491-Beyond GLP-1: Sarcopenia, Bariatric Surgery in GLP-1 Era with Aoife McMahon

Do GLP-1 medications like Ozempic cause muscle loss (sarcopenia)?

GLP-1 medications do not directly cause sarcopenia, according to registered dietitian Aoife McMahon, who has worked in weight-loss clinics, bariatric surgery, and weight-loss drug prescribing and now practices from a weight-inclusive lens. The risk to muscle comes from how the drugs work. GLP-1s suppress appetite, and appetite suppression can lead to undernourishment. Wherever there is significant weight loss, undernutrition, or malnutrition, muscle health is at risk.

Sarcopenia is assessed on two dimensions: muscle mass, meaning how much skeletal muscle a person has, and muscle function, meaning what their body can do, such as standing up from a chair. The two are connected but can change independently. Someone can lose muscle mass while their function improves, especially if they started walking, running, or strength training while losing weight. That can mask what’s happening underneath. Muscle loss can also affect the muscle that supports breathing, heart function, gut motility, and the pelvic floor.

Research on GLP-1s and muscle is limited and short-term. Much of it is weight-focused and does not ask whether participants are eating enough. Small studies suggest resistance training alongside a weight-loss intervention may reduce muscle loss, but few compare this with resistance training and no weight-loss intervention at all, which evidence from other areas suggests builds the most muscle and strength. Long-term effects on muscle and bone health, including the effects of weight cycling, are still unknown.

For anyone taking a GLP-1, regular meals and snacks with enough protein, carbohydrates, and fats matter even when appetite is low. For health professionals, informed consent should include nutritional adequacy and screening for disordered eating, along with a third option that is rarely presented: pursuing strength, mobility, and muscle health without weight loss as the goal. Aoife McMahon discusses this with Stephanie Dodier on It’s Beyond The Food podcast, episode 491.

Transcript

[00:00:03] Stephanie: Welcome to It’s Beyond the Food podcast, my sister.

[00:00:06] Stephanie: I’m your host, Stephanie Dodier, and today we have a guest on the podcast to talk about sarcopenia in the GLP era. So welcome to the podcast, Aoife.

[00:00:17] Aoife: Hi, Stephanie. Thanks a mil for having me on.

[00:00:20] Stephanie: Thank you for being here, and I have to give you a quick fact, so the listener will find funny as well. I could not pronounce your name-

[00:00:28] Stephanie: so I had to go to Google Pronounce as the French person who’s trying to speak English, and now learned how to pronounce Irish names. So you’re from Ireland, and I hope I pronounce your name right. Did I?

[00:00:40] Aoife: Yeah. Wonderful. Yeah, yeah, yeah. Um, Aoife is it, and I think once you come across one Aoife, then you, then you get the hang of it.

[00:00:48] Aoife: But when you come across- Yes … your first one, it always requires a bit of, “Okay, how do I say that?”

[00:00:53] Stephanie: And you gotta love YouTube, right? I had a mini course- Yeah … like a 10-minute video on the Irish language with French pronunciation, so I learned a bunch of stuff. So welcome to the podcast.

[00:01:03] Aoife: Thank you. Thanks a mil, Stephanie.

[00:01:05] Aoife: It’s great to be here.

[00:01:06] Stephanie: So you are a registered dietician in a weight-inclusive nutrition practice with decades of experience in various weight management, including bariatric surgery, now weight-loss medication. So I wanna pool your wisdom and talk about particularly sarcopenia, but first, walk us through your professional journey, ’cause I was reading your About page.

[00:01:31] Stephanie: I was fascinated. So talk to us- Mm … about your professional journey into this world- Well- … of weight management.

[00:01:38] Aoife: Yeah. I mean, any time I get a chance to talk about this, I do, so thank you, Stephanie. Um, yeah, I mean, I, I went into dietetics and my first job with a question mark around weight loss. Um, I was interested in how to support people to lose weight because at that time, um, I could see that people, uh, were unfairly treated.

[00:02:05] Aoife: People in a bigger body were unfairly treated, and I wanted to kind of help with that. And so yeah, went into bariatric surgery, um, and I was in a kind of a unique position as a dietician at the time in that I was also trained to prescribe weight-loss medications. Um, it’s not the same as the current GLP-1s.

[00:02:23] Aoife: Um, if anyone’s been on orlistat, they will know what that experience is like. Um, so I was involved in, in prescription of, of weight-loss medications, as well as running weight-loss clinics as well. Um, and it was, I learned a lot. Uh, it wasn’t what I expected.

[00:02:43] Stephanie: Hmm.

[00:02:44] Aoife: Um, I… There were a lot of clients that were coming in, um, and, uh, you know, having studied dietetics and running in weight loss clinics and, and bariatric surgery, I, I felt like I was giving the best kind of care available.

[00:03:00] Aoife: Uh, and at the same time, there were several patients, a significant proportion of the patients who weren’t getting what they wanted from the intervention. Um, so many patients weren’t expecting the weight loss that we would have anticipated at that point in time. Um, and I also noticed that people were becoming, some people were becoming more focused on the scales, what it means, um, would come into the clinic room and hop on the scales, and whether it went up or stayed the same or went down, that would dictate the entire session.

[00:03:40] Aoife: Um, and it was quite, there was quite a lot of emotion there. Um, and you know, initially I thought, okay, am I doing something wrong here? You know, is this something to do with what I’m doing? And then I started looking into the research and, and realizing that actually weight loss medications at the time, weight loss interventions, you know, as we all have done, us working in this sphere, um, we kind of started to see the wood from the trees, and that it’s not actually straightforward, that the, the panacea of weight loss, you know, it’s, it’s, it’s…

[00:04:10] Aoife: I, I didn’t see it anyway. Um, and that’s when luckily someone in the same department had started an intuitive eating journey, and she was kind of proposing these things as I was asking questions, and I also had a, an incredibly compassionate colleague who specifically for the bariatric surgery patients, she was from the area, and she was asking the questions like, “But what is this doing for the person?

[00:04:38] Aoife: How is this surgery affecting the person, um, beyond the weight loss results?” And, and it w- those two people were really enriching and supported me. Um, and I was still asking questions like, “But can, can we do intuitive eating but still lose weight? You know, can we, can we do this and then, but surely we can still lose weight.”

[00:04:57] Aoife: Um, and I suppose that was, yeah, that’s kind of the core story to how I got to, to where I am now and how I practice now and, and have continued to kind of go down that path.

