Back in the fraught winter of 2020 when covid vaccines were first authorized but not yet widely available, I found myself as a guest on the “Joe Rogan Experience” podcast.
My goal was to promote and discuss my book on the benefits of greater population density, so I didn’t come prepared to debate vaccines or covid. But Joe Rogan wanted to talk about it and asked me why I was planning to get vaccinated despite the side effects and low objective covid risks to a person my age. I told him the side effects didn’t sound so bad and a large reduction in risk was worth it even from a low baseline. That’s when he hit me with an unexpected cross — why didn’t I put more effort into losing weight?
I’m 6 feet tall, and I was 280 pounds at the time, putting me well into the official obesity territory. Losing weight would clearly lower my covid risks. I didn’t have a good snappy on-air answer, but the truth was like any overweight person, I’d thought about this a lot. And the fundamental problem, a point championed by the fat acceptance movement, is that the instruction Rogan had to give me — improve my diet and exercise — fundamentally doesn’t work.
There’s an endless, dead-end debate going on in the United States over obesity. On one side, you’ve got people beating the drum for dieting. On the other, there’s a movement arguing that since dieting doesn’t work, we should just accept people as they are. Nothing changes even as the U.S. obesity rate rises above 40 percent and kills more people than opioid addiction.
What’s needed is more acknowledgment that there is a path out of this dead end.
Nine months after appearing on Rogan’s podcast, I got an endoscopic sleeve gastroplasty — a surgical tool was inserted down my throat into my stomach, which was then stitched together to shrink its volume. This is one of several recent breakthroughs in developing medical treatments that, unlike scolding people about their diets, actually works.
There is also a broader recognition among obesity researchers that the causes of obesity are a complex combination of genetic, social and environmental factors that are most effectively addressed on a social level, much as smoking rates were reduced with policy rather than hectoring.
But to deliver on the promise of this progress, we need a society that’s willing to abandon the binary of “diet and exercise” versus “fat acceptance” in favor of promoting and investing in science-based cures and prevention.
Effective obesity treatments exist, and more are coming
It’s been established for years that bariatric surgery can effectively treat obesity.
The more recent development of endoscopic methods that don’t require abdominal incisions means they can now be done with even less risk of complications and even easier recovery. I’ve lost 55 pounds, my resting heart rate is down, I get less embarrassingly sweaty walking around Washington, D.C., in the summer, and I can do exercise — which is unquestionably healthy separate from any impact on weight — longer and more easily. These results are about average.
What’s definitely not average is doing the surgery. Of the 20 million Americans who qualify for bariatric surgery, fewer than 1 percent take advantage of it.
The cost, hassle and general anxiety around surgery is certainly part of the explanation. But what’s more frustrating is that additional, less-invasive evidence-based treatments coming to the fore aren’t getting much attention.
On June 4, 2021, Novo Nordisk announced what should have been big news — the Food and Drug Administration approved a medication that’s proven to be clinically reliable at reducing obesity. Patients in the clinical trials lost 6 to 12 percent of their pre-treatment body weight.
The drug, branded as Wegovy, is an obesity-specific reformulation of a compound called semaglutide that was already approved as a diabetes medication. It’s part of a larger family of drugs called glucagon-like (GLP-1) peptide-1 receptor agonists. This class of drugs works by targeting the hormonal system that we know drives sensations of hunger and satiety, making people feel fuller sooner and helping them make prudent choices about food consumption. Several other GLP-1 agonist drugs approved for diabetes use show promise as general anti-obesity medications. Another, Sexanda, was approved by the FDA in 2020.
These drugs are not miracles. Drug-based weight loss programs that also incorporate coaching claim average losses of about 15 percent. Clinical trials show more modest results than that. A 6-foot-tall, 250-pound man who achieved the optimistic 15 percent would still be considered overweight. But even small amounts can make a big difference. The human body is a mix of fat, lean muscle, water and structural tissue like your bones. For people within a healthy weight range, the heavier tend to be heavier on all four factors. But the difference between an obese person and a merely overweight one is overwhelmingly fat, so medications that generate a 15 percent reduction in body mass are creating disproportionately large reductions in body fat percentage and health outcomes.
