"I Lost Weight And My Health Improved" (did it?)

 Your lived experience is real. You lost weight, your health improved, and I'm not calling you a liar. But I'm still going to tell you that weight loss didn't cause it. In this episode, I get into the post-hoc fallacy, the neuroscience of the placebo effect, and why weight loss is the perfect storm for a powerful — but ultimately unsustainable — placebo response. The benefits are slim to nil. The risks are well documented. And there are always other options. 

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Transcript

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Hello, everyone, and welcome to Episode 13 of Season 6 of the Fat Doctor Podcast. 13 is unlucky for some, but not for me. I'm really looking forward to this episode, because it's something that I come across a lot, and something that you've probably come across a lot. In the past, I've really struggled to know how to respond to this question, or to this topic. But I'd say I have some ideas now, and I'm going to share those with you. Today we're going to talk about people who say — but hang on a second.
"I lost weight, and my health improved. So how can you say that losing weight doesn't improve your health? Like, that's bullshit, Asher. Like, you're clearly lying, because it happened to me."
And I want to say in this moment: that is not a lie. It did happen to you. You're not lying, you're not lying to yourself, you're not lying to other people, no one is suggesting that. That is real lived experience. You lost weight, and your health improved.
And still, I maintain that weight loss does not improve your health.
So today we're going to talk about how to reconcile these two things, these two truths, together. Because two things can be true at the same time.
The first thing I want to remind everybody is: just because one thing follows another thing doesn't mean the first caused the second. I can name several things that happened to me in the last few days where I did one thing and then another thing, and the two were completely unrelated — and that can apply here too, obviously.
We call this a post-hoc fallacy, a logical fallacy, where we just assume that because one thing happened after another, the first one caused the second. That's not necessarily the truth. But it is what we've been led to believe. It is what society has been telling us. It is what we've been conditioned to believe since we were infants — that weight loss will benefit your health. The weight loss industry has spent a small fortune in PR and marketing and branding to ensure that we believe this.
And when you believe something, you are far more likely to pay attention to the evidence that suggests it's true. Our brains are constantly searching for evidence to support our own beliefs, the stories we tell ourselves, the narratives we follow.
If you think you're an unlucky person — that's just the story you've been told, maybe something you grew up believing. And every time something doesn't go your way, you think: look, see, I'm an unlucky person. Your brain tends to ignore all the evidence to the contrary, so every time something does go well, every time you're fortunate, your brain ignores it, or finds a way to acknowledge but kind of dismiss it. You're looking for proof that what you believe to be true is true.
So if you grow up believing that if you lose weight, your health will improve, your brain confirms and reinforces that belief every time there's evidence to support it.
More often than not, the person says, "I lost weight and my joint pain improved." And I'm like, cool, how's your joint pain now? "Oh, that's terrible, because I gained weight." And that's the narrative — it all fits perfectly, except it's not true. Objectively speaking, there is a lot of evidence that weight loss doesn't improve joint pain, or if it does, it improves it so very marginally that it's not clinically meaningful. We've got studies — big studies.
Studies look at populations, they look at averages. That doesn't mean it doesn't happen for anyone. For there to be only a marginal average improvement — say, like, one point or 2.5%, as in one study — that means some people would have had more of an improvement, and some people would have had less. That's the law of averages.
So I'm not saying it doesn't happen. I'm not saying there's evidence that no one ever gets relief from joint pain at the same time as losing weight. I'm just saying that there isn't enough evidence to support the idea that weight loss causes improvement in joint pain. There's no evidence that it improves underlying pathology, there's no evidence that it causes a lasting effect, there's no evidence that it's clinically meaningful. That's just the raw data, the hard facts — and it's really difficult to believe when your experience is: yeah, I lost weight, and my joints improved. My pain went away. My blood pressure went down.
So people often say: why? Why do you think that happened, then? Go on, explain it to me. And I'm like, cool, let's sit down and get into it. Let's explain!
I can try to give some answers. I can't prove this is the reason — I don't have x-ray vision, I'm not psychic, I don't have the second sight. I'm not able to tell you exactly what happened to you as an individual. But I can tell you that even if your subjective experience disproves the evidence, there are many reasons why that might be the case.
