ZOE Science & Nutrition - Should you take Ozempic? The 5 things you need to know before starting GLP-1 drugs | Dr Ania Jastreboff

Starting point is 00:00:00 Welcome to Zoe Science and Nutrition, where world-leading scientists explain how their research can improve your health. It starts with a whisper, a name passed between friends and murmured in doctors' offices. Then it explodes across headlines. A magic injection that promises you dramatic weight loss. Something to silence your hunger, calm your cravings, rewrite decades of struggles with food. For some, it feels like liberation. For others, it sounds like a plot from a dystopian Hollywood movie, a miracle in a syringe from Big Farmer that you need because of a disease created by big food.

Starting point is 00:00:46 And there is a deeply uncomfortable twist. Stop the drug, and you gain the weight back. And in the worst cases, perhaps more. These medicines, a Zempic, Manjaro, are part of a group of medicines known as GLP1-based therapies. They target appetite itself. and they're now the fastest growing drugs in medical history, with around one in eight American adults reporting having tried a GLP1 drug. The pace of development is rapid.

Starting point is 00:01:15 New drugs in clinical trials promise even more weight loss. The claims are bold. However, history has taught us to be cautious about miracle cures. From thalidomide to Vioxx and Fenn-Fenn, we've all heard horrible stories of miracle drugs, turning out to have terrible side effects. There are many voices discussing GLP-1s. But if you want to understand these medicines,

Starting point is 00:01:40 we think you should speak to the scientists doing the research, not just those commenting from the sidelines. So today, I'm delighted to be joined by Dr. Anya Yastrobov. Anja is Director of the Yale Obesity Research Centre, a practicing physician, and one of the leading researchers at the forefront of GLP1 treatments. She has published no fewer than four clinical trials in the New England Journal of Medicine,

Starting point is 00:02:04 one of the world's most respected medical journals. She doesn't only analyze the data. She treats patients every day. And because of that experience, she wrote a best-selling book, Enough, Your Health, Your Weight, and What It's Like to Be Free. Together, we explore everything we now know about GLP1 drugs in 26, to help you or your loved ones make informed decisions. How safe are they?

Starting point is 00:02:30 Is it possible to stop taking them? What should you eat while you're on them? is microdosing a safe way for all of us to fit into that old pair of trousers? Let's find out. Ania, thank you so much for joining me today. Thank you for having me. Now, we always start the show with a rapid-fire Q&A, and we have some very strict rules, very difficult for scientists,

Starting point is 00:02:53 so you can say yes or no, or if you have to, you can have one sentence. Are you willing to give it a go? I'm willing. Have new clinical trials of GLP-1 drugs in the last couple of years change our understanding of what they can do. Yes. Can GLP1 drugs offer benefits beyond weight loss? Absolutely.

Starting point is 00:03:14 Once you stop GLP1 treatment, will the weight stay off? No. Should everyone who is overweight take a GLP1 drug? No. It's up to the patient. Is it safe to microdose a GLP1 to stay thin as I age? Small doses for people who have obesity. are appropriate, so it depends how you're using the term. Is there evidence that long-term use of GLP-1 medications can lead to unwanted side effects?

Starting point is 00:03:47 All medicines have side effects. And finally, what's the most common misconception about GLP-1 medications? One common misconception is that these are weight-loss drugs. Over just the last couple of years, I've watched these GLP-1 medications like a Zemphi, go from like promising research breakthrough to viral sensation and now just sort of medical mainstream in this incredibly short period of time. And what I know is that while all that's been happening sort of in the public view, scientists have been quietly progressing our understanding of how these drugs work,

Starting point is 00:04:23 who they can help, and trying to increase their effectiveness. And so there's a huge number of people talking on social media about GLP ones. But on this podcast, you know, the core of the idea is that we allow our audience actually hear from the scientists who are carrying out the research. It's really wonderful to have you here. And I would say the other thing that's nice is you're not just a research scientist. You're also a practicing physician. That's right. And so I think you also have that experience, not just of studying in the lab, but actually working with patients and understanding what it means. I guess the question I'm going to start with is sort of quite a simple one. What are these GLP-1 drugs and how do they work?

Starting point is 00:05:03 Yeah. So the medications. are medicines that treat obesity. And so in order to answer that question, I'm just going to share a little bit about what obesity is. Our bodies are super smart. They figured out forever ago that we needed to store energy. And they figured out, well, the most efficient way to store that energy is to store it as fat. So fat is a good thing. It enables us to survive as a species. But now, how much fat are we going to store. Well, our brain decides that, and our brain is informed by hormones in our body. We call them nutrient-stimulated hormones. So GLP is a nutrient-stimulated hormone. G-I-P-P-1 is a nutrient-stimulated hormone. Amelin is a nutrient-stimulated hormone. So these hormones communicate with our brain

Starting point is 00:05:52 and they say, I'm hungry, I'm full, I need to eat more, I'm good, I'm full. And basically, they help our brain set what we call a body fat set point or in the book that we recently published the enough point. So body fat set point or enough point. And so you might say, okay, great. Well, our body set this awesome biology. Why in the world do we have obesity? Well, we have obesity because of our obesitygenic environment. So an environment that is filled with ultra-processed food, lack of physical activity, lots of stress, lack of sleep, all these different things, basically put. push up our body fat set point or enough point on a population level. So what does that mean?

Starting point is 00:06:37 That means that anything that we use to treat obesity has to recalibrate or reset that set point. And that's what we think the medicines do. They work in the brain to recalibrate that body fat set point or enough point. I think that's one of the clearest explanations that I've heard of like a very complicated topic that has come up, you know, quite often on this podcast. Whenever you speak to somebody who's on one of these medicines, the big thing they talk about is this profound shift in appetite. And also, I think they often talk about being full very fast.

