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Thinking about using (or are using) weight loss meds? Here's what no-one talks about

The big lessons we’ve learned from weight loss surgery patients will help you get the best out of taking these medications.

By Kate Berridge RNcP MN (Hons), Tiaki Whaiaro

Saxenda, Wegovy, Ozempic and other drugs look like they’re the new magical solutions for weight loss.

They are impressive. The number of people on these medications is steadily increasing, even here in Aotearoa NZ. That’s despite the medication often being full price (ie, hugely expensive) in most cases and only having a couple of options available compared to the rest of the world.

In my role, I’m now starting to work with more and more people using these drugs.

I’m also seeing the same patterns I see in surgical patients:

- initial weight loss = happiness, relief;

- cravings slowly return = confusion, fear, shame;

- weight loss slows, stops or even possible regain = sadness, anger, fear, shame.

Using or planning to use weight loss medication?
Here’s what we’ve learned from weight loss surgery patients that will help you get the best out of the process for your long-term weight management.

First, it’s important to know a little bit of the science behind them to help you understand why they’re great, but not a magic wand that will solve everything for you.

These new types of medications are known as GLP-1 agonists. They mimic a naturally occurring hormone called GLP-1 (glucagon-like peptide 1) which:

-          triggers insulin release, lowering blood sugar levels

-          blocks glucagon, a hormone that raises blood sugar levels

-          slows digestion so less blood sugars are released

-          increases the level of satiety in the brain (how ‘full’ you feel after eating)

Metabolic bariatric surgery also does this by increasing the amount of GLP-1 in your system, but it has several other benefits:

-          it increases levels of PYY, a gut hormone that acts in a similar way to GLP-1, helping with appetite regulation;

-          it temporarily ‘cuts’ (dysregulates) the supply of ghrelin, the hormone which gives you the signal (true hunger) that the brain is low in energy and needs calories;

-          it physically restricts how much food you can digest at one time;

-          in the case of bypass surgeries, it has a lifelong effect on nutritional absorption, providing a ‘brake’ when a person eats too much fat/sugar.

 That’s why surgery is still the gold standard treatment for significant weight loss, with vastly better outcomes than GLP-1 medication.

However, surgery also costs a lot of money upfront compared to the monthly expense of medication. It’s also a one-off intervention, whereas there are ever-increasing options with medications, and they’re improving all the time.

Why weight loss medications aren’t a magic wand

If there’s one phrase most metabolic bariatric patients learn to loathe, it’s ‘surgery is just a tool’.

The effects of surgery are very impressive, but if you – for example – drink a high-sugar, high-fat liquid like a milkshake, you will get around the restrictive aspect.

GLP-1 medications are also wonderful tools for managing aspects of your body’s physiological signals around energy intake and the digestive process, but they can’t control everything involved either.

Lessons from decades of weight loss surgery patients

What I’m about to share is what I (and many others) have learned from working with thousands of weight loss surgery patients.

It may be hard to accept.

But please know I see the following play out every single day with surgical patients, and I’m now seeing it happen to those using weight loss medications.

A little bit of background may be helpful.

In 2007, I helped set up a public health metabolic bariatric surgery clinic. Highly motivated, carefully screened patients would get publicly funded gastric sleeve operations.

At the time, I – along with almost everyone else – thought surgery was the final, slam-dunk answer: give people surgery, they lose their weight or a significant portion of it, they’re fixed.

Except that’s not what happened.

My role was overseeing every patient and their care, from the strict screening process to the highly restrictive pre-surgery diet before surgery until 18 months afterwards.

I watched hundreds of eager, smart, lovely people have surgery, lose vast amounts of weight, become completely unrecognisable even to their families, and get super-excited about their new lives.

Then inexplicably, around the 8–14-month mark, almost every patient would slowly start going sideways. Weight loss would stop – as expected – but then they’d start to regain weight. At first a little, then more, but almost always tracking upwards. They would report terrific cravings and the return of eating habits from before their surgery that had disappeared afterwards.

