Thoughts on the New Weight Loss Drugs

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I’ve been meaning to write a blog about the new weight loss drugs for months now, but every time I start, I find myself having trouble with what I want to say, especially since so many of the anti-diet and fat-positive activists I admire have already written such important and insightful pieces on these drugs. For anyone looking for some in-depth research study analysis, I want to point you towards Ragen Chastain, a speaker, writer, and amazing fat activist, in addition to being a certified “statistics nerd” (her words, not mine!). Her Weight and Healthcare Substack is an invaluable resource that takes a hard look at “weight science, weight stigma and what evidence, ethics, and lived experience teach us about best healthcare practices and public health for higher weight people.” Ragen is adept at sifting through the research studies that the drug companies publish to sell the efficacy of these drugs and finding the myriad issues, conflicts of interest, and straight-up bad statistics that these studies exhibit. So please read what she has written on the topic of GLP-1 agonists.

In this piece, I am not going to get into the science behind how GLP-1 agonists such as Ozempic and Wegovy actually work. Instead, I want to talk about how these drugs (and the weight loss drugs that came before them) have become such a lightning rod in the discussion of weight. I was a teenager in the 90s, and I clearly remember when the drug Fenfluramine/Phentermine (Fen-Phen) entered the weight loss scene. There was such a fervor about it on the nightly news, and the marketing by the drug companies was intense. It was touted as a “miracle drug” that could “cure” o*esity, and everyone was going to their doctor to get a prescription. I also remember the news stories that came out. Famously, there was one in the Boston Herald about how Fen-Phen was linked to mitral valve dysfunction, pulmonary hypertension, and other cardiac abnormalities. Subsequently, it was removed from the market due to these risks. It took years before people were convinced that the harms that these medications caused outweighed the “benefits” of weight loss for higher weight people.

There has been a seemingly significant theoretical shift in the medical community over the past few years regarding higher weight (the “o” words”) and weight loss. Unlike previous decades, when people were told that their high weight was their “fault” and was caused by their “unhealthy lifestyle behaviors,” many medical professionals are now putting forth the message that one’s weight is largely out of one’s control (true) and is not necessarily due to “unhealthy lifestyle behaviors” (also true). Most physicians acknowledge that the BMI is a flawed measurement and that there are many factors that play into health other than weight (true again). But instead of pivoting away from using weight as an indicator of health, there has been a push by the medical community to classify o*esity and o*erweight as “chronic health conditions” that must be managed over one’s lifetime. In essence, the medical community is saying that while being fat isn’t your “fault,” it is still a problem and one that needs to be managed.

In our fat-phobic, image-obsessed culture, it makes sense why these new “miracle weight loss drugs” are creating such a stir. Higher weight people are being told, “Hey, we know that your weight is out of your control, but we can help you manage your ‘condition’ with these medications!” In addition, there is a lot of pressure on higher weight people to “get healthy” (even if many of them are healthy by every measure other than weight), and losing weight is still seen as something that will improve people’s health. The marketing that the drug companies have put forth is simply astounding. I feel like I can’t watch a TV show, peruse social media, or even read the New York Times without sponsored content popping up about these drugs. Add to this all of the celebrities and influencers who have been publicizing their weight loss “success,” I would be surprised if any person in a larger body wouldn’t be affected. Currently, I am in a small-mid fat, abled body, and I’d be lying if I said that I hadn’t thought about turning to these drugs. I can only imagine how those who are in much larger bodies than mine and/or in disabled bodies are tempted to try them.

The studies that have been put forth by Novo Nordisk (the drug company who makes Wegovy and Ozempic) have shown that while participants lost about two pounds per month over a 68-week time period (during which they were also dieting and exercising 30 minutes per day, six days per week), at 60 weeks, those who were still taking the medication experienced a plateau in their weight loss, and in a follow-up study the following year, two thirds of the weight they had lost was regained. Conveniently, the studies all concluded at the second year of testing, as we know that the majority of weight regain occurs between two to five years post weight loss attempt. Novo Nordisk also reported that taking their medication leads to positive health outcomes, but a closer look at their studies shows that there were no statistically significant improvements in HBA1C (a measure of diabetes), triglycerides, cholesterol, or inflammation markers.