These prescription drugs (mostly injections) are different from previous diet medications, like the scams that have long proliferated in the unregulated supplement aisles. And while they have unpleasant gastrointestinal side effects in some patients, they don’t pose the kind of serious safety concerns that the stimulant weight loss pills of 40 years ago did.
Why isn’t this a bigger deal?
Initial FDA approval of Wegovy received strikingly little media attention relative to the scale of the obesity crisis or the general level of interest in weight loss. Vaccines for covid-19 and therapeutics like Paxlovid have been widely hailed by political and public health leaders — with developments on page A1 of newspapers and scientists featured on magazine covers — and rightly so.
But for obesity breakthroughs, we don’t see the same large-scale jubilation among health officials or the public, no calls from elected officials for widespread distribution, no efforts to ensure equitable access and, generally speaking, very little interest in the development.
Neither of these methods has been widely embraced by the public health community either, despite incontrovertible evidence from meta-analyses that they work.
Most health insurance plans generally don’t cover weight loss medication. A startup named Calibrate made waves earlier this year by promising to give patients online GLP-1 prescriptions and to work with insurers to secure coverage. But as Bloomberg’s Emma Court reported on Aug. 15, Calbrate was mostly failing at this and instead getting patients access to discount drugs via a coupon program offered by Novo Nordisk that expired after six months. Once the discount ran out, patients were on the hook for the full $1,350 per month cost of the medication.
Doctors are reluctant to recommend courses of treatment that their patients won’t be able to afford, and guidance tends to follow that timidity. Major public health institutions downplay medical treatment or fail to mention them at all. Instead the mantra of diet and exercise rules as the Centers for Disease Control and Prevention’s Obesity Basics webpage says:
“Obesity is a complex disease with many contributing factors. Neighborhood design, access to healthy, affordable foods and beverages, and access to safe and convenient places for physical activity can all impact obesity. The racial and ethnic disparities in obesity underscore the need to address social determinants of health such as poverty, education and housing to remove barriers to health. This will take action at the policy and systems level to ensure that obesity prevention and management starts early, and that everyone has access to good nutrition and safe places to be physically active. Policymakers and community leaders must work to ensure that their communities, environments and systems support a healthy, active lifestyle for all.”
None of this is wrong, exactly, but it’s inconceivable that a major public health institution would discuss covid in this way without mentioning vaccines or treatments.
The CDC is correct to point to community level policy change as an important long-term prevention lever. But for those already with obesity — a huge share of the public — short-term remedies are useful and important. During bariatric surgery, a doctor makes small laparoscopic incisions in the patient’s abdomen and surgically alters his or her stomach to become significantly smaller. Study of this practice, in fact, helped to inspire the development of obesity drugs.
At first, proponents of bariatric surgery thought the causal mechanism of its success related primarily to the direct mechanical impact of a smaller stomach — with less space for food storage, patients would eat less. But subsequent inquiry suggested this wasn’t the case, or at least not the whole story. The main benefit of stomach surgery appears to be significantly altering the patient’s hormonal balance to reduce desire to overeat — exactly the cause of mechanism used by new obesity drugs.
The downsides to bariatric surgery are that any invasive procedure is inherently expensive and that, though perfectly safe in the vast majority of cases, there are always risks of error or complication when cutting into someone’s abdomen. In most recent years, surgeons have developed methods of performing endoscopic sleeve gastroplasty — doing the stomach surgery with small instruments inserted down the patient’s throat rather than cutting into the abdomen. This still involved general anesthetic and some risk, but speeds recovery time and reduces the odds of complications.
