Episode 95 | 30 May 2023
On this episode of the Alix Turoff Nutrition podcast, Alix sits down with Julia Axelbaum, RD.
Julia Axelbaum is a Registered Dietitian, board certified in obesity and weight management. She is the Director of Clinical Nutrition at Form Health, a telehealth obesity medicine startup, where she was hired as the very first employee and now leads a team of 21 dietitians. Julia studied Nutrition and Public Health at New York University and completed her clinical training at Beth Israel Deaconess Medical Center, a Harvard Medical School Hospital in Boston. Prior to joining Form Health, Julia was the program coordinator for a bariatric center in St. Louis, where she worked one-on-one with weight loss surgery patients, and developed the center’s first non-surgical, medical weight loss clinic. She sits on the executive committee of the Academy of Nutrition and Dietetics (AND) Weight Management Dietetic Practice Group (WM DPG), has her Certificate of Training in Obesity Interventions, and has published several research papers in the field. In 2022 Julia received the prestigious Weight Management Excellence in Emerging Practice Award through the WM DPG. Julia is passionate about expanding access to obesity treatment and increasing awareness of obesity as a complex, medical condition rather than a result of a lack of willpower. Her expertise lies in helping patients learn how to take control of emotional eating, develop a more balanced mindset and improve their relationship with food.
Some of the topics we covered in this episode include:
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The reason why weight loss is so hard
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Obesity as a chronic disease
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Weight bias and why it’s so harmful
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Medical and Non-Surgical interventions for obesity
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Eating Disorders and weight loss medications
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…and more!
Connect with Julia and Form Health on instagram (@formhealthofficial) or via their website at www.formhealth.co
Alix (00:04):
Hi, everyone. Welcome back to the podcast. I am here with Julia Axelbaum, who is a registered dietitian board certified in obesity and weight management. She is the director of clinical Nutrition at Form Health, which is a telehealth obesity medicine startup where she started as the very first employee and now leads a team of 21 dietitians. Prior to joining Form Health, she was the program coordinator of a bariatric center in St. Louis, where she worked one-on-one with weight loss surgery patients, and when she was there, she developed their first nonsurgical medical weight loss clinic, which I’m also really excited to hear about. She’s very passionate about expanding access to obesity treatment and increasing awareness of obesity as a complex medical condition rather than a result of a lack of willpower, which is why I’m so excited to have her here today to dive in to this topic further. I know obesity and weight loss medications and interventions have been a popular topic lately. You’re seeing it in the media, you’re seeing it on TikTok and social media., we’ve talked about it here on this podcast, but now we have an expert i to ask all of our burning questions. So hopefully I am here representing all of you with the questions that you’ve brought to me and I’m just so excited to have you here, Julia, welcome to the podcast!
Julia (01:27):
Thank you so much, Alix. I’m so excited to be here, and it honestly feels like I’m meeting a celebrity. I’ve been listening to your podcast, I think since you started. I just love what you do.
Alix (01:38):
Thank you so much! I’m so happy to have you here and I’m just so impressed by the work that you’re doing, and I’m really, really happy to have an expert here to talk to about this. You’ve done so much in this field, you’ve also been involved in research. There’s so much that she’s done and you can read her full bio in the show notes. But today, we’ll just start with… how did you get involved in the work that you’re doing?
Julia (02:04):
I went to NYU for nutrition. I studied nutrition and public health. After NYU, I completed my dietetic internship in Boston at a hospital, Beth Israel Deaconess. The hospital that I worked at in the program I was in, there was a very strong clinical focus. So most of our time was spent on the inpatient floors. There was a lot of enteral and parenteral nutrition, a lot of math, you know, behind-the-scenes work. And throughout my internship, as great as it was, I was realizing that I missed that patient connection, you know, helping work with patients to make positive change and motivate them. But I did spend two weeks during my internship doing a bariatric rotation, and I absolutely loved that. I felt like finally something clicked, and I just loved building relationships with patients, seeing their success over time, you know, working with patients to help motivate them.
(03:00):
What was so nice is the patients who were coming in were really excited to make changes and improve their lives. And so I just immediately realized that was a population that I love and want to continue working with. So when I was looking for my first full-time job, I was living in St. Louis, Missouri at the time. I worked at a bariatric center. And actually when I was brought on in 2016, the field of medical weight loss, non-surgical weight loss was still kind of new. It wasn’t that long ago, but it was still pretty new. There weren’t that many weight loss medications on the market. They weren’t all that successful at the time, but it was growing. And so the clinic actually hired me to, in addition to the bariatric work, to start a medical weight loss center there.
