102 – GLP-1s, hormones & the truth about weight gain with Rose Stokes

0:01So Rose, it's very exciting you to be here. We're going to be talking about the podcast you've recently released called A Matter of Fat. So no mincing on the words here. But I used to say to people, if I wasn't a hormone specialist, I would specialise in nutrition. And it's something that as a doctor, I was really not taught about at all nutrition. And I've taught myself a lot. a lot of it's common sense but there's so much noise there's so much concern are we doing the right thing the wrong thing are we under eating are we overeating should we be medicalizing it should we be preventing it what what about weight what about our metabolism blah blah and it's just like oh my gosh it's very confusing so you're going to try and unpick some of this and try to help so tell us a bit I'm I'm just want to like full disclaimer I am a journalist I'm not a healthcare professional so I'll let you I'll lean into you for the science stuff um but I can tell you what I know as somebody who has lived with obesity on and off for 30 years probably yeah but you're doing the podcast it's not just you on your own is it no so it's with Dr Giles Yeo who is one of the world's leading obesity scientists uh he's based at the University of Cambridge yeah he's super bright I've you know read some of his work I've listened to him but sometimes you need someone to translate the science and that's where your important role comes in really doesn't it?

1:29I mean hopefully like as a yeah I'm predominantly I suppose a health journalist but as somebody who has been following a lot of the science obviously with interest like not just as a journalist but in a very personal capacity I was starting to notice a lot of the most exciting science i.e the stuff that's coming out that's essentially um providing proof that the whole personal responsibility narrative around obesity and weight um is perhaps not as accurate as um we have previously thought um and by that i mean the idea that people are completely to blame for the size and shape of their bodies.

2:12And it struck me that I have found personally a lot of comfort in reading that science and understanding that science because obviously, as you know, there's a huge moral responsibility narrative and there's a lot of shame and there's a lot of blame when it comes to obesity, bigger bodies, weight, even carrying any weight that is deemed to be extra or excess or over or whatever. So for me, it was more about like, how can I get this science to people that could benefit from hearing it? And in a way that feels relevant to them, personal to them and helps them to forgive themselves, I suppose, in a way for something that was never actually their fault.

3:00Yeah, it's really important because things have changed so much. Even over the last 31 years, me being a doctor and the last 55 years of me being around, you know, when I grew up in the 70s, we really didn't have an obesity problem in the same way. And, you know, our food choices have changed, but so has our environment change. And also genetics have changed a lot as well. And it's really important, I think, having responsibility as a physician to individualize care and thinking about how we can prevent disease as well. And the problem I think, and I don't know what you think, but with obesity or people that have different body shapes, it's a lot about cosmetics, a lot about what does she look like in those jeans?

3:50What does she look like with that skimpy top or whatever? whereas I'm actually thinking beyond and because I'm sort of a scientist as well as a physician I'm thinking about what's going on with their adipocytes their fat cells what are the inflammatory chemicals and cytokines these these chemical messages being produced how's this affecting them because I think it's really interesting because I've met a lot of people who very morbidly obese but they never have diabetes they never have a heart attack the other people who are slim and they have heart disease and what's going on in their body what's how like you say there's genetic factors there's environmental factors of course there is food factors as well but they all have different um sort of um weights really and impacts on each individual person and i was taught once about you know don't listen to your patients louise don't believe them when they tell you that they hardly eat because it's all about food in you know calories in calories out exercising and I sort of over the years I really know my patients well as a GP I really got to know them and I did believe them I didn't I didn't believe this doctor who taught me that because I do believe my patients and the more you understand nutrition a lot of people are either under eating or they're not eating the right foods or they're not moving in the right way or there's other factors to play but it's this blame and shame that is makes it really difficult and now we've moved to a culture where well let's just inject ourselves and then we don't need to worry we can just stay sick on the sofa and eating what we like and that's not right either so your podcast is already starting to have these conversations which is really important yeah and I think um like just to sort of pick up on the injecting ourselves sort of narrative um I think like it is a complex thing and one thing that I do think is definitely okay so full disclosure I'm currently taking these drugs and as I explained to you like in a previous conversation like the reason I'm doing that I think a lot of your listeners will probably resonate with this I had my second child actually lost some weight in pregnancy because I was borderline gestational diabetic so I was on like quite a strict diet and then after that gained quite a lot of weight quite rapidly like just from postnatal you know not moving as much trying to stay up all night and be up all day with the toddler and all of that stuff and then so for me the reason that I decided to go back on them was that I've spent the past like well I think 11 10 or 11 months I was um at the gym doing resistance training three times a week I was doing two rounds of cardio and Pilates.