[00:05:11] Stephanie: It’s very reflective of the journey that most of us have had in the field, which is we start thinking weight loss is the solution.

[00:05:20] Stephanie: We go and practice. We see the result. We see the outcome. We’re like, yeah, but that really doesn’t work. And, and we start asking question, and then we discover intuitive eating. We’re like, but can we do two? Like, I call it phase two. Can we do two? Right? Intuitive eating, a wellness culture kind of help because I’m a lot in the health coaching space, like, can we do the two?

[00:05:41] Stephanie: And then there’s the last phase, which is phase three, which is like, no, we can’t do the two because it really doesn’t help any way to lose weight, and then we finally get on over the fence of, like- Yeah … weight inclusive, so. Mm. She’s lot of experience in weight management. Mm-hmm. And what I love is the breadth of different- dieting tool that you’ve experienced.

[00:06:08] Stephanie: Um- Mm-hmm … where do you see the parallel? So they were in the GLP-1 era, right?

[00:06:14] Aoife: Mm-hmm.

[00:06:14] Stephanie: There was a big wave of bariatric surgery. There was the first wave of weight loss. So where do you see the parallel? How do you think about that?

[00:06:23] Aoife: Yeah. Um, I think it’s a really good question, and something that I like to discuss quite openly and introduce into the conversation is, um, where have we seen this before?

[00:06:34] Aoife: Have we seen this before? Have we seen anything similar to this before? Um, and you know, from when I was doing deep dives in terms of weight inclusivity, intuitive eating, um, what I came across was that we’ve been releasing weight loss medications that are the next new cure-all since at least the ’70s. Um, and so we have been here somewhat before where there’s, there’s weight loss medications that promise to lose weight, keep it off for good.

[00:07:03] Aoife: Um, and some of the similarities that I see that, that are flags, right, that you kinda tune into is, is that specifically when we’re starting to talk about the GLP-1s, from early on they have been promising weight loss for good, and on their website saying this is weight loss that goes off and stays off.

[00:07:24] Aoife: Um, and from my perspective as a, a, a research-based, evidence-based clinician, um, and when I looked at the research, that hasn’t been shown yet. Um, and so yeah, drawing parallels between weight loss medications and interventions that have been pushed onto the market before, before there’s that actual evidence to back it up that there’s a, that, um, there’s that long-term research, um, that’s where I see parallels.

[00:07:51] Aoife: And I think, you know, it’s one thing hearing that, but if you have that strong hope to lose weight, then y- there, there’s still that capacity is people will still place that hope onto this new medication. Um, and that’s so understandable. Uh, and at the same time, I think it’s, I think we owe it to ourselves to demand higher standards of these weight loss inter- in- interventions.

[00:08:19] Aoife: And, um, one of those standards being that it shows at least two to five years weight loss and keeping it off, um, which at the moment we don’t have that with the, the GLP-1 medications.

[00:08:34] Stephanie: And, uh, curious, I haven’t done a podcast on bariatric surgery for years, but-

[00:08:39] Aoife: Mm-hmm …

[00:08:39] Stephanie: the last time I did, the statistic was also clear that bariatric surgery wasn’t the answer neither.

[00:08:46] Stephanie: So has the statistic changed on bariatric surgery being lasting weight loss?

[00:08:54] Aoife: Yeah. This is, I think, a more nuanced conversation, and, um, I- I’m still weight inclusive at my core, and I’ve kind of shifted in question in terms of informed consent and, and medical autonomy at my core. Um, I, I think that when it comes to bariatric surgery, there can be similar trends.

[00:09:16] Aoife: So what we see is the initial weight loss is this majority- Mm … of the, the weight lost in the first kind of 6 to 12 months, and then it stagnates, and then we can see weight regain. Um, I don’t wanna- Yeah … overstate or understate. Yes. So I don’t wanna overstate and say that, well, everyone who loses weight regains it, because actually that would discount lived experiences of people out there with bariatric surgery who have lost weight and it has maintained somewhat.

[00:09:41] Aoife: Um, and at the same time, there are plenty of experiences of people, if we’re to only take weight loss alone as an outcome, who have regained weight. But where I think the nuance comes in with the bariatric surgery is when we start to ask more questions beyond the weight loss as well.

[00:10:01] Stephanie: Which we’re gonna get into, like medical condition that comes after, so.

[00:10:06] Stephanie: Mm. I wanted to put this out there because what I’m seeing from an outsider perspective is that there’s a big narrative on bariatric surgery 10 years ago, and now that GLP-1 is here, pe- like, a- and we’re seeing that even the medical professional that were big bariatric proponent, bariatric surgery clinic are now turning into GLP clinics and providers, right?

[00:10:29] Stephanie: Yes.

[00:10:30] Aoife: Mm-hmm. Yeah, yeah. Um, I was at a… Well, I was talking at a recent conference ab- um, in London, um, a bariatric surgery and obesity conference. Um, and it’s clear that there is a shift at the moment from bariatric surgery in terms of services and what people are offering to GLP-1s because they can see the shift in, uh, demand.

[00:10:56] Aoife: Um, we’re not necessarily seeing that bariatric surgery is going to go away, but there’s, there’s a lot of upheaval at the moment in that area. Um, yeah, yeah.

[00:11:07] Stephanie: Mm.

[00:11:08] Aoife: It’s interesting.

[00:11:10] Stephanie: So let’s get into the conversation around sarcopenia and we’ll call it side effects of these weight loss intervention.

[00:11:20] Aoife: Mm-hmm.

[00:11:20] Stephanie: So let’s talk about sarcopenia.

[00:11:21] Stephanie: Let’s start with the beginning. What is it?

[00:11:25] Aoife: Yeah. Good question. Brilliant question. Just something

[00:11:30] Stephanie: you said, right? What is sarcopenia? What is

[00:11:32] Aoife: sarcopenia? Um, so I think it’s helpful to talk about sarcopenia in terms of, you know, when people are looking to diagnose sarcopenia, they look into a couple of things.

[00:11:45] Aoife: One is muscle function and someone’s capacity to move, and the other is muscle wastage, so the muscle mass, how much muscle someone has. Um, and if someone, for example, depending on the diagnostic tool, if someone’s not able to go from seated to standing comfortably, then they might be deemed as sarcopenic as well as, um, muscle wastage.