(03:46):
So alongside seeing the pre and post-bariatric patients, I worked to create this medical weight loss center. It was very popular. It grew and grew. I was there for four years. and then after four years, I actually got connected with a brilliant entrepreneur whose name is Evan Richardson. He had the idea to create a telehealth medical weight loss program where all of the care would be delivered through an app. And I loved this idea. I felt like after building something on a smaller scale, I was really excited to be able to reach more people. You know, we had patients who would drive hours to our clinic, and the idea of being able to reach people and meet with people who may live in more remote areas that didn’t have access to a medical weight loss team of specialists was really exciting to me.
(04:37):
and then the other thing was also just knowing that one of the best predictors of weight loss is support and accountability and ongoing support. And so the idea of a person having a phone in their pocket at all times and that being a way that they can connect to a support team, really inspired me. So I moved to Boston. I started with Form Health as the first employee, and four years later I’m the nutrition director here. We see thousands of patients all throughout the country. We have 21 dietitians, we have about 20 obesity medicine doctors, and we’re continuing to grow, which is super exciting.
Alix (05:18):
That’s amazing. Wow. And so you wound up back in Boston.
Julia (05:23):
Yes, exactly. So that was a coincidence. My husband is from St. Louis. and he’s a resident physician and he matched to residency in Boston, so I followed him back to Boston.
Alix (05:34):
We have that in common (residency) and we’ll have to talk about that later. But that’s amazing. I have so many questions but the timing of all this sounds really amazing because you said 2016 you started in St Louis and were there for four years which brings us to 2020. Telehealth was a newer thing, but COVID changed the landscape of telehealth and insurance and all technology. I don’t know if that was purposeful timing, but that sounds like a happy coincidence if anything.
Julia (06:09):
You know, it’s so funny. I started at Form a little bit before Covid actually. So it really was a coincidence. When Evan, the CEO had this idea, it was before Covid. Telehealth was not as big of a thing. Even when I heard about the job, if I felt like I was being hired to just see patients fully remotely, I don’t think I would’ve taken the jo because that sounded scary, you know, at the time I was so used to being in an office every day and interacting with people. But because it was kind of more of the creative side helping to build the program, and at the time it wasn’t technically a remote company, the employees would go into an office which made me excited about it. But a few months later when Covid hit, we actually had just started seeing patients. We had maybe 15 patients at the time but we were already set up for it. So that was a happy coincidence in terms of people just being a lot more open to the idea of telemedicine.
Alix (07:13):
That’s very interesting. So when you started in 2016, there wasn’t the number of drugs available that there is now. Were you using weight loss medications? What interventions were you using at that time?
Julia (07:27):
There were a few weight loss medications and they worked okay. Most of them that were out would produce about 5 to 8% weight loss. Thankfully, we’ve come a long way. Now we have much better medications on the market. But it was a combination of medications and intensive lifestyle intervention. We had dietitians and we had either the bariatric surgeons who were prescribing medications or we also had one bariatrician obesity medicine doctor. So it was a combination. Patients would come see the dietitian every two weeks in the beginning, and then it went to every month but it was hard because they had to drive into the clinic to see us every time, and there was traffic and there was parking, and, you know, there just were all those extra barriers that don’t exist with telehealth.
Alix (08:19):
Yeah. Especially if you’re coming from a remote area, and we can talk about the social determinants of health, but it’s another, barrier. You need to have the time, you need a car, you need childcare. There’s a lot of factors that go into just being able to get there.
(08:35):
And how would people find you? Is this something that someone would need to qualify for? And what would be the difference between someone who is coming to you for non-surgical interventions versus going the bariatric surgery route?
Julia (08:53):
So in St. Louis, our center was connected with the hospital. So that helped. It was a big hospital system, and we would get referrals from doctors seeing patients at the hospital. We also had a lot of online marketing and things like that, but it was a pretty well known bariatric center as a center of excellence. and what I was seeing was that there were a lot of patients who either their insurance would require that before they got bariatric surgery, they had to work with a dietitian for six months to kind of prove that they can stick with a plan. And, I have some thoughts on the matter. There are so many barriers to getting the care that people need when people are living with obesity.
(09:33):
And this is an example. So oftentimes you would have to work with the dietitian first for six months and then get surgery. Or maybe they wanted to get surgery, they showed up at our clinic, and then it turned out they didn’t qualify for whatever reason or there were people who really wanted to get medical help losing weight that didn’t want surgery or maybe they hadn’t tried medical weight loss or anything else first, which is what a person should try before they go the surgical route. So people would come in for different reasons. And now, thankfully, and this started even when I was at the Bariatric Center, medications are something that are often used even post-surgery, because oftentimes there’s weight gain. And that is something that oftentimes bariatric surgeons will prescribe now.
Alix (10:15):
Interesting. What were some of the early medications that you were utilizing?
