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Sunday, April 14, 2024

The Future of Weight Loss Looks a Lot Like Its Past

A revolution in weight loss is apparently underway. It started in 2021, when the FDA approved the diabetes drug semaglutide for weight loss. The weekly injectable—sold under the brand name Wegovy—can help users lose 5 to 10 percent of their body weight, leading commentators to describe the drug as both a “medical breakthrough” and a “silver bullet” for obesity. Elon Musk says he’s taking it, Kim Kardashian is rumored to be using it, and everyone from Hollywood to the Hamptons reportedly wants a prescription. 

Soon, there will be a new weight loss medication on the block—and it’s even more potent than its peers. Last fall, the FDA fast-tracked the review process for using tirzepatide as a weight loss drug after a clinical trial showed that people with BMIs labeled “overweight” or “obese” lost a staggering 22.5 percent of their body weight on the highest dose. If all goes according to plan, that will make Mounjaro the latest in a fast-growing biomedical sector—spanning everything from bariatric surgery to deep brain stimulation for binge-eating—that aims to combat, if not cure, the problem of “excess” weight. 

For pharmaceutical companies, the race to market is financially motivated: Wegovy and Mounjaro cost more than $1,000 a month. Weight loss drugs are rarely covered by insurance, but people who can afford them have proven they’re willing to pay. And the market seems effectively limitless: Despite an ongoing “war on obesity,” more than 1.9 billion adults globally are considered overweight or obese, and the number of prospective users is growing every year. Now doctors—desperate to treat what is widely seen as an “obesity epidemic”—are coming on board. In January, the American Academy of Pediatrics recommended such medications for kids as young as 12. 

The victorious narratives gilding drugs like Mounjaro are already being positioned as a direct challenge to fat activism. For decades, the movement has pushed for social and economic opportunity for people of all sizes through civil rights, fat pride and liberation, and biomedical evidence itself. Thanks to prominent voices like Aubrey Gordon and Michael Hobbes, many people now know that “lifestyle changes” like calorie restriction and exercise fail to produce sustained weight loss for 97 percent of people and that many dieters end up gaining back more weight than they lost. But what happens to the strength of these arguments when a weight loss drug seems to work?

Like other purported weight loss solutions, Mounjaro promises “to fix weight stigma by making you thinner, instead of removing the stigma,” says Susanne Johnson, a fat activist and family nurse practitioner in Pennsylvania. In so doing, these drugs and surgeries further exacerbate anti-fat discrimination. Instead of criticizing people in larger bodies for their perceived lack of willpower—that old “calories in, calories out” adage—people can now blame those in bigger bodies for something more akin to a techno-pessimist, or even anti-science, stance: “Just take the miracle cure!” 

The history of the weight loss industry is more akin to prospecting for gold or investing in crypto than transplanting organs and developing antibiotics; less a story of scientific progress than an endless cycle of wild speculation, where boom inevitably gives way to bust. Fen-Phen was a miracle until it was linked to heart valve damage. Intermittent fasting was going to fix what caloric restriction couldn’t until researchers showed the two produce exactly the same results. And then there’s the complicated case of bariatric surgery.

From their inception in the 1950s, operations like gastric bypass (which reroutes food away from the stomach, inducing malabsorption) and gastric sleeve (which involves partially amputating the stomach so it holds less food and produces fewer hunger hormones) have been sold as a potential panacea, says Lisa Du Breuil, a clinical social worker at Massachusetts General Hospital. While fewer than 1 percent of people who qualify actually undergo bariatric surgery, those who do can lose up to 70 percent of their “excess” weight (or the weight above a BMI of 24.9). 

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But Du Breuil, who specializes in eating disorders and substance abuse disorders, has seen some of the worst of bariatric’s side effects. People can develop dumping syndrome—wherein sugar-rich meals leave the stomach too quickly, causing sweating, dizziness, rapid heart rate, and vomiting. Gastric bypass in particular raises the risk of postoperative alcohol abuse. Rates of suicide and self-harming behaviors also rise in the years after bariatric surgery. And even when people follow strict post-operative diets, malnutrition, tooth loss, gout, and new or resurging eating disorders are possible. “It can be really challenging to get a full picture,” Du Breuil says. She learns about new side effects all the time.

Semaglutide and tirzepatide—both part of a larger family of GLP-1 receptor agonists—were developed for diabetes management at lower doses. When pharmaceutical companies noticed their trial participants were also losing weight, they realized “if we can turn the volume up to 11, we can really enhance this side effect,” says Johnson, the nurse. “That means you’re also turning up the other side effects.” 

The primary complaints from users of Ozempic, Wegovy, and Mounjaro sound like the kind of thing you can fix with a bottle (or three) of Pepto Bismol: nausea, upset stomach, diarrhea, and what one patient called “power vomiting.” But these might be less like classic “side effects” of a drug than a mechanism of weight loss itself, as The Guardian recently reported. By making the feeling of eating (and, in some cases, even hydrating) actively disgusting to the user, the drug curbs their consumption—similar to the experience of bariatric patients, who can only fit a few ounces of food in their stomachs at a time. 

