Episode 346: Over the last few years GLP-1's for weight loss have exploded and it feels like everyone is on them. I talk to registered dietician nutritionist Melainie Rogers about how these medications work, the dangers with them and the impact they are having on recovery, weight stigma and the body neutrality movement.
Melainie Rogers is the founder and chief executive officer of BALANCE Eating Disorder Treatment Center™, the only privately held eating disorder treatment center in New York City offering fully licensed outpatient programs. BALANCE holds licensure as a Partial Hospitalization Program (PHP), Intensive Outpatient (IOP), and as a mental health clinic under the New York State Office of Mental Health.
Under her leadership, BALANCE provides multi‑level care (PHP, IOP, evening programs, step‑down groups, virtual options) to adolescents and adults of all genders, integrating therapeutic, nutritional, experiential, and body‑inclusive modalities.
She is also the founder of Melainie Rogers Nutrition, LLC and Redefine Wellness, platforms through which she offers coaching, education, and resources to clinicians and individuals recovering from disordered eating.
00:00:00
Intro
00:05:52
00:14:18
00:17:52
00:24:47
00:33:16
00:42:55
00:50:01
01:00:15
01:10:57
01:17:30
01:31:06
01:36:51
Chris Sandel: Hey! If you want access to the transcript, the show notes, or the links talked about as part of this episode, you can head to www.seven-health.com/346.
Hey, everyone. Welcome back to another episode of Real Health Radio. I’m your host, Chris Sandel. I’m a nutritionist and a coach and an eating disorder expert, and I help people to fully recover.
Before we get on with today’s show, I just want to say that I’m currently taking on new clients. If you are living with an eating disorder – it doesn’t matter whether this has been going on for a matter of months or multiple decades – and you want to reach a place of full recovery, I would love to help. I know the idea of full recovery can feel like this pipe dream or it can feel very distant or it’s for someone else, but I truly believe that everyone can fully recover. So if this is what you want help with in your recovery, then I would love to be able to support you.
If that’s of interest, you can send an email to info@seven-health.com and just put ‘coaching’ in the subject line and I can send over the details.
So, on with today’s show. Today I have a guest interview, and my guest today is Melainie Rogers. Melainie is the founder and chief executive officer of BALANCE Eating Disorder Treatment Center, the only privately held eating disorder treatment centre in New York City offering fully licensed outpatient programmes. BALANCE hods licensures as a partial hospitalisation programme, an intensive outpatient, and as a mental health clinic under the New York State Office of Mental Health. Under Melainie’s leadership, BALANCE provides multi-level care, so PHP, IOP, evening programmes, stepdown groups, virtual options, to adults and adolescents of all genders, integrating therapeutic, nutritional, experimental, and body-inclusive modalities.
She’s also the founder of Melainie Rogers Nutrition LLC and Redefine Wellness platforms, through which she offers coaching, education, and resources to clinicians and individuals recovering from disordered eating.
Today on the episode, we are talking all about GLP-1s. These are the injectable weight loss drugs going by the names of things like Ozempic, Wegovy, Saxenda, etc. It’s a topic that I’ve wanted to cover in detail before – I think in previous episodes with guests, sometimes we’ve touched it in passing or spent a little bit of time on it, but I’ve never really dedicated a whole episode to this topic, and it’s something that I think is really important given what is going on at the moment and feeling like everyone is starting to take these drugs.
As part of this episode, what we look at is Melainie’s background and how she got into working in eating disorders; we then look at GLP-1 medications and do a little bit of a primer for people who don’t know about this. And I’d say most people don’t really know all the details connected to it. So we look at how these medications work in the body, how they impact things like appetite and digestion and hunger hormones and metabolism. We go through a study that looked at their efficacy and what the study actually showed.
We talk about what happens when someone stops taking these medications, the rise of eating disorder symptoms linked to GLP-1s, how these drugs and the narratives created by the pharmaceutical companies have really shifted our conversations around weight stigma, how celebrity and influencer endorsements shape the public narrative about these medications, GLP-1s’ impact on Health at Every Size and body neutrality and these movements, and where we think things are heading over the next 5 to 10 years.
I know it can feel like recovery is even harder these days because it does feel like everyone is taking GLP-1s, and it does feel like these are these wonder drugs, and why wouldn’t you be taking these things? So I think this is such an important issue. There are moments when Melainie was very diplomatic in her assessment of these things, but knowing how easy it is for the eating disorder to hear what it wants to hear, I can assure you that I was not very diplomatic when talking about these and I was very blunt in how I see the harms of these impacting society at large, but especially people within eating disorder recovery, so this episode should leave you in no uncertain terms about my thoughts on these medications and the harms I believe that they are causing and will continue to cause.
With that intro out of the way, let’s get on with the show. Here is my conversation with Melainie Rogers.
Hey, Melainie. Welcome to the podcast. I’m very excited to chat with you today.
Melainie Rogers: Thanks so much, Chris. It’s great to be here.
Chris Sandel: We’re going to spend a lot of today talking about GLP-1s. It’s actually a topic I haven’t spent that much time on. It’s come up in passing on some podcasts, but I definitely haven’t dedicated a whole episode to it. It was interesting; I had in my notes “I’m going to do a whole episode on this myself” and then received an email from you like a week later. I was like, “Oh, this is perfect.”
Melainie Rogers: Serendipity. That’s great.
Chris Sandel: Exactly. So this is how we’re going to spend the majority of our time, and I know there’s probably going to be a lot that we’re not going to be able to cover because there’s so much to cover. But yeah, you seem to be someone who knows a lot about this, and I think it’s having such an impact on eating disorders. So I think it’s a very important thing to cover.
00:05:52
Before we get into that, do you want to just give the audience a bit of background on yourself? So for people who don’t know who you are, what training have you done, what do you do in your day-to-day?
Melainie Rogers: Sure, absolutely, Chris. To start off, I’m Australian, so we share that in common. Originally from Melbourne, Australia, but now living in New York City. I’ve been here for 25 years. I came out to New York to do my clinical master’s studies in clinical nutrition because I was on the pathway to become a registered dietitian, is what I wanted to do, thinking that I wanted to get into preventative medicine, really.
While I was doing my internship, which is part of becoming a registered dietitian here in the States, and I think in most places, I was interning at a centre here – it’s called the Obesity Research Center, and it’s actually one of five centres in the country. It was the reason why I decided to come to New York in the first place, because being a little bit of a nerd and loving the research and wanting to be close to the research, the research in the States is obviously more prolific than in Australia. That was why I wanted to come here specifically.
So I was able to intern there, and while I was there, Chris, I was working with a multidisciplinary team who were working with people with binge eating disorder. And this was 25 years ago, so this was before ‘binge eating disorder’ had a full diagnostic code. It wasn’t even recognised in the DSM-IV and 5, which are the diagnostic manuals that they use for illnesses.
What was fascinating about it is, unlike traditional weight loss methods that you and I may have been trained in with our nutrition backgrounds of ‘calories in, calories out’, this was a multidisciplinary team where they had a therapist, an RD, which is a dietitian, an MD, a psychiatrist, and a sports physiologist. And when I saw that whole cohort of people from multi disciplines, different disciplines where we’re looking at the psychology behind eating, we’re looking at the behaviours behind eating, we’re looking at obviously the nutritional aspects of eating and the medical and the psychiatric, it blew my mind. For me, it was like the missing piece.
It’s not just calories in, calories out. People have a relationship with food, and that is very emotional and cultural and psychological. So that blew my mind. And it was then that it triggered something in me where I thought, “This is complicated, and I want to know more.”
So I went away to several different conferences to learn more about eating disorders. I went away to a number of different conferences and learned more about eating disorders and started to put the pieces together, and I ended up working at the research centre for a couple of years as well before going into private practice on my own.
What was pivotal about that time, Chris, was, like many of us in the field of eating disorders, about 80% of us have our own lived experience with an eating disorder. But eating disorders also tend to keep us in a place of denial where, for many of us, we don’t actually believe that we have an eating disorder. That unfortunately turned out to be my case, where I was going away to these conferences, I was learning all about eating disorders and behaviours, I was looking back and reflecting on my own behaviours in my early twenties and thinking, oh gosh, that wasn’t just uber-healthy eating and running crazy marathons all the time. That actually was an eating disorder. And then I got treatment for it, etc., thank goodness.
But that also gave me a lived experience perspective in addition to the clinical information and the research I was learning about best practices. So that led me to then open my own private practice as a registered dietitian here in New York City, and I specialised in eating disorders. I was one of very, very few in the city at that time. Thank goodness we have many more now. I brought on several different RDs to work with me over the years and formed a small group practice specialising in eating disorders, and then after about 7 years doing that, I was in private practice for 7 years and then realised that in New York City we only had one outpatient treatment centre and we needed more. We needed at least one more.
