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  • Older Americans Are About to Lose a Lot of Weight

    Older Americans Are About to Lose a Lot of Weight

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    Imagine an older man goes in to see his doctor. He’s 72 years old and moderately overweight: 5-foot-10, 190 pounds. His blood tests show high levels of triglycerides. Given his BMI—27.3—the man qualifies for taking semaglutide or tirzepatide, two of the wildly popular injectable drugs for diabetes and obesity that have produced dramatic weight loss in clinical trials. So he asks for a prescription, because his 50th college reunion is approaching and he’d like to get back to his freshman-year weight.

    He certainly could use these drugs to lose weight, says Thomas Wadden, a clinical psychologist and obesity researcher at the University of Pennsylvania, who recently laid out this hypothetical in an academic paper. But should he? And what about the tens of millions of Americans 65 and older who aren’t simply trying to slim down for a cocktail party, but live with diagnosable obesity? Should they be on Wegovy or Zepbound?

    Already, seniors make up 26.6 percent of the people who have been prescribed these and other GLP-1 agonists, including Ozempic, since 2018, according to a report from Truveta, which draws data from a large network of health-care systems. In the coming years, that proportion could rise even higher: The bipartisan Treat and Reduce Obesity Act, introduced in Congress last July, would allow Medicare to cover drug treatments for obesity among its roughly 50 million Part D enrollees above the age of 65; in principle, about two-fifths of that number would qualify as patients. Even if this law doesn’t pass (and it’s been introduced half a dozen times since 2012), America’s retirees will continue to be prescribed these drugs for diabetes in enormous numbers, and they’ll be losing weight on them as well. One way or another, the Boomers will be giving shape to our Ozempic Age.

    Economists say the cost to Medicare of giving new drugs for obesity to just a fraction of this aging generation would be staggering—$13.6 billion a year, according to an estimate published in The New England Journal of Medicine last March. But the health effects of such a program might also be unsettling. Until recently, the very notion of prescribing any form of weight loss whatsoever to an elderly patient—i.e., someone 65 or older—was considered suspect, even dangerous. “Advising weight loss in obese older adults is still shunned in the medical community,” the geriatric endocrinologist Dennis Villareal and his co-authors wrote in a 2013 “review of the controversy” for a medical journal. More than a decade later, clinicians are still struggling to reach consensus on safety, Villareal told me.

    Ample research shows that interventions for seniors with obesity can resolve associated complications. Wadden helped run a years-long, randomized trial of dramatic calorie reduction—using liquid meal replacements, in part—and stringent exercise advice for thousands of overweight adults with type 2 diabetes. “Clearly the people who were older did have benefits in terms of improved glycemic control and blood-pressure control,” he told me. Other, smaller studies led by Villareal find that older people who succeed at losing weight through diet and exercise end up feeling more robust.

    Such outcomes are significant on their own terms, says John Batsis, who treats and studies geriatric obesity at the UNC School of Medicine. “When we talk about older adults, we really need to be thinking about what’s important to older adults,” he told me. “It’s for them to be able to get on the floor and play with their grandchildren, or to be able to walk down the hallway without being completely exhausted.” But weight loss can also have adverse effects. When a person addresses their obesity through dieting alone, as much as 25 percent of the weight they lose derives from loss of muscle, bone, and other fat-free tissue. For seniors who, through natural aging, are already near the threshold of developing a functional impairment, a sudden drop like this could be enfeebling. Wadden’s trial found that, among the people who were on the weight-loss program for more than a decade, their risk of fracture to the hip, shoulder, upper arm, or pelvis increased by 39 percent. An analogous increase has turned up in studies of patients who undergo bariatric surgery, Batsis told me.

    Read: Ozempic makes you lose more than fat

    The effect of dieting on muscle and bone can be attenuated, but not prevented, through resistance training. And obesity itself—which is associated with higher bone density, but perhaps also reduced bone quality—may pose its own fracture risks, Batsis said. But even when a weight-loss treatment benefits an older patient, what happens when it ends? People tend to regain fat, but they don’t recover bone and muscle, Debra Waters, the director of gerontology research at the University of Otago, in New Zealand, told me. That makes the long-term effects of these interventions for older adults very murky. “What happens when they’re 80? Are they going to have really poor bone quality, and be at higher risk of fracture? We don’t know,” Waters said. “It’s a pretty big gamble to take, in my opinion.”

