Addressing Diet Culture and Future Outlook

Well, welcome guys. Again, I echo everything that Een said. This space was really meant to like build community. and I really, from the bottom of my heart, for each one of you for being here, thank you so much. Today we're doing two things at once. We're building community and we're recording a podcast where hopefully other people will learn from all the incredible things that we're gonna talk about today So again, I want to introduce Dr. Soa. She is a dual board certified internal medicine and obesity medicine specialist, author, entrepreneur, mom us social media starlet in my view. And I love your take on social media and where it's intersecting intersect ing with all this conversation and dialogue around weight loss And Dr. Goldman, also author of her brand new book, When Life Happens. I am so excited because there's so much synergy between what you do and what both of you do and your books as well. So they're just great pairings together and psychologist who's going to walk us through all the mind, body, spirit changes that happen. and this pairing really could not be better. So I would like to just allow each one of you, Dr. Soa, what is it about this field, what is it about your job that you love the most? Oh, I love people telling me just you have given me absolute freedom. Thank you for telling me this is not my fault. So way back when I was training at NYU, I learned I'm an internist by primary training. and I took care of a lot of very sick people at the very end of their diseases and I just knew that where I wanted to focus my life was on prevention and all of the diseases we were treating in clinic, they'd say, tellell your patient to lose some weight. And I'd be like, yeah, I know they've thought that before, but what are we telling them to do? How are we helping them? And there were very few options at the time. And you know there was this field, emerging field of obesity medicine. when I found it, I was like, o I can help them. And so now being able to help people so easily and readily in the world is kind of willing to accept it now, the best part of my job is just when people say, than you for releasing me from years of shame, stigma just thank you. That's just the best. It's too early for me to tear up, but I hear my patients say this so often. and you I didn't get to do all the training that you've done. and so I've learned a lot from you along the way. and of course, my patients are primarily in the forty five to fifty five. So I've learned so much and my patients say the same thing And Dr. Goldman, you know thinking about how far we've progressed when it comes to just mental health, May is Mental health awwareness mononth. And so I'm excited to have you here. You know, what is it about your job that you love the most? and what is what You know When you go to bed at night, what are some of those also sort of fun things that you hear from your patients? So first of all, thank you so much for having me And similarly to Dr. Soa, when I was trained at NYU and when I worked at Bellevue Hospital, we go way back. Yes, we go way, way back. I just learned this before we started shooting that these two have been besties for a decadade. Yes yes U But it' it was it's really what what got me and also like helps me, I'd say sleep at night, so to say, is similarly, you know, the thank you, you've changed my life. and or the I feel hopeful when I felt hopeless. And I specialize in the treatment of obesity and stress management, body image as well as general mental health But it was when I worked in the hospital, I remember patient after patient coming in and being like, I know what I should do. And all the doctors are telling me what I should do, but I can't do it. or how do I take that first step? And I always said that's where I come in, right? L either myself or the dietician or somebody has more time unfortunately in the hospital setting. you don't have as much time with clients. But being able to be that person that they can just, you know unload on and tell me everything and feel seen and heard. And when clients just cry in my office because they're like, oh my God, I never actually felt seen or heard before. and it's really, you know in the helping field I really is that that, you know, I think that's why we go into the field that we're in. Yeah. abbsolutely. Well, since we've let the cat out of the bag, that you've known each other for like a decade, I thought it would be really fun to talk about this landscape ten years ago, before we kind of get started and talking about today, So where were we in the field of obesity medicine in twenty ten twenty fifteen? It was super nascent. I am one of the first obesity medicine doctors in the whole country. I was one of the first people prescribing GOP one medications And it became very clear to me even once I found the field that a prescription did not equal success. And I'm still singing this from the mountaintops because a prescription is a part of the solution, but obesity is a disease of every organ system, including the brain and how we think and behave. And people translate that and they say that that's oh, you just need to help them like exercise or tell them to eat. No. You really have to help people learn how to think. And so early on, somewhere deep in my gut, I knew this about my patients and I knew that I would be doing another disservice if I was just like, here's a prescription, buy good luck And so back at the time, we did have medications. We have first generation antiob obesity medications and we also back around that time had our first GLP ones for we were prescribing it when I was a resident at the eterans' Affairs hospital. Exactly. So that might have been for type two diabetes because we had type two diabetes was two thousand five, but we have GLP one medications for obesity starting in about twenty ten. But at the time, people were very reluctant to share their stories with the world because they didn't feel great and they weren't quite sure if it was working. and it felt like a really big deal to take a shot. And at the time you had to take a shot every day. So how did I meet Rachel, doctor Rachel? I recognized that the brain and the psychological component was missing. and that's how I had reached out to her being like, okay, how do you do this? Now how do we start to incorporate this into practices too? How do we even bring this in? Because sometimes there's such a barrier for getting everyone In academic medicine, we use the words multidisciplinary approach. That is so great in theory in practice, so people don't have time and money to go around to everyone you might want them to go to. So I think it's really important for the multidisciplinary approach to be to learn from those who know better than you, and that's how we go back Yeah, and actually, so before we met, I was at Bellevue Hospital working in the bariatric surgery department. So I came from originally how we met. But then I was like, okay, now we're out in front of practice.. what I wanted to share is that in the hospital setting, we do have that multidisciplinary approach. So I was the behavioral health provider within the surgery department for about five and a half years. And so again, if we think back, that was twenty ten, I was there for about five and a half years. I left in twenty sixteen. and everything we know now is finally now out in the world R? Like so coming around with GOP wes, medication, treatment options being more readily talked about, not just more readily available and accessible. but we've been doing this for years and talking about it. But yes, it's very difficult to see the personal trainer, the dietician, the behavioral health provider The medical provider, so we do have to lean on each other and learn from each other. Yeah. And can we quickly talk about twenty twenty two? twenty twenty two, twenty three, but definitely twenty twenty two. Big on TikTok was all about Ozempe And you mentioned something before we started recording, just about Being one of the first doctors prescribing what's now known as, you know, the GOP ones around that time. So what was it like in twenty twenty two? Oh, it was still like people would look at me like I had three heads, even though it was starting to become known on TikTok, which was amazing because I think that that is one of the