The end of dieting

0:03Today's episode of Today Explained is a rerun, but we have updated it with some news. Perhaps you saw President Trump recently announced a deal with two drug companies that's going to result in a drug drug drug. drugs. Perhaps you saw that he then revealed who in his administration is taking them. And we have Steve, we're Steve Seguir, head of public relations for the White House. He's taking it. Classic. Perhaps you saw someone then fainted in the Oval Office during that announcement. Classic. Here's the thing. These drugs appear to be working. Obesity rates in the U.S. are declining, but there are still unknowns.

0:41The relationship between diet, weight, and health seems like it should be clear by this point, but it's really not. Coming up on Today Explained, why the gospel on weight loss is always being rewritten, and how medications have added a brand new chapter.

1:06You're listening to Today Explained. Sumita Mukhopadai is a writer and editor who was very anxious when she was hired as the executive editor of Teen Vogue back in 2018. Like everyone else, Sumita had seen The Devil Wears Prada, and she knew that the fashion industry was unforgiving. But not long after she started there, she realized that things were changing. You know, I entered the fashion industry at a really unique moment where there was an increased interest in plus fashion. And so when I got the job at Teen Vogue, I started having all these fashion brands reaching out to me to be like, wow, we're so excited.

1:44We're launching a plus collection. We'd love to talk to you about it. We'd love to send it to you. How does it feel to be a fat fashion editor? And at the time, I had kind of newly gained the weight. And so I wasn't totally embracing it. I wasn't, I didn't, it didn't feel empowering. It was almost felt like something that was happening to me where I was like, oh, wait, I'm fat. Like, you know, I had to kind of get over that first step before being like, I'm fabulous. I love being fat. Okay, so you're in a period where Teen Vogue has become more accepting. It is okay to be a person in a larger body.

2:18And in fact, there's even some sort of advocacy or activism around the fact that there is more than one body type. And then you get some news that, again, changes how you see and experience all of this. What happened? While I was at Teen Vogue and kind of as I was leaving Teen Vogue, I had had a series of stressful family related things happen. My father passed away of diabetes related complications. My mother was diagnosed with breast cancer. I had this really hectic job and I was managing all of it. And my stress response was eating. and it was not just eating. It was like really not taking care of myself ultimately, right?

3:06It was taking Ubers. It was getting takeout. It was kind of not really having a lot of time for myself. And that did lead to some unwanted weight gain on my part. And I was having some mobility issues. I was having trouble kind of, I just thought it was because I was exhausted because I had never had these experiences, but I was having trouble getting up and down the stairs on the subway. and I would just chalk it up to like, oh, I'm just so busy, you know, like I have to take Ubers because I'm like busy and I'm exhausted. And I was having trouble keeping up on walks and I was having trouble sleeping.

3:39I wasn't feeling well. And, you know, on top of that, my clothes weren't fitting. And so I went to the doctor and, you know, this is after I had left Teen Vogue and like kind of after the pandemic, I decided to start the process of, you know, figuring out if I was okay and also, you know, what I could do because I knew and I understood that diets don't work, right? Like I knew I could restrict what I was eating, but eventually I'd gain the weight back and I really wanted something. I really wanted a strategy that would be more effective. And so I went in and got my blood work done and, you know, pretty much every indicator was elevated.

4:18So I was, had become pre-diabetic, my cholesterol was elevated. And so those scared me, right? Like I had just lost my father to exactly the things that I'm now looking at in my blood report. And so I was like, you know, I think it's finally time for me to really take this seriously and figure out, you know, a strategy to move forward. And she suggested Manjaro.

4:45It is a injectable that you take weekly. It slows your digestion, basically is how it works. and in doing so, it reduces the rate at which you can eat and how hungry you get. And so, you know, I decided to go on it.

5:03What did that mean for you? Like once you start taking it, what happens? Do you mean emotionally or physically? Both. Both. Entirely, I mean both. Thank you for asking. Yeah, yeah, for sure. I mean, emotionally, it was really hard to make the decision to go on it. I saw it as two things. I saw it as a betrayal to the kind of body positivity and feminism that I had ascribed to of loving yourself at any size and not trusting pharmaceutical interventions. And also there was another voice inside me that was like, this is how bad it's gotten, girl. Like you couldn't control this and now you have to take a drug.

5:37That's how not well you are. And so a lot of self-judgment, a lot of shame came out with the decision to go on the medication. Physically, it is a bumpy road. It was for me. For me, I struggled with very intense nausea. So one of the ways that it works is since it slows your digestion, if you overeat, you feel very sick. And then a lot of digestive issues. It is very hard to go to the bathroom when you're on it. You have to take all kinds of laxatives. They now have additional prescriptions they put people on that are taking it to help support with, you know, regular bowel movements. And so it was not the best physical experience.

