Ladders to Health

Imagine taking a monthlong retreat where your focus is to eat regularly available foods selected and prepared for you by dietitians. In 2019, 20 healthy volunteers—10 men and 10 women of roughly the same age and body mass index (BMI)—did this for a study at the U.S. National Institutes of Health. 

For two weeks, half the group received three meals per day of ultra-processed foods such as potato chips, sugar-sweetened drinks, French fries, and processed meats, including bacon, sausage, and cold cuts. The other half ate three meals a day of minimally processed foods such as vegetables, fruits, nuts, whole grains, milk, eggs, fish, and meat. 

Each group then switched menus to spend the next two weeks on the opposite diet. Dietitians carefully calibrated both diets to contain identical amounts of calories, sugars, fiber, fat, salt, and carbohydrates. The groups had up to 60 minutes to eat as much as they wanted of each meal.

The results: Participants presented with ultra-processed foods ate more, consumed more calories per day, and gained weight. When presented with minimally processed foods, participants felt full sooner, ate less, consumed fewer calories, and lost weight. This small but significant randomized controlled trial provided the first scientific confirmation of what observational studies suggested for years: Ultra-processed foods cause people to eat more calories and gain weight. 

Our fattening food supply 

“Highly processed food is so palatable; it makes us crave it,” says Caroline Apovian, MD*, co-director of the Brigham’s Center for Weight Management and Wellness. “Our genes didn’t change in the last 50 years, but our environment certainly did—the industrialization of our food supply.”

The food industry is all in on ultra-processed foods, which now make up 60% of what most people eat daily in the U.S. From sweets and sodas to many pantry staples including cereals and breads—ultra-processed foods are altered with additives, preservatives, and other ingredients to make them pleasing in taste and appearance. In addition to evidence these foods drive weight gain, they are linked with increased rates of type 2 diabetes, heart disease, and cancer. 

Apovian says emerging evidence also suggests ultra-processed foods may make the brain resist leptin, a hormone that causes feelings of fullness when eating. 

“We think there’s inflammation that occurs and causes a defect in the pathway that blocks leptin,” she says. “Then we have leptin resistance, which makes us hungry, so we eat more and gain weight.” 

For years, food companies have branded products as low-fat, low-carb, or other labels to appeal to consumers and increase sales. A 2023 joint investigation by The Washington Post and The Examination revealed a new tactic used by food companies: paying dietitians who collectively have millions of social media followers to promote sugary products on social media, with many distorting the Health at Every Size movement using the hashtags #HealthAtEverySize and #AntiDiet. 

According to the investigation led by journalists Anahad O’Connor, Caitlin Gilbert, and Sasha Chavkin, “The analysis of thousands of posts found that companies and industry groups paid dietitians for content that encouraged viewers to eat candy and ice cream, downplayed the health risks of highly processed foods, and pushed unproven supplements—messages that run counter to decades of scientific evidence about healthy eating.” (For more information on social media’s influence on health, read “Truth, Lies, or Marketing?”)  

*Disclosure: Apovian is a former scientific advisory board member and received consulting fees in 2022 from Novo Nordisk, the maker of Ozempic and Wegovy.

Diet culture

Both the body acceptance movement and the U.S. weight loss industry emerged in the 1960s. By the 1970s, ads promoting thin bodies and diets filled magazines targeted at women, and what we know today as “diet culture” took off. Over time, the weight loss industry’s profits soared, raking in $135.7 billion in 2023 alone.

Kathy McManus, MS, RD, LDN, director of the Brigham’s Department of Nutrition, disputes the myth that thin equals healthy. “Losing weight alone doesn’t improve your overall health,” she notes. “But companies put millions of dollars into marketing, and their messages are convincing, whether it’s for diets, supplements, or food products. It’s easy to be susceptible.”

Whether you’re 20 or you’re 80, people want a quick fix. But fad diets rarely work long term because they are not sustainable.

Kathy McManus, MS, RD, LDN

In 2020, a survey published by the U.S. Centers for Disease Control and Prevention (CDC) reported nearly 17% of Americans ages 20 and older were on a diet to lose weight or for other health reasons. On any given day, approximately 45 million adults are dieting. And there are countless diets to try, such as ketogenic or juice diets that eliminate specific food groups like carbohydrates or fats—or fads that involve severely restricting calories and nutrients.

