GLP-1s like Ozempic: Revolutionizing the Fight Against Obesity with Dr. James Hill

Dan is joined by Dr. James Hill, co-founder of the National Weight Control Registry.

Dr. Hill shares his insights on the evolution of weight management research, the rising obesity epidemic, and the implications of GLP-1 medications, like Ozempic, for weight loss. Dan and Dr. Hill also discuss the psychological aspects of weight management, the importance of healthcare provider conversations, and what exactly is "food noise."
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Special Guest: Dr. James Hill

Check out Dr. Hill's Podcast: Weight Loss And ...

Podcast episode: Talking with your doctor about GLP1s

Pre-Order his upcoming book:
LOSING THE WEIGHT LOSS MEDS
In the U.S.

In Canada

Or his previous book:
THE STATE OF SLIM
In the U.S.

In Canada

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Chapters

• 0:00 Introduction: Why Talk About Weight Loss Maintenance?
• 1:59 Meet Dr. James Hill & His Journey into Obesity Research
• 6:05 The National Weight Control Registry
• 8:00 America’s Weight Shift: Trends from the 70s to Now
• 10:45 Childhood Obesity & Rising Health Risks
• 13:00 Why Excess Body Fat Is Harmful
• 15:28 GLP-1 Medications: How They Work and Why They Matter
• 20:33 Food Noise, Side Effects, and Misconceptions
• 25:17 Deciding to Stay On or Come Off GLP-1s
• 34:35 Supporting Patients: The Role of Therapists & Providers

