The Weight Comes Off Easy. Now What?

James Hill:
Welcome to Weight Loss And, where we delve into the world of weight loss. I'm Jim Hill.

Holly Wyatt:
And I'm Holly Wyatt. We're both dedicated to helping you lose weight, keep it off, and live your best life while you're doing it.

James Hill:
Indeed, we now realize successful weight loss combines the science and art of medicine, knowing what to do and why you will do it.

Holly Wyatt:
Yes, the “And” allows us to talk about all the other stuff that makes your journey so much bigger, better, and exciting.

James Hill:
Ready for the “And” factor?

Holly Wyatt:
Let's dive in.

James Hill:
Here we go.

Holly Wyatt:
Jim, I think obesity medicine has a new problem.

James Hill:
Oh, my God. What now, Holly?

Holly Wyatt:
Our treatments are working.

James Hill:
Oh, my God. That's a problem?

Holly Wyatt:
Yeah. I mean.

James Hill:
Wait. Now, wait a minute. We've spent our entire careers trying to get better treatments. And now you're telling me that's a problem?

Holly Wyatt:
Exactly. Think about it. For most of our careers, we didn't have to ask whether 25%, 35% weight loss was too much. We just couldn't produce it. We couldn't produce it without surgery, for sure.

James Hill:
I went for decades without asking that question, Holly, because we were just constantly trying for more, more, more. So the treatment answered the question for us. You lost what you could. We were happy if we could get, you know, 5, 10, 15. We didn't even dream of 30% weight loss.

Holly Wyatt:
And now the treatment may not set that ceiling anymore.

James Hill:
And this changes things because if we can produce 20 to 25% weight loss, the question isn't just, can we do this?

Holly Wyatt:
Yeah, it becomes, should we do it? For whom should we do it? And what's the goal?

James Hill:
Oh my gosh, we're back to precision approaches, Holly. It's not just how much weight comes off. What are they losing? Fat, muscle. What happens when the medication stops? This is when you and I have hammered and hammered and hammered. The problem is not solved when you reach weight loss. You have to keep it off. What happens to diet and physical activity?

Holly Wyatt:
Exactly. And eventually you get to even a bigger question. What does successful obesity treatment actually look like now?

James Hill:
Wow, that's really interesting. We're reframing our measures of success. So maybe the biggest thing these drugs have changed isn't just the amount of weight people can lose.

Holly Wyatt:
No, Jim, they've changed the questions. They're creating more questions and different questions.

James Hill:
All right. So that's where we're going today. I see it clearly now, Holly. I see the problem and I see where we're going.

Holly Wyatt:
Yep, we're going to be talking about what happens when weight loss works.

James Hill:
So, as always, what do we know?

Holly Wyatt:
Yeah, let's make sure we're all on the same page, because the game really has changed. We talk about that all the time. The game has changed. How did we get here? What has changed so rapidly?

James Hill:
Yeah, now we've had medications for a long time. I mean, as a junior researcher, I was involved in different kinds of medications, looking at them for weight loss. They produced some weight loss, but wasn't very impressive. And most people weren't extremely happy with the amount of weight they lost.

Holly Wyatt:
And some of them had side effects that they ended up being drugs we couldn't use anymore, you know, didn't turn out to be.

James Hill:
Yeah, there's a whole history of drugs that were approved and withdrawn from the market for weight management because of negative side effects.

Holly Wyatt:
Yeah. So I would say we had lifestyle and we had some older medications, but they produced weight loss. We were really happy, I think, with 10%.

James Hill:
10% would be a good lifestyle program, right?

Holly Wyatt:
Exactly.

James Hill:
10%, a good lifestyle program. Even the older meds combined with lifestyle didn't do. We were lucky if we got 10% there.

Holly Wyatt:
Yeah. And then came this new generation in semaglutide.

James Hill:
Semaglutide. Wow. It hit like a sledgehammer.

Holly Wyatt:
Yeah.

James Hill:
15%.

Holly Wyatt:
And that was kind of that threshold where people are starting to get closer to their happy weight. I always said when we started to get around 15% and some people getting more than 15%, we're starting to get more people are saying, “All right, this is a good amount of weight loss. I'm happy or happier with this amount of weight loss.” And then came tirzepatide.

