Food and Health Fact #204

My interview of Adriane Fugh-Berman, MD appears below. But first, the Wall Street Journal has published my review of “The Fruit Cure: The Story of Extreme Wellness Turned Sour.” The review can be accessed here. Also, I can be found on X (formerly Twitter) at @FoodHealthFacts, where I post and share items (mostly) related to food and health.

Adriane Fugh-Berman, MD is a Professor of Pharmacology and Physiology and also the Department of Family Medicine at Georgetown University Medical Center. Dr. Fugh-Berman co-directs the M.S. program in Health and the Public Interest and directs PharmedOut, a GUMC research and education project that promotes rational prescribing and exposes unethical pharmaceutical marketing practices. She has published many key articles in peer-reviewed literature on the area of industry influence on medicine.

After the Washington Post editorialized in favor of expanding access to obesity drugs in November, they published your letter to the editor, in which you said the editorial omitted important information. What information was missing?

The editorial was highly promotional, as most news stories are, and called the drugs a “breakthrough,” “extraordinary,” and the “medical sensation of the decade.” It also called the drugs “safe,” glossing over the unknowns and ignoring known risks of the drugs, which include pancreatitis, gallbladder disease, kidney problems, and suicidal ideation, and possibly increased risk of thyroid cancer. The drugs also cause vomiting and diarrhea, perhaps because they cause a partial paralysis of the gastrointestinal tract, so food sits rotting in the stomach for days.

The editorial also advocated for Medicare coverage, even though these drugs cause muscle loss, a bad thing in elders. (That’s one of the reasons I oppose having these drugs covered by Medicare.) Many older adults have low muscle mass already , and these drugs cause loss of lean body mass as well as fat mass. Besides, being moderately obese may reduce cardiovascular risks after age 65. Questions also remain about the effect of these drugs on Black Americans, three quarters  of whom have a BMI classifying them as overweight or obese. Less than 8%  of trial participants were Black in the tirzepatide trial.

Obesity drugs have received a lot of favorable attention – The Economist has claimed they could “end obesity” – and have had very high uptake. But experts in different fields have raised concerns about them. The concerns most often cited are side effects, cost, health effects (such as sarcopenia), and disincentives for users to pursue weight loss through lifestyle changes. What are your fundamental concerns with the drugs?  

There’s no evidence these drugs are effective in the long term; besides, few people can tolerate them long term. Although several medical associations hold that obesity is a disease, it is actually only a risk factor. Obesity is a risk factor for hypertension, hyperlipidemia, and diabetes, but is too often used as a surrogate for these conditions. Many thin people are hypertensive or diabetic, and many higher-weight people have normal blood pressure and don't have diabetes or hypercholesterolemia.

Data linking obesity to disease is confounded by lack of exercise, poor nutrition, socioeconomic factors, depression, and discrimination (somehow it is societally acceptable to discriminate against higher-weight people). Ragan Chastain is a fat activist who has written eloquently about this issue and the problems with data on obesity and weight loss drugs. Judy Butler of PharmedOut and I interviewed Ragan and Dr. Joel Lexchin on this topic on our Pharmanipulation podcast – it’s the “Fat and Fiction” segment.

The risks associated with obesity may actually be due to weight cycling, and the risks higher-weight people take to try to lose weight. As Judy and I wrote in MedPage today, “ While  a higher BMI may be associated with health risks in a population, BMI is a poor predictor of cardiometabolic health in individuals.” In fact, some extra weight may be protective. Compared to normal weight, being overweight (BMI 25 to <30) was associated with significantly lower all-cause mortality, and grade 1 obesity (BMI 30 to <35) was not associated with higher mortality. An obese person with normal cholesterol, blood pressure and blood sugar, who exercises and eats well, should not be medically persecuted. 

Health outcomes can be improved without losing weight, and research supports a weight-neutral strategy. The emphasis should be on improving cardiorespiratory fitness, because even in the absence of weight loss, exercise training can improve most cardiometabolic risk factors associated with obesity. And unlike weight loss, increased physical activity and cardiovascular fitness consistently decrease mortality risks.

Another concern is that Americans are already highly medicated, with nearly half the adult population taking at least one therapeutic monthly. And a 2021 study showed that many drugs contribute to weight gain. Have there been rigorous studies about how weight loss drugs interact with other drugs?