Transcript

0:00

[Music] We've quite a different type of episode for you today, and although not directly about psychotherapy, today's topic is something that therapists frequently deal with in the consulting room. And throughout our conversation, my guest and I discussed the impact and implications for therapists. One of the ways that I identify podcasts, guess, is that I stumble on something that I know nothing about, but I'd like to know more about. Then I run off to the internet and ask it,"Who are the top researchers in the world in this area?" And so several months ago, I was the middle of exercising and pondering various diet-related things, and it hit me. That while I know a lot about weight loss, I know absolutely nothing about weight loss maintenance. And it also hit me,"I don't even think that I've ever heard anyone talk about weight loss maintenance in an informed way." So, off to the internet I ran, and about 24 hours later, I hear back from today's guest, one of the top handful of researchers in the world on weight loss maintenance. He happened to be doing publicity for his forthcoming book on weight loss maintenance for people who have lost weight using GLP1 medications, drugs like ozempic. So the conversation that you'll hear today is mostly about GLP1 medications, how they work, considerations for taking them, etc. Honestly, I wasn't that interested in this topic before reading his book, but both his book and this part of our conversation was really fun, and I feel very differently about these drugs now. The conversation that you'll hear next week will be much more about weight loss maintenance, which spoiler alert is notably different from weight loss. But first, if you're new here, I'm your host, Dr. Dan Cox, a professor of counseling psychology at the University of British Columbia. Welcome to psychotherapy and applied psychology, Rye Dive Deep, with leading researchers to uncover practical insights, pull back the curtain, and hopefully have a little bit of fun along the way. If you enjoyed the show, do me a huge favor and subscribe on your podcast player, or if you're watching on YouTube, hit the like and subscribe button. It's one of the best ways to help us keep these conversations going. This episode starts with my guest responding to my question about how we got into studying weight loss maintenance. So without further ado, my very special guest, Dr. James Hill. Well, I actually started out studying, you know, how body weights regulated, and when I was a graduate student, and an early researcher, I was interested in why so many people maintain a constant weight across their life. All right, fast forward. That didn't happen anymore. So I was actually interested in the regulatory mechanisms because back in the 70s, when I went to graduate school, most people stayed the same weight throughout most of their life. And it was only later on that we realized the population was steadily gaining weight. But what really got me interested in weight loss maintenance was a project that I started in the early 90s with a very famous psychologist, Reena Wing. We started the National Weight Control Registry. And Dan, this is a project that literally started over a beer. We were in a meeting together and we went and had lunch. And yeah, maybe we had a adult beverage. And we were saying, you know, you see in the media how nobody succeeds at weight loss and the people that do are weird and psychologically different. I wonder if that's true. And then we kind of realized that's not a bad idea. What would happen if we go out and try to find these people? So we did. And we started a registry of people that are successful. We didn't know if there were two people, ten people, a million people out there. And over the years, we studied upwards of 10,000 people who had lost weight and kept it off over the long term. Really successful people. And so I just want to jump back to something you just said. So you were saying when you went to graduate school in the 70s that people sort of maintained, right? So if they were a little like if they were on the slender side, if they're a little in the heavier side, that that persisted, right? And which is something I think. But what you also said is that's not the case anymore, right? Right. So it was where we recognized as a country that we had a problem was in the mid to late 1980s because the government does a survey called the National Health and Nutrition Examination Survey. They do it constantly now. But back then they did it every three, four or five years. And one of those came out in I think it was the mid 80s. And what it showed is, oh my gosh, the weight of the population has increased. There are more people who are gaining weight than there ever were before. That's kind of when the research community, the public health community realized, hey, wait a minute. This obesity thing is something we maybe should take seriously before then, not very many people cared about obesity, not very many people studied it. And since the 1980s, what we've realized is the weight of our country has gone up and up and up. It creeps up every year. And now we have enormously high rates of overweight or obesity back in the 1970s, not very much. Huh. And I'm assuming that that shift is consistent across a number of whether it's developed countries or Western countries. I'm assuming that's not just a US thing. Yeah, it is true. Timeline doesn't line up exactly, but it lines up pretty closely. So, you know, sometime probably in the early 80s is when the rates of obesity started being noticeably higher. Now, you can say, this is probably something that was happening under the surface all along. So it was only in the 80s that we started seeing that. So the iceberg is coming up to the surface gradually, but we don't see it, you know, come above the surface until the 80s. And that's when we noticed that objectively, we had numbers to show that obesity was increased. And