More Problems With Obesity First Medicine - Part 2

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In part 1 we discussed a New York Times article about so-called “Ob*sity First Medicine” (OFM) which suggests that higher weight people with health issues should be targeted for weight loss treatment (in this case specifically the new GLP-1 diet drugs) treating them differently than thinner people with the same symptoms/presentations/diagnoses.

Today we’re going to look at an opinion piece in WaPo that discusses the same phenomenon. 

The piece is written by Leana S. Wen, MD MSc FAAEM. Dr. Wen has an impressive bio and while openpaymens shows that she took nearly $1.2 million from the pharmaceutical industry from 2021-2023, none of that was from the manufacturers of these drugs. When this happens, my first guess (until I see something that suggests otherwise) is that this is someone who is most likely a product of a healthcare culture rife with weight stigma where “everybody knows” has replaced scientific method when it comes to higher weight people and healthcare.  

Let’s get into this opinion piece which is called “How ‘ob*sity first’ health care is transforming medicine.” (As always, I don’t link to articles that contain weight stigma, but I give enough information to google them if you want to.)  Note that the article is full of weight stigma, including the use of the weight loss industry’s “person first” language toward higher-weight people. The quotes from the article are indented below, you can skip them to reduce the weight stigma you are exposed to.

Health care is undergoing a major paradigm shift. Some clinicians are shifting away from treating chronic conditions such as hypertension, heart disease, diabetes, back pain and fatigue — long the bread and butter of primary-care medicine — and toward targeting their common root cause: ob*sity.

Proponents of this “ob*sity first” movement point to decades of research that tie ob*sity with more than 200 other health conditions, including heart failure, premature death and 13 types of cancer. Nearly 9 out of 10 people with Type 2 diabetes — itself a major risk factor for adverse health outcomes — have ob*sity or are overweight.

Oops. Even if we believe these claims (the links given to support them lead to fact sheets and seriously questionable evidence, so I absolutely don’t accept them at face value) there are still serious issues here. Dr. Wen, along with these “proponents,” are making a classic research methods class mistake - confusing correlation with causation based on weight loss industry claims and a pile of “research” linking weight to health issues that wouldn’t stand up to the rigor of a middle school science fair. I wrote about this in detail here. The idea that “ob*sity” (which, remember, doesn’t even have a consistent scientific definition) is “causing” these health issues ignores confounding variables including weight stigma, weight cycling, and healthcare inequalities, as well as the fact that thin people have all of these same health issues.

Beyond which, I would argue that this is not a paradigm shift at all. Higher-weight people have been blowing the whistle for decades on healthcare providers who are so obsessed with making us thin that they fail to listen to or offer treatment for the reasons we actually showed up. This is nothing new.

Scientists have long known that when ob*sity is successfully treated, many other ailments improve or disappear altogether. But until recently, weight-loss treatments were limited. Many patients did not experience appreciable change with diet and lifestyle modifications alone, and other options, such as bariatric surgery, were seen as dramatic steps. As a result, physicians had little choice but to address the complications of ob*sity rather than the disease itself.

Nope. The word “known” is not accurate here. Science has “long assumed” or has “long refused to consider any idea other than…” would be more accurate. In fact, science has found that “In correlational analyses, however, we uncovered no clear relationship between weight loss and health outcomes related to hypertension, diabetes or cholesterol, calling into question whether weight change per se had any causal role in the few effects of the diets. Increased exercise, healthier eating, engagement with the health care system, and social support may have played a role instead.”

The rise of GLP-1 medications such as semaglutide (under brand names Wegovy and Ozempic) and tirzepatide (Zepbound and Mounjaro) has made it possible to change focus. These therapies are remarkably effective in inducing weight loss (though Ozempic and Mounjaro have only been approved for managing diabetes). Research published in the New England Journal of Medicine shows that people receiving once-a-week injections of semaglutide lost an average of nearly 34 pounds in just over a year. Another NEJM study found those on tirzepatide lost as much as 52 pounds.

This paints an incredibly rosy picture of these drugs. I’m not sure why she is discussing one year outcomes of semaglutide when the four year outcome study is published. While the one year found about a 15% average decrease in weight, the four year outcomes showed that it was down to 10% average already and, far worse, they started with 8,803 participants but only had 921 participants left at the four year weigh in.

In the last sentence of the above paragraph, the words “as much as” are doing a LOT of work. I don’t know if it’s intentional or out of ignorance of the actual studies, but she seems to be working hard to pain these drugs in the best possible light rather than being honest. In fact, 2.7% of people who took Tirzepatide for 88 weeks failed to lose even 5% of their body weight, 7.9% failed to lose even 10%, 15.9% failed to lose 15% and 30.5% failed to lose 20%. This is important since they are touting the mean weight loss as 25.3%. Their long-term study found that 10.5% of people who remained on the drug had already regained 20% of more of the weight they lost in a year and we don’t have a clear picture of the rest of the sample. The claim is that they “maintained” weight loss, but Eli Lilly (the drug manufacturer who funded and were significantly involved in the study) defined “maintained weight loss” as having regained less than 20% in one year. I have a full breakdown of this study here. 