Speaking to some of my colleagues, I decided that I would take the leap and open a treatment centre. And I knew nothing about running a treatment centre or whatever, so I brought in some people who knew a little bit about it and I opened BALANCE, which is my eating disorder treatment centre here in New York. We’re one of only three in the city that specialise 100% on eating disorders. And that’s what I’ve been doing for the last 16 years: working in this level of care. Your viewers may or may not be familiar, but outpatient care is just a level below residential. Residential is 24/7, sometimes called rehab in the substance industry. So it’s the level just below that. It’s called a day programme or partial hospitalisation. It’s 30-40 hours a week, 6 hours a day, 7 days a week.
So our clients come to us, Chris, they usually take medical leave from work or from school. It’s pretty hardcore. I have a team of therapists, a team of RDs. We have our psychiatrist onsite as well, and our medical team are usually in their own locations. We treat across the spectrum of all eating disorders.
Binge eating has always been my area of specialty since that internship that I mentioned earlier, and very near and dear to my heart is working with our population who are in higher weight bodies, where there’s so much weight stigma and weight bias. And now with our topic today, when we’re talking about GLP-1s, we’re also seeing in higher weight bodies using GLP-1s, going through sometimes significant weight loss, and actually developing atypical anorexia as a result of that. And I’m sure we’ll get into that later.
So those two groups of people, binge eating disorder and our atypical anorexia clientele, both in higher weight bodies, are areas that are very near and dear to my heart.
Chris Sandel: Definitely. I definitely want to cover that piece with you. We can cover it now, because from my perspective, I think we have a lot of labels for different eating disorders, and a lot of that labelling, from my perspective, is solely based on the size of body that that person is in. The person that you’re describing with ‘atypical anorexia’ versus what was going on before when they were ‘binge eating disorder’ – the exact same thing. We’re just giving this thing a different label because of someone’s body.
And I think that’s a damaging thing. There’s this competition within eating disorders, like some of them are better than others, and this one’s all about willpower and this one’s about losing willpower. I think it makes absolutely no sense to me.
Melainie Rogers: Totally.
Chris Sandel: In that we’ve got the same thing going on. We can have some slightly different things occurring; some people there’s times where there’s more food being eaten, some people there’s more exercise going on. But fundamentally, under the hood, the same thing is happening for each person.
Melainie Rogers: Oh, absolutely. The similarities, exactly. It comes down to weight bias and weight stigma, and still very, very real, very, very prevalent, Chris.
00:14:18
Chris Sandel: Just so I understand more, and then we’ll get on to GLP-1s, before you went out to the States, with the training that you had, how much had there been a focus on eating disorders and how much did you think you would end up in that line of work?
Melainie Rogers: Never. Never imagined. Back home in Australia, and it’s similar here, you do an undergrad in science, usually, with a major in biochem or physiology. I did biochem. Never imagined. My journey was around wanting to go into preventative medicine or preventative nutrition. It was really precipitated by my grandmother, who was a woman in a higher weight body. I just remember as a little girl growing up very close to her, she was always on a diet. Always being told “You shouldn’t be eating that, you should be eating this.” And she was a feisty person, so she’d lose her temper every now and then and tell everyone to be quiet.
But I just remember her struggle, and then unfortunately she developed heart disease and then passed away from a heart attack when I was quite young, and it was the first member of my family to lose. It had a huge impression on me, Chris. So that was what set me on the path of – well, at the time, “I’m going to be a doctor so I can prevent people from dying from heart disease” and then realising that doctors usually get to the disease state when it’s already developed. It’s not usually preventative. So that’s why I transitioned and went into nutrition, again, thinking that I’d do preventative cardiovascular work or something like that.
And I think now, when I look back on that, as much as my grandmother struggled, I think it was very helpful for me – perhaps the silver lining – to have a family member that I was very close to and see their active distress with trying to take care of themselves from a health perspective and being told “Your weight’s still too high” and being threatened with all the things and just seeing that firsthand, how hard that struggle was for her. I think it really gave me empathy as to what so many of our clients go through and the weight stigma, etc.
So that was really the journey I was on. Maybe cardiovascular, maybe diabetes, which is also why I came out to New York to join the Obesity Research Center, thinking, “My goodness, that will be close to the research around diabetes. If I’m a nutritionist, I’m pretty sure I’ll be employed for the rest of my career if I plug into that.”
And I do want to just say for your audience, I’m using the word ‘obesity’; it’s not a word we like to use in the eating disorder world. It is the technical name or the official name of that centre, so that’s the reason I’m using that particular ‘o-word’, as we call it. But I’m not a believer in that distinction, to be honest with you.
Chris Sandel: Cool. Thank you for mentioning that. Let’s get on to GLP-1s. I think it would be useful for – I know there’s probably lots of people who have heard a lot of things or have seen this coming up in their social media feed or have seen it in the news. I don’t know where everyone’s understanding is with this, so I think it would be useful to have a little bit of a primer and explain a little bit of this before we get into some of the nuances with it.
00:17:52
As a starting place, what are GLP-1 medications? What were they originally intended to be used for?
Melainie Rogers: Absolutely. Great stuff, Chris. I love this. I teach at NYU, so I had to do a deep dive so I could explain it right from the go with my students there.
GLP-1s are actually a naturally occurring peptide hormone that the gut produces, the small intestine produces, when you eat food. It is produced in response to the food to then send a signal to your pancreas to produce insulin. Insulin, as we may know, is the hormone that then goes along in the bloodstream and unlocks cells for the blood glucose to be accepted into the cell for energy. It’s the whole blood glucose insulin piece, and that’s the communicator, if you will.
GLP-1, otherwise known as – the official term is ‘glucagon-like peptide-1’, and it’s glucagon because it’s glucagon-like, which is another hormone in there, and then it’s called a peptide because it’s made up of amino acids, and it’s called 1 because it was the first one to be identified. That’s the scientific mystery behind it.
So anyway, GLP-1s are naturally occurring in the body in response to food, help with blood sugar management via insulin. What’s interesting about them, Chris, is they have what we call a half-life of two minutes. What that means is that they’re released and within two minutes, the body has already started to deactivate them. So they’re very, very short term, constantly being produced. And that’s a safety measure so that the body doesn’t overproduce and it’s not circulating in the body for hours, and then you’d have a massive glucose crash. They only last for about two minutes.
The GLP-1RAs that we’re using in the likes of Ozempic, which I’m sure many people are familiar with that name. What they’ve done is taken that hormone, that peptide, and they’ve tweaked it just a little bit. Semaglutide is what they’ve called it. Semaglutide is basically that GLP-1, and it’s been tweaked by 3%, and that tweak has allowed several things to happen.
Number one, it no longer just lasts for two minutes; the half-life is now a week. That’s important.
Chris Sandel: That’s quite the jump.
Melainie Rogers: Quite the jump, and that’s important because if you think about marketing a medication – what we’ve seen with our clients with diabetes, for example, often they have to inject several times a day, for example. So this has taken that phenomenon from having to monitor your blood sugar several times a day to once a week. I mean, that’s a game-changer as far as compliance, as far as comfort, or discomfort, shall we say, convenience, all those things. So that’s huge.
The second thing that was also refined, if you will, in that slight chemical manipulation was it’s much more specific. So when it binds onto its little receptor or when it docks on that receptor site on the cell, its adhesion or its connectivity is much more specific and stronger, if you will. So the response or the efficacy, the efficiency of it, is much more than the normal occurring hormone.
So that’s GLP-1Ras, that slightly modified version of the natural occurring hormone. Novo Nordisk were the first to take that and make those modifications, made it a game-changer, released it as Ozempic, as you know, specifically for type 2 diabetes.
Chris Sandel: And when was that?
Melainie Rogers: That was 2017. GLP-1s have actually been around since 2010, but not this version. The earlier versions, also developed by Novo Nordisk – they’re the big diabetes pharmacological firm – those other versions didn’t have this one-week lifespan piece, they were less efficient, etc. So this was a real game-changer with those slight modifications to the chemical structure of it, Chris.
Then what they observed – and this is true of any medication that comes out – when there is an observation of another side effect that could be seen as helpful or useful if used in a different way, then sometimes that drug is then developed for that secondary purpose. And in this case, they saw weight loss with people using the GLP-1RA, the Ozempic, so then they developed the same chemical but just in a higher dose and released it as Wegovy specifically for weight loss.
