‘Are we over-medicalising weight loss?’
Dr Katie Musgrave takes aim at the over-medicalisation she believes has crept into the healthcare system – not least with weight-loss drugs
I thought I might write about my recent weight-loss journey and no, I’m not talking about using Mounjaro. Mine involved a gym membership, signing up for a series of more challenging swimming events, and reducing my lunch from a two sliced sandwich to one slice. Over the course of a few years, the pounds have dropped off (or more precisely a stone and a half). Of course, this is only one individual example, but it reflects an approach that I believe many of our patients may benefit from where feasible.
The papers are reporting far and wide on the miraculous weight-loss journeys that many celebrities have gone on (courtesy of GLP-1 inhibitors), so I thought for balance I might report on my own. GLP-1s can be a good option for some patients – especially those living with comorbidities. However, I think for most of our patients, sustainable lifestyle change should remain the cornerstone of care.
Now before you splutter on your coffees, going: What would she know? She clearly has the privilege of good genes and has never suffered the affliction of a serious weight problem – it’s worth addressing the role of genetics.
My Dutch grandfather was a morbidly obese chain smoker who dropped dead from a heart attack. He held the village record for the most boiled eggs eaten in one sitting (I am not joking). My parents, both obese, have not had a BMI in the twenties since their twenties. All my aunts and uncles are overweight, and several died of weight-related causes in their 50s and 60s. Genetic predisposition obviously plays some role, but it is only part of a much more complex picture.
However, I was an easily bored child, and there was a leisure centre across the road. My parents signed me up for the swimming club from a young age, and I’d train several times a week. I learnt to love exercise. My mother – with her lifelong membership of Weight Watchers – was determined we would have a healthier start than she had, and moderated our portion sizes. My family’s tendency towards obesity was averted by developing better habits and building up good muscle mass as a child (improving my metabolic rate). These early habits and the environment into which I was born went on to shape how I approached my health for the rest of my life.
Visiting my sisters who live in Australia, it really is extraordinary how differently their culture views sport and exercise – as a necessity for all, children and adults. In Britain, we seem too ready to accept inactivity and isolation, preferring screens and junk food.
And without any further ado: weight-loss jabs. Are we really going to capitulate and declare the obesity crisis solved, just because Big Pharma would like everyone to be dependent on medication? Don’t forget that these meds come with a range of side effects, and need to be used long term in order to be effective (weight being otherwise rapidly regained).
Increasingly, it seems we offer a pill for every ill. Poor sleep – have melatonin. Low libido – take Viagra. Feeling sad or anxious – here’s an antidepressant. Stuck indoors – don’t forget your vitamin D! Poor diet – you’ll need iron, folate and B12 too. Eating rubbish and not exercising – weight loss jabs will sort that out. Many of these treatments are appropriate and effective when used judiciously, but the pharmaceutical industry and wider healthcare systems make billions from expanding the scope of treatable conditions. But is it true that medication is always the best first-line answer?
Many of the conditions we treat with medication would be addressed far more effectively by lifestyle changes – but doing this is often complex and requires consistent support and resource. Doctors can be quick to accept the narrative we are fed that our patients need XYZ drug to counter the problems that have occurred as a result of inactive and isolated lives. But wouldn’t it be far better to change the environments that cause many of these problems in the first place?
I know I am fighting losing battle, against corporate giants (and helpless, disillusioned doctors). The pharmaceutical and tech companies work hand in glove with government ministers, and there’s a lot of money to be made.
But surely we all recognise that a life dependent on pills and jabs is neither healthy, nor desirable? Our role as GPs is not to reject medication, but to use it thoughtfully alongside advocacy for healthier lives. If we do not advocate strongly for the public to lead healthier lives – involving nutritious food, time outdoors and plentiful exercise – then what hope does our society have?
Because, all too often, the drugs don’t work – and they really can make things worse.
Dr Katie Musgrave is a GP in Devon
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READERS' COMMENTS [11]
Please note, only GPs are permitted to add comments to articles
Of course, we are. There’s money to be made.
I run hockey training on a Sunday morning for 4-8 year olds. Somewhat unbelievably, the only children I coach are the children of other GPs who played hockey, and non-verbal autistic boys whose parents have recognised exercise in a team sport might be a way to bring them out of their shell (which it seems to). Maybe team sports will be the salvation of all our GP problems. Perhaps we could even have exercise on prescription!
