Multiple glucagon-like peptide-1 (GLP-1) agonist medications, created for the treatment of type 2 diabetes mellitus, are now labeled for the treatment of obesity. By activating GLP-1 peptides, these medications affect body weight in many ways, including inhibiting glucagon and stimulating insulin release, and resulting in an average loss of 5% to 15% of body weight sustainable for at least 12 months.1–3
Family physicians may feel angst when patients request these medications, considering that weight and body mass index (BMI) are flawed health metrics, and the current societal desire for thinness has murky origins. However, weight stigma is also real and detrimental.4
Many physicians have been trained to think of obesity as a disease and, therefore, inherently harmful.5,6 However, mortality is not correlated with BMI, and weight loss is not correlated with improved health even in patients with diabetes and cardiovascular disease.7 Nearly all intentional weight loss results in eventual weight gain beyond baseline weight.8 Chronic dieting and weight cycling can result in depression, increased blood pressure, eating disorders, and increased all-cause mortality.9–12 Two people with the same BMI can have different health behaviors, life experiences, and body compositions, resulting in vastly different health status and quality of life.13
The cultural fear of weight gain and larger body size has insidious origins. Larger bodies were assumed to be an attribute of people of color. They were associated with being “feminine” and “overly sensual” in the aftermath of the slave trade, and colonialists purposely distanced themselves from indigenous diets.14 The White European ideal of being “frail and delicate” and having “rational self-control” allowed women to distance themselves from the working class, who they saw as requiring more strength and substance.14 Patients with larger bodies are affected by weight-based marginalization driven by commercial and societal forces.15 Patients may be unable to detach from the societal discord they feel from being overweight.
Given the sociopolitical origins of our weight-focused culture, how should we address our patients' desires to achieve a certain weight, even if there is no strict medical need to do so?
As with all shared decisions, we can start by providing objective information and using a STEPS approach, which outlines a medication's safety, tolerability, effectiveness, price, and simplicity.16 For example, the long-term effects of GLP-1 agonists on the pancreas are unknown (safety). Adverse effects can include nausea, vomiting, diarrhea, and bloating due to gastroparesis (tolerability). GLP-1 agonists' effectiveness may be limited since most people regain weight when they stop taking the medication (effectiveness). These medications are expensive (price), and injections are more complex than oral medications (simplicity).
We can also redirect the conversation toward health-promoting behaviors. Because patients often seek validation from physicians to lose weight, we can acknowledge their goal while emphasizing a more holistic approach to health, encouraging patients to engage in exercise they enjoy and eat nourishing foods that make them feel good and not deprived. We advocate for a Health at Every Size approach: rather than focusing on changing weight, patients should embrace opportunities to develop a patient-centered collaborative plan that includes nourishment, intuitive eating, joyful movement, sleep, and stress reduction, which result in improved long-term health outcomes.17 Through these behaviors, patients reap the benefits of dietary variety and cardiovascular exercise while allowing their bodies to find their inherent homeostatic set points.18
We must also empathize with patients experiencing weight-based marginalization. Even without a medical need for weight loss, we can work with patients toward an informed approach that respects their bodily autonomy and recognizes their societal discord and experiences living in larger bodies. Prescribing a GLP-1 agonist may be appropriate for these patients.
Although patients will likely continue to request GLP-1 agonists and other weight-loss remedies, we do not have to embrace a weight-centric approach. We can listen to patients, validating their needs and goals. We can promote healthy behaviors and acknowledge the dissonance of living in a diet-entrenched society with the understanding that weight loss may not be the answer.
Editor’s Note: Dr. Shaughnessy is an assistant medical editor for AFP.