is that, is that slope sort of, is that the trajectory of the slope, is that like consistent over the last several decades or has that gotten steeper or shallower? Great question. So really from the time we noticed, say the mid 1980s to 2000 is a really steep increase. Since 2000, it's been more of a gradual increase. So you can think of two slopes, a very quick slope and then a much slower slope. The other thing that's happening is the data suggests that even though total obesity rates are going up very slowly, the weights within those are increasing. So we're in the category, we would say, are obese? Those weights are even higher. So the category increases a little bit, but within the category, the average weight is even increasing. So the people that are heavier are getting even heavier. And I was trying to remember, I can't remember if it was your podcast, if it was another one, where I just heard something like that. That the folks who sort of had fallen that obese cat, that the mean, the average weight gain across the population is not necessarily the best metric for conceptualizing what's happening. Exactly. So that, and please, correct me where I'm wrong, what kind of the idea is the slender-ish, I don't know if this, and feel free to correct my language. The slender-ish folks are staying slender-ish and the folks who are falling into the obese category, they're staying in that category, but their weight is increasing. Is the terrible weight, is it? Now that's generally true, but so if you divide the population into, say, not overweight, overweight or obese, the obese category is increasing gradually. The overweight category is staying about the same, which means the not obese category is decreasing just a little too. So you're saying that the number of people in those three categories, that the distribution slowly moving over, where folks who are in-- Yeah, you're exactly right. It's slowly moving from lean to obese with that middle category, sort of the turnover category. People are entering from leanness to overweight at the same rate going from overweight to a obese. I think I could probably talk to you for days, not minutes. I don't want to get too far off where I don't want to miss the target too much here, so just one more question on this, probably. Are we seeing these-- I know the categories are slightly different, but are we seeing these changes also in kids? Oh, OK, go for it. Yeah, it's even worse in kids. I mean, if there's something people should be upset over, it's the increased obesity in kids. Because again, going back to the 1970s, there is virtually no obesity in kids. You had a few kids that were overweight and chunky and every now and then are the obese kids. It was not an issue, while adult obesity has more than doubled in that time. Childhood obesity is more than tripled, and we're still conservative about how we define childhood obesity. And what that has led to is now we're seeing type 2 diabetes, which is an adult disease in kids. I think I'm probably not exaggerating to say in the 1970s, there were zero cases of type 2 diabetes in kids. Today, it's very, very frequent. Wow. So totally preventable. Totally preventable. What's amazing, Jim, is-- so I was born in '81. So when I go back and watch older media, or hell, even if I go back and look at pictures from when I was a kid, and you looked at-- or you watch movies from the '80s, the quote unquote overweight kid, it was like-- he or she was not really that normal kid. Now, therefore, you see on the playground all over. Yeah, I-- Dan, I tell people to do that. Go back and look at pictures from the 1930s and the 1940s. Even adults, they look emaciated. You have these skinny, stick figures. And yeah, every now and then, you see someone that's a little overweight and they stand out, and that's changed a lot today. And I think, you know, going again, just '80s, like the '80s. And I mean, I guess that's partially because I'm getting older. But to me, the '80s was yesterday. And it's just like you just look back at media from that time point and it's like, wow, it has changed so much. So this is a question-- here's the question. Okay. What's unhealthy about being overweight? What's unhealthy about being overweight is-- and it's not really overweight, it's over fat. Okay? So you get the big guys with the extra muscles and everything. That's not unhealthy. What's unhealthy is when you get higher amounts of body fat. Okay? Where somebody fat is good. Body fat is useful. But when you get too much, the major-- there are a couple of reasons we're concerned, but one of the major reasons is the extra fat basically interferes with your metabolism. It causes you to be resistant to insulin. It causes inflammation. And leads to all the chronic diseases, diabetes, heart disease, kidney disease, etc. Much of those diseases can be traced back to having too much fat, which interferes with metabolic processes in a way that they aren't functioning well. You're resistant to insulin. You develop diabetes. You have more fat in your blood. You develop heart disease. Your kidney still functions as well. You develop kidney disease. So the excess body fat leads to metabolic derangements. It also leads to problems of arthritis and joint overload, knee replacements, hip replacements, gynecological problems. Just about every system you look at is negatively affected by having excess body fat. So I think about it and tell me if I'm wrong here, but that like there'd be few physical problems for lack of a better word that aren't correlated with being overweight. That is just a generic baseline is just associated with all sorts of negative physical outcomes. Yes. And again, let me say that there are exceptions. So there are some obese people with obesity who don't have metabolic derangements, but the majority do. If you know, we can predict pretty well from your excess body fat, your risk of developing some of these chronic