Evidence that these things lead to large scale / society wide obesity in populations where cheap junk food is not widely available?
ETA: On an individual basis of course there have always been obese people, but even then it was almost entirely limited to people of means who could eat what amounts to a modern western diet before it became readily available to the masses (William Howard Taft, Henry VIII, etc.). Maybe those mechanisms played a part in the development of obesity for those particular individuals. But for society at large, I think it takes the availably of widespread cheap junk food.
One might view obesity on the context of human history. Food was often scarce, and naturally we adapted to take maximal advantage of available nutrients.
There is no doubt easy availability of delicious junk food in quantity, fast food emphasizing taste and cost over nutrition, less exercise and physical work and increased stressors increase the incidence and prevalence of obesity.
People are much more than their weight. and everyone deserves basic dignity and positivity. Some people deemed overweight are metabolically healthy. But there is no doubt many chronic diseases that impact quality and length of life are related to excess weight. It will be with us as long as plentiful food is available but our genetics reflect earlier times.
Medications like Ozempic are not the best solution. Much of the weight lost seems to be regained after discontinuing the medication; the mindset “just take it for a while and stop” is common but may not work as well as hoped. Cost is considerable. Muscle as well as fat is lost. Long term sequelae not yet fully known. No doubt some of the results are impressive. But probably less effective than changing attitudes, exercise, food choices and culture. But easier, and you can’t fault people for starting somewhere, especially when it seems to work.
Just guessing here but if you have a pill that keeps you from getting fat then you may gain eating habits that tend to make people fat. Stop the pill but keep eating thinking there are no drawbacks and it should be no surprise what the result is.
Assuming we do get there, it would be much more complicated than that. These types of medicines which mimic or block the effects of hormones can cause changes to the bodies own systems which don’t bounce back to baseline once meds are stopped. Prednisone, for example, causes the bodies natural system for producing steroid hormones to be down regulated when taken long term. Opiates will similarly cause the body to down regulate the production of endogenous opioids, this being one of the causes for withdrawals in people trying to stop opiates. There are many other examples, and a complicated system like hunger almost certainly will have areas where the body’s natural production of various hormones will have been changed while taking a medication, and not bounce back to baseline immediately after stopping the medication.
I do agree that the availability, engineering, and marketing of junk food are extremely important in the obesity epidemic. There is even good evidence that the problem with “sedentary lifestyle” is not so much the lack of exercise part, but the consuming of junk food while working, gaming, screen viewing, etc.
In my opinion, I don’t know if I can think of junk food really as the cause, like MTB bacteria is the cause of tuberculosis. I think it is probably more like cancer, where there can be lots of causes, and lots of pathways that different people can take to get to the same end result.
As for BMI, it is a perfectly fine population measure as used by researchers studying obesity. Is an easy to collect measure that captures much of the variance in weight related health. It is not appropriate to use on an individual level in a doctor’s office. The doctor should be able to take a much more sophisticated look at the patient in front of them, not simply BMI \ge 30 = lose weight.
I don’t think it is just eating habits. Your body does not want to easily change its weight. It may be unsurprising much weight is regained after stopping medication, but people often have the mindset they could simply discontinue the medicine after losing a substantial amount of weight without any problems . This may not be the case.
Your diet is FAR more important to your weight than exercise.
That is not to say exercise is not important (it is). Just that it takes a silly amount of work to burn-off the calories from a Big Mac. Something most people will not do.
To be clear…definitely exercise. Just know it will not be the primary means of reducing weight. A better diet is the better route to losing weight.
I agree with you about lack of exercise, which I think will turn out to be only a small part of the problem. I also agree with you about BMI.
I think we can split hairs about initial causes, and I agree that there are other sources of obesity not related to junk food, although those things like leptin receptor deficiency, Cushing’s disease, and things like that are probably only minor contributors on a population scale.
Getting away from official standard of care thinking and into speculation (these are no longer official medical recommendations ), I think two other aspects will turn out to be major factors. I think fructose will turn out to be a particularly strong contributor for causing obesity. I’m of the opinion that the switch from sucrose to high fructose corn syrup was a major reason obesity really started to become more common in the 70s and 80s. I’ve come to think of it almost as a weak poison. The other is alterations in gut microbiome, where research is still lacking. Based on personal experience, however, I’m of the opinion that part of what causes hunger to go out of control when attempting to eliminate eating a modern western diet is that gut bacteria that depended on things like fructose start dying off and producing hormones to signal the brain to crave junk.
Based on personal and friends/family use of semaglutide and liraglutide, I think that most patients are using these drugs in a way quite different from that studied.
One issue is irregular dosing due to cost.
Another is that the approval studies combined use of the drug with an obesity treatment (calorie restriction) that is proven to work in the short to medium term [url= Medicare's search for effective obesity treatments: diets are not the answer - PubMed]but may cause long-term weight gain[/url]. My sample size is small, but I see patients using the injections instead of calorie restriction rather than in addition.
