Summary of Key Principles for Success

Welcome to Zoe Science and Nutrition, where world leading scientists explain how their research can improve your health. I'd like to tell you about my good friend Liz . For as long as I can remember, she's struggled with her weight . She's tried all sorts of diets and supplements , but nothing has ever worked in the long run . She loses the weight, but it always comes right . And she's suffered from a sense of guilt and failure, her battle against her hunger and weight has seemed impossible to win . But finally, in early twenty twenty five, Liz had a breakthrough . She discovered a Zempic and then later Manjaro, and these drugs were a revelation . Although she had some difficult gut symptoms in the first few months, her hunger disappeared overnight , and the weight that had clung to her for decades melted away . What had seemed like a failure of willpower had turned out to be a disease causing hunger, and it's been amazing to see . But although this felt like a victory , she does have some new worries . Now she can only eat small portions of food, she's worried she won't get enough protein and that her muscles will waste away or that she will miss out on vital nutrients and get sick. This is a growing concern and something that far too few people are talking about. Today we're tackling this head on. I'm joined by Dr. Federica Armarti, head nutritionist at Zoe and scientist at Imperial College London to explore the science and the reality behind GLP one medications. Her new book, The Appetite Reset , arrives at a moment when these treatments are increasingly popular, yet still misunderstood. Federica has written a very practical book filled with specific nutrition advice on how to prepare for GLP ones to reduce the risk of side effects. What to eat while you're on them? And what to eat if you plan to come off them? By the end of this episode, you'll understand how these drugs work , how you can adjust what you eat to avoid side effects, and what to eat to ensure you get all the nutrients and protein you need while you're on them. Federica, thank you for joining me today. Jonathan I'm really looking forward to today . You know the rules ? Yes, no or a one sentence answer if you have to. Yeah, are you ready to go? Ready to go? Is it true that you can eat what you like if you're on GLP one drugs like Manjaro? No . Can these drugs change your behavior beyond food? Yes . Do a zempic or Manjaro work for everybody? Not necessarily. Can taking GLP one drugs lead to muscle wasting? Yes . Do people need to be on these drugs for life? Not always. And finally , what one thing should everyone know before taking a Zempic or Manjari . These drugs help to reduce your appetite, but they don't help to improve a poor diet . These GLP one drugs like Wagovian and Zempic have taken the world by storm . An astonishing one in ten Americ have already tried them . And because of their popularity, we get a lot of questions from people worried about what to eat during treatment to get the best results and stay healthy , both for themselves and for loved ones . So I'm really delighted to have Zoe's head nutritionist, Dr. Federica Ramarty with me today . And you have now just written an entire book The Appetite Reset which covers these exact topics because we've been having so many questions about them and that book is available for pre order now. That's right. So that's really exciting . Let's start with the basics, Federica What are GLP one drugs . So GLP one drugs are a group of medicines that basically act like a hormone that our gut producers. So they're the same sort of structure. So if you imagine we've sort of taken the shape of this hormone, copied it, and created a drug that acts in the same way on the receptor but doesn't break down so quickly. The drugs have a much longer life in our body. So instead of being broken down within a couple of minutes it persists for a week. So it's a much longer duration of effect. Why do these drugs cause us to lose weight? So these drugs literally switch on a system that already exists in us, but just makes it last longer. And they do this by reducing the speed at which your stomach empties, so the speed at which food travels down your gut . This means that your stomach is full of food for longer. And you know, that feeling when you're like, Oh , I don't really want to eat anymore. So that helps reduce food intake . It also acts on the pancreas. So the pancreas is the organ that's involved in making incidin after you eat sugars . And it does this in a really clever way though. So it actually increases incidin secretion only when you have carb ohydrates. So it means that you don't run the risk of too much insulin without the carbohydrates, which can lead to hypoinsulinemia, which could be very dangerous. So these drugs are really clever in the way they help the pancreas to create more insulin . And they also act on the brain, the hypothalamus, right? Hypothalamus is our central control system for appetite regulation. And these drugs go directly to the brain and go, We don't need to eat we're not we're hungry, filled up . Amazing. And so they are literally sort of just switching off the need for me to eat just with an injection. Just with an injection, you have this massive powering up of our natural body's system that actually has evolved over thousands of years to help us feel satiated and help us go about our day with quite minimal amounts of food, appetite physiology is actually built for us to feel satiated with quite a little amount of food because for most of our time on Earth, we've had quite scarce food supply . And so the way that this works is actually to be activated with just the right foods, to keep us full for a long time so we could continue scavenging and hunting and building our dens and all this stuff. So when we realize that these drugs are just activating system that's already there . I think that's where the interesting part is and we can start to unravel, well, why have we got to a point where we actually even need these drugs if that system already exists? Do they really work? And do you consider them miracle drugs? They do work. There's no such thing as a miracle drug. They still have side effects. They don't work for everyone. They're the biggest revolution in metabolic medicine we've ever seen. So that's super exciting. We finally have a drug that can actually help people to improve their metabolic health at a time when metabolic diseases are the leading cause of disease to death disability. You know, before these drugs, biatric surgery was the intervention which saw really good results for metabolic disease and obesity. But now with these drugs it's like unlocked its accessibility to millions more people predicted to be millions in the next few years . But we know that over ninety percent of people who access these drugs do so outside of a complete support system. So they don't have exercise support, psychological support , and most importantly, dietary support . That is a problem. So we have this amazing drug. It works. People reduce their food intake by thirty percent to forty percent . That's a big change, right? But without the correct framework around that treatment, you run a real risk of undernourishing yourself and making the overall metabolic picture worse than when you started. And that's why I wrote this book. ninety percent, nine out of ten people accessing the drug right now are doing so kind of flying blind . And that's because we're mainly getting it a little bit like we might just get something delivered in a box from Amaz on. Yeah. And then there's also this sort of online market for the unregulated versions of these drugs. So it's an even bigger problem. So there's a black market of what we call compound drugs. So it's the ones that haven't been made by the big manufacturers . And so if you add that on top, you see that there's this real potential for a very powerful drug that's just being accessed way too easily. So there's definitely issues here with how it's being regulated, right? It should be tighter. And there's something on TikTok. You can buy online, you can go to like an online pharmacy and