[00:12:10] Aoife: Um, the important thing to remember though is that it’s, it’s a spectrum, and if, uh, myself as a clinic- clinician, if I was only concerned when someone was at the place where they weren’t able to stand up from their chair, then that wouldn’t be, that wouldn’t be great. So we wanna be conscious and be thinking about muscle health before it gets to that place.

[00:12:31] Stephanie: Mm.

[00:12:32] Aoife: Um, and I suppose the other thing that we can mention here is that, so I said mu- muscle function as well as muscle mass. Um, and they’re, they’re, they can be connected, but they’re also independent. So sometimes people can lose muscle mass but have an incredible capacity to continue to do some of the day-to-day activities that they were doing before, so they might still be able to do significant walks or exercises or whatever it is.

[00:13:03] Aoife: So p- there’s, the body has a capacity to continue that. Um, that runs a bit of a risk of masking sometimes, um, and that’s why I think it’s important that we talk about both someone’s capacity to move and also their underlying muscle health. Um, yeah, yeah. There’s a couple of other things that are, I suppose, worthwhile talking in and around that too.

[00:13:31] Stephanie: So connect the dots for me and the listener

[00:13:34] Aoife: Mm …

[00:13:35] Stephanie: sarcopenia being muscle wasting on a spectrum, right?

[00:13:39] Aoife: Mm.

[00:13:40] Stephanie: Yet someone could be losing muscle mass and yet still function while somebody else cannot. Do we know why that is?

[00:13:50] Aoife: Um, one of the common themes that’s gonna come up today, Stephanie, is that the research is quite scant.

[00:13:56] Aoife: Let’s

[00:13:57] Stephanie: talk

[00:13:57] Aoife: about this. If we’re looking into the research, yes. Um, and I would love to see, you know, a lot of the research is quite weight-focused as well, um, and I would love to see more non-weight-focused research on muscle function over time, as well as other professional physiotherapists, all of that, um, involved in the research too.

[00:14:20] Aoife: Um, but yeah, I mean, if you’re talking about your actual muscle mass, to ta- to spend a moment talking about that, so we’re thinking about skeletal muscle, the muscle on your bones. This is the muscle on your arms, on your legs, and it helps you to do day-to-day activities. Um, so to put this into perspective, it’s the things that if you’re r- running through the door and you’re kind of using your elbow to push down the handle, and you’ve got shopping bags in a couple of hands, and the kids are running past and they kind of half knock you over but you manage to steady yourself, all of those things, that’s quite a simple…

[00:14:56] Aoife: We take that for granted, but all of those movements require quite a good strength and, and, and muscle Um, and there’s another kind of muscle that’s, that we have, and that’s our, the, our internal muscle that’s supporting our organs. So we often think about muscle for movement, but actually our breathing is supported by muscles, our heart health is supported by muscles.

[00:15:22] Aoife: Um, gut motility, gut health, gut movement, pelvic floor as well is supported by muscle. Um, so it can seem quite a, a simple question when it comes to muscle wastage, but already when we’re looking into it a little bit more, there’s a few things going on when, um, someone might be experiencing mu- muscle decrease.

[00:15:47] Aoife: Some of it may be more obvious muscle and some of it may be internal. Um, but yeah, someone can be- Yeah … experiencing a change in that muscle but still be able to, to walk on a day-to-day basis initially.

[00:16:01] Stephanie: So when we’re talking about, we’ll call it other types of muscle, we could include in that, I’m gonna get a little bit geeky here, but fascia, right?

[00:16:08] Stephanie: Mm-hmm. The structure that upholds. Fascia, it’s a, it’s a new, new stru- be- I’m, I’m a… Back 15 years ago, I had a personal training certification in my weight loss journey, did some fascial stretching course. So fascia is an unknown muscle structure, but that’s what really upholds us in our, like that wraps up like Saran wrap.

[00:16:29] Stephanie: That’s the example I used to give to people, right? And the other one is, like, the joint structure, tendons, right?

[00:16:36] Aoife: Mm-hmm.

[00:16:38] Stephanie: That’s also included in muscle structure, I guess.

[00:16:42] Aoife: Mm-hmm. Yeah. Yeah.

[00:16:45] Stephanie: So sarcopenia is the loss of all these types of muscle, which, correct me if I’m wrong again, that as we age occur naturally also.

[00:16:58] Aoife: Yeah. Yes. Yeah. And that’s where a lot of the measurement tools comes from, and when someone is diagnosed as, as sarcopenic, you’re looking at the muscle wastage and a decrease in functionality.

[00:17:13] Stephanie: Okay. And what we’re seeing now in weight management technique is that there’s an acceleration of sarcopenia due to those weight loss medications.

[00:17:24] Stephanie: Is that correct?

[00:17:26] Aoife: There’s

[00:17:28] Stephanie: looking at the- Again, research is scant- Yeah … but.

[00:17:30] Aoife: Yeah. Yeah, yeah. Looking at the research, it’s, um… I find, I find muscle research really challenging in this area. And as you said, the GLP-1 research is quite scant. So, I mean, in an ideal world, we’d have research which follows people over time who are engaging with GLP-1s for weight loss and also engaging in non, um, GLP-1, um, kind of fueled weight loss and control, and see, see the muscle wastage there and over time.

[00:18:03] Aoife: At the moment, there’s various pockets of research, and there’s no clear, um, from where, where I was looking at the research, there’s no clear indication that there’s, um, significant overall muscle wastage and decrease in functional capacity. Um, so there can be some levels. Some studies indicate that maybe thigh muscle might break down sooner than the rest of the body.

[00:18:32] Aoife: Um, but we just at the moment, as I said, a theme of today’s podcast maybe, we just don’t know, and there’s big question marks around that at the moment

[00:18:44] Stephanie: There’s no evidence to support that. There’s perhaps some early observation. Is that what we’re seeing then in clinical observations?

[00:18:56] Aoife: Clinically, again, when I’m lo- when I’m assessing someone clinically and they come in, um, to session and they’ve had significant weight loss, there’s a few things that can be happening.

[00:19:06] Aoife: Again, sometimes, sometimes people, like, can experience an improvement in movement alongside weight loss. Some people experience a significant worsening in terms of fatigue, and there’s a whole spectrum within that. And again, I, I come at this, I, I do think this area of research is really challenging because I do think the research being weight-focused has robbed us from being able to have all of these answers, um, about muscle function capacity ’cause there’s a, there’s that underlying focus on weight loss.