6:37I was eating. I mean, I'm not going to talk about the calorie deficit, but I was in what was the recommended calorie deficit and my weight did not change at all. And I got to the stage where we are hoping that we can have another child. And I'm trying to put my best foot forward in terms of having been through pregnancy before setting my body up in a way that would put my best foot forward. And I wanted to lose the last bulk of weight that was between where I am now or where I was then and where I was when I began my last pregnancy. and the I got really desperate I was so like knackered from looking after two small ones like not eating as much trying to eat staying calorie deficit also exercising all the time like it was just like banging my head against a brick wall and um and so what I have found and what I think is really interesting is this sort of narrative of like it being easy taking these drugs I call that it somehow makes it easy or like it's like a cheating or it's you know the easy way out which to me sort of stems from this idea that fat people are fat because they haven't been working hard enough or trying hard enough right because if you didn't believe that then you wouldn't believe it to be cheating and the other thing I think is really interesting is I would use a lot of words to describe my experience of GLP ones but easy is not one of them like I both times have like the first time I took them um was very inadvisably six months postpartum um and I properly crashed out like really bad had terrible anxiety and just couldn't eat anything um and was just yeah and then this time um still I've had much more success and and have like actually my my weight is going down which is what I wanted um but the side effects are hard like for me or have been like that's not to put anyone off but you know it's not it's not what I would say and and and also in the meantime had discovered um you know a bunch of nutritionists who were switched on to the idea that you know the reality is a lot of people are taking these drugs and and they need advice um and so followed recommendations of like I have a friend Dr Federica Amati who works at Zoe she um had just recently written a book on this subject and she and so I followed the recommendations in that and this time it's been much better I've managed to sustain like not lose any muscle which is the thing that people worry a lot about and but without all of that guidance like the difference in my experience was huge and and so for me a lot of what I'm hoping to do is not um just to be very clear like this podcast isn't a jlp1 podcast it's more trying to address like I don't know about you but I feel like the conversation around weight and bodies in 2026 is more confusing than it's ever been like no one really knows what to think and feel we've got like extreme thinness like back um on the red carpet we've got you know and this has all come years after you know just actually really not that long after the whole body positivity era and the sort of mixed messaging the not knowing if people around you are taking drugs the sort of secret not sort of quiet shrinking like a lot of things that that mean that whether you're overweight obese whatever or or just you know not the size you want to be knowing how to feel about yourself how to feel about other people all of these things are more confusing than they used to be I think because there's a certain degree of not knowing what yeah I totally agree and you know when I was a medical student in the 1980s it was the first time they did gastric banding and gastric bypass operations and I used to work with a surgeon there who did a lot of those operations and people would be seen by a psychologist before.

10:54And it was incredible to see weight loss, like I'd never seen before in people. But then because their stomach was so small, obviously because of the banding operation, they often had a lot of nutritional deficiencies and they'd come back for follow-up and their nails would be breaking, their hair would be falling out, their skin changes. And obviously it's very expensive to have the surgery. It's very skilled or it was, especially the first operations really were so there was you're limited by the number of surgeons so the advent of GLP-1s has been good and bad for lots of reasons and you know as a doctor what anything we give and prescribe has to be very individualized and give our patients the information and knowledge as well and as many people know I don't prescribe GLP-1s but I know a lot about them I've read a lot about them and the people or the doctors that I really respect who do prescribe them, quite a few of my colleagues in the US are very experienced, but they also make sure their patients are eating really well, that they're exercising properly.

11:59They almost have a, well, some of them do have this shared care agreement where they, you know, well, they'll put them through the machine metabolism. They'll look at everything that they're doing. They involve a personal trainer. So that's really important and very responsible of them. And some of them are just on the lower doses as well. Whereas some of my patients seem to get them from their hairdressers and it's one size fits all with no information at all. And so you can't say that those two patients, if you like, are having the same experience or the same outcome as well. And so anything in medicine where things are tarred with a negative brush, we have to look at the whole experience of what else is going on.

12:40Because, you know, as individuals, we have to have responsibility what we eat but like you say that's why the book is so important or working with a nutritionist who really understands um what you what how how your body is working but also for me as a physician i'll always be thinking about metabolic effects so as you know obviously i think a lot about hormones and so many women put on weight if they've got low testosterone if they've got low progesterone, if they've got low estradiol. And a lot of my work is moving away from thinking about menopause and period stopping. It's thinking about these individual hormones.

