Lets Talk Skin - Dr Mick Crotty

Welcome back to Season 2 of Let’s Talk Skin 🎙️

In this episode, Dr Farah is joined by Dr Mick Crotty to dive into one of the most talked-about topics in health and aesthetics right now - GLP-1.

From what GLP-1 actually is to how it works in the body, Dr Mick breaks it down in a clear, no-nonsense way. Together, they explore the wider impact - from weight management to skin health, ageing, and overall wellbeing.

It’s an honest, informative conversation that cuts through the noise and gives you the facts — so you can understand what’s hype and what’s real.

If you’ve been curious about GLP-1 and how it might affect your skin and health, this is the perfect place to start.

Transcript

SPEAKER_00 0:21

I actually saw you on um future beauty. I was doing a talk after you and um I learned so much in that like space of time and I'm I'm a GP or chain GP so you know I I have a little bit of knowledge about uh obesity and anti-obesity medication, but really after listening to you I I knew nothing. You know, it's it turns out that I didn't didn't know anything about it. But let's start off with an introduction. Um maybe if you could tell us a little bit about yourself and how you uh got into um what you're doing now.

SPEAKER_04 0:59

Yeah, so Mick Crowdie is my name. Uh I'm also a GP by training, uh, and then over the last kind of 10 or 15 years I've more uh specifically focused on obesity care, um, so medical weight management um and yeah, and that led to me uh transitioning from kind of normal GP work into kind of community-based kind of obesity care, which is what I do full-time now.

SPEAKER_00 1:23

Yeah, that's great. Just for people who are completely uh new to this, even even some doctors, um how like what what what is like what is the anti-obesity medications and how how would you describe it working by biologically?

SPEAKER_04 1:42

Yeah, so broad question. Can am I coming through clearly? You are sorry, my uh my your video is a bit jumpy on my side, but um yeah, so obesity management medications, uh most of them are based on kind of a natural fullness hormone that our body produces. Uh so they kind of mimic this hormone and communicate with the subconscious part of our brain where appetite and weight are regulated. Yeah, so we know that in people who are living with obesity, um, and when we say obesity, I suppose we mean excess weight that's having a negative impact on health. It's not necessarily a body mass index, it's not necessarily uh, you know, being a certain size or shape, it's uh that I'm living with excess weight and it's having a negative impact on my medical metabolic health, my physical functional health, my psychosocial health. Uh so health is impaired. Uh so when people take these medications, it communicates with that part of the brain. Where with many people with obesity, there is a dysregulation of appetite in the brain, there is hyperactive reward pathways uh in the brain for food. So we're kind of you know, we're dealing with this kind of biological drive to take in more than our body requires a course of time. And these medications treat that area of the brain to essentially kind of level the playing field for people. Um, and and most people as a result then male uh less hungry, fuller quicker, fuller for longer, more satisfied by food. They're not thinking about food, and I suppose more recently people will describe it as uh kind of the food noise reduces, they just don't have the same um you know constant kind of uh uh intrusive thoughts about food and dieting and uh and restricting things.

SPEAKER_00 3:25

Yeah, and how does this dysregulation come about? Is it something that you know I suppose uh traditionally people would say, well, just stop eating and you lose weight, you know. But can you tell us a little bit more about this dysregulation and how you know a person might have difficulty controlling that?

SPEAKER_04 3:44

Yeah, so I suppose there's there's many different reasons why somebody might live with obesity. Uh, genetics plays a huge role, somewhere between 40 and 70% of our risk of whether we're going to develop obesity over the course of our life is genetically linked. About 80% of the genes that are associated with obesity are coding for what's happening in that subconscious kind of caveman, cavewoman part of our brain, the hypothalamus and the limbic system. So those parts of the brain genetically can be predisposed to people having a problem. And then any number of things over the course of our life, from you know, our childhood, puberty, pregnancy, menopause, medications, adverse life events, you know, pain, sleep, you know, lots of different things can affect weight. And we can't ignore the environment we live in, yeah, the availability of ultra-processed, calorie-dense, kind of cheap, convenient foods. So I suppose the way I like to think of it is our biology has evolved to help us survive in a world where food is scarce. Now that biology is meeting an environment where we are stressed and we're not sleeping, and we're commuting, and we're more sedentary, and we're sitting in front of screens, and we have access to, I suppose, energy and nutrition that a caveman would be delighted with. Um so the combination of genetics, biology, environment, and life experiences is how and why people develop kind of you know the weight they are. Uh, and then the real challenge of it all is that irrespective of how my weight gets to here, once I'm here, now my body is defending this weight. So, you know, we're not supposed to lose weight, uh, and our biology will defend the higher level. It's almost like we have this thermostat, this set point, this memory in our brain for weight.

SPEAKER_01 5:26

Right.

SPEAKER_04 5:26

Um, and and you know, most people I meet have have done diets, they've lost weight lots of times before. Yeah, but the weight tends to come back over time. Um partially because what they're doing is not sustainable, not healthy, kind of, you know, not a long-term option, uh, partially because life gets complicated and they don't have the same energy to engage in some ridiculous diet. But a lot of it then is to do with kind of changes in our biology, you know, changes in hunger hormones, fullness hormones, metabolism, craving, reward all get upregulated in order to get our weight back to where it was before.