reasons That these drugs became so popular. onene, a weekly injectable, two data that showed it was so effective for weight loss, and three people sharing their journeys in a social media setting, But still the average person. when I launched my book in early twenty five, january twenty five, pick up your copy of the Ozembic Revolution if you have not already. Yes. So we were the first book on these medications for the consumer. And we had to call it the Ozempic Revolution because nobody knew what a GOP one was. And still at the time when we were going to the big media outlets and going to big podcasts, people were like It seemeems niche. Like two years later, I was Yes. And everyone's talggking about it, you claiming to be an expert, which I think is I think it's great that we've broken down so much stigma barrier. but I think something has kind of accelerated so fast that we, again are kind of back to this idea that a prescription equals success and it doesn't. And so we need to make sure that we're using these medications responsibly. Yeah. Were you seeing sort of like the interesting responses about sort of what you were seeing on social media was a lot of people's emotions about what was happening, right? Oh my gosh, she looks to this or to that, or is it, you know is it cheating or is it that? And so you know I wanted to just set that stage as we kind of now go into a little bit more science, just to remind everybody Really like how fast really it's been that this field of medicine has really just kind of come on the scene, but also at the same time, that you've had doctors thinking about this for a really long time. So in your book, The Ozemic Revolution, you say that weight gain is not about lack of willpower, it's biology. So let's get down What is the metabolic foundation for obesity? and why is it so hard to lose weight? Why is it just not exercise more, eat less because it's a disease of neurohormonal dysregulation. You know, that's my favorite phrase. Every time I take something with other, I say it. I think it's so important for people to understand that fat is not just a nuisance. It's a very, very powerful endocrine driver and it is deeply related to hormones. And when excess fat comes on, it is because hormones have been dysregulated. We are animals and we for millions of years, kept bodies kind of in sync. We have been put into an environment that has disrupted the way that our hormones talk to each other. So our brain talks to our gut, talks to our fat cells,, talks to our muscle, to our heart. everything is interconnected. And so in the environment we live in, and when adopacity begins, excess fat The way that these hormones talk to each other becomes dysregulated. It becomes blunted, it becomes over corrective. It just goes haywire. And it's so important for people to know that because this is not about willpower. because Sure, you might want to try you might have some success putting in effort, great, but you're still overriding the hormonal dysfunction in that. And if I told you to hold your breath and sit to the bottom of the pool and stay there for five minutes, it's not going to happen because your hormones are going to and you're going to get a signal from your body to go up to the surface. And it's kind of the same thing. You could b yourself not to eat, but you're going to have all of these drivers saying you must eat because we are here to survive. So just it's about hormonal dysregulation. We do live in a world unfortunately that drives this dysregulation. We know that there's been a steady steep incline from nineteen eighty where the chart just keeps going up. Only recently do we see potentially a small tick down for the first time ever these medications. And so that is fantastic because now we have a tool to kind of fight what has been like the ball rolling. And the problem with hormonal dysregulation is that it drives epigenetic change. And epigenetics is a layer on top of genes that kind of expresses how we as a society move forward to the next generation. So epigenetics can get passed on on a layer around us, but then de even to the next generation. So I'm very excited about what these medications can do in terms of their ability to help fix the hormones and then kind of reset the stage What happens in the future. And there's so much crossover there between what I talk a lot about, which is the estrogen, progesterone, testosterone, and those sex hormones and how you can't out fox the big M is what Oprah told me, and it's stuck perfectly. know you can't really out yoga your way out of some of these things. And that imagery of like sifting to the bottom of a pool, you can't do it, even if you say, just sit there for five minutes. Your body's not going to do it, right? So there's so many hormonal changes So my question for you, Dr. Goldman, these hormonal changes are happening. Sometimes we're now in our thirties, in our forties, and women start to feel so just disconnected from their body. Mbe their body's changing. I know for me Even the last couple of nights, I just couldn't sleep and I'm always a great sleeper that feels so unlike me. What is kind of these psychological sort of Reason behind this rift. Maybe you forget your why or your passion, like things are changing and your brain is telling you different things than it used to. And it's so hard because as those changes are happening, Most people's automatic thoughts jump to what's wrong with me Y.. automatic. R. You are probably like, why am I not sleeping? What is wrong with me? What did I do wrong? And then I just yell at myself while I'm laying in bed. Heather, come on. You know you're the best sleeper. And that's why then you stay up at night even later because now you keep talking to yourself And this negative spiral, right? I know, I'm in your head. I know, I know. So then the negative spiral starts happening and it keeps you up at night because you're like trying to figure out what am I doing wrong There's nothing you're doing wrong. It is hormonal. It is our bodies changing. And I think that's always my like if you could take anything away, it is the fact that it is not your fault, right? But so many times we get stuck in our head thinking it must be something I did. Well, and social media tells me there's so many quick solutions in it. maybe I picked the wrong one and maybe the magnesium is not The glyc you don't have citrate. You don't have the good enough bedtime routine and you need your electrolytes and your magnesium and your ey everything Right. Exactly. Yes, you need that too. What people forget is we actually don't need any of that We actually need to go back to the basics, which I love something you and I said earlier today or you said when we were talking, is you need to get your labs done. You need to talk to your doctor. you need to ask questions, you need to feel empowered and be an advocate for yourself and speak up and say, this doesn't feel right And I know it's not me. There's something else going on. And I think that's the first step. Yeah. I mean, it's so hard to admit it. It's so hard. You know. It's really, really hard to admit it. So we talked about the whole idea that it's not willpower, there's biology Can we debunk this whole you know, where did the ho just move more and eat less? What's a more compassionate way for us to biologically sort of start to thinking about, know, if you've been struggling with weight gain or your whole life, right or just more recently, which I think is sometimes hard because if it's new to you, you don't know what's happening. What are some more compassionate ways to think about our biology? And like what are some of the first steps for women to take You know, no one's ever asked me a question in that way before and I've done a lot.. Yeah. Okay, so the first let's start with where do you start first? It does actually go back to labs. I'm a very big believer in going to someone who understands labs. Unfortunately I think fortunately, I think that it's changing a little bit. But unfortunately, a lot of the primary care labs don't look at obesity as a disease. There's a very simple test called fasting insulin. If you order it in someone, it's cheap, it's easy before ten AM in the morning and you pair it with a fasting glucose, you can calculate something called a HMA IR score and it predicts insulin resistance fifteen