Hacker News Reader

Comment by alabastervlog | Hacker News Reader

Diet and exercise methods don't[1] work for most people, for loss and especially for healthy weight maintenance.

With extreme levels of direct, personal involvement by multiple professionals (which is what rich people / celebrities have historically used, and variations of which have been studied by researchers) the efficacy level reaches "sort-of OK, but still not great". That's crazy-expensive, though, so not a realistic solution for the masses, plus the results are still pretty lackluster despite the cost.

[1] Could, hypothetically, yes "CICO", technically anyone could lose weight, but they in fact do not work when applied in the real world, statistically speaking.

View on HN

Perhaps anecdotal but generally society doesn't seem to be setup to reward people making good choices.

Before the GLP-1 drugs became mainstream for weight loss, I know friends who were overweight who had enough money[0] to go on programs where your entire meal days are planned for you[1]. They'd ship you enough food for 2 weeks at a time, but you never had to think about what you were going to eat, it was all pre portioned and decided by your meal plan as part of the program.

They saw really meaningful results, lost weight, and as long as they were on the programs, they kept it off. As far as I could tell, the food wasn't anything special beyond being properly proportioned and nutrient dense - certainly achievable on ones own - but it seems the rigidity of it - that is, the fact they didn't have to make food choices every day - made it easy to stick to. The food prep itself was easy too - mostly throw it in a single skillet, microwaving it or putting it in the oven on a tray or in a baking dish was all it took.

I watched as they got healthier they were more active, felt better, seemed generally overall much happier.

Once the program was over or they for whatever reason had to stop, it didn't take long for the weight to come back, and they had discovered a big part of their problem was food anxiety - not knowing what they wanted to eat, having trouble with food cravings etc.

This has lead to me to suspect there are some seriously chronic issues with food culture in the US - namely, we haven't made doing the objectively best thing the easiest thing. Its too often out of reach due to cost, availability or time - which also speaks to other interconnected issues in the US that are going unaddressed.

For example, I know these programs worked exceedingly well for those I saw on them, why aren't they cheaper? Why don't we subsidize such things to nudge society in a better direction with food choices? We already subsidize the bad stuff - we should move those subsidies to better options.

[0]: I'm talking breakfast, lunch, dinner, and a small allotment of daily mini meals - really snacks.

[1]: This is the problem. To do this, you have to be of upper class means just to afford the food, and thats not even including the cost of the program associated with it, and in some cases its simply a meal delivery program and there's no additional anything, and its still expensive

USA food is absolutely crazy. Lots of stuff that’s banned in the EU. Lots of high fructose corn syrup. If you eat out, portion sizes are off the scale. I ordered a starter salad at a restaurant once when I was over on business, and it would have fed me for the entire day! (Won’t even start on the sauces!)

Everything involving food is screwed.

>If you eat out, portion sizes are off the scale

And yet in a sister thread about Deliveroo we have people talking about what a "game changer" the delivery services are, eating 2 takeout meals a day without really understanding what's in the food. People eat too much.

Soda in the US is batshit crazy, and has gotten way worse over recent decades. People will have the equivalent of a couple of candy bars worth of sugar with a lunch (and then do it again for dinner... plus have the equivalent of one or two more candy bars between meals) when they'd probably be grossed out by the idea of having a pile of skittles or something with their burger. But liquify it, and it's fine I guess?

We have free refills (was rare until some time around the late '90s—see the '80s film Gleaming the Cube where there's a sign on a Pizza Hut in a scene near the end of the movie advertising a special on pitchers of soda, which probably seems weird to anyone used to just having their soda constantly topped off, or walking to the fountain and doing it themselves) so it's easy to thoughtlessly sip down three or four glasses of soda with a long meal, and to-go sizes at fast food joints have ballooned in size in the last 20 years or so, like, the medium sizes are often larger than what I'd have classified as a large before.

This is normally because those diets are unsustainable, or not sustained at any rate. If you change your habits such that you start introducing more calories, it's not a question of "if" you'll gain back weight, but when.

It's only fairly recently that we seem to have a better grip on what makes caloric restriction more sustainable, and accounting for effects like metabolic adaptation. Even then that information doesn't seem to reach most people.

