Why Weight Loss Drugs Alone Won’t Change Your Habits with Thomas Wadden

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:

Today, we are diving into a really big question. Do the old rules of weight loss still matter in the GLP-1 era? We've been talking about these new drugs. Have things changed because of them? With all the excitement around these powerful new medications is diet, exercise, your habits, your routines, are they still important? Or can the medications really do all the heavy lifting and you can just forget all that other stuff?

James Hill:

What a great question, Holly. Now, I think we know these meds are game changers, but the question is, are the behaviors we've relied on for decades still important? And what happens if you stop the meds? That's what we're here to explore today.

Holly Wyatt:

And to help us unpack this, we've brought in one of the true pioneers of behavioral weight management, someone who shaped our understanding of psychology and behavior, both in terms of weight loss and weight loss maintenance.

James Hill:

Listeners, you're in for a treat from our guest today. Dr. Tom Wadden is one of the most influential obesity researchers in the world. He's the Albert J. Stunkard, and we may talk about Albert J. Stunkard a little later. He's the Albert J. Stunkard Professor of Psychiatry at the Perlman School of Medicine at the University of Pennsylvania, where he served for 24 years as the director of the Center for Weight and Eating Disorders. Tom has developed many behavioral interventions for weight management that can and have been implemented in clinical settings. He is the expert on combining behavioral and pharmaceutical interventions for treating obesity. He's a former president of the Obesity Society, and in a couple of weeks, he will receive the George Bray Outstanding Scientific Achievement Award in Obesity Research from the American Society for Nutrition. He has mentored a generation of obesity researchers and clinicians. Tom, thanks for joining us today.

Thomas Wadden:

You are so welcome and such a pleasure to be with you. And I know your audience knows that you two are among the world's authorities on weight management, and that's why you have this podcast. Thanks for including me.

James Hill:

Sure. All right, Holly, you want to start us off?

Holly Wyatt:

Yeah, let's jump right in and let's just go to that question. I know so many people are kind of thinking about this. Do the old rules of weight loss still matter now that we have these new medications?

Thomas Wadden:

I think that many of the old rules still apply. However, I think there's been a real change in patients' experience in being able to reduce their food intake and their calorie intake to get to that 500 to 700 calorie a day reduction. And that change makes it a lot easier for people to lose weight than it may be when they're just doing an old-fashioned calorie counting, point counting, and the like. If you talk to folks, most of them will say, you know what, I'm just not thinking about food all day long. I'm not thinking about my favorite foods. There's been a real reduction in the food noise. And so you spend less time now saying, well, let's try to figure out how do we shave off calories to get to the 500 and 700 to calorie deficit. And instead, let's focus on trying to eat a healthier diet. It's not going to be that hard to shave off the calories. The medication will help you do that. But you still want to eat a healthy diet full of, you know, lean meats, fish, fowl, more fruits and vegetables and the like. So that's one of the old rules, but you're able to get to the energy deficit, the calorie deficit in an easier fashion.

Holly Wyatt:

Do you think people are doing that? Or do you think they're just eating less of maybe not the healthier options, you know? The same foods, just less of them because they're not as hungry.

Thomas Wadden:

Holly, that's the question I wonder about, along with are people exercising more as a result of being on these meds? And when you try to find any answers about it, I can't find them.

Holly Wyatt:

Yeah.

James Hill:

Yeah, we can't either, Tom. And it looks to me like you've done this for a long time and you and I have worked together for a long time. In this one, the meds are doing the heavy lifting on weight loss. Okay. So you're saying, is how I eat going to affect my weight that much? I don't think it is, but I think there may be other things that those behaviors do. So I think it's reevaluating our goals. And you know as well as I do, most people go into this and the one thing they want is weight loss. Well, I think the meds are giving them that. Can we sort of recalibrate people to understand some of the other aspects that eating healthy and exercising are going to bring?

Thomas Wadden:

Yeah, it's almost as if I don't have to worry about how I'm going to get 500 calories off.

James Hill:

Yes.

Thomas Wadden:

Focus on what looks like a healthier diet. Can I eat some fruits and vegetables, which I've never been very interested in, but now all of a sudden, since I don't have to eat them to lose weight, they are more appetizing to me. So I think it's freed people up from the preoccupation of having to count their calories or their points. They're using less headspace on calorie reduction. And now you might be able to focus on food in a different fashion that way. The other side of it, which I know I don't need to convince you of, is that you really do need to focus on your physical activity because physical activity is such an important predictor of cardiovascular health. The more you exercise, the healthier your heart, decreasing your chances of diabetes and other illnesses, more energy, more quality of life. And I have no evidence that taking these injections are necessarily getting people to increase their activity. And it's such an important part of the equation that you wanted to do that.