[00:19:37] Aoife: Um, but when I’m looking in a clinic and someone comes with significant weight loss, um, sometimes it happens alongside an improvement in movement, and for those people, initially, validation. You know, ’cause there’ll be people who are listening who have that experience, “Well, I lost weight and I was able to do loads of things,” or, “I lost weight and I was able to do a 5K,” kind of thing.

[00:19:59] Aoife: Um, and I don’t wanna take that experience away from people because that’s a, a lived experience. Uh, and at the same time, it doesn’t give us the whole picture. A lot of the time when people have lost significant weight, there could be some muscle wastage that’s happening. Again, this is one of the question marks that we have.

[00:20:20] Aoife: Um, and at the same time, they may have increased their exercise because we know that people who are going on weight loss journeys often will have a, a kickstart in, uh, exercise as well. That’s right. They might have started to do the Couch to 5K, right? So they may have this underlying muscle wastage while their function at the moment is improving because they’re engaging in a 5K.

[00:20:43] Aoife: Um, so supporting someone to, to separate that out ‘Cause it can be quite understandable and easy to say, “I lost weight and I was able to run 5K, therefore weight loss equals improved movement.” Um, but it’s a bit more complex than that.

[00:21:01] Stephanie: And I think that’s what’s important for the listener to understand that part.

[00:21:05] Stephanie: Like, if your, if your, if your experience has been that in the past, because I, I know a lot of people in the past have lived that, then for X, Y, Z reason they’ve regained the weight and now they’re like, “I need to lose weight again so I can be more mobile.” Mm-hmm. Well, it’s important for you to not make it a fact that it was weight loss, but really piece out your experience the last time and say, “Was it just weight or was it the fact that I was going to the gym, I was walking, I was- Mm

[00:21:37] Stephanie: training, and what if I just did that? What would happen,” right? Like, it’s important- Yes … to piece it out.

[00:21:44] Aoife: Yeah. Yeah. Let’s get curious. Like, a, a lot of people think that it’s, it’s GLP-1s or nothing, or weight loss or nothing. And I think, again, coming back to informed consent, there’s a third option there that’s not always presented.

[00:22:00] Aoife: Um, and that’s pursuing muscle health, function, exercise, improvement, mobility, without weight loss being at the focus. Um, and being able to explore that with someone or their, their, their goals. Well, what is it that you’d like to do, and how did weight loss serve that purpose in the past? Um, and is it worth, is it worthwhile considering this, this other option based on some of the experiences that you’ve had or some of the information that we know about GLP-1s?

[00:22:32] Stephanie: I’m gonna kind of take a sidebar and talk about psychology here because when we’re talking about health-promoting behavior like movement, we, what I think, this is my opinion, what is missing in the discourse is the psychology of habit-building, right? So people, what I find often, they can’t comprehend how they could build a habit of moving their body if it’s not about weight loss, right?

[00:22:58] Stephanie: They just, the motivation of weight loss is what made them move before. So if we take away the weight loss, how am I gonna motivate myself to, like- Mm … move, do some strength building, mobility exercise? It just, that piece is, like, not there and they, th- the only way they know to motivate is through weight loss.

[00:23:20] Aoife: Mm. Yeah. And sometimes, like, I will, I will, uh, take some time in clinic with someone to get curious about what this path might look like because it can seem really unknown, unfamiliar. How- Yes … yeah, as I said, how can I do weight loss if, or how can I do exercise if weight loss isn’t the goal? Um, because everything’s been oriented around that, and some of the questions we might go through is, you know, is there ever, was there something you enjoyed doing as a child?

[00:23:50] Aoife: Um- Yeah … is there anything that you got, uh, enjoyment out of before? Um, is there anything you’ve ever been curious about? Is there any kind of movement you’re, you’ve been curious about? Is there anything you know you do not like? Um, because a lot of people don’t feel that permission to not like forms of exercise as well, especially the forms of exercise that are promoted in diet culture spaces too.

[00:24:13] Aoife: Yeah. Um, so being able to create that space to for- to form their own, um, relationship. It’s that relationship with exercise, isn’t it? ‘Cause that can have a significant effect on how people engage with exercise.

[00:24:27] Stephanie: Yeah, and it’s like if we go, like evidence-based into that world of psychology, it’s self-determination.

[00:24:33] Stephanie: For looking at health-promoting habit, the, the gold standard to motivate long-term sustainably is self-determination, which is an intrinsic motivation- Mm … as opposed to extrinsic, which is weight loss.

[00:24:50] Aoife: Mm.

[00:24:51] Stephanie: Right? So one of the question or the conversation I like to have is, like, do you wanna just move for weight loss and then once you’ve lost the weight, stop, or do you wanna keep the movement- Mm

[00:25:04] Stephanie: and protect your muscle mass as you get older? Then we have to, uh, detach it from weight loss. Mm. You have to build it on its own- Yeah … in order for you to move for the rest of your life.

[00:25:15] Aoife: Exactly. And, and that’s where we do have research, right? We, we have research in people who aren’t pursuing weight loss that actually that can support muscle mass growth as well as, um, mobility, stamina, improvement in movement.

[00:25:31] Aoife: Uh, whereas that’s where when we, when we draw that comparison, that’s where we can really see that in the GLP-1 research, there’s plenty of question marks around what can happen to preserve the muscle health there. And, and even more so when we start bringing in the, the topic of weight cycling as well and, and if that occurs.

[00:25:52] Stephanie: So when we’re looking at the GLP-1 research, we’ll go back to sarcopenia. The … What you said is there’s no … There’s a lot of observation that there’s muscle mass loss, but because most of the research come from GLP-1 manufacturer, there’s not a clear correlation that’s been established between the two. Is that correct?

[00:26:11] Aoife: Yeah. Like, whenever we’re talking about significant weight loss, um, like we see in other areas, there is a risk to muscle health. Where there’s malnutrition, where there’s undernutrition, there’s a risk to muscle health, and the link there with the GLP-1s is that GLP-1s don’t in of themselves cause sarcopenia- Yeah

[00:26:33] Aoife: but GLP-1s can lead to appetite suppression, that’s their mode of action, and appetite suppression can lead to undernourishing the body, and that’s where the risk of sarcopenia muscle wastage increases.

[00:26:51] Stephanie: So that, that’s very important. Like, the mechanism of the drug in itself is not what- Mm … causes muscle wasting.

[00:27:00] Aoife: Mm-hmm.

