Dr Louise Newson [00:00:00] Some of you might know already, but this podcast has been nominated by the British Podcast Awards for the Listeners Choice. So, we really need your votes, because it would be such an honour and thrill to do well in this so if you go to the show notes and click on the link, it won't take you long. Please just vote for us. Thank you so much!

Dr Louise Newson [00:00:23] On my podcast today, I've got Dr Jack Mosley, who's a GP registrar and an author. He's also the son of the late Dr Michael Mosley. We have a conversation about nutrition, about GLP-1s, what they're good at doing, and what perhaps they're not so good at doing. And we talk about fat, the role of fat, how it can be detrimental for our future health, and also, obviously, talk about hormones. So it's a great conversation. Hope you enjoy it!

Dr Louise Newson [00:00:53] So Jack. Great that you're here from Manchester, which makes me feel very nostalgic, because I spent many happy years in in Manchester, and actually, you did some of your GP training, where I did my GP training. So small world!

Dr Jack Mosley [00:01:08] Thank you so much for having me. And like you were saying, we've, we've worked in some of the same hospitals and the same GP practices as well. Which is very interesting.  

Dr Louise Newson [00:01:18] But, you know, medicines really changed. So it was 25 years ago that I became a GP. And you know, we didn't. We had a bit of obesity, but not much. The NHS was not on its knees as it is now it was, we were really, we've always been really holistic in our care, but now it's just, everyone's shattered. Everyone's, the system's broken. And I was in hospital a year ago when my middle daughter fractured her pelvis. And I was really shocked by not just the patients, really lot more overweight than patients that I looked after when I was in hospital, but the staff as well, actually. And then it's impossible to get food in a hospital, like impossible to get fresh food in a hospital, you know? So it's the system is set up to fail us in the way when we're thinking about obesity and being overweight, it's so easy to put on weight, isn't it?  

Dr Jack Mosley [00:02:17] Without a doubt, I think we live in this toxic food environment. We're surrounded by these processed junk foods wherever we look. And these foods are, they're designed to be addictive, and they're designed to overwhelm our, you know, our natural satiety sense, and that, you know, sense of fullness, and like you say, it's actually very relevant for the NHS on so many levels, and not just the patients, but the staff too. So when you go to a hospital, a lot of the canteens, they're very beige food. You've got, you know, vending machines all over the hospitals. So especially when people are so stressed, they are, they're not reaching for the broccoli. They're not reaching for the veg. They are reaching for, you know, those unhealthy snacks, like the Mars bars, the chocolate bars and crisps.

Dr Louise Newson [00:03:10] And it's easy to eat badly. You know, I've always looked at my diet, but I wasn't taught much at medical school about nutrition. Most of what I've done is I've learnt myself, but I had pancreatitis a few years ago, and was really ill, and I really, really, then looked at my nutrition. Was there anything I could do to help the pain and discomfort I got after, and then I have migraine as well, so if I ate a ready meal, it would trigger a migraine. So I'm sort of lucky, and not lucky that I can't just eat awful food, but it is so easy now more than it ever has been. But sometimes it's when we have something that happens to us and we realise that we feel so much better eating well, then it spurs you to think about your patients. And I know you know your late father, Michael, was an incredible, incredible man, educator, like just the way he thought beyond the box. But he had an experience, didn't he, where he changed his nutrition and, you know, looking at type two diabetes and trying to prevent disease as well with and treat disease with food, which was a bit out there when he was started to talk about it, wasn't it?  

Dr Jack Mosley [00:04:20] Yeah, without a doubt. So he famously was able to reverse his own type two diabetes through diet, which the medical establishment at the time thought, you know, type two diabetes is this chronic condition. You just take more and more pills and eventually end up on insulin. After around 10 years, he was able to lose around 10 kilos.

Dr Louise Newson [00:04:42] Which is a lot of weight isn’t it!

Dr Jack Mosley [00:04:44] Yeah! No, it's a significant amount of weight. And a lot of that weight goes, you know, initially, actually off your liver and your visceral fat. And he was able to lose that weight and keep it off and stay in remission of type two diabetes. And I think. I completely relate to this. Having their own personal experience makes a huge difference. In fact, you know, I've, I've always been quite skinny. I thought I couldn't put on weight, but I, when I started work as a junior doctor, I managed to put on 15 kilos of weight, within the first year of work as a junior doctor. And like I said, it comes back to that. It's that you're very stressed as you don't know your place in the hospital. I was commuting to work a hour each way, you know, munching on sweets and yeah, again, eating beige food in the hospital, eating celebrations given by really grateful patients.