Julia (10:23):
Phentermine was one of the first big ones and that works fairly well. It’s about 5-6% weight loss. Unfortunately it has kind of a bad reputation because people think of phen-phen and people are nervous about it not being safe or not being effective. Also, it’s technically approved for short-term use whereas we know obesity is a chronic condition that needs treatment for the rest of a person’s life. And so it was okay and it still is okay. It definitely does help people. But we have better options now. And then at the time, there were just starting to be some other options like Qsymia and Contrave and Belviq which is actually no longer on the market. So it was sort of the start of some of those different combinations of medications and they were finding when you put these two medications together, it can do a good job at helping someone lose weight.
Alix (11:25):
I want to get to the medications, but before we do, I’d like to get your perspective and expertise on whether is considered a chronic disease? Is it something that someone can just use willpower and overcome? How does the medical community see it?
Julia (11:54):
Such a good question. And I’m really excited to talk about this because I’m very passionate about it. Obesity is a multifactorial complex, chronic disease, and it was designated as a disease by the American Medical Association in 2013. For so long we’ve been told, “oh, you just have to eat right” or “You just have to exercise more”, “You just have to have stronger willpower and you’ll lose weight”. But what this implies is that it’s a person’s fault because they haven’t been doing these things until now if they are struggling with their weight. But the reality is, so many people are doing those things and they still struggle with their weight. And that’s because the disease of obesity is so much more complex than we give it credit for. It’s not a person’s fault. It’s not that they’re lazy, it’s not that they’re unmotivated.
(12:43):
The reality is there are so many factors beyond just the food that we’re putting into our mouth every day and beyond our willpower. And actually, the science shows us that many of these factors are biological. Every person is born with a set of genes that makes it easier or harder for them to maintain a healthy weight. And obesity is actually about 70 to 80% heritable. So it starts as early as what’s going on when we’re in the womb, how we’re fed early on in life and so on. And it actually makes a lot of evolutionary sense. If you think back to hunter-gatherer days where our bodies are programmed to favor energy conservation for survival. Our bodies want to be taking in excess calories and not moving as much, because if there is a long period of time where we don’t have food, that’s how we survive.
(13:37):
So what’s really cool actually, is that when we look at brain imaging there’s evidence that shows us that the brain plays a huge role in regulating our weight. So there are pathways in all of our brains that tell us whether we should eat more or eat less, or store more or store less. And those pathways don’t work the same for every person. They’ve done studies where they actually take a group of people and they put them into a locked study chamber, and they feed them the exact same thing. And what they see is that not everyone’s weight responds in the same way, because there are so many influences, such as hormones, the way our gut talks to our brain, what medications a person’s taking and environment and how our biology interacts with our environment. For one person, they may walk past a cupcake shop and smell a cupcake and be so tempted to have a cupcake and maybe not be able to just have one, but need three to feel satisfied. Versus another person might walk past and say: “okay, that smells good, but that’s okay, I’ll get it a different time”. So it’s very complicated, but ultimately it’s so important that we move away from the blame and shame and start asking the question of what are these other factors that are contributing to a person’s weight? And absolutely, nutrition and physical activity and behavior change affect our weight. Absolutely. But we can only start intervening with these things once we first address what’s really goi
ng on, what other factors are actually getting in the person’s way.
Alix (15:10):
That’s a great explanation. and it just brings up so much for me because you can’t deny that there’s a divide in our field of people working with individual’s on intentional weight loss, and then people who feel that intentional weight loss can never be appropriate. And that’s a huge conversation. But at the same time, we’re all kind of trying to do the same thing, which is reduce weight bias and weight stigma and improve access to care. So what is weight stigma and weight bias? How does it impact patients? And what can we in the medical field, whether you’re a dietitian, a therapist, a doctor, what can we be doing to reduce that?
Julia (15:59):
Weight bias is holding negative attitudes about people’s weight, or harming or shaming a person because of their weight. And weight bias has a really large psychological impact. There’s an increased risk of depression, anxiety, poor body image, suicide. But the ironic part about all of this is that weight bias, actually, the stigma, the shaming, actually has been shown to worsen obesity. It causes people to turn to food as a coping mechanism to deal with the shame. It causes people to avoid going to the gym.
Alix (16:36):
People are scared of going to doctors.
Julia (16:38):
Exactly. So that’s the sad irony of weight bias in general and it’s widespread. We see bias in the workplace- it’s been shown that people with higher BMI are less likely to get hired even if their resumes are exactly the same. It’s all over the media. It’s always those characters in a larger body that are shown as messy or lazy or the ones making fun of themselves. And the sad part about all of this is that it’s extremely prevalent among medical professionals, doctors, nurses, and even dietitians. There’s a lot of weight bias and studies have shown that medical professionals have a lower desire to treat patients with a higher BMI and they spend less time with patients with a higher BMI and they’re less likely to perform certain screenings.
