How GLP-1s are Changing Nutrition Conversations with Dr. Michelle Cardel

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So the focus switches from defending that calorie

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deficit to nutritional adequacy, actually making sure that patients

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are getting enough: Enough calories, enough protein,

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enough fiber.

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Hello, and welcome to the Scale Up

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Your Practice podcast, brought to you by Obesity Canada.

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I’m Doctor Roshan Abraham,

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family physician and associate professor at the University of Alberta.

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And I’m Michelle McMillan, a lived experience advocate with Obesity Canada.

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For decades, dietary advice

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and healthcare has been reduced to one phrase, “Eat less and move more.”

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We treated nutrition as a math equation and body weight as a measure of willpower.

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Today, the science of obesity has evolved, and our approach to nutrition

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must evolve with it.

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We’re moving away from blame-focussed calorie restriction and toward highly

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personalised medical nutrition therapy,

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ensuring our patients are nourished, supported, and heard.

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Today’s episode is supported

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by an unrestricted educational grant from Eli Lilly Canada.

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We thank them for helping us bring this podcast to clinicians across the country.

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Today, we are focusing on medical nutrition therapy.

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Specifically, we want to look at how clinicians can work with patients

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to understand their nutritional needs and build care plans with their patients

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that feel realistic, respectful,

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collaborative, and individualised.

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Today, we’re joined by Doctor Michelle Cardel.

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Doctor Cardel is a registered dietitian and an obesity and nutrition scientist

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who has spent twenty years

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focused on developing evidence based lifestyle strategies.

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She is also the Co-Director for the Center of Cardiovascular and Metabolic Disease

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at the University of Florida and a Senior Medical Director at Kailera Therapeutics.

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Welcome to the show, Michelle.

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Thank you so much for having me.

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So we wanted to get started with a question.

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Why is now such an important time to rethink our approach to nutrition?

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With the advent

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of GLP-1s and increased utilisation of GLP-1s,

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I think we’re learning a lot of different things.

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One, we’re seeing more acceptance that obesity

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is a chronic disease and deserves long term care and treatment.

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And simply telling patients to eat less

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and move more is not just incorrect,

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but actually doing much more damage than it is good.

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And with the advent of GLP-1 and increased utilisation of those medications,

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we really need to take

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a very different approach to nutrition and lifestyle than we did

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when we were thinking about standard behavioural weight management alone.

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Yeah, it’s a brave new world out there, right?

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There’s been a fundamental shift in things.

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I’d be interested because I know that you’ve been in this field a long time.

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I’d be interested to know what brought you to this field

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and why you’ve stayed in this field for,

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I believe, over twenty years at this point. Yes.

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I actually thought I wanted to be a physician.

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And when I was in undergrad, I did three medical mission trips,

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really positive experiences, and also showed me

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that that probably wasn’t the right route for me.

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And so I basically graduated college not really knowing what my next step

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was going to be, but I had started

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being a hospice volunteer when I was in undergraduate.

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And being part of that experience was a real privilege.

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I got to be a hospice volunteer for about ten years total.

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But it’s a real privilege to be with people at the end of life.

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And oftentimes you see that people want to share

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and they want to talk about their memories and the best things

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that happen in their life, but also some things that they regretted.

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And during that time, some patients that I was lucky enough

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to work with shared how they felt that

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their lifestyle and, in particular, nutrition

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may have played a role in their disease risk.

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And ultimately what led to their terminal disease that put them in hospice.

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And, you know, I was nineteen years old when I started in hospice.

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I was not thinking about how nutrition or lifestyle would impact,

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you know, quality of life or, you know,

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how we live or even how we die, you know, decades later.

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And those conversations really prompted

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my interest in nutrition and I started a master’s

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in nutrition, never having taken a single nutrition course.

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But in that first class, I knew I had found my thing.

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I had never had that feeling before.

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And so I ended up doing the master’s in clinical nutrition,

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the PhD in nutrition sciences.

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And about halfway through my PhD, I said, I still want that clinical side.

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That’s really important to me.

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And that’s when I did the registered dietitian training as well. Wow.

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Thank you for sharing that. Yeah.

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So obviously your interest came from a very,

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you know, human based, you know, caring for people place.

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You’ve said a little bit about it, but, you know,

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if we expand on that a little, what did the experience teach you

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about the role food and nutrition can play in the overall quality of life?

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We know from the data that nutrition can play a significant role in a variety

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of aspects of our life in terms of physical health, mental health.

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It has, you know, connections with social health,

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emotional health, all these things.

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I mean, food is such a central part of who we are as humans.

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It’s how we show love.

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It’s how we connect with others.

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It’s how we grieve.