SPEAKER_00 6:00

Yeah, okay. Yeah, that's I mean, I suppose when you look at you were talking about the diet and how we're we're eating a lot of ultra-processed foods, etc. But you know, if you go to the shop, it is actually really difficult and really expensive to buy whole foods, isn't it? It's it's just that's just the way it is at the minute, and it's so much easier to reach out to the ultra-processed stuff because it's quite easy to fill you up temporarily. Um, but yeah, and so you were saying like an appropriate candidate, like an appropriate patient to to be prescribed these kind of medications is someone who has obesity that so uh excess weight that's impacting their health. So you know, it doesn't have to be erased BMI necessarily. That's what you were saying, yeah?

SPEAKER_04 6:45

So I suppose there's the light well, there's the licensing of the medications. So medications are licensed for uh and where they're proven to be safe and effective is in a cohort of people. So in the clinical trials, they looked at people with a BMI greater than 30 or greater than 27 with a significant weight-related medical issue like blood pressure, cholesterol, diabetes, uh severe arthritis. So that's what's in the licensing of the medications, and in those cohort of people, we know that these medications, when used appropriately, are safe and effective. Uh now, again, you know, as a healthcare professional, I might meet somebody who's got a BMI of 28, I might meet somebody who's got a BMI of 34, you know, and and you know, BMI doesn't necessarily tell us about health. We need to look a little bit further. So I would consider kind of BMI as a screening tool. Yeah. And then if somebody has an elevated BMI, we need to look a bit further. We need to look at, you know, maybe, you know, what's their waist circumference, you know, where is excess weight being carried. We need to look at kind of how it impacts on their health and well-being.

SPEAKER_02 7:46

Yeah.

SPEAKER_04 7:46

And if health and well-being are affected, then I suppose that's the more modern definition of obesity. But if somebody has a BMI less than 27, then really we don't have good safety data about the use of medications in that cohort of people.

SPEAKER_02 8:01

Yeah.

SPEAKER_04 8:02

So that's the challenge is kind of where we have the evidence for safety and effectiveness. Uh, but then it on a case-by-case basis, it's it's all about for me, uh I suppose balancing up the potential benefits to somebody's health from treatment versus the potential risk from treatment. And on a case-by-case basis, if the benefits outweigh the risks, then then it's something to consider. Um and and then I suppose it's it's about kind of you know, people understanding what are the risks, what are the costs, and how it should be used. Uh, and usually the biggest sticker for people, you know, is the fact that these medications will be required lifelong. Yeah. That they're not a quick fix, they're not a shortcut, they're not a short-term intervention, it's not like doing a diet. Yeah. Uh these are like taking a testosterone medication, a blood pressure medication. Uh, it's like taking an inhaler for asthma. It's the same kind of principle that they will be required long term.

SPEAKER_00 8:56

Yeah, and I suppose, you know, I I've actually referred a few people down your way, you know, but they they worry them the main worry is about taking it lifelong, you know. Um what how would you how would you describe that to someone who is considering um any of these anti-obesity medications? Like, you know, that it is safe, I suppose, you know, what what what what would you say to that to kind of alleviate the fears about having to take it long term?

SPEAKER_04 9:27

Yeah, so I suppose these medications have been around for more than 20 years in the treatment of diabetes. Uh, we've been using them for maybe kind of 10-15 years for the treatment of obesity, and then there's newer medications coming around. So we have long-term data about safety and effectiveness of the medications. If we kind of look at it, I suppose the commonest side effects people and issues people were into initially are going to be kind of gastrointestinal issues, so nausea, heartburn, constipation, diarrhea, um, they're they're the commonest things, and and they're kind of they can be navigated by focusing on patterns of eating, food choices, slow kind of titration of of the dose. So that's kind of you know quite manageable. But for some people, they the medication won't suit them. Uh, for other people, you know, they'll have uh very few of those side effects. Longer term, if somebody loses a significant amount of weight, uh then weight loss can contribute to people developing gallstones. Okay. And two to three percent of people on these medications will develop issues with their gallbladder. Uh, about two in a thousand people on these medications can encounter something called pancreatitis, which again is is not insignificant, it's potentially dangerous, uh, but it we we feel it's the medication causes weight change, the weight change causes gallstones, the gallstones cause pancreatitis. So, you know, if I lost weight through, you know, keto or intermittent fasting or a restrictive diet, yeah, then potentially similar things could happen. As far as kind of longer term, we have reassuring data, you know, on the safety long term. Um, people shouldn't use these medications if they are currently pregnant or considering a pregnancy. Uh, they shouldn't use them if they're breastfeeding. So contraception is going to be very important. Uh, but really for me, it's it's balancing up okay, long term, what's the potential side effect and cost of the treatment versus what's the potential side effect of not treating somebody? Absolutely. So if I meet somebody and they have high blood pressure, high cholesterol, pre-diabetes, then the long-term kind of consequence of not treating that person's obesity is potentially cardiovascular disease, progression to diabetes, and health issues. Equally, I suppose if I meet somebody and their weight is at a certain level and it is impacting their health in certain ways, how might that weight affect their health in 10 years' time? Absolutely. So I'm particularly considering is a progressive issue. So it's balancing up risks, benefits of treatment versus no treatment. And and then for many people, it's it's talking about you know how they need to be focused on nutrition and movement and sleep and stress while on these medications. Like we talk to people with you know with high blood pressure about salt and sleep and stress and exercise. Um, other things would be then kind of you know, for many people, medications may not be uh an effective treatment because different people respond differently. So talking about things like bariatric surgery, which is another fantastic treatment for people, too. So it's presenting different treatment options, talking about the pros and cons, and then finding the right treatment for the right person, you know, yeah, which which can change up.