(17:34):
So that makes it so there’s more misdiagnosis. If you think about a patient coming in, maybe complaining of leg pain and the doctor saying, “oh, you just have to lose some weight and your leg will start, stop hurting, right”. Versus someone in a smaller body saying the same thing, they might do more tests to figure out what is it that’s going on? I’ve heard so many stories, just terrible stories from patients of feeling dismissed for real pain that they were experiencing, or the doctor just saying, “you know, you just have to lose weight and you’ll be okay.”So like you mentioned, no wonder patients are less likely to want to go to the doctor, and because they’re going to the doctor less, there’s even worsening health outcomes.
(18:22):
And another place where we see weight bias actually is when it comes to health insurance. Insurance companies are not covering very much of obesity treatment and obesity coverage really lags behind nearly all other chronic diseases. And I think this is because as a society, we still very much have the mindset that obesity is a cosmetic issue. That it’s not a metabolic disease. And because of all of this, only about 1 to 2% of all patients living with obesity who would qualify for and benefit from weight loss medication are actually being prescribed them.
Alix (19:00):
Wow. Hopefully that’s changing, but there’s still a ton of stigma, and I see it all over the place, and the way that the media is covering this really great advancement in science and obesity care that is taking place. And of course these medications are being misused in some cases, but I just see that furthering the bias and stigma. When this very difficult conversation comes up of whether obesity itself worsens health outcomes or can you be overweight and still be healthy? And peopleargue that in our field all the time while not addressing how intertwined so many disease states are with being overweight. And that’s, to me, something you can’t deny. It’s not bad or good, it’s just a fact
Julia (20:08):
Right. I think about how everyone has these examples of, you know, “my grandfather smoked this entire life and never got lung cancer and died at the age of 103, so clearly this is all made up. Smoking doesn’t increase your risk of lung cancer.” There will always be those examples. But what we know and what the science proves is that having a higher BMI does increase a person’s risk for many different conditions. Even ones that we don’t even think about. Like diabetes is one that everyone knows, but having obesity actually increases a person’s risk of developing certain cancers. And that is actually a lot less known. There are so many different comorbidities associated with obesity, and you can absolutely live a healthy life and still technically have a higher BMI and nutrition and physical activity make such a big difference for our health. But at the end of the day, having a higher BMI does put a person at much higher risk for a lot of different diseases.
Alix (21:10):
It’s such a strawman argument. And we all have them. My dad had bariatric surgery, he had the lap band years ago, and since having that, a
lot of things improved. But the reality was by the time he got the lap band, his kidney function was already declining because of the impacts of his weight from so many years of living with diabetes, that if he would’ve had an intervention earlier, maybe wouldn’t have ever been on dialysis. And again, that’s an example of an individual argument. So now at Form Health, you have a team of dietitians, so it’s not just that medication is being given out without any sort of lifestyle coaching. How does the process work for someone who comes to you? Can anyone, even if they are underweight, come to you and get medication? What is the process like?
Julia (22:16):
Our program, is a medical weight loss clinic, and we work with patients with obesity. So in order to qualify, in order to sign up for Form Health, a person has to have a body mass index above 30 or a BMI of 27 with comorbidities. So we’re not working with someone who just wants to lose a few pounds. We’re really focusing on the medical side of weight loss. And absolutely we support people’s goals, but that’s the population that we’re working with. So in order to sign up, patients go through a questionnaire to see if they qualify. Because we are remote, we have to be super careful to be safe. So we require all of our patients to have an active relationship with a primary care physician. We use the primary care physician as a partner in the patient’s care.
(23:07):
so if there’s anything that comes up outside of what our obesity medicine doctors feel comfortable treating or what’s within their scope, then we always have the PCP to work with as well. So we collect medical records from the PCP and patients also have to make sure they qualify based on filling out a whole medical questionnaire to see if they would be an appropriate candidate for weight loss. And when patients join, they get set up with a care team and the care team is both an obesity medicine doctor and a registered dietitian specialized in weight management. And we take a holistic approach, we’re looking at all the factors going into the person’s weight. We want to know what are the things that have gotten in the way for you in the past and how can we help you?
(23:53):
So for some people, weight loss medication is so, so helpful, but it’s not the best fit for everyone. And even when a person starts a weight loss medication, these aren’t magic pills.You don’t just take them and get skinny. What I often like to compare them to is someone who is really struggling with anxiety or depression, where the treatment for this person would be therapy plus medication. And a lot of times a person who’s dealing with really severe depression or anxiety, wouldn’t even be able to make effective change through therapy until it’s treated with the medication.
