On today’s show, we’re going to dive into the topic of GLP-1 agonists, a class of medications that stimulates your pancreas to produce more insulin, slows down digestion, and promotes feelings of fullness. The benefits are that it can help lower your blood sugar level, it can lead to weight loss, and it may reduce the risk of cardiovascular events in people with type 2 diabetes. But judicious use is essential because these drugs have serious GI side effects and an increased risk of cancer, so it’s important to make sure that your decision to take them is well-informed and that you’re making it with eyes wide open.
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When it comes to GLP-1 drugs, there’s no right or wrong decision. Only the one that’s right for you. But you need to make sure that you’re making that decision with eyes wide open. I’m Dr. Robynne Chutkan, gastroenterologist, microbiome expert and author. And I’m here to help you find gutbliss.
On today’s show, we’re going to dive into a topic that, to be honest, I’ve been avoiding since I launched the podcast last April. And that is the very socially and emotionally and politically charged topic of GLP-1 agonists. And by way of background, GLP-1 drugs are glucagon-like peptide-1 agonists, a class of medications that is used primarily, or at least were used primarily, to treat type 2 diabetes. They work by mimicking the effects of a natural hormone called GLP-1, glucagon-like peptide. But they are not actually glucagon-like peptide-1. They are GLP-1 agonists, meaning they mimic the effects of that hormone that occurs naturally in our bodies. And that hormone helps to regulate blood sugar levels. How does it do that? It stimulates your pancreas to produce more insulin. It slows down digestion, and it promotes feelings of fullness. So the benefits are that it can help lower your blood sugar level. It can lead to weight loss, and it may reduce the risk of cardiovascular events and heart attacks and things like that in people with type 2 diabetes.
The side effects are not surprisingly GI because this drug works primarily on your gut. The side effects are nausea and vomiting and diarrhea and some more serious side effects like pancreatitis, inflammation of the pancreas, gastroparesis, which is a paralysis of the stomach where it’s not contracting properly, and even bowel obstruction. GLP-1 agonists are typically administered as injections under the skin, sometimes weekly or monthly. Some others require daily administration, and you probably know them best by the brand names Ozempic or Wegovy, or semaglutide as the generic. So that’s some background information. I have asked my friend and colleague, Janet Jumper, nurse practitioner, to join me for today’s episode. But our goal is not to tell you that these drugs are fantastic and you should use them, or that they’re terrible and you should avoid them. It’s to give you an additional perspective about them. And really, it is just our perspective as two practitioners. I’m a gastroenterologist, Janet is a nurse practitioner. Between us, we have over 60 years of medical experience. So when we come back, Janet is in the Gutbliss podcast studio, and we’re talking about our particular perspective on GLP-1 agonists when we come back.
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We are back talking about GLP-1 agonists. So Janet, we have talked about this offline a lot. And now we’re going public. So, general thoughts?
Well, I think, you know, it’s a tricky thing to talk about with your friends and family and in the general public, because you want to make sure that you are kind and loving to the people that you’re talking to and that you’re accepting of everyone’s lifestyle choices. I think for me, the thing that I struggle with is a concept of, “I’ve done everything I can” and now I’m here. And we’ve talked a little bit about that, you and I. What does it mean to, I’ve done everything I can, and how does that impact your mental ability or desire to act on a medical intervention that is life-altering in many ways. So you had spoken to that a little bit about the “I’ve done all that I can” philosophy and I wonder if you wanted to talk about that a little bit more.
Sure and just to put it in perspective here, we’re talking today primarily about people who are using GLP-1 agonists for weight loss, not so much people who are diabetic and it’s been prescribed for their diabetes, irrespective of weight. And I do hear that a lot also, “I’ve tried everything”. And particularly in a lot of my menopausal patients and friends, and one of the things I’m constantly reminding people is that in menopause, your body changes, which means you have to make changes to accommodate those hormonal and physiological changes. And one of those changes is that typically, if you are eating the same diet, you are now gaining weight where you were previously maintaining. And so one of the things that is often necessary is eating differently and eating less. So you may need more protein, you may be able to tolerate fewer carbs, even the complex carbs, and you may generally just need to eat smaller portion sizes. And so what I often hear from people is, “well, I’ve tried everything, you know, I eat almost nothing and I still don’t lose weight”. But when they go on the drug, and they eat less, they lose weight. So, you know, it’s sort of like, well, have you tried eating less? Because that’s what’s going on here. But I think it’s important to distinguish that one person’s “I’ve tried everything” is “I have done everything I can do”. That’s not necessarily everything that can be done. It’s what is possible for them. And I try to think about it in terms of running. So I’m a distance runner, but I am not fast. And I have friends who can get out there and run a seven-minute mile. And it’s not that I couldn’t run a seven-minute mile, but what is required for me to run a seven-minute mile is a lot more effort than what may be required from them. So I think the same kind of thing, right? Some people, their “tried everything” may be not that much. It may be me and my 10 minute mile and somebody else their “tried everything” might be their seven minute mile. They’re more successful at that. But I think part of the danger is that we are medicalizing something and we’re putting it in a particular context where maybe it doesn’t fully belong.