    Villareal told me that doctors should apply “the general principle of starting slow and going slow” when their older patients are trying to lose weight. But that approach doesn’t necessarily square with the rapid and remarkable weight loss seen in patients who are taking semaglutide or tirzepatide, which may produce a greater proportional loss of muscle and bone. (For semaglutide, it appears to be about 40 percent.)

    Then again, when given to laboratory animals, GLP-1 drugs seem to tamp down inflammation in the brain; and they’re now in clinical trials to see whether they might slow the progression of Alzheimer’s disease and dementia. Their multiple established benefits could also help seniors address several chronic problems—diabetes, obesity, fatty liver disease, and kidney disease, for instance—all at once. “Such a ‘one-stop shop’ approach can lead to reduction of medication burden, adverse drug events, hypoglycemic episodes, medication costs, and treatment nonadherence,” one team of geriatricians proposed in 2019.

    Overall, Batsis remains optimistic. “As a clinician, I’m very excited about these medications,” he told me. As a scientist, though, he’s inclined to wait and see. It’s surely true that some degree of weight loss is a great idea for some older patients. “But the million-dollar question is: What’s the sweet spot? How much weight is really enough? Is it 5 to 10 percent? Or is it 25 percent? We don’t know.” Waters said that if Medicare is going to pay for people’s Wegovy, then it should also cover scans of their body composition, to help predict how weight loss might affect their muscles and bones. Wadden said he thinks that treatments should be limited to people who have specific, weight-related complications. For everyone else—as for the hypothetical 72-year-old man who is prepping for his college reunion—he counsels prudence.

    To some extent, such advice is beside the point. Older people are already on Ozempic, and they’re already on Trulicity, and some of them are already taking GLP-1 drugs as a treatment for obesity. Truveta reported that the patients in its member health-care systems who are over 65 have received 281,000 prescriptions for GLP-1 drugs across the past five years. Given the network’s size, one can assume that at least 1 million seniors, overall, have already tried these medications. Millions more will try them in the years to come. If we still have questions about their use, mass experience will start providing answers.

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    Daniel Engber

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  • Just How Sweaty Can Humans Get?

    Just How Sweaty Can Humans Get?

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    This summer, I, like so many other Americans, have forgotten what it means to be dry. The heat has grown so punishing, and the humidity so intense, that every movement sends my body into revolt. When I stand, I sweat. When I sit, I sweat. When I slice into a particularly dense head of cabbage, I sweat.

    The way things are going, infinite moistness may be something many of us will have to get used to. This past July was the world’s hottest month in recorded history; off the coast of Florida, ocean temperatures hit triple digits, while in Arizona, the asphalt caused third-degree burns. As human-driven climate change continues to remodel the globe, heat waves are hitting harder, longer, and more frequently. The consequences of this crisis will, on a macroscopic scale, upend where and how humans can survive. It will also, in an everyday sense, make our lives very, very sweaty.

    For most Americans, that’s probably unwelcome news. Our culture doesn’t exactly love sweat. Heavy perspirers are shunned on subways; BO is a hallmark of pubescent shame. History is splattered with examples of people trying to cloak sweat in perfumes, wash it away by bathing, or soak it up with wads of cotton or rubber crammed into their shirts, dresses, and hats. People without medical reason to do so have opted to paralyze their sweat-triggering nerves with Botox. Even Bruce Lee had the sweat glands in his armpits surgically removed, reportedly to avoid on-screen stains, several months before his death, in 1973.

    But our scorn of sweat is entirely undeserved. Perspiration is vital to life. It cools our bodies and hydrates our skin; it manages our microbiome and emits chemical cues. Sweat is also a fundamental part of what makes people people. Without it, we wouldn’t be able to run long distances in high heat; we wouldn’t be able to power our big brains and bodies; we wouldn’t have colonized so much of the Earth. We may even have sweat to thank (or blame) for our skin’s nakedness, says Yana Kamberov, a sweat researcher at the University of Pennsylvania. Her team’s recent data, not yet published, suggest that as human skin evolved to produce more and more sweat glands, fur-making hair follicles disappeared to make room. Sweat is one of the “key milestones” in human evolution, argues Andrew Best, a biological anthropologist at the Massachusetts College of Liberal Arts—on par with big brains, walking upright, and the expression of culture through language and art.

    Humans aren’t the only animals that sweat. Many mammals—among them, dogs, cats, and rats—perspire through the footpads on their paws; chimpanzees, macaques, and other primates are covered in sweat glands. Even horses and camels slick their skin in the heat. But only our bodies are studded with this many millions of teeny, tubular sweat glands—about 10 times the number found on other primates’ skin—that funnel water from our blood to pores that can squeeze out upwards of three, four, even five liters of sweat an hour when we need them to.