SPEAKER_00 12:21

Absolutely, it's life-changing, you know, once once you get into it, but you do have to make the some changes yourselves as well. Um is can I ask you a question? The the pancreatitis and gallstones, is that from the rapid weight loss, or is that um a bit of the medication and the rapid weight loss?

SPEAKER_04 12:43

So I suppose we we know gallstones uh um happen when people lose weight, they're more likely to happen if people lose weight rapidly. Okay. Um many people living with the BC might all might might already have gallstones because they've done every diet that's out there, they've done the meal replacements, they've lost weight multiple times before. So they might already have the gallstones and then they go on a medication, lose weight, and the gallstones become aggravated. Okay. Um so so weight loss causes gallstones, but I suppose with these medications, because people potentially can lose a lot of weight, and some people may lose it quickly, then that's where kind of the the risk of gallstones arises. And that's why you know I'm looking at this when I meet somebody, I'm looking at it as a 40-year project, not a 40-day project. Yeah, so so again, you know, there is no rush, you know, we don't kind of crank the dose, we don't go at it uh, you know, too aggressively. Um but you're trying to kind of get a balance for people. Yeah. So you know, if people are losing weight rapidly, might they lose more muscle mass? That's another kind of consideration with these medications, and that's why you know, when on these medications, people need high protein, they need resistance exercise to try and maintain their muscle. Um, so it's not all about weight loss, it's actually should be much more around health, maintaining health, improving health, function, quality of life long term. Um, whenever I meet patients, I tell every single patient, I'm not going to make you skinny, I'm not gonna make you happy, uh, because that's not what happens. Uh we potentially can uh improve health, we can improve function, we can improve quality of life. Um, but you know, many people, even with these treatments, may not be a weight they want to be, they may not be the weight they need to be for their health. But these are treatments that are kind of incrementally over time kind of moving people in a in a positive direction as far as their health.

SPEAKER_00 14:30

Yeah, absolutely. I suppose to explain to some of the listeners that might not necessarily understand the importance of protein intake and muscle preservation, you know, I suppose uh if you could tell us what happens to the body of someone loses weight too quickly with relation to you know muscle loss, etc., that might be helpful for some of the listeners.

SPEAKER_04 14:52

Yeah, so I suppose when we lose weight, whether we lose weight with a diet, with a medication, with bariatric surgery, weight loss, uh, there is always going to be a percentage of that weight that is lean mass. And some of that is muscle, some of it is connective tissue, some of it is uh fluid. So if we look kind of at some of the studies, uh and and most of the studies are looking at muscle volume, so how big my muscle are my muscle is rather than actual muscle fibers. But uh in the studies, somewhere probably between 25 and 35 percent of the weight that people lose on medications uh is lean mass, so and and a high proportion of that then is is muscle. And there's a couple of considerations. People living with obesity uh in general have more muscle because they're carrying around a heavier load, so they have more muscle, so they potentially have some to lose. Uh but if people are losing weight more rapidly, if they're not getting adequate protein or resistance training, then the concern will be they will lose more muscle. And muscle is going to be vital for our health, our stability, uh, metabolic health, you know, for long-term avoiding things like frailty, uh, falls, osteoporosis, you know, and different things. So we want to at all costs try and preserve muscle. So, which is why our hope is that if people lose weight kind of gradually and they're also focused on nutrition and movement, uh, that we will mitigate some of that muscle loss. But interestingly, in the studies, despite people losing some muscle, they still become fitter, healthier, more functional. Um, so so that's the challenge. And again, if we look at muscle volume, so the size of muscle, muscles have some fatty tissue in them. And when you lose weight, potentially you lose some fatty tissue from within your muscles as well. So, so which is why the volume of muscle might might get smaller, but actually the number of muscle fibers may not reduce by the same amount. Um, but equally, this is the exact same discussion if somebody is going on a restrictive calorie-controlled diet. It's the same discussion if somebody's having bariatric surgery. The medications don't, in and of themselves, do anything kind of detrimental to muscle. It's that when we're losing weight, we lose some muscle. Yeah. Um, but what we don't want to run into is an issue where uh long term people are becoming frailer, they're becoming uh, you know, that you know, skinny arms, skinny legs, um, you know, because of loss of huge amounts of muscle mass. Sacropenia, I suppose, medically is what we think about. Um, and and that's where I suppose if somebody is not living with excess weight, so let's say somebody doesn't have a significant amount of excess fatty tissue and they take one of these medications, then potentially a much higher percentage of weight that they lose is going to be muscle because they don't have as much fatty tissue to lose. So that's why, and and then if somebody stops, if somebody stops the medication and our body weight goes back up to its original level, potentially we're regaining fatty tissue but not muscle. Right. So if somebody took the short term, lost fatty tissue and some muscle, stopped it, regained weight, but predominantly fatty tissue. Now they're back at their original place, but their body composition has deteriorated, their health has deteriorated, which is why these are not kind of short-term treatments, they need to be long-term.