And I’m wondering too, as I’m hearing you talk, what do you think the role of the ability to change your eating habits is in the setting of the weight loss drugs? Because I think another thing that we’ve talked about, and again, there’s different categories of people using the GLP-1s. Is it for medical treatment? Are you trying to reduce your cardiac risk? Are you morbidly obese? I mean, there’s all kinds of reasons why these are being used. But do you think it’s possible for someone who’s using these to then sort of be motivated to radically change their diet? Because what I’m seeing is people are doing it, but they’re still eating all the ultra-processed foods. They’re still not taking in enough fiber. They’re still not really managing their diet and the food landscape in the way that you and I really feel has to be done in order for us to change our microbes, to heal leaky gut, to manage dysbiosis, to prevent autoimmune disease, all of those things. So do we think that has the capacity to happen, that someone’s going to lose weight and then say, gosh, I feel so good, I really want to do these other things? Or do you think it’s just an excuse to continue to eat the ultra-processed foods that we’ve been eating and just sort of be thinner?
Unfortunately, the drug does not direct you in those directions we’d love people to go in, and I think there’s an analogy to be made between bariatric surgery. So 20 years ago when bariatric surgery was much more popular and for those who may be less familiar – we’re talking about anti-obesity surgery, different surgical techniques that involve bypassing parts of the digestive tract or even removing parts of the digestive tract for weight loss. And when the surgical techniques sort of first came on the scene (and again, I think they were at their heyday somewhere around 20 years ago, 10 years ago), the directive was that we are going to combine this with behavior modification. So before we cut out a part of your stomach or put a big balloon in or bypass something, we’re going to make sure that you have nutritional training and you have behavioral therapy so that after the surgery, you’re going to be eating and drinking completely differently. And we saw that that really was not the case. So that unfortunately, many people regained the weight after the surgery. And of course, the surgery, like these drugs, has really problematic side effects too.
Yeah, we do have more information on the addictive properties of ultra-processed foods, which I wonder if that would play into anybody’s ability to sort of change differently from the bariatric surgery era. But that’s a debate that we could get into, you know, all day long. And the book Ultra-Processed People that you reference a lot is really good. Chris Van Tulleken, Ultra-Processed People.
But the addictive thing is important because now, I mean, if you follow this stuff in the scientific literature and the popular press, you are starting to see now that GLP-1 agonists are being hailed as, you know, sort of the cure for addiction, right? There was a huge article in the New York Times a couple of days ago about addiction, and the interviewer was talking about GLP-1 agonists, not just for obesity and sort of food addiction, if you will, but also for alcohol, etc. And there’s been lots of sort of reports about that. There haven’t been that many peer-reviewed placebo-controlled trials, but the idea that you stop sort of ruminating about the thing, whether it is alcohol or food or whatever it is. The problem here, though, is that this is only going to last while you’re on the drug. We don’t really have direct evidence that when you stop taking the drug, this new behavior, which is you’re thinking less about the food that you previously had been over-consuming and now you’re not, or the alcohol, or whatever it is, that behavior is not permanently altered when you get off the drug. And so that’s a real concern for me because we have seen time and time again in the medical community, and it’s a playbook that works. That’s why we see it over and over again, where the medical community tells people: “There’s nothing you can do; this is what’s happening to you”. You’ve seen it with autoimmune disease. You have Crohn’s, there’s nothing we can do. We don’t know what causes it. This is how it is but take this drug and it will make you feel better. And yes, you take the drug and the drugs often – if you think about drugs like biologics, etc. – they can put you into remission, but at a cost, right? They increase your risk of infection, they increase your risk of cancer. That doesn’t mean we shouldn’t use them. I personally have prescribed these drugs hundreds of times, maybe thousands of times in patients, and they have been life-changing and life-altering, but I always recommend that we use these drugs on top of lifestyle diet modifications. And there are those patients, in my experience, it’s a fairly small group, who don’t respond to the diet or lifestyle changes and need those drugs. But there are huge groups of patients who are simply put on these drugs, they’re told “there’s nothing you can do, take this drug”, who would respond well to fairly simple diet and lifestyle changes. So I think we’re seeing the same thing and to me what it does is it takes away people’s power and autonomy over their body.
