Weight and Healthcare

In part 1 I started writing about the basics of hernias in higher-weight people, including the fact that these surgeries are common targets for BMI-based denials of care, where a higher-weight patient's healthcare is held hostage for a weight loss random. In part 2 we dicussed the issues with the weight loss recommendations that are so commonly given to higher-weight patients when their care is held hostage for a weight loss ransom. In part 3 I'll give some ideas about how to advocate if you are in this situation as well as some research to help back you up. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

This is the Weight and Healthcare newsletter! If you like what you are reading, please consider subscribing and/or sharing!In Part 1 we discussed the basics of hernia repair for higher-weight people. In part 3 we'll discuss the options for fighting BMI-based denials for hernia care. While I take the stance that people of all sizes deserve equitable care, in Part 2, I want to talk about the issues with these weight loss recommendations (this is a piece I've been meaning to write for a while so I'm incuding it in this series, but know that this isn't just about hernia repair but about anytime weight loss is recommended or required for a patient to be “optimized” for surgery.) Today we're going to look at it from the perspective of someone who agrees with these recommendations (which I d not) and/or of somene who is so desperate for care that they are willing to try to pay the weight loss ransom (which is a valid choice, but one that patients should never be coerced into making by a healthcare system that holds their care hostage.) Even in these circumstances, there are multiple issues with these weight loss recommendations including feasibility, side effects, and long-term prognosis.Feasibility and Side EffectsThe first question to ask is the feasibility of the requirement. “Optimization” for surgery doesn't happen in a vacuum and it doesn't matter if something would make the patient's surgery easier or improve their outcomes if it is not possible and/or if it harms the patient more than it helps them. Despite this, the feasibility/likelihood of the patient experiencing the required weight loss is, in my experience, far too often not discussed or even considered.I have met with patients who were told they needed to lose 40% of their body weight whose surgeon told them to eat less and exercise more. This is an “intervention” for which about a century of research has found the likelihood of losing even 5% of body weight is quite low and the likelihood of maintaining it is incredibly small (though we'll get to that.) The doctor might as well have told the patient to grow 6 inches to change their BMI sufficiently.Enter GLP-1s. Here again we're seeing patients being prescribed these drugs not based on the drugs' actual capacity to create (at least short term) the required weight loss but based on the sincerely held personal belief of the provider that any amount of weight can be lost with these drugs.In the recent research article that Angela Meadows, Louise Adams, and I published on GLP-1s for weight loss, we included tables in the supplemental materials that include information for all of the phase 3, placebo-controlled trials of GLP1-s for weight loss. One of the reasons I am glad these tables are out in the world is so they can be used in these discussions.As the tables show, about half of people don't ever reach average weight loss in these trials with around 5-15% failing to lose even 5%. For semaglutide, the STEP 1 trial only looked at weight loss up to 15%, and 49.5% of the subjects failed to lose even 15% of body weight over 68 weeks and in the STEP 3 trial, even when combined with a restrictive diet, 64.3% of subjects failed to lose even 20% of their body weight over 68 weeks. For tirzepatid, the SURMOUNT 1 trial included weight loss up to 25% and 63.8% of the people on the maximum dose (15mg) failed to lose even 25% of their body weight over 72 weeks. In the 2-year weight loss analysis of the SELECT trial ( Ryan et al., 2024) 95.1% of patients failed to lose 20% of their body weight, average weight loss was down to 10%, and at four years the study had lost 89.5% of participants! Other studies showed significant loss of muscle mass as part of the weight loss.You can find the tables here in the supplemental materials. If you are being told to use GLP-1s to qualify for healthcare I also have a case study here that offers more information and some specific scripting that you can use.Then there is the recommendation for weight loss surgery. This is a surgery in which a healthy, correctly functioning digestive system is surgically manipulated into what would otherwise be considered a disease state in order to force restriction and produce weight loss. It is a very serious surgery with the potential for very serious side effects that can have significant negative impact on long-term quality of life and even be fatal. I wrote about the basics of these surgeries here. I also have a series about weight loss surgery and long-term quality of life in which researchers admit sparse and low-quality evidence, and that in multiple studies health-related quality of life was the same between those who had surgery and those who didn't.At the bare minimum, giving the patient correct information about the likelihood of these surguries of actually leading to the weight loss that is being demanded in order for the patient to get the surgery they actually need is incredibly important when the patient is being refused a surgery that they need but recommended to undergo a surgery that alters an entire body system in a way that is, by and large, irreversible with potentially life-altering and even fatal side effects. A 2022 study called “Predictors for weight loss after Roux-en-Y gastric bypass: the trend and associated factors for weight loss” by Eghbali explains that while most people expect to lose more than 70% of the “excess weight” in reality the mean total weight loss is about 32% at 1-2 years. So, even if the patient is willing to have this surgery (and risk the significant side effects) and even if they could reach the mean total weight loss, that would still not necessarily be enough weight loss for the patient to qualify for the surgery they actually need/want.Medical interventions must be evidence-based and wishin' and hopin' and thinkin' and prayin' that all higher-weight patients will be outliers and experience more weight loss than the research suggests is likely (even in the short term) so that they can be seen as worthy of surgery is not ethical, evidence-based medicine.Long-Term OutcomesWe know that the vast majority of weight loss attempts end in weight regain and that regain with GLP-1s has been shown to be even faster than with lifestyle interventions. Guidelines around weight loss for hernia repair typically brush this off with simple admonitions that amount to “don't do that.” Given that intentional weight loss changes the body physiologically to induce weight regain, using the equivalent of “doctor, it hurts when I do this….well don't do that” here again falls seriously short of ethical, evidence-based medicine.Even if someone believes that people could lose any amount of weight and maintain that weight loss, medicine must be practiced in the context of reality. That means understanding the risks of delaying the surgery while the patient attempts weight loss that research shows is unlikely to unlikely to ever happen, and considering the risks of weight regain on the surgical repair, which research shows is highly likely to happen. This is especially important given the existence of research for other procedures that finds that weight loss prior to surgery, including through weight loss surgery, does not improve outcomes.The sad reality, which is all too common, is that there isn't enough research about hernia repair when it comes to higher-weight people. And as long as the healthcare system is comfortable allowing higher-weight patients to suffer and die unless or until they can comply with a directive to lose weight, those with power, privilege, and leverage to make change will need to do whatever can be done to fund and conduct the research that is needed so that people of all sizes can have equitable care.In part 3 we'll discuss the options for patients who are dealing with BMI-Based Denials for hernia care.This month's online workshop is Weight-Inclusive Sleep Apnea Management with special guest Dr. Lisa Erlanger! There is a pay-what-you-can option so money isn't a barrier and all registrants will receive a video. Details and registration are here! If you appreciate the work I do here, you can support my ability to do it by becoming a free or paid subscriber!Liked the piece? Share the piece!More researchThe Research PostMore resourcesThe Resource Post*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings' Fearing the Black Body – the Racial Origins of Fat Phobia and Da'Shaun Harrison's Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