Dr Louise Newson [00:05:39] So easy on the wards isn’t it!  

Dr Jack Mosley [00:05:40] Exactly No, without doubt. So I think it's so easy to put on weight in this, in this day and age, and I think that's a lot to do with the environment, really.

Dr Louise Newson [00:05:49] That's a lot. I mean, I know you're tall, but that's a lot of weight. And so how did you lose it?

Dr Jack Mosley [00:05:55] I lost it just by making kind of small changes over time. I, you know, started cooking some of my own food. I stopped eating sweets on the way to hospital. And, you know, I think I was lucky that my parents taught me quite a lot about, you know, cooking and eating well and that sort of thing. So I didn't make any drastic changes, but I just, you know, made a few small changes and started, I'd kind of stopped exercising as well, which I think was adding to my stress.

Dr Louise Newson [00:06:24] Yeah, it's interesting, because obviously your mum's amazing cooking, because she's devised so many recipes and everything else. And it's very easy to look at your mum and dad. You know, your mum's really lean. She's probably got very good metabolism as well. But knowing your father in later years, he just looks so healthy and lean. So it's easy to think, oh, he's lucky, but actually, he worked at it and really changed his nutrition, didn't he?  

Dr Jack Mosley [00:06:51] He definitely, you know, he was addicted to chocolate, and he had a massive, sweet tooth so, and I think that's what made him so relatable, because, you know, he was saying, you know, he thought willpower was overrated, and but you had his whole idea was really ingraining these healthy habits and making sure that, you know, you set up your own food environment so that you weren't tempted by these foods. You know, he, like I said, he famously ate all our chocolate eggs. This was before he he changed his ways, but he was definitely a chocolate addict, and he just managed to really change his diet and lose his weight and keep it off.

Dr Louise Newson [00:07:40] And I do think, you know, as a doctor and a patient, as patients, we have to have responsibility for our health. We can't just expect people to medicalise us and treat us all the time. And I mean, I used to have really sweet tooth, and I've never been particularly overweight, but I was bigger as a medical student as I than I am now, and that's probably because I was drinking alcohol, which I don't drink now, anything rubbish, like you say on the wards you're doing on call, like, what else do you do? It's really difficult. So you go to the vending machine, you get some stuff from the, you know, the nurses station. If it's three in the morning and you just want to keep awake, and then having three children when you're awake, you know, I just didn't look after myself in the same way. But then you start to feel better. And now my blessing and curse is migraine, because it stops me eating junk food, and I have to be really prepared. I always make food, and I always have it in a little yoghurt pot, so I'm out and about, and I've got something there, or I've got nuts or whatever as a snack. But for most people, it's not so easy. And I can see, you know, whenever you go and fill up with petrol, like there's nothing that I would eat in those places or drink, actually, other than, yeah, maybe some water. But it's impossible, often, for people to access food. So we do have an obesity crisis, don't we?  

Dr Jack Mosley [00:09:02] We definitely do. And like you say, well, for you, I mean, you've gone through some horrible experiences like, pancreatitis is extremely nasty. You know, migraines are very, very nasty to some people can leave you incapacitated for a few days. I think, you know, not everyone even knows how big a role nutrition does play in that, which is interesting as well. And yeah, the petrol station example is so relatable to everyone, because how easy is it to, I mean, how hard is it to go to the petrol station and not pick up that bar, the sweets or the chocolate bar on that long journey. And I think it's also interesting when, when you are stressed. So you know, stress serves a useful evolutionary benefit, especially in the wild, because you get that sugar rush and you're prepared for the fight or flight, but when it's chronic, then you have that constant sugar in your bloodstream and the cortisol and it can really lead to these maladaptive eating habits, and that, like what you alluded to, is either a vicious cycle or a bit of a virtuous cycle of when you're not feeling well and when you're feeling stressed, you can, you know, you eat rubbish, then you feel worse, and then it gets into this vicious cycle.

