Why people get so worked up about GLP-1s (and why it holds us back in our quest for health.)

Weight loss is hard. I’ve struggled with my physical appearance for as long as I can remember. I was the only chubby girl in gymnastics class. I stood out like a pebble in a pile of twigs. I taught myself as early as ten years old to suck in my tummy after being made fun of for its round shape. My earliest memory of dieting comes from around that time. I also remember the struggle - quite vividly - of running after someone during a game of tag; the burning in my lungs trying to keep up with my moving legs, far far behind the kid I was supposed to catch.

All of these memories are like battle scars. Being fat, or anything other than the collective ideal of healthy and beautiful, can do that to you. It feels like being at war with yourself, food, the mirror, and both the secret and not-so-secret judging of all eyes around you.

I think that if I hadn’t experienced this, I wouldn’t have chosen this profession. I ended up here by trying to heal myself, and when I realized I could, I wanted to help others. Certainly not in an evangelist type of way, to where I want to convert people into a newfound doctrine of wellness, but in a sincerely empathetic way that sees and feels the body’s struggle to adapt to an environment which is seldom permissive of weight-friendly habits. Not inherently, at least.

As many experts can tell you, a big cause of weight loss and maintenance struggles is appetite dysregulation. When I was eight years old, I could eat just as much as a grown adult. I was insatiable. While that wasn’t the only reason I was overweight, it was probably the most difficult one to correct.

Even now, as a fitness professional with what doctors consider a healthy weight, appetite is still the hardest thing to control. I eat a nutritious, balanced diet; I have a plethora of evidence-based strategies and coping mechanisms under my belt. I am well-versed in the biochemistry of hunger, but some days that doesn’t make it any easier. I workout 6 days a week, average 8,000-10,000 steps a day, and I have a fairly athletic body but I can still outeat my 185-pound-husband any day, if I allow myself to.

When GLP-1s started to flood the mainstream conversation with their growing evidence of aiding in appetite regulation, I remember feeling a very nuanced sensation: mainly hope, slight envy, and a shrug of resignation. I felt hope, because there had never been an effective way to deal with excessive appetite; envy and resignation because these drugs were not meant to help just anyone — they were designed for patients with either existing or high risk of chronic metabolic disease. I, luckily, haven’t fallen into that category since I was a kid. Considering how short their supply continues to be, aesthetics is not enough to hog a life-saving intervention.

“Fit for TV,” a new Netflix documentary on the reality show The Biggest Loser is bringing attention back to the several setbacks that come with a rapid decrease in body size. We can have a whole separate conversation about the inhumanity and abusiveness in the methods they employed, but for now I want to highlight the fact that most of the participants gained all the weight back, if not more. The handful who didn’t, either managed to continue exercising and maintain an energy balance despite their reduced basal metabolic rates, or got on a GLP-1.

Jillian Michaels, the infamous trainer from the show, has come out on multiple outlets to bash the use of weight loss medications. At first glance, her criticism seems reasonable. She questions the risk-benefit ratio between side effects and results, she cautions of weight regain, unknown long-term effects, and she rightly emphasizes the importance of lifestyle change over a “quick fix.”

Michaels is far from being the only one making this type of argument. GLP-1s attract heavy criticism from holistic health activists, who feel strongly that natural living, diet, and lifestyle are the only adequate means for achieving wellness, and weight management. However, this is where the rabbit hole begins, because the line between natural wellness and rejection of scientific advances starts to get blurry, and that makes people develop asymmetrical critical thinking, favoring “evidence” that aligns with their personal bias, and rejecting that which doesn't.

For example, it is valid to raise concerns over a drug’s side effects, which is why all medications go through a lengthy and rigorous process that can last a decade or more, with substantial costs involved, extensive clinical trials, and the work of thousands of scientists, different agencies, and often multinational organizations. Ironically, most natural wellness defenders promote and sell various supplements that do not go under the same degree of testing and regulation, and make extraordinary claims that do not pass their own rigor, safety, and effectiveness test.