So those are the two. It’s the exact same chemical, just in a different concentration, if you will, or dosage, one for diabetes and one for weight loss.
The big stumble there, though, Chris, if I may, is that all this was happening during Covid. And I don’t know if you remember during Covid, but here in the US of A, when people started to see that people were losing weight on Ozempic, a lot of people who wanted to lose weight themselves but didn’t have diabetes started buying up Ozempic. We had a shortage of Ozempic here, so people who needed Ozempic for their diabetes couldn’t get it.
Then there was a phenomenon whereby the government can put in a temporary request for other pharmaceutical companies to make that product while there is a shortage, and they did that. It’s called compounding. And that was only supposed to be for a short term until those supply chains were put back and there was no longer a supply shortage. However, those companies haven’t gone away even though technically they’re slightly illegal. But they’ve modified some of their versions so they’re still on the market, and those are the Ros and the Hims & Hers that are out there. Serena Williams is advertising Ro at the moment. You may have seen that.
00:24:47
Chris Sandel: When the drug was developed, my assumption is that a lot of the clinical trials were then done around diabetes management, “We’re using this for diabetes management.” Have there then been clinical trials done with this for this ‘off label’ usage of it at this higher dose that is then used with weight loss?
Melainie Rogers: Absolutely, great question. Yes. It’s called the Step 1 Study. Again, done by Novo Nordisk, which is typical. It is their drug so of course they need to do research on it. It’s basically over two years, Chris, and what they did is they put people on the Ozempic equivalent semaglutide but at the weight loss levels, and they put them on that for 68 weeks, so just over a year, and they observed weight loss and did all the different testing, etc.
Interestingly, they were also making sure to make any observations around cardiovascular complications because they didn’t want a repeat of fen-phen from a decade or so ago. So they observed weight loss over 68 weeks and then they stopped cold turkey the medication and then observed for another 52 weeks what happened. It took lots of research and data.
After 52 weeks off that medication, they found that weight regain happened, as we would expect. At the end of 52 weeks, though, they were able to say that clients maintained a 5% weight loss after a year off the medication. Now, Chris, you and I are both scientists, and what’s curious to me is 68 weeks on the medication – why only 52 weeks off the medication? Why not continue for 68 more weeks or even longer? I think you and I both know the answer to that.
Chris Sandel: Yeah, for sure. I would also say that the majority of people going on this medication, one, aren’t hoping for a 5% reduction, but two, will then feel pretty disheartened when they initially have a 20%, 30%, whatever big reduction that then gets reduced back down to a 5% reduction.
Melainie Rogers: Exactly. And that’s our concern, Chris. Two things there. These medications are absolutely intended for lifelong use, and the manufacturers are saying this. This is not a medication that you go on for short-term weight loss and then come off, because the medication is altering the brain and the gut in a way that willpower or any kind of behavioural interventions just will not be able to sustain that weight loss. The body will fight back, as we know it does. And that’s a protective measure.
What we’re scared about it several things. We’re concerned about several things. One, that people don’t appreciate that it is a lifelong commitment. number two, we actually don’t know what 10 years or 20 years on this medication is going to have as far as side effects. Or does it wear off? Does it stop being effective and people regain the weight even then?
And the other piece is that what we do know is that when people do come off that medication, they eventually not even just regain the weight, but they usually regain extra pounds because your body composition changes when you lose weight – any weight, but when you’re losing that kind of weight, you’re stripping away a lot of muscle. So therefore, when you regain weight, you don’t tend to regain as much muscle. Your metabolic rate ends up being lower, even though you end up at a higher weight.
It’s that phenomenon of yo-yo dieting, or weight cycling we call it, Chris, as you know, that we believe actually is the culprit behind metabolic illness. Not the start weight that you were at in the first place. And I think the general public doesn’t know that nor appreciate it, and certainly that’s not the messaging they get.
Chris Sandel: My take on this is it’s the weight cycling with the weight stigma that comes along with all of this. And weight stigma in and of itself has a huge impact on the body, has an impact on stress hormones, has a really big impact on metabolism. So many things are impacted when you’re feeling like “I’m living in a body that I shouldn’t be living in, that is ridiculed. I’ve got to go to the doctor and I know the doctor’s going to tell me this thing and that thing.” That has a really big impact on someone’s health.
Melainie Rogers: Absolutely. And I’m sure you know, Chris, the research now is even suggesting that, again, leaving weight out of it, it’s actually that kind of discrimination and oppression and these kind of psychological stressors that can have as much if not more detriment on people’s health and longevity than just weight as one datapoint.
And I think that’s a really important thing for us to be considering, and is being considered in our field, but it hasn’t adopted or acknowledged in the general health care systems. I would suggest even globally. We’re here in the US, you’re in the UK, but I would suggest it’s fairly similar in what our doctors are still advocating or telling clients to do.
Chris Sandel: Yes. And I would say if anything, it’s getting worse again because now we have this medication; why wouldn’t you be doing this? It’s now unhealthy for you not to be thinking about taking this medication. So you’re now getting served this whole new layer of shame. Because before, you could put it down to you just couldn’t make it work, but “now what’s your excuse?” type thing.
Melainie Rogers: Exactly. More shaming. More moral judgment. Chris, if I may, if you’ll allow me, what I found so absolutely infuriating is up until Ozempic came out, the messaging from the health care system, but also the diet industry – and remember, the diet industry, at least here in the United States – I think it’s upwards of $74 billion, maybe $80 billion a year is spent on weight loss in this country. That’s a lot of people who are heavily invested in people dieting and believing and leaning into that.
So we’ve got all this messaging about “It’s loss of willpower, and people who regain the weight, it’s your fault, it’s your fault, it’s your fault.” And then when Ozempic comes out and all the research, the research does a complete 180 without acknowledging that we have been blaming people for all these decades for something that is not their fault. They didn’t even attempt to apologise; they just almost gaslit society and just said, “As we know, losing weight and keeping it off is 95% chance of impossible, so now we have this medication that we think can help people.”
I was so furious to read that because, again, they’ve known this research all this time, but no-one was telling people that diets fail 95% of the time and they actually do damage.
Chris Sandel: Yeah. “We’re happy to admit it now when we’ve got something that can get round it, or supposedly get round it, but before, that’s just not true, you just need to make this change and that change.” Yes, a lot of blaming of people.
Melainie Rogers: Yeah.
00:33:16
Chris Sandel: I wonder – again, staying in this primary area when talking about GLP-1s – what are the drugs doing to things like appetite or digestion or hunger hormones or metabolism? I know you’ve touched on these a little bit, but I think it would be useful to go into this in a little more detail if you can.
Melainie Rogers: Absolutely. They’re pretty cool hormones, actually, if you want to think about it like that. The original hormone slows down the passage of the food through your intestinal system, and the reason it does that is so that the absorption of the nutrients from the food that you’re eating can happen at a slow, steady pace so you don’t end up with a massive big uptake of glucose, which wouldn’t be good for you and the body wouldn’t be able to manage it all.
So it’s really so synchronised. Food comes in, the hormone’s released, it slows everything down so we can have a slow absorption and breakdown of the food, and it also then starts to signal some satiety signals. Ghrelin and lectin, you’ve probably heard of those. Lectin slows down and tell us that we’re starting to get full, etc. So it does that.
Then with Ozempic or Mounjaro or Wegovy, etc., the other medications, they do exactly that but they do it at such a level that people now are experiencing a lot of nausea, vomiting, artificial fullness, etc. A lot of GI distress actually is one of the very, very common side effects.
Chris Sandel: So in a lot of ways they’ve been marketed as “this helps you to naturally eat less”, but actually what’s happening is people are just not eating enough. And they’re not eating enough while not realising they’re not eating enough. It could be just “I don’t have any appetite” or “I’m having these uncomfortable symptoms that are associated with it” which means there is then a decrease in energy coming in. Which then has a huge knock-on effect in terms of people’s physical health, mental health, psychological health, because as much as everyone is deathly afraid of food and eating food and that we shouldn’t be having food, it’s like – we need energy to run our bodies and to run all the systems and organs and everything within our body. So when you’re not getting enough, that’s not good for one’s health.
Melainie Rogers: Absolutely. You hit it on the head, Chris. You explained it so well. In fact, a term that’s being kicked around right now is ‘medically induced anorexia’. Because it is undereating to a point that isn’t optimal for your health.
And as you said, with weight loss, that is the side effect of this drug – even though it’s intentional. We’re seeing people losing amounts of weight that are above and beyond what even might improve biomarkers. If you look at the research – I’ll start with this: we know that you can be ‘healthier’, if that’s important to you – and again, it’s a person’s choice. But you can be healthier at any weight and size by doing various different things in your life. For example, getting more sleep, eating more consistently throughout the day, reducing stressors, taking care of your mental health, as you said. Things of that nature. Weight is only one small piece.