Dr Louise Newson [00:10:19] It's very hard to get out of it. And I'm very interested in, you know, the role of insulin with other hormones as well. So cortisol and insulin, go very closely together, don't they? And, you know, it's sort of since I qualified, people talk more and more about, you know, the sugar peaks and troughs, the insulin being coming squeezed out of the pancreas and that has a real effect on the pancreas. The pancreas gets tired. The system gets tired. You know, this metabolic syndrome that occurs is actually very common, but also fat cells. Lots of people think that fat is just a bit of blubber, and you've already said something about visceral fat. So the internal fat around our hearts and our digestive system is very different to the fat on our externally, sort of on our thighs or bottoms or whatever. But fat is metabolically active, isn't it?  

Dr Jack Mosley [00:11:16] Yeah. So the Yeah, so you've got those, some of the two kind of key fats that we talk about are, yes, visceral fat, which is that nasty, metabolically active fat that clings to your organs and causes, you know, it clogs up your liver, it clogs up your pancreas, and can lead to all sorts of health problems like type two diabetes, but can also lead to, You know, cardiovascular disease, heart disease, stroke, and then you've got the more, you've got that subcutaneous fat that's under the skin, which is a lot safer type of fat, and actually that's not really metabolically active in the same way. And yeah, there's the there's a kind of concept of the personal fat threshold where people beyond a certain weight, you know that fat kind of starts over spilling, so it goes from the subcutaneous fat and starts clogging up your your belly, really, and that's really the dangerous fat.

Dr Louise Newson [00:12:19] Yeah. And I'm very interested in inflammation, and we've got lots of cytokines or chemicals from our fat cells, our adipocytes that that get released into the system and increase inflammation in the body even more. So it's so it's important. It's not just how we look, it's what's going on in our systems. And as doctors, obviously, we treat diseases, but we want to prevent diseases as well, don't we? And it's, it's so important. So you've read in this book food noise, how weight loss, medications and smart nutrition can silence your cravings. And I really like this smart nutrition because, like, I really enjoy food, but I think the trick is being able to eat and then not feel hungry. It's quite a good hack though isn't it.

Dr Jack Mosley [00:13:02] Exactly, yes. I wrote that, the book Food Noise, because I was kind of, I was seeing how the GLP-1s were really sweeping the world. There was this fascination about that, and for good reason, because they are very effective at weight loss. But people, you know, people don't a lot of people don't necessarily understand the risks and rewards, the side effects and how to manage them, and that these are, they're not magic bullets. These are really powerful drugs. So we really need to approach them with kind of care and knowledge. I think.

Dr Louise Newson [00:13:44] I think that's crucially important. So when I was at Manchester Royal Infirmary in the 1990s, I was working with an upper GI gastrointestinal surgeon, and they started doing gastric bandings. Which shows how old I am, but it was a revolutionary weight loss treatment. And so they would see the patients, would see a psychologist beforehand, and then they would have this banding. And I'm sure, you know, the first banding operations, they were far too tight. So literally, people could only have a thimble full of food. And women would come back to go, this is amazing. I've lost X number of dress sizes. I'm really slim. But then their hair would start to fall out, their nails would split. They couldn't get any vitamins in. And then we realised a lot of people were using things like having things like Quavers crisps and liquidising them to get them so that they were, you know, really small volume, so they would still be eating rubbish, but they would nutritionally, they would not be well at all. And a lot of them then had their banding reversed. So then it made me really think about this relationship with food. Is very different to alcohol and smoking, which are optional. No one has to drink or smoke. We have to eat. But if you haven't had you know, you've grown up in a household where food is really important and it's cooked from fresh but if people haven't, and then a lot of these foods like you say they are addictive, and we know they're addictive, but they also, then people crave it. There's an addiction, so they've got this cycle. So, GLP-1s like you say, do have a role, but, but then, and I think in the book, you're very clear that they're not really the first go to for a lot of people.  

