To worry about friend's weight loss?

[Annabel28]

I'll try to keep this as brief as I can - keen for this not to descend into a pro vs anti-weight loss jabs type thread but I could really do with some advice.

I have a good friend who I've known since school. We both went separate ways (geographically) after university but have always stayed in touch and I really like her and care about her. She's had some difficult experiences in life and I'm glad that I've been able to be there for her in the past.

In the last few years she gained quite a bit of weight - always assumed this was related to having kids etc. but it was a substantial amount, she told me her BMI hit 40 and she was starting to avoid walking places because it was becoming uncomfortable. In April she decided to start weight loss jabs privately which she gets from an online pharmacy. She started to lose weight rapidly and would send me a lot of photos of her journey/progress. I was initially really supportive of this journey because I've seen so many people (including family members) struggle with the health consequences of obesity and traditional diet/exercise methods just haven't worked. However she's 9-10 months in to treatment and to be honest I'm a bit staggered by the amount of weight loss. She's gone from a BMI of just over 40 to a BMI of 20 in this period (don't know in kg because she only shares her BMI with me). She is still taking/accessing the weight loss jabs and says she needs to continue them. She seems happy but almost hooked on losing more weight.

Slight disclaimer here - I am a mental health professional by background and if anyone had lost this % of weight over that time period by dieting I would be assuming they had entered eating disorder territory (this is an area I work with and know a lot about). Although my friend is delighted by her weight loss she still seems to view herself as "a fat person" and still seems driven to lose more. I really don't know where this is going to end and she's reluctant to talk about the more emotional aspects of the weight loss.

Is it normal/reasonable for her to still be on medication even though she's a normal BMI? What would be the standard protocol?

For people on this medication, how have you coped with the psychological affects of so much weight loss and is there anything I should be doing/saying to support my friend?

TBH I'm a bit disturbed that so many private companies sending these medications out don't seem to offer concurrent psychological support but I suppose there are cost issues and ultimately their first priority is profit, not the consumer's wellbeing.

I read that when you're taking the jabs, you lose your appetite so completely that they have to tell you to make sure you aim to eat one full meal a day.

When I was only eating only one full meal a day, they told me at the ED clinic it still wasn't enough to keep me healthy and made me eat more to avoid in-patient. I had been diagnosed with anorexia. And yes, I had started out morbidly obese.

The amount of rage is huge. Doctors made me get fat again (I'm a size 14 from their stupid maintenance guidance, would be bigger if I hadn't jacked it in when I did) but NOW companies are allowed to accept payment from people for a jab that makes them eat like I did when I got diagnosed. Eat the way I was told not to. Eat the way I was when I had to have blood test every week an threatened with in patient treatment because I was still sick and not eating enough.

Why are they allowed to do it but I'm not? Oh yeah, because they're paying for it and I can do it for free. Being able to starve yourself without paying 100s a month is bad, but need help to do it then you can buy the privilege for a premium!

I'm so angry about it. I never wanted to regain weight. At least not more than 18.5 BMI, but they made me. I have severe body dysmorphia now. Blood tests every week to show me how "unwell" I was from the starvation. Is that not a problem for these people too? Apparently not. They're allowed to do it... Because they're paying for it.

But, as I said before if anyone questions my weightloss and eating behaviours this time, I can just lie and say I'm on the jab. No one will bat an eyelid if they think I'm paying to be this way.

Some private prescribers stop prescribing as soon as people reach a 'healthy' BMI of 24.9, others will continue prescribing until people are in the mid-range of a healthy BMI, 22 or 23.

Beyond that, there are individual discussions about maintaining that weight, either with or without continued medication. Your friend could be on a continued prescription to maintain her weight loss but I don't think there are any prescribers who would support a weight loss to BMI 20 or less.

Many of the private prescribers do have support teams / coaches etc, some are better than others. My friend who was given an NHS prescription had zero psychological support.

It is difficult when you have been overweight, particulalry those who have had weight problems since childhood or adolescence. So many of us have a warped perception of how we look. Also, depending on age / lifestyle / exercise you can lose weight attain a healthy BMI but still have areas of fat - e.g. on your lower belly.

Is your friend eating healthily? Lots of veg, not much UPF? Is she exercising to build / maintain muscle? I would encourage her to do that so she is focussing on living a healthy lifestyle, rather than pounds or inches. Can you ask what their goals are now that they are a healthy weight, or whether they have a weight range that they will be happy within. Some people have a 7 pound window that allows flexibility.