fill out your details and never actually speak to a doctor and get the prescription in your post or even yeah to your point, box arrives with the drugs with very little support around the dosage, how to increase it, when to stop, but more importantly from my point of view, how to eat, how your lifestyle needs to change, what to expect in terms of side effects, you know , what we know now from trials and from real world data is that the best way to manage the gastrointestinal side effects, which are by far the biggest reason people stop is through diet. It's the best way to manage them, right? So if we don't give people this advice , then we're not really setting up for success . And by not setting up for success, what we see is this huge drop off, depending on which study you look at, it's about fifty percent to sixty percent of people stop taking the drug within a year. fifty to sixty percent of people stop within a year. In some analyses, it's two thirds of people stop because they can't tolerate the side effects or because they can't afford to keep paying out of pocket for it. And so we then have two problems. The side effects could have been managed with diet, right? And the second problem is if you're stopping because of access issues, cost issues, you're likely to just go from max dose to zero. So there's no tapering down and that is a massive predictor of how much fat mass you're going to regain . So there's so many opportunities for us to make this drug more effective and more toler ated for the population that want to take it and need to take it . And the need to take it point is where as well we're not giving people enough information. I think to your point, Jonathan, these drugs feel like you might just be ordering some vitamin D. People are taking them quite freely, even when they're not in the populations that they're really designed for. We know that a lot of people already aren't eating enough of the right foods to support their health and their long term goals . And so if they're also taking an appetite lorine drug that drastically reduces their food intake , we're putting their body at even higher risk of undernourishing themselves. And that is a real red flag. If you're a nineteen year old girl with a BMI of nineteen, you can buy this drug online and inject yourself with it. And the long term damage that can do is really quite shocking. And I think we need to empower listeners to understand these risks so they can make more informed decisions about what they're doing and also really push for tighter regulation on how they're dispensed. Thank you, Frederick. I want to get into all of that. But could I just start with just a simple understanding maybe of what the drugs are and what you're supposed to do if you go on to them? And for start, there's a lot of different names, right? I'm thinking Wagovi, Manjaro, a Zemp . Yeah. Are they all the same ? And if you start to go on to these drugs , what would the experience normally be that a doctor would take you through? Yeah. So it's important to note I work with doctors. I can't prescribe these drugs, but of course there's lots of evidence now so we know what the best practices are to improve success. So Wagovi and Ozempic are both semi glutide based drugs, so GLP one receptor agonists. They're just licensed for different outcomes. So the Ozempic is for type two diabetes, with govious for weight loss, a slightly higher dose. Manjaro is a dual agonist, JLP one and GIP , they're like little mates . They act together in slightly different ways on those systems on the pancreas, on the gut motility and your brain. But they sort of complement each other. So Manjaro has more weight loss effect. You lose more of your body weight . Now the way that they're supposed to be sort of taken is the bit that everyone misses out is a pre drug phase where you're supposed to really think about your diet , really support your gut microbiome because if you actually prepare your gut before you start the drugs, you reduce that risk. So the pre drug phase, you know, ideally like a couple of months before, it really depends on how your diet already is and how your metabolic health is. So how is your liver functioning? Do you have fatty liver ? How is your gut functioning? We'd want to target that and improve everything before you start treatment. The analogy I use in my book, The Appetite Reset is to think about this like driving a Ferrari. These drugs are like a Ferrari in terms of medicine, but if you're taking a Ferrari on a really dusty, rocky track , it's not going to be a smooth ride. If you take them on a lovely ly fresh tarnaced road, it's going to be smooth. So prepare your surface . I love that your Italian ancestry is coming out here with a Ferrari example, Federica. You gotta prepare the surface, and we've got to do that by feeding your gut microbiome, feeding your gut the fiber it needs, feeding your liver with the lovely fruits and veggies and healthy fats that it thrives with, right? It will massively improve your experience of starting the drug. So there's a whole phase there. Once you start the drug, start at the lowest dose and titrate up. Every patient is different . Someone might be responding really quickly to the drug at quite a low dose, and then you stop there. Don't carry on going out for no reason because that's when people come off the drugs and feel quite ill. Could you clarify what the side effects are and then are you saying the side effects are worse if I'm taking a higher dose of the drug. Yeah, so because we don't know what people's lowest effect of doses until they go on it , if you go straight to the top, straight to the hero dose , then quite a lot of people will feel quite ill, so they'll have the constipation, the nausea , those are the biggest two. Sometimes diarrhea and that can be paradoxical. So where you have constipation and then diarrhea with it, which is uncomfortable. Sounds unpleasant. It is vomiting in fewer cases . And then there's more serious side effects that are rare r , but your doctor should tell you sort of to look out for if you're very persistent pain . It could be due to a gallbladder or your pancreas struggling. And again, setting the scene in the pre drug phase really helps to reduce that risk. But if you imagine if you go to Max dose and you're someone who's quite sensitive to the drug, you'll instantly feel really nauseated, like you might vomit, your constipation's gonna be really aren' inttolerable very quickly . Whereas if you titrate up from like a small dose and when you say titrate up yeah so if you just increase your dose very gradually maybe the lowest dose will be the most effective for you as a patient. You might be like actually I'm already losing weight , I'm already reducing the intake of the foods that I wanted to reduce. My food noise is already improving. So my mental health is improving. You stop there. Or you just go up a little bit at a time until you get to that dose where your side effects are to lerable and you're seeing the metabolic effects of fat loss and reduced food noise that is going to be supportive of your health outcomes . So that's a really big one . Then the other one is what we mentioned earlier, making sure that your GI symptoms are being managed with diet . So these symptoms of nausea, constipation, vomiting, sometimes diarrhea, reflux, these are all symptoms that can be managed with diet. There are ways to manage all these symptoms with dietary intervention . We talked about some of the side effects as you stop in a way we've almost jumped over, I guess the thing that I hear from like friends and family who are on these drugs which is that, like the transformation in how hungry they feel and what they want to eat . What is that experience for somebody who starts on these drugs? I'd like to let you into a little secret . I'm a big snacker. Most days I eat a big healthy breakfast and lunch and I still crave a snack , especially mid afternoon. If I'm at home, I can usually find something I feel good about eating , but when I'm out in a bow, this is usually imposs ible . And honestly, sometimes I just don't want to eat yet another bag of nuts. So I end up in a