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And the fact that it’s so integral

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to every part of the human experience is such a beautiful part.

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And it’s, it’s such a privilege to be part of this field.

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I really love hearing that.

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For a long time when we talk about obesity, medicine and science,

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the systemic message from health care professionals was to limit intake,

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leaving patients to constantly push back against their own biology.

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Now, just as you mentioned, with treatments that regulate appetite,

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how does the clinician’s role really shift to supportive eating patterns.

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There is a fundamental shift.

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Before, what we did with standard behavioural weight management is thinking

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about managing those external factors that drive eating behavior, whether it is

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emotional eating, stress, alcohol.

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You know, we often would prescribe self monitoring

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as a way to, really

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all of this was in service of defending that calorie deficit.

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But now with GLP-1 medications, we have treatment

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that actually addresses the biological drivers of obesity.

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So the focus switches from defending that calorie deficit

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to nutritional adequacy, actually

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making sure that patients are getting enough

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calories, enough protein, enough fiber that they’re hydrating enough

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that they’re, you know, prioritising physical activity and resistance training,

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prioritising that restorative sleep and that stress management.

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And it really thinks about things in a much more holistic perspective.

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Yeah.

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I mean, I think it’s one of the pieces that,

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you know, we’re still coping with a little bit with the new treatments.

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I mean, I can speak from my personal experience, I’ve been around this planet

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a little while and I’ve lived in the eat less, move more culture for much more,

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much longer than the current culture around

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obesity being a chronic disease, you know, driven by biology.

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And I know when I started treatment because I had always been told eat less,

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move more.

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I’m like, this is perfect. I’m not hungry.

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I don’t have to eat, which was great until I did some blood work

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and I didn’t feel so hot.

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And it was like,

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oh, you’re deficient in, oh, here’s six things that you’re deficient in, right? So

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I’d be

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curious, how do you address with your patients?

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You know, that misconception of they’ve always been told,

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just eat less, move more.

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And they’re now like, “I can eat less.

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And now you’re telling me that I should actually eat stuff?” Like this,

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this is a difficult message for you to get to the people that you work with,

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is it not?

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It’s a really hard thing for people to reconcile.

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I think your experience is quite representative of what

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many people have experienced, and it is a shift.

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And it’s funny, I have talked with patients

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and they’re like, “Michelle, it’s amazing.

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I won’t even think about food till four o’clock.”

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And it’s like, ooh, that’s actually not the goal.

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You know, what’s amazing about these medications

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is that it quiets the food noise.

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And this is an opportunity to help develop and sustain

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those healthy habits that you’ve likely been working on your whole life.

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And now the medications are addressing the biology, and that helps

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facilitate the behaviours that you’ve already been working on for so long,

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for so hard, and helping people

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shift their mindset into how they think about food.

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Food, oftentimes, from what I’ve heard from patients, and Michelle

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I’d love to hear your take on this, is that food was almost the enemy in a sense.

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It was something that was always trying

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to be controlled and minimised as much as possible.

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And the freedom that these medications give

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and the improvements in the relationship with food.

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When for the first time in your life, you’re not trying to hit to stay under

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a ceiling of calories or points or, whatever the designation was, grams.

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For the first time, we’re actually shifting to minimum targets.

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And that’s what I talk a lot about with patients.

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“This is the minimum amount of calories I want you to eat.

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This is the minimum amount of grams of protein or fiber or,

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you know, liters of water or whatever it is.”

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And once people see that shift, they’re like, oh, it is way more

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fun to go track towards

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a minimum than it is towards a maximum.

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Yeah.

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You’re speaking the truth that I feel I have, I’ve felt and I’ve experienced.

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Yeah, it, you know, if you’ve spent your whole life

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fighting biology to always be under something,

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whatever that under is, to suddenly shift that thought to, okay,

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you need to eat at least this much protein.

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You have to make sure that you’re getting

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at least you know, this much fluid in your body.

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Like I think it’s easier, but it takes-It does take a mind shift, right?

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Because for the longest time it’s been the other way.

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So yeah, I think that’s important for, you know, our listeners,

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particularly clinicians to appreciate that you’re probably going to have to wait

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till that moment in your office where you see that change.

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Like, the flipping of the chart in the mind, as I would say.

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Right. That point where they go, “Oh.” Yeah.

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And I do see also needing

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to do some reeducation around

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what nutritional adequacy and balance looks like,

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particularly, around where I see it the most is around carbohydrates.

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There tends to be a significant fear

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around carbohydrates and a belief

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that even on a GLP-1, carbohydrates need to continue to be restricted.

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And my personal take is that when you’re on a medication

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that so severely limits appetite,

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I personally, unless it’s medically

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indicated or very important to the patient, in which case

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we always want to engage in patient centred care and follow the patient.