James Hill:
Tirzepatide, 20% at the higher doses. Wow.

Holly Wyatt:
So it got even better.

James Hill:
But we're not done yet, right? Those are the two that are out there now. But there are a whole bunch more coming down the pike.

Holly Wyatt:
Yeah, including a triple agonist that will probably be out in 2027 sometime. And it's looking like producing maybe 30% or close to 30% weight loss.

James Hill:
Wow. There are a lot of people that don't need to lose 30% that might be on these medications.

Holly Wyatt:
And that's what we're going to talk about, because how do we decide how much weight loss? We've always been limited before, and now that limit may be going away. So when we talk about clinically meaningful weight loss versus weight loss, weight loss that our patients want or that's meaningful to them. That's going to start to change things. We're going to have to have to ask a lot of different questions.

James Hill:
For many, many years, we try to convince people to be happy with 10% or 8% or whatever. And that was a tough one because people really weren't. And I think you were right. I think the 15% mark is a rough mark at which you don't have to, you don't have to convince people of success. People see it as success and they want it.

Holly Wyatt:
Yeah. So what happens, Jim, when the treatment no longer determines how much someone can lose? When the treatment doesn't have a ceiling, basically. We always had a ceiling. We didn't have to talk about how much weight loss because there was kind of a max before they were going to plateau. Now, what happens when the treatment no longer determines necessarily how much someone can lose?

James Hill:
So whose responsibility is it to take a look at that? Is that the prescribing physician? Is it the patient themselves? Is it a lifestyle coach? I mean, who steps in and says, “Holly, you know what? You don't need to lose any more weight.”

Holly Wyatt:
Yeah. So that's one of our questions that we're going to be asking. I think that's a big one.

James Hill:
Are we going to answer it?

Holly Wyatt:
I don't know if we're going to answer it, but we're going to ask it.

James Hill:
We're going to talk about it.

Holly Wyatt:
So we came up with six new questions that these new generation drugs are putting out that we didn't have to answer before. But now we're going to need to answer. So the first question we've been talking about is, how much is enough? And I think the best way to look at this is, let's do a patient example so people can kind of understand what this is.

James Hill:
Give us an example.

Holly Wyatt:
So let's say, Kim, she's 52. She has a body mass index of 38. She has prediabetes, high blood pressure. She's had high cholesterol. And she wants to reduce her cardiometabolic risks, or she wants to be healthier. But she also comes in and says, “I want more energy. I want to move easier. I want to be able to get up and down and my joints not hurt. I don't want to think about food and my weight. I've thought about food and my weight my whole life. And I would like not to have to think about that as much. And I want to lose enough weight that it feels meaningful to me. I want it to be not just a little bit. I want it to be something that makes a big difference for me.”

James Hill:
Okay.

Holly Wyatt:
And then eight months later, you know, this is what she wants. Eight months later, she comes back. She's lost, let's say, 25%.

James Hill:
Wow. So that's great.

Holly Wyatt:
Yeah. She's lost 25%. So let's say she started around 220. She might be at like 175.

James Hill:
Wow.

Holly Wyatt:
Kind of give you an idea there. It would depend on a couple of things, but that would be kind of in the ballpark. And let's just say she's lost 25%. Her hemoglobin A1C has improved. She's no longer meets the criteria for prediabetes. Her blood pressure, cholesterol has improved. She talks about the food noise. She doesn't think about food all the time. She loves that. Her hunger's decreased. She's more satisfied. She feels better. She has more energy. And her weight now is currently stable. So she's not losing anymore. She's maintaining. But she comes and she says, “I'd still like to lose some more. I've lost 25%, but I'd like to lose some more.”

James Hill:
Wow. That's a tough one.

Holly Wyatt:
What do we do with that?

James Hill:
How much is enough?

Holly Wyatt:
Or how much is too much?

James Hill:
How much is enough? And what should be the outcome? I mean, why does she want to lose more? Metabolically, wow, she's really improved. But there may be some other reasons. She may feel like she wants to look better. I don't know. This is a complex issue.

Holly Wyatt:
But we have never had to really look at this question.

James Hill:
We never have because she never before reached an amount that.

