Today's newsletter is a day late (but not a dollar short), because I had the misfortune of coming down with a cold with a nasty cough towards the end of my trip to Asia (I had a running bet with myself on whether I would break a rib or literally cough up a lung first). I had intended to wrap up this newsletter on either my 4-hour layover in Seoul or my 7-hour layover in LAX, but my brain was mush and I was hanging on by a thread. My husband does tell me I was quite the picture on our actual flights (one 4-hour, one 10-hour, one 2-hour), huddled with my white face mask and my pillowy black eye mask. He said adding a hat would have really been the cherry on top. Sigh. So now that I'm back home with my Throat Coat tea and feeling mostly human, here you go...enjoy!
I’ve told the story before of a patient I had years ago when I was still offering “non-diet weight management” (which I eventually realized was not a real thing) at a healthcare facility I worked at. During our first session, when I asked her about what she does for exercise, she forcefully told me that she had recently done a 6-week fitness bootcamp class and didn’t lose any weight, so she wasn’t going to exercise anymore because there was no point. (So there!)
I said something about physical activity having a bajillion benefits, even if it doesn’t produce any weight loss. She was having none of it.
Today, I still discuss the many health benefits of exercise/movement/physical activity (provided it’s an activity you enjoy or at least are fine with, and it reasonably fits into your life so it doesn’t become a stressor). Because it’s true. There are reams and reams of research papers demonstrating thatphysical activity has DIRECT benefits for physical and mental health.
In spite of that, many people falsely view it as something that has INDIRECT benefits for health. In other words, if exercise helps you lose weight, then that weight loss helps you be healthier.
(It’s with a heavy heart that I add exercise/movement to the list of things that diet culture has ruined.)
What the research says
A recent research review confirmed what previous studies have found: at every point on the weight spectrum, physical activity improves health. When someone has what’s called “cardiorespiratory fitness,” the associations between higher weight, chronic disease and otherwise poor health all but disappear.
Cardiorespiratory fitness in this case doesn’t mean being an athlete. It basically means getting the recommended minimum of 150 minutes per week of walking brisk walking or some similar activity.
I wonder what would happen if we were also able to wave a magic wand and get rid of the weight-based stigma and anti-fat bias that can:
- Create a lot of stress, which is directly bad for health.
- Make people in fat bodies delay getting things like preventive health screenings because they don’t want to go to the doctor and get another lecture about their weight. This is also directly bad for health.
So when publications such as The Atlantic write things like…
“Ozempic killed diet and exercise. Doctors might be slow to admit it, but Ozempic and other GLP-1 drugs are making dieting and exercise obsolete.”
…I have to wonder if people are pursuing “health” or are they just pursuing thinness?
The idea that weight = health is so ingrained in our society and in our healthcare system, that I can’t really blame anyone who thinks losing weight is essential to improving health.
But while lots of research has found associations between higher weight and various health issues, associations can’t establish cause and effect.
Why weight loss might not improve health
One of the best research articles I’ve seen for tying together the various threads about the harms of dieting is the 2013 review article “Long-term effects of dieting: Is weight loss related to health?”
The authors looked at whether weight loss improves health by reviewing health outcomes from long-term randomized controlled diet studies. Specifically, the looked at whether weight loss diets lead to improved cholesterol, triglycerides, blood pressure, and fasting blood sugar. They also looked at whether the amount of weight lost made a difference.
They found that, overall, there were minimal improvements in these health outcomes in these studies, and what improvements were observed were just as likely to happen among dieting participants as they were among control group participants. So weight loss didn’t matter.
The authors did find a few larger improvements — lower blood pressure, reduced diabetes medication use and fewer new cases of diabetes or strokes. However, they also identified factors that muddy the relationship between the weight loss and these health outcomes, such as increased exercise, healthier eating, and engagement with the health care system.
For example, if you lose weight but are also exercising more, eating better and/or finally getting regular preventive healthcare (because you’re participating in a study that includes it), and your health improves, weight loss often gets the credit, even if one or more of these other changes is actually responsible.
