Ozempic Pills, Triple Agonists, 50% Weight Loss & Groundbreaking Peptides with Dr Spencer Nadolsky

Here’s a run down of what we discussed in today’s episode: GLP-1s, Peptides & Weight Loss Drugs Explained The Future of GLP-1s Beyond Weight Loss Could GLP-1s Treat Dementia & Other Diseases? The Next Generation of Weight Loss Peptides Retatrutide & Oral GLP-1s: What's Coming Next? The Biggest Risks of GLP-1 Medications Emotional Blunting: An Emerging GLP-1 Concern? Will GLP-1s Make Weight Stigma Worse? Can You Practice Intuitive Eating on a GLP-1? Using GLP-1s Without Losing Food Freedom Check in with today’s amazing guest: Dr. Spencer Nadolsky www.drspencer.com www.instagram.com/drnadolsky www.youtube.com/@drnadolsky https://joinvineyard.com/ Disclaimer: The content in this episode is for educational and entertainment purposes only and is never a substitute for medical advice. If you’re struggling with with your mental or physical health, please work one on one with a health care provider. If you have heard yourself in our discussion today, and are looking for support, contact the free NEDIC helpline at 1-866-NEDIC-20 or go to eatingdisorderhope.com. Learn more about your ad choices. Visit megaphone.fm/adchoices

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:00Speaker 00

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• 0:29Speaker 01

  There are GLP-1 receptors all over the body, and they're only now starting to tease it out. There certainly seems to be an effect in multiple places of the immune system, though.

• 0:41Abbey Sharp?

  Welcome to another episode of Bite Back with Abbey Sharp, where I dismantle diet culture rules, call it the charlatan spinning the pseudoscience, and help you achieve food freedom for good. Whether you're scrolling social media or commuting to work on public transport, it's become an inescapable reality that thinness is back at the center of our culture. Celebrities are disappearing, GLP-1 medications have gone mainstream, and the big business of selling weight loss is booming. I've spent plenty of time discussing the harms of the resurgence of the ultra-thin beauty ideal, but GLP-1s themselves deserve

• 1:25Abbey Sharp?

  a much more nuanced discussion. These medications are neither miracle drugs for all, nor should they be treated as villains. They are powerful medical tools, and the real conversation lies somewhere in the middle. So today, I'm speaking to Dr. Spencer Nadolsky, a board-certified physician specializing in obesity medicine and the founder of Vineyard, a virtual care clinic designed to support folks on GLP-1s with interdisciplinary, evidence-based care. We will be diving into the future of GLP-1s, risks that we are not talking enough about, emerging benefits, and upcoming peptides. At the end of the

• 2:10Abbey Sharp?

  The episode, I will share my perspective on how this GLP-1 future may impact intuitive eating. Now, before we get into it, I would love for you to take a quick moment to subscribe to Bite Back if you love deep dives into relevant nutrition questions. And also, don't forget to check out my YouTube channel and social platforms at Abby's Kitchen if you're looking for shorter form responses and takedowns of diet and wellness culture myths. All right, friends, let's dive in. Well, Spencer, thank you so much for joining me. I'm just, I'm so excited to learn from you today. This is just such an incredibly important conversation. So thank you so much for joining.

• 2:46Speaker 01

  Thanks for having me on, as always.

• 2:48Abbey Sharp?

  Before we get too into it, I wanted to hopefully clear up some terminology because I think, you know, people often use, you know, GLP-1 peptides, the glutide, and then of course, like the brand names like Ozempic interchangeably, but they're not necessarily the same thing. Can you kind of explain some of these than the differences in simple terms?

• 3:09Speaker 01

  Yeah, just real quick. Peptides, like an umbrella term, amino acids linked together, we learn about this, I mean, through dietetics or whatever, medical school, it doesn't matter, even basic, like, organic chemistry. But the term has been used now to basically talk about any of these peptide, almost medicines, basically, that have some sort of biological activity in our body. And one of those peptides, and the reason I think they've all become quite popular are the GLP-1 receptor agonists. Just real quick, GLP-1 stands for glucagon-like peptide I. It's a natural hormone that comes from our intestines. It's released after we eat usually

• 3:53Speaker 01

  carbohydrate-containing foods, helps our pancreas make more insulin. I can go into how that was kind of discovered, but for the terminology, then.

• 4:05Speaker 01

  Basically, scientists recreated our own natural GLP-1 and made them receptor agonists that don't get broken down by our own body. And then throughout the years, they've been out for about 20 years now, and throughout the years, they've modified it, modified it to where now they're hitting different receptors, not even GLP-1 at the same time. And then there's the ones that people know are semaglutide. You said semaglutide is like tomato, tomato. There's a lot of debate, whatever. It doesn't matter. That's, that was like in 20, it also was approved in 2016, 17 as Ozempic. They made a higher dose version called that Wegovy. That one's used for weight management. Ozempic's used for type 2 diabetes. And then there's

• 4:49Speaker 01

  terzepatide, which everybody has heard of, Zepbound for weight management, Monjaro for type 2 diabetes. That one's technically a GLP-1 slash GIP co-receptor agonist. And then everybody's talking about ritatratide, or as other people say, retitratide, tomato, tomato. It's a triple agonist. It actually hits GIP, GLP-1, and glucagon. So there's, these are small component of the various peptides that people are talking about, but these are the most popular and I believe the most efficacious, the ones that have actually have good studies around them. But that's like the brief breakdown of the terminology.

