On Weight Loss
I'm a frequent visitor to HackerNews, a site similar to Reddit for community curated links, articles and discussion, mostly focused around technology. It's one of my favorite parts of the internet, truly one of the final bastions of cogent, (usually) thoughtful, and compelling discussion around issues of the day.
An article was posted recently from Nature that elicited a lot of discussion on the efficacy of weight loss drugs and their place in our weight loss journeys.
Context
I am not blessed with an amazing metabolism. Weight management has been an omnipresent thing my entire life and plays a huge role in my self-image to this day.
Losing weight is hard: emotionally, psychologically, physically. People don't ask to be fat and society glamorizes bodies (thin, petite women or ripped, muscular men) that are not representative of the majority.
Growing up, my parents tried to help me attain a healthy weight. The simple fact was that they didn't know how. This isn't to fault them, they themselves didn't grow up with the knowledge or tools. It wasn't until I met someone who did have that knowledge and those tools that I started making positive progress in my weight loss journey.
Even then though, it wasn't easy. I had to learn not only what to do, which was leveraging weight lifting and different dieting techniques, but how to continue those activities as life changed.
I only bring in my personal anecdote to give some credibility that I have had these same struggles, doubts and fears on how to live with being overweight in the past and how to maintain health going forward.
Contention
One of the threads of discussion in the HackerNews post elicited an emotional reaction tied to the above. The commenter outlined their weight loss journey up to now which included the following:
- Losing weight through diet and exercise.
- Their conclusion was that losing weight in this manner was difficult, mentally, physically and socially.
- Losing weight through fasting.
- In this specific instance, fasting every other day. Their conclusion that losing weight in this manner was difficult, yet a bit more managable.
The common thread through both of these methods was difficulty. They are both mentally and physically taxing. You are restricting yourself. You are fighting against urges that aren't necessarily manifested consciously.
The key takeaway however is that they tried different things that worked. Diet and exercise worked, albeit commanding sacrifices in their lives in order for them to.
It's natural to try and find things to alleviate this burden; whether that's through drugs or surgery, anything to reduce the stress, anxiety, ostracization and shame. The fatal flaw is only relying on drugs or the results of surgery to solve the underlying issue.
Drug-Assisted Outcomes
The results of these weight loss drugs, orlistat, naltrexone/bupropion and semaglutide (Ozempic, Wegovy) to name a few, are definitive. They have proven to increase the rate of weight loss in those overweight to a much greater degree than without.
While there is still a lot to learn in terms of the greater risk profile as more people start taking these drugs, early indications show that side effects are generally mild.
Unlike liposuction, which actually removes fat stores from your body, these weight loss drugs suppress appetite in order to let the thermodynamics of your body go to work. This is where the long term efficacy of these drugs is called into question.
In many weight loss drug trials, not only is the drug itself assisting weight loss, but participants (both in the control and drug group) receive "lifestyle intervention" which usually consists of an exercise and diet regimen. After participants are deemed to have met their target weight during the trial, it is expected that leveraging these skills will enable them to maintain that new target weight without having to take the drug.
This takes us back to our earlier discussion about the difficulty of maintaining these lifestyle interventions long term.
Temporary or Permanent Assistance
One passage that I think is particularly illuminating from one of the semaglutide trials (emphasis mine):
In those who continued semaglutide after randomization, weight loss achieved during the run-in period not only was sustained but continued, reaching a plateau at week 60 to week 68 and ultimately resulting in an estimated reduction of 17.4% over the entire trial. In contrast, participants who switched to placebo at week 20 gradually regained weight. The benefits of continuing semaglutide treatment for 68 weeks, rather than switching to placebo after 20 weeks, are consistent with findings from other withdrawal trials of antiobesity medications. These results emphasize the chronicity of obesity and the need for treatments that can maintain and maximize weight loss.
Relying solely on weight loss drugs without having an independent foundation of diet and exercise is inviting danger. If for whatever reason, these drugs become unavailable, price prohibitive or their risk profile changes, there is nothing to fall back on.
What scared me in the HackerNews discussion was the willingness to abdicate that independent foundation and be content with staying on weight loss drugs long term; treating the drug as an end instead of a means.
Control
I personally took this mentality as weakness. Not that this person is weak, but that relinquishing control of something that you ultimately do have control of, is weakness. You may think that leveraging a drug is taking responsibility, and it very well may be in the context of short-term assistance while the underlying foundation is built, but it is ultimately a crutch to the underlying issue.
That issue being discipline. We all control what our hand puts in our mouth. It is a choice. We don't always need to make the right choices, but we need to make enough right choices to maintain a healthy body.
Does this mean you count calories every day? Maybe. Does it mean you need to work out 5 days a week? Maybe. Does it mean you have to do absolutely nothing at all because you've been blessed with a blast furnace of a metabolism? Maybe.
The point is everyone is different and learning how your body operates in order to make those right choices is critical. For a vast majority of people who are not genetically predisposed to obesity, "knowing thyself" and figuring out what works for you long term should be the ultimate goal.
Finding Tools
I would be remiss if I didn't try to end this post with recommendations, potential solutions for people looking for the "how". These things won't work for everyone but at least they've worked for me in the past.
Like I said before in the previous section, these things also require more discipline than normal. Going into these things half-cocked, especially if it's your first time, is destined to fail.
Dieting
- Calories In, Calories Out: By far the simplest and most general way of thinking about how our bodies process calories. Calories in, calories out is hotly debated and when you dig into what actually goes into each side of the equation, things become less clear but for the sake of simplicity, eating at a caloric deficit will result in weight loss.
- Intermittent Fasting: At it's core, intermittent fasting is about limiting yourself to windows of eating throughout any given day. There are variations (16/8, OMAD) in the window length but the science behind it involves depleting the sugar stores within your body, so it then switches to burning fat.
- Keto: Short for ketosis, Keto is a high fat, low-to-no-carb diet that maximizes fat burning. When you stop eating carbs, your body enters ketosis and starts producing more ketones. Your body uses ketones as energy instead of glucose (which comes from breaking down carbs). Ketones are created in the liver by breaking down stored fat in your body. Especially if you are weight training, keto is a great way to save off muscle loss (which during a caloric deficit, can induce gluconeogenesis, or breaking down muscle for glucose).
Exercise
- Do Something You Can Maintain: The key to any sustainable exercise routine is one you can stand to do multiple times per week. Diet is the most important part of weight loss but including exercise is the key to long term success. If that's walking, biking, running or lifting, do something you can get into a routine and maintain.
- Weight Lifting: If there's anything you can do to build long term success, it is lifting heavy things. Building muscle creates a positive feedback loop in your body. The more muscle you gain, the higher the energy demand on your body to maintain that muscle (higher basal metabolic rate, BMR). The more energy required, the more calories your body needs to inherently burn to maintain itself by doing nothing but existing.
Dieting and exercise has been a defining thing in my life, whether I like it or not. I've learned to accept its place and deal with the consequences, but it was not an easy road. I lost 100lbs in high school, gained a lot back in college, lost it again years later, gained it back again. I'm now in a more stable place in life where I can prioritize my nutrition and exercise, where I can have more control.
Not everyone has that privilege, which is why I empathize with the struggle, but that doesn't mean we should accept excuses. The information is out there, there are people willing to help. Many people have the ability to make their health a priority, it's just recognizing and taking the steps to start the process.