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But in general, as a guideline, I would not recommend continuing

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on highly restricted diets in combination with a GLP-1 medication.

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Thank you.

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Thank you so much for everything that you’ve just said.

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That is always in my mind as a family doctor and

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even when we’re

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combating weight bias and stigma, both from a patient perspective

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as well as from the medical establishment perspective.

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I do really think it’s important for us to continue having these conversations

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and to advocate for this type of approach, if you will,

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that these are there to complement, these are part of a multidisciplinary

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approach to therapy and that we need to see it as such.

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There is a massive amount of stigma surrounding what people eat,

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especially for people with larger bodies or those living with obesity.

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It leads to shame, missed or delayed diagnoses, complicated relationships

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with food, as we’ve mentioned, or disordered eating behaviours.

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How does this systemic weight bias show up in standard dietary advice,

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and what can clinicians do to mitigate this when they’re seeing patients?

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First off, everything you said is so spot on.

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So I just want to acknowledge that.

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And also to say, I do think that there is a great deal

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of weight bias and stigma often related to dietary recommendations.

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I mean, even the simple premise of just

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“Eat less,

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move more” is inherently stigmatising.

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It’s like asking somebody with asthma to just breathe better,

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you know, or somebody living with depression to just cheer up.

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It’s like, wow, like, I’ve never thought of that before.

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I mean, it’s truly almost insulting.

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Actually, it is insulting.

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And I understand that not everybody understands

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the pathophysiology of obesity, but we need to.

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This is why podcasts like yours are so important in the education around that.

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And to highlight that this is biologically driven,

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this is genetically driven, and we need to bring the same empathetic

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and evidence-based care and approach to the disease of obesity

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as we would any other chronic disease and condition.

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I know that you’ve done a lot of work around the concept of food noise,

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and that’s a concept that I personally use.

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I know there’s lots of nomenclature out there about what people use

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to describe it.

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I call food noise “those intrusive thoughts about food,” right?

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From the moment you wake till the moment you sleep

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in the night, you know, at every single point of the day.

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There’s a little, you know,

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talking in your mind about things.

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So I’d be curious when you’re dealing with patients,

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you know, how does recognising this..

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As a real thing– Because a lot of times, I think

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a lot of people like myself thought, “Everyone is like this.

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I just can’t control it.” Right?

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So how do you explain that, you know, that concept of food noise?

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And do you find it helps relieve some of the interalised blame

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that people have around those food noise thoughts?

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Absolutely.

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What I have seen is when people are able to, for example, get on a medication

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where the food noise is reduced, it’s very validating when they see

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like, “This wasn’t a reflection of me

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or my willpower or my discipline.

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This was a real phenomenon happening within my body,

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and now that it’s reduced, it

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allows for all this additional time

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and cognitive effort to be redirected

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to other things.” And it’s very I’ve seen it

00;16;59;06 – 00;17;04;09
be very liberating for people to have that food noise reduced.

00;17;04;09 – 00;17;07;15
And also the realization that, “Holy

00;17;07;15 – 00;17;11;27
moly, do other people walk around the world not experiencing

00;17;11;27 – 00;17;18;09
this food noise all the time?” Like it’s such a huge difference in the experience.

00;17;18;10 – 00;17;21;10
And when people I’ve heard people argue

00;17;21;10 – 00;17;24;27
against food noise, that it’s just a reflection of hunger.

00;17;25;16 – 00;17;29;01
To me, that’s telling me that they’ve never experienced food noise.

00;17;29;03 – 00;17;30;24
Exactly. Yes.

00;17;30;24 – 00;17;33;24
I can honestly say it’s real because I remember

00;17;33;25 – 00;17;38;18
after starting treatment and I just had one day where I realised

00;17;38;25 – 00;17;42;17
like partway through the day that I hadn’t thought about food.

00;17;42;17 – 00;17;44;21
And I had this epiphany that,

00;17;44;21 – 00;17;48;22
“I bet this is what people who don’t live with obesity.

00;17;48;24 – 00;17;51;23
I bet this is how their brain works all of the time.”

00;17;52;07 – 00;17;56;11
It’s a major epiphany, and it’s weird because it’s backwards, right?

00;17;56;13 – 00;18;03;00
Only by developing the treatment did we realise that this was a real thing.

00;18;03;00 – 00;18;06;00
It wasn’t just, you know,

00;18;06;02 – 00;18;08;17
as we would say, in people’s heads. Yes.

00;18;08;17 – 00;18;14;04
And it’s been, so I was fortunate to be part of the study team

00;18;14;06 – 00;18;19;02
that developed the first scientifically validated food noise questionnaire.

