Excellent discussion. One takeaway - I don’t think it’s enough for a Harvard medical weight loss clinic to say that (paraphrased) “efforts are made to encourage children and their families to eat better and move more”. I’m curious how many of those clinic directors, physicians and academic leaders have actually spent time reaching out to legislators and school boards about state and school policies regarding the kinds of food served daily, or have refused sponsorships from companies whose products might be counterproductive to their patients’ healthy living. A lesson learned through the pandemic is “see something, say something” but money and power sadly often speak louder.
A friend of the family and physician once gave me some valuable advice, he said “stay away from doctors.” Of course, doctors are invaluable and I’m grateful for the medical care I’ve received. However, let’s abandon the idea that medicine and big pharma is a miracle panacea for poor lifestyle choices.
This is not to say that there aren’t decent physicians out there. We need to be informed and refuse to naively accept medical advice. The medical industry is losing the trust and confidence of the consumer and for good reasons. And yes, we not a patient when the goal of the industry is to create a lifelong consumer of medical interventions.
I fully agree with Callie Means. Clearly the food and medical industry have created a financial goldmine with lifelong consumers. As for the American Academy of Pediatrics, this organization is a danger to children between gender affirmation (puberty blockers and cross-sex hormones), over medicating children with amphetamines for ADHD and this new recommendation re obesity (Ozempic / surgery). What parent trusts the recommendations of the AAP?
I was married to a physician and have attended many dinners hosted by drug reps. Those dinners were invariably held at five star restaurants where the alcohol flowed freely. At other times, drug companies would sponsor a dinner at a meeting that cost tens of thousands of dollars. The drug rep was a known individual who regularly hosted these high end events, and was familiar with many of the physicians.
As a non-American subscriber, one thing that struck me about the podcast was how Americans (I live in Australia) seem completely blind to the fact that there is something very wrong with the food culture in America. What counts as “food” includes things like pop tarts and twinkies (which I saw for the first time when I visited the US in 1995) and I recall being shocked in the supermarket because the only available bread was soft and sweet and all the cheese was bright orange. When I first arrived I couldnt figure out how to even buy what I considered normal food - unsweetened, unprocessed bread and dairy. Then portion sizes were at least twice as big as what I was used to, fast food was ubiquitous and people ate it as an a normal meal for lunch, maybe even every day, and the menus of “family” restaurants were wall to wall fried and sweetened food with each plate enough to feed several people. I had been raised to consider McDonalds a treat, and not actually real food. Like having chocolate cake for dinner. We could have it very occasionally but it was not a genuine meal.
I say this only because I don’t know how you turn this around. It takes generations to create a culture around food - what is a normal amount to eat, and what food even is. Are insects food? Pigs? Nettles? Dogs? Our culture tells us. From the outside it seems like a good part of America’s problem with obesity is not so much genes as a deeply unhealthy concept of eating taught to children, generation after generation and reinforced by what is available to eat and what people are conditioned to consider normal. The American diet it literally hard to stomach for people coming from outside the culture and yet those within it must struggle to gain that perspective.
Very well put. As the European in this conversation, I couldn't agree more.
One thing that saddens me about Calley's argumentation, however, is the picking of individual food items and saying "those are the devil". I mean OF COURSE you shouldn't eat pop tarts all day. But treats have always been here and they always will! It is up to each family and individual to realize that maybe 60–70% of what's in the supermarket is to be consumed in VERY SMALL quantities or not at all. Educate yourselves on nutrition, people, and stop looking for the villain. Today it's seed oils, tomorrow it's candy... well, nutrition is not black and white like that. Candy can be good IN VERY SMALL QUANTITIES. It's not a sexy explanation and it's not a sexy conspiracy explanation but that's how it works.
And if you do a lot of sports (like A LOT), then a lot of Calley's argumentation also doesn't hold up. But I understand he was speaking about sedentary individuals mostly.
Putting pressure on policymakers is nice but first do the work on yourselves.