The only reason we havent got even more people on mounjaro is supply. in 2032, these drugs should be off patent, cheaply available, made by the world and their wife, and i suspect about 40% of the population will be on them long term, with a cognitive shift towards obesity being a “disease of affluence”
Katie: I fell your article is brilliant. I also used to point my patients to https://m.youtube.com/watch?v=aUaInS6HIGo – 23 and a half hours. But we ( and our government) are in the clutches of the need to sell stuff – for growth and their profit – rather than self care as individuals and a society.
I think these drugs are a TOOL to aid weight loss. If you continue to eat junk and not exercise, then you will not lose much weight and it will be an expensive approach to obesity. People seem to forget that you have to address your diet, take up muscle strengthening exercise, and change your approach towards eating in order to be a successful GLP-1 user.
Of course the weight will go back on if the new habits formed are abandoned when the drugs cease. Hopefully, for many chronically overweight people, the new slimmer version of themselves that can be achieved will be motivation enough to maintain good habits.
If the obesity cannot be managed any other way, then GLP-1’s are a life changing medication.
Surely, it is far more dangerous to be obese, than to use a tool that can bring about a normal BMI ?
Yep! Great article- I often feel we are being… is it paternalistic- by not facilitating patients to take charge of their own destinies and develop autonomy. They ask for help to lose weight and to live a healthy life. And keep them dependent on our prescriptions. And medication reviews. Appalling. Since when did a ‘quick fix’ resolve the deep seated issue? Hmm.
An excellent and important article, alas too late to change the slide towards pharmageddon.
We’ve been impotently promoting diet and exercise for decades, with endless emphasis on lifestyle change, yet obesity rates have soared.
The reclassification of obesity as a “disease” is the final nail in the coffin, as responsibility has been removed from the patient and thrust upon the hapless GP.
Those preaching lifestyle change are King Canutes failing to turn the tide.
When patients “want to discuss their weight “ with us, there is only one thing they desire…..fat jabs. Lifestyle discussion is impatiently tolerated as an annoying preamble to their real agenda.
As restrictions loosen and prices fall, huge swathes of the population will be on these drugs, free on prescription, and of course we will be responsible for all the follow up, titration, side effects, complaints etc..Remember, people never value a drug they don’t pay for as much as one that cost a fortune.
The only positive is that there will be an inevitable backlash in a few years when an increasing minority suffer media-hogging side effects that will demonise these drugs in the future.
Your educational needs around the complex chronic health condition of obesity are showing again. Comparing a small amount of weight loss in someone who has never lived with obesity with the endocrine changes that maintain an individual’s excess fat in obesity is like suggesting we don’t need to treat sepsis because you managed a paronychia by letting the pus out.
The stigma of obesity and managing the lack of awareness and support available from many healthcare professionals is causing harm in patients living with this condition.
Follow the evidence base Katie, unless of course that’s only something you do when it supports your preconceptions.
Some good posts here. I’d add that the human body obeys the laws of thermodynamics. Consistently too few calories and you’ll be undernourished, consistently too many and the excess calories will be stored as fat. This is the first law of thermodynamics, the conservation of energy, and is inescapable.
Then on top of that, we have an economic system that worships GDP growth and corporate profits above an individual’s health, and which depends on selling more and more fast food, UPFs, and fat and sugary treats for the (evolution-enabled) quick dopamine fix. So we not only get one-fifth children worldwide who are undernourished but also two-fifths adults worldwide who are overweight! And at the same time, we have decreasing exercise levels across society.
Perhaps, the fixes need to be both an individual’s effort but also governmental – easy, free access exercise and outdoor activities, regulations on dys-foods like UPFs etc. It shouldn’t be left to GPs (whose hands are tied behind their backs) nor to Pharma to devise “cures” and rake in their mega-profits.
I find it strange weight loss clinics offer little advice for patients who want to try prolonged fasting. I’ve tried a couple of 3 day and three two day fasts and found it fascinating how it would take almost two days before ketones appeared in my urine. Increasing fluid intake to avoid becoming dehydrated was probably the greatest challenge and having plenty of engaging activities seemed to help. I felt energised and more alert so it seems true the brain functions well on ketones. The only side effect I noticed was slight nausea on my third days.
Goodness that sub-headline: “over-medicalisation […] has crept into the healthcare system”
Right. In the same way that Usain Bolt creeps along the 100m track.