Is anyone not obsessed with weight? The health care field certainly is. Researchers have found ties between high body weight and an oversized list of unhealthy conditions. Payers have invested enormous amounts of money in decreasing individuals’ body weights. A Congressional bill would promote behavioral therapy for obesity and extend Medicare coverage for drugs treating obesity.
And yet weights continue to rise around the world, and the phenomenon starts at very young ages.
The rapidly expanding use of GLP-1 drugs has been life-altering for many, but brings its own disappointments: They’re extremely expensive, require continual use to be effective, have potentially negative effects on muscle mass, and are usually abandoned by patients. Paul T Jaeckel, a private practice dietitian at Paul Jaeckel Nutrition, warns that they tend to become “forever” medications.
Surgery is also expensive, with risks of its own, and its effects often don’t last.
In this Lean Digital series, we’ll feast on the contributions of digital technologies to weight control: remote monitoring and coaching, adherence support, genetic and phenotypic testing, nutritional advice, and more. These technologies can accompany or replace other medical interventions such as medications. I’ll also set a place at the table for activists who oppose the obsession with reducing weight and who call for obesity to be destigmatized. This first article in the series lays out what the medical field currently knows about weight.
Weighing the Problem of Obesity
Why is there a worldwide epidemic of obesity now, during the past 40 to 50 years? It comes from a convergence of several trends, according to leading public health and medical investigators. My interviewees came up with the same basic list.
First, there’s just more food available. Dr. Andres Acosta, Mayo Clinic researcher and co-founder of Phenomix Sciences, says that everyone but the richest people were undernourished for most of the duration of the human race, and that our bodies have evolved to eat as much as we can when we have the opportunity to do so.
Naturally, commercial interests are eager to capitalize on our predilections for large portions of highly processed foods with hidden salt and carbohydrates, as conveyed in this recent cartoon.
The tendency toward weight gain is also beset by sedentary jobs, sedentary leisure activities (notably television and video games), sweetened beverages, decreased sleep, and social isolation.
In short, our world is easier and more fun to live in, and we are hard-wired to take advantage of it.
Research has established a strong genetic component to one’s weight. Other factors that enter into weight, besides what we traditionally call “will power,” include:
- Changes that hormones, age, smoking cessation, and other factors make to our metabolism and therefore how the body handles calories
- Emotional needs for comfort and relief from stress
- Cultural factors, such as what one’s relatives expect one to eat
- Environmental factors, such as the availability of fruits and vegetables versus fast food restaurants in one’s neighborhood, or whether streets have sidewalks and are safe to walk on
- Stresses, including lack of sleep and lack of time to prepare healthy, well-balanced meals
Dr. Kate Behan, chief medical officer of Arcadia, cites several examples of social determinants of health that are relevant to weight: access to healthy foods, and limited ability to exercise due to cramped housing, unsafe neighborhoods, and communities without public spaces that promote exercise.
True hunger is creeping back to many threatened regions of the world, usually caused by wars and disrupted supplies. But the phenomenon of plenty, not deprivation, is more prominent at this time.
A Dissenting View on Body Types
Our society is certainly obsessed with weight. So are many other societies, and as American views of health and fashion spread—and as these societies get heavier too. But a protest movement against the negative perceptions of fat has also arisen.
This protest movement, inspired by the movements against racism, sexism, homophobia, etc., tells people to accept fatness and obesity. Some people talk of “fat pride.”
Certainly, there is plenty of evidence that people of greater weights suffer from discrimination and abuse. The medical profession itself is rife with improper handling of the many people whose weight is much greater than the medically recommended limits.
Gradually, alert researchers and doctors have adopted a more nuanced view of weight and strategies to change it. An important turning point was a 2005 study in JAMA published by a team led by Katherine Flegal of the Centers for Disease Control. Flegal showed that obesity was not strongly associated with increased morbidity, throwing into doubt the value of the sometimes extreme treatments that are often recommended.
Some advocates for the obese raise objections against what they call the “medicalization” of this condition, just as people with some psychological conditions are now doing. Some feel that obesity shouldn’t be treated as a problem at all; that the problem is how people view the obese. Other advocates want weight handled as a lifestyle issue that each person themselves should choose how to handle.
A recently released book that explores Flegal’s impact, as well as many other psychological, historical, and sociological themes, is Unshrinking: How to Face Fatphobia by philosopher and social activist Kate Manne. She places body size in a cultural and historical context that may stretch many readers’ thinking, and I recommend the book to medical professionals as well as the general public. I won’t try to summarize her many points, but I’ll note that she ignores some problems known to be caused by fatness, such as the effect of heaviness on knees and backs.
We’ll see in this series that the medical profession and health researchers are beginning to align with the views of the fat activists, while continuing to try to reduce weight. Sophisticated researchers and clinicians understand that reducing weight is not a simplistic matter of reducing calories and increasing exercise. Society is increasing “medicalization” in some ways through the growing use of surgery and drugs, but decreasing it in other ways by improving behavior interventions and using digital IT to help people stick to regimens more easily.
Sara Shanti, a partner specializing in health care at law firm Sheppard Mullin, says that many practitioners are using the terms “weight health” or “body health” instead of “weight loss.” And you might note that this series avoids the term “overweight,” because it implies that there are good weights and bad ones.
What Have GLP-1 Medications Accomplished?
GLP-1 medications have been prescribed to control diabetes over the past ten years, but only recently did studies show they have an effect on weight as well. They might be something of a miracle drug, with potential even for reducing addictions and Alzheimer’s symptoms, perhaps even Parkinson’s disease. Two relatively recent GLP-1 drugs, Tirzepatide and Semaglutide, were shown to be particularly effective in a recent study.
But like most drugs, GLP-1 medications have serious downsides. They cost more than $1,000 per month. The medications have serious, unpleasant side effects, causing most to go off the drugs early for a variety of reasons. Furthermore, people who go off the drugs have a high probability of regaining the weight they lost—a problem that the digital solutions in this series can help with.
Yet the potential of GLP-1 drugs to reduce health care costs related to obesity are attracting coverage from more and more payers.
Arcadia has done research on disparities in GLP-1 treatment for diabetes among Medicare patients, which mirror familiar problems in other areas of health care. Behan says, “Usage of GLP-1s in affluent areas is 6% higher in aggregate than other areas. When accounting for diabetes prevalence between these two populations, the disparities are intensified. Our analysis found that affluent areas have a 28% higher rate of GLP-1 fills per 1,000 diabetics than elsewhere. Analysis of other populations, such as Medicaid recipients, would likely reveal even greater disparities.”
In the following articles of the series, we’ll look at how digital interventions are making verifiable improvements in weight-related goals. The next article shows how precision medicine, powered by AI, can help choose the right approach to weight control.
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