One of the more complex situations that I often get asked to write about, or asked to help advocate for, is hernia repair in higher-weight people. This situation can be quite complicated and a lot depends on the person, their specific condition, and their situation. The goal of this three-part series is to offer a starting point for discussion and advocacy. In part 1 we'll look at some of the basics around hernias, hernia repair in general, and hernia repair (or lack thereof) in higher-weight patients. In part 2 we'll look at the issues with the common weight loss recommendations higher-weight patients often receive, and in part 3 we'll look at specific concepts to advocate for care and research to provide some support. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

I write about many different examples of weight stigma in healthcare including BMI-based denials of care in which healthcare is held hostage for a weight loss ransom. Sometimes these BMI-based denials don't mean that a procedure is denied everywhere, but that it is denied in a certain facility. One common example of this is when a procedure is requierd to be done in a hospital rather than an ambulatory surgery center. This can be make the procedure much more difficult to schedule and exponentially more expensive. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

I've written extensively about the weight loss industry's attempt to co-opt the concept of weight bias and stigma Lately I've been noticing (and in some cases involved in,) a concerning trend which I would describe as people (knowingly and even unknowingly) weaponizing the concept of weight bias to shut down weight-inclusive work to benefit the weight-centric paradigm. (I've written about the two paradigms here.) .Here are three recent examples that happened to me: Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In part one we went through some of the basics around the research that considers higher-weight and cancer risk, progression, and outcomes. In part 2, we'll consider some of the research more deeply. These won't be full deep-dive analyses (if you want that, let me know in the comments,) instead we'll dig into the questions we discussed in part 1. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

I have had a number of requests to discuss the research around cancer and higher-weight. This is an incredibly complex and nuanced subject. I'm going to start with a two-part series. Part 1 will be an overview of basic concepts and possible issues with the current research. Part 2 will dig into some of the actual research. If you have other topics that you would like me to write about or specific research you would like me to analyze, please feel free to add it in the comments. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

Reader Barbara recently brought the study “Association of Weight Cycling with MRI-Based Thigh Muscle Quality and Knee-Adjacent Ob*sity” to my attention.The study sought to determine if repeated weight gain and loss (also known as weight cycling or yo-yo dieting) was associated with sarcopenia which they explain is defined as a loss of muscle strength and muscle mass and a decline in physical performance. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

I received a request from reader Chris who said:I know that you write about the problems with research all the time, but I would really like a post that names the main problems with the research that would be easy to send someone so that they could understand.I'm happy to help. For this post I've chosen the top three mistakes I see. Of course, there are plenty more, I've chosen these three (and called them deadly sins) because when they happen, it means that the research is fatally flawed. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

I have written before about options for patients who are facing a BMI-based denial of care which occurs when their healthcare is being held hostage for a weight loss ransom. In that series I talk about three options to try to get surgery. A couple months ago I gave a talk on weight-neutral joint pain management with Dr. Julia Bruene and Dr. Jeremy Alland, both Sports Medicine Physicians at Midwest Orthopaedics at RUSH in Chicago. During the talk Dr. Bruene mentioned two pain reduction procedures that might be options for harm/pain reduction for patients with knee osteoarthritis whose care is being delayed/denied by a BMI-based care denial. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

I have received a ton of requests to write about the paper “Are people with metabolically healthy ob*sity really healthy? A prospective cohort study of 381,363 UK Biobank participants” Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

Recently a number of people directed me to a video online that discussed weight stigma and asked me to respond. I'm not naming names because this person is far from the only one to make this mistake, they apologized, and they didn't choose the clip that was selected. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

