Episode 2
The Weight of Change: Integrating GLP-1 Therapy with Physical Activity
In this episode of the Movement Prescription Podcast, Callum sits down with GP and lifestyle medicine experts Hussain and Suzy to explore the transformative role of GLP-1 agonists in obesity management. They discuss how medications like Saxenda and Wegovy work to modulate hunger and satiety, and emphasize the importance of pairing these treatments with lifestyle changes—especially regular physical activity—to achieve sustainable weight loss. The conversation also delves into potential side effects, the benefits of preserving muscle mass through resistance training, and the broader challenges faced within the NHS. Tune in for evidence-based insights and actionable strategies for integrating pharmacological and lifestyle interventions in the fight against obesity.
Produced with support from the British Society of Lifestyle Medicine.
Find us at https://themovementprescription.co.uk/ and join the conversation!
Transcript
Intro: Hello, and welcome to the Movement Prescription Podcast. This week,
Speaker:Intro: we have a slightly different episode where both Hussein, Susie, and I are on the podcast.
Speaker:Intro: Hussein recently has become a bit of an expert in GLP-1 agonists,
Speaker:Intro: and so Susie and I decided to interview him.
Speaker:Intro: It's quite a wide ranging episode where we initially talk about what they are,
Speaker:Intro: their licenses for use, their side effects and their effectiveness before importantly
Speaker:Intro: going on to talk about lifestyle and particularly physical activity.
Speaker:Intro: At the end Hussein has some real action points and calls to action whether you're
Speaker:Intro: a health professional, work in the physical activity sector or just someone
Speaker:Intro: that's really interested in their own health. We really hope you enjoy.
Speaker:Callum: Hey guys how's it going?
Speaker:Hussain: Very well thank you.
Speaker:Suzy: Hi, Callan.
Speaker:Callum: This is a slightly different episode today. And Hussein, if someone's tuning
Speaker:Callum: in for the first time, can you give us a quick introduction to you and what you do?
Speaker:Hussain: So my name's Hussein. I'm a GP based in the West Midlands, and I have an extended
Speaker:Hussain: role in lifestyle medicine with a number of different options sort of in a portfolio career.
Speaker:Hussain: I work at the Royal College of GPs alongside yourself as one of the Physical Activity Champions.
Speaker:Hussain: I also work at Parkrun as the Health Partnerships Lead.
Speaker:Hussain: And I'm the Lifestyle Medicine Course Lead at Red Whale, GP Update, as many of you will know.
Speaker:Hussain: So creating content there and also leading their obesity course.
Speaker:Callum: Great, thanks. And often on TV, don't forget that.
Speaker:Hussain: Well, every now and again.
Speaker:Callum: Good morning. Great Britain.
Speaker:Callum: So today i susie was gonna open with a great question which she posted me earlier
Speaker:Callum: susie before i steal your sandwiches i'm gonna let you you ask that question.
Speaker:Suzy: Hussein this is a this is an episode with a difference because obviously we're
Speaker:Suzy: entitling it the the glp ones and physical activity but why are we talking about
Speaker:Suzy: a medication on the movement prescription podcast that's.
Speaker:Hussain: A fantastic question. And I think its answer is quite complicated,
Speaker:Hussain: but I'll give you a simple one.
Speaker:Hussain: When we think about how GLP-1s are going to be used, physical activity has a
Speaker:Hussain: really important aspect to every part of that.
Speaker:Hussain: Not just how we should prepare patients before they start treatment,
Speaker:Hussain: Not only that the evidence shows that physical activity, in particular resistance
Speaker:Hussain: training during treatment, yields better results.
Speaker:Hussain: And I think most importantly, physical activity has been shown to be probably
Speaker:Hussain: the biggest lever that the patient can pull to prevent weight regain after stopping these injections.
Speaker:Hussain: And that's visibly important, not just for the patient so they don't go through
Speaker:Hussain: yo-yoing exercise of losing weight and the psychological trauma that that leads to.
Speaker:Hussain: But when we think about the cost of tizepatide on the NHS, which is one of the
Speaker:Hussain: leading GLP-1s and GIP injections, that's coming in at around £20,000 per quality adjusted life year.
Speaker:Hussain: And that's just right on the threshold for NICE in terms of what they would
Speaker:Hussain: class as being cost effective.
Speaker:Hussain: If we see significant weight regain on these injections, then we aren't going
Speaker:Hussain: to get that benefit, sadly.
Speaker:Callum: You're saying for people that are listening, and loads of people have heard
Speaker:Callum: about GLP-1 agonists, Wigovi, Tersepetide, some people might not have.
Speaker:Callum: And just could you give a really quick start of six about what GLP-1 agonists
Speaker:Callum: are, what they do, and maybe just briefly touch on the different names that
Speaker:Callum: we might have heard in the media.
Speaker:Hussain: So GLP-1 is a class of medications that you may have heard of recently,
Speaker:Hussain: but it's been around for a little while because we've been using it in type 2 diabetes.
Speaker:Hussain: Now, GLP-1 is naturally produced in the body.
Speaker:Hussain: It's actually produced in the small intestine, predominantly in the final part,
Speaker:Hussain: which is called the ileum, out of L-cells.
Speaker:Hussain: And when we eat meals, it responds to that,
Speaker:Hussain: releases GLP-1, glucose-like peptide, and it then acts on the brain to promote
Speaker:Hussain: the release of chemicals which make you feel full.
Speaker:Hussain: It's one of the short acting, um, hormones, if you think of it from that sense.
Speaker:Hussain: So it, it controls your hunger and satiety over short periods of time,
Speaker:Hussain: you know, over sort of minutes to hours, while you have longer acting, um,
Speaker:Hussain: hormones, things like insulin that, that will be controlling your hunger and
Speaker:Hussain: appetite levels over much longer periods of time.
Speaker:Hussain: So insulin, leptin, they generally are slow and your long-term control of appetite,
Speaker:Hussain: while things like peptide YY and GLP-1, these are all things that the body's
Speaker:Hussain: producing and just controlling it a more finite, shorter period of time.
