Weight Loss injectables: The easy way out?

Music. And welcome to Change Your Relationship with Food, the podcast hosted by me, Kyla Holley.

With many years' experience as an eating disorder and bariatric therapist, I know exactly what it takes to help you break free from your diet history and develop a more healthy relationship with food. Please follow this podcast to make sure you don't miss a thing. Before we start, I need to ask a big favour. I know we have an amazing community of people listening to this podcast every single week.

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Last week, I had the pleasure of being invited to one of these dinner meetings. This is what they call them, where normally a pharmaceutical company invite a whole load of health professionals along. They give you dinner and you also get a chat, a presentation from other health professionals. And in this case, there were two presenting. One was an endocrinologist and the other one was a cardiologist.

And we went along at the invitation of a company. I'm not going to say who it is because I wonder at the end of this podcast whether I would ever get an invitation again. But anyway, it was a company that produces one of the GLP-1 weight loss injections, one of the GLP-1 agonists, and they invited us to this dinner.

So we went along to the presentation. What was interesting was that they were presenting some new research that had been done, which was proving that the GLP-1 injectables had a benefit, an overall health benefit, especially from a cardiovascular point of view. So that's what they were presenting, this new research for us. But it was interesting. The first person to speak was the endocrinologist. she stood up, gave us a little bit of a background, and then she was going to present two.

Potential patients where prescribing this particular injectable might be beneficial for them. And the first case study she presented was a character called Wendy. And a picture of Wendy came up. She's made up, but they put a little picture of a woman up there and tell you a little bit about her, what she does for a living, the fact that she's got a couple of kids and, you know, a little bit of background information about her. But one of the interesting things about Wendy, her BMI was 27.

The endocrinologist was putting this to the group as a case study. And she said, okay, here's Wendy. Wendy comes to see us. And her question to the group was, how would we talk to Wendy about weight loss? And she threw this question out there and there was a lot of silence because we were all looking at each other. And I leant across to my colleague and friend who was sitting next to me, who is a nurse at the bariatric practice that we work at.

And I said to her, I wouldn't talk to Wendy about weight loss because her BMI is 27. and we know that there's so much stigma attached to... Medical professionals and the way that they approach these talks to people about weight loss. Imagine, for instance, the group of health professionals she was presenting to were a whole different variety of people. There were nurses there, there were GPs there, there were psychologists there, there were probably a whole load of other people that had come in.

Don't know quite what professions were in there, but there were a whole lot of us. I knew that there was an anaesthetist there, there was a surgeon there, all different people. And you've got to imagine, what if this Wendy character presented for a sore throat? Let's say that she had tonsillitis. Off she goes to her GP and she says, ouch, my throat really hurts. He looks down, he or she, the GP, looks down into her throat and says, oh yes, you've got a case of tonsillitis.

By the way, Wendy, let's talk about your weight, shall we? What's the likelihood of Wendy feeling confident in the future to go to the doctor about anything? Let's say Wendy has knee pain. Is she going to say to herself, what's the point in going to the doctor? Because the doctor's just going to go, well, if you lost some weight, your knees wouldn't hurt.

How inhibited is Wendy going to be to go and visit her GP if she knows that every time she trots along there, the GP is going to want to talk about her weight. And we know, we know from the research that this inhibits people. People at a higher weight often are avoidant of going to the doctor, especially if it's something that they feel somehow the doctor might connect to their weight.

But even for things that are completely unconnected, something like tonsillitis, people are still reluctant to engage with healthcare professionals if it's going to turn into a conversation about their weight. So I kind of stayed in the background and a bit quiet because, as I say, I was a guest of the company and I didn't want to be that person to create waves in what was a fairly public presentation.

However, one thing I do know is a study that was done, I think, in 2016, and it came out of Denmark. And this study was conducted to establish the mortality risks connected with BMI. And what they found in this study was actually that a BMI of 27 was the optimal BMI. I'm going to run through a little bit about BMI in a second. I have done a podcast on this before, but I will recap it in case you haven't heard that one.

But what they discovered in this study, which wasn't that long ago, really, in academic terms, and it was a very large study, that there has been this upward shift in what they consider to be an optimal BMI. And what they think is that that is a result of preventative treatments that are involved in weight-related conditions and things like type 2 diabetes.

So in the past, when we didn't have the very viable treatments for people at a high weight, the risk of being at a high weight was much higher. And now we have those treatments, the risk factor involved in weight isn't quite as bad as it used to be. So if we know from this study that the optimal BMI to have is 27, which officially puts you in the over 8 category, should we actually be talking to people at a BMI of 27 about their weight at all? Or should we just let them be?

