Weight and Healthcare

I received the following email that I’m sharing with permission:

I’m [name], I’m a family doctor and I recently attended your excellent pediatric grand rounds presentation at [organization.] I’ve been a fan of your work for a while and you did not disappoint! During the Q&A you talked about bodily autonomy in a coercive system. I would love to see you write about that on weightandhealthcare.

Thanks, and I am happy to!

Get full access to Weight and Healthcare at https://weightandhealthcare.substack.com/subscribe

A lot of the questions I’m getting during Q&As right now (from healthcare providers AND from patients) are about possible uses for GLP-1s - from blood pressure to alcohol and substance use disorders to Binge Eating Disorder to lymphedema and lipedema and more- “Do GLP-1s really help with…” is becoming a very common question, and I think that’s by design.

There are reasons for this - many of those reasons I would argue are being purposefully created by the drugs’ manufacturers, so today I’ll break down some of what’s happening and then tell you what questions we would need answers to in order to know if GLP-1s really help with…

Get full access to Weight and Healthcare at https://weightandhealthcare.substack.com/subscribe

In Part 1 we started looking at a commentary piece in Medscape by Dr. Yoni Freedhoff called “The Bell Tolls for the Diet Era.”

In part 1 we looked at his big feelings about medical professionals who dare question the use of GLP-1s for weight loss. Today we’ll look at his big feelings around weight-inclusive work and fat acceptance.

Get full access to Weight and Healthcare at https://weightandhealthcare.substack.com/subscribe

If the name Yoni Freedhoff sounds familiar, it may be from the Natasha Wiebe’s guest postabout her experience going to an “ob*sity” summit. She recounted:“Yoni Freedhoff is a physician from Ottawa and I had seen him featured in at least one documentary on ob*sity and on other media platforms. I had low expectations, and he exceeded those. At the beginning of his talk, he shared the question that he had asked of a number of Large Language Models (like ChatGPT and Claude): how much weight a person could lose today given these latest WL drugs and bariatric surgery? They all gave some answer around 95% of excess weight. He then proceeded to talk about this as if this were science.”

It seems that Dr. Freedhoff has a lot of opinions he would like to share because he wrote a commentary piece for Medscape called “The Bell Tolls for the Diet Era.” Of course, no power on this earth will convince me to give it traffic so I’m not including a link. I’ve given you enough information to google it if you want and I’ll break it down here with commentary.

Get full access to Weight and Healthcare at https://weightandhealthcare.substack.com/subscribe

In part 1 I started writing about the basics of hernias in higher-weight people, including the fact that these surgeries are common targets for BMI-based denials of care, where a higher-weight patient’s healthcare is held hostage for a weight loss random. In part 2 we dicussed the issues with the weight loss recommendations that are so commonly given to higher-weight patients when their care is held hostage for a weight loss ransom. In part 3 I’ll give some ideas about how to advocate if you are in this situation as well as some research to help back you up.

Get full access to Weight and Healthcare at https://weightandhealthcare.substack.com/subscribe

This is the Weight and Healthcare newsletter! If you like what you are reading, please consider subscribing and/or sharing!

In Part 1 we discussed the basics of hernia repair for higher-weight people. In part 3 we’ll discuss the options for fighting BMI-based denials for hernia care. While I take the stance that people of all sizes deserve equitable care, in Part 2, I want to talk about the issues with these weight loss recommendations (this is a piece I’ve been meaning to write for a while so I’m incuding it in this series, but know that this isn’t just about hernia repair but about anytime weight loss is recommended or required for a patient to be “optimized” for surgery.) Today we’re going to look at it from the perspective of someone who agrees with these recommendations (which I d not) and/or of somene who is so desperate for care that they are willing to try to pay the weight loss ransom (which is a valid choice, but one that patients should never be coerced into making by a healthcare system that holds their care hostage.) Even in these circumstances, there are multiple issues with these weight loss recommendations including feasibility, side effects, and long-term prognosis.

Feasibility and Side Effects

The first question to ask is the feasibility of the requirement. “Optimization” for surgery doesn’t happen in a vacuum and it doesn’t matter if something would make the patient’s surgery easier or improve their outcomes if it is not possible and/or if it harms the patient more than it helps them. Despite this, the feasibility/likelihood of the patient experiencing the required weight loss is, in my experience, far too often not discussed or even considered.