Also understated is the impact of one's environment, and social support systems. It's much harder if you break from what your family and friends are doing. Some habits, I've seen with my own two eyes, can be regarded as an obligation.

I really believe the odds can turn around for a larger demographic, with a more optimal approach. Let's not forget that we've had far more invasive procedures than ozempic available to help facilitate weight-loss (like gastric bypass), and people still gain back weight on those, if they refuse to change their habits. Drinks, junk foods, and deep fried foods are not satiating compared to their caloric density, and that remains true regardless of surgery and pills. Nothing changes until it's internalized that binging has a price.

> Drinks, junk foods, and deep fried foods are not satiating compared to their caloric density, and that remains true regardless of surgery and pills.

But it doesn't remain true on GLP-1 medications, which is why they're so popular.

It does remain true, that's the entire point. With GLP-1 you can be more full than without, but that doesn't mean that a baked potato and french fries grant equivalent satiety! Your body also adapts somewhat to the medication.

If you factor in metabolic adaptation, then re-introduction of surplus calories will lead to regaining weight, even if they weren't as many calories as before.

For the reports of mediated cravings, also: some people don't just overeat from physical cravings, but for emotional satisfaction. A binge session on comfort food has almost nothing to do with hunger. This is something addressed through therapy, not pills.

I wouldn't argue for a strict equivalence, but research shows (https://papers.ssrn.com/sol3/papers.cfm?abstract_id=5073929) that people who go on GLP-1 drugs shift their food habits to decrease consumption of calorie-dense processed foods. It's hard to 100% prove this is causal (or that "calorie-dense processed" means low satiety), but it matches widely reported anecdotes (https://www.nytimes.com/2024/11/19/magazine/ozempic-junk-foo...) that GLP-1s cause hyperpalatable junk food to be unappealing. For me personally, I can't even eat a full slice of cake anymore.

I'd hold out for stronger evidence, because my own anecdotal experience is that those on GLP-1 periodically feel sick but otherwise still seek out the same foods they always had. Also they are very much still capable of binging, on days they don't feel particularly sick.

I wonder how much of that is education.

Most people also don't seem to know that weight loss is simply Calories in - calories out, what their BMR is, how to track calories. Most people, even educated people, still seem to believe things like they have slow metabolism, that herbal teas can help, doing situps will reduce belly fat, and number of dumb shit the market tries to sell.

As a nation were just far too focused on $$$, and instead of focusing on fixing the root of the issue, were only incentivized to bandage the problem with producing more things that will make $$$. Sell shit food, people get fat, sell crap products for weigh loss, drugs, surgery, etc

Weight loss is not simply calories in - calories out. Fat is not burned and its metabolism does not change your weight.

Oxygen/CO2 exchange in the lungs is also a major component of weight change. Further, your body homeostatically manages your metabolism so in the long term you often return to the same weight regardless of your current calorie consumption.

And that's just addressing first order weight parameters.

It is calories in/out. Other mechanisms factor in, but I’ll bet anyone my bottom dollar they’ll lose weight if they eat 700 kcal/day.

Yes, breathing is literally how weight is lost, I’m not sure what your point was there.

Weight loss is absolutely a result of CICO, please site a source that states otherwise.

I have never heard another source citing Oxygen/CO2 exchange as a factor for weight change, again, please site a source. O2 levels are certainly a factor of cardio health which can be correlated to overall health and weight.

Yes, macros also matter. But, nothing matters as much as the simple math of calories in/calories out. Its disingenuous, borderline irresponsible, to suggest otherwise.

https://www.bmj.com/content/349/bmj.g7257 is one analysis of oxygen/CO2 exchange being a major component of weight loss. As the authors say, it's really a question of chemistry; the CO2 you metabolize from your fat has to go somewhere.

To be clear, I think your instinctive reaction is correct. It would be extremely silly for someone to read this analysis and conclude that they'll lose weight if they learn some special breathing technique to maximize CO2 output. The point is that "calories in - calories out" as a diet strategy is the same kind of error.