I was really disappointed that Bari didn’t push the panel harder on how to implement diet/exercise solutions in the real world. As a working mom, I’m doing my best to get my kids ready and out the door to school and I don’t have time to make breakfast from scratch. The end of the day struggle is just as bad when I’m rushing to make dinner for a hungry family. While everyone was nostalgic for the 60s and 70s, most of the parents who make the meals these days also work full time and don’t have an entire afternoon to make healthy from scratch. I left very disappointed with the entire panel for making me feel like I’m part of the problem but without offering any solution. All the public health messaging in the world isn’t going to get me the time and energy I need to make non-processed meals.
I agreed with Calley on many of his substantive points but his insufferable smug demeanor made me not want to agree with anything he said. He needs to tone it down a bit and not be so constantly outraged in a room with adults.
Bari, I loved the podcast episode. I am a family nurse practitioner in Texas, and I have been having multiple patients a day asking for this drug. I am afraid of what will happen if we put hoards of patients on it. Muscle wasting due to decreased appetite, therefore decreased protein intake concerns me. You should have Dr Gabrielle Lyon on your show. She is an absolute expert on protein, muscle, and longevity medicine.
Mr. Means is right and wrong. Right in that the food and pharma industries have contributed greatly to the US obesity epidemic, and wrong to attack GLP-1s as not being an important part of an integrated GLP-1/nutritional guidance/exercise treatment protocol...such as Dr. Anekwe offers at her clinic. A company like Calibrate (https://www.joincalibrate.com/how-it-works) offers this type of integrated approach, and is offering obese patients hope and a feasible path forward to much better health. You would have to be a zealot to think that this is not a step in the right direction
Just listened to the podcast. I grew up in the 1970s and 1980s. I look back at the photos of my family and friends (back in the day when we actually printed out photos for everyone to look at, what will the current generation look at to remember this time...but that is another discussion) they were all thin. Perhaps not in Olympic shape, but normal body size. In 25 or 30 years, the genetics of the USA hasn't changed in perceptible ways, yet the family photos certainly have. It's the food and lifestyle. It has to be. Point taken about doctors arguing that we have a predisposition for obesity. But that is where we no longer have any level of self control and have too much immediate gratification. We have a predisposition for all kinds of bad behavior (perhaps why the ancients jotted down texts like the 10 Commandments and thought about the Seven Deadly Sins). Yet, our society doesn't teach things like self control. Anyways, I encourage you all to look at photos of society up until the mid 1980s, you'll see the obvious difference. The upside is we stopped smoking. The downside is we started eating mounds of pizza, fast food and processed cookies and gained 50 pounds.
I listened with interest to this, and it turned out to be a really worthwhile discussion, although one which occasionally devolved into a somewhat frustrating shit-show. Please indulge me:
1. Calley Means is generally correct about nearly everything he asserted about the science and of metabolic syndrome and dysfunction, but he doesn't have the public relations game that Drs. Anekwe and Prasad do. I would argue that Means's sister, Dr Casey Means does indeed have the professional demeanor as well as the medical chops to argue all the factual information Calley wanted to communicate without sounding combative and rhetorical. Dr Casey Means is an effective, measured communicator of metabolic health issues and facts, and I wish we could have had her as part of this discussion. Furthermore, either she or someone like Dr David Perlmutter could argue better why a pharmaceutical intervention like Ozempic isn't going to necessarily make actual long-term health outcomes better, as Ozempic is treating a symptom of a lagging indicator of dysfunction, which it doesn't cure.