• 5:31Abbey Sharp?

  Okay. That's super helpful for folks that are just trying to catch themselves up because it's, it's all moving so quickly. So hopefully we can kind of clear things up in this, in this episode. But I want to kind of dive right into that, that peptide science for a moment because I just feel like we're really on the precipice of just some super interesting and amazing discoveries. And I'm very exciting about, excited about that. But you know, obviously, weight loss is what has made GLP-1s like Ozempic and Moncero and these medications famous, but it's also quite possible that weight loss might not even be the biggest contribution of medicine for some of these medications as we go down

• 6:12Abbey Sharp?

  the line and have more data. But you know, we're now seeing reports and emerging research on just a wide range of potential benefits or applications that have nothing to do with the number on the scales. So I'm curious, from your perspective, at this moment in time, which emerging applications or uses for these drugs do you feel has the strongest evidence?

• 6:36Speaker 01

  So beyond weight loss, I would start thinking about cardiovascular disease prevention, whether it's primary prevention, preventing that first heart attack versus secondary prevention. The primary prevention has yet to be kind of, they're studying it right now, but the secondary prevention, it looks like, hey, these things do prevent more heart disease events, whether it's strokes, heart attacks, peripheral artery disease, angina, and that sort of thing. So I'm really interested in the heart disease prevention. Beyond that, you know, just based off of what my patients are saying and what, you know, some of these newer studies, the addiction is really interesting. Just, you know, a few years ago, one of my

• 7:20Speaker 01

  TikToks, so stupid, one of my TikToks went viral because I was like, hey, you know, these drugs have been out for a while, and we've been using them for a while, but these ones are getting stronger and stronger and going from like, say, semaglutide, which seemed to help people drink less, drink less alcohol, but then going to terzepatide, there was even, it seemed like there was a more pronounced effect, just anecdotally. And all of a sudden, my patients were like, you know what, I've noticed is that like, I usually drink a few glasses of wine a night, if not a bottle, and, you know, obviously, that's not good for weight loss, but they, it was just the way they described it was just like, and I just, it had no effect. I like, didn't want it anymore. It was really

• 8:04Speaker 01

  weird where they'd usually go and even if it's a habit, like not even, they didn't think about it, they just stopped doing it. So I think the addiction thing, obviously anti-inflammatory. There are some interesting things like my patients with psoriasis and psoriatic arthritis, rheumatoid arthritis, but I'm most interested in the cardiovascular disease prevention. But some of these other things that you wouldn't even really think about related to weight are very fascinating.

• 8:29Abbey Sharp?

  So when it comes to the heart disease and also a lot of these other potential kind of applications, if we take the weight loss piece out of it, because obviously if in an individual who is higher body weight is going to be at more risk, a higher risk of heart disease, but are these things happening independent of the effect of the weight loss?

• 8:54Speaker 01

  Yeah, that's what it appears to be. There was an older drug called alba glutide many years ago, you know, not like early 2000s, it was the 2010s where they, it was for type 2 diabetes, but that didn't really help people lose much weight. So yes, it helps with blood sugar, but it also that without weight loss, that was helping people prevent heart attacks. So it was like, okay, there's, there's some evidence that, hey, maybe beyond the weight loss, but it still had a blood sugar lowering effect. So maybe, maybe it's related to blood sugar. But the most recent one was semaglutide. They did this trial called the SELECT trial, a huge trial, or average like three, four, or five

• 9:36Speaker 01

  years, somewhere in there, thousands of people. And they found that like, people didn't even lose that much weight compared to their usual study of somewhere around average of 10% total body weight loss. But then they started breaking it down and it's hard to tease out and do all these analyses where they go, okay, did people start preventing heart attacks even before they lost weight, all these different things? They, through their statistical analyses, they looks, appears that they're somewhere around like two thirds of the effect. Is related to reducing heart attacks without the weight loss.

• 10:09Abbey Sharp?

  Right.

• 10:09Speaker 01

  So like, honestly, it's hard to really tease it out. But there seems to be a substantial component of these medicines that help reduce major adverse cardiovascular events beyond the weight loss. It's super fascinating.

• 10:25Abbey Sharp?

  Yeah, and I'm not sure if we have, you know, strong data to be able to understand what is going on outside of the weight loss and the blood sugar management piece, which of course we know to impact all of these other potential conditions. Like now I'm seeing some early, you know, chatter about it being a solution for endometriosis or, you know, neurodegenerative disease like dementia, Alzheimer's. Is this an inflammatory kind of, is it hitting on an inflammation piece? And if so, like, what is, what do all these things have in common that GLP-1 may be able to act on?

• 11:05Speaker 01

  Yeah, there's certainly an immune system modulatory effect. And if you follow like the bench researchers, like I'm not a bench researcher, I'm a clinician, but I see patients and I try to stay up on that. But I'm good friends with some of the people, you know, one of the guys that even discovered GLP-1. So I'm always talking with him and looking at what he says. And it's funny because they're pretty humble in saying, we don't really, they don't know exactly.