00;18;19;02 – 00;18;23;25
It’s a five item questionnaire called the Food Noise Questionnaire. And

00;18;24;27 – 00;18;26;00
what we’re seeing in the

00;18;26;00 – 00;18;30;22
data is almost a fifty percent reduction in food

00;18;30;22 – 00;18;34;27
noise for people when they’re put on a GLP-1 medication.

00;18;34;28 – 00;18;37;28
I mean, it’s… It’s

00;18;38;00 – 00;18;39;22
life changing.

00;18;39;22 – 00;18;42;07
Yeah. Fifty percent.

00;18;42;07 – 00;18;43;28
Oh, I did not know that.

00;18;43;28 – 00;18;46;05
I have to go review that paper.

00;18;46;05 – 00;18;47;18
Is this from 2025?

00;18;47;18 – 00;18;49;20
Well, we haven’t published it yet.

00;18;49;20 – 00;18;52;09
Okay. Sorry.

00;18;52;09 – 00;18;55;08
I was just quickly looking something up because this is actually really exciting

00;18;55;08 – 00;18;56;19
for me as a family doctor.

00;18;56;19 – 00;19;01;22
I’m trying to find ways to bring this into our academic clinic practice

00;19;01;28 – 00;19;04;13
with our residents and teaching them around

00;19;04;13 – 00;19;06;16
sort of a multidisciplinary approach to obesity.

00;19;06;16 – 00;19;08;17
And the Food Noise Questionnaire had come up,

00;19;08;17 – 00;19;12;14
but I didn’t know if it, again, it was just in my preliminary research.

00;19;12;14 – 00;19;16;02
So that’s something that we can all look forward to once it is fully published.

00;19;16;03 – 00;19;16;26
Exactly.

00;19;16;26 – 00;19;21;07
Before we get into what this looks like in day-to-day practice, like I’m jumping

00;19;21;07 – 00;19;23;18
the gun right now, I want to share something

00;19;23;18 – 00;19;26;23
that may be helpful for clinicians listening who are thinking,

00;19;26;23 – 00;19;29;26
“I want to do this better, but I need more tools.”

00;19;29;26 – 00;19;33;00
If you’re looking to strengthen your approach to obesity care,

00;19;33;00 – 00;19;36;08
I’d encourage you to check out Obesity Canada’s Calibre Course.

00;19;36;08 – 00;19;39;13
It’s an accredited course designed for healthcare professionals

00;19;39;13 – 00;19;44;07
who want practical, evidence-based tools they can apply right away.

00;19;44;13 – 00;19;50;06
Calibre includes a mix of self-paced learning and live interactive sessions,

00;19;50;06 – 00;19;53;29
and the next cohort runs September 3rd through October 7th.

00;19;54;01 – 00;19;57;17
You’ll find the link in the show notes, and if you’re watching on YouTube,

00;19;57;17 – 00;20;01;27
you can scan the QR code on screen to learn more and register.

00;20;01;27 – 00;20;05;25
So talking a bit about what it looks like in a busy clinical practice,

00;20;05;25 – 00;20;09;07
if we need to collaborate with the patient to assess

00;20;09;07 – 00;20;12;11
the role of nutrition interventions in their specific journey,

00;20;12;23 – 00;20;18;06
how do we actually do that and create an individualized plan for them?

00;20;18;09 – 00;20;23;17
In an ideal world, you would be referring out to a nutrition

00;20;23;17 – 00;20;26;23
professional, like a registered dietitian who can

00;20;26;23 – 00;20;29;23
spend, you know, sixty minutes

00;20;30;10 – 00;20;33;12
meeting patients where they are; getting a full history;

00;20;33;12 – 00;20;36;25
really understanding what drives their eating behaviour;

00;20;36;26 – 00;20;38;10
their socioeconomic status;

00;20;38;10 – 00;20;43;08
what’s accessible to them; what are their likes, dislikes, preferences, allergies

00;20;43;09 – 00;20;46;19
in order to create really personalised recommendations.

00;20;46;20 – 00;20;50;19
However, that’s also not always possible,

00;20;50;19 – 00;20;54;28
both within a clinical setting, but also from an accessibility standpoint.

00;20;54;29 – 00;20;59;23
So I know that physicians and healthcare providers are always really limited

00;20;59;23 – 00;21;03;05
on time. So if you’re able to

00;21;04;07 – 00;21;05;25
not make assumptions

00;21;05;25 – 00;21;09;16
about what anybody is eating, I would say start with that.

00;21;09;18 – 00;21;12;27
Ask questions, approach it with curiosity.

