While the weight loss and diet market contracted by 21% in 2020 due to the covid-19 pandemic, it’s expected to rebound in 2021, likely surpassing its record high of $78 billion in 2019. The problem? The entire industry is based on a false premise: that being overweight or obese is itself a health problem, even potentially a chronic illness. Even worse, the marketing for weight loss products and programs propels weight discrimination and stigma, which are vastly more harmful to a person’s health than being obese is in itself.

When I mentioned in a newsletter recently that weight was actually a pretty poor indicator of health, I received many replies that amounted to body shaming, which made me realize that it was way, way, way past time for a deep dive into the science on weight stigma and health at any and every size. It’s worth taking a moment here to remind all of my readers that I am always happy to engage in good-faith conversation regarding scientific evidence, and strive to create an informative, engaging, and supportive community. As such, I do not reply to messages that are not in good faith, and trolling and bullying will get you removed from my e-mail lists and blocked from my social media accounts.

Yes, it’s ingrained in our society to associate health with weight. So, let’s dig into the science demonstrating why we all would benefit from collectively ditching this mentality and instead adopting a weight neutral approach to health.

Don’t Conflate Overweight and Obese with Unhealthy

Many chronic diseases are associated with obesity, including heart disease, type 2 diabetes, nonalcoholic fatty liver disease, and cancer. But, correlation does not equal causation. A collection of important studies from the past 20 years have revealed that overweight and obesity themselves are not the risk factor, but instead are a symptom of an underlying health challenge (like chronic stress, gut dysbiosis, hypothyroidism or insulin resistance) and/or are an indicator of poor health-related behaviors (like sedentary lifestyle or poor diet quality), and it is actually these latter factors and not bodyweight itself that increase risk of chronic illness.

An important 1999 prospective study of over 25,000 men evaluated BMI relative to other risk factors for cardiovascular disease (CVD) mortality and all-cause mortality (a general indicator of health and longevity) over at least a 10-year follow-up period. While overweight and obese individuals, on average, had an increased risk of dying from cardiovascular disease (obese men had a 2.6X higher risk of dying from CVD) or from any cause (obese men has a 1.9X higher risk of dying from any cause), they were also much more likely than normal-weight men to be sedentary. When the participants were striated based on physical fitness in addition to weight, a very different picture of the true risks for mortality emerged.

Compared to fit normal-weight men, normal-weight unfit men had a 3.1X higher risk of dying from cardiovascular disease, overweight unfit men had a 4.5X higher risk, and obese unfit men had a 5.0X higher risk. But, physical fitness was incredibly protective at all sizes: overweight fit men only had a 1.5X higher risk of dying from cardiovascular disease, and obese fit men only had a 1.6X higher risk, compared to fit normal-weight men.

The difference was even more stark when comparing relative risk of all-cause mortality. Compared to fit normal-weight men, normal-weight unfit men had a 2.2X higher risk of dying from any cause, overweight unfit men had a 2.5X higher risk, and obese unfit men had a 3.1X higher risk. But here’s the kicker: fit overweight and obese men only had a 1.1X higher risk of dying from any cause compared to fit normal-weight men! The implication here is that, while fit overweight and obese men still had a slightly higher risk of dying from cardiovascular disease compared to fit normal-weight men, they had higher levels of protection from non-cardiovascular disease-related mortality in order to have near identical all-cause mortality risk.

The authors concluded that low fitness was an independent predictor of mortality in all body mass index groups after adjustment for other mortality predictors, and was of comparable, if not of greater, importance to diabetes co-morbidity, elevated serum cholesterol, hypertension, and smoking status. The only risk factor that was clearly more important than fitness was previously-diagnosed cardiovascular disease.

Overall, this study showed that sedentary people were more likely to be overweight or obese, and that it was the poor cardiorespiratory fitness that increased risk of all-cause mortality rather than being overweight or obese itself. In fact, obese individuals with at least moderate cardiorespiratory fitness had about half the mortality rate compared to normal-weight but unfit individuals. And, other studies (like this one and this one) have shown consistent results for both men and women, irrespective of whether BMI, body fat percentage, body fat mass or waist circumference is used to differentiate overweight from normal-weight individuals.

Furthermore, these studies show that, rather than exercise being protective because it is a weight-loss tool, living an active lifestyle is protective regardless of weight, which is why a 2004 editorial concluded “Physicians, researchers, and policymakers should spend less energy debating the relative health importance of fitness and obesity and more time focusing on how to get sedentary individuals to become active.”

Additionally, studies reveal that overweight and obesity are actually very poor proxies for measuring health and disease risk, and it would be much more helpful from a medical perspective to dissociate weight from the risk assessment and instead look directly and health behaviors, like activity.

A 2008 study showed that overweight and obesity were not synonymous with being metabolically unhealthy. This study evaluated cardiometabolic health of over 5,400 participants, and deemed them metabolically abnormal if 2 or more indices were elevated (including blood pressure, serum triglycerides, fasting plasma glucose, C-reactive protein, HOMA index [a measure of insulin resistance], and serum LDL “bad” cholesterol). Among overweight individuals, 51.3% were metabolically healthy; among obese individuals, 31.7% were metabolically healthy; and, among normal-weight individuals, 23.5% were metabolically abnormal. These data bust the myth that people who are overweight or obese are unhealthy and that people who are thin are healthy by default.

This study went further to evaluate risk factors other than—but striated by—weight for poor cardiometabolic health. Among normal-weight individuals, being older, male and physically inactive increased risk of metabolic abnormalities. And among overweight and obese people, being middle-age or older, male, and a race/ethnicity other than non-Hispanic Black, as well as imbibing more than two alcoholic beverages per day, smoking (current or ever), having a sedentary lifestyle, and having a high waist circumference each independently increased risk of metabolic abnormalities. Physical activity was the most protective for both normal-weight and overweight/obese individuals, the more metabolic equivalent tasks (MET; a measurement of the energy expenditure per kilogram bodyweight during physical activity, with 1 MET being roughly equivalent to burning 1 calorie per kilogram of body weight per hour) per day, the better (the most active group had >280 METs per day).

Not only does this study prove that you can be overweight or obese and be perfectly metabolically healthy, it also demonstrates that a substantial proportion (nearly one quarter) of normal-weight individuals have 2 or more metabolic abnormalities linked to increased risk of cardiovascular disease and diabetes that may go unrecognized because of the erroneous assumptions that normal weight equals healthy and overweight and obesity equal unhealthy. Making assumptions of health based on bodyweight does everyone a disservice, propelling weight stigma and the health detriments thereof for overweight people (we’ll get into this next), while also failing to identify risk factors for normal-weight people. In fact, a 2017 analysis concludes “It is not possible to determine a person’s health status on the basis of their weight.”

A quick aside on BMI: The body mass index, or BMI, which is calculated from height and weight, is the standard when it comes to describing body composition from a scientific perspective. While there are obvious limitations to this measurement for individuals (the classic paradox of the ultra-lean body builder who has an obese BMI, or someone who is “overfat” with a normal BMI), it’s a pretty good scientific tool for representing the average body composition of a group. In addition, many of the studies I’m referencing use secondary measures like waist-to-hip ratio, body fat percentage, body fat mass, or waist circumference.

I want to emphasize that I am not implying that being overweight or obese is automatically healthy, but rather that you can be healthy while overweight or obese because health behaviors and underlying conditions are driving chronic health problems rather than the weight itself. So, if you’re overweight or obese and eat a healthy diet, live an active lifestyle, manage stress, and get enough sleep, losing weight is unlikely to make you healthier. And, if you’re normal weight and eat junk and live the couch potato lifestyle, you may not be as healthy as society views you.

The Rise of Fatphobia, Weightism and Sizeism

The astute reader will have noticed that, in the study I discussed above, physically-fit overweight and obese people still had a 50% to 60% increased risk of dying from cardiovascular disease, and a 10% increased risk of dying from any cause, compared to equally fit normal-weight people, yet I have summarized the results focusing on physical fitness as the important contributor to mortality risk and not weight itself. The discrepancy here can be explained by the health detriment of weight discrimination and weight stigma—we’ll discuss how these impact health in the next section, but first, let’s talk about the history of and the ways in which weight stigma manifests.

If you’ve never been overweight, and especially if you do not identify as belonging to an underrepresented marginalized group, you may not understand the chronic social stress that comes from being judged constantly, even subconsciously via implicit biases. In my health journey, I lost over 100 pounds twice, once in my early-20s and once in my early-30s (I regained the weight back and more in between). Both times, it was remarkable to me to reach a threshold of weight lost where, all of a sudden, strangers would smile and make eye contact with me, hold doors open for me, or strike up a conversation while we were both waiting in line—I had lost enough weight to no longer be invisible. But, no matter how much weight I lost, no matter how fit I got, especially through the silent struggle to maintain that lost weight, the feeling of being less-than still haunted me, driven in part by the trauma of being bullied as a kid, but even more so by the persistent thousands of small ways society demonstrates value for thin people and lack of worth for everyone else.

Fatphobia can be traced to the early 1900s (when racist, xenophobic and religious influences combined to shift the previous association of fat with prosperity to instead associate it with the lowest social status and blamed on character flaws such as laziness, gluttony, or lack of self-discipline) and it has been ingrained in Western societies for a century. But, a 2019 examination of fatness as a social justice issue highlights a few key historical contributions, and the special interests behind them, to the current cultural assumptions that overweight equals unhealthy and that losing weight is simply a matter of trying hard enough. Of note, the collection of health professionals, government health officials and lobbying groups that began promoting the idea that obesity was a disease in the early 1980s (based on a collection of flawed, correlative studies) were financially supported by the pharmaceutical and weight-loss industries. The Shape Up America! Campaign and the “war on obesity” declared by the Surgeon General in 1995 were financially supported by Weight Watchers, SlimFast, and Jenny Craig. Also in 1995, the World Health Organization issued a report recommending that “overweight” be defined as having a BMI greater than 25 (because it’s a nice round number, not because studies showed this was a cusp for negative health effects), but a major contributor to writing that report was the International Obesity Taskforce, which was primarily funded by the pharmaceutical companies that made the diet drugs Xenical and Meridia (Hoffman-La Roche and Abbott Laboratories, respectively). It’s worth emphasizing that the presence of private funding and special interests doesn’t automatically undermine the credibility of a campaign or policy, but rather the confluence of undue influence from brands likely to benefit financially and lack of scientific foundation.

Throughout this time, well-designed studies continued to show a lack of causality between overweight/obesity and morbidity and mortality.

A 2005 study (which incidentally controlled for gender, age and smoking, which many other studies prior to that time did not do) found that individuals in the overweight category (BMI between 25 and 30) had lower mortality rates than people in the normal weight category (BMI between 18.5 and 25), while those who were underweight (BMI less than 18.5) had the highest mortality rate in the whole study. Further striating the data by age and smoking status was even more interesting. For example, in people over 70-years old, being underweight increased mortality risk by 1.69X whereas class II obesity (BMI greater than 35) only increased mortality risk by 1.17X—having a normal BMI or class 1 obesity (BMI between 30 and 35) were comparable in terms of mortality risk, and overweight had the lowest mortality risk. And in never-smokers aged 25 to 59, both overweight and class 1 obesity had lower mortality risk (36% and 23% lower, respectively) than normal weight individuals, but underweight and class 2 obesity had identical elevated mortality risk at 1.25X. This study is often quoted as the first evidence of the “obesity paradox”, but this study built on a body of research dating back at least to the mid-1990s. See also Using the Obesity Paradox to Inform Goals.

In 2013, the American Medical Association voted to label obesity as a disease, despite the fact that its own expert panel recommended against it. That same year, a meta-analysis of 97 studies, including more than 2.88 million individuals and more than 270,000 deaths (can we just get a collective “wow” for what a huge dataset that is?!), confirmed that class 1 obesity overall was not associated with higher mortality, and that overweight was associated with significantly lower all-cause mortality, compared to normal-weight individuals. Given that a BMI of 25 to 30 is associated with the lowest mortality, shouldn’t we redefine this as normal weight or healthy weight?! One interpretation of this data is that we have an epidemic of underweight, rather than epidemic of obesity (not to mention how this terminology pathologizes obesity despite the lack of scientific rationale for doing so, but I digress).

Studies now show that medical discrimination against overweight and obese people is a major problem. A 2017 analysis paints a disconcerting picture that aligns with my own experiences. When overweight and obese people go to the doctor, they’re likely to have their symptoms attributed to their weight, without diagnostics being performed, and instead be counseled (with more than a sprinkling of fat-shaming microaggressions) to lose weight. These common experiences lead overweight patients to delay seeking healthcare in order to avoid the stress of interacting with disrespectful and dismissive healthcare providers. The combination of assumptions by healthcare providers and hesitancy to seek medical care by overweight individuals leads to less preventative medicine than normal-weight individuals, as well as higher levels of undiagnosed or misdiagnosed health conditions. For example, a 2006 study of more than 300 autopsy reports found a 1.65X increased likelihood of obese patients, relative to normal-weight patients, having a significant undiagnosed medical condition (e.g., endocarditis, ischemic bowel, lung carcinoma), misdiagnosis, or inadequate healthcare that may have contributed to their death. It’s not that obesity increased the risk of these medical conditions, but rather that it increased the risk of dying from them due to inadequate healthcare.

