GLP and Me: An Obesity Crisis by John Stelmach, M.D.

How I got here, I don’t know. Well, actually, I do know; I just want to kid myself about it. Let me tell you where I am because a lot of people are here with me. I’m 63, and I had a BMI that was out of control, at least for me. It sneaks up on you like the buildup of sludge at the bottom of a pond. Silently below the surface, out of plain sight, it starts to accumulate as what’s on the surface of the water slowly drifts to the bottom to become sludge. You don’t notice it, but it doesn’t stop—day after day, year after year, like so many things. One day, you wake up, and the pond is full, filled to the top. What was once a beautiful pond, full of life, is now a swampy, overgrown, insect-infested mess. No onlooker could see what was once a vibrant pond, teeming with life. My body, the sludge, and the filled pond snuck up on me. I tried to dredge it a few times, but it always filled back up. I thought, “You just have to work at it, and you can keep it open and full of water, not sludge.” It always filled back up, the slow, relentless trickle of sediment turning into sludge, never stopping. I knew what it would take to keep it open, but there wasn’t enough work or strength that could humanly be done to make a permanent change. You get to the permanent end, but then you realize nothing is permanent; it always slowly morphs back to what it was. Enough with the metaphors—let’s get down to the facts of my story and what I’ve learned. I am an orthopedic surgeon with 33 years in practice. You’d think I’d know better, and I do know better. The fact that I’m well-versed in all aspects of the musculoskeletal system, physiology, exercise, and nutrition didn’t help. I’ve also operated through nine inches of fat to get to someone’s hip joint; that didn’t help me lose weight. I’m also very disciplined because becoming an orthopedic surgeon requires a lot of it. In other words, I had knowledge, discipline, and a BMI of 37. Hmm. The first bit of knowledge that occurred to me: obesity is complicated. Let’s be clear: what follows is not a scientific paper. It’s my perspective after seeing many patients struggle with obesity over the years in my practice.

I’ll try to insert some scientific studies, but it’s difficult to do this because I’m not sure which ones to include. It’s hard to decide between articles sponsored by Big Pharma, the food industry, or the exercise industry. If these studies were helpful, we wouldn’t have an obesity rate of 40% in the United States. In other words, this is just my spin on it. Let’s start with the bottom line, a fact that will make the medical community and nutrition experts apoplectic. Here it is, the fact that will have them telling jokes about how dumb orthopedic surgeons are when they mention me: If you’re over 50 and have a BMI above 35, the only way you’re going to lose weight and keep it off is by using GLP-1 medications. That’s the fact. I’ve spent 33 years trying to get people to lose weight so they can walk, with no success. There’s been the odd patient who did it, and we can celebrate them, but the vast majority of patients are losers—not in the good way. What follows is a combination of my knowledge, what I’ve learned from talking to thousands of patients, and personal experience. The typical pattern of weight in obese patients as they go through life is to lose weight for a while and then gain it back, plus some. Most of the patients in my sphere, including me, are in this upward spiral of weight gain through the years. I’ve been around long enough to witness this in many patients as they age.

