Losing weight for good - let’s get real
Oprah after GLP1-agonist therapy
I heard a story on a podcast recently where the guest told of his experience attending a U.S. cardiology conference, where he was quite surprised to note that the cardiologists were all looking remarkably svelte! And the reason: GLP-1 agonists, variously known as Ozempic, Wegovy, Saxenda, or Mounjaro. Think about that for a minute. Despite meticulous grounding in the dangers of excess weight (heart disease being front and centre); access to the best research on the most effective methods to maintain a healthy weight; despite superior intellect, application and, one presumes, wealth; and despite the professional imperative to appear healthy and in control, on the whole, these cardiologists couldn’t do it without pharmaceutical help.
Or what about Oprah? She suffers no lack of emotional insight; can afford to hire any number of personal chefs and trainers; and her weight fluctuations have been subjected to forty years of global public scrutiny? Just like the cardiologists, it was a GLP-1 prescription which has had the most lasting impact. Or Serena Williams, who has lost 31 pounds on a GLP-1 agonist, who summed up many people’s frustrations beautifully when she said: “I worked so hard, ate so healthy and could never get down to where I needed to be at. It’s not about a lack of “self-discipline.”
While GLP-1 agonists are potentially game changers, they are also not always the answer and it’s likely that for most people who do try them, they won’t be the complete answer. In any case, for now, it’s a moot point while access in Australia remains restricted. Rather, the purpose of these examples is to illustrate that weight control can be hard stuff indeed.
So why is it that we can achieve so much but we can’t lose weight for good?
It’s not a moral failing. It’s your environment and your physiology.
Of course, food is everywhere, embedded in our social fabric, while, at every turn, advertising prompts us to use food to heighten our good times and smooth our lows. It’s all prodigiously unhelpful for any dieting attempt. See: Gimme, gimme shiny food!
And we’ve been selected for survival over millennia in the presence of food scarcity. It’s true some people are more exceptional Darwinian “success-stories”, being genetically inclined towards greater appetites or more efficient metabolisms. But genes are only one piece of the puzzle. While the Australian gene pool hasn’t dramatically changed since 1990 (and the population certainly wasn’t going hungry 35 years ago), the proportion of adults living with obesity rose from 12.8% in 1990 to 30.2% in 2022. (Ref) This upward trend is apparent in every country globally, except possibly France and Germany, though other data disputes this. (Ref). The drivers are different though: in France a Government-driven health initiative, Programme National Nutrition Santé is perhaps behind the fall in obesity. The program is a multi-pronged approach, endorsed from the top, which has been running since 2001. Knowing the importance of aesthetics in the French psyche, there may be a socio-cultural element at play as well, which is harder to replicate.
In contrast, in Germany, the fall may be due to changing eating habits, and in particular lower meat consumption. Interestingly, animal welfare and the environment have been more front of mind than health in driving this change. Plant-forward and plant-based eating will most certainly also feature in subsequent articles and was recently endorsed by the Scientific Recommendations for the American Dietary Guidelines. See this article.
Meanwhile, in Australia, despite the existence of an Australian National Obesity Strategy, which meticulously lays out evidence-based steps for reducing the nation’s waistlines and makes a compelling financial argument for so doing as well. (Ref) Despite the embedding of this strategy in a larger National Preventative Health Strategy (NPHS) (Ref) Despite the latter’s findings that the public ranked a healthy weight highest of all health issues. And despite public consultation for the National Obesity Strategy calling for a population-wide approach that incorporates systems change. (Ref) Despite all this, there appears scant political will. So you’re on your own.
Obesity rates in selected countries across the world
Source: YakEvery4395 via Reddit/DataIsBeautiful based on WHO data
Disclaimer: The term obesity is used solely in the technical sense as equating to a BMI >30, while overweight refers to a BMI between 25 and 30. Yes, BMI is an imperfect measure, especially at an individual level, but for populations it remains useful and very widely used.
We want it but for most of us it’s really hard.
And despite the welcome ascendence of the body positivity movement, surveys suggest people would prefer not to carry excess weight. The Australian Longitudinal Study on Women’s Health found 95% of women with overweight or obesity wanted to lose weight. (Ref) Data for men is scarce, but the US NHANES (2009-2010) survey found overweight and obese men were also unhappy with the status quo, though less so than women, with 74% of men versus 88% of women dissatisfied with their weight. (Ref) Meanwhile, a global study found 35% of adults were attempting to lose weight when surveyed. (Ref)
We also have good knowledge on what works best for losing weight (to be covered nest, though it’s nothing magic). However, only about 40% of people living with obesity who embark on a weight loss effort will achieve at least 5% initial weight loss, with half of these people attaining at least 10% loss, usually within 6 months. (Ref) The sting is that losses are generally regained over about five years. (Ref)
Ten percent doesn’t seem like a lot and we regain it anyway. Besides the frustration of retracing hard-won losses, weight loss is usually accompanied by a loss of lean mass, namely muscle, while regains will be skewed to fat. (Ref) (Ref) At the same time, pleasurable eating occasions are foregone, which might also mean less socialising and thus reduced wellbeing.
