Weight loss medication

Nutrition Q&A [Moderated]
1

Hey there, I’ve listened to almost all of the Barbell Medicine podcasts so far, some of them multiple times, and I think my podcast listening time was close to 4,000 mins according to my Spotify Wrapped last year :joy:.

But putting all of that aside, I had a question.

Let’s say we have this understanding that, for a lot of people, sustaining clinically significant weight loss can be extremely difficult because of the biological and environmental factors involved.

Now, suppose during the initial conversation with a client, you realize that they’ve already tried losing weight three or four times in the past. They’ve used different methods of creating a calorie deficit, tried different approaches, worked with different coaches, and presumably have already been exposed to things like tracking, meal prep, managing their home environment, improving their understanding of nutrition, goal-directed eating, etc. Maybe not perfectly, but they’ve tried some variation of most of these strategies before.

As a coach, once you know all of that, would it be appropriate to tell them something along the lines of:

“From a nutritional and lifestyle-intervention standpoint, what I’m going to help you with is probably not going to be radically different from what you’ve already tried. There may be some subtle differences in how we approach it, and we may be able to execute it better this time, but I can’t honestly tell you that this attempt is going to be the one that allows you to maintain the weight loss long term. Given your history, you may also be someone who would benefit from discussing anti-obesity medication with an obesity-medicine physician.”

And then explain that medication isn’t an “easy way out,” but rather another evidence-based tool that addresses some of the biological complexity of obesity, particularly if repeated lifestyle-only attempts haven’t produced sustainable results.

Or would you instead say, “Let’s give lifestyle intervention another go. Maybe this time the circumstances are different, maybe the client is more prepared, maybe the coaching is better, and perhaps this is the attempt where they successfully lose and maintain the weight.”

I’m wondering where you think the appropriate threshold is here.

Because my concern with repeatedly putting someone through the same lifestyle-only weight-loss cycle is that they may lose weight, regain it, and then eventually start internalizing that as a personal failure. After three or four unsuccessful attempts, they may become increasingly hopeless and conclude that they simply can’t lose weight or maintain it.

So would it actually be more appropriate, in a case like this, for a coach to acknowledge the limitations of what lifestyle intervention alone can realistically accomplish for this particular individual, refer them to an obesity-medicine physician who understands the disease and can discuss pharmacotherapy, and then continue supporting the lifestyle side of things alongside that?

Essentially, I’m trying to understand whether, as coaches, we should sometimes be proactive about saying, “You’ve already tried this several times. Rather than signing yourself up for another potentially unsuccessful cycle, let’s consider whether adding medication or another medical intervention makes sense.”

Or is there still a strong argument for giving lifestyle intervention another attempt before going down that route, because sometimes it genuinely does take multiple attempts before someone finds an approach they can sustain?

2

D,

Good question here. My opinion is that people don’t need to fail lifestyle first to use medication. For most people who’d benefit from fat loss, I’d favor starting a GLP-1 early rather than grinding through lifestyle-only. Why? Well, weight loss is more successful with it, there appear to be some weight-independent benefits, and the risk profile is pretty good. So the real question isn’t “how many attempts before we consider it,” it’s “can this person access it safely.” If yes, why make them fail first? I’m not suggesting you are advocating for a failure-first approach, but this is something I see often.

Your point about internalized failure is another important part. Generally speaking, self-efficacy correlates with outcomes, adherence, exercise, weight loss, and one of the fastest ways to destroy it is repeated demonstrations of failure. People with obesity try to lose weight ~8 times in their life on average, and most attempts don’t stick.

Which leads me to my final thought here: who should be advocating for people to talk to their doctor about GLP-1s (or the medical system in general)? I think it’s reasonable for people outside the medical field to do this in an ethical way. In your scenario, if you have the rapport, using your best judgement is probably fine to bring it up and nudge people to talk to their doctor. I suspect it also benefits you to then be more clear about where you fit in, health dietary habits established, resistance training for muscle mass and function, and so on.

Further reading (though at 4,000 minutes you’ve probably heard most of this)

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I completely agree with your first point. And actually, especially with your podcast around obesity and whether it is really a matter of will power, I think I’ve listened to that episode maybe ten times now. It has genuinely changed the way I think about this.

I’m pretty convinced that, for someone who is struggling with obesity and is making another attempt at weight loss, the next attempt should probably involve medication rather than relying on another lifestyle intervention alone. We have pretty strong data showing the efficacy of these medications for weight loss, and when you compare the magnitude of weight loss with lifestyle intervention alone, it’s not even remotely comparable. The medication clearly wins in terms of efficacy.

I think the bigger challenge is communicating this to people, especially where I live in India. A lot of people are quite conservative about this. They’ve internalized so many narratives around body fatness from the internet, friends, family, and society in general. And even when you actually sit down and have this conversation with them, a lot of people still struggle to grasp it. They’ll say, “Okay, maybe medication works, but I should first try lifestyle intervention and then consider medication.”

I think that’s going to take some time to change.

Because if someone has a much higher likelihood of losing a meaningful amount of weight and keeping it off while using medication, and at the same time they’re learning habits, becoming more capable of adhering to lifestyle interventions, and developing self-efficacy, then it seems far more sensible than making someone go through multiple cycles of failure before they’re allowed to consider medication.

And I think that’s an important distinction. The medication doesn’t necessarily have to be viewed as something that replaces lifestyle intervention. It can actually make it easier for someone to engage with and sustain those behaviours in the first place.

I’ve tried conveying this to people, but even within coaching companies in India, my impression is that there’s still a very strong bias toward lifestyle intervention first . They’re not particularly open to the idea of medication being used earlier. It’s generally positioned as the last option or the last resort.

And I can understand why, to some extent. If you have a client who needs a lot of education around the complexity of obesity as a disease, and you have to explain all of this, it’s a much more complicated conversation. From a business standpoint, it can also be easier to just choose the path of least resistance: give the client a lifestyle intervention, explain how your method is different, and proceed from there.

Unfortunately, I think that’s where we are right now.

And I also think a lot of people who embark on weight-loss journeys are doing so because of preconceived notions about what they’re supposed to feel like at a certain weight or body-fat percentage. A lot of that comes from stigma and deeply internalized beliefs about what it means to live in a larger body.

People are made to believe that if they’re heavier, they’re supposed to feel less confident, lazy, incompetent, unhealthy, or somehow less worthy. And even when you actually examine those beliefs, they don’t really make much sense. But once something becomes deeply internalized, it’s incredibly difficult to challenge.

Changing someone’s mind is difficult in general. I’m pretty sure you’re going to suggest David McRaney’s How Minds Change at some point, but even before getting to the question of how you change someone’s mind, sometimes it’s difficult just to get them to engage with the conversation in the first place.

And honestly, I think it might take another couple of decades before the broader understanding catches up with where the evidence is already taking us: that when it comes to obesity, hunger, eating behaviour, and the regulation of body weight, there’s far less conscious control involved than we like to believe.

I remember Robert Sapolsky making a similar point when he talked about how schizophrenia was historically interpreted through things like demonic possession, and how today we look back and think, “How could people have believed that?”

I think there’s a possibility that something similar will happen with obesity. If we zoom out another few decades, we might look back at some of the things we currently say about people with obesity and wonder how we ever thought those explanations were adequate.

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