    Our dampness isn’t cost free. Sweat is siphoned from the liquid components of blood—lose too much, and the risks of heat stroke and death shoot way up. Our lack of fur also makes us more vulnerable to bites and burns. That humans sweat anyway, then, Best told me, is a testament to perspiration’s cooling punch—it’s so much more efficient than merely panting or hiding from the heat. “If your objective is to be able to sustain a high metabolic rate in warm conditions, sweating is absolutely the best,” he said.

    Read: You’re probably drinking enough water

    And yet, in modern times, many of us just can’t seem to accept the realities of sweat. Americans are, for whatever reason, particularly preoccupied with quashing perspiration; in many other countries, “body odor is just normal,” says Angela Lamb, a dermatologist at Mount Sinai’s Icahn School of Medicine. But the bemoaning of BO has cultural roots that long predate the United States. “I’ve read discussions well back into antiquity where there are discussions about people whose armpits stink,” says Cari Casteel, a historian at the University of Buffalo. By the start of the 20th century, Americans had been primed by the recent popularization of germ theory to fear dirtiness—the perfect moment for marketers to “put the fear in women, and then men, that sweat was going to kibosh your plans for romance or a job,” says Sarah Everts, the author of The Joy of Sweat. These days, deodorants command an $8 billion market in the United States.

    Our aversion to sweat doesn’t make much evolutionary sense. Unlike other excretions that elicit near-universal disgust, sweat doesn’t routinely transmit disease or pose other harm. But it does evoke physical labor and emotional stress—neither of which polite society is typically keen to see. And for some, maybe it signifies “losing control of your body in a particular way,” says Tina Lasisi, a biological anthropologist at the University of Michigan. Unlike urine or tears, sweat is the product of a body function that we can’t train ourselves to suppress or delay.

    We also hate sweat because we think it smells bad. But it doesn’t, really. Nearly all of the sweat glands on human bodies are of the so-called eccrine variety, and produce slightly salty water with virtually no scent. A few spots, such as the armpits and groin, are freckled with apocrine glands that produce a waxy, fatty substance laced with pheromones—but even that has no inherent odor. The bacteria on our skin eat it, and their waste generates a stench, leaving sweat as the scapegoat. Our species’ approach to perspiration may even make us “less stinky than we could be,” Best told me. The expansion of eccrine glands across the body might not have only made our skin barer; it’s also thought to have evicted a whole legion of BO-producing apocrine glands.

    As global temperatures climb, for many people—especially in parts of the world that lack access to air-conditioning—sweat will be an inevitability. “I suspect everyone is going to be quite drippy,” Kamberov told me. Exactly how slick each of us will be, though, is anyone’s guess. Experts have evidence that men sweat more than women, and that perspiration potential declines with age. But by and large, they can’t say with certainty why some people are inherently sweatier than others, and how much of it is inborn. Decades ago, a Japanese researcher hypothesized that perspiration potential might be calibrated in the first two or three years of life: Kids born into tropical climates, his analyses suggested, might activate more of their sweat glands than children in temperate regions. But Best’s recent attempts to replicate those findings have so far come up empty.

    Read: The man who did not sweat

    Perspiration does seem to be malleable within a lifetime. A couple of weeks into a new, intense exercise regimen, for instance, people will start to sweat more and earlier. Over longer periods of time, the body can also learn to tolerate high temperatures, and sweat less copiously but more efficiently. We sense these changes subtly as the seasons shift, says Laure Rittié, a physiologist at Glaxo-Smith Kline, who has studied sweat. It’s part of the reason a 75-degree day might feel toastier—and perhaps sweatier—in the spring than in the fall.

    But we can’t simply sweat our way out of our climatic bind. There’s a ceiling to the temperatures we can tolerate; the body can leach only so much liquid out at once. Sweat’s cooling power also tends to falter in humid conditions, when liquid can’t evaporate as easily off of skin. Nor can researchers predict whether future generations might evolve to perspire much more than we do now. We no longer live under the intense conditions that pressured our ancestors to sprout more sweat glands—changes that also took place over many millions of years. It’s even possible that we’re fast approaching the maximal moistness a primate body can produce. “We don’t have a great idea about the outer limits of that plasticity,” Jason Kamilar, a biological anthropologist at the University of Massachusetts at Amherst, told me.

    For now, people who are already on the sweatier side may find themselves better equipped to deal with a warming world, Rittié told me. At long last: Blessed are the moist, for they shall inherit the Earth.

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    Katherine J. Wu

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