Weight Loss Drugs: A Dietitian's Perspective
The other day I listened to Ezra Klein's podcast: Our Brains Weren't Designed for this Type of Food and while the information in this episode was mostly thorough and informational, there were some real missing points. As a dietitian who works every single day with people wanting to honor their health, learn to eat well and in alignment with their body's needs, and understands the profound risks of dieting and restriction, I have a lot to say in reaction to this conversation. I have a lot of respect for Ezra Klein and really enjoy his podcast and work. I just wish that the discussion was more well-rounded, nuanced, practical, and more about real life.
First, I wish people like Ezra Klein would interview clinicians who actually communicate the science to people in real life, rather than just folks in the research world. Don't get me wrong, we need people doing research and I am so grateful that science exists to further understand the world, our human condition, and nutrition specifically better. However, I often feel frustrated with the lack of perspective of real life people when these types of discussions take place. There were huge holes in the discussion and my goal here is to explore them more fully with the hope that it helps any of you who may be researching these drugs, weight loss studies, and nutrition science generally have a little more context and a different perspective provided.
If you'd like to listen, feel free to do so on Apple Podcasts or Spotify or just search the title above. NOTE: please know yourself and your limits. If a podcast that talks about weight, bodies and food feels like something that would not be health-promoting or positive for you, please skip this post and podcast.
Here's a breakdown of specific timestamps during the conversation and my thoughts in reaction. I will sum up my thoughts at the end of this blog post to tie it all in and provide some take home messages to consider.
4:00 Assumption about food intake and body fatness. Calories in, calories out reasoning.
Throughout the podcast episode, Ezra and his guest acknowledge that there are flaws with the calories in, calories out explanation for body size. They explain that they understand that body size is not directly related to the amount of calories that one consumes. What wasn't mentioned is that that metabolism can adapt (especially prone to down-regulation) based on intake. If someone is under-consuming calories/energy, the body will adapt by down-regulating metabolic rate, thus creating a system in which you are eating a small or maybe even "normal" amount of food, but you are consuming more than your body uses. In folks who chronically diet, this can happen perpetually. One can down-regulate their metabolism through inadequate intake, then feel defeated and starving, then eat/binge/overeat, then gain weight (even if intake is not overdoing it) due to a lower metabolic rate. Below, we talk about the Biggest Loser Study, but it's important to understand here that extreme dieting interventions can create a down-regulated metabolism years after the intervention, known as persistent metabolic adaptation. I would have loved to hear more about the flaws in this simplified explanation about body weight. There are people in larger bodies who genuinely do not eat in excess and I wish this was noted more specifically and directly. If we talk about this more, this helps to decrease the stigma and discrimination people experience in larger bodies and would serve to improve health by fostering more belonging, connection and safety for people of size. I will explain more about the science of this below.
6:15 40 - 80% of body fat difference is determined by genetics. Body fatness is highly genetic.
I was glad that they acknowledged the role that genetics play in body size. I just don't understand why we can't seem to accept that bodies come to this earth in all shapes and sizes. Most other things that are primarily genetic are considered examples of human diversity and maybe even beauty. Eye color? Eye shape? Height? Shoe size? Why do we accept those differences in ourselves and others as the product of our parents and their parents, whereas body size is considered culturally as a moral failing if it doesn't exist in very narrow windows of "appropriate weight". (side note: BMI is a whole subject to break down but you can click this link to have a basic primer on the topic).
They say that they understand that this is primarily genetic, but then seem to let this go as they continue to explore weight loss interventions, weight loss studies and the results of these. If I were there as part of the conversation, I would have thrown out the idea of: what if it's okay that bodies come in all shapes and sizes? What if it wasn't considered wrong or bad for someone to be in a larger body? What if this world was safer to exist as a person of size? If we never pathologized fatness, people wouldn't start dieting, and never dieting has a hugely positive impact on health. Please note, I'm running off of the definition of dieting as this: when a person prioritizes their aesthetic appearance above their health. In other words, dieting is when people do not align their eating with their body's needs—dieting is an intentional manipulation of body and food, a withholding of essential fuel and nutrients for the purpose of shrinking one's body. Dieting is NOT the same thing as health. They are separate concepts. I would have insisted we explore this distinction if I had been part of the conversation.
7:30 Weight is related to behavior.