I don’t blame anyone who feels like they need to try these drugs. For some folks, losing 10-15% of their body weight (the average weight loss reported by researchers) could feel like it makes a huge difference in their quality of life. What I find distressing about these drugs is how hard they are being pushed by the media and medical community despite the long list of side effects and potentially harmful health outcomes that can occur. Wegovy has a Boxed Warning (the FDA’s most serious warning) due to it increasing one’s risk for thyroid cancer, acute pancreatitis, acute gallbladder disease, stomach paralysis, as well as an increase in suicidal ideation, among other risks. But it seems that the medical community feels that losing weight is worth the risk to fat people’s lives. That even though folks report nausea, diarrhea, vomiting, constipation, and stomach pain while on these drugs, it’s okay as it is just the price to pay for one to become “healthy.”

I wish that instead of telling higher weight people that their weight is a problem that can be “solved” by taking these medications, the medical community could instead focus its energy on reducing weight stigma in healthcare, as this (along with weight cycling or yo-yo dieting and healthcare inequalities) has been found to have much more of a profoundly negative effect than weight on one’s health. I wish that we lived in a society that didn’t prize thinness so much. And I wish that everyone could see that weight is just another human characteristic that exists on a continuum and that bodily diversity is a real thing, not something that has to be “managed” or “controlled.”

Blaming the Victim

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Perhaps you caught last month’s news story about a tech CEO who was hit by a car and killed crossing a street in Acton. He was a friend of mine from college. The driver took away a leader from a company, a husband from a wife, and a father from two young daughters, and severely derailed the trajectory of their own life in the process.

Some of the details omitted from the published story include that he was crossing the street to meet his wife for dinner and that the driver hit him while he was in a crosswalk. Try telling that to the internet trolls who left some ignorant comments suggesting that my friend may have been looking at his phone or crossed without looking.

Their comments got me thinking, and I remembered that blaming the victim is largely about fear. Admitting that we have limited control over our fates is scary, so much so that some of us find some comfort in assuming that a victim must have made some error and brought their end upon themselves.

Looking back, I experienced some of this myself with my three back surgeries. When I had the first operation to remove a tumor, some people questioned how I could possibly have developed one and suggested that I must have grown up under high voltage wires or that I did not take care of myself. No, my environment was fine, I was an athlete, and I had a balanced diet (by adolescent standards). When I had my first spinal fusion, some people assumed I must have done something stupid in the weight room to necessitate the repair, but no, it was really just the fallout from a freak accident and residual structural issues from the tumor. The next year, when I had to have a second fusion because the first one did not work, some people figured the surgeon must have screwed up or that I did something wrong with my rehab. No, sometimes surgeons do everything right and the patient can look on paper like the ideal candidate to heal well, and yet, in a small percentage of cases – including mine – problems still arise.

Our health is no exception to the reality that our outcomes are only somewhat in our control. We live in a culture that blames “overweight” people for their size, that if they only were disciplined enough to eat less and exercise more that they would be thinner, while the reality is that long-term weight regulation is largely regulated by factors unrelated to our behavior. We look at scary diseases and hope we can ward off morbidity and mortality by creating and avoiding dietary demons, yet people of all ages and behavior profiles still get sick and die.

A few days after my friend was killed, my daughter and I had a close call ourselves while I was walking her to school. We got to a crosswalk, I hit the button to activate the flashing yellow lights, the cars in both directions stopped for us, and we began to cross. Before we could make it across, an SUV pulled out from the school’s driveway. Perhaps the driver saw the stopped cars and thought they were waving her in. Regardless, without looking in our direction, she turned onto the street towards us and hit the accelerator. I started running, and it was a close enough call that I arched my back in order to avoid the corner of her front bumper. When I glanced back at the driver, she looked horrified. As we continued on our way, the driver repeatedly yelled to us, “I’m so sorry!”

I was angry, just as I was when I heard my friend died. I was angry at both drivers, and I was mad at our society that normalizes and enables careless driving. However, beneath my anger was fear. We live in a world in which someone can do everything right and still have things go very, very wrong, which is horrifying, and we attempt to shield ourselves from this fear by assuming that victims brought their fates upon themselves.