• 11:29Abbey Sharp?

  True scientists.

• 11:30Speaker 01

  Yeah, it's good because like I could sit here and say, oh, it's, but there are multiple places in the immune system, they seem to have an effect. And whether it's the cell surfaces versus systemic, probably all of them. There are GLP-1 receptors all over the body and they're only now starting to tease it out. There certainly seems to be an effect in multiple places of the immune system though. And the immune system really like, that's what controls our inflammation. People just say inflammation, it's like, what does that mean? Well, like, I don't know if I could take a hammer and hit my finger. Acutely, we want that inflammatory response that helps heal it. But when we have too much adipose tissue and whatever else is going on in our environment, we chronically are causing our immune system to cause inflammation, which.

• 12:15Speaker 01

  We need it acutely, meaning at that one time, and then it should calm down. But if it's always activated, that's where the issues come. So the GLP-1 receptors all over the body maybe modulates it to where it kind of dampens things down in certain parts. I know for the cardiovascular disease, they still don't know exactly likely related to the immune system. But then there could be things about like the lining of our arteries, the endothelial tissue. Could be something there. It also helps with our lipid metabolism, you know, the stuff, the proteins that carry our cholesterol. And then obviously, there's a blood pressure effect. There's all sorts of things going on.

• 12:51Abbey Sharp?

  Yeah.

• 12:52Speaker 01

  But I think the common denominator is that like, it doesn't seem to be, I mean, like, PCOS, I'm sure you've talked about that, which is now PMOS.

• 13:01Abbey Sharp?

  Yep.

• 13:01Speaker 01

  But I have patients that haven't had periods in years that are normal. And they get on the terzepotide. It's terzepotide more so than semaglutide, again, anecdotally.

• 13:14Abbey Sharp?

  Okay.

• 13:14Speaker 01

  And all of a sudden, they start having normal periods without weight loss. And now people are like, well, they reduced very quickly their calorie intake, maybe, but they don't really lose much weight and their periods normalize. I think there's something going on all over the body. I don't know.

• 13:32Abbey Sharp?

  Wow. I mean.

• 14:08Abbey Sharp?

  This is so exciting. It's so exciting to just be right, right at the edge of this and to see it grow. And, you know, speaking of evolving medicine, I want to go back to something you mentioned at the top, which is this kind of peptide umbrella that, you know, as we mentioned earlier, you know, GLP-1 is just one example of a peptide hormone, but there are thousands of naturally occurring peptides in the body and arguably an infinite number and all possible peptides that could theoretically exist. Like, who knows? And, you know, so we currently, I believe, have over 100 approved peptide drugs worldwide, and that includes, you know, some of Glutide, but there's hundreds more peptide therapeutics

• 14:48Abbey Sharp?

  in clinical development. Are there any upcoming peptides, you know, in the weight loss or metabolic health space that you think we should be on the lookout for that you're particularly excited about?

• 15:00Speaker 01

  Yeah, so I mentioned how there's GLP-1 and then there's GIP, GIP, glucose-dependent, insulinotropic polypeptide. It's a mouthful. That's why we just say GIP because I'll screw it up if I try to say it too quickly. But so the backbone of terzepatide is more, it's more of a GIP type of molecule that just also hits GLP-1 receptors and retatruteide or retatruteide is also the same, but also hits glucagon. So what people are trying to think is that there's something about the GIP, but without the GLP-1, the GIP doesn't seem to be as effective. So I think what they're going to find is that there are certain

• 15:41Speaker 01

  combinations that are synergistic with each other, and there's not any one peptide necessarily that I'm like, oh, gosh, that one's going to be great. They're now combining multiples in one molecule instead of this unimolecular, it's multiple receptors that it's hitting. So I'm really interested in these, you know, triple, even quadruple or quintuple receptors. Now, having said that, they have to then do the studies all over again because it's also possible, on the other hand, that hitting multiple things could hurt people.

• 16:18Abbey Sharp?

  Right.

• 16:19Speaker 01

  That we didn't know. That's why they have to do the studies. I mean, the peptides that people are pushing right now. And I'm not like anti-peptide, I'm just like pro like, hey, I'm just cautious.

• 16:30Abbey Sharp?

  Yep.

• 16:31Speaker 01

  So I'm like, hey, can we, instead of making this claim, can we actually like, do the studies? I know people are saying they feel great on this, but like, you know, it's possible that we're not seeing all the bad stories that are occurring, or there could be something harmful, you know, in a few years from taking this chronically that we're just not seeing. So that's kind of the spiel.

• 16:50Abbey Sharp?

  And you mentioned, and you mentioned retitutide, can you say it again?

• 16:56Speaker 01

  You can just say, you can call it reta.

• 16:57Abbey Sharp?

  Ready, reta, reta, retitutide, I'm not even gonna bother.

• 17:01Speaker 01

  You can say retatritide, retitutide, whatever.

• 17:04Abbey Sharp?

  Retatritide, retatritide. It is a mouthful. What, what's your take? I mean, I believe that one's still in phase three trials, is that correct?