This is the Weight and Healthcare newsletter! If you like what you are reading, please consider subscribing and/or sharing!In part 1 we looked at the basics of the Look AHEAD Trial of weight loss to improve cardiovascular outcomes. The trial was cancelled 9.6 years into its intended 13.5 year follow up for “futility” when analysis found no statistically significant difference in cardiovascular outcomes between a group that engaged in “intensive” caloric restriction, exercise, and, in some cases, diet drugs, and a group that got three counseling sessions a year about diabetes management.One of the claims that I often see people make is that the group that maintained at least a 10% loss had better outcomes. We saw this recently in the write-up of the Foundayo trial, in which they claimed, without context that “patients who had a weight loss of 10% or more through a lifestyle intervention had a 21% reduction in cardiovascular events.” I mentioned in that piece that this was an analysis of a small subgroup. There are some real caveats around this and other claims about the 10% weight loss group so let's dig into it.For this we'll look at “Four-year weight losses in the Look AHEAD study: factors associated with long-term success” by Wadden et al.As always I'll indent the quotes so you can skip the weight stigma. In their writing ILI is the abbreviation for the weight loss group and DSE is the abbreviation for the control group.In general they discuss the weight loss:“At year 4, 35% of ILI and 18% of DSE participants achieved the study-wide goal of losing ≥7% of initial weight (P < 0.0001), and 23% and 10%, respectively, lost ≥10% (P < 0.0001).”Said another way, the study goal was to produce weight loss of just 7% or more of body weight and 65% of the people who were subjected to these “intensive” interventions including diet drugs didn't hit even that modest goal. Also, 23% of the ILI group lost 10% or more of body weight, but 10% of people in the control group that didn't do any of these interventions did so as well. This again raises questions about the necessity of such extreme restriction even for people who believe that weight loss creates health benefits (which, again, this study does not show, since there is no way to determine if any health differences are from weight loss or behaviors, and research that actually sought to answer that question found no relationship between small amounts of weight loss and health changes in correlational analysis, and posited that it was more likely that behaviors, social support, and engagement in the healthcare system were likely to be driving the health outcomes.)The authors of the Look AHEAD paper also point out that:“significantly more DSE than ILI participants (45% vs. 26%) had gained above their baseline weight at year 4 (all P values < 0.001)”What they aren't being clear about is that the DSE (control) group had modest weight gain from baseline while not participating in a weight loss intervention. Meanwhile, just four years in, more than a quarter the ILI (intervention) group weighed more than when they started. Now, there is nothing wrong with being higher-weight or gaining weight, but I would say that there is something seriously wrong with a so-called healthcare intervention that subjects people to “intensive” food restriction, physical activity, and diet drugs and then has the opposite of the intended effect for at least 26% of the participants. This particularly does not age well given that we now know that the intervention would be cancelled for futility for failing to impact the intended health outcomes.When it comes to the group who lost 10% the Look AHEAD authors write that:“[Figure] 3 shows 887 ILI participants who lost ≥10% of initial weight in the first year and shows the number of these participants who achieved a loss of this size at year 4 (N = 374) or, alternatively, maintained losses of 5.0–9.9% (N = 251), 0–4.9% (N = 174), or gained above their baseline weight (N = 88). As shown, fully 42% of this subsample achieved a loss ≥10% at year 4, and a total of 70.5% maintained a loss ≥5%. It should be made clear that “fully 42% of this subsample” refers to 42% of 35% of the original sample. So out of the 2570 original people in the intervention arm, 887 participants (about 35%) lost ≥ 10% at year 1. But at year four, only 374 (about 14.5% of the original group) were still at 10%.Percentage wise, that means fewer than half of the people who had lost 10% or more of their body weight in the first year were still at or over 10% by year four and that, overall, only about 15% of the total group managed 10% weight loss for even 4 years. But there is more to this story, let's look at their Figure 3A that shows the weight trajectory of this group:Image text: Figure 3 A. Weight loss trajectories over 4 years in the 887 participants in the Intensive Lifestyle Intervention (ILI) who, at year 1, lost ≥ 10% of initial weight. The figure shows the number of participants who, at year 4, maintained a loss of 10% or more of initial weight (N = 374), of 5.0–9.9% (N = 251), or of 0–4.9% (N = 174) or who gained above their baseline weight (N = 88).You'll note that everyone has regained from their low point, 9.9% (88 people) had already regained more weight than they lost and the majority are still on a trajectory to continue to gain weight after this follow up.If we go back to their quote, they claim that this figure shows percentages of people who “maintained losses of 5.0–9.9% (N = 251), 0–4.9% (N = 174).” I do not think that the word “maintained” reflects the reality that these people's weight trajectory is going straight up. Catching a group of people at 5% weight loss on their way up is not the same thing as “maintaining” a 5% weight loss.Content note: This next section talks about calories, exercise, disordered eating/eating disorders, if that may be harmful to you you can scroll down to “Discussion.”The researchers note that “Participants who maintained the [10%] loss, compared with those who did not, attended more treatment sessions and reported more favorable physical activity and food intake at year 4.”Again, this begs the question as to whether behavior or weight loss actually created any health difference. It also begs another, much more troubling question. Below is their Figure 4 which shows the characteristics of the subset of subjects who took self-reported surveys about their food and exercise behaviors. Note that those who maintained a 10% loss in general were consuming about 1565.5 calories a day (fewer than the 1,570 calories subjects in the Minnesota STARVATION study were given during the starvation stage) and burning about 2,000 calories weekly through exercise. Applying the Paffenburger Activity Questionnaire that these authors are using to the Minnesota STARVATION study participants, those participants were expending about 2200 calories per week. One thing the authors don't mention in this sub analysis, or the original analysis, is the possibility that they created disordered eating/eating disorders in part of their population and then celebrated it as “long-term success.”DiscussionThe first sentence of their discussion section states:“Participants in the Intensive Lifestyle Intervention achieved a 4.7% reduction in initial weight at year 4. This loss is among the largest reported at this length of follow-up for individuals in a randomized controlled trial who were treated by a lifestyle intervention”I do not think that this is the flex they think it is. Giving people less food and similar activity to a study on starvation over four years produces 4.7% weight loss - an amount of weight that some people fluctuate monthly through their menstrual cycle? The phrase “who cares?” comes to mind.To further demonstrate the issues with this study, in the discussion section these authors compare their “maintainers” to the National Weight Control Registry which I have discussed before as perhaps the worst example of the truly ridiculous methodology that passes for “science” when it comes to weight loss and health.In general, when people cite the Look AHEAD study as proof of efficacy of weight loss interventions, you can suggest that they look back at the actual findings of the study. Even these authors are honest that “Look AHEAD's study design prevents us from definitively determining the contribution to long-term weight loss of the lifestyle intervention's different treatment components.” What they aren't so clear about is that Look AHEAD's study design prevents them from knowing if weight loss had anything to do with any of the health benefits.Especially since, as we talked about in part 1, research finds that weight-neutral interventions can produce similar or greater benefits with less risk. In general, whenever someone claims that a study shows that weight loss creates health benefits, the first question you can ask is “what mechanism was used to determine whether weight loss or behavior change created the differences in outcomes?” If there isn't one, then they can't conclude that weight loss did anything at all.If you want to learn how to read between the lines of weight and health research, this month's online workshop is about exactly that. I'll teach you the basics of breaking down research and analyzing media article and social media to break through the BS and get to the truth of what the research finds (and what it doesn't). There is a pay-what-you-can option so money isn't a barrier and all registrants get a video. Details and Registration here!If you appreciate the work I do here, you can support my ability to do it by becoming a free or paid subscriber!Liked the piece? Share the piece!More researchThe Research PostMore resourcesThe Resource Post*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings' Fearing the Black Body – the Racial Origins of Fat Phobia and Da'Shaun Harrison's Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

People make a lot of claims that the Look AHEAD trial offers some sort of support for the efficacy of weight loss diets. So in this two-part series we're going to look back at the Look AHEAD trial - what is was, what it found, and what it didn't. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

I've received a ton of reader questions about Eli Lilly's GLP-1 weight loss pill Foundayo, which was recently granted FDA approval. In Part 1 we'll talk about the study itself, in Part 2 we'll break down the discussion, limitations and talk about the special treatment the government gave this drug. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