Speaker:Hussain: Now, in terms of the agents that we've got, the first one that was predominantly
Speaker:Hussain: used in the UK was called Saxenda.
Speaker:Hussain: It's the trade name. The drug name is called loraglutide.
Speaker:Hussain: And that technology appraisal was released in 2020.
Speaker:Hussain: Before that, it was used for type 2 diabetes. But in how we work in the UK,
Speaker:Hussain: things have to be authorized for an indication. So for it to be used in weight
Speaker:Hussain: loss only rather than type 2 diabetes, that was 2020.
Speaker:Hussain: Then we had semaglutide, which trade name is called Wagovi. And that had its
Speaker:Hussain: technology appraisal issued in 2023.
Speaker:Hussain: And a lot of people, they know Wagovi, but the probably more well-known version
Speaker:Hussain: of semaglutide is a Zempic.
Speaker:Hussain: And now a Zempic is how it's authorized and licensed in type 2 diabetes.
Speaker:Hussain: So it's the same drug as Wagovi, but slightly different dose range because we
Speaker:Hussain: found that the majority of the weight loss benefits come in the higher doses.
Speaker:Hussain: So Wagovi is just think of it as a higher dose range to a Zempic.
Speaker:Hussain: And then the most recent one which was actually only authorized in december 2024.
Speaker:Hussain: Is to zapatide which is it
Speaker:Hussain: has a trade name manjaro and interestingly with to zapatide it's trade name
Speaker:Hussain: for type 2 diabetes and for weight loss is the same so just to sort of keep
Speaker:Hussain: the stop to buck the trend so to speak they've they've done it that way and
Speaker:Hussain: i think it's sensible because otherwise it just leads to a lot of confusion.
Speaker:Hussain: And that one's unique because unlike with semaglutide and loraglutide,
Speaker:Hussain: tezapatide has been authorized for both primary and secondary care.
Speaker:Hussain: So this is coming into primary care and that means a much wider audience of people.
Speaker:Hussain: And just to give you the impact that this is going to have, 2.8 million people
Speaker:Hussain: are eligible for tizepatide.
Speaker:Hussain: And it's estimated that one in five GP appointments will be related to either
Speaker:Hussain: starting titrating or managing in some way patients on specifically tizepatide.
Speaker:Hussain: So it's, it's both a challenge, but also an opportunity because if we know that physical
Speaker:Hussain: activity is a key element to ensure healthy weight loss and maintenance,
Speaker:Hussain: then this could well be the driver for change within primary care to get more
Speaker:Hussain: lifestyle, not just physical activity,
Speaker:Hussain: but more lifestyle medicine within primary care.
Speaker:Callum: A couple of things to just pick up on. I suppose, from my understanding,
Speaker:Callum: the research looks pretty good.
Speaker:Callum: The Wigovi, maybe 11% weight loss over 12 months is what they report,
Speaker:Callum: whereas the Majora terzepatide is 22% over 12 months.
Speaker:Hussain: So over 72 months. So over a longer period of time, so 72 months.
Speaker:Hussain: But although there's been no head-to-head trials between the two,
Speaker:Hussain: from what you can tell from looking at the different trials that have been done,
Speaker:Hussain: tisepatide does look more effective at weight loss.
Speaker:Hussain: And the key difference is tisepatide is a dual receptor.
Speaker:Hussain: It works both on GLP-1 and GIP, which is gastric inhibitory peptide.
Speaker:Hussain: Um, and there are a number of drugs down the line, which also work on either
Speaker:Hussain: dual or even triple because there's, there's something there's,
Speaker:Hussain: there's, there's a glucagon, um, receptor, which, which some,
Speaker:Hussain: um, drugs like retarutide, um,
Speaker:Hussain: and servutide is acting on.
Speaker:Hussain: So there's a lot of scope. This is not the, you know, we are by no means near
Speaker:Hussain: the middle of this story.
Speaker:Hussain: We're probably right in the first chapter of where this could potentially be going.
Speaker:Callum: And from my understanding, I've prescribed oral GLP-1 agonists for diabetes,
Speaker:Callum: but most of the stuff in the news is about weekly injectable forms because they're the most effective.
Speaker:Callum: And you talk about it being a big story. It is a huge story. It's all over the news.
Speaker:Callum: Susie, have you seen much of it?
Speaker:Callum: Have you know no doubt read the news what are your thoughts and and and experiences
Speaker:Callum: of kind of these drugs and and.
Speaker:Suzy: Yeah it's interesting isn't it because these are you know in in
Speaker:Suzy: the data they are fantastic class of drugs but they have got the the propensity
Speaker:Suzy: to maybe bankrupt the NHS if they're adopted as widely as they could be so I
Speaker:Suzy: suppose as general practitioners and you know with my various hats on you know
Speaker:Suzy: my lifestyle medicine hat on you know you begin to ask well if you're prescribing this,
Speaker:Suzy: is this a sticky plaster or are we dealing with the underlying pillars of health?
Speaker:Suzy: Are we dealing with the unhealthy food environment that we're living in?
Speaker:Suzy: Are we dealing with the environment that leads us to be sedentary, et cetera?
Speaker:Suzy: With my diabetes roll hat on, these are fantastic drugs for diabetes and I don't
Speaker:Suzy: think we should be, I think we need to,
Speaker:Suzy: is there enough to go around for the people who need it the most?
Speaker:Suzy: You know, forever talking about the people who need things the most,
Speaker:Suzy: whether that's lifestyle interventions or indeed medication.
Speaker:Suzy: We're aware of people getting them online from online pharmacies and completely
Speaker:Suzy: inappropriately getting them from online pharmacies.
Speaker:Suzy: So there's an overwhelming amount of information. It's quite difficult to focus our thoughts on this.
Speaker:Suzy: Have I prescribed much in the way of injectables only within patients who've
Speaker:Suzy: been started the injectables by the diabetes team.