Alix (24:43):
That’s such a great comparison for people to truly understand. I think more people might be able to relate to that.
Julia (24:52):
And a lot of us have been there, right? It’s like you take the medication to kind of, and I’ll hear this quote often from patients “be on the same playing field”. They’ll say “I finally know what it’s like to just be a normal person around food, where my brain isn’t constantly thinking about food, or I’m not constantly starving.”
Alix (25:11):
Or someone with ADD that medication can give them the opportunity to suddenly be able to study at the same level as someone without ADD.
Julia (25:23):
Exactly. And if they don’t study for the test, they’re still not gonna do well.
Alix (25:28):
They can’t just rely on the medication alone to pass the test, but it’ll help them sit still and focus.
Julia (25:31):
Exactly. So it absolutely has to be used in combination with a reduced calorie diet, regular physical aand behavior change in order to promote weight loss. And these weight loss medications are actually indicated for long-term use. Again, because obesity is a chronic condition. And so the help that they get that helps them lose the weight initially is what they actually have to keep up long term in order to keep the weight off. I think of weight loss medications as also weight maintenance medications.
Alix (26:02):
Okay. So that’s a big question… whether these medications aresomething that someone has to take forever? And it seems like it might be a case-by-case basis. It seems like there might be more research, but essentially these are indicated for long-term use versus something like a phentermine, which was a short-term medication. What are the medications that you utilize at Form?
Julia (26:22):
Yes. We only use FDA approved weight loss medications. there is a lot of scary stuff out there. People hear of the words “weight loss pills” or “diet pills” which is referring to a number of untested over-the-counter supplements that are not proven to be effective for weight loss or not tested for safety. But our physicians only prescribe FDA approved medications. and like I mentioned, these medications are used in conjunction with a reduced calorie diet, regular physical activity and behavior change. There’s a bunch out there now and a very popular class of medications, which is all over the, the media right now is these GLP-1s. and those have actually shown to have much better weight loss than some of the ones we were prescribing back in, in 2015-2016 at the in-person medical weight loss center that I was working at.
Alix (27:18):
The question of FDA approval…there’s a big myth out there that these medications are only for people with diabetes, but in the higher doses, these are FDA approved for weight loss.
Julia (27:36):
Right. So, so within this class of medication, several of these meds actually did start out as diabetes medications and what they saw was that there was this side effect where patients who were taking these medications were losing weight and so because of that, they developed them in a higher dose specifically approved for obesity as weight loss medications. And this is part of the stigma… people will say, “oh, these are diabetes medications and people with obesity are taking them away from people with diabetes” And I feel that’s part of the stigma that people with obesity….their medical condition isn’t serious enough or this is their own fault. They shouldn’t get to take away these medications from people who really need it. They don’t deserve then.
Alix (28:24):
Not to mention, how many people with obesity also have co-occurring diabetes?
Julia (28:35):
Yes. Very common. So a lot of times it can treat two different things at the same time. And when the physicians’ are thinking about how to choose which medication would be a good fit for which person, that’s actually something that they’re taking into consideration…whether the person has other medical conditions that may benefit from one treatment option over another. So if a person has diabetes, like you’re describing, their doctor may prescrib eone of the GLP-1 receptor agonists such as Wegovy which not only promotes weight loss, but also helps to manage blood sugars.
Alix (29:13):
Okay. And on the topic of FDA approval, there’s this conversation about compounding pharmacies where people are going to, let’s say a med spa or any of the other ways I see people are getting these, but the doctors are sending them out to a compounding pharmacy. Is that something that happens? Is that safe? Is that something to look out for?
Julia (29:41):
Yeah, I don’t know exactly what they’re doing at these compounding pharmacies, and that’s what’s scary to me. It could be totally fine, but I just don’t know. I don’t feel confident in that. No. And so I wouldn’t send a person to get a medication that we don’t know is being tested
Alix (30:01):
Completely.
(30:03):
They’re not going through the same rigorous procedures and testing and certifications and all the thingsw that they have to go through. And I know people don’t trust the FDA and all but there is regulation with these medications, and it’s not just someone mixing them up in their basement. Not to say that’s happening at these compounding pharmacies
Julia (30:24):
Exactly.
Alix (30:25):
But there’s oversight.
Julia (30:29):
Yeah. You want a third party overseeing that what you’re taking is actually what you think.
Alix (30:33):
Yeah. And it does seem a little bit tricky because I’m just looking at it from the business side of things. And of course, there’s an opportunity for people to step in and make a lot of money here. And there are a lot of programs that are popping up, saying, “we can get you this medication without insurance” and maybe we could speak to that a little bit. There seems to be an issue with the cost of these medications right now for some people. At Form, do you offer and support with getting the insurance coverage? Ho
w does that work?
