Dr. Sarah Stombaugh:
This is Dr. Sarah Stombaugh, and you are listening to the Conquer Your Weight Podcast.

Announcer:
Welcome to the Conquer Your Weight Podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here’s your host, obesity medicine physician, and life coach, Dr. Sarah Stombaugh.

Dr. Sarah Stombaugh:
One of the things you hear about all of the time with GLP medications is, oh my gosh, that medication quieted the food noise for me, and it really created the space to allow me to lose weight in a way that I felt like I should always have been able to do, but this time it was finally easier. And when I say easier, I don’t mean like that’s a bad thing. You know, there’s no guilt, there’s no shame, there’s nothing associated with easier. It’s associated with, oh my gosh, this medication finally fixed some of the underlying hormonal and metabolic derangements that happen when we’ve been dealing with chronic excess weight for a period of time. And it allows our diet to take effect in a way that it never could before.

So let’s talk about the GLP medications. We’re talking about medications like Wegovy, medications like Zepbound. This will apply honestly to any GLP medication. But when you are looking to lose weight with the GLPs, one of the amazing things is that it does quiet the food noise and people will describe how they help to use it heal their relationship with food. Now I’m Dr. Sarah Stombaugh. I’m a board-certified obesity medicine physician. And one of the things that I believe very strongly is that we should help to heal our relationship with our body, our relationship with our food, so that we can achieve lasting weight loss. And GLPs are one of the most amazing tools that we can do this. So whether someone has a formal history of eating disorder, whether even now they’re struggling with things like overeating or binge eating, many people experience what is significant food noise that has really made it challenging for them in the past to lose weight. And GLPs can be one of the tools in the toolbox, or not the entire thing, but one of the tools in the toolbox that allows all of those changes that you’ve been trying so hard to make to finally, finally take effect. So let’s talk about this. And why does food noise happen in the first place? And then how do GLPs fix that? How can you use them as a tool to create some space in your weight loss journey to heal your relationship with food? And then what does it look like long term, whether you’re on or off the medications? Because that’s a question we get all the time. Those are the things that we are going to be going through as part of today’s conversation. So let’s talk about why food noise happen in the first place? I think one of the biggest misconceptions in our society is that food noise is psychological, that you just have, you know, a lot of cravings and desires and practiced habit over time of eating foods that are not in line with your goals. And so therefore you are addicted to eating or sort of craving and desiring to eat those types of foods. And while that is a very small piece of the picture, what’s actually true is that struggling with our weight, a lot of times we think about like fat as a symptom. We think about, okay, I ate unhealthy and I gained weight. And so now I have fat or adipose tissue in my body. And that is, you know, that’s the end result. But what if we think about fat as the cause? One of the really challenging things is that adipose tissue or fat tissue on our body is actually very hormonally active. And people don’t always think of that. A lot of times people think about fat as this like blob of tissue that sits in their body. But that blob of tissue, fat tissue, adipose tissue, is actually very hormonally active and can try signaling on certain things like insulin and leptin, which are two of the most important hormones when it comes to how our body processes energy.

Now, we’ve talked about insulin before, but insulin is our energy storage hormone. When we eat carbohydrates, when we eat protein, insulin is released in order to take that energy and store it away for later. It helps shuttle glucose into cells for use. It helps to signal, or it comes from the pancreas, but helps to signal, okay, we need to store this energy if we have more than we need. So it checks in with all the cells of the body. Hey, do you have the energy you need? Okay, if you do, we have excess energy, what are we going to do with it? It is helping to say, okay, let’s take that energy and store it away for later, whether that’s being stored as glycogen in the liver, whether that’s being stored in fat throughout the body. Insulin is our energy storage hormone. And one of the biggest challenges is that when we are struggling with our weight, when we have increased body weight, increased adipose tissue on our body, it is a big driver of insulin resistance. The challenge with insulin resistance is that the body is saying, like, hey, I actually don’t necessarily need any more energy right now. But the body’s like, “Well, I’ve got this energy, what am I supposed to do with it?” And so the body sends out even more insulin in order to store away the food that you eat. And so then the body starts to ignore that signal. It’s like the boy who cried wolf, like, okay, well, if you’re just gonna scream louder, I’m just going to ignore that. And over time, the body drives up insulin higher and higher. This is actually one of the very early changes that we see on labs, for example. So a lot of times people are thinking about, oh, is a hemoglobin A1C elevated or even a blood sugar elevated? But before we see elevations in either of those blood sugar numbers, the first thing that we’re seeing is an elevation in the insulin number.