This is a question that was ringing around in my head as part of this presentation. So just to recap a little bit about BMI, because this is something, it stands for body mass index, and it's something that's widely used in the medical profession, but it didn't start there. BMI was created about 200 years ago by a Belgium mathematician. So not a doctor, not a health practitioner, not related to health whatsoever. And it was designed to be able to calculate what the average man was at the time.

So at the time, the people that he studied to get this calculation that easily throws up a number, that's basically your height related to your weight, throws up this number and then you can be categorized. So it was the experiment and the calculations were done at the time on the average Western European man. So it didn't account for all sorts of different things like different cultures, different genders, anything like that.

It was all to do with Western European men and they were looking for the average. It had nothing to do at the time with health.

It wasn't in any way, shape or form a measure of somebody's individual health. It wasn't actually until about the 70s when Ansel Keys, who was famous for a lot of things at that time, there's got a lot of things to blame Ansel Keys for. He did something called the Minnesota Starvation Experiment. Which actually was very interesting because it showed us what happens when people go through the process of starvation, both physically and psychologically.

But also, he and a group of his colleagues actually promoted the idea of the BMI scale as a quick way to screen for obesity. And they categorized it that a BMI between 18 and 25 was considered healthy. Again, they attached that word to the BMI scale. If you're between 25 and 30, it's considered overweight. Over 30 BMI is considered obese. And those figures have sort of stuck.

And the problem is whatever number those calculations spit out for you, it really has nothing to do with health necessarily. You can be at a healthy weight, say a BMI of 23, and be very unhealthy. You could have lots of things going on for you health-wise, which are absolutely awful. You could be dealing with very, very big health issues. It just so happens that your BMI is 23. Likewise, your BMI could be 29, and you actually really don't have any health issues at all. You're active.

You eat a varied and nutritious diet. You know, your bloods would come up absolutely fine. There doesn't necessarily have to be anything wrong with you just because you present at that higher weight.

Anyway, back to Wendy, because we digressed a little bit. Back to Wendy. The big question is, I think, someone with a BMI of 27, should doctors be prescribing these injectables for them? And should you be asking for an injectable if your BMI is 27? And in all honesty, I'm a bit of a fence sitter when it comes to this because I can really see the pros and cons. I think the answer to that question is for some people, yes,

and for other people, no, which is, as I say, a bit non-committal of me. But... The pros, I suppose, if your BMI is 27 and you decide that your weight is in some way causing you a problem, whether that's causing a lack of confidence or whether you feel that you've got an inability to exercise because of your weight, who knows? But for some reason, you decide you would like to lose a few pounds, which when you think about it is almost universal.

This is what people are out there doing as we speak. People are dieting, people are doing all sorts of things to lose weight. They're going to the gym, all many and varied things. So what is it that makes us as a society think that going to your GP and saying, hey, I would like to drop a few kilos, a few pounds, can I have one of those injectables, please. Why is there such a stigma around using that method to lose those three kilos as opposed to going on a diet or going to the gym?

Why is that? Ask yourself that question. Where does this stigma, where does this bias come in where some members of society will say, no, that's not on? So why should someone at a BMI of 27 wait? Why? Why wait until they have health conditions associated with their weight?

We find this quite a lot in bariatrics because when I first started out in the industry, a lot of the patients coming through were at a very high weight, the sort of high weight where there were lots of health implications already for those people. And as time's gone on, I've noticed that more and more people are presenting for surgery at lower weights.

And what they're saying is, I don't want to be at the stage where I have diabetes, or I don't want to be so immobile that I'm having to use a stick or a walking frame or being a wheelchair. I don't want to wait until I've got all those health issues before I do something. So they're viewing the surgery as a preventative measure. And you would argue, and I haven't got any stats to back this up, but you would argue from a cost to society point of view, that's probably quite a wise thing, isn't it?

If we look at the sort of financial toll that we are all responsible for as taxpayers, that we have to pay for chronic disease, isn't it better maybe to get in early and say, hey, I'm going to have this surgery so that I don't become bigger and bigger and bigger as time goes by, if that's what's been happening to you over the last few years. And do the injectables fall into the same category? Why wait until these problems occur?

Why not do it now? And why have we as a society got a problem with that, where we think someone's not doing it in the right way, in inverted commas. A lot of people think that this is the easy way out. And this is something I hear all the time with people that come to me prior to having bariatric surgery. Their worry is, will people think this is the easy way out? Will they think I should have tried harder? Will they think I should have struggled for longer before I took the easy way out?

