What is "obesity-first"medicine?
And why it's basically the opposite of the way I practice
Welcome to Chief Complaint! For those of you who are new, this newsletter features intermittent musings about medicine, gender, parenting, and body liberation — all from your friendly neighborhood primary care doc. I’m so happy you’re here.
First, a few bits and bobs to share:
I was on Virginia Sole Smith’s amazing Burnt Toast podcast, talking about medicalized fatphobia and why doctors are just so bad at being nice to their fat patients. I’d be so honored if you’d give it a listen.
I will be talking with the Columbia University Narrative Medicine program on Tuesday 12/3 at 7 pm EST on Zoom about my career as a physician and a writer. If you’re interested in how we tell stories about illness and wellness, please register here.
The Association for Weight and Size Inclusive Medicine will be having its kickoff event on Wednesday 12/4 at 8 pm EST on Zoom. We’d love to have you join! Please register here. It’s aimed at health care providers, but all are welcome.
The other day in my primary care clinic, I had two patients in a row who told me the exact same thing.
(Medicine is always like this — conditions always show up in twos and threes! And yes, medicine is highly superstitious. If you say the phrase, “Wow, things are quiet today,” you will be shunned and disinvited from eating the break room donuts because you’ve brought on a maelstrom of drama.)
The first patient was a woman in her 60s who had been using Zepbound for several months — that’s a GLP1/GIP agonist, similar to Ozempic (which is a GLP1 only), used to treat diabetes and for weight loss. She got it from an online obesity medicine doctor who charged her about $600 a month for the drug.
(She had asked me to prescribe it, and I did, since centering my patients’ bodily autonomy is one of my core values as a doctor. But it wasn’t covered by her insurance, and would cost thousands a month at the pharmacy. So she turned to a telehealth company that sources the medications itself.)
She had lost weight, a fair amount. Her body mass index had moved from the 40s to the low 30s. When she came to see me the other day, she told me she was happy with the result.
But she was frustrated with one nagging problem.
“My knee still hurts, Doc!” she complained. “I can’t tell you how many orthopedic surgeons told me that my knee would stop hurting if I just lost weight.”
She gestured down at the offending knee, and the cane she used to stabilize herself as she walked around. “Well, I did lose weight. But it’s still killing me.”
The next patient had a similar story — although in some ways, it was also quite different. She had recently given birth, and she was breastfeeding. She had lost a lot of weight after delivery, as some people do, especially when considering the intense metabolic demands of feeding a newborn human.
“I’ve lost so much weight,” she told me, after showing me a photo of her nine-month-old. (Super cute, obviously. Looked exactly like her.)
“It’s strange, though. My knee still hurts,” she said. “I thought the weight loss would fix it.”
I looked back in her medical record. Two years before, I had talked to her about knee pain — we had thought, at the time, it was related to her long hours lifting boxes in a warehouse.
Now, thirty pounds lighter, she was still experiencing the pain. She never had time to get to the physical therapy sessions I had prescribed, since the PT office was a few towns over, she didn’t have a reliable ride, and they could only schedule her in the middle of the workday when she was — yep — lifting boxes at the warehouse.
Back to back, following clinical medicine’s law of twos, I had patients tell me the same thing: they had lost weight, and they had been led to believe that would cure their knee pain.
But it hadn’t. Their knees still hurt. A lot.
Weight loss wasn’t the magic bullet they were hoping it would be.
Lately, I’ve been seeing pieces in major newspapers (see here and here) about “obesity-first medicine,” where doctors prescribe medicines for weight loss as the first step in any treatment plan.
Several readers have asked about my thoughts on this approach. And it seems to be, well, pretty much the exact opposite of the way that I practice medicine.
The doctors interviewed in these articles say they start their “obesity-first” treatment plan by trying to reduce their patients’ body mass indexes — usually through use of a GLP1 agonist — and that miraculously, every other medical problem falls away.