Dr Jack Mosley [00:15:21] Yeah, so, and that's what I kind of tried to highlight in the book. I'm not necessarily for or against these medications, but and they can be really beneficial to certain people who are living with obesity, who are living with an obesity related diseases, and have tried a lot of these other dietary options, because it is like we talked about earlier, with the food environment. It is very difficult for some people in this food environment, this food environment. And as well, some genes also play quite a big role in weight with regards to, I think the key with these weight loss medications, if you are to do them, is to make sure you are eating this nutritious food. We're overfed, but we're under nourished. So people are really eating this kind of calorie rich but nutrient poor foods. So like you say, back in the day, you know, you'd be liquidising Mars bars, eating quavers, so that can lead to its own form of problems. And they did a study in America that showed half of people living with obesity have some micronutrient deficiency already, so you could be exacerbating that problem if you don't change your diet and if you don't change your lifestyle. So I think if you are thinking of taking these weight loss medications, you need to really think about as an opportunity to change that those lifestyle behaviours without that pesky food noise.

Dr Louise Newson [00:16:43] Yeah, and that food noise is, is really can take over a lot of people's lives. And what some people who I know, who have taken GLP-1s has said that they just don't feel hungry and they love it, but then they don't go out for to the restaurant, they don't go to people's for supper, or, you know, they've had to adjust the amount that they eat, but then they're not enjoying food in the same way. And that that can be really restrictive, actually, can't it?

Dr Jack Mosley [00:17:11] Yeah, I think it's a very interesting time that we live in, in that, you know, already people are probably become a bit more socially isolated. I think food is a very binding experience. You know, a lot of our socialising does revolve around food. So once you remove that, then that could be an issue. And especially, yeah, people may not be going out for dinner. They may not be doing dinner parties in the same way, that sort of thing, or even having a kind of family dinner in the conventional way. So, so there are, you know, this is going to have a massive impact on the whole of society, I think.

Dr Louise Newson [00:17:48] Yeah, and so with sugar cravings and food cravings, I see it a lot in women. Obviously, I see a lot of women in the clinic, and we see a lot of menopausal women, perimenopausal of women, but also a lot of women with premenstrual syndrome, PMS and premenstrual dysphoric disorder (PMDD), and I used to get it before I had my periods this few days before it's just like, Oh, I just want to eat chocolate. I just want to eat a real carb craving. And I thought, oh, maybe it's just in my head. But then my period come and I'd feel fine and I wouldn't, wouldn't make wouldn't need that in the same way. But we know that these hormones, estradiol, progesterone and testosterone actually have really important cardiometabolic functions, and so insulin can be really altered when we don't have estradiol and progesterone in our bodies. So a lot of women that we see when we balance their hormones, their metabolism, can change. Their cravings can reduce, but also their ability to just function. You know, their brain comes back, but also their bodies as well. They're more likely to exercise, more likely to have the motivation to cook. And I feel it's a shame if they're going to like the GLP-1s before having their hormones balanced.

Dr Jack Mosley [00:19:01] Yeah. I mean, it's really, really important, because, like you say, that period around perimenopause and menopause, your hormones completely change, and the decline in estrogen and testosterone and progesterone, they can have big effects on you, especially changings in body composition. So we kind of talked about that visceral fat and the subcutaneous fat a lot before menopause, a lot of it that fat is more stored in subcutaneous, but it can kind of navigate to visceral fat through menopause. Also, things like muscle loss can accelerate at menopause, and other things like osteoporosis. So that's where there, you know, these GLP-1s, there are some beneficial effects, potentially, if people are able to lose weight on them, but then you also have these other factors, like we know, one of the risks of GLP-1s is that a significant amount of the weight you lose is muscle or lean body mass, and I do also have some concerns for it could, in certain people who aren't eating the right nutrition. It could actually potentially exacerbate things like osteoporosis, especially, I think, in menopausal women.

Dr Louise Newson [00:20:17] And that's a real concern, because we know osteoporosis is really common. Some people quote one in two menopausal women. And certainly, one of the reasons I take hormones is to protect my bones and try and keep them strong. But Osteosarcopenia, long word, bone loss and muscle loss, as we don't have hormones, is really, really common, and it's sort of been ignored for a long time. You know, frail old ladies with their Zimmer frames, but actually they've lost their muscles, they've lost bone density, they've lost their hormones. So thinking about preventative medicine, giving hormones will help their muscles, it will help their bones. But with the GLP-1s, if they're losing bone density, they're losing muscle and their menopausal it's like a double whammy, isn't it? Well, it can be.

Dr Jack Mosley [00:21:07] Yeah, and I think there are, Yeah, there are exactly, there are definitely risks there. And you know, we know from the studies that 25 to 40% of the weight you lose is lean body mass, and a main component of that is muscle. And you know, muscle is so important for longevity. But also, you know, living a healthy, independent life in later age, so kind of living happy and independent, which is just obviously so important to so many people.  