diseases. But everybody will do it, but the risk is much, much higher. If there were no obesity, type 2 diabetes would be a rare condition. So it's sort of like smoking in that, you know, everybody has those anecdotes of their 95 year old grandma who all, you know, smoked two packs a day and was totally fine. But we all know it's just ridiculously obvious that smoking, you know, the probability of cancer and all sorts of other negative things. Totally a probability thing. Excess body fatness gives you a higher probability of developing some chronic disease than not having excess body fat. Okay. So we want to get into talking about GLP ones. Yeah. And we're going to spend a few minutes just sort of talking about that broadly. And obviously, I think at least the one that's in the media the most is ozemic. Yep. How did GLP ones work? So let me start by saying these drugs have revolutionized how we think about obesity. I can't emphasize enough what a breakthrough, a disruption. I say a positive disruption in our field. These drugs have done. The way they work is people discovered researchers discovered that there are signals from the GI track that go to the brain and affect food intake. Okay. These are GLP one. Okay. That happens naturally. So naturally your gut is telling your brain something about the amount of food there. What these drugs do is they mimic the effects of this natural GLP one, but they're much more effective. So they hit these brain receptors that your natural GLP ones would hit. But they number one, they stay around longer. So naturally when you your gut elicit GLP one, it goes to a brain receptor receptor. It may stay there only a short period of time. These drugs stay there longer. So they really have an enhanced effect on reducing your desire for food. And that's essentially what they do. They do some other things. They slow gastric emptying, which also seems to contribute to you not needing as much food to fill to fill full. They shut off what people talk about food noise, always thinking about food, etc. But the major thing they do is to make you happy eating far less food than you were eating before. That produces significant weight loss in most people. And in the book you talk about food noise, which I'd never sort of heard that phrase before, but I felt it was a really helpful phrase because you know often you think about people we eat often more or not super hungry. And so that sort of food noise to me in some ways is that that sort of gets caught up in there. And that these GLP ones is not just you know that it's you know I could see oh feeling less hungry, but will I still eat more because that's what I do that's my coping mechanism or whatever. But it also seems to be effective at least in many cases in terms of damping that down where that feeling that desire that maladaptive coping mechanism even kind of abates. Yeah, this whole term food noise. It's actually a new term I hadn't heard it probably much before a year or so ago. But I got to tell you it connects with people if you've experienced this and you hear the term food noise that's explained to you you get it right away so many people said oh my god that's exactly it's like a radio is always on about food. Eat eat eat eat all the time and for whatever reason and we don't know how these drugs tend to shut that down and people will say for the first time ever I don't hear this food noise. Now one of my colleagues here said what we need is a pill that people who have never experienced food noise can take and see what it's like to experience food noise. If you haven't experienced it it's a little hard to understand you know but if you've experienced it these people know when you explain food noise to them they get it they say that's it. And so one of the big things that people report on the gel P one based medications the food noise goes away. Now I think it's going to be fascinating for researchers to figure out what is that where does where does the food noise come from how are the meds shutting it off fascinating science to figure out why but the long and short of it is the decrease in food noise is one of the big benefits that patients report taking the meds. So if folks are who do you think should you know strongly consider taking gel P ones so I guess the thing is who shouldn't take gel P ones and and they're they're very few no to say who wouldn't qualify that the choice to do it is a different one. It's not approved for pregnancy it's not approved for young kids certain types of thyroid problems but really I mean you never know what you don't know it is proven to be surprisingly safe. Most people who take these get some side effects they're mostly GI side effects that kind of GI side effects you would expect nausea vomiting diarrhea some of that in most cases they're fairly mild and fairly transient there are examples of where some people just can't tolerate the side effects and that's one reason a lot of people just continue the meds. But they've turned out to be surprisingly safe and so the decision to take them I think becomes a personal decision or certainly a decision you want to talk to your health care provider about and it really relates to you know how how big a deal is weight loss in your life there are some people that are overweight and they're perfectly happy and health wise they're okay etc. But if you're having health issues or if losing weight is such a big deal for you it may be worth considering taking these so there's no like obviously what you're saying I mean I feel like you know we should put up the the quick you know a sticker of you know talk to your physician and all that stuff. But that aside and sort of those couple of caveats aside are there any I don't know life situations psychological profiles any anything that where you see like yeah maybe this isn't so helpful for these people or maybe this it like you know in terms of those considerations of what folks should you