It was absolutely devastating. Some gained relatively small amounts of weight, but they had to fight for it, often to the point of despair. Some patients regained every kilogram they lost.

Adding to the awfulness was the reaction of family, friends, and many medical staff, who all blamed the patient. The patient had failed.

Even the patients thought it was down to their poor behaviour and lack of self-control.

No one knew why it was happening or how to help them, but I was determined to find out.

The missing link

Over the next few years, thanks to a lot of observation and study, it became clear.

Before surgery, patients were using food far, far more than they realised to help regulate their emotional state.

In fact, every moment of their lives was regulated by food, whether the emotions were ‘positive’ (eg, happy, joy) or ‘negative (eg, anger, sadness, fear).

Most weren’t aware of or had only a small sense of their emotional state.

They managed their lives by using the little boosts of ‘happy’ hormones that they’d get when they ate. Often, they were ‘preloading’, eating ahead of time to cope with their day, followed by relief eating at night. Some people would binge, some would graze throughout the day.

Surgery interrupts that pattern. Not only are you finally losing weight at pace, but for about a year or so, you’re riding an amazing wave of positivity. There’s lots of recognition for your efforts, your new look, new clothes, your confidence soars, and most importantly, there’s a sense of finally belonging in the world.

That’s a near-constant haze of happy hormones for almost the whole time, with no food required.

In our industry, we call the first year after surgery ‘the honeymoon’ because most people spend a lot of time in this blissful state, and it’s so easy.

But anywhere from around 8-14 months (some get less than this, some get longer), the brain and gut connection comes back online. The hormonal effects wane, then end. Cravings begin to reappear.

There’s also a double whammy around this time. Life is settling back to ‘normal’ as there’s very little that’s ‘new’. Everyday stressors come back into focus, but there’s no happy haze to help you get through it.

People need to soothe themselves. If you ate before to help you manage your emotional state, it’s most likely you’ll return to it. Others transfer or add other methods including the use of alcohol or drugs, gambling, overspending, tidying/organising, exercising, workaholism. It can be anything that short-term offers a hit of relief. Long-term, it’s heading for a crash because these manage symptoms but don't address the underlying cause.

I now know this process is completely normal. There’s nothing broken or failed about patients who behave this way or who regain weight. It’s what we expect because you can’t change what you don’t know.

However, I also know that if you learn new ways to recognise and regulate your emotional and mental state, you can develop a much better relationship with food and eating long-term and be far more effective at managing your weight and health.

Not perfect, but manageable.

The pattern is similar with weight loss drugs

Unsurprisingly, people using new weight loss drugs show the same patterns as surgical patients:

-          the joy of having an ‘answer’ and the loss (or at least, dialling down) of cravings;

-          the initial weight loss;

-          the slow escalation in cravings and the patient response (restriction, self-criticism);

-          weight loss that slows, then stops;

-          long stalls, even possible regain while still taking the drug.

The difference is it seems to be a faster process, with the ‘honeymoon’ phase lasting perhaps only a few months.

It’s not that the medication isn’t working. If you’re taking it properly, it is: there’s usually little to no physical feelings of true gut hunger, food is moving more slowly through the body, blood sugar levels are being curbed.

The power of your heart & mind

Finding a way to manage your weight long term isn’t a passive process where you take the drug and boom, you’re fixed.

Most people underestimate the power of their emotions. Here’s a real life example of head hunger trumping the powerful physiological processes of both surgery and weight loss medication.

Nadene is a gastric sleeve surgery patient and someone who’s also used Saxenda. She now works for me and has given me permission to share these details.

“When I had my surgery, I was told I wouldn’t feel hunger, from the moment I woke up and for the first year or so. I couldn’t remember a time in my life when I didn’t ‘feel’ hungry, so I was especially looking forward to this part of the process.

“Literally, from the moment I woke up, I was hungry – ravenous. I didn’t tell anyone because I thought there must be something wrong with me.