[00:27:00] Stephanie: It’s the nutritional impact- Mm-hmm … of the GLP-1 that then consequently leads to muscle wasting.

[00:27:11] Aoife: Yeah. They- that- that’s when we’re talking about, um, early on when I said we don’t wanna be waiting until someone can’t sit up out of their chair before we start thinking about muscle health, right? It’s if someone, um, is taking a GLP-1 and their nutritional intakes are significantly affected, uh, that’s where we need to be thinking about risk factor for muscle wastage and, and function.

[00:27:33] Stephanie: So if we deep dive a little bit into this, when we’re talking about that nutritional impact, we’re talking about eating less overall, right?

[00:27:43] Aoife: Mm-hmm. Yeah.

[00:27:44] Stephanie: And also the body using the muscle mass to feed itself, is that there’s two mechanism here?

[00:27:51] Aoife: Mm-hmm. Yes. Yeah, yeah. Um, and for people who are taking GLP-1s, my experience is that- Some of them kind of unexpectedly find themselves under-nourishing themselves and their own body.

[00:28:09] Aoife: It’s not something that they go into taking a GLP-1. A lot of the time when people are taking a GLP-1, it’s because based on their assessments at the time, that’s what they feel like is best for their body. Um, they’re often doing what they think will help them, whether it’s health, whatever it is. Uh, and then they find themselves over time, shortly or over a longer period of time, um, with a significantly decreased…

[00:28:35] Aoife: The, the amount of food they’re eating isn’t enough. And I- as I said, this isn’t everyone. Um, people can be on GLP-1s and not reduce how much they’re eating. Some… And, um, weight loss isn’t the same across the board. It does- it isn’t guaranteed across the board. But for people who aren’t eating enough, um, oftentimes they find themself in that place unexpectedly.

[00:28:58] Aoife: And in a clinic room, I, I can be with someone, um, and recently I’ve had someone who was drinking two smoothies a day every day for six months, and they… You know, one of the things we know from the research is the research is not asking the questions, are people eating enough on these drugs? We don’t know that.

[00:29:20] Aoife: That’s another massive question. Um, and healthcare professionals, when it’s a pharmacy, for example, who are prescribing these drugs, um, they’re not encouraged nationally to ask the questions to figure out is someone eating enough to fuel their body. And so, you know, my background is eating disorders, so often by the time someone’s coming to me, um, that’s part of their story.

[00:29:43] Aoife: They might not even know they’ve developed an eating disorder or walked into a situation where they’re significantly under-nourishing their body because there’s been no, um, kind of protective points along the way. Not from the research- Mm … not from the drug companies that I’ve seen, um, and nationally as healthcare professionals, asking about nu- nutritional adequacy is not encouraged as much as, um, I think should be.

[00:30:13] Stephanie: Okay. Let’s unpack here. So what we’re saying is in the research, the nutritional aspect, the nourishment aspect isn’t… There’s very little research coming out of those drug manufacturing, very little research looking at the nutritional status of people. Like it’s a, we’ll get there another day, that’s not important because we’re achieving weight loss, which is the goal.

[00:30:36] Stephanie: No matter what the consequence are, we’re achieving weight goal- weight loss and that’s it. So we have to be aware of that.

[00:30:42] Aoife: Mm-hmm.

[00:30:44] Stephanie: And then two, w- and, and I’d love, without putting names, but I’d love to get your opinion on that. We have a lot of nutritional professional who are-

[00:30:55] Stephanie: Counseling GLP-1, pushing GLP-1- Mm … and perhaps are not even looking at the nutritional status of those individual because again, the achievement of weight loss being the number one-

[00:31:10] Aoife: Yeah …

[00:31:10] Stephanie: goal, it’s achieved. Example, the two smoothie a day thinking, “Oh, I’m eating a lot of spinach and blueberries, so I’m good.”

[00:31:18] Stephanie: Mm-hmm. Meanwhile, the quantity is not enough.

[00:31:20] Aoife: Mm-hmm. Yeah. Yeah. Um, it’s what I’d love to see more. I’d- I- I- as an eating disorder professional, as someone who works with eating disorders all the time, I’d love to see more conversations about malnutrition, supporting people to recognize the risk to malnutrition of these interventions, the impact of the- the impact of malnutrition, and that, um, malnutrition can happen regardless of body size, regardless of age, um, and that no matter what body size you are in, your body has nutritional requirements.

[00:32:01] Aoife: And at the moment, um, I don’t think that that conversation is, is there.

[00:32:09] Stephanie: You’ve mentioned a few times eating disorder, right?

[00:32:12] Aoife: Mm.

[00:32:14] Stephanie: So when people end up in your clinic working with you with GLP-1, example the, the case of too smoothie, th- draw the link for me on the eating disorder

[00:32:27] Aoife: Can I ask what you

[00:32:27] Stephanie: mean?

[00:32:27] Stephanie: Connect the

[00:32:28] Aoife: dots.

[00:32:29] Stephanie: So that person that showed up thinking that they’re on GLP-1 thinking they’re drinking two smoothie a day, probably full of fruits and veg- vegetables, spinach- Mm … whatever-

[00:32:38] Aoife: Yeah …

[00:32:38] Stephanie: thinking they’re doing well, and you diagnosing them with an eating disorder. How does that happen?

[00:32:46] Aoife: The society we’re in at the moment, and this is something I discuss with my clients as well, um, diet culture, pursuit of weight loss, as you mentioned, pursuit of weight loss at all costs is promoted, normalized, encouraged. We all hear it in office chat. Um, and GLP-1s just seem like part of that. They’re almost being normalized as part of that pursuit of weight loss.

[00:33:13] Aoife: Um, in the general public, there’s not, uh, eating disorders aren’t taken seriously or even if we remove the clinical term, distress around eating, um, isn’t taken seriously. And so it’s, it’s very understandable for me that someone could seek this treatment out thinking that it would be a good thing for their health.

[00:33:39] Aoife: Um, another point to pop in there is, you know, unfortunately us as healthcare professionals perpetuate weight stigma a lot, and there’s a lot of my clients who would have been heavily encouraged to take GLP-1s. Um, so there’s pressure from different areas. They may have internalized messages from childhood, from teenage years, early adult, from all around.

[00:34:00] Aoife: We’re swimming in this ocean.

[00:34:02] Stephanie: Yes.