shop looking at a huge variety of snack bars , and they all seem great until I turn them over to look at the food label . And then I get really frustrated . There's this long list of unrecognizable ingredients plus a ton of added sugar. If I'm feeling strong willed, I resist . But let's be honest, I'm hungry and I'm tired, so often I eat it anyway . But once my hunger has subsided, it leaves me feeling furious with the big food companies that sell these products with all their fake health claims and offering nothing that's actually good for me. I've complained about this to the team at Zoe frequently . So imagine my surprise when our chief scientist Sarah Berry said she thought we could solve this and create a snack bar that was actually good for my gut health. There have to be some benefits to being a CEO, so rather selfishly, I said yes as long as you can do a dark chocolate flavour . And today I have some incredibly exciting news. We've created the Zoe Gut Health Bar, a snack that's designed to taste great and support your gut health. The Gut Health Bar is filled with plants, carefully selected by Sarah and our team of gut health scientists. It's delicious and satisfying to eat and it contains a huge diversity of plants with their cell walls preserved , which we talk about so often on this podcast and it's designed to feed your gut microbes. It's got seven grams of plant protein , a huge eight grams of fiber , and twelve to thirteen plants in each bar, depending on the flavour. My favourite is a seventy percent dark chocolate bar, but my co founder Tim Spectre prefers the Raspberry and Goji Berry flavor. Perhaps I'm biased, but I think our Gutter Health Bar is delicious . And I love the fact that it takes time to chew instead of being hyper palatable and stuffed full of artificial additives. Ever since I got the first samples, I never leave the house without a couple of these in my bag. I can't wait for you to try them for yourself and let me know what you think. Head to Zoe. com slash snack bar and try it for yourself . That's zoey dot com slash snack bar. Your gut will thank you . So I'll never forget the first woman I was working with who told me this and we were talking about side eff ects and potential risks and she said, I'll take all of those risks if I can continue to have the amount of mental space I now have. So what's really interesting about food noise is that this wasn't a term or something that we looked at as clinicians until these drugs came to market . Suddenly, lots of patients started reporting that their food noise had gone down. And Federica, what is food noise? It's not just like, I love food. I'm thinking about what I'm gonna have for lunch in a nice way. That's not what it is. And it's also not I'm genuinely hungry and therefore I'm gonna think about what I'm gonna eat at the snack. It's not that. Food noise is persistent , pervasive, and sometimes rumor and so like going over and over and over in your head, thoughts about food , where you're going to get food , how healthful your food is, whether you've reached your macros. The really interesting parall els with food noise is that patients with obesity that report food noise behaviors have a lot in common with patients with eating disorders and that describe how much it takes over their mental space. It's not a pleasant experience and it takes over your day. So if you can imagine Jonathan from the moment you wake up to the moment you go to sleep, all you're thinking about is food, its effect on you, how you're going to get it, where you're going to get it from , is it good for you and you have anxiety around that ? And to have that completely switched off by these drugs is one of the most transformative effects of these drugs. And so this is why when you talk about GLP one receptor agnosis or Ozempic Wigovi, they're really brain drugs and fat loss drugs. Like they're not cosmetic weight loss drugs. Their big effects are these two. And then some of the emerging evidence on inflammatory effects, right? Anti inflammatory effects. It helps us to really understand why certain individuals struggle with food so much and it's nothing to do with willpower . It's everything to do with the way our brains are wired and the environment we live in , which actually makes that responsiveness worse. And it also does this. We're starting to see for alcohol, smoking , and gambling addiction . So why these drugs offer such a window of opportunity is because they help to make space for dietary and lifestyle changes that that patient can then take with them for the rest of their lives. And we're talking here about the people who should be taking these drugs or the correct populations . That food noise element doesn't apply to those who like microdosing or taking it for vanity reasons . But it's such a powerful additional benefit in terms of mental health for patients who really suffer with vod noise. Federica, is this why people lose weight on the drug? Certainly one of the main reasons, yes, because as we said, appetite regul ation is really a brain exercise. So if we think brain is the control center and the messages come from your gut primarily . There's a four stage system that helps to regulate your appetite. The first one is cephalic , so in your head . And the cephalic system is seeing your food , interacting with it, so smelling it, tasting it, anticipating . This can only happen if you're actually preparing whole foods , if you are opening a packet or you are drinking your lunch , that is bypassed . So this is a problem in our current food environment, like ultra processed foods everywhere. People literally do drink their lunch at their desk. So you're skipping one of the first steps in appetite regulation. Have you ever been really hungry and you're like making lunch or you're making breakfast and you start salivating sure. Your mouth is watering, your tummy's rumbling. That's physiological effect s of your brain being like, yo, there's food coming. I'm now thinking about being a child and thinking about my mother preparing lunch. And that is definitely what's going on. She's like, you know, you're like, Oh, can I have a snack? She's like, No, 'cause I'm making lunch and you're getting hungry . That is part of the appetite response. It actually primes your pancreas to start secreting insulin. So there's actual physiological consequences to interacting and preparing your food. If there's one health act that is unsung is like preparing your own food actually helps with your metabolic health. Then you taste it, your taste receptors, everything is having a party. It's great. Travels down to your stomach. Now your stomach plays a really important role with appetite regulation because it's got stretch receptors. So this is a very physical response. When you eat foods that take up space in your gut, they stretch your stomach . And these send signals straight back to the brain to say, okay, we've received food. This is about twenty to thirty minutes after you've started your meal, right? So this is like minute minus two phalic in your stomach half an hour later, another round of satiriti signaling from the stretch receptors. The drugs that slow the empty of youring stomach means that that stretch receptor activation is longer because your stomach stays fuller for longer. It's also why people who have very high volume diets with things like broccoli, cauliflower, rocket . So these foods that take up a lot of volume tend to have better appetite regulation because their stomach stretches more and they feel more satiated from their meals. We've got to try and distinguish fullness from sati because fertility is longer term and fullness is quite short term. We want people to help feel satiated from their meals. So your stomach's emptied and it goes into your small intestine. This is the third phase now . In your small intestine, there are lots of these really clever cells that make hormones for us when they sense nutrients and they send messenger signals to our brain GLP one, GIP , PY to say, Hey guys, we've got nutrients. We've got some cool building blocks for working with. Now this is like an hour and a half after you've eaten maybe it changes