years before you'll see it reflected on something called hemoglobin A one. This you taught me, and I think this is so important We're kind of talking about the place to start is like get some facts. This is the whole reason I actually I started a company in the first place because I felt like it was so important. People still don't know about it. I actually created at home testing kit so people could do this for themselves to see it. And then beyond that, you want to start to look at cholesterol panel in a way that picks up metabolic syndrome. So we've been hyper focused on bad cholesterol, LDL, and we've missed looking at triglycerides. and triglycerides are a reflection of kind of free fat and sugar floating around. and it tells me that there's insulin resistance brewing too eighty percent of my patients who need to lose weight, I see dysfunction right there. And then move beyond it, you'll see dysfunction in other labs, thingsings like ferritin. Are you so fatigued you can't move anymore and you've been dismissed by the fact that you have zero iron stores. Yeah. You know How's your B twelve? How's your vitamin D? How are these vitamins that make you help you feel good so that you can kind of be yourself? So I look at those labs. Beyond that, we know that there are other hormones that we don't test for in the lab. It's very expensive that become dysfunctional. So if you lose a lot of weight once in your life, you'll probably hyperfixate on that and you'll think, o God, I did it once. whyy can't I do it again? Oh, you know why? Because of hormones? Because you did it once. and just today I was on the train in listening to podcasts about Ross Matthews. comedian and he was on that terrible show, like celebrity Fit Cub, I think it was. Oh yes. And he was saying how he once lost a lot of weight that and he lost forty pounds in six weeks. And the host was like, how? And he' like, I just ate nothing. And then right after I ate two Domino's pizza then I gained all the way back and more came on, right Yeah And then I couldn't do it again for fifteen years until I tried kind of a different approach. And that's because when you lose weight the first time, your body, you are animals. Remember kind of come back to that and your animal says, get back to your set point. So we're going to lower our basal metabolic rate and we're going to make it very hard for you to lose weight again. So we're going to make it so that not only do you gain weight the first second you see food again, but we're going to have you overshoot it and we're going to make you exist on less calories so that we're good. L your body doesn't get that we live in the modern world and have an abundance of food. And so it's really, really hard. Even if you've done it before, even if you kind of buy into this idea of willpower, greatreat, do all of the things that we know get back to the basics. Let's move our bodies, let's eat whole foods. let's do these things. But if they're not working, we need to look at the hormonal dysfunction, and how can I help you treat it? If you came to me and said, I don't feel well and I discoverred it's your thyroid because of hormonal dysfction, and you have hypothyroidism, we're going treat it. And that's exactly how I look at obesity too. Yeah. OkayK, I like that answer. I'm glad I asked you a question. You hadn't heard before, just kind of the way you frame it, you know. So doctor Goldman, the nothing works for me spiral I want your take on cognitive behavioral therapy and really kind of digging into like what is the psychological intervention where you see people at this stage where they're feeling frustrated, they're feeling stuck, and they're just kind of in that negativity spiral What's the real thing, you know, that they can consistently work on to change their thought patterns So most people, I think the first automatic thought is, why is this happening to me? R? And then like, well and nothing is working. Yeah. Nothing is working for me and why is this working for me? O why is this happening to me? And I like to remind people, so in cognitive behavior therapy, it's the basic idea that our thoughts, emotions, and behaviors are all like So if for're having a thought of why is this happening to me, or nothing is working for me, it's gonna to keep us exactly stuck where we already are. It is not helping us move forward in anything. So the first thing we can do is actually, which is not easy, but if we can pause and then ask ourselves, is that a helpful thought Is the question, why is this happening to me helpful? Sure, if you can start getting answers and maybe go to the doctor and understand the why, sure, there's probably something going on. But instead, I like to reframe it and think, what can I do about it? right? What action can I take? We can go to the doctor, we can learn about different options, we can get our labs done, things like that. But we all have these automatic negative or unhelpful thoughts in psychology, we call them cognitive distortions. They're like all or nothing thinking, should statements. All or nothingking. so real comment Yeah If I don't have an hour, I'm not to do it at all. Yeah If you don't have an hour to work out, I it's not going to be worth it. So if I can't home cook every night, I'm not gonna to home cook at all. Right? Uber Right or nothing thinking. the way I actually kind of redefined it, like that's a dieter's mentality If you've ever been on a diet in your life, you probably have all or nothing thinking also. Other people have a to. But it's kind of that dieter's mentality. And we have to slowly get out of that all or nothing rigid thinking and think more openly, more flexible thinking, more of what we call a growth mindset of something is better than nothing. If I have twenty minutes to take a walk, I'm gonna do that. It's better than nothing. If I can home cook a few nights a week, that's better than nothing. Yeah. But it takes work. I do wantna acknowledge it is not easy to change our thoughts. The first step is awareness.. Like, oh, I have these unhelbtful thoughts. We all have them And then what can I do about it? Yeah. ye. I will add to that. I have people write it down. So part of the recoommnation is I say catch your negative thinking in my practice. So I just have like a column in this little diary I have people keep and I'm like,'t you don't have to do anything about it because if I give them the task of like Here's the negative thought, and then we're gonna teach you how to move to the paradigm. like are paralyzed. I'm just like catch it. And then we'll figure out how to work it. And once you start writing it down, you recognize you have the same similar pattern. wrrak it down while I'm trying to fall asleep at night, is that gonna keep me up? it down. write down. Aually I actually recommend when people have thoughts before they go to bed to write it down because what your brain is doing, it's actually keeping them on repeat so you don't forget. So then if just write it down feel like you can release it. I feel like, did you ever see the Jerry Seinfeld episode where he says he writes his jokes down in the middle of the night and he can't read it in the morning. That's what happens to me Okay, great. All right, Dr. Soa, let's get right into peptides. And by getting right into peptides, what the hell is a peptide? I said we have to talk about this day because it is everywhere. I know it's all over your feed. You're hearing about it at the gym. Okay So I'm gonna stand in my soapbox here. So peptides just mean the order of amino acids, and we have peptides medications that we've been using for decades. So insulin is a peptide. Okaykay? Okay, so not so foreign? No. Like we're using this term as some like magical name. L we have grossent. We have I think like thirty FDA approved, yeah, thirty FDA approved peptides that we use across all mediums and allergy and oncology OzZemic, we goV epbound. theseese are peptides too. But now we've verged over and people saying that they're like, oh, I'm not on one of those drugs. I'm on a peptide Okay So it's kind of like saying, I'm not on a medication. I'm on a medication. And then that brings this whole exactly, exactly. And it brings this whole level of like shame bias. So I don't need a GOP one, I'm going to be on a peptide. And then take it a step further, a lot of the peptides that you're hearing