The most common prescription for weight loss is dieting despite the fact that it has long been known that the majority (77%) of people who lose weight gain all the weight back (and often more) within five years.

Adapted from Am J Clin Nutr 2001;74(5):579–584.

This can be attributed to the concurrent rise in ghrelin (which increases hunger, see The Hormones of Hunger) and drop in basal metabolic rate that occur when we lose weight, especially quickly, which effectively means that the more weight someone loses, the more willpower they need to continue to maintain a caloric deficit. If losing weight makes us healthier, why does the body fight so hard against it? Even more problematic is yo-yo dieting because during weight loss, the body loses some muscle mass as well as body fat, but during the weight regain phase of yo-yo dieting, fat is regained more easily than muscle. The net effect is that yo-yo dieters have a greater risk for type 2 diabetes, cardiovascular disease, and non-alcoholic fatty liver disease than if they simply remained overweight or obese, in addition to having an increased risk of depression and eating disorders. See TPV Podcast Episode 353: Beach Body Yo-Yo

It’s also worth noting that scientific studies have not proven that intentionally losing weight prolongs life, and some studies even show the opposite! A 1995 study showed that women aged 40 to 64, who had never smoked and who had no pre-existing conditions, who intentionally lost over 20 pounds had an increased mortality rate during the follow-up period. And a 1999 study from the same research group showed that men without pre-existing conditions who intentionally lost over 20 pounds had a 48% increased risk of diabetes-associated mortality during the follow-up period, and men with pre-existing conditions who intentionally lost over 20 pounds had a 25% higher rate of cancer mortality. Both of these studies show that intentional weight loss can improve outcomes in some situations (for example, for type 2 diabetics), but worsen outcomes in others. A 1999 review summarizes “In view of the potential risks associated with weight loss and weight cycling, it is suggested that public health may be better served by placing greater emphasis on lifestyle changes and less attention to weight loss per se.”

Plus, weight discrimination isn’t just in the exam room. Overweight and obese people experience discrimination in education and employment, in addition to healthcare, along with frequent microaggressions and subliminal messaging in their daily lives. And, it’s considered socially acceptable in our culture to body-shame people for their weight, and to give unsolicited advice on weight loss. It’s probably no surprise that, over the same time period as the “war on obesity”, the prevalence of weight discrimination in the USA increased from 7% (in 1995-1996) to 12% (in 2004-2006). You may think that weight discrimination is always expressed as negatives (for example, a kid once shouted at me when I was out for a run “hey fatso, you’ll have to run faster than that to burn all that blubber off!”—incidentally, I was a normal BMI at the time), but even well-intentioned statements can propel weight stigma. For example, complementing someone on how great they look after losing some weight actually communicates that they had less value when they were heavier and more value now that they’re lighter. If that person struggles to continue to lose weight or maintain the weight they lost, they internalize that feeling of low self-worth.

In the next section, I’m going to dive into the science explaining how incredibly harmful weight discrimination and stigma are, but I hope that my readers are already willing to honestly reflect on their own behavior in this regard, and commit to no longer judging people based on their weight (I recommend taking Harvard University’s Implicit Association Test on weight). And, I can personally commit that, as I build my new website (subscribe to my newsletter to learn more), I will be updating all of my healthy weight loss content, including how I present my own health journey, to fully reflect this research because I acknowledge the contribution that weight loss success stories can have to propelling weight stigma.

Weight Stigma Is SUPER Harmful to Health

While obesity is often blamed for metabolic syndrome (that combination of risk factors including insulin resistance, inflammation, hypertension, elevated serum lipids, etc.), a variety of studies show that it is weight discrimination and weight stigma (a.k.a. fatphobia, weightism, healthism, body-shaming and fat-shaming) behind the increased risk of type 2 diabetes and cardiovascular disease, while lowering life expectancy. And, the magnitude of effect is high.

An important 2011 study of over 900 non-diabetic adults examined how weight discrimination affected blood sugar regulation, relative to BMI, waist-to-hip ratio, and waist circumference. Weight discrimination was assessed by asking the participants how often on a day-to-day basis (from never to often) they experienced:

1. being treated with less courtesy than other people
2. being treated with less respect than other people
3. receiving poorer service than other people at restaurants or stores
4. people acting as if they think you are not smart
5. people acting as if they are afraid of you
6. people acting as if they think you are dishonest
7. people acting as if they think you are not as good as they are
8. being called names or insulted
9. feeling threatened or harassed

Similar questionnaires were used to assess perceived discrimination in the studies I’ll discuss below, too. Blood sugar regulation was assessed by hemoglobin A1C (HbA1C), which is a good indicator of average blood glucose levels over the previous 2 to 3 months. (High HbA1C [above 6.5%] is indicative of type 2 diabetes, and a recent study showed that, for every 1% increase in HbA1C above 7%, diabetic patients experienced a 21% increased risk for any cardiovascular disease event and a 37% increased risk of dying from cardiovascular disease.) While higher BMI, waist-to-hip ratio, and waist circumference were linked to elevated HbA1C, the study showed that weight discrimination exaggerated the increase, independent of other health behaviors like smoking, exercise, and fast food consumption as well as other covariates like age, race and gender. And, did you catch that important data point? Weight discrimination increased average blood glucose levels (indicative of insulin resistance) independent of exercise.

People with high waist-to-hip ratios and who also experienced weight discrimination had the highest HbA1C levels in the study. This is particularly interesting when you consider that high levels of chronic stress are strongly associated with increased waist-to-hip ratios (due to cortisol’s impact on abdominal fat deposition, see for example this study), and that stress reduces insulin sensitivity, see 3 Ways to Regulate Insulin that Have Nothing to Do with Food.

A 2014 study of over 7,000 participants showed that weight discrimination is also inflammatory. Similar to the previous study, participants were given a questionnaire to gauge their experiences with weight discrimination and systemic inflammation was assessed by serum C-reactive protein (CRP). While CRP did increase proportionally with BMI, participants who experienced weight discrimination had exaggerated CRP levels relative to BMI, with the exception of those with class III obesity (BMI > 40) where CRP was similarly elevated whether they experienced weight discrimination or not.

Another 2014 study in 45 healthy overweight to obese women showed that experiencing weight discrimination elevated oxidative stress, as measured by F2-isoprostanes, even after controlling for covariates including income, education, and global perceived stress. One thing that was really interesting about this study is that they assessed both exposure to and consciousness of weight stigma using a questionnaire that asked participants about 50 specific weight-stigmatizing situations. Weight stigma is harmful to our health, even when we’re not aware of it.

Given the results of the above-summarized studies, it’ll come as no surprise that weight stigma increases cardiovascular disease risk. A 2017 study of nearly 27,000 adults evaluated the link between cardiovascular disease and perceived weight, gender, and racial discrimination in the USA. Participants who experienced weight discrimination had a 2.56X higher likelihood of myocardial infarction and a 1.48X higher likelihood of minor heart conditions, after accounting for BMI, smoking, alcohol consumption, major depressive disorder, stressful life events, age, sex, income, education, and race/ethnicity. (Racial discrimination but not gender discrimination also increased risk of myocardial infarction and minor heart conditions, in addition to additionally increasing risk of arteriosclerosis). As you might expect, individuals who experienced multiple forms of discrimination had the highest risks of cardiovascular disease in this study.

A 2015 analysis of two different datasets (the Participants in the Health and Retirement Study, which included over 13,000 participants, and the Midlife in the United States Study, which included over 5,000 participants) revealed that weight discrimination was associated with a nearly 60% increased mortality risk, even after accounting for age, sex, race/ethnicity, education, BMI, subjective health, disease burden, smoking history, depressive symptoms, and physical activity. This study also found that, in general, mortality risk increased more in association with weight discrimination than for other forms of discrimination. The authors conclude “In addition to poor health outcomes, weight discrimination may shorten life expectancy.”

Why Is Weight Stigma So Harmful? Stress!

The most logical question to ask here is: Why? What explains the harmful effects of weight stigma, and with everything that we know about immune-modulating adipokines like leptin and adiponectin, how can science explain weight stigma, rather than adiposity itself, as the driver of increased disease and mortality risks?

Quite simply, stress.

As a 2014 review article puts it: “The fact that humans must eat to survive makes weight stigma unique, as eating itself may be a context for stigmatization, providing multiple, repeated, daily opportunities for experiencing weight stigma. There is no in-group favoritism among overweight individuals as they themselves tend to internalize weight bias, show implicit attitudes that prefer thin individuals to fat individuals, and typically do not glean positive esteem from their weight-based group identities. Moreover, the greatest weight stigmatization comes from family members and close friends – people who would typically be unconditional sources of social support and safety.” In plain English, we experience weight stigma every time we eat, we internalize that bias and believe it ourselves, and there’s no safe space.

The physiological stress response related to the psychosocial stressor of weight stigma has been measured in a variety of ways.

One very clever 2012 study of 99 young women who perceived themselves as overweight clearly demonstrated the stress response related to weight stigma. The study participants were asked to give a recorded speech, some were told that they would be viewed by an audience on a video recording while others were told that the speech was audio only. Throughout the speech, blood pressure was continuously monitored—mean arterial pressure is well-known to elevate in response to stress. Not only was mean arterial pressure higher among women who believed they were being video-taped compared to those giving what they believed to be an audio-taped speech, but the effect increased with BMI. Basically, the higher the BMI, the more self-conscious the women were about being judged, and the higher their stress response.

A 2016 study of 28 healthy young women (half normal-weight and half obese) evaluated heart rate variability (HRV; which is sensitive to changes in autonomic nervous system activity due to stress—stress lowers HRV) in response to monetary and social incentive delay tasks (which measure social information processing via first anticipated and then received positive, negative, and neutral outcomes in the form of money or facial expressions), relative to experienced weight discrimination assessed with a series of questionnaires. Women with obesity had lower HRV when experiencing negative social outcomes compared with normal-weight women, and this was exaggerated in women who had experienced weight-related teasing.

And a 2014 study showed that the experience of weight stigma, as assessed by questionnaires, significantly increased morning salivary cortisol, the cortisol awakening response (salivary cortisol 30 minutes after waking minus salivary cortisol at waking), and serum cortisol measured from fasting morning blood samples. This has also been shown in studies that experimentally manipulate weight stigma. For example, in another 2014 study, participants were shown a 10-minute video containing weight-based stigmatizing scenarios or a neutral video—those shown the weight-based stigmatizing scenario video exhibited sustained cortisol reactivity, independent of their bodyweight.

A 2017 study of almost 1000 participants showed that individuals who experienced weight discrimination had more than double the risk of having a high allostatic load, which is the cumulative maladaptation of multiple physiological systems (i.e., cardiovascular, sympathetic/parasympathetic nervous, HPA axis, immune, and metabolic) in response to chronic stressors. This was after accounting for covariates, including: age, race/ethnicity, household income, education, smoking status, and physical activity. And, those who experienced long-term discrimination (at least a decade) had a 3.36X increased risk of high allostatic load.

It’s worth noting here that chronic stress increases the risk of depression and anxiety, cardiovascular disease, obesity, diabetes, autoimmune diseases, chronic headaches, memory problems, digestive problems, and infections and is linked with poor wound healing. These effects are believed to be mediated by the activation of the hypothalamic-pituitary-adrenal axis (HPA axis) and the impact that cortisol and other adrenal hormones have on immune function. (See How Stress Undermines Health, How Chronic Stress Leads to Hormone Imbalance, and 3 Ways to Regulate Insulin that Have Nothing to Do with Food).

Plus, Weight Stigma Drives the Obesity Epidemic

There is a common perception that fat-shaming (whether framed positively or negatively, and whether by a well-meaning friend or your doctor) encourages overweight individuals to lose weight, but it actually has the opposite effect.

As summarized in a 2018 review article, experiencing weight stigma triggers behavioral changes linked to poor metabolic health and weight gain, including overeating, smoking, excessive alcohol consumption, and exercise avoidance. For example, a 2017 study showed that, when overweight and obese people experienced weight stigma at their gyms, they developed negative attitudes toward the gym, maladaptive coping behaviors, weight bias internalization, unhealthy weight control practices, and lower self-reported physical and emotional health—and here’s the kicker, all that was regardless of how frequently they went to the gym.

The combination of chronic psychosocial stress along with maladaptive behavioral changes in response to weight stigma results in a substantially increased risk of becoming and remaining obese.

A 2017 study showed that weight-based teasing of adolescents (average age was 15) predicted higher BMI and obesity in adulthood at a 15-year follow-up (when the participants were 30 years old). On top of that, weight-based teasing during adolescence also increased risk of binge eating, chronic dieting, eating as a coping strategy, unhealthy weight control, and poor body image. Interestingly, this study striated by whether the teasing occurred from peers, from family members or from both, and found that, for women, teasing from family members increased risk of obesity more than teasing from peers (2.58X compared to 1.84X), but for men, teasing from peers but not family increased risk (2.44X).

Weight discrimination increases likelihood of obesity in adults, too. A 2013 study of over 6,000 participants aged 50 and over in the USA, showed that individuals who experienced weight discrimination had a 2.54X higher likelihood of becoming obese if they weren’t at baseline, and a 3.2X higher likelihood of remaining obese if they were at baseline, at a 4-year follow-up. This effect was independent of age, sex, race/ethnicity, education, baseline BMI, and other forms of discrimination. And a 2014 study of nearly 3,000 people over the age of 50 in the United Kingdom similarly showed that weight discrimination increased risk of weight gain and increased waist circumference, along with a whopping 6.67X increased risk of becoming obese at a 4 year follow-up (but no increased risk of remaining obese for those who were at baseline). The authors conclude “Our results indicate that rather than encouraging people to lose weight, weight discrimination promotes weight gain and the onset of obesity. Implementing effective interventions to combat weight stigma and discrimination at the population level could reduce the burden of obesity.”