from person to person. I'm sort of generalizing. So an hour and a half later, you're still getting satiety signals because you've had a nourishing meal that has proteins and fats and vitamins and minerals, okay ? Through this one intestine, right? Takes a while to go through it. It's actually quite long this int morningestine. You get the colon. If you've had a high fiber meal , you have plenty of fiber reaching your colon, okay? The first part of your colon has more of these cells ready to go. They're like, what am I going to get? Feed me . They release GLP one and PY from the same L cells. They get released from the same cells and they have amazing effects on your satiety. This is like two to three hours after your meal, okay? So you now have lots of fiber . You've eaten a like eighty plus score on the very hot meal with loads of fiber, nuts and seeds, broccoli. It's great . And your gut is now saying there's still more nutrients for us here. Your gut microbes break that fiber down, they produce short term fatty acids and other fatty acids that interact with these specialized hormone cells in your gut that then segment send sign theals up, JLP one, PY, again, GIP, getting released again. So whilst the drugs have this really prolonged time they act. So it's like burning a really long bonfire, yeah. If you eat a diet that is built to work with our appetite and satiety signaling , you will feel satiated from a meal for hours, even though the individual life of the molecules is only minutes. So it's like little crackles throughout instead of like one massive bonfire that runs forever . So the magnitude of the effect of the drugs is like a thousand times bigger than our own hormones we make. For some people are like m youraking own natural ozone pic, you can't do that because our own natural ozone pick works very differently compared to the drug. So we have to be super clear. It's like thousands of orders of magnitude, okay ? But if you have a diet that supports your natural signaling patterns, then you do have a much higher chance of being able to feel satiated not having so much food noise from the internal stimuli. I think what you're saying is that being full isn't just the period when there's like a lot of food in my stomach and that that's sending messages, which I think is how I've thought about being full, but that we now understand that as the food sort of continues its journey and goes into the small intest ine and eventually into the colon where all the bacteria are. And actually even when it gets the bacteria they're saying like our body is able to say wow, there's all this fiber. I'm really happy. And it's then sending like our own GLP ones up to the brain saying, Hey, I'm still feeling satiated to use the word you said, still feeling full . And you're describing this is the way that if everything is working inside us , that a traditional healthy meal would keep us full for many hours. And it's not just that I've stuffed myself, it's actually that my body itself is sending these signals to my brain two to three hours later saying actually everything's still good , we're full, I'm really happy with what you ate and therefore I'm not having this really strong hunger cues. Have I got this right? That's correct. And am I right in suspecting that the sort of ultra processed food that we generally eat doesn't do this same thing. So the way I think it's helpful to frame it to understand is if we understand its evolution. So when we used to forage food, right, we would get plenty of very fibrous, tough roots , seeds, berries, tubers. That was the majority of our diet. And so our body has evolved in a way that having that very high fiber diet and you see this in the Hads of Tribe today , where they upwards of ninety grams of fiber a day, right? This very high fiber diet actually helps our body to feel like it's getting what it needs and that satiety signaling continues . Even though compared to our modern Western diet or the SAD , Standard American diet sad. In terms of calories, in terms of energy, we're eating way more with the SAD with our modern diets compared to Hunt Garer diet . And yet we're starving, right? We feel hun gry all the time in our modern food environment . Whereas that very, very high fiber diet helped hunter gatherers and our ancestors to continue with their day, continue hunting, continue gathering with much fewer calories. Now, what's really cool is when you have a gut microbiome that's very dialed into this system , you produce even more of these short chain fatty acids. So the higher fiber intake from a diverse range of fibers , the more you produce short chain fatty acids. Short chain fatty acids have energy in them, which our gut microbes can use and they can confer to our body to use. This is where it gets super interesting. Maybe ten percent of our energy needs comes from the short chain fat acid produced from our microbiome . But if you amp that up to a really high fiber diet, it could be as much as like thirty percent . So you're now getting energy and satiety from your gut microbes , which means you don't need to then go out and look for more food. So if you contextualize it in that way and you compare it to our diet now where more than ninety six percent of us don't reach the minimum dietary amount of fiber per day where we are overconsuming refined carbohydrates, meat products and massively underconsuming a variety of plants. You start to understand why that signaling system is not operating . Because the brain's there and it's waiting for signals , but our internal sort of fireworks are not being let off, so the actual signaling from our gut isn't happening in the way that it's supposed to help our brain. On top of that, you look at brain structure changes. So we know that children who are born in families that already have obesity, their hypothalamus is slightly differently wired, so they're actually less able to feel satiety . And then you add on top of that , when you have increased fat mass, another hormone called leptin really interferes with the hypothalamus. It can be called something called leptin resistance, which then means that even your fat mass tends to help you feel less hungry when you have enough of it, but if you're left and resistant, even that doesn't work . And then you have advertising , the availability of food absolutely everywhere. You can't escape it. Everything is stacked against us in a way where it's actually harder to remain a healthy weight when you consider that entire picture of how we're supposed to eat and live and where we're actually living and eating and the generational effects we're now seeing because we're sort of two or sometimes three generations into being overweight or having obesity. A lot of your book is talking about practically what should you eat in order to get the benefit ? For a lot of us, I think we see, well, you take this drug and people lose a lot of weight and it's obvious that they're feeling much better and they seem to have more energy than they did before . So why do we even need to worry about what they're eating? Especially when you're taking these drugs, you have to eat the correct foods. Otherwise you won't feel better and you won't be improving your long term health. For patients living with obesity, there was a review published just last week, first three months of treatment mostly result in just fat loss, which is what we want. We know that twenty percent to forty percent of weight loss can be from lean mass. Your muscle and your bones, but actually it's phased. So the first phase of weight loss is more targeted to fat loss, especially in this population of patients that have excess body fat . But then once that body fat starts to come down , you have this real increased risk of losing lean mass. When you have very rapid weight loss, there's this real risk of losing the lean tissues that you're trying to hold on to, which is why I think these drugs are correctly referred to as fat loss drugs because that's what you're trying to lose. You don't want to lose your lean mass. Like at any age, right? You want improved body composition. Ideally, you want more lean mass , stronger bones, and reduced