The list of complications doesn’t end there. For example, both GLP-1 receptor agonists may increase the risk of thyroid cancer—one of the many BMI-linked diseases that supposedly makes weight loss absolutely imperative for people in larger bodies. And there’s good reason to believe that other side effects will reveal themselves in years to come, as the number of long-term users grows. 

The biggest surprise for many prospective patients is that long-term weight loss isn’t guaranteed—a reflection, perhaps, of the faulty assumption that people are obese because they overeat. Current estimates suggest that the average bariatric surgery patient regains 30 percent of the weight they lost in the 10 years after surgery. One in four regain all of their weight in that time. And 20 percent of people don’t respond to surgery in the first place. 

The same is true for GLP-1 receptor agonists: If you stop injecting, the weight returns. 

In case it wasn’t clear by now, biomedical weight loss interventions often mimic the deadly logic of anorexia, bulimia, or other forms of disordered eating, says Erin Harrop, a clinical social worker and researcher. Harrop would know. At the height of their own eating disorder, Harrop wished they could fill their stomach with air instead of food, or cut their stomach out, or wire their jaw shut. Later, they learned these things exist—in the form of gastric balloons, gastric sleeves, and even a magnetic jaw trap

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It’s no surprise, then, that some people who undergo bariatric surgery experience a resurgence of a preexisting eating disorder, or develop a new one. Frequent vomiting, never knowing what foods will upset your stomach, and feeling pressure to maintain a post-surgical weight—“you can create an eating disorder that way,” Du Briel says.

But semaglutide and tirzepatide promise to fulfill an even stranger fantasy: eliminating appetite itself. While a drug like Mounjaro works on numerous fronts—including preventing the body from storing fat and “browning” existing adipose tissue—it’s the feeling of being untethered from desire that seems to fascinate patients and physicians alike. People for whom the drug works often say, “I forget to eat,” says Fatima Cody Stanford, an obesity medicine specialist at Massachusetts General Hospital’s Weight Center. 

If doctors really believe that obesity is the greater of any two evils, then this approach makes sense. When it comes to bariatric surgery, for example, a review of the medical literature suggests it is, on balance, associated with a reduction in all-cause mortality—or death of any cause*—*compared to patients with high BMIs who don’t go under the knife (though such studies are profoundly limited, as they often do not control for social factors, like income or education). Many hope that semaglutide and tirzepatide will one day prove just as vitalizing.

But eating disorders kill too. In many contexts, sustained hunger is considered a travesty. And desire—for food, or anything else—is a great way to know you’re alive. “It’s wild to me that we see no appetite as a positive thing,” says Shira Rosenbluth, an eating disorder therapist who works with people of all sizes. Anna Toonk agrees: “I realized that there are worse things than being fat,” she told The Cut last fall. “The worst thing you can be is wanting to barf all the time.” 

Ultimately, the proliferation of drugs like Mounjaro means medicine is not only in the business of dictating “normal” weights (a thing it still hasn’t quite figured out), but “normal” appetites. What was once an intuitive process, in which your body tells you what it needs, became a dictate under diet culture: You tell your body what it can have. Now medicine promises a radical reset: With the right drug, your body will hunger for nothing at all.

Weight loss technology can’t be stopped entirely—nor should it be. Everyone has the right to choose what they want to do with their bodies. But informed consent is built on information, and we may not have enough. Mounjaro was fast-tracked by the FDA based on studies designed to observe weight loss over just 72 weeks, a small fraction of the time real patients will be on the drug. At the very least, patients should be informed that in the first years after a drug hits the market, they are participants in an ongoing experiment. 

As biomedicine’s war on obesity continues, people must work harder to combat anti-fat bias—not on a technicality, but as part of the expansive vision of justice fat activists began articulating more than 50 years ago. For semaglutide, tirzepatide, bariatric surgery, and their ilk are neither miracles nor cures. There have always been fat people, and there always will be, whether they’re “non-responders” to treatment, refuseniks, or languishing on the waitlist. Notably, even those who experience dramatic weight loss after surgery or on injectables may still be overweight or obese, depending where they started. 

Perhaps most importantly, the American weight loss discourse must move away from a reflexive scientism, which has enabled biomedicine to subject the entirety of human experience to its single-minded scrutiny. Weight, like almost every aspect of embodiment, is not an exclusively biological phenomenon or a clear-cut medical “problem” to solve. It is shaped by countless factors, like power distribution in society, personal psychology, and that most frightening of forces: the desire for more.

If you or a loved one is struggling with an eating disorder, the National Eating Disorders Association Helpline is available at (800) 931-2237.

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