[00:34:02] Aoife: Um, it makes a lot of sense to me that someone would seek out a GLP-1 for themselves. Um, and at the same time, um, or one of the things that I like to remind myself of, and I’m not exactly su- who said this quote first, but it’s, you know, it’s the idea that we prescribe for fat people what we would diagnose as eating disorders in thin people.

[00:34:29] Aoife: And I have had people experience just that, the fact that they were losing weight initially on a GLP-1 and they were getting praise and nobody was clocking that they weren’t eating enough to fuel their body, and no one was recognizing how tired they were feeling or how distressed they were becoming or maybe more obsessed with the mirror, the scales, their food.

[00:34:54] Stephanie: Mm.

[00:34:54] Aoife: And then all of a sudden, for some people who fall under a sudden, certain body weight, because not everyone will with a restriction eat- restrictive eating disorder, there are plenty of people out there who maintain a restrictive eating even if it’s not an eating disorder and will be in a bigger body.

[00:35:10] Aoife: But for some people who fall into that lower weight category, all of a sudden the commentary flips and people are concerned about how much they’re eating, and they’re asking them if they’re okay. And I’ve had this with clients, and they are bamboozled. Why is everyone concerned now? Where was this before?

[00:35:29] Aoife: How … I mean, I haven’t done anything different. So for me, I can completely understand why, how that can unfold, and I, I think it’s quite common.

[00:35:40] Stephanie: Yeah. Well, I mean, it’s reflected in, like, star culture, right? Mm-hmm. We’re looking at those actors and singers, and we’re seeing their picture. They’re underweight to a certain degree, and we’re like, “Oh my God, eating disorder.

[00:35:55] Stephanie: We’re concerned for them.” But meanwhile, the one who, I won’t name her, but lost a bunch of weight because she was in a larger body, lost a bunch of… We- we’re not concerned now. We’re not concerned for her nutrition status or mental health because she’s now just okay- Mm-hmm … versus the person, right? So, so for, for people who are not in clinic, like they’re listening to this podcast, we’re seeing that in the media.

[00:36:17] Stephanie: You’re seeing it. You’re observing that behavior culturally.

[00:36:22] Aoife: Mm-hmm. Yeah. Yeah. It’s the water we swim at the moment. Um, and- Yeah, it, it, it just makes sense to me that people can end up in that situation, and as I said, I think, I think it’s more common than people realize, and I think because GLP-1s and eating disorders are even

[00:36:43] Aoife: Again, I said sometimes people can fall into that clinical category. Sometimes they don’t, and it’s distress around eating. Um, people can start to, because of the taboo and the shame around that, it can take people a while to recognize that they might be struggling, to roo- truly recognize or notice that even in their gut somewhere something feels like it may not be right.

[00:37:06] Aoife: It can be a, a while for people to realize that, and, um, I would say to those people, um, to listen to that if they’re currently feeling the pull for GLP-1s or if they find themselves already taking it. There’s no judgment. Um, and at the same time, you deserve to be able to ask yourself, “Is this serving me?

[00:37:29] Aoife: How is it impacting me?” Mm-hmm. Um, yeah, and listen to that.

[00:37:36] Stephanie: So very little research on the nutritional aspect or the side effect of GLP-1. Um, lots of observation, right? Lots of undernourished, be it in just volume or type of food, and the consequence of it. So someone who would be on the GLP-1, and I’ve had this conversation a number of time, then needs to become very intentional with their nutrition.

[00:38:04] Stephanie: Am I correct?

[00:38:05] Aoife: Mm-hmm. Yeah.

[00:38:06] Stephanie: What would that look like? How do you counsel people from that perspective?

[00:38:10] Aoife: Yeah. If, if someone, based on their assessments, feels that a GLP-1 medication, and, and I treat this the same with bariatric surgery as well, if they feel that that truly is the, um, the route that they would like to take, then people who are making those decisions deserve to be supported to meet their body’s needs while engaging with those kinds of interventions.

[00:38:34] Aoife: Um, and that involves Yeah, supporting them to reflect on what their How the medication is impacting them, how the medication is impacting their body’s capacity to fuel itself. Um, so hunger, uh, many people find it as a, an annoying or frustrating thing that we feel, and if only we didn’t have to feel that, then that would be great.

[00:39:01] Aoife: But, but actually hunger is such a core thing to support us to nourish ourselves. And so while someone’s on the drug, um, it’s about having those reflections to see is their body able to engage with hunger to support themselves, to nourish themselves? Um, and based on whether that is or isn’t there, the core un- there’s a core underlying need whether you experience hunger or not, your body needs nutrition.

[00:39:29] Aoife: Mm. So if you’re choosing to engage with a GLP-1 and the appetite is, is suppressed, it’s still important that you’re getting regular meals, regular snacks. When it comes to muscle health, we know that protein is supportive and helps our muscles. Um, and so making sure that you’re getting that, that regularly is really important.

[00:39:49] Stephanie: Yeah. And that’s what I mean by intentional nutrition. You can call it gentle nutrition. You can … Has different name, but it, it, you, for most people, have to shift into being very intentional with- Mm … eating the various types of food they need to eat, and in the quantity they need. And that’s where the cognitive- Mm

[00:40:08] Stephanie: dissonance is for most people, but-

[00:40:10] Aoife: Mm …

[00:40:10] Stephanie: the, the kickback is like, “But if I eat what I want, then I’m not gonna lose weight,” right? And that’s this- Yeah … very, like, space that people get into.

[00:40:21] Aoife: Yeah. Yeah. Yeah. And the other thing that I will say before I kind of respond to what you’ve just mentioned there is I mentioned protein first, um, and that is associated with muscle health, and it’s supportive for our muscle health, but sometimes in weight intervention spaces, we can get caught up in the protein that the other things get left by the wayside and don’t get a, don’t get a mention.

[00:40:43] Aoife: Um, your body, it’s, uh, it, it’s really hard for your body to support your muscle health if it’s not getting other forms of energy too. Carbohydrates are essential for your brain to function, for your muscles to feel, to, for you to feel energy to use your muscles. Um, and the last, or one of the other things that rarely get a mention is fats.

[00:41:05] Aoife: Um, this happens in bariatric surgery, and it happens in GLP-1s. You know, all of a sudden when someone’s on a weight loss intervention, we don’t care about fats anymore. Um, and fats are … I’m not just talking about, quote-unquote, healthy or unhealthy fats. It’s the whole fat spectrum. Fats are incredibly important and utilized in all, so many systems within your body, and they’re also important f- to help your body feel like it’s being nourished.

