Medical Alchemy, Miracle Drug
Examining a recent 60 minutes interview on new ideas surrounding obesity and a revolutionary treatment called Semaglutide, aka Wegovy
When I started this newsletter, I wanted to keep a positive tone and talk about ideas - not people (there’s enough of that going around as it is). That’s still my goal. It’s in this spirit I wish to discuss the recent 60 Minutes segment on obesity and a new treatment called “Semaglutide.” It’s an anti-obesity drug sold under the name “Wegovy” and “Ozempic,” though Ozempic is a lower-dosed formulation specifically used for diabetes. Wegovy is expensive, hard-to-find, and undeniably effective. This effectiveness has caused a bit of a stir in the medical community, with many docs rethinking obesity, its pathology, and how to treat it.
I will mention here that the company producing this anti-obesity drug is a paid advertiser of 60 Minutes (which the show acknowledges). Also, the two featured doctors serve as advisors to companies making anti-obesity medications (which the show also acknowledges). I mention this to focus exclusively, and in good faith, on the ideas presented in the segment, NOT to speculate on ulterior motives or special interests. And those ideas do warrant deeper examination…
Here is the interview in question.
Obesity is a genetic disease?
One of the claims made during the interview is that diet and exercise factor little in the development of obesity; genetics is the main cause. This is anathema to the so-called “traditional” understanding of obesity. To support this argument, it’s stated that children born to obese parents are much more likely to become obese themselves.
However, the way this idea is framed makes it seem that obesity is hereditary. As if an “obese gene” gets passed down through a specific inheritance pattern… like achondroplasia or hemophilia. This is certainly not true. It is accurate to say there are genetic aspects to obesity; some people are naturally more heavyset or naturally thinner than others. Simply put, it’s much more probable that, like traditions and belief systems, habits surrounding diet and exercise are passed down from generation to generation.
Additionally, this new provided explanation fails to account for epigenetics, which is the study of how behavior and environments influence gene expression. Put differently, the things that people do and the environment in which they live affect how their genes work. Can you think of some “things that people do” that could contribute? Yes, diet, exercise, sleep, etc. - all things considered foundational in general health. This all goes to show that the trouble isn’t in understanding the development of obesity, but in the execution of its treatment: namely, lifestyle change.
It’s one thing to say there is a genetic component to obesity; it’s another thing entirely to say obesity is a genetic disease.
Obesity is a brain disease?
In addition to making statements about genetics, it’s also stated that obesity is a brain disease because the “brain tells us how much to eat and how much to store.” To further support this point the doctor cites the reality show “The Biggest Loser,” where morbidly obese contestants are put through rigorous training to see who can lose the most amount of weight. Of those who went on the show, it is stated that 96% regained any weight lost. This apparently is an example of how obesity is a brain disease because, to paraphrase, the participants’ brain brought their weight back up to what it thought it needed.
How can this be?
In a voiceover, the concept of a “set point” is explained. A set point is a range of weight your brain is in charge of maintaining by controlling your food intake and storage. To give an example, a person will gain weight in the context of a chronic stressor (Covid is the example given during the interview). Maintain that weight gain for long enough and the person’s set point will “recalibrate,” leaving them with a higher number on the scale.
However, set point theory doesn’t explain obesity’s links with age, prevalence over time, people with lower income in developED countries, people with higher income in developING countries, et cetera et cetera. Additionally, if set point increases are related to chronic stressors, then it would be better to address the chronic stressor rather than prescribing costly medications. Third, it stands to reason that if a set point can be recalibrated higher without the use of medication, then it certainly can be recalibrated lower without meds. Finally, regarding exercise cessation and rebound weight gain, rebound effects also occur when discontinuing medication. Blood pressure meds, antidepressants, and opioids (among others) can have withdrawal symptoms and/or a rebound effect after stopping. The same is true for Semaglutide.
Furthermore, the logic behind the statement “the brain controls how much we eat” betrays a faulty assumption: that we are powerless against our brain’s cravings, compulsions, and desires. To flush this out, let me offer some examples. 1) If you aren’t feeling particularly loving towards your spouse, you can still choose to act lovingly. 2) If you are feeling too tired to exercise, you can still choose to exercise. 3) If you feel a need to gamble, you can still choose to do something other than gamble. 4) And if you’re feeling hungry, no matter how hungry you feel, you can still choose not to eat. The notion that a person’s brain is “in charge” is a step towards a world where choices are meaningless.
In fact, this is supported by how Wegovy works. From their own website, it states that Wegovy reduces hunger which, in turn, leads people to eat less. This is corroborated in other studies of GLP-1 agonists (the specific class of medication to which Wegovy belongs). This drug can cross the blood-brain barrier and influence your body’s appetite, resulting in a consistent decreased food intake and concomitant weight loss.
To point out the obvious, this is the exact same way dieting works. A person who wishes to lose weight will consciously eat less calories than they expend, thus losing weight. The main difference between dieting and Wegovy (other than the obvious) is the presence of hunger. To be fair, obese patients can experience excruciating hunger pangs. Anecdotally, as a strength coach and med student I’ve had clients and patients describe the difficulties of losing weight, defined by these harrowing bouts of hunger. Drew Manning, trainer and founder of “Fit2Fat2Fit,” experienced this when intentionally gaining weight to understand what his own clients endured. Doctors treating patients with Semaglutide hear how patients are consistently less hungry and more sated, making it easier to eat less food. The company making Wegovy touts this on their website, and rightfully so.
It’s not nothing to eradicate hunger pangs in the pursuit of a healthier weight. However, experiencing hunger does not preclude the ability to make choices.
Willpower, Shmillpower.