He Said, She Said: Weight Loss for Athletics

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He Said

“You’re an RD, right?” That’s what one of my patients asked me last year shortly before he got up from the table and walked out of my office, never to return. It was more of a rhetorical question, really, his polite way of telling me I don’t know how to do my job.

He and I were only in each other’s lives briefly, as that was not only his last visit, it was also his first. His new patient paperwork stated that he wanted to lose weight in order to complete a marathon. Upon reading that, I contacted him in advance of his visit and offered a heads-up that I would help him to run his best, and as a consequence of doing so, he might also lose weight; but I would not be helping him to lose weight in hopes that it would improve his running because – contrary to popular belief – that is not how things actually work.

Although I suspected he would respond by cancelling the appointment, to his credit he had an open enough mind to meet with me and discuss our different points of view. Elite marathon runners are all very skinny, he told me, so it only seemed logical to him that if he could alter his body to look more like theirs, then he would in turn become a better runner.

Way back in my sophomore year of high school, I held the same belief. When I looked at those teammates on my track team who were faster than me, I noticed that for the most part they were leaner than me. Consequently, I attempted to change my body by restricting my fat intake (Back in those days, people were scared of fats the same way people nowadays fear “carbs.”) in hopes that I would also run better.

In fact, I ran worse. My mom took me to a dietitian who educated me, dispelled some of the nutrition myths that I held, and convinced me to increase my fat intake. My times in all events dropped, and I was the fastest I had ever been in my young running career without my physique ever changing all that much.

Having a leaner, smaller, or lighter body can certainly have athletic upsides sometimes, just as having a heavier or larger body can sometimes be advantageous, and I am not arguing otherwise. However, a significant difference exists between an athlete who naturally has a given size or shape versus someone who tries to force his or her body into that mold. That is where so many people, like my 15-year-old self and the patient I mentioned earlier, get tripped up.

Anecdotally, we see many examples of athletes who perform worse after intentionally losing weight. Last month, I wrote about how CC Sabathia has struggled since cutting his carbohydrates in an effort to lose weight. He and his slender frame are in the midst of experiencing the two worst seasons of his career, both of which have come since he lost weight.

Sabathia gave an interview earlier this year in which he talked about the fatigue he now experiences. Carbohydrates are our main source of energy. Now that he follows a low-carbohydrate diet, no wonder he currently tires early in games now. Only twice in my life have I failed to complete bicycle routes that I set out to ride. The first was when I fell off my bike in Montana and fractured my back. The other was when I was briefly experimenting with a low-carbohydrate diet and did not have the fuel necessary to make it home.

This summer, I had a couple of rowers come to me hoping to lose weight so they could compete in lightweight crew. Each of them believed that if he could shed enough weight to just make the 160-pound cutoff, he would dominate. However, they were not taking into account that the processes necessary to alter their bodies (over-exercise and/or dietary restriction) were likely to leave them unable to put forth optimal performances. A well-nourished and properly-trained 159-pound athlete is probably going to row much better than his or her 159-pound teammate who maintains that weight by existing in a state of depletion.

At the same time, let us acknowledge that not every athlete is already at the weight at which they can perform his or her best. Some athletes, just like the rest of the population, are subject to behaviors, such as emotional overeating, that might be impacting weight. However, putting the horse before the cart means directly addressing issues that might be hindering performance while allowing weight change to naturally occur or not occur as a consequence. To try losing weight in hopes of becoming a better athlete though is to have the process backwards.


She Said

Some of the individuals who come to see me for nutrition counseling are student athletes who are struggling with an eating disorder (ED). These cases are particularly challenging, as one of the cruxes of being an athlete (at least at a competitive high school or college level) is making sure one is in top physical condition to succeed in one’s sport. While this desire to be in the best athletic condition might be approached in a healthy and manageable way by some individuals, for those who are predisposed to EDs, it can sometimes start, trigger, and/or worsen the individual’s ED.