2. Dr Anekwe was a mixed bag. On the one hand, I respected her professionalism and composure, particularly in the face of criticism. And I truly believe she and her fellow clinicians believe in their mission. But she was unable to ever say effectively that the reason why recommending that good diet and exercise "doesn't always work" is that (1) there is so much more education about food and nutrition required to make a change in most people's lives, especially when the facts often run against cultural and community norms, and (2) she did not acknowledge something that just about *anyone* who is into health and nutrition knows: What normie establishment medicine thinks is a good recommendation for diet might be 10-30 years behind the times, and she never explained what those dietary recommendations were, which may be what we now know to be bad recommendations. The idea that an obesity clinic doctor (was it her colleague, quoted at the beginning of the podcast?) would say of an obese patient, "She exercises 5-6 times a week to no avail," is redolent of the 90's calling and wanting their health advice back, and it makes you sound like less of an authority to be minded. Calley Means is right that the medical establishment is a stodgy place of often questionable effectiveness. Dr Anekwe and her colleagues appear to be willing to settle on this sort of low-evidence, "woke medicine" model of "It's genetics. It's not your fault", and if she doesn't really believe that, she bungled an opportunity to set the record straight. That said, she is correct about the primary measures of diet, movement, sleep and stress management. I'll give her that, I just wish she sounded more up-to-date with the studies. There are doctors that appear to stop learning out of med school, and there are doctors that are curious and write books on the leading edge of medical science and Anekwe seems like neither; she just doesn't totally appear to understand the literature. If we really think the primary cause of obesity is that we have somehow evolved a major genertic mutation in the last 50 years and that it's nothing to do with changes in diet—all of a sudden?—we're in real trouble with the state of evidence-based medicine. Dr Prasad and Means are correct here: people haven't changed, but the food production, incentives and cultural norms have.
3. Dr. Vinay Prasad (now I know how to pronounce his first name—thank you) is somebody I follow on the 'Stacks and who I rate highly, and his opinions fell where I would hope they would, in the sensible middle, with nuanced understanding. While not a doctor directly involved in obesity, he was a good voice to have on for his strict attitudes to following the data, something we see less of. I largely agree with his few interjections about Calley's weaking his own argument, and appreciated his input.
4. Bari did a good job pushing back where necessary, and this is why I pay money for the Free Press. But she came off as inadequately sussed when she framed the only two scenarios on offer, which were essentially "Will power and personal responsibility", a framing designed to make people make a frowny face, and "taking a pill", which most people should be skeptical of, yet will be beguiled by. The former is a kind of "conservative" straw man which takes attention away from focus on the lack of education OF and BY our health authorities and the discipline required by ordinary people to swim against the tide of our cultural, post-industrial food economy where corn and sugar are subsidized to such a degree. This common idea of what we are told by health authorities we ought to be doing, and what a big downer it all is to the average person—you see it in our advertising, movies and TV shows—is a cultural trope that people who pursue fitness largely become less susceptible to. On the one hand, it makes Bari someone readers and listeners can relate to. On the other, it somewhat detracts from furthering the conversation, as it can't escape its "normie" moorings.
Getting obesity to drop purely on account of lifestyle and dietary interventions IS the correct goal, but it is also a wicked problem on the level of solving problems brought on by a changing climate, because you have to change everybody's mind, and you aren't going to be able to.
If it is the excuse by Drs Stanford and Anekwe to effectively "give up" on pursuing true health for unhealthy patients for the easy road of pharmacological interventions and ignorance, I would say they aren't trying hard enough, or are not able or competent enough to marshal the courage and resources to make more of an impact. I fear for a medical establishment that doubles down on its own feeling of fecklessness and inefficacy, and that is how Anekwe's clinic came off in this debate.
I think it was Vinay who advocated for a strong public health campaign, citing evidence that the campaigns have worked in the past (e.g., smoking, vaccines) and suggesting that the public trusts public health officials. That may have been true in the past, but those days are gone after COVID. Trust in public health officials is at an all-time low!
I find it a little frustrating when people complain about the problems and distorted incentives created by the political process. And then say that the solution is to use the political process to improve public policy. If it didn’t work the first time, it's not going to work the second time. All three participants seemed to do this.
In my opinion, change is going to occur in the cultural sphere, from the bottom up. It’s going to be families, friends, communities around podcasts like this one, and innovators in the private sector who objectively look at the evidence, question the mainstream guidelines, and take different steps to actually improve their health. It won't be easy given those distorted incentives, but I wouldn't hold my breathe while we wait for policymakers to solve this. Any changes to occur at the level of public policy or large public health institutions are going to be lagging indicators.
