The end of dieting

Speaker 1 Today's episode of Today Explained is a rerun, but we have updated it with some news.

Speaker 1 Perhaps you saw President Trump recently announced a deal with two drug companies that's going to result in much cheaper weight loss drugs.

Speaker 1 Perhaps you saw that he then revealed who in his administration is taking them.

Speaker 3 And we have Steve Westeve Senior, head of public relations for the White House.

Speaker 3 He's taking it.

Speaker 1 Classic. Perhaps you saw someone then fainted in the Oval Office during that announcement.

Speaker 1 Classic. Here's the thing: these drugs appear to be working.
Obesity rates in the U.S. are declining, but there are still unknowns.

Speaker 1 The relationship between diet, weight, and health seems like it should be clear by this point, but it's really not.

Speaker 1 Coming up on Today Explained, why the gospel on weight loss is always being rewritten and how medications have added a brand new chapter.

Speaker 2 Support for Today Explained comes from Crucible Moments. What is that? It's a podcast from Sequoia Capital.

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Speaker 2 Hosted by Sequoia Capital's managing partner, Rulaf Botha. Crucible Moments is returning for a brand new season.

Speaker 2 They're kicking things off with episodes on Zipline and Bolt, two companies that are still around with surprising paths to success. Crucible Moments is out now and available everywhere.

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Speaker 1 you're listening to today explained sumita mukapadai is a writer and editor who was very anxious when she was hired as the executive editor of teen vogue back in 2018 like everyone else sumita had seen the devil wears prada and she knew that the fashion industry was was unforgiving.

Speaker 1 But not long after she started there, she realized that things were changing.

Speaker 11 You know, I entered the fashion industry at a really unique moment where there was an increased interest in plus fashion.

Speaker 11 You know, and so when I got the job at Teen Vogue, I started having all these fashion brands reaching out to me to be like, wow, we're so excited. We're launching a plus collection.

Speaker 11 We'd love to talk to you about it. We'd love to send it to you.
How does it feel to be a fat fashion editor? And at the time, I had kind of newly gained the weight.

Speaker 11 And so I wasn't totally embracing it. I was, I wasn't, I didn't, it didn't feel empowering.
It was almost felt like something that was happening to me where I was like, oh, wait, I'm fat.

Speaker 11 Like, you know, I had to kind of get over that first step before being like, I'm fabulous. I love being fat.

Speaker 1 Okay, so you're in a period where Teen Vogue has become more accepting. It is okay to be a person in a larger body.

Speaker 1 And in fact, there's even some sort of advocacy or activism around the fact that there is more than one body type.

Speaker 1 And then

Speaker 1 you get some news that again changes how you see and experience all of this. What happened?

Speaker 11 While I was at Teen Vogue and kind of as I was leaving Teen Vogue, I had had a series of stressful family-related things happen.

Speaker 11 My father passed away of diabetes-related complications. My mother was diagnosed with breast cancer.
I had this really hectic job, and I was managing all of it. And my stress response was eating.

Speaker 11 And it was, and not just eating, it was like really not taking care of myself ultimately, right? It was taking Ubers. It was getting takeout.
It was kind of not really having a lot of time for myself.

Speaker 11 And that did lead to some unwanted weight gain on my part. And I was having some mobility issues.
I was having trouble kind of,

Speaker 11 I just thought it was because I was exhausted because I had never never had these experiences, but I was having trouble getting up and down the stairs on the subway.

Speaker 11 And I would just chalk it up to like, oh, I'm just so busy, you know, like I have to take Ubers because I'm like busy and I'm exhausted.

Speaker 11 And I was having trouble keeping up on walks and I was having trouble sleeping. I wasn't feeling well.
And, you know, on top of that, my clothes weren't fitting. And so I went to the doctor.

Speaker 11 And, you know, this is after I had left Teedbog

Speaker 11 and like kind of after the pandemic, I decided to start the process of, you know, figuring out if I was okay and also, you know, what I could do because I knew and I understood that diets don't work, right?

Speaker 11 Like I knew I could restrict what I was eating, but eventually I'd gain the weight back. And I really wanted something, I really wanted a strategy that would be more effective.