And speaking of, and I think that the one of the things we’ve talked about too, is how big pharma sort of plays into that and the use of pharmaceuticals plays into the ability for you to feel like you’ve lost power. This drug is the only thing that can heal you now. And referencing back my experience with, you know, that sort of aha moment where I realized that actually I had the power to manage this problem, my inflammatory bowel disease, my Crohn’s, and then see that happen. But it does take time and perseverance. And you’re afraid, you’re afraid of what will happen if you do the hard thing and avoid the easy thing, because the easy thing is kind of what’s being told to you is the best thing.
Absolutely. And sometimes the only thing. When we come back: power versus blame. Okay, so power versus blame. And this is something that I really struggle with as a physician. I want people to feel empowered to make changes to improve their gut health, but at the same time, I don’t want them to feel like I am blaming them and saying, it’s your fault. And sometimes it’s difficult to separate out those messages because if you say to somebody, well, there’s more you can do, right? Have you really done everything you can possibly do to lose weight? Or have you really done everything you can possibly do to put your Crohn’s in remission, maybe what they’re hearing is: it’s your fault that you have Crohn’s disease. Now Crohn’s disease and obesity are not the same thing. Just to be clear. There are additional factors that are beyond people’s control that are often involved in an autoimmune disease, even though there may be some triggering factors that led the disease to be expressed that are under your control, but they are generally much more complex diseases where there’s much less of a direct line you can draw between somebody’s behavior and the end result, whereas with obesity, I think that’s a little bit different.
Well, I think this conjures up some ideas for me about sort of empowerment and blame and shame and regrets. And so one of the things that I really like to talk about with people is how negative emotion can actually be good, a little bit of it, and that can inform change behavior. And I love Daniel Pink’s book, The Power of Regret, if anyone wants to read that book. It really talks about regret as a motivator. And then reflecting back on my own journey with Crohn’s disease, we haven’t talked about this, maybe in another episode we can talk about my daughter who’s a cancer survivor, I have lots of regret and shame about maybe decisions that I made and things that I did. But in the end, what I really get back to is how did that ideology inform how I could change my behavior? So I’ll give you an example. For my Crohn’s disease, I really ate a lot of sugar as a kid. And we talked about this, the fat-free diet fad of my high school and college days. I mean, I ate almost nothing with fat in it. So I ate foods that were very high sugar foods in addition to then also enjoying sugary foods. And so I feel like my personal belief is that that changed my microbes enough to create inflammation and be at least a contributor, turning on my genes for my Crohn’s disease. That is what I believe. No one has to believe that with me, but that’s my own personal belief.
And there’s pretty good evidence that it can work like that with autoimmune disease.
Right, right. And maybe some other factors, maybe birth control pills, I was not a C-section baby, but I was a breech birth. So who knows how that impacted things? You never know, but we’re not gonna go deep dive into all those things. But what I do want to say is, I definitely felt that I had a sugar addiction and I got into very bad habits in college and after college with having high sugar, high quantity sugar snacks. Like snacking in front of the television was my favorite thing to do. And even into my adult life with my kids, like my favorite thing to do would be put the kids to bed and get my little dessert, a handful of chocolates or whatever, and sit down in front of the television at nine o’clock at night and have a handful, another handful, and another handful. My point to people is this, especially when we’re talking about weight loss or addictive behaviors, etc. is that I feel like I was able to change my microbes enough and the cravings that I have enough to overcome some of those sugar cravings. I don’t even feel that I need to do that when I’m at home. But I will tell you that if the kids are in bed and I’m going to sit down in front of the television and it’s nine o’clock at night, the first thing that I think about even now and when I’m not hungry, maybe I’ve already brushed my teeth, I know I’m going to be getting in bed in 30 minutes, I know it’s not good for me, is that I want to go and get something out of that pantry and eat it. I don’t, but I can feel the trigger happening. I can feel the desire, whether it’s comfort, whether it’s an addiction, who knows. But I just want to give a little relatable anecdote for people, not because I overcame something and I’m so amazing but because we’re all struggling with these things and the more honest we are the more open we are the more we talk about things – and in another episode I mean I had an eating disorder in high school we can definitely talk about that – the more we talk about these types of things we can let people know that it’s okay, it’s okay to have regret. I wish I could do that over. I wish there are things I could do about my daughter’s cancer journey over. I wish there are things I could do about my failed relationships over. But the fact of the matter is, I use that information to inform my decision moving forward. And that can be taken full circle back to the Ozempic talk and discussing power versus shame and how we can take over the power to make a change.