SPEAKER_00 18:05

Yeah, makes uh sense. And like I suppose you you have a lot of information, you go through everything, you know, you tailor a program specific to the person, you're looking at the uh metabolic uh function, you you know, the risks going forward, etc. Um like what are your what for the listeners that are maybe choosing the easy option of buying um prescription products online? Um what what is your advice to them? You know, I know we can just log in online, I know people buy them online and just use away without considering all the possible risks, I suppose, without this in-depth assessment that you would have with them necessarily, do you know?

SPEAKER_04 18:47

Yeah. Yeah, and it it terrifies me. Yeah, it keeps me up at night, to be honest, uh, that that this is happening. Like you wouldn't go online and source chemotherapy for your cancer. No, you wouldn't go online and source kind of blood pressure medications.

SPEAKER_01 19:02

Yeah.

SPEAKER_04 19:02

Uh, because again, who knows what treatment is right for somebody and what's appropriate. So I suppose the challenge is, in my view, if we are considering these medications, people are smart. People need to have information to make a good decision for their own health. Uh, and to get that information, I think we need a proper assessment, looking at what is somebody's history, what is their weight history, what is their medical history, how is weight affecting them.

SPEAKER_02 19:27

Yeah.

SPEAKER_04 19:27

Um, looking at kind of, you know, is it appropriate for somebody to take medication? Then they need to know what are the side effects, what are the risks, how to use it. They need to be able to go to somebody if they're having a side effect, having a problem. Like you would kind of, you know, if if if I start somebody on a blood pressure tablet in general practice, you know, again, it's not a case of here's the tablet off which you and I'll see in five years. It's a case of, you know, come back in six weeks, we'll recheck your blood pressure, we'll see if you're having side effects. So, similarly with these medications, people need support, they need guidance, they need to know what's normal and not normal. Uh, they'll need to know how to navigate kind of the challenges that will arise, they need to know what to expect. That, you know, they'll they'll initiate the treatment, they'll navigate the side effects, then they'll be in a phase of response where weight is changing, health is changing. Eventually, weight is going to stabilize and they will stop losing weight and their appetite will come back a little bit, which is totally normal on these medications. But then people think it's not working and they stop the medication. So normalizing what they should expect, you know, trying to kind of you know foresee challenges, and and then there's always going to be things that happen in life that make things more complicated. Absolutely. So it's it's kind of looking at that and saying, okay, how do we navigate that?

SPEAKER_03 20:36

Yeah.

SPEAKER_04 20:37

And looking at, you know, the person, you're looking at the person, you're not looking at a number on the scales. Uh, it's interesting, a lot of these places people can go online, you know, you have to have a picture of yourself standing on the scales, but they don't ask you for a picture of your height. So they're just they're just interested in weight. And yeah, like even with these medications, you know, when you follow up somebody and you say, How are you doing? The first thing people will tell you is how much weight they've lost.

SPEAKER_01 21:00

Yeah.

SPEAKER_04 21:00

And we kind of really need to park that because it's really important to know why are people losing weight? Is it because they're feeling sick all the time, they're averse to food, they're miserable, which can happen.

SPEAKER_01 21:10

Yeah.

SPEAKER_04 21:11

Or is it because they are having a regulation of appetite, they're feeling well, the food noise has improved, and they're able to focus on good nutrition and movement. So, you know, one of those things is a side effect, one of them is a benefit. Both will cause weight loss, but one is more healthy than the other. So, so again, it's it's kind of supporting people to know what's happening and to know kind of you know when when they encounter challenges. You know, should they, you know, it's not a one size fits all, it's not gonna be the same medication, it's not gonna be the same protocol for increasing dose with everybody. So it's about kind of tailoring it to the individual.

SPEAKER_00 21:44

Yeah, yeah, absolutely.

SPEAKER_04 21:45

And that's what we do for every other area of health, you know.

SPEAKER_00 21:47

I know, it is it is scary. And um what was I gonna say? I mean, for me, I I'm trained as a GP. I left GP about three years ago and I work in medical aesthetics, and you know, like that people People are, you know, what's scary about it is people are using for like a source of knowledge is TikTok. Like people are looking at TikTok for advice about skincare, uh, injections, and you know, all this kind of crack. So it's the the education part, I suppose, it's somewhat lacking, and um, I suppose we could just do our best and try and support that. Um but can I ask you just to kind of um get back into do women come into you worried about their skin laxity? Like are they worried about this isempic face? You know, is that something they ever bring up with you or or or is that something that's just left at a later stage? Do you know for women that have a lot of extra weight? Yeah.