The Evidence for Health at Any Size

If you are overweight or obese, it can be challenging to let go of years of social programming eroding self-worth and making you feel like you’re a failure (believe me, I’m still working on it). On the flip side, it can be challenging to let go of the privilege and esteem that comes with maintaining a svelte figure. But, that’s exactly what the scientific research supports. In fact, losing weight likely shouldn’t be the goal at all, nor should it be used as a metric of success. Yes, you can throw out your scale (or do what I did and put it in the garage with the luggage, just to use it to weigh suitcases for traveling post pandemic). It is far, far, far more important to instead focus on health-related behaviors, like eating a veggie-focused nutrient-dense diet, getting enough sleep, living an active lifestyle, and proactively managing stress (in addition to smoking cessation, moderating alcohol consumption, and addressing mental health challenges). A 2011 review article calls this way of thinking a “weight-inclusive approach (emphasis on viewing health and wellbeing as multifaceted while directing efforts toward improving health access and reducing weight stigma)… [which] rests on the assumption that everybody is capable of achieving health and wellbeing independent of weight, given access to nonstigmatizing health care.”

The 2008 study described in detail above shows that overweight and obese people absolutely can be metabolically healthy. The following studies show that obese people who aren’t metabolically healthy can measurably improve their health… without losing weight. Better yet, this weight-inclusive approach to health (also called weight neutral) shows lasting physical and mental health benefits when weight-loss centric approaches fall short.

A 2005 study in 78 obese women, aged 30 to 45 and who were chronic dieters, evaluated the efficacy of a program created by Dr. Lindo Bacon called “Health at Every Size” compared to a typical behavior-based weight-loss program for one year, with follow-up at two years. The principles of the Health at Every Size program are:

• “Accepting and respecting the diversity of body shapes and sizes.
• Recognizing that health and well-being are multidimensional and that they include physical, social, spiritual, occupational, emotional, and intellectual aspects.
• Promoting eating in a manner which balances individual nutritional needs, hunger, satiety, appetite, and pleasure.
• Promoting individually appropriate, enjoyable, life-enhancing physical activity, rather than exercise that is focused on a goal of weight loss.
• Promoting all aspects of health and well-being for people of all sizes.”

Even though the women in the typical behavior-based weight-loss program group lost an average of 5.2 kilograms (about 11.5 pounds), they didn’t see improvements in serum lipids or blood pressure. The Health at Every Size group, on the other hand, did not lose weight but had significant improvements in total serum cholesterol, LDL “bad” cholesterol and blood pressure (systolic and diastolic)! They also had reduced hunger and disinhibition (loss of control that follows violation of self-imposed rules), and an improved score in an eating disorder evaluation. Even better, 100% of the women in the Health at Every Size group had improved self-esteem, whereas the women in the traditional diet group had decreased self-esteem (53% of them expressed feelings of failure compared to 0% in the Health at Every Size group). These health improvements were maintained at two years for the Health at Every Size group, but the traditional diet group regained most of the lost weight by the two-year mark.

A 2009 study in 144 premenopausal overweight and obese women compared the Health at Every Size program to a social support group (small-group counseling facilitated by a registered dietitian and clinical psychologist) and a control group (instructed to follow their usual lifestyle habits) for a 4-month intervention period and a 16-month follow-up period. While the Health at Every Size group did lose an average of 2% of their bodyweight, the primary advantages were decreased susceptibility to situational eating, disinhibition, and hunger.

I think it’s worth emphasizing here that our diet and lifestyle choices are super important for our health—this research does not support the idea of giving up, doing or eating whatever we want, or not caring. Instead, the idea is to dissociate the desire to lose weight from the intention to improve health, and re-emphasizes the incredible health benefits we can experience with a nutrient-dense anti-inflammatory diet, active lifestyle, managed stress, and sufficient sleep. See The Importance of Nutrient Density, The Importance of Exercise, How Stress Undermines Health, and Sleep and Disease Risk: Scarier than Zombies!

If Not Weight, How Do We Measure Health?

So, if body weight isn’t a very good metric of health, how DO we measure health? It first helps to define being healthy more robustly than the typical medical definition of simply being free of disease.

I define physical health as:

• Being unburdened by symptoms of disease
• Having energy throughout the day (no “crash”)
• Enjoying daily movement and activity
• Sleeping well and awaking refreshed
• Having a sense of wellbeing (that’s both literal and a euphemism)
• Not needing “crutches” or willpower
• Having good mental health

And, I define mental health as:

• Generally feeling happy and enjoying life
• Having good mental clarity, problem solving, and memory
• Not having brain fog or cognitive challenges
• Having balanced and proportional emotional responses
• Communicating effectively
• Having the ability to cope in a productive (not destructive) way
• Enjoying play and engaging with others, laughing easily and genuinely
• Being comfortable with boredom
• Not needing “crutches” or willpower (yep, this goes on both lists)

When we combine these indices of physical and mental health together, they reflect the underlying biology. They are collectively the signs that we have no nutritional deficiencies and have well-regulated neurotransmitters and hormones, a healthy gut, healthy immune system, healthy cardiovascular system, etc. This is discussed more in TWV Podcast Episode 436: What Is Health, and How Do You Measure It?

While most of these metrics are subjective, it is possible to quantify some of them using biotrackers (for example, measuring HRV as a proxy for stress, or giving us a sleep score, or a miles equivalent for our activity level). For the rest, we can use semi-quantitative analysis approaches, like scoring a qualitative measure (like mood or energy level) on a scale from 1 to 10 or by measuring how frequently they occur (like how many headaches per month). And, we can track all the above metrics of health by keeping a simple journal, noting on daily basis:

• Energy levels
• Mood, malaise, emotional responses
• GI symptoms and stool quality/frequency
• Skin health (can also include things like fingernails, hair, etc.)
• Pain: headaches, body aches, joint, muscle
• Cognition (IQ boosting games that give a score are a fun way to track this)
• Sleep quality (subjective, or measure with a tracker)
• Stress, baseline and response (or measure HRV)
• Activity (or measure with a tracker)
• Any symptoms of health conditions

If you’re troubleshooting, you may also want to note what you ate that day to help draw links and find patterns between symptoms, diet and lifestyle.

And, of course, a doctor’s exam is still beneficial! A doctor can add to our understanding of our health with a complete exam (which would include general appearance, heart exam, lung exam, head and neck exam, abdominal exam, neurological exam, dermatological exam, extremities exam, and male and female exams), measurements of vital signs (like blood pressure and body temperature), and various tests like fasting blood sugar and insulin, hormone profiles (stress hormones, sex hormones, etc.), a lipid panel, other blood work (like CRP and other inflammatory markers) and other tests (like gut microbiome analysis).

And, while the negative emotions I felt in response the aforementioned fat-shaming newsletter replies reveal to me that I still have some emotional work to do to reach body acceptance, I am committed to tuning out the body shaming that originates with an overly simplistic view of health, one based on bad assumptions that are contrary to the scientific evidence. I know that enjoying a spontaneous 3-minute dance party to goofy music with my kids and feeling good as I power up a hill on my morning walk with my dog are far more indicative of my health than whatever the number is on the scale or on the label of my jeans.

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The post Can You Really Be Healthy at Any Size? appeared first on The Paleo Mom.

As we all collectively say good riddance to 2021, we’re also preparing to be inundated even more than usual with body-shaming, emotionally manipulative marketing for weight-loss programs, detoxes, and supplements to help us loose the “quarantine fifteen”. Before you invest in weight loss-centered New Year’s resolutions, I want to point you to my in-depth article Can You Really Be Healthy at Any Size? that discuss the value (or rather complete lack thereof) of this type of goal. Okay, now that we’re on the same page about weight loss versus health, let’s talk about the real challenge holding us back from achieving our goals: habit!

Why Focus on Habits for New Year’s Resolutions?

About 40% of the day-to-day actions we take aren’t goal-directed behaviors (i.e., conscious decisions), but rather are behaviors driven by stimulus-response associations that are performed automatically requiring no conscious thought, i.e., habits. And, when a goal conflicts with a habit—for example, a weight loss goal conflicting with a habit of eating junk food in front of the TV in the evening—that’s where achieving the goal requires that dreaded word… willpower. It takes a huge amount of effort to not do something that we normally do completely unconsciously in response to a stimulus as simple as our environment. And, as soon as we aren’t paying attention, we revert to our habitual behavior, undermining our progress towards our goal without even thinking about it! This is why a close look at the habits that are interfering with our goals is such a critical aspect of New Year’s resolution success (and success at adopting healthy changes to diet or lifestyle any time of the year).

In fact, studies have shown that people who are score highly in measures of self-control don’t actually achieve their goals because of exerting that self-control. Rather, these people are highly effective at forming good habits that contribute to successful outcomes!

When I make New Year’s resolutions, they are always habit centered. For example, if my ultimate goal is to lose weight, I make resolutions that focus on habits that contribute to weight loss and better health in general. The resolution isn’t to lose 15 pounds, but instead I resolve to: quit snacking; eat a high-protein breakfast every day (like soup); go to bed an hour earlier; and lift weights and work at my treadmill desk more often. These resolutions (which should all contribute to achieving and maintaining a healthy body composition, see Healthy Weight Loss) mean the health benefits don’t cease when I hit my goal, and because there’s no timeline involved, I’m less likely to lose my momentum if I don’t reach that goal quickly.

So, to help inure all of us to predatory marketing this new year, let’s dive into the science behind habit formation and center our resolution priorities on healthy habits that can last a lifetime.

The Science of Habit Formation

Scientifically, habits are defined as a routine behavior that is performed automatically and unconsciously in response to a stimulus, and that is insensitive to devaluation of reward and contingency degradation. What does that mean? Habitual behaviors are performed the same way every time we encounter its stimulus, even if the perceived benefit we derive from the behavior decreases over time, and even if we can no longer distinguish a cause and effect of our behavior. If you’re a wee bit weirded out by the idea of 40% of your daily actions being performed without conscious thought or intention and without even a bona fide link to an expected outcome or benefit, it’s helpful to know that there are huge advantages to habits.

Habits are a form of learning and start out as a goal-directed behavior, reinforced by reward, and performed routinely in the same context every time. At the beginning of this learning, multiple parts of the brain are being used to perform the behavior, most notably the striatum in the basal ganglia and the prefrontal cortex. (The basal ganglia is the region of the brain associated with emotion, memories, pattern recognition, procedural learning and control of voluntary motor movements. The prefrontal cortex is the region of the brain associated with executive function and cognitive control , including attentional control, cognitive inhibition, inhibitory control, working memory, cognitive flexibility, information processing, planning, reasoning, problem-solving, organization, and decision making.) As the behavior is repeated and mastered, the prefrontal cortex is used less and less to perform the behavior while the basal ganglia takes over. Eventually, the prefrontal cortex isn’t used at all to perform the habitual behavior, freeing up valuable executive function for other tasks.

This is why you can hold a conversation while you drive or cook dinner. The actions you’re performing have become a habit so your prefrontal cortex can do other things at the same time. This is also why the behavior becomes dissociated from the reward or even expected outcomes—the part of the brain that processes action and effect, and much of the sophisticated reward circuitry in the brain, is no longer involved! The context the routine started in becomes the habit stimulus, and the behavior can now be performed automatically in response to the stimulus, without the need for conscious thought! It’s actually quite an amazing learning system! The habit learning system increases efficiency, saving valuable mental energy, but comes at the expense of flexibility.

Aside: There’s an interesting role for the endocannabinoid system in habit formation, with CB1 receptors mediating the switch from goal-directed behavior to habit, see CBD: Panacea, Snake Oil, or Somewhere in between?, Podcast Episode 393: CBD, and Podcast Episode 420: CBD for Pain Management. There are some interesting studies showing that CBD can reduce some habitual behaviors, like binge eating or drinking, but reinforce habit learning in animal models. The jury is still out on whether CBD could help with habit-centered resolutions!

When it comes to habit-centered resolutions, this may mean both forming new good habits as well as breaking old bad habits. Let’s go into detail in terms of how habit learning versus unlearning are different in practice.

How to Form a Good Habit

If you’re forming a good habit, you are learning to do something in response to a stimulus, i.e., there’s an action that you are working on repeating routinely in a stable context until it’s automatic. This new beneficial action may replace a detrimental action you used to perform in response to the same stimulus (e.g., drinking water instead of soda with lunch—lunchtime is the stimulus, drinking soda is the old bad habit and drinking water is the new good habit), but it’s still considered habit formation with the new habit dislodging the old habit from the basal ganglia.

How do you form a habit? The following protocol comes from a scientific paper offering guidance to physicians to help improve their patient’s health by focusing on habit formation.

1. Decide on a goal that you would like to achieve for your health.
2. Choose a simple action that will get you towards your goal which you can do on a daily basis.
3. Plan when and where you will do your chosen action. Be consistent: choose a time and place that you encounter every day of the week.
4. Every time you encounter that time and place, do the action.
5. It will get easier with time, and eventually you should find you are doing it automatically without even having to think about it.
6. Congratulations, you’ve made a healthy habit!