I recently heard from Samantha C who was suffering from what she described as “absolutely crippling plantar fasciitis.” She shared her story of battling medical weight stigma to get care. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In Part 1 we started discussing the study Two Years After Stopping GLP-1s, Most Patients Sustain at Least Some Weight Loss by Bartelt et al. which I identified as possibly the worst, and definitely among the top 3 worst, studies I've ever analyzed.In part 1 we talked about the platform (Epic Research), the researchers, and the basic methodology for reporting. Today we're going to get into the analysis. Remember that there are two sources, the first is the actual article, the second is what I am calling the supplementary materials that is a pdf that is linked (though not at all clearly) in the article.We'll compare the claims made in the article to the data shown in the supplementary materials. I think as we get into this it may be helpful (and maybe just a bit comforting) to remember that this was not published in a peer reviewed journal - it's Epic publishing Epic's research on Epic's website.We'll begin with the most basic claim: “we studied 188,722 patients who stopped using a GLP-1 medication after being on it for at least 90 days and who lost at least 5 pounds while on it.”You might be thinking “wait - in Part 1 you said the study population was 323,782, what happened to the other 135,060 people? Let's go on this journey together. We'll start by looking at their data. In the supplementary materials, Table 1: Characteristics of the Study Population looks like this:So they say in the article that they studied 188,722 patients but the very first line of the supplementary materials chart about the study population says that the total number of patients was 323,782. But it gets a bit weirder, if you add up all the participants in the different age categories you get 323,750, 32 short. If you add up the totals across the drug groups you do get 188,722, if you add up the participants in the weight loss category you get 323,782. If you add up the diabetic status you get 323,782. What is going on here? Maybe they originally looked at 323,782 records of which only 188,722 were not excluded for some reason, and maybe 32 of the participants did not have an age on their electronic health record? At least the number of people across the drug groups in the supplementary materials chart matches the number of people they claim to have studied but this is, in the absolute more charitable description, an extremely confusing way to present this data.In part 1 we discussed the fact that the inclusion criteria were not particularly stringent but the biggest issue, to me, is that the researchers appear to have just done calculations with whatever data they happened to have, but reported it and drew conclusions as if they had consistent data on all participants.For each of the three drug groups (semaglutide, liraglutide, tirzepatide), they present an interactive graph that shows “the proportion of patients by amount of weight regained or lost after stopping [liraglutide/semaglutide/tirzepatide].”Let's dig in.In the article we find Figure 1 - Proportion of Patients by Weight Change After Stopping Semaglutide we can see in the lower left “n=139,972 patients.”But if you look at the supplementary materials you find Table 2 Proportion of Patients by Weight Change After Stopping Semaglutide. This is the table from which they are drawing the data for Figure 1.The final column of the supplemental table is “patients” and the number in that column represents the number of the original 139,972 patients who had taken (and subsequently stopped taking) semaglutide for which the researchers had a weight at each month of their calculation. At month 1, the researchers had a weight for 68,754 of the patients and this number trends steadily downward until month 24 when they only had weights for 2,650 of the original 139,972 patients. At literally no point does Figure 1 in the original article give data for the n=139,972 patients the label claims.In the liraglutide group the graph in the article says n = 23,377. The supplementary tables show that in month 1 they had weights for 11,580. That steadily declined until month 24 they had weights for 1,268 of the population.In the tirzepatide group, the article says n= 25,373 patients. At month 1 they had weights for 12,909 patients which steadily declined until at at month 24 they only had a weight for 145 people (that is not a typo, they were doing the two year calculation upon which they drew their bold conclusions with only one hundred and forty five of the original 25k+ people represented!)This is such a bonkers way to do this that I actually emailed them, using the semaglutide table as an example, to make sure I was understanding this correctly. They assured me that I was:“Yes – there were 139,972 total patients on semaglutide who met the conditions in the study cohort. The patient count in Table 2 represents the number of patients that had a weight reading in a given month, so patients can be represented in multiple months.”So let's discuss the “key findings”At 24 months post-cessation, 56% of semaglutide, 52% of liraglutide, and 55% of tirzepatide patients kept the weight off or lost additional weight.Complete weight regain occurred in 23% of semaglutide, 21% of tirzepatide, and 27% of liraglutide users at 24 months.Weight trajectories stabilized after 12 months, with only small variations in the distribution of weight outcomes through year two.Remember that when they state these 24 month findings (or when in the title they say “Most Patients Sustain at Least Some Weight Loss,”) these statistics are drawn from information for only 1.9% of the semaglutide group, 5.4% of the liraglutide group, and 0.57% of the tirzepatide group. When they say kept the weight off or lost additional weight, subjects would qualify if they maintained 1% of the weight they lost. EDIT - I'm adding this paragraph for additional clarification based on a great comment below. If you look at their percentages, it can seem like a lot of people didn't regain weight. For example in the Semaglutide group, for example, at 1 month the “doubled their weight loss group” was 5.01% of 68,754 participants. That's that's about 892 people which is 0.64% of the original 139,972 people. At 24 months it was 25.89% of 2,650 people. That's about 686 people which is about 0.49% of the original 139,972 people. As I mentioned in part 1, we also don't know if this miniscule percentage of the total group even actually stopped taking the drugs, or if they started getting them from a different source that did not add them to their medical chart.What happened to the 98.1% of the semaglutide group, 94.6% of the liraglutide group, and the staggering 99.43% of the tirzepatide group for whom the researchers did NOT have a weight at 24 months? Is it more likely that people who were regaining weight did not come back to get weighed in? These researchers have absolutely no idea and they don't seem to care.(They said that weight trajectories stabilized at 12 months so even if we look at the data at 12 months they only had weights for 12.7% of the semaglutide group, 18.5% of the liraglutide group, and 8.1% of the tirzepatide group.)Under limitations they state “We allow a patient to be included in each month, using their highest weight in that month. Patients who have repeated weight measurements might be the extremes of weight change.”Gentle readers, I would say that this is the least of their limitations. The fact that they are stating these incredibly broad conclusions about weight regain (including in the title!) based on a tiny fraction of the data they've led us to believe is included, and that they AT NO POINT disclose any of that in the main paper is, to me, unforgivable. Horrifyingly, in researching this piece I found other studies that actually cited this one so I'll end this by saying that this study completely lacks the academic rigor or appropriate methodology necessary to be used to counter research showing high rates of weight regain after GLP-1 cessation. GLP-1s are being taken by a huge percentage of people and being prescribed (and in some cases pushed) by many prescribers, research like this has the potential to do incredible harm by generating blatant misinformation. We have to do a whole lot better than this.This month's online workshop is How to Be Your Own Medical Advocate. You'll learn strategies to advocate for yourself to help you get the evidence-based, compassionate, healthcare you deserve, and what your options are if you don't. There's a pay-what-you-can option to make sure money isn't a barrier and all registrants get a video in case you can't make it live. Details and registration are here! If you appreciate the work I do here, you can support my ability to do more becoming a free or paid subscriber!Liked the piece? Share the piece!More researchThe Research PostMore resourcesThe Resource Post*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings' Fearing the Black Body – the Racial Origins of Fat Phobia and Da'Shaun Harrison's Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