Holly Wyatt:
Right. The treatment maxed out. We couldn't get there. So it was always about like, let's get as much weight off as we can. That's what I would say. Let's go for as much as we can. Most of the time. Occasionally, I'd have a person that I would have to back off because they'd lose too much. But that was rare. So rare. Now, this isn't rare. We're getting in these situations where this isn't going to be rare.

James Hill:
So what is optimal weight loss for Kim?

Holly Wyatt:
Yeah.

James Hill:
She can probably produce more weight loss than is optimal for her. Wow. We've never seen that before.

Holly Wyatt:
Right. So we're going to be talking about maximal weight loss and optimal weight loss.

James Hill:
And they're not the same.

Holly Wyatt:
They aren't necessarily the same. And so how do we define that? We've never had to do that. So this is one of those questions that I think is going to be popping up more and more. And we don't have a history of really thinking about it because we've never been in this situation.

James Hill:
So are people discussing this with their health care providers, you think?

Holly Wyatt:
I hope so. But like I said, I don't think this is something… I haven't had to deal with this.

James Hill:
Again, the obesity specialist probably can handle that. But how do the primary care folks who aren't really trained to manage weight deal with this?

Holly Wyatt:
I think even the obesity specialists, I mean, we're having to think about it differently. Do we think about metabolic targets? Do we think about patient targets? Do we think about a broader health?

James Hill:
Well, there's quality of life issues. You and I have always pushed back against the people that say the only reason to lose weight is to improve metabolic health. That's one reason, but it's not the only reason. Feeling better, better quality of life, or certain outcomes, how do you balance all this?

Holly Wyatt:
And can there be too much weight loss? And then you get to a certain point. Body mass index continues to go down. When do you say too much is too much?

James Hill:
Wow.

Holly Wyatt:
I don't know.

James Hill:
That's a good one. I don't think we have the answer to that. But what I would say is this is a topic that we need to be discussing more.

Holly Wyatt:
Yeah. That maximal weight loss doesn't equal optimal weight loss. And how are we going to figure that out? And what factors are going to be included in there? Before it was like, okay, we know 5%, we get some benefit, that's good, and we didn't really have to think about the other end of this at all.

James Hill:
Yeah, wow, that's a good one.

Holly Wyatt:
Question two is one we've talked a lot about on the show, but this is a new question. I rarely thought about this very much. What are we actually losing?

James Hill:
Yeah, so if Kim lost 25%, that gives us magnitude, but not quality. How much fat did she lose? How much lean? how much muscle? What happened to her strength? What happened to her physical function? Is body composition enough? Just getting a DEXA to say you lost this much fat and this much fat-free? Or should we care more about function, how she can function in daily lives? So the question here, Holly, is the scale gives us one outcome, but what are the other outcomes other than the scale that we should be paying attention to?

Holly Wyatt:
And do some of these outcomes, for instance, your functionality or your lean tissue, should they be driving how much weight loss?

James Hill:
Wow.

Holly Wyatt:
Are they part of the equation to figure out, should she lose five more percent? Should she keep losing? Should we be looking about what's going on with her muscle before we make that decision?

James Hill:
You know, that's really an issue. I think a lot about it with aging folks, given that I am one of those, is muscle, preserving muscle is critical, not just for longevity, but for function as you age. And if you lose too much muscle, I worry that these people are going to be sarcopenic and they're not going to be able to function and that we've actually done more harm than good.

Holly Wyatt:
That's a perfect example for Kim. I mean, she's metabolically, she's improved. Let's say she looks perfect from a metabolic standpoint. And I don't think that's the only thing, but she looks really good metabolically. But you do a DEXA scan and you notice that, she's lost a lot of muscle and maybe you do some function tests and that's going down. Does she keep losing weight because she wants to? Or do you push back and say, “Look what it's doing now. We're going in a different direction and some other health parameters.” I mean, that's the tricky part.

James Hill:
It's another tough question.

Holly Wyatt:
Yeah. All right, Jim. Question three. And this is one we talk about a lot too, but I'm just thinking more and more about it. Who needs which drugs?

James Hill:
Well, we didn't have that problem before because we didn't have a lot of different alternatives. Now we do. Semaglutide, 15 percent, new drugs, maybe 30 percent - does that affect which drug is prescribed for which person?

Holly Wyatt:
And there's so many in the pipeline. Right now, people may be thinking or listening, saying, well, there's not that many out there, but there are so many coming. I think in the next several years, I think we're going to move to where we are with blood pressure pills, where we have lots of different categories and we can combine them.