• 17:12Speaker 01

  Yes, they just reported the phase, there are a few of, they're studying for type 2 diabetes and, and weight management. They just reported the big Triumph study. There's multiple Triumph studies, but the Triumph one at the, at the American Diabetes Association, they presented it just like a month or so ago. Just, we're getting very close to bariatric surgery level weight loss, just for everybody listening. So like, for intensive lifestyle, we see somewhere like 5% to 7% total body weight loss. And then you get, you get bariatric surgery, which is like 30% or so. But kind of that in-between is what we didn't have. And that's when semaglutide goes, oh, we get 15%, and then you get terzepatide, which is like 22%. Now with reta,

• 17:57Speaker 01

  it's very close to 30%. The average was 28% or so. But there are a lot of people that hit much higher than that. And so, you know, you start adding in some of these other receptor agonists that they're talking about. And now, I mean, I don't know, average of 40, 50%. As you mentioned earlier, though, it goes beyond the weight. There's people, there's effects of these peptides or drugs that go beyond the weight that people are even more excited about because at some point it's like, okay, we're just going to be like turning everybody into a skeleton or something, you know, we gotta actually make sure people

• 18:38Speaker 01

  are living longer and better, not just turning them into a skeleton. So, but Reta is extremely exciting because it also has an LDL cholesterol lowering component. People think that you just lose weight, you're going to lower LDL. It does a little bit, but something about Reta, in terms of that, there's a glucagon component, it goes GLP-1, GIP and glucagon. There might be something about the glucagon that helps you recycle more of your LDL cholesterol particles so that all of a sudden it looks like a cholesterol lowering drug too, on top of the amazing weight loss and anti-inflammatory effects. So, pretty cool. Again,

• 19:15Abbey Sharp?

  Very.

• 19:16Speaker 01

  The studies look amazing, but now they have to show that like, hey, we gotta make sure this isn't harming somebody's heart. It looks good on paper, but that's why you have to do it because there have been drugs in the past where it looks good on paper and then all of a sudden, oh gosh, we actually, we're causing more heart attacks. So, it doesn't seem to be a signal for that, but like, that's why they had to do the studies.

• 19:35Abbey Sharp?

  Right. And I mean, I think we, we still have a long way to understand, you know, every single nuance of best practice for, for all of these, these medications. But when you say 40 to 50% weight loss, you know, my thought automatically goes, okay, well, what happens if that person decides they go off of it and they're rapidly going to be gaining back 50% of their body weight? What are the potential implications of that?

• 20:04Speaker 01

  Yeah. So, this is what I always say. So, not, so it's meant to be a long-term medicine. However, side effects, preferences, costs, costs are the big one right now. People are like, I can't afford this anymore. It's like, oh my God. Well, shoot, like, I don't know what to do. We, you know, they, a lot of them go and get gray market stuff. They can go and order this stuff from China and then reconstitute. I call it bathtub tirzepatide or bathtub Reta. And, you know, people laugh, but it's like people are, you know, desperate. They want to stay on this stuff. So, I'm not an idiot in saying, nobody should come off of this. But inevitably, some people will. Most people regain weight. Some people regain some of

• 20:46Speaker 01

  the weight. Some people regain like half their weight. Some people seventy five, some people all of it. And then some people gain even more than what they had lost. So it's kind of a spectrum. And in these cases, we just try to, we try to find other non GLP one medicines, maybe.

• 21:03Abbey Sharp?

  Yeah.

• 21:03Speaker 01

  Amolin is another one that people are really excited about. It's another hormone that comes from the pancreas that also has effects on satiety and they're creating very long acting agonists of of amolin and then it seems to be combining that with some of these other receptor agonists. It seems to be at least additive, if not maybe even synergistic in some cases. So I, I think that in, I mean, we're just, we're just at the beginning. I think we're ten to twenty years from now. I don't even know. I don't even know. There might be a, a ten, a ten receptor.

• 21:40Abbey Sharp?

  Yeah.

• 21:41Speaker 01

  A deca. I don't know what they, what they call it. A deca, deca.

• 21:45Abbey Sharp?

  Well, I mean, people are already stacking peptides on their own, right? Like you think about not necessarily, you know, those that are, you know, Ozempic and but folks are just kind of on the black market, buying their own kind of peptides.

• 22:01Speaker 01

  Yeah.

• 22:01Abbey Sharp?

  And figuring out the ones that they want to combine together, which, I mean, I don't know how you feel about this, but I of course worry because we, again, like you mentioned, like, we don't have studies on how these things necessarily interact, the synergistic effects. Plus, of course, when you're buying things underground, you really don't know what you're getting. So all those things are definitely concerned.

• 22:23Speaker 01

  Yeah. And you know what they'll say is they'll be like, hey, Abby, you're, you're just, you're just in the pocket of Big Pharma or something. You don't want people.

• 22:29Abbey Sharp?

  Of course.

• 22:30Speaker 01

  Or, or whatever. And they'll say that, they'll say the same. And I mean, you know, like, God, you know, you have a large following. I have a pretty decent following. It's like, you know, I could make a lot of money if I just said, buy my peptide, I vetted this peptide, I put my label on it, and I could do it. I could make a lot of money. It's like, no, I'm actually losing money by not telling you to take these peptides.