SPEAKER_04 22:48

Yeah, yeah. So so people do bring it up. Yeah, and it's interesting again. You hear about a Zempic face, a Zempic bottle, Zempty hands, that's a Zempty everything. You hear about nature's a Zempic. So that's that's kind of a brand name uh that people that's it's in the zeitgeist now and kind of it's applied to everything. Yeah. Because actually, it is weight loss related changes in your body composition, distribution of weight. So if people lose a significant amount of weight, whether it is with medication, surgery, you know, lifestyle intervention, the same things happen. It's not any more uh with kind of medications than any other intervention, it's it's a function of how much weight people lose.

SPEAKER_01 23:25

Yeah.

SPEAKER_04 23:26

Uh so you know, for most people, with the usual response to medication, so if we're thinking like semiglutide, where somebody might see maybe a 10 or 15% body weight change, if we're seeing kind of pterzepitide where somebody might see on average up to about a 20% body weight change, in general, for most people, uh that percentage of weight change is is not usually going to contribute to significant issues with skin laxity and excess and excess skin in general. Most people, it's probably going to be something they'll encounter when they start seeing a 25-30% kind of body weight change. Okay. If people are losing a lot of muscle mass, that's that's where they can kind of notice some kind of laxity as well. Equally, then it's it's a bit like you know, in pregnancy, uh, you know, uh skin changes are very much kind of their genetic, they're they're individual. There's very little people can do to kind of avoid it because it's a function of how much weight they lose. Uh obviously, we hope that if people lose it more gradually, it's more healthy and more sustainable, but but we don't have good evidence for that.

SPEAKER_02 24:27

Yeah.

SPEAKER_04 24:28

Um, and and again, I suppose the the challenge is that that can be a side effect for some people. Change in my relationship with food, change in my kind of pleasure from food, again, it can be a side effect. I would see these as side effects. Uh the that's why this has to be balanced by a significant benefit to health. It's not about getting people to a certain size, a certain shape, a certain weight, it's about improving their health and well-being kind of long term. Uh, so if somebody has an improvement in their function, their medical metabolic health, you know, their their brain space, that they're not constantly kind of having this uh this kind of internal food noise, then then that is justification for some of the kind of the the side effects people might uh experience.

SPEAKER_02 25:11

Yeah.

SPEAKER_04 25:11

Um but it but again it's it's it's it's a balanced kind of conversation. Um but it the hope is you know if people are are doing this in a sensible, supported way, that uh should minimize that. Yeah, yeah. But definitely people yeah, and and again, back to your point about kind of social media, a lot of the concerns are driven by this scaremongering that happens on social media uh you know uh about you know adverse effects and side effects. Um and and like we don't see it, you don't see people doing TikTok videos on the side effects of a blood pressure tablet or an inhaler, um, but yet we see it for we see it for obesity management medications, and and there it's very interesting because again, a lot of that is weight bias, it's weight stigma. Somebody living with obesity is blamed and shamed for having excess weight, it's it's put down to a lack of personal responsibility, whereas it's not.

SPEAKER_00 26:11

You're frozen there for a second.

SPEAKER_04 26:18

Are you back because the the challenge is speaking to somebody who is educated and knowledgeable on the topic, and uh certainly we're doing a lot, kind of the Irish College of GPs is doing a huge amount around educating GPs, particularly because if we can if we consider that you know 25% of the Irish population uh potentially are living with obesity, you know, up to 50 or 60 percent of the Irish population have overweight or obesity, you know, these are not kind of uh medical issues that are going to be treated in specialist centres, you know, it's it's it's going to be treated kind of in the community, and then it's known what is safe, what is appropriate, and how to kind of counsel and guide people. But the big challenge it takes time, you know, it takes a conversation.

SPEAKER_00 27:02

Absolutely, and it takes a a lot of time because as you say, like we've gone through a lot of different kind of things to consider before before before starting these medications. From my like point of view, I do see some some women, you know, a good few women that maybe would have had a lot of excess weight previously, and you know, because they had a lot of excess weight, they they did have a lot of excess weight loss leaving their body quite loose and you know, lax. And I'm wondering is that uh, you know, and for for these, you know, they're kind of looking at isolated treatments for like their arms and their fingers and your stomach, but would really like it they really need surgical intervention to remove the excess skin. And I suppose is that something that I suppose that will come into part of your follow-up discussion, etc., for for somebody who was going to have massive weight loss.