Traditionally, the response is: oh, it wasn't the weight loss, it was the lifestyle changes that you made to lose weight that caused the improvement. When people say lifestyle changes, they mean you changed your diet and you exercised more, and it was the exercise that improved the joint pain. And I dislike this answer almost as much as I dislike the idea that weight loss improved your joint pain. I put them on a par with each other.
It's the standard thing I hear from a lot of supposed Health at Every Size experts. A lot of the books I've read say: yeah, we've got to stop blaming weight, but instead we should be exercising and changing diet. And that's because a lot of the Health at Every Size people are dietitians, exercise experts — that's their job, so of course that's where their focus lies.
But I don't buy into this at all. I'm sorry. I really don't. I don't think it was just the change in diet. I don't think it was just that you exercised more. And the reason is because there are studies that support this — it isn't just exercise either. It's not just one thing, it's never just one thing.
I will say, though, that there is something to be said about when you set your intentions. When you say, "I'm gonna do this thing, and when I do this thing, this is going to get better," oftentimes there are so many little things that change about our behaviour, about the choices that we make. We bring a different energy, a different flavour to our lives during that period of time. And I suspect that that does have an impact. I really do.
So the implication that eating better and exercise is an essential part of healthcare — I reject that. I really do. I respectfully disagree. I'm not saying that you shouldn't exercise, I'm not saying you shouldn't be concerned about nutrition. I'm just saying that this idea that eating well and exercising is a fundamentally important part of keeping and staying healthy — I think that is steeped in diet culture. I think that is just as bad as saying that losing weight is a fundamentally important part of staying healthy. I disagree with all of those things. I think the answer is far more complex and nuanced.
I do think that people who are actively pursuing weight loss tend to make a concerted effort to be "healthy." So they often choose to get better sleep, or to spend more time outdoors, or to eat meals regularly, to not starve themselves, to stay hydrated — there are often so many little things that we do. And these intentional changes make you feel better. Not because it's exercise and diet, but because these things reduce your stress, they help with your mental health, they reduce your cortisol levels, they help your nervous system regulate better. All of these things have a really positive impact on you in general, and certainly on any symptoms you're experiencing.
So I do think that these intentional changes — this different energy, this different flavour, the way that we behave when we are on a weight loss programme of some kind — definitely has an impact. But I don't think it's as simple and basic as "watch what you eat and make sure you exercise," as much as Health at Every Size experts would like us to believe. I don't think it's that simple.
I also think that a lot of these changes actually shouldn't be driven by weight loss. If we're pursuing weight loss and making all these changes — sleeping better, drinking more, and so on — and we're doing that in the pursuit of weight loss, then when the weight loss plateaus, we give up on these things. And that's the exact opposite of what we should be doing. If we're not linking any of these things to weight loss, then we won't be bothered when the weight loss plateaus.
So if you're like, do you know what, I'm very conscious of the fact that I do not hydrate as often as I should — that I will often prioritise work or socialising or productivity over listening to my own thirst cues and drinking fluids. If you're the kind of person that lives on coffee because that's the only way you can stay awake — coffee is a diuretic and will dehydrate you, I get that, no judgement — but if you want to make a change, if you're like, you know what, I really need to get better at hydrating, that should just be because it's good to stay hydrated and listen to your thirst cues. Not because you're doing it to lose weight, because if your health doesn't improve, if your joint pain doesn't get better, if you don't lose weight or maintain the weight loss, then you'll give up on the hydration part because you'll think, well, that didn't work.
But if you're just hydrating because you just think, you know what, that's just a good thing — or more importantly, I deserve it. I deserve to be well hydrated. Being dehydrated sucks. You have all sorts of symptoms from being dehydrated, sometimes very chronic and low-grade, and you don't notice them, but it does affect you. You shouldn't be in a permanent state of dehydration.