In the sports where weight control is believed to be paramount to success (e.g., gymnastics, ballet, track and field, etc.), this focus and, in some cases, obsession with being “lean,” “fit,” or “cut,” can result in the athlete eating in a restrictive manner (e.g., cutting out carbohydrates, only eating vegetables and protein) and exercising excessively. Initially, these individuals seem to be doing the right thing, taking care of themselves and making the sacrifices needed to become the best at their sport. The problem arises when the obsession with weight, food, and exercise takes over the athlete’s life. Examples of this include avoiding social situations that involve eating in order to train harder at the gym, exercising even while injured or sick, and panicking when being faced with foods that are not on the “clean eating” food list.

While these scenarios are red flags in and of themselves, the physical ramifications of these behaviors are serious as well. One of the most common outcomes that results from overtraining and undereating in female athletes is the Female Athlete Triad. This syndrome is characterized by three conditions: energy deficiency with or without a diagnosed ED, menstrual disturbances or absence of period completely (amenorrhea), and loss of bone density resulting in osteopenia or osteoporosis. In a nutshell, when an athlete is not eating enough to fuel her training, this can lead to dangerous health problems.

Some health professionals believe that individuals who are dealing with the above problems can continue to participate in their sports as long as they are getting nutrition education from a registered dietitian and having regular check-ups with their primary care physician to make sure they are medically stable enough to compete. While I agree that for some individuals it is just a matter of education and monitoring, for those with EDs, allowing them to continue with their sport could greatly hinder the recovery process. An ED is a multifaceted problem that needs a full treatment team including a therapist, dietitian, and doctor who is knowledgeable about EDs. The focus should be on helping the athlete become physically healthy while dealing with the underlying psychological issues that are part of the ED.

When I am working with a student athlete who is exhibiting disordered eating and/or excessive exercise, I always defer to the physician on the treatment team to make the call about whether the patient is medically safe enough to participate in his or her sport. The work I do with the patient centers on helping them understand what their body’s needs are fuel-wise. This might include educating the patient about carbohydrates and why they are a necessary macronutrient (for athletes and non-athletes) and how to eat to improve one’s athletic performance.

If you or someone you know seems to be struggling with an ED related to being an athlete, it’s important to take action. Talk to your doctor as soon as possible to prevent the situation from becoming worse. Find a therapist and a dietitian who are adept at working with athletes who struggle with EDs. It is also important to alert the sports team’s trainer and coach to the problem, as they will be an integral part of the treatment team. When all of these pieces of the treatment team are in place, the likelihood of recovery is much higher.

“Weight that will stay off”

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TextThe above text exchange appeared in my Facebook feed, placed there by a personal trainer (whose name I blacked out from the image) who shared it to promote his business, a testimony to his prowess and the results he can bring to his clients who are seeking to lose weight.

Let’s talk about results. Losing weight is relatively easy and numerous paths to weight loss exist. Keeping off the lost weight, well, that is a completely different story. Research shows us that about 95% of people who try to lose weight will ultimately regain it (whether or not they maintain the behaviors that created the weight loss in the first place) and of that 95%, 60% of them will end up heavier than they were at baseline.

Said differently, if 100 people intentionally lose weight, five of them will keep it off, 38 of them will return to baseline, and 57 of them will end up heavier than when they started.

These facts may not be talked about very much in our weight-loss-obsessed society, but they are no secret. At the 2013 Cardiometabolic Health Congress, data were presented showing that this pattern of weight loss and subsequent regain was virtually identical regardless of the mode somebody used to lose it. That is why some people in the healthcare field say that the best way to gain weight is to go on a diet.

So when the trainer refers to his client’s 10 pounds of lost weight as “Weight that will stay off,” on what is he basing that claim? Based on the research, if he says something like that to 20 of his clients, 19 times he will be wrong. Not only is he misleading people with false promises and expectations, but he is putting them at high risk for weight cycling and the negative consequences with which it is associated.

Chances are better than not that the client in question will eventually regain the 10 pounds he or she lost plus more. What will the text exchange between the trainer and client look like then?

The sad thing is that I think the trainer in question is actually a good trainer in terms of the mechanics of his profession. He just needs to be more careful about the lessons he is teaching his clients. Had he responded to his client’s text with a sentiment along the lines of, “Losing weight feels important to you right now, but let’s remember that being physically active is doing wonders for your health and well-being regardless of what happens with your weight,” I would not be writing this blog.