• 22:52Abbey Sharp?

  Correct.

• 22:52Speaker 01

  So it's not the money.

• 22:53Abbey Sharp?

  I know.

• 22:54Speaker 01

  We're trying to be ethical here.

• 22:55Abbey Sharp?

  I know. And so, speaking, you know, we've talked about a lot of injectables, but we're now seeing things like the Ozempic pill or oral semaglutide. How do you think that these oral GLP ones or peptides are going to potentially like change the weight management landscape even further?

• 23:16Speaker 01

  Yeah, so the way that they manufacture this, there's a special outer coating in this pill. And it helps, the reason you can't take, can't just inject it into our mouth and be like, why don't we just drink it? And you see these like semaglutide drops or terzepatide drops.

• 23:35Speaker 01

  I mean, you're the dietitian, but our stomach acid degrades the peptides. And so we don't absorb any. So that's why you have to inject it. So they made this special packaging with Novo Nordisk has the patent for this. So it's just semaglutide, you don't see it with terzepatide. And it buffers the acid. You can't take it with much water, can't take it with food. So the oral Ozempic or oral Wegovy, just a tiny little sip of water, 30 minutes, 30 to 60 minutes before eating or drinking anything else in the morning. So it has about the same effect as what you would see with the injection, the lower dose injection. They just made a higher dose Wegovy injection.

• 24:16Speaker 01

  But so it's decent, but they own the patent. So I don't know who else is going to have, or maybe someone else is trying to figure out how to orally create this. Now Eli Lilly just came out with their oral drug. It's called orforglipron or Fondeo is the trade name. Now that's a small molecule. It's not even a peptide. So they created a molecule that is small and not a peptide that can actually be absorbed. It can be taken with food, water. The issue is it's not as effective as the oral Wegovy or the semaglutide, even though it's better absorbed. There are some things, I mean,

• 24:59Speaker 01

  it's possible that becomes more popular. So we'll see what type of technologies they come. They're talking about like patches and somehow

• 25:08Abbey Sharp?

  Yep.

• 25:08Speaker 01

  Getting getting these peptides into our interstitial fluid right under skin, kind of like a continuous glucose monitor.

• 25:16Abbey Sharp?

  Yep.

• 25:17Speaker 01

  I'm sure there's going to be all sorts of technologies that are like, how do we get this into people's system without having to inject weekly?

• 25:24Abbey Sharp?

  Yep.

• 25:24Speaker 01

  So that's the future.

• 25:26Abbey Sharp?

  Right. Oh, my gosh. And I mean, obviously, at this point in this conversation, we've we've really focused on all the, you know, exciting and almost miraculous things that this, you know, new class of weight loss medications may be able to do. But I feel like it would be irresponsible if we weren't talking about some of the risks or some things that we may see down the road. And I think, you know, obviously, the unpleasant GI side effects, especially at the start can be, we've talked about that a lot. A lot of folks have, you know, discussed that. There's also, of course, the, you know, discourse around potential nutrition deficiencies, muscle or bone loss, things like that. Are there less common but even more serious risks

• 26:08Abbey Sharp?

  or emerging potential risks that people should maybe be thinking about?

• 26:13Speaker 01

  Yeah, the one thing that people are talking about is the blindness, the N A I O N. And, you know, I've had my buddy who's an ophthalmologist or retinal specialist, and we've gone over it. He sees it in his clinic. And some of the studies are mixed. Some show it looks like a less of a risk. Some show a little bit more of a risk compared to some of the other type two diabetes drugs. If there's one that I would be like, okay, just let's make sure we minimize the potential for this. Gallstones are a very well-known risk, but that's likely due to the weight loss that you see, the rapid weight loss that you've seen. So obviously, I'm trying to make sure people don't lose weight too rapidly.

• 26:55Speaker 01

  That would help with the muscle as well, the muscle concerns. Those are like the big thing. There are some other weird side effects that I see that people don't talk about enough. And I've just on, I don't know, when I was on ABC and Washington Post talking about, people get a flatness.

• 27:12Abbey Sharp?

  Yes, I was going to ask you about that.

• 27:14Speaker 01

  Yeah, we call it anhedonia, like a loss of pleasure for things that you found pleasurable before. You don't have depression. Anhedonia is a part of depression. But you don't have any other depressive like symptoms. You just like don't find pleasure in the things you like to do. And it's usually hobbies. And I usually see this at higher doses, but you see on, I'll see on Reddit and a few other places that like they'll get it at sometimes at lower doses. You know, the studies show it looks like most people improve their anxiety, improve their depression and most of their mental health improves. But once in a while, people have this effect where again, it's good to dampen things down if you have this overdrive of super pleasurable things like

• 27:58Abbey Sharp?

  Yep.

• 27:58Speaker 01

  Alcohol.

• 27:59Abbey Sharp?

  Yep.

