The Big GLP-1 Debate: What the Science ACTUALLY Says

GLP-1 medications such as Ozempic, Wegovy, Zepbound and Mounjaro have become one of the most controversial topics in health and fitness.

Are they “cheating”? Are people with obesity simply lacking willpower? Are these medications safe? And what does the research actually show about weight loss, appetite, muscle retention, metabolic health, and long-term outcomes?

In this episode, we sit down with Dr. Spencer Nadolsky for a comprehensive, evidence-based deep dive into GLP-1s. Rather than relying on social media opinions, we examine what the scientific literature says about:

• How GLP-1 medications work
• Expected weight loss outcomes
• Effects on hunger and appetite
• Muscle loss and body composition
• Safety and side effects
• Long-term use
• Common misconceptions and myths

As always, our goal was not necessarily to promote and sensationalize nor condemn and dismiss GLP-1s, but to provide an objective discussion of the current evidence so you can make more informed decisions.

If you’ve seen strong opinions online and wanted a balanced explanation grounded in research, this episode is for you.

P.S., If you want to support us and would like monthly lifting workouts, you can join the Momentum by Sohee fitness app. http://momentumbysohee.com

If you are interested in fat loss science, you can purchase Ben's best-selling comprehensive fat loss book, Everything Fat Loss. http://geni.us/EverythingFatLoss

Transcript

SPEAKER_04 0:00

Today we're joined by special guest, Dr. Spencer Nodolski, a board-certified obesity and lipid specialized physician. You may know him as the Doc Who Lifts. He is the founder of Vineyard, an online, all-inclusive, metabolic, and weight loss medical platform that specializes in DLP1s. Alongside his brother, he co-hosts the podcast Docs Who Lifts, where they talk about nutrition, fitness, and medicine through the lens of two physicians. Spencer's goal is to show everyone that lifestyle is medicine. How are you doing, Spencer?

SPEAKER_01 0:26

I'm great. Thanks for having me in. That was Vladin trying.

SPEAKER_03 0:30

I was nervous.

SPEAKER_00 0:31

That was like a whole penny. You did it. No wonder it took so long. You did it.

SPEAKER_03 0:36

Did I miss anything important? I feel like I covered the main stuff. You did it. College athlete, division one athlete, right? Wrestling.

SPEAKER_00 0:44

Father of three.

SPEAKER_01 0:45

Has been doctor of memes.

SPEAKER_00 0:51

So I'm particularly excited for this episode. I know that lots of people are excited for this because when we have posted QA's requests on our Instagram stories, the number one topic that I have been requested has been GLP ones. And I my policy is even if I'm well read on this, a personal trainer talking about medicine is not legit. That is outside of scope of practice. It's dangerous territory. I would prefer just not to do it. So when people message me and say, hey, I've got a question about Azempic, could you blah blah blah, I always skip it. So I'm particular, particularly excited to have you on. But also, I want to proceed this by saying that this is probably quite a controversial episode because so many people have opinions on GLP ones, and I know that you get a lot of backlash online when you talk about them. Even when you talk about them from a what I think is a fairly innocuous angle.

SPEAKER_01 1:47

Yeah. Reasonable stuff that I say, people get mad at anyway. So it doesn't matter what I say at this point.

SPEAKER_00 1:52

So I think maybe the nice caveat or disclaimer at the beginning of the episode is when you talk about medications, I think a lot of people will be like, I have read that there are some bad side effects. We'll talk about that later. But then the flip side of that is some people get really good results. So you have people from two opposite ends of the spectrum who have very uh personal, strongly held beliefs. So when you talk about medication, some people are like, I can't believe that you're promoting this. Why are you not telling people to lose weight naturally? Whereas other people are saying, I don't like that you are talking about the downsides of this because for me it was amazing. And I think it's hard, it's hard. It's a hard balance to uh strike, I guess. But I'm confident that we can do a good job on this episode.

SPEAKER_01 2:40

It's gonna be great.

SPEAKER_04 2:41

First things first, we're gonna cover the basics of GLP1s. Yeah. Give us a basic primer on GLP ones that a five-year-old could understand. What does it stand for? What do they do? And what is the mechanism through which they work?

SPEAKER_01 2:52

I don't know if I could explain this. I think about my kids and how young they are.

SPEAKER_03 2:55

Okay, maybe 12, 12-year-olds. Yeah, some around 12. Yeah.

SPEAKER_01 2:58

But GLP1, glucagon-like peptide one, yeah, a natural hormone that comes from our intestines that basically helps our pancreas do its job, gets more insulin out, gets the blood sugars down. I like to tell the story that when in the 1960s, they were doing experiments to see what would happen to insulin release when people would drink some glucose versus injecting it straight into the veins. And I always say, like, I would think that if you injected glucose straight into the veins, you would have a larger spike of insulin uh because it was getting to the the uh glucose, it's getting straight to the pancreas. The pancreas releases the insulin to help get the sugar into the cells. But it turned out that the people ingesting the glucose had a larger spike, and they called it this incretin effect, like an intestinal secretion of hormones, something about the intestines. And it was years later, a couple decades later, they started figuring out the different types of incretins. It's a really cool story, but um uh one of them was this GLP1, glucagon-like peptide one. So, yeah, what it does is basically helps your pancreas make more insulin. Um later on, they started figuring out all these other things it does in the body, including some appetite regulation. And so the issue though is that it gets broken down very quickly, like within one to two minutes by this uh enzyme that we have in our body. I know we're talking about like this is for people just trying to learn a little bit. If anybody cares, it's called DPP4. You don't really need to know that, memorize it, but it gets broken down very quickly. So then big pharma trying to figure out how to utilize this, they're like, oh, can't just put big bags of human GLP1 and infuse people all day. So uh there was this um this Bronx VA physician doing a research project and found the Gila monster. I don't know if you guys know what a Gila monster is, these little lizards. And people out there listening to this media go, oh yeah, the lizard venom, we're injecting lizard venom. Well, he was interested in this because these Gila monsters go like a long time without eating. And I don't think it ended up having anything to do with them not eating, but they f found a part of their their venom or their saliva um looked like GLP1. Oh and so they got a little component of it called Exodin 4, and uh they saw it was resistant to that DP the DPP4 enzyme, it was resistant to being broken down. So that ended up being a few years later, being the first GLP1 in 2005 approved called Bietta or Xenotide. So the big pharma then had to figure out how to make GLP1 modified so that it lasts longer in the body. And then through the years, um they modified it more and more to what we have now, these super drugs. But basically, um they originally made for type 2 diabetes. They weren't broken, you know, these inject the GLP1 receptor agonists, they're not broken down by our own enzymes, so they can last longer. And our pancreases uh they helped our pancreas make more insulin and actually protected the pancreas. There were more there were drugs in the past that would like supercharge our pancreas and burn them out, but these actually helped save our pancreatics of the beta cells, they're called. Um, and then they helped people lose weight, whereas the other drugs that helped you make more insulin made you gain weight. So it was like a really big deal back, you know. I was like in med school when these things were coming out, not to not to date me.

SPEAKER_03 6:28

Way back when.

SPEAKER_00 6:30

Way back when, you know. Um so the intro gray, obviously, for people what let's have it as like an umbrella. So GLP ones are a category, yeah, and then you have specific compounds, and then you have drug names. So just fly through them super quick, just so people are like, oh, that's the one that I've heard of.

SPEAKER_01 6:51

So people think of Ozempic, that's semaglutide, it's the same medicine as Weigovi. Ozempic is is branded for type 2 diabetes, weGovy is for weight management. Ozempic, though, has become like the Kleenex, though. So everything's like an Ozempic. Yeah. Even though that's it's that's semaglutide. And that's actually a little bit later of a generation than like that Bietta I was talking about. They're multiple generations past that. Um, and then we have terzepitide that people know as Monjero or ZEP bound, and that's actually uh a dual incritin coagonist, meaning it they they took the one of the other incritins that are out there, not just GLP1, but GIP, and kind of modified this molecule peptide to hit both receptors. Yeah. So it's not just a GLP1, but everybody calls it a GLP1 anyway. Um, and so that's that's the other really popular one. And then the one that everybody's talking about right now is called retatrutide or tomato tomato retitrutide. I don't know. I was gonna say I was gonna say we can have a whole discussion on that because I've talked with Eli Lilly and and Novo Nordisk, and actually everybody pronounces it differently.

SPEAKER_00 7:57

I feel like with all of these, people say like semaglutide or semaglutide. Okay. Yeah, people I think people will, even if they don't necessarily know about GLP1s, they don't want to care about how they work, blah, blah, blah. People go, ah, Azempic. And I think it's important to realize that Azempic is, like you say, the most well-known, but it's part of a family. Yeah. So kick things off super quick. Who are they for and who are they not for?