I love that connection. And just to go back to what you said about when the kids are in bed and you sit down at nine o’clock in front of the TV; a lot of that is a conditioned response. It’s Pavlovian, it’s Pavlov’s dog. The kids are put away, it’s quiet. And so that is what so much of compulsive overconsumption is. It is a maladaptive coping mechanism. And it’s interesting to me when people – I had this conversation with a friend recently, and she was telling me about a friend’s substance abuse. And she said, well, she’s, you know, she’s just trying to treat her ADD. That’s what it is. But it was said in a way that absolved the person of any responsibility for the substance abuse because she was medicating for her ADD, of course, duh. And so that is what addiction is. And that is what actually some of the things like ADD and ADHD are, they are maladaptive behaviors that we have put in place to try and deal with something. Right, in the case of ADD, maybe it’s difficult to focus. So I’m gonna do these five things at once, or I’m gonna distract myself or whatever it is, or I am a single mother and it’s finally the end of my day and I feel like I should be rewarded in some way and this is a reward that I’m having. And so to your point, recognizing doesn’t mean that we don’t do them, but recognizing them is the first step in sort of diffusing the power they have over us. Awareness and acceptance.
Yeah. So to bring it back to the GLP-1 agonists, and honestly, it’s such a difficult topic. We were both at a health and wellness conference in the fall in Palm Beach, and there were a lot of opinions, a lot of strong opinions about this. And where I settle is sort of where I settle with the biologics in my treatment of inflammatory bowel disease. And I’ll be the first one to point out, I’m not an obesity expert. In fact, I don’t treat obesity in my medical practice. I never have as a main thing that I treat. Are some of the patients I treat with digestive disorders, overweight? Sure. But if somebody comes to see me for weight loss, I tell them that’s not what I do. But if I use the analogy of a biologic, these are powerful drugs that have the ability to change people’s lives and sometimes save people’s lives. That is indisputable. But what is also indisputable is that they are not judiciously used. They are over prescribed. And a lot of the people who they’re being prescribed for are being presented with them as this is the only option. There’s nothing else you can do. And that’s the part I object to. And that’s the part I don’t just object to, I feel very strongly that when you present it that way, what you do is you take away their power to really have dominion, if you will, over their own body. And that’s the problematic part of all of this.
Yeah, take away the power to try anything different or something different.
Yeah, or to feel like you can. And I laugh about this because I think my family thinks that I’m one of those people who are like: I can go into the lion’s cage and the lion will know that I come in peace and I will not be harmed by the lion. And they’re like, you will be the first person that lion, that lion is gonna tear you to shreds, right? So, you know, there are some things that you cannot do no matter how hard you believe. And I have had patients with Crohn’s and ulcerative colitis who no matter what they did, they went above and beyond everything I asked them to do, and their disease did not respond. And I happily wrote that prescription for Remicade or Humira or Stelara or whatever it was. And I believe that, I mean, I have had patients where I have had to beg them to say, listen, you have been doing this diet for six months and you are actually not just not getting better, you are getting worse! Please, I beg of you, consider a biologic.
Yes, yes, absolutely.
That is, you know, I think it’s a useful analogy for these drugs. There are patients out there who are struggling, who are in danger of having a cardiovascular event, dying from all kinds of different causes because they cannot get their weight under control. But unfortunately, that’s not the majority of people who the drug is being prescribed for.
That’s right. So yeah, I think it’s just presenting a different way and talking about it openly. I mean, this is not meant to be with judgment. It’s meant to be with love and care, but also for people to know that they can bring it up and that they can feel empowered to think about their own decisions and choices. I think it’s also hard as a health care provider to be sort of preaching about something or giving your opinion when maybe people don’t feel like you’ve necessarily walked in their shoes. So again, that’s what the analogies are for, is to try to give you a relatable idea, a compassionate idea, something that gives someone the ability that it’s familiar on some level with the person who’s talking to them about it.
And I want to remind people that when it comes to GLP-1 agonists, when it comes to biologics, when it comes to any one of these medical decisions, there’s not a right or wrong path. But these are different paths that do lead to different places and that’s what you need to be aware of. Janet, thanks for sharing your perspective with us. Always a treat to have you on the show.
I want to leave you with three takeaways about GLP-1 drugs for the treatment of obesity:
1. Judicious use is essential because these drugs have serious side effects, not just the GI symptoms, but also an increased risk of things like pancreatitis and cancer.
2. If you are going to take one of these drugs, make sure you have a structured plan for diet, lifestyle, and behavioral changes while you’re on the drug, and even more importantly, for when you get off the drug, ideally with the help of a practitioner who has some expertise in this.
3. And finally, there is no wrong or right decision when it comes to these medications, only the choice that is right for you. But I want you to make sure that that decision is well-informed and that you’re making it with eyes wide open.
So that’s it for this episode of the Gutbliss podcast on GLP-1 agonists and making an informed decision. Go to Gutbliss.com for my free 7-day microbiome reboot course. If you like what you’re hearing, drop a review and hit that subscribe button. And remember, dirt, sweat, vegetables – the best prescription for a healthy gut.
The information presented in this show is not meant to be medical advice. Consult your doctor before making any decisions about your health. The patients discussed are real people, but names and identifying features have been changed to protect their privacy.
