What No One Wants to Admit About the New Weight Loss Drugs

By Daniel S. Frank, MD

Of all the scientific and technological advancements I’ve witnessed in many decades of medicine, when it comes to changing vast numbers of people’s lives, nothing–and I mean absolutely nothing–compares to the new weight loss drugs. Watching patient after patient walk into my office, 30 pounds, 50 pounds, even 100 pounds lighter, sometimes not even recognizing them, is nothing short of miraculous. The best data from the New England Journal of Medicine shows patients dropping an average of 22% of their body weight, with some losing significantly more. Follow up studies continue to demonstrate benefits in diabetes, sleep apnea, fatty liver disease, osteoarthritis of the knees, heart failure, and kidney disease. 

It’s probably best to categorize all these new agents into a group we would call “GLP-1 receptor agonists,” where GLP-1 is a hormone that tells the body, “Hey, you just ate and you’re not hungry,” and a “receptor agonist” is just a chemical that triggers a reaction in the body, whether produced ourselves after eating too much pizza, or purchased from Lilly or Novo Nordisk and injected. 

These drugs are showcasing some uncomfortable truths. We don’t actually have a word in English to describe something we all know is a lie, but we pretend is true in the interests of social harmony. The Japanese call it, “tatemae.” I had my first exposure to tatemae when I was five years old.

One day, my mother brought home a box of Raisin Bran cereal. Hoping to switch me up from the usual Cap’n Crunch and Rice Krispies, she excitedly poured out a bowl, added milk, handed me a spoon and disappeared to put away some laundry.

What abomination in the cosmos permitted a perfectly fine set of bran flakes to be adulterated by these small, dark, repugnant, wrinkly balls, I had no idea, but I promptly began plucking all of the raisins out of the cereal and throwing them in the trash, likely leaving a few on the floor as well. When my mother returned, she asked, “Honey, what happened to the raisins?” Not wanting to disappoint my mother, who loved me more than anyone ever has or will, I answered in the most logical, straightforward way I could. “Some boys came to the house and stole all the raisins.”

This white paper is about lying, and my mother answered matter-of-factly, “Oh, I see. Some boys came and took the raisins. Well, you should just eat the cereal flakes instead.” Even as a five-year-old, I knew my mom did not believe me, and I also knew she was pretending to believe me, just as I pretended to not dislike raisins. Our lies were born, not of treachery or deceit, but of love. 

We had the Wrong Diagnosis and the Wrong Treatment, but Failed to Say So

A typical complicated internal medicine patient has high blood pressure, adult-onset diabetes, sleep apnea, high cholesterol, and osteoarthritis of the knees. He might be on seven drugs and a CPAP machine to go with his five diagnoses, but he actually only has one diagnosis: obesity. For years, physicians knew this, but it sat in the far reaches of our minds because we did not have effective treatments, shy of the big step of weight loss surgery. Inexperienced and less skilled physicians might waste valuable office visit time repeatedly berating patients to diet and exercise, but the more sophisticated among us knew this was a fool’s errand. After an initial discussion of the basics (some low carb diet variant, get rid of the booze, moderate exercise), we’d just toil away, making diagnoses and writing prescriptions for the consequences of obesity without targeting the source. Why berate a patient over something he or she cannot change? We ignored the obvious, did our best to manage patients, and those Raisin Bran Boys just kept mysteriously sprinkling on additional diagnoses: gallbladder disease, heart failure, kidney failure, liver disease, gastroesophageal reflux, blood clots, well, the list goes on. Sure, these diseases exist in thin people, but significantly less often. I don’t think I’ve ever put “obesity” on a death certificate, but it would have been truthful to do so. 

If you’re old enough, you might remember those Maytag repairman commercials, where Maytag claimed their appliances were so reliable that the repairman just sat around in his shop, bored. It wouldn’t be quite as dramatic for physicians, but if obesity were eliminated in our country, where 75% of the population is overweight or obese, healthcare utilization would probably drop by half. 

The Most Important Reason to Treat Obesity is NOT for the Health Risks

It’s the most painful lie to uncover, but uncover we must. The most important reason to treat obesity is not for the health risks of this disease. It is for the emotional, social, and psychological costs of being overweight. Obese individuals face significant discrimination in society, chiefly in the dating marketplace and in employment. Anyone who says beauty comes in all shapes and sizes has clearly never thrown up a profile on Tinder and never hit the pavement trying to get a job in sales. Why do we want to think it is those Raisin Bran Boys keeping your good friend from finding a great boyfriend or girlfriend, or getting that internship during college? Because it is a painful admission that our society is vapid, shallow, and superficial. We don’t want to live in a world like that, where being thin and attractive matters so much, regardless of what is on the inside. Most of us find it repugnant. But being repugnant does not make it any less true. 

Obese patients will come to my office saying they have struggled with their weight for many years and are “concerned about the health risks.” They are embarrassed to just come out and say they want to be thin because if they are thin, they will live a better life and feel happier. Sometimes I play along, as my mom did with me, creating our own private tatemae, and say, “Yes, there are many health benefits. We should get you treated.” Other times, I point out the obvious. Being thinner will help a person emotionally, psychologically, and socially.

Think about it, if I treat someone’s high blood pressure for 20 years, I will reduce their chance of a stroke far in the future, but that patient obtains zero concrete benefit now. If I take 35 pounds off someone, he or she will achieve an immediate benefit in addition to reducing future health risks. 

It just kills me when I hear about “legitimate” medical uses of these drugs for things like diabetes versus “cosmetic” uses, as if there is some moral hierarchy going on here. Is the suffering of a young person in the dating pool any less important than a patient with a blood sugar that is a shade over target? It’s an absurd distinction. 