You should be able to nourish your body with fluids on a regular basis, and that should just be because you deserve it. Not for any other reason. Not because you're being healthy, not because you're trying to avoid getting sick, not because you're trying to treat a particular illness, not because you're trying to lose weight — just because you should. Just because it's good for you. You deserve good sleep, you deserve to rest. You deserve to spend some time outdoors. You deserve a safe space to be able to walk outdoors. You deserve to not be inundated with negative messaging. You deserve all of these things. You're worthy of them. Whoever you are, wherever you're at, for no reason whatsoever other than you just deserve them.
So that's part of it.
But moving on from that, I want to talk a little bit about the placebo effect. And we don't talk about this enough. The placebo effect is fucking spectacular. It's so fascinating. I can spend days reading about it — all these articles, what they know, what they don't know — I really find this stuff interesting, because it's incredible how much power over our body our mind has.
The placebo effect isn't all in your head. I think people just think, oh, it's all in your head — but it's not in your head at all. The placebo effect involves real, measurable, biological changes.
When someone believes that a treatment is working — whatever that treatment might be — their brain genuinely releases actual chemicals: neurochemicals, endorphins, dopamine, opioids, cannabinoids. We release natural painkillers from our brains because we believe that a treatment is working. That's the power. It's not the power of suggestion, it's not all in your mind — your brain is marvellous. The connection between your brain and your body is amazing. I can't really find the words to express how fascinating it is.
These real, measurable biological changes reduce pain, they reduce inflammation, they reduce all sorts of symptoms. They are not imagined. They show up in blood results, they show up on brain scans. This is real stuff.
And the key mechanism at work here, from what we understand — and I certainly link a lot of these articles in the back of my No Weigh book, because I think it's really interesting for those who are interested, and they're some of the only studies that don't mention weight loss, which is quite nice — the key mechanism is expectation. When you expect to feel better, your brain acts on that expectation before, during, and after the treatment. Isn't that amazing?
So when we look at things like pain — a lot of the placebo effect studies focus on pain — there's a particular part of the brain: the rostral anterior cingulate cortex, in case anyone's interested, and the pontine nucleus, the cerebellum — parts of the brain that get lit up on brain scans. And they release several things. The big one, the one that we've spent a lot of time measuring, is endogenous opioids. You all know what an opioid is? Endogenous means we make them ourselves. Did you know your body creates its own opioids?
And this is what happens when we expect to receive relief. These endogenous opioids bind to opioid receptors and they reduce pain. In the same way that morphine, or codeine, or any other opioid you can name binds to opioid receptors and reduces pain, so do the endogenous opioids that we create in our brain and release in response to the expectation that a treatment is working.
And this is why they've done studies where they take naloxone — or Narcan — which is an opioid blocker. And that can actually reverse the placebo effect. So we know that opioids are involved.
There's not just opioids — there's also cannabinoids. Do you know what a cannabinoid is? We also release endogenous cannabinoids, which are chemicals similar in nature to cannabis. They bind to specific cannabinoid receptors in our body that also help with pain relief. And it's not just pain — all of the effects we see with cannabis, the reduction in stress, the nervous system regulation, and so on — we make our own endogenous cannabinoids, and that's also part of it.
There's also dopamine — another neurochemical released during the placebo response. Dopamine is really important in the reward anticipation part of our brain. Anyone who has ADHD probably knows about dopamine.
Parkinson's patients are a really fascinating group to look at here, because Parkinson's is all about dopamine and the dopamine centres in the brain. Parkinson's patients show measurable dopamine release with placebo. So they'll be in a study, and people who get the placebo drug will still release dopamine in their brains, and that will show an actual, measurable improvement in their motor function. Parkinson's brains, unfortunately, are not making enough dopamine — that's the main problem — and so this is incredible. A placebo can improve Parkinsonian symptoms by getting the brain to release dopamine. That's how amazing the placebo is.
And there are two things going on here when we talk about expectation. Expectation is a top-down response — it's a cognitive process. Our brains assume something is going to help, and the brain begins acting on that belief, biochemically, biologically, measurably, before any effect can physiologically occur. So our brain is acting before anything else happens.