James Hill:

It's such an important question because I read these articles, usually in financial media and so forth, saying, oh, these things are going to change the way people shop. All their gyms are going to be just overwhelmed with people. I'm not sure, Tom. I don't know that we have enough data to be able to say that just losing weight on these meds is going to get people motivated to make the other choices.

Thomas Wadden:

Well, I think there's one interesting paper by Dr. Lundgren out of Copenhagen, and it was a study that used liraglutide 3.0. That was one of the early GLP-1s. And she had people who were assigned to first lose a lot of weight. They lost close to 28 pounds on a low-calorie diet run-in for eight weeks. And after they've lost weight, they were assigned a placebo or to an exercise program or to liraglutide, the drug, or to the combination of liraglutide and drug. And it turned out that the people who got exercise or drug plus exercise had by far the biggest improvements in their cardiorespiratory fitness. The liraglutide people who lost weight and kept the weight off, they were not improving their fitness. So I think that really do need to focus on exercise for the benefits it's going to confer, not having to worry about using exercise for weight loss.

Holly Wyatt:

Right.

Thomas Wadden:

I have a friend who wrote the step diet program and it was very instrumental in making me think about my steps as a way to control weight for sure. But now you don't need to think about that per se in terms of getting your caloric deficit.

James Hill:

See, I think that is a key. You don't have to worry about what you eat or whether you exercise for the weight. They're for different purposes. And this is so critical because we know people come to you, people who come to us, all they're looking for is the number on the scale. Now, when they get the number on the scale, is that an opportunity to sort of help them understand there are other aspects of success?

Thomas Wadden:

Yeah, and there are other aspects of success that are going to really improve your health overall, that you're going to go beyond the improvements you get from these drugs. We should acknowledge that these medications are remarkable in how they are improving health, that they are helping people, you know, prevent the risk of heart attack and stroke if they've already had one. They're helping people with their sleep apnea. They're getting better control of type 2 diabetes. So even as we don't know what sort of changes are being made in diet and physical activity, we're seeing some impressive improvements. But I do remain concerned that people, as you suggested, Holly, maybe I'm still eating a diet that's a poor nutritional quality. I'm just eating less of it. And wouldn't it be better to try to get a heart-healthy diet going there?

Holly Wyatt:

That's what I worry about, too, because we know that weight loss is what motivated people to change their diet. I couldn't even get people excited about physical activity to maintain a weight loss, right? They just concentrate and you did some of the papers on the happy weight. And if they didn't, you know, that was the motivation behind it. And so now how are we going to get people motivated to increase physical activity because it's good for you? That hasn't worked. I mean, we can show them the data. We've had the data for a very long time. We can tell them. I think people know that. I think they'll repeat it back to you. But it still doesn't seem to be enough of a motivator for some people. You know, this is not everybody. For some people to say, I'm going to spend the time and the effort to move more for that reason. And that's what worries me, really.

Thomas Wadden:

I agree with that. And I do think paradoxically that it may be, and I have seen this in a couple of people, this is not universal, but it may be that once people have had some success in losing weight, that they do feel a lot more comfortable in being physically active. And so what we were trying to get people to do to lose weight, now they can do as a consequence of having lost the weight. They can start to be physically active. And I've had a couple of people who have taken up, one took up swimming, another has been taking up pickleball. And they are very pleased that they can be more active. One is going to the gym frequently. But it's still an issue that we need to address. And there's just so much research to be done in this area. I don't know about you all, but I feel like, gee, we are just at the beginning of this revolution.

James Hill:

Makes you wish you were younger, doesn't it, Dr. Wadden?

Thomas Wadden:

Well, Jim, I must say, if only we had more time in our...

James Hill:

Hey, Tom, I want to talk a little bit about who's prescribing these. And so we interact with a lot of physicians that really are experts in obesity. And my guess is they're giving these patients a comprehensive sense of what to do and so forth. But we all know they're going to be prescribed by primary care people, some of which know more and others less about obesity. And then you and I both hang out with registered dietitians who are trying to play a role here. Is there a role for them with the physicians that might not be the obesity specialists to get people going?