Starting point is 00:07:18 What's going on there? So you raise hunger. A lot of people talk about food noise, which is different than hunger. It's appropriate to be hungry as humans. If we had no hunger, we would die. we wouldn't have any inclination to eat. Food noise is what patients talk about now that they stop experiencing it when they're on the meds. Food noise is disruptive, persistent, intrusive. People would go about their day and they would constantly be pulled towards what am I going to

Starting point is 00:07:49 eat next? What's going to be for lunch? What's for dinner? I need to plan it out. I have to make sure I don't eat too much or I eat just enough of something or not something else. Food noise is something, though, that we didn't know existed until people started taking the medicines, and then they experienced the silence. So we did not know food noise existed until it didn't, until it was quieted. So I think it's really important to consider that the medicines are teaching us about that. Now, what is food noise? It's a manifestation of our bodies or our brains biology, making sure that we have enough, making sure that we don't starve, making sure that our body fat set point or enough point is high enough that we survive. Now, we don't understand why our bodies would

Starting point is 00:08:42 set a defended fat mass or a fat mass set point that is higher than what is healthy long term, right? That excess or extra fat ends up leading to detrimental effects on our health because the fat spills over into our organs, our organs end up moonlighting as fat storage facilities and they can't do the job that they're supposed to do. But what we do think is that that food noise is one of the things that keeps pulling people back up in terms of carrying more weight or more fat. So we don't know exactly how the medicines change that, but we do know that as they recalibrate that defended fat mass or that set point, as they recalibrate it down, that food noise quiet. your body says, hey, your brain says, hey, I have enough.

Starting point is 00:09:28 I don't need to finish what's on my plate. I don't need more. I'm good. Are these drugs doing anything beyond impacting our sort of appetite and food noise? We knew for over 20 years that specifically GLP1 receptor agonists, they of course work on the islet. They work in the pancreas. They increase the secretion of insulin. That's how they were discovered.

Starting point is 00:09:53 they were developed for the treatment of type 2 diabetes. So we already knew about those peripheral effects. But now there's additional effects. So the weight effects, we think, are specifically in the brain. But other effects in the body, whether it's the pancreas or the vasculature, inflammation or other things, those are peripheral effects, but there's still effects of the medications. If I take this drug, it's not only acting, you know, in some specific,

Starting point is 00:10:23 specific part of my brain to do with appetite. Actually, it's acting in many places across my body, and one of those has an impact on my blood sugar control. Yes, yes. So anywhere there's receptors for that specific hormone, whether it's GLP1, GIP, Emmeline, what have you, the medicine will work there. It will work in the brain to regulate weight or specifically fat mass, and it will work in the periphery, for example, the pancreas, as you mentioned, to regulate blood sugars. And that's why these medicines were developed specifically for diabetes. And then it was noted as a side effect that these medicines also helped in terms of weight. And then that was followed.

Starting point is 00:11:07 And this is how the development continued in terms of looking at these medicines, not only as ways to treat type 2 diabetes and improve blood sugar control, but also for weight and obesity treatment. That's really interesting. So actually, sort of the biggest thing it's now being focused on is, almost like a completely unexpected beneficial side effect of drugs that were originally trying to solve for bringing down your blood sugar if you had diabetes? Hi, Professor Tim Specter here. Have you heard about our documentary The Gut Health Challenge? We challenged Sarah, Rob and Lucy to transform their health in just six weeks by improving

Starting point is 00:11:44 their gut health. If you've ever wondered how Zoe works, this documentary reveals all. When our participants started, they struggled with everything from Breast. rain fog and sleep troubles and low energy. Can eating the Zoe way address these issues and improve their health markers in just six weeks? You'll get a behind-the-scenes look at Zoe and discover some great, actionable advice from Federica and Sarah. Follow their journey by searching gut health challenge on YouTube. So 20 years ago was when the very first GLP-1 receptor Agnes was approved by the FDA for the treatment of type 2 diabetes. And one of the things that was noted was that our patients were not only not gaining weight, right?

Starting point is 00:12:30 90% of people who have diabetes are overweight and have obesity. And it was noticed, oh, they're losing weight, whereas something like insulin, giving someone exogenous insulin usually causes weight gain. And so we wanted therapies that would not cause weight gain, right? Because why would you give someone a therapy that ultimately may actually contribute to the progression of their disease. At the root cause of type 2 diabetes is obesity. So here we had this therapy that not only improved the blood sugars and not only

Starting point is 00:13:04 improve the blood sugars without causing hypoglycemia, but also led to weight loss. That is fascinating. So our body is naturally making these hormones. Yes. What I guess is happening in like a normal, you know, health. state in terms of what's going on with these hormones, and then what's different if I go and inject myself with one of these? I love it.

Starting point is 00:13:34 I love it. And this comes to another myth, which I'll hopefully circle back around to at the end. Let's take GLP1 as an example. So, GLP1 is stimulated when we eat food. Okay? So it's nutrient stimulated. We eat food. It gets released.

Starting point is 00:13:52 The hormone helps. to signal to our brain, hey, I just ate. I'm good. The medicines are gLP1 receptor agonists, meaning that they target the receptor for the hormone, wherever that receptor might be. In the brain, the pancreas, different parts of the body. So it targets that receptor. It is not the hormone. The medicine is not the hormone. It is an analog of the hormone. It works on the same pathways as the hormone works, but our body would never make this much of this hormone. So these are much higher doses in a way, which here's the myth. A lot of people, and colloquially, these medicines, people refer to them as GOP-1s. They're not GOP-1s. They're not the hormone our

Starting point is 00:14:43 body makes. They're synthetic. They're a medicine. They work on the same pathway, but they are not the hormone. And so they basically just, they target the same pathways and they signal to our brain and various tissues in our body, whatever it is that they're signaling. So is there an analogy you think about this like all over my body, there are sort of all of these little locks into which I can put a key. Yes. And the GLP1 is naturally made after I'm eating food. It gets secreted in your gut. It gets secreted from your gut. And they act differently in different parts. of the body, depending on where the receptor is. When they work in the pancreas, they help us secrete insulin.