about are just super unregulated. and there is a push right now that they're trying to get the FDA to kind of allow them to be compounded again. Well, there is a reason that the FDA said no, we are not going to put these fifteen twenty We're not going to allow people to use them because we've actually studied them and they do not show benefit or they show harm. So now we're importing kind of research grade chemicals, peptides in from China generally, and we're allowing people to sell them at my gym, at my very nice expensive gym. The trainers med spies. Yeah. I'm on a peptide. what is in that? So there was just an amazing paper released that showed up to seventy one percent of peptides on the market that were studied in a lab were contaminated. They were not they were and we do not know what they are. So I want people to be really careful because even I I was at a breakfast yesterday with very high powered women and they were like, oh yes, I'm doing this injection and I feel like my skin's going. and my knee pain doesn't hurt anymore. And I'm like, why are you taking?? So please, please, please be careful. Yep Pepides are great. Pepides being sold to you as some tincture that will help and science hass studied these and theyve said it doesn't work. so don't do it. And you know I think also a lot of people don't realize that they're also mixed with other things. L there's usually a base and people don't realize that.ike I had clients that were on different peptides and I remember asking them, what are you really on? Because every week they would come back with a different side effect that was not a positive side effect And they're like, I don't understand. I'm taking the exact same one I took last time. And I'm like, but what is it? And they don't even know what it is. So just you have to be extra mindful and careful because they're not regulated. They're kind of like some of the supplements that are out there that are, you know, they're not FDA regulated. You don't really know what you're taking So just like another push to see even worse even worse than supplements. Sulements, you can just There's third party testing and there is Not all, but you can check that. But out of these kind of non branded peptides across the board, we really have to be careful. So please, it seems so alluring, like someone else has the fountain of youth. What I find crazy as the people on Instagram who came after me for years saying that I was going to give people cancer using talking about GLP ones, the FD approved GLP ones that I was doing something harmful, snake oil. There is same now are prescribing theons regulated medications. What do you think is the psychology behind? And you know, I feel you because for the vast majority of my career, compounded hormone therapy was the way and is probably still in many pockets of the country, the way most people get their hormone therapy. And explain to me why psychologically, whyy does it feel safer or easier to take a medication that's unregulated? What's that loophole in the brain versus something that is more well studied. Well, that's a good one too. I must say I haven't call me the next Oprah. Exactly, right. So there's a few things. First, I think everybody wants a quick fix Right. And it is easier to get your hands on one of these peptides than going to a doctor, getting labs, getting, you know a prescription. Yes. If your insurance covers it, if your insurance doesn't cover it, going through all of those loopholes to begin with And then I also think it is what the world has been telling us and what society has been telling us about obesity and individuals in larger bodies, right? So there was or still is, unfortunately. I think we've come a long way. But there is still a lot of shame and stigma around individuals living in larger bodies becausecause of that thought of, well, they just must be lazy, or it's just,, why can't they do it if I can do it type of thing, which is not true because we know it's biology. But because of that, I think people don't want to say that, you know, I need this or I am on this And also, you can't get a prescription for some of these medications if you do not meet a certain criteria because yes, it is a disease. So you know I think the individuals that are getting on and getting the peptides are not meeting the criteria. They don't have diabetes or they don't have obesity or another metabolic disease. kind of their only option. And what we're seeing, especially on social media or media in general, is I hate to say it, but it's a headline, Shrinking body is. And if people are seeing shrinking body is, people then start to internalize, well, if they are now thinner or losing weight, should I be. What's wrong with me? If they're doing it, I should be doing it because as humans, we compare It's actually a survival tactic that our brain does compare in order to survive. Oh good. So it's not just me. It's not just you. Okay. But it's what we do with that comparison. Our brains are wired to compare in a survival way. Like you're in the woods and what tool or weapon is your you know Eemy have, that's what our brains are wired to do. That survival. notot the way to look at somebody and be like, oh, they lost weight. How can I do that? And then I think that's where this is all coming from. Yeah. Okay. Now since I have both of you here, let's talk about the mind body spirit, the biology, the metabolics and the psychology behind starting a GOP one And starting to lose the weight. You know what do we see in terms of that mind body spirit? You know Both of you, either one of you can kind of start thinking about this, but what are a lot of the changes that women feel as they begin to use a medication, maybe going through the fears of the long term use or the stigma of using them, the cost of using them. And then when they start to lose weight And then once they reach their goal weight Like how much time do we have? I know, I know. So I know we're going to feel very similarly on this. So I think it all begins and ends and the middle through is all about the way that you think about this process. And I think this is what's really missing in a lot of people's journeys right now They're getting medications asynchronously or through a doctor and it's just a prescription And you know there's actually sixty six percent of people stop these drugs by one year. Side effects are a big part, but I also believe that not feeling emotionally supported is a big part. So at the beginning, I always ask people, why is your why for doing this? Let's just clock it. Like giveive me something that's not rooted in vanity and I'm going to write it down because I know they'll forget it. So I will have to remind them of that because weight loss the same thing. Yeah, weight loss starts to become, I probably learned it from you. You know, weight loss starts to become pretty focus for a while. I find that the I wrote a whole chapter on this, I call the ten pound panic. The first hurdle that people face is when they lose ten pounds and they've lost ten pounds before and it's generally where they don't believe that I can continue to help them, you know, especially when they're significant we loss ahead of them. It's kind of like the old trauma of just the you self sabotage and it's again just like, why me they start to go This might work for everybody else. It might have worked for the first ten pounds, but it's not going to work for the next sixty. And they al's all they know. Exactly. And you start and it's like it's self preservation too. They're ready to prepare themselves for failure. And so I think people need to be told, hey, like you're going to have these thoughts and everybody thinks they're the only one who thinks these things. And I'm like, no, everybody thinks these things. They're like, how are you in my head I've treated thousands of patients. I know, and I anticipate what you're going to feel. Yeah. And then what we need to warn people about and warning is that sounds so scary, but support people through is that the changes that then happen. We were just talking that ozempic personality is having a moment right now. And what does that mean? It means Your relationship with things that brought you joy changes. And so we call it anhedonia. and it's just kind of like a flattening of mood. And so we need to work on helping people find other