By the way, if you ever want to start a scientific argument, bring up this paper among doctors and scientists. It never fails to start a big argument that is usually concluded with "human metabolism does not violate the conservation of mass/energy" (many doctors and scientists believe that "burning fat" with oxygen causes you to lose weight directly).

"Burning" fat doesn't violate conservation of mass/energy. Instead, weight loss occurs primarily through co2/oxygen exchange that is connected to metabolism.

https://www.bmj.com/content/349/bmj.g7257

(note I don't totally agree with this paper, and agree that if you eat almost no food, you will lose weight, and that exercise definitely seems to increase the metabolic rate and increased mass exchange in the lungs. Like I said, it's complicated).

I'm not being disingenous or irresponsible- I'm describing mainstream science based on biophysical data.

I don't think its accurate to say "weight loss occurs primarily through co2/oxygen exchange". CO2 being breathed out is the just the end product of weight loss.

Thanks, I appreciate that link. I had a chance to read this today and found it very interesting.

Apologies for the tone in my original comment. I misdirected work stress this morning.

>your body homeostatically manages your metabolism so in the long term you often return to the same weight regardless of your current calorie consumption

Then exercise more. That's how you increase the "calories out" part of the equation.

Yeah, it takes willpower.

I don't disagree that increased exercise is associated with weight loss. I don't think I denied that. We're mainly disagreeing about mechanisms. Ultimately, fat metabolism does not violate the conservation of mass/energy.

> willpower

I mean, sure, but if it was just willpower for everyone then we'd all speak 10 languages, play piano, be buff as hell, be emotionally stable, and no one would be an alcoholic.

But we're squishy apes that are regulated by hormones and live busy messy lives with cars that are probably needing a tire rotation 3000 miles ago and putting it off a few more miles won't really hurt.

Or it doesn’t take any willpower at all. I certainly don’t have to do this, and I’m thin. I eat whatever I want, whenever I want.

So why can I do that, but others can’t? It would be comforting to just say that I’m better. It would also be a lie.

There are generally a few answers to this. But they all boil down to:

* You never used to be fat.

Once you become fat, your body's homeostatic set point is permanently altered. Your body never destroys adipocytes — it only shrinks them. If you stay within some range of your current homeostatic set point, your body will either increase the size of your adipocytes, or decrease their size, depending on whether you're over- or under-consuming. But, after a certain amount of overconsumption, your body will actually create new adipocytes... And once you have them, you can never get rid of them, minus expensive and dangerous surgery.

The best you can do is shrink them. But, keeping the adipocytes shrunken takes significant willpower. So basically, once you get fat, you're going to have a hard time.

Pretty much the only alternative is somehow tricking your brain/gut into not getting hungry when it "should." Ozempic, etc seem to somehow allow you to not feel as hungry even when your adipocytes shrink, or at least alter your perceived set point to be more-shrunken. Bariatric surgery is similar although much more dangerous. (Liposuction actually removes adipocytes, but it's quite dangerous — and it doesn't remove visceral fat cells, which are the worst kind of fat from a health perspective.)

Now, there's a separate question of "why do some people get fat initially?" And that can result from poor childhood nutrition, or genes (e.g. Samoans), or exposure to certain chemical compounds (e.g. certain psychiatric medications), or natural aging (recent research indicates middle-aged mice, and probably thus middle-aged humans, have their stem cells trigger more adipocyte production), or just lifestyle. But it's the initial weight gain that ends up trapping people into the higher homeostatic set point, which is very difficult to recover from, even with dieting and exercise, since you will need to keep yourself basically constantly hungry either by eating less or by exercising much more even after you "lost" the weight — because while you lost weight on the scale, you didn't lose adipocytes, and adipocytes do not want to be kept empty.

I lost weight by measuring calories, shedding ~25% of my body weight. It's still a battle and will always be. I keep exercising the whole time - I'm training for my first marathon right now (I've run the distance before, just not in an official race), but my weight slides up, I adjust, it slides back down. I think some people are just built to like food, it's not a matter of education.

Rehashing my regular humans are not calorimeters post.

Metabolism is driven by hormones, it’s very possible for signaling peptides to prevent weight gain no matter how much a person eats.