Starting point is 00:15:25 So that brings down blood sugars. In the brain, they help the brain know, hey, I'm full. They give you satiety signals. And so if I am living with obesity, is it that my body is no longer making the same levels of GLP1 that you'd expect that means that I'm not hunger? Or is it that my brain somehow isn't, like, responding to the normal amount. Yeah. It's a really good question. I don't think we have enough information to know the answer. People with obesity make GLP one. They secrete GOP1. People with type 2 diabetes do as well.

Starting point is 00:16:02 There's some question of whether people with type 2 diabetes may secrete less after a meal. You're not replacing something that your body doesn't have. You're giving your body a lot more of something than it would naturally make. it is using the natural pathways or communication systems that your body already has in place. So could we talk maybe about those different drugs now? Because I think a lot of people listening will have heard of Azenpic, Manjaro, and I know that you just completed a new study, the latest, I think. One, I'm going to pronounce this wrong, Retatutride. Red at Trutide.

Starting point is 00:16:46 We did a phase two, and that was published in 2023. And that is not yet, I think, licensed in the states or elsewhere. No, we're doing the phase three trials. So we can try. I'd love to talk a little about that. But there's like a series of these drugs. And so my question, I guess, is how are they different from one another? And what's different between that and just the GLP one that I'm producing right now?

Starting point is 00:17:07 Because I had lunch just before this podcast. So each of these medicines is very different. They are different molecules. They can target one receptor. For example, GLP1 receptor. When you say a receptor, I'm thinking still again, like the lock. The lock. Yep, exactly. It's the lock. They can target one lock. They can target two different types of locks. So two different types of keys for two different types of locks,

Starting point is 00:17:28 even though it's not actually two different types of keys because if it's one molecule, it's one key that fits both locks. Oh, clever. Yes. So you have molecules that target one receptor or one lock. So that's something like somaglite, which is ozempic or wagovi. You have medicines that it's one molecule or one key that targets two locks. So that's trezepatide like Manjaro or Zepound. It targets GLP1 and GIP receptors. And then you have medicines, like you mentioned, retitrutide or retatrotide. Redatutide targets three receptors. It targets GIP, GLP, and glucagon. So one molecule that targets all three of those locks. And those are just some examples. There are many, many other molecules and medicines in development that target one, two, three.

Starting point is 00:18:22 There may be some down the road that are in development that are targeting maybe more. The first version of these drugs basically targeted these GLP1 receptors. That's like this lock. And that was the simple explanation that you were giving to me about hunger. However, in my body, there's actually a number of different hormones that are related to this process that affects hunger and the set point you're talking about. And so these newer drugs are starting to say, oh, I can create a molecule that doesn't just hit one of these, hits two or even three of these sort of locks in my brain. And so these are three slightly different in my body.

Starting point is 00:19:02 Naturally, I'm actually creating like three different hormones that affect my hunger somehow. And so these latest drugs are starting to hit more of them in order to try and get me to lose more weight. Well, it's not only about weight loss. Weight reduction is just part of the story. Treating obesity is about optimizing or improving health. That's the goal. I think the more interesting aspect or thing to think about is how can targeting these different receptors also impact other parts of our health? So first, I'll just start with. GIP and GLP 1 were actually discovered around the same time. GIP was actually discovered before GLP 1. and they both are hormones that help our pancreas secrete more insulin. Okay. Glucagon is a different type of hormone. It uniquely, there's receptors in the liver, and so it may impact liver health. So for example, with Reda-Trututide, which targets GIP, GLP1, and glucagon, and there's other medicines, for example, servutatide, which targets GLP1 and glucagon. Both of those have a glucagon component. They may have, and it looks like they do

Starting point is 00:20:18 have, beneficial impacts on liver health. So they help remove fat from the liver. And I'll give one more example, because this is part of the next wave, amylin analogs. So amylin is a hormone that is co-secreted with insulin. When we release insulin, we also release amylin. It looks like amylin also helps with satiety. It also acts in similar ways to GLP1, but also in different ways. And so the question will now be, well, what are the additional potential impacts of creating amylin analogs and pairing these, for example, with GLP1 receptor agonis or using amylin analogs by themselves? I had understood that the health benefits that came from taking these drugs was as a result of the weight loss. Part of it, yes, absolutely.

Starting point is 00:21:15 But I think you're saying that isn't the only way in which these drugs can help your health. And so potentially you might have a new drug that gave the same amount of weight loss as an old drug, but might be better for health because it's actually affecting these other parts of my body. Well, different aspects of health. So let's say that you are a person and you have cardiovascular disease, you have heart disease, right? And let's say that the beneficial effects are specifically from GLP1 receptor agonism. And we don't know, right? But there is evidence, for example, in the select trial, which was this very large, more than 17,000 individuals in this trial. Most of these trials, and this is one example, look at individuals who have had a heart attack.

Starting point is 00:22:02 a stroke, something before. They're looking at preventing. Can we prevent a second heart attack, a second stroke, a second cardiovascular event? And so somaglite reduced the risk that you would have another event. And so the investigators were interested in looking at, well, was that all because of the amount of weight they lost? Or was it something else? And can I confirm that if you are living with obesity or indeed overweight and you lose a significant amount, of weight, you would expect to be healthier and reduce your risks of the heart attacks and all of

Starting point is 00:22:39 these sorts of things. So it's a combination of the two. So we did another trial. This was with Trezepatide looking at individuals who have pre-diabetes. And we treated them for three years. And we saw very interesting things. First of all, trezepatide compared to placebo significantly decrease the chance that you would develop type 2 diabetes. So it was a 94% risk reduction. Nearly 99% of people who received transepatide did not develop type 2 diabetes over the course of the three years of the trial. And how would that compare with the people who didn't take the drug? The placebo group, there was a higher incidence of development of type 2 diabetes. And the question was, and a lot of people ask this, is what happens if we stop transepatide?