Here’s how this pattern forms. The patient gets motivated by something and starts a diet, adding an exercise program. It doesn’t matter which diet or exercise program they try; there are as many as there are commercials on TV and streaming services. They all fail for the same reason, at least according to me. The patient sets a goal to shoot for— an ideal weight to reach. It doesn’t matter if it’s realistic or not; the result is the same. If they don’t get there, they get disappointed and depressed and eat their way to a higher BMI. If they do get there, they figure they’ve reached their number, so they return to normal eating. This is the same eating pattern that made them obese in the first place, so they bounce up to a higher BMI. Rinse and repeat. All the while, the patient feels worse and worse as time goes on. This leads to giving up, ending the cycle with a straight trajectory toward unchecked weight gain. For whatever biochemical, neurological, or scientific reason—beyond my knowledge, yes, the orthopedic surgeon jokes are partially true—the bottom line is there’s a perception of hunger that’s always there. It doesn’t matter if it’s physiological or psychological; it doesn’t go away. It’s the little devil that sits on your shoulder and whispers, “Eat; it’s okay, we can justify this. We’ll make up a reason why it’s fine.” This is the classic “if you can’t kid yourself, who can you kid?” Normal-weight people don’t get this. They think, “Just have discipline, and you won’t eat.” It doesn’t work that way; the voice never stops as it wears you down. This voice, often called food noise, is like a pack of wolves hunting an elk. They don’t jump on the elk and kill it because there’s too high a risk of injury. Instead, they wound it and have patience. They run the animal down relentlessly until the wounds weaken it to the point where it can go no further. The elk didn’t stop because it lacked discipline; it stopped because it could persevere no longer. Such is food noise: it never stops until it wears you out and you quit. Normal eaters don’t understand the food noise concept. To them, it’s like a different dimension; they don’t even know it exists. I guarantee those living in the dimension of food noise know it exists. Normal eaters have no concept of it, illustrated when one says, “Oh, I forgot to eat today.” We food noise people never forget to eat because we’re always thinking about the next meal, and we’d better eat now in case we miss the next one. “I’m going to the gym to lose weight” or “If I get my joint replaced, I can exercise, and then I’ll lose weight.” I hear this all the time. It makes sense: “I’ll just increase my metabolism, and I’ll lose weight.” Here’s another reality everyone will hate: exercise is a terrible way to lose weight. If it were effective, there’d be no obesity crisis. The trouble is that your metabolism increases initially, but it slows after your body adjusts to the increase. The problem is that the louder-thannormal food noise stays at the same increased volume. The result: the weight doesn’t stay off, and you end up with a higher BMI.

One relevant study compares the Hadza tribe in Africa to sedentary Western workers. The tribe routinely runs 10 to 20 km a day to maintain their lifestyle. You’d think their calorie requirements would be through the roof. In fact, their bodies adjust, and their metabolism allows them to have a relatively normal caloric intake, similar to Westerners with sedentary lifestyles. This shows how your body adapts to an exercise program. The same happens to us Westerners, but the food noise we’ve developed, for whatever reason, remains. Hold on, I know what you’re thinking: you think I said exercise is bad for you. That’s not what I said. I said exercise is a terrible way to lose weight. Exercise is essential for your health and very good for you. It just doesn’t address the major cause of obesity, which is food noise. In fact, it makes food noise worse. I know this from personal experience. I enjoy physical activity—not going to the gym, but working on my farm for 10 hours on a weekend day. I’m starving afterward and almost can’t eat enough to satisfy myself. The math problem is that the calories I burned weren’t as much as I ate afterward. The more active I am, the more I eat and crave food. Food noise wins again.

The fitness folks hate this one. “If you just exercise, you’ll lose weight.” I hate to tell everyone, but there are obese people who exercise, work on muscle strength and cardiovascular health, and are still obese. If there’s an exercise class enthusiast reading this, you’ve seen them—the overweight person in the aerobics class who never loses weight but still attends regularly. Imagine how they feel: all that work and still overweight. It’s amazing the effort some people put into losing weight. No lack of discipline, just a misunderstanding of the problem. They aren’t going to outrun the wolf. For a while, there was a concept of “fit and fat.” News pieces on TV and other sources touted this idea. This is another attempt to explain why people exercise and don’t lose weight without understanding food noise. Those who are fit and fat are truly an evolutionary miracle. They can do strenuous physical labor and maintain a stable caloric intake. In a doomsday famine scenario, these people would survive nicely because they’ve adapted to keep caloric intake level while their metabolism adjusts. This is an attempt to put a bright side on our modern obesity plight. “I’m going to do the carnivore diet; those carbs are the cause of my weight problems.” There’s some truth to this. Excess carbs are endemic to our modern American food culture. They’re generally cheap to grow, produce, and process, becoming the food of the masses. This is a whole different discussion regarding the food supply, farming, and food processing.