Dr Louise Newson [00:21:42] But also muscle is metabolically active. We've talked about fat cells metabolically active in a negative way, but muscle is actually very metabolically active in a positive way. So people who have more lean muscle, their metabolism is going to be different actually. And muscle can produce lots of hormones as well and very anti-inflammatory substances. So people might look the same externally, but their body composition, and we have a DEXA scan in the clinic, and you can see the difference internally. So where that visceral fat is, where their muscles are, it's really important, isn't it?  

Dr Jack Mosley [00:22:16] Yeah, no, it really is. And I think that the body yeah, body composition. I mean, there are limits to BMI, which is a kind of normal assessment of who is health, described as healthy, overweight, living with obesity. But um, that body composition is so important because some people, unfortunately do have more visceral fat than others. Some people like you say have more muscle than others. And during that perimenopause and menopausal period, so from the age of around, from the age of your early 30s, you start to lose 5% of your body weight every decade, so 5% of your muscle mass every decade. And that can really accelerate from 60s onwards. So, you've all these compounding factors. So that's why I think it's so important to consider, you know. So firstly, you know, eating, yeah, eating enough protein because your appetite is really restricted if you are taking these GLP-1 weight loss medications. So getting enough protein is important. But also, these other things that are good for bone health, like, you know, calcium, magnesium and vitamin D, is really important. And then thinking about doing some strength training actually, is very important for some people, and weight bearing exercises that can, so weight bearing exercise, what I mean by that is kind of,  you know, things like dancing, running, racket sports, all of these things that put pressure, healthy pressure on your on your bones, and can help, really, with things like osteoporosis.

Dr Louise Newson [00:23:52] Yeah, it's really important. My husband's a surgeon, and sometimes he sees people with a BMI, body mass index of 50, like they're morbidly obese, and they need surgery. And GLP-1s certainly have a role there. But when he talks to them, they're like, there's no way I can change my diet, there's no way I'll exercise. And they just think, this is going to be a magic drug, which, yes, it could be, but it's not helping internally. And I think looking at the nutritional status of our patients is crucially important, isn't it?

Dr Jack Mosley [00:24:23] Yeah!

Dr Louise Newson [00:24:24] But so I was talking to someone last night who, you wouldn't look at him and say, he's overweight at all. He'd drunk a bottle of wine as he came home and sort of eats maybe a little bit more than he should. And he said, you know, I think I might just take a GLP-1. I'm just gonna have a micro dose and just see how that goes. And I just told him that he was really stupid. And um he said, everyone's doing it. And he's not medical! He's just been reading stuff about it. But I see quite a lot of patients. I don't prescribe GLP-1s, we don't prescribe in the clinic. But they're sort of my shape, but they want to get in their bikini for the summer, and doctors are giving them GLP-1s without any nutritional advice, without looking at their exercise, without thinking about cutting down their alcohol maybe, I just feel a bit uncomfortable with that. I don't know what you think?

Dr Jack Mosley [00:25:16] That's, and that's why I kind of wrote this book at the end of the day, it's the wild west out there of online pharmacies, you know, people are not provided that much information about these medications. They're not provided that much advice about nutrition and lifestyle strategies. So these medications, they're not a cosmetic drug, and they're not a medication to get, you know, lose a few kilos for the wedding or get beach body ready. These are powerful drugs which have some potential downstream consequences, especially for people who are described as a kind of healthy BMI, but and especially for people who don't change their diet while they're on them, I think that is so crucial to have the right nutritional strategies in place.

Dr Louise Newson [00:26:02] I think this is where your book does come into play really well, because, you know, you've got some even lovely pictures as well. And you know how we can still eat, and they're not particularly difficult things to cook, are they? And, you know, they're not like, got loads and loads of ingredients, but there's nice colour, there's going to be vitamins in this and nutrients, which is really important. So because a lot of people, when they lose their appetite, will just have little snacks of things that, like you say, their nutritional status probably be worse than it was before they started these drugs sometimes. So, so what you're really saying is, if you are going to take them, it has to be done in conjunction, well, I would say, with hormones, if they need hormones, but that's fine. You agree with that, but looking at nutrition as well is crucially important, isn't it?