Thomas Wadden:

I think there's a critical need for registered dietitians. And again, they can spend their time on different issues. When I look at these weight losses and I suspect you all think the same thing, when you're losing 15 to 20 of your weight and you're doing that in the first 8 to 12 months,

Thomas Wadden:

I automatically think about, well, what's happening in terms of your body composition?

Thomas Wadden:

And when we had very low calorie diets that Oprah popularized back in the late 1980s, the big concern was making sure people got enough protein, dietary protein, to prevent the loss of bodily protein. So it really does worry me that if people are going on these medications and they feel like, well, I'm not hungry, so I'm just not going to eat or I'll just eat some cheese and crackers or something, it worries me that people are not getting the protein that I think is necessary to maintain body composition. So dieticians should be seeing these folks and saying, you probably should be getting 75 grams of protein a day. You're a bigger guy. You should be maybe getting as much as 100 grams of protein and help them identify where are the foods that have protein. They may want to get on one of these, high protein shakes. They want to meet lean meat, fish and fowl, cottage cheese, whatever it is.

But that's really a major concern. And laughing about where we are in our careers, Jim, I don't know about you, you get a whole lot of physical activity, I know. But I'm certainly, I think, at risk of already losing muscle mass because I'm 72 and you get that stage of age, you start to lose it. And if you get on one of these drugs and you're losing so much weight, so rapidly, you could be losing vital skeletal muscle mass and be set up for sarcopenia, which I'm sure you all have talked about on this show before.

James Hill:

Yeah, I think, Tom, there's more and more evidence suggesting that your muscle mass is a great predictor of your longevity. And again, we could argue about some people think on these meds you lose proportionally more muscle than you would otherwise. But at the end of the day, if you're losing 20, 25 percent of your body weight, you're going to lose a good deal of muscle any way you go.

Thomas Wadden:

Yeah, you have to. When you do the weight loss the old fashioned way with diet, exercise and behavior therapies we did for many years, people would lose about 8 percent of their weight. Let's say that they lost 20 pounds, but only about 10 to 25 percent of that weight loss came from muscle mass. And now, at least with semaglutide in one of the studies, 39% of the weight loss came from, fat-free mass from muscle.

James Hill:

And Tom, we're going to talk in a second about when people go off the meds. But one of the things I worry is if you lose a lot of weight, when you lose 25%, and then you regain their weight. I mean, we know from look ahead and other studies that you could actually end up worse than when you started, especially if you're old like you.

Thomas Wadden:

Yeah, we're worrying about the same things, Jim, because I do worry about that.

Holly Wyatt:

So this kind of leads to another question that I had then. Given these new drugs, what you're telling people in terms of behaviors, has it changed? Have you changed what you classically would say are the behaviors you could be doing or even should be doing during weight loss if you're on the drug?

Thomas Wadden:

Yeah. In many ways, that's where I think the old rules apply, Holly, that I think people still have to develop a meal plan that they're going to stick to and plan out what breakfast, lunch, and dinner are going to be and what their snacks are going to be. Because in many cases, they don't have a meal plan. They may just forget to eat all together. So I think that you need to get a schedule and to eat on the schedule and try to deal with the fact that you may not be that hungry, but to still eat something. And then picking the foods in that meal plan gets to be particularly important. And it's the, for me, the high protein foods are the first thing I'm worried about. Then I want to look at fruits and vegetables, getting more of that and more fiber. And finally, I think water is very important to get in your eight glasses of water or maybe more if you're a big person. That's going to help with keeping people regular with laxation. It's going to keep your kidneys functioning and the like. So having a meal plan, developing a habit that will support you when things get a little crazy in your life is very important. What you don't need to do is count the calories.

Holly Wyatt:

Yeah. It reminds me of bariatric surgery, the kind of advice or behaviors you recommend if someone's had surgery. I think that kind of seems parallel, you know. Eat protein first, potentially, to make sure you're getting enough. If you don't think you're going to be able to eat very much, then let's make sure you get in lean protein before you get in something that doesn't have as much nutrient density that could help you. Have you changed in terms of what you tell them about physical activity? Have you switched to saying we should be doing a little bit more resistance training or you think it doesn't really matter?