Starting point is 00:23:28 and people started to gain back weight. On average, they gained back about 7% of their body weight within about a four-month time span, and more individuals started to develop type 2 diabetes. The bottom line was, in order for the beneficial effects of the medicine to be seen, whether that was maintenance of the weight loss, whether that was prevention of type 2 diabetes, improvement of blood pressure, improvement of cholesterol, the medicine needed to be continued. So it's not just for the weight. It's for the weight and it's for all of these other downstream obesity-related beneficial effects. And we shouldn't be surprised, right?

Starting point is 00:24:08 Obesity is a chronic disease. Chronic diseases require chronic treatment. If you were taking a blood pressure medicine and your blood pressure improved, what would happen if we stopped that blood pressure medicine? Your blood pressure would go up. With medicines to treat obesity, it comes back to what we talked about at the beginning, which is that what do these medicines do? They recalibrate the body fat set point. They recalibrate the enough point. So if a medicine is stopped, that set point goes back up

Starting point is 00:24:41 and the weight follows. That's clear. There's something rather depressing about it, of course, at the same time, that you need to keep taking this thing forever. So we've had this obesity, epidemic. We've now got this drug, which is magical. But I think a lot of people feel like, well, I ought to be able to sort of take this thing and be cured. And you're saying that's not really the case. This is like an ongoing treatment. But is it depressing that if somebody has high blood pressure, that they would have help from a blood pressure medicine? Or is it wonderful that we have treatments for people, that we have options for people, whether they have high blood pressure, whether they have diabetes or whether they have obesity. And the added difference with

Starting point is 00:25:29 obesity is that obesity is related to over 200 obesity-related diseases. And so if we treat obesity effectively and safely, then in essence, aren't we preventing, mitigating, or treating over 200 other diseases, and that has an incredible impact on the health of our world. So I totally agree with that. I think that what probably quite a lot of people listening will say is, yes, but why are we in that situation in the first place? Our obesitygenic environment. We have to work on our obesitygenic environment. There's no debate. So as we are hopefully changing and reshaping that obesity to be a default healthy one, that will help prevent obesity and those who don't yet have it.

Starting point is 00:26:21 But for the people who have obesity, if they are seeking treatment, we would like options for them. I love that. And I love the passion comes through really, really strongly. So I would love now to talk about like our latest understanding, you know, we're here in 26 and this is obviously, you know, I think you paint a picture of how fast this has been moving. And you've been at the center a lot of this research. Before we do that, I think there's an important topic that I'd like to touch on briefly. Most drug studies are funded by the drug manufacturers. And I know that this has been true for all four of those studies in New England Journal of Medicine.

Starting point is 00:27:01 And I think the question that a number of listeners are going to have is, well, does that mean that I can't trust the results? And does it mean that I can't trust you? Yeah, I mean, it's a really great question. And I think that for any disease, this is how we develop new therapies. It's working together. A company may not be seeing patients in clinic. They may not know what the patient is asking for, what the patient is experiencing in the same way that I'm not in the lab making the medicines, nor are my colleagues. So I think it's really working together, just as we would for any other. disease, any other complex chronic disease. Will you just talk me through for a minute how science makes sure that these results are, in fact, true? Because clearly there's an enormous amount of financial interest from a pharmaceutical company to prove that, like, this drug is safe, there's no side effects, and it works

Starting point is 00:28:07 really well, because then they make billions of dollars of revenue. how as science and scientists do we make sure that we don't just get fake results? Yeah, absolutely. It's incredibly important. So there are multiple steps that these studies have to go through. There is constant communication with the FDA, the EMA, to ensure that the steps are taken and that the trials are conducted in such a way that they demonstrate, are these medicines safe? are there toxicities that we would be worried about? Are they effective? And there has to be a balance. So this actually brings me to one thing that you asked about in the very beginning, which is this

Starting point is 00:28:49 microdosing. All it means is little dose. Now, we use little doses for our patients all the time. Maybe the patient only needs a little dose, right? Maybe they don't need the larger dose, which is very common for any disease, including obesity. But the medicines haven't been studied in people who don't have obesity, right? Maybe overweight with an obesity-related disease, but not without that, right? And so the FDA doesn't have the data it needs to know whether the risk-to-benefit ratio is a good one for someone who doesn't have obesity, who doesn't have overweight with an obesity-related disease.

Starting point is 00:29:27 That is exactly why we do the trials. People listening maybe wondering, are you employed by one of these pharma companies? and do they get to just write the paper and then it gets published? What's the actual situation? Yeah, no, I'm not employed by any of the companies. I do serve as a scientific advisor to many companies, as many of my colleagues do in every field of medicine. In terms of the papers, I write every word.

Starting point is 00:29:55 You have authors that are academic, and you have authors that are from the companies, and we work together. But for the papers that I lead as a first, author, everyone knows. I'm going to write that first draft. I'm going to integrate all of the different feedback from all the authors, the academic authors, the authors who are sites for the trials, and from the companies themselves. So integrating all the comments and then working with the journal and getting feedback. We get peer reviews, right? So external experts who are

Starting point is 00:30:30 reviewing our papers. And I love that rigor. Can we talk a bit about what the latest, I guess, facts are about these drugs. And maybe we can start with what the latest trials reveal about how much weight can be lost from these newer versions of these drugs. Yeah. I don't even want to say long ago because it wasn't that long ago. But the threshold that the FDA set for these medicines was losing at least 5% of your body weight, right? So if somebody weighed, let's say, 200 pounds, that would be 10 pounds. or let's say somebody weighed 100 KG, it would be 5KG. That was the threshold that was set.