While a person who eats nothing will clearly lose weight knowing that isn’t helpful as it’ll lead to a substantial loss in quality of life and most probably it is not long term stable.

In my case I have ME/CFS at the same time that I have uncontrollable weight gain, I also did extended fasts to keep the weight off as best I could. It wasn’t a willpower thing, having to manage both while making enough money to survive is incredibly difficult and it was impossible to keep all the plates spinning at the same time. Post Exertional Malaise is very real for some people and triggers can cause me to be bed-bound for months on end. Thankfully not so much anymore since I’ve found a good combo of very strong medications.

When almost half the country is obese/overweight, these kind of medical conditions are not the cause. For 99% of people it is not a metabolic disorder.

What I am talking about is people saying things like "Wow you have fast metabolism", without even understanding what metabolism is. Having twice as fast metabolism would mean my body requires twice the amount of calories for the same cellular activity. That'd be terrible!

The truth is I am skinny because i barely eat and if I eat 500 calories above my calculated BMR, I gain 1 pound a week just like the science suggests. I think this is the fact for most people.

>While a person who eats nothing will clearly lose weight

That's a strawman. What I am saying is take your BMR+caloric expenditure from exercise - 500 calories, not starve yourself.

When giving a generalization it's important to constantly note that exceptions exist. On the percentage of exceptions I think it's higher than commonly thought for a few reasons, most autoimmune disorders are still undiagnosed and will remain undiagnosed for the duration of the persons life. Consider hEDS for example, a walking bag of symptoms yet still 20 years to get diagnosed from onset of symptoms for those who are eventually diagnosed - again most are never diagnosed.

The other reason is that autoimmune conditions can be induced - it's not a genetic switch where you have it or you don't though there is a substantial genetic component especially with regards to susceptibility. People with my genetic background hEDS from multiple TNXB SNPs are extremely susceptible. The US population is also in new circumstances - we're several generations into the generally accepted medical advice that intermittent fasting will impair your metabolism. Prior generations would fast much more frequently than todays, they would just call it skipping meals.

While what you are saying is technically correct the framing of it leads to poor conclusions and suboptimal strategy, it will meet the stated aim of weight loss but not meet the implied aim of a maintainable lifestyle. The source of the calories is incredibly important given the effect that has on the hormones, and the cadence of calories is also very important. Instead of counting calories a person would be better of eating one meal a day of heavy caloric foods with the occasional multi-day fast would be far more productive. Augmenting this with a GLP-1A would be even more productive.

That's a good point but consider that a lot of modern countries, were not seeing the same obesity epidemic. Its hard to believe the difference between say 5% obesity and 40% obesity is from metabolic disorders in populations.

>While what you are saying is technically correct the framing of it leads to poor conclusions and suboptimal strategy, it will meet the stated aim of weight loss but not meet the implied aim of a maintainable lifestyle. The source of the calories is incredibly important given the effect that has on the hormones, and the cadence of calories is also very important. Instead of counting calories a person would be better of eating one meal a day of heavy caloric foods with the occasional multi-day fast would be far more productive. Augmenting this with a GLP-1A would be even more productive.

I think you're right that there is an effect, if you have any data to back this up I'd love to this see. My assumption is the effects were talking about (in anyone who doesn't have a metabolic disorder), is a difference in 100-200 calories in metabolic rate. In my personal experience, which I admit is not the most convincing, simply counting calories regardless of source tracks very accurately with the expected weight gain/loss based on estimates.

NONETHELESS, I think my original point stands, that there is a ton of misinformation on how weight loss works.

You have to be careful how you define metabolic disorder, do you mean entirely genetic of which there are not many, or do you mean auto-immune of which there are very many. To the point I'd even suggest that it's the dominant factor. Also there are no places in Latin America which has 5% obesity - it's more like 5 to 20%. Really only leaves Sub Saharan Africa, and parts of South East Asia. Additionally Europe is 5-10% so it's not a 1st world 3rd world split as you are presenting.

Anyway, if you are interested in researching check out the field of dysautonomia - there are many good books on the topic. It's an established science but not well known so people are unlikely to come across it by chance.

The main problem is that these conditions are severely underdiagnosed, thankfully people can now access GLP-1As without diagnoses so are no longer reliant on the competence of doctors.