Then they shifted into a nod to weight being related, at least somewhat, to behavior. I agree. Yes, there are instances where a person is very out of sync with their body, possibly overriding fullness cues, eating habitually when not hungry, etc. that could contribute to a caloric surplus. Let's also acknowledge that one could be existing in a malnourished body, not aligning their intake with their needs, under-consuming calories and energy. That person may even have a diagnosable and/or serious eating disorder. In those cases, please refer to people like me! In a one on one setting, I could explore with them what their beliefs are about food, what their experiences have been surrounding food and body messaging, what kinds of diets they have done in the past, etc. There is hope for healing for folks who fall into this category!
As mentioned in other parts of this podcast, the vast majority of people who exist in larger bodies are actively attempting to diet to lose weight. The statistics put it at about 2/3 people in bodies considered "obese" (air quotes because ew, that term is so stigmatizing and dehumanizing) diet and attempt to lose weight each year. So, these folks are engaging in the supposed "recommended" behaviors, however, the results are not working—especially if you define "working" as weight loss at all costs. I wish the host and guest explored more expansive ideas about what "working" could mean as far as a behavioral intervention around food. Could we count better sleep, improved mood, increase in physical activity, more connection to the body and its cues, etc. as "working" even if the number on the scale doesn't change? This weight loss at all costs idea really has GOT to be thrown in the garbage. As long as we're laser-focused on weight loss at all costs, we will continue to miss the point of behavior changes with food and movement.
8:10 Hunger arises out of circuits in your non-conscious mind and influences on our calorie intake.
Yes, and. Hunger is not the full story about appetite. People eat for all kinds of reasons: the celebrate, to connect, to grieve, to love, to human. We also eat based on memory of eating, which can be mediated by actually putting food on a plate. Eating on the go, in a frantic grazing pattern will be felt differently than sitting down to food on a plate and having a memory of eating a meal. For more on the role of memory in eating, check out this study.
10:00 Ezra shared an experience with chips on the table while out with friends.
Ezra's friend has a completely different experience with food than Ezra. But let’s ask why? I would want to understand more from Ezra: why are you preoccupied with food? What has your eating history been? What has your dieting history been? What kinds of messaging did you and do you receive about food and body? What are your beliefs about food and body? Ezra and his guest want to talk about genetic proclivities, but don’t want to explore the environmental elements that contribute to being more susceptible to overeating. We know that people will overeat when deprived. There was no mention whatsoever in this context about the role of dieting/deprivation/restriction (mental or physical) and its role in appetite regulation. We know that when people are deprived of food, they will become preoccupied with it, struggle to regulate their intake, hoard food, and/or engage in other similar behaviors. One very notable study about the effects of starvation on the psychological and physiological body is found in the Minnesota Starvation Study. To read an in-depth review of the study, click here.
12:25 Video game to “earn” food.
They talked about food reward responsiveness or relative reinforcing value of food to describe the difference between Ezra and his friend. I’m also curious about food scarcity, food availability, food/diet history. In addition to possible genetic difference, it feels important to explore different experiences that these two people have had through time which will impact their food behaviors significantly. It's not just genetics here, and it seemed a bit irresponsible to ignore the glaring fact that food experiences, including dieting and other restrictive behaviors, will impact your ability to sit down at a table with chips and feel at peace.
16:30 Discussion about purifying ingredients in food that mediate their seductiveness and dopamine response in the brain.
Ezra and his guest make the point that the motivating level of food has shifted throughout time since the hunter/gatherer days. As we purify food and other substances we can stimulate and strengthen behavior: salt, umami, carbohydrates (both starches and sugars), and fats. They gave a nod to the fact that these food being highly rewarding is adaptive, positive and healthy. Being highly motivated for calorie dense foods is and was important for our survival as a species. In this discussion about what makes foods highly rewarding to us, it feels super important to also explore experiential things that increase the reward in the brain. The more food is restricted, off limits, or considered bad, the more pleasure, enjoyment and excitement people get from eating it. Here's a study to further explore this phenomenon. It felt irresponsible to me that they were having this discussion comparing food seductiveness to cocaine without also exploring and acknowledging the role that restriction, dieting and deprivation play in the reward itself. To restate what I've already said, reward (dopamine response) increases as restriction, dieting and deprivation take place. If we want to explore how to mediate reward from our current food supply, which I'll acknowledge is highly rewarding especially as compared to most of human history, we also need to talk about the rise of dieting, intentional weight loss, and restriction around food.
20:45 Comparing cocaine to purification of foods.
