Diet & Exercise: Primary, Co-Equal, or Simply a Good Idea?
Diet and exercise is a dominant concept in obesity care that’s in the midst of an identity crisis. In The Atlantic, Daniel Engber sums up one point of view, writing:
“Ozempic killed diet and exercise. Doctors might be slow to admit it, but Ozempic and other GLP-1 drugs are making dieting and exercise obsolete.”
While this is easy to say – and great for sparking a lively conversation – the truth of the matter is much more nuanced and complex.
The Great Realignment
Rather than declaring diet and exercise to be dead, we suggest that that a realignment of conventional wisdom about obesity care is underway. The old thinking was that obesity is primarily a problem of a poor diet – or more broadly, a problem of diet and exercise. So obviously, the best solution would be to correct the underlying problem. Tell and help people to adopt healthier habits of diet and exercise.
But empirical evidence has made the flaws in this thinking unmistakeable. Engber sums it up nicely:
“This insistence on the status quo has begun to seem a little strange. It’s long been known that prescribing dieting and exercise simply isn’t that effective as a treatment for obesity. People may slim down enough, at least initially, to prevent or help control type 2 diabetes, said Tom Wadden, an obesity researcher at the University of Pennsylvania who has been involved in clinical trials of both lifestyle modifications and GLP-1 drugs as treatments for obesity. But he told me that amount of weight loss will not reverse sleep apnea or prevent heart attacks or strokes.”
The realignment involves accepting that obesity is really a medical problem. Not a behavioral problem. In other words, it is a genuine disease that requires treatment to avoid bad health outcomes.
Adjuncts, Combinations, and Compliments
For insight on evolving views of the role of diet and exercise in treating cardiometabolic diseases such as obesity, a stroll through the indications for the drugs for hypertension, high cholesterol, diabetes, and obesity is instructive.
The approach to hypertension offers the most mature thinking about the role of drugs. An ACE inhibitor like lisinopril is indicated simply “for treatment of hypertension.” That’s it. Further into the prescribing information, one can find more expansive language about “comprehensive cardiovascular risk management,” including references to diet and exercise. But nothing to suggest that these medicines are subordinate to diet and exercise.
For cholesterol and diabetes, the subordination comes into view. Drugs are indicated as “adjuncts” to diet and exercise. But they are also indicated without qualification to prevent strokes, heart attacks, and deaths.
For obesity, prescribing information makes it clear. These drugs are to be used only “in combination with a reduced-calorie diet and increased physical activity.” No nuance there. It implies that obesity means the patient has been eating too much and moving too little.
Let Go of the Bias
We all harbor biases. But the bias that poor diet and exercise habits is a reliable explanation for obesity is destructive. It imposes a judgment on many people who have spent lifetimes paying attention to these lifestyle factors and live with persistent obesity nonetheless.
It’s time to let go of that destructive bias and simply treat obesity while supporting patients in their lifestyle goals.This does not have to be so hard.
Click here for free access to Engber’s excellent essay and here for further perspective on the role of lifestyle therapies in the era of GLP-1 therapies.
Catherinettes in Paris, 1932, photograph by Agence Meurisse / Wikimedia Commons
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December 27, 2024
