Dr. Lisa Erlanger returns to the podcast for a conversation with Julie Church, RDN, CD on GLP-1 agonists, medications widely prescribed for weight loss. Through a weight-inclusive lens, Lisa explains GLP-1 agonists history, current use, and side effects with a special attention given to the unique considerations for individuals with current or past eating disorders. Spoiler alert— these medications are not game changers, bodies still need food and nourishment to thrive! Despite what the shiny marketing says about these being “miracle drugs”, safe and long-term weight suppression is not possible.
To find Lisa: Dr. Lisa Erlanger’s website
As mentioned on show: GLP-1 Agonist Medications: Informed Consent Resource
Medical Students for Size Inclusive Medicine
Dr. Lisa Erlanger’s Appetite Podcast interview, A Physicians Journey to Weight Inclusive Medicine
Connect with Opal:
Thank you to our team…
Editing by David Bazzi
Music by Aaron Davidson: https://soundcloud.
Sound engineering by Ayesha Ubayatilaka at Jack Straw Studios
Transcription by Rev.com
Julie Church (00:07):
Hello and welcome to the Appetite, a podcast brought to you by Opal Food and Body Wisdom Eating Disorder Treatment Center in Seattle, Washington. This is a podcast about all things food, body movement, and mental health. And I’m Julie Church Dietitian and co-founder of Opal, as well as the nutrition director. And today I’m your host. And today we get to have Dr. Erlinger back on to be able to dive a little bit deeper into one specific area that I think most of us are aware of is weight loss medications and weight inclusive care. So if those of you haven’t listened to the last episode, Dr. Erlanger is a local Seattle physician trained in family practice. She works currently at the Emily program in the Puget Sound area, which is an eating disorder treatment clinic also. And she is a clinical professor at the University of Washington Medical School. And our paths crossed probably almost 20 years ago in just sharing clients that were struggling, that were college students in this neighborhood that were struggling with food and body issues. And our professional relationship has grown and developed. And I certainly very much value her wisdom and her thoughts and heard just recently a little bit of her thoughts about the weight loss medication scene right now in 2023. But I would love Lisa, welcome back and to just, gosh, I don’t know where to start with the weight loss medication piece. Where do you want to start?
Dr Lisa Erlanger (01:36):
Thank you for having me back. Yes. I always love talking to you and boy, it is a scene. What a great way of characterizing
Julie Church (01:44):
It. Yeah. Today I saw Virginia Soul Smith’s Burnt Toast newsletter about Oprah. She was like, I don’t want to talk about Oprah, but just whatever. Weight Watchers now being basically a clinic model offering medications because Weight Watchers as a diet they’re saying is no longer enough,
Dr Lisa Erlanger (02:08):
Right? It’s as we talked about last time, all these companies that have been selling us weight loss all these years through eating less and moving more and telling us it was our fault when it didn’t work.
Julie Church (02:21):
Now
Dr Lisa Erlanger (02:22):
They’re saying, dieting doesn’t work. We need our medicine. And it’s coming from everywhere. People are talking about these medicines. And first I just want to extend just compassion to all of us, especially people struggling with disordered eating or recovered from an eating disorder actively recovering, having weight loss be the topic of every news story, every conversation, every meal. Watching people’s bodies change rapidly is so hard. And it can be, particularly if we have a personal or professional commitment to weight inclusive care and non-diet approaches to life, to have people say that this is a game changer. This changes everything.
Julie Church (03:14):
Yeah. What do you think that means and what do you believe about that? And maybe, okay, wait. I would love if you could give a little mini teach on what I’m even talking about. What are we even talking about in terms of this new wave of weight loss medications?
Dr Lisa Erlanger (03:29):
That’s great. And I want to start by saying that I don’t think it’s a game changer.
Julie Church (03:34):
Okay.
Dr Lisa Erlanger (03:35):
It’s a game changer in that it’s making this game of trying to care for ourselves sustainably and compassionately really difficult. It is not a game changer in the sense that it is not suddenly possible to safely and sustainably suppress your body weight forever in a way that it wasn’t possible before.
