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COMMENTARY
Sylvia Gonsahn-Bollie, MD
October 31, 2022
#MyOzempicJourney has gone viral on TikTok. People are calling their doctor’s offices requesting semaglutide (Ozempic) by name to get the same dramatic weight loss transformations they’ve seen online.
Sylvia Gonsahn-Bollie, MD
As an obesity expert who was an early adopter of the glucagon-like peptide 1 (GLP-1) agonists, the class of medication semaglutide belongs to, I have mixed feelings about its new popularity as well as other weight loss medications. However, I’ll try to present a nonjudgmental view of the clinical considerations of weight loss medications. Specifically, I want to discuss the benefits and potential harms of using weight loss medications.
First, let’s start with a bit of housekeeping on what we call these medications. Medications used to reduce weight or treat obesity are commonly called “weight loss medications.” But the correct US Food and Drug Administration (FDA) term is “anti-obesity medications” or “AOMs.”
The term “anti-obesity” can be offensive to some patients. So my preferred term is “metabolic medications,” which emphasizes that “weight loss medications” do more than induce weight loss. Metabolic medications also improve metabolism and, for some medications, also improve cardiometabolic health. Therefore, in this piece, I’ll use the terms “weight loss medications,” “metabolic medications,” and “anti-obesity medications” interchangeably.
Let’s start with the benefits of metabolic medications.
Treat the root cause of hormonally driven weight gain. Obesity is a complex medical disease with health consequences beyond the scale. In the past 10 years, our understanding of the pathophysiology of obesity has increased significantly. Fitness, healthy food choices, and other lifestyle changes are foundational to weight loss and obesity treatment. But for many people, these lifestyle changes aren’t enough to lose and sustain weight. The development of medications that affect the incretin pathway, like GLP-1 agonists, is groundbreaking. GLP-1 agonists mimic the body’s natural satiation pathway, which helps improve hunger, decrease energy intake, and improve glycemic control. Moreover, these medications suppress the body’s “weight regain” mechanisms.
Provide more tools for metabolic equity. Everyone is not playing on the same metabolic playing field. We know this from studies of twins which show a genetic predisposition to gain weight or develop obesity. Additionally, weight regulation is more complex than “calories in vs calories out.” Over 70 weight gain triggers make some people prone to gaining weight. A common misconception is that taking a weight loss medication is cheating or giving the patient an “unfair” weight loss advantage. However, the opposite is true. In a person with insulin resistance, diabetes, or obesity, metabolic medications only level the metabolic playing field by addressing the underlying weight gain triggers that prevent weight loss.
Result in less blame for “failed” lifestyle changes. “I failed my diet.” I can’t tell you how often I’ve heard this phrase or said it myself. People unfairly experience blame and shame when they don’t lose significant weight through lifestyle changes or regain the weight. However, data shows most people will lose only 2%-5% of their body weight with lifestyle changes alone. Studies show that up to 80% of weight will be regained within 5 years. These sparse numbers are due to more than willpower. As I mentioned, powerful neuroendocrine pathways signal your body to regain the lost weight. Taking metabolic medications suppresses these pathways.
However, in addition to the benefits, the recent popularity of weight loss medications like semaglutide does highlight some potential harms.
Weight bias. An obsession with thinness has been the standard of beauty in Western culture for over a century. As Dr Sabrina Strings highlights in her thought-provoking sociological book Fearing the Black Body, this preoccupation with thinness has both racist and sexist origins. Even the standard body mass index (BMI), the most commonly used tool for obesity screening, is biased. Prompting calls for body composition and other metabolic health indicators to be used for health assessment instead of the standard BMI, as I wrote in my previous Medscape column. The prevalence of weight bias in society and healthcare raises the question, “Are we using metabolic medications for thinness or health?” Obviously, as clinicians, our goal is health optimization. However, we must be careful not to let weight bias obscure our objective clinical assessment.