Callie is understandably angry. The bottom line is most people don't care enough to look at their diet and lifestyle and demand better food and lifestyles from our leaders. The system is set up to keep us sick and dependent on drugs. I work in Pathology I see diet/lifestyle diseases everyday we have 5 years olds with fatty liver. Our priorities are not align with health
Bari, ware the panel’s thoughts on this?
https://amp.cnn.com/cnn/2023/03/13/business/lunchables-in-schools/index.html
Excellent discussion. One takeaway - I don’t think it’s enough for a Harvard medical weight loss clinic to say that (paraphrased) “efforts are made to encourage children and their families to eat better and move more”. I’m curious how many of those clinic directors, physicians and academic leaders have actually spent time reaching out to legislators and school boards about state and school policies regarding the kinds of food served daily, or have refused sponsorships from companies whose products might be counterproductive to their patients’ healthy living. A lesson learned through the pandemic is “see something, say something” but money and power sadly often speak louder.
A friend of the family and physician once gave me some valuable advice, he said “stay away from doctors.” Of course, doctors are invaluable and I’m grateful for the medical care I’ve received. However, let’s abandon the idea that medicine and big pharma is a miracle panacea for poor lifestyle choices.
This is not to say that there aren’t decent physicians out there. We need to be informed and refuse to naively accept medical advice. The medical industry is losing the trust and confidence of the consumer and for good reasons. And yes, we not a patient when the goal of the industry is to create a lifelong consumer of medical interventions.
I fully agree with Callie Means. Clearly the food and medical industry have created a financial goldmine with lifelong consumers. As for the American Academy of Pediatrics, this organization is a danger to children between gender affirmation (puberty blockers and cross-sex hormones), over medicating children with amphetamines for ADHD and this new recommendation re obesity (Ozempic / surgery). What parent trusts the recommendations of the AAP?
I was married to a physician and have attended many dinners hosted by drug reps. Those dinners were invariably held at five star restaurants where the alcohol flowed freely. At other times, drug companies would sponsor a dinner at a meeting that cost tens of thousands of dollars. The drug rep was a known individual who regularly hosted these high end events, and was familiar with many of the physicians.
As a non-American subscriber, one thing that struck me about the podcast was how Americans (I live in Australia) seem completely blind to the fact that there is something very wrong with the food culture in America. What counts as “food” includes things like pop tarts and twinkies (which I saw for the first time when I visited the US in 1995) and I recall being shocked in the supermarket because the only available bread was soft and sweet and all the cheese was bright orange. When I first arrived I couldnt figure out how to even buy what I considered normal food - unsweetened, unprocessed bread and dairy. Then portion sizes were at least twice as big as what I was used to, fast food was ubiquitous and people ate it as an a normal meal for lunch, maybe even every day, and the menus of “family” restaurants were wall to wall fried and sweetened food with each plate enough to feed several people. I had been raised to consider McDonalds a treat, and not actually real food. Like having chocolate cake for dinner. We could have it very occasionally but it was not a genuine meal.
I say this only because I don’t know how you turn this around. It takes generations to create a culture around food - what is a normal amount to eat, and what food even is. Are insects food? Pigs? Nettles? Dogs? Our culture tells us. From the outside it seems like a good part of America’s problem with obesity is not so much genes as a deeply unhealthy concept of eating taught to children, generation after generation and reinforced by what is available to eat and what people are conditioned to consider normal. The American diet it literally hard to stomach for people coming from outside the culture and yet those within it must struggle to gain that perspective.
Very well put. As the European in this conversation, I couldn't agree more.
One thing that saddens me about Calley's argumentation, however, is the picking of individual food items and saying "those are the devil". I mean OF COURSE you shouldn't eat pop tarts all day. But treats have always been here and they always will! It is up to each family and individual to realize that maybe 60–70% of what's in the supermarket is to be consumed in VERY SMALL quantities or not at all. Educate yourselves on nutrition, people, and stop looking for the villain. Today it's seed oils, tomorrow it's candy... well, nutrition is not black and white like that. Candy can be good IN VERY SMALL QUANTITIES. It's not a sexy explanation and it's not a sexy conspiracy explanation but that's how it works.
And if you do a lot of sports (like A LOT), then a lot of Calley's argumentation also doesn't hold up. But I understand he was speaking about sedentary individuals mostly.
Putting pressure on policymakers is nice but first do the work on yourselves.