Every month, paid subscribers can participate in an Ask Me Anything and the study I'm writing about today was brought to my attention during the June AMA. It is, if not the worst, one of the top 3 worst studies I have ever analyzed so strap in because we are going for an EPIC ride. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

Some of you may know that I'm a Board Certified Patient Advocate. I don't currently do a lot of individual advocacy because my speaking schedule doesn't allow for the necessary time availability so I typically either work on complex or emergency cases, or on cases that are not strictly timebound - most of these are people who are dealing with a BMI-based denial of care, meaning that their healthcare is being held hostage for a weight loss ransom. This is one of those situations and I am, as always, sharing this story with permission and anonymously by request. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In part 1 we began discussing the study ““Please step on the scale”: The experience of being weighed promotes sustained systolic blood pressure level” by Incollingo Rodriguez, Nunes, & Kirschner, published in 2026 in the Stigma and Health Journal.The study sought to determine the impact of weighing in a medical appointments on blood pressure, cortisol, and perceived stress. In part 1 we looked at the participants, the intervention, and the baseline findings. In part 2 we'll consider the limitations, recommendations, and conclusions. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

I recently spoke at the Association for Weight and Size Inclusive Medicine's Spring Scientific Assembly. Speakers were grouped into blocks and this study was presented by the lead author, Angela C. Icollingo Rodriguez in the same block as me and I think it's an important area of study. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

I've received a bunch of reader questions that can be summarized as what the hell is going on with GLP-1s and Medicare? Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In Part 1 we talked about the basics of the studies around GLP-1s and cancer. In part 2 we looked at a study of relatively early data around breast cancer. In part 3 we began discussing a Guardian article that made broad, unsubstantiated claims about these drugs and cancer. Today, in the final part of this series, we'll take a look at the three studies the Guardian author quotes. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In part 1 we discussed the basics around the current studies considering possible impacts of GLP-1s on cancer (if you haven't read part 1 yet you might want to as I will refer to the things discussed in that post.) In part 2 we looked at a study that explored correlation between GLP-1 use and cis women with breast cancer. Today we're going to look at a Guardian Article that many of you asked me to discuss. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In part 1 I discussed the basics of the deluge of studies coming out looking at GLP-1s and cancer. If you haven't read part 1 yet, I would recommend doing so as I'll be referring to it a lot as I move through the rest of this series.Today we're going to look at a study that considers relatively earlier data around GLP-1s and breast cancer. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In Part 1 we looked at a study that questions common assumptions about weight and health. Today the lead author, Natasha Wiebe will share her reflections on her attendance and presentation of the paper at the Ob*sity Summit in Montreal, Quebec. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

I've previously written about research from Natasha Wiebe et al. that questions assumptions around weight and health. Today I'm back to discuss a new study “Associations of ob*sity, systemic inflammation, and hyperinsulinemia with the incidence of non-communicable chronic disease and mortality: A prospective cohort study” by Natasha Wiebe MMath, Stephanie Thompson MD, Peter Stenvinkel MD, Aminu Bello MD, Matthew T. James MD, and Marcello Tonelli MD.In part 1 we'll discuss the study. In part 2 I'll publish a piece written by Natasha about her experience attending a weight loss industry event to present her findings. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In Part 1 we started talking about emails that I've been receiving from readers about the weight centric backslide including some initial ways that we can identify the issue and push back. Today we're going to dig deeper. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

I've received a lot of reader emails like the one below from reader Jeannie.I feel like I'm seeing so many people, including dietitians and doctors, who used to be staunchly non diet getting back on the weight loss bandwagon. Suddenly they're all “you can fight weight stigma and promote weight loss” and “o-word is a metabolic disease” - and “use people first language” and it's like they were claiming to be non diet but it was only because they didn't think they could shrink us but now they think these drugs can and they are showing their true (anti fat) colors and people (including doctors) I thought respected me and believed in non diet care are showing me that they've always thought I would be better thin, or that my fatness is a disease, they just didn't think they could make me thin (or not “diseased”) and now they do. Is there anything we can do to fight against this? Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In part 1 we began discussing the study “Potential mechanisms for change in diabetes prevention programs: A systematic review” including the authors and the premise. Today we'll look at the methodology and the findings. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