fat mass to healthy levels. Now, if you don't support yourself with the correct diet, there's a few main concerns, micronutrient deficiencies, right? So we know that because of the diet we already have, many of us are living with micronutrient deficiencies already. So folate is a really good example, iron in menstruate in women. So if you then have even fewer opportunities to get your nutrients and your diet quality is poor , I mean it's not looking good. Micronutrient deficiencies are going to be an issue. So you might have heard the term nutrient density is very popular now because of these drugs. Nutrient density just means that each mouthful of that food is actually delivering a lot of nutrients. No prizes for guessing, some of the most nutrient dense foods we have are plants. So if you have a poor diet and you would drastically reduce your food intake but still poor diet, micronutrient deficiencies are a big risk. The next one is protein. So like protein is the one you hear a lot about. It's absolutely true. Because you're eating way less food , you have to make sure that the food you are eating contains enough protein . However , just eating loads of protein is not going to save your muscles unless you do resistance training. It doesn't have to be some crazy exercise. It can literally be your some bands at home . You can start by lifting tins or bottled water. Like start from where you are , but make sure you're using the muscles in a way that actually causes some sort of strain so that you're keeping that muscle mass and keeping it active, basically. As you'll remember from our Zoe protein principles, it's one of the only times when actually the recommended amount of protein grams per kilograms of body weight does go up. So we're looking at one point two grams to about one point six grams of protein per kilogram of body weight. It's hard to work that out. Like I would struggle to work that out myself and it's my job. So it's more about what foods do you need to include? Very high quality protein foods, you know, eggs, poultry, cheese, and yogurt, but also nuts and seeds, products like tofu, soy based products, beans and lentils as well. These all help to achieve enough protein your day if you're making sure they're at every meal basically. Hydration is often overlooked. When you have less of a drive to eat , you're also reducing the amount of fluids you're getting in your fruit, vegetables. They all contain water. Or if you eat soups and stews, they're all water containing food. So if you eat less, you also have less of a drive to actually drink so your, thirst response can be dampened. The result is, you know, constipation being a huge problem . Dehydration and constipation are not friends. You're going to make it so much worse. And also dehydration can make you feel really tired, give you headaches, make you feel sluggish. During treatment, there is a real risk of dehydrating yourself. So make sure you're drinking water . Things like smoothies and soups are really good, especially when you start to get used to that feeling of fullness . The fourth one is this nutrient density idea. So like every single mouthful plays a role when you're taking these medications because you're eating so much less . One of the side effects of these drugs that is not often talked about but can be very serious is that when you have this reduced reward circuitry it can lead to something called anhedonia. So you stop enjoying the things you used to enjoy . And for some patients I've worked with, that stopped them taking the drug because they stopped enjoying their lives. But you can help that energy and that mood by focusing on fiber, very specifically fibre . And it goes back to the role of our gut microbes. When I was researching the book, the amount of times I came back to the role of the gut microbiome in this picture , I was actually astonished. There's lots of evidence that shows how focusing on feeding our gut plays a pivotal role . And we see this a lot in the effects that fiber has specifically and diversity of fibers in the diet. ninety percent of people are effectively self medicating . They're finding this online . They are overweight, they are self medic ating . What happens if they just continue to eat the poor quality diet that they were eating beforehand? Let's look at the real world data because we have it. So by some estimates, two thirds of people stop taking the drugs because they don't feel well. They have GI side effects. Longer term picture wise, one of the red flags and one of the worries is this yoyo effect of coming on and off of the drugs can be actually detrimental to long term health in a way that if you imagine you've lost lots of weight, you haven't changed your diet, you haven't changed your lifestyle, you haven't done any resistance training , and you're in that group of people that have taken it for long enough where it's not just fat loss, it's now lean mass . If you then come off the drugs, you will regain the weight lost mostly as fat mass. It's much easier for our bodies to store fat mass. So there's a term for this which is called sarcopenic obesity and it's this idea that you have increased fat mass and much reduced lean mass . And this doesn't necessarily mean that weight or your body won't necessarily be that much bigger , but the proportion of lean mass to flat mass is worse . And the real risk is that is that you actually end up with weaker bones, less muscle mass , and more fat mass than you started with , which then turns the picture back around to increased metabolic health risks. So increased risk of type two diabetes, increased risk of fatty liver disease, increased risk of hypertension, name it. So all these metabolic conditions that we're trying to reduce and that the drug is so effective at helping to reduce. If you have a good enough framework around these medications, there is a world in which you could come off them and not have that worse health outcome in the long term. So we know a lot of patients come off them and don't go back on them. The majority of people who go back on them are those who then see an rapid increase in weight again and they're like, okay, I'll give it another go. But there is a subset of people. And I have a few patients who have successfully reduced their dose and now don't take the drugs and two years on have maintained their fat mass loss. I'm not saying that's for everyone. Some people will need to take these for life , but there's a world in which you personalise the approach and support people to have the best possible outcomes for their biology and their background. So in your experience, you have seen people lose a lot of weight, come off it and keep the weight off. Yeah. But you've also seen people, which I've definitely seen as well lose the weight, come off it, get really hungry , and then find that inevitably they're therefore going to put the weight on. They do. And often it's quite a big proportion of the weight loss comes back on within the space of six or twelve months. Just before we come on to like okay, what are all the practical things that you can do? Yeah . What about people who are just going to stay on the drug? They're like, this is magic. I didn't have side effects so I've got through them. It's magic. I'm going to keep taking it and I'm just going to keep eating the food that I was eating beforehand. I'd say it's quite hard to take these drugs long term and not eat in a way that supports your gut and your body because you will get the side effects. If you have any intervention that restricts your food for very long periods of time, you always run into the risks of decreasing your resilience, your immune system really struggling, your brain health struggling, your lean mass, your muscles and your bone struggling. There was a patient in the UK who had scurvy. For bleeding gums, people couldn't understand what was going on . He'd been taking these drugs without any support and just hadn't been eating fruits and vegetables, basically. I wouldn't say it's big numbers right now, but there was a case study of a patient who had started to have really severe brain health issues and the case report described this