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Anti-Obesity Drugs in Sociopolitical Context

Abstract

This literature review critically examines the use of Body Mass Index (BMI) as a diagnostic tool for obesity, highlighting its historical and scientific flaws. The diagnosis and treatment of obesity is heavily stigmatized and reflects deeper socio-economic and racial biases. Fatphobia, or anti-fatness, is deeply rooted in white supremacy and colonial history. I argue that anti-fatness and weight-based discrimination significantly impact health outcomes, rather than body fat percentage alone. The way that the medical system focuses on body size rather than the overall health of patients perpetuates harm and yields even poorer health outcomes. To genuinely improve the lives of fat individuals, we must dismantle anti-fat systems and remove barriers to healthcare, job equity, and basic infrastructure by implementing legal protections, rather than simply promoting weight loss. This review emphasizes the need for a holistic approach to health that considers socio-economic factors and systemic discrimination.

Journal Summary

Recently, two anti-obesity medications, Ozempic and Wegovy, which are primarily prescribed for type 2 diabetes mellitus (T2DM), have shown promise in causing weight loss. The 2022 scientific journal “Ozempic and Wegovy for Weight Loss, Pharmacological Component and Effect” by Abdullah Mohammed, et al explores the pharmacological components and effects of these medications on weight reduction, summarizing findings from existing clinical studies.

Ozempic is a glucagon-like peptide-1 (GLP-1) receptor agonist primarily used to manage T2DM. Clinical studies indicate that semaglutide can also promote significant weight loss. Ozempic's mechanism involves binding to GLP-1 receptors in the brain, reducing food intake and increasing feelings of fullness. This leads to a decrease in body weight and improvement in glycemic control. Wegovy, also a GLP-1 receptor agonist, is the same drug as Ozempic but two times the dose, specifically approved for weight loss for fat people even without T2DM. Administered as a weekly injection, Wegovy has shown effectiveness in inducing sustained weight loss. The STEP trials demonstrated that participants using Wegovy experienced an average weight loss of 15.8% over 68 weeks. Wegovy's pharmacokinetics involve prolonged activation of GLP-1 receptors, enhancing satiety and reducing hunger. GLP-1 receptor agonists like semaglutide mimic the action of the natural hormone GLP-1, which regulates appetite and blood sugar levels. By slowing gastric emptying and promoting a feeling of fullness, these medications reduce caloric intake. Clinical trials have shown that GLP-1RAs, including semaglutide, can result in weight loss from 5% or up to 10-15% of body weight. However, sustained weight loss requires ongoing lifestyle modifications, as discontinuation of the medication leads to weight regain. Common side effects of GLP-1 receptor agonists include gastrointestinal issues such as nausea, vomiting, diarrhea, and constipation. Other potential side effects include increased heart rate, fatigue, headaches, and changes in thyroid function.

Obesity as a Disease

How does one get an obesity diagnosis? There is one single criterion used for diagnosing someone with this disease: The Body Mass Index (BMI). A person’s BMI is their weight in kilograms divided by the square of their height in meters, rounded to one decimal place. It does not account for muscle mass versus body fat. For these reasons, the BMI has been widely proven to be an ineffective health measure. The BMI was also never intended to be a measure of health in the first place.

The BMI was created in the 1800s by a statistician named Adolphe Quetelet, who did not study medicine, to gather statistics of the average height and weight of specifically white, European, upper-middle-class men to assist the government in allocating resources. It was never intended as a measure of individual body fat, build, or health (Karasu, 2016). Quetelet is also credited with founding the field of anthropometry, including the racist pseudoscience of phrenology. Quetelet’s L’homme Moyen would be used as a measurement of fitness to inspire, and as a scientific justification, for eugenics (Eugenics archive).

Studies have observed that about 30% of "normal” weight people are “unhealthy," whereas about 50% of "overweight" people are “healthy” (Rey-López, et al, 2014). Thus, using the BMI as an indicator of health misclassifies 75 million people in the United States alone. “Healthy*” lifestyle habits are associated with a significant decrease in mortality regardless of baseline body mass index (Matheson, et al, 2012).

*I put “healthy” in quotation marks here because the definition of an individual’s health is oversimplified and depends on many socioeconomic factors.