I have met with patients who were told they needed to lose 40% of their body weight whose surgeon told them to eat less and exercise more. This is an “intervention” for which about a century of research has found the likelihood of losing even 5% of body weight is quite low and the likelihood of maintaining it is incredibly small (though we’ll get to that.) The doctor might as well have told the patient to grow 6 inches to change their BMI sufficiently.

Enter GLP-1s. Here again we’re seeing patients being prescribed these drugs not based on the drugs’ actual capacity to create (at least short term) the required weight loss but based on the sincerely held personal belief of the provider that any amount of weight can be lost with these drugs.

In the recent research article that Angela Meadows, Louise Adams, and I published on GLP-1s for weight loss, we included tables in the supplemental materials that include information for all of the phase 3, placebo-controlled trials of GLP1-s for weight loss. One of the reasons I am glad these tables are out in the world is so they can be used in these discussions.

As the tables show, about half of people don’t ever reach average weight loss in these trials with around 5-15% failing to lose even 5%. For semaglutide, the STEP 1 trial only looked at weight loss up to 15%, and 49.5% of the subjects failed to lose even 15% of body weight over 68 weeks and in the STEP 3 trial, even when combined with a restrictive diet, 64.3% of subjects failed to lose even 20% of their body weight over 68 weeks. For tirzepatid, the SURMOUNT 1 trial included weight loss up to 25% and 63.8% of the people on the maximum dose (15mg) failed to lose even 25% of their body weight over 72 weeks. In the 2-year weight loss analysis of the SELECT trial ( Ryan et al., 2024) 95.1% of patients failed to lose 20% of their body weight, average weight loss was down to 10%, and at four years the study had lost 89.5% of participants! Other studies showed significant loss of muscle mass as part of the weight loss.

You can find the tables here in the supplemental materials. If you are being told to use GLP-1s to qualify for healthcare I also have a case study here that offers more information and some specific scripting that you can use.

Then there is the recommendation for weight loss surgery. This is a surgery in which a healthy, correctly functioning digestive system is surgically manipulated into what would otherwise be considered a disease state in order to force restriction and produce weight loss. It is a very serious surgery with the potential for very serious side effects that can have significant negative impact on long-term quality of life and even be fatal. I wrote about the basics of these surgeries here. I also have a series about weight loss surgery and long-term quality of life in which researchers admit sparse and low-quality evidence, and that in multiple studies health-related quality of life was the same between those who had surgery and those who didn’t.

At the bare minimum, giving the patient correct information about the likelihood of these surguries of actually leading to the weight loss that is being demanded in order for the patient to get the surgery they actually need is incredibly important when the patient is being refused a surgery that they need but recommended to undergo a surgery that alters an entire body system in a way that is, by and large, irreversible with potentially life-altering and even fatal side effects. A 2022 study called “Predictors for weight loss after Roux-en-Y gastric bypass: the trend and associated factors for weight loss” by Eghbali explains that while most people expect to lose more than 70% of the “excess weight” in reality the mean total weight loss is about 32% at 1-2 years. So, even if the patient is willing to have this surgery (and risk the significant side effects) and even if they could reach the mean total weight loss, that would still not necessarily be enough weight loss for the patient to qualify for the surgery they actually need/want.

Medical interventions must be evidence-based and wishin’ and hopin’ and thinkin’ and prayin’ that all higher-weight patients will be outliers and experience more weight loss than the research suggests is likely (even in the short term) so that they can be seen as worthy of surgery is not ethical, evidence-based medicine.

Long-Term Outcomes

We know that the vast majority of weight loss attempts end in weight regain and that regain with GLP-1s has been shown to be even faster than with lifestyle interventions. Guidelines around weight loss for hernia repair typically brush this off with simple admonitions that amount to “don’t do that.” Given that intentional weight loss changes the body physiologically to induce weight regain, using the equivalent of “doctor, it hurts when I do this….well don’t do that” here again falls seriously short of ethical, evidence-based medicine.

Even if someone believes that people could lose any amount of weight and maintain that weight loss, medicine must be practiced in the context of reality. That means understanding the risks of delaying the surgery while the patient attempts weight loss that research shows is unlikely to unlikely to ever happen, and considering the risks of weight regain on the surgical repair, which research shows is highly likely to happen. This is especially important given the existence of research for other procedures that finds that weight loss prior to surgery, including through weight loss surgery, does not improve outcomes.