Julia (31:11):
Yeah, so technically any physician can prescribe one of these medications. So one of the questions we get asked is, “why don’t I just ask my PCP for one of these weight loss medications, what’s the point of going through a center like yours, a medical weight loss clinic?” And the difference is the physicians who are prescribing medications at Form are obesity medicine doctors who are very well specialized and experienced in this field. And they know of all the ways to make it more likely that a person will get this approved by their insurance. So they are very experienced at what to fill out on the prior authorization
Alix (31:50):
And coding…
Julia (31:52):
Yeah, exactly. And they also very creative…some of the medications are actually two different medications that are combined into one, and they sell it, typically as both medications in one pill but that’s a lot more expensive. So if someone’s insurance doesn’t cover that, our doctors might prescribe the two medications separately and the patient just takes them together and it’s a lot more affordable that way. So they’re really experts in this and they know how to help people who maybe don’t have insurance coverage.
Alix (32:23):
That’s a really good point. And again, just to go back to the weight bias that is present in medicine….If someone goes through additional certifications to become an obesity specialist, you would hope they are also much more aware of working with this population and very passionate about it, and hopefully less likely to be biased.
Julia (32:48):
Right, I feel that one of the things that makes us so different from the experience that many of our patients have had at other clinics and centers with other clinicians, is this non-judgmental, compassionate care that we deliver where….I see this the first time I meet with a patient at our initial consult, and they start telling me their story, and I say: “You know, wow, that must be really hard. I believe you.” And there’s this loosening of their body, the sigh of relief of “oh my gosh, wait, you actually believe me?” And I often think about the population of people who are dealing with chronic pain, where they go from doctor to doctor to doctor saying, “I’m in pain and there’s nothing showing up on scans”. And the doctor’s like, “alright, I hear you saying that, but there’s nothing I could do. I don’t see anything on your MRI
Alix (33:48):
Sounds like IBS. You explain your symptoms and they’re like, “yeah, okay lady”
Julia (33:50):
Right? And then think about when finally a patient sees a doctor who says, “yeah, I believe you, let’s figure this out together. I’m on your team.” And what a relief for these patients who have gone maybe even their whole lives being told that they just need to get it together. They just need to stop being so lazy. They just need to follow the rules.
Alix (34:12):
That’s amazing. I’m very happy to know that there are resources out there. And you said that you work with people all over the country?
Julia (34:25):
Yes, all over the country. and we accept almost all insurance, which again is another reason I just feel so passionate about being able to deliver care to everyone who needs it, not just the rich and we have our clinicians are all throughout the country as well.
Alix (34:41):
And I’ll link all this in the show notes for anyone interested, and I’ll give you Julia’s info. What is the average timeline that you’re working with a patient? How long is your follow up with them?
Julia (34:57):
So there’s no requirement that a patient stay in the program for any certain amount of time because it’s so individualized. We do have 50% of our patients sticking with us for over two years, actually which is amazing because the weight loss industry is notorious for high, early-dropout rates. But it really depends on what the person needs and what they’re needing support around. Many people stick with us long term because like we’ve talked about before, research show us is what works for a person to lose the weight is actually what we have to keep up long term in order to keep the weight off and so we have a really high level of support. Patients see their registered dietitian every two weeks. They see their physician every month, so they have three visits a month, plus we have support groups and all these different cooking classes and things like that throughout the month. And in between sessions, patients have the ability to text their doctor or their dietitian anytime. They also send in food photos as th
eir photo journal and their dietitians are reviewing that and offering feedback and tips. So it’s a really high level of support and accountability and in my personal opinion, I feel the reason why patients really stick around a long time is because we develop such strong relationships with them where again, they feel believed, they feel heard. It’s kind of like once you find that therapist that that works well, often you’ll stick with them long term.
Alix (36:29):
That’s amazing. That’s the goal for all of us, is to have a trusting relationship to come back to and people go through, just like anything highs and lows in life. If you deal with depression, you might be good for a while and then something triggers it. And food is very related to emotions and so someone might be stable for awhile but then need additional support. So on average, how much weight loss are you seeing with the interventions that you’re doing as a whole?
Julia (37:05):
At Form we see an average of 15% weight loss from a person’s starting weight at 12 months and actually in clinical trials on weight loss medication, we see 5 to 10% when it’s weight loss medication in combination with lifestyle change. It’s obviously completely individual and every person is gonna have a different weight loss journey. But one thing to say to that is it doesn’t seem like a whole lot of weight.
