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.
ALL humans change body size over time; that’s normal and expected. But sometimes medical issues predate a particular BMI. Such an important nuance to explore clinically.
I would really be uncomfortable in an obesity first medicine environment because it would just mean that I have to do the thing that I have tried - and failed - to do so many times in my life, yet again, in order to receive treatment for other issues. It took me so long to recognize that a treatment modality with a 95% failure rate is not a good treatment and yet it continues to be prescribed to me and if I'm not in the 5%, it's my fault, there's something wrong with me, not with the treatment. I've worked hard to develop a healthy relationship with food, and I have and also have stayed at a steady body size for about 4 years as a result. But I'm no longer swinging the pendulum from restricting to bingeing. I am no longer liking myself when I'm restricting and hating myself when I'm bingeing. I can buy clothes and have a good idea that I can continue to wear them because they'll still fit. I enjoy maintaining a movement practice because it makes me feel good and strong in my body. When I was moving in order to change how my body looked the habit would inevitably fade away if I didn't see an aesthetic change.
So no, obesity first medicine is not good for my health. By removing the need to change my body size, I've been able to more consistently engage in healthier behaviors than I ever did when I was trying to shrink myself.
I had to chuckle a bit at this knee pain/GLP-1 anecdote — I recently interviewed a personal trainer for my newsletter who shared their slightly frustration about a longtime client attributing their *improvement* in knee pain to their use of Ozempic (when this trainer knew that the improvement was likely coming mostly from the very specific lower-body strength and mobility programming they were doing together!). Kind of the inverse of these patient stories. It's not (always) the weight!
Thanks so much for this, Anna! I totally agree — fatphobia is so deeply engrained in our culture, that so many of us have internalized it. Looking forward to reading the interview.
My experience is that most primary care providers have been "obesity-first" for decades. The WaPo story about someone being told to lose weight when they come in about their wrist isn't, I don't think, an extreme example at all. When I was 20, I went to a doctor to get a form filled out so I could study abroad. The doctor used the time to lecture me about weight and told me if I didn't lose weight I would "die loveless and alone." (I swear to God she used those exact words. They are seared into my brain.) I got another doctor to fill out the form, studied abroad, and among other wonderful things, fell in love. I've also been lectured about my weight by several other providers, including one who I "screened" by asking her ahead of time if she would be willing to not discuss my weight with me, and she said yes...and then launched into a conversation anyway. And I don't think it really matters, but I'm straight-sized! I know people who have been told to lose weight when going in for ear pain.
An "obesity-first" approach seems like something a provider does if they want to avoid having to actually listen to their patients, or do much other than lecture and/or prescribe GLP-1s. I *really* appreciate that you don't take this approach.
Another hard layer to this, I think, is knowing how doctors talk to other doctors about this. Obesity first really makes me think, "Oh, these doctors just see me as an obese person, and nothing more." It's basically a whole approach to medicine now to just ngaf about the actual people? It makes me sad, and reminds me of this article written by a friend of mine about finding out how her doctor talked about her to other doctors. https://www.today.com/health/diet-fitness/weight-loss-drugs-doctor-apology-rcna131589
Anyway, thanks for your take on this. I'm glad to see someone is pushing back against this.
What a great article! Thank you for writing about this. I’m a medical sociologist, I do media around medical gaslighting and this is such an important part of the conversation. Look forward to following!
Hi Mara, I wanted to tell you how much I LOVED your pod episode with Virginia Sole-Smith! I am so encouraged by you and the way you describe your journey as a physician in caring for all your patients, and am super excited about AWSIM! Keep up the great work, and thank you on behalf of SO many people, in particular women, who suffer disproportionately because we all swim in the Soup of Patriarchy.
Also, I just ordered your butter reco, "What Kind of Woman," as a gift to myself. Best to you and yours for a safe and restful holiday season. Wishing you sleep and laughter. Well not at the same time though. :-) Kate
As a family doctor who incorporates obesity medicine in my daily practice in whatever way makes sense for my patients, I think a couple things are being equated here that shouldn't be. A doctor who recommends weight loss for a wrist injury is just being fat phobic, it's not part of a therapeutic approach (if anything excess weight would probably be protective in a wrist fracture scenario). There is good evidence that BP and blood sugar control can improve with weight loss, not in all people but in many, so when a patient has a borderline elevated pressure I offer them options of DASH diet, increased movement, blood pressure medication, and medication to help with weight loss if they meet criteria. I (and I think anyone who uses these approaches for a few years) can see that weight loss does reduce need for separate treatment of things like hypertension, diabetes, GERD, joint pains, sleep apnea in many cases but not all (because there are genetics and other environmental factors that may be at play). I tell patients ahead of time that all of these things are multifactorial so if they still need other medication for other things or they need multiple medications, it doesn't mean it's their fault; it may just be the nature of their disease.