Julie Church (04:00):
Okay, that’s great. That’s a great things. How they changed. Hey, mic drop
Dr Lisa Erlanger (04:04):
Bodies are the same as they were last year, which is that our bodies really defend the energy stores and the tissue they’ve built up so preciously over the years. Our bones and our muscles and our brains and our nerves. Thankfully our bodies defend that and really work to keep us from losing weight. And I will dive into the new weight loss meds, but I’ll say this is true of any weight loss med. It’s true of weight loss surgery, which will have to be another
Julie Church (04:37):
Podcast. I know. Okay, that’s not the hot topic right now, but
Dr Lisa Erlanger (04:40):
But it’s true of all of them. But today, I think we’re speaking of the medicines that are called the GLP one medicines. This is Semaglutide Liraglutide. It’s Ozempic. Manjaro is similar. These are medicines that mimic a hormone the body makes called GLP one. It’s a satiety hormone. So as you eat this hormone, I’ll say that again. So as you eat regularly, this hormone is released from the gut and it’s received by organs all over the body, including the brain and the stomach to say, we’re getting food, we’re getting food, we’re getting more food. Now maybe we have enough. So a very clever idea, what if we administer that hormone and trick the body into thinking it’s had enough
Julie Church (05:40):
Food?
Dr Lisa Erlanger (05:42):
And these medicines were actually first approved and used quite widely and very effectively as diabetes medications. And that’s because one of the things you need when you’re eating is for the pancreas to secrete insulin, which is the way your body absorbs sugar and fat from your meal and unlocks the cells to let the fuel in. So everything works the way it’s supposed to work. Well in diabetes, whether it’s type one or type two, there isn’t enough insulin given the body’s circumstances to get that fuel into the cells. The GLP one hormone. One of the things it does is stimulate the pancreas to release insulin, thereby helping the body lower blood sugar levels after a meal by moving the sugar into the cells where it’s supposed to be to run our wonderful machine. So it was first released as a diabetes medication, and it’s been extremely effective as a diabetes medication. I have found many providers found that its effectiveness was limited by the fact that many people lost their appetite, developed nausea or vomiting or bowel dysregulation, and really had trouble taking it even at a diabetes dose, which is substantially lower than the weight loss dose.
Julie Church (07:12):
One
Dr Lisa Erlanger (07:13):
Of the problems I had with my patients with diabetes taking it is that patients with diabetes are often afraid to eat all they’re hungry for because they’ve been taught that their blood sugar rising is their fault and that the solution is to eat less. And so they’re already often not nourishing adequately and regularly, and when they lose their appetite, it’s even harder to do. So it actually turns out it’s really hard to treat blood sugar in someone who’s eating erratically, irregularly, because one of the best ways to manage blood sugar is to eat regular, nourishing, satisfying, balanced meals. And so when people lose their appetite, that just gets really difficult. But of course, so
Julie Church (07:55):
Complicated, right? So complicated. Okay.
Dr Lisa Erlanger (07:56):
Yeah, keep going. But of course the weight loss industry was like, wow, people are losing their appetite and not eating what? That’s exactly what we want. Exactly. Bingo. But most people on it for diabetes, if they lost weight, it was somewhat modest. And some people don’t change their weight at all. So we have a medicine that it makes sense that it suppresses appetite. People take less in, but they weren’t really losing enough weight. So let’s give more of it.
Julie Church (08:32):
So the dosing is more, it’s significantly larger, and that’s what got approved as a weight loss, and it got fully approved by the FDA to be for weight loss purposes. True,
Dr Lisa Erlanger (08:41):
Yes. Now some of the medicines at some of the doses have FDA approval for weight loss, but in medicine we often use medications. Yeah. Off-label.
Julie Church (08:54):
Okay.
Dr Lisa Erlanger (08:55):
So there’s several medications at several doses that are used in this way for weight loss. Can I dive into what the study show?
Julie Church (09:05):
Sure. Yes. Tell us.
Dr Lisa Erlanger (09:06):
Tell us. Okay. Well, I like to start a debunking session. I’m about to
Julie Church (09:13):
Run. Please. Please.
Dr Lisa Erlanger (09:14):
Considering what would we hope the research showed? So if we consider that there have already been millions of prescriptions for these weight loss drugs, drugs that people are expecting they may have to take for the rest of their lives, and they’ve been recommended for children as young as 12. So people might be taking them for 70, 80, 90 years.
Julie Church (09:40):
Yeah.
