My understanding is that GLP 1 meds work in multiple ways including increasing satiety, but that some significant number of people are still eating the same crap. Just less of it. But also less of whatever healthier choices they had previously eaten as well. That is the point of the article I cited above: there perhaps even more importantly needs to be effort made to prioritize “consumption of a varied diet comprising fruits, vegetables, whole grains, lean proteins, nuts, seeds, and legumes.”
Statins and high cholesterol is similar in that the target as narrowly defined as some specific numbers, the weight on the scale or LDL, for example, will be achieved by the medicine even when excellent effort at lifestyle modifications did not. And overall healthspan/current function optimization still needs effort at making behavior choices that don’t automatically happen in the modern world.
Personally, I would consider affecting blood sugar levels by triggering insulin release , blocking glucagon secretion and slowing stomach emptying to be affecting metabolism. It’s not like the only way to affect metabolism is to speed it up or slow it down. Maybe the satiety affect is not exactly an affect on the metabolism - but it causes a lack of appetite and hunger. And while I suppose I can only speak for myself, there is no willpower whatsoever involved when I’m not hungry and have no desire to eat . I don’t need willpower to resist heroin I don’t want to inject, why would I need willpower to resist food I don’t want to eat?
Certainly. But that’s 90% of the problem and the hardest one to solve. A fast food diet with an appropriate number of calories is probably better on average than a more varied one with a significant excess.
I have a friend who, by any qualitative metric, has a healthier lifestyle than me. He eats better foods and exercises far more often. But he’s obese and I’m not, because despite my relatively poor diet I only eat once a day and typically have <1500 kcal, while he eats constantly (I know this because I go on hiking trips, and he just eats almost continuously, even when just traveling in the car). He probably has better HDL than I do, though mine isn’t bad. It’s just those minor benefits are dominated by the obesity, which causes him physical problems as well, like a broken ankle that’s taking forever to heal.
Agree. The low hanging fruit is obesity. A shit diet of 1200 kcal/day beats the pants off a ideal diet of 3500 kcal/day.
Be nice to max perform both quality & quantity. BTDT, have (had actually) the results to show for it. But it’s friggin difficult. And prohibitively so long term.
Hence why I speak of a willpower gap. If there is no gap at all, then there is no difficulty whatsoever. You just don’t eat. If the gap is wide (intense, continual feelings of hunger) then a typical person will just not be able to summon enough will to overcome that in the long run. Maybe for days or weeks, but not years.
Somewhere between those points is a “well, I could eat, but I don’t have to” sized gap. Where it may take a bit of conscious effort to override the feeling, but not so much to be unsustainable. If satiety is improved, a too-wide gap can be moved to this range.
Yeah, metabolism is conversion of food into usable energy and then using that energy (and then eliminating the waste). It’s a purely physical process. Satiety and feelings of hunger have nothing to do with that except inasmuch as the body evolved to maintain equilibrium and so increase hunger when energy stores are low. But there is no inherent reason why the two are linked, and I think it’s clear that something about modern civilization has made the link less robust.
“Varied” don’t mean healthy, but assuming you meant varied in a healthy eating pattern, such as the Mediterranean diet or the DASH approach, I am not convinced of that. I don’t have solid proof to the contrary so I will refrain from continuing the back and forth, but I strongly suspect that is untrue. It would shock me. There is lots more to healthspan than what the scale says or what a few lab tests say.
Stack up a 176 pound 5f4i, BMI just over 30, person who exercises regularly and eats any of a variety of established healthy nutritional dietary patterns (my personal ideal being plant forward with a variety of vegetables, fruits, legumes, beans, whole grains, and modest amounts of fish, chicken, and may a bit of red meat), against the 150 pound person same height and gender (over 15% less weight, pretty good results for GLP-1 use), not exercising, eating ultraprocessed fast foods and Twinkies, just not much of it because of the GLP-1 they are on?
I don’t care if their lipids and fast blood glucose are identical. I will definitely expect better long term health and function from the heavier one with good habits. Less likely to experience depression, to develop dementia, to become long term physically disabled, to get any of many cancers, to develop sarcopenia, and more.
And of course the person who ate that diet and exercised regularly, is in fact less likely to hit that BMI over 30.
The difficult part for most, I believe, is not eating a mostly appropriate number of calories when eating that sort of nutrition plan and exercising regularly, that pretty often just happens; the difficult part for most is staying true to that nutrition plan when our environment is full of the crap all around us.
I understand that many on GLP-1s will have less cravings for crap. When so that makes the healthier nutrition plan achievable. But I believe there still has to be the conscious choice to eat the healthier choices, and to exercise.