But beyond expectation, there's also something called conditioning, which is more of a bottom-up response. Our body learns that this treatment worked last time, so it starts responding to the same cues that worked before. If it's a pill — same colour, same shape, very familiar — the body goes: oh, this pill worked last time, this is going to work this time. It could be the clinic you're in, the clinician you're working with, or it could be the routine, the ritual of weight loss. Whatever the active ingredient is, it reminds the body, and the body goes, oh yeah, that's familiar, I know this — so it's conditioning. Even when there's a placebo, when nothing is actually happening, your body thinks it's happening, and that's enough.
So there's expectation and there's classical conditioning.
And then it gets even more interesting. There's something called the enhanced placebo. The evidence is quite old — I haven't found any really recent studies on this, so we're working off older information. But the enhanced placebo effect is this observation that the strength of the placebo response is influenced by a number of things. For example, the route of administration — injections produce a stronger response than pills. Interesting when you think about weight loss injections. It's because it's an injection, and your body takes it more seriously.
The elaborateness of the ritual involved also matters — the more steps you have to take, the more the body thinks, this is going to work. That's the expectation. And if there's technology involved — a machine, something tangible and concrete — the brain will respond by increasing its expectation.
Also: the authority and enthusiasm of the clinician, or whoever is prescribing or suggesting it. It really helps if they have an MD. When a doctor says it, it's more powerful than when a nurse says it. It shouldn't be — that's bullshit — but that's just the way it is. It's authority, but also enthusiasm. If someone's giving you the sales pitch, you are more likely to buy into it. That's why advertising exists in the first place.
And then you've got the open-label placebo, and I love this the best. Here's the thing: patients can experience significant symptom relief, even when they are explicitly told that they are receiving a placebo. There's a really great study that looks at IBS — people know they've got the placebo, there's no trickery involved — and yet the expectation still operates. Isn't that fascinating? Even if someone says to you, a placebo can help you — that in and of itself is setting an expectation. The expectation that: oh, the placebo will work. Like, placebos work, so even if you're getting the placebo, it's still going to work.
And when we think about conditioning, it's automatic. Conditioning is automatic. We don't have any conscious say in this. A lot of what's going on is subconscious. Our bodies have learned that if we take a pill, or do a certain thing, that will result in a particular outcome — and so we're conditioned to respond to that. We don't need to consciously believe it's going to happen for it to function. Our body can respond in spite of what our conscious mind — our prefrontal cortex, the thinking part of our brain — is saying. Even if it says, that's not going to work, it's a placebo — the cerebellum, the pontine nucleus, the RACC, those things are working independently. They'll keep working.
So you might be thinking, alright, that might work for pain and whatever, but what's that got to do with anything? The placebo effect produces measurable changes — not just shifts in perception, actual biological, measurable changes. We have neuroimaging, PET scans, MRI scans that show activation of particular parts of the brain. We've seen the way the placebo effect can affect the immune system, how it can have anti-inflammatory effects, how it can affect cortisol levels, how it can affect our autonomic nervous system — the part of the nervous system that controls heart rate, blood pressure, all of that stuff. It's amazing.
And then, I guess, at some point in time — and this is what a lot of the literature on the placebo effect alludes to — why do we make this distinction? Why are we trying to make a distinction between real and placebo? If we're seeing that impact, what difference does it make whether you get the active ingredient or not? It's almost like we're just being technical here. Who cares? If your brain is genuinely releasing opioids and anti-inflammatory molecules, and your immune system is improving, and your autonomic nervous system is resetting — who cares whether there's an active ingredient or not? It's real. It's not make-believe. It's real.
And so then you can make the argument: well, hey, hang on a minute, Asher — if the process of losing weight, whatever that looks like to you, the diet, the counting the calories, the downloading the app, the injection — if the process in and of itself is improving your health by reducing your pain, reducing inflammation, improving your cortisol, balancing your hormones, all of this stuff — if it's working, what difference does it make?
It's almost like: Asher, you've just disproved your own theory. You've just proved my point. It does work. Placebo or not, it's still working. You just said it's real, so it's working — so why wouldn't I do it? And this is where it gets really important.