Now, you want to be careful when you’re testing that because obviously if you’ve just eaten a meal and then you test your insulin level, you’ll see that that number is appropriately elevated. But at a time where you’ve been fasting, so first thing in the morning after you haven’t eaten in eight or 12 hours, testing your insulin level at that time should be when your insulin level is at its lowest. And so getting an idea of our fasting insulin level, particularly when we put it in a calculation called the HOMA-IR, we look at what is your insulin level compared to your current glucose level. Is it an appropriate insulin level for that glucose number? That can give us a really good idea if someone is struggling with insulin resistance. So all of that to say, this is driven by having excess adipose tissue stores in the body, our body has insulin resistance. One of the challenges with insulin resistance is that it can drive carbohydrate cravings, particularly cravings for sugar, for flour. One of the things we see that comes up with insulin resistance is actually a hyper-responsiveness after someone eats carbohydrates. So let’s say someone eats especially a processed carbohydrate, they feel their energy go up, they feel it crash back down because of that significant insulin response. And now that crashing back down, they may actually tip into the hypoglycemic or low blood sugar territory, which feels counterintuitive, but they do that they ate sugar, their insulin was hyperresponsive, it drops them down, they tip into this hypoglycemic category. So hypoglycemia can be caused by other things as well, but sometimes can be caused by insulin resistance, which then drives really intense sugar cravings because your body’s trying to bring your blood sugar back up into your normal range. So insulin resistance can be this driver of sugar cravings. Additionally, when we have adipose tissue in our body, we have leptin resistance. And so adipose tissue in our body with elevated leptin levels, our body leptin is a fullness hormone. It’s a signal to say, hey, you should stop eating. So when we think about a typical meal, you’re eating a meal, you have a leptin signal, and your body says, Oh, okay, I’m feeling full, I should stop eating. Now, one of the things that’s interesting is that when we have chronic obesity, we have that excess fat mass on our body, we actually experience elevated levels of leptin, which makes you think, oh, you would experience fullness sooner because your body doesn’t need as much energy source because you have fat mass stored on your body. But the challenge is our body also starts to ignore that signal. So we get a leptin resistance where the body has elevated fat mass, the body consumes a meal, but the body is not recognizing the signal of, hey, you’ve had enough, you should stop eating. So people with chronic obesity both are dealing with insulin resistance, where they design desire to eat more frequently, particularly sugar foods, as well as then leptin resistance, where their body is not telling them it’s full appropriately. So eating more sugary foods more often, and when they are eating, takes longer or more amount of food before they feel full. So these two challenges, in and of itself, can make it extremely difficult to lose weight. You then partner with actually losing weight. And if you’ve had this experience before, which just about everybody I’ve talked to who’s been on a weight loss journey has, trying to do a diet in the past where there was no medication involved, a calorie restriction type of diet, it goes really well at the beginning and there can be really significant weight loss. People see the number on the scale just flying down, you know, the first many weeks or a couple of months. Things are feeling really good. And then the body starts fighting back. And the body is like, oh my gosh, why is this like where is this caloric restriction coming from? I am so like, am I dying? Is there food scarcity? And so your body is not going to let you die. Your body is not going to let you starve to death. Your body starts sending out signals like ghrelin, which is a hormone that tells us to go eat. Your body starts sending out signals to go eat, and they send out that signal intensely. So all of a sudden, your body is dealing with intense physiological hunger.

This is not a psychological thing. This is an intense physiological hunger where your body is like, go seek food so that you do not die. So all of these things in a typical weight loss journey are really working against you such that it can be incredibly challenging to lose weight. And one of the biggest frustrations that I sometimes have is that people who do not have underlying metabolic disease, people who’ve not struggled with their weight frequently, do not get this because their body is not signaling in this way. And so someone who does not have insulin resistance, someone who does not have leptin resistance, someone who is, you know, going through a bulking and cutting journey as part of an intensive weight training program, like good for them. It’s amazing they can utilize their body in that way. And it’s very different from losing weight in the setting of chronic adipose tissue and deranged metabolic signaling, which is where medications like GLPs come in and they are such a game changer. There’s a reason these medications have become so, so popular is that people realize, oh my gosh, because is this what people feel like all the time? Is this what skinny, like naturally skinny people feel like? Is this? And the answer is yes. Now, not if you’re overdosed on GLP, you know, not if you’re incredibly sick and throwing up or anything like that, but if you’re talking about your brain finally feeling quiet, absolutely. That is what people experience, which is why these medications have become life-changing for so many people. So let’s talk about what the GLP receptor actually does. So these medications are signaling at the GLP receptor. So they’re targeting that receptor. And when that receptor is turned on, it works in a couple of different pathways in the brain. A lot of our hunger and signal, or most of our hunger and signal is regulated from the brain. Sometimes we think about it being regulated from the GI system, from the stomach, but most of it is regulated at the level of the brain in the hypothalamus. And there’s a pathway that regulates fullness, there’s a pathway that regulates hunger. A lot of times we think about hunger as just two sides of the same coin, but there are actually two parallel pathways that run in the brain. And they do cross-signal with each other, of course, but they are two parallel pathways that run within the brain, one to say, hey, I’m hungry, one to say, hey, I’m full. And those pair, you know, both of those things can be affected, which is why sometimes on these medications, people may notice that they are less hungry less often. They may also notice when they sit down to eat a meal that they’re eating a smaller amount of food. And both of those things or either of those things can be happening, but both of those pathways are signaled by GLP.