Speaker 11 And so I went in and got my blood work done. And, you know, pretty much every indicator was elevated.
So I was, had become pre-diabetic. My cholesterol was elevated.
And so those scared me, right?

Speaker 11 Like I had just lost my father to exactly the things that I'm now looking at in my blood report.

Speaker 11 And so I was like, you know, I think it's finally time for me to really take this seriously and figure out, you know, a strategy to move forward. And she suggested Manjaro.

Speaker 11 It is a injectable that you take weekly. It slows your digestion, basically, is how it works.
And in doing so, it reduces the rate at which you can eat and how hungry you get. And so,

Speaker 11 you know, I decided to go on it.

Speaker 1 What did that mean for you? Like, once you start taking it, what happens?

Speaker 11 Do you mean emotionally or physically?

Speaker 3 Both.

Speaker 1 Both entirely. I mean both.

Speaker 3 Thank you for asking.

Speaker 11 Yeah, yeah, for sure.

Speaker 11 I mean, emotionally, it was really hard to make the decision to go on it. I saw it as two things.

Speaker 11 I saw it as a betrayal to the kind of body positivity and feminism that I had ascribed to of loving yourself at any size and not trusting pharmaceutical interventions.

Speaker 11 And also there was another voice inside me that was like, this is how bad it's gotten, girl. Like you couldn't control this and now you have to take a drug.
That's how, that's how not well you are.

Speaker 11 And so a lot of self-judgment, a lot of shame came out with the decision to go on the medication.

Speaker 11 Physically, it is a bumpy road. It was for me.
For me, I struggled with very intense nausea.

Speaker 11 So you, you know, one of the ways that it works is since it slows your digestion, if you overeat,

Speaker 11 you feel very sick. And then

Speaker 11 a lot of digestive issues. It is very hard to go to the bathroom when you're on it.
You have to take all kinds of laxatives. They now have...

Speaker 11 additional prescriptions they put people on that are taking it to help support with, you know, regular bowel movements. And so it was not the best physical experience.

Speaker 11 And then, you know, at a certain point, I got used to it, but I think it was more that I just got used to managing the side effects. They never really went away for me.

Speaker 1 You have made, interestingly enough, being on Moonjaro sound absolutely horrible, but

Speaker 1 I appreciate you being honest about the side effects because I don't hear talk about the side effects very often. What was the good in this? What kept you on it?

Speaker 11 It does something. And I think it's physiological.
And a doctor can speak more eloquently to this, but it does trigger something in your brain a hormone that suggests that you're satiated right and so

Speaker 11 it started to help me feel satisfied with less

Speaker 11 One of my behaviors is I tend to compulsively eat in the evening, whether it's stress or just fun or boredom or binge watching TV, whatever it might be, I will sit down with like an array of snacks and kind of eat mindlessly, not always keeping track of how much I'm eating, not necessarily food that had good nutritional value.

Speaker 11 When I was on Manjaro, I would finish dinner and I pretty much would not physically be hungry in the evening and I just wouldn't have space to eat anything else.

Speaker 11 And if I got the munchies, I started to reach for healthier snacks because I noticed that I digested them easier.

Speaker 11 And so if I just like ate an apple or some grapes, you know, like I ate so many freaking grapes,

Speaker 11 or you know, a handful of carrots or whatever that might be. And all the things we tell ourselves, and we're like, this is the healthy choice.
Let's make the healthy choice.

Speaker 11 The healthy choice all of a sudden became easier.

Speaker 11 And so, that was part of why I stayed on it. That it really gave me this release from this yearning that I always had, where

Speaker 11 it wasn't a challenging decision. I didn't feel a lot of strain around it.
Whereas historically, when I would beat myself up for eating at night, I never felt like I could stop.

Speaker 11 And with the kind of pharmaceutical intervention, I was able to stop.

Speaker 1 Okay, so there are pros, there are cons. How is it going?

Speaker 11 I guess when Manjaro hit the market, they had given a manufacturer's coupon to early people, to people that had first started taking the drug.

Speaker 11 And, you know, I don't read the fine print, Noelle. Like, I don't know.

Speaker 1 Like, no one does, girl.

