Healthcare's Weight Loss Best Case Scenario Problem Part 2 - GLP-1s

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In part 1 we discussed the issues with the decades-long practice of healthcare providers prescribing behavior-based weight loss not based on the evidence (which shows that the vast majority of patients will lose weight short-term and then regain it long-term) but on the belief/hope that every one of their patients will experience the very rare “Best Case Scenario” of significant, sustained weight loss. Today we’re going to talk about how the new GLP-1 weight loss drugs are taking this problem to new lows.

I want to start by clarifying again that the idea of “best case scenario” here is based on those in the weight-centric paradigm who believe that weight loss is an important healthcare outcome. For those in the weight-inclusive paradigm weight loss is not a healthcare intervention at all let alone a best case scenario.

The two newest drugs in the GLP-1 class are semaglutide (brand name Wegovy for weight loss) and tirzepatide (brand name Zepbound for weight loss) which is a GLP-1/GIP co-agonist.

With these drugs one of the issues with the “best case scenario” problem is around the amount of weight that patients are told they can expect to lose.

The research shows the average weight loss for Wegovy is about 15% and the average weight loss for Zepbound is about 20% depending on dose.

But healthcare providers telling patients that they can lose this amount of weight, even short-term ,are still making a version of the “best case scenario” mistake.

This is the average weight loss in relatively short-term trials. But in these trials about half of the participants did NOT lose this much weight and from around 5% to around 15% of people didn’t even lose 5% of their body weight.

And that’s with the shorter studies. The four year SELECT trial for semaglutide had an average weight loss of only 10%, and in two years 32.2% failed to lose even 5% body weight (and they had such a high dropout rate that they didn’t even report the four year totals.)

Healthcare providers claiming that patients can lose “as much weight as they want” are, of course, making the “best case scenario” mistake.

In the existing research weight loss levels off, so it is also not reasonable or evidence-based to expect that those who stay on the drugs longer will lose more weight. Current studies show that when people go off the drugs the regain the weight (even more rapidly that people regain weight after behavior-based interventions). The drug companies claim that people can maintain weight loss if they stay on the drugs for the rest of their lives but there is no research showing that will actually work. In fact, 10.5% of people people regained more than 20% of the weight they lost in the first 36 weeks over the subsequent 52 weeks in the tirzepatide withdrawal trial while still taking tirzepatide (others may have regained but the authors obfuscated this by defining “maintained” weight loss as having regained less than 20% in a year.)

But here is the scenario that inspired me to write this piece. I have heard from seven different patients over the past month and a half who are facing BMI-based healthcare denials. This happens when a patient’s healthcare, often surgical care, is held hostage for a weight loss ransom (I have a do-it-yourself guide and research collections for those dealing with this here.)

In all of these cases these patients were being asked to lose between 40% and 60% of their body weight. Beyond the major issues with asking people to lose weight at all for surgical care, let alone this amount of weight, in all of these cases these patients were recommended Wegovy. In all of these cases there was almost no chance that Wegovy would create the weight loss that the healthcare system was requiring in order to consider these patients deserving of the care they need.

This is even beyond the typical “Best Case Scenario” mistake. These patients are suffering and they need healthcare, and that care will be delayed while they take weight loss medication their doctors told them to take (medication that can have serious, sometimes fatal, side effects especially at the megadoses used for weight loss,) that has almost no chance of making them eligible for the surgery they need, despite what their doctors have told them. What the provider making this recommendation should also be expected to know is that the patients’ conditions are likely to deteriorate over the months that they attempt weight loss (and this is true regardless of the method of weight loss) which can mean that even if they were able to lose the weight over months/years their surgical outcomes may be worse because of the deterioration of the condition over that time. And, with these meds as with other weight loss recommendations there is, again, essentially no chance that they actually will lose the required weight.

Of course this is exacerbated by practices that are being pushed by drug manufacturers, healthcare providers, and randos on the internet that are not evidence-based including claiming that if people stay on the meds for life they will maintain weight loss and that they can avoid regain and/or muscle mass loss through exercise and protein consumption but those are subjects for another day.

Patients don’t just deserve accurate informed consent conversations, they are ethically entitled to them. Doctors and surgeons making recommendations and claims like they are the Attending in Fantasy Land Hospital does not come close to qualifying.

If you find yourself on the receiving end of the Best Case Scenario Mistake, here are some options:

Ask the provider “what does the research show are the chances, statistically, of losing [the amount of weight they are suggesting] and what are the chances, statistically of gaining it back?

You can add a bit of an intro like “Just to ensure that I’m getting true informed consent…”

Now, there is no guarantee that the provider will give you correct information. You can also take the information here and bring it up proactively “I have some concerns about this plan. I know that the trial for Wegovy show that only about half the participants lost even 15% of their body weight, which is far less than you want me to lose, and that took 68 weeks. I don’t want this to keep getting worse for more than a year, especially given how unlikely it is that I’ll lose the amount of weight that you want me to lose. Is it possible to just move forward with my procedure now? (And, again, you can find more resources for these conversations here.)

Medical Students for Size Inclusivity have a GLP-1 informed consent document that you can find here.

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*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.