Dr Jack Mosley [00:26:50] Like you, I would say, Yeah, I'm a kind of, you know, diet, diet first approach, because I think that is clearly very, very important. And there are kind of several ways of doing that I kind of discuss in the book. But like I say, for some people who who have really struggled with their weight, they can be beneficial. But I just think you do need that right dietary approach and yeah, like you say, I think other there's lots of other factors involved in weight, in weight gain, and hormones are clearly a massive factor in that.

Dr Louise Newson [00:27:20] And for men as well, you know.

Dr Jack Mosley [00:27:21] Yeah.

Dr Louise Newson [00:27:21] You know, I've, there's quite a lot of people who are younger as well that have low testosterone, and they've got into this cycle. And in fact, I saw a lady in my clinic on Monday who'd had really bad PMDD, premenstrual dysphoric disorder, and she had low hormones, and I'd given her some hormones. She also had some endometriosis as well, and a lot of urinary tract infections, so I had given her some hormones, and her testosterone level was really, really low as well. So she had that, and she felt amazing. And then she'd lost seven kilograms in weight, and she's just changed her whole, she's only 22 but she changed her whole diet. She'd been on the contraceptive pill for six, seven years. She's off that. Obviously. She changed her exercise, I changed nutrition, and I did her hormone blood test, and they were on the high side, and she's on a really low dose of hormones. And I said, you know, I think your ovaries have just started working again. So she's stopped her hormones, and she's but she's got this new lifestyle. And you know, you see that in men as well who take testosterone sometimes, taking that testosterone means that they're metabolically things are changing and improving, then they exercise more, they lose weight, they, you know, they their whole lifestyle changes, and then they don't need testosterone forever. But I think it's looking at everything in conjunction. And yeah, that doesn't always happen in medicine, because it's very siloed, isn't it?  

Dr Jack Mosley [00:28:45] No, exactly, yeah. That's what we were kind of talking about before this started. Really how, unfortunately, a lot of medicine is quite siloed. There's not anywhere near enough nutritional teaching, at medical school and all the way along. I think it is so important, you know, to look at clearly, clearly, modern medicine has made massive impacts for the good to people's lives, but I think the nutritional and lifestyle side of things is somewhat ignored, really, and I think it's people are kind of starting to understand that a little bit more over the last decade, only really over the last decade. I would say.

Dr Louise Newson [00:29:26] Yeah, it's taking a while, so it's great. I've really enjoyed this conversation, but I always leave with three take home tips. So you're sort of at the beginning of your career in some ways, as GP, writer, educator. What three things do you think your work is going to make the biggest impact on over the next decade?  

Dr Jack Mosley [00:29:48] What three, so what three areas? Or...

Dr Louise Newson [00:29:50] Yeah, what things in 10 years' time, what three things do you think that you'll will make a difference to as many people as possible? Because clearly, you're doing great educating. What would you like to see change to improve the health of people?

Dr Jack Mosley [00:30:05] What I would like to see, I think, firstly, we talked about this kind of toxic food environment. I think you do need some more. Something does need to change with, you know, putting some regulations and making some changes to how we, you know, advertising of these highly processed junk foods and some of the taxation of these foods, I think that could make a big difference. Secondly, I would say I'm so passionate about nutrition and teaching, you know, what makes a healthy diet, and I think that is so vital, you know, to, for everyone. But actually, I think especially for clinicians who are seeing people in primary care in hospitals, being able to be armed with up to date, up to date, understanding of how these things work is so important. And I think thirdly, these GLP-1s they, they're not a passing fad. They're not going away anytime soon. So, I think we need the right advice and the right information out there with how to deal with them and how to, and how to use them safely and effectively. Like I say, they're not for everyone, but for some people, they can be beneficial, but I think you still need the right nutritional and lifestyle strategies alongside it.

Dr Louise Newson [00:31:32] Absolutely. So if you are thinking of taking them, don't just do it on your own. Make sure you get really good advice.

Dr Louise Newson [00:31:38] Exactly. Yeah.  

Dr Louise Newson [00:31:40] Ah Thank you so much. I've really enjoyed it. Thank you.  

Dr Jack Mosley [00:31:42] Yeah, no. Thank you so much for having me. It's been great. Thank You

ENDS

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