Speaker 11 I thought that was my insurance covering it. Like, I didn't understand that, like, the reason it cost that much was a coupon and not my insurance.
And so the coupon is rescinded.

Speaker 11 And overnight, the drug becomes $600 to $800 a month. I think it was like, I think it was $800.

Speaker 11 And they were like, we can do this other coupon that will get you to like $600.

Speaker 11 Like, I'm kind of like, these aren't the exact numbers, but all I'm saying is like, it was an insane amount of money that I was like, what?

Speaker 3 Like,

Speaker 11 I live in New York City. You can't just take on another payment like that.

Speaker 3 That's crazy.

Speaker 11 Yeah, exactly. Exactly.
I think the combination of the cost and the side effects. And I had lost a lot of weight.
Like, I think I lost 50 pounds about

Speaker 11 and I was feeling great and I was like you know let me just try without it let me phase out of it and so I came off the drug at the end of 2023 and you know I will say like maintained the loss for quite a bit of time I probably gained like 10 to 15 pounds within like two or three months and that was definitely not a great mental experience.

Speaker 11 Like I definitely came back to that feeling of control of like, oh my God, I'm losing control. I'm losing control.

Speaker 11 And, you know, but I was excited because I had made some lifestyle changes that I was maintaining. And that felt like a really positive intervention.

Speaker 11 Now, this is like the first interview I'm doing about this in like six months. And so I will say the last six months have been really stressful for me.

Speaker 11 I launched a book. I got married.

Speaker 3 Nothing like.

Speaker 11 thank you nothing like gaining weight for your wedding um but

Speaker 11 i started you know, some of the things that I had been committing to, like cooking and getting enough, you know, my steps every day and all of that, like fell to the wayside a little bit.

Speaker 11 And so the weight started to creep on and creep on and creep on. And now I've probably gained back like 60 or 70% of what I lost,

Speaker 11 which has been really hard.

Speaker 11 You know, it's hard and it also feels like it's forcing me to really face my relationship with my health and my own body and to like, it's like I understand the options that are out there, but the options are limited.

Speaker 11 I wouldn't even say that I would necessarily go back on it because when I think about it, I just get sick to my stomach again. I'm just like, oh, I just don't know if I can go through that again.

Speaker 11 But the, you know, it's been a roller coaster, emotional roller coaster, having the kind of high of like, oh, like the weight came off, and then to like be, feel like I'm back to square one, even though I know in my mind, in my heart, and my spirit, I am not.

Speaker 1 Sumida Mukopadai, writer and editor. Coming up, is the age of diet and exercise over?

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Speaker 14 You're listening to Today Explained.

Speaker 3 I'm Dan Besseson. I'm an MD by training.
I'm an endocrinologist. I'm here at the University of Colorado in Denver, and I do clinical work taking care of patients at our county hospital, Denver Health.

Speaker 3 And I do research here at the medical school. I'm also the director of this building called the Anschutz Health and Wellness Center.

Speaker 1 Dan, you have 47 jobs, man.

Speaker 3 All right,

Speaker 1 let's talk about the beginnings of this sort of cultural and medical interest in obesity.

Speaker 1 When did doctors start thinking of obesity as something that needed to be fixed, something that needed medical attention?

Speaker 3 I think there's always been people with really high weights that doctors thought, well, that's probably a health problem.

Speaker 3 But I don't think it entered entered the general public consciousness until sort of the late 80s to the mid-90s.

Speaker 14 The disease is obesity, but obesity is just a symptom of the real problem we as a nation face.

Speaker 15 Frances, you've been overweight since you can remember. Since a child.
About early teens.

Speaker 14 Americans overeat. We are obsessed with food, and it's an obsession that's killing us.

Speaker 15 And when Greta was one year old, she weighed 100 pounds. Almost 100.
Almost 100. That's a lot.

Speaker 3 I think people looked around and thought, what's going on here? There seems to be more and more people at higher weights. And NIH had an expert panel that defined obesity using BMI.

Speaker 3 BMI is sort of controversial, but that was the point at which we had this accepted standard. And shortly after that, the CDC looked at data they had and said, what's been happening with obesity?

Speaker 3 And I think they were sort of shocked to find there was just a dramatic increase in the number of people with obesity. And so in 1999, they published these maps, these CDC obesity maps.