I am comparing modern countries so that relatively a lot of the factors, like access to food, stay the same as the US.

My question is, why does Switzerland, Norway, Sweden, France, Denmark have a <20% obesity rate, and Japan, South Korea have <6%, but the US has 40%+? Certainly this isn't all from metabolic disorders, undiagnosed or not?

You can also perhaps compare data historically. People have never been this overweight, and likewise people have never been eating this many calories. You can a historic chart showing caloric intake and BMI are strongly correlated (both countries with higher intake are higher BMI, and over time, rise in caloric intake is associated with higher BMI) https://www.sciencedirect.com/science/article/pii/S030691922... https://ars.els-cdn.com/content/image/1-s2.0-S03069192220005...

Lastly, metabolic disorders can be caused by being overweight and inactive, so I think the causality is often opposite the direction you're suggesting.

Your logic is scattered and incoherent. You still haven't pinned down your definition of metabolic disorder, as mentioned my definition includes those caused by auto-immune. I explicitly stated that poor quality of food eaten too regularly is causative in many cases, genetics and lifestyle also plays a factor. You're hung up on the number of calories, my position is that is entirely secondary to what those calories are and the cadence of intake. There needs to be a gap in the intake for the natural GLP-1As to take effect. The point of having a mental model is to help make wise choices to optimize an outcome - your model is reductive and far too simplistic and elides many important factors that should be considered. Your position was more tenable in the absence of the data we now have. GLP1-As work, people know it works, and no amount of 'diet and exercise' is the one true path to enlightenment religiosity is going to cause people to unlearn it. I understand the strong desire to blame people for their choices, empathy is painful, and I understand the assumption that there is a price for everything - that nothing comes for free. But that presupposes a prior optimal homeostasis which for a variety of reasons we did not have. Modern diets / lifestyles created a problem that now modern medicine can help with. As a side benefit the medication works for those with my genes where diet and exercise simply wouldn't work. And in my case it's not a modern ailment, people with my genetic profile have had a rough life since before Hippocrates.

In 2018, 73.6% of american adults were overweight, obese or severly obese.

https://www.niddk.nih.gov/health-information/health-statisti...

> Most people also don't seem to know that weight loss is simply Calories in - calories out

It is a problem of education. For example, in reading the common research that shows basal metabolism, which you can’t control, will rapidly undo most of your conscious gains from caloric balance manipulation. And that in those with severe metabolic syndrome, the body will reduce BM to starvation levels before giving up a single fat cell.

Are citizens of skinnier countries better-educated, then become less-so if they move to the US and (typically) pack on weight?

If it's not education keeping other countries skinny, why would adding more education be the way we get out of it?

(This works for other explanations, too, like "oh they have more willpower"—so do they lose willpower if they move to the US? No, more likely, a complex combination of factors mostly outside individual control are why they're skinnier in their home country and fatten up after moving to the US; more likely, it's harder to be skinny here)

>Are citizens of skinnier countries better-educated, then become less-so if they move to the US and (typically) pack on weight?

"skinnier" countries have way different lifestyles, less driving, more walking, less fast food culture, etc. They don't need to be educated on weight loss because they naturally are not prone to it due to these socioeconomic conditions.

Yes! One thing that would be pretty likely to work is radically changing our city layouts, patterns of settlement, methods of commute, density of living, food quality, food prices & price structuring, worker protection & time-off laws, and a bunch of other stuff.

In the meantime (so... indefinitely, because moving the needle on one of those things would be the work of a lifetime) we now have drugs that can do it.

> keeping other countries skinny

Those countries basically don't exist, or rather they just haven't caught up yet. From 1985 to 2016, there are 117 countries where obesity has increased by more that 10.0% (in absolute terms). In no country was the increase less than 1.9% (which was vietnam, where 1.9% in absolute terms is a 10x increase in the percent of people who are obese).

Diet and exercise don't work for most people, because they don't exercise enough and don't follow their diet. Simple as.

"Stop drinking" doesn't work for most alcoholics, because they go back to drinking. Simple as.