If the worry then shifts to weight regain, there’s mountains of data that show most diets fail, both in the short and long term, and the way a lot of wellness influencers nowadays gain popularity is by promoting restrictive diets such as keto, carnivore, plant-based, etc, and through the implementation of caloric restriction methods that are not well-suited for the average person, especially not for those who may have a genetic predisposition to high food-drive or eating disorders. We can see this first-hand with the contestants Michaels herself coached.

One thing we have to understand as a collective, and as a way to have medical literacy, is that all drugs and medical interventions carry risk and have side effects. So do natural supplements, by the way, which according to research now account for 20% of liver failure in the United States. So to argue about the future unknowns for a drug, but not for anything they promote, is naive at best, hypocritical at worst. Who would have known that making people eat less than 800 calories and exercise 4 hours daily would backfire on the individual’s capacity to keep the weight off?

Overall, people tend to have strong opinions on the way a person chooses to lose weight, medical reasons aside. I don’t have any citable research for this, so I will speak from my own perspective. We as humans seem to have an evolutionary need for perceived justice. We like watching others struggle, and the struggle is what makes them worthy. We love an underdog, someone who comes out triumphant despite the challenges. On the other end, we also love the criminal who got the verdict they deserved, the cheater who got called out for skipping line. Primatologist and neuroscientist Robert Sapolsky has a whole chapter in his book “Determined” about “The Joy of Punishment.” Brought to this context, I think we see people who use GLP-1s as cheaters who take the easy way out while the rest of us have to struggle.

Overweight people carry this stigma on them, that the reason they are fat is from personal choice. The only instance we remove blame from an overweight individual is when it is a child, so then we blame the parents. Our understanding of human biology has made huge leaps in the last decades, and perhaps we can’t expect the masses to keep up with the rapid pace of knowledge and technology. Galileo never convinced the Church that the Earth revolved around the Sun in his lifetime. Little do most people understand about the genetics of weight and metabolism, environmental factors, epigenetic changes through generations, socioeconomic influences, etc.

I know from my own experience, that I didn’t choose to be an overweight kid, and neither did my parents. Could they have had more knowledge on how to raise a child with such a high food drive? Maybe. Growing up in Mexico I ate a diverse diet, rich in fresh foods, with some questionable choices like fast food and ultra processed snacks, but mainly whole, nutritious foods. My mom is a great cook and she was raised on organic farm-harvested crops, chickens, and eggs. Yet, she also struggled her whole life with “always being hungry.” So, could I have inherited my food drive from her? Research says it is likely.

I managed to reach a healthy, and even aesthetically pleasing physique, through lifestyle change alone. But the fact that I did doesn’t mean I get to think that others can or should do it the same way. My job as a fitness coach is to help people implement and improve healthful habits, but I cannot possibly have the arrogance to expect every single individual reach the same outcomes purely out of my guidance. Different people will have different struggles, and each one will need a specific strategy or intervention. My scope ends where the medical specialist’s begins.

I would encourage my fellow colleagues to not fall into the heuristic of reducing weight gain to lack of discipline and hard work. Equally, I advocate that my clients receive medical guidance from an evidence-based specialist. The market always takes advantage of the desperation of people and many companies are now offering unregulated versions of these drugs, with no guidance or support from a physician, and that is dangerous. One of my clients, for example, fit the BMI requirements for GLP-1 use, but suffers from hypoglycemia, which would’ve been risky for her overall health. She couldn’t have known that if she hadn’t consulted with a doctor first, and in her case, exercise and better nutrition have been sufficient to help her lose 40 pounds at a sustainable pace while increasing her fitness and strength.

I think this specific worry from critics is well justified. In many instances, people do not need GLP-1s as a first option, but an improvement in lifestyle. And in the case that they do, pairing it with an appropriate exercise and nutrition program will make sure that patients reap the most benefits without jeopardizing their metabolic health. Nobody is arguing that.

Let’s get out of this binary way of thinking where there is no nuance. Health is complex, so now more than ever we need to avoid simple, single-layered answers, if we want to thrive in today’s world. I remain hopeful that, unlike with Galileo, knowledge will prevail during our lifetime.