SPEAKER_04 27:57

Yeah, and and I I suppose to date with the medications that are available, it it's not something we commonly see. It's probably much more common after bariatric surgery that people would encounter it uh because bariatric surgery is a stronger treatment. People tend to lose more more weight, uh, and they have probably more excess weight to lose. So, so again, you know, it is certainly uh a consideration. The other part is, you know, many of us are conditioned to believe, you know, once my weight gets to a certain size, life will be sunshine and lollipops, and I'll be happy and life is still the same, yeah. Yeah, the same kind of life are there, but but that's not what we're sold in in society. Uh, excess skin can be an issue, and and things like compression hosiery um and garments are kind of very, very important from a comfort point of view, a movement to allow people to do physical activity. Uh, surgical intervention is going to be vital, but the challenge is uh it's very limited in its availability in Ireland. Certainly it's it's not available in the public system uh as it's as it stands. Uh it there is limited availability privately in Ireland. Yeah, it's considered it's considered cosmetic, which which it is not. It is quality of life, it is function, it is something that might limit somebody from from you know moving and exercising the way the way they want to, and it's it's can be very detrimental, you know, to some somebody from a psychosocial point of view. Uh so but yet it is still considered this aesthetic cosmetically issue, which which it's not.

SPEAKER_00 29:21

Yeah, and that's I suppose that's was my next question was was there a a pathway for them into plastics publicly, but you're saying no. Um I know there is um a consultant that's a plastic surgeon in the UK, I must actually send you on his details. He he he specializes in um transforming bodies that have so much excess skin overall, and he does it safely and he gets amazing results. But it just gives them more comfort, I suppose, you know, when they have all that excess skin carrying around. But um I'm sorry now you uh there was one other thing I wanted to ask you about I suppose GLP1s and their influence on inflammation, I suppose, beyond weight loss, you know, like your chronic inflammation, your chronic diseases, etc.

SPEAKER_04 30:10

Yeah, so I suppose how we think about obesity is changing. Now we think about obesity as a complex, progressive neuroendocrine disease. We think of it as a systemic inflammatory disease. So we know that fatty tissue and excess fatty tissue is pro-inflammatory. Uh so we look at our kind of inflammatory cytokines, our kind of inflammatory markers are elevated in people with obesity. It's really interesting if you look at things like arthritis, uh, hand arthritis, so osteoarthritis in the hands, yeah, is more common in people living with obesity. Now, we think of obesity causing arthritis because we're carrying around a heavier load and it's kind of loading our joints, but actually we we don't walk around on our hands, we don't wait there on our hands. But yet people with obesity have more osteoarthritis in their hands because they have systemic inflammation.

SPEAKER_01 30:56

Yeah.

SPEAKER_04 30:56

Um, and I suppose it is a happy and positive side effect of the medications in treating obesity, that we can improve inflammation, immune system. There isn't a system in the body that that obesity can't affect. So, medical, physical, you know, if we look at gastrointestinal, skin, respiratory, you know, reproductive health, like obesity affects all of these areas. And inflammation is definitely one common pathway by why it affects things. The challenge is that not every person has inflammation because of obesity. And if you look at the cause of obesity, how much of it is, or the cause of inflammation, how much of it is obesity, how much of it is nutrition, how much of it is you know genetics, it's it's very difficult to tell. And one of the things that I see happening is that online, particularly on social media, you will have a lot of people saying, Oh, we're going to treat the insulin resistance, we're going to treat the inflammation with these medications. Well, we don't want people to lose weight, but we're going to treat your inflammation with them. Yeah. And potentially giving those medications to people who don't have obesity under the guise of treating inflammation, which, if you scratch the surface, is really just diet culture 2.0. It is actually just kind of putting a medical veil on wanting to cause somebody to lose weight. Yeah. Trying to get them into the body that they kind of strive for. At the moment, we don't have safety, effectiveness, kind of data from randomized controlled trials looking at use of the medications in that way. So if somebody has obesity and we treat them, inflammation can improve. If a person is not living with obesity and they have inflammation, medications would not be indicated. So this is the challenge, but but that's where that's where it gets really nefarious online. In that kind of like we're now conditioned to think insulin resistance is the cause of all the world's problems. Inflammation is the cause of all the world's problems. God forbid, like perimenopause is like a boogeyman that's hiding in a closet ready to jump out at women. But it is this is what, and then God, none of us are getting enough protein, none of us are doing much, like it's constantly fear-mongering around these areas, and some people will have challenges, some people will not.

SPEAKER_01 33:04

Yeah.

SPEAKER_04 33:05

But but the the like you know, and particularly like we would see so the commonest person that will be seen in a weight management service is a woman. Uh, the commonest age is going to be between the age of 40 and 60, because that is the population who is the most targeted with weight stigma, bias. You know, we shouldn't be getting older, we shouldn't be gaining weight, we should be kind of young forever. Uh, and and kind of there is so much of this scaremongering about perimenopause, loss of muscle, uh, inflammation, insulin resistance, and and these medications sometimes are being promoted to kind of try and manage that in somebody who doesn't live with obesity. And now, maybe in 20 years' time that is how they will be used, but at this moment in time, that's not based on evidence, it's not based on science. And and again, this idea of microdosing, which like you know, in general practice, you don't talk about micro-dosing a statin, micro-dosing a blood pressure tablet. We just use low doses, and we always start with low doses, but yet online you'll hear about micro-dosing GLP1s, and it's it's almost kind of you know put out there as in, well, it's not really a medication, there's not really side effects because you're only taking a little bit, which is not the case. Like, this is a prescription medication, but it is it is people pushing an agenda, you know, using these medications in a way that they are not proven to be safe or effective for their own purposes. And I spend a lot of time talking about obesity, so that is excess weight that's affecting health, yeah, versus the cultural desire to be pin.