Weight, however, as you well know, and that number on the scale is conflated with health. It’s like the proxy. Depending on the number on the scale is how healthy or unhealthy you are. And nothing could be further from the truth.
So we’ve got a lot of people who are believing in that because they’re being told that. They’re losing excessive amounts of weight that are then causing damage and malnutrition within their body. In other words, in seeking out health – which I believe is why most people are motivated to use these medications – they’re actually creating an unhealthy situation for their body.
Chris Sandel: Yeah. When I think about someone with an eating disorder starting to use this medication – and it’s not that everyone who doesn’t have an eating disorder is in perfect health to begin with; there’s a lot of dieting, there can be restriction, there can be lots of things going on on a spectrum before we get to the point of an eating disorder. But when someone’s got an eating disorder, it’s often that this restriction has been going on for a longer amount of time. There’s more depletion that has started to occur that is then having a more obvious impact on them. And when I say obvious, I mean from a symptoms perspective, even if they’re not necessarily noticing it or making the cause and effect connection. It’s having an impact on them.
And then at that point, someone starts this kind of medication, and that is just pouring gasoline on a fire that’s already going. I think about what we’re wanting in terms of recovery; it’s this real reconnection with interoceptive awareness and someone’s ability to hear hunger and fullness cues. And I know that can often be later on as part of recovery; in the beginning there can be a little more of a meal plan’s more important or we just need to be eating in a structured way irrespective of what’s going on in terms of hunger and fullness. But there is this idea of we need you to be able to reconnect, and we need to be doing the things that allow and assist that to happen.
From everything you’ve just described there in terms of how these medications work and the impact that they have, this is really doing the opposite. It’s disconnecting someone from being able to hear these things.
Melainie Rogers: Absolutely. You perfectly described, Chris, all of our intuitive eating, which is really just tapping into our internal regulatory system that we’re born with. Hunger, fullness, satiety. Dieting completely messes up that whole piece and instead of it being an internal experience of what your body needs and what your body is telling you, we externalise it by counting calories or measuring food or portions or whatnot.
And this is completely then, really, anaesthetizing that whole system, really is what it’s doing. There’s no chance of being in touch with your natural regulatory system unless you maybe come off the medication, and then of course, all of that system comes back online, and people panic. And this is where we’re seeing an uptick in disordered eating and distressed behaviours as people desperately try to cling to and maintain that weight loss, perhaps not understanding that without that medication, it’s almost impossible to sustain the weight loss.
Chris Sandel: Yeah, because you’ve been, in a sense, blunting certain signals getting through, and now we’ve removed the thing that was blunting those signals getting through and we’re now really seeing how hungry we are. And it’s not just like I’ve got hunger for today; it’s I’ve got hunger for the last 52 weeks that I’ve been on this medication or however long, where I’ve in essence got myself into a hole but I just didn’t realise it. I didn’t realise how big this debt was, and now I’m finally getting that. But someone doesn’t understand that. They’re just feeling like “But before I wasn’t eating as much and that was fine, and why can’t I do this now?” and we get back into the willpower piece of “I should be able to do this.”
Melainie Rogers: And the shame piece. We’re very, very good at saying that “If this isn’t working, it’s your fault” as opposed to saying “My goodness, why wasn’t I alerted to this? Why wasn’t I screened?” And we’ll get into that.
What comes up for me, Chris, for people who are listening, it’s almost the same as – let’s say you fell over and you broke your leg, and it hurt, and you went and got a cast on your leg and you got the crutches, and you took some appropriate pain medication for that first week or so, and that really helped to bring the pain down to a tolerable level. It would be the same as saying, okay, you’ve taken pain medication for one day; take the pain medication away, and now you do that pain control on your own. You just can’t, because the chemical is not in the body that’s blunting those pain signals. You might be breathing and breathing and breathing, but the pain is going to escalate because you don’t have that medication that’s blunting that signalling and that intensity. In the same way, we can’t expect people to do something without that chemical being available in their body at that level to do it for them.
00:42:55
Chris Sandel: What have you been seeing in your clinical practice with people either coming in who are dealing with eating disorders who are also on these GLP-1s, or people who are asking you questions about it? I’d just be interested to hear your experience and what you’ve noticed within this space.
Melainie Rogers: A mixed bag, Chris. Three categories of people, I would say: those who come in who are actually on the GLP-1s; those who’ve been on them and they couldn’t handle the side effects or they maybe didn’t see any change, so they’ve come off them; and then we have other clients who are GLP-1 curious, or Ozempic curious, and they’re asking all the questions about do we recommend it and should they go on them, etc.
So it’s been interesting to try and navigate those conversations. Our goal as health care providers, we do have our opinions, of course, and hopefully our opinions are informed by the research, but it is very important for each individual client to be very neutral, I think, in providing the facts, looking at their own individual situation and trying to figure out, “Maybe this could be a tool for you, but also, we need to make sure that we know X, Y and Z and you’re aware of X, Y and Z.”
Because the medications, from everything I’ve read, they don’t just magically work. You do need to do some behavioural changes around food and activity. So they’re kind of a combination of those things. Again, there’s some education there. But those are the very personalised conversations we’re having with each client depending upon what they feel is the best fit for them.
And as much as we’re talking about some of the drawbacks of these medications, Chris, if one of my clients truly wanted to go onto Ozempic or Wegovy or Zepbound, and they truly wanted to do that and we had a lot of conversation and processed it, I’m certainly not going to stand in the way of them doing that if they feel that’s best for their health, and then we would figure out a way to manage it.
I think it’s not helpful for us as health care providers to also shut the door on certain things that clients may feel is best for them as well. But as long as they’re informed. I think the key thing is informed and also assessed, and particularly with eating disorders and disordered eating, to know the risks of a relapse with those conditions.
Chris Sandel: It is the whole informed consent piece. Also, if I’m being really honest, it does make me feel very uncomfortable to think of someone with an eating disorder going down this route because I don’t see it ending particularly well. In some ways we may have a ‘better’ year or 18 months or whatever while I’m on this, but we’re kind of kicking the can down the road. And that’s best case scenario.
So yes, I’m onboard in terms of people have unconditional permission and unconditional positive regard and all of those things – and I feel uncomfortable about saying “Hey, I think this is a good idea.” If I’m being totally honest.
Melainie Rogers: I would agree with you, Chris, 110% on that one, if they’re actively in their eating disorder. What it brings up for me is when I first started out in the field, bariatric surgery was the go-to treatment for people in higher weight bodies. And when I came to the US of A, the FDA, who are the governing body on medications that get approval here and certain procedures – and in this case, the LAP-band had just obtained FDA approval.
So a number of surgeons I was working with at the hospital where I started, GI docs and surgeons, started to do LAP-band surgery on a number of clients. That was my first job, working in bariatric surgery, and work as a nutritionist then was to do the preliminary screening and screen for disordered eating and eating disorders, and particularly in this case often binge eating disorder, which was most prevalent for people in higher weight bodies.
What we found is that those clients that we screened and flagged for having really quite disruptive binge eating disorder, those who then committed to a six-month or nine-month treatment just working on their eating disorder behaviours who then had surgery had far better outcomes. And then there were others who, for various reasons, did not treat the eating disorder and had the surgery and had a lot of behaviours come back but just in a morphed version as the surgery and the anatomical changes allowed. And that was heartbreaking for them as well.
As a field, we’ve been looking at, what do we know historically where we’ve had something similar or similar scenarios with different medications or procedures? What did we learn from that, and what is helpful to this current scenario?
Just 100% in agreement with you, Chris: if our clients are actively in their eating disorder, I don’t think there’s a place for these weight loss drugs, because we know it’s contraindicated to recovery from an eating disorder. However, I have met several people now who did get treatment for their eating disorder historically, binge eating disorder in this case, and then after a few years of being in a really good place, did decide to go on Zepbound or Wegovy for weight loss and kept their treatment team and kept monitoring for any kind of uptick in eating disorder behaviours, and their report – this is very anecdotal because it’s only two or three people I’ve spoken to, but that seemed to take them to a place that was comfortable and okay for them.
So that’s a scenario: do the treatment, get into a stable place, and then maybe if you still feel that that’s helpful, it could be. But again, having wraparound services with your treatment team. That is something that I have certainly seen and heard about.
