Interview With Dr. Katie Rickel: "Weight loss is not just about eating less and moving more"

In an interview with Structure House CEO Dr. Rickel, she emphasizes the effectiveness of GLP-1 medications in treating obesity, and she describes the holistic, personalized approach used at Structure House. Dr. Rickel explains the stigma associated with weight loss medications as well as the importance of balancing genetics, willpower, and lifestyle in weight loss.

Could you briefly explain what GLP-1 medications are? 

GLP-1 medications are a class of medications that have been used for many years to treat obesity.  These drugs mimic the effects of the hormone glucogan-like peptide 1, which increases insulin production and promotes a feeling of satiety through delayed gastric emptying. Additionally, as GLP-1 receptors are also present in brain regions believed to be involved in reward addiction, it seems that these medications lead patients to find food less rewarding and less pleasurable.

How does Structure House’s approach differ from other weight loss programs, particularly in supporting individuals using GLP-1 medications?

Structure House’s approach is unique in three key ways – it is residential, it is holistic, and it focuses on long-term success (rather than just short-term weight loss). To elaborate – first, Structure House is the only residential program that offers weight loss medication therapies. Effectively, patients leave their outside lives to come to our sprawling campus in Durham, North Carolina, where they reside in a luxury apartment and can focus exclusively – for several weeks – on their weight management efforts. 

Our physicians on-site prescribe their medication and meet with them weekly to ensure that their dosages are optimized, their side effects are managed, and that their first month (usually the most challenging) on the medication is as comfortable as possible. 

Second, our approach is holistic.  Rather than just meeting once with a physician to get a prescription, our patients take part in a robust treatment program that addresses their nutrition, fitness, and psychological needs. Patients meet regularly with registered dietitians (individually and in groups) to learn strategies to optimize nourishment while intaking less food (focusing on nutrient quality) and eat 3 meals daily prepared by our Executive Chef who customizes meals to each patient’s preferences and needs. Patients also meet several times a week with exercise physiologists to engage in strength training programs that assist in the preservation of lean muscle tissue during weight loss.

Finally, patients meet individually and in groups with a team of life coaches and therapists to learn strategies to cope with stress, to find new sources of pleasure in life (as the reward of food becomes diminished), and to learn more about how to navigate their lives beyond food and eating.

Structure House’s program focuses on long-term success rather than simply short-term weight loss on the scale. We acknowledge that patients may opt to discontinue medication use once they have reached their weight loss goals, and our programming is designed to equip them with the nutrition, fitness, and mental health tools to assist them in their lives at home, both while continuing their medication course and also if they eventually discontinue medication.  

In what ways does Structure House deal with the stigma and shame associated with weight loss medication?

Many individuals have described feeling a sense of shame and stigma when taking these medications, and many report that they therefore keep this treatment a secret from loved ones.  They fear being judged for “not being able” to do it on their own. 

For many, Structure House is the first and only setting in which they have been surrounded by others who are familiar with the struggles of living with excess weight and who understand deeply that losing weight is not simply a matter of “eating less and moving more.” 

Patients participate in structured groups and activities – as well as unstructured social interactions – with like–minded people, and this helps them to feel as though they are not alone. Further, since patients at Structure House are at all points in their weight loss journey (some considering medication, some just starting, some currently taking medication, some considering transitioning off medication), they can give and get support from essentially versions of their past and future selves. These kinds of interchanges serve to destigmatize and support.

How does Structure House personalize its program to cater to the unique needs of each individual, especially considering the varying responses to weight loss medications?

Since Structure House’s program does not JUST prescribe medication, our treatment staff can adjust the multitude of other factors that could help optimize success and breakthrough plateaus. Patients work individually with dietitians who monitor both their micro- and macro-nutrient intake, and these dietitians can make recommendations to adjust those in ways that will expedite weight loss if a patient is not seeing the expected results. 

Further, if a patient is struggling to adhere to the dietary or fitness programming, our life coaches and therapists can work individually with that patient to address barriers to motivation, enhance emotional regulation skills, or work with family members who may be acting as negative influences on the patient’s progress. 