Speaker:Suzy: But I'm fully aware with my other hat on, my LMC hat on, the medical politics
Speaker:Suzy: side of, you know, GPs are worried about the workload that is no doubt coming
Speaker:Suzy: their way, which will be slightly different in Scotland to what's coming your
Speaker:Suzy: way, Hussein, in England, I think, just with the different rules.
Speaker:Suzy: But, you know, it can feel overwhelming.
Speaker:Suzy: There are so many different types of GLP-1s and combinations that it can feel
Speaker:Suzy: very confusing. That's to use your word there, Hussein.
Speaker:Suzy: So I, you know, I have various views and I'm looking forward to learning from
Speaker:Suzy: all the work that you've done, Hussein, just helping to clarify and,
Speaker:Suzy: you know, what is within our power?
Speaker:Suzy: Because a lot of these prescribing decisions come from on high, don't they?
Speaker:Suzy: You know, once those decisions have been made, what is within our power?
Speaker:Suzy: How can we get the best out of these medications?
Speaker:Callum: For listeners, Susie not only gave an incredibly eloquent response,
Speaker:Callum: but she's also cuddling a 12-week-old puppy who is trying to bite her.
Speaker:Callum: And it's a masterclass in multitasking, isn't it, Hussain?
Speaker:Hussain: Absolutely. I was so thrown by that. No, I'm joking. I heard the question. It was fantastic.
Speaker:Hussain: Does it fix the underlying issues? No.
Speaker:Hussain: And I do fear that if it's not used as a tool,
Speaker:Hussain: then we will just exacerbate a lot of the kind of inherent issues as to why, unfortunately,
Speaker:Hussain: 70%, well, just under 70% of men and 60% of women are unfortunately overweight
Speaker:Hussain: and obese, and they're living with that. And so,
Speaker:Hussain: What we should think of it is not as the answer, but as a tool to support weight
Speaker:Hussain: loss, because we know physiologically, weight loss is extremely challenging.
Speaker:Hussain: Forget about the environment element that they're also having to combat and
Speaker:Hussain: the reason why the weight gain has happened.
Speaker:Hussain: It's really hard to achieve. So if we can utilize these injections, but it has to be done.
Speaker:Hussain: Alongside lifestyle support, not just nutrition and physical activity,
Speaker:Hussain: but beyond that in terms of how do we try to support the kind of the holistic
Speaker:Hussain: approach of both community elements, the stress that may be going on,
Speaker:Hussain: whether it be work, family,
Speaker:Hussain: how can we support patients in a long-term, in-depth way?
Speaker:Hussain: Because if all they're going to get is GLP-1, then I can assure you they will
Speaker:Hussain: lose weight, but then they will regain the weight.
Speaker:Hussain: And they are going to be either having to take GLP-1 injections for the rest
Speaker:Hussain: of their lives, or they're going to be aggressively yo-yoing in weight up and down.
Speaker:Hussain: And that, that's, I think will be a massive shame.
Speaker:Hussain: But I do fear that in terms of the rollout, in sort of the hope for scalability.
Speaker:Hussain: That we will see corners being cut.
Speaker:Hussain: And when corners are being cut, you will not lead to the long-term benefit that
Speaker:Hussain: you could potentially extract from this.
Speaker:Hussain: And you can see it in studies. There was one study that looked at a group of
Speaker:Hussain: patients, all had a year's worth of loraglutide, so that version of the GLP-1.
Speaker:Hussain: Now, one group had no physical activity support.
Speaker:Hussain: The other group had physical activity support. And it was in the sort of realm
Speaker:Hussain: of two sessions a week, half an hour, predominantly strength resistance training.
Speaker:Hussain: Now, when you looked at a year after stopping loraglutide.
Speaker:Hussain: The group that had just the GLP-1, no physical activity during that year,
Speaker:Hussain: had gained six kilograms on average.
Speaker:Hussain: But the group that had physical activity during that year, but not during the
Speaker:Hussain: year once they stopped it, they were left to their own devices after that.
Speaker:Hussain: They only gained two and a half kilograms. So that's a big difference.
Speaker:Hussain: And when you're thinking about the two and a half to six, when you then extrapolate
Speaker:Hussain: that across the population, that's many, many pounds. and that's also obviously
Speaker:Hussain: an improvement to their health as well.
Speaker:Hussain: So I think on many different fronts, we need to be careful not to rush these
Speaker:Hussain: things out and instead focus on how do we produce the wraparound support that's
Speaker:Hussain: necessary to make sure that patients have now an option to support them in healthy
Speaker:Hussain: weight loss rather than,
Speaker:Hussain: for example, you see the headlines of take GLP-1s to get people back to work.
Speaker:Hussain: And it's just such an over-reduction of the complexity of what an illness like
Speaker:Hussain: obesity is to think that somehow if you inject people, they'll be more likely to work.
Speaker:Hussain: There's so many other barriers that prevent that.
Speaker:Hussain: But I think it's really important that we consider that and we consider the whole package.
Speaker:Callum: Hussain, I really want to pick your brains from all the work you've done on
Speaker:Callum: kind of what the lifestyle and the physical activity look like.
Speaker:Callum: But before that, you mentioned two kind of really scary statistics earlier on,
Speaker:Callum: which is that 2.8 million people in the UK will be eligible and that it will
Speaker:Callum: account for 20% of all GP appointments in 12 years' time when it's fully rolled out.
Speaker:Callum: And that's based on the NICE guidance that was released in, was it December,
Speaker:Callum: which talked about everyone that's above a BMI of 35 will be eligible?
Speaker:Hussain: Yeah so that was specifically the technology the
Speaker:Hussain: nice technology appraisal for to zepatide because unlike the other glp ones
Speaker:Hussain: in the past to zepatide will be open in terms of where it can be prescribed
Speaker:Hussain: prescribed it doesn't need to be in specialist services yeah it will be open
Speaker:Hussain: to be described across and in the nice committee kind of guidance notes,
Speaker:Hussain: They explained that obesity is a chronic, long-term condition that affects many
Speaker:Hussain: people and therefore needs to be accessible, treatment needs to be accessible
Speaker:Hussain: in a wide range of places.
