How Dare There Be Effective Drugs for Obesity?

Yoni Freedhoff, MD


April 15, 2021

Recent studies published in JAMA and the New England Journal of Medicine highlighted the remarkable efficacy of once-weekly injections of semaglutide for long-term weight loss, with average losses of 16% and 14.9% over 68 weeks, respectively. Given the challenges of maintaining weight loss and the benefits of weight loss for many weight-responsive diseases, quality of life, mobility, and reduction of risk for chronic noncommunicable diseases, you might expect such a drug to be released to uniform cheer.

You'd be wrong, though, because when it comes to obesity, many would seemingly prefer there to be no effective pharmaceutical treatments. The loudest voices opposing medications for obesity, though they often share talking points, usually fall into one or more of these four categories:

  1. The food-is-medicine proponents

  2. The lifestyle-is-medicine proponents

  3. The weight-biased

  4. The obesity denialists

The first two groups' arguments are the most obvious and generally involve some riff on, "Why would anyone take medication for obesity? They just need to go on the <insert diet here> diet," or "Whatever happened to eat less, move more?"

The weight-biased, of course, tend to perseverate around what they perceive to be the moral failings of people with obesity and frame medications as a reflection of their purported weaknesses, while the obesity denialists frame everything as a medico-pharma conspiracy for a disease that they believe doesn't exist and therefore requires no treatment.

Of the four groups, I'd venture that the most prevalent are the weight-biased. And here I'm not speaking of explicit bias but rather implicit bias — which, when it comes to healthcare professionals having negative feelings toward those with obesity, is well documented and has been shown to affect care.

The Reactions

In the discourse that followed the release of these two recent studies, there were disparaging remarks about the cost of medications, frequent suggestions that the drug's primary mechanism of action is nausea (rather than what is for most — a transient or minor side effect), and complaints about the drug's requirement for long-term use. Also apparently problematic was the fact that for many people, the 15% weight loss achievable from a single medication will still have them weighing more than some table says they ought to.

Notable too was that the majority of these doctors weighing in on what they perceived as the drug's shortcomings were physicians who don't practice obesity medicine and who had probably never prescribed a glucagon-like peptide 1 analogue or followed and counseled a patient in the context of weight management. Perhaps I'm old-fashioned, but I would never presume expertise in a field where I didn't practice. But of course, everybody eats, and consequently everybody is an expert, it would seem.

Be a True Ally

All this is to say, obesity is a chronic noncommunicable disease that medicine treats like no other. With all other chronic noncommunicable diseases, when indicated and when lifestyle means are insufficient or undesired, physicians rightly and readily recommend and prescribe long-term medication or combinations of medications.

Take hypertension. Our patients can in theory choose to go on low-sodium diets, lose weight, increase their exercise levels, improve their sleep hygiene, treat their sleep apnea, and focus on mindfulness. Doing so would in many cases lead to marked improvement — and in some, remission — of their disease. But if their efforts fail, stall, or are found to be insufficient, or if they simply state that they're unlikely to find the time, energy, or interest to make such lifestyle changes, we invariably and unhesitatingly — free from judgment about their character — prescribe them antihypertensives with the understanding that they are likely to be long-term medications, barring any major lifestyle changes.

Yet with obesity, which too is in theory modifiable through lifestyle means, many physicians are not only hesitant but plainly opposed to prescribing medications in the first place, let alone for long-term use. And those who do will often demand patients "try" to lose weight first before they are given the prescription (as if they haven't probably been trying their whole lives already, and as if there isn't a tremendous amount of privilege involved in perpetual intentional behaviour change in the name of health).

With respect to costs, perhaps they'd be lower were more physicians comfortable prescribing these medications. With respect to the nausea, it's minimal or transient for most. But even if it wasn't, if the mechanism of action was nausea, and people in the studies voluntarily stayed on them for 68 weeks despite the nausea, what would that say about the drug's perceived benefits to the individual and the burdens associated with obesity? Finally, with respect to subtotal weight loss, how many chronic noncommunicable diseases are you aware of that are wholly treated with monotherapy?

True physician allies for patients with obesity are those who treat obesity like any other chronic disease, where treatment can of course involve lifestyle counseling, encouragement, and support — but which, when appropriate, also includes the option of pharmacotherapy and, regardless of patient behaviour changes, is free from blame.

Yoni Freedhoff, MD, is an associate professor of family medicine at the University of Ottawa and medical director of the Bariatric Medical Institute, a nonsurgical weight management center. He is one of Canada's most outspoken obesity experts and the author of The Diet Fix: Why Diets Fail and How to Make Yours Work.

Follow Yoni Freedhoff on Twitter: @YoniFreedhoff

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