• 27:59Speaker 01

  Obviously food and, and, and that can be beneficial, but to a point to where my favorite example is the first one that I really started noticing this a couple of years ago where they, I had a visit with, with them and they were talking about, yeah, things are going okay. I'm like, okay, tell me more. And like, well, I don't know. I, I haven't been exercising. I really'd like to lose more weight and it looked like they gained a little bit of weight. And I was like, well, what's going on? Like, I don't know. I don't feel like exercising anymore. And I was like, well, that's kind of weird. They're like, yeah, I love exercise. I just don't feel like doing it anymore. And they're, and I was like, when did this happen? And it started like, whatever, six months ago. And I'm like, well, six months ago, I'm looking back at the chart and like, what'd we do? Well, we went up in your dose. That's kind of weird.

• 28:43Abbey Sharp?

  Yeah.

• 28:44Speaker 01

  And, and so, but, and then I saw a few more patients that month and I started asking like, how's your mood? And they, they don't, they kind of beat around the bush because they, they just think it's maybe a seasonal depression thing or something else going on. And then when you start talking to them, it's, it was always at the higher doses. Like, so for example, terzepatide goes up to 15 milligrams and it was, I kept seeing it around 15 milligrams. And then I kept, I started reducing their doses and all of a sudden they felt better. In fact, the one, that first patient, I reduced their dose down to 10 milligrams. I'm like, let's just see if this is the medicine. All of a sudden, they started exercising again, then they lost 20 pounds more and they felt amazing. And it was like, okay, something weird's going on. And then it just dozens of patients, we just submitted an article about a case series of this. So anhedonia

• 29:29Speaker 01

  is one. Again, I don't, it's not, you know, actually in the news and in the newspaper, Novo and Eli Lilly were both like, no, this, there's no data to support this. I'm like, yeah, because you didn't actually look for it.

• 29:44Abbey Sharp?

  Yeah.

• 29:45Speaker 01

  Like, if you don't look for it, it's not gonna be there.

• 29:47Abbey Sharp?

  No, of course not.

• 29:48Speaker 01

  And so I thought that was kind of funny. They're gonna have to study it because there's like, I'll bet the farm that it wasn't just anecdotal because you'll see it everywhere on Reddit.

• 29:57Abbey Sharp?

  That's a big one.

• 29:59Speaker 01

  Yeah. So another weird thing is you kind of see UTI-like symptoms. Weird. And they don't have UTIs. Again, you should always rule out a UTI, most common thing. And you're always like, okay, are they, you know, going through menopause and you do vaginal estrogen or something like that? No, it's not that. Okay. Are they constipated to where everything's backing up? So it feels like they gotta go pee? No, it's not that. And then it's like, you take them off the medicine, goes away, put them back on, comes back. Weird thing. I've used anti-spasmodic type of medicines, something called highest sciumine, and it worked. And then I started talking about it. A urologist was like, yeah, we're studying this because we noticed this too. Weird. I don't know what's going on, but it just

• 30:40Speaker 01

  kind of goes back to GLP-1 receptors all over the body and however organs are interacting. I don't know.

• 30:46Abbey Sharp?

  Yeah, yeah. No. And I mean, as you're, you're talking about this, this kind of like, you know, you're tweaking things a little bit up, a little bit down. I'm, I'm just reminded, and I hope that our listeners are reminded, why it's so important to work with a physician if you are, you know, entertaining the idea of, of taking one of these peptides because it is so much trial and error. And unfortunately, and I'm sure you know this too, like, a lot of folks are just kind of going online, putting, filling out a form, getting the pep, getting their, you know, Ozempic delivered to their door with no kind of constant monitoring of these symptoms because, you know, that, what you You just described with your with your patient who was, you know, not interested in

• 31:30Abbey Sharp?

  exercise anymore. That could be the difference between them, you know, being able to continue to keep muscle on despite the weight loss and them losing that metabolic muscle.

• 31:42Speaker 01

  Yeah, it's like, well, we don't like the whole point of doing this is to get healthier, not to just, you know,

• 31:48Abbey Sharp?

  Be skinny.

• 31:48Speaker 01

  Stop eating.

• 31:49Abbey Sharp?

  Yeah.

• 31:49Speaker 01

  I would say, and you know, shout out to the dietitians. I have I have a team of really good dietitians and every one of my patients gets their own and they'll find things because they'll, you know, they'll have meetings with them sometimes weekly, every other week and they'll send me a message like, hey, they said this and it may not be necessarily a nutrition thing, but but they'll screen for like eating disorders because it's like, we have to be very careful. It's like, okay, this person's clearly wanting to starve themselves. We can be like, hey, you gotta have this conversation. And it's like, you know, we monitor the weight loss and weight loss is one thing and usually can tell you if they're starving themselves, but like there are certain ways that people speak about food and that they'll pick it up

• 32:33Speaker 01

  and be like, hey, you really got to be careful about that. So I got to shout out to my dietitians for helping out there. I wish everybody had their own dietitian to go through this.

• 32:42Abbey Sharp?

  Yeah, I mean, absolutely.

• 32:49Abbey Sharp?

  And and that's a really important point because, you know, obviously not everyone on a on a medication like this is misusing it, but they are being misused and they and very easily can be misused because access is so widespread now and people can just pick them up in a medisbar, order them online. They can lie about their BMI, they can lie about their intentions. Are there any kind of like red flags that that you pick up on that in just how people are describing their intentions, their goals, their relationship with food that makes you think, okay, this might not be a good fit?