Speaker:Hussain: If we expect the huge proportion of our population to be going through specialist
Speaker:Hussain: weight management services, it's never going to happen.
Speaker:Hussain: Do you know what I mean? It's never going to, they're already inundated with huge wait lists.
Speaker:Hussain: For example, what's your wait list up in Scotland? And mine,
Speaker:Hussain: it's about two to three years.
Speaker:Callum: Yeah, the wait list is massive. But I think, I agree, we need to know about this.
Speaker:Callum: It's coming our way in like a tidal wave, isn't it? But also 20% of new appointments
Speaker:Callum: that just, where does that come?
Speaker:Callum: We're in a system that is bursting at the seams anyway.
Speaker:Callum: I think those statistics will scare a lot of people, I'm sure.
Speaker:Callum: And we need the systems, as you mentioned, in place.
Speaker:Hussain: Exactly. And currently there's a trial called the Surmount Real trial,
Speaker:Hussain: which is based in Manchester, in primary care, where they're assessing just
Speaker:Hussain: that, you know, how can it be delivered?
Speaker:Hussain: More than likely, it's going to be outside of your traditional kind of clinic sessions.
Speaker:Hussain: And also, who's delivering it? Because I think from what most evidence shows,
Speaker:Hussain: it doesn't need to be clinician-led all the time. I think there obviously needs
Speaker:Hussain: to be a prescriber there.
Speaker:Hussain: But that wraparound support, that could be group consultations for example.
Speaker:Hussain: The physical activity groups that could be linking in with local physical activity
Speaker:Hussain: partners into the current referral pathways that they could have dedicated ones
Speaker:Hussain: for these kind of presets.
Speaker:Hussain: So that scalability is going to be really important. Now, the worry is that
Speaker:Hussain: they're going to go for kind of the minimum effective option,
Speaker:Hussain: which I think isn't right in this case.
Speaker:Hussain: I think obesity is too complicated and too important a societal issue that we
Speaker:Hussain: should go for the minimal effective dose.
Speaker:Hussain: And my hope is that what we will see is potentially a shift in how even primary care is delivered.
Speaker:Hussain: So we start to understand that 10 minutes or 15 minutes or even 20 minutes is
Speaker:Hussain: not an enough time for long-term conditions.
Speaker:Hussain: And instead, we need an approach which is based on intensive support and then
Speaker:Hussain: a titration down where, for example, they come in and they have maybe a 12-week,
Speaker:Hussain: once a week group consultation with support from a dietician and a health coach.
Speaker:Hussain: And then, yes, they have the prescriber who's doing the GLP-1 maintenance and
Speaker:Hussain: ensuring that is done correctly and safely.
Speaker:Hussain: And then slowly, then that gets weaned off. But they have support for one,
Speaker:Hussain: two, maybe even three years.
Speaker:Hussain: That support may suddenly turn into 12 weekly e-check-ins, etc..
Speaker:Hussain: But I think that's what's necessary. And, you know, Susie made a point of that,
Speaker:Hussain: you know, people are going online, filling out an online form,
Speaker:Hussain: getting a prescription from the pharmacy, and they're not speaking to anyone.
Speaker:Hussain: You know, they're not seeing anyone. In fact, today, the General Pharmaceutical
Speaker:Hussain: Council actually issued guidance saying that that can't happen.
Speaker:Hussain: You know, you have to at least, you know, touch base with the patient.
Speaker:Hussain: The patient has to at least have a port of call in terms of contacting someone
Speaker:Hussain: if they have issues, et cetera. So that's been tightened up a little bit now,
Speaker:Hussain: but it's still, that's not gold standard care.
Speaker:Hussain: I wouldn't even call that kind of like bronze standard care,
Speaker:Hussain: what a lot of people are getting. And the vast majority are getting it that way.
Speaker:Hussain: In terms of accessibility to these injections, because for a long time we've
Speaker:Hussain: had national shortages.
Speaker:Hussain: And that's because the drug company just did not predict the level of response to these medications.
Speaker:Hussain: And so Nova Nordisk, which does like Wagovi and Sexenda, like it takes a long
Speaker:Hussain: time to increase production and for that to actually filter through.
Speaker:Hussain: Now, Eli Lilly, which make Tizepatide, like they've kind of had a bit more head
Speaker:Hussain: start in terms of they've seen what the market is like.
Speaker:Hussain: And so there isn't any stock issues currently for Tizepatide.
Speaker:Hussain: So I can see a future where stock isn't going to be a problem anymore.
Speaker:Hussain: It's going to be about actually delivering this because it's estimated that
Speaker:Hussain: through the NHS, even in primary care, it will take 12 years to get through
Speaker:Hussain: everybody that's eligible.
Speaker:Callum: I'm stuck for words. There's so much to process. There's a couple of things
Speaker:Callum: I suppose that I wanted to touch on.
Speaker:Callum: And one Susie and I actually have talked about.
Speaker:Callum: We talked a bit about what physical activity is needed.
Speaker:Callum: And I think Susie had said previously that are we at risk of switching one kind
Speaker:Callum: of issue of obesity with another, which is sarcopenia and muscle loss?
Speaker:Callum: And so, yeah, maybe you could kind of tell us a bit about the evidence behind that, Hussein.
Speaker:Callum: And then the other thing is, you know, we've got quite a few patients that have a similar issue.
Speaker:Callum: The pharmacy issues, they're kind of prescribed online, no follow-up.
Speaker:Callum: And they have come in with side effects. And I think the side effects aren't
Speaker:Callum: well publicized as far as I'm aware.
Speaker:Callum: And so I think it would be really helpful possibly from a listener's perspective
Speaker:Callum: to know what those side effects of the medication are. So maybe start with the
Speaker:Callum: side effects and then tell us a bit about, you know, sarcopenia and resistance training.