Thomas Wadden:

I think it does matter just in terms of following the CDC guidelines. You certainly want to be doing two days a week, some kind of strength training to maintain your muscle mass and your strength and your functionality. And there's always the question, and this is where, you know, you keep saying we need research. There's always the question, can you prevent some of the loss of skeletal muscle mass by doing resistance training? I spent time, as did a guy named Joe Donnelly, who you all know well, trying to see when people are losing weight on very low calorie diets, could resistance training prevent the loss of lean body mass? And it's mixed findings on it, but it's certainly resistance training is good for other things, even if it's not going to help you keep that lean mass. I think it probably benefits it, but we don't know yet. We just don't have the studies on it.

James Hill:

And it's likely that the combo of high protein and resistance can be synergistic there because I think people are a little naive about what high protein can do for muscle without the stimulus, which is activity. So if you've got the protein and you use the muscle, there's an effect, but the protein alone isn't really going to do it for muscle. It may do some other things.

Thomas Wadden:

Right. Now, so, I think that we've got the same view of the fact that people need to pay attention to what they're eating for sure, and they need to pay attention to their physical activity for the long term. So, Holly, I'm interested in your experience with patients who need sort of special support because they're having adverse GI events. We know about 45% of people report that they have some nausea, and then 35% they're going to report that they've got constipation and another 25% vomiting. We find that. I'm just curious, in your experience, what do you do with these persons to help them manage the GI side effects that come up? Not everybody experiences them for sure, but for those who do.

Holly Wyatt:

One thing is you go slower than you think with the dose escalation. I think a lot of docs and patients feel like they need to get up to the some max dose or this optimal dose quickly. And I find that that's not necessarily required. I say, I want you losing weight on the least amount of medication possible. And that kind of goes hand in hand, usually with having less of those side effects. So that's one of the major kind of tools I use. And if they start having those side effects, I'm going to hold. We're not going to increase dose.

And then I do think it is kind of playing around with food sometimes. What is better for them? You don't want things that are large volume. Some people are very sensitive to the volume. So is it about a volume thing or fiber, which unfortunately we want to increase fiber for other reasons, but sometimes fiber is not the best thing when you're on these medications. So then it's looking for what foods may be causing a problem and can we substitute, kind of being a detective. I really think you have to do just like you have to do with everybody when it comes to weight loss, what's working, what's not working. And it really kind of support them through it, small meals, and know that we can even back down on a dose if we need to. I don't think we know the optimal dosing necessarily for these. I mean, I know they've been through the FDA, the trials, but I think we're going to get better at figuring that out. And it's going to be different for different individuals.

Thomas Wadden:

Things that you're saying are so consistent. What our registered dietician, Sharon Leonard, says is that you really need to see what foods seem to be associated with these symptoms. And for in her experience, they're often the fried, greasy, oily foods. So if you start the medication and you're going out for burgers and fries, you may increase the likelihood you're going to have a problem. But she does also say there are some patients who are just very sensitive to the dose, have a lot of nausea. And for them, she says, we sort of treat them like they're on the pregnancy diet. So they may be getting small things, crackers, they maybe get ginger chews and things like that. People vary dramatically in terms of their sensitivity to these side effects I've found. And so you just meet them where they are. But that's where I think, again, a registered dietitian is critical, who's going to take time to talk with.

James Hill:

I agree. I think it's an opportunity for dietitians to step up. And these meds are a tool, but who better than the dietitian to know how to use that tool along with the lifestyle tools?

Thomas Wadden:

And I think the seductive thing, Jim, is that if you look at the studies of tirzepatide, that they only provided nine visits with a registered dietitian over 72 weeks and they got a 20% weight loss. So you feel like, who needs a dietitian?

James Hill:

Right. I want to switch gears for a second. So I think the three of us would totally agree that these new medications are game changers in a very positive way. They are welcome, welcome tools. People are reaching their happy weight. And for those of you that don't know, that's a weight that Dr. Wadden and Dr. Gary Foster found that people who go into weight loss programs, weren't going to be happy until they lost 20, 25% of their weight. And traditionally, we've not been able to do that. And now people are reaching their happy weight. So Tom, why does all this data suggest that people aren't staying with these meds over the long-term if they're so effective?

Thomas Wadden:

Yeah. Those are questions that are beyond my pay grade.

Holly Wyatt:

Oh, come on.

James Hill:

No, no, no. You can't get off this easy. You know about everything.