James Hill:
They're going to be single, dual, triple agonists. They're going to be injectable. They're going to be oral. They're going to be combined, not combined, different modes of action. I mean, my gosh, it's going to get interesting out there.

Holly Wyatt:
Yeah, different durations. We're going to maybe have one where you can do something, you know, just give yourself a shot once a month. I mean, they're all different things, all different ways. So we're going to have all these different doses and types of drugs and the potential of really trying to match a little bit of who needs which drug.

James Hill:
So Holly, can you envision a scenario where let's take one of our, really qualified obesity docs who decide to prescribe a drug less effective for a person because another drug might produce too much weight loss.

Holly Wyatt:
That's what we do in high blood pressure. There's certain drugs that are more potent than others, and we don't always go for the most potent drug for the person. So you really start to think about what's the most effective drug, but becomes not just about that. Which one's really best for the person.

James Hill:
But that's different because for decades, it's been which medication can produce the most weight loss. And now it's a whole different ballgame.

Holly Wyatt:
Yeah, it's which drug, at what dose, for which person, for how long. That's where we're going. So lots of questions really rolled up into that one question that we're going to have to start answering.

James Hill:
So do you see this going toward precision obesity medicine?

Holly Wyatt:
Yeah, just like I think the analogy to blood pressure medication is valid in that we have a bunch of different types of medicine and we tend to match and we start to learn about which people have high blood pressure for different reasons and certain drugs may target certain people. So yes, I do think we'll get more precise with it.

James Hill:
All right, question four. This is my favorite, as you know, Holly. What happens after weight loss? For decades, we focused on weight loss and pretty much only on weight loss. Maintenance was an afterthought because not very many people reached the point where they thought about maintenance. But now what we're seeing, even though these medications are incredibly effective, 15, 20, 25, 30 percent, discontinuation of medications is probably more common than long-term usage. And over and over and over, we see statistics showing that people who discontinue the drugs are highly, highly likely to regain the weight.

Holly Wyatt:
Yeah. So it's a new question because we have to think about this. I know that people can stay on the medication and that's one option. But when we look at the data, that's not what most people are doing right now. I think one of the newest studies shows that about eight, nine, I think it was 84 percent by two years had discontinued for people who weren't taking it for diabetes. So people aren't staying at a long term. And so the question is, okay, what are we going to do after the weight loss, especially if they are going off that drug?

James Hill:
I think it's really interesting to revisit reasons why people may stop the meds. I think early on, it was cost. Cost and availability.

Holly Wyatt:
Or accessibility. They lost. We couldn't get the drug. We couldn't find it.

James Hill:
But I think that's changing now. We've done some podcasts on this. Anhedonia. A lot of people don't like the way the medications make them feel even, with no highs and lows. People miss food. What we realize is that food plays a role other than just weight. There are social aspects, et cetera. We're seeing some of these rare conditions. People talk about losing their hair and having eye problems and so forth. So I think we're seeing a sort of a evolution in the reasons that people stop the meds.

Holly Wyatt:
Yeah. And I think there's a group that just, they come to me and they say, I just want to try.

James Hill:
Yeah.

Holly Wyatt:
You know, maybe there is nothing wrong really, but they just say, I just want to give it a try. And I think that's reasonable to let them understand that they need to have a plan and they're going to have to do something, but to let them try. So to talk about what happens after weight loss and to have a plan. And I think other questions is, what about all this stopping and then restarting? Because I think we're going to see a lot of that.

James Hill:
Stopping, restarting, intermittent use, lower dosage, microdose. I mean, all this stuff is going on and we have very little, almost no scientific evidence to support it. But it's happening in the real world.

Holly Wyatt:
And what I worry a little bit about is we are creating maybe a new kind of weight cycling.

James Hill:
Yeah, I think that's really an interesting point. And the other thing, you know, I get most of my information from the Internet, Holly. And so out there on the Internet, they're saying, oh, when I go back on the meds, they don't work as well the second time. Do we have any data on that?

Holly Wyatt:
I don't know. I haven't seen a study. I would have to look specifically to answer that question.

James Hill:
Boy, there's just.

Holly Wyatt:
People have always said that about every type of treatment.