How long is eventually in this context? Unfortunately, it’s a myth that it takes 21 days to make or break a habit. For the vast majority of us, it takes dedication and commitment to repetitively perform a task for a much greater length of time before that task becomes automatic.

In fact, research shows that the average length of time it takes to form a new habit is 66 days, but that the time required for form a habit varies from 18 days to 254 days (about 8 months)!!!! This likely varies from person to person, but also by type of habit and the individual challenges each of us face to making a specific change. Chances are good that if it’s a habit you’ve unsuccessfully tried to create before, it’s going to take a longer amount of time to get it right this time.

Fortunately, there are some things that you can do to support habit formation and potentially speed up the time investment.

First, start off with a positive attitude.

A study evaluating the psychological determinants of habit formation (using daily flossing as the habit being formed) revealed that starting out with a positive attitude about the new behavior being performed predicted a higher level of automaticity after four weeks and habit maintenance at 8 months. (Other determinants that positively impacted habit formation were stronger prospective memory ability and higher levels of past behavior.) In this study, participants were motivated with persuasive information about the benefits of flossing and instructed to floss daily. A questionnaire measured attitude by asking strongly agree to strongly disagree with statements related to the information.  Basically, the more the person understood the benefits of flossing, the more likely they were to form a strong flossing habit! Ah, knowledge is power!

You can apply the insights from this study by taking some time to learn why a certain habit will help you reach your goal. This is why I’ve worked so hard to create top-quality detailed educational resources like my collection of online courses. My students report high levels of success in adopting and sticking with diet and lifestyle changes to support their health journeys. My Foundations of Health online course is a great place to start if you have health-focused goals for 2021 like wanting to eat better or lose weight in a healthy way, and my AIP Lecture Series intensive online course is perfect if you need to dig deeper into the links between diet and lifestyle and chronic illness!

Second, think about how you can up the reward.

Once a habit is formed, the behavior becomes dissociated from reward; but in the learning phase, boy oh boy, does reward make an impact! A simple neurological loop, called the habit loop, is at the core of every habit. The habit loop consists of a stimulus or cue, an action performed in response to the stimulus, and a reward that reinforces the loop. Studies show that increasing the perceived reward strengthens habits beyond the impact of repetition, meaning that it takes fewer repetitions for a rewarded behavior to become a habit compared to an unrewarded behavior.

There are different types of rewards. An obvious one is pleasure, defined as positive and immediate sensory outcome, why delicious foods or intoxicating substances can be habit-forming. Another form of reward is intrinsic motivation, wanting to perform an action because of anticipated inherent enjoyment of doing so. Intrinsic motivation is a more powerful reward than extrinsic motivation (being motivated to do an action to please others). Another form of reward is positive outcome expectancy, understanding a good effect will result from the action—another way that learning can help support good habit formation.

You can apply the insights from these studies by thinking of ways to up the reward ante when you perform your repetitive task. This doesn’t mean eating a chocolate bar right after working out as a reward, but rather thinking about the inherent reward from a task and finding a mindset where the task itself is associated with a positive experience or anticipated outcome. This is where gamification can be super handy! For example, if your goal is to make walking 10,000 steps a day your habit, a fitness tracker that rewards you with a push notification congratulating you when you reach your daily step count can be very helpful! Also, it’s okay if the reward is delayed (some studies show it might even be better to be delayed!) as long as it’s clearly associated with the behavior.

It’s also helpful to avoid negative outcome expectancy. Studies have shown that associating a negative experience with a task devalues the reward. Remember, this isn’t an issue after a habit is formed, but it can stop habit formation right in its tracks! So for example, if you’re looking to create a new habit of working out in the mornings, it’s helpful to reign in the intensity to a level where exercising is enjoyable. Going so hard at the gym that you throw up isn’t going to help you form an exercise habit (or muscles for that matter).

How to Break a Bad Habit

In contrast to habit formation, breaking a bad habit means that you cease doing something, and it’s not replaced with a new action (e.g., quitting snacking means that eating between meals isn’t replaced with any particular behavior). It is definitely tougher to break a bad habit compared to forming a new habit (as Yoda says “you must unlearn what you have learned”, easier said than done!). So, as you ponder your goals for 2021, first think creatively in terms of habit formation. Is there any way you can translate your goal to forming a good habit or replacing a bad habit with a good habit?

If you really need to break a bad habit and there isn’t a good habit to replace it with, let’s start with the one thing not to do: exerting willpower!

Studies that have looked at behavior repression (using willpower or self-control to not do something) show that it causes a rebound effect. For example, one study found that people who suppressed their thoughts about eating chocolate ended up consuming significantly more chocolate than those who didn’t. A similar study found that smokers who tried to not to think about smoking ended up thinking about it and craving it even more.

So then, how do we break a bad habit? There are two science-backed options.

One option is to create some kind of interference with the behavior that forces the prefrontal cortex to kick in so you think about what you’re doing. For example, a study showed that if people are forced to eat popcorn with their non-dominant hand at the movies, they’re able to break the habit of snacking at the theatre. (This same study found that habitual popcorn eaters even ate stale popcorn [ew!] without thinking about it, more supporting evidence that reducing reward doesn’t break a bad habit.) Other studies have shown that if you can delay the behavior long enough for conscious thought to kick in, the brain to switch to a goal-directed behavior (or a goal-directed inaction).

The best way to break a bad habit is to remove the stimulus. Studies have shown that removal of the cue or trigger for a habitual behavior is one of the most effective ways to break a bad habit. This is why so many people find it easier to quit smoking while on vacation and why wellness retreats can be such a great jump-start for a health journey. Similar studies have shown that changing the environment is important for treating substance abuse. You can apply the insights from this research by thinking through the habit you want to break and identifying the stimulus or stimuli. If it’s not possible to remove the stimulus entirely, think about how you can change or disrupt the stimulus enough that your prefrontal cortex has to kick in and you can switch to goal-directed behavior instead. This can be as simple as moving the snacks to a new cupboard.

Also be aware of unintentional removal of a good habit stimulus. For example, a study showed that a break from school or work for the holidays can disrupt the healthy habit of going to the gym. This is why it’s so easy to derail from our healthy lifestyle over the holidays (and so much work to get back on track in January!).

One last strategy that is worth mentioning: mindfulness. In one study, mindfulness practice reduced craving-related eating by over 40%. In another study, mindfulness practice increased success of quitting smoking by a whopping 5 times over the American Lung Association’s Freedom From Smoking (FFS) treatment! Learn more about mindfulness in How Stress Undermines Health.

Let the Good Habits Take Over

When we are distracted, stress, anxious, or tired, we fall back on habits, whether good or bad. This is both why bad habits can undermine our ability to progress towards a goal and why good habits can keep us on track—without the need for willpower or self-control—even when life gets overwhelming. So, instead of fighting a powerful form of learning, think about the good habits you can form to ditch the on-again-off-again cycle for good.

To promote habit formation:

1. identify the new behavior you intend to turn into a habit and the specific context you wish to trigger your new habit
2. develop a positive attitude about your new behavior through education and/or identification of reward or positive outcomes
3. translate that intention into action with sustained repetition of your behavior when you encounter the stimulus within a routine

It’s always easier to replace a bad habit with a good habit, but in the absence of a suitable good habit replacement, identify and remove the bad habit triggers. Maybe this means rearranging your desk to stop a grazing habit at work, or driving a different route home to avoid the drive-thru.

And note that habits can be created iteratively. If your goal is to increase your vegetable intake to 8 servings per day, your first action may be to add a serving of veggies to your lunch every day. After that becomes habit, your new action may be to add a serving of veggies at breakfast. After that becomes habit, add a serving of veggies at dinner. Keep going, small step by small step, until you reach your desired vegetable intake. It can be much easier to make lasting positive change when large and complex goals are broken up into smaller and more easily attainable habits.

Focusing on habit formation also requires frequent reevaluations. Sometimes our efforts to form a habit can wane without us intending to do so. This is why I don’t limit myself to resolutions once a year, but make them any time a little extra resolve is needed.

Citations

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The post Habit Formation and New Years Resolutions appeared first on The Paleo Mom.

I wrote about my journey into Paleo and creating the AIP in My Personal Journey With the Autoimmune Protocol, but ultimately, The Paleo Mom was not just an outlet for my enthusiasm about the Paleo diet, but also an authentic connection to like-minded people in the outside world.

My 10 year anniversary is a unique opportunity to reflect on some of my achievements and big milestones over the last decade and to celebrate my personal growth, my family’s evolution, and the great reward that it has been to help so many people regain their health.

How I Got My Start With AIP

Following the launch of The Paleo Mom blog in November 2011, despite the rapid and stark improvements in my health, I still had some symptoms that were left unresolved. I found two websites at the time that combined overlapping-but-not-identical lists of foods (thank you Professor Cordain and Robb Wolf for the original inspiration) and that dubbed them “The Autoimmune Protocol”.  I decided I needed to try eliminating these additional foods, so as a New Year’s resolution for 2012, I eliminated all of the additional foods deemed problematic for autoimmune conditions.

The scientific explanations for these additional eliminations weren’t robust enough to satisfy me however, so I dove into the scientific literature on immune function and the intersection with prolamins, agglutinins, phytates, glycoalkaloids and lysozyme. Not only did this journey uncover some fascinating science that tickled my brain, but sharing this information really resonated with my audience at the time. So I began to piece together the scientific validation for these theories and sew together a guideline for implementation. Thus the Autoimmune Protocol was created.

And even though the AIP made a tremendous difference in my own health, the best part of my work on the Autoimmune Protocol is the amazing friendships, colleagues and community I’ve found through it.

A Podcast is Born

I don’t actually know how I ended up on a reviewer list for Eat Like a Dinosaur by Stacy Toth and Matthew McCarry of the RealEverything (then Paleo Parents) blog, but I did. It was probably thanks to my website name making my compatibility obvious, in addition to having achieved a critical mass of social media followers in my first 4-5 months of blogging. It’s a darn good thing that I loved the book because Stacy reached out to me on social media and we booked our first phone call. Our first conversation turned into many more, and when she asked if I would co-host a podcast with her…I was in!

Nine years later, Stacy and Matt have been my biggest and best supporters through the years, introduced me to other Paleo bloggers, and ultimately helped me to find confidence in my knowledge and the value of my unique voice.

My First Book Deal

As The Paleo Mom grew and grew, and my content list got longer and longer, it was getting harder to ignore those: “when are you going to write a book” questions. After much thought and discussion with my husband, I decided that I did not want to write a book. Once my kids were both in school, I intended to return to academia and research. The universe had other plans however and ten months after I launched my blog, I was approached by two different publishers a week and a half apart from each other. You thought I could cram an impressive amount of science into a blog post? Well give me a book deal and hold my red wine! The Paleo Approach was born out of the immense amount of scientific research that I had compiled to create the ‘protocol’ portion of the AIP: A detailed breakdown of the science of why, and how these certain foods can exacerbate our existing health conditions. The Paleo Approach was published, and it officially was released on January 28th, 2014.

First Book Signing Event

Once The Paleo Approach was finally published, my local Whole Foods store in Atlanta held my very first book signing event. It was super exciting to see 60-70 people lined up waiting to meet me and have me sign a copy of my book for them in front of the huge display that my local Whole Foods had created for me. I mean, I was just a stay-at-home mom who started a blog for my own interest, and now I’m literally giving out autographs?! This was a surreal moment for me and a huge celebration for myself and my family.

The ‘Second’ Book

For those of you who might be familiar with my style by now, to say that I am a “go big or go home” personality would be an understatement. Let’s just say that my original plan to write a complete guide to managing autoimmune disease and lifestyle was overly ambitious, and the laws of physics (and book binding) precluded me from including everything I wanted to in one single volume of The Paleo Approach. Thus, my second book ended up as a companion cookbook to The Paleo Approach, and included over 150 recipes that are AIP-compliant, (and that was nearly double the amount of recipes typically published in any cookbooks at that time)…did I mention I am a bit of an overachiever?

True to form, even cutting the master book into two published prints was a challenge, and each book contained as many pages that could be physically bound into a book by my publisher at that time. The Paleo Approach Cookbook was released in stores and online retailers on August 26, 2014 and was a very long labor of love. I started working on both books in October, 2012 and yes, therefore the creation of the books occupied nearly two years of my life.

My First Employee – I Guess I Run a Business Now?

Through the process of being an engaged mom to two young girls, working on my blog (almost exclusively while they were at school or asleep!)- at that time I was publishing 5 blog posts a week – and writing two university-textbook-length best-selling books on the Autoimmune Protocol simultaneously, I realized this was simply too much for one person to keep up with. In the Summer of 2013 I hired my very first employee.

Since then, my team has gradually expanded (with a few past team members graduating on to follow other passions) and evolved into a diverse and talented team of passionate women, who ensure I am at my best so that I can help as many people as possible. I am where I am thanks to the dedication and hard work of all past and present employees, each of whom has been instrumental in keeping my website running, creating my e-books, marketing my courses, and developing content for social media and other projects. Through these 10 years, I have learned how to transition from a solo entrepreneur, into an authentic, vulnerable, yet fearless leader who surrounds herself with people who want to change the world.

