Let’s Cut Through the Noise about Ozempic & Obesity
As the appetite for Ozempic grows, the ideological divide about obesity widens
ICYMI 👉
The debate around obesity’s causes—from the fast food industry to the failure of individual willpower—is decades old. What’s new are the highly effective GLP-1 weight loss medications (Ozempic) and heightened ideological divides on the subject.
I’ve written extensively about the pros and cons of Ozempic (here and here). Today’s post is for anyone struggling with their metabolic health—from menopausal weight gain to obesity and diabetes—who is tired of getting medical advice (and sometimes medical reprimands) from politicians, celebrities, and wellness experts online.
Let’s cut through the noise.
The debate about obesity drugs has intensified since President-elect Trump nominated RFK, Jr., to lead Health and Human Services and President Biden declared that Medicare should pay for Ozempic prescriptions. This is not, of course, because obesity has anything to do with politics but rather because of the bizarre degree of certainty emanating from various public figures’ mouths about simple solutions to a complex problem. Doctors, wellness influencers, and elected officials on both sides of the political spectrum seem to conceptualize obesity as either a problem of personal habits or a genetic problem whose victims have little control over their medical destiny. This framing pits willpower against drugs, nurture against nature, and is dangerously detached from reality.
Suggesting that replacing high-fructose corn syrup with cane sugar in Coca-Cola will meaningfully improve the obesity problem in this country is as ridiculous as rubber-stamping Ozempic as the sole treatment for it. Claiming that obesity stems from genetics alone is as preposterous as touting body positivity as the solution for serious metabolic problems. Yet the hot takes keep on coming!
On one end of the spectrum are fitness gurus like Jillian Michaels who say that obese Americans should reject Ozempic and simply eat better and exercise. Dr. Casey Means wants to expose the food industry for making and keeping Americans sick—and the pharmaceutical industry for drugging us for profit and personal gain. Her brother, lobbyist and health influencer Calley Means, claims that if Medicare covers the cost of Ozempic, drug companies will become richer and conversations in the doctor’s office about lifestyle changes will be rendered obsolete. “No incentives for healthy eating or exercise - straight to Ozempic,” he asserts. Michaels, Means, and RFK, Jr, are chafing at the American Academy of Pediatrics’ new guidelines that encourage doctors to prescribe weight loss drugs to patients under the age of 12 who are diagnosed with obesity.
On the other end of the spectrum are those who adopt a strictly medical model for obesity. In a segment on 60 minutes last year, Dr. Fatima Cody Stanford, an obesity specialist at Mass General Hospital, argued to Leslie Stahl that obesity is predominantly genetic and is not about “willpower.” Oprah Winfrey ditched her role at Weight Watchers in solidarity, arguing that beating the drum of “diet and exercise" not only sets people up for failure; it perpetuates the social stigma associated with living in a larger body. This stance aligns with the “Health at Every Size” (HAES) movement which aims to help people shed the shame of obesity and recognize that health is not measured by BMI alone. The main difference is that HAES rejects GLP-1 medication use in favor of body acceptance, whereas Oprah and doctors like Cody Stanford endorse its use.
Who is right? In my opinion, all of them and none of them at once. Of course I agree that regular exercise and nutritious eating are essential for health. I agree that pharmaceutical companies profit off of sick Americans. I agree that processed foods and other elements of the U.S. food industry set people up for chronic disease. I agree that obesity has genetic components. I agree that our healthcare system needs reforming in order to incentivize doctors to spend time with patients instead of simply prescribing medications.
On the other hand, the data are clear that lifestyle changes alone are rarely sufficient for patients with obesity. The American healthcare, pharmaceutical, and food industries do a lot of good and aren’t going to change overnight. Ozempic is already putting a dent in the obesity epidemic and reducing the risks of heart attack, stroke, and complications from type II diabetes. If we had a cancer drug as effective as Ozempic, no one would be shouting, “Get to the root cause of the cancer FIRST!!”
Of course Ozempic isn’t a panacea; it’s a tool. It isn’t appropriate for every person who struggles with obesity or metabolic health. It works best when it is paired with education, lifestyle changes, and careful medical monitoring. It has potential side effects. It can also do harm. But so does not treating obesity. So does moral outrage over manufacturing, prescribing, or ingesting effective medications. So does sitting around waiting for reforms of Big Pharma, Big Sugar, and American healthcare before treating a public health epidemic.
I vote we quit it with the false dichotomies. Telling someone with obesity not to take Ozempic and “just eat better!” is like telling someone with asthma not to take their inhaler and “just breathe better.” Similarly, inappropriately telling someone that genetics alone are responsible for their weight problem—or, perhaps worse, that body acceptance is tantamount to treating their long term risks of cardiovascular disease—deprives them of agency over their health.
It turns out that two things can be true at once. With appropriate medical guidance, hormones and health habits can be optimized simultaneously. Body image and sugar consumption can be addressed in tandem. Physical exercise and weight loss medication can be prescribed together. Nature and nurture have always coexisted.
In other words, complex problems require complex solutions.