Then the question becomes, if the goal is weight loss why should someone spend all this time, effort, and pain dieting and exercising when they can just take Wegovy and get the same results? It’s a valid point that’s hard to argue. To answer we must look at what diet and exercise offer, if anything, that Wegovy does not. Before I begin, let me just say that this is a difficult issue to untangle. I don’t want to be perceived as the “bad guy,” but a good doctor functions from both from truth and compassion, in telling our patients what they need to hear and not what they want to hear. So, to me, the bad guy perception is something I must risk in this pursuit. It’s in this respect I offer the following…
Lifestyle change is difficult to implement. It takes a long time, and the road is bumpy. People who navigate it successfully will most likely experience bouts of weight regain and feelings of failure along the way. It’s hard. Especially in a modern world that is built upon and incentivizes comfort. Diet, exercise, and change itself are certainly not comfortable. However, that long difficult process is not a consequence to be avoided, but the goal itself. Let me explain with an analogy.
Why do refineries exist? If you pump oil out of the ground, is it ready-made to be used by your car? No. It must go to an oil refinery to become diesel, butane, propane, whatever. The same you find with gold. Out of the ground, it’s riddled with impurities that lower its value. Gold then goes to a refinery and withstands extreme heat to become usable, valuable, “gold.” Diet and exercise are equivalent to these refining processes, offering both medical and non-medical benefits.
Non-medical benefits are what makes lifestyle change foundational not only in obesity, but in overall health. It is a difficult process and its purpose is to refine… to transform. In other words, the person who gained 500 pounds will not be the same person who loses it. This is something that coaches, like the aforementioned Drew Manning, understand better than doctors who prescribe vague notions of “diet and exercise.” These types of processes cannot exist without difficulty. Much like gold, which must endure scorching and sweltering heat, a person enduring the pain of dieting and exercise develops into a disciplined, perseverant person - all part of character building. Character building is defined by denying yourself old desires (e.g. McDonald’s, Cheetos, and Netflix) when you desperately want to give in. This is the wonderful difficult process of developing perseverance, endurance, discipline, and willpower. Weight loss is a desired side effect.
When a person embarks on this process and comes out on the other side, they have also attained wisdom. To continue with the gold analogy, the process has burned impurities from them and they’ve become more valuable. It’s with this hard-won wisdom and character that they can contribute to other people’s well-being, their community, society at large, etc. This is the goal: to get our patients to the best position from which they can contribute. This is the reason why diet, exercise, and lifestyle change are the bedrock of obesity treatment and sound health.
A counterpoint may be something like why force someone to go through, as you call it, this “painful process”? You are condemning them to pain, failure, and reinforcing the stigma that obesity is an obese person’s fault instead of providing an effective solution.
To this I say a couple of things. First, let me address the issue of “fault.” To me, fault is irrelevant. It is entirely possible that a person’s obesity is not their fault, For example, there is burgeoning research regarding “obesogens” and “food environments” that could influence a person’s ability to lose weight. However, it’s also entirely possible that it is their fault. I don’t say this to shame people, and saying this does not stigmatize an obese person as “less than,” merely that they are human (just like you and me). Focusing on fault and tying it to shame and stigma shifts responsibility from patient to provider. This is done all in the name of doing away with “blame.” I am saying here that the blame game is a game NOT worth playing. Obesity may not be someone’s fault, but it is still their responsibility.
With a drug like Wegovy, the temptation will be to overprescribe. It will be the medical professional’s responsibility to refrain from doing this and continue to emphasize lifestyle change as the rightful health foundation. To do this, as doctors (both present and future) we must remove ourselves as the heroes of our patients’ story, and encourage them to become their own.
Second, it is not “do no pain,” but “do no harm.” Which scenario does more harm? In one scenario, we outsource health to Wegovy and similar medications. In the other scenario, we recognize Wegovy’s value but limit its use and double down on encouragement and lifestyle change. This future doc says the former.
One may again say that this condemns someone to needless pain and jeopardizes their health. My response is that that view strips from them an opportunity to grow, strips from us an opportunity to counsel, and condemns our patients to a life of pharmaceutical dependence.
And therein lies the trouble with Wegovy and obesity. If we view this breakthrough as the revolutionary innovation that it is, limit its use, and remain committed to promoting lifestyle change, then Wegovy truly is a miracle drug. But, through clever use of semantics, if we absolve our patients of responsibility, outsource it to medications like Wegovy, and substitute it as the new paradigm of health, then we reduce this miracle drug to little more than medical pyrite.
What an incredibly thought provoking article. You did an excellent job of dissecting the information presented in the 60 Minutes segment. So much to think about and consider as more drugs are manufactured and become available, while also maintaining the truth of our own responsibility regarding our individual health. More insightful information like yours and more education of how to live a healthier lifestyle in today's "instantly gratifying" world are needed so we, as people of all ages, may continue to make better choices for ourselves and our overall health. Thank you.
This is so thoughtfully written. I applaud you for taking it on, even at the risk of being perceived as the "bad guy", because I think this is so important. At first I hesitate to even comment, because I too would never want to be perceived as passing judgement, but it seems like this drug along with the AAP's updated recommendations on treating childhood obesity with medication and surgery could take us down a frightening path. Sometimes it feels like the way the healthcare system is setup in this country is failing us - always reacting to issues instead of educating patients on how to live a healthy lifestyle to prevent them. And even if doctors are discussing diet and exercise with their patients, what type of "dieting" education is actually being provided? If it's to follow the USDA food pyramid which has a base of carbs and little amounts of fat and protein, I'm not surprised individuals are starving yet not losing weight. I am by no means a trained dietician, but rather a mom who has to rely on these recommendations because they impact how my children are taken care of by their doctors as well as how they are fed in school. It's hard not to feel disappointed.