Surely you must admit it is true in the extremes. Is someone with a BMI of 50, but on a Mediterranean diet, healthier than someone with a BMI in a normal range, maybe isn’t surviving completely on Twinkies, but eats a fair amount of fast food and hasn’t made any particular effort to reduce red meat, etc.?
My friend isn’t in quite that bad shape but he’s easily in the 35-40 BMI range. He absolutely does eat “a varied diet comprising fruits, vegetables, whole grains, lean proteins, nuts, seeds, and legumes”. He doesn’t cheat in that respect. He just eats a lot.
But somehow I’m still more fit, despite exercising less. I can hike longer and more energetically. He broke his ankle stepping on a root badly; I can jump off a modest boulder. When we’re snowshoeing, I can keep a faster pace in deep powder for longer.
I don’t think this is anything special on my part except that I weigh less. Everything is downstream of that. I’d break my ankle too if I had to wear a 100 lb backpack to put me in the same BMI range.
Am I more liable to get cancer? Possibly. But there are enough other factors in my favor that I doubt it’s a clear win.
The impact of exercise is not a linear function. The first unit of it brings much more benefit than the next with continued returns but diminishing returns.
You exercising less than he is but still exercising is still exercising. A little goes a long way.
I maintain that being morbidly obese while eating a healthy nutritional pattern and exercising regularly is a rare occurrence. Not quite spherical cow level. Non zero, maybe? But is simply difficult to eat 3500 plus KCal of beans, greens, etc. For most people 300 KCal of banana (three medium bananas) would be harder to finish eating than 300 KCal of Oreos (six regular cookies). And would leave them not hungry for a while.
The disconnect that about modern civilization that has made the food-satiety link less robust is the constant availability of those food choices. Obesity was much less frequent when all we had to choose between were healthier option. And morbid obesity less yet.
I feel like the thread has gone off topic, but I’d personally argue that the other solution to the willpower gap isn’t GLP-1 and other anoretics, it would be to teach people more realistic strategies for getting healthy.
If you hurt and you’re hungry, and you’re still years away from success, that’s just not an appealing strategy and so people will give up on it.
If you use an approach where people aren’t ever suffering, and never really notice the change, you’re more likely to succeed. For most people, really all they need to do is to successively incorporate one improvement rule at a time, with gaps of months in-between for their body to adjust, where the rules are things like:
Replace pasta with beans and lentils.
Look for higher fiber foods.
Switch to sugar alternatives.
Replace sour cream/mayonaisse with greek yogurt.
Avoid deep fried foods.
Switch to frozen yogurt.
Swap your candies for no-sugar added dried apricots.
Walk up the stairs at work.
Get a dog and walk it.
Etc.
If you eliminate high palatability items, one by one, and swap with “still pretty good” alternatives, that’s liable to significantly affect the overall trajectory of a person’s weight and health. At some point, you may need to get in there and start talking about portion size but, again, you can approach that as incremental adjustments, where the person’s body barely notices the adjustment.
If no willpower is necessitated by the strategy then willpower doesn’t become a breaking point.
Except… even your strategy only seems to work for a small minority of people.
We are programmed by evolution to eat calorie-dense foods. Why? because for millions of years it was the critters that did that who lived long enough to reproduce. Our environment, where calorie dense food is plentiful and easily available, is unnatural.
We’ve been preaching all sorts of strategies for decades to lose weight, including ones that are very sensible and incremental. For all but a handful they don’t work. For all but an even smaller group they don’t work long term.
It’s time to stop faulting people for “lack of willpower” when, apparently, 99% of people don’t have the necessary willpower to lose substantial weight and keep it off long term. On the flip side, I don’t think that means everyone 10 pounds over some arbitrary ideal needs to be medicated, either. But for many people it’s the medication that makes weight loss possible - as noted by a prior poster losing weight still requires some work and effort on the part of the person in question.
Sorta. The thing which really motivates people is seeing real progress towards their goal. And if that goal is reduced weight and increased stamina, then those 9 example steps at e.g. 6 months per step means 4.5 years with very little actual improvement to show for it. By holding the rate of inconvenient change below the level that’s needed to produce motivating progress, the whole project is self-sabotaging. Just as much as the wacky crazy “starvation for 3 months” diet is a self-sabotaging plan; nobody is going to be voluntarily miserably hungry living on e.g. carrot sticks for three months. No matter how much that changes their BMI.
The deep problem with real obesity is that people spent decades building up both the weight and the eating habits and taste preferences to support the growth and maintenance of that excess poundage. Biology is slow. In most cases you’re not going to undo decades of neglect with less than decades of effort. Sustained effort. Getting adults to buy into that sustained effort for very slow, borderline imperceptible results is darn hard.