Speaker:Hussain: Yeah, no, very good question. So starting off with the side effects,
Speaker:Hussain: they will never ever be well sort of published.
Speaker:Hussain: I don't think it's something that anyone wants to advertise, but they are there.
Speaker:Hussain: And I'd say they're higher than what you'd normally get in most of the medications
Speaker:Hussain: we prescribe. And you can tell that because of the adherence,
Speaker:Hussain: like long-term adherence.
Speaker:Hussain: So over 12 months is pretty low. It's like under 10%.
Speaker:Hussain: So that's telling you that, you know, this is something that people are struggling
Speaker:Hussain: to maintain on, but there's lots of, and it's interesting, actually,
Speaker:Hussain: there's lots of lifestyle factors that improve the side effect profile.
Speaker:Hussain: And often it's that issue of, because they haven't got the lifestyle factors
Speaker:Hussain: quite aligned, it makes it much harder to tolerate.
Speaker:Hussain: So the most common ones are all gastrointestinal. We're talking about nausea,
Speaker:Hussain: diarrhea, vomiting, abdominal pain, constipation as well.
Speaker:Hussain: And then also there's injection site reactions these
Speaker:Hussain: are things that you inject yourself you put it into the
Speaker:Hussain: subcutaneous tissue so you're advised to
Speaker:Hussain: rotate around four different spots around the body
Speaker:Hussain: but you can get reactions where the skin will become inflamed etc now there
Speaker:Hussain: are rare but more serious side effects and it's hard to know exactly the kind
Speaker:Hussain: of incidence of these because in you can get data from the trials but generally
Speaker:Hussain: when you look in real life data you tend to get more of these than you get in the trials.
Speaker:Hussain: And we're talking about things like increased suicidality.
Speaker:Hussain: So there's been about 150 case reports of increased suicide risk and self harm behavior.
Speaker:Hussain: And weirdly, or maybe even not weirdly, but this is seen in bariatric surgery as well.
Speaker:Hussain: So we don't know if this is a symptom of rapid weight loss or a symptom specifically
Speaker:Hussain: of, you know, separate, that's bariatric surgery and GLP-1 medications do it,
Speaker:Hussain: but there seems to be a, um, element between the two.
Speaker:Hussain: And the other one, which is thyroid cancer.
Speaker:Hussain: So both papillary and medullary cancer, thyroid cancer is more common or at
Speaker:Hussain: least I'd say associated because there's no causation that's been proven through
Speaker:Hussain: here, but there's an association. So there was.
Speaker:Hussain: In patients between one to three years of use of GLP-1s, there was a 58% increase
Speaker:Hussain: in terms of relative risk, sorry, absolute risk.
Speaker:Hussain: But when you need to bear that in mind, that sort of 58%, so that is,
Speaker:Hussain: yeah, quite a chunk increase.
Speaker:Hussain: But thyroid cancer is actually really rare. So you're making a really rare cancer
Speaker:Hussain: into something that's slightly less rare.
Speaker:Hussain: So when you look at a population, we probably aren't overly concerned by that.
Speaker:Hussain: And because they're such small numbers, any increase will always look like a
Speaker:Hussain: huge percentage when it probably isn't such.
Speaker:Hussain: Now, in terms of how we can sort of minimize these side effects,
Speaker:Hussain: we know that patients that have higher fiber and water in their diet tend to get less constipation.
Speaker:Hussain: Those that have lower saturated fats and smaller portion sizes have less nausea.
Speaker:Hussain: Um if they have a diet
Speaker:Hussain: that's high in vitamin a d e k
Speaker:Hussain: and beta carotene you tend to see less of
Speaker:Hussain: the kind of nutritional deficiencies that you may get so it
Speaker:Hussain: just really kind of really sells the importance that when someone's on a reduced
Speaker:Hussain: calorie diet which will naturally happen when your appetite's been significantly
Speaker:Hussain: suppressed the quality becomes even more important okay Because if you're eating
Speaker:Hussain: less of not such good quality food,
Speaker:Hussain: that's going to have a much bigger impact in terms of the lack of fiber,
Speaker:Hussain: the lack of nutritional elements.
Speaker:Hussain: So patients need to be supported with this, not just when they're on the GLP
Speaker:Hussain: ones, but beforehand, you know, it needs to be kind of like a phased approach
Speaker:Hussain: where you bring in these elements of nutrition and physical activity,
Speaker:Hussain: and then the medication gets inserted at the right point.
Speaker:Hussain: Does that make sense? Now, exactly what point that will be, that will need to
Speaker:Hussain: be studied and to decide what is the most sensible point to start a GLP-1.
Speaker:Hussain: In reality, what's happening is people are just going onto the GLP-1 and then
Speaker:Hussain: they're having to try and work this all out afterwards with minimal support.
Speaker:Hussain: And that's not going to lead to long-term benefits. Now, you asked about the
Speaker:Hussain: sarcopenia question. So that's sort of losing muscle mass.
Speaker:Hussain: And that is an interesting question that He's got people on both sides of the debate. Okay. So, okay.
Speaker:Hussain: Now, firstly, agreement as to how common sarcopenia is within obese patients
Speaker:Hussain: is not clear because there's wide range.
Speaker:Hussain: From one study to the other, you can see different proportion of patients that
Speaker:Hussain: are suffering with sarcopenia while obese.
Speaker:Hussain: And that can sometimes sound quite counterintuitive because you think,
Speaker:Hussain: well, surely they've got significant muscle mass.
Speaker:Hussain: That's not the problem, but no, you can get sarcogenic obesity,
Speaker:Hussain: but that's generally seen in older populations.
Speaker:Hussain: Okay. So older populations that are less active, they generally have lower muscle
Speaker:Hussain: mass and higher body fat ratio.
Speaker:Hussain: And that's one of the reasons why NICE tell us if they're over 65,
Speaker:Hussain: you shouldn't be using a BMI.
Speaker:Hussain: You should be using a waist to height ratio to try to pick that up because the
Speaker:Hussain: BMI may be great, but actually it's great because they've lost like eight kilos
Speaker:Hussain: of of muscle and gained eight kilos of fat.