Starting point is 00:31:12 Now that seems like a pretty low bar. Why was that threshold set? It was set because with diet and exercise, if somebody lost between 3% and 7% of their body weight, there would already be metabolic benefit. For example, if they had diabetes, it may improve their blood sugars. If they had pre-diabetes, it may help prevent it. So with that degree of weight reduction,

Starting point is 00:31:34 there was already health benefits, right? And the FDA wants to know what are the health benefits of what we're doing, right? So that's why that was set. Now, with the newer medications, we started seeing weight reduction of more than 15%, more than 20%. And now the medicines that are to come, we're looking at weight reduction. That's 25%. Maybe 30%. 30% of your body weight.

Starting point is 00:32:03 And then you're approaching what you would see with bariatric surgery, with weight loss surgery. And not only that, if the medicines are targeting different mechanisms, you can use them in combination. So if a medicine has a GLP1 receptor component, you don't want to pair it with a medicine that also has that component. But if you have a medicine that, for example, targets GLP1 receptor, or GLP1GIP receptor, and then you have an amylin analog, or some, it's targeting, some other receptor, you can pair them for additional weight benefit. And we did this, and we still do this, with older medicines. There were medicines, and there still are medicines for obesity treatment that are not GLP-1-based or not nutrient-stimulated hormone-based medications. And we use them in combination. But I'm going to just come back to one very important point, which is that it's not just about

Starting point is 00:32:56 the weight reduction. Yes, weight reduction is important for health. Treating obesity is about improving health. It's about optimizing health. So it's weight as well as some of the direct peripheral effects of these medicines. So, Annia, can you tell us what the latest data tells us about the impact of these drugs on actual health conditions? So one, we of course see that these medicines result in weight reduction and treating obesity and reducing adipose, right, reducing fat mass. We also see improvements in heart health, kidney health, um, improvements in lipids, improvements in blood pressure. I'll give some examples.

Starting point is 00:33:35 So with somagliteite, we already know that it can improve heart health in terms of preventing a second heart attack or stroke in somebody who's had a heart attack or stroke. And now somaglotide is approved for people with cardiovascular disease. Obstructive sleep apnea is another common obesity-related disease. And now, trezepetide, there's a trial that was conducted with tresepetite surmount OSA, or surmount obstructive sleep apnea, that demonstrated improvements in those who have obstructive sleep apnea, and now triceptide is FDA approved for the treatment of obstructive sleep apnea, a medicine.

Starting point is 00:34:12 The medicines are being looked at for kidney outcomes, for blood pressure. Another aspect of health is liver health. So basically, these medicines are helping to remove fat from the liver that can have a lot of detrimental effects on our health. are these likely to end up being drugs that we start to think of as being valuable, not just in order to either lose weight, as many people listening this will think about, or to deal with health conditions that are direct results of obesity? The short answer is yes. As an example, Trezabotide is FDA-proof for obesity treatment. The FDA calls it chronic weight management. It is also FDA-proof for obstructive sleep apnea. Somagliteide is FDA-proof for obesity treatment. It is also FDA-proof for cardiovascular disease, as well as mash, a form of liver disease. So I guess to your question about will they be used for

Starting point is 00:35:15 people who don't necessarily have obesity, I think the one caveat would be that if they don't have obesity and they're taking a medicine that causes weight reduction, we'd have to balance that, right? Because then you'd want a medicine that maybe targets those things, but doesn't lead to that significant amount of weight reduction. And the older medications that were GLPone receptor agonists, they didn't result in as much weight reduction. What actually happened was that the scientists wanted to extend their half-life, meaning help them to last longer in the body. So instead of taking them multiple times a day or once a day, those were the original ones. How do we make them last longer, a week or maybe a month, right? And as they were trying to make them last for longer,

Starting point is 00:36:07 they found that they led to more weight reduction. And part of the thought is by them acting longer, do they have more opportunity to do whatever it is that they're doing in the brain to act on those receptors in the brain? But by making them last longer, they also happen to have. have more impact on weight. We are in our infancy of understanding. Can we talk about side effects now? Anything that's new, I think there's always this question, how safe is this in the long term? What do we know about the potential long term side effects of GLP ones? And like, what level of concern should somebody have as they're thinking about that? Yeah. So the most common side effects are gastrointestinal, nausea, diarrhea, constipation, and in some instances, vomiting.

Starting point is 00:36:57 These are quite short-term effects, right? Like, I'm going to get that side effect quite rapidly after I start to take the drug. Yes, usually. Usually if people have side effects, it's at that start and when the dose is increased. Are there any known long-term effects that maybe you don't feel at the beginning, but, you know, are risks that will build up if I keep taking this drugs for years? Well, there are rare side effects that we talk about with our patients so that they know and they can look out for them. One is increased incidence of gallbladder disease. So with any form of weight reduction, whether it's bariatric surgery or diet and exercise and these medicines, there can be gallbladder disease. And so we counsel patients if they

Starting point is 00:37:43 have abdominal pain, that they shouldn't ignore it, right, that they should get treatment for it. Most often, patients can resume taking the medicines, right, once their gallbladder is removed. We also continue to monitor for pancreatitis. So pancreatitis is increased in people who have type 2 diabetes versus people who don't have type 2 diabetes. So we don't use these medicines in people who have pancreatitis or, you know, acutely are having pancreatitis. or if they develop pancreatitis, then we stop using the medicine. Again, we counsel our patients on abdominal symptoms so that they know.