James Hill:
That's exactly right. But there's so much we don't know. I mean, boy, this is a fertile time for researchers in this area to ask some of these questions.

Holly Wyatt:
And I think with the weight maintenance, I mean, we've gotten so much better at producing the weight loss. We all need to catch up because we're not nearly as good at what happens if they go off. And so we need to spend more time in that area, I think.

James Hill:
Well, if you look out there, there's tons of support for losing weight. You may say some of it's good and some of it's not so good. There's not a lot of support out there for keeping weight off. Because we've never had a market for it.

Holly Wyatt:
Exactly.

James Hill:
For the first time, maybe we have a market for weight loss maintenance.

Holly Wyatt:
I don't know what that says about us, Jim. There's never been a market for it, but now there is. All right. Question five. And we talked about this question in our last two episodes. What is lifestyle's job now? We talked about, are diets getting better? Are we moving more when we're on these meds? What is role of lifestyle when we look at this?

James Hill:
Yeah, I actually think the role of lifestyle becomes more important, but in a different way. Take nutrition, Holly. All of my career, nutrition has been focused on helping people eat a diet to lower their weight and help them treat or avoid obesity. Well, you don't need that with the medications, but it plays a different role. First of all, you're eating maybe up to 30% less than usual. So the risk of nutrition deficiencies is really high because now in 70% of what you used to eat, you have to get 100% of the nutrients you need. So we're seeing nutrient deficiencies. And the other thing about nutrition is I'm really interested in long-term, even these people who stay on the medication after the wait stops. The data would suggest that if you stay on the medications, you're going to plateau, but you may not regain it. What's the role of nutrition? What happens to appetite there? I think we just need to refocus nutrition. I think it's more important than ever.

Holly Wyatt:
Yeah, because in theory, if you stay on the medications long term, your appetite stays low, you're going to be able to eat less calories for years.

James Hill:
Forever.

Holly Wyatt:
Yeah, for years. And what does it mean if you are not eating that low level of calories and not getting the nutrients in? What does that mean for your long-term health? Even though you're at a lower body weight, how do you match that up?

James Hill:
And the same thing for physical activity. I mean, it's pretty clear you don't need to exercise to lose weight on these medications. But there again, we've approached physical activity as helping lose weight, but physical activity does so many other things. It optimizes your metabolism. It helps your mental health. It helps your attitude. I think more than ever, let the medications do the heavy lifting on the weight loss, but let's position physical activity as contributing to health and quality of life in a very important way.

Holly Wyatt:
Yeah, I think both of us had hoped, and we just did two episodes, our last two episodes. Yeah, I'm still trying to recover from those two episodes. I think I had hoped that when you were on the medication and you didn't have the food noise, that it would allow you to make better quality choices. So even though you're eating less food, you would tend to pull and eat more vegetables or more fruit, or you would tend to maybe make better choices. And then the same thing for activity. If you lost some weight, your knees were better. You felt like you could move. You had more energy. People talk about feeling like they have more energy. Doesn't necessarily seem like it may be translating into moving more.

James Hill:
That's something that concerns me. I still think we really need to help people make the lifestyle changes. And I think lifestyle isn't becoming irrelevant, Holly, but I think its job is changing. It's doing something different. The meds can do the weight loss. Lifestyle can do many, many positive things other than weight loss.

Holly Wyatt:
Yeah, which really moves us to this last question. All this really kind of comes together in this last new question. What counts as success?

James Hill:
Well, that's easy, Holly. Happiness.

Holly Wyatt:
Oh, yeah. And that's a big piece of it, Jim. But I think this is going to be kind of complicated.

James Hill:
Oh, I agree. Because we focused before on weight and metabolic health, right? That's what we focused on.

Holly Wyatt:
Yeah.

James Hill:
But it's beyond that.

Holly Wyatt:
Now we have this whole lifestyle piece coming in.

James Hill:
Yes.

Holly Wyatt:
That you can do this without these changes. So it makes it even more complicated. So let's go back to Kim. I want to go back to Kim because I think this is a great example. So let's just, we already talked about her weight went down, metabolically, everything is improving. Her blood pressure is good. Her blood sugar is good. And let's just say Sarah also feels good. Her food noise is down. She has more energy. She doesn't think about food all the time. Her hunger and cravings are easier to control. She feels better. And so even let's even add in, she says, yes, I'm happier now. Let's just go ahead and say that. And then, though, when we look at other factors, other health behaviors, her diet quality is poor.