Bam! No more hypertension, or back pain, or diabetes, once the patient loses weight.
Sounds nice, doesn’t it? It’s kind of the medicalized version of the magical thinking I see sometimes around GLP1s from my patients, which I’ve written about for NPR.
“Dr. Gordon — I want to take Ozempic because I’ve been having a lot of stress in my marriage.”
“Dr. Gordon — I want to take Ozempic because I’m not used to wearing pants this size.”
Sadly, a lot of people overestimate the healing powers of these drugs.
It’s a testament to how deep fatphobia runs in our culture: they think being fat is the source of every problem, and getting thin is always the solution.
Ozempic has been around long enough for me to take care of several patients who’ve lost a significant amount of weight on GLP1s. Many of them are happy with the results, and plan to continue the medications indefinitely. But these patients would be the first to tell you: Nope, it definitely doesn’t fix everything.
So if the way I practice is the opposite of “obesity-first,” what does that mean in practice?
I sometimes define size-inclusive medicine as asking myself this question: “How would I treat this person if they were thin?”
This framework is the core of my size-inclusive approach. With extremely limited exceptions, I don’t bring up my patients’ body size — unless it’s a topic patients themselves want to discuss.
We treat their medical problems with the myriad of treatment options we have at our disposal: medications, surgeries, and yes, “lifestyle changes” like exercise, veggies for dinner, cutting back on alcohol, prioritizing sleep.
If a person with a body mass index of 24 had hypertension (and they do; every day I take care of thin people with high blood pressure!), my first response would not be to tell them to lose weight. My first response would be: “Let’s get you on a blood pressure medication. And exercising regularly. And quitting smoking.”
If a person with a body mass index of 24 had diabetes (and again, they do!), I would also not recommend weight loss. My response would be the same as above: medications, regular exercise, cutting back on the sugary Monster Energy drink habit, etc.
So that’s what I tell my patients in bigger bodies, too. Some patients may lose weight in the course of treatment for other conditions; some may not. And that’s okay.
The difference between my approach and “obesity-first” is this: I don’t measure the success or failure of our treatment plan by the number on the scale.
Mostly, I worry that an “obesity-first” approach alienates our patients.
Over and over, my patients tell me stories of doctors who wouldn’t take their concerns seriously, doctors who forced them into a discussion about their weight when the patient had scheduled an appointment to talk about something else.
Back in May, I was interviewed on a Washington Post podcast that also featured a Post columnist who shared a story. He broke his wrist, and was told to lose weight by the doctor he saw for it. For a broken wrist!
What a ridiculous and upsetting story. Of course he felt disrespected, and stigmatized, and reduced to a number from a full and complex human who needed care for his broken bone.
It’s an extreme example, but I fear that’s exactly what “obesity-first” medicine advocates for. Discussion of BMI at every opportunity. Zoning in on weight, and ignoring that patients may have other health goals or concerns they want to discuss.
I just don’t think “obesity-first” medicine is patient-centered. Perhaps my approach is “obesity last.” Or “obesity as a totally separate phenomenon that I don’t take into consideration when treating high blood pressure, or heartburn, or depression.”
I’m also not convinced that obesity is a disease that warrants treatment. There’s so much conflicting evidence about the relationship between body size and risk of disease. We just don’t fully understand the way adipose tissue interacts with genetics and environmental factors to cause medical problems. So for now, I’ll focus on what we do know: many patients in bigger bodies feel extremely unwelcome in doctors’ offices, and I can do a great job taking care of them by focusing on specific medical issues, not simply their BMI.
Still, sometimes it feels funny to be advocating for a treatment approach that focuses on each individual condition, since that’s what my specialist colleagues do.
I’m eternally grateful for their expertise. But a lot of patients get fed up when they see one doctor for the heart, and another doctor for the kidneys, and their schedule gets packed with doctors’ appointments, and they hate having to pay for parking, and when they want to discuss anything that’s outside of the specialist’s scope, they’re told: “Oh, just ask your primary care doctor about that.”