Weight Loss Specialist

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“Luck is the last dying wish of those who want to believe that winning can happen by accident. Sweat is for those who know it’s a choice.”

Suggesting that achieving our goals is up to us if only we work hard enough sounds motivating on the surface, but really it makes no sense. So, what, the 99.2% of players in the U.S. Open main draws who walked away without a title did not realize all they had to do was work hard and choose to win? Outcomes that rely on factors beyond our control breaking our way are not automatically there for the taking if only we put our mind to it.

Where that quote originally comes from is not clear to me, but I know I first heard it from a personal trainer who cites it as one of his favorite quotes. According to said trainer’s Facebook page, he now employs a certified “Weight Loss Specialist.” Awesome.

Here is the problem: If a supposed specialist is giving you the information you supposedly need to lose weight, and achieving your goal is framed as a choice that is entirely in your control and can be attained through hard work, and you do not achieve your weight-loss goal, then who is to blame?


If we mislead people into believing that weight loss is entirely up to them and they do not achieve (or more likely maintain) it, they typically turn their frustration and disappointment on themselves with berating thoughts like, “I have no willpower,” “I need to be more disciplined,” “I’m such a loser,” and “I just need to work harder next time.”

Behaviors that in and of themselves were beneficial to health independent of weight loss, such as being physically active or eating fruits and vegetables, are abandoned because they did not lead to weight loss. Restriction gets taken up a notch. They pursue an even more rigid diet and/or intense exercise regimen, not realizing that these behaviors themselves can make weight increase and/or lead to health issues. A colleague of mine calls it “paradigm blindness.” In other words, many people do not realize that their presumed solution to being “overweight” actually exacerbates the condition, so they keep adding more of the supposed solution to the ever-worsening issue.

I used to help (and I use that verb loosely, as I was actually part of the problem even as I thought I was part of the solution) people with weight loss earlier in my career too, but that was before I knew better.

Well-constructed research, my clinical experience, and the experiences of many of my fellow dietitians teach us that weight loss is typically not in one’s control. Sure, our behaviors do matter, but other factors, such as genetics, environment, medical conditions, and personal history, are either partially or completely out of our hands.

The paradox is that any true “Weight Loss Specialist” would know that nobody by that title actually exists. Healthcare practitioners are supposed to help people with, you know, health, which is why Joanne and I take the focus off of weight and instead focus on behaviors that can actually make a difference.


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A couple of people sent me the link to this article about identical twin brothers who performed a nutrition experiment on themselves.  One of them adopted a diet very low in fat while the other followed a diet extremely low in carbohydrates.

By the end, neither one of them felt well.  One brother concluded, “We should not vilify a single nutrient.  It is too easy to demonize fat or sugar, but that enables you to let yourself off the hook in other ways.  The enemy is right in front of us in the shape of processed foods.”

While I agree with the first part of what he said, his last sentence undermines his initial point.  Just as it makes no sense to scapegoat a particular nutrient that exists in the larger context of one’s eating pattern, it is similarly ridiculous to blame a particular form of food (in this case, processed food) that exists in the vast expanse that is one’s overall lifestyle.  To do so is to badly oversimplify what is a very complex picture.  Exclusion, oversimplification, and blame rarely lead to good nutrition.

The people I have seen who have been able to attain and maintain good health are the people who find balance: balance in their eating, and balance in their lifestyles.  Every food has its pros and cons and therefore no food is “the enemy.”  Even processed foods have their upsides: enjoyment, convenience, shelf life, price, etc.  Otherwise, nobody would ever eat them.

While eating processed foods all the time clearly has ramifications, so does never eating them.  Decreased enjoyment, social isolation, weight gain (yes, gain), preoccupation with food, and eating disorders can all result from this kind of restriction.  Misled by a culture of dieting and nutritional scapegoating, many well-intentioned individuals struggle with these issues.  Joanne and I regularly work with such patients at our practice, where we help them to find a healthier relationship with food and ultimately better health overall.

The time to leave exclusion and scapegoating behind is now.  Instead, understand that every food can have its place in a healthy lifestyle.  Pursue balance.  We are here to help.