13:19And there are a lot of people who are in their 20s and 30s with low testosterone. They have normal regular periods, they have enough estradiol progesterone. But testosterone is really important for your metabolism as well. And then when the progesterone goes or estradiol goes, again, you get these metabolic shifts people are more likely to put on weight and so treating the underlying cause is really important and people sometimes I speak to in the clinic once I've balanced their hormones with the right type of biode again to a hormone treatment they say gosh I wish I'd done this first because I've been battling with my weight for years and nothing's out you know.

13:57I believe it right and ultimately it's like something that Giles talks about is yeah I think uh I mean eight and ten prescriptions for GLP-1s are women. We know this. And the highest uptake is people age 30 to 49. So that sort of captures the whole peri to like menopausal and then post-menopausal women segment. And I think the vast majority of the current users are like being that group of people. and what Giles says is that these drugs are in effect hormone treatments right but we don't really know much about the interactions and effects of fluctuating sex hormones and the effects on these drugs and vice versa so I think it's really important and it's sort of a lacking area specifically highlighted on a sort of emerging thing if we're going to notice that so many women or so many of this group are predominantly those affected.

15:00And it's really important because we don't have research in so much in the health of women, we don't have research because it's never needed to be done. It isn't done and it's still ignored. And a lot of research in GLP-1s has not taken into consideration changing hormones or hormone treatments. And then when they do talk about hormone treatments, they're often talking about a contraceptive pill, which is a synthetic hormone. It blocks our own hormones working. So we have to be thinking very differently, actually, about those natural bioidentical hormones we prescribe and the synthetic contraceptives, because they're going to have very different effects on GLP-1s.

15:37And what's interesting is we know that the GLP-1s will help to reduce inflammation in the body, and so do the natural hormones as well. And so whether they have a dualistic effect, you know, synergistic effect. We still don't really know. So there's a lot that's needed to be understood. And that's really crucially important for people to be asking the questions and thinking in a really holistic way when they're going to start a journey thinking about one of these treatments. And I think also one thing, one of my biggest frustrations after we finished recording the pod was just how much I felt like I was being like smacked in the face with the idea that you know what we have seen in obesity research and treatment and all of the different um uh you know pharma industry all of the investment like this is a global like everyone is interested the speed of innovation that can be achieved when everyone is interested in the outcomes and then you look at something like women's health where you have all of these neglected areas where women are suffering and you think wow imagine if that power was put behind like solving endometriosis or finding a way to make it livable and and then you realize like oh my god you hear from giles like so this is coming down the line this is coming down the line this is coming down the line and you start to think oh my god like as much as i came into this wanting to talk about obesity and the way that it impacts women specifically i'm now thinking why aren't you helping us in other areas like because you could and like the speed that these issues can be resolved like when they have the force behind them and the other thing I think is really interesting and important that um I wanted to touch on before but because I think you and I have spoken quite a lot at length before about iron deficiency um one of the really important things um about GLP-1s and as you say like having the correct nutrition and this is why like a lot of the private the way that the private companies are dispensing these drugs without wraparound care means that a lot of people are in the dark and they're just feeling their way through it and if you have a low appetite which I actually do at the moment and I'm really struggling and I'm having to make really sensible decisions about what I do eat when I do eat because I need to make sure that every bite counts more but you and I actually last year when I when I went on the before and crashed out, I ended up severely iron deficient.

18:10And I'm not surprised. I mean, I was postnatal anyway, but also I didn't really eat anything for four weeks. So or like maybe longer, in fact. And it's quite easy to become nutrient deficient when you're not eating normally. And when you have a suppressed appetite, it's really important to make sure that you're hitting certain nutrition goals so that you don't lose muscle for instance also become deficient in different areas specifically as women that we're more vulnerable to I think that these are sort of upcoming sort of parallel issues that we need to be very aware of and in terms of like making sure that women are properly educated on how to take these drugs well if I don't think like and I want to say this explicitly I don't think these drugs are for everyone I don't think that they are like a panacea.

19:00I think that they should be used if they are used in order to hit a pause button so that we can sort out all of the reasons why people are ending up like this in the first place or, you know, why, as you say, in the 70s, like obesity wasn't so much of a problem. Like there's a massive policy angle on this. I think that governments need to do way more to improve our food environment, to improve like our nutrition, education, all of these things. I don't think I personally don't want these drugs to become the thing that stops innovation or stops the drive to improve those other things. Because from a policy angle, it gives a convenient way of just sidelining the issue.