patient as possibly having early onset of dementia. And then they found out he was just massively mic ronutrient efficient for his brain. And it's because if your dietary quality doesn't improve on these drugs , then you are definitely going to run into an issue of complete undernourishment. So when you take these medications , every single meal counts more than if you weren't taking them because you have fewer meal opportunities to actually improve your health. And Federick, you talked about the food noise , but does it also change the sort of food you want to eat? It's a good question. So there isn't like data that has quantified this , but anecdotally , some patients really do change the food preferences. They're like, Oh, I can't even think about eating that. And that the biggest group of foods for that is fatty foods. A lot of people report just not wanting to drink alcohol or if they get a beer or have a glass of wine, they don't finish it. So it does actually change some behaviors and preferences for food. Hopefully it will help you to be less attracted to certain food groups, but it doesn't automatically improve your overall food choices. You might remember Lucy, our participants from the documentary, Dream, Luc y. Yeah. One of the big changes she reported was that she never used to eat chickpeas and chickpeas were obviously recommended as one of the foods to incorporate. And within weeks, she felt like she wanted chickpeas and she couldn't explain it. She was like, I never ate chickpeas. I didn't think I liked chickpeas. And that is a really beautiful example of gut microbiome driven hunger. Gut microbes love the chickpeas, populated, really like her abundance of these grew and they send signals through the vagus nerve to your brain to tell you eat more chickpeas so we can survive please. That's brilliant. So you could have your microbes start to help you exactly shift what you want to eat. A few are the ones that love Oreos and McDonald's and more of the ones that love chickpeas. Crowd out the Oreo noise exactly. If you know someone who's taking a Zempik and Wanjaro or perhaps thinking about taking them, why don't you share this episode with them right now. You'll give them the knowledge to eat the right way, whether they're preparing for those weight loss drugs or on them today and ensuring they don't miss out on key nutrients or protein so they can get the best possible results for their health. Genuinely, you could really change someone's life. So go ahead, share the link with them now. So I would love now to switch to where you're going now, I think, which is what should you do when you're starting out on these GLP ones to reduce the side effects. And then I would like to talk about the more longer run changes. Yeah, great. So we talked a little bit about the pre phase and trying to really nourish your gut microbiome, reduce any kind of constipation before you start. So the pre phase is very focused on fiber and gradual increase of fibre because most of us are deficient in fiber. So how do you help people go from baseline which is around fourteen grams a day to twenty , twenty five and thirty before you start the medication . There are some major groups of foods that have fiber so like pulses, that includes chickpeas and lentils and beans. Nuts and seeds are really important as well, including those in your everyday diet. Fresh fruit because it's hydrating. And then you want to try and incorporate whole grains. So whether that's barley, buckwheat, try and replace your wh likeite rice or pasta not at every meal, but as often as possible once a day, try and have whole grains instead. If you incorporate those foods into your diet and gradually increase , that will help to increase your fiber intake , help your gut, help to repair your gut barrier that might be a little bit leaky, as we say , and start to populate your gut microbiome with the guys that we want to see in there. Now this, is really interesting. This will also naturally increase that short chain fatty acid production and it will increase the nutrients in your diet that actually make the GRP one production, GIP and PY production go up naturally. One of my patients was doing the pre diet and decided she didn't want to start treatment because that pre diet was helping her to lose weight, helping her to feel better already. So she was like, I'm going to wait before I start the medication because actually this dietary intervention is already helping me. Great, that's fantastic. During treatment , prioritize protein, nutrient density , making sure that you're getting hydration, enough hydration focusing on these micronutrients that we know. So the nutrient density and the micronutrients go hand in hand. If you're having nutrient dense foods, like broccoli, light cauliflower , light berries, light nuts and seeds, and legumes, legumes are anything that's kind of a bean adjacent food, but also green peas, which are often really accessible to people. And these are just helping you with fibre? No, they help you with fiber and they also have excellent protein profiles, especially when paired with whole gra ins. So if you pair whole grains, say like a barley with lentils or beans with spelt , they then have the complete amino acid profile in the right amounts so that you're getting really good quality protein. Then during medication you know that each bite counts and that you run a higher risk of dehydration. So you're prioritizing structured meal times. So this is a framework that's in the book which really help s you to keep on track to making sure that you just give yourself enough planning so that you're not left guessing because when your appetite is reduced, it's quite easy to say, well I'm not hungry. I'm not going to eat. By giving our gut a clear idea of when food's coming, it helps to reduce the side effects. Our bodies love to predict when things are happening because they can't see what you're doing or thinking. So if you have very clear breakfast time, lunch time and dinner time. Now, for some patients actually , they prefer to spread things out with snacks too because their appetite is very reduced and you don't want to eat past the point of fullness on these drugs. Very important you will feel uncomfortable. But telling your body right breakfast is say it's like nine AM every day ish within the hour . That's also critical for your gut motility. Gut motility is what helps everything keep moving and we want that. We want to go to the Lee regularly . We want to give our gut that stimulus to say, okay, it's the morning, wake up, start moving things along, and breakfast is the way to do it. So having your breakfast at the same time every day than having your lunch planned and prepared but so that you know you're going to have something that's nutrient dense and that will make the most of that meal. So I often recomm end something with you because it is really hard to find nutrient dense foods like in a supermarket or at a quick sort of lunch place, right? I know we talk a lot and we think a lot about how to help people snack better . And so having a very healthful snack with you , nuts, fresh fruit. Our Gut Health Bar is literally made for this . Having that with you means that you have something that's nutrient dense, high in fiber, good quality protein with like minimal additives that's in your pocket that you can take with you. If I am then going to be a bit hungry mid afternoon, in this case you're saying it's actually good to snack. Another opportunity for nutrients because actually was I actually taking something really healthy and the danger is that if I'm not doing any snacking, I just might not be able to eat enough to get all the nutrients I need across these exactly that. So it's almost like the opposite of everything we've been told. Well, it's not the opposite of everything we've been told as long as your eating window is reasonable. So I'm not recommending people just graze all day, but just be aware that it's better to stop eating as soon as you start feeling full and then having a healthy snack like a couple of hours, three hours later , it then is trying to either push past your point of fullness and then