SPEAKER_01 8:24

Yeah, so they originally indicated for type 2 diabetes, and you know, they knew through animal studies that there was an effect on appetite and obesity, and uh it was actually one of the earlier generations, the Lira glutide, that they were in 2014, where is first approved for weight management. So we have both type 2 diabetes and a weight management FDA label indication. Now, type 2 diabetes is pretty plain and simple if you diagnose this criteria based on blood sugars, various types of blood sugar tests. But obesity before was very what they call anthropometric, meaning like if you have a BMI of 30 and above, you're on label for this. Doesn't matter what anything else, BMI of 30. And then they said if you have a BMI of 27 plus what's called a weight-related comorbidity, meaning anything related to weight. So high blood sugars, high blood pressures, uh sleep apnea, obstructive sleep apnea, urinary incontinence, reflux, anything like knee arthritis, hip arthritis, uh, lipids, those those types of things. You could have a 27 plus one of those, and then you'd qualify. You don't have to have the 30. So that's technically what it was on label before, but over these years the definition of obesity has not been so clear-cut because you can't just take a BMI cutoff because there are actually people with who are thinner but metabolically unhealthy because they're storing their fat differently from someone else. And so anyway, the the gist is though, it's supposed to be currently used for type 2 diabetes and obesity.

SPEAKER_00 10:04

We have just done uh not that long ago an episode on BMI and discussing why some people might be in a higher BMI category, but like you say, have no comorbidities or quality of life issues, whereas some people could be in a lower category but have worse health risks. So hopefully people will be on board there.

SPEAKER_04 10:23

Yeah. What about what are the most common side effects of GLP1 medications?

SPEAKER_01 10:27

Yeah, so the most common side effects are GI related by far. Nausea number one. And actually it's it's highest at the beginning when you start the medicine, and every time you kind of go up the dose, and you look at the trials that you see these the line graphs of uh people reporting nausea, and it's like spikes at the beginning. And then over time people get used to it and it starts going uh lower and lower. And actually, it when they originally came out, people are like, the reason people are losing weight is because they're so nauseous and they're throwing up. Okay, that's classic. Yeah, that's yeah, it's it's it does contribute maybe a tiny bit. They've actually, through the studies and looking and reporting, they've teased it out to a very small percentage of the weight loss can be explained by nausea, but the nausea goes away for pretty much most people. Yeah, it can be minimized with nutrition um and lifestyle and proper titration of the medicine. So, like a lot of the trials, and the reason that people were getting this is because on the label it just makes you go up in the dose every every month. Uh, and the trials were written that way, like you just they're just gonna crank you up no matter what, which you're like, I'm feeling terrible. Not a good idea to go up on the dose, but that's the way those studies were originally. They've changed them now to where people, if they're doing all right and don't want to go up, they can stay at the lower dose. So um, you really can minimize it though with like lower fat types of foods in the in the beginning. People are like, what I can't I can't eat a pizza. It's like you can, and patients can stress test it in the beginning, like wings, chips, pizza, whatever. But like I always caution, I'm like, you can eat these things later, and if you want to try it now, but like just be prepared. You could get a lot of nausea from from that. So with proper nutrition and proper titration, you can usually minimize it in the beginning, and then eventually it just it goes away for pretty much everybody. That's by far number one. Okay. Number two would be number one for prevalence, not severity, right? Yeah, although, yeah, I would say you can get like most people, it's mild to moderate nausea. Once in a while, people get severe nausea, they're throwing up. My thing is like with our clinic, we're very proactive, so like the nutrition and all that stuff's there, but like I want to make sure people don't have to go to the hospital because that's where it's like, that's where you see all the bad reports, and then they never want to use the medicine again. So um we we can use anti-nause medicines if they're really doing poorly, but sometimes they get like refractory nausea and vomiting, and they gotta get a bag because that's where you see oh, kidney problems. Well, the kidney problems are from people getting dehydrated from uh from vomiting and not being able to drink anything.

SPEAKER_04 12:59

When when the nausea is more severe like that, is it because their dose is too s too high to start with? Or is it even if they start more conservative, that can still happen?

SPEAKER_01 13:08

It can still happen. It's rare that that type of thing happens, but it happens. There are people probably watching this going like, oh yeah, that happened to me. I see. But I see it a lot when people were already kind of feeling bad and they went up in their dose and they should have just stayed at the same dose. And sometimes insurance forces them to go up because of the way the studies were done. Oh, because they're they're they're following the label, yeah, and the FDA label. It's like interesting. So now, but now the new it's the good doctors did this originally, but like the big thing now is like just don't go up if you're if you're losing weight at a at a good rate. Yeah, yeah. Um, but yeah, I uh I I did want to go back to like what the what they're originally you know used for, like the before the side effects though, like type 2 diabetes, like these things are remarkable at lowering people's blood sugars. And then for weight loss, uh the reason that they're such a big deal and that people are going crazy about them is because lifestyle we see around five to six, maybe seven percent total body weight loss on average over the course of a year, and people like I lost 100 pounds doing lifestyle. It's like, yeah, we're looking at averages with like big randomized intensive coaching trials. Um, bariatric surgery on the other hand, somewhere around 30 or so percent. So then with when we go v. Symaglutide, the first in 2021, this first trial started coming out, it was like about 15%. So it was all of a sudden we had something between lifestyle and bariatric surgery. And then now with like terzepatite is like over 20%, a little bit over 20%, and then Retta is close to 30%. So I just wanted to go back to that because it's like these things are quite remarkable in their effects on not only blood sugar but weight loss. Yeah, but the side effects can happen. Um, this the second most common side effect we see is like constipation.

SPEAKER_00 14:55

Yeah.

SPEAKER_01 14:56

So nausea is high in the beginning and then uh goes away over time. Constipation, though, is constant, like so you have to stay ahead of it.

SPEAKER_04 15:06

So as long as you're on the medication, you're probably gonna have constipation issues.

SPEAKER_01 15:10

And it won't, it just won't go away on its own like nausea will. And so really focusing on fluid fiber, obviously, and then physical activity. The things that are already good for weight loss, like basically make sure you're definitely doing that. Like, yeah, because and if you have some constipation, assume that it might worsen a little bit. It's not usually so bad to where like you gotta go get disimpacted at the ER or something like that, but you do want to stay ahead of that. Um reflux, we see a lot of reflux if you have a history of reflux, and that the the medicine slows down the gastric emptying, how how readily your stomach releases um contents into your intestines. And so, like if you have reflux and things are slowing down, it has more of a chance to come back up.

SPEAKER_04 15:57

Right.

SPEAKER_01 15:58

So usually it gets better over time, but if you have bad reflux, it could worsen.

SPEAKER_04 16:02

Yeah.

SPEAKER_01 16:02

Those are like the most common things. Sometimes we see some diarrhea. Um uh beyond that, though those are those are pretty well managed though.

SPEAKER_04 16:11

Remember in the guest lecture a few months ago, you mentioned I don't know if I'm pronouncing this correctly, anhedonia.

SPEAKER_01 16:17

Yeah.

SPEAKER_04 16:17

Is that common, would you say?

SPEAKER_01 16:19

So uh so I just we're just publishing a case series on it, and uh I was just it was just like the Washington, I was quoted in the Washington Post and I did something on, I think it was ABC, and like Lily and Novo Nordisk, who everybody thinks I'm a shill for, and I I am in certain ways. We'll get to that later. We've got that question. But they were they asked them, they're like, there's no data to support this, and I'm like, well, hold on a second. You guys in the studies, you actually have to look for it. So it's like if you're not looking for it, of course, there's not really any data. And the patients, what I noticed is the patients were.

SPEAKER_00 16:53

We need a quick definition because it's oh yeah, yeah, yeah, yeah.

SPEAKER_01 16:55

Yeah, totally. Okay, and hedonia, not like depression, it's it's like a lack of motivation. You just kind of feel meh, like kind of indifferent about things. You don't want to do any hobbies, but you're not depressed. It's like a like a disinterested, yeah. You'd but you're but you're not like you you're not feeling sad, you just kind of feel like meh, you're like nothing. Yeah, your feelings, you're not you don't have highs, you don't have lows, you're just kind of there. And I I I noticed this in some patients once I started getting to the higher doses, and and they wouldn't have said anything until I started just asking them like what's going on. Like one patient was just mentioned, you know what, I just haven't been exercising recently. I'm like, when did that start? And I noticed it started when we went up to the highest dose. And I was like, okay, that's interesting. And I was like, maybe this is just a one-off. And and you know, the thing is like seasonal affective disorder, like seasonal kind of depression can kind of look like that. It's not a seasonal affective disorder, usually isn't as severe, and so you kind of get a little anhedonia with that. Uh and anhedonia can be a part of a of a major depression, it can be part of it, but it's not the whole um thing. And I start asking a few other patients, I'm like, How are you feeling? They're like, I feel good. I'm like, but how are your hobbies? Like, I start and all of a sudden more and more were starting to say, you know what? Now that you say that, I haven't been cooking as much, which you think with the medicine you don't cook, but like they still enjoyed hobbies, yeah. Hobbies gardening, planning, planning events. They stopped, and they were like, Yeah, I don't, I I just noticed I haven't done that as much. And I was like, Okay. So I started taking them down in their doses and they started to improve. I'm like, okay, there's something weird here. Then I made a uh a TikTok and a uh Instagram about it, and all of a sudden people are coming out of the woodwork. In fact, more of my patients who saw it were like, that's me. So I don't I don't think it's it's not super common, but it I and there's biological plausibility, meaning like the drugs work in the brain in parts of the brain that um that have to do with pleasure and the reward center with dopamine. And like I'm not a neurobiologist, I know enough to be dangerous, so that's why I work with with the case series. I got one of my neurobiology friends to go over the science because I'm like, I don't want to say something stupid.