00:50:01
Chris Sandel: Sure. Again, I have my concerns about that as well just because someone who has a history of an eating disorder, where they are then getting back into a lower energy state where this isn’t spontaneously happening – like it’s one thing, if I reflect on clients that I work with, yeah, there’s a period during recovery where eating is a lot higher because you’re not just eating for today; you’re eating for everything that’s happened before it. There can be the extreme hunger, there can be eating a higher amount, and then that naturally tapers off as recovery gets further and further along. Someone can get back to eating a ‘normal’ – and by normal I mean normal for what they need to meet their day-to-day demands.
Whether we’re two years down the road or five years down the road or seven years down the road, to then bring in a medication that has an impact on their ability to properly hear their appetite and hunger and all of these things, my gut instinct is like, you’re playing with fire in a scenario like this.
So even with the people you’ve mentioned in an anecdotal fashion of like it seems to be going okay for them, there’s a part of me that’s like, let’s see in a year’s time, in three years’ time, in five years’ time. Because I think there’s a lot of – especially when someone’s losing weight and supposedly doing it in a healthier way or a better way or whatever adjective you use, there can be a lot of “Oh, everything’s fine. Yeah, everything’s working really well. Gosh, it’s so much easier. I wish I’d found this earlier in my recovery.” It kind of works until it doesn’t, and then there’s that moment of like “Oh wow, how are we here again?”
I’m saying all this because I know the way that people will hear some of the comments you’re making, and I know that there are especially people where they’ve recovered into a body that feels very different to the body they had either before their eating disorder or during their eating disorder, and there’s a lot of discomfort, and they’re still trying to navigate and work their way through that body acceptance piece and living in this different body and making peace with that. So I’m just conscious of, I don’t want people getting ideas without me at least giving my two cents: I wouldn’t be recommending this.
Melainie Rogers: Good job, Chris. Honestly, I would second it. I kind of feel a little bit irresponsible even sharing those couple of anecdotes in my effort to try and provide both sides of the story, so to speak. But I agree with you. And for your listeners to know, the number one rule – ‘rule’ is not the right word, but the number one thing that we tell all of our clients is dieting is never to be entertained, because the risk of relapse is just so huge for any of us.
That body image distress, to somehow work through that without going into intentional weight loss, because if you have that – because those of us that develop an eating disorder usually have that genetic vulnerable. It only requires your weight shifting down again to switch it back on, no matter how much you may feel that you could be in control of such a scenario or catch it before it happens. Often this thing takes over very quickly, and before we even realise it. And part of the hallmark of an eating disorder is also just not realising that you’re already down the rabbit hole before you realise you were. So I totally support you in that stance, Chris, for sure.
Chris Sandel: In lots of ways I’m glad you mentioned it because I know people are going to be having these kinds of thoughts, like “Well, what about…?” So by you saying this, it’s given me a chance to be pretty blunt and flag this, like well, no, I wouldn’t be suggesting that at all.
Melainie Rogers: Absolutely. Listen to Chris, everyone. Listen to Chris. He’s 100% right, absolutely.
It brings also the other piece into it, Chris, where people are starting to play around like micro-dosing or just going on them for a short period of time to make weight for a certain event. So there’s a lot of that sort of stuff that’s going on that blows my mind as well. I don’t even know where to start with that. But yeah, I think it is good that we’re at least putting that on the table and having conversations around it.
And again, I think it’s natural in this culture, in this very thin ideal, unrealistic beauty standards for guys and gals, actually, that people are going to have a lot of distress if their body doesn’t conform, and the desire to use one of these medications if it may reduce some of that distress, I so get the appeal. I think we all do.
Chris Sandel: For sure.
Melainie Rogers: And we’re also saying, if you can, try and push back on diet culture and try and stay true to your recovery and get to that place of body respect, body neutrality, body acceptance. It doesn’t have to be body love, but even just getting to that place of body respect and neutrality I think is a huge accomplishment.
Chris Sandel: Definitely. When I think about recovery, there are different stages with it, and we have the recovery piece that is what people think about as recovery, like “I’ve got to do the eating piece and I’ve got to change my exercise.” It’s very much those early stages and doing a lot of that nutritional rehabilitation.
But I actually think that real recovery is a lot of the stuff that is coming after that piece. It is doing a lot of the real body acceptance work that you made reference to. It’s understanding, how can I find other ways of coping? Because really, what I find – people don’t necessarily go into an eating disorder looking for a way to be able to cope, although some people do, but it ultimately becomes that thing for someone. So recovery therefore is, how do I do that in other ways?
And that then shows up in lots of different changes around how someone’s living or how they spend their time or their relationships they’re in or their relationship to things like money or work or sex or whatever it may be. That, for me, is the longer part of recovery in a lot of ways. The in-the-trenches nutritional rehabilitation, depending on how someone does it, if someone knuckles down, a year, 18 months probably. But it’s then another two, three, five years of doing the other stuff.
And in a lot of ways, there is no end point. I totally think that people fully recover, but I’m not recovering from an eating disorder and I’m constantly doing personal development stuff in terms of how can I be a better dad, how can I be better as a partner, how can I show my emotions more, how can I be more open, all of these different aspects of being a human and continuing to do that kind of stuff. But yeah, there is then probably a two, three, five year consolidated period where you’re doing that in a lot of ways to say, “Cool, I’m doing this so that the eating disorder doesn’t come back. I don’t need that in any way in my life.”
Melainie Rogers: Yeah. Gosh, you described that so well, Chris, as far as those stages. It’s so true. I love all the personal development pieces that you mentioned, and along with that, 70-80% of us – in fact, I would say 100% of us – I say ‘us’ because of my own lived experience – is anxiety, depression. We call them comorbidities, but those other mental health challenges that usually cluster with eating disorders. Perfectionism, some of those personality traits, rigid thinking, black-and-white thinking, or impulsivity.
So a lot of recovery is getting through those three to five years exactly and figuring out different coping mechanisms and body acceptance, and for many of us I think it’s then managing your anxiety for the rest of your life in the way that you would manage diabetes, for example. Figuring out when your perfectionism might be tripping you up and how to refocus the perfectionism in a way that is supportive and not damaging or making yourself crazy, etc.
That lifelong management of those mental health challenges I see as definitely a part of the piece as well. And figuring all that out so you don’t relapse. Because as you know – and I’m sure you’ve spoken to many people who are able to get on the other side of that velvet rope and look back and just talk about how empty their lives are in those eating disorder years. So empty and so small. They make our lives so small and so painful. Certainly not wanting to go back to that.
01:00:15
Chris Sandel: For sure. You mentioned earlier on about – was it Serena Williams or Venus Williams? I can’t remember which of the Williams sisters it was.
Melainie Rogers: Serena.
Chris Sandel: Yeah, and how more broadly, there’s a lot more celebrities or influencers endorsing a lot of these things and really shaping the public narrative around this. Talk a little more about this, because I think this is obviously having a huge impact on how we think about these medications, often putting up people on pedestals around this stuff and really showing one side of these stories.
Melainie Rogers: Absolutely. When Serena Williams came out that she was actually on a GLP-1, that came out just as the US Tennis Open was on here in August/September. So it was all very well marketed for maximum impact. I’m a huge tennis fan. Serena is the GOAT. So honestly, look, of course anyone can make their own personal decisions; however, I was immensely disappointed when I saw her advertising that she had been on – is on – this medication. And also talking about specifically how much weight she had lost.
And I appreciate that my lens is the eating disorder lens, so I’m thinking “Oh no! All of these people out there with disordered eating are going to jump on the bandwagon, because if the GOAT says that she needed it, then gosh, you must need it too.”
And there were a couple things that really disturbed me about it. Number one, intentionally or not intentionally, that also I think gives permission for everyone in the gym to now say, “Okay, if Serena’s using it, then I need it too”, and number two, when I heard her story, she said that as someone who can obviously move mountains and has in her career, and she gave it everything she had after having two kids and now in her early forties, and her body just wouldn’t go back to where she wanted it to be. She’s quoted as saying, “I knew what my body needed”, and that was a GLP-1.
It just disappointed me so much because the reality is, our bodies change, and it’s natural change through the aging process – a woman now in her early forties, but also a woman who’s now had two kids. Our bodies don’t respond like they did when we were twenty, no matter how much we may push. And I’m sure that if anyone’s going to be able to maintain a certain fitness level or whatever is of value to her, then she could.
So that was immensely disappointing to me because, again, it’s signalling this idea that the changes of natural aging and these milestones, particularly for women with going through childbirth and having kids, is no longer excusable, perhaps. Like “Here’s this medication that can make all the difference. It’s the thing that was missing.” Again, it’s a lack of acceptance of the natural process of our bodies changing. Which, of course, is our society. But it just saddened me so much to hear her say that because that message, of course, is going to have ripple effects in society at large, and particularly among women of a certain age. And we’re seeing that. And again among athletes.