I'm flirting with the idea of starting these as I have put a huge amount of weight on after an injury and that combined with menopause means that I am not losing any weight at all, so have been following a number of threads. What happens when you lose the weight seems to be quite a grey area

1. Stop injections and put some / a lot of weight back on.
2. Move to a maintenance dose, very low dosage ......for Life.....

A BMI of 20 is obviously firmly in the low end of the healthy range so she must be feeling hugely better. In such a short time frame though I imagine that a) she has little confidence in herself that she could "go it alone" and b) if she hasn't in tandem been exercising and lifting weights, she is probably not very toned and therefore doesn't feel terribly thin/attractive as yet.

As her friend with a background in supporting eating disorders, are you physically close enough to her to offer support with lifestyle changes - an active holiday, a Pilates or yoga retreat holiday, ask her to virtually partner you on Bodycoach or similar? If she builds confidence in her physical appearance that may help with moving to 2 and then 1 on a sustainable basis?

Genuinely interested in others thoughts as I the one thing that is putting me off right now is the lack of an exit plan.

@Agix kindly, your situation is different. You were anorexic. People with anorexia would never be allowed to be prescribed the jab, so your comparison of the both is unfair.

She may not be being truthful with the supplier OP.

I can't use these because I had pancreatitis in the past (due to migrating gallstones in the common bile duct) so I had to do it the hard way. Generally my attitude to anyone using the jabs is good for you, but stories like this remind me of the whole VLCD in the 90s where people got stuck on the meal replacements and couldn't go back to normal eating for fear of putting all the weight back on. Anyone with a BMI of 20 who is pushing for more weight loss is suffering from disordered eating. I have no advice to offer other than to say I think you are right to be concerned. I suspect that these jabs will become harder to obtain in the future.

I'm on the jabs and have lost a lot of weight reasonably quickly, now a bmi of 23. I think maybe it takes your brain to catch up a bit as I'm aware I'm a healthy weight, a size 8-10 and look slim in photos but when I look at my body all I see is more fat to lose (that could be because I have some loose skin). My supplier now I'm a healthy bmi has moved to a maintenance dose (a lower dosage than I'm currently on) although if I still lose I'm not sure how long they will continue this for but it is easy to lie, I could just tell them I'm a heavier weight than I am and they would continue to prescribe

Is it normal/reasonable for her to still be on medication even though she's a normal BMI? What would be the standard protocol?

Yes it's normal/reasonable to still be on medication now she is in the healthy BMI range. The "standard protocol" is varied and personalised. If she continues to lose weight then it is likely that her prescriber will stop prescribing it for her. Working out how to maintain a healthy weight range is as much of a challenge as losing the weight in the first place.

For people on this medication, how have you coped with the psychological effects of so much weight loss and is there anything I should be doing/saying to support my friend?

You're the mental health expert that works with people with eating disorders, so I would imagine that you know more about this than any one individual who has lost a significant amount of weight.

Personally, and it is a very individual opinion, I cannot stand people wanting to talk to me about the "emotional" or psychological effects of losing weight. It's usually patronising and simplistic, often coloured by their own issues around eating and weight. The NHS would not be offering "concurrent psychological support" for people on WLI or for those who have had bariatric surgery.

You could ask your friend what her long term plan is for maintenance and just try to listen and be a good friend without judgement.

I was on Wegovy for just over a year. Initially BMI 33 now 25. When my BMI hit 24 the provider stated their protocol was to not prescribe any further medications. There is some variance here, if you have weight related co morbidities you can be prescribed the medicine with slightly lower BMI, some providers continue on a maintenance dose for a while. You are always asked your current weight and sometimes photographic evidence but this relies on being honest. I can't think of any of them that would prescribe for someone with BMI 20 if they had been honest about this. As for psychological support, there isn't any really as let's be real, they just want your money. I've coped really well with my weight loss, I'm still a bit heavier than ideal BMI but I'm eating much more intuitively, really enjoying my exercise again especially long hikes and I feel so much better and more energetic. I think you know yourself from your mental health background that your friend probably needs some support in this as may be entering eating disorder territory / body dysmorphia. It's hard to offer support unless she's asking for it though as she may interpret this as judgement (regarding jabs, there is so much of it).

Until her BMI is lower than 18.5 she’s not actually underweight. As long as she stops then she should be ok. The point about these jabs is precisely the unnaturally fast weight loss so you can’t really compare it with losing weight normally.

The crunch is whether she can normalise eating after this dramatic weight loss and whether she can modify her self-image to understand the fat person in her head is gone.

Thanks for these responses - helpful to know about the usefulness of maintenance medication now she's in the normal range.

Also sad to read that NHS weight loss programmes apparently offer no psychological input at all as I would have thought obesity management would require an MDT approach, although appreciate not everyone would want to/benefit from looking at psychological aspects of weight loss.