So is it even worth it?
Bear in mind that the average Australian man and woman gains weight throughout their adult life, so even slowing gains can be viewed as a win. The following chart comes from the latest Australia Bureau of Statistics’ National Health Survey.
Proportion of adults with overweight and obesity by age group.
Source: National Health Survey (2022). (Ref). Overweight and obese in both men and women is defined as a body mass index (BMI) of >25 kg/m2 and >30kg/m2 (calculate here), respectively.
But, while holding steady over the years deserves a pat on the back, the more stringent argument for maintaining a healthy weight is compelling. Excess weight increases the risk of type 2 diabetes, fatty liver disease, high blood pressure, heart disease and stroke, osteoarthritis, Alzheimer’s disease, depression, several cancers, kidney disease, sleep apnoea, gastric reflux and infection. (Ref)(Ref)
The following table is derived from a Government scientific review into managing weight in Australia and shows the percentage increase in risk for various conditions with a body mass index (BMI - calculate here) in the overweight or obese range. (Ref - p.27) It’s sobering, but we need to be clear-eyed. The report also concurred that, on average, all lost weight is regained over about five years, regardless of dietary strategy or starting weight. It’s against this background that I hold a favourable opinion of GLP-1 agonists and bariatric surgery.
Health risks of excess weight.
This is all a bit grim. What’s to be done?
Eventually, public health will come to the party as governments around the world are starting to do (another article on this coming too…). If you have anything to do with primary school canteens, you’ll see the progress that’s been made in a generation. And childhood obesity has (almost) plateaued at 8.3%, though overweight is still climbing strongly to include 27.7% of children. (Ref) Or change may come from the bottom up, in a manner that hasn’t been possible previously. As GLP-1 agonists become more common, demand for calorie-dense ultra-processd foods and fast-food may decrease, as has been observed amongst GLP-1 users to date, an effect which may drive a change in the food environment for all of us. (Ref)
In the meantime, even moderate weight loss and even temporarily (aka yoyo-ing) has value, as it is now understood that most of the negative health outcomes associated with excess weight are caused by its inflammatory effects and that even temporary weight loss can reduce inflammation for a period to reduce lifelong bodily wear and tear, potential muscle losses notwithstanding. (Ref)
And, despite the long odds, some people do lose weight long-term. The US’s National Weight Control Registry (NWCR) has collected data since 1994 on more than 10,000 successful weight losers. On average they lost 66 lbs (29.9kg) and kept it off for 5.5 years. So weight loss is not a complete unicorn. We’ll look at intel from successful losers in the next article.
Oookay. So the odds are against me reaching and staying at the ideal healthy weight of my dreams (at least not without a prescription and probs not even then). So where does that leave me?
Fortunately, there’s another way, and it’s gaining traction. Here the focus is on nutrition rather than a reductive focus on weight loss. The body and it’s appetites are not weaknesses to be overcome or ignored but something to be nurtured and fulfilled. Crucially, this is an exercise in pragmatism and self-respect, not indulgence.
Here the concept of self-compassion can be invoked. Think of yourself in the third person as if you were your own child (or even a pet), who depends on you and whom you love unconditionally. Naturally, you want the best for them, but you also want them to be happy today. This requires balance, with ongoing consideration and adjustment to strike the optimal course. Removing weight loss as a goal means you can stop the self-flagellation in failing to achieve that most elusive of targets. In accepting that weight loss might not be in your future, you can stop postponing your life for a day that will likely never come and redeploy your effort and drive into more self-affirming practices.
But what about the health risks? Yikes! I’m not ready to down tools just yet…
Well, remember that yoyoing can have value, despite everything you’ve ever heard. But if you try and fail to lose weight then the health risks are the same as if you don’t try and don’t fail and the latter may be a better use of your time and self-esteem. But, and this is a good one: eating healthily, even if too much, can improve health, regardless of weight loss. These were the results of the five-year Predimed randomised controlled trial where overweight adults (average age 67 years, average BMI 30) were assigned to a low fat diet, a Mediterranean diet with extra olive oil, or a Mediterranean diet with extra nuts. In general, the Mediterranean diet (with oil) was better than the low fat diet for weight loss and the Mediterranean diet (with nuts) delivered the best waist circumference result. This was despite a modestly higher energy intake in the two Mediterranean diets compared to the low fat group, plus a higher proportion of that energy coming from fat (41% compred to 37% in the low fat group). (Ref)
Effect of a high-fat Mediterranean diet on bodyweight and waist circumference: a prespecified secondary outcomes analysis of the PREDIMED randomised controlled trial (Estruch et al, 2019)
And the two Mediterranean diets also delivered a significant reduction in risk of a number of chronic diseases. Extra virgin olive oil appears to have the edge but one is not forced to choose and, in matters of nutrition, diversity is usually a better strategy!
So, it’s almost the case that we need to stop thinking about weight loss and think more about adding nutrition in rather than subtracting calories to live our most healthy lives. But old habits die hard - and it’s interesting too - so next week we’ll look at what works to lose weight and what doesn’t.