know if this will work for people or if it's a good idea for people are not. Yeah you know we always worry about the psychological aspects and some of the previous medications that have been developed for weight loss tend to maybe have some negative psychological effects you know one medication more suicide ideation etc. We haven't seen any of that with this medication now we've been developing medications for a long long time and most of them have either been not sufficiently safe or not sufficiently effective but one of the things that we benefited from is we kind of know where to look for problems now some drugs about heart problems some have had psychology problems etc. So the good news is for this round of drugs they've looked at all that and so far we haven't found any major watchouts now we don't know what's going to happen down the road but right now these things have turned out to be pretty darn safe. Do you think that and we're going to talk about sort of obviously getting off of the getting off of the drugs which is a lot of where your book comes in. Is there anything wrong with staying on the drugs long term. Absolutely not and and that's one of the things that we talk about in our book our book was written for people who cannot or decide not to continue the meds but we say right up front. If you take the meds if they work for you if you're feeling good if you tolerate the side effects and you want to stay on them forever that's okay. The other thing is you forever you don't have to decide forever right now you can say look my strategy is to go long term you can always change that just like if you go off the medications you can always go back on them so one of the things we want people to understand you have some options. And your job is to figure out the option for you one option is going on the meds staying on the meds long term we do that for diabetes medication blood pressure medication heart medication lots of medications that people take and plan on basically taking the rest of their life. If it works for you that's a very very viable option. But you talk about some other ones I never thought of before so what are some of the reasons why people decide to get off of the drugs and again as we're talking to these people we we heard ones that we wouldn't have anticipated so we were surprised the two big ones side effects and not covered by insurance these drugs are very expensive. And we hear lots of stories of you know I went on these drugs my insurance paid for them went along just fine my insurance decided they weren't going to cover them now and I can't afford to do it those are the two big ones but there are other reasons to one of the most interesting ones that that I have come to understand is people actually miss food. If you think about it we food serves many more many more functions than just nutrients for us so you know I wanted things I dearly love I love going out to dinner with friends and having parties and dinner parties and everything well a lot of people in these medications is like I don't want to go out to eat because I just don't want any food nothing nothing seems good and you know that affects everybody else and so. There's that aspect of it and and again we're not making any judgments here if that's something that impacts your quality of life that's a very very fair reason to say I want to go off them another one is you still have a lot of people who feel like they shouldn't need a drug to be able to manage their weight and they're okay to say I'll do it as a short term tool. I'm not comfortable thinking about taking a drug forever to do this another one people that want to get pregnant they say you know right now it's not recommended it's not that we know it's bad it's just that there are no research studies that are done so we don't know so cautiously where we're not recommending that so those are some of the big reasons what you said at the the in your book my memory serves I feel like it was a couple but I could be misremembering who were maybe both on the drug I don't remember but that it was the their social life was very much based on having dinner parties are going out to dinner with friends exactly and they just and I was just sort of like as I read that you know is one of those times where I sort of put the book down and just say wow that's you because you don't think you think like well well I'm a little less hungry but I can still go do these things but if it's if it's so if the drug impacts your system so much that food is just totally undesirable. That's going to I just thought it was just blew my mind I never thought about it and think about it and so you're out to dinner with somebody like that and that's sort of influences the whole thing and you know they're not going to you know food doesn't taste good to them it kind of you can see socially you can see where that would have an impact and and many many people revolve a lot of their social life around food yeah yeah of course so one of the other things you said would be good to them and you know the other things you said which is people just not wanting to or not feeling kind of okay with staying on the drug long term so I don't know if you've watched but there's a recent Netflix documentary about the biggest loser the TV show I purposely not watched it because I know it's going to make me angry got it got it so they had a gentleman I'll probably watch it yeah yeah so I watched it up but the guy on there who had lost a lot of weight and gained it back and so this was as I was sort of reading your book and thinking about all these things a lot so the timing was kind of perfect for me and one of the things he talked about the GLP ones and he said you know he said something like you know I just don't feel right about taking the drug or you know it feels like cheating or something like that so how do you what would you say to folks like that we actually have a little blurb in the