Thomas Wadden:

I think a lot of this is economic and that people either find that their insurers are not going to be covering the drug continuously. We've just had at our university that the insurance plan is not going to be covering the medications the way it was because there's such demand for it. So if you're not getting insurance coverage for it and you feel like I can't afford these medications any longer because even at the best circumstances, they're now about $500 a month out of pocket. They were $1,200. Now they're $500. Even in the best of circumstances, they're very expensive. So I say it's above my pay grade, but I do think a lot of it is the economics of it and the fact that the drugs are not covered by probably 50% of insurers. They're still not covered by Medicare unless you've got a history of stroke, heart attack, etc.

So in terms of people who have good coverage and decide to stop taking the drug, it's a terrific question. I think part of it is the mistake of thinking... I've achieved what I want. I've lost the weight. I've cured myself of my problem with weight, and I can stop taking the drug. And I think everybody knows, you mentioned George Bray earlier. George Bray has said for the last 30, 40 years, weight loss drugs only work when you take them. And the fact that you regain weight when you don't take them shows you just how well they work. And so I do think that a lot of what we have to do when you start talking about these medications, is to introduce the possibility that these medications will be used like the same medications you take for your blood pressure, for your cholesterol, for your diabetes, and they potentially are aids that could help you for a longer term than 40 weeks. And don't make the mistake of thinking just because you've reached a dream weight or a happy weight or whatever it is that now you can stop. Now you do need the medication to help you maintain the weight. Just like I've been on a statin for 20 years, I've tried to come off of it, but I cannot come off of it and keep my LDL cholesterol down despite all the behavior change I make.

Holly Wyatt:

But I like that you said that you said you tried to come off of it. You have tried to come off of it.

Thomas Wadden:

Definitely.

Holly Wyatt:

Well, if someone wants to try, and that's what I think some patients who could afford it but say, you know what, I don't know that I want to be on this drug for the rest of my life. Maybe they do have a little bit of nausea or they don't enjoy food as much. I mean, there's some people who say, you know, I used to really like to go out to eat, that was a big family thing we did, and now it's just not the same. So for those people who want to give it a try, I don't know that that's a wrong thing to do. And what would you suggest? How should they think about that?

Thomas Wadden:

Oh, I think it's very reasonable to decide I'd like to see what it's like to try to maintain my weight without the medication. I think that's completely reasonable. And I had a patient who's just finished up a study with us and said, and we talked about, are you going to continue on it because he has good insurance? He said, "Well, you know what? I'd really like to come off the medication just to see what my hunger is really like. It's been so long since I felt hunger the way I originally did before I knew what fullness was. So I'd like to at least check in and see what that would be like." But Holly, I suspect you feel similarly, that if you want to come off the medication, bring the dose down slowly. I think the toughest thing is to go from a full dose of semaglutide or tirzepatide and say, okay, we're stopping the dose like they do in all the clinical trials. Let the dose come down slowly and the person can see as we take away medicine, here's what I have to add in terms of behavior. So it may be that I am at 5,000 steps and I've got to get up to 10,000 steps. It may be that I am eating fewer calories, but now I've got to really pay attention to the fewer calories so I can match what I was eating when I was on the medication. So if you take away the medication, I think you will have to add more behavior. But people can figure that out and they may decide, "You know what, I can do it. I'm going to be successful. And if I need the medication again, I'll go back to it."

Holly Wyatt:

Exactly. That's success. I think people think, oh, you could go off the med, be successful for some period of time, regain a little weight, go back on the med. That's success. That's, I think, how we're going to have to look at this.

Thomas Wadden:

Agree.

James Hill:

You're speaking our language, Tom. And as our listeners know, Holly and I've written a book that'll come out the end of this year on how to keep the weight off without the meds. And we say right up front, we're big fans of the medication, that if you're on the medication, you're doing well, it works for you, keep taking it. It's fine. And we also say that the available data strongly suggests that if you stop the medications without a plan, you're going to regain the weight. So the reason we wrote the book is to give people options. We're saying, if you want to try it, we're going to give you what we think is your best chance of doing it. But we very much, as Holly says, is if you go off it, you need to come back on the drugs. There are lots of options there. I think one of the problems, and you said it, is people still don't see obesity as a chronic disease. It is a chronic disease. Those of us in the field know that. But we see so many people, they're on the meds, they lose the weight, they say, "Oh, man, I've got it. I don't need these meds anymore." And then they stop without a plan. The food noise comes back. The hunger comes back. What I think we have to do is to give people many, many options that range from chronic use of the meds, just like the statins forever, to going off and managing lifestyle, to many things in between, which is what you've done your whole career, combining meds and behavioral treatment.