[00:41:30] Aoife: Just like with the protein, just with, like with the carbohydrate, just like with the fat, nothing hits those spots li- like those particular nutrients. Um, so we can’t get away with- Just feeding your body protein and carbohydrate with it without the fats too because your body will start to, to notice the impact.

[00:41:48] Aoife: And again, like what you said, Stephanie, about being really intentional while you’re on a GLP-1, your appetite may be dampened so you may not have the cravings that you had before. And regardless of that, it’s still important for your body to, to get those, um, that nourishment as well

[00:42:05] Stephanie: And we’re seeing a lot of influencer, we’ll call them GLP-1 influencers, saying, “Well, I understand that sarcopenia is a risk with GLP-1.

[00:42:15] Stephanie: I’m gonna do a lot of weightlifting to compensate-

[00:42:19] Aoife: Mm …

[00:42:20] Stephanie: the risk of sarcopenia with GLP-1.” But again, is there any evidence to that?

[00:42:27] Aoife: I- yeah. Again, um, I’m gonna sound like a bit of a broken record here. Um, so in terms of GLP-1 specific research, I’d love to see more of it. Um, and then in terms of research as a whole, again, just like with the nutrition, we know that, um, when someone is having sufficient nutrition and protein and, and other macronutrients, it helps with muscle health and muscle maintenance through into elderly years.

[00:42:51] Aoife: And I think most people would like to be as independent as possible- Yes … for as long as possible, right? Um, with, with weight loss, um, with resistance training, sorry, coming back to your question- Yeah … um, there is evidence to support that it can in some cases, um, uh, you know, people who add resistance training alongside a weight loss intervention don’t experience the same level of muscle wastage.

[00:43:21] Aoife: Um, so there’s small, again, this is small research. Um, however, we don’t see much research that looks at people who aren’t engaging in weight loss interventions at all. So a lot of the time the control is weight loss intervention plus resistance training, or weight loss intervention. Um- Not resistance training

[00:43:43] Aoife: and we don’t see… Yeah, yeah. And we don’t see- We don’t

[00:43:46] Stephanie: see that third bucket.

[00:43:47] Aoife: The third bucket without any weight, um, weight intervention and doing the weight lo- and the resistance training. Um, again, there are, there’s some evidence from other areas that, yeah, if you have resistance training without a weight loss intervention, that results in the most muscle mass gaining and, and strength gaining.

[00:44:04] Aoife: But, um, so we can start to pull these pieces together, but again, we can’t make solid con- conclusions at the moment.

[00:44:13] Stephanie: And I, being, I- I think it’s very important then that I push you to say you sound like a broken record, because I think that’s what people need to hear. Like, there’s a lot of claim out there.

[00:44:24] Stephanie: Like- Mm-hmm … it, it’s the Wild, Wild West on the- Yeah … internets and social media- Yeah … about like, oh, like there’s this influencer who does like weight training, so it’s okay to take GLP-1 because if I do weight training, I won’t, quote-unquote, have any consequence. Well, that, that’s- Yeah … not supported by evidence.

[00:44:43] Stephanie: Like, there’s-

[00:44:44] Aoife: Yeah

[00:44:45] Stephanie: So it’s important to keep saying we’re a broken record, and almost all the people I interview on GLP-1 say the same thing because there’s very little evidence.

[00:44:54] Aoife: Mm-hmm. Yeah. Ex- exactly that. Exactly that. And I think it is important instead of overstating or understating the evidence, it’s clocking these things.

[00:45:03] Aoife: It’s a mass experiment. It can be described as a mass experiment, what’s happening at the moment with these GLP-1 medications, and I’m really interested to, to know what will happen 10 years down the line, 15 years down the line. Even the research that we do have is short-term. Um, I mentioned earlier weight cycling.

[00:45:23] Aoife: There’s some evidence that that can have negative impacts on your muscle, uh, muscle mass, but, um, we wanna know the long-term, the long-term effects. Uh, the other, the other thing that I wanted to mention is that if people have engaged with weight loss in the past, um, ’cause some people might be listening and saying, “Well, I’ve already yo-yo dieted,” or, “I’ve already engaged with GLP-1 medications.

[00:45:45] Aoife: Have I, have I caused muscle wastage?” Or might be worried about that. Um, and what I say, I suppose, you know, I work with people who’ve engaged in restrictive behaviors, um, or currently are, and the body has an incredible capacity to heal. Um- When nourished, right? And through some of the evidence that we see, if someone’s continuing to cycle, there’s a higher risk of muscle wastage.

[00:46:17] Aoife: Whereas if someone makes that brave decision to see what else is out there or what could it be like if I don’t engage with a GLP-1, um, then that allows your body to be nourished. And even if you have engaged with a lot of weight loss interventions in the past, a lot of the time, um, we see, uh, kind of replenishing over time.

[00:46:40] Aoife: Um, and again, I’m putting another caveat on top of that in that someone might, um, lose weight and, but if they, then there’s, if they’re later in life or if life throws a curveball, if they develop a, a serious illness or a condition, um, your body’s much better able to fight that if they haven’t just entered a kind of muscle depleted state.

[00:47:07] Stephanie: Yeah. So when we’re thinking about sarcopenia and weight management, we have very little evidence on the GLP-1 front. Is there more evidence around bariatric surgery because it’s been here for longer?

[00:47:24] Aoife: Hmm. I was looking into this before today’s session, um, or h- being on the, the podcast. Yeah. Um, and it was, it was an interesting exercise in this has not been looked into that much.

[00:47:40] Aoife: This has not been looked into that much.

[00:47:43] Stephanie: Um- Yet again, the same answer, very little research.

[00:47:45] Aoife: And, and it’s also difficult because, like with bariatric surgery, again, so I like to mention that people report having the bariatric surgery, and they notice the weight loss, and they notice that their mobility significantly increases.

[00:47:58] Aoife: And at the same time, I also treated people who had bariatric surgery, and do now, who’ve e- experienced, experienced a significant weight loss, and their movement levels are debilitating, or their energy levels are so low that they can’t use their muscles. Um, so bariatric surgery, it’s a, it’s a whole conversation in and of itself, and there are m- this is where we come back to the initial thing of one thing is muscle mass and preserving muscle health so that we can maintain our stability, stamina, balance when the kids are brush- or the grandkids at that stage are brushing through the door.