Speaker:Hussain: So it's really mindful of that. Now for the majority of younger patients that are obese.
Speaker:Hussain: Sarcopenia is relatively rare because if you're being active and getting on
Speaker:Hussain: with your day, you're actually probably got slightly more muscle mass than most
Speaker:Hussain: because you're literally having to move and bear higher levels of weight.
Speaker:Hussain: Now, GLP-1s don't uniquely reduce muscle mass when you have the weight loss process.
Speaker:Hussain: This is something that happens with any rapid weight loss. You will have about
Speaker:Hussain: 25 to 40% muscle mass loss. Okay.
Speaker:Hussain: And that isn't just purely just muscle, but we call it fat free mass.
Speaker:Hussain: So that's muscle, but it's also like body fluids, organs, tissues.
Speaker:Hussain: You know, there's lots of things that contribute into that fat free mass.
Speaker:Hussain: Now, the majority of it is likely going to be skeletal muscle.
Speaker:Hussain: But at the moment, no studies have looked at breaking the fat-free mass down
Speaker:Hussain: because in terms of what you'd need to use as a modality, you'd have to use
Speaker:Hussain: MRI to work that out because DEXA just tells you kind of what's bone.
Speaker:Hussain: It tells you what's fat, but then the rest is kind of like, it just lumps it in one big group.
Speaker:Hussain: So DEXA is, is, is very easy to do on a trial setting with lots of patients.
Speaker:Hussain: MRI is a lot more expensive and arduous. So hopefully there'll be studies that
Speaker:Hussain: explore that so we really get an idea.
Speaker:Hussain: But what we find is that the more rapid the weight loss is, the more likely
Speaker:Hussain: you are to see a drop in muscle mass.
Speaker:Hussain: But interestingly, the GLP-1s all have different levels to which we see this.
Speaker:Hussain: Now, not in head-to-head trials, but looking at separate trials.
Speaker:Hussain: Um, tizepatide seems to be better at preserving the muscle mass loss compared
Speaker:Hussain: to semaglutide, which is the Zempic-Wagovie.
Speaker:Hussain: For example, we saw with the Zempic and sort of the semaglutide trial,
Speaker:Hussain: that was 39% fat free mass lost, while with tizepatide, it was 25%.
Speaker:Hussain: So a significant difference.
Speaker:Hussain: Now, in terms of how do we minimize the muscle mass loss, we come back to lifestyle.
Speaker:Hussain: Okay. The number one thing is physical activity.
Speaker:Hussain: Resistance training will very much help to prevent that muscle mass loss to as a severe level.
Speaker:Hussain: And then the other bit is increased protein intake. So if you've had increased
Speaker:Hussain: protein intake, it's not really the timing during the day.
Speaker:Hussain: It tends to be the total amount that's being consumed in the day that also preserves muscle mass.
Speaker:Hussain: And it's all because of the signaling that happens when your body absorbs a
Speaker:Hussain: higher dose of protein. It's all signals to the muscles to try to regenerate
Speaker:Hussain: and to increase structure.
Speaker:Hussain: So generally, overall, what we're seeing, we want to have a slower approach to the weight loss.
Speaker:Hussain: So using lower doses for a bit longer rather than higher doses for shorter.
Speaker:Hussain: We want a higher protein intake and we want to encourage them to include resistance
Speaker:Hussain: training that doesn't have to be in the gym.
Speaker:Hussain: You know, that could be home workouts that can be getting them to do some gardening,
Speaker:Hussain: whatever it is we just need to test the muscles and try to have a more old body
Speaker:Hussain: approach to preserve your muscle mass thanks.
Speaker:Callum: Usain that was a big answer to a number.
Speaker:Hussain: Of questions that I just splurted.
Speaker:Callum: Out so that was great Susie have you got any questions.
Speaker:Suzy: No I was just furiously making notes there because I can almost visualize like
Speaker:Suzy: a one-page summary of the lifestyle interventions that we need to go alongside
Speaker:Suzy: this one tool and what I would call the obesity jigsaw.
Speaker:Suzy: So I tend to do this in mental health. I talk about the mental health jigsaw.
Speaker:Suzy: Um, and I can almost see the one page summary now.
Speaker:Hussain: And that's what we've done at the Red Whale, um, lifestyle medicine course that
Speaker:Hussain: we've created like a visual gem, which sort of brings it all together so that
Speaker:Hussain: you can be like, okay, these are the key points that we need to consider.
Speaker:Suzy: Cause I think, you know, that there's a, the last thing we want to do on this
Speaker:Suzy: show is create any form of moral panic. We want to actually put people back
Speaker:Suzy: in control and say, well, actually, okay, here is this situation and it's coming
Speaker:Suzy: our way, whether we like it or not, but actually here's what we can do about it.
Speaker:Suzy: This is what's within our, what do they call it? The locus of control.
Speaker:Hussain: Yeah.
Speaker:Hussain: And it's a potential opportunity. Yes, there's a threat.
Speaker:Hussain: Absolutely, there is a threat that this will just be overly relied on and considered
Speaker:Hussain: sort of a more effective way to improve the weight of a population rather than
Speaker:Hussain: through lifestyle intervention.
Speaker:Hussain: Or we could say, look, this is actually an opportunity to embed proper lifestyle
Speaker:Hussain: medicine within primary care because for so many people, it's in their interest.
Speaker:Hussain: It's in the interest of the patient.
Speaker:Hussain: It's in the interest of the commissioners. It's in the interest of also primary
Speaker:Hussain: care because we don't want to have to have patients constantly coming back and
Speaker:Hussain: maintaining them on lifelong treatments.
Speaker:Hussain: So apart from the pharmaceutical company, this is in the interest of everyone involved.