SPEAKER_00 34:39

Yeah. Completely two different things, yeah.

SPEAKER_04 34:42

Socio-cultural norms. And and now maybe somebody is living with both issues, yeah. And and there's nothing, I'm I'm not judging, and there's nothing wrong with something wanting a leaner body, uh, but that is not what obesity medications are designed for or proven to be safe and effective for.

SPEAKER_01 34:59

Absolutely.

SPEAKER_04 35:00

But uh and one of the concerns is like and you probably see it as well online, we've really lost control of the narrative around these medications from the medical side of things, because there are people who who kind of are not healthcare professionals who are kind of talking about these in in other ways. Or or you know, you will have many people who might be experts in their own obesity, who've been on a journey with their own obesity and treatment and responded in a certain way, and they're they're talking about that. That doesn't necessarily make them experts in everybody else's obesity or anybody's. Absolutely.

SPEAKER_00 35:32

I mean, there's so many other factors to consider. I know, I know, and you see the same with with um, you know, skin treatments, etc. You know, people comparing like for like, and you know, it's not like for like, you know, there's so many other factors to consider. But what the other thing I see popping up a lot on Instagram recently is supplements, people to buy supplements and shakes to go on, especially if you are if you are on GLP1, you need this. You know, what are your thoughts on that?

SPEAKER_04 36:01

Yeah, so there is no good scientific evidence or guidelines around the requirement for supplementation when on these medications.

SPEAKER_01 36:09

Yeah.

SPEAKER_04 36:09

But people are seeing a gap in the market, and and you know, they're they're kind of trying to address that. Uh, in general, uh, again, many people when they're on these medications, you know, traditionally they're not so restricted that they can't kind of consume a balanced diet.

SPEAKER_02 36:24

Yeah.

SPEAKER_04 36:25

But people need to prioritize protein, prioritize fiber, prioritize real foods, get enough water. Uh, if somebody just can't in their day-to-day kind of integrate enough protein in their diet, then it's reasonable to supplement it. But it should be supplementation, not replacing my breakfast or lunch or dinner. Yeah. Um, because again, kind of, you know, protein powder, protein bars like these, these are again processed foods, but we'll we'll accept kind of ultra-processed in one way, but then not in it another way. Yeah. So we would advocate that people would would, you know, focus on healthy eating, real foods, uh, in general, as much as is possible, uh, you know, kind of get getting their nutrition in that way. And then if if it's not possible, then you know, supplementation, but there's no good guidance uh or evidence for use of these uh supplements. Yeah, if you're and and that's where you know I think a lot of people, if they are struggling to get their protein and their requirements, then then they need to be seeing a dietitian to kind of guide them on that. Yeah, I'm a GP, I'm not a dietitian. I wouldn't dream of giving somebody kind of you know detailed nutritional advice because it's it's outside of my field.

SPEAKER_01 37:29

Yeah.

SPEAKER_04 37:30

Um so so again, that's where we need, that's where the the multidisciplinary aspect of this comes in.

SPEAKER_01 37:35

Absolutely.

SPEAKER_04 37:36

You know, for me, a dietitian's role is not weight loss. A dietitian's role is nutritionally supporting the person uh for their health. Uh, a psychologist's role is not weight loss, it is psychologically supporting the person uh, you know, for their health. And that's why, you know, you see, let's say on an oncology team in cancer care, you have a dietitian, you have a speech and language, a physio, uh, a social worker, a psychologist. They're not treating cancer, they're supporting the person. And increasingly, that's the way we think about obesity is that you know, a medication or a lifestyle intervention or bariatric surgery is treating the person's obesity, and then they need these additional kind of supports to further health, you know. Um, so it's it's not just taking a medication, it's it's a medication to regulate my biology to facilitate me putting into practice the knowledge I have, but then I may also need support nutritionally, psychologically, kind of with movement kind of uh as well.

SPEAKER_00 38:30

Yeah, absolutely. Um the last thing I'll I'll finish on this because I'm sure you are busy and you have your clinic to go to, etc. But what I had recently was a lady just coming in and she was having a conversation about her friend who is on this weight loss journey. And um, but what she did was what her friend did was she went online, she looked up what type of bariatric surgery she would like to get. She had a consultation, one consultation online with a doctor abroad, and was accepted for this of her own choice, by the way, without all this information. Went abroad, got her surgery. Can you please tell our listeners the dangers of doing that?