The Real You Is Sexy

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Aerie, the lingerie branch of American Eagle, is going with a “The Real You Is Sexy” campaign for their spring line.  My understanding is that the ads are not retouched in any way and show the models just as they were when the photographers took their pictures.  Aerie deserves credit for this move, but this change alone does not fix the underlying problem.  The greater problem is with us, not the fashion industry.

Reality is more complex than I am about to make it seem, but the basic premise is that we compare ourselves to models, feel pressure to look like them, feel bad about ourselves for not looking like them, and adopt certain behaviors – healthy or not – in an effort to match them.  Other advertisement campaigns that do retouch photos can dramatically alter a model’s appearance making him or her seem flawless.  When such a picture is held up as the ideal, we are comparing ourselves to someone who does not even exist.  As such, who can possibly live up to that standard?  Aerie deserves credit for at least removing this as a factor from the equation.

The larger problem though is that we compare our bodies to others in the first place, and that is not going to go away even if the fashion industry completely does away with retouching.  For example, I work with a patient who watches women leaner than herself pass by in town and feels bad about herself as a result.  No retouching there; she is comparing herself to people she sees with her own eyes.

We do not know what somebody does to look a certain way.  I do not know any of the Aerie models and I have no idea what they do to maintain their looks, but chances are neither do you.  They might look the way they do because they are genetically predisposed to have that figure and on top of it take excellent care of themselves.  On the other hand, they could also look that way due to eating disorders, overexercise, or other unhealthy behaviors.  One of my patients, a former model who is working to overcome anorexia, tells me of the pressure in the industry to gain a certain look at any costs, healthy or not.  If a model gets his or her frame through an eating disorder, are we really to look up to that image as an ideal just because there is no retouching involved?  In that sense, we still should not be using models – retouched or not – for a point of comparison.   

To further the point, we should not be comparing our bodies to anybody else either.  I discussed with my patient, the one who compared herself to other women in town, that we have no idea what those women do to maintain their looks.  Some of them are probably perfectly healthy, while others might struggle with eating disorders or other unhealthy behaviors.  Some of them are deeply unhappy and live rigid lives in isolation so they can do exactly what they need to do in order to maintain their physiques.  Some of them would laugh if they knew other people look up to them because no matter how great somebody else says they look, they still hate their bodies themselves.  I know all of this because I just described patients of mine.  These problems are much more prevalent than one might think.

It is time to stop comparing our bodies to others.  Weight, waist-to-hip ratio, and other anthropometric measurements do not define us and should not determine our self-worth.  Love and accept yourself the way you are now, not X pounds from now, and focus on leading a healthy lifestyle built on a foundation of balance.

How should one measure health?

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“I really like your blog posts.  They’re really well thought out and are a step above what I imagine normal nutrition blogs are like.  It’s like the philosophy of nutrition or something.  Question, though, when you say this: ‘Joanne and I advocate focusing on health rather than weight.  In that sense, weight outcomes are only somewhat interesting to us.’  I think you’re right, but it also seems challenging to measure one’s health without focusing on weight.  There are very few things a person can do other than stepping on a scale (without regular blood draws and periodic EKGs [electrocardiograms]) to measure their health.  In other words, how do you recommend someone measure their health to see if their health is improving?”

The above email arrived in response to a blog I posted earlier this month in which I compared the slim hopes of winning the lottery to the poor success rate of weight-loss endeavors.  Indeed, Joanne and I do advocate adapting lifestyle changes in pursuit of better health as opposed to taking a weight-centered approach because the latter rarely turns out well.

Furthermore, weight in and of itself is generally not a good indicator of health (although there are some exceptions to this generality, such as for a patient who is recovering from anorexia nervosa).  About a decade ago, I had a weekly doubles game with three other guys.  One player was very lean and clearly had the lowest body mass index (BMI) of any of us.  Was he the healthiest in the group just because he was the lightest for his frame?  After we had been playing together for a few months, I got a call one afternoon saying he had had a heart attack.  I came to find out he was also diabetic.

So if not by weight then, by what should we measure our health?

First, we need to understand that just because a measuring tool is convenient and easy to use does not mean it is valid.  In other words, just because gaining access to a scale and stepping on it are actions that most people can perform does not mean that the resulting data are automatically useful.