Thomas Wadden:

I wanted to know when people come off the meds if in fact they come down in their dose and then come off the med. Do you think there's anything we've learned from the National Weight Control Registry that could help these people? I'm sure you've discussed the National Weight Control Registry.

James Hill:

So we have, Tom. And one of the things Holly and I talk a lot about is we've been interested for a long time in weight loss maintenance, but nobody ever cared about weight loss maintenance because nobody ever got to the point where they wanted to be in weight loss maintenance, right? So what we've been thinking a lot about is the behavioral strategies for weight loss are different from weight loss maintenance in many ways. In some ways, traditionally, behavioral treatment of weight loss, you can go and sort of take a time out. You don't go out to eat. You don't go to buffets.

You take yourself out of this thing, and it works for a while. But with weight loss maintenance, you got to live your life. And so I think by separating... What we feel like is if we don't have to do the weight loss, this is great. We can concentrate on weight loss maintenance, which is exactly what we learned from the National Weight Control Registry. We learned that there was very little similarity in how they lost it, but a lot of similarity in how they kept it off. And so we're approaching this, and this is a lot of stuff we learned from the National Weight Control Registry, we're approaching it three-pronged. What can you do on the diet side when you come off the meds? What's going to happen? Your hunger is going to come back. The food noise is going to come back. Okay. What you can do on the physical activity side, these people in the National Weight Control Registry do an hour a day of physical activity. So how are you going to build up to do that? And the third one, and Holly's really led the way here, is your mind, how you can use your mind more, to be ready to solve the problems that are going to come up, resilience and positivity and how you approach not just weight, but how you approach your whole life.

Thomas Wadden:

Yeah. I like the expansion. I mean, I always think about the four cardinal behaviors of the weight control registry folks, you know, weighing yourself regularly.

James Hill:

That's right. Regular feedback. And they keep saying, how am I going to know if I'm gaining weight if I don't weigh myself?

Thomas Wadden:

Yes, exactly right. So, I think that there's a lot to be said for trying to get people prepared before they come off these medications, obviously, that they've adopted all the behaviors that you see in people in the National Weight Control Registry. And then, Holly if you can, in addition, arm them with a new mindset that's going to prepare them for the fact the food noise is going to come back and the like.

Holly Wyatt:

Yeah. And, Tom, I'm even thinking of it, there's a transition period. This is almost new. This is, to me, it's kind of new. Jim and I have been thinking about weight loss and weight loss maintenance as being separate. But I almost now see a transition period between the two. And as they're coming off the meds, you do need to get them ready.

You can't just flip a switch. It takes some time. And so this new kind of transition period, I think we might be hearing more about or thinking more about and making it very, you do this purposefully. It's not just you just stop the meds and see what happens. You really have a strategic plan to do that. One question I wanted to ask you, because I'm getting, people are talking about this and I want your input. A lot of times when people go on the meds, they really talk about the noise. The food noise is zero and appetite is very, very low. And when they then stop the meds, a lot of them are saying, oh my gosh, it's coming back and it's stronger than ever or more than it used to be. And I'm wondering, is it more than it used to be or do you think it's that they finally now have realized what it feels like not to have it? You know, is it because now they've experienced a different way that they've never experienced before that when they go back to this food noise, it feels even more intense because now they've felt what the absence of food noise is.

Thomas Wadden:

Yeah, it's like being inside and it's a cold day outside, but you're nice and warm inside and you open the door and you get smacked in the face by it. You get smacked in the face by sort of the obesogenic environment again. It's like, geez, I can't believe how many sort of entreaties there are to be eating all the time. I can give you an answer to some of these questions when we finish analyzing the study we're finishing up, which is just looking at changes in appetite, both objective eating, how much people are eating, and in subjective experience of appetite. Because we've done a, this is getting too technical, but we've just looked at people when they're coming off the medication in a double-blind fashion to see what happens to them with their appetite changes. I think that's an interesting concept you've got. I do want to go back to the issue of why people come off these medications and try just to address the fact that many people, despite going on these medications, still seem to have a lot of shame about it.

James Hill:

Yeah.

Thomas Wadden:

A strong sense.

James Hill:

It's cheating. Oh, you didn't pay the price and feel the pain.

Thomas Wadden:

You should be able to do this on your own.

James Hill:

Yeah.

Thomas Wadden:

People look at me and a lot of people say, you look great, but are you using a medication? Aren't those dangerous?