00;21;13;05 – 00;21;16;23
I think sometimes the assumption is that somebody living

00;21;16;23 – 00;21;20;22
with obesity doesn’t know much about nutrition.

00;21;20;22 – 00;21;23;22
In my experience, it’s the exact opposite.

00;21;23;22 – 00;21;28;22
People living with obesity tend to know so much about nutrition.

00;21;28;22 – 00;21;31;22
They can tell you the calories

00;21;31;22 – 00;21;36;05
in every food, the grams of, you know, every macronutrient.

00;21;36;06 – 00;21;39;18
Obesity is not a reflection of a knowledge gap.

00;21;39;18 – 00;21;43;21
So taking the time to understand what are the areas

00;21;43;21 – 00;21;47;15
the patient is most interested in modifying

00;21;47;15 – 00;21;51;04
or making changes to understanding where they would like more support,

00;21;51;06 – 00;21;54;13
particularly when you’re in a time constrained session.

00;21;54;21 – 00;22;00;06
I actually had a follow up question, and that was: What should clinicians

00;22;00;07 – 00;22;04;10
be considering if a patient is starting or already taking an obesity medication?

00;22;04;10 – 00;22;07;27
And I’m wondering specifically if there are things if we’re going to

00;22;07;27 – 00;22;12;25
refer out to a registered dietitian, which in some parts of Canada,

00;22;12;27 – 00;22;14;04
especially in Alberta,

00;22;14;04 – 00;22;17;26
through the primary care networks, we do actually have access all clinicians,

00;22;17;26 – 00;22;19;29
all primary care providers who are affiliated with

00;22;19;29 – 00;22;23;29
the primary care network do have access to a registered dietitian.

00;22;23;29 – 00;22;27;11
What sort of things should they be including as part of that

00;22;27;11 – 00;22;29;00
referral process?

00;22;29;00 – 00;22;31;04
If they’re going to refer out?

00;22;31;04 – 00;22;34;17
Ideally, you want to be referring out

00;22;34;17 – 00;22;38;20
to a dietitian with expertise and experience in GLP-1s.

00;22;38;22 – 00;22;42;19
It is a very different recommendation model than standard

00;22;42;19 – 00;22;44;08
behavioural weight management.

00;22;44;08 – 00;22;49;03
And if somebody is not able to refer out and you,

00;22;49;17 – 00;22;52;24
because of time constraints or whatever it is, need to provide

00;22;52;24 – 00;22;57;08
a very quick and dirty recommendation, then what we would recommend

00;22;57;09 – 00;23;01;09
is something that is called the 30-30-30 rule.

00;23;01;09 – 00;23;05;02
You want at least thirty grams of protein at each meal,

00;23;05;07 – 00;23;09;16
thirty grams of fiber daily, and thirty minutes of physical activity

00;23;09;17 – 00;23;12;26
each day, ideally with resistance training twice a week.

00;23;12;26 – 00;23;16;12
And if you can throw some information in there about hydration,

00;23;16;14 – 00;23;20;28
that would be a bonus because many people realise that GLP-1s suppress appetite,

00;23;20;28 – 00;23;24;26
but they don’t often realise that GLP-1s suppress thirst signalling.

00;23;24;26 – 00;23;28;26
And so that’s why you’ll often hear that somebody on GLP-1,

00;23;28;26 – 00;23;29;26
they’ll have their coffee

00;23;29;26 – 00;23;33;03
in the morning out of habit, and then they often forget

00;23;33;03 – 00;23;36;28
to drink, you know, anything besides that the rest of the day.

00;23;36;28 – 00;23;39;28
And that can contribute to headaches, dizziness,

00;23;40;01 – 00;23;43;01
you know, fatigue, dehydration, etc..

00;23;43;07 – 00;23;45;20
I really like that 30-30-30 rule

00;23;45;20 – 00;23;48;29
because that is something that as a patient, it sticks in your mind.

00;23;48;29 – 00;23;50;08
You can walk away.

00;23;50;08 – 00;23;54;09
And even if I don’t take notes at the session, like specific notes,

00;23;54;11 – 00;23;59;16
30 of this, 30 of this, 30 of this, like that’s enough that I can either

00;23;59;16 – 00;24;03;29
remember what the three 30s are or I can reference in our next appointment.

00;24;04;00 – 00;24;05;09
Like I’d be like, oh,

00;24;05;09 – 00;24;09;17
I remember the 30 grams of protein and the 30 grams, the 30 minutes of exercise.

00;24;09;17 – 00;24;11;09
What was the middle 30 again?

00;24;11;09 – 00;24;16;16
And so it gives us a framework to start talking about things.

00;24;16;16 – 00;24;18;11
And then it also gives a framework

00;24;18;11 – 00;24;22;06
for clinicians to, “Okay, so you’ve got the 30-30-30 down.