19:45I don't want my children to be taking these drugs. Because the way that I see it is I would love for, you know, this to give us the time to correct the environment so that we are helping future generations be more healthy. Whether or not that's how the moment is going to be seized or not, I don't know. Yeah, I think it's having the right people educating in the right way and the people without their own agenda or their own conflicts or whatever. and certainly just bringing up three children my youngest daughter's 15 my oldest is 23 even in those eight years food choices have really changed it's a lot harder to access a green grocers it's a lot harder to eat in season it's actively harder to get good meat you know all of those things is really you know you have to go out of your way to buy an apple now but it's really easy to get a packet of crisps or whatever when you're well and also i mean as you say and then And there's like trends as well.

20:45Like, you know, there was the big vegan trend. There's like, I mean, all of these things, they do factor in. And I, you know, my husband was vegan, currently not, currently vegetarian. But like all of these things that I have, like, I'm not saying that that's a bad thing at all. But ultimately, like, there are certain groups that need to, if you're going to change your eating habits quite drastically, that need to understand the implications of that on their broader diet and the role of nutrition in their health. I totally agree. And all three of my children have low iron. And picking up on the iron deficiency, it's really interesting and it's quite hard to diagnose because a ferritin level and iron level could come back as normal.

21:28And I say normal in inverted commas because it could still be low and causing symptoms. And so we also, what I've realized when we've got data from the 1980s about it, which is only 40 years ago, just to remind listeners, that people taking contraceptives, especially oral contraceptives, it can block absorption of zinc, vitamin B vitamins as well. So a lot of people will be nutritionally deficient because so many of us have taken the contraceptive pill thinking it's a hormone and of course it's not. You can't see a nutritional deficiency. It often catches up later with people. And we really need to be working.

22:11I work closely with people who understand a lot about supplements, people I really value. And that could be really, really useful because often that's a final piece of the puzzle. So I really do think if someone is thinking about GLP-1 or just thinking about losing weight without a GLP-1, the nutritional value like you say of every mouthful should count regardless you know I I have migraine which is a blessing and a curse but it the blessing is it means I have to eat healthily like I can't slip up I can't miss a meal because I'll get a migraine I can't eat processed food because it will trigger a migraine so I'm sort of lucky because I have this like over me the whole time do you know what I mean I can't I know what you mean I mean I can't hoover up the girls you know whatever birthday cake because i it will just if i have a migraine then i'm out of function and i can't work so it's but i can see how easy it is to just slip and the iron deficiency thing i think is is a really big issue um but generally speaking i think we have um i mean also when you're talking about weight and weight loss which tends to be a conversation that more women are like interested expert expert in because they've had to be but also because of the pressure put on women via the like beauty standards and what have you um I actually lost a load of weight without these drugs when I was in my late 20s like a significant amount very quickly like I want to say uh a lot like a third of my body weight in under a year and I um got shingles so like there are you know you know a lot of these things people picture as like we'll solve all your problems however and as you said you know you've had patients that have have been living with obesity that have had never any problems with diabetes never any problems with this stuff like it's not a given that like weight and has it doesn't have like a necessarily like completely straight line to absolutely and that is actually what giles is most interested in studying like he says I want to know why you can drop two people down into the same environment and one of them ends up obese and the other one doesn't like why is that and why does that person's obesity mean that they're diabetic and that person's obesity doesn't and like he's studying all of that which I think is part of his sort of like superpower and also what he brings to the pod yeah it's so important that we do think about this so we're not naming and shaming people we're not judging them because there are a lot of slim people that are really unhealthy and we can see that externally but internally because as a physician I worry about future health as well it's not how we are here and now it's it's as we age as we get older so looking at what we're eating making every mouthful count looking at how we move how we exercise our sleep how we relax our hormone balance all of those things are foundational regardless of our body size really and we we all want quick wins but we can't have them I realize so much more as I get older nothing happens overnight but any good habits you know you just chip away at so well like and also like I'm coming at this from um obviously I've mentioned that my second pregnancy I then was closer towards diabetic and I um and my mum was diagnosed pre-diabetic and so and I had a grandmother that was diabetic so I am and because I was like on the borderline of gestational diabetes I'm now I think twice as likely to develop type 2 diabetes in my lifetime and all of these things so for me um you know there are you know massive questions I have to ask about like how to look after my metabolic health how to try and avoid um my like ending up in that situation and I think you know it's so interesting because there's such an intersection as you say between like you know hormones and I you know one day I will at some point get my hormones looked at but um in my family at least that we I mean we all had our own way of of discussing this like science hadn't really caught up with it but we called it like we all have the fat gene whatever that is it was just a sort of mythical idea that that you know on certain side on that side of the family like people were predisposed to gain weight like now the science is catching up with like why that is and that's super interesting to me but by no means do I think there's a quick win and I actually also don't think that GLP-1s are it first of all they're prohibitively expected for loads of people like we're only talking about a certain segment of society that can actually access them if they want to um via like because the NHS amount that they can prescribe is so small so we're looking already just at a certain income bracket and not enable the people that are able to afford it but also you know there's a lot of questions around how you sustain the health like the the the weight loss how like you know life after glp1s and um and i think yes you know a lot of people can go you can you've seen them everyone knows someone that's gone on these drugs and like half their body weight right but for me we really need to move away from this whole like before and after narrative that's been spun to us on Instagram of like if you looked at me 10 years ago I think it was literally 10 years ago I was there being like hey look I lost all this weight and like there's nothing worse than like a reformed smoker my mum always says but like also someone that has lost a lot of weight i i did and i was and it was actually sort of how I became a journalist I was writing a blog and a lot of people started paying attention about how I'd always been overweight and now I've lost all this weight and this is like you know I've worked it all out and blah blah blah and I remember at the time saying to my mom like oh I want to write a book about it and she was like I say this with love wait until you regain the weight and then write a book because like obviously like she knew that this was not the end of the story and actually hilariously that is what I'm doing but but you know mum knows best but the point is is that you know this idea that the after means the end i i've lost all this way i'm finished when actually i found personally that trying not to regain weight was harder than being overweight in the first place in terms of the psychological plate that it puts you in because once you have and quite publicly like lost quite a lot of weight like I was posting about it everyone around me was talking about it a lot and all of this um when you regain you feel extremely aware of it and very ashamed of it and I found that that impact on my even when I was quote-unquote you know everyone in my life was saying oh look you look the best you've ever looked and all of this mentally I was in tatters It was awful because I was so scared of putting weight on.