I know good-old-fashioned dieting is falling out of favor (for most people, it never worked anyway) now that we have these bright, shiny new weight loss drugs available. But one thing most people did when they were dieting was increase their exercise. Unless they were doing some really weird diet, they also probably ate more vegetables, if for no other reason than that they’re low-calorie. They probably also opted for lean protein sources (such as chicken breasts), so they were probably also reducing their saturated fat intake.
No appetite? You still need food
While many people who are using a GLP-1 weight loss drug to lose weight are also exercising and choosing nutritious foods, I also see a lot of people who aren’t, and so are many of my dietitian colleagues.
What perhaps concerns me the most about this is when post-menopausal women taking these drugs have almost no appetite and don’t see that as a concern — even though having no appetite doesn’t mean our body doesn’t need nutrients.
And, no popping vitamin and mineral supplements isn’t a solution, because nutrients from food exist in a complex food matrix, and the synergy between nutrients and other healthful components of the food, including fiber, healthy fats, and protein, is what really supports health.
About that protein: after age 35 to 40, we start losing muscle unless we are intentional about including a decent size serving of protein with every meal and working our muscles with exercise. That becomes more important the older we get. Couple that with the fact that whenever we lose weight, however we do it, we lose muscle along with body fat. There’s no such thing as spot reducing or selectively losing fat. So when I see older women’s bodies shrinking and they think, “I have no appetite…great!” and “Yay, I don’t need to bother with exercise anymore,” it scares me.
Or, as one of my dietitian colleagues says to her patients in that situation, “What’s going to happen when you fall and can’t get up? What’s going to happen when you don’t have the strength to get up off the toilet?”
How GLP-1s might improve health
I know there are headlines every day about how people taking GLP-1weight loss drugs have lower risk of cardiovascular disease, fatty liver, sleep apnea* and possibly Alzheimer’s disease.
The assumption (at least by the public) is that it’s the weight loss from these drugs that’s reducing health risks. But what the studies make clear is that it’s other mechanisms of the drug, known and unknown, that are likely responsible.
For example, these drugs may reduce inflammation. And don’t forget that these drugs were originally approved for the treatment of type 2 diabetes, because they have direct effects on mechanisms in the body that help keep blood sugar from getting too high. It was only when researchers noticed that people on these drugs also lost some weight that they decided to jack the dosing and start studying them specific for weight loss.
Also, in all the weight loss clinical trials for these drugs, participants were also expected to eat less and exercise more, and in some cases received intensive nutritional counseling. So, yeah, nutrition and exercise matter for everyone.
*(Now, sleep apnea can be helped by weight loss in some people, but thin people can get sleep apnea, too, and CPAP machines also help manage sleep apnea.)
Why honesty is the best policy
People have complicated reasons for wanting to lose weight. They might:
- Feel that it’s simply what we’re “supposed to do”
- Want their body to look a certain way (or feel that it has to in order to be loved and accepted)
- Want to escape weight stigma (this part makes me cry, because it shouldn’t fall on individual people to do this)
- Be capitulating to pressure from their doctors
- Have a health problem that is actually helped by weight loss (this can be true in a few cases, even though generally there are not causal links between weight and health).
But whether by dieting or by drugs, I think it’s disingenuous to say, “I’m losing weight for my health,” when really someone’s losing weight because they don’t want to wear plus size clothing. I believe that no one is obligated to pursue health (because, hello, body autonomy). But I also think that most people do care about their health and are willing to put at least some intention and effort into caring for it.
Aiming for a smaller number on the scale or a smaller pants size and thinking that’s health, while ignoring the things — nutrition, physical activity, sleep, stress reduction, preventive healthcare — that directly support health, may leave them wondering, “What the hell happened” somewhere down the road when they realize they have sarcopenia (age-related muscle wasting), osteoporosis (maybe only finding that out after they break a bone), neurological issues (from lack of B vitamins), or other issues related to poor nutrition and lack of physical activity.
This is why I support truly informed decision making, including honesty and reflection on what it is we really want for ourselves and why. This is important when considering weight loss — but in other areas of life, too.
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Disclaimer: All information provided here is of a general nature and is furnished only for educational purposes. This information is not to be taken as medical or other health advice pertaining to an individual’s specific health or medical condition. You agree that the use of this information is at your own risk.
Until next time,