My Official Hashimoto’s Diagnosis

After publishing The Paleo Approach in early 2014, I realized I had become completely run into the ground, (talk about not practicing what you preach!) irony at its finest. My adrenals were shot, my autoimmune symptoms were super high, and I had officially hit a wall. I remember attending a school family dance with my oldest daughter in early spring 2014, when I ran into the mom of one of Adele’s classmates. She was a nurse at a local functional medicine clinic and told me about the new doctor there and how they had been giving out my book to their patients. Fast forward to: I made an appointment and he decided to run a full thyroid panel (among many other insightful tests), which quickly diagnosed me with Hashimoto’s Thyroiditis, a new addition to my growing autoimmune disease list (I mean, I know I said I am an overachiever in everything – but achieving autoimmune disease BINGO was not necessarily what I meant!). See Grief Upon Diagnosis: Uncovering Hashimoto’s Thyroiditis

This doctor changed my life and he is still my trusted health partner to this day. I am so thankful for all that I have learned in my own research and experimental journey, but I would not be where I am without the support of amazing medical practitioners along the way who believe me, listen to me, and stand by my side as we troubleshoot one thing at a time!

My First Big Book Tour

In the fall of 2014, I joined Stacy Toth for the middle leg of her 3-week book tour with her husband, Matt McCarry (during which Matt went home to look after their three boys) to celebrate the release of their third book, Real Life Paleo. I met up Stacy, Matt and our friend, Russ Crandall, for a cooking demo and book signing in New York city. At this point, I had done a few book signings, seminars, and cooking both on camera and in front of live audiences, but never had I had to improvise so much! We were missing ingredients and equipment, and somehow, it made it a hilarious bonding experience for each other and extra fun for the fans who came out to meet us. We wrapped up the evening with a delicious dinner at Hu Kitchen and by enjoying the freezing cold view from the top of the Empire State building. From there, Stacy and I did events (that all went much smoother!) in Chicago, Atlanta, Phoenix, San Diego, Portland and Seattle. We were supposed to also go to Minneapolis, but a giant snow storm forced a change of plans! But, we did make it just a month and a half later (and tacked on signings in Nashville and Toronto, too)!

It was my first experience with the city-a-day type book tour (which I also did for The Healing Kitchen and Paleo Principles), exhausting and exhilarating, a wonderful opportunity to meet hundreds of lovely people, connect with old friends, and make new ones.

Website Revamps and The Technology Journey

Through my 10 years in the blogging and website development space, The Paleo Mom website has gone through several iterations of technology evolution. I began my online journey hard-coding and manually editing the html of the menus every time I posted on the ‘Blogger’ platform. Within the first year of blogging however, I decided to migrate to WordPress which was a big learning curve, and eventually hired a company to do a revamp in 2014. The custom theme was pretty, but the functionality was still average.

In 2016, I met my trusted developer and friend David at Bizbudding.com who did a complete professional blog redesign and he has been my amazing collaborator and developer ever since! The final product that you continue to enjoy today has only been enhanced by my outstanding graphic designer who continues to amaze me with her visionary process and creativity.  See My Personal Journey as a Blogger

Awards and Content Acknowledgement

In 2014, I began to receive various awards for my blogging content. Okay, I guess this isn’t just a hobby after all! I was truly finding my passion and purpose through this journey, and the message was resonating with so many people.

Also in 2014, The Paleo Approach became a New York Times Bestseller, and all of my other books received national best seller recognition as well. At the risk of sounding like I’m giving an awards acceptance speech, I would not be where I am without all of you! The empathy and understanding that this community has for each other through chronic illness is unmatched. Teaching people how to empower yourself with knowledge and science, and discover your own strength through even the most challenging health journeys, was an underserved portion of the population, and we are all better for learning, adjusting and bravely stepping into the world of healing diet protocols, together.

Speaking Events and Appearances

When I joined the Paleo world, I brought it into my entire home for my family to also benefit from, and I became well versed in the principles and lifestyle fairly quickly. With my newfound expertise in the Paleo field, I hosted my very first live event in 2012 at a local martial arts studio on the basics of Paleo.

As The Paleo Mom popularity grew, and as my books continued to be best sellers, I had to transition from a purely online presence to live events, adding travel and speaking gigs to the mix. The first big speaking engagement that I had was at the Ancestral Health Symposium in 2013 in Georgia. Part of the allure was that it was my local area and I did not have to travel. The event went over extremely well and not only did I find my feet as a speaker, but my authenticity and vulnerability (not to mention I’m a complete ham as soon as I have a live audience to perform for) really seemed to resonate with the audience. I quickly started attending nutritional, functional medicine, and Paleo community conferences, both for professional and public audiences, and often asked to keynote, which I happily accepted in most all cases.

In February of 2019 I hosted a live workshop to 100 people who traveled from all over the world to meet me in California to learn, explore, connect and relax over a long weekend. I taught nearly 15 hours of seminar over the weekend, covering a wide range of topics from therapeutic diet and lifestyle, to gut health, to sustainable weight loss. The weekend was such a success that I immediately hired a videographer when I got back home and made it a virtual workshop experience available for everyone!

But, I have discovered that traveling is probably the hardest thing for me to do physically, and I often become ill afterwards. I was finding that, between the time to prepare a presentation, attend the event, then recover afterwards, it was getting harder and harder to complete my other projects. So, prior to the pandemic, I had found myself starting to turn down many speaking opportunities in order to limit to 4 or 5 speaking gigs a year, something I intend to continue once in-person events fully resume.

My Chance at Fame! (Please, Hold Your Applause)

With the increasing popularity of the Paleo movement, and a little sprinkle of serendipitous introductions, I was given the opportunity to pitch a network television cooking show centered on the Paleo lifestyle. After two years of working with the network, I filmed an entire pilot episode of Paleo Bites. The goal of the show was to go beyond just recipes and share the science behind this powerful way to take control of your personal well-being. We focused on the science behind foods, sourcing good quality ingredients, and cooked up a delicious Paleo meal on air. And, because the Paleo approach doesn’t just end with our diet, each week, we would learn some important tips for staying active, managing stress, and other important aspects of a healthy lifestyle.

Because of the wonderful magic of the internet, the entire episode is actually available online and can be watched here. Unfortunately the show was not picked up, and I had to continue my journey to fame through good old fashioned hard work and lots of blog writing! 😉

AIP Certified Coach

In 2017, Mickey Trescott and Angie Alt of AutoimmuneWellness.com and I teamed up to create a practitioner training program for the Autoimmune Protocol. Mickey and Angie were some of the very first people I bonded with online when I started with the AIP almost ten years ago (read more here), and their contributions to our community are truly invaluable.  Our early conversations about our experiences with the AIP helped inform many of the topics I focused my research on. Mickey and Angie have spearheaded the scientific study collaborations, raised funds for AIP research, and created some of the best AIP books and digital resources out there. And, as health coaches with autoimmune diseases themselves, they’ve helped so many people regain their health with the AIP, the perfect experience to complement my own in creating a robust program to train health and wellness providers in all the inner workings of the AIP. If you’re interested in becoming an AIP Certified Coach yourself, you can learn more here. And, if you’re looking for an AIP Certified Coach to work with 1-on-1, you can find the directory of our program graduates here.

The AIP Lecture Series

Throughout the marketing for the AIP Certified Coach practitioner training program, it became apparent that there was demand for a course to teach non-health-professionals the nuance and science behind the AIP and support them through their own healing journeys.

So shortly after the AIP Coach program launched, I went right back to my desk to begin developing the AIP Lecture Series. The first class launched in January 2018 and I am about to start my 10th session of the course. This is the only forum where people are able to get personalized guidance and support for their AIP journey from me directly, and learn all the important science behind the eliminations and lifestyle factors. If you are struggling with your own AIP journey, have hit a plateau and would love to interact directly with me to troubleshoot your AIP issues, consider joining the next course in January 2022. I would LOVE to have you!!

Podcast Picked Up by a Network

Though our podcast has gone through several evolutions, (if you dare, you can dive deep into the archives to hear all of our different intros and how our style has improved over time) very recently, we have achieved a significant milestone: We were picked up by a network!

The slow evolution of our podcast has happened over our 9+ years, but the true essence of uncovering what the science says, and sharing fact-based evidence for all of our episodes has garnered us a large and loyal audience. In episode 400, we officially changed our name from The Paleo View, to The Whole View to better represent our all-encompassing viewpoints of a holistic and healthy diet and lifestyle.

Taking Ownership of the AIP

For many years, I was very hesitant to own up to my role in creating the AIP. Even now, I truly see the popularity and success of the AIP as a group effort and a community-driven phenomenon. However, I have reflected on my role and am truly so proud of myself for seeing the gaps, and striving to fill them.

I took something that existed only in a very rudimentary form (two different food lists in two different book asides), and through my research and writing, I expanded it, refined it, fine-tuned it, gave it scientific credibility, and popularized it. At the same time, like a master baker creating a gorgeous wedding cake using a collection of ingredients that likely came from different sources, I had a starting place, inspiration and mentors, colleagues and like minded individuals, all in addition to my research skills and my own passion—all of this, and my own ingredients created something so beautiful.

This is why I resonate with the term creator, rather than founder or inventor or originator or architect or engineer or developer, because it can encompass both my invaluable work to make the AIP what it is today but also acknowledges the contributions of so many others. See My Personal Journey with the Autoimmune Protocol

My Personal Life

Some other noteworthy things throughout the last decade of working on The Paleo Mom include moments that you will not find in any of my archives. My beautiful girls have grown from sassy little toddlers into equally precocious, wonderful and determined young women (I have a teenager who is going to start learning how to drive in the new year, guys! Eek!). I have watched in awe as my husband, David, has grown from an assistant professor, to a valued administration team member in a tenured position at a prestigious university. And, my husband and I both became an American citizens in the summer of 2019 after living in the USA for fourteen years. The two cats I adopted in graduate school grew old and passed away in that time, and we brought two new cats into our home. And, our family grew by 4 feet (paws, to be exact) as we welcomed our newest fur baby, Soka, a Portuguese water dog, into the family in April 2020. I now get to start every morning, rain or shine, with a 4-mile hike in the woods with my super smart, super cuddly, mud-loving (but not bath-loving), high-energy pup.

I have not only grown in mental resilience and strength, but since 2013 I have been working with a trainer at a local CrossFit gym where I have achieved many personal fitness records and participated in several CrossFit opens. Two of my favorite highlights, my first toes-to-bar and the day I became a member of the 300 club in January of 2018 when I successfully deadlifted 310 pounds and celebrated with the appropriate amount of grunting and screaming!

I made sure to feed my other interests and talents along the way, and I became a professional improv performer for a few years, doing evening gigs at local theaters. I taught my family how to camp, shared my love of music (both my girls play piano), and still make time for gardening, home projects and crafts.

I have faced a lot of health ups and downs, both personally and with some immediate relatives. In 2019, my dad had a massive heart attack (he was dead for 20 minutes) which had me flying internationally, supporting family, and then heading directly to a live event, while heading home just before the onset of the COVID-19 pandemic. The adrenal crash and burnout from that year was one for the record books, and if there is any silver lining to a global pandemic, it gave me all of the permission to rest, recover and reset fully from the intensity of 2019!

I’ve learned a lot about myself over the last decade. I’ve learned that I am not good at pacing myself. I want to do everything I like, all the time, at the same time. It has taken learning some lessons the hard way to truly master practicing what I preach, and even then, I make mistakes! This is one of the many reasons I make sure to surround myself with such a wonderfully competent team! There’s just no way I could accomplish my goals without such amazing people by my side! I’ve also learned that heels aren’t worth it and I really care about having comfortable feet.

Personal Growth

Throughout the last decade I have learned so much as an entrepreneur, as a mother, but also as a human! I had to learn how to delegate, how to say “no”, and how to value my own work appropriately and competitively. This journey has really helped me know and understand who I am as a person, which translates to every aspect of my life. It guides my hobbies, how I use free time, what I say when family calls and wants to unload stressful information onto me, how to manage a teenager’s complex emotions, and how to set and enforce boundaries in both work and life to stay healthy. There were some very hard-won lessons as I forged my path as a blogger and businesswoman, but also opportunities to develop myself as a unique leadership voice in our community.

I’ve learned so much over the last decade, not just scientific facts and the skills needed to effectively communicate them, but also about myself, who I am, and the impact I want to have in the world.  And finding my strength as a blogger and science-leader has quieted that little voice of doubt at the back of my head that followed me through most of my life.

I have learned (and also studied the research) about the power of embracing body positivity. I have continuously followed the science, even when it has begun to forge a different, and sometimes uncomfortable, new path through old dogma and historical messaging (i.e., you CAN be healthy at any size!). I am a staunch advocate of anti-diet culture and evolving towards what we do know, versus what we thought we knew. Ten years ago, I began to find my voice within the confines of diet-culture; Now, I want to use my voice to push back against it. And, I want to model health independent of thinness in my choices and my actions.

What Is Next for Dr. Sarah?

While the Paleo diet has never had a central organizing body, it has always been policed by enthusiasts who follow as unyielding and irrevocable the yes-no food lists presented in any of the early Paleo books, websites or podcasts. When I posted my recipe for Simple Roasted Green Beans in December 2013, my social media was bombarded with comments all-caps yelling: DON’T YOU KNOW THAT GREEN BEANS ARE A LEGUME?!?! This recipe is sacrilege! This is diet dogma. Dogma is defined as a set of principles laid down by an authority as incontrovertibly true.