While epidemiologists use BMI to calculate national obesity rates, the distinctions between weight classes can be arbitrary. Ever notice that the weight classes on the BMI are nearly intervals of five? In 1998, the National Institutes of Health lowered the overweight threshold from 27.8 to 25—making roughly 29 million Americans "overweight" overnight—to match international guidelines (Butler, 2014). Critics have also noted that those guidelines were drafted in part by the International Obesity Task Force, whose two principal funders were companies making weight loss drugs.

Jackie Scully, Senior Research Fellow at the Unit for Ethics in the Biosciences, University of Basel, in her scientific journal titled “What is a Disease?” states the following: “As the business literature shows, new clinical diagnoses are often welcomed primarily as opportunities for market growth (Moynihan et al, 2002). One recent example of this is female sexual dysfunction (FSD). The huge commercial success of sildenafil (Viagra) for erectile dysfunction in men provides a strong motivation for drug companies to identify an equivalent market (that is, condition) in women. And some ethicists feel that drug companies were, to put it mildly, over-involved in the medical consensus meetings held between 1997 and 1999 that effectively drew up very inclusive clinical criteria for the definition of FSD (Moynihan, 2003)."

How can one diagnose a person with a disease and sell them medications solely based upon an outdated measure that was never meant to indicate health in the first place, especially when obesity has no proven causative role in the onset of any chronic condition? (Kahn, et. al., 2000), (Cofield, et al, 2010).

This is why the term “obese” is recognized as a slur by fat communities. It's a stigmatizing term that medicalizes fat bodies even in the absence of disease. The word directly translates to "having eaten oneself fat" in Latin. Obesity, as a medical diagnosis, doesn’t have much ground to stand on. Aside from being overtly incorrect as a medical tool, the BMI is used to deny certain medical treatments and gender-affirming care, as well as insurance coverage. Employers still often offer bonuses to workers who lower their BMI. Although science recognizes the BMI as deeply flawed, it's going to be tough to get rid of. It has been a long-standing and effective tool for the oppression of fat people and the profit of the weight loss industry.

To treat obesity, patients must eat less. Making someone smaller still means they will be healthier, right?

Fatness and Mortality

The idea that obesity is unhealthy and can cause or exacerbate illnesses is a biased misrepresentation of the scientific literature that is informed more by bigotry than credible science (Medvedyuk, et al, 2017). Fatphobia existed long before fatness became medicalized. Yes, obesity is correlated with conditions such as cardiovascular disease, hypertension, and diabetes, but some scientists are looking into possibilities that don't equate correlation with causation. Obesity has no proven causative role in the onset of any chronic condition (Kahn, et al, 2000), (Cofield, et al, 2010) and its appearance may be a protective response to the onset of numerous chronic conditions generated from currently unknown causes (Lavie, et al, 2009), (Uretsky et al, 2007), (Mullen, et al, 2013), (Tseng, 2013). A portion of these correlated conditions are likely brought on by the stress of being part of one or more marginalized groups with little to no support or basic access in society. Weight stigma itself is deadly. Research shows that weight-based discrimination increases risk of death by 60% (Sutin, et al, 2014).

Dieting also poses serious health risks. The reason that these weight loss drugs are so successful by comparison is that dieting is unsustainable and does not lead to prolonged weight loss. Over 50 years of research conclusively demonstrates that virtually everyone who intentionally loses weight by manipulating their eating and exercise habits will regain the weight they lost within 3-5 years, and 75% will regain more weight than they lost (Mann, et al, 2007). Evidence suggests that repeatedly losing and gaining weight is linked to cardiovascular disease, stroke, diabetes, and altered immune function (Tomiyama, et al, 2017). If most fat people have historically tried to lose weight their whole lives through dieting, this has major implications on overall health. Prescribed weight loss is also the leading predictor of eating disorders (Patton, et al, 1999).

Another factor that may be impacting fat people’s rate of mortality is that they are being mistreated at the doctor’s office. I have personally heard dozens of stories about doctors refusing to treat or investigate a problem that a fat person came in for until they lost a certain amount of weight, only to discover years later that the problem was unrelated to their weight and has progressed severely because it went untreated. Fat people are often mistreated and looked at with disgust and disdain in medical settings, leading them to avoid going to the doctor in shame or fear of abuse. This can seriously worsen health issues. Fat stigma in the medical establishment (Puhl, et al, 2012) and society at large arguably (Engber, 2009) kills more fat people than fat does (Teachman, et al, 2003), (Chastain, et al, 2009), (Sutin, et al, 2015). This impact is too significant not to be taken under consideration.