You know from my biography that I have an undergraduate degree in mathematics.  For a statistics class project, I analyzed the November 6, 1997 trade between the Red Sox and Rangers that sent Aaron Sele, Mark Brandenburg, and Bill Haselman to Texas in exchange for Damon Buford and Jim Leyritz.  In an effort to determine which team got the better end of the deal, I analyzed the past performances of the trade’s cornerstones, Sele and Leyritz, and determined which metrics were the best predictors of the outcome that ultimately mattered most: team wins.  Some statistics, like strikeouts for a pitcher or home runs for a hitter, are easy to compute and understand, but it turned out that other metrics that were more complex to calculate and comprehend were better predictors of team wins.

While I was in the process of switching careers, I did a similar project in my nutrition assessment course in which I tried to determine which anthropometric measurement is the best predictor of cardiovascular disease.  The results were complex, but the conclusion that I reached is not the point of this blog entry.  The point is that just as I found with the baseball project, the ease of obtaining a particular measurement has nothing to do with the utility of said measurement.  In other words, just because it is easy to count the number of home runs a player accumulates or to step on a scale and find out our weight does not mean that these numbers are great indicators of team wins or our health, respectively.

With that in mind, let us now turn our attention to just some of the ways we can measure health.  This list is far from complete, but it gives a sense of all of the measurement tools healthcare practitioners have at their disposal.

We have anthropometric data, such as waist circumference, waist-to-hip ratio, body fat percentage, and BMI.  We have the numerous biochemical markers that doctors can examine through blood and urine tests, including blood glucose, insulin, total cholesterol , LDL (“bad cholesterol”), HDL (“good cholesterol”), triglycerides, red blood cells (RBC), white blood cells (WBC), and markers of liver health, protein stores, electrolytes, and inflammation.  Clinical indicators include hair and skin quality, finger nail appearance, and tests for hydration status.  Electrocardiograms and blood pressure readings comprise part of a cardiovascular system assessment.  Men and women can screen themselves for signs of testicular and breast cancer, respectively, through regular exams.

When I was a personal trainer, I used tests like the eight-repetition maximum bench press, Rockport walk, and sit-and-reach to assess my clients’ fitness and track their changes over time.  In my realm of nutrition, dietitians will sometimes use tools, such as a 24-hour recall or food frequency questionnaire, to assess the health of one’s food intake.  Aside from one’s intake of fruits and vegetables, for example, one can track other health-related behaviors themselves, such as physical activity duration and frequency as well as usage of tobacco, alcohol, and recreational drugs.

Health is not just about the physical; emotional and psychological health is also important.  This is not my area of expertise, but I am sure psychologists and psychiatrists have ways of screening for and assessing the magnitude of conditions ranging from depression to schizophrenia.

With all of these different tools we have for assessing and tracking health, the criteria that one uses has to be individualized, which is why it is important to talk with your healthcare team about how you should track your own health.  For example, diabetics may measure their health in part by monitoring their blood sugar at home and keeping their A1C under a benchmark value set by their doctors.  A patient with a family history of cardiovascular disease may monitor his health in part through periodic blood lipid level checks and self-monitoring of blood pressure at home.  A patient with celiac disease may monitor her health in part through bone density screenings and tTG blood tests.  A patient with a history of skin cancer may measure his health in part through routine screenings with the dermatologist.

The permutations of how to measure health are endless and must be customized with the help of your doctor and any other healthcare practitioners who are on your treatment team.  Just because weight is easy to measure does not mean one should put much stock in the number or even track it at all.

The Lottery

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Ralph Francois, of Quincy, won $1,000,000 playing Mega Millions. Marjorie Teixeira, Frank DiMascio, and Christine Cummings, of Melrose, Watertown, and Dedham, respectively, all won lottery prizes on the same December day. Stanley Goryl of Smithfield, Francis McPherson of Somerville, Marque Scott of Fall River, Patricia Cannata of Attleboro, and Linh Dang of Dorchester are just a few of the 15 locals who won at least $1,000,000 through the lottery last month. Their pictures, smiling and holding up enlarged replicas of their winning tickets and prize checks, are both evidence of their victories as well as enticements to the rest of us suggesting that we can be winners too.

