Beyond Ozempic: Why one size doesn’t fit all in weight loss

I grew up in Birmingham, Alabama, which is generally associated with a diet of all fried food. Prior to medical school, I thought many adults around me would eventually succumb to a diagnosis of hypertension and diabetes since they didn’t appear to think either was a big deal. However, my medical education quickly revealed that these co-morbidities were not merely inconveniences but were linked to some of the leading causes of death in the U.S. Moreover, I discovered that simple dietary changes could play a crucial role in prevention. Naturally, as a medical student, I felt compelled to share this knowledge with anyone willing to listen.

Fast forward to the tumultuous year of COVID-19 in 2020, and a new buzzword emerged in the public discourse – ‘co-morbidities.’ Suddenly, the connection between obesity, diabetes, hypertension, high cholesterol, and the heightened risk of severe illness became widely recognized. This realization served as a collective wake-up call, prompting a collective decision to take health matters more seriously. However, in addressing these health concerns, it’s crucial to move beyond a one-size-fits-all approach and explore individualized strategies for weight loss.

The recent approval of GLP-1 and GIP agonist medications, including Wegovy and Zepbound, triggered a flood of information in various media. Amidst this surge of opinions, it’s crucial to acknowledge that only a few voices in this conversation hold board certifications in Obesity Medicine, Gastroenterology, and Nutrition to provide evidence-based recommendations. As a physician, I fall into this category and have observed the prolonged struggles of our patients who, for years, adhered to the age-old advice of “eat less and move more.”

My additional training revealed the intricate pathophysiology of obesity, challenging the simplistic guidance often offered. Witnessing patients’ efforts through intense workouts and restrictive diets without weight change highlighted the need to reevaluate traditional approaches and acknowledging the complexity of obesity management.

Decades of conventional weight loss advice centered on simple nutrition and lifestyle changes. The approval of Phentermine in 1959 and the advent of laparoscopic bariatric surgical procedures in the 1990s marked significant milestones. Despite widespread insurance coverage for bariatric surgical interventions, there’s a low uptake, leading to the introduction of less invasive endoscopic approaches, like the gastric balloon and endoscopic sleeve gastroplasty.

In recent years, the landscape of obesity management has continued to expand with the introduction of newer medication classes, such as GLP-1 and GIP agonists. These medications provide additional options for individuals navigating the complexities of weight loss, marking a significant shift from the traditional advice that has prevailed for decades.

As we stand on the brink of a comprehensive understanding of the “why” behind obesity, it’s evident that this multifaceted issue varies significantly from one patient to another. The myriad factors contributing to obesity encompass diverse eating habits, including emotional eating, snacking, unhealthy food choices, overeating, binge eating, undereating, and variations in basal metabolic rates. Additionally, individual differences such as the need for larger quantities to feel satiated, rapid gastric emptying leading to quicker hunger, or slow gastric emptying resulting in rapid satiation further complicate the landscape.

One of the biggest challenges in obesity management is the pervasive stigma that patients have endured throughout their lives. Confronted with judgment and often made to feel that their condition is a moral failing, individuals battling obesity are repeatedly advised to “try harder.” This unfounded perception not only leaves patients feeling isolated but also serves as a catalyst for emotional eating, perpetuating a harmful cycle.

In my advocacy efforts, I highlight a glaring example of this stigma in insurance coverage. While Ozempic (semaglutide) is covered for diabetes treatment, the same medication, Wegovy (semaglutide), approved for weight loss, lacks similar coverage. This discrepancy raises a crucial question: if obesity and poor diet frequently precede diabetes, why not address and treat the condition before patients reach a more critical stage of illness? It is imperative to shift the narrative surrounding obesity, moving away from moral judgments and towards a more compassionate and comprehensive approach to care.

As physicians, we must improve education on nutrition and obesity management for medical students and resident physicians. Prioritizing comprehensive teaching and screening based on specific phenotypes allows for the empowerment of future health care professionals to leverage data for optimal, personalized management choices.

Recognizing obesity as a chronic disease demands long-term follow-up, rejecting a one-size-fits-all approach. Identifying suitable candidates for interventions, including medications, less-invasive bariatric endoscopic procedures, and surgery, is crucial. Embracing the diversity of patient experiences underscores the need for a nuanced approach to obesity.

Treating obesity involves understanding each patient’s unique circumstances, ruling out potential contributing factors, and fostering a holistic approach to health. Education should extend beyond dietary recommendations, encompassing stress reduction, hydration, quality sleep, and judicious use of medications and procedures. By championing personalized care, we can pave the way for more effective, compassionate, and sustainable obesity management.

Janese S. Laster is a gastroenterologist and obesity medicine physician.

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