“For the first week after surgery, I could barely tolerate more than a few teaspoons of a liquid diet at each meal before it was deeply uncomfortable to eat more. But I still felt intense hunger all the time. Even when I couldn’t physically ‘stomach’ eating anything more, I desperately wanted food.

“At one point, the thoughts in my head went a bit crazy, and I wondered, had they just put little cuts on my torso and told me they did the operation but didn’t actually do it? Was this some placebo trick?

“Then, on day 7, I coughed. The pain was intense. I could feel my insides pulling in places where things shouldn’t, as if there were stitches in there (which there were!).

“Over the next day or so, it led me to a huge realisation. If they (the surgical team) were right and my brain’s ability to have true ‘hunger’ signals was turned off, then why was I so desperate to eat?

“And that’s when it hit me. This 'feeling' was all in my head. I finally had my first glimpse of its power. Apart from a handful of times, I’d probably never been truly hungry in my life. And yet, I was always ‘hungry’.”

Twelve years later, having regained 30kg over that time, Nadene tried Saxenda. The same pattern repeated, even with the advantages of:

-          having had surgery and going through these stages before;

-          heavy exposure to other patient experiences and her own personal work on emotional regulation.

When she first started, she had weeks of nausea, even at low doses, a common side effect. This is also when she saw most of her weight loss, and she puts a lot of that down to the low-level nausea. It’s important to note this is not the true effect or intent of the medication.

After 12 weeks, the feeling of nausea tapered off, and that’s when she also noticed cravings returning. Her weight loss stopped.

Unfortunately, she was one of the unlucky ones who had other ongoing, deeply uncomfortable side effects, which meant she had to stop using it. 

We’d describe Nadene’s mental experience as ‘head hunger’ (because the sensation seems to be in the head).

To me, it’s often more accurate to say ‘heart hunger’, as in it’s a sign of an emotion/s buried deep inside that needs soothing. You’re barely or not aware of it, other than as a craving, a need, an urge that won’t go away.

No medication or surgery will change this. Drug companies and surgical teams can do marvellous things to control the physiological processes in the body and dial down the effects on the brain, but no-one can take away your long-learned method of soothing yourself that are now deeply encoded as neural pathways in your brain.

What can you do to help yourself?

In my experience, most people who’ve lived or are living in a bigger body struggle to feel.

Learning how to feel and what to do with those feelings will have a big impact on your life and your ability to manage your weight.

Learning about embodiment

A lot (almost all) of a disembodied person’s day-to-day emotions occur deep below their level of consciousness. Repressing – depressing – authentic emotional responses is something you learn when you’re very young.

If, as a child, you expressed your genuine feelings and that created a frightening response like anger, annoyance, or indifference in your main caregiver/s, you learned it was painful.

However, you still needed a way to manage emotions because they didn’t go away. Instead, over time, you developed ways to keep them inside. Slowly, you become less aware of them.

Eating is one of the first methods of soothing we learn. Certain types of food like fat and sugar ping those ‘happy’ hormones that bring feelings of calm and contentment.

That’s why, as adults, when we have a craving – a need to soothe an unconscious emotion, as opposed to true physiological hunger – most people choose fatty or sweet foods, not broccoli.

Once learned, it’s so effective that there’s often never a need to learn further methods as you mature.

You manage your fear, anger, discomfort, and pain by eating to maintain levels of the hormones that bring contentment and contain who you really are.

Over time, like any drug, you need more of it to get the same effect, and that’s one of the contributing factors to gaining weight.

This is a very once-over-lightly explanation. Everyone varies in how they use food and why. I’m skimming over decades of research that shows the incredible complexity involved in why people gain weight and how they manage emotions. There are a million other components to these processes because everyone is unique.

But in my experience, most patients who are or who have lived in a bigger body have very little or no awareness of why they get cravings or why there’s seemingly always ‘noise’ in their head around eating. To them, it's ‘normal’ and maybe they assume it's the same for everyone, but other people are better at managing it.

Your super-smart conscious brain – maybe your neurodivergent, super-smart brain – will bring up all kinds of very logical-sounding arguments for the reasons why you crave and eat.