Each step to purify creates increase chance of addiction and health risk. Dopamine stimulating nutrients in food as a comparison not everyone agrees that food addiction is a thing, however, we have concentrated dopamine stimulating properties which creates food that is more enjoyable than our ancestors would have had access to. I agree with the points that our food is more palatable than it has been for all of human history, however, see the above paragraph for more information about why comparing food reward to drugs is highly problematic.
25:45 Discussion about prohibition of highly palatable foods and the impact of marketing on our food intake.
There is strong corporate interest, food marketing is a billion dollar industry. The guest stated that the strong motivational drive to eat is not the same as addiction to cigarettes, alcohol, cocaine, etc. and they acknowledge this. I appreciated this nod to nuance here.
31:25 Discussion about appetite and body fatness regulated by the brain.
Appetite goes up and down to regulate body fatness. “Tasty human food” creating fatness in rats tried the experiment with humans later on after discovering the “cafeteria diet” and humans over-consumed calories. All this tells us is what we already know: we are capable of overconsumption. Does this mean we will? How do we navigate our current food environment in which we live? There was no exploration of this, which felt frustrating for me as someone who does this exact work day in, day out. It feels like these types of podcasts are happy to interview therapists to find out how to bridge the gap from science to practical life, but for some reason when the topic is about food the only interview the researchers. Ezra, please bring someone like me on the podcast to help bridge this gap for folks! There are ways to navigate our current food environment to allow for all the things we all want for each other and ourselves: enjoyment with food, peace around food, ability to connect to the body, meet the body's needs, celebrate with family and friends around food, all while honoring your health.
36:50 Sensory specific satiety.
I liked this point about the common phenomenon we've all experienced as kids where we're full from dinner but still have room for dessert! Very fun to have a name for it—I'd never heard that before.
39:40 Increase in snacking through time as a culprit of "obesity epidemic".
I think it's interesting to understand that part of what we're experiencing in our current food culture climate is one of increased snacking. Part of this could be due to the confusing messaging people have been given about "6 small, frequent meals" or possibly "saving calories for the end of the day" ideas that are so common in diet culture. People are afraid to eat! People think that "healthy eating" means eating the least amount possible so they skimp on meals or skip them altogether, then snack because they're starving and some even talk themselves into the snacking "not counting". I can think of a million reasons people are snacking more and I wish they talked about that. I also wish that they acknowledged that the "obesity epidemic" has a long and complicated history tied in with corporate interests, bad science, and questionable motives. They neglected to mention that the cut offs for what is considered obese changed overnight during the nineties and that the metric for determining "obesity" is ubiquitously considered non-scientific and basically meaningless, especially on the individual level. They threw around all kinds of words but didn't define them or explain them, and I understand they have limited time on a podcast episode, but this kind of clarification feels really important to parse out when discussing interventions for body sizes deemed wrong, when the way they deem these bodies as wrong is very, very questionable at the start.
41:56 Study with bland liquid food from a straw.
In lean people, normal calorie level was maintained on this bland, liquid diet, however, in people in larger bodies, calorie intake plummeted. Ezra and his guest act like the study results is all about food cues and food reward. What about the possibility that the people of size wanted to lose weight to be safer in this world and saw this as a chance to diet to lose weight? What if it was about a desperation to lose weight, not about what the brain is saying about appetite or food cues? Or could the results possibly be about the larger people being more habituated to restriction and starvation, since we don’t know for sure that they weren’t chronic dieters? There was no exploration about why people in larger bodies would have their calorie intake plummet with this intervention. It is very plausible that this was due to seeing an opportunity to lose weight since most people in larger bodies are attempting weight loss at any given time.
45:10 Set Point Theory.
A defended level of body fat is regulated by the hypothalamus. This phenomenon is asymmetric: our bodies are better at protecting against weight loss than weight gain. In other words, the body allows for weight gain easier than it permits weight loss. Our individual set point tends to increase as people gain weight. The heavier weight becomes the new normal, and the new defended weight. Weight loss diets typically end up with a weight higher than starting weight due to this theory of set point.
This is all true. Yes. So, what do we do with this knowledge? Continue to encourage people to diet to lose weight, knowing that they'll gain more weight than when they started? Or, do we work to stop the unhealthy pattern of weight cycling and dieting, and instead focus on actual health patterns around food? I much prefer the latter. Health is not the same thing as dieting, and it's so important to make that distinction. I was a bit aghast that Ezra and his guest kept nodding to the futility of dieting, while also continuing to act as if intentional weight loss the intervention we need. Intentional weight loss is overwhelmingly not health-promoting. Weight cycling is associated with increased risk of insulin resistance, depression, cardiovascular risk factors, and diabetes.
