The Dangers of "Obesity First" Medicine - Part 1

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Many of you reached out to me about two articles. One in the New York Times by Gina Kolata about so-called “Ob*sity First Medicine” - OFM (you may remember Kolata from a different article I wrote about that essentially lobbied for insurance coverage for weight loss drugs and failed to disclose that each person interviewed was on the payroll of the drug companies.) Another an opinion piece in the Washington Post by Leana S. Wen. We’ll discuss the NYT article in part 1, along with some general issues and the WaPo article in Part 2. 

The New York Times piece is essentially about treating higher-weight people with health issues differently than lower-weight people with the exact same symptoms/diagnoses. What those espousing OFM (most of whom seem to be people who profit from “treating” “ob*sity”) appear to be doing here is trying to standardize an Occam’s Razor approach to the healthcare of higher-weight people. We’ve discussed this mistake here before, but the idea is that the “simplest” explanation is probably correct. The problem here is that the “simplest” explanation (that being higher-weight is at the root of health issues, and that weight loss is the solution) ignores confounding variables including weight stigma and weight cycling, and has been an abject failure for about a century. Still, here we go again - if a higher-weight person has an actual health condition, OFM, per the NYT article, while they may get treatments for their actual health conditions, the focus would be on lowering their weight (with this article discussing the use of weight loss drugs for that purpose.)

In truth, the more I’ve read about this the more it seems to me that so-called “ob*sity first” medicine is being pushed by the weight loss drug companies, the people on their payroll, and the “patient advocacy” groups they fund. The more I read about it, the more I think that  what they actually want (but don’t want to come out and say) is an “Our highly profitable drugs first” approach to healthcare for higher-weight people. 

Let’s dig in.

According to the article, in OFM:

 “the idea is to treat ob*sity with medications approved for that use. As ob*sity comes under control, they note, the patient’s other chronic diseases tend to improve or go away.”

The article continues:

“Dr. Caroline M. Apovian, an ob*sity medicine specialist at Brigham and Women’s Hospital in Boston, puts it, “You get the weight loss, and you’ve treated the high blood pressure, the fatty liver, the diabetes, the high cholesterol, the high triglycerides.”

Here Kolata notes that she “has advised companies that make the ob*sity drugs.” In fact Apovian was quoted in Kolata’s other article, which I wrote about this on June 4, 2022, at which point she had taken $3,740.00 in consulting fees from Novo Nordisk. Now the OpenPayments database shows that she is up to $68,843.06 in general payments from Novo Nordisk and another $11,070.16 in associated research funding.

Beyond that, this claim just isn’t true. Later the article admits that, in fact, the health benefits that are being credited to the diet drugs are happening before much weight is lost, but I’m getting ahead of myself. 

The article claims:

“Experts also describe another advantage: Patients often keep taking the ob*sity drugs, while many who are taking drugs they need to be healthy, like statins, abandon them.”

In lieu of a citation, Kolata links to another article she wrote for NYT (“Patients Hate ‘Forever’ Drugs. Is Wegovy Different?”) which says ”In one small study, patients stopped refilling prescriptions for months at a time, perhaps because of side effects, lack of availability, or insurance and cost issues. But anecdotally, doctors and patients say, those who begin taking the drugs are continuing.”

Let’s be clear, the research that she, herself, cited does not support the assertion for which she, herself, cited this article. Instead she’s going with anecdata from a few doctors and patients talking about what the patients “intend” to do.

In truth, the longest outcome research for the new GLP-1s (a four year study for Wegovy) found that  89.5 percent of participants did not even make it to four years. 

The article is honest that:

“Still, there are as yet few examples of rigorous studies to show that medical conditions accompanying ob*sity go away when it is treated. Large clinical trials that randomly assign patients to an ob*sity treatment or a placebo are needed to establish whether the medicine has the hoped for effect on multiple conditions.”

Yes, that is absolutely true. That’s how this is supposed to work. Beyond which, as I mentioned earlier, the article also explains that in the clinical trials that show actual health benefits, those benefits happened before much weight was lost. Which is to say that if the medications are effective for these health conditions, it’s not because the “treated” “ob*sity” first since the health changes happened before significant changes in weight. 