Dr Lisa Erlanger (09:41):
What would we hope the study showed?
Julie Church (09:44):
I dunno. What are your thoughts? Well, I mean, the people that want to make this a weight loss drug would want to see actual sustained weight loss, and I would assume a pretty large percentage of the body weight. I dunno, high numbers is what I would assume.
Dr Lisa Erlanger (09:58):
If you were going to take it, what would you hope the study showed?
Julie Church (10:03):
Not a lot of side effects too. I guess I would want it to just do only what it’s supposed to be doing. Not anything else.
Dr Lisa Erlanger (10:08):
Yeah, exactly. And I would assume that the FDA was watching for those same things. I think so When I look at a study like this, I’m wondering, did the study include people like me or my patient? Did the medicine do what they’re saying it does? And did it do it safely and effectively? And did most people who started the study stay in the study? And if they didn’t, why did they drop out and what happened to them? And then was it studied for as long as my doctor is telling me to take it, right?
Julie Church (10:52):
Yeah.
Dr Lisa Erlanger (10:52):
Because if I’m expecting to be on it for 50 years, do we know if it’s safe to take for two years, three years? How long do we know? So when I dove into the research, I saw that sadly, none of that is what has been found. The medications were approved on a 56 week study. They called it a 56 week study. But we can quickly do the math and say that means one year, 56. What? So funny. Exactly. It sounds good. One year. Yeah. What we saw is that at the beginning of the study, there was pretty rapid weight loss in the groups taking the medicine and more weight loss in the people taking higher doses. But there’s actually pretty significant weight loss in the placebo group as well, which shows us what I think we know, which is that the less you’re able to eat, the more rapidly you will lose initially.
Julie Church (11:54):
Okay. Yeah.
Dr Lisa Erlanger (11:55):
Right. Unless you’ve weight cycled a lot, in which case the body actually can become very resistant to changing body size even if you’re not eating. But most interventions, the less you can eat, the more rapidly you will lose weight. But what we saw in these studies is what we also see with any type of intervention that helps us eat less, which is that even when people stayed on the medications, after about 16 weeks, the rapid weight loss stops and it begins to plateau. So that by the end of the 56 week study, even the highest dose group had plateaued and had actually begun to gain weight. And that’s when the study was stopped. Now, ethically in research, if nearing the end of your study results are changing rapidly, you don’t stop the study because you have to actually know what’s happening because you can’t really say that what happened at the beginning is what’s going to happen at the end if it was changing. But it’s not surprising that weight was starting to go had plateaued and starting to go up because the way these medicines work, it’s not magic. It helps the people taking them to restrict food. They’re eating less. And as we learned in our first episode, the body is elegantly designed to prevent you from withering away into nothing if there’s no food around.
(13:29):
And it becomes very clever at getting you to eat what food is around. And it actually begins to conserve energy in a way that will conserve or even gain energy stores without you eating a whole lot more. So the longest study to date that’s been published on these medications for weight loss at weight loss doses is 104 weeks. Which is two years. Two years, exactly.
Julie Church (14:04):
Wow.
Dr Lisa Erlanger (14:04):
And while some people have maintained or have regained to a level of weight that’s still below their starting weight, we know that if we really want to see long-term effects of a diet, we have to look out five to 10 years. We know that if people stop these medicines, they regain the weight right away and we don’t know, but we can guess that even if they continue them, they will slowly regain the weight. And that’s just the weight loss part. I have all those sorts of other things to tell you about them.
Julie Church (14:39):
I know. I was going to say, the other piece is I was wondering about the sort of health status related to it. So many people are relating to that.
Dr Lisa Erlanger (14:51):
Yeah. Well, do they make people healthier? There was a lot of excitement around an announcement by Novo Nordisk, which is the company that makes the medicine, that a study showed that people taking these medications had fewer heart attacks, cardiovascular events that was publicized before it was ever published in a peer review journal
(15:15):
And picked up by the news and by doctors long before we could actually read the study. The study is available now, and what we saw is that there were fewer cardiac events in people taking this medicine, but the number needed to treat, meaning the number of people who would have to take the medicine in order to prevent one heart attack was very large. And the cost both human and financial of taking this medicine over that period of time. I’ve seen calculations from a local physician, but it is immense multiples of, for example, how many people and how much money has to be spent on cholesterol lowering medicine to prevent one heart attack, or how many people need to increase the amount they exercise by 20 minutes a day to prevent one heart attack. So it does seem to prevent heart attacks. We don’t know why. We also don’t know if those benefits would be sustained over the number of years. People will have to take it to sustain their weight loss
Julie Church (16:26):
Because
Dr Lisa Erlanger (16:27):
There are those physiologic adaptations to starvation we talked about last time, where we see drops in blood pressure, drops in inflammation, drops in blood sugar levels when people are initially under nourishing.