The sad reality, which is all too common, is that there isn’t enough research about hernia repair when it comes to higher-weight people. And as long as the healthcare system is comfortable allowing higher-weight patients to suffer and die unless or until they can comply with a directive to lose weight, those with power, privilege, and leverage to make change will need to do whatever can be done to fund and conduct the research that is needed so that people of all sizes can have equitable care.

In part 3 we’ll discuss the options for patients who are dealing with BMI-Based Denials for hernia care.

This month’s online workshop is Weight-Inclusive Sleep Apnea Management with special guest Dr. Lisa Erlanger! There is a pay-what-you-can…

Get full access to Weight and Healthcare at https://weightandhealthcare.substack.com/subscribe

One of the more complex situations that I often get asked to write about, or asked to help advocate for, is hernia repair in higher-weight people. This situation can be quite complicated and a lot depends on the person, their specific condition, and their situation. The goal of this three-part series is to offer a starting point for discussion and advocacy. In part 1 we’ll look at some of the basics around hernias, hernia repair in general, and hernia repair (or lack thereof) in higher-weight patients. In part 2 we’ll look at the issues with the common weight loss recommendations higher-weight patients often receive, and in part 3 we’ll look at specific concepts to advocate for care and research to provide some support.

Get full access to Weight and Healthcare at https://weightandhealthcare.substack.com/subscribe

I write about many different examples of weight stigma in healthcare including BMI-based denials of care in which healthcare is held hostage for a weight loss ransom. Sometimes these BMI-based denials don’t mean that a procedure is denied everywhere, but that it is denied in a certain facility. One common example of this is when a procedure is requierd to be done in a hospital rather than an ambulatory surgery center. This can be make the procedure much more difficult to schedule and exponentially more expensive.

Get full access to Weight and Healthcare at https://weightandhealthcare.substack.com/subscribe

I’ve written extensively about the weight loss industry’s attempt to co-opt the concept of weight bias and stigma Lately I’ve been noticing (and in some cases involved in,) a concerning trend which I would describe as people (knowingly and even unknowingly) weaponizing the concept of weight bias to shut down weight-inclusive work to benefit the weight-centric paradigm. (I’ve written about the two paradigms here.) .

Here are three recent examples that happened to me:

Get full access to Weight and Healthcare at https://weightandhealthcare.substack.com/subscribe

In part one we went through some of the basics around the research that considers higher-weight and cancer risk, progression, and outcomes. In part 2, we’ll consider some of the research more deeply. These won’t be full deep-dive analyses (if you want that, let me know in the comments,) instead we’ll dig into the questions we discussed in part 1.

Get full access to Weight and Healthcare at https://weightandhealthcare.substack.com/subscribe

I have had a number of requests to discuss the research around cancer and higher-weight. This is an incredibly complex and nuanced subject. I’m going to start with a two-part series. Part 1 will be an overview of basic concepts and possible issues with the current research. Part 2 will dig into some of the actual research. If you have other topics that you would like me to write about or specific research you would like me to analyze, please feel free to add it in the comments.

Get full access to Weight and Healthcare at https://weightandhealthcare.substack.com/subscribe

Reader Barbara recently brought the study “Association of Weight Cycling with MRI-Based Thigh Muscle Quality and Knee-Adjacent Ob*sity” to my attention.

The study sought to determine if repeated weight gain and loss (also known as weight cycling or yo-yo dieting) was associated with sarcopenia which they explain is defined as a loss of muscle strength and muscle mass and a decline in physical performance.

Get full access to Weight and Healthcare at https://weightandhealthcare.substack.com/subscribe

I received a request from reader Chris who said:

I know that you write about the problems with research all the time, but I would really like a post that names the main problems with the research that would be easy to send someone so that they could understand.

I’m happy to help. For this post I’ve chosen the top three mistakes I see. Of course, there are plenty more, I’ve chosen these three (and called them deadly sins) because when they happen, it means that the research is fatally flawed.