sources of joy other than food and alcohol. A lot of our social constructs are and our contracts are based around similar interests. And sometimes that's just a lot of eating and drinking. especially in cities like this, my younger patients, if they go on a medication and their whole desire they're like, what do I do on a Saturday night? I'm like o Let's go to the burbs and go bowling. L you are five other things to do, you know. Yeah. So it's just I just think it's so important to recognize that the mental hurdle is a big one. Yeah. and it's interesting because when I worked at the hospital for bariatric surgery One of the things that we did was I led a support group for people before they had surgery to talk about all of the changes that to be expected. R Rachel did it first. You're right. Like know from bariatric surgery eighteen years ago. I mean, literally, I was trained in this area and More than fifteen years ago, we had these groups and I remember the clients sitting there being like, that's not to happen to me, That's not gonna to happen to me. And I would say to them, you're going to think that this is not going to happen to you. And I guarantee that some of it will. And I think being prepared is the most important part because It's going to look different for you, but there are gonna be emotional changes and things along the way that you're going to question and you're gonna to get in your own head or relationship changes or how do you go out on a Friday night or how do you date? L all of these things How do you talk to your kids about it I get this one a lot. I get that one a lot too because again, a lot of their daughters, they don't want to create sort of negative yes. But you know what the key is so interesting because you know this idea of support groups for bariatric surgery, if anyone has ever gone through bariatric surgery, and a lot of people who are in GOP ones now did at one point There's a lot of more money in the hospital setting around that surgery. And so there was a lot more prep and you're right. I always say if I could make it in a perfect world, everyone on a GOP one would see a therapist or at least have us like a behavioral health provider group setting, a support group to lean on and to learn these things along the way. Because there are so many things and clients come to me before they start them, maybe after they started them and it's nothing new. L your experience is new, but the specific kind of things going on aren't now. and there's so much that I think we can be prepared for, which is, you know kind of the idea of my book is this, like I want you to be prepared for when life happens. And a key actually CBT tool is let's anticipate What might happen, not jumping to worst case scenario. But let's anticipate like, okay, I'm going to start this medication. Say somebody's dating, how am I going to go about doing that? Well, let's talk about it. Let's come up with some sample scripts. Let's role play a little bit. Let's go through it. becausecause once we have a plan, it takes the stress level down, it takes the anxiety away, it takes the overwhelming feelings away, and we can do it. But those thoughts and feelings just start spiraling. The Anxiety, the overwhelming feelings skyrocket And then you feel stuck. So having a plan, I know. that's wonderful. It's fun to like have these like in real life aha moments of like, you know, really just also I love the idea of the support group that's actually you have like your cohort. you go through something with somebody because I always feel like as a clinician I want to be there with you, but certain populations, it's nice to have somebody who gets it, who's going through it, like in the trenches with you. For the clinicians listening, in the course we taught, I kind of gave the framework. I did this in my practice. I did a ten week course, right with group medical management And the support aspect, people loved. And so for anyone thinking about kind of bringing this into their practice, I actually think that this is just really something that people love and they need. And it could just be a support group. I mean, there are some online forums and groups available that are run by actually patients. And the Obesity Action Coalition is a great organization for people to connect with other individuals going through the same thing Wonderful. Yeah. Well, I know we could talk forever. and I still have a few more questions, but I wanna leave room for people to ask questions as well. But I think it's really important for everybody who's listening after this listening to the taping. what are some of the major lifestyle changes when you're on a GOP one that patients need to incorporate. So medically, what are some of those? And I also would love to learn sort of like how you've kind of created products help women through that. And then how do we, that will be my next question for you, like change our daily habits because it is hard Okay, so what do you the things if Cliff notes version of what I need you to know. I mean, I wrote a whole book. There are a lot of things I need you to know but how it's how to feel well on GLP one medications. GLP one medications don't just decrease your hunger through hormones, they also decrease your thirst drive. And so a lot of the side effects And the description of how people feel on these medications is due to dehydration and inadequate electrolytes. So if you're eating less, you're getting in less salt, magnesium, potassium, and you're just drinking less. And so I have all of my patients wake up Start their day with water and electrolytes, and it makes them feel like they can tackle the day. And even though they might not have an appetite, they're neutral, they feel well. and then I want them to go by mid morning and have protein. So so many people on these drugs are like, I don't have an appetite. This is amazing. And then it's four o'clock and they haven't had anything to eat or drink. And no matter if the drug is suppressing your hormones or not you're going to feel like crud by that point. And so hydration and then opening up your appetite is what I call it by having a small amount of protein. and that can be a protein shake, It can be cottage cheese, something that's like high density protein for a small amount And we really need to focus on protein, but also not forget fiber because a lot of the side effects from this drug are GI related, constipation, diarrhea, often they're cycling. So you don't have the same side effect every day. So you need to make sure you're getting both insoluble and soluble fiber in. So I don't actually teach calories in my practice. I really just teach macronutrients and I say, okay, I'm going to give you a rough guide and I'm going to show you visually what it looks like of how to get in thirty grams of protein at every meal. I really do want you getting in three meals a day Fasting has a place in the world, but not on these medications. You're not going to feel well, and you're going to lose muscle mass if you do that on these medications. And we really wantna make sure we prioritize keeping as much muscle as possible. So it really is just about how we get nutrients in our body throughout the day, so hydration, protein, fiber. And that's a strong foundation. It's a new way of looking at food though. and we really have to remind people, we should not celebrate that you're not eating. okay? That's very, very, very important. You're eating less. You can make better choices. This is amazing. You are freed from the food noise, but you still must eat Yes, yes.. Oh, and then to put put the button on that, out of this whole method that I developed in my practice of how to make people feel well, I've never had a patient have to stop because of side effects. I actually developed a whole product line. It's called So Wellell. I'm very proud. Female physician, founded, no outside funding and we provide the system for this to develop habits. So it's electrolyte, protein and fiber and stick packs. and you just kind of like go one, two, three throughout your day because habits are hard. So I was like, how do I just give it to you Be I kn my patients needed it too. Yeah, yeah. So that's like the million dollar question. How do we how I mean, gosh, there's like books and books and books and like you know tail's oldest time of like how do we change our