29:26I was exercising literally every hour of the day, eating nothing. So I just think, I mean, part of what I want is for us to move away from this notion that losing weight will solve all of your problems. Like, I really believe that that's not true. You can make health choices to improve certain markers in your body if that is right for you, if that's what you know if it's sustainable if it's livable for you like really importantly but I don't think that simply losing weight is is gonna solve everything like I really don't think that and I am so passionate about um about people I mean first of all like weight stigma for me is that is one of my biggest drivers like the things the things that I've experienced in my life absolutely horrendous and obviously as a GP like what you said about someone saying to you like you know that they're lying essentially that is the way that I have been treated in a lot of my interactions with the health service in my life and I think you know it does have such a profound impact on your personhood and I'm a mother now I have two small children I don't know if they have the fat gene or whatever but I think a lot about how I can try and embed in them like different values different ways of looking at health different ways of understanding themselves so that they don't suffer the way that I did but you know no that's really important advice to end on really that we need to be thinking how we're talking as clinicians we need to be understanding more we need to have more training in nutrition and we need to be believing and listening to our patients which is what I say so often not just about food choices but also about hormones about symptoms and so forth and we need to be making the decision that's right for us as the time's right for us and not be judged by any treatment that we make so I'm very grateful for you being so honest and candid and wish you luck with the rest of the podcast series which That's great.

31:33So before I end, I always ask for three take-home tips. So three things. People might be here thinking they might, some listeners will be on GLP-1s, some people might be thinking about them, some people will have their own views, but that's fine. This podcast isn't really about GLP-1s. It's really people who are thinking, right, the time's come, I'm really going to think about changing my weight in a positive way, but it's never going to be a quick win process. What are the three things that you would say people should start to do or start to think about? Well, I want to be really candid as well, because I think a lot of people come to me and they say, oh, yeah, I feel exactly the same.

32:09I'm a BMI 26 or something. And I think, so one thing I want to be really candid about is like, get, you know, you have to be realistic about where you are. And there's a big difference between having a problem, having a weight problem and having a problem with your own weight like those are two different things um second is like understanding that it is a process and that you know and it's not gonna solve all your problems like I personally having lost a lot of weight um very very saw that very clearly that you know weight loss isn't in itself um the silver bullet that that people think it is um and also just um trying to move away from blame.

32:56Like for me, the biggest learning that I've had, like doing this podcast with Giles, is really finally internalising the idea that this was never my fault. Like it was not something that I was doing wrong. So great advice. Thank you so much, Rose, for your time today. Thank you so much for having me. Really great. Thank you.