This is the Weight and Healthcare newsletter! If you like what you are reading, please consider subscribing and/or sharing!Diabetes Prevention Programs are a group of programs that are created to prevent the onset of Type 2 Diabetes, often in people who have been identified as at-risk. Most include behavior changes, social support, and include weight loss as a metric and/or the primary outcome. The assumption is typically that any health changes and/or reductions in the development of T2D are because of any weight loss. In discussing these programs previously I've expressed the concern that any differences in health/T2D development were more likely due to behavior changes/support than any weight loss and that, because of their insistence on a weight-loss focus, the programs likely included much more restriction than is necessary to create any health changes, which could create harms including weight cycling (which can actually drive T2D,) weight stigma (which can actually drive T2D,) and disengagement from behaviors that might actually support health and make T2D less likely (with the clear and critical understanding that whether or not someone develops T2D involves myriad factors, many of which are completely outside of their control, including genetics.)Enter the new systematic review “Potential mechanisms for change in diabetes prevention programs” which sought “to investigate potential mechanisms for change in diabetes prevention programs (DPPs), and assess the strength of associations.” Their hypothesis was that “ Weight loss would be less strongly associated with improved health than other mechanisms.” SummaryA group of researchers, several of whom work in weight inclusive Type 2 Diabetes preventions and management, sought to fill a gap in research around Diabetes Prevention Programs (DPPs). These program seek to delay/prevent onset of Type 2 Diabetes and typically include multiple interventions but often target an end goal of weight loss. There is a significant lack of research that even attempts to determine which aspects of DPPs might actually be responsible for any benefits and which might be unhelpful or cause harm. These researchers undertook a systematic review to attempt to determine just that. The AuthorsWe'll begin, as we always do, with the authors. Spoiler alert, this is going to be much shorter than these typically are. The study received no funding and the authors disclosed no conflicts of interest. I'll do my usual deeper dive into their work and, as a reminder, working in the space in which you are researching is not considered a conflict of interest that requires disclosure but is something that always makes me give extra scrutiny to methodology. As usual, if you want to skip this part you can scroll down to where it says “The Study.”Margit I. Berman is an Associate Professor at the Graduate School of Professional Psychology at the University of St. Thomas. Dr. Berman is the author of a “A Clinician's Guide to Acceptance-Based Approaches for Weight Concerns: The Accept Yourself! Framework” This is not a DPP program but does have a section on Health at Every Size™ approaches to Diabetes and Cardiovascular Health. [Note: that Health at Every Size is the trademarked brand of the Association for Size Diversity and Health) Martha Burla - per LinkedIn currently works at the Feinberg School of Medicine in the Department of Medical Social Sciences where she supports research on patient reported outcomes and shared decision making. She is also pursuing a PhD in Health Sciences from Rush University with the hope of continuing to research patient decision making and autonomy.Hannah Martin - per her Linkedin she is a PhD candidate at the University of Otago, Dunedin New Zealand. Her research focuses on Intuitive EatingMegrette Fletcher - is the owner of Inclusive Diabetes Care, LLC which offers free and paid resources for weight-inclusive diabetes care. Full disclosure, Megrette and I have worked together including speaking on the same panel and on a writing project.Elizabeth A. Michaels - per LinkedIn, works at Christopher Rural Health Planning Corporation Primary Care including Coordination of Diabetes Program in accordance with AADE Standards , Individualized Nutrition Consultation and Diet Instruction, Nutrition Therapy for Emotional Eating, Personalized Meal Plans and Recipe Development, Provision and Marketing of Community Health Classes, Development of Educational Resources and Materials, Diabetes Medication and Insulin Management, Continuous Quality Improvement Tracking, Patient Goal Setting and Ongoing Support, Auditor AADE Programs, and Development and initiation of CDCs Diabetes Prevention ProgramLauren Brittany Beach- Per LinkedIn they are an Assistant Professor at Northwestern University's Department of Medicine Social Sciences and Department of Preventive Medicine in the Feinberg School of Medicine and “a leader with a strong track record of scientific research and business development across a wide variety of therapeutic areas, including infectious disease, oncology, cardiology, endocrinology, nephrology, rare disease, and more. In my roles as Assistant Professor, ADVOCATE Center Director, and Robert H. Lurie Comprehensive Cancer Center Executive Team member at the Northwestern University Feinberg School of Medicine, I am recognized for innovative and high impact contributions in research, mentorship, education, and service. I have 20 years of experience translating results from cutting-edge science into narratives that resonate with funding agencies, regulators, clinicians, and the public. I have experience directing interdisciplinary teams in the United States and globally of up to 60 people to solve complex research and operational challenges on time and on budget. Trained in genetics, law, and epidemiology, I am a skilled data scientist and technical writer with experience in research and regulatory communication in both the discovery and clinical research domains.”Michelle L. May - per LinkedIn May is an Associate Professor in the Psychology Department at Arizona State University and the creator of the Am I Hungry? Mindful eating program offering “experiential mindful eating workshops, retreats, and corporate wellness programs. We have trained over 800 health and wellness professionals in over 40+ countries to offer mindful eating programs, coaching, and therapy in their communities, practices, and workplaces.“Pamela J. Bagley - per LinkedIn Bagley is Coordinator of Biomedical Research Support at Dartmouth Biomedical Libraries.Heather B. Blunt - is a Research and Education Librarian, Public Health Lead in Medical and Health Sciences at the Dartmouth Biomedical Libraries with subspecialties in Medical and Health SciencesThe StudyThe authors begin by explaining diabetes prevention programs (DPPs), including that they can vary but often have multiple components including medical and/or psychosocial interventions. They point to the DPP-ILI (Intensive Lifestyle Intervention) as a typical intervention that focuses on creating 7% weight loss using multiple components. They also point out that in one study the DPP-ILI reduced diabetes incidence by 58% compared to a placebo, but that participants don't necessarily find the program either “helpful or tolerable” and the programs often having drop out rates from 40-80%. They also note that the DPP-ILI contains multiple elements - change in weight, physical activity, food, social support, psychological change, education, and self-monitoring and self-awareness that may impact onset of diabetes. Finally, the authors point out that “despite their efficacy, it is possible that DPPs may include harmful elements such as exposure to weight stigma or healthism.” I'll also add, based on about 100 years of research, exposure to the harms of weight cycling since the vast majority of people who lose weight will gain it back.Here the researchers hit on an issue I would suggest is not just with DPPs but with all health interventions that are based on weight loss. As these authors put it, “it is striking how little is known about which components of these interventions cause a delay in diabetes onset, and which components may cause harm.” As is, again, the case with almost all, if not all , research that tries to claim that weight loss create health benefits, more than twenty years in, the research into the DPP-ILI “was not designed to test the relative contributions of dietary changes, increased physical activity, and weight loss to the reduction in the risk of diabetes.” Given our culture's obsession with weight loss (driven by, and with tremendous profit to, the weight loss industry,) the assumption with the DPP (and in general) is always that weight loss (and, typically, very small amounts of weight loss) causes health benefits, literally ignoring all of the behavior changes and other components that precede both the (small, typically temporary) weight loss and the health changes/benefits. The researchers note that “clinicians have focused on the importance of weight loss…recommending weight loss, however, may be a particularly likely candidate to cause harmful or null effects in DPPs.”Considering weight loss, the researchers note that long-term weight loss is “not achievable for most people” and, further, that weight loss programs can induce or exacerbate weight stigma and expose participants to discrimination. They point out that despite the “transient” nature of weight loss in DPPS, “the delayed onset of diabetes can be largely retained, suggesting that mechanisms other than weight loss may contribute to the benefits.”In part 2 we'll look at the study methodology and what they found.If you think my work is valuable, and you want to support my ability to do it, you can become a free or paid subscriber. Both support the work I do here! Liked the piece? Share the piece!More researchThe Research PostMore resourcesThe Resource Post*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings' Fearing the Black Body – the Racial Origins of Fat Phobia and Da'Shaun Harrison's Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