00;24;22;07 – 00;24;22;18
Maybe.

00;24;22;18 – 00;24;27;15
Can we talk a little bit about hydration?” Like you can slowly add other things in.

00;24;27;23 – 00;24;30;29
And you’re not because what can sometimes happen

00;24;31;00 – 00;24;34;11
I speak as a patient is you start feeling overwhelmed,

00;24;34;13 – 00;24;37;29
like there’s so much information and I’m trying to take it all

00;24;37;29 – 00;24;41;03
in, but I can’t take it all in and I feel like I’m missing things.

00;24;41;03 – 00;24;44;02
So yeah, I love that.

00;24;44;02 – 00;24;45;02
And I love how you talk

00;24;45;02 – 00;24;48;25
about that, Michelle, that it’s- it can be a helpful starting point.

00;24;48;25 – 00;24;52;29
And then after you, you know, integrate that into your lifestyle,

00;24;52;29 – 00;24;57;05
then you build, you know, on new habits from there.

00;24;57;14 – 00;25;01;11
So for many people living with obesity, like myself,

00;25;01;13 – 00;25;06;02
unfortunately, we carry a lot of history.

00;25;06;03 – 00;25;10;17
We don’t walk into your office- It’s the first time you’re meeting me

00;25;10;17 – 00;25;11;27
and it may be the first time

00;25;11;27 – 00;25;16;01
I’m meeting you, but I’ve got thirty years of meeting health professionals

00;25;16;01 – 00;25;19;26
that are history in my mind, good, bad and otherwise, right.

00;25;19;28 – 00;25;21;11
that you don’t know about.

00;25;21;11 – 00;25;26;00
But I’m living with and unfortunately, around some of that history,

00;25;26;01 – 00;25;30;02
you know, there’s some shame because we’ve been shamed and blamed.

00;25;30;05 – 00;25;33;27
You know, as I said, this is a new concept that this is,

00;25;34;06 – 00;25;37;10
you know, a chronic disease driven by biology, right?

00;25;37;10 – 00;25;41;05
There was a lot, even in the medical community about,

00;25;41;07 – 00;25;41;21
you know, it’s

00;25;41;21 – 00;25;45;18
kind of willpower and bad choices and, you know, those kind of things.

00;25;45;18 – 00;25;50;09
And so that kind of led to a little bit of frustration, right from patients.

00;25;50;11 – 00;25;55;29
You know, we got a lot of advice that maybe wasn’t very helpful about things.

00;25;56;00 – 00;26;00;22
And, you know, sometimes if people make assumptions about,

00;26;00;24 – 00;26;04;03
you know, that you don’t know anything about nutrition, you’re just dumb.

00;26;04;03 – 00;26;07;28
If you just knew more about nutrition, you wouldn’t be obese, you know?

00;26;08;01 – 00;26;11;27
So you tend to feel like you’re not heard and you’re not cared for.

00;26;11;28 – 00;26;14;28
So, you know, based on your work,

00;26;15;16 – 00;26;18;27
maybe you could provide some advice, some direction,

00;26;18;27 – 00;26;24;06
some experiences about how you deal with that with your patients and,

00;26;24;24 – 00;26;25;11
you know,

00;26;25;11 – 00;26;26;20
and how that-

00;26;26;20 – 00;26;30;06
You’ve already talked about it being personalised- So how that flows from,

00;26;30;14 – 00;26;33;29
you know, dealing with all the things that I just threw at you.

00;26;34;14 – 00;26;39;08
And then somehow working with that person as an individual human

00;26;39;08 – 00;26;42;08
being that you have to work with as an individual.

00;26;42;09 – 00;26;43;28
Do you have any thoughts about that?

00;26;43;28 – 00;26;46;08
Too many. Haha. But

00;26;47;23 – 00;26;48;16
I, before we go into the

00;26;48;16 – 00;26;53;17
recommendation piece, I just want to share a story that I think

00;26;54;14 – 00;26;57;20
it’s really important for people to understand.

00;26;57;20 – 00;27;02;17
Because this is a story of my mom’s best friend, they grew up together

00;27;02;17 – 00;27;06;26
in Puerto Rico and she lived with obesity,

00;27;06;26 – 00;27;13;23
and she was having issues with her heart for years.

00;27;13;25 – 00;27;18;23
And she kept going to health care providers and saying, “Something is wrong,

00;27;18;23 – 00;27;22;16
something feels wrong.” And every healthcare provider

00;27;22;16 – 00;27;26;10
she went to told her she just had to lose weight.

00;27;26;11 – 00;27;29;11
She just needed to eat less, move more.