I’ll bet all of them are extremely negative about you as a person, and they’re backed up by a world dominated by diet culture. Diet culture tells you every day that if you’re big or eating ‘bad’ foods, then you’re lazy, greedy, useless – insert a deeply negative word of your choice here.

This is all deeply shameful, one of the most intensely distressing emotions a human being can endure. If you’re living with an underlying sense of deep shame that never or rarely lets up, and is buried deep inside, you’re going to need a lot of soothing and be often almost completely unaware of why.

That's why Nadene could feel 'hunger' all the time, and why cravings seem to randomly ‘pop’ up throughout the day. That's emotions trying to get out, and triggering a need to soothe instead.

Getting into the body work

Let’s go back in time to Nadene’s surgery. She’s just woken up from getting a gastric sleeve, a very serious, life-changing operation. She can remember being a little excited but mostly highly anxious.

On waking up, a completely relatable emotional response might be an enormous sense of relief, but there’s probably also:

-          high levels of worry and overwhelm at the process ahead (recovery from surgery, a severely restricted diet);

-          fear of the unknown (a lifelong change in what and how much she can eat);

-          excitement and trepidation of what a ‘new’ life might be like.

Nadene has no idea of her feelings after surgery other than ‘anxiety’. The far more overriding memory is her strong urge to eat. She now knows she was completely disembodied at the time, so the urge to eat was all those types of feelings screaming at her for relief in the only way her brain knew how.

The embodied patient is rare

An embodied person is someone who can notice a big or small emotion at the moment or close to when it’s happening, correctly identify it, and then respond to it in a caring and meaningful way that soothes them.

If a toddler cries because they fall over, it’s easy to see that they are comforted when their mother picks them up, cuddles them, reassures them that their fright and pain are understandable, and helps them with a plaster on their scraped knee.

You’ll need to develop the adult version of that process of compassion and understanding.

Sometimes, the best soothing option for you might be to eat.

But it can also be:

-          identifying your needs

-          setting boundaries that support your needs

-          offering words of comfort to yourself

-          reaching out for help

-          meditation

-          walking or running or another physical activity

-          gardening

-          cuddling the dog or cat (or both).

The list is as endless as there are people on the planet. Sometimes, you’ll need one method; sometimes, you’ll need several. Big events may need repeated soothing sessions over long periods of time. What soothes you may change over time.

This process can be affected by something like weight loss medication or surgery, where ‘happy hormones’ are triggered repeatedly. However, this is only temporary.

In my previous role at the surgical clinic, patients were desperate for soothing and frantically trying not to eat.

It truly was carnage. It so deeply affected me that it inspired me to complete a Master's in Nursing on what metabolic bariatric patients need after surgery.

The finding was that the self-care skills required to flourish after weight loss surgery are not innate. None of what I’m talking about here will magically appear or become clear to you because you have surgery, take medication, or lose weight.

Even me telling you this in this article won’t make it happen

Learning who you are, your needs, and how to recognise and regulate your emotions are critical, and they take a concerted effort. You’ll need to then practice it over your lifetime.

The role of aftercare

My whole life is now about supporting people through this process because it’s tricky to figure it out by yourself.

I use what I've learned from the thousands of people who’ve gone before you.

How much help do you need?

Think of it like the story of Goldilocks and the Three Bears and finding the perfect bowl of porridge.

Some people need a small bowl, the occasional helping hand. Some need a middling-sized portion. Some need more.

It also takes time. Inevitably there will be falls. Changing and growing for the better will mean adjusting and tweaking what you do, as everyone does over their lifetime.

When you think you've got it, life might swipe you sideways on a quiet Tuesday afternoon. You might need another bowl or two.

You may be reading this and thinking ‘oh, now I know it, I’ll feel/do it’. I wish that were true, but that's the logical head believing it can safely move on without the need for an exploration of your emotional side.

Worse, it can also use this knowledge as a bat to hit you when you feel you’re ‘failing’ at some future point.

