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)

3

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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4

I’m confident this is posted elsewhere or in a podcast somewhere, but when you say “weight loss”, what threshold is generally considered that for consideration of GLP-1s? The recs seem to go by BMI of 30+, or 27+ with a weight-related comorbidity, but for someone who trains, is there a BMI+WC equivalent, or does the “comorbidity” addition capture the majority of people who should be considering it but are under the “obesity” threshold?

5

This is a good question. I could take the easy way out and use the catch-all: when the benefits outweigh the risks. While true, that’s not terribly useful for explaining my thinking surrounding this.

Many people who train will still be carrying fat in the wrong places (e.g. liver, muscle, around the heart, kidney, pancreas) at a level that causes harm/increases the risk of harm. Those people are likely to benefit from weight loss, and as a result, GLP1s. Unfortunately, we don’t have a way to identify these people easily, as BMI, WC, DXA, a1c, and so on all catch this group of people long after excess fat has been a problem. One of the earliest tells would be a marker of insulin resistance, such as the TyG index, which can be calculated from labs you probably already have.

I talk about my beef with the definition of obesity more here:

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6

Thank you! Will have a listen.

Edit: Forgive me, just trying to understand the “garage” idea here in relation to the other metrics:

Let’s say we have person A, a 40 year old 6’ male whose Fib4 and TyG comes in under range and they also have low LDL/apoB, and BP around 110/70, but has historically looked mildly overweight and has a waist of 35-36" with a calculated Navy BF of around 20%.

Person B is the same (40 y/o male, 6’), but has a smaller waist (say, 32"?), has a calculated BF of around 13%, but has elevated TyG (“moderate”) and LDL in the 60th+ percentile range.

I think the obvious thing for the first individual is to still try and get their waist circumference down, but I imagine the second person would be a greater cause for concern from a metabolic standpoint? Obviously theoretical here, just trying to ensure I understand how this risk works. It seems like person 2’s “garage” would be more full.

7

Yes, person B is the person who would benefit the most health-wise from losing body fat. I don’t know that person A would benefit from reducing their waist, save for a possible psychological benefit.

8

Thanks, and that’s interesting; I’ve been partway to this position in my understanding but didn’t realize the extent that “TOFI” is found in the gen. pop.

Please let me know if these are covered elsewhere as I don’t want to take up much more of your time:
-In the above example, would person A be at longer-term risk of developing metabolically-unhealthy obesity? There’s this study that seemed to address this, (https://www.jacc.org/doi/10.1016/j.jacc.2018.02.055) but the people in the transition group from metabolically healthy to metabolically unhealthy obesity had substantially higher trigs, so perhaps that illustrates that TyG captures these people sufficiently to account for this risk.

-I know the long-term adherence for fatloss-maintained is fairly abysmal for lifestyle-only interventions in obesity, but shifting from the general population to the “regularly lifting and caring about blood markers/weighing food/etc” group found in populations like those here or in other fitness communities: do we have any idea if the adherence is as poor? If someone wanted to/needed to lose 5% of their bodyweight at “overweight” BMI levels, for instance (not specifically thinking men or women in this case), would they likely be as indicated for medication if we are talking purely from the standpoint of adherence?

Thanks again for the info, glad to start understanding this better.

9

I believe most of this is covered in the podcast I linked earlier, but briefly, excess adiposity drives harm in a dose dependent manner. The more it’s elevated and the longer, the worse off people generally are. The problem is that we cannot identify the condition before it starts causing harm from a cardiometabolic standpoint, where TyG, elevated blood pressure, dyslipidemia, etc. all come after the fact.

Long term maintenance of weight loss does not appear to be very good, though some individuals will do well. I think we should use whatever interventions are necessary to improve someone’s health in accordance with their preferences.

10

Thanks for the clarification. I appreciate BBM’s hard work on this subject, prior to your podcasts I had always known weight loss was practically difficult from client experience, but I had no idea the overall picture was so dismal.

Long term maintenance of weight loss does not appear to be very good, though some individuals will do well. I think we should use whatever interventions are necessary to improve someone’s health in accordance with their preferences.

Completely agree, and hopefully GLP1s and similar will become more affordable as more generic forms are trialed in the future, as cost is a significant hurdle for many.

11

Agree 100%. One interesting (to me) place that I think pharmaceutical development is headed, is prevention. Whether it be in individuals with overweight, which I suspect almost certainly have some degree of “adipositis” (a made-up word for dysfunctional subcutaneous fat, which we think drives the cardiometabolic harm of obesity), or even before then in those at risk. I suspect we’ll see some stuff there soon!

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12

That’s definitely interesting, and is a potentially longer term paradigm shift, depending on the extent of its efficacy and acceptance. Prevention apart from lifestyle hypervigilance would be a pretty amazing option for those vulnerable.

But it also naturally brings up the question of how we conceive of “freedom”, and how we got to this point in the first place. Is it really “freedom” to have a plethora of foodstuffs products able to hijack our biology so effectively that we see large disparities in average fat mass between cultures, such that those disparities shrink when more foodstuffs are introduced? No simple solutions of course, but it’s a strange place we’re in.