habits? But what's your personal kind of experience philosophy around like habit changing. So it's actually pretty simple. We don't need to overhaul our whole lives nor can we. So I think breaking it down to what can I actually do today? Because for instance, a lot of our patients Maybe they've never exercised in their life, and they're not eating properly because maybe they don't know what a protein and fiber and all these things look like, and they don't drink enough and they don't get enough sleep, and they're stressed, right? So that's a lot. And if you think about it, then people are like, oh my God, I have this laundry list of things to do I don't know where to begin so I'm not gonna to do any of it, right? So really you all or nothing. It's exactly the dieter's mentality I'm telling you. So then it that's hard to shake. I know. It is. But then the question is, what is one teeny little thing I can do today And it could just be putting a glass of water by your bed and waking up and having a glass of water when you wake up, right? So thinking about, I always like to think of it as look at your key behaviors, your health behaviors, so water, food intake Moment, stress management and sleep. One of those is a great place to start, but start teeny. If you have never exercised in your life or you haven't in the past few weeks, start with what you have to meet yourself where you are today and accept that you're not who you were five years ago. You're not who you thought you were going to be in five years from now, maybe, but actually meet yourself where you are And we can also think about reframing certain things. Exercise that word can be really overwhelming for people who have never exercised. Yeah. So just how are you gonna get movement in today? That's literally where I start with my clients. How can you get more movement in today? So just pick one of those and start. And the more you do it, you're gonna start building confidence because you're like, oh my God, I can do this. and that feels good. And then that's gonna give you the motivation to do it again. And if you're like, I can just do five minutes, I'm gonna do it at least for five minutes Nobody does it for just five minutes. You do it for ten minutes. You do it a little bit more, a little bit more. And before you know it, you actually made a change, a I like to think of it, a change that has lasting change and big impact. Yeah. It sounds like give yourself some grace and give yourself sort of that you know, a space to start small and it makes a big difference You had to look on your face like you had something in your mind. the movement because even for people who exercise, we should all be moving more. So how can you increase movement is such like just a neutral question Yeah for everyone. for everybody. And again, I come back to how do you make habits? I really doar people write things down. like it put it on a sticky note. If you want to do it, put on a sticky note inside your mirror, put it in your, you know and just pick one thing. And then you build upon it, right We talk about habits stacking. There's a reason that that is like, that's a great idea. In my practice, I'm like, you're gonna to do this on week one. you're like, what do I eat? I'm like, we're not talking about that yet. You're only gonna to do this one thing. And week two, you're going to add this in. then week three, we're really gonna to start to change your diet. And then week four, we're gonna really focus on movement. people feel that's the thing. It's like you start doing it behind. Exactly it works because we're starting so slow. And then to be more specific, like I love having people write things down too. But you have to have that plan and be specific. Like saying I'm going to exercise more isn't a specific enough plan. It's like, okay, I'm gonna to start walking at least three times this week, twenty minutes each day, for instance Like you want to be very specific. There's actually a term called we call it smart goals. It means specific, measurable, attainable, realistic, and timely. And I truly believe if you set a smart goal, you are setting yourself up for success. And that's how you can start with like pick one habit, set a smart goal, and you're gonna do it. Like I can almost guarantee you're gonna to make it happen And then if you don't, it's okay too. Well Well. Do know what I tell my clients? If you don't do it, it doesn't mean you failed. It means this week was just too challenging. And then you have to go back and again, make it smart. If it is specific, measurable, attainable, realistic for your current life and timely. you will do it. Yeah. And I love that because one of the things I say a lot is like one size does not fit all, everyone needs a tailored approach. And if it's know too protocolized that just might not fit for someone's life, someone that might fit for their life. There's so many different ways of doing it, but tailoring it is so important I still have so many questions, but I feel like you guys do too. Do we want to do a little Q and A? Okay, before we do a Q and A, I just wantna, you know, just your last thoughts here. L if someone is listening to this, they feel this is so just what is your one thing you want them to leave with GOP ones and all of the medications coming in the pipeline in this class, they are not the easy way out But it shouldn't have to be hard. We have long been conditioned that weight loss should be painful, no pain, no gain. Oh, right? Yeah. But people have that in their heads. Yeah. And so it should not have to feel hard. You shouldn't have to be suffering from side effects. You shouldn't feel alone. You shouldn't feel like you're doing it wrong or it's not working That and it's not about willpower. It's biology. It's biology, baby. So mine goes so beautifully with that because I was gonna say that it's not your fault and to stop blaming yourself and that help is out there. These medications are a great treatment option that's available as well as other treatment options It's Medal Health Awareness Month. Help is available. It is not there's nothing wrong with you for seeking help. It's actually very brave and a strength. So help is available. I feel like we ended on a very positive note. So thank you all for watching and listening at home. We're gonna go to the Q and A session, which is just for us here So get on my email list if you would like to come to the next event and let's get into it. So I can walk around the microphone or if you feel like you can just yell, That's fun too. Thank you so much I'm so great to that I'm here. Such great information for both of you. My mind is so overstimulated. One thing I want to I'm a diet culture dropout. So I just want to say that. has this changed the dieture the people copping from fad diet to fad diet because I watched my mother do that, right? And so that I have a thirteen year old daughter. so I wanted to be really careful. I didn't model that. And my son was always a really big boy and a doctor told him at ten years old that he was obe in front of him. They should have told me it, right? And I was pissed. I blew them up. I went on blast because I have a concierge business that works with clients with eating disorders. so very, very educated in this And my son that sat with him, he just told me a few weeks ago that he's been uncomfortable in his body until getting on a GLP one, o for a short time because he's twenty. But he he said, Well, why do you think I wear black kac in school every day?? And he just told me this, he's never told anyone. and that doctor that said that he was not obese. He was a big kid. now he's six foot two and he just was just like it shamed to him. But I'm wondering if the bariatric all the surgeries have gone down, if the diet culture has changed, because all that that was such I mean a multi billion dollar industry of diet culture, right? But like I've been on a GLP one since I was shamed. I was shamed. and I didn't care. I told people I am on one because I was traveling doing on a TV show and I noticed any time I got on a plane, it was an excuse for me to binge out on food So I wanted to maintain weight while I was filming this TV show. So people were like, why are you on that? D, And I got changed for it.. Great time. had so many good layered questions in there. Okay. I write in my book and I say this all the