Despite these testimonials that fill us with hope, most people do not walk away a winner.  Massachusetts lottery players, on average, will only win back $0.72 for every $1.00 they spend on lottery tickets. According to a study by Bloomberg, state lotteries “have the worst odds of any form of legal gambling” in the country. To put things in perspective, one reportedly is 1,400 times more likely to die in an asteroid apocalypse than he or she is to win Powerball. As if the odds themselves were not concerning enough, playing the lottery can sometimes spiral out of control. A link on the Massachusetts State Lottery’s website directs people to where they can get help for compulsive gambling.

Some people enjoy gambling, including the lottery, and as one of my friends said to me recently, “You can’t win if you don’t play.” Going about it with a sporting attitude for the sake of entertainment and excitement is one thing, but nobody actually believes that playing the lottery will really net a profit, right? Wrong. According to a couple of 2005 surveys put out by the Consumer Federation of America and the Financial Planning Association, 21% of the surveyed Americans believe that winning the lottery represents the most practical way for them to accumulate several hundred thousand dollars. I imagine one would be hard pressed to find a legitimate financial adviser who would suggest that playing the lottery is a sound investment strategy.

Given the time of year with people around me making all sorts of resolutions, the clear parallel between playing the lottery and resolving to lose weight has been on my mind. Joanne and I have written extensively about the chronic failures of weight-centered dietary approaches. Although the exact outcome depends on the specific parameters of the given study in question, research across the board shows that the chances of keeping off lost weight are poor. According to one group of researchers, “Less than 20% of individuals that have attempted to lose weight are able to achieve and maintain a 10% reduction over a year. Over one-third of lost weight tends to return within the first year, and the majority is gained back within three to five years.”

Joanne and I advocate focusing on health rather than weight. In that sense, weight outcomes are only somewhat interesting to us. However, for programs and approaches that revolve around weight, shouldn’t the results at least be better than this?

However, just like people who play the lottery despite the terrible odds of making a profit, we get sucked in by glamorous testimonials, peer pressure, advertisements, and the like, all encouraging us to lose weight. We enter the weight-loss game with the expectation, whether by delusion, misunderstanding, or overconfidence, that we will be the rare exception who comes out on top. “You can’t win if you don’t play,” right?

The difference is that we are not playing a game; we are playing with our health. At best, the weight-loss-weight-regain cycle postpones behavior change that will actually improve our health. More likely, the cycle itself can leave us in a less healthy state, either physiologically, psychologically, or both. Furthermore, just as the lottery can lead to a gambling addiction, weight loss pursuits can lead to serious eating disorders which add a whole new layer of complexity to one’s health problems.

Instead of entering a game that you are likely to lose, leave weight-centered approaches behind and focus on making healthier choices. No, lifestyle change is neither sexy nor rapid. Lifestyle change does not make for good reality television. What it can do though is increase your chances of getting healthy and staying that way.

The Wrong Idea

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In addition to the many patients I see for eating disorders, I often have individuals come to see me for help with weight loss. This goal is completely understandable in the current context of our society. Most of us have been told by numerous sources that weight loss is essential for health, and only if we are at the “right” weight will we live long and healthy lives. And up until about five years ago, I would have agreed with this assumption.

But, as I have written about in many other blogs, I’ve had a paradigm shift. There is more and more scientific evidence out there that weight and health are not inextricably linked. In fact, it is completely feasible for someone to weigh considerably more than the BMI and weight charts tell her to and to be perfectly healthy. In contrast, I have seen countless patients in my office who are at their “ideal” weights, yet are using extremely unhealthy measures to stay there and have numerous health issues as a result.

Therefore, I am concerned when the New Year comes around, as I know that our office will become busier than ever with people wanting to lose weight. I’m afraid that prospective patients will have the wrong idea about what I will and will not do. As a registered dietitian, I am knowledgeable about nutrition for health promotion. This means I can provide nutrition education for my patients and help them figure out ways to establish some healthier eating habits.  While these healthier eating habits may lead to some weight loss, weight loss will not be the inherent goal of our work together. If any weight loss occurs, it is just the byproduct of the lifestyle changes one instills. It isn’t the primary goal.

Maybe 2014 will be the year that we can all start taking our eyes off of the scale and instead focusing on making healthy lifestyle changes instead.