I think it's good for people to know that many come to practice obesity medicine due to personal struggles with weight and diet culture, so obesity medicine does not mean fat phobia. Also some obesity medicine doctors still have obesity themselves, because not everyone responds the same to treatment. Matthea Rentea, MD is one example, she has a podcast too.
It's also important to separate services that are just prescribing compounded GLP-1s based on a questionnaire (something that provides access for many, is quite lucrative for providers but may not be safe) vs comprehensive medical weight loss /metabolic health programs vs people like me who incorporate it into primary care or specialty practice (where if anything it loses me money but is very rewarding).
Finally, some things you may want to clarify in your post: Mounjaro and Zepbound are the same GLP-1/GIP medication, just branded differently, but Ozempic is a different medication with no GIP action (though agreed that they are similar). The patient who is getting the medication through telehealth is likely getting a compounded medication which is not FDA regulated and may be unsafe (unless they are actually getting it from overseas where it's much cheaper). Zepbound with a manufacturer coupon is currently $650/month, so if they were my patient I'd encourage them to switch to the actual medication.
Thanks so much for your thoughts -- I am honored that you're reading.
Thanks for the rundown of the glp1 / gip brand names; sorry if that wasn't clear in my original post.
Mounjaro = zepbound = tirzepatide = GLP1/GIP
Ozempic = wegovy = semaglutide = GLP1 only
I think part of my reluctance to name a particular BMI or percentage reduction in body weight as a treatment goal is because it seems quite high risk - high risk for contributing to body dysmorphia and disordered eating, and ultimately stigma and health care avoidance.
So for somebody with NASH, for example, I might recommend a GLP1A, and define treatment success as an improvement in their transaminitis, or define treatment success as reduction in visceral adipose tissue visible on ultrasound. That patient might lose weight with this treatment plan, but my focus is on the visceral adiposity rather than BMI. I guess I think of weight loss as a possible side effect rather than a quantitative treatment goal in an of itself, because I worry that approach can cause a lot of psychological harm, and the ultimate goal is preventing/reversing liver disease rather than achieving a certain BMI. Does that make sense?
The same might be true for cardiovascular disease, or kidney disease, etc. As I've said many times, I think GLP1A are amazing medications that can really help people. So I might prescribe a GLP1A and define treatment success as preventing heart failure admissions, or prevent further reduction of GFR. I would think of weight loss as a side effect rather than the treatment goal, because focusing on a weight goal has so many harms.
And of course all of this changes if reduction in body weight is a stated goal from the patient, although again, I'd gently encourage them to consider a more holistic or multifactoral approach to assessing health, since BMI or a specific body weight isn't always clearly connected to more rigorous disease outcomes.
Thanks for the ongoing dialogue. Your patients are lucky to have you.
I am glad you are offering these medications for these medical indications! To be clear, I also encourage patients not to focus on a goal weight or BMI, though I will tell them that 5-10% weight loss in those with obesity is associated with reduction in comorbidities and when I use medications for the goal of weight loss (particularly non-GLP-1s for those who can't access them) that's what would be considered an effective treatment but that everyone responds differently and I don't think it's healthy to focus on the goal of a "normal" BMI since it's not a perfect measure and it may not be achievable for them, at no fault of theirs.
I understand the worries about harm of focus on weight, which is why I enjoy reading your work! But I am prescribing these medications in a context where I'm trying to push back against diet culture which I think creates a lot of obesity and health issues (including eating disorders). I think by not offering medication that helps push back against metabolic adaptation and increases in hunger hormones with weight loss, many patients (given the culture we live in) often end up doing cycles of dieting which slows their metabolism and puts them in a worse spot. Even if we don't make weight a goal, society makes weight a goal so I feel that if we tell people to eat more vegetables, move their bodies, and they do it but they don't see weight loss or maintenance it can be very discouraging to people and they stop and may end up in a worse spot health-wise. I have seen this in my patients, and that's when I encourage them to consider medication support just like they might use a medication to support blood pressure or mood or something else they might find more acceptable, and educate that there are health benefits to the lifestyle changes they made, but if they're looking for weight loss then the research shows they are doing themselves harm by making changes they can't maintain but there are treatments that can help.
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.
Thanks for sharing your perspective.
Yes, thank you for this. I've not yet had a doctor recommended GLP1s, but my response would be "How much food do you imagine I'm eating, anyway?"
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.