It's tricky because we are geographically not close so I feel I just get snapshots of how she is via whatsapp/facebook but as you say will just continue to listen to her.

FWIW I don't regard myself as an "expert" at all, I think that when it comes to mental health usually the only expert is the individual themselves, hence I'm interested in individual experiences/viewpoints. If anything I worry the fact that I've previously worked with eating disorders might colour my view and make me worry unnecessarily.

The lack of psychological support is not really good enough I think. I did mine alongside a Noom subscription as I wanted to overcome my emotional / stress eating which is what led to my rapid weight gain in the first place. I was well aware that the jabs would only help with weight loss and not the underlying cause. But this takes some personal insight and I think it's really overlooked. It wouldn't be hard to incorporate some mandatory modules alongside the subscription to help you maintain healthy patterns.

I'm well aware of the judgement that surrounds these jabs and really don't want her to think I'm criticising/judging.

It's so good to hear positive stories like yours - I grew up watching my mum struggle with obesity and traditional dieting her whole life and wish she had more options when she was younger.

Has she been doing 'the work' or just relying on the jab? If she hasn't actually changed her lifestyle she would need to stay on them

Thank you, I don't tell many people in 'real life' because of the reactions. I've always struggled with my weight but mostly managed to keep a BMI of around 26/27 because I'm quite active despite the over eating. I've usually been able to diet/exercise it off but then I hit my mid 30s, stressed myself out to anxiety/burnout through my healthcare job and weight rocketed. I just couldn't get it under control with conventional methods I think because my cortisol was so high and I was in fight or flight mode constantly. It's been a life saver and now I'm working really hard to maintain it, had a lot of private counselling, much less stressed and anxiety under control. Hoping to maintain it for as long as possible.

I hate to suggest ,
she may not be truthful with her pharmacy , I thought below BMI of 24/25 , they won't prescribe.
Which sadly makes the situation worse ,and it has become an obsessive goal , to be thinner, then thinner still.
These injections are to help you think less of the obsession of food ,amongst other things.
But sadly it can be replaced by the obsession of the jabs themselves.

The medication makes you look and act like you've ED. In some people. It stops you wanting to eat and weight loss is addictive.
I do worry for people on these drugs sometimes. If they were suffering from anorexia it might never get picked up. I guess they just think well, the person can just stop taking the jabs. But they get addicted to that feeling.

Don't people get horrendous side effects from these jabs?

I am overweight but fit, and used to feeling quite healthy so I don't think I would cope well with the digestive disturbance.

Some people on some occasions get mild to moderate gastric side effects. The figures quoted in the patient info is 1 in 10. So most don't. If you do, they are often things like a bit of nausea, or they can be easily sorted with OTC treatments or slight changes to diet. It's no different to every other medication with regard to side effects.

If you're overweight you would not be prescribed weight loss injections, unless you deliberately tried to lie to fraudulently obtain prescription only medication.

None of this is relevant to the OP's questions about her friend.

As 20 is a normal BMI I wouldn’t worry about it tbh

It is directly relevant as I was wondering what kind of digestive discomfort her friend is having to put up with to lose weight and how it would affect her health overall to continue to take this at a fairly low weight.

People I have seen who have lost a lot of weight too quickly, or too much, on injections tend to look rather ashen in pallor and like they have had the air let out of them rather than toned and fit. Rather like if you had an illness causing weight loss.

My gut reaction is she has lost far too much in the timescale and is now addicted to the weight loss.

I started the injections at the same time and have lost far less, have gone from bmi of 39.6 to 32.4 in the same timescale. Some people do lose it quicker but even a 5 stone loss for me in that timescale would have only dropped my bmi to 28 starting from same bmi as your friend.

Your friend has taken drastic measures if she has really dropped from 40 to 20 in same time, if she was my friend I would be concerned too.

However she may stop soon and just be trying to adjust to her new normal etc and how to go on from here, maybe just see how she is and check in with her regularly over the coming months

@SharpOpalNewt well, given that you didn't post any of that content in your first post, it was not clear what the relevance was. But thank you for clarifying.

So, she is likely not be having any digestive discomfort, given the stats.

I don't look ashen, or like a deflated balloon. Or like I'm ill. I look massively more healthy than when I was morbidly obese. The OP has not said that her friend looks like that either.

I’d have been far more worried about her when her bmi was 40.

You HAVE to "do the work". The jag doesn't magic fat away, eating in a calory deficit does, just like every other diet. The difference is, and the reason that it's successful, is because it's easier to eat in a deficit because you aren't permanently starving.