book that basically says it is not cheating you're what these drugs really demonstrate clearly is keeping losing weight keeping weight off is not just will power it's more than will power because have people who have tried for years to use will power alone and failed now they fix the biology and they succeed so we talk about it do not feel it's cheating in fact it's leveling the playing field you were added disadvantage because of your biology now the medications fix that so don't feel bad about that you're simply now leveling the playing field so for you know a lot of my listeners are most of them are either therapists or therapists and training and so these are you know these are conversations that are going to be coming up in therapy room about people who are considering taking these medications and thinking about therapists talking to clients and obviously the therapists you know they're going to they're not experts in the biology the physiology of it or any of that sort of thing but how do you think that they could help people think through their decision making around taking these medications I think they play such a critical role and I'm glad that we have a chance to talk to them what I have I've started asking a lot of people who start the GLP meds what's your long term plan you know the number one answer and thought about it all they're thinking about is getting the way to and that's that's the way weight management work for decades and decades people never get beyond getting the way to with these medications what we find is people can actually reach or nearly reach their goal weight so the question is can you can you help people by having them think early on what's your long term plan so let's let's do an example here let's say you come to me and I are you're prescribed a GLP one med and I'm saying Dan this med is going to help you reach or nearly reach your goal weight in maybe a year what are you going to do then is your plan to stay on it forever is your plan to figure it out later on see how you feel what's your plan okay and I think I think you've got three big options here one you can stay on it forever okay the therapist there there are a lot of things we can do to improve health so you take the drug you're going to stay on it forever so the drugs during your weight but it's not doing other aspects of your health or your mental health one of the things I worry about is you don't have to exercise to lose weight on these meds and I think exercise provides so many other things you don't have to have what we call in the book a healthy mind state to keep the weight off but you do have to exercise and have a healthy mind state in order to maximize the benefit on your quality of life of the weight loss so there are things you can do to help drugs if you're doing the heavy lifting on the weight therapist can work for other aspects particularly the mind state part another option is to lose weight on the meds and then say I'm going to keep it off with lifestyle one of the things we know is unless you have a strong plan you're going to regain it now it's pretty interesting you talk about these people on the meds so many of them have told me how they're taking the meds I said no problem I could stop the meds I got it everything's going to be okay boom they stop the meds the hunger comes back the food noise comes back the weight comes back that's why we wrote our book to say look you don't have to regain the weight if you stop the meds but you do have to have a strong plan and then the third possibility that I think we're going to see more and more is people going off the drugs on lifestyle and using the drugs either intermittently at low doses etc a combination of focusing on lifestyle and medication I think all three are viable choices anyone you choose is okay and you can change that you may say I want to do it forever you may decide no you may want to go to lifestyle decide you'd rather do the drugs one of the things we really emphasize everybody's different and there's no one way for you you have different options so is it the case that if you that you can manipulate the dose and that that will that your hunger will you know that that it will go up and down like a slider is it that sort of continuous that's where we need the research Dan the hope is that we can figure that out the problem is and and keep in mind these drugs are still early on and how we use them etc so what I think you're going to see over the next few years is some very exciting research does lower dose work does intermittent use is it a rescue strategy while everything's going great on lifestyle is fine what it's not you go back on drugs we just don't have any data but the potential options are really exciting there so if you're a patient or if you're a therapist who has patients and you want to find somebody in your community who really has some a GP in your community who really has some or nurse practitioner whatever who really has some expertise on this stuff because the reality is is that most physicians can't have expertise on everything right and so but you want to find somebody who really knows what they're talking about to refer patients to or you're the patient yourself and you want to talk like how would somebody go about finding somebody in their community you know who really would be you know have some expertise on this to talk to that's a really great question and I'm going to give you one example I have a relative I'm not going to mention any names here who's very overweight and you know with relatives have she have to be careful about bringing this up so I've never brought it up I've always thought the drugs could be an option what I found out I had nothing to do with this I found out this person when on the meds had horrible side effects and basically said I said I'm not doing it well they were probably prescribed by a physician that didn't know exactly how to do it because if you were