No. Many antipsychotics, some antidepressants, diabetes medications, corticosteroids, can cause weight gain, as well as other medications.

Last year, a 60 Minutes segment on obesity drugs featured a professor at Harvard Medical School saying, in effect, that the weight loss drugs are needed because people are helpless when it comes to exercising willpower about food (“throw it out the window,” she said). What do you think?

Dieting doesn’t work long term, and obesity is not due to lack of willpower. Junk foods are overpromoted, and people in low-income areas often have little access to fresh produce but lots of access to fast food and junk food. Most higher-weight people in the U.S. have tried and even succeeded in losing weight, but then may gain it back. Weight cycling may be worse for your health than staying fat. Again, everyone should exercise. These drugs may be useful in a very small percentage of very overweight people to lose enough weight to be able to exercise, but that’s a very small number of people. And we know that these drugs are commonly being used for cosmetic weight loss.

The same professor also said, “the number one cause of obesity is genetics.” Do you have a thought on this? 

A lot is due to genetics. But there are a lot of factors. I eat more than any fat person I’ve met, but I’m “normal” weight. People have different metabolic rates.

Last year, the American Academy of Pediatrics endorsed having children take weight loss drugs. What did you make of this?

This is a horrible idea. Many fat kids lose that fat when they, uh, grow. We should be encouraging children to have healthy body images, not making them obsessive about their weight. These drugs have mental health effects, and kids’ brains are still developing until about age 24.

The factors behind weight gain, and obesity, are multi-factorial, but it’s clear that something has changed in the United States over the past 40 years, given the sharp rise in obesity. What do you identify as the changes that have contributed to the United States now having one of the highest obesity rates in the world?

Redefinition. In 1998, the number of overweight and obese individuals in the U.S. increased overnight by 37 million, when an NIH task force redefined overweight as a body mass index (BMI) ≥25 kg/m², and obesity as BMI ≥30. This fact deserves more attention. Many stories talk about how obesity rates have gone up, but much of that rise is due to this redefinition. Other interesting info about the CDC, and industry- funded obesity organizations is available in this article.

Are there specific measures or tools you recommend to individuals trying to prevent weight gain or to lose weight?

Sure. Exercise!  That is the most important thing, even if it does not result in weight loss. Eat nutritious foods, including a lot of plants; cook most meals at home; enjoy food; treat diabetes, hypertension, and hyperlipidemia; and stop worrying about weight.

You are the director of PharmedOut, a project at Georgetown University Medical Center that advances evidence-based prescribing and educates health care professionals and students about pharmaceutical and medical device marketing practices. How do the obesity drugs fit into the issue set you focus on at PharmedOut?

PharmedOut advocates for the rational use of drugs, opposes overtreatment and the medicalization of normal life, and believes that pharmaceutical and medical device companies should have no input into the education of health care providers. We battle unethical drug promotion, and weight-loss drugs are a great example. Drug company promotion has created buzz, and exaggerated the benefits of and trivialized the risks of these drugs. They have used typical pharma tactics including using key opinion leaders and  creating or taking over advocacy groups, including the Obesity Action Coalition.

When it comes to public policy focused on addressing obesity, do you think there are lessons to learn from the campaign to reduce smoking?

Policy changes around tobacco drove use reduction, and policy changes around sugar-sweetened drinks – for example, no soda machines in schools – and junk food could also make a difference. Advertising of junk food should be regulated, especially to children and youth, and these foods should be heavily taxed. And by the way, drug companies learned a lot from tobacco companies about marketing.

More generally, what do you think should be done – whether through public policy, or anything else, to 1) treat the people already living with obesity and 2) prevent the onset of obesity?

The food industry has figured out the ideal combination of sugar, salt and fat to keep us eating snacks that are bad for us. We should ban, restrict, or heavily tax sugar-sweetened drinks, and rein in the advertising and sales of sugary and fatty processed snacks and fast foods. Meat should go back to being expensive, so we eat less of it, and fresh produce should be subsidized. We need to reduce food deserts in low-income areas, and make fresh produce available in stores or farmers markets in low-income areas. On a personal level, exercise regularly, use ten-inch instead of twelve-inch dinner plates, treat high blood pressure and other cardiovascular risk factors, and ignore the scale. That applies to everyone, not just higher-weight people – these actions promote health in everybody. And we should all fight fat intolerance.