Speaker:Callum: The other thing that strikes me, the opportunity is that if people are losing weight,
Speaker:Callum: they've probably been wanting to do it for years and they probably get an emotional
Speaker:Callum: boost from the fact that they are being successful and that kind of wave of
Speaker:Callum: that offers a real opportunity to try and embed some of these other things like
Speaker:Callum: being more active and eating better.
Speaker:Hussain: Yeah and we know that when we compare in terms of when to start GLP-1s those
Speaker:Hussain: that have already lost five percent at least of weight through lifestyle interventions
Speaker:Hussain: do better and lose more weight on the GLP-1s compared to those that are going
Speaker:Hussain: from a cold start, so to speak.
Speaker:Callum: There's been so much gold in this from you, Hussein, which has been awesome.
Speaker:Callum: I suspect we're 30 odd minutes in and it's going to be a double listen,
Speaker:Callum: probably for me anyway, to take notes.
Speaker:Callum: But I wondered, Susie, I'm going to put you on the spot. You mentioned the jigsaw.
Speaker:Callum: Talk to me, visualize that jigsaw for us and then maybe Hussein can add any
Speaker:Callum: other pieces to that jigsaw and that can be our kind of conclusion to the episode?
Speaker:Suzy: I guess for me with a jigsaw I tend to base
Speaker:Suzy: it around the pillars of lifestyle medicine and I'll
Speaker:Suzy: just loosely put them in but I will tailor that to the patient in
Speaker:Suzy: front of me and I'll say well listen of all of these ones that I've briefly mentioned which
Speaker:Suzy: is the most important one to you because usually when you access one you're
Speaker:Suzy: going to start having a ripple effect on all of
Speaker:Suzy: the other ones so I would start with the bare bones sometimes
Speaker:Suzy: if I haven't got time I'll actually just give it to them and say listen this is for you
Speaker:Suzy: to work on when you go home you didn't realize you're going to get homework from me
Speaker:Suzy: there is a schoolteacher inside me um if
Speaker:Suzy: I had longer you know there's there's so many things I don't even
Speaker:Suzy: know which one to pick up on but I just I loved what you're saying there he's
Speaker:Suzy: saying about actually in terms of adherence because that's a major problem with
Speaker:Suzy: it actually if you if you're aware that you can take control of that and and
Speaker:Suzy: make changes like you know increasing your fiber and your water intake and that's
Speaker:Suzy: going to stop you from being as constipated you know then that's that's that's
Speaker:Suzy: a really good starting point so,
Speaker:Suzy: doing the simple things well, which is what I start most of my talks about lifestyle medicine with.
Speaker:Hussain: Absolutely. And I think, I think you use the, these injections and the benefit
Speaker:Hussain: they give them as Callum rightly said, in that it can give them that motivation that it's fine.
Speaker:Hussain: Things are finally working and what you need to instill and what you need to
Speaker:Hussain: get right from the beginning of this process is that this is a temporary effect.
Speaker:Hussain: It doesn't leave permanent impact.
Speaker:Hussain: So you need to start working on those pillars of lifestyle medicine for when
Speaker:Hussain: this injection is stopped, what are you going to lean on?
Speaker:Hussain: You know, is your sleep still going to be really poor? Is there going to be
Speaker:Hussain: still a high amount of stress, which drives you to have an unhealthy relationship with food?
Speaker:Hussain: You know, do you, have you considered how you're going to alter your,
Speaker:Hussain: your portion sizes and the kind of foods that you eat, et cetera.
Speaker:Hussain: So it's kind of like a window of time where a lot of work can be done.
Speaker:Hussain: And we're always thinking and planning about the end day. You know,
Speaker:Hussain: what is the end day of these medications and what is the plan after that?
Speaker:Hussain: Because I think most people don't want to just lose weight. They want to maintain on that weight loss.
Speaker:Hussain: And so it's going to be so important for GPs with an extended role in lifestyle
Speaker:Hussain: medicine to be the kind of leaders within the clusters, networks,
Speaker:Hussain: to be able to support patients in that.
Speaker:Hussain: Because unfortunately, and actually NICE, very much clearly documented this in their notes.
Speaker:Hussain: In primary care, it's very patchy in terms of the lifestyle support patients can get.
Speaker:Hussain: Interestingly, the drug company said that they did a survey and nearly all the
Speaker:Hussain: GPs said that there was loads of lifestyle support within primary care,
Speaker:Hussain: which NICE luckily didn't quite believe, and I don't think anyone would.
Speaker:Hussain: So yeah, what I'm hopeful for is that we can, in that pillar approach,
Speaker:Hussain: I think is absolutely important because pretty much every pillar is associated
Speaker:Hussain: in some way with obesity.
Speaker:Hussain: All of those are important.
Speaker:Hussain: And when we think about looking at the studies, yes, physical activity,
Speaker:Hussain: strength training seems to be really important. Protein, yeah, that's important.
Speaker:Hussain: They're kind of the things that have been tested. It's very hard to test improvements
Speaker:Hussain: in sleep. It's very hard to test improvements in relationships,
Speaker:Hussain: improvements in stress.
Speaker:Hussain: But we know anecdotally, and when we're supporting patients, they have a huge impact.
Speaker:Hussain: They have a huge impact. And obesity is a long-term condition,
Speaker:Hussain: just like all of the other ones that we manage.
Speaker:Hussain: And an injection, a medication is never going to be the answer because it wasn't the problem.
Speaker:Hussain: Patients didn't have a GLP-1 deficiency. That isn't the disease.
Speaker:Hussain: If that was the disease, then fine. This is the solution, but it's not.
Speaker:Hussain: Instead, we're trying to work on the physiology that we understand to buy patient
Speaker:Hussain: support in trying to get the body to a lower weight because we know that it doesn't like to do that.
Speaker:Hussain: And it's got lots of fail-safe mechanisms to stop you losing weight and to make
Speaker:Hussain: it really hard to lose the weight.
Speaker:Hussain: The biggest concern I've got is not that lifestyle won't be implemented along these injections,
Speaker:Hussain: is that we are not going to do any work in the environment because that, in fact,
Speaker:Hussain: is what's meaning that people have to have such a scaffolding around their life
Speaker:Hussain: in terms of protective behaviors and ways to manage their life that it's unmanageable
Speaker:Hussain: for many to achieve that.