I was really disappointed that Bari didn’t push the panel harder on how to implement diet/exercise solutions in the real world. As a working mom, I’m doing my best to get my kids ready and out the door to school and I don’t have time to make breakfast from scratch. The end of the day struggle is just as bad when I’m rushing to make dinner for a hungry family. While everyone was nostalgic for the 60s and 70s, most of the parents who make the meals these days also work full time and don’t have an entire afternoon to make healthy from scratch. I left very disappointed with the entire panel for making me feel like I’m part of the problem but without offering any solution. All the public health messaging in the world isn’t going to get me the time and energy I need to make non-processed meals.
I agreed with Calley on many of his substantive points but his insufferable smug demeanor made me not want to agree with anything he said. He needs to tone it down a bit and not be so constantly outraged in a room with adults.
Bari, I loved the podcast episode. I am a family nurse practitioner in Texas, and I have been having multiple patients a day asking for this drug. I am afraid of what will happen if we put hoards of patients on it. Muscle wasting due to decreased appetite, therefore decreased protein intake concerns me. You should have Dr Gabrielle Lyon on your show. She is an absolute expert on protein, muscle, and longevity medicine.
Mr. Means is right and wrong. Right in that the food and pharma industries have contributed greatly to the US obesity epidemic, and wrong to attack GLP-1s as not being an important part of an integrated GLP-1/nutritional guidance/exercise treatment protocol...such as Dr. Anekwe offers at her clinic. A company like Calibrate (https://www.joincalibrate.com/how-it-works) offers this type of integrated approach, and is offering obese patients hope and a feasible path forward to much better health. You would have to be a zealot to think that this is not a step in the right direction
Just listened to the podcast. I grew up in the 1970s and 1980s. I look back at the photos of my family and friends (back in the day when we actually printed out photos for everyone to look at, what will the current generation look at to remember this time...but that is another discussion) they were all thin. Perhaps not in Olympic shape, but normal body size. In 25 or 30 years, the genetics of the USA hasn't changed in perceptible ways, yet the family photos certainly have. It's the food and lifestyle. It has to be. Point taken about doctors arguing that we have a predisposition for obesity. But that is where we no longer have any level of self control and have too much immediate gratification. We have a predisposition for all kinds of bad behavior (perhaps why the ancients jotted down texts like the 10 Commandments and thought about the Seven Deadly Sins). Yet, our society doesn't teach things like self control. Anyways, I encourage you all to look at photos of society up until the mid 1980s, you'll see the obvious difference. The upside is we stopped smoking. The downside is we started eating mounds of pizza, fast food and processed cookies and gained 50 pounds.
I listened with interest to this, and it turned out to be a really worthwhile discussion, although one which occasionally devolved into a somewhat frustrating shit-show. Please indulge me:
1. Calley Means is generally correct about nearly everything he asserted about the science and of metabolic syndrome and dysfunction, but he doesn't have the public relations game that Drs. Anekwe and Prasad do. I would argue that Means's sister, Dr Casey Means does indeed have the professional demeanor as well as the medical chops to argue all the factual information Calley wanted to communicate without sounding combative and rhetorical. Dr Casey Means is an effective, measured communicator of metabolic health issues and facts, and I wish we could have had her as part of this discussion. Furthermore, either she or someone like Dr David Perlmutter could argue better why a pharmaceutical intervention like Ozempic isn't going to necessarily make actual long-term health outcomes better, as Ozempic is treating a symptom of a lagging indicator of dysfunction, which it doesn't cure.