6:22And then, you know, at a certain point I got used to it, but I think it was more that I just got used to managing the side effects. They never really went away for me. You have made, interestingly enough, being on Munjaro sound absolutely horrible, but I appreciate you being honest about the side effects because I don't hear talk about the side effects very often. What was the good in this? What kept you on it? It does something. And I think it's physiological and a doctor can speak more eloquently to this, but it does trigger something in your brain, a hormone that suggests that you're satiated.

7:00Right. And so it started to help me feel satisfied with less. One of my behaviors is I tend to compulsively eat in the evening, whether it's stress or just fun or boredom or binge watching TV, whatever it might be. I will sit down with like an array of snacks and kind of eat mindlessly, not always keeping track of how much I'm eating, not necessarily food that had good nutritional value. when I was on Manjaro I would finish dinner and I pretty much would not physically be hungry in the evening and I just wouldn't have space to eat anything else and if I got the munchies I started to reach for healthier snacks because I noticed that I digested them easier and so if I just ate an apple or some grapes I ate so many freaking grapes or a handful of carrots or whatever that might be and all the things we tell ourselves this is the healthy choice let's make the healthy choice The healthy choice all of a sudden became easier.

7:57And so that was part of why I stayed on it, that it really gave me this release from this yearning that I always had where it wasn't a challenging decision. I didn't feel a lot of strain around it, whereas historically when I would beat myself up for eating at night, I never felt like I could stop. And with the kind of pharmaceutical intervention, I was able to stop. Okay, so there are pros, there are cons. How is it going? I guess when Manjaro hit the market, they had given a manufacturer's coupon to early people, to people that had first started taking the drug. And, you know, I don't read the fine print, I don't know.

8:39No one does, girl. I thought that was my insurance covering it. I didn't understand that like the reason it costs that much was a coupon and not my insurance. And so the coupon is rescinded and overnight the drug becomes six to$800 a month. I think it was like, I think it was 800. And they were like, we can do this other coupon that will get you to like 600. Like I'm kind of like, these aren't the exact numbers, but all I'm saying is like, it was an insane amount of money that I was like, what? Like I live in New York city. You can't just take on another payment like that. That's crazy. Yeah, exactly.

9:16Exactly. I think the combination of the cost and the side effects, and I had lost a lot of weight. I think I lost 50 pounds about. Oh, wow. And I was feeling great. And I was like, let me just try without it. Let me phase out of it. And so I came off the drug at the end of 2023. And I will say maintained the loss for quite a bit of time. I probably gained like 10 to 15 pounds within like two or three months. And that was definitely not a great mental experience. Like I definitely came back to that feeling of control of like, oh my God, I'm losing control. I'm losing control. And, you know, but I was excited because I had made some lifestyle changes that I was maintaining and that felt like a really positive intervention.

10:05Now, this is like the first interview I'm doing about this in like six months. And so I will say the last six months have been really stressful for me. I launched a book. I got married. Thank you. Nothing like gaining weight for your wedding. But I started, you know, some of the things that I had been committing to like cooking and getting enough, you know, my steps every day and all of that like fell to the wayside a little bit. And so the weight started to creep on and creep on and creep on. And now I've probably gained back like 60 or 70 percent of what I lost, which has been really hard. You know, it's hard and it's also feels like it's forcing me to really face my relationship with my health and my own body.

10:52And to like, it's like I understand the options that are out there, but the options are limited. I wouldn't even say that I would necessarily go back on it because when I think about it, I just get sick to my stomach again. I'm just like, oh, I just don't know if I can go through that again. But, you know, it's been a roller coaster, emotional roller coaster, having the kind of high of like, oh, like the weight came off. And then to like be feel like I'm back to square one, even though I know in my mind and my heart and my spirit, I am not.

11:27Sumita Mukhopadhyay, writer and editor. Coming up, is the age of diet and exercise over?

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15:57You're listening to Today Explained. I'm Dan Bessison. I'm an MD by training. I'm an endocrinologist. I'm here at the University of Colorado in Denver, and I do clinical work taking care of patients at our county hospital, Denver Health, and I do research here at the medical school. I'm also the director of this building called the Anschutz Health and Wellness Center. Dan, you have 47 jobs, man. All right, let's talk about the beginnings of this sort of cultural and medical interest in obesity. When did doctors start thinking of obesity as something that needed to be fixed, something that needed medical attention?

16:41I think there's always been people with really high weights that doctors thought, well, that's probably a health problem. But I don't think it entered the general public consciousness until sort of the late 80s to the mid 90s. The disease is obesity. But obesity is just a symptom of the real problem we as a nation face. Frances, you've been overweight since you can remember? Since a child. About early teens. Americans overeat. We are obsessed with food. And it's an obsession that's killing us. And when Greta was one year old, she weighed 100 pounds. Almost 100. Almost 100. That's a lot. I think people looked around and thought, what's going on here?

17:27There seems to be more and more people at higher weights. And NIH had an expert panel that defined obesity using BMI. BMI is sort of controversial, but that was the point at which we had this accepted standard. And shortly after that, the CDC looked at data they had and said, what's been happening with obesity? And I think they were sort of shocked to find there was just a dramatic increase in the number of people with obesity. And so in 1999, they published these maps, these CDC obesity maps. Maybe some people have seen those. And they really brought a lot of attention to what really looked like an epidemic.