time. GLPN medications are an antidote to diet culture And an end to yoyo dieting, which is the most harmful thing to us. That's what diet culture has done. Start, stop, lose, gain, lose, gain. What does that do?akes It sets us up for cardiomometabolic problems. It makes us unhealthier. So to me, GLP on s were an amazing solution to really help people lose weight and then to maintain that weight loss. This point that you bring up that diet and wellness is a multib billion dollar industry is a real problem because this is cut into that. And so then what am I seeing now is the diet cultrification of GLP ones. So people who, I mean, I get targeted with ads got ten pounds to lose, W to get ready for summer? That's diet culture all over again. So now we' arere getting to diet culture marketing. We're getting to diet culture use of these drugs, and we are doing the same thing we did before, which is yoyo dieting. What does that lead to? Worse health outcomes. It does. And we're so primed and ready for it because unfortunately We all grew up with it, and as the story with your son How could that doctor do that? How, how in this day and age, but the trauma sits with you for so long and you're just human. you're just trying to survive. And so you we're just open for this sort of marketing. I got put into jail on Instagram because I was just talking about these medications, but I believe that we need to have much stricter government level control on how we're talking about these medications, how we're using them. It's a midlife problem right now. It's just women are like, go on all the drugs. O need to lose ten pounds. Go on everything Right, And I think that's the problem because we're talking about menopause so much and we're which is good. It's a great thing. But we're talking about it and so many people are going through it and then we're hearing about medications that can help people lose weight and feel better that I think everybody is now trying to get in that industry, so to say, right? I mean, right It's also just capitalism coming back at up drops Be appetide is not orily available Do not buy a trizepetite drop. I mean these are big companies that are trying to tell you that these things will work. And so unfortunately, I think it's bringing it back up, the diet culture. Has the surgery? Absolutely. ye. No, it has. a ofs Yeah. Well, the band, you know, I used to say years ago, they're taking more bands out than putting them in. and that's been going on since twenty ten, maybe Some hospitals do, I'm not going to name many names. Some do. But I mean, people are still getting bariatric surgery, but the numbers have one hundred percent. You know, definitely they have gone down. And I think they're going pick up again, to be honest. You know, Oh, why do you think they'll pick up So there's you know' more acceptable to Yes and no. I think which we didn't touch on, but it's important to mention. So obesity again, is a recurring complex disease, Chronic disease, which means that you have to have treatment and it has to be managed for the rest of your life. Yeah. And I think love this. L rarely do I get into a room where people speak my literal same language you know me. And something we didn't say though was because we made a great pairing. Yes. But because it's a complex, recurring chronic disease, a medication, you know, just like diabetes, just like hypertension You're going to go on and you're going need to do something for the rest of your life in order to manage it. That something is usually a combination of things, right? Working out a little more, you know, being healthy in terms of your food choices, your hydration, something, your medication, your treatment option I think some people, well, you I don't know, I kind of take back what I say about biatic surgery. I'm not a hundred percent sure. becausecause more medications are coming out, there's going to be less of needing to take an injection every week. There's going to be the pills, there's going to be some injections once a month. We don't know what's on the horizon But I do think some individuals are going to stop taking the medication or the injections and need something more and or not want to take something like an injection or a pill. So I don't know. I don't think bariatric surgery is going to go anywhere, but I do know that the numbers are down They're really down. You know what's interesting? So there is a max that people can lose on these medications and that is very hard for people to understand. And it is this diet culture phenomena where already thin people are taking the medications. we're talking about people getting too skinny.s not the majority of people on these medications, right? And we need to not forget bariatric surgery as a solution when you have significant excess weight to lose. And what I find, I have a handful of patients who just came to me and they said, I know it's recommended for me. but I just don't ust But really what they're saying is they don't trust themselves and they don't want to undergo surgery if they can't lose weight in the first place. And so a GLP one allows them to lose weight, then they're like, okay, I think I believe this now.' go get surgery. It might not need the GLP on s, It might need them again, but then can go on and lose the full amount of weight to really get to a healthy We do see that a lot. and we even saw that years ago in bariatric surgery that clients would be on a medication first because they didn't want to take that big step of getting surgery. So they would be prescribed an anti obesity medication first, lose some of the weight and then see, okay, I can do this or I need this or now they're decreasing their risk even during surgery because they had some of that inial way. Yeah, right. Yeah. I just wanted to share the quick happy ending of this story with my son. So he did at the end of that crying and sharing with me, tell me, this is the first time I feel confident in my body and he's in Fire Academy. So that's the end I don't wantave you with doctor's office. Well and that's, but that's where these medications are giving people hope that have literally lost hope Naomi, what's your question Y no pressure. The question is what do we do with our patients who maybe have lost weight and are eating the protein and they're getting movement in and done CBT and they're on they're like mas on their toes. and they're not necessarily obese. So like the bariatric surgery is not want to be covered and there not might be Czy So what are we doing for those patients who you know, we know aslim resistance you can be skinny fat, right? Like this like terminology of like if you don't like that. No, no, no, no, no. I like this is a tough scenario. because I think and then we have these patients who then And then all of a sudden and this brings you in doctor Hirsch like, you're menopause, menopause and then the hormones are fluctuating and causing more of this insulin resistance. So what are we doing for them? they've been like they lost the weight, they're doing well, they're like, I've done all the things and now this weight is coming back. Yeah, ye Well, so okay. So people we need to guide our patients to understand that fifteen percent total body weight loss is a massive success. If you can achieve more than that, you're going to have better health outcomes. Not everyone is going to get to a normal body composition or a normal BMI, and that's okay because where you've gotten them with fifteen plus percent body weight is truly a miracle. I mean, when we started in this field, we were giving lectures like, just five percent will improve your health. just five percent, right? fifteen percent moves the needle on every health metric. And so I try to get all of my patients to fifteen percent total body weight loss if they have that to lose Beyond that, not everyone is going to get to the ideal. but I do believe in medication, I actually learned this term from you, medication stacking, where I layer in other medications. So GLP one s, I try to kind of optimize to the most efficient GLP one out there, and there are new ones coming. Reditrueide will be out in twenty seven It's like Q one, I believe, and that has even better weight loss results than Tz appetide. So optimize and then you might consider adding in other medications. So our older FA approved weight loss