SPEAKER_03 19:11

It's not like you're being responsible here.

SPEAKER_01 19:12

I'm trying to be because I'm like, you know how people go out of their wheelhouse and I'm like, I I know enough to be dangerous here. So but there's clearly something going on. I think if I had to guess, maybe around 10, 15% of people would would get that. It's not a high number, but you really have to ask them. Like it won't show up on a depression screening.

SPEAKER_02 19:33

Yeah.

SPEAKER_01 19:34

Um and so I think that's why like there's no data for that. Like, well, you gotta ask them, you gotta actually search for it. Um, but that I would say that is that's one of the I don't want to say it's a weird side effect, it's one of the side effects that I've seen that like just isn't really talked about as much. I think it's being talked about now more. Yeah. And there are a few other things, like uh people are getting like UTI like symptoms once in a while.

SPEAKER_02 19:57

Yeah.

SPEAKER_01 19:58

Without they don't have UTI though. There's no bacteria, there's no infection going on. They just feel like that same UTI like kind of doesn't feel nice. Yeah, like they have to they feel like a little bit of urgency, like they have to pee, and a little maybe a little bit of burning and uncomfortable. Um and and when I talked about that on online once, a few urologists were like, we're looking into this because we saw the same thing. Bizarre. And so I think we're gonna see some more come out of that, but that's relatively rare as well.

SPEAKER_00 20:26

So we have a couple of questions about specific side effects that are very uh well discussed and argued. Oh yeah. But I think just quickly before so he asks the first one, this actually I think leans into part of the reason why so many people are skeptical of medications, because when a medication hits the market, like you say, you kind of have to study for some things before you know whether they're there or not. So when you start hearing cases like, well, people might feel that they're maybe not depressed but going towards that direction, I think it leans into that that fear that people have that we don't quite fully understand what's going to happen. Um so I just think it's it's kind of worth acknowledging that just because a side effect might not have been very well discussed at the moment, it doesn't mean that you're not looking for them.

SPEAKER_01 21:19

Yeah, I mean, because they they've looked at mental health and they they show on average, it looks like overall mental health actually improves, like anxiety improves greatly. Um, usually depression usually is alleviated or not worsened. They've they were worried about suicidal ideations. There were some case reports out there, and what it looked like, if anything, there's either no effect or maybe there's an improvement there in quality of life. But yeah, the the Sanhedonia thing's really interesting. It's the really high doses, usually, and it's relatively rare.

SPEAKER_04 21:49

Yeah, that's good to know. Let's move on to body composition and health. Do GLP ones cause muscle loss?

SPEAKER_01 21:55

Yeah, this is one of my favorite questions. Uh there's somebody that went um Um on the national news and made a big deal. Yeah, I saw you responded to that one. It was like now it's been a few years. And it was like, well, wait, wait a second, you gotta be careful about what you say, because like basically what happened in one of the in the early Weigovi trials, the somagide trials, the step one trial, they did they do a subset of patients got DEXA scans versus placebo. And it was very small. It was like a I don't know if it was like a uh a twentieth or tenth of the patients got it. Not very many. And I don't know how they even selected who got DEXAS and who didn't. And it looked like they lost something around 38, 39%, what's called fat-free mass. Um and everything that's not body fat for listeners.

SPEAKER_00 22:44

And it doesn't necessarily muscle tissue.

SPEAKER_01 22:46

Perfect. You should actually, you know what, you should have my uh you should have Grant Tinsley on last episode. Yeah, he's my chief science officer and he does all our research on body composition. He'll be able to explain it better, so I'm not gonna uh butcher it. But it the DEXA scans don't look at muscle directly. Uh you can kind of infer it based off of um um the the different tissues, but it's it can't look at muscle directly. Um but they usually you see only like 25-30% in in weight loss trials. So I was like, what's going on with semaglutide? Well, I don't know. These things do have fluid, they can cause fluid shifts and glycogen water can looks like fat-free mass. So is it possible that? I don't know. But terzepatide though, a more powerful drug that has more weight loss and has the same kind of GLP1 effects, but it has that GIP effect that I was talking about too. That was only 25%, right where you'd kind of expect it to be. And then now there have been more and more studies with MRIs and all this stuff, looking like it looks about what you'd expect if somebody were to just do a calorie deficit, whether it's bariatric surgery or diet without exercise, by the way.

SPEAKER_02 24:00

Yeah.

SPEAKER_01 24:01

We are running our it's called a prospective study, meaning we're not we're not randomizing people to like no lifting weights versus lifting weights. We're just giving them our program and watching what happens to them. And we did a case series as well. Um, and so far, I I and from what other people are my followers are telling me, it looks like if you lift pretty hard, you can usually cut that in half. So instead of you know 25, 30 or so percent uh fat-free mass loss, uh, you can cut it down to like you know 15 or so percent. In our case series, though, they someone gained gained fat-free mass uh and muscle. They were getting stronger.

SPEAKER_04 24:43

They were recomping, recomping.

SPEAKER_01 24:45

And then the other big controversy is is like, well, are we even measuring the the right thing? Like, shouldn't we be measuring like function and like how they're doing? Like, I I make a joke on, you know, I make these stupid jokes on Twitter about like, oh yeah, well, they're sorry, their fat-free mass uh went down quite a bit, but um, you know, now they didn't have a heart attack, now they didn't, uh now they're able to uh do pull-ups. Like I have patients that even you know, we watch their body fat and composition, most have improvements, but sometimes they still lose uh what looks like a a bit more on the on the DEXA scan, but they're they're doing pull-ups and deadlifts now more than they've ever done before. And so it's like are are we measuring the right thing? So that's a big controversy. But basically, the the more they look at this, it looks very similar to like if you were just a diet without exercises.

SPEAKER_04 25:38

Standard calorie deficit. Yeah. So would you say then it's not that the GLP ones inherently cause muscle loss, but if obviously it puts you in a sustained calorie deficit and you're not resistance training with high effort, that would then lead to obviously less preservation of muscle mass.

SPEAKER_01 25:53

Yeah, no, that's that's exactly right. It's just it's in regular life without these medicines, it's really hard to sustain the calorie deficit. And there there are there's some suggestion that there may be some uh mitochondrial benefit in the muscle, but like you know, the people studying it are are very cautious to make these claims because there's just kind of some preliminary things that it looks like if anything, it would be beneficial, but they're they're not gonna make that claim until they look further.

SPEAKER_00 26:21

Um what about bone loss?

SPEAKER_01 26:23

Yeah, it's it's pretty much the same answer.

SPEAKER_00 26:26

Um I feel like I should say bone density rather than bone loss. Like people aren't randomly losing bones, but you know, I just lost your femur. Your femur's gone. Your femur's gone. Yeah. Uh yes, same kind of thing. So like people might have seen I've just that sorry, I didn't mean to interrupt. It just it reminded me of the viral image of a bone that looks like a sponge.

SPEAKER_01 26:46

Yeah. That was so I did that video because I was like, are you kidding me? I'm like, I I actually did the reverse lookup. I'm like, what is this from? The only thing I could find it was that viral social media post, meaning someone used AI to generate this where they on the it was like a surgical um table where they were cutting things out and putting it on like specimens. And they had one that was like solid, and then the other one that was like so porous it looked like a sponge. Yeah. And I'm like, what? And so the gist is that like, yeah, you're gonna lose bone mineral density as you lose weight. And they've they've looked at this and it doesn't look like doesn't look any different than if you were not to resistance training. In fact, there was a study with one of the older drugs that Lyraglutide I was talking about, and the resistance training cut cut like minimized completely like I I don't know if it completely resolved or completely eliminated it, but it really minimized the bone mineral density loss, and which is you know, it's not not a thing like if you have an older, this is the concern, if you have an older um patient who has osteoporosis and they don't have if you're on the on the fence of like do they really need to lose weight? Like you maybe that would be harmful because you can it's not the medicine's not eating away their bones, but like just weight loss in general, maybe we shouldn't have this patient lose weight. Oh, I seem to be able to do that. So that's something we should consider.

SPEAKER_00 28:11

Because I think for anyone who's kind of unsure about this, just to super summarize, calorie deficits, especially aggressive calorie deficits, can result in loss of lean body mass and bone mineral density anyway. So if someone goes on a medication where they suddenly drastically reduce their calorie intake, it is very much expected that their lean body mass will go down. It's very much expected that they might lose bone mineral density. When you hear people on social media kind of fear mongering about this, the question isn't necessarily whether it happens, it's whether the medications are doing it above and beyond what you would expect from lifestyle.

SPEAKER_04 28:50

And the answer seems to be no.

SPEAKER_00 28:52

I'm I'm fed up with with people. The easiest way to talk about this is make a very scary video rather than here's what the research says on body mass loss. It's Ozempic is chewing up your muscle too. Shreds, they said shreds. They use that word.

SPEAKER_01 29:07

They're shredding your pretty extremist. Yeah. And yeah, if you try to do nuance, like reasonable you'll get 10 likes, you talk about shredding, you're gonna get tens of thousands of likes. Yeah.