Julie Church (16:42):
So is the prevent and health just synced up with that being a time they’re just under nourishing
Dr Lisa Erlanger (16:47):
Themselves. So we don’t know. That might help. Some people report feeling great when they lose weight on these medications. Some people report having more energy, being more mobile. One of the things we hear a lot from people who’ve struggled with food and body relationship over time is what a relief it is to have appetite suppressed. And we hear people talk about food noise being suppressed, which is not surprising. We’re taking a satiety hormone, and that can be such a big relief, and we don’t really know yet are those people for whom food noise was abnormally high or were those people who were chronically undernourished and therefore their body was asking for more food. And we just don’t know. But I wouldn’t begrudge anyone who is feeling relief at being smaller or having less disruption in their food and body relationship pursuing this. Of course, we want to experience less stigma and experience less distress. My concern is that there are also very high levels of side effects. People report being repulsed by food, not being able to eat vomiting, not being able to enjoy meals with friends. There is some stigma around losing weight this way. So while it’s very respectable to go to the gym and eat healthy and get fit and trim, it’s kind of a shortcut.
Julie Church (18:22):
Interesting.
Dr Lisa Erlanger (18:24):
A
Julie Church (18:24):
Lazy way to do it.
Dr Lisa Erlanger (18:26):
I mean, there’s nothing lazy about starving yourself, but yes. That maybe we know the research around people who lose weight with bariatric surgery shows that they don’t accrue the same social approval as people who lose weight through diet and exercise. And so I would expect it’s similar with the weight loss drugs,
(18:46):
But even more importantly is that the study didn’t look at a lot of the side effects I care about when I’m thinking for myself or my friends or my patients. They did not look at long-term disordered eating or relationship of food and body or long-term blood sugar management or relationship with the healthcare system. We know with other diets, patients tell us that when a physician prescribes weight loss, and I go and I do exactly what the physician told me, and then over time it doesn’t work. That disrupts trust in the healthcare system. And also when patients regain weight, they’re less likely to come for follow-up. And that when patients believe that they weigh too much, they’re less likely to engage in self-care and healthcare behaviors at all, less likely to exercise regularly, more likely to eat in disordered ways. So I really care about what happens to these people over time and their relationships with themselves and their bodies and the healthcare system. We also don’t know what happened to all those people who dropped out of the study. What are their outcomes? Because a certain number of people need to take this medicine for one person to lose an amount of weight they’re happy with. But how many people are harmed by taking the medicine? And essentially what cost are we asking people to pay to be perhaps one of the people that lose a lot of weight?
(20:22):
We’re already seeing in Europe that the companies are being investigated for increased reports of suicidality, self-harm, and suicide. And this has been true with all the other weight loss drugs and with bariatric surgery.
Julie Church (20:38):
True, true. So it’s like why wouldn’t it happen in this population or with this medication also? Right.
Dr Lisa Erlanger (20:44):
Exactly. And I mean, you’re probably thinking the same thing I am, which is we know it’s also higher in people with eating disorders. And I wonder just the undernourished brain is a mildly irrational, very emotional brain. And we see increased suicidal thinking in people who are undernourished intentionally or unintentionally. But there may also be a direct effect of the medication. And there may be increased cancers, definitely thyroid, but maybe pancreas. And there is increased pancreatitis, which can be life-threatening. And this is just in two years in adults.