ALL humans change body size over time; that’s normal and expected. But sometimes medical issues predate a particular BMI. Such an important nuance to explore clinically.
I would really be uncomfortable in an obesity first medicine environment because it would just mean that I have to do the thing that I have tried - and failed - to do so many times in my life, yet again, in order to receive treatment for other issues. It took me so long to recognize that a treatment modality with a 95% failure rate is not a good treatment and yet it continues to be prescribed to me and if I'm not in the 5%, it's my fault, there's something wrong with me, not with the treatment. I've worked hard to develop a healthy relationship with food, and I have and also have stayed at a steady body size for about 4 years as a result. But I'm no longer swinging the pendulum from restricting to bingeing. I am no longer liking myself when I'm restricting and hating myself when I'm bingeing. I can buy clothes and have a good idea that I can continue to wear them because they'll still fit. I enjoy maintaining a movement practice because it makes me feel good and strong in my body. When I was moving in order to change how my body looked the habit would inevitably fade away if I didn't see an aesthetic change.
So no, obesity first medicine is not good for my health. By removing the need to change my body size, I've been able to more consistently engage in healthier behaviors than I ever did when I was trying to shrink myself.
I had to chuckle a bit at this knee pain/GLP-1 anecdote — I recently interviewed a personal trainer for my newsletter who shared their slightly frustration about a longtime client attributing their *improvement* in knee pain to their use of Ozempic (when this trainer knew that the improvement was likely coming mostly from the very specific lower-body strength and mobility programming they were doing together!). Kind of the inverse of these patient stories. It's not (always) the weight!
That interview here, if you're interested :-) https://howtomove.substack.com/p/a-queer-personal-trainer-on-compassion
Thanks so much for this, Anna! I totally agree — fatphobia is so deeply engrained in our culture, that so many of us have internalized it. Looking forward to reading the interview.
My experience is that most primary care providers have been "obesity-first" for decades. The WaPo story about someone being told to lose weight when they come in about their wrist isn't, I don't think, an extreme example at all. When I was 20, I went to a doctor to get a form filled out so I could study abroad. The doctor used the time to lecture me about weight and told me if I didn't lose weight I would "die loveless and alone." (I swear to God she used those exact words. They are seared into my brain.) I got another doctor to fill out the form, studied abroad, and among other wonderful things, fell in love. I've also been lectured about my weight by several other providers, including one who I "screened" by asking her ahead of time if she would be willing to not discuss my weight with me, and she said yes...and then launched into a conversation anyway. And I don't think it really matters, but I'm straight-sized! I know people who have been told to lose weight when going in for ear pain.
An "obesity-first" approach seems like something a provider does if they want to avoid having to actually listen to their patients, or do much other than lecture and/or prescribe GLP-1s. I *really* appreciate that you don't take this approach.
Another hard layer to this, I think, is knowing how doctors talk to other doctors about this. Obesity first really makes me think, "Oh, these doctors just see me as an obese person, and nothing more." It's basically a whole approach to medicine now to just ngaf about the actual people? It makes me sad, and reminds me of this article written by a friend of mine about finding out how her doctor talked about her to other doctors. https://www.today.com/health/diet-fitness/weight-loss-drugs-doctor-apology-rcna131589
Anyway, thanks for your take on this. I'm glad to see someone is pushing back against this.
Thank you, Tamar!
What a great article! Thank you for writing about this. I’m a medical sociologist, I do media around medical gaslighting and this is such an important part of the conversation. Look forward to following!
Hi Mara, I wanted to tell you how much I LOVED your pod episode with Virginia Sole-Smith! I am so encouraged by you and the way you describe your journey as a physician in caring for all your patients, and am super excited about AWSIM! Keep up the great work, and thank you on behalf of SO many people, in particular women, who suffer disproportionately because we all swim in the Soup of Patriarchy.
Also, I just ordered your butter reco, "What Kind of Woman," as a gift to myself. Best to you and yours for a safe and restful holiday season. Wishing you sleep and laughter. Well not at the same time though. :-) Kate
Thank you for such kind words, Kate! That means so much. Happy new year!!!
As a family doctor who incorporates obesity medicine in my daily practice in whatever way makes sense for my patients, I think a couple things are being equated here that shouldn't be. A doctor who recommends weight loss for a wrist injury is just being fat phobic, it's not part of a therapeutic approach (if anything excess weight would probably be protective in a wrist fracture scenario). There is good evidence that BP and blood sugar control can improve with weight loss, not in all people but in many, so when a patient has a borderline elevated pressure I offer them options of DASH diet, increased movement, blood pressure medication, and medication to help with weight loss if they meet criteria. I (and I think anyone who uses these approaches for a few years) can see that weight loss does reduce need for separate treatment of things like hypertension, diabetes, GERD, joint pains, sleep apnea in many cases but not all (because there are genetics and other environmental factors that may be at play). I tell patients ahead of time that all of these things are multifactorial so if they still need other medication for other things or they need multiple medications, it doesn't mean it's their fault; it may just be the nature of their disease.