Because it was the scientific foundation for the Paleo diet that originally attracted me to this way of life, I was surprised to confront such a strong desire for a completely static template, unresponsive to new scientific insight, and an unwillingness to consider alternate interpretations of how to best implement the actionable information from scientific studies. Science isn’t static.

The green bean controversy was merely the first time of many that I have confronted Paleo diet dogma to the exclusion of science. See Ditching Diet Dogma

My training as a scientific researcher has always permeated my approach to diet and lifestyle principles. I guess it’s once a scientist, always a scientist. My extensive experience of actually performing scientific research gives me an appreciation for the effort and passion that goes into scientific studies, as well as knowing the academic scientific research community intimately.

I’m completely open to new science challenging my conclusions and I will always let you know when new data changes the landscape with regards to a health topic.

In July 2012, I posted an article titled “(Re)Defining Paleo”, where I discussed the importance of defining a diet based on what we do eat, and not what we eliminate. That’s because it’s not the foods we avoid that make a diet healthy or unhealthy, but rather what we actually consume. And, the most fundamental property of a health-promoting diet is one that supplies the body with all of the nutrients it needs to function optimally.

Enter: Nutrivore

Over the years, I’ve come to resonate with a different label for the way I eat. I think of myself as a Nutrivore.

The goal of a Nutrivore diet is to fully meet the body’s physiologic needs for both essential and nonessential nutrients from the foods we eat, also called nutrient sufficiency, but without consuming excess energy (i.e., staying within daily caloric requirements).

Being a nutrivore is about the overall quality of the whole diet, and not about a list of yes-foods and no-foods. Even though eliminating empty calorie foods helps to achieve nutrient sufficiency without overeating, no food is strictly off-limits. In this way, being a Nutrivore is a diet modifier rather than a diet itself—a nutrivorous approach can be layered atop of other dietary structures and priorities in order to meet an individual’s specific health needs and goals. As I launch this new website outside of the dogma of diet culture, I have been able to truly put the science first and develop a completely new way of thinking about food.

I have just launched my new e-book, Guide to Nutrivore, and I am so looking forward to officially launching the website Nutrivore.com in the next couple of months!

My Thanks to You

I want to extend my sincere thanks to you for trusting me to deliver facts, scientific evidence and educational resources to inform your day-to-day choices. It is a responsibility that I take very seriously.

I am grateful to belong to a broader community of like minded individuals who respect science, who are open to new information placed in context and with nuance, and who are willing to engage in respectful discussion on the interpretation of novel data where the burden of scientific proof falls short of reaching consensus. I am grateful for our shared values of equality and inclusiveness, and that you appreciate the honesty and integrity with which I produce resources, create content, and communicate.

I am grateful for your continued engagement and participation in virtual conversation on social media and in response to my newsletters, articles and podcast episodes. I am grateful for the perspective of your shared stories and experiences that complement and contrast with my own. I am grateful for your continued support and enthusiasm. From the bottom of my heart, thank you for your support.

Cheers to another 10 years ahead!

The post Reflecting on a Decade of Health Education appeared first on The Paleo Mom.

Covid-19, the pandemic infectious disease caused by the novel coronavirus SARS-CoV-2, has directly caused at least 584,000 deaths in the USA (a case fatality rate of about 1.8%), and nearly 3.3 million deaths worldwide (a case fatality rate of about 3.5%). Variants of concern (slight mutations of the novel coronavirus that give it a competitive advantage) have emerged from areas of high community spread—they are more contagious and, in some cases, also have higher rates of severe and critical disease and higher mortality (see also Natural Approaches to Cold & Flu Season (and Covid-19!), Covid-19 and the Gut, and Covid-19 FAQ: Do Face Masks Even Work?).

We have all had to adjust our lives in response to the pandemic, from wearing face masks and social distancing, to isolation and quarantine, to virtual school and work, to the economic impact felt in so many households (see Covid-19 FAQ: Do Face Masks Even Work?, How to Prepare for a Coronavirus Shutdown, TPV Podcast Episode 398: How We’re Coping with Quarantine, TWV Podcast Episode 410: How We’re Coping with Quarantine, Part 2, and TWV Podcast Episode 428 Quarantine Holidays). But, there is finally some good news: Scientists have delivered a pathway through to the other side of this pandemic by developing effective and safe vaccines in record time. And, while there are still logistical challenges to overcome in the vaccination effort (especially globally), one of the biggest hurdles here in the USA is vaccine hesitancy.

My most thorough resource for understanding the vaccines is my epic 6-part podcast series, so if you still have questions after reading this article, make sure to check these episodes out:

• TWV Podcast Episode 440: Covid-19 Vaccines Part 1 – mRNA Vaccine Technology In this episode, Stacy and I examined the history of vaccines, the very real statistics on vaccine-induced injury, and the advances that led to mRNA vaccine technology along with the inherent advantages of this platform.
• TWV Podcast Episode 441: Covid-19 Vaccines Part 2 – Pfizer/BioNTech vs Moderna In this episode, we looked at the safety and efficacy data from the phase 2/3 clinical trials for both the Pfizer/BioNTech and the Moderna covid-19 vaccines, including subgroup analysis.
• TWV Podcast Episode 443: Covid-19 Vaccines Part 3 – FAQs In this episode, we answered listener FAQ, including concerns about adverse events including autoimmune disease, fertility, and the current state of evidence in terms of safety concerns for pregnancy and children.
• TWV Podcast Episode 444: Covid-19 Vaccines Part 4 – Myth Busing In this episode, we talk about the myths surrounding antibody-enhanced infection, the for-profit argument, mRNA vs. DNA, traces of controversial tissue cells, and hidden foreign bodies. We also cover who should wait to get the vaccine and vaccine aftercare.
• TWV Podcast Episode 454: J&J and AstraZeneca Covid-19 Vaccines In this episode, we look at how adenovirus vaccines work and the safety and efficacy data from the phase 2/3 clinical trials for both the Johnson & Johnson & Janssen and the AstraZeneca/Oxford University vaccines, including a deep dive into immune thrombotic thrombocytopenia (what the news is reporting as a rare type of blood clot).
• TWV Podcast Episode 455: Covid-19 Vaccines – Real World Data and Updated Studies In this episode, we talk about new studies in pregnant and lactating women, breakthrough infections, updated vaccine studies for the second dose, variants of concern coverage by vaccines, monoclonal antibody therapies and menstruation irregularities.
• TWV Podcast Episode 468: The Delta Covid-19 Variant In this episode, we talk about the mutations that make the Delta variant so much more contagious, what that means for vaccine efficacy, and public health measures to protect ourselves and our communities.
• TWV Podcast Episode 473: Answering Listener Questions LIVE! In this live Q&A with our Patreon, we answered several questions related to the covid-19 Delta variant and the covid-19 vaccines.
• TWV Podcast Episode 492: The Omicron Variant of Covid-19 In this episode, we dive deep into the omicron variant of covid-19, including its mutations, where it likely came from (mice!), what makes it so transmissible, its symptoms and how they differ from previous variants, whether or not it’s actually more mild than other variants, how good of a job vaccines are doing at protecting us, and why this variant was able to displace the Delta variant.
• TWV Podcast Episode 493: How to Prepare for Omicron Covid-19 Infection In this episode, we cover latest science on the causes of long-covid, and the chances of other health problems caused by covid-19 like increased diabetes risk and long-term olfactory dysfunction. We also review the importance of vaccination and boosters, mask wearing and upgrading to N95 or KN95 masks, and continuing social distancing as first line protection against the Omicron variant. We then examine the links between nutrients, diet habits, and lifestyle and susceptibility to covid-19 infection, including vitamin D, vitamin C, zinc, magnesium, a veggie-forward diet, getting enough sleep on a consistent basis, and living an active lifestyle.

And, of course, these shows build on the covid-19 science discussed in:

• TPV Podcast Episode 394: Covid-19 In this episode, we address all things coronavirus, also known as covid-19. What exactly is this disease? What are the symptoms? How is it spread? And what can we do to reduce our risk of infection?
• TPV Podcast Episode 396: Covid-19 FAQ In this episode, we answer listeners’ questions on covid-19. What does the latest data say on what to expect? What are the biggest risk factors? And are there ways to minimize our risk or symptoms if we do get sick?
• TWV Podcast Episode 401: Covid-19 NEW FAQ  In this episode, we answer even more listeners’ questions on covid-19. What is our way out? What about vaccine development? Do non-medical grade face masks really make a difference? Rapid testing? and reinfection?
• TWV Podcast Episode 412: Covid-19 FAQ, Part 3 In this episode, we talk about how quarantine is impacting our gut microbiome, if healthy habits and supplements can lower our risk of getting sick, and if science has advanced on what we know about antibodies and immunity.
• TWV Podcast Episode 425: Covid-19 FAQ Part 4 In this episode, we dive into even more coronavirus discussion, focusing on the long-term impacts of covid-19, the validity of reinfection cases, and the science behind covid-19 reactivation.

So, let’s start at the beginning, the amazing scientific advances over the last few decades that make the rapid (but not rushed) development of the covid-19 mRNA vaccines even possible!

The Scientific Base for mRNA Vaccines

mRNA-based drug technology is extremely exciting. mRNA is the intermediate step between DNA instructions and production of the specific protein that DNA encodes. In our cells, DNA in the nucleus is first transcribed into mRNA, which is transported out of the nucleus and into the cytoplasm, where it is translated into protein by ribosomes in the cytoplasm or endoplasmic reticulum. While mRNA was first discovered in 1961, the initial proof-of-concept experiments showing the feasibility of mRNA-based drugs were performed in 1990. Cells can be transfected with mRNA by encapsulating it within a cationic (positively-charged) lipid envelope, which facilitates entrance into the cell via endocytosis and exit from the resulting endosome into the cytoplasm. There, the mRNA is translated into protein by the cell’s ribosomes.

There are many applications of this technology. In the case of mRNA vaccines like the new covid-19 vaccines from Pfizer/BioNTech and Moderna, mRNA encoding a subunit of the pathogen is delivered to cells, resulting in production by our own cells of an immunogenic foreign protein (antigen) that has no infectious capacity. This bypasses a common problem with traditional subunit vaccines, maintaining tertiary and quaternary protein structure throughout vaccine production, storage and administration. This technology has also been used in clinical trials to create personalized cancer vaccines, where mRNA for a mutated tumor protein is delivered to an area near the tumor, instructing the immune system to attack cancerous cells. Another application is protein replacement; for example, this technology has great promise for treating cystic fibrosis. Before 2020, over twenty mRNA-based candidate drugs had entered the clinical trial stage, including personalized cancer vaccines and vaccines for HIV, influenza, tuberculosis, RSV, and tick-borne encephalitis. Preclinical work on mRNA-based drugs for protein replacement included treatment for type 1 diabetes, autoimmune myocarditis, congenital lung disease, asthma and allergies.

Recent advances in mRNA-based drug technologies (including improvements to increase protein translation, modulate innate and adaptive immunogenicity, and improve mRNA delivery and halflife), in addition to coronavirus research following the SARS and MERS pandemics, set the stage for the rapid development of the covid-19 mRNA vaccines by both Pfizer/BioNTech and Moderna.

Advantages of mRNA Vaccines: Speed of Manufacture

In fact, one of the huge advantages of mRNA vaccines is their potential for rapid, inexpensive and scalable manufacturing.

For example, it took a mere 2 days after the virus genome was sequenced in January, 2020 for Moderna to create the mRNA sequence that produces a membrane-bound and prefusion confirmation stabilized version of the SARS-CoV-2 spike protein. Moderna was then able to ship its first vial of vaccine to NIH for trials 41 days after that. This short timeline wasn’t because the vaccine was “rushed” and no corners were cut, but instead this rapid development is thanks to the technology itself making mRNA vaccines extremely quick to design, develop and produce!

This awesome platform advantage also means that the covid-19 vaccine can be modified for new variants of concern or strains as they emerge. Newly published data shows that the Pfizer/BioNTech is about 90% effective against the more-contagious B.1.1.7 variant (first identified in the United Kingdom), but there’s some data indicating that neither the Pfizer/BioNTech nor the Moderna vaccine (nor natural immunity for that matter) will be as durable against the B.1.351 variant (first identified in South African) nor the P.1 variant (first identified in Brazil). To clarify, both the Pfizer/BioNTech and Moderna covid-19 vaccines offer protection against these variants of concern (after the second shot), but because neutralizing antibody binding to the virus variants is about 6-fold lower (but above threshold for protection), it’s expected that immunity won’t last as long against these variants. It’s also expected that the durability of protection against the B.1.617 (the variant fueling India’s current covid-19 crisis) will also be lower. Both Pfizer/BioNTech and Moderna are testing a third booster to improve coverage against the variants, and have released preliminary data showing efficacy.

Advantages of mRNA Vaccines: Safety

The second major advantage to mRNA vaccines is safety. First, because mRNA is non-infectious and non-integrating, there is zero potential risk of infection or insertional mutagenesis. That means that the mRNA vaccines do not and can not alter our DNA (and, for reference, neither do the adenovirus vector covid-19 vaccines, since adenoviruses lack the enzymatic machinery needed to alter DNA, see TWV Podcast Episode 454: J&J and AstraZeneca Covid-19 Vaccines). There is no immunogenic vector to be concerned about and no need for an adjuvant. Additionally, mRNA is degraded by normal cellular processes—its half-life ranges from 3 to 30 hours. (This is an awesome property for vaccines, but a challenge for protein replacement applications.)