SPEAKER_04 39:15

Yeah, so bariatrical surgery, when it's done appropriately, uh with proper assessment, proper counseling, proper understanding of what it means and how it will impact on life, and proper follow-up is a very safe procedure. Uh the problem is when it's done without proper assessment, when people don't know what to expect, what are the potential risks and benefits, how they should approach food, how they should be eating. Like the number of people who return from abroad and they're contacting clinics or they're contacting support groups looking, you know, what should I be eating, what should I be doing? Which is information they should have had in advance. Yeah. So again, no more than medication, surgery is not a cure, it's a treatment, uh, but a treatment that changes our biology so that we can engage on the things we need to engage on. Yeah. And people need that support. Again, uh, I suppose from the medical side of things, you know, if people run into uh issues with side effects or problems, and and their clinic is abroad, I suppose, you know, do they have the the support they they require? Um, but uh and and it's not uh it's not one size fits all. Like there are there are some clinics who do things uh in quite an evidence-based way, there are other clinics who don't. The problem is it's very difficult for me as somebody who's a relative kind of interest and dare say expert in this area to tease out what is a reputable, decent clinic versus one that's not. So, what chance does a patient have of kind of absolutely, yeah, absolutely. And the marketing, uh I suppose that's the other challenge, is these are often heavily marketed, particularly to younger women. Um, is that that's where the algorithm is picking up, that's where the the marketing is focused. Um, and potentially people who are feeling quite vulnerable, uh, who have other issues going on. Uh, there is potential implications for you know fertility, pregnancy, you know, in the future. Uh there is there's lots of potential implications. So again, we're we're all you know, you will see the before and after photos, you will see the body transformation, yada yada yada. You don't know anything about that person's journey, you don't know any if this is a real or photoshopped, you don't know kind of how is their mental health, how is their nutrition, how are they feeling? Are they having side effects? So we're getting promised this body transformation, but it but equally, you know, you won't see a before and after photo for blood pressure. Oh, here's my sphigamonitor with kind of the higher blood pressure, here's my normal blood pressure. Yeah, you know, it's it's not celebrated in the same way. Um and but the marketing is so aggressive, uh, is so challenging, you know. Um, and and you can understand people are desperate for treatment, they want to improve their health, their quality of life. And if they can't get it in a way that is affordable and and accessible here, you know, they're they're advocating and they feel feel they're doing the best for themselves going abroad. The challenge is again back to information, they're just not getting all of the information they require to make an educated decision.

SPEAKER_00 42:04

Absolutely, and potentially detrimental to their health as well and well-being. Um but yeah. So what was that was so interesting? I I really enjoyed uh chatting to you today, and I'm sure my listeners will be very interested in um learning more about this too, because you know, uh I think every day in clinic there will be somebody I'll be speaking to about um possibly being you know, seeing somebody about um getting started on GLPs or you know, anti-obesity medication. Um but again a little bit of stigma still around obesity, like mental health, that's like, oh, you know, we don't want to talk about that or we'd be too embarrassed to talk about it. Um can you tell our lists how they can see you? Or what is your process? Yeah.

SPEAKER_04 42:49

Uh if if they want to, if they just want to see me, then uh we're on Instagram, mybestwit.ie is uh the Instagram. We do lots of kind of educational videos and just talking about obesity in general. Um obviously I have my clinic in Docky in Dublin, uh, and we see people in person, we see them remotely by video consultation when when it's appropriate as well. Um so that's kind of um obviously a private clinic uh that that I run as well. Um and and I suppose the the challenge with all of this is is you know, this obesity is a lifelong chronic disease. People will need care and support. So a lot of people, you know, the biggest challenge is starting a conversation in the first place, whether that is with their GP, with a specialist, it's it's kind of you know, uh, I never underestimate the uh the bravery it takes for somebody to come in and have these conversations because it because they can feel quite vulnerable. Uh so that's where I suppose for me, you know, I treat obesity like I treat blood pressure cholesterol diabetes. It's no different, it's not a person's fault, it's a medical issue. They deserve treatment, it's just about finding out what treatment is right for them. Um, and and again, you know, my hope is in the future GPs will be resourced to treat obesity, you know, through um uh know the HSE that they will have you know chronic disease management for obesity they will have access to kind of treatments as well so we need to push for that because again I I can't see everybody uh in in the country but but that that's you know where things need to go and then I should pre be seeing the people who have more severe complex kind of issues going on. Um but yeah I I think for me uh you know it is all about the conversation it's all about the kind of shared understanding of things and then you know uh whether or not that person wants to consider treatment and what that means for them.

SPEAKER_00 44:30

Yeah. And do you have a waiting list or do uh or can people see you relatively quickly?

SPEAKER_04 44:38

Yeah we're we're not too bad. We there is myself and we have a number of other doctors who work in my clinic as well. So uh so we're doing okay on on the waiting as usual in a couple of weeks people can get in get in get in to see it. So there's no major pressure on on appointments at the moment which is good.

SPEAKER_00 44:51

That's good. No that's good accessibility is so important too and it's great that you have other doctors um you know like yourself that people can go to and get like proper advice from um about this important subject but thank you so much uh for taking like for joining us and doing this and um I will yeah thanks a million