James Hill:
I'd want to know what's her diet quality. And we don't routinely measure that.

Holly Wyatt:
Yeah. She's sedentary. She is not getting activity.

James Hill:
So I would want to say what's happening to her strength and her function.

Holly Wyatt:
Yeah. On one hand, she's happier. Her metabolic health is looking good, but her diet quality is poor. She's not moving. Her strength, her function, her muscle function may be going the opposite direction now. What do we do? What do we say? Is that success? How are we going to have to start looking at those things? How do we help her make that decision? Should she lose more weight?

James Hill:
Yeah. And I don't know that she's thinking about this. And I think she should be thinking about this.

Holly Wyatt:
Yeah. I mean, you could see a different scenario where her metabolic markers are better, but she's not feeling better. I mean, you could see all the different combinations. I just did a presentation and I now have three buckets that I'm looking at. The metabolic markers that we've always wanted to improve. A big reason why we want people to lose weight. The personal kind of how the person feels. So that happiness and also that food noise and the things that really impact the quality of their life. And then the third bucket now is this health behaviors and lifestyle piece because they're not all necessarily going in the same direction.

James Hill:
Is success having people taking meds and being at a normal weight with poor diet and no physical activity.

Holly Wyatt:
Yeah. I don't know.

James Hill:
And doing that for decades. See, this is the thing. Weight loss is short term. Maintenace is forever. So if you take a 30-year-old person and they lose weight and they stay on the meds, they could be on those medications three, four decades.

Holly Wyatt:
And so we have good data to say that, like, improving blood pressure and improving blood glucose and et cetera that have good outcomes, health outcomes. But I don't know we have the data to say which is more important or how does it balance out.

James Hill:
I think you're going to have opposing forces. You're going to have a lot of forces promoting better health, but you may have some forces going in the opposite direction. And I think what we're saying is we should pay attention to those.

Holly Wyatt:
Yeah, which is more important. I don't know for sure. I don't know that we know for sure.

James Hill:
In the short term, I think the improvement in metabolic health probably is, but I worry over the long term whether some of these negative things now begin to outweigh the positive things. I just don't know.

Holly Wyatt:
And then add in, it is important how Kim feels and how she's living and the quality of life part of this is very important. And the fact that she doesn't think about food all the time. Very important.

James Hill:
You and I talk to a lot of people that use the meds, and some people are like that. They're very happy. But there are other people that they've lost the way, but they just don't feel good. They have no energy.

Holly Wyatt:
All right. So a physician, you see someone, and their metabolic profile has improved dramatically, but they don't feel good. What do you do about that?

James Hill:
Yeah. What do you do? You know, that's the questions. And so that even gets us down to, Who gets to decide?

Holly Wyatt:
That's the questions. And so that even gets us down to, who gets to decide?

James Hill:
Yeah.

Holly Wyatt:
And you brought that up at the beginning.

James Hill:
Who decide? Who's responsible?

Holly Wyatt:
Is the clinician?

James Hill:
I don't have an answer, but we need to talk more about this.

Holly Wyatt:
Yeah. Is Sarah deciding?

James Hill:
[29:16] I think it's probably shared responsibility.

Holly Wyatt:
I do. I do think that.

James Hill:
We have to sort of format those conversations.

Holly Wyatt:
Yeah. So those are six questions, new questions that have changed, that people are now talking about that I think we need answers to or we're going to be looking at in the future years for sure. So let's now, though, switch a little bit. So what should someone do about it? We always like to put some pie in the plate. So they're sitting there right now. What kind of advice can we give them, Jim?

James Hill:
Well, I'd say, first of all, don't use the scale as the only measure of whether treatment is working. Yes, it's a measure, but it's not the only measure. There are others.

Holly Wyatt:
Yeah. So if you're someone and you're taking one of these medications, here's some things to think about. Yeah, don't just use the scale. Think about other things like we've been talking about today. And then I think know what you're trying to accomplish beyond weight.

James Hill:
Yeah, we try to get people to think about assume you're going to lose the weight. Now, what else is important for you?