Traditional vaccines carry with them a small, but nonzero, risk for vaccine-induced injury, including severe allergic reaction, encephalitis, Dawson disease, immune thrombocytopenic purpura, pneumonia, and Guillain-Barré syndrome. In most cases, the risk from natural infection is much greater than the risk from vaccination; for example, the risk of mild to severe immune thrombocytopenic purpura from the MMR vaccine is 1 in 40,000 but the risk from rubella infection is 1 in 3,000. Even in the case of Guillain-Barre syndrome, which is linked to 1 in 1.25 million influenza vaccinations, newer studies are showing that natural influenza infection has an even stronger association with Guillain-Barré, implying that the annual flu vaccination may actually decrease the overall incidence.

The results from the Pfizer/BioNTech and Moderna covid-19 vaccine phase 2/3 clinical trials indicate no increased risk of these kinds of serious adverse reactions, including no risk for new or worsening autoimmune disease. And while it was always possible that a serious adverse reaction could occur with a low enough frequency that it would not be detected until much larger numbers of vaccinations are administered, ongoing monitoring of vaccine side effects and adverse reactions have only turned up one low-frequency adverse event: serious allergic reactions to the covid-19 mRNA vaccines. This is thought to be caused by a rare allergy to polyethylene glycol (PEG), which is one of the four lipid nanoparticles in the lipid envelope of both mRNA vaccines. PEG can also be found in some other vaccines, many medications and laxatives. If you have a history of anaphylactic allergic reactions, you’ll be asked to stay for 30 minutes instead of 15 after your vaccination for monitoring, so medical treatment can be administered just in case.

As an aside, ongoing monitoring did turn up a rare adverse event to the adenovirus vector covid-19 vaccines, immune thrombotic thrombocytopenia (typically misrepresented as rare “blood clots” in the media). This is discussed in detail in TWV Podcast Episode 454: J&J and AstraZeneca Covid-19 Vaccines, which I encourage you to listen to, but it’s important to note here that detecting this rare adverse effect is exactly what community monitoring is for. The FDA pause on administering the Johnson & Johnson/Janssen vaccine allowed for education of vaccine recipient and healthcare providers. Immune thrombotic thrombocytopenia requires medical attention and is highly treatable, but the treatment is not the same as embolisms or thromboses. Also, make sure to sign up for v-safe when you do get your vaccine, so you can participate in ongoing monitoring—it’s really important!

While the original phase 2/3 clinical trials did not collect rigorous safety data in pregnant or lactating women, subsequent studies have shown no obvious safety signals to be concerned about. This is especially important because pregnant women are overall 3 to 3.5 times more likely to require ventilation and 70% more likely to die from covid-19 than their age and risk factor-matched controls, with advanced maternal age (AMA) women at even greater risk. Pregnant women aged 35–44 years are nearly four times more likely to require invasive ventilation during covid-19 infection, and have approximately double the mortality rate of nonpregnant women of the same age

A study of pregnant v-safe participants who received either the Pfizer/BioNTech or Moderna mRNA vaccine revealed that they are more likely than age-matched non-pregnant women to experience injection site pain but less likely to experience headache, muscle ages, chills, and fever as side effects of the covid-19 vaccines. And, the incidence of pregnancy loss and adverse neonatal outcome (including preterm birth and small size for gestational age) were similar to incidence rates reported in studies conducted before the Covid-19 pandemic. (That’s good news and an example of v-safe in action!)

A prospective study of pregnant and lactating women showed that the mRNA vaccines induced similar levels of antibodies compared to non-pregnant and non-lactating women, and higher levels of antibodies than pregnant women after natural infection. And vaccine-generated antibodies were found in all umbilical cord blood and breastmilk samples, indicating that some immune protection was transferred to the baby. A further prospective study conducted in Israel in lactating women showed that 97% of breast milk samples contained protective levels of IgG antibodies (20.5 U/mL) against SARS-CoV-2 by 5 to 6 weeks after the first shot (about 2 to 3 weeks after the second shot). Neither of these studies reported any adverse events.

The results from the Pfizer/BioNTech phase 2/3 clinical trial in adolescents aged 12 to 15 has also shown an excellent safety profile, with similar levels of immune response as seen in adults, and similar frequency of side effects (more on side effects below).

Advantages of mRNA Vaccines: Efficacy without Adjuvants

The third major advantage to mRNA vaccines is efficacy. Our cells can actually produce much more antigenic protein via this platform than can be delivered using traditional vaccine platforms like subunit, conjugate, live attenuated or inactivated virus. The protein is then presented to the immune system via the major histocompatibility complex (MHC). Additionally, in the case of the covid-19 vaccines, the spike protein mRNA was slightly modified to add a transmembrane anchor, so the antigenic coronavirus spike protein also presents itself to our immune systems! Another advantage of adding this transmembrane anchor is that the spike protein produced by our cells after vaccination doesn’t enter the circulation (i.e., the bloodstream), so it can’t bind with ACE2 receptors and interfere with our renin-angiotensin system. (As an aside, both the Johnson & Johnson/Janssen and AstraZeneca adenovirus vector vaccines deliver DNA instructions for a modified spike protein to also include a transmembrane anchor! Yay!)

The first injection primes the immune system and the booster shot a few weeks later ensures a more robust and durable immunological memory! This elicits an effective and strong T cell and humoral immune response—without the need for adjuvants! In fact, that second shot of the mRNA vaccines increases our production of neutralizing antibodies by about 10 times! And, that doesn’t just increase our protection, it also leads to longer-lasting (i.e., more durable) immunity.

Adjuvants (most commonly aluminum-based molecules) are added to traditional vaccines to stimulate the immune system so we develop a more robust immunity against the antigen. This broad immune stimulation is why people with autoimmune disease and other inflammatory diseases can sometimes experience a flare after vaccination. However, the immune response after vaccination with mRNA vaccines is targeted against the foreign protein, activating the same pathways that our immune systems use to fight off any virus. Certainly, a transient increase in autoimmune symptoms is still possible, in the same way that fighting off a cold or flu can trigger increased symptoms, but the lack of adjuvant in these vaccines is very good news for autoimmune disease sufferers.

In fact, the ingredients of these vaccines are devoid or worrisome compounds (PEG allergy excepted). For example, the Moderna vaccine contains the following clean ingredients:

• the mRNA strand,
• four lipids which make up the lipid envelope (SM-102, PEG2000-DMG, cholesterol, and DSPC),
• four pH buffering agents (tromethamine and tromethamine hydrochloride, which are both common drugs for metabolic acidosis, and acetic acid and sodium acetate, which are both naturally found in our blood), and
• sucrose as a cryo-stabilizer.

And that’s it! No wonky preservatives, stabilizers or residuals!

The Pfizer/BioNTech and Moderna phase 2/3 clinical trials showed that both vaccines prevented about 95% of symptomatic covid-19 infections. Both vaccines were at least 90% effective at preventing severe and critical courses of covid-19 and 100% effective at preventing death from covid-19. The results from the Pfizer/BioNTech phase 2/3 clinical trial in adolescents aged 12 to 15 showed 100% efficacy against symptomatic covid-19 infection (this age group is at much lower risk of severe disease and death, so this clinical trial couldn’t test efficacy, but it’s expected to also be high). That’s highly efficacious!

Sub-group analysis of the phase 2/3 clinical trial results for both the mRNA vaccines—stratified by age, race, ethnicity, sex, baseline BMI, and the presence of known risk factors for severe disease, including chronic lung disease, significant cardiac disease, severe obesity, diabetes, liver disease and HIV infection—revealed similar vaccine efficacy (85% to 100%) across all subgroups. Autoimmune disease is not a risk factor for severe covid-19, unless you are taking immunosuppressant drugs to manage your disease. So, people with autoimmune disease were included in the covid-19 clinical trials but not analyzed separately in the sub-group analysis. In the detailed adverse event reports included in the FDA Briefing Documents for both Pfizer/BioNTech and Moderna, there is no difference between vaccine and placebo groups in terms of new autoimmune disease incidence or symptom flares of preexisting autoimmune disease. (It’s worth noting here that this is consistent with several large-scale prospective studies of traditional vaccines that indicate absolutely no link between vaccines and autoimmune disease or autoantibody formation, like this one.) More good news!

This high efficacy and safety across all subgroups is excellent news! And, even better, real-world data also bears this out!

In a CDC study, 3950 healthcare workers, first responders and frontline workers (who have high risk of workplace exposure) where tested every week during and after vaccination with either of the mRNA vaccines, capturing both asymptomatic covid-19 infections and symptomatic ones. The vaccines yielded 80% immunity by 2 weeks after the first vaccination and 90% immunity by 2 weeks after the booster.

A similarly designed study of healthcare workers in Israel who were vaccinated with the Pfizer/BioNTech covid-19 vaccine, showed a 97% reduction in symptomatic infections and an 86% reduction in asymptomatic infections in fully vaccinated healthcare workers compared to unvaccinated healthcare workers.

In a Mayo Clinic study, over 39,000 asymptomatic adult patients were screened for covid-19 prior to surgery or other procedures. The first vaccine dose prevented 72% of asymptomatic infections while full vaccination prevented 80% of asymptomatic infections.

And a study of hospitalized adults over the age of 65 in the USA who received either the Pfizer/BioNTech or Moderna covid-19 vaccines, the first shot was 64% effective at preventing a severe case of covid-19 requiring hospitalization whereas full vaccination was 94% effective at preventing severe disease requiring hospitalization.

That’s more good news, including real-world data showing vaccine efficacy against asymptomatic infections, too!

In fact, there are very low numbers of breakthrough infections after full vaccination (i.e., getting covid-19 even after being fully vaccinated). Some breakthrough infections are expected because none of the vaccines are 100% protective. The CDC reports that, as of April 26, 2021, there were only 9,245 covid-19 positive infections among the over 95,000,000 fully vaccinated Americans at that time. Also, as expected, almost all of the breakthrough infections were asymptomatic or mild. A very, very small number (about 6.4%) of breakthrough infections were severe enough to require hospitalization, including 122 older adults with preexisting conditions who died from covid-19 after being vaccinated. Studies have also shown that viral load is about 4-fold lower in fully vaccinated people with breakthrough infections, so while you can still be contagious if you get a breakthrough infection, you are much less so than unvaccinated people. Even more good news, the covid-19 cases are dropping as a result of vaccinations (and probably some other helpful factors like warm summer weather), so hopefully we’ll get to a point where vaccination means you can throw those masks away soon! Hang in there! See also Covid-19 FAQ: Do Face Masks Even Work?

Okay, time for an important aside: This article is focused on the covid-19 mRNA vaccines, but the two adenovirus vector DNA vaccines: Johnson & Johnson/Janssen and AstraZeneca/Oxford vaccines also do not include adjuvants and have very clean ingredients. The concept behind these vaccines is similar to the mRNA vaccines in the sense that they deliver the instructions for our cells to produce the spike protein of SARS-CoV-2. In this case, an adenovirus (which normally causes a mild or asymptomatic common cold and completely lacks the enzymes require to alter our DNA, making them an excellent DNA delivery vehicle for vaccines) that has been made replication incompetent delivers the DNA instructions to our cell nuclei, which then transcribe the DNA into mRNA and then translate the mRNA into membrane-bound coronavirus spike protein. These vaccines are also built on decades of research (I actually used adenoviruses for gene therapy research during my PhD!). Their efficacy profiles are similar (about 70% effective against symptomatic infection, 80% effective against severe and critical infection, and 100% effective at preventing death from covid-19), but do note that we can’t directly compare these to the mRNA vaccines since they were tested at different times in different countries after variants of concern became dominant). And, both adenovirus vector vaccines have a similar very low frequency occurrence of one notable adverse event, immune thrombotic thrombocytopenia (misrepresented in the media as “blood clots”). I have created a more in-depth resource where I go into detail about these vaccines here: TWV Podcast Episode 454: J&J and AstraZeneca Covid-19 Vaccines.

More Durable Immunity than Natural Infection

Early data shows a longer-lasting production of neutralizing antibodies against the SARS-CoV-2 spike protein after vaccination than natural infection, with higher levels of neutralizing antibodies four months after vaccination compared to four months after natural infection.

Immunity arising from natural infection with covid-19 is likely limited—while the absolute numbers of confirmed covid-19 reinfections remain a fraction of a percent, studies in other coronaviruses imply that natural immunity does wane. Immunity from common cold-causing coronaviruses lasts about a year, and immunity from SARS-CoV (responsible for the 2002-2003 SARS pandemic, also the coronavirus most similar to SARS-CoV-2, about 80% homology) lasted up to six years (see TWV Podcast Episode 425: Covid-19 FAQ Part 4). This is likely attributable to the fact that the novel coronavirus manipulates our immunes systems to evade detection, downregulating interferon production and interfering with antigen presentation by the MHC—this manipulation of our immune response is absent in the covid-10 vaccines (see Covid-19 FAQ: Do Face Masks Even Work?).

This is why public health officials recommend getting vaccinated even if you’ve already had covid-19, waiting until you have completely recovered from infection or 90 days, whichever is less.