SPEAKER_04 29:18

But take these peptides, and those are fine. The peptides are fine. We don't know where it came from. Sarcasm, please. Yeah. Okay. One of the criticisms about taking GLP ones for weight loss is that when you stop taking the medication, you gain the weight back.

SPEAKER_01 29:31

Yeah.

SPEAKER_04 29:32

Is this a valid criticism?

SPEAKER_01 29:33

Yeah, and this kind of goes into the idea of obesity being chronic, a chronic disease, and people get mad at that term. It's just it's literally just the definition of what a disease would be. Yeah. Um, so the chronicity, and you've talked about this on certain posts. Like you look at um when people lose weight, you know, Kevin Hall mathematically determined how much appetite was increased by how much.

SPEAKER_00 29:58

Uh one of his one of his studies was a hundred calories per kilo of weight loss.

SPEAKER_01 30:04

Yeah. And so we had him on a podcast, and I I explained my analogy, and he was like, okay, that's an okay analogy. He gave a better analogy. And it was actually really good. You gotta imagine um uh losing weight like you're pushing a boulder up a mountain, a hill, yeah, and it starts getting steeper and steeper and steeper. So you're you can only push it up so much. So let's say that's like lifestyle.

SPEAKER_02 30:25

Okay.

SPEAKER_01 30:26

The the GLP1 medicine helps push it up further.

SPEAKER_02 30:30

Okay.

SPEAKER_01 30:31

Even though it's getting stronger. So if you remove that, that like what you can call it, like a motorized, like I don't know, tractor or something helping you push behind you, or someone else pushing, like a superhero or something like that. Like a muscle man like this guy. Yeah, like this guy. Look at him. You remove this muscle man, yeah. And and all of a sudden the bold you can't hold that boulder anymore. Uh, and and that's that physiologic pushback via appetite. The boulder's coming down.

SPEAKER_04 31:00

You're going back to the back.

SPEAKER_01 31:01

Yeah, you're you're like, holy god, I can't. And and you can, and then you'll stop it right where you were able to kind of stop it before uh as much effort as you can. So when you remove the medicine, uh that appetite comes back and it comes back like it's you just lost all that weight. So not only do you have the appetite that you had before, but all that added appetite from losing the weight, because now your body's like, uh huh, you don't have your super muscly superhero over here uh helping you out. There now there are some nuances to this because the obesity doctors will be like, obesity is a chronic disease, you gotta everybody's gotta take this forever. It's a chronic medicine, just like blood pressure medicine. Okay, that's a good analogy, but there are people that can come off of it. There, I don't know, so maybe around 10% of people or so that take these medicines are able to stop the medicine, keep most of their weight off, at least for a year or so. And so um there's a whole I have a hypothesis of why those people, I think those are the people that didn't have the strong appetite issues in the first place. But some people can do it, but most of the people will regain their weight, and not everybody regains all of it. That's that's a you know, some of it, some will gain 30%, some will gain 50, 75, some will gain all of it, and there's small people may regain all of it plus some.

SPEAKER_04 32:17

Yeah, but I mean GLP1 medications are not meant to be taken super short term anyway.

SPEAKER_01 32:22

They're not supposed to be, so but people do that.

SPEAKER_04 32:24

Yeah, that's true.

SPEAKER_00 32:25

This I mean, in some ways, I want to skip my next question analysis instead. But one thing that I want to touch on is when you say obesity is a chronic disease, if you were taking high blood pressure medication, you wouldn't say, I'll take it for eight weeks and then stop. Exactly so when you say to someone, Well, this might be a lifelong medication, a lot of people get very angry about that because it kind of leans into the big farmers getting you hooked on their medication kind of thing. But a lot of that I think stems on people's interpretation of what obesity is. Yeah, if they view it as, well, you've just gained a few pounds, why don't you diet? It looks like people are taking a shortcut that they then need to be on that train ride for the rest of their life rather than viewing it as this is a medication for a disease. Um typically that's ongoing. Like my Crohn's disease, my medication is supposed to be for decades.

SPEAKER_01 33:19

Exactly. Have you heard talked about weight bias on the podcast? But like this is like the best example of because people don't get upset about people taking their blood pressure medicine. That's true. They get upset about this though, because it comes back to like we believe that weight should be moralized and that if you're not able to have a thinner body, you're just not motivated and you don't have any willpower, and you're just kind of a piece of crap. I don't know. People just think of that. I don't know, it's in our society. We have some questions on that coming up. Yeah.

SPEAKER_04 33:51

This is actually a really great segue to our next session section, which is on criticisms and misconceptions. Yeah. Right. Taking GLP1s is cheating. Discuss.

SPEAKER_01 34:02

Yeah. I mean, first of all, I always think about like when you think about cheating, like you usually think about a sport event where you got some unfair advantage to win something.

SPEAKER_00 34:13

That's a good analogy. That's a really good analogy. You know, right? Like, because if someone's taking a medication, what exactly are they cheating? Yeah. Yeah. Cheating at what?

SPEAKER_01 34:21

Yeah, I mean you think about like, you know, cheating on your partner, like they make it moral, you know? Like, but this is if you think of it differently, like, no, we're treating a condition. No, nobody thinks you're cheating your blood pressure. Take a blood pressure. It always goes back to blood pressure. It's just the easiest one to that's a really good analogy, though.

SPEAKER_00 34:39

Uh it actually reminds me of uh some people think that taking an epidural is cheating compared to nothing. Actually, yeah, because you have to endure the pain. It's like you're not getting any prizes for going through the pain.

SPEAKER_03 34:49

The baby needs to come out.

SPEAKER_00 34:50

That is literally why I said when So he was talking about whether she wanted an epidural or not. I was like, you don't get a prize for it being hard. That's true.

SPEAKER_01 34:57

That's actually that's good. And people do like have strong feelings about that. Like, think that epidural so you don't miserable. Yeah.

SPEAKER_04 35:04

And you don't think of this as a even my doctor, the day of when we checked in, basically said, I would struggle, I would strongly suggest considering it. Very much uh unless you've done special training to prep to do it without, it might be a really tough experience.

SPEAKER_00 35:19

Yeah, very much a kind of if the option is there to make it easier, why wouldn't you? And and I do get it because for a long time, people, if they wanted to lose weight and improve their health, lifestyle was the way or it was surgery, essentially. So now these groundbreaking medications have come along that have closed the gap on the average weight loss between lifestyle and surgery. It's like suddenly there's a shortcut that didn't exist before. And I think especially shortcut's the wrong word. I'm quoting what other people might say. But I think especially for people who have been there and done that, there can be a kind of an ingrained weight bias where they're like, Well, I did it through lifestyle, why do you have to take medication? kind of thing.

SPEAKER_01 36:03

Some of the people with the most weight bias are those who have been successful. I'm like, oh man, you should know. But like they because they've actually done it, they believe everybody can do it. And it's like, well, I don't know, you maybe their appetite is way worse than yours. I I think I like the genetics of it too, because like I can tell my body wants me to be thinner. Like same. I've talked about this like nauseum. Like and and I have patients, I have patients that exercise way more than I do, and they they count, they they do all the tracking way more than I put a lot more effort. They put way more effort into it. And they're in a body that's much larger with a lot more body fat. And it's like I'm kind of on cruise control, eating all my swarm and stuff. I don't I don't eat like I I don't eat like a bad dietary pattern, but it's like I don't count my cat, like I don't do any of this.

SPEAKER_04 36:52

Quite relaxed.

SPEAKER_01 36:53

Yeah. And so I don't think people understand that.

SPEAKER_04 36:56

I I really think it's this idea of, well, I had to work really hard to achieve my weight loss, so it makes me angry that the at the idea that someone else could achieve the same weight loss and have to struggle less.

SPEAKER_01 37:07

Yeah. Think about it, think about with like um think about in like other technology, like before we had to uh walk places. Yeah. Then all of a sudden we got horses, and then you did you play the Oregon Trail or whatever oxen and all that. Yeah, you're yeah, we well, we you know, we won the revolution. The revolutionary war, you wouldn't know that. Uh it's just a British American joke for anybody listening here. But um, but yeah, think about then like cars, trains, planes. It's like, no, you gotta you gotta hitchhike across the country to go from New York to LA instead of taking a train. I did it, you have to do it. Obviously, you want it to be safe. Like we don't want to just because you think about um you can think about certain drugs and whatever to we could start using it for like things that make you feel good. Oh, cocaine makes me feel great. I'm all up and I can do whatever I want. Obviously, there are some health issues that if you're taking cocaine and other drugs to make yourself feel a certain way, but these drugs aren't like that. They actually improve outcomes, they're very safe. So, like, why are we making it miserable for people just because we've moralized weight, I guess.

SPEAKER_02 38:20

Yeah.

SPEAKER_00 38:20

I think on the on the moral front, that's a perfect time to discuss a very common criticism of GLP ones in general is that they reinforce diet diet culture. What are your thoughts on that?