Holly Wyatt:
Yeah, new question to ask yourself.

James Hill:
New question. Pay attention to nutrition and, to strength, to activity, to physical function. I think we talked about on the last podcast, these aren't going to improve automatically. You're going to have to intentionally address these.

Holly Wyatt:
Yeah. And like we always say, and we say this on so many episodes, think about the long-term plan, not just the period where you're losing weight, not just active weight loss.

James Hill:
The last one, I think it's the last one, is that talk to your clinician about what successful treatment means for you because it may be different for different people, but that's a conversation that you can have with your healthcare provider.

Holly Wyatt:
And that's where I think we're gonna be going. I think we now have these three buckets, these three different areas and all of it's important. And it is gonna be having this conversation, talking about what's important. What does your clinician think's important in terms of your health? What do you think is important? And then also looking at these lifestyle pieces.

James Hill:
All right. Are we ready for some rapid fire?

Holly Wyatt:
Yeah, let's do some rapid fire. All right, Jim, are you ready?

James Hill:
I think so.

Holly Wyatt:
All right. First one, maximum weight loss or optimal weight loss?

James Hill:
Give me a softball to start. Optimal weight loss.

Holly Wyatt:
Okay. Not what I think we would have said before, though.

James Hill:
Well, I know. That's right.

Holly Wyatt:
We would have said it's the same thing, right? Get as much weight. I've said, I don't know how many times that, let's get as much weight off as we can. I've said that so many times. I think that's not something I want to say.

James Hill:
Rethink that.

Holly Wyatt:
Yeah.

James Hill:
All right, Holly. Scale weight or body composition?

Holly Wyatt:
Ooh, I'm going to say and, both. And also function.

James Hill:
Yeah.

Holly Wyatt:
All right, Jim. Strongest drug at the highest dose for everybody?

James Hill:
Again, that's a yesterday sort of thing. The answer is no. You have to look at the right treatment for the right person. All right, Holly. What about losing weight now and then figuring out maintenance later?

Holly Wyatt:
Oh, that's an easy one. Bad plan. Absolutely not.

James Hill:
It is. We hammer that over and over and over.

Holly Wyatt:
Yeah. All right, Jim. The medication's working. So lifestyle matters less?

James Hill:
No. The job of lifestyle is different. It's changing. But I think if anything, it matters more. All right, Holly, 22% down, everything looks great, but Sarah wants 5% more, yes or no?

Holly Wyatt:
Oh, nice try, Jim. Maybe. I'm going to need more information. I don't have enough.

James Hill:
Okay, okay.

Holly Wyatt:
Patient wants to stop the medication. Talk them out of it or help them make a plan?

James Hill:
Oh, good one. Help them make a plan. You and the patient need to side together. It's not the clinician's job to decide the outcome. If they want to stop, help them make a plan to avoid weight regain. All right, Holly, perfect A1C, perfect blood pressure, weight down 25%, but never exercises, eats terribly. Is that treatment success?

Holly Wyatt:
Yes and no.

James Hill:
No, no, no. You can't do that in rapid fire. You've got to give an answer.

Holly Wyatt:
Then you need to stop asking questions that don't have one answer because that, you know, there's success in that and there's definitely some not success in that.

James Hill:
All right. I'll give you that one. Fair enough.

Holly Wyatt:
All right. Next one. GLP-1 for life?

James Hill:
Maybe. For some people, not for everyone.

Holly Wyatt:
Yeah. All right. I like that.

James Hill:
If Sarah is happy with her weight, but her clinicians think she should lose more, what happens?

Holly Wyatt:
Now we're getting into who gets to decide.

James Hill:
Yeah.

Holly Wyatt:
And, you know, it could go the other way too.

James Hill:
Yeah.

Holly Wyatt:
If Sarah is not happy with her weight, but her, the clinician thinks she…

James Hill:
Wants her to lose more.

Holly Wyatt:
Yeah. I mean, it can go both directions. This is a hard one, Jim.

James Hill:
It is a hard one.

Holly Wyatt:
I think that, you know.

James Hill:
Who decides.

Holly Wyatt:
Yeah. I think both get to decide. And that's, that's going to be, it's going to be interesting. All right. Better number on the scale or a stronger body?

James Hill:
Easy. Stronger body.