Because you said it was weight loss. You said, I lost weight, and then my symptoms improved. But if it was the placebo effect, it wasn't the actual weight loss — it was the expectation of the weight loss that improved your symptoms.
And then beyond that, you have to understand that weight loss has potential benefits, but it also has side effects.
And I think that's the key here.
On the one hand, weight loss is essentially a perfect storm for a strong placebo response. It involves significant effort on your part, there's a lot of social reinforcement, there's a lot of clinician approval, there's cultural validation, there is a powerful expectation narrative. You have been conditioned to believe this is going to work since you were very young. So of course all of these factors are independently boosting that placebo response.
It's a very real, very biological improvement that has happened as a result of a placebo response, as opposed to the actual physical act of losing weight. And if that's the case, then weight loss is not the active ingredient — something else is the active ingredient here.
So that's the benefit. Now let's talk about the risks.
First of all, weight loss is unsustainable. So if the improvements in health are dependent upon the placebo — dependent upon the social reinforcement, the clinician approval, the cultural validation — if they're dependent upon all of this positive reinforcement, then they will disappear when the weight loss plateaus, and eventually when weight begins to be restored.
And then your brain will interpret that as: oh, see? When you lost weight, things were better. Now you're gaining weight, things are worse. You've just proved my point — you do need to lose weight in order to improve your joint pain, or blood pressure, or whatever it is you're focusing on.
But you see how you got tricked there? Sure, that's one way of looking at it. But another way is that the placebo effect is dependent on certain things happening, and if it's hinging on weight loss — and weight loss is unsustainable — then it's not going to work.
Weight loss is harmful, folks. I've talked about this, we've spent the last few episodes talking about this. Eating disorders, weight cycling, the Minnesota Starvation Experiment — think back to all the different ways that weight loss is harmful. It is not a case of "hey, why not try it, what's the worst that could happen?" It is harmful.
That weight loss injection? It works for a period of time. Nobody knows how long, because there are no studies that have looked into the long-term effects of GLP-1s. I'm not denying the experience you get when you go on it. Ozempic does help you to lose weight — actually it doesn't help you lose that much weight. Wegovy helps you lose a lot of weight. Ozempic, not so much. Mounjaro — a lot of weight, for sure. Not denying it.
However, there are side effects. There are lots of side effects. And if you're doing it because you've been told it's going to improve your health, there's no evidence to support that. None whatsoever. It just doesn't exist. There's not a single study out there that says, take this drug, and it's going to improve your health. Even with the claims about anti-inflammatory properties, this, that, and the other — that's smoke and mirrors. There's no actual evidence.
Bring me the studies. We'll dissect them together. I'll show you why that study doesn't prove that weight loss injections — Ozempic, whatever — are going to fix your rheumatoid arthritis, or PCOS, or whatever it is you're being told it'll fix. Those studies don't exist.
But the harms do. I do know what the side effects are. There's no question about how these drugs harm you. There's absolutely no question about it.
So please, remember: when you're doing anything, any treatment whatsoever, you've got to ask — do the benefits outweigh the risks? In this case, the benefits of weight loss are slim to nil. And yes, there's a placebo effect, no one's questioning that, no one's doubting that, no one's doubting your lived experience — but that doesn't mean it's worth it for the risks.
If you're the kind of person who's like, yeah, when I lost weight my joint pain was better, and then I gained weight back and now my joint pain is worse, so I'm going to keep losing weight — I mean, you know for yourself that it doesn't work long-term, because it didn't. If it did, you wouldn't be worried about your joint pain anymore. I've never met somebody who went, I lost a ton of weight, my joint pain improved, and five years later my joint pain is still fine. I'm sure there are a few of them out there, but they're few and far between. For the vast majority of people, they lost weight, their joint pain improved, they gained weight, their joint pain got worse.
Sometimes they lost weight and their joint pain got worse. Lots of times, actually. The placebo effect didn't work.