“Whether you’re 20 or you’re 80, people want a quick fix,” McManus says. “But fad diets rarely work long term because they are not sustainable. And they can have negative side effects, from nutrient deficiencies and dehydration to nausea and headaches or worse.” 

McManus’s colleague, Nancy Oliveira, MS, RD, LDN, CDCES, manager of the Nutrition and Wellness Service, says, “Patients often turn to fad plans and products in sincere attempts to feel better. It’s important for us as dietitians to listen, educate, and build trust so patients turn to us for guidance.” 

Oliveira adds, “I encourage our dietitians to understand what is trending and to talk about potential effects of a certain supplement or dietary strategy.” 

Breaking through stigmas 

One of Oliveira’s patients, Val Mayo, will never forget when she went to a weight-loss clinic on Newbury Street in Boston decades ago. 

“The woman weighing me said, ‘I know you want to lose weight because you’re really unhappy with yourself,’” Mayo recalls. “I thought, ‘No, I’m not!’” 

These stinging remarks were the opposite of what Mayo was seeking: support, accountability, and help to improve her health. 

On her journey to better health, she tried liquid diets, calorie counting, and prepared meal plans, as well as a diabetes prevention program. But after years of trial and error—coupled with a sedentary job—she steadily gained 5 to 10 pounds a year. 

When a visit to her primary care doctor showed she had developed a few health conditions, Mayo sought help from medical professionals. Her physician referred her to Oliveira, which set her on a path to a healthier lifestyle. 

The complexities of obesity 

Mayo is one of more than 130 million adults across the U.S. with obesity. According to the CDC, 14.3% of American adults had obesity or severe obesity in the early 1960s, while 51.6% of adults are affected now, per the measurements used.

BMI—which estimates excess body fat using a ratio of weight to height—has become a standard measure, indicating that a person with obesity has a BMI of 30 or higher. However, BMI does not account for muscle mass, bone density, racial and sex differences, or the location of body fat such as abdominal fat, which is associated with health risks. 

“I strongly encourage physicians not to tell a patient they need to lose weight solely because their BMI is 30 or higher,” says Oliveira. “The conversation needs to be much more nuanced.” 

McManus notes there are many other indicators and approaches for measuring unhealthy body fat, including waist circumference, waist-to-hip ratio, and waist-to-height ratio. “BMI or weight is just one piece of getting healthy,” she says. “No single measurement should stand alone.”

Just over a decade ago, in 2013, the American Medical Association recognized obesity as a treatable disease that increases people’s risk for cardiovascular diseases, cancers, diabetes, sleep apnea, and osteoarthritis.

‘Food is medicine’

With Oliveira’s help, Mayo began tackling aspects of her lifestyle, including improving her sleep, increasing exercise to four days a week, and shifting her eating habits. 

“Growing up, my mother used to say, food is medicine,” Mayo says. “But before meeting Nancy, I did not realize the amounts of calories in different foods. After logging my foods every day with an app, I started to understand what nutrient-filled foods looked like.” 

Oliveira, McManus, and the Brigham nutrition team encourage patients to embrace a permanent, sustainable shift toward healthier eating habits backed by years of studies. They promote evidence-based foods and dietary plans shown to significantly decrease the risk of cardiovascular disease, diabetes, some cancers, and other conditions, including potentially lowering the risk of dementia. Three eating plans consistently ranked highest by scientific research for flexible, balanced approaches are the Mediterranean diet, the heart health-focused DASH diet, and the brain health-focused MIND diet. In fact, the Brigham was a primary site for randomized clinical trials of DASH (Diet Approaches to Stop Hypertension).

“Our goal is to support individuals in every way we can using research,” McManus says. “As clinicians, we want to emphasize the positives about foods we want you to eat versus saying ‘don’t eat this or that.’ We design meal patterns to help reduce patients’ risk for chronic disease.”

For Mayo, Oliveira recommended a list of foods to eat weekly, including leafy greens and vegetables, nuts, beans, and fish. Foods once rare for Mayo became her new norm—from avocados to cottage cheese to smoothies. 

McManus adds, “We help people with expectations and to work through long-established habits so, over time, they can reshape some of their behaviors and begin feeling better about lifestyle choices they’re making.”