I will say this, the last point I wanted to make on that, Chris: after talking about this at a number of conferences in the last couple of months, I think we all agree that if Serena were on that medication during her high-performance years, there’s no way she could’ve become the GOAT, because she would’ve been exhausted from lack of fuel intake; 31 pounds is how much she lost, which I would suggest is mostly muscle because she is/was just a powerhouse of muscle. So she’s stripped away a lot of her muscle, and I do wonder quietly in the gym what her strength is now on that medication.
Yeah, a sad thing to see for someone that I respect so much.
Chris Sandel: For sure. And there is a human element to that as well. Just because she’s a tennis star or just because she has this money or whatever it is, she, like everyone else, can have body insecurities. She can feel upset or disappointed that this has changed and “I don’t have this body of being the 20-year-old” or whatever. So I don’t think that you can say she shouldn’t feel that way. It makes sense that that’s there.
Melainie Rogers: Of course.
Chris Sandel: It’s just, as you say, she is then actively promoting this thing that then has this huge knock-on effect on so many other people.
I do also want to say that we as a society really do put sports people up on a pedestal as being fit and healthy, and I think that, yes, they are often very ‘fit’, meaning that they are very good at doing a particular sport or a particular activity, whether that be running the 100 meters or swimming in a 1500 or whatever it may be. But that doesn’t actually tell us how fit they are really, in terms of doing all the activities that we need to do in life as a human being. And it definitely doesn’t tell us anything about how healthy they are.
I’m saying all this because we can then incorrectly make the assumption of like, when she was in that body that was this muscular or had this physique, that was obviously the healthier version of her. That is just absolutely not true. There can be people who are setting PBs, who are winning races, who are anything but healthy and definitely anything but fit outside of this very narrow band of an activity.
Melainie Rogers: That’s a wonderful point, Chris. A wonderful point, absolutely. It’s so true. I feel some self-consciousness speculating on Serena Williams because I just adore her, as many people do.
But it does remind me of when Michael Phelps came out, the wonderful US swimmer, and spoke about mental health and depression. He struggles with depression. To your point, we never know what’s going on in these people’s lives, and who are any of us to really be commenting? However, we are. [laughs] But I thought it was magnificent when he came out and spoke about mental health.
And to your point as well, Chris – again, I’m feeling a little self-conscious here about it, but these people are humans, and we do layer all this pressure and expectation that “You should be the representative of what a healthy woman looks like.” She didn’t sign up for that. Serena is doing life her way, and so she should. So that is an important reminder.
Chris Sandel: Yeah. The bit she’d signed up for is then when she becomes a spokesperson for this. That’s where I start to be like, okay, I pulled back a little bit; now you are actively having an impact on lots of other people.
But if we’re staying in the tennis realm, I remember reading Andre Agassi’s book. Have you read Open?
Melainie Rogers: I haven’t read it, no.
Chris Sandel: I highly recommend people read Open. It is a fantastic book. He is incredibly open in the book. But what he talks about is he is broken by the end of his tennis career. His body is just absolutely in pieces because of all of the training and the tennis and the everything he played. And most people would be like, “Wow, he’s so fit and he had this career that went on for this long” and the book makes you realise, yeah, he has aged a lot because of his chosen sport and everything he put into doing that.
So there is a difference between “I am getting very, very good at this one particular thing” and then someone being truly fit and healthy.
Melainie Rogers: Yeah, great point. I’m eager to read that book now. I’m a little bit scared, actually, because I do know a little bit about his history and such like that. I was like, oh my gosh, it could be quite debaucherous. But we’ll see. [laughs]
Chris Sandel: Yes. There’s probably a lot for people who are in – I can’t remember it well enough to remember if he talks about particular types of training or things that could be triggering for people, but I remember him when he was losing his hair and he talks a lot about this, just the amount of insecurity that he had around that. He was having to wear wigs, he was having to wear bandannas on top of wigs and playing in a serious tennis match where he’s noticed that his wig has now moved and ended up losing the match because he’s not able to concentrate.
Just recognising, you’ve got someone who is the top of their game in this thing and yet there is huge amounts of insecurities around his image and “What will people think if they realise I’ve lost my hair?” Talking as a guy who shaved his head because he was losing his hair. Culture has changed around that, but at the point that he was doing it, it wasn’t the done thing. So yeah, there’s a lot of insecurities that he had around that piece, and it had a huge weight on him.
Melainie Rogers: Wow. I’m going to read that. I’m putting it on my list right now, Chris.
01:10:57
Chris Sandel: We talked a little earlier about this, but there is this big cultural shift around GLP-1s, around weight loss. It felt like we were going a little more towards the body acceptance, body positivity – and I know there’s issues with body positivity, but we were going in a certain direction. There was more Health at Every Size. I wonder if it’s feeling like we’re now heading in a different direction; whatever inroads we’d made there, we’re now going back and taking some backsteps there because “We used to believe that, but now there’s this other way that we can deal with this.” So tell me your thoughts on this piece.
Melainie Rogers: Honestly, Chris, it felt like whiplash, didn’t it? I was so proud of our field, but the general public and getting that message out there and thinking, gosh, people are really understanding. They’re really seeing diet culture and really understanding these mechanisms and these systems, etc., and that it’s not actually healthy.
And then Ozempic comes out and it’s like, “No, we were just joking. We’re going over there.” I will say, I was saddened. I was truly saddened because it did feel that all of that movement over here was just people tolerating something that they didn’t want to tolerate. And I understand that, and it also makes me – reconfirms or highlights again just how much pressure people feel, and distress, to be in a body that is perhaps outside of the so-called norms of our society, and that desire to fit in and look similar in shape and size. And again, weight stigma.
So what it really tells us is weight stigma never truly went away. It maybe was just slightly on pause, but not really. And actually, I think there were a lot of people over here in that body positivity movement who actually had a lot of self-loathing, possibly, and so much so that – because the key thing here, Chris, is that 1 in 8 American adults has tried a GLP-1, and we do not know the long-term effects of this medication.
Right here, there’s a lot of movement around anti-vaccinations around kids. However, a lot of people are jumping on and using GLP-1s when we have no idea what the long-term effects are. At least with the vaccinations, they’re quite a lot more researched. Again, it just speaks to how deeply embedded and internalised these beauty standards are and body image standards are, for the guys as well as the gals, and our nonbinary people as well. So it was whiplash for sure.
Chris Sandel: Yeah. It saddens me – and I’ve used this analogy before on the podcast, but if this was the 1950s and there was a medication that came out that said, “If you take this medication, you will no longer be gay, homosexual”, whatever, everyone would’ve been onboard with it. Because that was how that was thought about at that time. People were sent to psychiatric centres, they were put on drugs. It was an abomination. “We shouldn’t have been doing this, this is wrong.” So if that medication was invented at that point, it would’ve been, “Yeah, why would we not do this?”
We have now got to a point – and it’s not that everything’s amazing in that space now, but I think if someone came out with a medication at this point to say “If you take this you’re not going to be gay”, it’s not going to get the uptick. It’s not going to be the next GLP-1 where it’s like, “Yes, thank God, finally!” And that’s only because, as a society, we’ve changed our beliefs around this.
I don’t know what’s going to happen with GLP-1s, but I’m wondering at what point we get to where we’re like “Why are we doing this? We’ve had this cultural change on this in terms of our thinking around this, and we’re no longer thinking about this thing as this abomination.”
Melainie Rogers: It would be just so wonderful. I just think about the internalised distress of people and just being able to let go and just being able to be you in any shape or size or whatnot. And the piece that comes with that and the turning down of that self-loathing and internal criticism and all the things that really significantly impact our mental health – Chris, I truly, truly hope that we as a society can get there. And I really thought 5 and 10 years ago that we were on that track.
We’ve just taken a detour. As you said, we’re yet to know. We’re yet to find out where this is going to go. To be continued, I guess. Though I do know that the pharmaceutical companies are now coming out with the pill form of the injectables, which will make taking them more accessible for people who are anti-injection, etc. So I think we’re going to continue to see – I don’t think we’ve peaked yet with this whole piece. I think we’re still – I wouldn’t say nascent, but fairly nascent. Fairly much the beginning of it, and we’ll see where it goes.
I guess if you have me back on your podcast in 5 or 10 years from now, we can be looking back and making comments on what we’ve seen and observed.