• 33:25Speaker 01

  Yeah, so we try to be very careful about like not just doing it for small amounts of clinically meaningless vanity weight like and people are like, well, you know, someone with obesity will go, but I wanted to lose weight for vanity purposes. I think I don't really care as much about my health and that it's like, it's fine. It still has an indication with you. I'm not saying you. It's it's someone who's already pretty thin that like wants to get thinner. So like we're People, so we have a form because we're all in telemedicine. We're in all 50 states in the United States. And we have a form, but we also want doctor's records. And we start looking at their license and we look at records and we, it's, and there, we,

• 34:08Speaker 01

  some places will make you jump on a scale in a video. The problem is that can be quite intrusive for many. So we're trying to balance the, and the shame and stigma with also giving proper guidance. Cause you wouldn't go to the doctor's office and say, I don't want to step on the scale. Those people do that.

• 34:27Abbey Sharp?

  Yep.

• 34:28Speaker 01

  But like, you can see them visually.

• 34:30Abbey Sharp?

  Correct.

• 34:31Speaker 01

  And you can make a little bit better. So, you know, we see them and we can see selfies. We can see a video, but there's a, there's, there's certain things. We kind of combine it all together and like, hmm, this is a flag. But some people, you know, they'll, they'll come in with like a 20, whatever, 23 BMI. Like I, or, or they'll be at a higher weight even at first and they'll get down to like, we try not to go below a 21 BMI. Again, if we're assessing DEXA scan and looking at bone density, it's really strong and they're getting stronger, there's, there's some wiggle room there. But when somebody gets down to like, sometimes they'll come in, already been on a medicine. They switch to us and they have like a, let's say a 19 BMI. They're, they're thin. And like, I want to get down to an 18.

• 35:15Speaker 01

  I'm like, why, why wait? Now we're going to have a discussion, like what's going on here?

• 35:19Abbey Sharp?

  Yes.

• 35:20Speaker 01

  So the thing, things like talking about how they're just not satisfied with their body and, and things like that. And I can understand at certain points, but we really start picking up clues that there's clearly some body dysmorphia going on and we have to have this discussion and it's going to be very touchy, especially if you're, we text back and forth a lot because we're not doing video all, all day with everybody. We do videos and have video appointments when, you know, regularly scheduled or when needed, but sometimes in between appointments we text. And if you text, sometimes the. The bedside manner doesn't come through in text, or you have to be really careful. Like, hey, let's have a discussion of this and talk about why we shouldn't go up in your

• 36:03Speaker 01

  dose, or maybe whatever, to get down to an 18 BM.

• 36:08Abbey Sharp?

  Right.

• 36:09Speaker 01

  We don't want to like harm you.

• 36:10Abbey Sharp?

  Of course.

• 36:11Speaker 01

  So self taught, like you kind of see the way they talk about themselves, like, I don't think you're going to be happier if you're at a lower weight, that type of thing.

• 36:20Abbey Sharp?

  Yeah, that's really, really helpful. And you know, the last thing I kind of want to touch on, which I think absolutely, you know, would fall under the umbrella of potential risks, is the societal impact. You know, you've been quite vocal about combating weight bias and fat phobia in medicine, and I really appreciate that. And so, you know, one of the concerns that I have, even though I'm a vocal supporter of these medications, is that, you know, as these drugs become so normalized and widespread access, that we may end up creating essentially like a new kind of stigma, where folks in larger bodies who either can't, or don't want to, or should not take these medications for various reasons, are judged even more harshly.

• 37:05Speaker 01

  Yes, you're absolutely correct.

• 37:07Abbey Sharp?

  Yeah. And so, so what responsibility do you feel, you know, physicians, media, even people like me who communicate and talk about these medications, have to ensure that we're not reinforcing the idea that every larger bodied person has a kind of quote, quote, "personal responsibility" to pursue weight loss?

• 37:28Speaker 01

  Yeah, it's hard to combat it, but like, because here's, here's what I was seeing. Here's, here's how it's kind of gone. Like, hey, obesity is biological and of course environmental. Not going to forget the environmental, probably the most important part, but the biology and the environment interact together. People like, no, you just got to eat less, move more. It's just, you know, it's your responsibility. You got to do it. Okay, then all of a sudden, these drugs come out and finally like, okay, maybe it is biological. Well, now there's no excuse to be fat. That's what they're literally saying.

• 38:00Abbey Sharp?

  Yep.

• 38:00Speaker 01

  And like, hold on a second. Like we talked about before, not everybody wants to take these medicines. Not everybody's going to respond to these medicines. Some people are going to have side effects. And even the most powerful medicine, if somebody's 400 pounds, let's say, and they lose 50 percent. Let's say they're one of the responders, but they're five foot two and they get down to 200 pounds. They're still technically have obesity. So like, so I, when these first started coming out and I started seeing the shift and people going, okay, I guess it is biological, but now there's no excuse. It's like, well, you know, there's excuse of cost right now and everybody can afford that. But I agree with you that now it's going to be a new stigma where it's like, well, of course we have these drugs and anybody can just be skinny.

