Tue, April 4, 2023 at 10:32 AM CDT ·11 min read
The arrival of truly effective weight loss drugs marks the answer to prayers, the solution many have been awaiting desperately for decades.
Drugs such as Ozempic, Wegovy and Mounjaro can help someone lose 15% to 20% of their body weight – as much as 60 pounds for someone who started at 300 – far more than has been possible without surgery.
But some doctors, psychologists and eating disorder experts worry these new medications, originally developed to treat diabetes, could become a problem long-term.
Common side effects of these so-called GLP-1 receptor agonists – nausea, diarrhea, vomiting and constipation – can be significant. Nearly half of people with diabetes quit an earlier generation of the medications within a year, one real-world study showed, and 70% within two years.
Most people are likely to regain lost weight if they don't keep taking the drugs for life, and the psychological toll of that rebound could be damaging, psychologists predict.
Those who lose weight on the once-weekly shots will probably still need to exercise and eat well to see a health benefit. Substantial weight loss is generally associated with an improvement in health, but that has not yet been shown with these medications.
And people may not realize how much the companies making these $1,000-a-month medications are working behind the scenes to convince them they need the appetite-suppressing drugs.
"That's part of the problem with these medications right now: Big Pharma's influence on doctors and Big Pharma's influence on education," said Dr. Kimberly Dennis, a psychiatrist who specializes in treating addictions and eating disorders. "Everything we saw with the opioid epidemic."
The companies, society and many doctors are reinforcing the false idea that a certain body mass index equals health and another equals illness, she said.
"There are people at a whole range of sizes and BMIs that are healthy when you look at actual diseases," Dennis said. Weight loss drugs are "not a cure. For many of these folks, they have no actual illness."
Plenty of thin people have high blood pressure, for instance, and plenty of people who are considered medically overweight or obese don't, said Dr. Adriane Fugh-Berman, who studies pharmaceutical marketing practices at Georgetown University.
"It's not clear you're going to get improved health outcomes" from weight loss medications, she said.
And people with larger bodies will be blamed if they "fail" again to defy biology and keep the weight off, said Tigress Osborn, board chair of the National Association to Advance Fat Acceptance.
"Every time there's a new drug that promises to help people lose weight, the cultural focus on changing fat people into thin people becomes even more relentless than it already is," she said. "So-called advances in curing fatness always serve to remind fat people just how many people think the world should be cured of us."
Drug companies promote weight loss and medications
Drug companies, in particular Novo Nordisk, maker of Wegovy and Ozempic, have been building demand for their products for years.The companies have hired leading obesity medicine doctors. Novo Nordisk paid doctors just under $14 million in 2021 for education and training, government records show, while Eli Lilly, maker of Mounjaro, paid less than $1 million.
"Novo Nordisk believes that responsible engagement between pharmaceutical companies and the medical community is good for patients and advances care and science," Natalia Salomao, the company's senior director corporate brand, said in an emailed statement.
“Obesity is a chronic, progressive and misunderstood disease that requires long-term medical management," her statement said. "One key misunderstanding is that this is a disease of willpower, when in fact there is underlying biology that prevents people from losing weight and keeping it off.”
Novo Nordisk also provides funding for medical education on obesity, including one session for nurses called "Obesity: the Elephant in the Room."
Novo Nordisk was recently suspended for two years from a pharmaceutical lobbying group in the U.K. for quietly sponsoring a training program that was actually a “promotional campaign which Novo Nordisk knowingly paid for.” It marked only the eighth time in 40 years the Association of the British Pharmaceutical Industry sanctioned one of its members.
Pharmaceutical companies also are lobbying heavily to get insurers, including government-funded Medicare, to cover the cost of weight loss medications.
About 40 million of the 110 million Americans living with obesity have insurance coverage that includes weight loss medications, Salomao said.
"Novo Nordisk believes the most effective way for the millions of Americans who need anti-obesity medicines to be able to access and afford them is to ensure these medicines are covered by government and commercial insurance plans."
A study published in the New England Journal of Medicine last month found covering the cost of these medications for only 20% of eligible patients would cost Medicare $13 billion a year. Some argue this undercounts the savings that would come from improved health of those who lose weight.
Drug companies also support the Obesity Action Coalition, an industry-backed group that says it fights weight stigma. Novo Nordisk was the coalition's largest and only "platinum" donor in 2021. Lilly was two categories down in the "silver" category.
Ragen Chastain, a patient advocate and activist who researches the weight loss industry said it doesn't make sense for drug companies to say they're against weight bias while simultaneously pushing for insurers to cover their medications. "That's not actually an anti-weight-stigma position."
If drug companies really wanted to perform a public service, Chastain said, they "would focus on supporting the health of people of all sizes, rather than trying to shrink some people.”
Medical challenges of weight loss drugs
The human body has evolved to hold on to any extra pounds, interpreting weight loss as a life-threatening famine.That makes it extremely difficult for most people to lose weight and, especially, to keep it off long-term. Among many lifestyle changes over the past 40 years, people's weight has increased along with weight loss attempts, so focusing on weight loss is not an effective solution to improving health, a study in 2021 concluded.
Studies suggest this seesawing of weight may cause more health damage than simply carrying pounds.
One compilation of other studies in 2021 showed that weight cycling was associated with an increased risk for diabetes. An earlier study from the same Chinese researchers showed an association between weight cycling and a 40% higher risk of death, particularly from cardiovascular disease.
