day. The hard thing is the consistency. Truly. Because most people are really good at doing like I said like the eight weeks or the 12 weeks. Yeah. And it's it's no, we need to really take that long view and say like in five years.

What is this going to look like for? you. Another question that, well, actually, this was a question that got put into the chat box a lot from a lot of people. What advice would you have for anyone who has hit a weight loss plateau on the drugs? Yeah. One, my first question is, how much have you lost? So it's going to be different for each person.

It's going to be different for everyone. But these medicines are very powerful and very affected, but they're not as effective as bariatric surgery. Okay. And they're not going to necessarily get you to goal weight. Okay. These medicines average about 20% weight loss. Can I ask the question on top of that?

So is there a certain weight range that you should be on for these? And then if you're heavier, you should go, you should be opting for surgery. It's really independent for the person, what they're willing to consider. I do think that if you have more than 20, 30, 40% of your total body weight to lose, bariatric surgery is still an awesome option to consider. The current medications that we have will help people lose about 20% of their body weight. So I often see folks come in. They're like, I've been doing great.

I've lost my 25%. I'm stuck. And I wanted to lose 10, 20, 30 pounds more. And that's where the real like coaching comes in. Okay, we got to really dial in the nutrition. You know, we, I like to talk to people about body composition at that point. Are you strength training? Can we can we make some adjustment there?

Diet quality at that point. You know, you've lost the weight by eating less. And we've achieved the calorie deficit necessary, right, from your appetite being reduced. But was that nutrition high? quality nutrition can we improve the quality can we what can we work on as independent of the scale and like do we need to get back to basics in some way um plateaus are tough i mean and they're gonna happen um it's a weight loss journey just like any other even if you're on these medicines i do push back sometimes like why do you think you're in a plateau and then like well i've

only lost five pounds this month but i lost 15 pounds last month like that's not a plateau you're still losing. This is not a short-term thing. People lose 20% of their body weight over the course of a year. Yeah. Right? It should be slow and steady. The less you have to lose, the slower it's going to be.

100%. And the closer you get to your goal, the slower it's going to be. Yeah. And the more you have to give up our sacrifice or be more rigid, which sometimes it's actually not worth it. But that's the hard conversation to have. Yeah. I call it, you know, like the trap of.

the last 10 pounds. Like how far are you willing to go? And what's so cool about these medicines is they really remove that need to diet and sacrifice and count and be micro manage? Yeah. You know, to lose that 20% most people don't have to micromanage very much. They just kind of make sure they're eating nutritiously throughout the day. Those last 10 pounds, though, maybe you might have to micromanage it a little more.

are you willing to do that again? Most people are like, no way. Like my quality of life is great. Like I don't want to diet again. Then we're not going to lose those last 10 pounds. Yeah. Which is great. Fine.

Awesome. I mean, I went through that personally myself. I'm about 10 pounds up from where I had gotten to my lowest. And looking back now, like pictures and stuff was like, oh, it was a little too skinny. I wasn't lifting heavy enough. and I wasn't eating enough to support the training that I wanted to do. So I really kind of reoriented my training to start following a new kind of like progressive

overload training program and realized I needed to eat more to support that training. And I put on 10 pounds. I got a Dexas scan. It was all muscle, which is just like so cool. But, you know, sometimes we think the number we want to be is not the number where our body wants to be. or where we're going to feel our best or we're going to look our best or be athletic the way we want to be.

And so that number can kind of mess with your head if you're too focused on it. Yeah, and that's when it's good to have someone actually question what your real wants are because you can say you want something, but then when it actually comes down to do that, if you're actually questioned it as well, I thought I want it,

but I actually don't want it that much, as much as I want to be able to have a good quality of life. Well, and it's like I've got little kids, we go to Disney, we go to the beach or whatever. Like, I want to be able, to have a drink. I want to be able to I went to New York recently.

I had a slice of pizza and it was damn good and I don't want to go somewhere that has like a really awesome food and feel like I can't have it. Just to maintain a number on the scale. Sometimes it's about actually showing that person and listing all the reasons why it's better

to be 10 pounds heavier or five pounds heavier. I mean I feel better. I have more energy. My workouts are better. I'm sleeping better. I was too skinny. But that was the number I thought I wanted. And then I got there and I was like, no. Okay.

So I have three more questions for Yan. I call these a summer's wisdom. All right. Okay. So first question is, what are some mistakes you made early on in your career as a dietitian that you've learned from? Oh gosh.