Speaker:Hussain: For sure, you know, like many of us are lucky. Maybe we have enough time.
Speaker:Hussain: We have enough motivation. We have enough support. we have
Speaker:Hussain: enough finances to make it doable to lead a healthy
Speaker:Hussain: lifestyle but for others the environment they
Speaker:Hussain: live in means that the amount of work and finances they'd have to implement
Speaker:Hussain: to achieve it it's just unmanageable and so i worry that it's the environment
Speaker:Hussain: and making changes to that that's going to be left behind rather than even the
Speaker:Hussain: lifestyle support within healthcare i think that's probably just about doable
Speaker:Hussain: if we knock on the right doors yeah.
Speaker:Callum: I think that's a really key point and um one that we've highlighted across a
Speaker:Callum: few podcasts now is is is the role of the environment and uh or the importance
Speaker:Callum: of the environment and the role of the health professional and others in advocacy
Speaker:Callum: to try and make a change there and uh yeah i i think that's really key.
Speaker:Hussain: And i i wonder whether when we think about our role whether we're clinicians
Speaker:Hussain: whether we're coming from the physical activity sector.
Speaker:Hussain: And I wonder if what we need to consider is focus on the economic argument of this,
Speaker:Hussain: because often it's the economic argument that gets sold really well as to why
Speaker:Hussain: we shouldn't change the environment as it is, because it generates X, Y, Z.
Speaker:Hussain: But I think more and more now we're starting to realize that the biggest inhibitor
Speaker:Hussain: to economic growth is poor health.
Speaker:Hussain: And it's taken a humongous list of patients that are off long-term sick for
Speaker:Hussain: people to start to want to tackle that.
Speaker:Hussain: And that gets tackled not by trying to inject these people back into work.
Speaker:Hussain: That gets tackled by understanding what was the environment that led to.
Speaker:Hussain: The largest number of people within the working age being too unwell to work.
Speaker:Hussain: And it's just really upsetting.
Speaker:Hussain: You know, it's really upsetting. We've actually launched a lifestyle group consultations
Speaker:Hussain: for patients that have been off work for three months or more through the ICB,
Speaker:Hussain: through like a work well project.
Speaker:Hussain: And I'll be honest, I had some really bad biases. I thought no one's coming
Speaker:Hussain: to this. You know, I'm going to send out this text to patients.
Speaker:Hussain: None of these patients want to come and get support on lifestyle.
Speaker:Hussain: But hell, they're paying me,
Speaker:Hussain: so I'm going to do it. Now, I can just literally see on my computer, Dr.
Speaker:Hussain: Fleming, he's one of my colleagues, Joe Fleming, the clinic is inundated.
Speaker:Hussain: She's like, I'm scared now to open the other practices because I know that we're
Speaker:Hussain: going to have way too many patients than we can even consider dealing with in the next six months.
Speaker:Hussain: And so I think that tells you that these people, they're not work shy.
Speaker:Hussain: They They're actually, unfortunately, living in such an environment that they
Speaker:Hussain: find it exceptionally difficult to maintain work.
Speaker:Hussain: And that's the biggest disappointment, I think, in all of this,
Speaker:Hussain: that we've created an environment that causes that much illness.
Speaker:Callum: We need to get you on and respond to Wes Streeting.
Speaker:Hussain: Absolutely. He can come to the clinic anytime. He can come down and speak to them himself.
Speaker:Callum: All right well look that uh that's been really
Speaker:Callum: great from my personal perspective and hopefully for
Speaker:Callum: everyone listening as well uh as ever we'd love to hear your feedback and and
Speaker:Callum: if you want to be on the podcast let us know uh i'm gonna leave the final word
Speaker:Callum: with you hussein just like maybe two key take homes and you really just want
Speaker:Callum: to really hit home before uh before we we head into whatever we're doing you.
Speaker:Hussain: Know what rather than take homes callum i'm gonna give action points because
Speaker:Hussain: I need people to support in this project.
Speaker:Hussain: So for healthcare professionals listening to this that have a lifestyle,
Speaker:Hussain: either qualification or background or interest.
Speaker:Hussain: Speak to your partners, speak to the head of your clusters, say that you would
Speaker:Hussain: be happy to support the rollout of these medications when it comes and when it's properly funded.
Speaker:Hussain: And that it's super important that a wraparound lifestyle medicine support is
Speaker:Hussain: offered to these patients. So that's the part that you need to do.
Speaker:Hussain: Anyone from the physical activity sector that's listening to this,
Speaker:Hussain: this is probably your best opportunity to integrate into health.
Speaker:Hussain: Because And of all the things that we are going to consider,
Speaker:Hussain: NICE are very much going to push physical activity because it's got the biggest
Speaker:Hussain: evidence base for improving this.
Speaker:Hussain: So this is your chance to support these kind of patients directly through healthcare
Speaker:Hussain: and you can build up those relationships and think about how that will trickle beyond obesity.
Speaker:Hussain: You know, once you develop these relationships and these pathways and we can
Speaker:Hussain: break down the barriers that we get on activity for referral and all those kinds of elements,
Speaker:Hussain: we can hopefully start to see a
Speaker:Hussain: world where other long-term conditions are managed in the same way, okay?
Speaker:Hussain: In the same way, rather than just specific rehabs that they have to go with
Speaker:Hussain: long waiting lists that we can consider always as a packaged approach rather
Speaker:Hussain: than a troubleshoot approach that we have often with long-term conditions.
Speaker:Hussain: So yeah that's my big ask that people go out try to latch on to this opportunity
Speaker:Hussain: and let's make sure that it's delivered correctly amazing.
Speaker:Callum: Well thanks thanks Hussain thanks Susie lovely chat.
Speaker:Hussain: Thank you I.
Speaker:Suzy: Love those call to actions there well done Hussain.