For Most Patients, Diet and Exercise Always Were, and Always Will Be, Failed Treatments for Obesity 

The GLP-1s have uncovered another painful truth. The billions of dollars we’ve spent on WeightWatchers, Slim Fast, nutritionists, and exercise machines were a waste. You just need to see an effective treatment for obesity in action to realize how scammy and ineffective everything else was. I think most people recognized that these approaches were doomed to fail, but with zero alternatives, it was painful to admit it. The $70 billion we spent every year on weight loss schemes was a very wasteful tatemae indeed. 

A rather depressing research paper in the Medical Clinics of North America looked at the long-term outcomes (5–10 years) of diet and exercise for the management of obesity. Sure, anyone can lose weight on a diet, but it almost always comes back. At the five-year mark, almost all of the lost weight is regained, and generally the amount of weight loss in these approaches is not enough to cure obesity anyway. 

Another painful truth that is hard to admit is that the diet and exercise was not only a futile approach, but that it produced suffering in many patients. The GLP-1 agonists turn off excessive hunger, they remove “food noise” in the brain and make it easy to pick the good foods. Imagine trying to sharply reduce your caloric intake through sheer determination alone. Your brain perceives you to be in a state of semi-starvation. It is a painful experience. Patients suffer but lose weight, and when their brain is tired of suffering, it makes them gain it back. It’s one thing to tell people to lay off the Ho-Hos and pizza, but another to employ a strict, calorie-counting diet with no pharmacological support to try and achieve the drastic weight loss needed in the management of obesity. Diet and exercise only compounded the suffering of obese patients and provided them no benefit. 

No One Understands This Disease, Even Though We Can Now Treat It

Despite now having an effective treatment, we are still no closer to understanding the obesity epidemic. We don’t know why 11% of men were obese in 1980 and now it’s 35%. The world is not that different today. We had McDonalds and Burger King back then. Jogging was popular in the 1970s. Sure, kids are less physically active now than they were in 1980, but they were less active in 1980 as compared to 1880. We can reduce obesity by administering a satiety hormone to patients, but why does the body not self-regulate weight? Even now with an effective treatment, we are no closer to understanding this disease at all. 

Even the definition of a healthy body weight is unclear. Here’s a fun experiment. Get in a plane and parachute into one of those uncontacted tribes in South America and have a look around. Before you get murdered, you’ll notice that our species in its native habitat is really skinny. People are so overweight now in the developed world that we’ve forgotten what a normal Homo sapien is supposed to look like. Furthermore, we’ve glommed onto BMI as a measure of obesity, but it is a flawed measure, understating obesity in smaller people and overstating it in bigger ones. A 5 foot 1 inch female with a delicate bone structure who weighed 100 pounds in college and now weighs 130 pounds is 30 pounds overweight, but her BMI was always normal. Many professional football players are classified as obese when they are in excellent shape. 

BMI is another tatemae, medical professionals know this is a ridiculous, flawed measure, but we’re stuck with it and pretend it is way more accurate than it is. Actually, in one country, it is not a tatemae, and that is in Japan, where they modified the normal range to better account for Asian body types. There, a BMI > 25 indicates obesity as opposed to 30 in the United States.  

What Should We Be Saying About Obesity in the Effective Treatment Era?

Patients who want their disorder treated should do so, and no explanation, apology, or excuse is ever needed. I do think it is an error to get these drugs through a weight loss website, and I don’t think “obesity clinics” are the proper venue for treating this disorder. The whole thing sounds scammy to me. Because body weight impacts so many other organ systems and weight loss often requires changes in other medications, it is really best to have your general internist or family medicine physician manage obesity with GLP-1s. These are complex drugs that come with risks and benefits, and with side effects, but with the potential to cure diseases. GLP-1s are not right for everyone, and navigating this complicated landscape is best done by a primary care physician who knows you well, not by a website or clinic with a narrow focus only on weight loss. 

In our practice at MedNorthwest, we have a lot of experience with these medications. It’s concierge medicine and our patient population is better able to afford these expensive drugs. It’s a bit ironic that our monthly fee is way less than a month of a GLP-1, but then again, I can’t wave a magic syringe at someone once a week and get them to lose 50 pounds without really trying. Eli Lilly can do that. 

It’s important to point out what we do not do. We do not treat people who just want to lose 10 pounds for a party. We do not treat Hollywood types already at a normal, healthy body weight who just want to be ultra skinny. We do not berate overweight people for being overweight. We do not recommend multiple failed trials of diet and exercise to treat this disorder. We do not see obesity as anything other than a metabolic disorder that needs treatment. We do not recommend a special, complex diet and exercise program on top of a GLP-1, but we do recommend diets like the Paleo diet that get rid of most of the American junk we are eating these days. We do not want patients going on and off these drugs, losing and gaining back 30–50 pounds over and over. We do want to target a long-term, lean, healthy body weight in patients who are able to achieve it on GLP-1s. 

Even though I had nothing to do with the mysterious disappearance of raisins from my Raisin Bran that day, the very next week, a box of Kellogg’s Product 19 made its way to my childhood home on Greenvalley Road in Los Angeles. It would become my favorite cereal for the next 30 years. The Raisin Bran Boys never came back looking for raisins, but the unease I felt over that shared lie, that tatemae, well, it’s an unpleasantness that stuck with me. I resolved to be honest, even painfully honest, going forward. It’s why I write like this now. As for a healthy breakfast, only later as a physician did I realize, sadly, all breakfast cereals are probably bad for us, and those Raisin Bran Boys should’ve just taken the entire bowl with them. 

The opinions expressed in this article are solely those of Daniel S. Frank, MD and under no circumstances do they represent the official views or policies of MedNorthwest, well, unless you agree with them, in which case, sure, these are the official views and policies of MedNorthwest, a Washington Professional Limited Liability Company.