Holly Wyatt:
Okay.

James Hill:
All right. Better diet or another 5% weight loss?

Holly Wyatt:
Oh, Jim, that's mean.

James Hill:
Pick one.

Holly Wyatt:
That is mean. I'm going to say better diet, probably.

James Hill:
Probably.

Holly Wyatt:
Yeah. You started this, Jim, so.

James Hill:
All right.

Holly Wyatt:
All right.

James Hill:
Who gets to decide what successful treatment looks like?

Holly Wyatt:
And that really is the question, isn't it?

James Hill:
It is. And that's what we talked about. And we don't have the answer, but it's a question that we need to discuss and we need to talk about it. And people on the medications need to think about it. People prescribing the medications need to think about it.

Holly Wyatt:
But I love it that we have these new questions, Jim.

James Hill:
Yeah.

Holly Wyatt:
I mean, the field really has changed. The game really has changed. I mean, for the longest time, I felt like we were trying to answer the same questions. Now we have these new questions because everything has changed so much for us.

James Hill:
All right, Holly, vulnerability time.

Holly Wyatt:
Okay.

James Hill:
I'll start. You've spent your whole career trying to help people lose weight. What's it like to finally have treatments that make you ask whether someone needs to lose any more weight?

Holly Wyatt:
I've never been in this situation. So I'm happy about it because that's what we've been trying to get to, right? Where we could actually produce this amount of weight loss. So it feels good, but it also feels strange. Some of the things that I've said for so long no longer make sense. And so having to really think about this and make, some new decisions and help people make some new decisions is exciting, but also just a little bit scary because it is so new and we don't have all the data. Yeah, new territory. And we're not sure about some of these answers to these questions. All right, Jim, let me give one for you. What's something you believed about successful weight loss for most of your career that these medications are making you rethink?

James Hill:
This is a good one, Holly. And this is one I think a lot about. I believed, and I said over and over and over, it is necessary to be successful at weight loss maintenance to have a high energy flux. You have to have a lot of energy in and a lot of energy out. Maintaining weight with low energy in and low energy out, it's not feasible for most people. The medications allow you to do that. They allow you to lose weight at low energy flux. You eat less and you can move less. And it works at least in the short term. So I'm having to rethink that whole thing because I would have told you before the medications, it's not going to be possible to keep weight off without a high energy expenditure consequently matched by high energy intake.

Holly Wyatt:
So it's like we almost have this new physiology.

James Hill:
New physiology.

Holly Wyatt:
You didn't think could exist in very many people. And now it's existing in a lot of people.

James Hill:
It's existing in the short term. I still want to see over the long term, but I will have to say it's made me rethink my position on this.

Holly Wyatt:
But we've got to study that. I don't think we know what that...

James Hill:
We've got to study it. That's right.

Holly Wyatt:
What that means. Oh, such an interesting time. All right, Jim, sum it up for us.

James Hill:
All right. So here's the pile on the plate, Holly. For most of our careers, the limits of our treatment were determined by the questions we ask. How do we get more weight off? The pharmacology has now changed what's possible. That has changed the questions we ask. We're now asking how much weight loss is enough? What are we actually losing? Which treatment is right for the right person? What happens after weight loss? What's the job of lifestyle now? And ultimately, the big one, what does successful treatment look like and who gets to decide?

Holly Wyatt:
Wow.

James Hill:
The drugs have changed the game. Now, obesity care has to change with it.

Holly Wyatt:
We've got to change with it, too.

James Hill:
We do. Wow.

Holly Wyatt:
All right. This was good.

James Hill:
A good episode. Hopefully we made you think. We'll see you next time on Weight Loss And.

Holly Wyatt:
Bye, everybody.

James Hill:
And that's a wrap for today's episode of Weight Loss And. We hope you enjoy diving into the world of weight loss with us.

Holly Wyatt:
If you want to stay connected and continue exploring the “Ands” of weight loss, be sure to follow our podcast on your favorite platform.

James Hill:
We'd also love to hear from you. Share your thoughts, questions, or topic suggestions by reaching out at weightlossand.com. Your feedback helps us tailor future episodes to your needs.

Holly Wyatt:
And remember, the journey doesn't end here. Keep applying the knowledge and strategies you've learned and embrace the power of the “And” in your own weight loss journey.