‘I knew this, so why did I do/eat XYZ?’

Truly ‘knowing’ something deep inside yourself takes work and time, and having a guide can be really helpful.

My role at Tiaki Whaiaro (tiaki ‘care’, whaiaro ‘self’) is to be that guide, using techniques I’ve learned and trained in over the past 15 years.

It's not me telling you what to do.

Think of it more like we’re taking a walk on the beach. You’re fixated on the destination at the end of the beach, where you think everything will be 'ok'.

As we walk there, I’m going to be pointing out the importance of the soothing sound of the waves and the feeling of your feet in the sand, how to avoid flying manure from a seagull overhead, and why you might want to look carefully at the weird bits of driftwood scattered about. You'll start to look around more and see things you hadn't noticed at first, like the old firepit and crushed-up shells.

These are metaphors for the skills you'll need. You might need to see the driftwood or notice the sand many times, and my job is to guide you through it.

It helps you that I've walked this beach many hundreds of times with other people who have a lot in common with you.

It's also very much tailored to your needs. For example, in the last few years, there’s been a lot more information on just how many metabolic bariatric patients are neurodivergent, with significant numbers of my patients (and patients worldwide) undergoing testing for ADHD and autism.

Getting a diagnosis will change the way I work with someone to better suit the way their brain works.

How long does it take?

Some people have a few hour-long sessions in the first few months of taking medication (or the first 12-18 months after surgery).

At key points – which vary from person to person – it can be helpful to get reassurance about what’s happening physically and mentally and to find, learn and practice strategies that work for your specific needs.

For others, it might be checking in once a month, quarterly or six monthly. Some people do intensive sessions every few weeks for several months and never need to return. Many others come back when they get stuck or when something happens that’s so overwhelming that they recognise they need more tools or, more often, a refresh of the tools they already have.

I wish I could give you a definitive answer. I wish I could wave my magic wand and make this better for you. But there's no magic here.

What I can say is that because I have the privilege of working with so many people, I’m always learning more and finding better ways to help people walking that same beach. I’m constantly studying the latest research and reading new theories. I’ve trained in specialist, compassion-based counselling techniques. I attend and present at international conferences.

While I'm confident as a guide, there are always gems that come up that will help someone at some point, and I want to ensure I'm always offering you the best options.

None of this is your fault

It took decades for the medical community to understand how and why people come to be in bigger bodies.

Did you know:

  • There’s a strong genetic component – the strongest of all genetic traits apart from height.

  • Adverse childhood events play a massive part.

  • There’s a disease process that affects the brain at a physiological (not consciously controlled) level. It can be triggered by someone being 5kg over a certain weight or 25kg over it, or by something else entirely. Science can't tell us that right now. All we know is at some point, the brain flicks into a disease process affecting energy intake and expenditure and it's not possible to undo that.

  • Your adult weight is impacted by events that happened to you before you were born. For example, if your mum was depressed and/or had a restricted diet while she was pregnant with you, you’re more likely to be born with naturally higher levels of ghrelin. That means your base hunger level can be significantly higher (more intense, more frequent, longer lasting) than a person whose mother wasn't affected.

  • New research from decades of studying children into adulthood has revealed another major factor. If you were bullied as a child or in your early teens and didn’t receive the emotional support you needed, your likelihood of being in a bigger body by the time you’re 18 is almost 100%. Bullying ALONE can affect how your body reacts to energy intake.

These are just a few of the long, long lists of factors that can lead people to need help managing their weight, even with tools like medication and/or surgery.

I know people hate to hear the word ‘tool’, but medications are just part of the answer to managing weight loss, not the magic wand we all wish for.

If you are thinking about taking medication, or you already are, please know it’s not as simple as passively taking a drug and losing weight.

However, I’m hopeful that as more people learn about how to do the additional work on their mental and emotional side, we’ll see more people successfully managing their weight over their lifetime.

Copyright: Kate Berridge, Tiaki Whaiaro (2025)



 

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