Patients with obesity are giving us another chance — let’s not squander it

Individuals with obesity have long felt stigmatized and shamed in health care settings.

Providers have too often sustained the popular (mis)perception that weight loss is a simple matter of calories in vs. calories out, and that people with obesity just need to get up off the couch and put away the cookies.

Now that more effective treatments are available and obesity is widely recognized as a chronic disease, many people with obesity are ready to give their providers another chance. It’s essential that we do not waste this opportunity by jumping to conclusions again.

Weight bias within our community can take many forms. Sometimes, it’s seen in thoughtless indignities such as a lack of adequately sized waiting room chairs or hospital gowns. Perhaps most often, it takes the form of ineffective advice: providers repeatedly telling a patient to “just eat less and exercise more,” even though they’re already doing everything right and it isn’t working. Sometimes, it manifests as dangerously substandard care, such as when a provider assumes that the health problems a patient presents with are caused by their excess weight, without doing a full workup.

Experiences like these have led many people with obesity to actively avoid seeking care.

Now, though, powerful new anti-obesity medications have changed the calculus for some of these individuals, and they’re ready to give treatment another chance. These individuals are newly optimistic for two reasons. First, the GLP-1-type treatments themselves are vastly more effective than previous options, giving patients reason to hope that they may actually be able to lose a significant amount of weight and keep it off. Second, these medications’ targeting of dysregulated hormonal pathways has broadened awareness that obesity is a chronic disease rather than a failure of willpower, leading to expectations that providers may be less judgmental.

We need to avoid replacing one too-easy answer with another. Just as weight management is not as simple as calories in vs. calories out, caring for patients with obesity is not as simple as just measuring their BMI and writing a GLP-1 prescription.

There’s no silver bullet in obesity care

Although the guidelines for anti-obesity medication eligibility are based on BMI, BMI is just a screening tool — it doesn’t replace a thorough evaluation and clinical judgment. Not everyone with an elevated BMI necessarily has obesity, nor is everyone with obesity a good candidate for anti-obesity medications.

The new GLP-1-type anti-obesity medications are indeed game-changers, but they aren’t a silver bullet. Obesity is an extremely complex, heterogeneous disease, and there’s no single solution that works for every patient. A treatment plan needs to be highly individualized and comprehensive, identifying and addressing every contributor to weight gain and every barrier to weight loss, taking a multifaceted approach that includes diet, physical activity and behavioral change, as well as pharmacotherapy when appropriate. Different combinations of treatment approaches work better for different people.

It’s also important not to conflate obesity care with weight loss. Obesity care is more than just weight management. It includes addressing all the patient’s weight-related comorbidities, along with their respective medications and potential interactions, and it requires a clear focus on the patient’s overall health, not just their BMI. This means making sure that anti-obesity medications are complemented with sustainable healthy lifestyle changes as well as with ongoing long-term support.

Respect requires empathy — and avoiding assumptions

Now that we have more effective anti-obesity medications in our armamentarium, and we’ve heard so much about demand outstripping supply, it may be tempting to assume that any eligible patient with obesity will want to try them. Although many people with obesity are eager to obtain treatment and may proactively ask about anti-obesity medications, it’s important not to jump to conclusions when patients with obesity present for other health issues.

Before launching into a GLP-1 sales pitch, it’s best to ask patients for permission to discuss their weight — and to ask about their weight history before making any recommendations. It’s demoralizing for a patient who has just lost 60 pounds to see a new provider and immediately be asked, “Have you considered losing weight?”

As providers, we naturally want to encourage our patients to lose weight — obesity is associated with more than 200 other health conditions, and losing weight can improve many of them (including cardiovascular risk) — but we need to meet our patients where they are. Some will not be ready to take anti-obesity medications. Knowing that starting medication for a chronic disease is a long-term commitment, some individuals will prefer to try medically supervised lifestyle interventions first to see how much success they can achieve with diet, physical activity and other behavior modifications. Once those factors have been optimized, they may be ready to reassess their weight-related health goals.

Regardless of the plan of care chosen, it’s critical to keep the lines of communication open to enable honest, respectful discussions about the patient’s evolving risk factors, health goals and treatment options.

We’ve come a long way from the oversimplified “calories in, calories out” understanding of obesity, but we’re still dealing with a complex disease with many unknowns. We can’t let GLP-1s become the new shortcut, rushing to prescribe based solely on BMI. These revolutionary new medications are giving us an opportunity to reconnect with patients with obesity and demonstrate not only that we aren’t blaming them for their inability to lose weight, but that we see them as individuals who deserve the same consideration and quality of care as patients with any other chronic disease. Let’s seize this opportunity.