Alix (37:33):
I was gonna say, people have such a skewed perception of how much weight you can lose in a period of time. But to put that into perspective. Let’s say you have a patient starting at 300 pounds, 15% of their weight would be 45 pounds. So within a year, losing 45 pounds, that’s a little bit less than a pound per week, which I know I’m always having this conversation with my clients when they’re super bummed if they’re losing a pound per week but I explain to them… that’s incredible!
Julia (38:07):
Incredible, yeah. And I mean, it took years and years to get to this point so it’s not like it’s all gonna come off in the first few months. And the other thing that we really are focused on are the health outcomes. And studies show that even just losing 5 to 10% of a person’s starting weight can help significantly reduce the risk of a lot of different complications that come from excess body weight and improve overall health.So we absolutely support people in continuing to lose weight if things are going great and they have these bigger weight loss goals but I never want a person to discount what a 5% weight loss might do for you. They can come off their medications just from losing 5% of their weight. lost you.
Alix (38:47):
Yeah. And when I hear all of the talking points about why these medications aren’t good, one of them is that there’s this perception, which I know has been disproved from the research, that people are losing large amounts of lean muscle mass, but really, you can lose large amounts of lean muscle mass when you lose weight too quickly.
Julia (39:08):
Exactly. There’s nothing different about the medication. So we work with patients on high protein diets and on strengthening exercises. \
Alix (39:16):
A fear that people have is that if they go on these medications that you can’t eat meals throughout the day? If that were to be the case that someone was unable to eat regularly, would the dose be adjusted?
Julia (39:34):
Yeah. The goal is not to starve, it’s not to just fast all day because then a person would risk losing lean muscle mass and significantly reducing the speed of their metabolism making it much more likely that they’d gain back the weight. So the goal is to eat but to be able to eat in a controlled way. So if a person gets to the point where they’re just not hungry to ever eat that probably means that the dose is too high and they would probably work with their obesity medicine doctor to go down in the dose to find a place where they just feel sort of level like they can eat and feel satisfied with a portion that they feel good about and then move on, and they’re not thinking about it all day long.
Alix (40:15):
There is concern about side effects mostly being gastrointestinal. do those go away? How often are they happening? Would that be something that would cause someone to need to come off these medications?
Julia (40:28):
So the gastrointestinal side effects are the most common, especially with these GLP-1s. Nausea a big one and constipation. Part of how the GLP-1’s work is they slow down gastric emptying which means that food actually stays in your system longer. It takes longer to get digested and come out. So it makes sense why people would have some nausea and maybe some constipation. A lot of times what we see is that when a person first starts taking a medication, they experience this, but the physicians go up in dose pretty slowly and they make sure that the patient is at a place where they’re feeling okay before they g
o up in dose again. So if a person is experiencing all of these side effects, they’re not gonna just keep going to a higher and higher dose.
(41:13):
Sometimes a certain medication is just not the right fit for a person. And there’s no way to know that ahead of time. So there’s a lot of trial and error that comes with the whole world of weight loss and medical weight loss and we tsay this to our patients the first time we meet them: “We’re here, we’re your team. We’re gonna figure this out together. Some of this we have to just try and see what works and then make changes”
Alix (41:37):
Like an antidepressant…. we have to see how this works with your unique chemistry.
Julia (41:43):
Exactly.
Alix (41:44):
And we might not get it on the first try.
Julia (41:48):
Exactly right. So it takes some tweaking and that’s why it’s so important to work closely with a team instead of just getting prescribed or just buying this medication.
Alix (42:04):
And just for my own curiosity, as I do work with some people who are on these medications, do they give anything to counteract the constipation other than increasing fiber, magnesium, that kind of stuff?
Julia (42:23):
Usually the first steps are really conservative….water, movement, either fiber coming from food or fiber coming from pills. If that’s not working, then the doctors can prescribe something to help
Alix (42:39):
And I’m thinking that I do have patients who are already struggling with constipation and then they get on these medications and it’s just worse. So it’s probably something that was maybe there already but it’s just exacerbated by the medications.
Julia (42:54):
Right. So again, it takes trial and error. It just takes some time to figure out the right fit or the right person. If a person already is struggling with nausea, constipation, maybe making food take longer to go through the system isn’t the best idea. Maybe a different type of medication would actually work better. But for the most part, most of these medications work by targeting pathways in the brain, boosting the pathway that basically tells us to eat less and store less, and suppressing the pathway in the brain that tells us to eat more and store more. but they all kind of work in slightly different ways within that framework.
Alix (43:33):
Okay. let’s say someone comes to you with an eating disorder of any kind. How would, how do you approach that? Because that could be super complex.