Starting point is 00:38:19 There are other things that patients come to us after they've lost a significant amount of weight. So hair loss is one. And we saw this with bariatric surgery. When patients were losing a significant amount of weight very rapidly, they would experience hair loss. And we can see this with these medicines as well. Other things that have come up and questions are muscle loss or bone loss. loss. Again, these are things that we see with any form of weight reduction, and now they're coming

Starting point is 00:38:46 up with these medicines because people are losing a significant amount of weight. And this brings me to a very important point, which is that when these medications are taken or prescribed, they need to be paired with healthy diet and physical activity. Because the goal of obesity treatment is improving health. And there's no medicine out there that can help us eat more health fully or move more. And so really for optimizing health, it's pairing both. It's pairing the medicines that help recalibrate the amount of fat that your body wants to store with the healthy diet and physical activity. One thing I'm struck as I'm listening to that is the risk of taking the drugs for a short period of time, losing a lot of weight, then coming off the drug

Starting point is 00:39:33 for whatever reason. And you're saying you should stay there and then getting back. And I think about this because we've talked a lot about the problems of doing this through yo-yo dieting, right? That's come up often on other podcasts. But here you can do something really extreme, right? You're saying you could lose 30% of your weight and then come off it. Are you potentially in a worse place if you do that because you sort of lost the muscle through this? Then you go back on. And so you really, really want to make sure that if you're going into this, you're describing, you know, you need to be aware you're going to have to stick with it.

Starting point is 00:40:04 There's one study with Laragliteide and exercise. It was published in 2021. And the people who paired Laragliteid with exercise did better in terms of maintaining their lean mass. And obviously the medicine was helping in terms of the fat loss. Do you know someone who's on a GLP1 like Monjaro or a Zempec? Or perhaps someone who's thinking of starting one. Maybe like me, you know, people who've tried a GLP1 and then giving it up. If so, why not share this episode with a lot of that?

Starting point is 00:40:34 right now and replace social media noise with the very latest scientific information about GLP-1s in 2026. In a world where we're surrounded by conflicting messages and influencers making bold claims, why not share clear science-backed insights? I'm sure they'll thank you. So I'd love to pull all of this together now and say, okay, we've talked about all the science. What does this mean for like a real person who's consistent? considering starting out on one of these new therapies.

Starting point is 00:41:09 We talked a lot about living with obesity. How do I translate that to me saying, well, I weigh this amount. Like, is this relevant for me? The studies have included participants who have BMI, a body mass index of greater than or equal to 30, or a body mass index of greater than or equal to 27 with an obesity-related disease, like high blood pressure, like high cholesterol. The studies have also looked at people who have type 2 diabetes irrespective of BMI.

Starting point is 00:41:43 And could you just paint me a picture? So if I have, for example, a BMI of 27 or 30, what does that mean? Greater than 25 is greater than or equal to 25 is overweight. Greater than 27 was a midway point that was chosen within that overweight range. But if you look at the labels, So the FDA labels for somaglite, trisepidate, if you look at the labels for these medicines,

Starting point is 00:42:07 what they actually state now is overweight or obesity. They don't state the BMI criteria for the indication, right? So it's looking at the whole individual and seeing where is the data in the trials, and then what is the risk to benefit ratio for that person. And so are these just sort of slightly arbitrary cutoffs that, you know, you and other, used in trials to decide who's in here, and we don't know that it won't work great if your BMI is 26 or 25, or do we know, like, this really only makes sense as you're starting to get into those levels? So it's not arbitrary. It's based on morbidity and mortality. So it's based on older

Starting point is 00:42:57 studies. But again, BMI is not a great measure. It was designed. as a screening tool, not a diagnostic tool. And so we really need to, if we're going to continue, which I think we're going to continue using BMI, we need to revamp it by age, sex, and race ethnicity. That's what we need to do, yeah. So let's say you go and see your doctor. They say, yes, this makes sense for you. We want to start. What should you think about as you're about to begin treatment?

Starting point is 00:43:29 And I'm particularly thinking that a lot of people drop off these drugs quite quickly. So what do you need to do to maximize your chances of this succeeding? Because after all, you told me I need to be on this forever, right? So I need to make this work. Yeah. So, I mean, my approach with patients is I like to see where they are, what their expectations are, what their goals are for their life, not just for this, but in general. And I always start with the biology.

Starting point is 00:43:57 So there's a shared understanding of what the disease is and what we're trying to accomplish and do. And then I invite them to ask questions, right? So I invite them to ask me questions about side effects, about potential other things that may happen beyond weight reduction, right? When somebody loses a significant amount of weight, there's a lot of things that change in their life. So we start to have that conversation. And a lot of that first visit is focused on what are the side effects and what are ways to mitigate those side effects. We learned very quickly not to go up on the dose quickly, and most of my patients do not go up once a month. Also, even if they're not having side

Starting point is 00:44:38 effects, if a patient is losing weight on a certain dose, we don't increase. That dose is working for that patient. There's no need at that moment in time to quickly dose escalate. The weight did not come on overnight. Why would we want it to come off overnight? Now, what are ways that you can help mitigate side effects besides start low and go slow. There are several things that I talk about with my patients. One is not eating past the point of fullness. So you're going to feel full earlier. Tracking which foods may exacerbate your symptom. That's the second thing. Our patients tell us that fatty foods tend to exacerbate their symptoms. For some people, it's spicy foods or carbonated beverages, but fatty foods seem to be a common theme. So eating less fried foods, less French fries,

Starting point is 00:45:26 or chips, eating less of those foods while you're dose escalating. You can always come back to those once you're at a stable dose and you plateau. And sometimes I have people just keep a diary, right? It's hard to keep track of what foods you may have eaten. Then the third thing is eating more frequently, but smaller amounts. And then the final thing is staying well hydrated. So being dehydrated can actually exacerbate people's nausea. And when people are less hungry, they also tend to be less thirsty. and food has water. So if somebody's eating less food, they are also taking in less water. So that's the final thing.

