Americans were told “diet and exercise” was the key to better health, but lifestyle changes were never that life changing. Medication is. This episode was produced by Miles Bryan, edited by Jolie Myers, fact-checked by Laura Bullard, engineered by Patrick Boyd and Andrea Kristinsdottir, and hosted by Noel King. Transcript at vox.com/today-explained-podcast Support Today, Explained by becoming a Vox Member today: http://www.vox.com/members Semaglutide (GLP-1) weight-loss drug Wegovy, made by pharmaceutical company Novo Nordisk -- designed to treat type 2 diabetes, but widely known for their effect on weight loss. Photo by James Manning/PA Images via Getty Images. Learn more about your ad choices. Visit podcastchoices.com/adchoices
Chapter 1: What sparked the discussion about body mass index (BMI)?
During the 2024 Olympics, a player on the U.S. women's rugby team, Alona Mar, got a ton of attention for talking about her body mass index.
I do have a BMI of 30. Well, 29.3 to be more exact. I've been considered overweight my whole life. I remember vividly one time in high school, I had to turn in the physical to the office, and right at the bottom of the page, it said overweight.
Ms. Ma'am went on to win a bronze medal and also to illustrate the absurdity of BMI. But doctors and insurance companies still use this number to make judgments about your health. And then just yesterday, a global panel of experts advised that we measure obesity differently.
The relationship between diet and weight and health seems like it should be clear and knowable by this point, but it's really not. Coming up on today explained why the gospel on weight loss is always being rewritten and how medications have added a brand new chapter.
Chapter 2: How has the perception of obesity changed over time?
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You're listening to Today Explained. Sumita Mukhopadhyay 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 unforgiving. But not long after she started there, she realized that things were changing.
You know, I entered the fashion industry at a really unique moment where there was a an increased interest in plus fashion. 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. 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. And so I wasn't totally embracing it. It didn't feel empowering. It almost felt like something that was happening to me where I was like, oh, wait, I'm fat? You know, where I had to kind of get over that first step before being like, I'm fabulous. I love being fat.
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. And in fact, there's even some sort of advocacy or activism around the fact that there is more than one body type. And then you get some news that, again, changes how you see and experience all of this. What happened?
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. 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. And it was 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. And that did lead to some unwanted weight gain on my part. And I was having
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Chapter 3: What led Sumita to consider medication for weight management?
some mobility issues i was having trouble kind of i i just thought it was because i was exhausted because i had never had these experiences but i was having trouble getting up and down the stairs on the subway 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 um 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 and, you know, this is after I had left Teen Vogue and like kind of after the pandemic, I decided to start the process of, you know, figuring out. If I was OK and also, you know what I could do, because I knew and I understood that diets don't work right.
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. And so. I went in and got my blood work done and, you know, pretty much every indicator was elevated. So I had become pre-diabetic. My cholesterol was elevated. And so those scared me, right?
Like I had just lost my father to exactly the things that I'm now looking at in my blood report. 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. 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, you know, I decided to go on it.
What did that mean for you? Like once you start taking it, what happens?
Do you mean emotionally or physically?
Both, both entirely. I mean, both. Thank you for asking.
Yeah, yeah, for sure. I mean, emotionally, it was really hard to make the decision to go on it. I saw it as two things. 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. And also there was another voice inside me that was like, this is how bad it's gotten, girl.
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Chapter 4: What are the side effects of Manjaro?
I probably gained like 10 to 15 pounds within like two or three months and And that was definitely not a great mental experience. Like I definitely came back to that feeling of control of like, oh my God, I'm losing control. I'm losing control. 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.
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. I launched a book, I got married. Congrats. Thank you. Nothing like gaining weight for your wedding. But 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. 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, which has been really hard.
You know, it's hard and it's 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. 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.
I'm just like, oh, I just don't know if I can go through that again. But, 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 and my heart and my spirit, I am not.
Sumita Mukhopadhyay, writer and editor. Coming up, is the age of diet and exercise over?
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I'm Dan Bessison. 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, and I do research here at the medical school. I'm also the director of this building called the Anschutz Health and Wellness Center.
Dan, you have 47 jobs, man. All right. Let's talk about the beginnings of this sort of cultural and medical interest in obesity. When did doctors start thinking of obesity as something that needed to be fixed, something that needed medical attention?
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Chapter 5: How did Sumita's relationship with food change on Manjaro?
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. Maybe some people have seen those. And they really brought a lot of attention to what really looked like an epidemic. 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.
And what was the something that doctors decided they should do?
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. So people with a modest increase in their weight might change their diet and increase their physical activity. People with a more severe weight problem might take a medication instead.
And those at the highest weight might benefit from surgery. For most Americans, lifestyle is what was suggested. And I think at that point, we were still early in understanding the biologic basis of weight regulation. And 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.
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.
Obesity, a major problem that has increased dramatically since 1990.
Based on these numbers rising of obesity, saying, you know, people ought to move more and eat a healthier diet.
When it comes to physical inactivity, obesity, diabetes, the fact of the matter is we're moving in the wrong direction in terms of these areas.
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Chapter 6: What challenges did Sumita face after discontinuing Manjaro?
I think there's a couple ways to look at that. 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, could... reduce the risk of developing type 2 diabetes by half. It was a really dramatic study.
And so it was really based on that that people said, gosh, this is achievable and it has clear health benefits of 5% weight loss.
I'm just doing the math in my head. If you weigh 200 pounds, that's take 10 pounds off.
Yeah.
300 pounds, take 15 pounds off. That feels like nothing.
It seems like a small change in weight, and yet it had dramatic benefits. 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. Most people want more weight loss than that. It's not a weight loss that most people get. 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. A little bit of weight loss helps.
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?
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. What has happened over the last 25 years is a real explosion in our understanding of the biology that underlies weight regulation.
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Chapter 7: Is the era of diet and exercise coming to an end?
How long have you been in this line of work, Dr. Dan?
I'm an old person with kind of gray hair. I prescribe Fen-Phen. So I've been doing this for, gosh, whatever, almost 30 years.
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. 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.
Yeah, I would use the term game changer. There's never been anything like this. We've done studies with older medications and, you know, the medications worked okay, but people weren't happy with them. These medicines just, not only the ones we have now, which are semaglutide and trisepatide, but the ones that are coming after that, that are in clinical trials.
We're at a time now that medications are likely to provide the kind of weight loss that we used to only see with bariatric surgery. I understand that there's more than 100 medications in this anti-obesity medication pipeline. We've been doing studies with some of the next generation, and they're even more effective than the semaglutide and trizepatide are.
Oh, damn.
Yeah. And, you know, when we have somebody go to bariatric surgery, we prepare them for that. 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. You know, either you have surgery or you don't and you get what you get.
Medications are going to give that kind of weight loss, but we're not preparing people for that. 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. 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. When people see someone losing weight, they wonder, what are you doing? Do you have cancer? Who do you tell that you're out of medicine? What do you tell them about why and what your goals are? What are your goals? How much weight do you want to lose? And how will you know when you're done?
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