Anti-Fatness as Anti-Blackness

The issue of anti-fat bias is directly rooted in white supremacy. The ideal thin body was constructed as a marker of whiteness and “purity” before any of this was ever made to be about health. Dr. Sabrina Strings has spent her career studying this history. In her book, Fearing the Black Body: The Racial Origins of Fat Phobia, Dr. Strings discusses how constructions of race led to the thin ideal. “Over the decades, the rise in biracial children would break down the way that slave owners saw Blackness and whiteness. To combat the hypocrisy they created, owners invented new ways to dehumanize the enslaved population. They made a calculated decision to start putting more value on white physiques versus Black ones. In her research, Strings found that Black women’s bodies were otherized even more than Black males. For colonizers who hadn’t seen diverse body types before, they quickly categorized the Black female figure as ‘deviant,’ ‘greedy,’ and ‘overtly sexual.’ The fact that we still use these terms to describe fat bodies today is all the evidence we need to understand that fatphobia is directly linked to racism, not health. This mindset was also strengthened by Protestantism. Slave owners looked for any way to prove their power over the enslaved people, and they frequently used religion as ‘proof’ of their racist superiority. Additionally, Protestant belief encouraged various ways to become closer to God, which included eating as little as possible. This would resonate the most with white women. They had as much to do with perpetuating fatphobia as their husbands. White women were desperate to show their own power against Black women on the plantation, and the difference between their bodies was the perfect rift. And so began the centuries-old belief that thinness is beautiful, and fatness is ugly” (Sassenrath, 2023).

Revisiting the Journal with Context

Thinness has been an important value throughout history in the United States. Our positive associations with thinness and negative associations with fatness have led to a collective schema that is black and white, good versus bad, beautiful versus ugly, healthy versus unhealthy, and life versus death. This has led the FDA to approve Wegovy as a weight loss drug with haste, after just sixteen months of testing. It is known that going off the drug will result in rapid weight regain, so patients are expected to be on it for the rest of their lives when there have been no long-term studies. We do not yet know if the drug will have long-term effects, yet it has been approved for kids as young as twelve (FDA, 2021). As of July 2024, Novo Nordisk has a market cap of $633.01 billion (Marketcap).

Wegovy is prescribed along with diet and exercise, which has been proven to lead to weight regain and eating disorders. Patients are being prescribed Wegovy and Ozempic when they are fat, but otherwise metabolically healthy. If this drug is truly a game changer for public health, we should be measuring how patients' health improves over the long-term rather than how much weight they lose. For example, if these drugs improve heart health, they should be prescribed as a heart health medication for patients with heart disease, rather than prescribed as a weight loss fix based on body size alone. With the evidence we have, we know it is possible to be fat and healthy, so these drugs may be solely cosmetic in many cases.

Future

If we want to improve the lives of fat people, we will remove barriers to care, not try as hard as we can to make all fat people disappear. That will never happen. If we truly cared about the well-being of fat people and not their disappearance, we would work to dismantle the systems that oppress them and abolish anti-fatness.

Currently, fat people have next to no legal protections for being discriminated against (NAAFA, 2023). Fat people are denied housing, (Kariss, 1977) jobs, and receive less pay and promotions legally because of their size (The Economist). They are denied access to clothing, seating, transportation, and other human rights because infrastructure has been designed to exclude them. Fat people have less likelihood of receiving a fair trial (Beely, 2013), and are denied necessary surgeries (Barrett, 2022) ––but not weight loss surgery that amputates the digestive tract. Fat people are denied gender-affirming care (Conley, 2023), in vitro fertilization and reproductive healthcare (Muir, 2024), even adopting children (Carter, 2009). Fat children have been removed from their loving parents because when their diets failed, it was seen as neglect (Badshah, 2021). Fat people have disproportionately high suicide rates (Wagner, et al, 2013), and are facing medical malpractice and mistreatment (Kolata, 2016).

Can a drug fix that?

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