SPEAKER_01 38:35

Yeah, I mean, it depends on the context and what you're using it for, you know. So, like um a lot of the the popularity of these drugs on social media, they they got big because of like Hollywood stars. Yeah, and this was especially bad because there was a shortage a few years ago. It was terrible. I hope we never have this issue again. But these miracle drugs are out. Finally, people have hope. They're expensive, so only like the people that have a lot of decent amount of money can access them or they have good insurance. Uh but then the Hollywood stars started using them who didn't have any indication. Right. And when I say any indication, they didn't have type 2 diabetes, and they didn't have a an amount of adipose tissue or body fat on their body that was causing any harm. They were using it to lose, and they're still using it by the way, and it's getting worse.

SPEAKER_02 39:24

Yeah, yeah, I agree.

SPEAKER_01 39:25

Uh, to lose I'd call vanity weight. And and I say that in people people get mad because there are people with obesity and a lot of weight that they don't care about the health issues from it. They want to look better. And honestly, it's okay if they want to use it for those purposes because they're gonna get healthier and and at the same time. I don't care if what their reason is. But if people don't have a clinical reason for it and are using it for vanity purposes, that pretty much is is it's like a superpowered diet culture. Because now all of a sudden, instead of the grapefruit diet or whatever the heck crash fad diet that's out there, now they have something that like it works extremely well to the point where like yeah, you if they want to become a skeleton, I suppose they could.

SPEAKER_00 40:13

I can't remember I can't remember who it was, but I remember someone doing a Hollywood speech at whatever award ceremony and even making a joke that Izempik was making an appearance.

SPEAKER_04 40:23

Mickey Glazer. Yeah, she was the host of one of the this is how this is how I'm like what is it called? One of the award ceremonies.

SPEAKER_00 40:30

But I think I think especially at the moment because there is such a strong thinness culture in Hollywood and the fact that quote unquote heroine chic is now back in. Yeah. So I think when you see very, very thin celebrities kind of inadvertently promoting that Ozempik is the way to get there or whatever GLP one of their choice, I think I think it's important to acknowledge that that is a diet culture phenomenon, but that doesn't or shouldn't detract from people are using these to improve their quality of life. It isn't a it it isn't a weight loss drug, we'll get to this later. It isn't just you want to lose five pounds, so you're taking a medication. That I don't think should be how people view this.

SPEAKER_01 41:14

Yeah. It's un unfortunately like people are gonna I it was so obvious that they're it was gonna happen. Of course. It was so obvious. And you know, we can talk about the new myostatin inhibiting drugs as well, but basically the drugs that are gonna sh shut off the governor over muscle growth. And it's so obvious that bodybuilders and then people are gonna be abusing this as well.

SPEAKER_00 41:36

I've been reading about m like myostatin inhibitors for I don't know, decades. Like bodybuilders, it would be the holy grail.

SPEAKER_01 41:43

The holy grail.

SPEAKER_00 41:44

And now we now we have those are gonna they're trying to pair those with these drugs because like, oh gosh, we can prevent any muscle loss and maybe it was the same with Psalms where if there was if there was medication that might help retain muscle tissue in say elderly patients or injured patients or whatever, bodybuilders were on it immediately. I can build more muscle with this drug that hasn't really been researched. I'm on it. So any drug that has a any drug that has a body composition benefit will get abused by people who want to change their body composition regardless of health.

SPEAKER_01 42:21

Yep. And we can we can talk about the I've spoken about this before. There is a a harm reduction in bodybuilders using this versus like the clin butyroll and uh T3 and some of the other crazy drugs that they're taking. So it's like, well, these this is like not as harmful as those, and you know, maybe it'll save them from something, uh some sort of uh the anabolics that they're taking, maybe it'll help prevent heart attacks, I suppose you could look at it that way. But certainly I do think there's a big um push for the diet culture, but it doesn't, it shouldn't, like you said, detract from those who really need it.

SPEAKER_00 42:55

I think just quickly before So he asked the next question, I think T3 is actually a good example because no one would say that it's a bad medication. Like there are people who need thyroid medication, but if there is a weight loss consequence of that, bodybuilders use it. Even when I was in my probably teenage years, I heard people using thyroid drugs and like you say, Btra Agnes or Ambutra or whatever. So uh yeah, it being abused doesn't immediately invalidate whether it's uh useful for other people.

SPEAKER_04 43:28

Yeah, I also think it's important to emphasize that viewing GLP1's medications as necessarily perpetuating diet culture is quite a one-sided myopic view of it. Uh especially if you as you were saying, ignore all the other health benefits that can come out of it when used responsibly. But yes, there is a problem of it being abused and misused, very much so. And that's I think a very worthy conversation to have. Yeah. Yeah. I'm gonna ask this, I'm gonna try and I don't know why. It's making me laugh.

SPEAKER_00 44:01

But I already know your answer. Okay. We have we have to ask it because people people care. They don't understand this.

SPEAKER_04 44:07

Are doctors paid by big pharma to promote GLP1s?

SPEAKER_01 44:11

Yeah, no. So no, it's a great it's a great question because I get I s I'll make it on like once a week or every other week. This is why I had to ask it. I see people sending you a pharmaceutical. I'll post it on threads like just a reminder, we don't make money. Now the nuance there is that you can become a consultant. So I did uh one year ago, I did a consulting uh thing for Novo Nordisk where I went and talked with like their whole team about how I would use their medicines and what I what my patients tell me and they paid me what $6,000 for the day.

SPEAKER_04 44:45

So it's like, well, that's not so bad.

SPEAKER_01 44:48

Yeah, you can and it's it's all you can look it up.

SPEAKER_00 44:49

It's good it's um I thought the brown envelope would be big enough.

SPEAKER_01 44:53

I wanted one of those golf tournament size checks, honestly, to put in my car when I left. Yeah. That would have been ideal. Um but you can actually go on uh you can type in open payments and type any doctor's name. Now the thing is like you can do you can do speaking for um big pharma. You can like like I could sign up to do this for like the Lily or Nova or or even other drugs, and you can do like they're called pharma rep um like dinners. And the doctor goes and they get paid a few thousand dollars to do a talk. And they're very strict though, you can't talk about off-label usage, or it's it's you have to stay on label, you're just basically teaching other doctors, and the big pharma will pay for that. But at no time can you prescribe something that's FDA approved and get what's called like a kickback, because people are like, You you prescribe this, you make money off them. The only way I make money is my patients pay me to see me, and I tell them whatever if they can should have the drug versus not have the drug, regardless of diet and exercise stuff.

SPEAKER_04 45:59

That's that sounds like you're simply being a physician.

SPEAKER_01 46:01

Yeah, so it's yeah, and so and that's it. So then people are like, Yeah, but people come to you because they want to get the medicine, and I'm like, I know, but they would come to me for diet and exercise too. Like, my I'm a diet and exercise shill, I guess, as as well. I don't know. So, but but there there's another thing, but the actually the people um you can sell compounded medicines in some doctor's offices, they you can buy the compounded version at a very low cost, and now they're outlawing the compounded versions, and there's a whole that would take hours of discussion. But uh at one point you could compound this G OP1 medicines and you can buy it at a low cost and sell it to to your patients at a much higher price. I don't think that's ethical because we're not supposed to get paid because then why would you kind of being a wholesaler?

SPEAKER_00 46:52

You're buying in bulk and then reselling.

SPEAKER_01 46:53

So the ethical dilemma is oh, I'm gonna make more money giving them this. Well, I'm screw the FDA approved version. I'm just gonna give them this and I'll make more money because you don't make money from the FDA approved version. So it's a little bit of unethical stuff there. And then obviously the peptide people online, they're you can get my coupon code in my in my bio. And these some of these people were making tens of thousands a month or more.

SPEAKER_04 47:21

And you don't have to be a medical doctor to plug them in the end.

SPEAKER_00 47:24

Yeah, this is one of those things that I think it's really important for people to understand. So there have been influencers, including myself, who have been approached and emailed from companies asking if we want to sell GLP1s or peptides or whatever. That is not the same as a doctor prescribing it. So if I was signed up to a company where I'm promoting a GLP one, it is not in the same way that you're prescribing it. It's compounded, etc. So if you could could you give a very quick, super quick example or definition of what compounded is and why it's separate to you prescribing something?

SPEAKER_01 47:59

Yeah, compounded a compounded version would come from a compounding pharmacy, and these places were usually used for when you had some allergy or some intolerance to an FDA approved version. They would they would take some sort of additive out. And so you send the script to the compounding pharmacy, and they're supposed to kind of put it together how you said. They take the components and put it in a little vial and whatever. And and what like there are different ways you can set it up with a compounding pharmacy, but like you just send them the script and they'll send it to the patient, and then they'll bill you some wholesale amount later, but you can bill the patient whatever you want. Or the way that I've done in the past, and I don't do the compounded GLP once, but I've done different compounded medicines depending on the patient what they needed. Um, I'm like, I don't want I don't want to take any payment for any uh medicine, so then they pay the pharmacy directly. But that's how you just send the medicine to the company.

SPEAKER_00 48:58

I think I think some people have a a view a very skeptical view of big pharma is is one thing, but then a kind of skeptical view of medical professionals because it's like the quote that doctors are drug pushers. Yeah. And that's obviously not the same as if you're actually making money from medication versus.