01:17:30
Chris Sandel: Yeah. And this is not the first medication by any stretch to be coming onto the market in terms of helping with weight loss. The track record is not great, whether we’re talking about amphetamines, fen-phen, ephedra. We have this thing that comes out, it’s heralded as this amazing thing; at some point, whether that’s a matter of months, a matter of years, there’s a recognition of like “Oh, we didn’t realise it causes cardiac arrest in the way that it does” or “We didn’t realise it causes this thing” and then it gets pulled, whether that’s forced upon them or it’s voluntarily withdrawn.
I know you don’t know this for sure, but if you were to predict, do you think that there will be the same pattern with this? From what you’ve seen in terms of the studies that are coming out or the information that’s coming out, is there a part of you that thinks in two years, three years, five years, there’s a point where they’re like, “Okay, this is no longer a thing”?
Melainie Rogers: There’s a chance of it. I’m not sure – perhaps the timeline might be a little bit more extended, because there’s just so much we don’t know, Chris. There’s a couple of things that we’re watching for. Two things. One is that the medication could lose its efficacy, meaning that even if you’re on it for four or five years, it may just stop working and people then start to regain the weight. And some research has suggested that, so that could therefore be “Okay, I could go through this weight loss only to regain five years later. I’m not even going to bother.” That’s one piece.
The second piece that we’re seeing is that when people go through the weight loss period, it’s very similar to the bariatric surgery and those other weight loss medications you mentioned, and even very low-calorie dieting, where there’s kind of this plateau period between the six to nine month period, and the body just doesn’t lose any more weight after that. What we’re seeing is that people will stay on the medication for another three months – this is US research – but there’s no further weight loss, and then they’re stopping the medication.
So there’s a massive discontinuation rate at that 12-month mark, which means there’s either a lot of people who think that “I will be the lucky one that can maintain this weight loss” or they don’t realise the implications of coming off it, and/or, here in the US, there’s insurance considerations and it’s still very expensive. So there’s a lot of factors, a lot of variables that could interfere with the ability to stay on that medication long term.
I’m waiting to see what that works out to look like. As far as the research, they were pretty astute with looking at cardiovascular concerns very early on because they didn’t want a repeat of fen-phen – which, for your listeners, was the medication for weight loss and then they found out a couple of years in that it was causing major heart complications for people and it was pulled. So they did include that cardiovascular aspect in the research in order to safeguard against that.
I’m not sure. I think that what we are seeing, though, is they’re now starting to layer the medications. There’s the GLP-1, which is the Ozempic, and then Mounjaro and Zepbound, which were brought out by Eli Lilly – they’re actually a doubling up of two of those gut hormones, and that’s getting even more weight loss. So instead of 10% or 15%, it’s now 20%, 25%. They’re now working on one that has three different hormones.
So I think over the next five or eight years, we may see more of the full picture. And then, as you know, they’re also doing research on different side effects where it could be helpful for other different disease states, etc. Who’s to know? But as I say to all of my students at NYU, this is definitely going to be a part of your career, whether it be for the next 5 years or the next 10 years. But knowing what these medications are and how to work with clients is going to be absolutely essential because they’re so prolific out there.
Chris Sandel: Yeah. It sounds like it’s doing what bariatric surgery does, but in a non-surgical way. And I don’t say that as a wonderful thing; I say that as someone who, if you look at the research around bariatric surgery, as time goes on, because of the way that it works, you’re not able to absorb what you really need. So there’s a lot of complications. The total calories you’re not getting enough of, but you’re also not getting enough of certain vitamins and minerals depending on what version of the surgery you get.
The same thing is happening here. You’re reducing someone’s calorie intake, and especially if it’s being reduced very significantly over a long period of time, yes, you can get to a point – and kind of the same with someone with an eating disorder. People with eating disorders, there are the unlucky few where it just continues to go down and down and down and down. And I know for a lot of people living with an eating disorder, that feels like that would be the best thing, and it’s like, no it’s not. But most people hit a point where their weight loss is just not going any further. Irrespective of what they’re doing in terms of the amount of exercise or the amount of restriction or whatever.
You can then be staying at this place and you get this incorrect feedback of like “Well, my body must be fine. If it wasn’t fine, if it wasn’t getting what it needs, it would continue losing weight.” It’s more like, no, it’s just got very, very good with turning everything down, turning everything off, because it doesn’t have enough to be able to run. Your body doesn’t want you to just die, so it will do everything in its power to keep you alive.
So the idea of “We’re seeing weight loss stall at this nine month mark; let’s throw a couple other things in there to see if we can get it going again” – my mind just explodes with this is such a bad idea.
Melainie Rogers: Oh, yeah. I totally agree, Chris. What it brings up for me is that you’re speaking to – these bodies are intentionally, or medically induced malnutrition. When people lose weight, it’s actually a form of malnutrition. Malnutrition is when we’re not taking in enough calories and protein to support the body and all of its systems. And as you said, those systems start to shut down. Menstrual cycle for women, and sweat mechanisms, and cognition, and the brain. All of those different things.
I think we have – and I don’t say this gleefully, but I imagine that we’re going to be in a situation where we have an unprecedented number of people in a Western society, where there is adequate access to food, who are massively malnourished. And when you think about that from a research perspective, I think we’re going to see people coming into the hospital with all sorts of different conditions because of malnutrition.
The other thing that comes to mind for me, Chris, is being that malnourished and then going in for some kind of surgery, whether it be an elective surgery or an essential surgery, the body’s already malnourished. So I’m wondering what we might see with recovery rates with surgeries and all these different knock-on things that may seem a little – not something that necessarily is so visible to us, but because of the sheer number of people that are on these, we may see more evidence of some of the unfortunate side effects that are not to the benefit of one’s health.
I just wish there was a massive public health campaign around just truly what this is doing to the body. And again, it’s up to people to make their own choices, but again, to be informed, to be screened. We’re pushing for a movement here in the States for RDs to be an essential piece of the prescribing, as we were with bariatric surgery.
Here in the States with bariatric surgery, a client had to be assessed by an RD before surgery and then had to be followed by an RD for the first year because of all of those different malabsorption problems that you discussed. So we’re pushing for a similar protocol to be put in place here to work with people and try and guide them in the safest way that we can, to try and minimise some of these concerns.
And again, speaking to that idea of now we’re doubling up on those peptides and we’re tripling them to get more and more weight loss, as you and I know – we mentioned earlier – no weight loss or minimal weight loss, 5% weight loss we know will improve people’s biomarkers. So the idea that we’re going for 20% and 25% and even 30% is about aesthetics. And I think it’s important that we just acknowledge that for what it is, because the diet industry, which conflates white with wealth, will say the thinner you are, or up to a level, the more in the normal BMI range, the healthier you are – but it’s all about how you get there.
Going back to the book about Andre Agassi, just because someone looks a certain way, does not mean that what’s going on on the inside is actually healthy or the healthiest version of themselves.
Chris Sandel: For sure. Just touching on a couple of things there – with the 5% weight loss thing, I haven’t dug in – maybe I need to do a whole separate podcast on that piece. I hear that all the time and I’m always a little like, I wonder what is actually going on here. In the whole scheme of things, 5% is a very tiny amount of weight loss. If we’re thinking about something like set point, you’re still within your normal set point band. You’re not changing anything fundamentally.
So what is actually going on? Is it the weight? Is it that someone is doing different behaviours and it’s those behaviours that are going on? Is there less internalised stigma with that person because there’s been this change, and how they’re perceiving themselves is having an impact on their health? I wonder if it is actually the physical shifting of that weight or there are all these other things that are going on that are connected to that.
But just in terms of the piece of we’re getting all these people who are then going to be malnourished and that’s going to have an impact on their capacity to recover from surgery or a multitude of things, the sad part for me is that that is true, and yet there will be the tiniest fraction where that is actually picked up upon. Unless you’re coming into the office and you’re visibly emaciated or you match up to some stereotype, it’s not going to be picked up upon. If anything, if someone’s still in a larger body, it’s like, “Well, maybe we could up your dosage of the Ozempic, or maybe this is because of the weight that you’re carrying that all of this is going on.” And the reality is, you can be in a body all across the weight spectrum and be malnourished, just as you could be in a body all across the weight spectrum and be well-nourished.
I think there can be a lot of things that are going on, there could be huge amounts of collateral damage, and it will just be missed because it doesn’t match up to this stereotype. It will be like, “Well, it couldn’t possibly be that.”