It's not clear whether the newer generation of weight loss drugs, which suppress appetite, will provide different long-term results than other weight loss approaches.
In the longest study, lasting 68 weeks – about 16 months – weight loss plateaued and started to climb again by the end, suggesting people's bodies had acclimated to the drugs.
"We certainly don't know what will happen if people are on these (weight loss drugs) for the rest of their lives, which is what Novo is suggesting," Chastain said.
Dr. Diana Alba, an endocrinologist at the University of California, San Francisco, said she's not worried about the long-term effects of these GLP-1 drugs, because similar ones have been on the market for decades to treat diabetes.
"We see obesity as a disease and we treat it like having high blood pressure, having Type 2 diabetes," she said. No one would expect blood pressure or blood sugar levels to remain just as controlled if someone stopped their medication for those conditions.
Ragen Chastain is the author of
"The Weight And Healthcare Newsletter" and the blogger behind Dances
With Fat.
Makers of these GLP-1 agonists freely agree that people will regain lost pounds if they stop taking the medications, as clinical trial participants did after the trials ended.
The drugs also come with a warning that they may increase the risk of thyroid cancer, acute pancreatitis, gallbladder disease, low blood sugar, kidney injury, damage to the eye's retina and suicidal thinking or behavior. The risks of serious side effects are small, but the more people who take them, the more will suffer.
Although the American Medical Association decided a decade ago to call obesity a disease, declaring someone "diseased" simply because they have a body mass index over 30 is inaccurate and perpetuates weight stigma, said Dennis, co-founder of SunCloud Health, a treatment center in the Chicago area.
"I cannot tell you if a person is healthy or unhealthy" simply from their BMI, she said. Instead, she needs other health metrics, such as blood pressure, fasting blood sugar and hemoglobin A1C levels, as well as information on diet and exercise to decide if someone in a large body also has an illness.
Fugh-Berman is particularly concerned about the marketing of these drugs to children.
The American Academy of Pediatrics changed its guidelines in January and now recommends aggressive weight loss methods for children as young as 2, including surgery and medications for those as young as 12.
Wegovy was approved in December for use in children ages 12 and up after approval of an earlier GLP-1 agonist from Novo Nordisk in 2020 for the same age group.
A clinical trial by Novo Nordisk showed that 134 adolescents with obesity or who were overweight and had at least one related health condition lost about 16% of their body weight over 68 weeks while taking Wegovy in addition to eating healthfully and exercising regularly. The 67 adolescents in the same trial who received a placebo lost less than 1% of their weight over that time.
But there's no data on these drugs longer-term among adolescents – who are laying down bone needed for the rest of their lives and dependent on calories for healthy sexual maturation, Dennis said.
"All the interventions that we've tried in the past decades to combat the 'obesity epidemic' have made things worse," she said. "And now we're doubling down and saying, 'Let's do the same things we're doing to adults that don't work – we just need to intervene earlier and give these things to our kids.' It's going to be a disaster."
Psychological challenges of weight loss drugs
Dieting is one of the leading risks for developing an eating disorder, said Dennis, also a member of the eight-person clinical advisory council to the National Eating Disorders Association. She worries the medications will lead to more disordered eating as people try to avoid regaining weight.Even if they lose pounds, people who overeat because of emotional or mental health struggles will still have those problems, Dennis said. "Weight loss does not cure eating disorders or trauma or depression."
Yo-yo dieting is clearly bad for physical health, "but boy is it bad for our mental health," said Erin Parks, a clinical psychologist and co-founder of the virtual eating disorder service Equip Health.
These weight loss medications commonly cause side effects of nausea or digestive problem. Parks said she would diagnose someone with an eating disorder if they came to her saying they couldn't eat because they were nauseated all the time – but they were happy about it. "That sounds like anorexia," she said. Plus, "making you nauseated on a daily basis is robbing people of the joy of life."
Alba, whose San Francisco General Hospital-affiliated clinic treats people with few financial resources, said she has some patients who don't really want to lose weight – and she sends them on their way.
For those who do, she considers the GLP-1 drugs a good option, if people can access and tolerate them.
Alba's clinic sees only patients with a BMI of 35 or higher (obesity is defined as a BMI of 30 or above), and most already have health problems that can be improved with weight loss, like knee pain, metabolic issues or fatty livers.
“I think you have to be able to give people the power to have options,” she said.
Parks said she doesn't blame anyone for feeling like they have to put themselves through misery to lose weight. "It's hard living in our fat-phobic society," she said.
The social attitudes about weight need to change, she and other experts said.
"We're tired of hearing about the next magic cure for fatness," Osborn said. "How about a cure for anti-fatness? How about a cure for weight stigma that isn't about (us) losing weight?"
Tigress Osborn, board chair of the
National Association to Advance Fat Acceptance, poses for a photo in
her home on June 9, 2022, in Chandler, AZ. Osborne sits in the chair
from which she often attends zoom meetings for the NAAFA.
People who are considering these weight loss medications should examine why they feel the need to lose weight. If they have diabetes, "that's one matter," Dennis said. "There are appropriate indications for these medications."
But for people who have obesity or are overweight with no medical issues, she said, the drugs "stand to do a lot more harm to a lot more people than good."
If you or someone you know needs help with disordered eating, contact the toll-free National Eating Disorders Helpline at myneda.org/helpline-chat or send a text to 741-741.