For now, let’s talk about protein/fat diets. These do work—that’s the problem. The math on carbs and protein is interesting. A 16-ounce steak has about 900 kcal, and eight ounces of cooked dry pasta has about 900 kcal. They’re about the same, except for how long they take to digest and make you feel satiated. The steak stays with you, but the pasta is digested more quickly, with a bump in blood glucose to boot. The pasta awakens the wolf of food noise quickly, so you’re hungry again. The protein and fat in the steak fend off the wolf longer, but it’s still there, stalking you. You don’t see it for a while, but after a few weeks, the food noise people are pounced on by the wolf. The craving for carbs is crushing, and you’re worn out again. The rebound weight occurs. Food noise is the problem, not the diet, so it fails again. Diet is an interesting topic—not dieting, but diet. There are so many diets, from carnivore to vegan and everything under the sun. There have been cabbage diets, carrot diets, and liquid protein diets. In my mind, all these diets prove humans are omnivores and can adapt to an infinite number of living conditions and food availability. I’ve seen obese vegans and obese carnivores. Food noise doesn’t care about the particulars of what you’re eating, just that you’re thinking about eating. The common-sense approach to an appropriate diet has many names and varieties. Understanding the effects of different food categories and how they make us feel is important. There are also metabolic effects that can dramatically change our health. The best diet seems to be: protein with some fat, fruits and vegetables (potatoes aren’t vegetables), and some carbohydrates, in that order of importance.

The most critical factor is portion control. Food noise must be kept at bay to eat a “normal” amount. If any group is left out, cravings begin, leading back to the cycle of weight gain. Ideal body weight and BMI are as confusing as diet fads. BMI as an isolated number isn’t 100% accurate for one’s ideal body weight, but it’s an indicator. Variations depend on many factors. The bodybuilder with an elevated BMI, classified as obese, is often cited to argue BMI’s invalidity. I hate to tell everyone, this is a very small percentage of people with an elevated BMI. To improve BMI accuracy, body fat percentage could be included to create a new scale, like a “Fat Percentage BMI Ratio” or FBR. Unfortunately, this requires knowing one’s fat percentage, and I’d rather not know mine. Knowing my BMI is bad enough. I adhere to the “if you can’t kid yourself, who can you kid” philosophy. I’d rather have a few outliers with falsely elevated BMIs than know my fat percentage. As an orthopedic surgeon, I know about bones. I’ve seen bones in all shapes and sizes of people and heard claims like, “I have big bones; that’s why I weigh a lot.” Here’s something else no one wants to hear: bones don’t weigh much. Bones are a miracle of divine engineering—lightweight and amazingly strong. Certainly, bones vary in size among people. The real weight comes from the meat on those bones. Water is 60% of our body and weighs one pound per pint, so that tallboy beer weighs a pound. The layout of bones also matters, particularly the pelvis. A narrow pelvis versus a wide pelvis makes a difference, e.g., pear-shaped bodies. It’s not the size of the pelvis bone, but the width requires more meat to cover it, hence more weight compared to a narrow pelvis. Shoulder width is important, too, but as age hits, things sag, not float, so the waist gets bigger.