Melainie Rogers: Yes. Really good point. And again, it harkens back to the fact that our docs do a great job – and I don’t mean to be anti-doctor, not at all, but their training doesn’t include looking at a lot of these things. It’s really the RD, and honestly, the RD in a hospital setting is not necessarily at the top of the hierarchy there to be influencing decisions. So I think you are right, Chris, that a lot of this will actually be missed because people aren’t necessarily even thinking to look for it. Time will tell us.
01:31:06
But if I may put that question back on you, what’s your prediction of what we might see? Do you feel that this will peter out over the next five years?
Chris Sandel: Honestly, I do not know. I can’t remember – I’m not old enough to have gone through the other phases, or I wasn’t aware enough to have seen what happened with amphetamines and fen-phen and all of the other versions of that. So I don’t know how big they were; I don’t know how much they were in the culture in the way that GLP-1s are in the culture right now. So I don’t have a good apples for apples comparison with this.
My sense is, just from what I understand about physiology, there is going to be a backlash connected to this. It is going to catch up with people, whether the pharmaceutical companies then admit that or have to do anything about it or whatever it may be. It could very much be the cigarette smoke and we take many, many, many years, decades before there’s an admittance of “Okay, we actually knew a lot more about this than we let on.”
Because for them, at this point, it feels like it’s printing money, so I would feel that it’s very easy to look the other way, it’s very easy to massage the figures, it’s very easy to be making this out to be the wonder drug it’s been sold as being.
But if it was to make a prediction, my prediction is that in 5 to 10 years, there will be civil suits, there will be class actions. There will be something that is going on connected to this. And I’m basing that on simply we don’t have a good track record connected to this. And as you’re talking about the doubling up and the tripling up, you’re just increasing the likelihood that things are going to go awry with this, and the sad thing is, people have too much of an appetite for it. Just like, “Oh, this is such a public health crisis. We need to do anything that we can.”
So I think that there will be a lot of things that get done because we think this is so urgent and we must, that for something else we wouldn’t be so gung-ho about it. That’s my hot take, and we can see in a decade where I’m at.
Melainie Rogers: Yeah, absolutely. And Chris, as you were saying that, I was thinking about the fen-phen, etc., and how this might be different. But if our prediction and our hope – when I say ours, I mean the field, at least here in the US – we’re seeing that study that I started talking about at the very beginning of our talk today, the Step 1 Study that did 68 weeks on the medication but only 52 weeks after, and if we continued for 68 weeks we would probably see full weight regain plus some – we know we would then probably see a decrease in the biomarkers, in a negative way, than baseline.
That’s not something someone’s going to market, right? That if you go on this drug, you’re going to lose all this weight, but then if you go off it, you’re going to end up in a worse place than you were before you started the drug. And that’s from the physiology of your dieting that we know is usually what happens for people. So talking about those civil lawsuits, I’m wondering whether because this is a medication-induced weight loss, we actually may see that – and again, I hope not – but a number of people who go back through that rollercoaster ride end up at a higher weight and with higher blood pressure and now with diabetes and some of the metabolic syndrome that they maybe did not have to the same degree before they went on the medication.
And maybe it’s at that time that they’ll turn around and say, “You sold us” – I could cuss right now, but I won’t – “You sold us misinformation, and our bodies are now paying the price for that with declined health status after going on this medication and going on this rollercoaster ride.”
Again, I certainly don’t hope that for anyone, but again, based on the physiology, as you’ve said and what we do know about how the body fight backs and that setpoint, those are the likeliest outcomes for those who come off the medication. And possibly if the medication loses its efficacy over time, for those people as well.
Chris Sandel: Yeah. I think given the scenario you just described there, it feels like unless there is something very obvious, like we see this very high uptick in cardiovascular disease or we see this thing connected to this biomarker, it will be very easy to explain away like “Well, you shouldn’t have regained the weight. That’s probably why you got all of those things.” I think you kind of need something that is very much a smoking gun, like “This is causing this specific thing”, to get to that place, unfortunately.
Melainie Rogers: Yes, absolutely. Which, again, we hope it doesn’t. We hope it doesn’t.
01:36:51
Chris Sandel: Yeah. I don’t want to have this be all doom and gloom, so I wonder if – what comes to mind if I ask you, what gives you hope in this moment connected to this? Even when it feels like the culture is regressing or this is taking things back in terms of where we were with Health at Every Size or with eating disorders, what is giving you hope in this moment?
Melainie Rogers: Gosh, what gives me hope? I think maybe two things. One is, for my clients who do have type 2 diabetes, this has been a game-changer for them. Once a week injection, their blood sugars are far better controlled. I’ve seen just fantastic, really great stuff there. Quality of life, etc. So that’s one really good thing.
The other thing that is coming through is I am hearing stories from my clients who are saying to me, “I’m really tempted. Everyone else I know is using it. But I don’t want to do that. I do know the science. I want to get to a place of true body acceptance. I want to live according to my core values of what’s important for me and not get caught up in the beauty ideals, etc., as hard as that is to swim upstream.” So I am hearing people say that and actively take a stand that “No, it’s tempting, but I’m not going to.”
That gives me a glimmer of hope that maybe all of this Health at Every Size and body positivity wasn’t lost, all of that great work, and that there will be some people who will continue to take that on and swim upstream with diet culture. And I’m really proud of them because I think it’s probably harder than ever right now.
Chris Sandel: Yeah, totally. I will second that. And just on that, what would you say to someone who’s maybe in the messiness of recovery, they’re doing the things that they should be doing to recover, it’s feeling hard, it’s not maybe going exactly as they planned, they’re knocking up against lots of discomfort and challenges, and there is a lot of thoughts like “Should I jump on this with everyone else?” Are there any parting words that you would like to share with that person?
Melainie Rogers: I would say hang in there. Hang in there, keep doing what you’re doing, baby steps. Keep going in the way that you’re going, because we do know it leads somewhere. And resist the temptation. I know it’s tempting, but I would say head down and try and block all of that out and just keep doing what you’re doing, because we know that it can and will get you to a place of further recovery or fully recovered. And hopefully from that place, you can have a broader perspective on this whole phenomenon and this whole idea about beauty ideals and body image and how it’s such a made-up concept in our culture. And it shifts and changes, and our bodies are not meant to shift and change according to whatever we feel is the culturally appropriate looking body for guys or girls at any one time.
Chris Sandel: Totally. I agree. And how you feel in this moment about all those things, the eating disorder is making them a lot more salient. Like how important this thing feels in your life or how distressing this is, that is part of the eating disorder. I think so much gets blamed on recovery, and I’m like, “No, that’s not recovery, that’s the eating disorder.” That’s the thing that is driving all of this. If it wasn’t for the eating disorder, this thing, yeah, there could be some physical uncomfortableness with it and it could be some unpleasantness, but what is driving the real distress and how painful this is is not recovery; it is the eating disorder.
And as you continue on, that does change. As you said, there’s a shift in perspective, in perception, and it does lead to a better quality of life.
Melainie Rogers: Absolutely. Well said, Chris.
Chris Sandel: Melainie, this has been wonderful. I feel like I can chat with you forever. Where should people go if they want to find out more about you or more about BALANCE?
Melainie Rogers: They can go to our website, which is balancedtx.com. You can check us out there, and we’re obviously on Insta. Soon to be on TikTok. But Insta is probably the best place to see us in addition to our website, Chris.
Chris Sandel: Cool. I will put all of those in the show notes, and thank you so much for your time and imparting your wisdom on this stuff.
Melainie Rogers: Thank you so much. It was such a pleasure. Hope to do it again sometime in the future. We can look back.
Chris Sandel: Yes, we’ll do a reflection.
Melainie Rogers: Absolutely. Thanks, Chris.
Chris Sandel: So that was my conversation with Melainie Rogers. I hope you found it useful. This is a topic that I’ve wanted to cover for a really long time. I think this is a really important moment because of what is going on with these drugs. So I hope that you found this useful for us to go through.
As I mentioned at the top, I’m currently taking on new clients. If you are living with an eating disorder, irrespective of how long it’s been going on, and you want to reach a place of full recovery, then I would love to help. You can just send an email to info@seven-health.com and just put ‘coaching’ in the subject line.
Okay, that is it for today’s episode. I will be back with another episode next week. Until then, take care and I will see you soon!
Thanks so much for joining this week. Have some feedback you’d like to share? Leave a note in the comment section below!
If you enjoyed this episode, please share it using the social media buttons you see on this page.
Also, please leave an honest review for The Real Health Radio Podcast on Apple Podcasts! Ratings and reviews are extremely helpful and greatly appreciated! They do matter in the rankings of the show, and we read each and every one of them.
Policies
Social
Copyright © 2009 – 2025
seven-health.com · All Rights Reserved.
Share
Facebook
Twitter