Julia (43:48):
Yeah. So one of the really tricky parts about this is that binge eating disorder, which is an eating disorder and some people who struggle with binge eating disorder can actually really benefit by working with a team and having a really high level of support and accountability. So we don’t want to make a blanket statement that we don’t accept patients with eating disorders because we have worked with many patients with binge eating disorder and we’ve seen such success. Now, if a patient has a current active eating disorder such as anorexia or bulimia, they do not qualify for weight loss they and we would recommend that they work with a team of experts, a therapist, an eating disorder dietitian to address that and weight loss is not indicated at that time. Some patients have histories of eating disorders. I think many patients who struggle with obesity have histories of eating disorders. If they’re at a point where they’ve gotten the help and they’re stable and they are cleared by their therapist to work with us, then we are absolutely open to working with them. We just always have to be super careful about making sure that that’s not something that’s creeping back in.
Alix (45:07):
Yeah. So you’re screening for that. And again, when you’re working with a team who is really experienced with this population, you’re much more aware of the signs and red flags when someone comes to you and you believe there might be something they’re not fully disclosing, or you may have to dig a little deeper into their history.
Julia (< span style="text-decoration:underline">45:29):
Right. And the nice thing is, we’re working so closely with the obesity medicine doctors…the dietitians and the obesity doctors are a team. So we never feel alone in a patient case. We always have the physician to chat with and talk through a challenging patient case and get their take on it. So it is very much a team approach.
Alix (45:47):
And do you work with any therapists or do you have a referral network that you can provide?
Julia (45:53):
Yep. We have a program that we refer our patients to. It’s not a part of Form Health, but it’s another program that works specifically in bariatrics and they do a lot of eating disorder work. And it’s also a, a telemedicine company, so it’s all remote. So we are able to refer patients to them
Alix (46:17):
That sounds like a really great extension of your team, because I do a lot of case work with clients’ therapists and there’s a spectrum of understanding and awareness of eating disorders. And sometimes we’ll be doing something in our work and then the therapist will say something super triggering so having someone that you’ve vetted is what’s so important about the work that you’re doing. You guys are all on the same page and it’s a safe place and team to come to.
Julia (47:03):
Yes, a hundred percent.
Alix (47:06):
So we talked a little bit about whether or not people can come off these, but before we wrap up, what would you say is something you want to let people know about just the social media hoopla of all this and how we can maybe all be doing a better job when we’re speaking about this?
Julia (47:31):
Yes. I think one of the important things to keep in mind is there’s this concept of people first language where instead of using terms like “the obese person” we say “the person with obesity”, the whole concept of people-first language is to see the person, not the disability. So a good example is someone who has cancer, we would never call them, “the cancerous person”. That’s not their identity. They’re “someone who has cancer.” So that’s one very concrete thing that we can all take away and start using today in the way we speak to address some of the bias. I think for each of us also just noticing our own thoughts and judgment around people struggling with obesity.
(48:18):
Noticing that and working to reframe that in our minds and reminding ourselves that it is a complex disease. It’s not a person’s fault, it’s not about willpower. It’s not that they’re lazy. I think education is so important just on the complexity of the disease. Like a lot of what we talked about today. It’s not well known. It’s still something that we need to educate the world and the doctors in medical school that it’s a complex chronic disease. It is biology based, it is brain-based. It’s not just that we like cake too much. So I think starting there, addressing some of the bias that we see every day in life at doctor’s offices on social media. Another thing that comes to mind is in doctor’s offices, making sure to provide proper equipment such as blood pressure cuffs that are big enough that they’ll fit all different arm.
Alix (49:16):
A scale that goes up high enough!
Julia (49:20):
Exactly Right. Just treating all people with dignity and respect
Alix (49:27):
It shouldn’t have to be said but it’s a good reminder because I understand where the frustration comes from because even if you’re not dealing with the disease of obesity, you may have body image issues and you may have dealt with a frustrating journey to weight loss. And so we see people where it seems like they’re taking the easy way out, but it is not the easy way out. It’s a tool that still requires a lot of work and support and understanding that there are going to be people misusing this, there are people who’ve misused things for as long as we’ve been around, but that’s not who these medications and interventions are really for. So let’s not get lost in that, the stuff that we see in the media and on social media and understand that these can really help people.
Julia (50:30):
Absolutely.
Alix (50:32):
So if someone wanted to work with you guys at Form Health, what’s the bes
t way to go about getting in touch?
Julia (50:41):
The best way is to go directly to our website to see if you would be a candidate. So formhealth.co. So it’s not com it’s just.co. and then you could do a questionnaire, take a quiz, see if you qualify. we also have an Instagram formhealthofficial, which a lot of our dietitians are featured on with fun tips, centered around healthy eating. But we would love to work with you and please get in touch if you’re interested.
Alix (51:10):
Amazing. I’ll link all that in the show notes. And thank you so much, Julia, for sharing all your expertise!
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