medications, one of them that I like to layer in is Crave. and I will write it generically, Naltrexone and wellbutrin. The Naltrexone component can be incredibly effective for cutting down on cravings specifically alcohol or excess sugar, especially in the nighttime, which is often really hard. And so don't be afraid of learning about the other medications and stacking them. And then also, if you're entering menopause, treat, treat midlife, treat perienopause, use the hormones. We know that women on GLP one' s and retrospective data plus HRT do better than those who are just on GLP onees. So Amen to that.mot trying to be a pharmacy over here, but on the medication. Well, you know, I mean, I would say it is though true. And I think you know when we think about the science Um As women lose estrogen, I have this fundamental belief that insulin and estrogen do talk to each other and signal to each other. And so your estrogen's declining, your insulin resistance going up. So I of course also think it's a good time to consider maybe estrogen replacement if they're otherwise you know, a good candidate for that. And I often think about how much poor sleep affects weight gain. So this is where like my besty progesterone comes in to like help so ensureuring they're sleeping I think that sleep is like so important for weight loss and I'm sure you could talk just about like that one I sa this week. So this patient She's a doctor She know she knows all the things. She. So this patient had bariatric surgery once and lost a lot of weight and then regained in midlife She could not actually go on HRT. We layered in another we layered in medications. She lost a little bit more weight. And then she properly treated her insomnia Which she used a really amazing tool. I can't remember what it is, but it was not cheap and it was a CBT training method. I was going to say CBTI is very Yes. But it was like this great app. She followed it. And for years she went in person, she did the things And something about this clicked and she came to me yesterday and she dropped the last twenty five pounds. I mean, I couldn't believe it was all sleep. just from sleeping better. So I'm going to say sleep and stress, I think is you know kind of one of the things that people really have to work on. like people miss. Th are two of the most important health behavior like getting your stress level down, which I know is easier said than done and getting better sleep. Yeah. so hormone stacking again for the win. and you can hormone stack your medications for weight loss and also like life stack, right? So you're also stacking all of the things Any other questions, Yes. Yes. So where can people go for the kind of mental health support that they need for how your life will change like your relationship, your partner might change your relationship or your in laws might change Sex may change Sddenly things get very strange. But Wight watchers was you not an ideal program for a lot of people. but it offered community and support and people could say, isn it just me or? And I thought that was The beautiful thing about weight watchatches is and I feel that that's beyond the prescription pad, that's what's missing is that people don't have a place men and women to go and talk about how strange life can get when you lose weight, how it changes More than just what's on the scale I mean, again, like so I do love White Wros for that reason as well, the community aspect and the support. And again, there are other support forums online and like theC and others that know people can kind of get that other lived experience support. But I would say you know seeking a mental health provider who is trained in this area or specializes in CBT, to be honest, cognitive behavior therapy and behavior change can be really helpful who is aware of this and the changes And I think I mean, again, in a perfect world, everybody would have a therapist, right? It's not so easy. But I think as we're going through midlife as well, like you with or without the weight gain or weight loss with the medications, but just as we're going through life, things are going to keep happening And I think having that support. I always say have your toolbox full of tools. A therapist can be a tool in your toolbox. Medication is a tool in your toolbox. Having support of friends and network and lean in on your friends and support can be a great tool as you're going through this to be like Hey, this is happening to me? Is that also happening to you? right? So I think the more that we speak up and share these experiences, the more you're going to hear, Oh, me too. it's not just me. So you know kind of find your people and let that be another tool in your toolbox. Yeah it is. But myice Iered this beautiful new space support grou. Oh yes. we could hold support groups here, of course. I know everyone's got more burning questions. I have one burning question that I'd like to ask the expert So I know we talked about this in the class at the Academy for Advanced Women's Health Medicine. and your class on GOP Oes is fantastic. And what I really feel like we strive at is really helping the clinicians who really see the patients with all these clinical things that we don't have perfect answers to And one of the things that we talked about, one of the things that I do in my clinic is I do prescribe lower than the standard dose, which people call microdosing, but it just means prescribing a lower than standard dose. And I do that for my patients who have fifteen, twenty pounds to lose and they really are doing E, They're sleeping, they're on their HRT. They're working out. And so is there anything about doing this safely? If you're going to use a very low dose, what do women need to know? I think So I think we're shifting from how do we look at who are these drugs appropriate for? On one hand, I don't want them to be marketed to everyone, and I don't want them to go from skinny to skinnier. But there a real it's a problem to me when people say, I was at this weight my whole adult life, even throughout my pregnancies, and then I hit forty five, I hit fifty, and then I put on twenty five pounds. And even if that still leads you to a BMI that's quote unquote normal or just overweight and technically doesn't meet the FDI criteria Well, I want you to look at body They feel the joint aches and pain. look at the positions that So it's a feel good. W. It is a feel good, but we are in the field of obesity medicine and even the pharmaceutical companies are starting to look at this in a different way. BMI criteria is easy, it set a standard, It got it out into the world. But really we have to look at metabolic health and what's metabolic health Fat composition. So I go off of body composition in those scenarios. And if you've put on twenty five to thirty pounds very quickly, that's fat. And so if I look at your body composition, you're probably going to meet obesity criteria and if you're BMI does not. And so yes, that's safe. I also think again, if you lived this one weight your whole life and then you're carrying thirty pounds,s like you're walking around with one of those, you know weighted fests all the time. That's exhausting. And I need to that really starts to affect quality of life. So I listen to the patient and I think you have to make clinical decisions based off of that. Yeah, I was going to say the same thing. I think generally stating, we can't just say like, yes, that's okay. I think making like really meeting the patient where they are and understanding their unique experience is so important. And that's why going to a specialist or a doctor not just the med spa or the gym to get your injection. b thing that like nobody's looking at if they're just getting a prescription to go from skinny to skinnier or from like Yeah things you know, like r. And so we have to make sure that someone is counseling. When you say safely, like the weight loss will come off, but are you really actually being the patient who is going to strength train? I have patients. are you eating regularly throughout the day? Are you eating so many exactly don't. Exactly. And like we're just go and Like roots can eat into your bones. And soy. Yeah, that's the safety in my opinion. and then not just developing an eating disorder too, which happens. You can develop one in your fifties, sixties, seventies. Yeah. abbsolutely