Public perception of weight loss surgery in the United States is currently very negative according to survey research published in the JAMA Surgery journal, with most Americans perceiving it as risky and an “easy way out” of weight loss that should be undertaken with hard work. Injected medications might alleviate safety concerns but could still spark the same sense that people should be able to lose weight with willpower alone. Which simply underscores how badly the country needs a more sophisticated discussion of these issues, since the reality is the metabolic reset offered by surgery or medication isn’t a substitute for improved eating habits — it’s what makes them possible.
We need a new debate
Much of the world is positively convinced that it already knows the cure for obesity and no drugs or surgery are required — the overweight simply need to change their diet and exercise habits. At the same time, there is a tremendous stack of evidence that hectoring people about diet and exercise does not in fact generate weight loss. Instead we simply see a proliferation of stress and anxiety in patients that empowers quacks and perhaps justifies bias and stigma.
Righteous pushback against the genuinely useless diet and exercise mantra has created a new politics of “fat acceptance” especially in certain left circles, which treats any discussion of body weight issues as akin to racist or homophobic discourse. Caught between diet and exercise and its enemies, the idea of effective treatments has no constituency.
The problem with diet and exercise is that while it is a useful framework for preventing obesity (especially in terms of establishing children’s habits) essentially nobody successfully loses weight in a sustainable way through this method.
As Harvard University evolutionary biologist Daniel Lieberman explores in his book, “The Story of the Human Body: Evolution, Health, and Disease,” the idea of maintaining a durable calorie deficit when food is objectively abundant goes against millions of years of primate evolution. In pre-modern conditions it was simply normal to go through periods of time when not enough food was around. That might be a single day when the hunt didn’t work out, a lean season when few crops were available or a whole bad year when bad luck with weather simply didn’t deliver the expected harvest. Animals capable of surviving such conditions need powerful instincts to eat a bit more than is strictly necessary when food is abundant. This is a habit that’s served Homo sapiens well for several hundreds of thousands of years, but happens to be dysfunctional under plenty that have existed for three or four generations at most.
Under these conditions, a staggering array of fad diets can and do work temporarily. Whether diet you’re doing: intermittent fasting, Whole30, paleo, low-carb, low-fat, South Beach or whatever else, you are simply crossing off the list a large share of the foods that happen to be around. This generates weight loss but also constant hunger. Meanwhile, the body’s response to starvation kicks in — metabolism slows and cravings for food increase in the hormonal system tries to inspire what it believes to be a Paleolithic hunter-gatherer to try harder to avert starvation.
Physical activity, meanwhile, though undoubtedly healthy as a general proposition is shown time and again to be a bust in terms of weight control. Working out simply does not burn that many calories, and intense exercise makes people hungry.
The fat acceptance movement combines these points with valid observations about the harm done to overweight people by bullying, shaming and biased treatment to promote an ideology that says we should stop worrying about the world’s ever-growing waistlines. In a widely hailed 2018 feature for Huffington Post, Michael Hobbes detailed the failures of the world’s anti-obesity efforts and the often-cruel treatment of overweight people before concluding that “there is no magical cure. There is no time machine. There is only the revolutionary act of being fat and happy in a world that tells you that’s impossible.” Hobbes, in turn, was largely recapitulating arguments from Paul Campos’ 2004 book, “The Obesity Myth.” These ideas mix freely online with classic feminist critiques of unrealistic beauty standards, with science-based criticisms of weight loss scams and fad diets, and with an emergent youth social justice culture that prizes the creation of new identities and new taboos to create a dissident conventional wisdom that there is no obesity problem to cure.
That would be convenient if true, but the balance of evidence is just overwhelming. While there are certainly healthy people at all weights, high body fat strongly correlates with stroke, heart attack, diabetes and other serious ailments.
There is no magic cure, but there are safe and effective treatments that complement hard work rather than substituting for it. We should be talking about their existence and how to put them within financial reach of more of the people who need them.
Thanks to Alicia Benjamin for copy editing this article.