Some people certainly can do that. And some can lose a lot of weight rather quickly and keep it off a long time. But that’s not the way to be for the public at large. And so is not a solution for a public health problem. No matter how much it may be a solution for a few certain individuals’ problems.
So far as I know, and so far as I can tell, there hasn’t been any research undertaken that uses an iterative, incremental approach over a course of 2-5 years to achieve improved health outcomes, and then tracked adherence post-success.
That’s certainly a theoretical outcome. At the moment, though, it’s just an imagined outcome.
As I understand it, there’s a fairly rigorous understanding of loss to fatigue. If an intervention is made and results in 2lbs of loss, then we can calculate the ideal point to make the next intervention. Maybe that’s 1 month, maybe it’s 6. Ultimately, you can’t really go faster than that and expect success. But, if you do keep above that threshold, then you’re golden. That’s just the true limit of achievable weight loss for the majority.
But I expect that, that’s much faster than you’re imagining it to be. And, particularly if you’re going in for a meetup with your doctor/coach every 3 months or so, and they’re tracking your progress, you’re going to see the direction of the arrow. They will see consistent, ongoing success and they will slowly feel the improvement.
Once you give people a realistic schedule and real evidence that it works and is working, and they’re discovering that they can just live day-to-day without having to do anything but continue a pattern that they’ve already been doing for months and months, that it becomes very easy to maintain adherence. Because you’re not being taught to diet, you’re being taught how to live correctly and you’re having it demonstrated regularly, through the process, how effective that is.
Or…yes, such a study would fail. I certainly don’t see the argument against running a trial. But pretending that one has already been run and that you know the result is false.
Getting people to do easy and obvious things, that would work, in my experience is one of the hardest things you could ever try to do.
Tell them that, if they snort rabbit ear wax and rub licorice juice in their armpits, that they’ll start to lose weight and you’ll have no problem getting a line of takers.
It’s not a matter of willpower, it’s a matter of a lack of excitement and the fear of having to give up on recklessness.
My personal guess would be that you’ve never met a person who had a long-term, organized plan to simply and rationally lose weight in a practical manner. Not once, in your whole life.
Now if that’s not true, then by all means we can start talking about other approaches (like GLP-1). But I’m pretty confident that it is true.
I’ve known several people who fit that description in my life. They came up with a plan, lost the weight, and kept it off for over a decade. Three, out of all the thousands of people I have known in my life. Just three. That’s comfortably less than 1%.
The rest? Yo-yo dieting. Exercising but no weight loss. A couple who descended into anorexia (definitely not where we want people to go). People who just gave up and resigned themselves to being heavy after years and years of failing to lose weight and/or keep it off.
A few who were able to maintain a stable weight, maybe gaining 10 pounds between high school and retirement. Again, very few. Often because other medical issues required them to be very careful about their diets.
We are programmed to hoard calories, not spend them. We are no longer required to expend much physical energy or effort to work or live our lives so even as our bodies want to consume more calories we have less need for them. On top of that, we live in a society where calorie dense, nutrient poor food is abundant and there are corporations who pay people full time to devise new and better ways to induce us to purchase food that is not good for us. Why is it surprising that obesity is a problem?
My suspicion is that the hunger reflex is actually extremely sophisticated; far more than anything that can be summed up in a sentence. It likely takes food composition, current fat stores, outside temperature, stress levels, energy usage, and dozens of other factors into account, as well as integrating this information over time. And the reflex has been refined for at least as long as mammals have been around.
It is, nevertheless, heuristic–it doesn’t have any long-term planning capacity, or ability to see the big picture. And it hasn’t been tuned to operate in an environment with unlimited food availability and a food industry that optimizes for selling us calories. Another 100,000 years and evolution would probably figure it out, but in the meantime it’s making bad eat/don’t-eat predictions.
Your statement is true if the goal is going from obese to normal weight. But if the goal is “getting healthy”, or healthier anyway, it works. I mean I can quibble with the individual steps but the idea is valid for health improvement, even if one is still … of generous BMI.
Excess fat is a problem itself but is also at least as much a sign of habits that in and of themselves, with or without obesity, are health impairments. These habits are not the result of moral infirmity, or laziness, or poor willpower. They are genetically inherited wirings that have served humans well for most of history that are just poorly matched for our recent environment.
I have a multitude of health issues, including T2D and a prolactinoma. Getting these things under control through medication, including Ozempic, has brought my BMI down from 34 (obese) to 26 (at the bottom end of overweight). 6 more lbs would take me down to normal range, but without increasing my Ozempic does from .5mg, it’s just not going to happen.