having terrible side effects you back it up you take low dose issue start so this is part of the problem there are physicians who know what they're doing with weight management and they're fantastic there are other physicians that prescribe it just like they would prescribe another drug here's your drug go out and come back in six months lots of people need some help doing that the question is who is there to help first place I would start is with a registered dietitian they are really getting very involved in this and their registered dietitians in every community what they can do is a couple of things one is they can help you manage the side effects there are things you can do on the diet side that can reduce the nausea etc they can make sure you get enough nutrition you know one of the problems with these meds people are eating sufficiently little little that they're actually nutrient deprived so a dietitian can can help with side effects they can help making sure you're getting the right kind of food we think higher protein is particularly useful for these meds so they can help get enough protein in your diet so that's one place to start another place to start and and I'm not sure how this community is is ramping up here but on the exercise side you need people who can work with you while you're on the meds to say look you don't have to exercise to lose weight but exercise is going to do so many other positive things for you and to take into account I think the fact that people are losing weight is a great opportunity to get them started on some of the exercise stuff and then the third group would be the therapist because you know the drugs don't affect your mind state and I hope we can talk more about that in the future and that's particularly important whether you want to stay on the drugs or go off the drugs so dietitians are out there and they're pretty pretty up on this problem exercise people check around talk to people who can understand how to do that and therapists I think are going to be critical in all this one of the things that I was thinking about is that they're I see they're probably a lot of folks who want to talk about this with their health provider but feel embarrassed to or they're worried that they're going to bring it up and their physician is going to be like no no no like no we don't do that or something that's going to sort of you know do you have any thoughts for those folks yeah we actually did a whole episode of our podcast on that we had a good friend of mine a physician Dan Bessesson who we did a hope podcast on how to talk to your physician about this and it is it's complicated number one we need the physicians to be better about this so the physician should be aware of it so you shouldn't be made to feel ashamed or you shouldn't be made to feel that you have to do it but you should be having those conversations in a non threatening way with your health care provider because they can help guide you so you say who should go on these and make sure health care provider should help you decide if it's the right thing for you you know now more than ever we have multiple tools to help with weight management these are one tool they're important tool but there are other tools so this is why your health care professional should be in a position to help recommend the right tools for you so Dan if I remember in the podcast basically said you know as a first step try talking to your physician try bring it up try this and that and at the end of the day you might have to see another physician there are plenty of people out there who can do it but he was very adamant try with your current physician if you have a good relationship with your physician try working on that but at the end of the day if you feel like you're not being taken seriously find someone that will take you more seriously that's wonderful and what I'll do is I'll link to that episode in the show notes for anyone who's listening that they can just go and listen to that that's wonderful so what's it like what's the experience like for people when they stop taking the meds so people are totally freaking out my stopping the meds because think about it you've experienced food noise for 30 minutes noise for 30 years now it's gone away and you're saying if I stop the drugs it's going to come back that would make me a little nervous you're saying I've never before been able to look at a donut and not eat it now I look at it I don't even want it I'm afraid of having to do that again and so there's a reason because what you know the meds only work when you take them when you stop taking the benefits of the meds go away now that maybe the good news on the jail P1 meds they don't go away right away they actually stay in your system a while so you have a little bit of a runway but what we try to tell people in the book is anticipated so we talk about the appetite finding the right appetite set point why you were overweight you're probably eating too much why you're on the meds you're eating too little so can we help you find an invitation you find an in between if you go back to the appetite you had before we know what's going to happen it's unrealistic to think your appetite is still going to go low so we want to help you find that right spot where your appetite is lower than it was before but higher on the meds okay how do you balance that we have balanced that on the activity side if you're going to eat more you've got to exercise more to keep from gaining weight and that's why people who focus on one solution foods the solution exercise the solution mental health solution it only works if all three are paired together so with a good plan you can eat more increase your exercise improve your mindset and maintain your weight that's a wrap on the first part of our conversation as noted at the top of the show be much appreciated if you spread the word to anyone else who you think might enjoy it until next time