Seeking medical support

During her first year working with Oliveira, Mayo made gradual changes and slow progress toward her health goals. When she asked for additional support to move forward faster, Oliveira referred her to an obesity medicine specialist in the Center for Weight Management and Wellness.

Her physician suggested weight loss surgery or a medically supervised weight loss plan, and at first Mayo rejected both options. After learning more about Ozempic, she decided to try it. Approved in 2017 by the U.S. Food and Drug Administration (FDA), the weekly injectable medication containing semaglutide treats type 2 diabetes and prevents major cardiovascular problems. It belongs to a class of drugs that mimics the body’s GLP-1 hormone, which reduces a person’s appetite and causes feelings of fullness faster.

I was skeptical at first, but these medications are groundbreaking…as long as people receive a lot of support and nutritional guidance.

Val Mayo, Patient

“I was skeptical at first, but these medications are groundbreaking,” Mayo says. “They can be helpful as long as people receive a lot of support and nutritional guidance at the same time.”

Apovian explains, “The biggest misconception with obesity is that weight is a matter of willpower. This bias makes people with obesity feel it’s somehow their fault and wonder what is wrong with them if they have difficulty losing weight with diet and exercise alone.” 

Over time, Mayo’s health continued to improve, and she met her goal to get two knee replacement surgeries last year to boost her mobility, an essential step to becoming more physically active. 

Adds Apovian, “A myth is that you don’t have to worry about healthy diet and exercise if you take these medications. But if you are not physically active and eat poorly, it’s bad for your health. Any kind of exercise is important, especially as you age.” 

This comprehensive care helps Mayo embrace a multifaceted approach. “Having a team of people help me tweak my eating habits and give me advice and support has helped so much,” she says. “It provides accountability and keeps me on track. I’m invested in living a healthier life.” 

Issues of access

While Ozempic has supported patients like Mayo, the newest classes of drugs containing semaglutide or tirzepitide are not a panacea. 

When word quickly got out about these medications’ effectiveness for weight loss through the media and celebrities, demand skyrocketed, causing shortages. Obesity medicine specialists continue to have long waiting lists, leaving patients looking for alternative ways to find these drugs.

Apovian says some people have resorted to compounding pharmacies, which combine, mix, or alter ingredients to create custom-made medications for individual patients. Compounding pharmacies nationwide are selling semaglutide formulated with B12 vitamin at a cheaper price than the scarce prescription drugs. 

“The FDA has no jurisdiction over compounded products, and we don’t know what’s in them,” she says. 

Other people have turned to weight-loss clinics or telehealth programs providing brief appointments and semaglutide prescriptions with minimal guidance. 

Another barrier to access is the expense. Most insurance plans do not cover these drugs, so cost can be prohibitive.

Proceeding with caution

These weight loss drugs also come with several potential side effects, including nausea, vomiting, and diarrhea, which often get better over time or with dose changes. More rare but serious risks include intestinal obstruction and severe gastroparesis, a paralysis of the stomach muscles. People with a family history of conditions such as thyroid cancer are cautioned against these drugs. 

“These medications have been game changers for patients who have been unable to lose weight successfully, but it’s still early,” says Oliveira, noting one of her patients developed new severe gastroparesis after starting the drug prescribed by her primary care physician. “In my opinion, patients should only start these medications under close guidance by an experienced weight management physician.” 

Studies are also showing that patients need to stay on these medications indefinitely to continue regulating appetite hormones. 

“These are lifesaving drugs,” says Apovian, “but obesity is a chronic disease. Just like with hypertension, you may need to increase your dose or add other drugs over time.”  

McManus advises, “While medications are an effective tool, what sometimes gets missed from the healthcare side and the patient side is they’re just one tool.” 

No single solution

Whether a person’s health goals are to prevent or manage chronic conditions, lose weight, or increase energy or strength, McManus says, “evidence shows many factors affect our overall health—the quality of our food, sleep, physical activity, and activities that reduce stress.” 

Recognizing the societal influences of easily available convenience foods and unreliable claims of influential health marketing, McManus suggests seeking the support of a clinician to address health goals and concerns, rather than going it alone or seeking answers online only. The teams at the Brigham help to personalize each person’s treatment plan based on their needs, she notes. 

“There’s no quick fix to achieving good health,” McManus says. “The key is to focus on developing a sustainable approach that supports the endgame—our overall health, wellness, and longevity.”