Julie Church (21:24):
Oh my goodness. Okay. And it is, it’s like that there’s so many angles, I feel is just really mostly disturbed by how short the studies are. I think from my standpoint, and maybe I’m ignorant to think that other medications that are coming out on the market and being approved would have more long-term backing, especially knowing this is literally, you must use it for the rest of your life. That’s the recommendation. It’s not a short-term medication that the ethics of having something be approved, not even anywhere close to a lifespan is so concerning. So
Dr Lisa Erlanger (22:01):
Exactly. And I think there are some dual standards when we think about how long a medication is tested before it’s approved, a lot of it depends on how it’s going to be used. So an antibiotic, I want to follow people a little after they’ve taken it to make sure there’s no unexpected side effects, but I just need to know it’s safe for that short period of time. And then most drugs are set up for a post-marketing surveillance so that if there’s something that happens at a very rare frequency but is serious, it’ll get picked up over time in marketing. And that’s how we’ve learned that some antibiotics, for example, can rarely cause tendon ruptures or that kind of thing.
(22:47):
But this medication is interesting because it’s being marketed as a treatment for a disease. A disease that’s been named obesity largely under the influence of lobbying groups paid for by the pharmaceutical companies that then develop this drug. But really in a lot of ways, it’s a lifestyle medication in that people are taking it because they want to be smaller, even if it doesn’t make them healthier. And if I’m thinking about something people are going to take for the rest of their lives in the hope that it will make them healthier, think of like a multivitamin fish oil.
Julie Church (23:34):
Okay.
Dr Lisa Erlanger (23:37):
I really want to know that it’s harmless
(23:41):
And it takes longer to know that something’s harmless than it does to know that has a positive effect. And I think in weight loss studies, a lot of shortcuts are taken that are intellectually a little dishonest. So the studies are based on the initial assumption that being large is unhealthy and undesirable, and that weight loss is a success of the intervention that we don’t have to go on and see are people actually healthier? Are they actually happier? Do they actually live longer? All we have to do is show that it makes big people smaller, and we can just say that was a success.
(24:28):
And that’s not a shorthand. We allow in any other kind of intervention research, particularly pharmacologic research. If you’re going to market a new blood pressure medicine, you are obligated not just to show that it decreases blood pressure, but that it actually reduces episodes of cardiovascular events that were typically associated with blood pressure. But with weight loss medicines, as long as it lowers the body size, it’s considered good. And so that’s where I think we get these situations where it was such a short test because it showed that weight loss occurred. We’ve already agreed implicitly as a medical and social community that if weight regains, that’s not the intervention’s fault. It’s the person’s fault. Right,
Julie Church (25:15):
Exactly. Right. That
Dr Lisa Erlanger (25:16):
Makes, boom, we’re done. But I think even more importantly, there’s been an official recommendation from the American Academy of Pediatrics that kids as young as 12 be offered these medications and there have been no studies in kids of that age, not even 104 weeks.
Julie Church (25:35):
Wow. And they’re ready being recommended. It just,
Dr Lisa Erlanger (25:38):
And these are kids that need to be growing and building bone and building brain,
Julie Church (25:43):
And then they’re going to undernourished themselves and they’re not respecting the long-term consequences of that undernourishment at all, thinking the body’s going to do something to make up for that. I just, I’ve seen it too much that just under nourishment. So basic nourishment is such a basic part of human existence that is not going to be dramatically changed by some new synthetic
Dr Lisa Erlanger (26:06):
Drug. And so how do we reconcile this with weight inclusive care when people understandably are so desperate to change a stigmatized body and to be healthy? And they’ve been told that this medicine will make them healthier and being smaller will make them healthy. And I know a lot of medical prescribers are struggling ethically with whether they should prescribe this medicine even though they understand the research to be pretty poor because of how reasonable it is for a person to want to escape being in a stigmatized body. And just individually, we’re all watching people who seem to be success stories.
Julie Church (26:53):
I think there’s a lot of people intrigued by it getting pulled in that wouldn’t have or done with dieting. And now having to go through a whole other process around, well, am I actually done with this medication too? Am I going to try this or not?