I used to really focus too much on carbohydrates. I really thought that most people were overeating carbohydrates and I wish I could go back to some of the clients that I worked with and not made them so scared of carbohydrates. I really used to really focus on macros too a lot with most people, numbers in like micromanaging nutrition. And as I work with more and more and more people, especially on these medicines, I realize that it's less about the specifics and it's more.

more about the big picture. I used to really get deep into the science and then nutrients and the vitamins and the minerals and like the macros and it's just those matter, but not as much as like the lifestyle. Makes sense. Another question then, what's one piece of advice you would have given yourself 10 years earlier? Oh gosh. Well, maybe not 10 years, but 20 years ago, I wish I had never stopped playing sports. So it was a time in my life.

So as a time of my life, I was an athlete. I was like, as a kid, I played in high school, all these sports. And then I went away to college and I wasn't on a team and I started drinking alcohol and I stopped playing sports. I had a three year period of my life where it didn't work out. And if I could go back in time and have either kept playing a sport or kept going to the gym or kept working out, I think that phase of my life, because that's what I gained really a lot of weight, that phase of my life would have gone much better had I kept. working out because it is such an important part of just like my mental health and my physical health and all of that do you play any sports i wish i'd never quit playing sports do you play any sports now even as pastimes so i don't like i i'm not on like a team or anything but like i i go to crossfit which

has like that feel it's not really crossfit it's just a functional fitness gym but it's the same like style um i go to crossfit i i strength train i have programs i run so i i do fitness yeah so i do fitness yeah in my sport. You know, grown-ups don't play enough sports together. Like, if I wanted to go join a basketball team right now, I have no idea where to start. Yeah. And like, that's the, when you've played sports your whole life,

you really recognize how important that kind of community element of it was as well, or being part of a team. So I think that's where, if you have functional fitness or cross-fitting, something like that, it is a good replacement for that. If there was one message, you would have, like the rest of the world to understand what would it be? Mind your own body and your own plate. Explain that for me.

Like why do so many strangers care what other strangers are doing with their bodies or their food? Like mind your own business. Like everyone's on their own journey. Everyone's living their own life. Everyone's trying their best. Like reserve the judgment for yourself and leave people alone.

Do you think that's ramped by social? media. Oh, it's awful. I mean, I love, I feel like I have a good community on Instagram, you know, people, I just black people. They're mean, you know, like, bye. Um, Twitter's the worst. Yeah. Twitter's. It's awful. I just, it's ruthless. And even like, even in just like the real world, though, like when you go out and, and your friends are like, what are you eating or, you know, I see you've lost some weight. What are you doing? My own business. You know, it really is not what other people are doing with their own bodies should be their business. Do you think that the general public don't understand the impact that passing comments they have can really affect people because they're just not educated on the topic?

Yeah. I think, I don't know what happened to the world, truthfully. I feel like over the past five years, people are just not nice anymore. Like, we've lost a lot of kindness and just respect and, like, how to exist in group settings. even like in on the internet i think that's complicated things i just i just people who just are not very kind anymore and people have lost a perception of like empathy for others you know and i wish people were more inclusive and more understanding and more you know those things i don't know people are mean these days and so yeah i i can't tell you and it and it hurts worse when it's somebody you care about right when it's a friend or family member that makes a comment um and so yeah i just wish people would be a little bit more you know everybody's going through their own stuff everybody's living their own life

and i think a lot of people make assumptions that what you see on social media is the whole story and it's not and so you might think you know somebody and you really don't and so i think we can all go a long way to just be a little bit more respectful of each other i always say to my clients well like your diet isn't just food it's also like what you could consume on a daily basis. So kind of having a look at, you know, even your feed, what you're consuming, is this having a negative impact on your well-being? Are you watching too much news that's going to make you feel awful about yourself and feel like the world's collapsing? So even what you're consuming and true social media and stuff like that is really important to. And who you surround

yourself with too, right? Like your friends and your family and your support systems, like they should want you to do well and support your health and well-being and if they don't, then it's worthwhile to have like a serious conversation with your family members or your spouse and hopefully if they love you, they're kind and they understand. And maybe you don't need to have that friend anymore if they're not. If all they do is invite you out to brunch to get drunk like and that's not your goal anymore and then maybe they don't need to be a friend anymore. So this has been unbelievable. What's, where can people find if they want to ask you any more questions or they want to try and work with you or just get in contact with you? Where can they find you to talk a little bit more about this topic?

A great person starts my Instagram. Some are the dietitian. So with a tea. A dietitian with a tea. I know the Europeans fell out of the sea. Some are the dietitian on Instagram. I'm also on TikTok, but that place scares me sometimes. And I'm on Twitter as well, but I try not.

to be and if you want to work with me I'm currently working with members through Weight Watchers Clinic which is only in the United States telehealth platform and so there's a quiz you can take if you want to be a member of Weight Watchers Clinic you just go to waitwatchersclinic.com unbelievable summer thank you so much for today really appreciate it