18:09If you had looked at those numbers and it was HIV or cancer, people would be quite worried. And people said, gosh, something is happening here. We should do something about this.

18:22And what was the something that doctors decided they should do? Yeah, I think that the NIH panel had thought about levels of weight and that treatment or what intervention somebody did should be based on how serious the problem was. So people with a modest increase in their weight might change their diet and increase their physical activity. People with a more severe weight problem might take a medication. And those at the highest weight might benefit from surgery. For most Americans, lifestyle is what was suggested. And I think at that point, we were still early in understanding the biologic basis of weight regulation.

19:03And we all eat, we all move, and it seems like we choose those things. And so the obvious first step was to say, maybe people just don't know what to eat. And if they just thought about it some more and ate less and moved more, that this problem might go away. So that was the first thought. And the Surgeon General had a call to action. Obesity, a major problem that has increased dramatically since 1990. Based on these numbers rising of obesity, saying, you know, people ought to move more and eat a healthier diet. When it comes to physical inactivity, obesity, diabetes, the fact of the matter is we're moving in the wrong direction in terms of these areas.

19:44The advice seems obvious. Change what you eat and move more. Do diet and exercise prove to work? I think there's a couple of ways to look at that. One is around this same time, there was a study published, the Diabetes Prevention Program. And what they found was that a modest weight loss, a 5 % weight loss, could reduce the risk of developing type 2 diabetes by half. It was a really dramatic study. And so it was really based on that that people said, gosh, this is achievable and it has clear health benefits of 5 % weight loss. I'm just doing the math in my head. If you weigh 200 pounds, that's take 10 pounds off.

20:33Yeah. 300 pounds, take 15 pounds off. That feels like nothing. It seems like a small change in weight and yet it had dramatic benefits. I got to tell you, I mean, I see people in clinic, and so I've spent, whatever, 20 years trying to sell the benefits of a 5 % weight loss. Most people don't buy it. Most people want more weight loss than that. It's not a weight loss that most people see in the mirror or that their friends are going to notice, but it has clear health benefits and has become a benchmark of what a clinically significant weight loss is. A little bit of weight loss helps. So what happened after the study was over with these folks who lost 5 % of their weight and then saw their health improve?

21:13Did they keep the weight off? Most lifestyle studies show that most people regain much of the weight. It's not like everybody regains all of the weight, but much of the weight is regained. What has happened over the last 25 years is a real explosion in our understanding of the biology that underlies weight regulation. I think now we think of weight much like we think about blood pressure or glucose, that there's complex biology that the body's got its own idea about what it wants to weigh. And what it seems like the body wants to do, it doesn't regulate around a set point. It regulates around a trajectory of gradual weight gain across the life.

21:55So the biology of weight really pushes back against efforts to change our diet. And so that's why people regain the weight is when they lose weight, the body goes, this is not good. And the people become more hungry. Their energy expenditure goes down. And these things tend to push the weight back up to where it was before. Were there, you mentioned two other ways that doctors saw of treating obesity, medications and surgeries. How common was it for a doctor to say, you, sir or madam, you're going to need medication, you're going to need surgery? I don't remember so much of that like 20 years ago.

22:32Only maybe one or two percent of people ever had that conversation, ever got that medication. And there are a number of reasons for that. One is the older medicines had some side effects. There were some bad stories about health problems with Fen-Fen and other medicines. Oh, Fen-Fen. If you took the diet drug combination known as Fen-Fen or the diet drugs Pondamin or Redux, you may have heart valve problems and not know it. Before Chicago area women are taking the makers of Fen-Fen to court. It's been one week since the prescription diet drug was pulled off the market. And I think, too, doctors and patients, doctors especially have this idea that, well, Mrs.

23:11Jones, you ought to be able to handle this on your own. This idea that weight is regulated, it's taken a long time to get any traction there. Doctors would say things like, you know, if you show me you can stick to a diet, well, then I'll maybe talk to you about a medicine. We don't do that with diabetes or high blood pressure. We're very quick to go to a medication in those conditions. So I think there's a lot of maybe bias and stigma directed at people living with obesity that we tend to blame them for their health problem. So medicines that weren't super effective and an environment that really thought that people could do this on their own.

23:46How long have you been in this line of work, Dr. Dan? I'm an old person with kind of gray hair. I prescribe Fen-Phen, so I've been doing this for, gosh, whatever, almost 30 years. You've been doing this for 30 years. Sometime in the last 24 months, I became aware of Ozempic. A lot of people became aware of Ozempic. I'm just wondering what the conversation was like in the medical community among doctors who do your type of work about the fact that there are these GLP-1 drugs that seem to work magically, work for a lot of people, and are now widely available. Yeah, I would use the term game changer.

24:27There's never been anything like this.