Starting point is 00:46:05 Can we talk about the quality of the food now? And of course on this podcast, it's bound to be something that we think quite a lot about. There's been a lot of discussion around the fact that you're suddenly eating much less than before and that many people on these drugs probably haven't been on the best diet anyway because part of the challenge of the abysogenic environment as you're talking about it's like all this ultra-process food and all the rest of it. But certainly if you suddenly reduce the amount you're eating, then what if any other challenges around getting the nutrients that you need?

Starting point is 00:46:37 And I guess on the more positive side, what do you see about the opportunity in this moment to actually change what you're eating and improving the quality of what you're eating? It's almost like putting yourselves in the shoes of someone who has obesity, someone who has experienced food noise or just they finish their day and they have followed this plan that they laid out of this perfectly healthy breakfast, lunch, dinner, and then after dinner they are hungry. They are pulled towards the ice cream in the freezer or the cookies or the biscuits in the pantry because their body wants them to get more energy.

Starting point is 00:47:20 Their body wants that to get them to that higher set point. And now they take the medicine and all of a sudden their brain says, you have enough. You don't need to eat more. Now, we have not gotten to the state yet where we can have medicines that change food preference, although there's a caveat there. Maybe some of these will. We don't know yet. We have to do that research.

Starting point is 00:47:48 but the freedom that patients now have, and so that freedom could be, okay, well, they also impact, for example, alcohol intake, right, some of these medicines. So somebody doesn't want another glass of wine, right? And instead, they'll have the water, right? Or they don't want another bite of the chips. Is there anything that you would be saying, look, I think it's really important you focus on these couple of things in your first, you know, six months say on these drugs? Absolutely. Number one, hydration. Very important. Prioritized protein, vegetables, fruits, all the things that we talk about whole foods to the extent that is possible within that person's sphere, within what that person has available to them. In terms of your

Starting point is 00:48:36 question about protein and other things, because people are full earlier, what I advise is try and eat those foods first because you're going to get full earlier and we will. We will, want your body to get all the nutrients that it needs in order to be as healthy as possible. If the dose is escalated too quickly, what we don't want is somebody to be eating very little and not to be able to get in all of those healthy, nutritious foods. That is rare, but this can happen in some patients if we're going up too quickly on the dose. So it's super important to not go up on the dose too quickly. If I'm going up on this dosage a lot faster than you're describing you do in your patients.

Starting point is 00:49:22 And, you know, I think there's a lot of people who get these drugs, you know, online in some way with quite limited amount of physician support. I think that is the reality for a lot of people around the world. Are there any particular risks that they should be aware of to watch out for in that situation? Yeah. These are not weight loss drugs. These are not weight loss AIDS. They are medicines, just like a blood pressure medicine. or a medicine to treat your heart disease, these are medicines.

Starting point is 00:49:50 Would someone take a medicine for their blood pressure or for their diabetes without the compassionate care of a provider? There are absolute detrimental effects. There are negative things that can happen if the dose is escalated too quickly, if it's escalated inappropriately, if a higher dose is taken than is needed, or a higher dose is taken at the outset, right? somebody doesn't dose escalate, maybe because they don't know or because the person who's providing them with the medicine didn't know. So it's incredibly important to make sure that the medicines are

Starting point is 00:50:27 treated as medicines and they're provided in a safe way as we would any other medicine for any other disease. It's really interesting to hear you talk about that because I think there's so much noise about this. People find ways to get this without ever physically seen a doctor. And I think it is treated almost like taking a vitamin supplement you might be able to take. So not treated with the sort of seriousness that you're describing. What is your message to someone who is thinking about it like that? Talk to your health care provider. Talk to your primary care doctor.

Starting point is 00:51:02 Ask the questions. This is new. The health care field is catching up. But find health care providers that can help you along this journey. I feel like that naturally pulls me on to a question. right at the beginning about people so-called microdosing on these drugs because as they're getting older, they want to stay as thin as they were when they were 25. What would you say to people who are doing that or thinking about doing that? We don't have the evidence yet. We need to know

Starting point is 00:51:32 what the risk-to-benefit ratio is. And in the same way that anytime somebody comes to us who has obesity, there's a choice to be made. You asked me very early on about, should everyone take these? Well, if somebody is seeking treatment, we should give them options, but we need to present them with the risk to benefit for those treatments as we would for any other disease. Are there any natural ways to increase your levels of these GLP ones to sort of manage your hunger, you know, long before you end up in the situation where you're with this, you know, this disease of obesity? We don't have a way to do that at this point. There are ways to help prevent obesity from developing, and those start early on before the onset of obesity, right? So being physically active,

Starting point is 00:52:23 moving, eating a healthful diet, all those things help prevent. But just let's not forget that there is a strong genetic component to obesity. And it's not just your parents. At this point, It's your parents' parents. We don't know when those changes, those recalibrations of the set point occur. Do they occur in utero? Are they generational? And I would argue that they are. There is one other topic that I really wanted to make sure that I got your answers on,

Starting point is 00:52:52 which is around exercise while you're on this drug. That's another area where it's been a great deal of discussion. What is your view? It's very important. It's very important. So at that first visit, we talk about side effects, and we talk about healthful diet and movement, whether that's to maintain muscle mass, muscle function, which is even more important than muscle mass, any incorporation of physical

Starting point is 00:53:17 activity or movement into the day. And let's not forget about resistance exercise, right? So it's cardiovascular and resistance, but meeting the patient or the person where they are, right? Wherever they are, adding a little bit and then along the way as they lose weight, adding in more and more and more. We're at time, but I'd like to ask one final question. Imagine that you're sitting here again with us in, let's say, five years' time.