Get full access to Weight and Healthcare at https://weightandhealthcare.substack.com/subscribe

I have written before about options for patients who are facing a BMI-based denial of care which occurs when their healthcare is being held hostage for a weight loss ransom. In that series I talk about three options to try to get surgery. A couple months ago I gave a talk on weight-neutral joint pain management with Dr. Julia Bruene and Dr. Jeremy Alland, both Sports Medicine Physicians at Midwest Orthopaedics at RUSH in Chicago. During the talk Dr. Bruene mentioned two pain reduction procedures that might be options for harm/pain reduction for patients with knee osteoarthritis whose care is being delayed/denied by a BMI-based care denial.

Get full access to Weight and Healthcare at https://weightandhealthcare.substack.com/subscribe

I have received a ton of requests to write about the paper “Are people with metabolically healthy ob*sity really healthy? A prospective cohort study of 381,363 UK Biobank participants”

Get full access to Weight and Healthcare at https://weightandhealthcare.substack.com/subscribe

Recently a number of people directed me to a video online that discussed weight stigma and asked me to respond. I’m not naming names because this person is far from the only one to make this mistake, they apologized, and they didn’t choose the clip that was selected.

Get full access to Weight and Healthcare at https://weightandhealthcare.substack.com/subscribe

This is the Weight and Healthcare newsletter! If you like what you are reading, please consider subscribing and/or sharing!

In part 1 we looked at the basics of the Look AHEAD Trial of weight loss to improve cardiovascular outcomes. The trial was cancelled 9.6 years into its intended 13.5 year follow up for “futility” when analysis found no statistically significant difference in cardiovascular outcomes between a group that engaged in “intensive” caloric restriction, exercise, and, in some cases, diet drugs, and a group that got three counseling sessions a year about diabetes management.

One of the claims that I often see people make is that the group that maintained at least a 10% loss had better outcomes. We saw this recently in the write-up of the Foundayo trial, in which they claimed, without context that “patients who had a weight loss of 10% or more through a lifestyle intervention had a 21% reduction in cardiovascular events.” I mentioned in that piece that this was an analysis of a small subgroup. There are some real caveats around this and other claims about the 10% weight loss group so let’s dig into it.

For this we’ll look at “Four-year weight losses in the Look AHEAD study: factors associated with long-term success” by Wadden et al.

As always I’ll indent the quotes so you can skip the weight stigma. In their writing ILI is the abbreviation for the weight loss group and DSE is the abbreviation for the control group.

In general they discuss the weight loss:

“At year 4, 35% of ILI and 18% of DSE participants achieved the study-wide goal of losing ≥7% of initial weight (P < 0.0001), and 23% and 10%, respectively, lost ≥10% (P < 0.0001).”

Said another way, the study goal was to produce weight loss of just 7% or more of body weight and 65% of the people who were subjected to these “intensive” interventions including diet drugs didn’t hit even that modest goal. Also, 23% of the ILI group lost 10% or more of body weight, but 10% of people in the control group that didn’t do any of these interventions did so as well.

This again raises questions about the necessity of such extreme restriction even for people who believe that weight loss creates health benefits (which, again, this study does not show, since there is no way to determine if any health differences are from weight loss or behaviors, and research that actually sought to answer that question found no relationship between small amounts of weight loss and health changes in correlational analysis, and posited that it was more likely that behaviors, social support, and engagement in the healthcare system were likely to be driving the health outcomes.)

The authors of the Look AHEAD paper also point out that:

“significantly more DSE than ILI participants (45% vs. 26%) had gained above their baseline weight at year 4 (all P values < 0.001)”

What they aren’t being clear about is that the DSE (control) group had modest weight gain from baseline while not participating in a weight loss intervention. Meanwhile, just four years in, more than a quarter the ILI (intervention) group weighed more than when they started. Now, there is nothing wrong with being higher-weight or gaining weight, but I would say that there is something seriously wrong with a so-called healthcare intervention that subjects people to “intensive” food restriction, physical activity, and diet drugs and then has the opposite of the intended effect for at least 26% of the participants. This particularly does not age well given that we now know that the intervention would be cancelled for futility for failing to impact the intended health outcomes.

When it comes to the group who lost 10% the Look AHEAD authors write that:

“[Figure] 3 shows 887 ILI participants who lost ≥10% of initial weight in the first year and shows the number of these participants who achieved a loss of this size at year 4 (N = 374) or, alternatively, maintained losses of 5.0–9.9% (N = 251), 0–4.9% (N = 174), or gained above their baseline weight (N = 88). As shown, fully 42% of this subsample achieved a loss ≥10% at year 4, and a total of 70.5% maintained a loss ≥5%.