If it's not worked in the past, or if it hasn't lasted in the past, why on earth do you think it's going to be different this time? Who told you that this time was going to be different? Why do you believe them? Why do you believe that guy on Facebook who's convinced you that he's an expert in perimenopause and he'll teach you a way to lose weight and you'll be able to keep it off? Why do you believe that guy? Honestly, that guy is a dick. He doesn't know what he's talking about. He doesn't even have ovaries. What the fuck does he know?
Why do you believe the doctor who's so desperate to force Ozempic down your throat? Honestly, stop and ask them — why? Why are you so obsessed with Ozempic? When was the last time — which conference have you been to? Which drug rep are you talking to? Why are you so keen to believe them?
They don't have the evidence. If they don't have the evidence, why are we so keen? It's because of the narrative, right? It's because we've been told and we've been conditioned to believe it.
And weight loss is setting yourself up for failure. You know that down the road the weight is going to come back on. And that's the part that always feels bad, for me. I know that living as a fat person sucks, I do know this — but losing weight and then starting to regain weight, for me, is worse. Worse than living as a fat person, in my experience. You decide.
And here's the thing that really bugs me: in almost all cases, there are other options.
You're like, oh, I lost weight and I dropped my blood pressure. And I'm like, cool — you could also take a drug and drop your blood pressure, and you could drop it significantly more!
Oh, I lost weight and I dropped my cholesterol. Cool, you could take a statin and drop your cholesterol. Oh, and this is when it gets really interesting — you don't necessarily need to drop your cholesterol. But I'm going to have to ask you to wait for the next episode to talk about that. You're in for such a shock. But there are other options! There are always other options! Why choose weight loss when there are other options? Better options — with better evidence, gold standard treatments. You don't need to pick the one that isn't going to last, that has lots of side effects and lots of worrying long-term impacts, just because they're pushing it on you. You can just say, no, can we try something else?
Can we try something that we know works? I'm really getting into the habit now — when they say, oh, you should take a GLP-1, I go: yeah, have you got any evidence that this works for my particular condition? And I have taken to Googling and trying to find if there's a study being done, because oftentimes there is. Novo Nordisk and Eli Lilly are spending a fortune on studies that look at certain medical conditions to see whether their drug helps them. There's one for knee arthritis. So I look at the study, I look at the end date — it's usually about ten years from now or something. And I'm like: we'll talk again in ten years. Once this study is finished, and we'll look at the results, and if the study really shows that taking this drug is going to improve this condition, we'll talk. But until the study is done, I need at least one piece of evidence before I'm going to take this drug that we don't even know is going to help me long-term.
So yeah, that's what I do now. I'm like: where's the paper? Where's the study? No, I know it only started last year. Once that's been published, we'll talk again.
That tends to shut them up. Because they don't have a study. It doesn't exist.
Anyway, that was my deep dive into the placebo effect. I don't know if that's helpful. I hope that's given you some food for thought. I hope it's given you some words for those people who are saying, well, of course it works, because it worked for me.
That being said, I don't recommend getting into conversations with those people. We have to be in a particular place in order to accept information that is contrary to what we are desperately clinging onto. More often than not, those people are not in a place where they're ready to hear anything to the contrary. I would strongly recommend not getting into a debate, don't try and win them over with studies about the placebo effect — they don't want to know. They're not interested. And if they don't want to know, they don't want to know. That's their prerogative. So don't waste your time.
But if you're wondering and you want to find out more, we'll be talking about it in — I'm going to say Chapter 6 of No Weigh. I think it's Chapter 6, I'm pretty sure that's where it all fits in.
Speaking of No Weigh — that's my book, by the way, for those of you who haven't been paying attention to me going on and on about it. I'm heading into, I think, the final week of self-publishing. All going well, the book will be available to pre-order on the 22nd of April. How exciting is that?
Please buy my book. If you're interested, I'd really appreciate that. More information to follow, no doubt.
Thanks for listening. As I said, next time we're going to be talking about whether or not we should be treating cholesterol and blood sugar and blood pressure. I'm bound to piss a few people off, but I'm coming with the evidence, I'm coming with the receipts — and then you get to make a decision for yourself.
Thank you very much for listening. Have a lovely week! Take care. Bye.