That’s why I love being a primary care doctor. I get to think about the big picture, and I get to think about our bodies as interconnected systems — of organs, yes, but also with other humans and the world around us.
So is it possible that’s what “obesity-first” medicine is? Holistic care, that treats the whole patient, not a series of related diagnoses? I think it’s important to take these questions seriously, even if I ultimately reject them.
For some patients, pursuing intentional weight loss does help them achieve their other health goals. I have patients who have found that medically-assisted weight loss helps them get more physically active.
I have other patients who use GLP1 agonists for other purposes — to reduce their blood sugar, or protect their heart, or to treat liver inflammation associated with adipose tissue — and find that they lose weight as a side effect. I’m not sure we know, really, if the weight loss is the cause or effect of reducing markers of metabolic syndrome.
There’s also a ton of new research coming out about GLP1 agonists, and I want to stay open to it. I never, ever want my size-inclusive approach to become so dogmatic that I ignore treatments that could help my patients live healthier lives.
Just last month, a paper came out in the New England Journal that looked at the use of GLP1 agonists to treat exactly what ailed my patients — knee pain! Researchers found that using these medications helped people with osteoarthritis of the knee improve both their pain and their function.
It’s not clear exactly how it stacks up compared to the mainstays of treatment, like physical therapy and anti-inflammatory painkillers like ibuprofen. Weight loss certainly wasn’t a panacea for the patients I saw the other day. But as a doctor, I think it’s really, really important that I stay open to data like this.
In some of my conversations with other size-inclusive doctors, we’ve been asking ourselves this question: What are our values, even if the science changes? Even if there’s new, irrefutable evidence that every single person with a BMI over 26 will live longer, disease-free lives if they take a GLP1 agonist? (There isn’t, but it’s a useful thought exercise.)
I’d still want my patients to feel like their own health goals are the center of every conversation. I’d still want my patients to have a powerful sense of their bodily autonomy, and that I’m a guide in helping them achieve that. I’d still want them to feel empowered to think through what it means — to them — to be healthy.
And that’s a much harder task than just doling out Ozempic to every person who walks into my office.
I’m curious: What are your thoughts about an “obesity-first” model of primary care? I’d love to hear.
A note about patient confidentiality: Trust is at the core of all of my relationships with my patients, and as such, I don’t share their stories publicly. Any patient story you read here — or in any of my writing that isn’t in the electronic medical record where I write thousands of words a day, ha ha — either has details removed so patients can’t be identified, details changed, or is a composite story that combines information from multiple patients. The essence of every patient story I share is true.
Excellent article that explains the issues with obesity first medication. As a dietitian I also have concerns with widespread use of appetite suppressing medicine when typically there is little to no assessment pre and post of nutritional intake. There are studies showing that average calorie intake of people in larger bodies is not higher than those in smaller bodies and there are higher rate of nutritional inadequacy.
Thank you so much for offering a nuanced and thoughtful perspective on this - especially as a doctor.
My own health problems started long before weight was an issue for me. And despite losing weight at various times (mostly by engaging in unhealthy eating behaviors - not entirely discouraged by doctors) my conditions have caused me to continue gaining weight. Although they are conditions that cause weight gain, my weight is still treated as a choice and a failing. If I would only try harder! Or choose the right weight loss avenues! And as more health problems mount, and more specialists tell me to “just lose weight”, my hopes for a life where I can pursue even the simplest of my dreams (have a job. Have my own living space. Get a dog.) evaporate, like I know many doctors I’ve seen wish my weight would. And it must be my fault. I was even recently told that if I didn’t have 35 hours to commit to weight loss every week (despite the nutrition and weight loss APRN failing to explain to me what these hours consisted of when I asked her) then I didn’t actually want to lose the weight and am not committed enough. It’s absolute baloney.
So, thank you - truly - for speaking up about this.