So GLP tells you it sends a fullness signal to your body saying, hey, I like feel like you just ate or feel like you’ve eaten recently, even if it has been a few hours, it also decreases hunger that comes in as well. There is also signaling at the level of the reward center of the brain. So we think about the dopamine reward center of the brain. This is where people think of a lot of addictive type behaviors occurring. So whether we’re talking about the desire for really sugary and processed foods, or we’re talking about other addictive behaviors like alcohol use disorder, other substance use disorders, but even across into other, really anything that stimulates dopamine, which can look like scrolling social media endlessly, watching Netflix endlessly, it can look like pornography, it can look like online shopping, it can look like gambling, it can look like a lot of different things that is regulated in the dopamine reward center of the brain. And GLP also stimulates there. And so people don’t get the same dopamine hit after eating these foods, which can really support that sort of psychological reward system pathway desire because we have a desire for food, we eat the food, we get the reward in a typical setting, and so it perpetuates that cycle. But when we can break that cycle because you don’t get the same dopamine response, all of a sudden the desire for that food becomes a lot less significant. So these two pieces together, both because you’re not hungry, you know, if you’ve had the experience of going to the grocery store when you’re hungry, all of a sudden a lot more things sound a lot good.

So you’re not hungry, you’re feeling more full, as well as this decreased reward system response from the medications really quiet down the food noise. And that can become the most amazing tool for how we support you in your weight loss journey. So when I’m working with patients, one of the things that I do that’s pretty unique compared to a lot of practices is that I actually don’t eliminate all sugar or processed foods from the diet. Now, obviously, the you know, the goal is to limit these in the diet. We don’t want them to be the entirety of the diet, but many of the patients that I’m working with recognize that they have a history of really pretty messed up relationship with food. And when something is just eliminated from the food list completely, we put it sometimes on a pedestal where all we’re thinking about, all we’re desiring, we’re like, oh my gosh, I just want that thing so badly. So it’s not about never eating a cookie for the rest of your life. It’s about when you eat a cookie, are you able to eat it slowly? Are you able to eat it as part of your meal? Are you able to savor it, enjoy the flavor, have a good experience of the cookie? Are you able to eat a single cookie as opposed to feeling like, oh, I need to eat five or 10 or more cookies because it’s been so long since I’ve had one and now I’m craving it so significantly? A lot of times when we can heal that relationship with food, it becomes really powerful regardless of what the long-term picture looks like, recognizing that nothing has to be off limits. When we think about food as fuel in the body, which GLPs allow the space for us to finally start thinking about food in that way, we think about what are the different roles that food serves for us. We have proteins, we have carbohydrates, we have fat. Each of those macronutrients serves a very important energy requirement in the body. Protein plays a really significant role in our body’s building muscle. Carbohydrates actually do that as well. They’re also the body’s preferred energy source, which is why people who are athletes will often eat pretty significant amounts of carbohydrates, even to fuel their body. Our body, though, actually does not require carbohydrates, which is why people do fine on something like a ketogenic diet. When I say do fine, I mean that they like they could survive, even though the body loves processing carbohydrates. It can process fats and survive on ketone bodies, which are an energy source as well.

Our body does also require fats. Fats are very important for a lot of hormonal signaling. They’re also a very concentrated energy source. So if you see any of those things where they’re like, this is 100 calories of olive oil and this is a hundred calories of, you know, chicken breast or strawberries, it’s like a lot of strawberries and it’s like, you know, a tablespoon of olive oil. So we do know that fat is incredibly concentrated, even when we’re talking about healthy fats, but it does serve a very important role as well. Fat and protein are big drivers of satiety naturally. And so including both of those in appropriate quantities can help to drive our body’s natural satiety fullness signals. So, all of that to say, we start thinking about what is food doing in terms of energy in the body? How does our body need to be fueled? And we start paying attention to things like, wow, I feel really good when I have a meal that includes a lot of fiber. I feel really good when I have a meal that includes a lot of protein. These tend to be the things that come out, right? We’re paying attention to let’s have protein, let’s have fiber. Those can be one and the same plant-based sources of protein. Different conversation for a different day. I do have a great conversation with Dr. Amanda Adkins from a couple of months ago now, where we talked about the role of a plant-based diet in weight loss and how that can be one tool. So it’s absolutely an option.