SPEAKER_04 49:18

And I I can also actually vouch for Spencer in that in my prior conversations with him, I've said, Oh, I have such and such person that I know who's inquiring about GLP ones. This is their background information. And you would say, Why are they trying to take GLP ones? They are they're they don't mean and they don't have any of the indications to take it. So you would actually say, You are not a good fit for this medication.

SPEAKER_01 49:38

Yeah, in fact, at my clinic, because I I my big thing is letting my doctors have autonomy. At other of these big online clinics, they have protocols that the doctors have to follow their protocols, which is kind of illegal. You're not supposed to tell the doctors what to do, but they all all these other places do it. Um when people come in, there are some people that are borderline, and like technically I'll make money if they stick around, but I tell my doctors like if you don't feel comfortable, if you don't think that they're a good fit, that that that's you have to you have to, it's your license, you have to make that call. So I it's it's it's very important to follow that instead of just like making extra money because yeah, if I wanted to, I could just go, you know what? Everybody's gonna get a little micro dose of XYZ and some other peptides, and I'll start printing money because like everybody wants them, and I could gatekeep it and just be like, here's a script, here's a script. Right. It'd be very unfortunately.

SPEAKER_04 50:31

I mean, I'm sure it does happen with a lot of metadops. Spencer's not one of them.

SPEAKER_01 50:35

Unfortunately, I have scruples. I don't know why. I can thank my parents, I guess.

SPEAKER_00 50:40

Uh if we if we kind of zoom out to bigger picture, one argument that I see people having online, we'd like to know your thoughts on it. Are what do you think GLPs teach us? GLP ones, you know what I mean. People abbreviate it. What do you think they teach us about the calories in versus calories out debate?

SPEAKER_01 50:58

Yeah, I I think it shows, and people get really mad about this, but I think it shows that like energy balance is true. And people are like, well, no, these medicines do way more than than energy balance. Yes, they have many metabolic effects beyond energy balance, but for the weight loss component the the mechanism is through appetite reduction. And they've they've shown in in very rigorous studies, whether it's animals or humans, that they eat fewer calories uh with the medicine and they are able to sustain it. So um they the medicines have many other metabolic effects, but from a weight loss specific lens, uh it kind of shows that it it comes down to energy balance.

unknown 51:42

Yeah.

SPEAKER_04 51:43

Yeah, it actually really surprises me to still see people nowadays trying to invalidate calories in, calories out by using, you know, they're like, oh, this this such and such happen. But the it can always be explained by the reminder that energy balance is dynamic, not static.

SPEAKER_00 51:59

And there's always an explanation for it. And more uh what's the word? More complicated than people realize. There are a lot of aspects that go into energy in and energy out.

SPEAKER_01 52:09

Yeah, yeah. So yeah, that what people are will they'll say these have metabolic effects beyond calorie restriction, and they'll say that I haven't changed the way I'm eating and I've lost 50 to 100 pounds. And I'm like, I I don't want to be mean, but it's like that that didn't happen. You you subconsciously were are eating fewer calories now. It's not, it's yeah, it's physically not.

SPEAKER_00 52:31

One of the one of the difficult things about that, which isn't actually very controversial for people that read research literature, is most people have no idea how many calories they eat. It's very easy to change the number of calories you are consuming without realizing you're doing it. Even in research studies where they try and get people to be accurate with calorie counting, even doing things like offering them financial rewards, calorie under reporting is such a huge phenomenon that people can often be off by 50% or 100% on the energy expenditure. So when people say I haven't changed how much w I'm eating, it's not mean. I know it sounds mean, it's not mean to not trust someone, because in general, you shouldn't trust someone's calorie reporting. If I told you I was eating two and a half thousand calories, you would immediately be like, that's how many he thinks he's eating.

SPEAKER_01 53:19

Yeah.

SPEAKER_00 53:19

It's probably not that. And that's just that's what it's like.

SPEAKER_01 53:23

Do you remember when I did my bodybuilding competition? Like uh it was like now it's I can't believe it's like 12 years ago. But uh uh Jeff Alberts was my coach at 3D MG, and he got me got me down to like 2,500 calories, which people are like, that's a lot of calories. And I'm like, I was starving. And he's like, You're eating this, but you're not you're not losing anymore. I'm like, Are you sure you're eating this? I was like, Yeah. But I I was eating, you know, a few strawberries here and there, a few things here and there. Okay, and it was it was like there's no way I was eating them. I was I was but I was still telling him I was, and oh, interesting because I I felt kind of bad about it. I felt like I don't know. I felt shame.

SPEAKER_04 54:01

So you were you were eating more, but telling him you were not, yeah, essentially.

SPEAKER_01 54:05

I think he and Eric Eric Helms were they were consulting each other, they're like, I'm pretty sure, but they didn't want to, and I was I felt the shame. I was like, I was starving.

SPEAKER_00 54:13

We should starving. We should maybe do an episode on Calorenda reporting, but one aspect or a couple of aspects, number one is a lot of people feel shame. If you say if you said I think you might be eating more than you think you are, it can often come across as quite accusatory. Yeah. So I understand why people get defensive. I totally understand that, and and that's very important to acknowledge. So one example of this to reiterate your point is a client came to me once and said they were only consuming 1400 calories a day and they weren't losing weight. Now, in general, without talking about their anthropometrics, how much they weighed, how tall they were, blah blah blah. If someone said I'm eating 1400 calories a day and I'm not losing weight, most people would go, oh my god, that's so dangerous. What are you doing? You have to tell them to eat more, blah, blah, blah. People hear a low number and they freak out. And we did a five-minute dietary conversation, not even a dietary audit, and she realized that she wasn't eating that because she was counting, say, Monday to Friday, but then weekends were lots of alcohol and binge eating and whatever. And a lot of the time it doesn't take much deep diving before you realize that people don't know how many calories they're it's it's hard to know how many calories you're consuming. Super hard.

SPEAKER_01 55:27

Um I don't even know how many calories I'm eating now. Same. Yeah, I have no idea. Yeah, probably say like three to four thousand. I don't know, somewhere or other.

SPEAKER_04 55:35

I mean, it's it's entirely possible for people to be underreporting their intake by a thousand calories, sometimes even more.

SPEAKER_01 55:42

And but there's it's it's this more moralizing weight. So, like, I I always make posts, I'm like, stop moralizing around how many calories your body wants. It's a it's still biological. They want it to blame their metabolism, and you guys have talked about this, I'm sure. It's not your metabolism that's broken, it's an appetite. But we've moralized calories so much that we feel ashamed when we can't eat fewer, to where people basically say, like, throw the science out the window. It's like, no, that's not true. Yeah, it's very tough.

SPEAKER_04 56:15

I remember when I was in my heavy dieting days, I thought that if I ate the edges of a pan of brownie, a count the calories would count less.

SPEAKER_01 56:24

That's amazing.

SPEAKER_04 56:25

Versus an actual piece, you know? And then I'm like, oh, I don't have to count those calories, it was only edges, and then that it's brownies, it's they're calorie dens, you know.

SPEAKER_01 56:33

That's what we do. When you're so hungry, you're just you I don't know.

SPEAKER_04 56:36

You're like, oh, it's fine, it's only a little bit, but then the little bit adds up really fast.

SPEAKER_01 56:39

Bite, licks, and tastes. That was your video for realties. Power many.

SPEAKER_04 56:43

Yeah, I remember that from uh eight years ago. I did a video on how the bites, licks, and tastes can add up to like, you know, a thousand calories or more a day, and you think it's no big deal.

SPEAKER_01 56:51

Here and there.

SPEAKER_04 56:52

It happens. What has the success of these GLP1 medications taught us about obesity that many people still don't understand?

SPEAKER_01 56:59

Yeah, I think this really goes into the biology that drives it. Yeah. And people are like, it's the environment. Like, yeah, of course, the environment was the thing that pulled the trigger, but our our biologies are are designed to eat more. And like, like Ben and I, like, I can tell that I have a resistance to weight gain. I can tell. Like I get fuller sooner. I have to force myself to eat more.

SPEAKER_00 57:23

I mean, you literally just after lunch said, I when I asked what you wanted for dinner, you're like, I don't know. I've I've you're so full.

SPEAKER_01 57:29

So full we had swarm and everybody listening, I love swarm and we had this huge swarm of red that I haven't had in so long.

SPEAKER_00 57:35

But to a lot of people, if you ate, I mean, to me, quite a normal size portion. It wasn't like you were having this huge meal.

SPEAKER_01 57:42

Not a smorgasbord.

SPEAKER_00 57:43

But if if you have had a decent sized lunch and then you're like, mm, I don't really want to talk about dinner, blah, blah, blah. A lot of people won't resonate with that because so many people, especially people with appetite dysregulation, the idea that you're not that fussed about dinner because you ate at what, 2 p.m. would be wild. Yeah. Because I've had clients who will say, it doesn't matter if I've just finished a meal, I'm thinking about my next meal.

SPEAKER_01 58:07

So that gets into the concept of food noise, which has always kind of been there, but people didn't realize they had it. Uh kind of this preoccupation with thinking about food. And I always tell what I call the the definition is like these intrusive constant thoughts about food. Yep. And I give some examples, and people are like, that's not food noise, and then they give their own personal anecdotes of what they believe food noise is. But I've had thousands of patients. I always ask them, and they always give me these different ways they think about it. But it's it's simply like they didn't realize how much they were thinking about food. Like you said, they just ate and now they're thinking about the dessert that they have left waiting for them at home, leftovers from the day before from their partner that they want to sneak away and eat pizza that's in the break room that they were trying to avoid, but they're still thinking about it while they're doing their work.