Furthermore, in the past decade, significant strides have increased the acceptance of body diversity and individualized healthy weight. However, people exploiting semaglutide and other medications off-label to become super-thin threatens the progress in body diversity acceptance. It also emphasizes the medications’ weight loss properties, which can overshadow metabolic medications’ life-saving benefits for people with a medical indication for taking semaglutide and other metabolic medications.
Health inequity. Newer GLP-1 agonists can markedly improve the health of people with diabetes or obesity. However, diverting metabolic medications to people for off-label or cosmetic use is causing medication shortages. Furthermore, the cost is prohibitive to people who need them most. The unjust access to newer anti-obesity medications worsens health inequity and health disparities.
Risky prescribing practices. The “street value” of an Ozempic prescription is $1200-$1500. The public views Ozempic as a safe drug, with “only stomach side effects.” Scripts are given without essential prescreening and monitoring to decrease drug risks. However, it’s easy to miss serious risks when selling prescriptions without screening and tracking. For example, GLP-1 agonists increase thyroid cancer risk in people with a specific family history. Again, it’s easy to overlook this risk without taking a family history. Lastly, all medications have side effects. Although GLP-1 agonists like semaglutide have undergone extensive testing, there are still risks for new side effects. Therefore, people taking semaglutide and other metabolic medications need monitoring.
Unhealthy weight loss. One celebrity boasted about her “18% body fat” due to Ozempic. This body fat percentage is at the lower limit of normal. Fat is an essential body organ, especially for women, who need higher body fat levels than men. Anti-obesity medications are intended to reduce excess fat levels to improve metabolic health, not make people underweight. Furthermore, another undesired side effect of GLP-1 agonists is the loss of muscle mass. Using metabolic medications in the wrong population increases the risk for lowering body fat and muscle below healthy levels.
Weight regain. Whatever you do to lose weight, you’ve got to be able to do even more to maintain weight loss. Weight gain is your body’s default mode. That’s why weight regain is common. Unfortunately, studies also show weight regain with GLP-1 agonist cessation. Weight loss and obesity treatment require a comprehensive biopsychosocial approach to maintain weight loss and improve health. If people only take weight loss medications without other lifestyle changes, it’s unlikely that the weight will stay off without the prescription.
As doctors and clinical prescribers, we can access the most innovative and effective weight loss and metabolic health improvement tools. Anti-obesity medications/metabolic medications are here to stay and will only improve as technology advances. Therefore, we must use our prescribing power to enhance people’s lives for not only short-term weight loss, but also long-term health improvement. That starts with ensuring we prescribe appropriate medications to the right persons. When we give people “weight loss medications,” we are also affecting their metabolic health.
Data, not societal trends, must guide our clinical judgment. The desire for people to alter their bodies to fit an ever-elusive beauty standard is as old as time. Last year, curvy was in. This year, thinness is back. That’s why we clinicians must check our biases, so that we base our medical treatment on facts, not fads.
Sylvia Gonsahn-Bollie, MD, DipABOM, is an integrative obesity specialist who specializes in individualized solutions for emotional and biological overeating. Connect with her at www.embraceyouweightloss.com or on Instagram @embraceyoumd. Her bestselling book, Embrace You: Your Guide to Transforming Weight Loss Misconceptions Into Lifelong Wellness, is Healthline.com’s Best Overall Weight Loss Book 2022 and one of Livestrong.com’s picks for the 8 Best Weight-Loss Books to Read in 2022.
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Credits:
Lead image: Novo Nordisk
Image 1: Sylvia Gonsahn-Bollie, MD
Medscape Diabetes © 2022 WebMD, LLC
Any views expressed above are the author’s own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: Are Weight Loss Medications for Health or Thinness? – Medscape – Oct 31, 2022.
CEO, Lead Physician, Embrace You Weight and Wellness, Telehealth & Virtual Counseling
Disclosure: Sylvia Gonsahn-Bollie, MD, has disclosed no relevant financial relationships.
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