2. Dr Anekwe was a mixed bag. On the one hand, I respected her professionalism and composure, particularly in the face of criticism. And I truly believe she and her fellow clinicians believe in their mission. But she was unable to ever say effectively that the reason why recommending that good diet and exercise "doesn't always work" is that (1) there is so much more education about food and nutrition required to make a change in most people's lives, especially when the facts often run against cultural and community norms, and (2) she did not acknowledge something that just about *anyone* who is into health and nutrition knows: What normie establishment medicine thinks is a good recommendation for diet might be 10-30 years behind the times, and she never explained what those dietary recommendations were, which may be what we now know to be bad recommendations. The idea that an obesity clinic doctor (was it her colleague, quoted at the beginning of the podcast?) would say of an obese patient, "She exercises 5-6 times a week to no avail," is redolent of the 90's calling and wanting their health advice back, and it makes you sound like less of an authority to be minded. Calley Means is right that the medical establishment is a stodgy place of often questionable effectiveness. Dr Anekwe and her colleagues appear to be willing to settle on this sort of low-evidence, "woke medicine" model of "It's genetics. It's not your fault", and if she doesn't really believe that, she bungled an opportunity to set the record straight. That said, she is correct about the primary measures of diet, movement, sleep and stress management. I'll give her that, I just wish she sounded more up-to-date with the studies. There are doctors that appear to stop learning out of med school, and there are doctors that are curious and write books on the leading edge of medical science and Anekwe seems like neither; she just doesn't totally appear to understand the literature. If we really think the primary cause of obesity is that we have somehow evolved a major genertic mutation in the last 50 years and that it's nothing to do with changes in diet—all of a sudden?—we're in real trouble with the state of evidence-based medicine. Dr Prasad and Means are correct here: people haven't changed, but the food production, incentives and cultural norms have.
3. Dr. Vinay Prasad (now I know how to pronounce his first name—thank you) is somebody I follow on the 'Stacks and who I rate highly, and his opinions fell where I would hope they would, in the sensible middle, with nuanced understanding. While not a doctor directly involved in obesity, he was a good voice to have on for his strict attitudes to following the data, something we see less of. I largely agree with his few interjections about Calley's weaking his own argument, and appreciated his input.
4. Bari did a good job pushing back where necessary, and this is why I pay money for the Free Press. But she came off as inadequately sussed when she framed the only two scenarios on offer, which were essentially "Will power and personal responsibility", a framing designed to make people make a frowny face, and "taking a pill", which most people should be skeptical of, yet will be beguiled by. The former is a kind of "conservative" straw man which takes attention away from focus on the lack of education OF and BY our health authorities and the discipline required by ordinary people to swim against the tide of our cultural, post-industrial food economy where corn and sugar are subsidized to such a degree. This common idea of what we are told by health authorities we ought to be doing, and what a big downer it all is to the average person—you see it in our advertising, movies and TV shows—is a cultural trope that people who pursue fitness largely become less susceptible to. On the one hand, it makes Bari someone readers and listeners can relate to. On the other, it somewhat detracts from furthering the conversation, as it can't escape its "normie" moorings.
Getting obesity to drop purely on account of lifestyle and dietary interventions IS the correct goal, but it is also a wicked problem on the level of solving problems brought on by a changing climate, because you have to change everybody's mind, and you aren't going to be able to.
If it is the excuse by Drs Stanford and Anekwe to effectively "give up" on pursuing true health for unhealthy patients for the easy road of pharmacological interventions and ignorance, I would say they aren't trying hard enough, or are not able or competent enough to marshal the courage and resources to make more of an impact. I fear for a medical establishment that doubles down on its own feeling of fecklessness and inefficacy, and that is how Anekwe's clinic came off in this debate.
I think it was Vinay who advocated for a strong public health campaign, citing evidence that the campaigns have worked in the past (e.g., smoking, vaccines) and suggesting that the public trusts public health officials. That may have been true in the past, but those days are gone after COVID. Trust in public health officials is at an all-time low!
I find it a little frustrating when people complain about the problems and distorted incentives created by the political process. And then say that the solution is to use the political process to improve public policy. If it didn’t work the first time, it's not going to work the second time. All three participants seemed to do this.
In my opinion, change is going to occur in the cultural sphere, from the bottom up. It’s going to be families, friends, communities around podcasts like this one, and innovators in the private sector who objectively look at the evidence, question the mainstream guidelines, and take different steps to actually improve their health. It won't be easy given those distorted incentives, but I wouldn't hold my breathe while we wait for policymakers to solve this. Any changes to occur at the level of public policy or large public health institutions are going to be lagging indicators.
Callie is understandably angry. The bottom line is most people don't care enough to look at their diet and lifestyle and demand better food and lifestyles from our leaders. The system is set up to keep us sick and dependent on drugs. I work in Pathology I see diet/lifestyle diseases everyday we have 5 years olds with fatty liver. Our priorities are not align with health