This is also why it’s so important not to skip your second vaccine dose! As I already mentioned, neutralizing antibodies go up about 10 times after the booster shot, which increases efficacy and is also expected to notably increase the durability of immunity, i.e., how long of a period of time the vaccines protect us.  The booster also dramatically increases protection against the variants of concern. For example, newly published data from Israel where the B.1.1.7 and B.1.351 variants dominate show only about 58% protection after one dose of the Pfizer/BioNTech vaccine (76% protection against hospitalization and 77% protection against death), but this increases to 96% protection against infection (98% protection against hospitalization and death) by two weeks after the second shot. So far, even the participants of the earliest vaccine studies still have protective levels of antibodies in their blood. They will be monitored for at least two years, and the persistence of antibodies will help determine whether or not regular boosters are required and on what timescale (anywhere from annual to every 5 years is likely based on what we know about immunity to other coronaviruses like those causing the common cold, SARS and MERS).

Speaking of making sure to get your second dose… If you received your first shot, but missed your window for the second shot (3-6 weeks for Pfizer/BioNTech and 4-6 weeks for Moderna) for whatever reason, emerging evidence says it’s still worthwhile to go ahead and get your booster at your earliest opportunity. (No, you don’t need to restart your vaccine course.) A brand-new unpublished study evaluating a 3-week timing between the two Pfizer/BioNTech inoculations versus a 12-week timing in adults over the age of 80 actually showed higher antibody levels with the longer timing! This doesn’t mean we should all delay (this research still needs to be peer0reviewed and it was performed in a specific demographic), but it does point to it being okay if life got in the way of that second dose and you’re now finding yourself in the situation where you need to catch up.

Pfizer vs. Moderna (vs. J&J)

There is very little difference between the Pfizer/BioNTech and Moderna covid-19 vaccines. Moderna has spent about ten years perfecting their lipid nanoparticle technology, which is why their vaccine is more stable and doesn’t require ultra-cold temperatures for storage and shipping. The mRNA sequences they deliver are nearly identical, and the differences in safety and efficacy between the two vaccines are within normal variability and standard deviation, meaning they’re statistically equivalent. While it hypothetically shouldn’t matter if you mixed and matched these two vaccines, because it hasn’t been specifically tested, best practice is to get both initial injection and booster from the same vaccine manufacturer.

It’s also helpful to note here that we can’t compare efficacy of the mRNA vaccines to the Johnson & Johnson/Janssen or AstraZeneca/Oxford vaccine, because they were tested at different times and in different countries, when different variants were dominant. To actually be able to make a statement of one vaccine being more efficacious than another, we’d need a head-to-head comparison trial. This is discussed more in TWV Podcast Episode 454: J&J and AstraZeneca Covid-19 Vaccines.

Post Inoculation Side Effects – What to Expect

The most common side effect of the mRNA vaccines are injection site reactions (like arm pain or bruising), which impacts about 90% of people. Systemic side effects—any or a combination of fatigue, headache, muscle aches, chills, joint pain, fever, nausea, vomiting and diarrhea—affect about half of people receiving the vaccine and are short-lived (up to a couple of days) and similar in frequency and severity to other traditional vaccines. It is common for side effects to be a little worse after the booster shot compared to the first injection, but there are plenty of counterexamples to point to. Some women also experience menstrual irregularities following the vaccination, likely mediated via cortisol (which increases during immune activation and infection and which impacts the hypothalamic-pituitary-gonadal axis, discussed in detail in TWV Podcast Episode 455: Covid-19 Vaccines – Real World Data and Updated Vaccine Studies and see How Chronic Stress Leads to Hormone Imbalance).

I can tell you that I had some mild side effects from the first shot that lasted about 36 hours (low-grade fever, mild chills, arm pain, and mild fatigue), so I planned ahead for the second shot and filled my fridge with leftovers and cleared my schedule. I definitely had more intense side effects after the second shot, about 30 hours of a sore arm and bad flu-like symptoms (fever, chills, muscle aches, joint pain, headache, stomach upset and fatigue), followed by two or three days of lingering mild joint pain. A great trade that I would do again in a heartbeat!

It’s important to differentiate here between a side effect and an adverse reaction. A side effect is an unpleasant but overall harmless secondary effect, whereas an adverse reaction is an unwanted/unexpected and dangerous reaction to a therapeutic. These side effects are all signs that the immune system is doing its job! Also, severity of side effects does not correlate with immunity, so having no side effect at all does not mean that you aren’t protected.

The same ways you would support your immune system if recovering from illness can help if you experience side effects on the more unpleasant end of the spectrum: rest, hydration and nutrient-density.

Busting Covid-19 Vaccine Myths

The many pervasive myths circulating on the internet about these covid-19 vaccines are simply false. No corners were cut in the testing of these vaccines; just like any new drug, community monitoring is important, but we are not guinea pigs here. Emergency Use Authorization does not mean that the vaccines weren’t fully and rigorously tested; it is an expedited approval system designed exactly for emergency situations like global pandemics. Pfizer/BioNTech has already applied for full FDA approval (the other vaccine manufacturers won’t be far behind), the main difference is longer duration of observation of the clinical trial participants (6 months worth of data compared to the 3ish months worth when they were first applied for their EUA).

The vaccines do not contain whole, intact virus and can not give you covid-19. The vaccines do not make you contagious—people can’t “catch the vaccine” from you. No immortalized cell lines originally derived from fetal tissues were used at any stage of design, development or production of either mRNA vaccine; and none of the vaccines contain any aborted fetal cells or tissues.

There is currently no evidence of female infertility as a consequence of either natural infection nor any covid-19 vaccine—the sequence homology to placental protein syncytin-1 is so low that autoantibody formation is extremely, extremely unlikely (only 4 amino acids are homologous, but at least 10 are usually required for cross-reactivity).

There is no evidence to support the myths that the vaccine will cause autoimmune disease or antibody-enhanced infection. There is no evidence that the vaccines will negatively impact hematopoietic stem cells. The spike protein our bodies make in response to the vaccines are membrane bound so they can not bind with our ACE2 receptors or damage the cardiovascular system.

None of the vaccines alter our DNA. The vaccines do not contain tracking microchips; in fact, Faraday’s law makes that technology physically (as in the laws of physics) impossible.

I bust these myths in detail and answer FAQ in these two podcast episodes:

• TWV Podcast Episode 443: Covid-19 Vaccines Part 3 – FAQs
• TWV Podcast Episode 444: Covid-19 Vaccines Part 4 – Myth Busing

Benefits to Long Covid

Studies suggest that anywhere from 10% to 30% of people infected with covid-19 have persistent symptoms beyond 3 months, qualifying as “long covid”. Long covid can be triggered even by mild covid-19 infections. There are a couple of different possible explanations for long covid. It could be chronic fatigue syndrome, an autoimmune disease well known to have infectious triggers. Or, it could be persistent infection, meaning the immune system doesn’t quite fully vanquish the pathogen. Or some people could have chronic fatigue syndrome and others a chronic infection, or both. In any case, a vast array of symptoms are possible—including chronic cough, chest pain, shortness of breath, fatigue, brain fog, memory and sleep problems—ranging from mild to severe, and can either be consistent day-to-day or fluctuate in both symptom severity and even what symptom(s) is being experienced.

There’s emerging evidence that getting vaccinated can improve or resolve long covid, although definitely more studies are needed. While various surveys have shown that about 40% of respondents saw improvement in their long covid symptoms after getting vaccinated, a preprint study performed in the United Kingdom showed that almost a quarter of long covid patients saw symptom resolution after either the Pfizer/BioNTech or AstraZeneca/Oxford vaccine. Either way, that’s good news for long covid sufferers.

What Can You Do After Getting Vaccinated?

You are considered fully immunized two weeks after your second shot, at which point, you are at much, much, much lower risk of contracting covid-19 and passing it on to friends and family. And that means we can participate in most the activities we enjoyed pre-pandemic, mask-free and without social distancing!

New CDC guidelines for fully vaccinated people include participating many indoor activities without wearing a mask or staying 6 feet apart, including grocery shopping if the store isn’t crowded, shopping at uncrowded shopping centers, visit an uncrowded museum, visiting a barber or hair salon, go to a movie theatre, attend a full-capacity worship service, eat at an indoor restaurant or bar, and even participate in an indoor, high intensity exercise class! It’s even low-risk to participate in small indoor gatherings with vaccinated and unvaccinated people, providing none of the unvaccinated are at increased risk for severe covid-19. We can also enjoy the outdoors without a mask, even in crowded venues like stadiums and concerts. And, for everyone tired of feeling like their brains are being impaled by a nasal swab, being fully vaccinated means no more covid-19 testing when you travel or if you’ve been exposed to someone who is infected, unless you have symptoms. You also get to skip the self-quarantine when traveling domestically in the USA or if you’ve been exposed to someone who is infected (again, unless you have symptoms). And, if your employer requires regular covid-19 testing, that should also discontinue once you’re fully vaccinated.

Some places where you still need to wear a mask include medical buildings (like hospitals, long-term care homes, doctor’s offices, and urgent care centers), public transportation (like airplanes, buses, and trains), and congregate living facilities as well as any location—including local businesses and workplaces—where mask wearing is required by federal, state, local, tribal, or territorial laws, rules, regulations, or ordinances. Many retailers will continue to require masks in order to enter and shop in their stores, at least until the vaccination rates are higher. Note that if you are immunocompromised or take a medication that suppresses the your immune system, you may not be fully protected even if you are fully vaccinated, so talk to your doctor. You may opt to continue mask wearing and social distancing. You can take a covid-19 antibody test to see what your titers are and make a data-driven decision.

While asymptomatic breakthrough infections are unlikely to be contagious, symptomatic ones certainly can be. If you develop any symptoms of illness after being fully vaccinated, even mild ones, wear a mask and social distance until you can get tested for covid-19, and continue until you get your test results back or until you’re fully recovered.

What about vaccinated parents of unvaccinated kids? Unvaccinated and partially-vaccinated people still need to take precautions, but small gatherings are still considered low-risk. As a parent of one partially- and one unvaccinated kid, I’m still wearing a mask in grocery stores and other indoor locations with strangers. The good news is that, as a higher and higher percentage of the population gets vaccinated, and the daily case counts continue to decrease, more and more activities will be considered low-risk. Check the CDC guidelines webpage for updates and new guidance on low-risk mask-free activities!

Who Should Get Vaccinated?

The covid-19 vaccines have proven to be safe and effective, and they are currently our best tool in fighting this global pandemic. In the USA, the Moderna and J&J covid-19 vaccines are currently approved for everyone 18 years old and older; and the Pfizer/BioNTech covid-19 vaccine is approved for everyone 12 years old and older.  A little over 35% of Americans are already fully vaccinated, but current mathematical models predict that somewhere between 70% and 90% of the population needs to be immune to SARS-CoV-2 in order for us to reach herd immunity. Herd immunity means that enough of the population is immune that the virus can no longer effectively spread from person to person. There’s even a possibility that covid-19 could be eradicated, like small pox, if enough people were to get vaccinated.

Of course, it’s important to build immune health with informed diet and lifestyle and by nurturing the gut microbiome, but there is no “natural” supplement or nutrient or diet or workout or amount of sleep that can make us immune to covid-19 (see Natural Approaches to Cold & Flu Season (and Covid-19!), Covid-19 and the Gut, TPV Podcast Episode 396: Covid-19 FAQ and TWV Podcast Episode 412: Covid-19 FAQ, Part 3).  Our only pathway to immunity (other than surviving a covid-19 infection, which as we’ve already discussed, includes high risk of morbidity and mortality) is getting the vaccine.

So, who should get vaccinated? Everyone who doesn’t have a contraindication diagnosed by their doctor. Yes, the vaccines do provide personal protection against covid-19, but the bigger reason for getting vaccinated is to protect our communities. While age and preexisting conditions certainly increase risk of morbidity and mortality from covid-19, there are plenty of tragic stories of perfectly healthy young people succumbing to covid-19. Herd immunity means we no longer have to roll the dice and hope that if we get it, we’ll get a mild or asymptomatic case and not suffer from long covid. And, in a way, we are in a race against the SARS-CoV-2 virus. Every new person infected is an opportunity for the virus to mutate, and it is possible for a new variant of concern to emerge that the vaccines do not confer protection against, resetting the pandemic clock and putting us all back to those dark days of Spring 2020. Even if you deem yourself to be at low risk, you could pass the virus on to somebody who is more vulnerable to severe infection or dying from covid-19, or you could be ground zero for a new variant of concern that the vaccine doesn’t protect against. If you’re unsure about whether the vaccine is safe for you given your personal health history, talk to your doctor.

I completely understand and have compassion for vaccine hesitancy, so I earnestly hope that his article has answered your questions, assuaged your fears, and helped you feel empowered with facts and information.  And, as a reminder, if you still have follow-up questions, I go into even more detail on the science behind the covid-19 vaccines in:

• TWV Podcast Episode 440: Covid-19 Vaccines Part 1 – mRNA Vaccine Technology
• TWV Podcast Episode 441: Covid-19 Vaccines Part 2 – Pfizer/BioNTech vs Moderna
• TWV Podcast Episode 443: Covid-19 Vaccines Part 3 – FAQs
• TWV Podcast Episode 444: Covid-19 Vaccines Part 4 – Myth Busing
• TWV Podcast Episode 454: J&J and AstraZeneca Covid-19 Vaccines
• TWV Podcast Episode 455: Covid-19 Vaccines – Real World Data and Updated Studies

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