It should be made clear that “fully 42% of this subsample” refers to 42% of 35% of the original sample. So out of the 2570 original people in the intervention arm, 887 participants (about 35%) lost ≥ 10% at year 1. But at year four, only 374 (about 14.5% of the original group) were still at 10%.

Percentage wise, that means fewer than half of the people who had lost 10% or more of their body weight in the first year were still at or over 10% by year four and that, overall, only about 15% of the total group managed 10% weight loss for even 4 years. But there is more to this story, let’s look at their Figure 3A that shows the weight trajectory of this group:

Image text: Figure 3 A. Weight loss trajectories over 4 years in the 887 participants in the Intensive Lifestyle Intervention (ILI) who, at year 1, lost ≥ 10% of initial weight. The figure shows the number of participants who, at year 4, maintained a loss of 10% or more of initial weight (N = 374), of 5.0–9.9% (N = 251), or of 0–4.9% (N = 174) or who gained above their baseline weight (N = 88).

You’ll note that everyone has regained from their low point, 9.9% (88 people) had already regained more weight than they lost and the majority are still on a trajectory to continue to gain weight after this follow up.

If we go back to their quote, they claim that this figure shows percentages of people who “maintained losses of 5.0–9.9% (N = 251), 0–4.9% (N = 174).” I do not think that the word “maintained” reflects the reality that these people’s weight trajectory is going straight up. Catching a group of people at 5% weight loss on their way up is not the same thing as “maintaining” a 5% weight loss.

Content note: This next section talks about calories, exercise, disordered eating/eating disorders, if that may be harmful to you you can scroll down to “Discussion.”

The researchers note that

“Participants who maintained the [10%] loss, compared with those who did not, attended more treatment sessions and reported more favorable physical activity and food intake at year 4.”

Again, this begs the question as to whether behavior or weight loss actually created any health difference. It also begs another, much more troubling question. Below is their Figure 4 which shows the characteristics of the subset of subjects who took self-reported surveys about their food and exercise behaviors. Note that those who maintained a 10% loss in general were consuming about 1565.5 calories a day (fewer than the 1,570 calories subjects in the Minnesota STARVATION study were given during the starvation stage) and burning about 2,000 calories weekly through exercise. Applying the Paffenburger Activity Questionnaire that these authors are using to the Minnesota STARVATION study participants, those participants were expending about 2200 calories per week. One thing the authors don’t mention in this sub analysis, or the original analysis, is the possibility that they created disordered eating/eating disorders in part of their population and then celebrated it as “long-term success.”

Discussion

The first sentence of their discussion section states:

“Participants in the Intensive Lifestyle Intervention achieved a 4.7% reduction in initial weight at year 4. This loss is among the largest reported at this length of follow-up for individuals in a randomized controlled trial who were treated by a lifestyle intervention”

I do not think that this is the flex they think it is. Giving people less food and similar activity to a study on starvation over four years produces 4.7% weight loss - an amount of weight that some people fluctuate monthly through their menstrual cycle? The phrase “who cares?” comes to mind.

To further demonstrate the issues with this study, in the discussion section these authors compare their “maintainers” to the National Weight Control Registry which I have discussed before as perhaps the …

Get full access to Weight and Healthcare at https://weightandhealthcare.substack.com/subscribe

People make a lot of claims that the Look AHEAD trial offers some sort of support for the efficacy of weight loss diets. So in this two-part series we’re going to look back at the Look AHEAD trial - what is was, what it found, and what it didn’t.

Get full access to Weight and Healthcare at https://weightandhealthcare.substack.com/subscribe

I’ve received a ton of reader questions about Eli Lilly’s GLP-1 weight loss pill Foundayo, which was recently granted FDA approval. In Part 1 we’ll talk about the study itself, in Part 2 we’ll break down the discussion, limitations and talk about the special treatment the government gave this drug.

Get full access to Weight and Healthcare at https://weightandhealthcare.substack.com/subscribe

I recently heard from Samantha C who was suffering from what she described as “absolutely crippling plantar fasciitis.” She shared her story of battling medical weight stigma to get care.

Get full access to Weight and Healthcare at https://weightandhealthcare.substack.com/subscribe