feeling really rubbish or ignoring that window opportunity to get extra nutrition in this case, yeah. It's important. And is that because if you overeat the side effects or the nausea will be this is when the vomiting happens in the nausea and really uncomfortable reflux you're literally taking a drug that makes that physiology happen. It's like that's slowing down. So don't push it. And then dinner time, making sure again that you have an opportunity there during treatment if you don't think you've hit like enough protein in the day , this is a good opportunity to make sure you're getting good quality protein because most people are at home or they have some control over what they're having. And remember that with protein, the window is like a whole day. So if you feel like you didn't quite get enough protein at breakfast, don't panic. Your muscle's not going to start wasting away as long as you eat enough protein in the day. And Federica, what types of food should you be eating to make sure you're getting enough protein? When I say that to my son, he's like, Well, I need to eat to stake. Protein equals steak. Yeah. Or maybe chicken breast. Is that what you mean? That's one of them. I think the ones to focus on, if you think about a protein pyramid, like what are the ones we want to get the most of? So the majority of the combinations we're trying to do are the whole grains with the legumes. So protein is an opportunity to get other nutrients too , right? So if you're getting a lot of your protein from like a legume with a whole grain, you're also getting fiber, you're also getting micronutrients, you're also getting other benefits. So try and have opportunities to have those combinations frequently. Nuts and seeds, another great one . And then soybean products. I have to say they are amazing for high quality protein with amazing protein packaging. The fiber of the micronutrients is really good. Then you have fermented dairy, so cheese , yogurt, cottage cheese , really, really great ways to get good quality protein with micronutrients again and fermented, right? So you're getting something good for your gut . Then oily fish comes next. So oily fish has omega three fatty acids in it, really important for our overall health. Also very important for our gut health, liver health, and brain health. So just three times a week, oily fish and these can make other dishes really flavor and you don't need to eat a lot of it to get really good amount of protein and omega three fatty acids. And above that you have eggs and poultry . So eggs and poultry also play a role and can be eaten fairly regularly, I'd say like every other day or four times a week . And then above that you then go to like the red meats. And red meat, if you want to eat it , that's fine. It is micronutrient dense. You don't need large portions of it, but it's not necessary to have a good amount of protein in your diet. There's been this spiking concern about getting enough protein if you're on these GLP one s saying well you're not eating very much so, you've got to eat lots of meat. Otherwise you're just not going to be able to get enough protein and you are just going to lose all of your muscles and in the long term become like a jellyfish on the floor. Yeah, o,kay let's go back a minute. We said if you have too much saturated fat and take fatty foods worse than these gastric side effects. If you're eating red meat, that's really quite high in saturated fat unless you're having film Mignon every time, which most people don't . So red meat is absolutely not the only way to do it. And neither is chicken, to be honest or eggs. There's that whole pyramid of foods that's going to support your protein intake. And can I just be super clear again here that that protein intake is pretty pointless unless you're doing this resistance training. So think resistance training first and then making sure you get enough protein throughout the day. There's a lot of foods to choose from in that protein pyramid and they all contribute to getting enough protein. So if someone's increasing dose , sometimes they really struggle to get enough food . There is an opportunity there to use a protein supplement, a simple like pe protein isolate, nothing fancy . That can be helpful for the days that you inc'rereasing dose , if you're really concerned, but you don't see like this wasting away with protein deficiency. It's usually a lack of physical exercise that's driving the lean mass loss. And it sounds to me as though you are more concerned about sort of overall nutrient shortage than saying that your primary concern is not getting enough protein . Even here where you have said that this is one of the areas where Zoe's protein advice is higher than elsewhere. Yes. If you hyperfocus on just the protein, then you miss out on the rest of the dietary picture, which is super important for overall health and for long term success. So that's why I like to focus on the foods that provide multiple benefits, the protein and the omega three's, the protein and the fiber, the protein and the ferments, because you have an opportunity there to then take multiple boxes. So it's really about your food quality and the nutrient density it's true. Nutral density is a really nice way to think about it because for something to be nutritious you're taking several boxes. And basically because I'm not eating so much it's actually I'm really wanting to get sort of like it's a three for one offer is sort of what I want out of my out of what I'm eating. Yes, exactly. And lower volume. So really important here, Jonathan, we talked about the importance of volume for the stretching of your stomach and actually during treatment, you don't need any more help with that because of the slowing down. So you want to have you end up having smaller meals at a smaller volume but really nutrient dense so you can get the most out of it every single bite and that is very different to the advice for post GLP one. So for people who are now tapering off the drug, they've decided they don't want to continue taking it or they can't afford to continue taking it. They start tapering off or they want to just see if they can continue their lifestyle new lifest yle without them . That's where volume ramp's right up. So then what you're trying to do is you change your diet again and you start to really work with that internal signaling we've spoken about and ramp up the high fiber, high volume foods that are actually still nutrient dense but lower energy density that help you to feel fuller for longer with less energy in the food, less calories in the f ood. And that is what I've seen in my clinical practice is the way that with slow tapering off of the drugs and this increase, this ramping up of high volume high fiber foods, you actually see success in people maintaining their fat loss, maintaining their energy levels, and getting back to a new lifestyle and new diet that supports their health goals in the long term. And so basically they were eating one diet before they started taking these drugs , they've used these drugs to lose a lot of weight. They were living with obesity or overweight, lose a lot of weight. And then you're saying that while on these drugs they were able to learn to eat a completely different way . And then after coming off the drugs, you have seen that if they then are ramping up what they're eating, but if they're ramping up and eating something that is very different from the diet they had before . In some cases they've been able to maintain the fat loss. Yes, and continue with their healthier lifestyle. So one of my patients, he drastically reduced his alcohol intake during treatment and he was able to continue that reduced alcohol intake after treatment too . The thing that seems to really set apart those who then go back on the drug after a while for because their weight isn't stable is the lifestyle elements and the diet. So resistance training, non negotiable, but if you can also then start to incorporate more cardiovascular training, that seems to help with the fat loss maintenance after you come off the drugs. So taking up something like tennis or running or spinning or swimming, something