00;27;29;16 – 00;27;32;26
Well, it turns out that she had a very serious

00;27;32;26 – 00;27;36;26
heart condition that had absolutely nothing to do with her weight,

00;27;36;26 – 00;27;39;26
and by the time they discovered it,

00;27;40;20 – 00;27;44;09
it was quite late and the disease was quite severe,

00;27;44;09 – 00;27;47;03
and she actually died on the operating table.

00;27;47;03 – 00;27;52;16
And so all this to say is that weight bias and stigma literally kills.

00;27;53;01 – 00;27;58;26
And checking in with ourselves as healthcare providers, doing something

00;27;58;26 – 00;28;03;29
like the Implicit Association test, which is available free online

00;28;04;00 – 00;28;07;20
to check in with yourself, where do you stand on this.

00;28;08;05 – 00;28;12;14
If you come out such that you are biased towards people

00;28;12;14 – 00;28;16;21
living with obesity, that doesn’t inherently make you a bad person.

00;28;17;20 – 00;28;19;17
All it does is that

00;28;19;17 – 00;28;24;11
it brings awareness to you to say, there’s some work I need to do.

00;28;24;13 – 00;28;29;28
Just like, you know, when new medications come out, you study those and you study

00;28;29;28 – 00;28;33;22
how to prescribe them, and you study what you need to share with the patients.

00;28;33;23 – 00;28;35;29
It’s very similar to that.

00;28;35;29 – 00;28;41;14
And so on the weight bias piece, it affects everything we do

00;28;41;16 – 00;28;45;02
as healthcare providers, the treatment options we provide,

00;28;45;04 – 00;28;49;18
the time we spend with patients, how patients feel in our care.

00;28;49;18 – 00;28;53;28
And there’s data to support every single aspect of what I’ve just said.

00;28;54;00 – 00;28;59;07
So first and foremost, I would say taking the time to check in

00;28;59;07 – 00;29;03;17
with yourself and to have a real honest look and assessment.

00;29;03;17 – 00;29;05;26
And take the time to learn.

00;29;05;26 – 00;29;08;26
Use the resources from places like Obesity

00;29;08;28 – 00;29;11;28
Canada and Obesity Action Coalition

00;29;11;28 – 00;29;15;14
to learn more how you can better support your patients.

00;29;15;23 – 00;29;19;18
So I guess one of my last questions, and we’ve asked this of a lot of our guests,

00;29;19;19 – 00;29;24;06
is how does a compassionate evidence-based and, in this case, approach to nutrition

00;29;24;06 – 00;29;29;19
therapy, change a patient’s long term relationship with food and their own body.

00;29;29;29 – 00;29;35;06
It can have such far reaching ramifications.

00;29;35;26 – 00;29;39;06
If it’s done well, for the positive.

00;29;39;06 – 00;29;43;09
If it’s done poorly, it can be disastrous.

00;29;43;09 – 00;29;47;26
So providing that empathetic, compassionate care,

00;29;47;29 – 00;29;52;01
approaching things with curiosity, providing support

00;29;52;01 – 00;29;56;13
and treatment and recommendations that can help facilitate improvements

00;29;56;13 – 00;30;01;18
in eating pathology, for example, what we’re seeing with GLP-1 medications

00;30;01;19 – 00;30;05;12
in a clinical trial that we have published in one hundred

00;30;05;12 – 00;30;09;25
and eighty people living with obesity who were on either

00;30;09;25 – 00;30;14;20
semaglutide or tirzepatide, we saw that over a six month period,

00;30;14;20 – 00;30;19;06
there were significant improvements in disordered eating pathology,

00;30;19;06 – 00;30;23;05
in overall well-being, in quality of life.

00;30;23;05 – 00;30;28;01
And that’s when it was provided with an evidence-based nutrition program.

00;30;28;01 – 00;30;32;19
So the more that we can provide that empathetic, compassionate

00;30;32;19 – 00;30;37;24
care and tools that are really tailored to the patient in front of you.

00;30;37;29 – 00;30;44;01
Not just considering medical history and age and sex or gender,

00;30;44;01 – 00;30;48;03
but also thinking about being culturally appropriate,

00;30;48;07 – 00;30;52;08
meeting them where they are in terms of the community they live in,

00;30;52;22 – 00;30;58;00
the resources they have access to, and truly providing those recommendations.

00;30;58;00 – 00;31;00;25
It’s such an important piece.

00;31;00;25 – 00;31;01;12
Yeah.

00;31;01;12 – 00;31;05;07
Mean, that’s just so true that you need to meet

00;31;05;07 – 00;31;09;08
the patient where they are and everyone is at a different place.