• 38:45Speaker 01

  It's like, that's not true. So now we're going to have to combat that. And I don't, I don't really know how to handle that other than just doing this and continually talking about it until the next wave. And I'm sure there'll be something else because inherently people have bias and I'm not, you know, I'm not some sort of saint. I, I've had it younger especially and I, every time some of these biases start popping into my mind, I have to go, okay, I noticed it. Now I gotta, now I gotta think back and start fighting it myself. And so it's not like everybody's perfectly, it's ingrained in our society, our cartoons.

• 39:31Speaker 01

  We watch The Simpsons and my kids, and I'm just like, oh my God, I have to teach them, no, please don't say that. And I'm like, oh God, you know?

• 39:39Abbey Sharp?

  Yep. Yeah. It's, it is, it is. It's, it's, it's in media. It's in children's media. I mean, we, we've literally just been birthed into this world and of, of, that is inherently unkind to folks in larger bodies. And, and it does take constant work as healthcare providers to kind of interrogate those thoughts on a regular basis.

• 40:01Abbey Sharp?

  But I really appreciate that, you know, the work that you do in this space. And I think this is the perfect place to leave it. I feel that, you know, these medications absolutely have the potential to be life changing for so many people. And I'm sure you've seen it be life changing for so many people. But I want to remind everyone listening that, you know, choosing to pursue weight loss or, you know, not, or I should say not choosing to pursue weight loss and not choosing to take a GLP-1 is not a moral failure. And, you know, every person deserves evidence-based care and dignity and respect, regardless of the size of their body or what choices that they make.

• 40:40Abbey Sharp?

  And so I'm very happy that we have evidence-based providers like you in this conversation. So thank you so much for all of your insights. I learned a lot and I hope our listeners learned a lot too. This has been very interesting.

• 40:53Speaker 01

  Thanks for having me on. It's been a pleasure.

• 40:55Abbey Sharp?

  What an incredible episode. You know, Spencer is truly a wealth of knowledge when it comes to GLP-1s. So definitely check out his socials and his virtual care clinic, Vanyard. Now, before we end this episode, I want to address one of the most common questions that I get as a dietitian, which is can I practice intuitive eating on a GLP-1? And I think that the answer to this is at least largely yes, with some potential caveats. The first principle of the official intuitive eating framework designed by Evelyn Trippleby and Elise Resch

• 41:33Abbey Sharp?

  is to reject the diet mentality. So if you are using a GLP-1 with the primary goal of intentional weight loss, I'm not sure we can say that it's fully aligned with the original philosophy of intuitive eating, which was developed as a weight-neutral approach to healing one's relationship with food. But one thing I've come to understand as a dietitian navigating a minefield of diet trends, wellness protocols, and polarized nutrition advice is that there is no single roadmap to health that works for everyone. What looks like healthy eating for one person may Actually be disordered for someone else.

• 42:14Abbey Sharp?

  Now, at its core, intuitive eating is about building a more peaceful, trusting relationship with food and your body. It's about letting your internal cues guide your eating more than external diet rules, while also making room for gentle nutrition, your health conditions, your preferences, your values, and yes, sometimes medications. For some people, a GLP-1 may actually make that process easier. If you've spent years feeling consumed by relentless food thoughts or battling biological hunger that made every meal feel like a fight,

• 42:52Abbey Sharp?

  quieting that noise may finally create enough mental space to help you reconnect with your body signals. While for others, these medications can make hunger cues so subtle that it's actually harder to eat enough or meet nutritional needs or experience the joy and social connection that food can bring. Neither experience is more valid than the other, they're just simply different. Ultimately, I don't think the most useful question is whether GLP-1s are compatible with intuitive eating. I think the better question is how do we use these tools in a way that protects our relationship with food instead of replacing one protocol

• 43:37Abbey Sharp?

  or set of rules that don't necessarily serve us with another that isn't perhaps quite right? Because whether you're taking a GLP-1 or not, you still deserve freedom from food obsession. You still deserve to eat with flexibility instead of fear. And you still deserve compassionate, evidence-based care that respects your autonomy. At the end of the day, GLP-1s are just that. They are a tool. They're not a measure of your worth, your willpower, or your health. If this medication helps improve your quality of life, that's wonderful. If it's not accessible to you, not medically appropriate for you, or simply

• 44:21Abbey Sharp?

  Not a choice that you want to make? That's equally worthy of respect. No one owes the world weight loss, but everyone deserves the opportunity to pursue health, however they define it, in a way that aligns with their own body values and life, whether that means losing 10 pounds for a high school reunion, getting blood sugars within range, or healing years of body dysmorphia and body distrust. As always, I don't want you to leave this episode asking, well, what's the healthiest thing I can do? I want you to ask, what is the healthiest thing for me? Because the answer to that question will never come from social media, or diet culture,

• 45:06Abbey Sharp?

  or even a podcast. It comes from finding the evidence-based approach that best supports your unique body, your mental health, and the life that you want to live. So if this episode resonated and you're looking for evidence-based care, I would highly recommend looking into Spencer's online clinic Vineyard, or speaking to your healthcare provider about what might be right for you. And on that note, signing off with Science and SaaS, I'm Abbey Sharp. Thanks for listening.