"Don't commit violent crimes" doesn't work for most violent criminals, because they go back to committing violent crimes. Simple as.

"Stop gambling" doesn't work for compulsive gamblers, because they go back to gambling. Simple as.

"Have superhuman willpower in a domain where I don't feel temptation" isn't a cure, it's unempathetic judgment.

5% of the US population self-report alcoholism.

Why does food addiction encompass 40% of the US population?

Possibly because you can completely avoid alcohol but you can't completely avoid food. Some large percentage of people who would have been addicted to other substances (due to less than optimal nature/nurture) but didn't, because they did not take those substances, instead became addicted to the substance of food.

It might be more useful to see addicts to every type of substance as a large pool of anxious people who came across a substance to self-soothe, and figure out how to address the anxiety problem first.

Cheaper, much easier to get, socially acceptable everywhere, ...

You won't get judged for eating alone at home, but start drinking alone at home...

The US population probably isn't much different from the rest of the world, in that regard. What's different about them is they live in the US. Drop foreigners from skinnier countries in the US, and, as a cohort, they'll gain plenty of weight (as with lifelong Americans, some individuals will buck the trend, of course)

It's a complex social-environmental, economic, and political problem.

"It doesn't work because it doesn't work. Simple as."

Yeah, we all know why it doesn't work.

Is it normal to expect a process to work when you don't follow the process?

Part of any process is the ability to follow it. If you tell me you can drive blind folded by just memorizing the streets and driving precisely -- does that mean the process really works if no one can do it?

It's normal not to call that an effective intervention when only a small minority of the population can pull it off.

Things that do work ultimately do so by that mechanism (of course!) but not via people trying to eat better and exercise more per se. They do it by changing the circumstances under which a person is making decisions about eating and living, so better eating and more exercise in-fact happen, consistently and enduringly.

From most- to least-effective, over the long haul, it looks something like this:

1) GLP-1 agonists & friends,

2) Move to a skinnier country,

[a large gap]

3) Months and months, probably with periodic long refresher-sessions every year or two if you want it to actually last, of high-touch expensive help from multiple specialists, amounting to hours per week. This is the gold standard for what "actually works" as far as what can be done as an intervention, before Ozempic and such, and its outcomes are... so-so.

[another large gap]

4) Basically any diet & exercise plans or attempts to simply "eat less and move more"

(throw gastric bypass and stuff like that in there somewhere, not quite sure where they fall)

Just like people are poor because they do not work enough to earn enough and spend too much money... Simple as.

I mean, you're not wrong.

The realistic solution puts car manufacturers and certain food processors out of business (unless they learn to compete as export-focused/non-addiction-based businesses), so... Yeah, maybe not so realistic. But the obesity stats of countries with robust public transit, walkable neighborhoods, biking infrastructure, and restrictions on highly-processed food speak for themselves.

In the end - as with so many issues - the question is if policymakers are going to throw capitalists or regular people under the bus.

Right, the non-drug solution that would actually work (we can observe it working in countries with different infrastructure, healthcare, culture, city design, food quality and costs and cost structures, and more—we can be fairly sure it's some combination of that stuff because the folks who live there put on weight if they move to the US) is "upend US society in a bunch of ways" so is, realistically, not workable, at least not on the scale of human lifetimes, though it still wouldn't be a bad thing to try to move somewhat closer to.

Well, no. The countries that have done this have almost invariably done it within a 30-year timespan. Japan after WWII, China at the turn of the century, the Netherlands starting in the 70s. Even American cities like DC have made significant strides just since the Covid pandemic.

Reminder that the US auto industry would have collapsed during the GFC without a bailout. Balancing food industry profits against the healthcare costs carried by the poor and middle class in this country becuse of the lack of access to high-quality food produces a net negative bottom line, one of many deleterious dynamics inflating both personal and public debt. But if you hide all of that, you get to go back to your constituents and say that you're supporting manufacturing jobs and shareholder value for their retirement funds.

It's a choice between securing a few people's livelihoods and lifestyles, and securing the general well-being of a lot more people. We could change that choice, and we could do it very quickly, if we wanted to. But people would rather CICO tut-tut strangers on the internet.

Reply on news.ycombinator.com