Again, a lot more research is necessary before any of this is understood. That’s not stopping some people though. The article quotes Dr. Ezekiel Emanuel, co-director of the Healthcare Transformation Institute at the University of Pennsylvania as saying “I’m very sympathetic to clinicians who say, ‘While the researchers are getting more data, we are going to try this approach.”

Dr. Emanuel is an incredibly famous bioethicist so I’m surprised to see him being sympathetic to clinicians who want to perform experimental medicine on higher-weight patients without discussing the issues around ethical informed consent, or the fact that thin people have all the same health issues but are not being singled out for a treatment-before-research approach. This warrants some deeper digging, but I noticed that Dr. Emanuel has been somewhat fanatically touting the supposed benefits of these weight loss drugs in outlets including the Washington Post, Yahoo Finance, and all over his social media. He seems to be all in on eradicating higher-weight people and preventing any more from existing without any discussion of the ethics of the negative impact of the stigma that viewpoint generates. 

While Dr. Emanuel is very sympathetic to clinicians performing experimental medicine on higher-weight people, I am not. The idea that simply existing in a higher-weight body and having health conditions (that thin people also get) means that doctors should just “try this” on higher-weight patients is dangerous and, without at least thorough informed consent, I would suggest unethical. 

The other big concern here is that these trials are being driven by pharmaceutical companies who promised their shareholders massive profits from these weight loss drugs. Remember that these didn’t start out as diet drugs but, rather, as type 2 diabetes drugs with a side effect of weight loss. The drug companies “took a bet” (per Novo’s CEO) that if they gave patients megadoses of the drug, they could maximize whatever side effects were producing the weight loss. I’ve written extensively about the issues with the trials and approval of these drugs and I’m not going to rehash that today. What I want to talk about is the clinical trials around effects other than weight loss. 

To that end, I want to start by saying that it’s possible that these drugs do have actual health benefits besides those associated with glycemic management and that’s worth studying. 

My concern is that the drug companies (in particular Novo Nordisk) have an incentive to get these drugs approved for health issues at the (higher) weight loss dosage, in no small part because of a loophole in Medicare Part D prescription coverage that says that, while Medicare won’t pay for weight loss medications, it will pay if the medications have other actual health benefits. We’ve also seen that they are shameless about manipulating the research methodology, statistics, and conclusions and, at least to me, it looks like they may be trying to p-hack their way to approval of these drugs for other conditions. 

All of which is to say, I do not take any of their claims of health benefits at face value. (Remember that time Novo Nordisk issued a press release claiming a 20% reduction in Major Adverse Cardiac Events for adults when it was really a 1.5% reduction that was only statistically significant for white men with an average age of 61.6 who had existing heart disease and didn’t have T2D? I do.) 

Again, it’s possible that the drugs have health benefits. It’s possible that they could create those health benefits at much lower doses than are recommended for weight loss. It’s possible that the health benefits are due to behavior changes that could be replicated without the drugs at all. We don’t know. That’s why we need actual, ethical, research. 

Finally, let’s assume that these medications actually do have all the health benefits they are claiming. Then people are being treated with medications for the conditions they have, not for “ob*sity” So even if (and it’s a big if) these drugs improve other health issues better than the treatments that are currently being used to treat those conditions, then this would be a  “better medications for these health issues first” approach, NOT an “ob*sity first” approach (and there would still be question to ask around side effects, cost, and more.)

Now, everything I’m seeing suggests that OFM actually means the new GLP-1 weight loss drugs first, but if this is interpreted as a “weight loss first” approach then it’s very likely that higher-weight people will experience delayed care for our actual health issues while we are pressured to try weight loss method after weight loss method, typically increasing exponentially in risk and cost (this is currently happening and has been an issue for decades, I feel that this effort toward OFM could increase that harm exponentially.) Even worse, when our actual health conditions get worse because of delayed/denied care, THAT is very likely to get blamed on our body size by everyone from doctors to researchers so we once again have a cycling wherein healthcare creates weight stigma, weight cycling, and treatment inequalities, then it blames the negative impacts of those on higher-weight bodies, then it uses those negative impacts to justify more weight stigma, weight cycling, and healthcare inequalities. 

In part 2 we’ll take a look at that WAPO opinion piece - which involves a lot of weight loss industry shenanigans - and what we can do to insure that our healthcare is health first and not size first. 

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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.