A final thought on bone variety in body types: I’ve had very heavy patients with stunningly small bones. When I think about it, bones and joints are durable. From an engineering perspective, imagine exceeding your car’s weight capacity by 50% and driving it—it wouldn’t last long. Extrapolate that to a human body 50% overweight; it takes 60 years for a knee joint to wear out on average. Joints are durable indeed. Health—what is it in relation to all I’ve written? There are three branches to a healthy lifestyle: weight, nutrition, and exercise. If these aren’t balanced, you aren’t healthy. If one is emphasized more than another, especially to an extreme, you aren’t healthy. Real-life examples are common. Let’s explore each. Weight The goal: lose weight by any means necessary. This is where fad diets fall, often nutritionally unbalanced. Another common method is smoking to keep weight down. Bariatric surgery is in this category, too. One can lose weight surgically, but at the cost of nutrient absorption. Weight in isolation misses many health factors, as it’s only one of three branches. Nutrition This is where I fell: very little processed food and a well-rounded diet, but way too much. Wellnourished but overweight nonetheless. This is hard for patients: “I’m eating good things; why am I overweight?” It’s the wolf tracking you in its relentless pursuit of eating. You can’t eat unlimited “healthy food” and maintain an appropriate weight. In the end, calories are calories, and we only need so many, unfortunately. Exercise I’ve discussed this already, but some struggle with it. There are exercise enthusiasts who eat fast food for most meals. Time and convenience are the wolf here. Many in this category take nutrition seriously, but it can’t be ignored. One group is the ex-jock—the high school football player in shape and eating like a horse, okay because of youth and activity. Life happens, and the wolf waits. They keep eating, but a sedentary job and decreased metabolism catch up. I see patients in their 50s, obese, who tell me how athletic they were in high school. The wolf gets them eventually. That’s it—my story and how it relates to what I’ve written. I was many of these things and tried some of them. Constant hunger and fighting appetite and portion control were my issues. When I started on a GLP-1, it was like a miracle. I stopped obsessing about food constantly. When I eat, I get full quickly and stay full for a long time, like a normal person. Regarding BMI, I’m aiming for the 29.9 club—the threshold from class one obesity to being classified as overweight. I’m resisting picking a specific weight because, as I’ve stated, once you hit a number, you “go back to normal.” That starts the weight gain cycle again—been there, done that, no thanks. My experience with these medications is quite a journey. Like many, I was dead set against them. I thought, “I don’t need that stuff; who knows what side effects there’ll be?” Like many medications over the years, I was sure these would be touted as a cure-all, then cause heart attacks, strokes, or cancer. They’ve been out for a while and seem okay. Usually, the five-year mark is when claims fall apart, in my opinion. This has passed uneventfully, a good sign. They’re not completely out of the woods, but they’re heading in the right direction. My decision to try them was gradual. While reviewing patients’ medications during office visits, I noticed how many were on GLP-1s. I never connected it to weight loss; I was just trying to get them walking painlessly. The final push came when talking to my wife’s two partners—she’s an optometrist—who lost a lot of weight. One raved about how great GLP-1s were and how the weight fell off.

This piqued my curiosity. Two ophthalmologists, the smartest people in the world (just ask them), decided to try it. I scheduled an appointment with my primary care doctor instead of prescribing it myself, as I usually do. I started on tirzepatide, the lowest dose. I didn’t notice any side effects besides loss of appetite and weight loss—exactly what I was looking for to get myself under control. Those ophthalmologists were right. The weight comes off, and I wasn’t worried about the next meal. Finally, I put the wolf in the zoo and out of my life. Regarding side effect concerns, I looked at it this way: at 63 with a BMI of 37, the endgame is known. If there are side effects, they must be weighed against the benefits of being overweight instead of obese. For me, it’s worth the risk. In my journey to lower my BMI, I realize I likely won’t reach a BMI of 25, considered normal. That’s almost 50 pounds from where I am now. In the words of Charles Barkley, “They’d have to cut off one of my legs to get me to that weight!” I know people who can do that, but I’d rather be overweight with two legs.

If you’re considering GLP-1s, here are some things to think about. First, if what I wrote makes no sense to you, they probably won’t work for you. You have to understand food noise and rejoice at the prospect of getting rid of it. Second, you need something else to do besides being a foodie. If your social structure revolves around food, eating, and food socializing, you might struggle to adjust that part of your life. My wife thought this would be hard for me, as I love to cook and eat. Fortunately, I have other hobbies to fill the void. A doctor friend who went on GLP-1s and lost weight stopped because he loved going out to dinner, and it wasn’t fun anymore. That’s a valid point—it’s a free country, and you can prioritize what’s important to you. I’d advise caution for younger, mildly overweight people starting GLP-1s. If you’re morbidly obese, they’re worth the risk. If you’re young, you have the reserves, metabolism, and information about nutrition at your fingertips. You have a chance to put the wolf in the zoo by building good behaviors. The longer you can fend off needing GLP-1s, the better, as they’ll be studied more over time. There you have it—my take on the obesity crisis. Hopefully, we’ll evolve to control our eating, but we won’t do it in time for me or you. When you think about it, maybe we did evolve to make these medications to control ourselves. Or maybe it’s a big conspiracy by Big Pharma and the food industry to keep us consuming. Who knows? All I know is there are 42 pounds less of me, and I feel a ton better.