Recently I wrote about research around GLP-1s and nutritional deficiencies. In summary, we looked at a study that showed that most of the clinical trials aren't studying this at all, and that when studies do consider this there are concerning findings, and, finally, the implications of all this.I was recently contacted by a Chicago-area private practice dietitian (MS, RDN, LDN) who had, in fact, written a letter to the editor of the journal that published one of the articles I looked at in Part 2, Malnutrition is Common in Patients Utilizing Glucagon-Like Peptide-1 Agonists Prior to Total Joint Arthroplasty, published in the journal Arthroplasty Today. The letter made important points about the study itself (including the lack of a Registered Dietitian among the authors) as well as issues with the measures chosen and more.This is where I would link to the published letter, except that it's not published. It was rejected, not on the merits of its arguments, but with a single sentence:“We appreciate your letter to the editor but I am not sure that we typically have registered dietician [sic] comment or collaborate on our research." Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

Remember when I wrote about the FDA Averse Events Reporting System and how the drug companies are required to report adverse events? Novo Nordisk just got a warning from the FDA for…not doing that. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

I'm very excited to announce the culmination of a project I've been working on for Project HEAL. They are an incredible organization that works to break down systemic, healthcare, and financial barriers to eating disorder healing. They already had a series of templates for insurance appeals and they reached out to me to create a blog post and templates to appeal weight-based denials and failure to accommodate. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In Part 1 we looked at the problematic justification used by the Colorado Legislature to pass legislation following massive lobbying from the weight loss industry and their astroturf “patient advocacy” groups.Today I am going to talk about the actual contents of the law and am grateful for input from an attorney with many years' experience in health care law and regulation who was willing to provide thoughts but did want to note that they are not admitted to practice in Colorado. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

A bill in support of weight loss interventions, particularly GLP-1 diet drugs, has passed the Colorado state legislature and been signed into law. Very similar bills are being pushed by the weight loss industry (and their astroturf “patient-advocacy” groups, particularly the “Ob*sity Action Coalition”) in individual states and federally with the goal of increasing insurance coverage (and through that the market, and through that the profits) for weight loss drugs and other weight loss interventions.I'm going to go through the bill bit by bit as it relates to weight science, weight stigma, healthcare, and areas that suggest weight loss industry influence. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

I got the following question from reader LouAnna who asked“I just saw that they are developing even more new weight loss drugs of the GLP1 type that (supposedly, of course) create even more lost weight. What ever happened to the claim that we just need to lose 5-10% ? Don't these new weight loss drugs already claim that they exceed that? Will it never stop?”This is a great question and I'm happy to offer my thoughts. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In part 1 we discussed a study that showed that malnutrition is very rarely studied in randomized controlled trials for GLP-1s. In part 2 we looked at the findings of research that studied nutritional deficiencies in GLP-1 users. Today we'll talk about the implications of these findings, including what we know, what we don't, and what we should. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In Part 1 we talked about a study that showed that most randomized controlled trials for GLP-1s failed to assess nutrition/possible nutrition deficits. Today I'm going to summarize some research that did look at these possible issues in people using GLP-1s. In Part 3 I'll talk about the implications of all of this. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

I subscribe to a borderline ridiculous number of medical publications from which I receive an absolutely ridiculous number of emails. One headline caught my eye “GLP-1s Bringing Back Scurvy?” Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

I received the following reader question:My name is Mary and I'm a family doc (you can use my first name if you print this.) I wouldn't say that I'm fully onboard with being weight inclusive but I've been reading your work and I can't deny that what you are writing makes sense and is grounded in research (some of which I had never heard of in any of my training.) I have been thinking about what you wrote when you said how important it is that we ask our patients questions instead of making assumptions. I will admit to making assumptions about diet and exercise with patients who are what you would call higher weight. Thank you for helping me see that, but I'm having difficulty with what to do instead and how to ask the questions and I thought others might be as well. Is this something you would be interested in writing about?Thanks for the introspection, the open-mindedness, and the great question, I'm happy to write about this. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In Part 1 we looked into the authors and methodology of the study The Acute Inflammatory Effects of Weight Stigma: An Experimental Pilot Study which was published in August, 2025. In part 2 we'll look at the results. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

A new study in this vein has come out that looks at the link between weight stigma and inflammation. The study is called The Acute Inflammatory Effects of Weight Stigma: An Experimental Pilot Study and it was published in August, 2025. In part 1 we'll look at the study authors and the methodology, and in part 2 we'll look at the results. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In part 1 we discussed the issues with the decades-long practice of healthcare providers prescribing behavior-based weight loss not based on the evidence (which shows that the vast majority of patients will lose weight short-term and then regain it long-term) but on the belief/hope that every one of their patients will experience the very rare “Best Case Scenario” of significant, sustained weight loss. Today we're going to talk about how the new GLP-1 weight loss drugs are taking this problem to new lows. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

When it comes to recommending weight loss, healthcare has always had what I call a Best Case Scenario Problem. I think the best way for patients to protect ourselves from this is to understand it so that we can spot it when it's happening so in Part 1 I'll examine how this works (in the past and currently) around behavior-based interventions and then in part 2 we'll look at how GLP-1s are driving an increase in this problem and creating even more harm and what we can do if this problem happens to us. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

I've had a bunch of requests to write about this so here you go! Novo Nordisk has a long and sordid history of misdeeds, many of which I've written about previously. Now they have a new one to add to the list. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