Holly Wyatt:

Well, no, I had a participant in State of Slim just the other day that said to me, I need to come clean with you. And I said, what? I'm on the medication. So can I still be in the program? And I'm like, are you kidding me? It's a tool. What are you talking about? Well, I don't feel like I'm losing the weight and I don't think it's fair for me to be, you know, in the group where other people are really having to work hard at it. And I'm like, oh, you know, we've got to change that. That's not the way to think about it.

Thomas Wadden:

Exactly right. And it's a hard thing to change that a lot of people just have it built into them that this is something that I should be able to control. It goes back to the old issue. You don't have enough willpower. You don't have enough self-awareness. And I'd have a long discussion with people before they start the medications just to get a sense of how they feel about meds. Some people say, I don't like medications of any kind. I don't want to be on a statin, on a hypertensive, etc. Okay, why not? We talk about that. And then if they are on other chronic meds, well, what makes weight different than these other conditions you're controlling? And try to take away some of that enduring shame and stigmatization about it.

James Hill:

Tom, can we train primary care physicians to do that?

Thomas Wadden:

It's a wonderful idea, and I hope that we can train them, Jim. I think that they are probably getting to be big prescribers of these medications.

James Hill:

But I'm not sure they're doing exactly what you did. And the other thing we tell people, when you put someone on the medication, you should ask them, what's your long-term plan?

James Hill:

Because we ask people, and the answer was, they didn't have one. They go on these medications to lose weight. They don't think about long-term. Are they going to keep on them forever? Are they going to try to go off? If you get people at least thinking about that at the beginning, I think it could be helpful.

Thomas Wadden:

Yeah. And I do think the language about the long-term use is important. And some patients say, I know I'll have to be on this forever. And it feels like it's almost a fiat that you're on this forever, as opposed to saying, you can use this medication as long as it's helpful to you. You have control over when you're going to use it when you're not. So it's not like you have to do this. Always good to have some sense of choice, some freedom.

James Hill:

We're running out of time. We better get to some listener questions.

Holly Wyatt:

Okay. I've got one.

James Hill:

You always have one.

Holly Wyatt:

I know. I always have a couple here. Is there a downside or a risk being on the medications in terms of long-term weight loss or in terms of, you know, do you think there's a downside to being on the medications? What's the risk of it?

Thomas Wadden:

Yeah. Holly, I think the medications look very safe at this time in terms of their safety. We keep having to monitor it. I've been doing reviews of mental health on these medications and haven't seen anything that alarms me, but we need to keep getting data coming in. But to my mind, there's not any safety signals at this point, I would say, to get off the medication. I do think that people have to talk about the medication with their family members to make sure that the family members feel like, I believe in, I support this, I can absorb the money that you're spending on them, that you can have some lack of harmony in families. Sometimes family members get scared because they don't think the medication is safe. So it's important to talk about that, potentially talk with the doctor. But at this point, I think these medications have been shown to be safe and effective in four years and keeping weight off in four years. We need more data, though.

James Hill:

Okay, here's one. The medications didn't do well for me. I couldn't tolerate them. Is there any hope for keeping weight off if I can't use the medications?

Thomas Wadden:

Well, I would read some of Dr. Rena Wing and Jim Hill's work on the National Weight Control Registry. Obviously, you need to lose the weight, and there are still behavioral programs around that can be a benefit. And I do think that's one of the issues we need to be on guard against. Behavioral treatment is still effective. It can still prevent type 2 diabetes. It can still help treat mild hypertension and the like. So don't give up on behavioral treatments that are provided by commercial purveyors now, including programs like Weight Watchers or Noom, to lose the weight. And then I think that there are things you can do to maintain weight loss, as we've learned from the National Weight Control Registry.

Holly Wyatt:

The other thing, this just brought to my thoughts here is sometimes people think losing the weight is going to solve all their problems. It's going to make them happy. Their relationships are suddenly going to be better. And that's not necessarily the case. So and that that some behavioral treatment and therapy really may come along, you know, need to be there to really get what the outcome is they want, which is really not a change in weight. It's what they believe that change in weight is going to bring to their life.

Thomas Wadden:

Great point. If you've got problems in relationships, weight loss is not going to solve your problem in your relationship. So that is where some talk therapy is probably going to be help to you. John Ferrett, a friend and colleague of ours, used to always say, if you've got a funny, odd personality before you lose weight, you're going to have a funny, odd personality after you lose weight. You need some help with your personality. Weight loss will solve some medical problems. By and large, your temperament, your mood is fairly constant, regardless of how much weight you have lost. That was a surprising thing in the Swedish Obese Subject Study of Bariatric Surgery. Mood improved for the first two years, but then two years later, you were back to your baseline mood. It's real like winning the lottery. You're happy for a couple of months, and then you're back to your general level of happiness or misery.