And there's a little bit of a question that I always ask around this.

It's a bit of a silly one, but it's a way of bringing this into context. What I discuss with people is, let's say I wanted to get to Sydney. So bear with me because this is a little bit irrelevant and out there, but it gives it some context and it makes me wonder why we don't judge this dilemma in the same way as we do people's weight. So let's just say I wanted to get to Sydney. Now, where I live on the coast of Australia is quite a few hours north of Sydney, but we have a local airport.

I can jump on a plane and I can be in Sydney in one hour. Obviously, there's a cost associated to that for me, but as far as being easy and time efficient, I can be in Sydney in one hour. If I didn't fly for some reason, I suppose my next option might be to take the train. Well, the train actually from here takes about nine hours. It's quite a long train journey. It stops in a number of places. It is, however, cheaper than taking a flight down to Sydney. So that would be another option for me.

Another option for me would be to jump in my car. That will take me about six and a half hours to drive to Sydney, but I've got other considerations. So there's pros and cons in all these different situations. I would have to pay for petrol. I would have to drive through the city, which might be difficult. And also I would have to park in Sydney, which is very expensive. So I would have to weigh up the pros and cons of doing that.

And then it gets a bit silly. And I always say to the people that I'm talking to, you know, these are silly options, but bear with me. The next option is I could ride a bicycle. So I could jump on a bicycle. It would take me, I've worked this out, one day and 11 hours to cycle to Sydney. Now, bear in mind, I couldn't do it in one stretch. So I would have to, again, weigh up the pros and cons. I would have to break that up.

Into, I don't know, and I'm not terribly fit, so I would probably have to break it up an awful lot. But someone who was a really fit and experienced cyclist might be able to do, I don't know, six hours cycling a day, eight hours maybe at a stretch. But you would have to factor in overnight accommodation and things like that. You would have to factor in, you can't take much luggage on a bicycle. And the last silly example is I could walk.

I could walk to Sydney. It would take me, get this, five days and four hours to walk to Sydney, but completely free of charge, apart from, and here's where the cons come in, apart from the fact that I would have to pay for five nights accommodation on my way down to Sydney, which would kind of defeat the object because that would cost way more than flying anyway. But do you see, all these different options to get to Sydney are all available to me. Each one of them has pros and cons.

But if I were to give you those options, what would you do in that circumstance? In all honesty, unless you've got a fear of flying, I imagine that 90 plus percent of you would say, well, I would fly. It's the quickest, easiest, most effective way to achieve my goal. And in this case, my goal is getting to Sydney. So let's flip this back to what we were talking about with weight loss. There are many ways that we could achieve that goal at, say,

a BMI of 27. we could eat as we do at the moment and we could go to the gym twice a day. There's pros and cons. There's costs associated with that, with gym membership. There's the time it would take to do that. But there are lots of benefits as well. Think how fit and strong we would become in the process of that. Would it actually, though, serve the purpose of losing weight?

Actually, it may not. Because if in the process of going to the gym, we are building muscle, and if we're not changing our dietary intake in any way whatsoever, and let's say for argument's sake, our dietary intake isn't great, then to be honest, no, we probably won't lose weight. So if weight loss is our goal, that is an ineffective way perhaps of achieving that goal. Another thing we could do, we could literally just stop eating. We could just eat fruit and vegetables.

Would we lose weight? We probably would. Are we actually providing for our body with great nutrition? We're probably not. Is there a cost to it? Maybe not because we're buying food anyway. We're just buying different food if we do that. Is it sustainable? I would argue, probably not. We could sustain it for a little while, but not very much longer.

So do you see where I'm going this? If our goal is to lose some weight, then why are we so judgy with the people that pick the most cost-effective, quickest option in order to achieve that goal? Why do we place judgment on weight loss when we don't place judgment with so many other choices that we make in life, like the trip to Sydney? We would never judge someone for flying. We would never say, oh, I see you flew to Sydney last week. Well, took the easy way out there, didn't you?

I mean, we wouldn't do that, would we? That would be crazy. And I think people would look at us as if we were mad. If we judged someone for flying and said, well, you could have walked, you could have cycled.

It's craziness. Yet, we judge that. We judge people with weight loss in a very, very strange way, I think. So in some ways, the pros, if you can achieve the weight loss you desire, let's say you want to lose 10 kilos, 20 pounds, and you can do that by using an injectable.