Dr Lisa Erlanger (27:05):
Right? I thought I was done. I thought I had made peace, and maybe now there’s something that says that I don’t have to make peace with this body. So I think there’s some important questions to ask oneself if they’re thinking about this medicine or prescribing this medicine. And the first is, what do I hope that being smaller will achieve? That’s even presuming you’re one of the people who could get smaller and I’m going to get there, but
(27:36):
What do I hope that being smaller will achieve and do I really have to get smaller to achieve those goals? And that’s really one of the fundamental questions of weight inclusive care because if a person’s goal is to be able to run with their toddler, I have a lot of smaller adult patients who feel like they’re too stiff or too out of shape or too distracted or too stressed to run with their toddler. And we work out a plan to build up that flexibility and that endurance and allow them to eat. If it’s knee pain and your weight inclusive provider can help you find a weight inclusive orthopedist and weight inclusive physical therapist, you don’t necessarily have to go back to essentially medically assisted dieting. And then how disruptive will it be for me and my relationship with my body if I lose my appetite? And for many of us who have recovered or have worked for years to recover from disordered eating, it’s really not worth when we really consider the will have to pay in terms of losing that sense of hunger and fullness and allowance of pleasure and nourishment. So what would that cost me if it really did cause me to lose my appetite in terms of the things I’ve gained through pursuing a weight inclusive life?
Julie Church (29:17):
Yeah, those are good
Dr Lisa Erlanger (29:19):
Thoughts. And then how will I know if it’s been successful or not successful and really be open with a prescriber if we’re pursuing that? What are our goals here and in what situations would weight loss still not be a good outcome? Because the fact is we don’t know yet, but we can guess that it’s not going to be safe or sustainable for most people. The medical students for size inclusivity, which is a fabulous international organization of medical students advocating for weight inclusive care and fighting against weight stigma in healthcare, has created a decision guide to full informed consent around these GLP one weight loss medications, and it’s available on their website, which we can link.
Julie Church (30:11):
Awesome. That’s awesome. That will definitely be a good link. I think the kind of pondering of this and trying to see how can we shield, if individuals are like, ah, I just don’t need any more info, or I don’t want to be marketed or be prescribed, I feel like maybe there’s a wave of when this will settle and not be such the craze. Do you think that that’s true or?
Dr Lisa Erlanger (30:37):
I do think so. It’s interesting. I’ve never heard more talk about weight loss, and I’ve also never heard more talk about weight inclusive care
(30:47):
And anti-fat bias in healthcare. I think that in some ways, the craze around these medications and the capitalization on it, just the profit and the cost and the pervasiveness is beginning to sound absurd to some people. I’ve noticed this particularly with pediatricians. When that American Academy of Pediatric Guideline came out, it’s almost like it shocked them into waking up to the way diet culture has pervaded the way we practice medicine, that the recommendations say, children as young as two should be referred to multidisciplinary intensive weight loss programs and children as young as 16 to bariatric surgery without any research supporting that it’s safe or effective. And so in some ways, we may have just crossed a line where it’s like, no, no, I don’t want to keep trying these things. I don’t want to keep injecting myself. I don’t want to keep being hungry. I don’t want to keep ending up in eating disorder treatment as fabulous as these programs are,
Julie Church (32:06):
Right, I wish our doors could be closed. Right? Yes.
Dr Lisa Erlanger (32:09):
I want to live my life without everyone telling me that I should be smaller and how to be smaller. And I am optimistic that the pushback we’re seeing is going to grow into a bigger movement.
Julie Church (32:26):
I can hear that. I can hear that. Honestly, those conversations, even when I’m podcasts, I’ve listened to about the topic that I don’t know these people. They’re not in my world. They’re not in what I would’ve thought of as the health at size sphere, and they are. They’re bringing up the topics that need to be discussed in the midst of this. So I appreciate hearing that and that is hope,
Dr Lisa Erlanger (32:49):
And I hear more and more from medical students that are asking for this information, and I’m being invited more often to speak at medical schools in required classes about anti-fat bias and weight inclusive care. And I think part of it is because of these medicines, because weight loss is so at the forefront of everybody’s mind and every office conversation if people want to know if it’s for real, because it sounds too good to be true. And it is.
Julie Church (33:20):
Yep. That’s great. Thank you. Well, thanks for helping us understand what we can in the midst of what is going on. I think we’re in the middle of it. So thank you. Thank you. Listeners, if there’s any more information you’d like about Opal as a clinic or about any other offerings we have, please check out Opal food and body.com and follow us on social media. We want to have a thank you to Jack Straw Cultural Center for Sound Engineering, David Bazzi for our editing, and Aaron Davidson for the Appetite Original Music. See you next time.
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