SPEAKER_04 58:53

Like anything and everything.

SPEAKER_01 58:55

Another patient was talking about how they went out to dinner and they usually think about the bread. They think about they can't even enjoy their company because they were thinking about food.

SPEAKER_04 59:02

I've I've experienced it. I I would say at the peak of my when my calories were the most restricted was when my food noise was smottest.

SPEAKER_01 59:08

Yeah.

SPEAKER_04 59:09

I'm sure when you were bodybuilding in bodybuilding prep, you had a lot of food noise.

SPEAKER_01 59:12

Just looking at recipes, thinking about whatever. It wasn't yeah, it was pretty bad.

SPEAKER_00 59:17

I have a story that I have talked about multiple times in the past. So uh I was having a conversation with my sister years ago, and by her own admission, she would say that she has struggled with her weight throughout her life. And I was dieting for a photo shoot, and at the time I was even by my standards, I was very lean. I was probably in the region of 8% body fat.

SPEAKER_01 59:40

I'd say negative 3%.

SPEAKER_00 59:42

Still trying to, you know, getting to the point where I've got glute striations and you know, very, very, very lean. And I remember her asking me how I felt, and I was like, I feel terrible, I feel like dog shit, like I'm so hungry. And most bodybuilders will know that when you say I'm in peak week or I'm leading up to peak week, I feel hungry all the time. And I said, even when I'm finishing a main course, I'm immediately thinking about what I want to eat later. And this is me at probably maybe eight percent body fat at the time, still trying to lose a few kilos. And there's my sister who has never even been close to a six-pack, who said, 'You she literally said, 'You have described how I've felt every single day for my whole life.' So I think it's to me, it's kind of crazy that bodybuilders and fitness professionals can diet for shows and understand at least briefly how brutal having a high appetite can be, but then stigmatize people who live with that forever because they think, well, I only felt like that because I was 8% body fat, not realizing that there are people with 40% body fat who still feel like that.

SPEAKER_04 1:00:48

And that's their baseline.

SPEAKER_01 1:00:49

Yeah. Isn't that amazing? I don't I don't know why there's a disconnect there, but they can't imagine that receptor sensitivities and thresholds and whatever are different for different people.

SPEAKER_02 1:00:58

Yeah.

SPEAKER_01 1:00:58

But yeah, the food noise, these medicines turn it because we've had appetite suppressant medicines in the past, and I they're non-GLP1 weight management drugs that are decent. They were okay. And bariatric surgery, but bariatric surgery, while help people lose a lot of weight, didn't have this effect of not only, you know, appetites down, but like you can have a lower appetite and still think about food.

SPEAKER_00 1:01:23

Correct me if I'm wrong, but it wasn't food noise the first time it was in a research paper was since GLP once.

SPEAKER_01 1:01:28

Well, I remember finding it, and it was like it's now become a discussion as a consequence of that rather than there are some discussions of this concept around like eating disorders and things like that. Uh this preoccup preoccupation with um with food. But like um uh since this, it's it's it's now people are just going like, oh my god, I didn't realize I even had this. Yeah. And so I think this is what shows that like I I mean when you're cutting, like I would eat huge salads and I would be full, but I was also not satiated. Yeah. And so people also imaging on jello. Yeah, like you can feel your stomach is full, but you're not satiated. So the the drugs work not only on a little bit of the fullness, but the satiety and and not just satiety, but also the food noise. So there are different components of the brain. I think when people start under I think this has helped people understand that there's a much larger biological component here than than they realize.

SPEAKER_00 1:02:29

So one of the reasons that I think people get so controversial and argue about this, do you think that people are focusing too much on the weight loss element of these drugs and not other consequences of taking them?

SPEAKER_01 1:02:46

Yeah, absolutely. And it's it's just obvious with our society and cultures that we focus on on the weight, and it's like cool to see these big numbers like, oh wow, smaglide hit 15%, trzepatide hits like 20, 22%, 21%, retatotride hits almost 30%, 28 or so percent. It's like wow. But then it's like, okay, so what? Yeah, cool for looking better and and maybe helping with knee pain and and uh hip pain and back pain and whatever, but like what about all the metabolic effects? And so like if we talk about like reducing risks, truly reducing risks of having a heart attack, that's a big deal. Less kidney disease, less liver disease. You don't have to get a liver transplant if you, you know, hit this earlier, uh sooner than later, and obviously the blood sugar control, which is what they're originally used for. So I think um if we start thinking about these as more health-promoting drugs, I don't I don't know if we're ever gonna get away from the late weight loss effect because it's just so like it's so easy to to look at. We can't see inside somebody's heart.

SPEAKER_04 1:03:52

Uh is it actually possible to experience the benefits of GLP1 medications, even if you don't have the weight loss happening?

SPEAKER_01 1:04:01

Yeah, so this is what they've looked at with like some aglitide with um uh they did this big study called the SELECT Trial or SELECT Study, and they were looking at people with a history of cardiovascular disease and obesity. And despite some people not really losing weight, they they were reducing the risk of heart attacks. So there's there are things about the medicine that lower your risk of various health uh conditions um and diseases that are independent of weight.

SPEAKER_00 1:04:30

This is actually kind of one of my gripes with not necessarily the body positivity community, because I know that term's been hijacked a little bit, but there are very some very much some anti-diet culture proponents, if you will, where talking about weight loss is forbidden and and prohibited, that I think their main gripe with this is they think view the drugs as promoting diet culture, not realizing that a lot of people are taking drugs literally reducing their risk of early death. Yeah. And I think it's such a shame that people are being scolded. And part of the reason I preceded this episode by saying it's controversial is because there are people out there who are taking medications who are like, I feel amazing, and I am scared to talk about it with my friends because they're gonna judge me.

SPEAKER_01 1:05:17

Yeah, I still have I still have patients who like I haven't told anybody yet.

SPEAKER_00 1:05:21

Like and we know we know people that have taken them and say I don't I don't want to tell people about it because I feel like I'm gonna get judged, even though they feel better. And that's not saying that some people don't take them and have side effects. Of course, it's not saying that. But I think it's such a shame that there are people out there who are scared to talk about their medication they're taking or whatever their condition might be, because they think that people are gonna judge them for it.

SPEAKER_01 1:05:47

Yeah, and they will get judged. That's an unfortunate truth. But I think it's becoming more and more normalized at this point to where, like, you know, for better or for worse, I mean, with the house. With people in the in the thinner people taking. It's like, okay, if they're taking it, I shouldn't feel ashamed for taking it for an actual legitimate reason. You know what I mean? So it is too bad, but I still have patients still feeling shame. I, you know, for friends and family should be helpful, but not all the time, as we know.

SPEAKER_00 1:06:16

It isn't always that way. Yeah. Okay. Finishing up the episode, we have some final questions. What is something the fitness industry gets wrong about GLP ones?

SPEAKER_01 1:06:27

Yeah, um, so most people think that uh obesity is uh a choice. Like that's what the majority of people think. And so, yeah, we talked about how, like, well, these medicine show it's biological. So they're gonna go, okay, yeah, it's biological, but now it's really a choice because you have to do these medicines. Yeah, well, you could you eat less and you could take these medicines and eat less, and then there's no more obesity. The issue is that not everybody responds to these medicines, and right now they're pretty expensive, so not everybody can afford them. But on top of that, I have patients, they don't lose a single pound using the terzepitide, and I'm waiting on retatride just simply until it's FDA approved, so I can get the legit stuff and not go off the gray market and give them the um the stuff uh from a bathtub. But um, but like there are people might not realize you're joking.

SPEAKER_00 1:07:19

I'm joking.

SPEAKER_01 1:07:20

I'm j I it's uh I'm being very I knew he was making money for it. Yeah, I'm selling it. I actually it's just an aside, I've in one of my obesity Facebook groups where we have the obesity doctors and and I I make jokes about bathtub, trusepotite, and retetrotite as my side gig.

SPEAKER_00 1:07:34

And every time people just die laughing because it's like that's not to me, that's not even uh um that controversial because I'm used to the bodybuilding community where they would buy things like psalms that were quite literally simbattubs.

SPEAKER_01 1:07:48

So be but people, you know, people think that now you can just take these medicines and it solves obesity. There are still gonna be people that have a ton of weight to lose, and even if they lose the average amount, like let's say with Reddit coming out, it's around 30%. Let's say they're you know 400 pounds. That would be 120 pounds, or something they're gonna be 280 pounds, which is a big improvement, but they still have obesity. So like you can't just it's it's not going to completely solve it. Yeah, they're you know, 10, 20 years from now, I have no idea. There's some things coming down the pipeline where you could maybe hit various receptors and turn everybody into a uh a skeleton, I suppose, potentially in the future, and get the muscle-building drugs everybody's kind of jacked and thin. But like for now though, I d I actually think while it helps some of the stigma around obesity, it might actually worsen it in some ways because now they go, okay, I understand the biology, but now it's really a choice because you could just take this medicine. I think that's one of the things that people are are getting wrong now, and I think they still need to understand that um there's a lot of uh a lot of differences in people with obesity.