I think it's good for people to know that many come to practice obesity medicine due to personal struggles with weight and diet culture, so obesity medicine does not mean fat phobia. Also some obesity medicine doctors still have obesity themselves, because not everyone responds the same to treatment. Matthea Rentea, MD is one example, she has a podcast too.
It's also important to separate services that are just prescribing compounded GLP-1s based on a questionnaire (something that provides access for many, is quite lucrative for providers but may not be safe) vs comprehensive medical weight loss /metabolic health programs vs people like me who incorporate it into primary care or specialty practice (where if anything it loses me money but is very rewarding).
Finally, some things you may want to clarify in your post: Mounjaro and Zepbound are the same GLP-1/GIP medication, just branded differently, but Ozempic is a different medication with no GIP action (though agreed that they are similar). The patient who is getting the medication through telehealth is likely getting a compounded medication which is not FDA regulated and may be unsafe (unless they are actually getting it from overseas where it's much cheaper). Zepbound with a manufacturer coupon is currently $650/month, so if they were my patient I'd encourage them to switch to the actual medication.
Hi Diana!
Thanks so much for your thoughts -- I am honored that you're reading.
Thanks for the rundown of the glp1 / gip brand names; sorry if that wasn't clear in my original post.
Mounjaro = zepbound = tirzepatide = GLP1/GIP
Ozempic = wegovy = semaglutide = GLP1 only
I think part of my reluctance to name a particular BMI or percentage reduction in body weight as a treatment goal is because it seems quite high risk - high risk for contributing to body dysmorphia and disordered eating, and ultimately stigma and health care avoidance.
So for somebody with NASH, for example, I might recommend a GLP1A, and define treatment success as an improvement in their transaminitis, or define treatment success as reduction in visceral adipose tissue visible on ultrasound. That patient might lose weight with this treatment plan, but my focus is on the visceral adiposity rather than BMI. I guess I think of weight loss as a possible side effect rather than a quantitative treatment goal in an of itself, because I worry that approach can cause a lot of psychological harm, and the ultimate goal is preventing/reversing liver disease rather than achieving a certain BMI. Does that make sense?
The same might be true for cardiovascular disease, or kidney disease, etc. As I've said many times, I think GLP1A are amazing medications that can really help people. So I might prescribe a GLP1A and define treatment success as preventing heart failure admissions, or prevent further reduction of GFR. I would think of weight loss as a side effect rather than the treatment goal, because focusing on a weight goal has so many harms.
And of course all of this changes if reduction in body weight is a stated goal from the patient, although again, I'd gently encourage them to consider a more holistic or multifactoral approach to assessing health, since BMI or a specific body weight isn't always clearly connected to more rigorous disease outcomes.
Thanks for the ongoing dialogue. Your patients are lucky to have you.
I am glad you are offering these medications for these medical indications! To be clear, I also encourage patients not to focus on a goal weight or BMI, though I will tell them that 5-10% weight loss in those with obesity is associated with reduction in comorbidities and when I use medications for the goal of weight loss (particularly non-GLP-1s for those who can't access them) that's what would be considered an effective treatment but that everyone responds differently and I don't think it's healthy to focus on the goal of a "normal" BMI since it's not a perfect measure and it may not be achievable for them, at no fault of theirs.
I understand the worries about harm of focus on weight, which is why I enjoy reading your work! But I am prescribing these medications in a context where I'm trying to push back against diet culture which I think creates a lot of obesity and health issues (including eating disorders). I think by not offering medication that helps push back against metabolic adaptation and increases in hunger hormones with weight loss, many patients (given the culture we live in) often end up doing cycles of dieting which slows their metabolism and puts them in a worse spot. Even if we don't make weight a goal, society makes weight a goal so I feel that if we tell people to eat more vegetables, move their bodies, and they do it but they don't see weight loss or maintenance it can be very discouraging to people and they stop and may end up in a worse spot health-wise. I have seen this in my patients, and that's when I encourage them to consider medication support just like they might use a medication to support blood pressure or mood or something else they might find more acceptable, and educate that there are health benefits to the lifestyle changes they made, but if they're looking for weight loss then the research shows they are doing themselves harm by making changes they can't maintain but there are treatments that can help.