Speaker 3 Maybe some people have seen those. And they really brought a lot of attention to what really looked like an epidemic.

Speaker 3 If you had looked at those numbers and it was HIV or cancer, people would be quite worried. And people said, gosh, something is happening here.
We should do something about this.

Speaker 1 And what was the something that doctors decided they should do?

Speaker 3 Yeah, I think that the NIH panel had thought about levels of weight and that treatment or what intervention somebody did should be based on how serious the problem was.

Speaker 3 So people with a modest increase in their weight might change their diet and increase their physical activity. People with a more severe

Speaker 3 weight problem might take a medication. And those at the highest weight might benefit from surgery.
For most Americans, lifestyle is what was suggested.

Speaker 3 And I think at that point, we were still early in understanding the biologic basis of weight regulation. And

Speaker 3 we all eat, we all move, and it seems like we choose those things. And so, the obvious first step was to say, maybe people just don't know what to eat.

Speaker 3 And if they just thought about it some more and ate less and moved more, that this problem might go away. So, that was the first thought.
And the surgeon general had a call to action.

Speaker 16 Obesity,

Speaker 16 a major problem that has increased dramatically since 1990.

Speaker 3 Based on these numbers rising of obesity, saying, you know, people ought to move more and eat a healthier diet.

Speaker 16 When it comes to physical inactivity, obesity, diabetes, factor of the matter is we're moving in the wrong direction in terms of these areas.

Speaker 1 The advice seems obvious. Change what you eat and move more.

Speaker 1 Do diet and exercise prove to work?

Speaker 3 Yeah, I think there's a couple ways to look at that.

Speaker 3 One is around this same time, there was a study published, the Diabetes Prevention Program, and what they found was that a modest weight loss, a 5% weight loss,

Speaker 3 could reduce the risk of developing type 2 diabetes by half. It was a really dramatic study.

Speaker 3 And so it was really based on that that people said, said, gosh, this is achievable and it has clear health benefits of 5% weight loss.

Speaker 1 I'm just doing the math in my head. If you weigh 200 pounds, that's take 10 pounds off.

Speaker 3 Yeah.

Speaker 1 300 pounds, take 15 pounds off. That feels like nothing.

Speaker 3 It seems like a small change in weight, and yet it had dramatic benefits.

Speaker 3 I got to tell you, I mean, I see people in clinic, and so I've spent, whatever, 20 years trying to sell the benefits of a 5% weight loss. Most people don't buy it.

Speaker 3 Most people want more weight loss than that.

Speaker 3 It's not a weight loss that most people see in the mirror or that their friends are going to notice, but it has clear health benefits and has become a benchmark of what a clinically significant weight loss is.

Speaker 3 A little bit of weight loss helps.

Speaker 1 So what happened after the study was over with these folks who lost 5% of their weight and then saw their health improve? Did they keep the weight off?

Speaker 3 Most lifestyle studies show that most people regain much of the weight. It's not like everybody regains all of the weight, but much of the weight is regained.

Speaker 3 What has happened over the last 25 years is a real explosion in our understanding of the biology that underlies weight regulation.

Speaker 3 I think now we think of weight much like we think about blood pressure or glucose, that there's complex biology that the body's got its own idea about what it wants to weigh.

Speaker 3 And what it seems like the body wants to do, it doesn't regulate around a set point. It regulates around a trajectory of gradual weight gain across the life.

Speaker 3 So the biology of weight really pushes back against efforts to change our diet. And so that's why people regain the weight is when they lose weight, the body goes, this is not good.

Speaker 3 And the people become more hungry, their energy expenditure goes down, and these things tend to push the weight back up to where it was before.

Speaker 1 Were there, you mentioned two other ways that doctors saw of treating obesity, medications and surgeries.

Speaker 1 How common was it for a doctor to say, you, sir, or madam, you're going to need medication, you're going to need surgery? I don't remember so much of that like 20 years ago.

Speaker 3 Only maybe one or 2% of people ever had that conversation, ever got that medication. And there are a number of reasons for that.
One is the older medicines had some side effects.

Speaker 3 There were some bad stories about health problems with Fenfen and other medicines.

