Weight-melting drugs sound more tempting than chocolate cake, but weight-loss drugs don’t cure obesity. And that’s okay, because obesity is not a disease to be cured. Obesity is just one risk factor for larger risk factors. Fat people are more likely to have high blood pressure, high cholesterol and diabetes, conditions that can increase the risk of heart attacks and strokes – but these are the important cardiovascular risk factors, not the obesity. Many thin people have high blood pressure, and many fat people do not.
The criteria used to measure obesity – body mass index (BMI) – are extremely flawed at best; many tall or muscular people (think football players) will appear overweight or obese on BMI because BMI does not distinguish between fat and muscle mass. In 1998, the number of overweight and obese people in the United States literally increased overnight by 37 million when an NIH task force (nearly 90% of whom had financial conflicts of interest with industry weight loss) overweight redefined as BMI ≥25 kg/m2 and obesity as BMI ≥30.
The framing of obesity as a chronic disease is a social construct that supports a large weight loss industry, including pharmaceutical companies and weight loss clinics. Labeling obesity as a chronic disease makes treatment a goal of weight loss rather than improving health outcomes. There is little or no evidence that weight loss alone reduces cardiovascular disease or death. What reduces deaths cardiovascular disease increases physical activity and improve cardiorespiratory fitness. And exercise reduces deaths from many diseases. A fat, fit person is healthier than a thin couch potato. In fact, repeated weight loss attempts can contribute to weight gain and cycling; Yo-yo weight is associated with significant health risks.
Of course, if obesity is a disease, the idea that a drug is necessary to treat it remains silent. And if it’s a chronic disease, it’s a lifetime on the drug.
Enter the highly touted new weight loss drugs.
A little background on these “miracle” drugs. When a class of diabetes drugs (GLP-1 agonists) showed an unexpected weight loss side effect, they were redirected to a new market. As weight-loss drugs, they are intended only for people who are obese or overweight and have another medical condition. This caution has not stopped doctors from prescribing them to patients who are simply overweight without additional health problems.
The risks of Wegovy, Ozempic and other similar drugs are very likely to outweigh the benefits in healthy overweight people. These drugs increase the risks acute pancreatitis, gallbladder disease, kidney problems and suicidal thoughts and may increase the risk of thyroid cancer. Advocates of the drugs only mention nausea, vomiting, and diarrhea because they don’t seem as serious as pancreatitis, cancer, or suicide. And although these drugs have been used – in lower doses – to control blood sugar in diabetics, there is no data on long-term side effects when used in high doses just for weight loss. The drugs will certainly lighten the wallets; their exorbitant prices reach up to $1300/month. Analysts predict obesity treatment could grow from a $2.4 billion category in 2022 to $54 billion by 2030.
Of course, some people lose weight with these drugs. But they spoil the pleasure of eating and the weight come back once these drugs are stopped. That means a life on the drug. Unlike a public health approach that tackles the systemic issues that create obesity (rates are highest in poor neighborhoods, where people have little access to healthy food or safe places to exercise). ‘exercise), these drugs only treat a symptom while diverting attention from mobilizing support to make changes needed to improve the social environment.
The marketing of new drugs conveys the implicit and damaging message that only drugs, not diet and exercise, will help people lose weight. The fact that participants in weight loss trials had to increase their physical activity and reduce their calories is not part of the hype around these drugs.
The messages supporting these new drugs undermine any real public health effort. What improves health outcomes are long-term healthy choices — with or without weight loss — not short-term restrictive dieting that leads to weight regain. Eating less saturated fat and more vegetables and fruits improves cardiovascular health and helps protect against cancer. Exercise reduces the risk of cardiovascular disease, diabetes, certain cancers and death, and is the most important thing people can do for their health.
While affirming the need to de-stigmatize obesity, messages about weight-loss drugs actually increase prejudice. Obese people face stigma and unfair judgments that they could lose weight if they simply changed their behavior. But the availability of repurposed diabetes drugs is increasing the pressure on obese people to lose weight. Ragen Chastain, an advocate for size acceptance and Health at all sizesdescribes these messages as a wolf in lamb’s clothingusing the language of stigma to sell weight loss rather than reduce discrimination.
The pressure is rising for insurance companies and Medicare to cover anti-obesity drugs. THE Obesity Action Coalition organizes patients who want to use these drugs to lobby for insurance coverage, but this industry-funded group is shilling for the drugmakers. Payers should stick to the evidence and resist coverage for these drugs. The goal should be better health, not weight loss.
Judy Butler is a research fellow. Adriane Fugh Berman is a professor of pharmacology and physiology.