And in the meantime, time, you can really use that time of weight loss to maybe reassess your relationship with food, look at feeding your body really well at the other side of the weight loss journey with the injectables, because there is evidence that if you simply come off them and keep eating the same as you were before, you're going to gain that weight back. So you could perhaps really use that time to reassess everything.

And as the weight comes off you and you feel lighter, then you might say, okay, now I'm going to start exercising because it feels easier. I'm in less pain. I've got more energy now to be able to do that. And if on the tail end of the injectable, if you got down to a weight that felt really good for you, and hopefully you would have somebody monitoring that, because when I get into the cons, this might not be a good thing.

If you get down to an acceptable weight and then you come off and then you eat really well afterwards and you add exercise in on a daily basis, then the chances are maybe you can maintain that weight loss. And then in hindsight, would this have actually been a good idea? Who knows? The other side you've got to look at with the. Firstly, side effects. And something really interesting was said at the presentation, and it was said by the cardiologist that did the presentation to us.

And he said, and I really hope he was joking. Please be joking. He said, a lot of patients will come back complaining of side effects, things like nausea and things like vomiting. And he said that he says to the patients, that's part of the deal. How do you expect to lose weight if you don't have those things? And also, he was saying that if nausea is meaning that you don't eat very much, well, then that's the drug working as it should do.

And I must admit, my friend and I exchanged kind of what the hell looks with each other, because I don't think it's fair or reasonable to commit someone to an extended period of nausea just to lose weight. I don't think that's the way these things should work. But for some people, the side effects are intolerable. If you were feeling sick all the time, I think that's intolerable.

I don't think you should have to put up with that. And I don't think that's a reasonable suggestion as a way to lose weight. So the side effects are unpredictable. Some people report that they have no side effects whatsoever. Other people do report side effects. So that's going to happen on an individual basis. The other con, of course, is the cost. They are not without cost, these injectables. and for a lot of people, they are simply out of their price range.

The amount that you have to pay per month is considerable. And for some people, that's going to count them out straight away. There's also a potential for misuse. So. This is why you really have to be monitored by someone, by your endocrinologist giving you these drugs, by your GP, by a nurse, by somebody who's sort of in charge of watching how you go, because the potential for misuse of these is huge.

People that have eating disorders and want to get down to a very, very low weight and are seeing these injectables as a way to do so, I personally think there has to be a stopping point. There has to be a point where somebody says, no, that's enough. We're not going to prescribe these anymore if your BMI drops too low.

Also, we've got to consider weight regain. Again, if you use these injectables to get down to a particular weight and then you go, oh, great, I weigh such and such now, I'm done and I'll go back to sitting around doing no exercise and eating takeaway every night and drinking loads of sodas, you are going to regain the weight. It's as simple as that. So I think. As I say, I'm a real fence sitter with the injectables.

There's quite a few on the market at the moment. There's going to be more coming. These are in our lives for the foreseeable future until something else comes along. And they're already looking at the same medications and making oral alternatives. So there are a lot of people out there who don't like the idea of injecting and needles. So to get them to a stage where you can take a tablet on a daily basis and it will have the same effect for a lot of people is very appealing.

And I think when they go and have an oral solution, that the popularity of these medications will increase even more so. So they are with us for a while until some other wonder solution, wonder drug comes along that may do the same thing in the longer term. Who knows what that might be in our lifetimes. But these are here to stay. And I think we all have to make our own minds up about it. I don't want to sway anybody in either direction with these because we're adults, we get to choose.

If they're a viable solution for you and you like the idea, I think you ought to be able to go ahead without the stigma that some people are attaching to them. It's your body you get to decide. However, we have to be cautious. We should take them seriously. They are a medication, something we're putting into our bodies. We should know the risks. We should be able to decide whether we can tolerate the side effects. And at the moment, we have to consider whether we can afford them.

So it's a bit of food for thought. And as I say, the reason this came up was because of the presentation that I went on.

And the two things that really stuck with me out of that was prescribing them for someone with a BMI of 27 when there's evidence that that BMI is actually, unofficially, the healthiest BMI you can be. And also that idea that the side effects are the mechanism as in how they make this drug work and I don't think that's right. I don't think the cardiologist should have said that and I really hope he was jesting when he said that this is what he tells patients.

I really hope not because you should be able to use these without feeling constant nausea and without vomiting every meal that you try to eat. So that's all for this week. As I say, food for thought. Next week, I will have a guest with me. I'm looking forward to that one. Thanks very much once again for listening. Please, there's still time to get your votes in for the Women Podcast Rewards. I would so appreciate it if you could just take five minutes just to cast a vote for this podcast.

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