This is the Weight and Healthcare newsletter! If you like what you are reading, please consider subscribing and/or sharing!In Part 1 we started discussing the “Million Pound Challenge” created by Toby Cosgrove and Dr. Michael Roizen in which they are “challenging” an unknown number of people to collectively lose one million pounds. In part 2 we'll discuss the program itself. (If you haven't read part 1, I recommend it to fully understand part 2.) As always I'll indent the quotes from the website so that you can avoid harmful weight stigma if you choose. They explain the program as a 3-step process:Step 1: Enroll Your OrgRegister your health system. Get access to a variety of resources in the Million Pound Challenge Tool Kit for your entire team.Step 2: Your Staff, Your WayEmployees can use the tools provided, join their own programs, work with providers—whatever works. Your organization decides how to structure participation.Step 3: Track ProgressThe only requirement? Track results with a monthly check with your Challenge coordinator. Watch as individual effort becomes collective momentum toward one million pounds.This is where they make things incredibly clear - literally the only requirement is to track weight loss. This isn't about health metrics, there is no way to make this program weight neutral or to focus on health - weight loss is the only metric and tracking it is the only thing the program requires.And when they blithely say “whatever works” let's be clear that a century of research finds that, unless their goal is to create weight cycling, nothing does. So there is no common intervention and all they are tracking is weight loss. Right. And how is weight loss tracked? Per the FAQs (emphasis mine)“Your Challenge ambassador must log your team's results monthly with your assigned Challenge Coordinator—this is the only requirement. Individual weights remain completely private. Only aggregate organizational totals are posted on the community leaderboard so you can see how your organization compares nationally.”Um, they aren't private if you have to share them with your company's challenge ambassador (and I have serious concerns that someone who would sign up for that job may be the last person that a coworker would want to tell their weight.) Workplace programs (or any programs) that include a weight loss component have significant risks to physical and mental health, including through eating disorders. But programs that compel people to compete solely on the basis of weight loss, as this one does, can actually encourage participation in dangerous behaviors in order to create weight loss.Measure your organization's progress, celebrate your success stories, and recognize your top-performing teams. Join leaders at quarterly events, Chamber Summit, Aspen Ideas Festival, and HLTH to keep momentum strong.Do. Not. Do. This. Another huge issue with this, and all workplace/organization weight-loss challenges, besides the issues with disordered eating and eating disorders and weight cycling, is that it can single out people who aren't participating or “achieving” in ways that create a hostile work environment for them. It can mean that those who have chosen an evidence-based weight-neutral path (either due to a history of eating disorders or other reasons) have to choose between their physical and mental health and being seen as “not a team player.” It can lead to organizations under valuing employees who, due to many reasons including disability, chronic illness, and more, cannot participate in the initiative at all (or in ways that make them “top-performing”) which can lead them to being seen by subordinates, peers, and bosses as a “drag” on the team or having less value to the organization. This is not surprising from someone like program co-founder Toby Cosgrove who once gleefully told the New York Times magazine that he didn't want to hire higher-weight people (as the CEO of the Cleveland Clinic,) but let's not follow in those bigoted footsteps.After 12 months, we'll have collectively proven what we've known all along—that sustainable health outcomes are achievable. Winners celebrated at HLTH 2026. Every organization recognized for leading the revolution.There is so much wrong with this that I scarcely know where to begin. As I said in part 1, “prove” is a very strong word so I expect robust research and lots of it (spoiler alert - I'm going to be disappointed again, but in no way surprised, again.) These two doctors should know better than to suggest that anything about “sustainable health outcomes” can be “proven” by a random “challenge” that only lasts a year has no common intervention, and only measures weight loss. This does not have the ring of sound science. The truth is, we can't even be sure how many of the participants would get thin enough that program co-founder Toby Cosgrove would think they deserved to be employed.I don't want to spend too much time analyzing the deck chairs on this titanic of a “challenge” but I do want to look at one of the “resources” they offer, called ‘Why Healthy Employees Don't Need Your Wellness Challenge.” First of all remember that this is NOT a wellness challenge (which would measure, you know, wellness) this is a weight loss challenge that only measures body size manipulation. Even if we ignore that, this “resource” is particularly horrifying, promoting the “Lifestyle 180” program. The program is based on the assumption that higher-weight people and those with chronic conditions are not already participating in health-supporting behaviors and should be “targeted”, by their employers (not their actual healthcare providers,) with “intensive, medically-integrated interventions.”Here again, this program teaches organizational leadership to see higher-weight people and those with chronic conditions as a liability to be solved and not as skilled and valuable employees, with the unspoken (except by Toby to the NYT magazine) takeaway to avoid hiring these people in the first place. This is likely to disproportionally impact higher-weight people, People of Color, and especially higher-weight People of Color. (Note that this is all wrapped up in the massive issues with U.S. employers providing healthcare which is, to use a technical term, a hot garbage mess that is beyond the scope of this post, but the idea that employers should have access to employee health information is obviously seriously problematic on its face.) The “resource” continuously suggests that employers focus on “the 20% of [ employees] driving 80% of the costs” ending with “that's where you win.”My main takeaway from this resource was that if an employer sent me an email that said “Your recent health screening showed some concerning trends We have a program specifically designed for you. Can we talk?” I should say, emphatically, no. Which would also be my immediate answer if asked to participate in this “challenge.”In Part 3 we'll talk about what you can do if your organization tries to push this kind of “challenge” on you.This month's online workshop is Weight-Neutral Joint Pain Management with sports medicine physicians Dr. Julia Bruene and Dr. Jeremy Alland. There is a pay-what-you-can-afford option and a video will be sent to all registrants.Details and registration here!If you appreciate the content here, you can subscribe for free to get future posts delivered direct to your inbox, or choose a paid subscription to support the newsletter (and the work that goes into it!) and get special benefits! Click the Subscribe button below for details:Liked the piece? Share the piece!More researchThe Research PostMore resourcesThe Resource Post*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings' Fearing the Black Body – the Racial Origins of Fat Phobia and Da'Shaun Harrison's Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

Reader Shannon Roosma-Goldstein, MPH, BSN, RN, NPD-BC recently reached out to me because a professional healthcare organization she belongs to had sent her an email encouraging her, as a member, to participate with the organization in the “Million Pound Challenge.”In Part 1 we'll look at the basic issues with the challenge and who is behind it. In part 2 we'll look at the details of the program, and in part 3 we'll talk about what you can do if your workplace announces a program like this, including with sample letters written by Shannon that you can use as a template. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

Behavior-based interventions (sometimes under the auspices of lifestyle medicine) can be evidence-based, health-supporting, and weight-neutral. Unfortunately, when it comes to recommending behavior-based interventions to higher-weight people, there are common mistakes that providers make. We'll talk about the mistakes and then what patients and providers can do to avoid and/or navigate them. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In part 1 we started looking at a study called Weight Regain after cessation of medication for weight management systemic review and meta-analysis by West et al. and in part 2 we looked at the findings. Today I thought it would be helpful to look at how the media is covering this study so we can see how these findings translate. If you haven't read part 2 (or, at least, the summary) then I recommend starting there. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In Part 1 we began discussing Weight Regain after cessation of medication for weight management systemic review and meta-analysis by West et al. Today we'll discuss the findings. This is a long one so I've got a summary and then a deeper dive. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe