Hello everyone, and welcome to Episode 14 of Season 6 of the Fat Doctor Podcast. I'm your host, Dr. Asher Larmie, and today I'm going to say some stuff that you might not want to hear, but I'm going to say it anyway.
Weight loss isn't going to help you live longer. I think you probably knew that, but actually there are a lot of things that you're doing right now, that your doctors are doing for you right now, that might actually not help you to live longer either. And drug companies don't want you to know this, doctors don't want you to know this, because if you knew it, it might put them out of a job.
Let's talk about preventative medicine. There are two different types of medicine, if we can distill it down. There's symptomatic medicine — you come to see me because you have symptoms, and it's my job as your doctor to figure out what is causing those symptoms and treat you. You've got an infection, I give you antibiotics. You have pain, I give you painkillers. Problem with your kidney, I address that. It's obvious — you have symptoms and they need treatment. But more and more now, you're going to see a doctor for what we call preventative medicine. That is where you have been diagnosed with a condition, or several conditions, that are completely asymptomatic and have no impact on you in the here and now, but could potentially cause problems down the line. You know that old saying, prevention is better than cure? So our job as doctors and healthcare professionals is to prevent that bad thing from happening in the future by treating this asymptomatic condition that you have right now, in the present.
So we're going to be talking about that today. But I'm going to start by saying, in case you didn't know, that weight loss will not help you to live longer. In fact, weight loss might cut your life short.
That's uncomfortable, isn't it?
The NHS claims that obesity reduces life expectancy by 3 to 10 years. That's a decade. So where do these numbers come from? It actually comes from one particular study, the 2009 Prospective Studies Collaboration paper. These people did not study a whole bunch of people, follow them over the course of their lives, and see who lived and who died. That is not what they did. They made projections. They created calculations. These were not observations, they were theories. And they were very problematic theories, because they made a whole bunch of assumptions.
They looked at obesity-associated diseases and assumed that being fat caused the disease. They assumed that if a person died from a disease that is associated with being fat, then they died because they were fat. There are all sorts of things at play — blood pressure, family history, genetics, having rheumatoid arthritis can increase your risk of heart disease, being on certain drugs can, having a history of migraines can increase your risk of a stroke. It's never just one risk factor, but they ignored all of that and just went: a fat person died of a heart attack, that's because they're fat. When a thin person dies of a heart attack, it's got nothing to do with their weight. When a fat person dies of a heart attack, it's because they're fat. That was the underlying belief they plugged into their calculation. And it gets worse — they also assumed that if a person lost the weight, they wouldn't have died.
None of that is true. These calculations are clinically meaningless. They are created solely for the purpose of pushing the weight loss agenda. If a doctor says to you that being fat reduces your life expectancy by up to 10 years, you're going to try to lose weight. That is the best motivator. But it's not true. It's based on lies.
The 10-year figure is the scary one. That comes from people who are severely obese — people with a BMI over 40. They collected data from almost a million people, but the people with a BMI over 40 were a very small portion of that data. We know that when you're making projections using calculations with very wide margins of error, the smaller the data you input, the worse the margin of error is going to be. It's like having a questionnaire filled in by a thousand people, but only looking at the results of 10 of them. And that's your headline. That's the 10 years.
Whenever you see that 3 to 10 years figure, you know it comes from the 2009 Prospective Studies Collaboration paper. But if you look at other studies, you see something very different.
There is the TONE trial — basically, they got a group of people to lose weight, they lost a significant amount of weight and maintained it, but it had absolutely no difference in mortality. There was also the Look AHEAD study, which looked at mortality but also at heart attacks and strokes, and found that weight loss did not have any impact on mortality or morbidity in any way, shape, or form. So we can say that with quite a lot of confidence.
The question is, does it go the other way? Does weight loss actually shave years off your life? I cannot say conclusively yes or no. There is a 2008 literature review that looked at 9 very rigorous studies and found that 3 of the 9 showed an increase in mortality following weight loss interventions. A third. Enough of a concern that researchers said they couldn't make any recommendations about weight loss based on that data.
The takeaway is very simple. Being fat doesn't shorten your life — that's an assumption built on shaky maths. When you look at the real data, there's no evidence that being fat shortens your life. Weight loss does not improve your life expectancy. There is even evidence that repeated weight loss may reduce your life expectancy. I can't say for sure, but it's possible. And until I know one way or the other, I don't feel comfortable engaging in weight loss anymore.
Moving on. I'm going to say something now that's really going to piss a lot of people off.
There are a number of medical conditions and scenarios where fat people have better survival rates. Anyone with coronary heart disease, anyone with high blood pressure, anyone with diabetes, anyone with heart failure, anyone with kidney disease, anyone with dementia, anyone with COPD — in any of those situations, being fat increases your life expectancy.
Fat people have better outcomes after surgery. Now, caveat — there are certain complications that are more common in fat people. Infections and blood clots are the two most common ones. But when it comes to blood loss, kidney damage, cardiovascular damage, respiratory damage — fat people always do better. The fatter, the better. Fat people do better in ICU. Fat people do better when they're on dialysis.
The way that medical professionals handle all of these phenomena — these massive studies that show that actually, being fat is better for you than being thin — is by calling it a paradox. The obesity paradox. Something that doesn't make sense, that they can't quite explain. But this is the problem. It's only a paradox if you already assume that fat causes harm. If you don't assume that fat causes harm, it's no longer a paradox, it's just evidence.
The weight loss industry has funded paper after paper with the sole aim of disproving the obesity paradox. They're so desperate, because this flies in the face of their narrative. But data is data. Raw data is very hard to ignore.
The medical establishment doubles down instead of saying, we thought it was this, but turns out it's this. Instead they go, oh, it's just a paradox.
In real life, fat may — and I'm not saying does, I'm saying may — offer a protective benefit, especially as we age. Frail people who are thin have more risk than older people who are fat. Being frail and thin does not serve you, especially as you get older. So maybe fat is protective. It certainly isn't shaving years off your life.
But here's the bit that I think is really going to stick in some people's crawl. There are studies showing that losing weight improves your numbers. You know what numbers I'm talking about — HbA1c, that's your blood sugar, blood pressure, and cholesterol. And we're all told that if you improve those numbers, that's going to improve your health. You do something in the here and now to prevent something bad happening down the line.
I remember being at a conference not too long ago. Someone put their hand up and said, how can you possibly say that this weight loss drug doesn't improve your health? It does — I dropped my blood pressure by this much, I dropped my cholesterol by this much, I dropped my blood sugar by this much. I've improved my health, and I've never felt better.
And I was like, never felt better. Hang on a minute. Because you don't feel blood pressure. You don't feel HbA1c. You don't feel cholesterol. You only know about those things because a doctor has told you what they are. What I do know is that the drug you're taking has side effects for pretty much everyone — the abdominal pain, the diarrhoea, the vomiting, the loss of appetite, the mood changes, the dizziness, the sweating. You feel those in the here and now.
There's a real disconnect between what you feel and what you feel. A lot of people say, I can feel my blood pressure. You actually can't. There's a reason they call it the silent killer. You are feeling something — I'm not denying your lived experience — but it's not your blood pressure that's making you feel that way.
I want to talk to diabetics now, because I have the most amount of information for diabetics. This is going to really piss some people off.
If you're a diabetic living in the UK, the current targets are 48 millimoles per mole — which is 6.5% — as a target. Now, 48 is literally the exact point where you tip over from not having diabetes to having diabetes. It's the first number on the scale. So the target for a lot of people is to get them down to basically not having diabetes. 53 sometimes for some people, but we've got really low targets for diabetics.
If you're a diabetic, you go to your doctor routinely every 3 or 6 months, they measure your HbA1c, tell you it's too high, and then go: what have you been doing? What have you been eating? You've not been exercising? Too many biscuits? That is the assumption. No one ever asks: anything changed? More stress than usual? Getting enough sleep? Are you in pain? Have you changed any medication? All of the actual reasons why HbA1c tends to go up. If you're not getting enough sleep, your A1C will go up. If you're in pain — you break your ankle, you have arthritis in your hip, whatever — your HbA1c will go up. If you're stressed, your A1C is going to go up. No one ever asks about any of that. They just say, what have you been eating? Tut tut tut. Aren't you naughty. And they'll tell you to lose weight, and then they'll plan to put you on a new medication or increase the dose of your current one, because they need to get you down to target.
The assumption is that the lower the blood sugar, the healthier the diabetic. Except that's not true. There's literally no evidence to support that. There's a study that says no anti-diabetic drug has clearly proven superiority over placebo in reducing actual clinical outcomes.
Here's the thing about diabetes. Like high blood pressure and high cholesterol, it's not doing anything to you in the here and now. If you have very high blood sugar, you will feel it — you'll be thirsty, you'll be peeing more, you'll be tired, lacking in energy. Symptomatic type 2 diabetes absolutely requires treatment, because it's bothering you in the here and now. But if you're asymptomatic — if your blood sugar is high, but not high enough to cause symptoms — then the only reason you know about it is because somebody did a blood test. And if that's the case, we're not worried about the here and now, we're worried about the future. Diabetes puts you at risk of heart attacks, strokes, foot ulcers requiring amputations, loss of vision, blindness, kidney problems. Of course we want to prevent those things. But just because we lower your numbers doesn't mean we're going to prevent them from happening. There isn't any evidence that lowering your numbers is going to prevent those outcomes.
When improvements do occur on diabetic medication — and there are certain drugs that have been shown to perhaps reduce the risk of heart attacks, though the evidence isn't very convincing — those improvements tend to happen independent of their effect on blood sugar. The blood sugar wasn't the point.
So if you're a type 2 diabetic who feels fine, has no symptoms, and only knows they're sick because of blood tests every few months — yet you're being treated with multiple drugs that have never been shown to improve your long-term clinical outcomes — you want to ask yourself why.
There have been multiple studies, especially one in the BMJ, which I'll link in the show notes, that have shown with a great amount of certainty that intensive glycaemic control — having very low targets like 6.5 or 7%, 48 or 53 millimoles — has no meaningful benefit compared to moderate control, which is somewhere between 7 and 8.5%. No benefit. In fact, there are more risks than there are benefits. Real costs to your health in the here and now, to theoretically prevent something from happening in the future — which apparently these targets don't even do.
So why do they have these lower targets? Because the people who set the targets are funded by the drug industry. The American Diabetes Association, Diabetes UK, NICE — they all have financial ties. The American Diabetes Association is paid a significant amount of money by Eli Lilly and Novo Nordisk and all the other companies selling weight loss or diabetes drugs. The lower the target, the more drugs you prescribe. And this is the case for cholesterol, and this is the case for blood pressure.
This is one of the biggest lies I expose in the book I'm writing — that more often than not, there's no evidence supporting the preventative treatment you're getting. Forget weight loss, just treating diabetes. Because we are all under the assumption that if we improve those numbers, we are going to be healthier, we are going to live longer. But those markers — you don't feel them in the here and now. It's all about a theoretical, hypothetical, future risk. And these drugs don't do anything about those theoretical, hypothetical, future risks. And weight loss definitely doesn't do anything about those future hypothetical risks — because we've got studies, we've looked at it, we've checked, and it didn't work.
The only people who benefit from these targets are the drug companies who are setting them. One could argue the doctors and nurses whose job it is to monitor them. If we raised the targets, you'd spend a lot less time with your doctor or nurse. And given that there's a major doctor and nursing shortage, that would actually free up their time to do something else. Wouldn't that be wonderful? The only people benefiting from this are drug companies, and they're the ones setting the targets in the first place. You'll find their fingerprints everywhere.
There's something called the QRISK3 score — a calculator where you can calculate your hypothetical, population-based risk of having a heart attack or stroke in the next 10 years. I do this with all of my clients. I put in their details, make the person fat, and show them the risk. Then I look at the same person but significantly reduce their weight — I'll literally take off 50 kilograms — press calculate, and the difference in risk is 0.3%, 0.4%. Always less than 0.5%. That is the difference between a really thin person and a really fat person. They keep telling you that your risk of a heart attack is so much higher because you're fat. It's not. It's 0.3%. And you can go calculate it yourself, you don't have to believe me.
I looked at the 10-year risk for a 50-year-old woman with no other risk factors, and I gave her a BMI of 21, then a BMI of 40. The difference in their cardiovascular risk was 0.2%. Go figure it out for yourself. Go reassure yourself. Check out the QRISK.
What does this all mean? It means that everything you've been told — to restrict your food, to punish yourself in the gym, to go on some crazy 800-calorie-a-day diet, to fast intermittently, to take a tablet or an injection, or have surgery — that all of these things are going to benefit your health because you'll lose weight, and if you lose weight, that will theoretically, hypothetically prevent something from happening in the future — whether it's death, a heart attack, a stroke, cancer — that's what you were told. And I'm telling you, not only is that not true about weight loss, but actually it's not true about a lot of things. These magic numbers that we're so obsessed with mean very little. They really do.
Even if you're diabetic, your HbA1c doesn't mean that much. So if you're not diabetic, imagine how little that HbA1c means. That guy at the conference who said he felt so much better because his HbA1c was down — I'm sure that feels like a really big thing for him, but it doesn't actually mean anything.
All of this stuff is based on a lie. Weight loss isn't going to help you to live longer. Your fat body may actually be protecting you. And the next time someone waves their bloodwork around and goes, look how good this is — just know that those numbers mean nothing. Not that I'm recommending you say that to anyone, because it's not a nice thing to say. I certainly didn't say that to that guy.
Preventative medicine is really about making drug companies rich, and very little else. I'm not saying there isn't any evidence that preventative measures work, because there is. I'm not saying stop all your medications — that is definitely not what I'm saying. But you can absolutely have a conversation with your doctor about your targets. Next time they tell you your HbA1c is 7.1, you can say, actually, I'm thinking about increasing my target to somewhere around 8, based on this study from the BMJ. Have that conversation with your own physician. You can say: I've read that intensive glycaemic targets are of no benefit whatsoever, so I would like to have a moderate target instead. I'm not interested in making drug companies richer. I'm quite happy puttering along moderately well controlled, as long as that's not going to have any impact on my long-term prognosis. And you can ignore the other people who are telling you that weight loss is going to reduce your A1C, because it really doesn't matter.
The book is available for pre-order on the 22nd of April. It'll be available on Kindle and in print. And I'm super excited about next week's podcast episode. Have a lovely week, and I will see you next time!
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