Starting point is 00:53:46 What do you think might be the most exciting next new thing that you might be talking about, which is like a dream of a study in front of us, but you could be sitting here talking about the results today? In the next five years, I'm hopeful that we'll have more than one class. of medicines to treat obesity. There's more than one type of obesity. Not everybody responds to these medicines. So I'm hoping we have different choices, different classes. We will have, we already have oral, so daily oral, weekly and monthly options, maybe even less frequent options. And most importantly, I think we will be five years farther in our understanding of how these

Starting point is 00:54:34 medicines impact health, of how treating obesity impacts health. And I think that's the most exciting thing is how can we help our patients lead healthier lives. Amazing. And I'd like to do a summary of, you know, just maybe a few of the things that we've covered because we've covered a lot of things today. I mean, the first thing that's obviously striking, as you said, you know, when you went to medical school, you didn't even study obesity. None of these drugs existed. And, And now you're saying that, you know, the latest version of these drugs that are just going to come through can potentially deliver 30% weight loss and then these extraordinary set of health benefits that follows. So this is really a sort of transformation in terms of this whole new class of drugs and the impact they have. The second thing I'm struck by is, you know, I thought of these as being GLP1 drugs and you've corrected me and said, well, actually, that's not even right.

Starting point is 00:55:32 You know, GLP1 is almost like one lock in my brain in my body that a drug can unlock to have benefits. But we've already found at least three of these different sort of locks as I was thinking about them. I think you described these as nutrient-stimulated hormones. And that basically there's probably loads more that we don't even know about. So potentially we're going to continue to have impact. And that interestingly, although the weight loss, is driven by the fact that these drugs change something in our brain that mean that basically we stop being hungry, we stop being surrounded by this food noise.

Starting point is 00:56:12 We actually have these receptors, these lots all around our body. And that as we're expanding these drugs, they're having a lot of impact on other areas. It in fact started originally in terms of managing blood sugar. There's all of these new sets of drugs that are doing things around the liver, which seems really exciting. And there are already a set of studies, a number of which you've been involved. with that show that, for example, I think it was semi-glutide. You said if you've already had some sort of heart attack or stroke and you take this drug, it's like dramatically reduces the chance

Starting point is 00:56:42 of a second one, which is pretty magical. And that another drug, I think it was trazebptide. Trezebate. Trisepetide. These are tricky names. He said a 94% risk reduction in getting diabetes. So these are like really big impacts outside of weight loss. You've also emphasized that all of these trials are about people living with obesity or who are overweight and this impact can be life-changing, that because of what's happened in their brain, like, this isn't something that, you know, traditional approaches were able to solve because, you know, we haven't talked a lot about it, but this whole, like, you know, just count your calories. Like, none of this works.

Starting point is 00:57:21 Well, it doesn't recalibrate. Because it doesn't change the set point that is in your body. But you're very cautious about what that might mean. for people who are using these drugs who aren't in those categories with that level of weight. And I think really emphasize that this is, you know, it's a serious medicine. You want to make sure you have a physician looking after you and you're quite cautious about this. In terms of, like, what does it mean to actually be taking these drugs? The first is the main side effects are sort of gastrointestinal.

Starting point is 00:57:54 So this is like nausea, diarrhea, constipation, and the key approach that you take in your clinical, and your colleagues is start low and go slow, which means, you know, the amount that you're taking is not very high to start with and you don't ratchet it up really fast. And you're saying if people are losing weight, actually don't need to increase that. Whereas for a lot of people, if you're ratcheting up the levels very fast and getting this very high weight loss, you're also increasing the chances of the symptoms. And that's a problem because what you're also saying is you've got to be on this for life. So if you do it for a bit and then you have bad symptoms, you give up, actually you're just going to go back to where you were at the start. So you need to

Starting point is 00:58:30 to get past all of these initial symptoms, and you need to think about this. Like taking your blood pressure medication, you're just going to take it for life. But you did have a bunch of other tips. The one you kept talking about was being hydrated, which is really interesting, like, you really need to drink with this. You need to rethink how you eat because suddenly you're going to eat much less. So you need to prioritize, like, the good stuff first. So all the things I think that we talk about on this show, you mentioned, you know,

Starting point is 00:58:54 whole foods and vegetables and protein, like get that first, because suddenly you're going to be full up much faster than before. And then finally, you know, I think on exercise, it was like a very positive message. Rather than being very anxious about this because you're losing weight and what will this mean for muscle mass. Actually, many people feel able to do a lot more exercise on these drugs. And so almost as you're making progress on them, then suddenly you can do more. But of course, it's really good for your health. And that is something that you want to encourage all of your patients to do as they're on this journey.

Starting point is 00:59:28 Yeah. I'll end this episode with something I think you'll like, a free Zoe gut health guide. If you're a regular listener, you know just how important it is to take care of your gut. Your gut microbiome is the gateway to better health, better sleep, energy and mood. The list just goes on. But many of us aren't sure how to best support our gut. I wasn't sure before doing Zoe, which is why we've developed an easy-to-follow gut health guide. It's completely free and offers five simple steps to improve your gut health.

Starting point is 01:00:01 You'll get tips from Professor Tim Specter, Zoe's scientific co-founder and one of the world's most cited scientists, plus recipes and shopping lists straight to your inbox. We'll also send you ongoing gut health and nutrition insights, including how Zoe can help. To get your free Zoe gut health guide, head on over to zoie.com slash gut guide. Thanks for tuning in and see you next time. You know,

ZOE Science & Nutrition - Should you take Ozempic? The 5 things you need to know before starting GLP-1 drugs | Dr Ania Jastreboff

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