00;31;09;08 – 00;31;13;15
And, you know, some of your patients may be super

00;31;13;15 – 00;31;16;15
well informed and some of your patients may be new to this.

00;31;16;15 – 00;31;20;21
And, you know, you have to kind of find that out first, right?

00;31;20;22 – 00;31;24;20
I mean, I think what I’d say to our clinician listeners is that,

00;31;24;21 – 00;31;28;23
you have an opportunity when they come to see you face to face

00;31;28;24 – 00;31;32;16
because we’re seeing a little bit of a shift.

00;31;32;26 – 00;31;35;05
There is a possibility they could get these medications

00;31;35;05 – 00;31;39;13
without ever sitting down with you and talking to you.

00;31;39;17 – 00;31;42;18
So the mere fact that they’ve come in

00;31;42;19 – 00;31;46;00
to see you, they’ve taken their time, you’ve taken your time.

00;31;46;01 – 00;31;50;10
It really is an opportunity as a clinician to step in and say,

00;31;50;21 – 00;31;54;11
I have an opportunity because that person has chosen to be here.

00;31;54;11 – 00;31;57;27
And, you know, they can probably get that med without being here.

00;31;57;27 – 00;32;00;23
So it’s a real opportunity to open that conversation.

00;32;00;23 – 00;32;03;23
So such a great point that you raised. Yeah.

00;32;04;12 – 00;32;06;07
And it’s so interesting, Michelle,

00;32;07;09 – 00;32;10;11
you’re so right of where people can access

00;32;10;11 – 00;32;14;07
these medications now and who they’re getting their information from.

00;32;14;07 – 00;32;18;13
There was a study done that showed that nearly fifty percent of people

00;32;18;13 – 00;32;23;02
learned about GLP-1 medications on social media, and only nineteen

00;32;23;02 – 00;32;27;04
percent learned about them from a health care provider.

00;32;27;04 – 00;32;30;10
So there’s a lot of great information.

00;32;30;10 – 00;32;32;04
There’s a lot of benefits of things

00;32;32;04 – 00;32;36;09
like social media and the democratization of information, but

00;32;36;10 – 00;32;40;24
it also allows for a lot of misinformation to be out there.

00;32;40;24 – 00;32;44;28
So taking that time, like you said, to assess, “Where is this

00;32;44;28 – 00;32;49;06
patient currently and how can I best support?” can make all the difference.

00;32;49;13 – 00;32;50;21
This has been so good.

00;32;50;21 – 00;32;54;07
I mean, there’s so many little nuggets that you’ve put in

00;32;54;08 – 00;32;55;21
that I hope our listeners

00;32;55;21 – 00;32;58;06
will take away from them, whether they’re clinicians or not,

00;32;58;06 – 00;33;02;01
because I know that we have some listeners who are just patients, right?

00;33;02;02 – 00;33;02;29
They’re living with it.

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And yeah, that’s amazing.

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Today, we talked about how to collaborate with patients

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to create individual nutrition plans.

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We also talked about why nutrition is important when prescribing

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obesity medications and how helping patients understand the biology behind

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hunger, fullness and food noise can reduce shame and systemic weight bias.

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You can find direct links to the Canadian Adult Obesity

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Clinical Practice guidelines, Obesity Canada’s education courses,

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as well as Doctor Cardel’s

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research on food noise in our show notes.

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Please visit them to dig deeper into the evidence.

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As a reminder, new episodes of Scale Up Your Practice drop every second Thursday,

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so make sure you are subscribed so you never miss an episode.

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And as I always say, if you found value in today’s conversation

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and I have no idea how you couldn’t find value, so I know you found value,

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please take a moment to rate and review us on your favorite podcast platform.

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It helps other clinicians find this podcast and join the movement.

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And until next time, stay curious, stay kind, and keep Scaling Up Your Practice.

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This podcast is intended for informational

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and educational purposes only and does not constitute medical advice.

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The content shared in this podcast should never be used as

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a substitute for professional medical advice, diagnosis, or treatment.

00;34;36;13 – 00;34;41;11
Always seek the guidance of a qualified healthcare professional with any questions

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you may have regarding your health or a medical condition.

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The information and treatment discussed in this podcast are based on

00;34;48;03 – 00;34;52;23
Canadian guidelines and approved practices as of the time of recording.

00;34;53;01 – 00;34;55;04
If you are listening from outside of Canada,

00;34;55;04 – 00;34;58;06
please consult your local healthcare professional to ensure compliance

00;34;58;06 – 00;35;01;16
with your region’s medical standards, guidelines and recommendations.

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The creators of this podcast disclaim all liability

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for any decisions or actions taken based on the content discussed.

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Listening to this podcast

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does not establish a professional or patient-client relationship.