While all patients at Structure House have access to individual sessions with our providers – as well as over 40 weekly workshops and seminars and 20 weekly fitness classes – they can mix and match the offerings so that their schedule is personalized to precisely meet their needs.

What role do you see GLP-1 medications playing in a comprehensive weight management plan that includes diet and exercise?

Eating in a caloric deficit and engaging in exercise that promotes lean muscle tissue retention will always be the two most important factors in weight loss. The GLP-1 medications, by promoting a sense of fullness and reducing the drive to eat, may make it easier – from a physiological and psychological standpoint – to eat in that aforementioned calorie deficit and to jumpstart the weight loss process so that exercise is more accessible and comfortable.

Therefore, the GLP-1 medications are not necessarily necessary (i.e., not all patients will need medication to be able to adhere to a calorie deficit) nor are they necessarily sufficient (i.e., if patients do not eat in a calorie deficit while taking the medication, they will not lose weight).

However, they can serve as a tool to more easily and comfortably adhere to traditional tenets of behavioral weight loss.

In what ways does Structure House support individuals who are transitioning off weight loss medications to maintain their progress?

For the last 46 years, Structure House has been an industry leader in helping people change their relationship to food so that they are no longer relying on food to meet non-nutritional needs like stress management, pleasure-seeking, and mood management. 

When individuals enroll in the Structure House program, they engage in programming that teaches them the patterns of food, exercise, and lifestyle management that would be necessary with or without medication.  Thus, many participants have found that a visit to Structure House while transitioning off medication has become an effective vehicle to learn to rely less on the assistance of the medication and more on the power of their newly formed and practiced lifestyle habits, in a supportive and structured setting.

Could you elaborate on the role of genetics and biology versus willpower in weight management, as mentioned in your statement?

The most current research on weight management suggests that individuals vary greatly in their experience while attempting to adhere to a calorie deficit. For some, the drive to eat and the “food noise” is nearly impossible to quiet, which leads to difficulties following any kind of plan that involves dietary restriction.  It is no longer believed to be an issue of just “trying harder.” 

For many, the physiological drive to eat will be stronger than the best laid plans, and in these cases, medication can be of great assistance.  Similar to how psychotropic medications (such as SSRIs) can give individuals enough relief from their depression or anxiety to take the behavioral action steps to improve their mood, these weight loss medication can turn down the food noise enough to enable someone to adhere to a plan of caloric restriction for weight loss.

Can you explain the ‘whatever works’ approach and how it is implemented in Structure House’s programs?

Unlike other “one size fits all” or “cookie cutter” programs, Structure House believes that long term weight management success will only be possible if the treatment matches the unique needs and preferences of the individual. 

For some, having more food variety and dietary choices to make will be overwhelming; for these people, having a more repetitive eating program will make the most sense. For others, having too much monotony feels overly restrictive and can lead to binging; for these people, including an adequate amount of choice and variation in food choices will be the key to long-term adherence. 

From a fitness standpoint, some individuals prefer to have a dedicated time in their day for a structured exercise program, while others may do better having a step goal or other monitoring system to ensure that they are staying modestly active through the day. 

Structure House aims to help each individual to find the unique eating and movement patterns that work with that individual’s lifestyle. The best program – if impossible to adhere to – is an ineffective program at best and a demoralizing one at worst.

As the CEO of Structure House, what do you see as the future of weight loss and wellness programs, especially in relation to new medications and therapies?

As aforementioned, weight loss medications are proving themselves as a very powerful tool in the arsenal of weight management therapies.

However, there will always be a sizeable number of individuals who would rather not introduce medications, who do not need medications to meet their goals, and/or who need extra support while taking these medications.

Just like psychotherapy is still widely used, needed, and beneficial for many individuals struggling with depression and anxiety (even as SSRIs are widely available), there will always be a need for the kind of behavioral weight management support (involving the realms of nutrition, fitness, and psychology) even with the rising popularity of these weight loss medications.