Speaker 1 Oh, Fenfen.

Speaker 17 If you took the diet drug combination known as Fenfen, or the diet drugs Pondamen or Redux, you may have heart valve problems and not know it.

Speaker 18 Well, for a Chicago area, women are taking the makers of FenFen to court. It's been one week since the prescription diet drug was pulled off the market.

Speaker 3 And I think, too, doctors and patients,

Speaker 3 doctors especially have this idea that, well, Mrs. Jones, you ought to be able to handle this on your own.
This idea that weight is regulated, it's taken a long time to get any traction there.

Speaker 3 Doctors would say things like, you know, if you show me you can stick to a diet, well, then I'll maybe talk to you about a medicine. We don't do that with diabetes or high blood pressure.

Speaker 3 We're very quick to go to a medication in those conditions.

Speaker 3 So I think there's a lot of maybe bias and stigma directed at people living with obesity that we tend to blame them for their health problem.

Speaker 3 So medicines that weren't super effective and an environment that really thought that people could do this on their own.

Speaker 1 How long have you been in this line of work, Dr. Dan?

Speaker 3 I'm an old person with kind of gray hair. I prescribe FenFen, and so I've been doing this for, gosh,

Speaker 3 whatever, almost 30 years.

Speaker 1 You've been doing this for 30 years. Sometime in the last 24 months, I became aware of Ozempic.
A lot of people became aware of Ozempic.

Speaker 1 I'm just wondering what the conversation was like in the medical community among doctors who do your type of work about the fact that there are these GLP-1 drugs that seem to work magically, work for a lot of people, and are now widely available.

Speaker 3 Yeah, I would use the term game changer. There's never been anything like this.

Speaker 3 We've done studies with older medications and, you know, the medications worked okay, but people weren't happy with them. These medicines just

Speaker 3 not only the ones we have now, which are samaglatide and trzepatide, but the ones that are coming after that, that are in clinical trials.

Speaker 3 We're in a time now that medications are likely to provide the kind of weight loss that we used to only see with bariatric surgery.

Speaker 3 I understand that there's more than a hundred medications in this anti-obesity medication pipeline.

Speaker 3 We've been doing studies with some of the next generation and they're even more effective than the samaglatide and trzepatide are. Oh damn.

Speaker 1 Yeah.

Speaker 3 And you know when we have somebody go to bariatric surgery, we prepare them for that.

Speaker 3 They see a psychologist, they see a nutritionist, they talk to other people who've had surgery and say, how was that for you? They think about it. And then it's kind of a go-no-go.

Speaker 3 You know, either you have surgery or you don't, you get what you get. Medications are going to give that kind of weight loss, but we're not preparing people for that.

Speaker 3 We're not, what does your life look like when you're not interested in food? I had a woman tell me, you know, my husband took me out to this fancy restaurant here in Denver for my birthday.

Speaker 3 He was so excited. I looked at the food and I thought, gee, this is not going to work for me.
So it makes changes in people's relationships with other folks.

Speaker 3 When people see someone losing weight, they wonder, what are you doing? Do you have cancer? Who do you tell that you're on a medicine? What do you tell them about why and what your goals are?

Speaker 3 What are your goals? How much weight do you want to lose? And how will you know when you're done? These are questions that we've never had to ask before. And we don't have good data.

Speaker 3 And people are willing to pay. So there's all these market forces with people just want a medicine.
They don't want a doctor. They don't want advice.
They just want the medicine.

Speaker 3 But they don't really know what they're getting into. So

Speaker 3 it's a bit of a chaotic environment.

Speaker 3 I think the key message I'd ask people to understand is this idea that weight is biologically regulated and that it has some health problems for some people, maybe even many people,

Speaker 3 and that ideally they find somebody that they can talk to, a doctor or a healthcare provider, that they can get useful information from over time because it's a journey.

Speaker 1 Dr.

Speaker 2 Dan Besseson, he's an endocrinologist. Miles Bryan produced today's show.
It was a rerun.

Speaker 1 Jolie Myers edited. Laura Bullard fact-checked.
Andrea Christen's daughter and Patrick Boyd are our engineers. I'm Noel King.

Speaker 11 It's Today Explained.

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