James Hill:

Okay, Holly, you know what time it is?

Holly Wyatt:

Vulnerability questions. Are you ready, Tom? This is where we're going to ask you the hard questions that's going to make you get vulnerable.

Thomas Wadden:

Okay.

Holly Wyatt:

Let me, I'll start. What's one thing you used to believe about weight loss that you've since changed your mind about? Maybe you got it wrong.

Thomas Wadden:

Well, this is sort of an odd answer, I guess, is that I used to think that anybody with a BMI of 30 or greater, which meant that you had obesity, should be losing weight. And I felt like you should want to be in one of the programs we're offered to improve your health, etc. Now I do have a lot more sympathy and attunement to the role of diet and physical activity. That if you are exercising regularly and eating a healthy diet and your cholesterol and your other numbers look good, it may just be that it's okay to accept your weight. And obviously the self-acceptance movement has been a very powerful one. Like, I don't want to be at war with my body all the time. I want to take steps to be a healthier weight, but I don't necessarily have to be at a average weight or what is considered a healthy weight by the CDC tables and the like. So I have more sympathy for sort of the weight acceptance movement in that regard.

James Hill:

All right. I have one for you. You're the Albert J. Stunkard professor, and you trained with Dr. Stunkard, who went by Mickey. Mickey Stunkard. Tell our listeners very briefly who he was. And my question is, what's the most important thing you learned from Mickey?

Thomas Wadden:

Well, Mickey Stunkard was a psychiatrist, and he happened to get into weight control because his mentor up at Cornell said, Stunkard, I want you to look at weight and come up with a cure for that. We've gotten pretty good at hypertension, so you take on weight. And so Mickey said, okay, I'll do it. And so he opened a clinic up at Cornell. And of course, Dr. Stunkard found out that weight and obesity was not something you're going to find a cure for. The thing that I found from him, Jim, that was just so important, because I'm a behavioral psychologist like you, or you may be more of a physiological psychologist who became a behavioral psychologist, was that Mickey just said there are just so many causes or contributors to obesity. And so he opened my eyes to looking at the genetics of the disorder, the endocrinology of the disorder.

Thomas Wadden:

Then he could look at it from an anthropological socioeconomic standpoint. So he really had such a broad perspective on how you have to view this condition as opposed to just thinking it's your eating and your exercise behavior. And I do think his most important work was to show that obesity is a highly heritable disorder. You didn't get to be, you know, five foot 10 by what you ate. You got there based on genetics. And a lot of people don't get to be 250 just on what they eat. A lot of it is their genetic predisposition. And one thing that I always was impressed by him was his compassion for people living with obesity. He had a book called The Pain of Obesity and really talked about what a stigmatized condition this is and how we can do one thing. It is to treat individuals with obesity with respect. Because so often they are treated disrespectfully, callously, blamed for their condition. So that's Mickey Stunkard in a nutshell.

James Hill:

Cool. Okay, Holly, let's sum it up, what we've learned today. I think we asked the question of, is there a role for behavior treatment in the era of new medications? And I think the answer we got is yes. The medications can do a good job on helping you lose the weight, but there are so many other ways that behavioral therapy can help us in what we eat, our physical activity, how we approach our weight in our life. So, yes, there still is a role for behavior therapy today. We welcome the drugs, but we still need the behavior therapy.

Holly Wyatt:

I agree. I think the behaviors still matter.

James Hill:

Behaviors matter.

Thomas Wadden:

They do matter. And I'm for the Registered Dietitian Full Employment Act.

James Hill:

I'm the same way. I think I just speak a lot to registered dietitians and I'm telling them, this is your time. Be bold. Step up. We need you.

Thomas Wadden:

Need you more than ever in some ways.

James Hill:

All right, Holly.

Holly Wyatt:

All right. If anybody has any comments or any ideas for new episodes, this is where we get our ideas. So please send them to us and we will be back with you next week. Thank you.

James Hill:

Thanks, Tom. It's wonderful having you with us. We'll see everybody next time on Weight Loss And.

Holly Wyatt:

Bye.

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:

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James Hill:

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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.