Crucially, the weight loss was accompanied by other health improvements. Not only did the medications decrease blood pressure and improve blood sugar control, but they also lowered the risk of strokes and heart attacks and reduced heart failure-related symptoms. Other studies have linked GLP-1 medications to better outcomes in a panoply of chronic ailments, from nonalcoholic fatty liver disease to chronic kidney disease.

Even more crucially, the health benefits occurred before much weight was lost. So, even if these drugs have health benefits, it had little to absolutely nothing to do with “treating” “ob*sity” which, let’s remember, just means weight loss. Further, there was no mechanism in the study (like a weight-neutral comparator group) that teased out the benefits of the behavior changes that study subjects were told to undertake vs. the medications. 

Lydia Alexander, an internal medicine physician, explained in an interview how she came to embrace GLP-1s and the “ob*sity first” approach. When she first started practicing, she would address a patient’s high cholesterol, sleep apnea, arthritis and other chronic conditions separately. She had a lightbulb moment when she started working in Kaiser Permanente’s medical weight management clinic and saw how closely interrelated they all are. To best help her patients, she said, “We have to treat the roots and not fruits of the problem.”

Ideally this paragraph would have mentioned that, in addition to pinning her entire career to selling weight loss and the concerning field of ob*sity medicine, Dr. Alexander is a consultant for Novo Nordisk who has, through 2023, taken a little over $12,000 in consulting fees and other money. Also, props for the rhyme, but it doesn’t erase that lack of critical science around confounding variables that I discussed above. 

Alexander, who decided to pursue specialty training in ob*sity management and is now president of the Ob*sity Medicine Association, told me about one of her patients. Four years ago, he had heart failure and was continuously short of breath. He had to be on disability because he wasn’t healthy enough to work. He struggled to care for his children and was depressed about his life situation.

Interrupting this completely unverifiable story of a patient (who, if he exists I have no assurance would be comfortable with his story being shared in WaPo,) the Ob*sity Medicine Association is a trade group that looks out for the interest of healthcare providers who profit from selling weight loss (“Find the tools you need to run a successful practice and advance your career in ob*sity medicine”), which I would suggest is another undisclosed conflict of interest for Alexander as President. Especially since Novo Nordisk and Eli Lilly are the only top level “Corporate Partners” listed on the OMA’s website:

Image Description:
Screenshot from obesitymedicine.org/corporate-partnerships/corporate-council

2024 Corporate Council Member

Obesity Medicine Association extends a special thanks to our 2024 Corporate Council members

*The Corporate Council will not serve to directly influence the decisions of the Obesity Meicine Association

Level 1

Novo Nordisk    Lilly

Ok, even if I believe that the council will not directly influence the decisions (which I don’t) that doesn’t mean that they won’t indirectly influence the decisions, so there’s still a lot of latitude for influence here. 

Per their 2024 Corporate Partnership Guide (which is 17 pages long and promises that sponsors can “reach thousands of ob*sity medicine clinicians, make an impression with existing and potential customers, build brand recognition with a variety of opportunities to get exposure” the Level 1 sponsorship is $50,000 with plenty of other opportunities for cash infusions from “corporate partners.” 

Now, opinion pieces don’t necessarily fall under the same ethics as reported pieces in terms of disclosing conflicts of interest, but ideally I would want doctors who are suggesting a treatment protocol for about 30% of Americans to do more than the bare minimum when it comes to the ethics of disclosing how the other doctors quoted in the story are deeply conflicted with the companies who will profit from this new protocol. 

Recognizing that ob*sity was the underlying cause of his multiple conditions, Alexander started him on a GLP-1 medication alongside a nutrition and physical activity program. Now, he no longer needs four of his six blood pressure medications. His heart failure improved so much that he is asymptomatic. He is back to full-time work. “He’s literally gotten his life back,” she said. “And he’s no longer depressed because he can take care of his children and be part of society again.”

Beyond the fact that anecdata is not remotely the same thing as evidence derived from research and that, again,  this story is completely unverifiable, this points out a lot of the issues with weight stigma in healthcare. First, a “ob*sity” medicine doctor “recognizing” that “ob*sity” is the underlying cause of all of someone’s health conditions (despite the fact that there are thin people with the same health conditions) is a little bit like a hammer “recognizing” that a nail is just what the doctor ordered. 

Note that, again, behavior changes were undertaken and there was no effort made to tease apart the impacts of the behaviors from the impacts of the drugs. Second, note that she didn’t say anything about weight loss - how much, if any, and when it occurred. Again, if these drugs have health benefits, they seem to happen before much weight is lost. Finally, depression is a complex issue and oversimplifying it to “productivity cures depression” and glossing over the opportunity to create a society in which people who are dealing with chronic physical and/or mental illness can be a part, is problematic on many, many levels.