50:48 Overfeeding trials. Some people gain a lot of fat, some don’t.
This points to the difference in metabolic rate and differences in metabolic adaptation to changes in caloric consumption. With this idea in mind, it makes me wonder why the premise of this entire conversation revolved around "how do we change people's body sizes through making them eat less food?" because we should know that while some people are eating out of alignment with their body's needs (i.e. eating too much or not enough), many are not eating completely out of alignment, yet we still observe differences in body size. I just can't understand why this connection never gets made.
51:35 Biggest Loser Study.
Participants tend to gain weight after filming. They also find that their metabolism is permanently lower, thus resulting in far easier weight gain. The guest never made the point that actual metabolic rate was altered even 6 years post intervention.
52:48 The time where Ezra says that we all know someone who has lost a lot of weight and kept it off. He made it clear that he believes the science is overly pessimistic about weight loss.
Ezra said: “Who are you going to believe? All these studies or your lying eyes? We all know people who have lost a lot of weight and kept it off for long periods of time, who have changed their bodies quite dramatically.” Huh? I thought this was a strange about-face in a podcast aiming to be so scientifically grounded. It's fascinating because if there was any bias with the scientists going into the interventions on weight loss, it would be PRO-weight loss. So, the fact that the science is as pessimistic as it is shows us that it is real. If there was a way, a diet, a magic food, a magic pill, it would be a slam dunk, billion dollar product. But, that just isn't the case!
It's as if the desire to believe that intentional weight loss efforts produce long-term weight loss is so deep, Ezra had to try throwing out his anecdotal observations. I get it, we want to believe weight loss efforts work. It's very hard to acknowledge that they usually don't. However, it's super important to understand that while intentional weight loss typically does not produce long-term results, working on your health does produce long-term positive results. Regular meals, balance, variety, movement, good sleep, fruits and veggies, etc. all impact health positively, regardless of whether or not the scale changes. I really wished they made that point!
55:40 Discussion about obesity and health. Data is clear that diet and exercise is not reliable for most people. Should we worry about this at all?
The guest makes the assertion that body size is causally related to health risk: cardiovascular, cancer, metabolic conditions, etc. “too much energy int he body number one cause of health concerns in this country”. I have two concerns about this: 1. the point above about how overfeeding doesn't lead to weight gain for every person...so why do we assume that every person in a larger body is over-consuming calories. 2. why are we not talking about why people consume excess calories (in the cases that they actually are over-consuming calories)? There are reasons for this, all of which I would love to explore with the individual to work toward aligning intake with the body's needs.
1:00:00 Weight loss diets and diabetes risk as an example of an intervention study. Bariatric surgery studies and the impact of health improvement with the surgery.
Why aren’t we talking about the negative outcomes of all of this as well? Weight cycling increases insulin resistance and increases risk for diabetes (studies linked above previously). We are so short-sighted in our intervention studies! We know that diabetes risk increases with weight cycling and we know that intentional dieting/weight loss efforts tend to lead to being at a higher weight long-term than when you started the diet! It makes me crazy when we're not going full circle to examine these studies critically. Bariatric surgery has benefits in the literature and it's important to acknowledge that there is risk involved with altering your body in such a way. There are risks to your health in addition to possible benefits observed. This is not a judgement for anyone who goes down that path, it's just a frustration with the lack of nuance given in context of the discussion about weight and health.
1:03:10 Semaglutide drugs GLP-1 receptor agonsists.
People also report that they are less worried about overeating on this drug, so it’s possible that they consume a more consistent intake which then allows them to be more consistently nourished which could also serve to prevent overeating. There are other possible explanations for the impact the drug has on people and I would have loved to explore that deeper if given the chance.
Overall, I feel frustrated with the lack of closing the gap in the discussions about diet and exercise and how it impacts real life people. I wish we acknowledged that people come in all shapes and sizes and that this world would be a much better place if the world were safer for people in larger bodies, if we didn't pathologize body size, if we honored our body through aligning our eating with what it needs, if we prioritized health over body size. I hope this exploration has been helpful for you in navigating all the food noise and headlines about weight loss drugs. I wish you all the best!