Last month, the New England Journal of Medicine published a study indicating that a medication originally used to treat diabetes, semaglutide, was also successful at promoting weight loss among relatively heavy individuals.
Aside from locating an actual fountain of youth, it’s hard to imagine something more desired than a drug that would promote weight loss. After all, how many people do you know who have tried everything? Weight Watchers (now WW), keto, paleo, intermittent fasting and juice cleanses have been in the rotation for millions of people with little (or no) sustained weight loss to show for it.
Weight Loss by Drug?
In the recently published study, semaglutide was found to promote both significant weight loss — 14.9% of body weight, compared to 2.4% in the placebo group — and improve cardio-metabolic risk factors, including a decrease in blood pressure and waist circumference and an increase in physical functioning. It appears to do this by suppressing appetite, leading patients to feel full more quickly.
What could possibly be wrong with an easier approach to weight loss for people who desire it — and who may reap health benefits from being a bit lighter? It turns out, there are many considerations, ranging from the practical to the more philosophical, that make a drug for weight loss potentially problematic.
Health Over Weight Loss
Kathleen J. Jackson — a family nurse practitioner who’s worked in primary care for over 30 years and spends a great deal of time working with vulnerable populations, especially patients with Type 2 diabetes — tells me that her biggest objection to a medication for weight loss is that it propagates the “quick-fix” mentality that permeates health care these days.
“How we eat and how active we are have far-reaching consequences for our physical and mental health,” says Jackson, who serves as a clinical assistant professor of nursing at Rutgers School of Nursing–Camden in New Jersey. “This drug may help some people, but weight loss isn’t always the goal. Healthy living is really the best ‘drug.'”
Jackson’s sentiments are undoubtedly influenced by the disconcerting history of weight loss drugs. From fatalities caused by Fen-phen in the 1990s (before it was pulled from the market) to more recent drugs with limited efficacy, serious side effects and time-limited use (making the possibility of weight regain likely) — it’s easy to doubt that semaglutide will be a miracle drug.
After all, in order for the drug to work long term, it will need to be taken continuously — and at a higher dose currently administered to people who take the drug for diabetes. This means that, for some, their weight will be treated as a chronic condition. (People in the study took semaglutide for 68 weeks.)
[READ: Is Weight Loss Even Important?]
Weight as a Chronic Condition
Viewing a person’s weight — no matter what it is — as a chronic illness or a problem to be fixed is considered objectionable by some. Behavioral genetic research suggests that weight is 50% to 90% heritable. In other words, weight is not necessarily as malleable as weight loss companies would lead us to believe.
According to eating disorders educator Oona Hanson, who’s based in the Los Angeles area, it’s difficult to determine if people can really make an autonomous decision about weight loss when there’s so much cultural pressure to be slender, no matter your genetic blueprint. “Imagine someone asking about any other group of people who are marginalized and oppressed and wondering if a magic pill could change their appearance so they could ‘fit in.’ The question we need to ask is: How do we change the systemic bias and prejudice that leads to stigma against larger people?”
Hanson’s views are in sync with a burgeoning body positivity movement promoted by writers, registered dietitians, psychologists and activists. The movement has existed for decades, but really took off in recent years on social media as #BoPo. Body positive practitioners and activists urge a paradigm shift that asks people to approach their bodies with appreciation, gratitude and acceptance.
Body positivity isn’t just pop psych; research findings suggest that acceptance is healthier — psychologically and physically — than trying to change the body via weight loss or many other means. People with more positive views of their body tend to eat more intuitively and have higher self-esteem.
Not irrelevant is the robust empirical finding that weight loss fails for approximately 95% of people who attempt it — at least pre-semaglutide. Further, negative consequences of attempts at weight loss include a disrupted relationship with food, disordered eating and weight gain. Although people are quick to blame themselves and feel assured that their next attempt at weight loss will work, there’s no evidence that willpower is the issue; research suggests dieting is the issue. Not only is weight largely genetically determined, so is appetite. That combination makes permanently dropping a significant amount of weight a tall order.
[READ: Fit and Fat]
Weight Loss Doesn’t Necessarily Improve Health
Would a weight loss medication change this? Accepting our bodies makes sense when changing them is impossible. But if it becomes possible, is it truly desirable? Does the potential for weight loss to improve health — at least, for some people — make weight different from other groups that are discriminated against (e.g., due to race, religion, sexual orientation). How much of our desire to lose weight is appearance versus health-driven?
Some research suggests that appearance is a bigger motivator for weight loss than is health. It’s not hard to imagine how semaglutide could be abused by those who can afford it: As a lower-dose Type 2 diabetes treatment, the cost is approximately $1,000 a month.
Dr. Natasha Larmie, a general practitioner in Hertfordshire, England, who goes by “FatdoctorUK” on Twitter and strives to challenge stereotypes surrounding weight loss, physical well-being and mental health, suggests that “individuals should be treated holistically, not according to a one size fits all healthcare system. There is reason for real concern that this new ‘miracle drug’ will be sold to the masses as a means of achieving weight loss as opposed to improving health.”
It seems unlikely that the use of semaglutide among relatively lighter people looking to drop 10 pounds would improve health.
In fact, weight loss doesn’t always improve health. In a classic review study published in the Journal of the American Medical Association, individuals characterized as “overweight” had lower mortality risk than those of “normal” weight. Another study suggests that many of the health markers often associated with weight, such as cholesterol, blood pressure, triglycerides and glucose levels may not change much at all when individuals lose weight.
Jamie Dunaev, a health psychologist at Rutgers University-Camden in New Jersey, suggests that balancing concerns about mental and physical health is essential. She asserts, “although weight loss on its own should not be the goal for most individuals, as this can lead to health-harming weight loss practices (e.g., disordered eating), weight loss may be one aspect of an overall behavioral health plan that an individual may work out with a doctor. What is important is that the doctor is sensitive to the goals and needs of the patient, treats the patient as a person and not a number on a scale and emphasizes behaviors over weight loss.”
In other words, although a drug may seem an easier approach than going for a daily walk, the benefits of being physically active extend beyond weight loss.
The lead researcher of the New England Journal of Medicine study, Dr. Robert Kushner, has been quoted as saying that semaglutide is a “game-changer” and “the start of a new era of effective treatments for obesity.” (He didn’t respond to my request for comments for this article.)
Although the study results are striking, it seems undeniable that the issues are complicated. We should ask whether weight loss truly has the potential to improve a particular patient’s health. If it doesn’t, we might then question just why we are so fixated on “fixing” their body.
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