To me, this example illustrates the strengths of prioritizing ob*sity treatment. From the start, clinicians regarded weight loss not as a cosmetic issue but as a medical imperative. Since lifestyle changes alone weren’t working, medications were added. The patient continued to receive care for all his other conditions, and when those improved, his treatment regimen was adjusted.

To me, this example illustrates a lack of disclosure when one interviews a doctor who has dedicated her career to weight loss, who is the president of a weight loss industry trade group that takes money from the manufacturers of weight loss drugs and who is, herself, a paid consultant for a company that makes the weight loss drugs she is recommending.

Such an approach will not work for everyone. Some people do not lose sufficient weight with GLP-1s or have to stop because of side effects. It’s not known whether the medications have to be taken in perpetuity and what long-term implications would come with lifetime usage. Moreover, weight loss alone is not the magic solution; many still need ongoing treatment for chronic conditions.

I appreciate the honesty here. In truth, for all the reasons mentioned, such an approach may not work for many people at all (remember that the Semaglutide 4 year study experienced an 89.5% dropout rate.) And, again, there is literally nothing in this opinion piece that suggests that an “ob*sity first” approach was helpful at all. Given that there is no method to tease apart the benefits of behavior changes vs the medications and that the health benefits happen BEFORE much weight loss, at most you could say that GLP-1 drugs may have health benefits, which should be tested through thorough, ethical research.

Then there is the issue of cost. The irony with Alexander’s patient is that because he went back to work, he no longer qualified for state Medicaid. His private insurance plan does not cover the medication. He is worried that he will gain back the weight he lost and reverse the remarkable progress he’s made.

All the research that exists says that he will, indeed, regain the weight he lost and lose cardiometabolic benefits. That said, the research also suggests that could happen even if he stays on the drug. Also note that this opinion piece is not not-so-subtly lobbying for insurance coverage of these drugs which is, of course, a priority for their manufacturers.

More than a decade ago, the American Medical Association officially recognized ob*sity as a complex chronic disease requiring medical attention. It was a major shift from implicitly blaming people for their weight to acknowledging that they need medical attention.

False. More than a decade ago, the AMA recognized “ob*sity” as a disease bending to the massive lobbying efforts of the weight loss industry and overriding the recommendation of their own Committee on Science and Public Health which, after studying the question for a full year, recommended against recognizing “ob*sity” as a disease in part due to a concern for  overtreatment which would expose higher weight people to unnecessary side effects. Which, I would suggest, is precisely what happened and what is happening here. 

The next part of this transformation is now happening. How much “ob*sity first” will become the norm depends on whether effective treatments will be made widely available. In my view, how to pay for ob*sity medications is one of the biggest health policy challenges facing the United States.

Stop this train, we have to get off. 

This sounds much more like lobbying for big pharma than science. Dr. Wen, the author of this op-ed  co-wrote the book “When Doctors Don't Listen: How to Avoid Misdiagnoses and Unnecessary Tests” which discusses “how medicine has morphed from thoughtful engagement between doctors and patients to cookie-cutter recipes that regard all individuals alike.” That’s exactly what “ob*sity first” medicine does - putting everyone with the same height/weight ratio on the same cookie-cutter drugs.

Encouraging healthcare providers to see higher-weight patients as walking, talking pathologies isn’t new, and while it has increased things like delayed appointments and patient disengagement from care, it has never improved the health (or healthcare) of higher-weight people. Higher-weight people deserve access to weight-neutral healthcare that stops trying to shrink us and focuses on supporting our health directly. Let’s have a healthcare system that is more dedicated to supporting the actual health of higher-weight people than to the eradication of higher-weight people, even if it doesn’t suit the voracious profit desires of the weight loss industry and their shareholders. 

If you are worried that your provider is practicing “ob*sity first” medicine rather than treating you ethically as an individual patient, here are some things that you can do:

• If they discuss prescribing a GLP-1 drug for anything other than glycemic management (the original approved use of these drugs,), you can ask what specific health benefits they expect the drug to have and the research supporting it. If they say they  are trying to create weight loss as a way to solve other health issues then you can ask what they would recommend for a thin person with those health issues. 

• You can ask directly - do you practice “ob*sity first” medicine. If they say yes you can say, I would prefer that you provide me with the same treatment that you would give a thin person in my situation. 

• If you aren’t interested in GLP-1 drugs and/or ob*sity first medicine  you can say “I’m not interested in those medications/that approach, what are the other options” and/or, if they continue to push, you can say “I’m exercising my right of informed refusal to those drugs/that approach, what are the other options”

Remember, this is your healthcare and your body.

If you need some support dealing with weight stigma at the doctor’s office, I have a video workshop that you can find here. There is a pay-what-you-can option so that money isn’t a barrier.

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More research and resources:
https://haeshealthsheets.com/resources/

*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 Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.