So a lot of times you think about protein, people are thinking about animal products, and that can absolutely be the case depending on you and your dietary goals. But plant-based proteins are also a phenomenal source of fiber. So people are feeling good, they have fiber, they have protein, and all of a sudden they’re recognizing okay, when I eat two or three meals a day that are really fiber-rich, that are really protein rich, my body feels good. It feels energized, it feels strong, and it’s really supporting the needs of your body, as opposed to when I may be snacking throughout the day, when I’m choosing some of those quick and processed foods more often. And I may still, on my birthday, on a really special occasion, look at the most delicious piece of cake or cookie or fill in the blank of whatever the thing from a great bakery and be like, wow, that looks really good. And I just want to say that that is okay. Every single day is not a special occasion. I’m a mom of young children. So, you know, on weekends I go to like many birthday parties and they’re serving like cheap grocery store cake and like every single little kid’s birthday party for my three children is not a treat. But what is a treat is when you are celebrating something special, when it’s your birthday, when it’s a family member’s birthday, when it’s a holiday, it is absolutely okay. And you should be enjoying foods that are, you know, traditionally we think of as celebratory type foods. It is okay to do that, but the power becomes where we talked about before, where you feel like I can have a cookie rather than feeling like I need to eat it really rapidly. I’m not even paying attention, I need to eat more than I want to. And sometimes this takes a lot of practice because we haven’t learned behavior over many years that these foods are bad foods. And if you were listening to the audio version, there’s a major air quote there because I do not believe in the morality of foods. There are no bad foods. All foods fill a role if we choose them to, and we can very intentionally choose to incorporate them in the diet.
So sometimes I will actually even work with patients to look at what are their trigger foods? What are those foods that in the past they would just eat and eat and eat and eat, and it would be a really significant challenge for them to stop doing that. And so they’re like, I just can’t see that food. I can’t have that food in my house, I can’t order that food. You know, there’s foods that they feel completely powerless around. And the GLPs create this amazing space where we can start to work through that. There’s an exercise where I do with my patients where they take one bite at a time of certain foods and they describe the texture, the taste, what is their experience and enjoyment of that thing. They talk about their hunger and their fullness. And the thing that shocks people every single time is whether we’re talking about a donut or a cookie or ramen noodles or peanut butter and jelly sandwich or scones or cake. Like I’ve done this exercise with many people in many different settings. And the thing that surprises them every single time is it usually takes a pretty small amount of that food before their desire and satisfaction for it is reached. And so we get to bring this intentionality and GLPs give us the space for that. Now the question becomes what happens? Okay, I lose the weight and I’d like to go off of the GLP medications. What I think is really important is that the GLP medications are designed for long-term use. They are designed to continue to support you in your journey. And generally speaking, how we lose weight is how we keep weight off. So I think one of the really damaging conversations that happen is happening right now is a conversation about like, okay, you lose the weight, then you stop the medication. When you stop the medication, you stop the effect of the medication. Now there is less adipose tissue. So you’ve lost weight, there’s less fat mass in your body. So there may be different hormonally signaling or hormonal signaling that’s happening, but you still are losing the effect of the GLP medication. So I believe very strongly that you as the patient, like you are the boss of your body. And if you want to stop the medication, I will support you in that completely. We do know that there’s data that a very small amount of people, maybe about five to 15% of people, can successfully get off of these medications, but that is typically someone who didn’t have as much excess weight to begin with, someone who did not hold that weight for a long period of time. So someone who gained weight over the course of two to five years will look very different compared to someone who’s been struggling with their weight lifelong, just in terms of metabolically what is happening in their body. So we do know that there is a small subset of people who may be able to taper off of these medications, which is why there’s so much conversation around us. Those people are loud, you hear those success stories, and that is wonderful for them. But do not let somebody else’s journey influence your own. Your own journey should be decided primarily by you in support with a board-certified obesity medicine physician who gets it and can help you make the right decisions.

One of the things that I think is awesome is that we are seeing everybody prescribe these medications. We’re seeing primary care physicians and cardiologists and sleep medicine physicians. And then of course there’s the med spa down that’s, you know, down the street, as well as the online programs. And if you are getting it from any of those sources and you are doing well, awesome. I am so happy for you. And if you are getting it from any one of those sources and you are not, you’re struggling, you’re looking for more support, I recommend to see a board-certified obesity medicine physician. I am licensed in Illinois, Tennessee, and Virginia. I see patients in person in Charlottesville, Virginia. I would be so happy to support you in your weight loss journey. Thank you for joining me today. We’ll see you all next week.