[00:48:38] Aoife: Um, preserving muscle mass long-term is beneficial, and then muscle function is another one, being, um, being able to do the walks that you like with other people, that kind of thing. And at the moment with bariatric surgery, it’s, it’s hard to draw conclusions ’cause there’s a whole variety of things that are h- that are happening in there.

[00:48:59] Stephanie: And the, for those who don’t know, there’s a whole variety of types of surgery that have different outcome as well. Like, it’s not like GLP-1, it’s one mechanism or two- Mm-hmm … right now. Like GLP-1 has, I don’t know, I’ve lost counts of how many types of surgery there is. Um-

[00:49:16] Aoife: Yeah, yeah, yeah. And the ex- exactly that.

[00:49:19] Aoife: The surgery can be physically restrictive, and then some surgeries can be a certain level of, uh, malnutritive, and then there can be additional elements to that, and that can reduce your, affect your absorption of calcium, which is really important for muscle health as well. And, and bones, which are the structure which hold up your muscles, and one of the things that I came across is that there, there are in, um, the malabsorptive bariatric surgery patients, there’s some evidence that there’s increased risk of fractures, which- Hmm

[00:49:53] Aoife: that’s related to bone health, but it’s also the muscles that kind of hold up the bone as well. Um, again, that would be a whole conversation in and of itself, I think, with the bariatric surgery, but there are some things that we can reflect on based on what’s coming out of there.

[00:50:08] Stephanie: Out of curiosity, is there any evidence or research around bone health and GLP-1 that you’ve came across?

[00:50:18] Aoife: At the-

[00:50:19] Stephanie: It’s too early.

[00:50:20] Aoife: With the… It’s, it’s too early, isn’t it, right, Stephanie? Yeah. You know, ’cause these things have come onto the scene for wei- for the purpose of weight loss and at the dose, the weight loss dose, they came onto the scene kind of 2023 and, and later in, in the UK and Ireland as well. Um, and for us to see the impact of bone health, again, this is why question marks, a lot of the time we have a po- po- when it comes to weight loss research we have a positive bias, and if we’ve a, a question mark, um, we can either dismiss it or assume that it’s all fine.

[00:50:49] Aoife: But bone health is a significant question mark whenever there is weight loss or malnutrition involved, undernutrition involved. So GLP-1s, there would be a risk. It’s something worth considering when it comes to bone health as well.

[00:51:02] Stephanie: Considering that there’s very little research evidence, so we do- so it’s a, it’s part of the gamble of the GLP-1 in 2026, we don’t know.

[00:51:13] Stephanie: So we may be losing the weight, but what happens to muscle mass? What happens to bone health? It’s an integration mark. Mm-hmm. So that has to be part of the conversation and the informed consent, that very- Mm … little research show the consequence.

[00:51:28] Aoife: Exactly. Exactly that.

[00:51:31] Stephanie: So we’re gonna wrap it up. You’ve spent your career protecting people, their relationship to food and their body, so when you’re looking at GLP-1 right now, um, what would be your wisdom, your advice, your thoughts to share with us?

[00:51:53] Aoife: GLP-1s in general, um

[00:51:57] Stephanie: Or weight management.

[00:51:59] Aoife: Mm.

[00:51:59] Stephanie: And so both ways.

[00:52:01] Aoife: Yeah. I think, I think it’s… I think people find it surprising that we’ve been here before. Um, like there was a drug, a weight-loss drug in the ’70s that was, I think, like 8% of US prescriptions at the time. It was significant at the time, and it had all of the hallmarks that this drug had, and yet it’s not around.

[00:52:22] Aoife: And all of the iterations since then are still not around. Um, so I think inviting curiosity and, uh, in and around that, um, I always want to say that I understand why people would feel the draw- Yeah … or to start taking GLP-1. And at the same time, if you’re feeling like your brain is thinking GLP-1 or nothing, or I need a GLP-1, if you’re feeling like you’re in that head space, that’s where it can be important to take a pause, a step, and getting curious, um, about the other options.

[00:52:59] Aoife: Um, yeah.

[00:53:02] Stephanie: Yeah. Curiosity and exploration.

[00:53:05] Aoife: Mm.

[00:53:07] Stephanie: Right?

[00:53:08] Aoife: Mm-hmm.

[00:53:09] Stephanie: What else could there be out there? And, and one thing I like to say to people, and you tell me what you think, the path of pursuing health without weight loss in many people’s life has never been tried, never been attempted, right? Yeah. I’m just saying, like, what if we explored that?

[00:53:29] Stephanie: Give that a chance- Yeah … with the proper support. And, and a lot of that lane is psychological support, right? Yeah. Counseling support. Because it’s not about macros, it’s not about, like, plans. It’s about, like, the psychology piece. Yeah. What if we gave that a chance?

[00:53:47] Aoife: Yes. Yeah. Yeah. And I will say personally, as a clinician as well, just like what I said earlier on where I felt like there was an emotional heaviness when I was part of that weight-loss clinic, I get absolute exhilaration when someone is taking that path and all of a sudden they’re starting to see the ways in which they can serve themselves, and the goals that they had, and the pressure that they can shed as well.

[00:54:19] Aoife: It’s not straightforward. It’s challenging at times, and I’m not gonna, I’m not gonna put that to the side. But for me personally, this is the most rewarding work I’ve ever been involved in.

[00:54:31] Stephanie: Yeah, because it’s, it’s life-altering. When… Like, you know, there’s those big claim in marketing, like, as ethical practitioner, we don’t like to use, but my client’s life has changed.

[00:54:44] Stephanie: It’s truly the case when people take that path genuinely and do the emotional, psychological work. That’s when life change, and it change- Sustainably Mm-hmm.

[00:54:56] Aoife: Mm-hmm

[00:54:58] Stephanie: So where can people find you and or work with you?

[00:55:03] Aoife: Yeah. Wonderful. Thank you. Um, so my Instagram is not as active as I’d like to be, but you’re welcome to follow me on there.

[00:55:10] Aoife: So I’m That Irish Dietitian, and you can reach out. Um, and then my, uh, podcast, I do a podcast, um, exploring bariatric surgery, GLP-1s as well, and that’s called Inside Bariatrics.

[00:55:25] Stephanie: Okay. It was, was a pleasure talking to you and, uh- Thank you so

[00:55:28] Aoife: much …

[00:55:29] Stephanie: we’ll stay in touch.

[00:55:30] Aoife: Wonderful. Thanks a mil, Stephanie