SPEAKER_00 1:08:55

Some of the particularly shit takes that I have seen online is using the fact that people are losing weight on a GLP1 medication as see, I told you all along that all you had to do was eat less. Yeah. As if they're mutually exclusive. It's it's almost to some people reinforce the idea that that weight is a willpower deficiency.

SPEAKER_01 1:09:19

Yeah, and I'm and I'm like, why do you think they couldn't eat fewer calories before? Also, I see the one about like, see, I told you body positivity was nonsense. I made a post about that.

SPEAKER_04 1:09:28

It's like Oh, I thought that recently.

SPEAKER_01 1:09:29

Yeah, because like no, those those things aren't mutually exclusive either. You can be body positive and still want to, you know, lose weight.

SPEAKER_00 1:09:35

It sounds counterintuitive to some, but I actually know side tangent, we won't get into this because I know it it will piss some people off, but I actually um online I'll say I know someone online who is in the body positivity community, and they said to me that they were concerned for their own health, but when they posted that they were exercising, people got mad at them because they thought it was reinforcing diet culture. And she said, I haven't even said that I'm trying to lose weight. Uh she said she was, but that wasn't what she had talked about. She was just exercising more, and people were attacking her for it. So yeah, anyway, we don't need to open that kind of words.

SPEAKER_04 1:10:16

Yeah. I mean, all of us to say weight stigma, as you were talking about, is very real, weight bias is very real, and there's so much stigma and shame around and misunderstanding around weight loss in general.

SPEAKER_01 1:10:26

Yeah. Yeah. It's bad.

SPEAKER_04 1:10:28

What's something you've changed your mind on about GLP1s?

SPEAKER_01 1:10:32

Yeah, you know, so one one of the things I do think a lot of people are going to be using these in the future, not for weight loss. So like I I see people trying to get thinner and thinner, but like it's possible that I would take one in the future not to lose weight. I don't want to lose any weight, but for cardiovascular disease prevention purposes, just a small little bit. The issue is that they have to study it in these lower doses, because they only they've studied it the higher doses, they know that helps prevent heart attacks in certain populations. So, in order to really know, I don't know, maybe it just takes a tiny little bit, but they have to study it. So I think one of the things I've changed my mind on, I do think most people are going to be on these things in the future. When that future is, I don't know. And I don't think it's it's not gonna be necessarily to get thinner like the Hollywood stars. It's literally for cardiovascular disease and multiple uh other prepared like Crohn's disease, all sorts of clays. I have patients that they've these drugs have worked better than their biologics for them. I don't know, crazy stuff. Soriatic arthritis.

SPEAKER_00 1:11:32

Can it over here potentially? I definitely don't feel like I should suddenly hop on those.

SPEAKER_04 1:11:36

No, I was gonna say probably not though.

SPEAKER_01 1:11:38

A little bit of Zetbound. I know a guy that microdoses these things.

SPEAKER_00 1:11:44

A clinic. Final question to round off the podcast is what is a hill you are willing to die on?

SPEAKER_01 1:11:51

Yeah, a hill that I'm willing to die on is that like if without these drugs, we aren't going to improve obesity. And I say that because uh maybe call me cynical about our efforts to improve our environment. Um people like you're a big pharma shill, clearly you're getting paid by novonordisc to be on their advisory boards. But like, I don't see us changing our environment so much to where we make a dent. I think we might have to um I hate to say it, like outdrug our way out of this thing. It sounds so bad saying it like out loud, but like a hill that I'm willing to die on is that diet and exercise and changing the environment isn't gonna work because I don't think we're gonna be able to go back to what we were a century ago or decades ago. Yeah. I just I don't think it's gonna happen.

SPEAKER_00 1:12:41

This actually reminds me of a thought process I had ages and ages ago where people say, Oh, well, your doctor is just going to prescribe you something, they're not going to try and get you to do this, that, and the other first. But quite literally, yes, sometimes, because if it's a complicated issue, if you went to a doctor and you had cardiometabolic risk risk factors that were um secondary to weight, for example, it isn't very easy for a doctor to totally overhaul your lifestyle, especially in today's world with the food environment that we have and the sedentary behaviors that we tend to have. So I do understand that you it's not necessarily about creating a shortcut for people, but you're limited on what you can actually do in the real world.

SPEAKER_01 1:13:28

Yeah, I always say too that the medicines really help people do those lifestyle things that they just couldn't do before. They all people know that, like, oh, instead of french fries, I should have probably eaten the broccoli. Like everybody knows, like, I shouldn't have that donut, I should eat the the apple in the break room. Oh, I shouldn't eat that pizza that they brought in for lunch, I should eat my homemade sandwich that I brought in. Well, people already know those things, and yes, I think we need to help with more nutrition education, whatever, but like the medicines then go zoop and they go, you know what?

SPEAKER_04 1:13:57

I'm gonna have my sandwich. Yeah, and they make the so it's not a knowledge issue, which is actually what we covered in a previous episode. It's not a knowledge deficiency. The application becomes a lot easier.

SPEAKER_01 1:14:05

Yeah, they all of a sudden feel like they can do it.

SPEAKER_00 1:14:07

I think in America, especially, with the foods that are on offer and the cost of foods that are on offer, I've always said it's very difficult to put the toothpaste back in the tube. And I don't think that you can suddenly create an environment where people find it easier to manage their weight from the outside in.

SPEAKER_01 1:14:26

So I wish we could. Like I'm you know, if if if somebody has a solution, it's not I don't think it's gonna happen though. Yeah, anytime soon.

SPEAKER_04 1:14:34

Isn't it also the case? And you can correct me if I'm wrong, I believe that obesity levels have stopped plateaued or they've started falling for the first time in decades.

SPEAKER_01 1:14:43

Yeah, so there there can be some room for error. I have some really smart epidemiology friends because like on the surface, though, it looks like yeah, things are going down. And it's plausible now since whatever Ozempic's been out since 2016, 2017, but people weren't using it as much for weight loss until like the early you know 2021-ish. But like at least plateauing, I think over the next 10 years we're gonna start seeing this decline. I mean, you're seeing it with economic changes, with restaurants are saying certain things, and Walmart and all these other places are seeing really changes in way people are purchasing.

SPEAKER_04 1:15:19

Interesting. And you think that the GLP1 medications have a lot to do with that?

SPEAKER_01 1:15:22

Yeah, and and when when these become much more you know affordable, and all of a sudden, like, oh, I can only afford the WeGovy, as opposed to the newest, like super expensive multi multi-drug um medicine that's out there. But like that will have profound effects. If everybody that has obesity right now got on these med work, we would see again, I'm not saying we're gonna solve obesity, but we'd see a a strong decline um in at least complications and the overall BMI of the of the nation.

SPEAKER_04 1:15:55

Does that mean you see the medications becoming more affordable and more accessible in the future?

SPEAKER_01 1:16:00

Yeah, I I think this is a competition thing. Um yeah. So like right now you call it a duopoly. First there was a monopoly, basically. One company had was doing a Novo Nordisk, and then Eli Lilly throws their hat into the ring uh with their blockbuster drug, and now it's a duopoly, but there are multiple other companies out there trying to throw their hat in the ring, and they're they look like kind of copycat drugs, they're kind of similar uh in the way that they work, but they they all work kind of the same and and pretty pretty well. And so I think someone's gonna come in and multiple are gonna come in and they're gonna price compete.

SPEAKER_00 1:16:37

Right.

SPEAKER_01 1:16:37

And we're gonna see it come down further and further and further.

SPEAKER_00 1:16:40

The same thing has happened with the drug that I take for Crohn's disease, like Humir in America for a long time was the biggest or one of the biggest, but then when generics were allowed to come out and all of a sudden the the price has dropped. So the one that I get now is a fraction of the price that it would have cost two years ago or whatever.

SPEAKER_01 1:16:59

Isn't that amazing? It's gonna happen, just gonna take time. And people are like, that's not fair. That's why they get their and that's why I don't get mad at people taking their Chinese peptides or whatever, they're super cheap. Yeah. And I get it, but I wouldn't prescribe it because there's risk involved, but like they're super cheap. So I understand why people do it. It's gonna happen though. It's gonna take some time, but it's gonna happen.

SPEAKER_04 1:17:19

Well, I guess that's the the future.

SPEAKER_01 1:17:21

The future is that we're headed toward.

SPEAKER_00 1:17:23

Yes. Yeah. I am very happy with today's episode. I know that it's a very emotionally charged topic for a lot of people for various different reasons. And I understand that you talking about it means that you often come in the firing line for again various different reasons from various different angles. Hopefully, people who have listened to this will appreciate how nuanced and well balanced you are. And if anyone is happy to share, I would love to hear anyone who has experience on this positive, negative, neutral, whatever. Just because I think discussion is good for transparency and I think lifting the the stigma that uh obesity medications have.

SPEAKER_04 1:18:01

Spencer, thank you for your time. That was really, really fun and informative.

SPEAKER_01 1:18:04

Thanks for having me out.

SPEAKER_04 1:18:07

High five.