Drugs that cause weight to melt away sound more tempting than chocolate cake, but weight loss drugs won’t cure obesity. And that’s OK, because obesity isn’t a disease to be cured. Obesity is just a risk factor for more important 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 it’s the important cardiovascular risk factors, not obesity. Plenty of thin people have high blood pressure, and many fat people don’t.
The criteria used to measure obesity – body mass index (BMI) – is hugely imperfect at best; many large-framed or muscular people (think football players) will appear overweight or obese on BMI because BMI doesn’t distinguish between fat and muscle mass. In 1998, the number of overweight and obese individuals in the USA increased literally overnight by 37 million when an NIH task force (nearly 90% of whom had financial conflicts of interest with the weight-loss industry) redefined overweight 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 the treatment goal weight loss rather than improved health outcomes. There’s little to no evidence that weight loss, by itself, reduces cardiovascular disease or death. What reduces deaths from cardiovascular disease is increasing physical activity and improving cardiorespiratory fitness. And exercise reduces deaths from many diseases. A fat, fit person is in better shape, healthwise than a thin couch potato. In fact, repeated weight loss attempts may contribute to weight gain and cycling; yo-yo-ing weight is associated with significant health risks.
Of course, if obesity is a disease, the idea that a drug is needed to treat it goes unspoken. And if it’s a chronic disease, that’s a lifetime on the drug.
Enter the new, highly touted weight loss drugs.
A bit of background on these “miracle” drugs. When a class of diabetes drugs (GLP-1 agonists) showed an unexpected side effect of weight loss, they were repurposed for a new market. As weight loss drugs, they’re intended only for those who are obese or overweight and have another medical condition. That caution hasn’t stopped doctors from prescribing them to patients who are merely overweight without additional health problems.
The risks of Wegovy, Ozempic, and other similar drugs are very likely to outweigh benefits in healthy overweight people. These drugs increase risks of acute pancreatitis, gallbladder disease, kidney problems, and suicidal ideation and may increase the risk of thyroid cancer. Proponents of the drugs only mention nausea, vomiting, and diarrhea because they don’t sound as serious as pancreatitis, cancer or suicide. And while these drugs have been used – at lower doses – to control blood sugar for diabetics, there are no data on the long-term side effects when used in high doses solely for weight loss. The drugs will certainly lighten wallets; their whopping price tags reach as much as $1300/month. Analysts are predicting that obesity treatment could grow from a $2.4 billion category in 2022 to $54 billion by 2030.
Sure, some people do lose weight on these drugs. But they ruin the enjoyment of food, and the weight comes back once these drugs are stopped. That means a lifetime on the drug. In contrast to a public health approach that tackles systemic problems that create obesity (rates are highest in poor neighborhoods, where people have little access to healthful food or safe places to exercise), these drugs merely address a symptom while distracting from mobilizing support to bring change necessary to improve the social environment.
Marketing for the new drugs carries 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 were required to increase physical activity and reduce calories is not part of the hype around these drugs.
The messages backing these new drugs undermine any true public health efforts. What makes health outcomes better is long-term healthy choices – with or without weight loss – not short-term restrictive dieting that leads to weight rebound. 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 claiming the need to destigmatize obesity, messaging around weight loss drugs actually increase bias. Fat people do face stigma, and unfair judgments that they could lose weight if they just changed their behavior. But the availability of repurposed diabetes drugs increases pressure on obese people to lose weight. Ragen Chastain, an advocate for size acceptance and Health at Every Size, describes these messages as a wolf in sheep’s clothing, using the language of stigma to sell weight loss rather than to reduce discrimination.
Pressure is building 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 drug manufacturers. Payers should stick with the evidence and resist covering 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.
