If calorie math is so simple, why do the best diet trials average only three to five percent weight loss, with about 80 percent of that regained within five years? When your body loses 10 percent of its weight, why can leptin fall by more than half and tell the brain you have starved far more than you have? If a locked calorie budget would keep the pounds off in theory, why does real life fill with hunger, food thoughts, a slower metabolic rate, and exercise that burns less? What does it mean that a fat mass set point can ratchet up with age, psychiatric medications, family history, and years spent heavy, then defend that high watermark so fiercely? Why is BMI such a crude bucket, and why might apple shaped visceral fat around organs, or sicker inflammatory adipose tissue, be far more dangerous than the same number on a muscular athlete? Can environment, hormone disrupting chemicals, and a move into a more obesogenic world explain why some people never had a weight problem until they changed countries? If exercise itself only moves the scale by a percent or two, why is it still central to insulin sensitivity, muscle health rather than mere mass, and keeping lost weight off? And if access is so broken that people turn to gray markets and compounded knockoffs that are not generics, how should we weigh cheaper supply against the chance they are not even getting the drug they think they bought?
Dr. Katherine H. Saunders is a physician entrepreneur and a leading expert in obesity medicine. Dr. Saunders is a diplomate of the American Board of Internal Medicine and the American Board of Obesity Medicine.
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