that is just very cardiovascular in its nature. And then really focusing on this high fiber, high volume foods so that you actually feel satiated but without drastically increasing the amount of calories you're consuming. Because when you come off these drugs, especially if it hasn't been that long, so if you've maybe taken them for six months , your body is like, wow, we've just come out of a famine . Like, you know, the signaling is there to say we have got to replenish our fat stores because that was a really bad famine and there might be another one round the corner, right? So your hunger is going to go , especially if you come off without tapering . So if you taper, if you like come off quite stony, you start to get used to your hunger again and you start to work with it. But if you go from like your dose to zero, it's suddenly like flood gates, right? And it's a normal physiological response. And it's not to say that you won't put any weight back on , but if you are able to maintain the new body composition so that the fat loss you've seen , especially the visceral fats or the fat around your organs that's really pro inflammatory , that goes away. That tends to go down with these drugs. That's the stuff you want to keep off. Your weight might come back up a bit, it might fluctu ate . But if you can keep it fairly stable after coming off the drugs, it's an absolute game changer and it is, you know, it's amazing to see the patients who've had that success. I want to kind of just caveat that. It tends to be patients who didn't have lifelong obesity . I think there are genetic factors and structural brain factors at play for those who have familial sort of several generations of obesity, that might mean that this approach doesn't work, and they may need to consider taking their medications longer term. Yeah, I was going to say I think it's wonderful that you're seeing people who can come off. I think one of the things that I've definitely really realized through this is that obesity is a disease. We now understand the way that ultra processed food is one of the things that plays into what happens to your brain and makes you so hungry and that when that 's out of control, there's nothing you can do . And just in the same way that it's clear this is not just about willpower at all. But I don't think that anyone listening to this who has tried to taper down the drugs or come off and realize the hunger comes straight back should feel bad. You know, you wouldn't expect to suddenly stop taking your blood pressure medication magically . Even if you've improved your diet, like have it all fixed. So I wouldn't want anyone listening to feel that it was bad continue to use this if it is having all of these benefits. Is that fair federally fair? And it's also fair that what we're seeing in real world data is people take it for a while, come off for a while, take it again for a while, come off for a while. So as long as that is structured and supported, that might be the way people do benefit from these drugs. There isn't like one right way to do it and everybody's different. So it's about understanding what works for you as an individual and making sure you have that support network in place. The more they're used, the more they become part of medicine. Hopefully, the more the framework is communicated and people understand what needs to happen alongside them. I think the big risk we have is that they are used in isolation . That's not going to have the desired effect and that's not what we need to be doing to improve people's metabolic health, basically. Federica, I think the book is great. I think it's incredibly timely because we are seeing this enormous number of people using these drugs for the first time and it's a really exciting, right? That in a way it creates this opportunity for people to change their diet and have all the profound health benefits that many others have been able to access, but it's so hard if you're living with this level of hunger. So I think it's brilliant. I'm going to wrap up and try to do a lot of this. I mean, the thing I'm most struck by actually is you said, like two thirds of people who have taken these drugs have dropped off. So that's an enormous number of people who haven't actually managed to stick with this and make it work. And a lot of that is due to side effects. And the second thing I think I'm really struck by is this idea that if you don't change your diet , you could lose the weight but still have all of these long term risks. And you said, particularly like brain health and immune system , you know, you might have less weight but you're not magically getting the benefit of a healthy diet. I thought on the positive side , I heard you say there's been a lot of fear about, well, actually all that's happening is you're losing like your muscles, but actually you're saying like in the first three months, the very new data says it's largely fat loss, which is good . After that as you're continuing to lose weight, it's like a mix of fat, which you want to lose. And then what you called lean mass , which I now understand is muscles and bone and obviously you want to minimize that. However, there's like, I guess two big issues. One is side effects and often the side effects are most intense at the beginning. So a lot of people bounce straight off because the side effects are too bad. And as you increase dose , that's particularly like constipation and nausea . And if you can prepare yourself in terms of making some changes to your diet before you start taking the drugs, you can really reduce the risk of those side effects. You also by being slower to increase the levels of the drug give you more time to adjust to it. And then I think the final thing is you need to really think about what you're eating when you're on these drugs. You can feel like magically, oh, I'm losing all this weight. Everything is brilliant, but actually there's a real risk that you're not getting enough of the nutrients you need. And so we talked about a number of different things that you should do. One of them, maybe the most moderate is think about the nutrient density of your foods. And I think you loved all of these foods where they're combining fiber and protein and all sorts of micronutrients. This is like you're combining whole grains and beans, for example , and chickpeas and lentils, just all of this magic, but also like broccoli and berries, all these sorts of things which are incredibly dense there . That's because the protein does matter. You do need to get more protein, but it doesn't mean that you have to be eating sort of red meat all the time. You talked about all these other foods like beans and yogurt and oily fish and eggs and indeed chicken that can give you a lot of this protein. Red meat still has all of this saturated fat, which also the fat is triggering issues. But you can combine getting all of the benefit . And of course the other benefit is fiber. We understand how much the microbiome is playing a role in all of this hunger and appetite control and so you get this right you're in a much better place . The other thing to be aware of as well as like eating all of this more fiber is hydration. If you're a little bit constipated going in and you start these drugs, it's going to get much worse. It's another reason you're going to give up . And then finally, what you said is well, you know, we talk about all this protein , but if you're not doing resistance training, then the protein's going in one end and out, the other is not doing any benefit . So actually you're going to be feeling better hopefully as you're starting to lose this fat, you need to add resistance training. If you can be doing that on top, then actually you're going to sort of keep up that musc le as you lose it and hopefully end up in a place where you feel wonderfully better. Exactly and where your metabolic health is actually set up for long term success. Professor Sarah Berry here. We've all experienced that familiar three PM slum, that moment where your energy dips, and you find yourself aimlessly rummaging through the kitchen for a quick fix. Biologically, that typically happens because high