Another issue is side effect management. Studies forced patients to do a fairly quick dose escalation, having to choose between side effects and being kicked off the study. Personally I have not heard of docs directing patients to do that. This is a bigger issue than with, say, statins, because the side effects seem to be much greater than with other classes of drugs a patient might be taking for life.
Yet another issue is switching around between drugs. I switched from semaglutide to luraglutide because of side effects. Never studied!
Especially for patients starting this who aren’t elderly, I think it will take more than a few decades to know the lifetime effect.
P.S. Not medical advice, but my personal thought is that the new drugs are still probably safer, or at least more reversible, than surgery.
Some people seem to think that weight loss is simply a matter of diet and exercise. But Oprah Winfrey has been wealthy enough for decades to afford a private chef, nutritionist and a personal trainer. And yet even with these advantages, she struggles with her weight. So I think it’s complicated.
And I’ve read articles about Ozempic and other GLP-1 agonists. I remember in one, a person said the medicine quieted the “food noise” or constant cravings. Another article said that patients lost the desire to drink alcohol. We’re still learning about these drugs and how they work.
I’d quibble with the terminology, but agree with the spirit of your post. I don’t think it’s at all complicated. It really is quite simple. Eat a healthy diet (and while there is no one definitive healthy diet, I think we know enough to say what’s healthy and what’s unhealthy) and barring some rare medical conditions, obesity will resolve. It’s just really, really, difficult. It’s like asking someone to bench press 300 pounds. It’s a simple process. Just lay on the bench, grab the bar, and push up. Simple ≠ easy.
It’s possible, but based on my personal struggles as well as those of the people I know, I think it’s unlikely. I think it would be difficult to overeat long term on things like non-starchy vegetables, healthy oils and fats like avocado and it’s oil, olive oil, salmon, true nuts, lean protein like chicken breasts, and so on. Anecdotally, I can’t think of anyone I know personally who eats a healthy diet and is obese. Doesn’t mean it’s not possible, but I think it’s highly unlikely.
I’m referring to those who are obese and have some sort of adverse health effects due to their obesity, be that excess daytime fatigue, joint pains, diabetes, hypertension, etc. It would take such a person time to lose enough weight to return to a state of optimal health, but they would get there if they were to stick to a healthy diet on a long term basis. I can’t cite a medical study, this is just my personal observations. But I don’t know anyone who is both obese (by which I meant that they are suffering adverse health effects due to their excess weight) and has been eating a healthy diet on a long term basis.
There is a qualitative difference between the ability to choose what foods to eat vs. the inability to choose what air to breathe. There is also a qualitative difference, although smaller, between the difficulty of choosing better foods and smaller food intake vs. the difficulty of kicking a drug habit. I’m not interested in blaming someone for overeating (or eating badly) any more than I am interested in blaming someone for being addicted to a drug. But I don’t think you’re doing the overweight any favors by equating overeating with drug addiction.
Full disclosure: I’ve never been addicted to a drug, so I can’t attest from first-hand experience.
I’m again speaking again from personal belief and not based on anything I learned in medical school. Based on my own personal struggles, I consider fructose to be an addictive substance. Certainly it’s less potent in terms of the harm that it causes than cocaine, heroin, or alcohol, but IMHO it’s no less addictive. Which isn’t to say that everyone who tries it will become an addict. None the less, based on my personal experience in trying to eat healthy and the many failures I’ve experienced over the years, I consider myself to be addicted to it.
FWIW, sucrose and HFCS both have about the same amount of fructose. HFCS was just so cheap that it could be added in large amounts to virtually everything.
The addictive hit isn’t fructose per se, it is sweetness. The all pervasiveness of HFCS resulted in children getting entrained to the sweetness hit and its dopamine rush, such that by adulthood many are indeed in expecting their bigger and bigger hit of it several times a day. Non caloric sweeteners hit the same pathways. There is some debate over whether to call that “just” a supernormal stimulus that hijacks reward pathways very useful in past times, or addiction, but functionally it seems like addiction to me. And like with other substances some of us are wired to be at greater risk of abuse than others.
Those advantages don’t in any way mean Winfrey doesn’t eat too much of the wrong foods (and exercise too little). As an analogy, the vast majority of home training equipment, no matter how good for you, live their lives unused, or at best as clothes hangers.
), I think two other aspects will turn out to be major factors. I think fructose will turn out to be a particularly strong contributor for causing obesity. I’m of the opinion that the switch from sucrose to high fructose corn syrup was a major reason obesity really started to become more common in the 70s and 80s. I’ve come to think of it almost as a weak poison. The other is alterations in gut microbiome, where research is still lacking. Based on personal experience, however, I’m of the opinion that part of what causes hunger to go out of control when attempting to eliminate eating a modern western diet is that gut bacteria that depended on things like fructose start dying off and producing hormones to signal the brain to crave junk.