My advice for treating obesity? On an individual level, it has to happen one patient at a time, ideally in the doctor’s office, by addressing whatever behavioral, lifestyle, genetic, hormonal and other factors are at play—then addressing each issue with a combination of counseling, behavioral health interventions, and pharmacology as needed—including evaluating the pros, cons and sustainability of each intervention.
On a societal level, we need doctors to care for the whole person and to be rewarded for spending time with patients on prevention and education. We need drug companies to bring affordable, safe, and effective pharmaceuticals to market. We need the fitness and nutrition industries to continue to promote evidence-based health habits while recognizing the limitations of exercise and dieting on metabolic health. We need the wellness industry to continue its work dismantling diet culture and shame-based messaging about obesity while acknowledging that body acceptance and medically appropriate weight control can coexist.
We need the federal government to disentangle drug companies from the FDA and from our medical education and healthcare delivery systems. We need the FDA to invest in equitable access to affordable, nutritious foods and to stop suggesting that Ozempic is superior to healthy eating. We need the FDA to invest in behavioral, hormonal, and metabolic health. We need a fuller recognition of obesity‘s diverse set of root causes. We need public acknowledgment that there is no single diet, exercise, degree of willpower, hormone or prescription medication that will improve metabolic health for all people.
Most of all, we need unfettered access to a primary care medical “home” for every American where physical, mental, and behavioral health meet. We need to treat the patient in front of us and to meet patients where they are. For example, one person might lose weight with hormone replacement therapy, another person with therapy for binge eating, and another with a high protein diet, and still another by adding in weight lifting—and that all four may benefit from GLP-1 medications for similar or completely different reasons.
There is no pill for self-awareness and agency. There is no amount of willpower to fix certain medical problems. There is only data, education, expertise, and trusted guidance. So, dear reader, beware of hot takes. Watch out for high degrees of certainty about complex health problems. And do your best to find a doctor you can trust. It’s a jungle out there!
Now tell me, where do you get your information about preventative health? What solutions make sense to you about tackling America’s obesity epidemic? I am all ears!
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Disclaimer: The views expressed here are entirely my own. They do not reflect those of my employer, nor are they a substitute for advice from your personal physician.
What sucks so bad is the fact that discussions of trauma—especially early childhood trauma— and how it impacts every single aspect of human development forever are almost never mentioned in these important conversations.
I grew up in a brutally abusive environment. Not a single change I attempted to make with my physical or mental health as an adult worked when I still believed shaming myself out of bad habits was possible. Understanding and doing the exceptionally hard, expensive, and time-consuming work of processing my childhood trauma has completely transformed every aspect of my health. And I know I got extremely lucky since not a single doctor has ever asked me about my childhood trauma unless I bring it up mySelf.
I have an older sister who experienced all of the same abuse that I did—only the ways she was sexually violated when she was very little tremendously impacted her weight. She’s extremely overweight and feels intense shame around her appearance every single day, not to mention terror that she may not live long enough to see her two beautiful kids grow up (she isn’t diabetic “yet,” so her doc can’t prescribe Ozempic!). But as her sister, I know on some deeper level, she would rather feel ashamed and afraid of the future than unsafe with no escape in the present. She would rather live in a body she knows others are disgusted by than to experience the utter repeated powerlessness she did when she was violently exploited as small child ever again. How the fuck could anyone who understands that blame her?
People—especially most academics and doctors who’ve seldom viscerally experienced violent trauma—think people like me and my sister are outliers. We are not. Because of the shame-motivation permeating our entire culture, the many, many people who’ve had horrible things happen to them in childhood have seldom learned to speak openly about them, especially not with powerful, authoritative figures like doctors. Furthermore, we don’t need sociopathic alcoholic dads or repeated experiences with violent child abuse to be fueled by trauma responses. Our entire domination-brainwashed, war-obsessed, racist, patriarchal culture is buried under so many layers of intergenerational trauma and profitable systems of overt abuse that most of us are too dissociated to even see the reality around us clearly.
The greatest gift of understanding and processing trauma is that one must come to understand the paradoxical extent to which something can be entirely NOT her fault and simultaneously also her most important lifelong responsibility. But if we don’t get the NOT our fault part first, the shame of believing it is will always lead us to believe we don’t truly have the ability to respond with any real agency. That is how trauma breeds—and that is why we are still stuck in the massive health crisis we’ve collectively inherited despite so much progress.
I am not obese. I could stand to lose a few pounds created when my activity slowed because of atrial flutter and medications for slowing the heart. However, that is not why I’m commenting.
What I’m watching is a change in the tenor of medical treatment as more women become physicians. There appears to be, in my view, strong correlation between a higher percentage of female doctors and medical treatment with more care and sensitivity.
I recognize correlational evidence can be impacted by other variables and that I should not over-generalize, however, my experience goes all the way back to being a Navy Corpsman during the Vietnam war when the male doctors often acted as if they inhabited Mt. Olympus, as the population of the sick and/or injured received care from the angels of care, the female nurses.
Good and thoughtful article that I like because it eschews the simplistic, recognizing the reality of complexity. So, thank you.