There is no doubt that the United States is in the midst of an obesity epidemic. Well over half the population is overweight or obese, despite concerted efforts to educate the public. The human and financial costs are almost unimaginable. The journal Health Affairs reported in 2009 that medical costs for the more than one-third of Americans who are obese were estimated at about $150 billion in 2008. We spend five times more on obesity each year than the government spends on the National Institutes of Health.
But the impact of obesity goes far beyond statistics. It deeply affects the way patients live. The stigma of obesity is overwhelming and unchecked. Every day I hear stories of cruelty and misunderstanding that bring my patients — and me — to tears.
We are failing to meet our public health goals and our commitment to patients as human beings. In part, this is because we live in an environment that promotes weight gain: All around us are single-serving high-calorie coffee drinks as large as wine bottles, unwalkable neighborhoods and fast, inexpensive, unhealthful food.
Against these pressures, medical professionals have few treatment options that work. Yes, we encourage patients to diet and exercise, but those tools alone are not a realistic solution to the crush of patients I see every day. Diet, exercise and lifestyle modification are starting points. In an environment in which the pressures pushing the population toward obesity are supercharged, we need supercharged interventions.
Yet we lack new tools to manage the disease. There have been enormous leaps in our understanding of the causes of obesity — insights into metabolism, breakthroughs in perspective on craving. It is quite clear that once someone gains weight, the body will turn on a host of defense mechanisms to maintain that higher weight. Most people are trying to fight biology and not just “habits” when they try to lose weight.
Unfortunately, we’ve been stymied by an unrealistic and naive conversation about the risks and benefits of medications to manage obesity. Yes, there are risks with any medication, but there are even more serious risks with obesity and the associated cruel treatment of the obese inherent to our society. It has been more than a decade since doctors have had a new obesity drug to work with.
Three new therapies went before the Food and Drug Administration in the past year, and the agency found all three provided reasonable weight loss that physicians desperately need to manage patients. Yet none of those drugs has been approved; the FDA found them wanting because of concerns about their risks.
I am not arguing that there are not risks associated with medical therapy for obesity. But even the theoretical risks pale next to the risks of undertreating obesity. As a doctor on the front lines, I’ve seen hundreds of patients — hardworking, medically conscientious people — progress to diabetes, cardiovascular disease and degenerative joint disease. I’ve seen patients lose their feet, kidney function and vision to complications from diabetes and obesity. I’ve seen lives cut short and families devastated by heart disease. These are not hypothetical risks of obesity. This is what I see daily.
It’s time for a reasonable conversation about what kind of medication risks doctors and patients should be willing to accept in return for benefits that hold the potential to fight this disease. Demanding that obesity drugs carry no real or possible risks sends the message that the disease I treat every day isn’t serious and that the rare risk of a major side effect outweighs the insidious complications of obesity.
The FDA needs to establish clear guidelines on what risks are acceptable. It needs to talk to doctors and patients about what is at stake in the battle over obesity. And it needs to hold drugmakers responsible for quantifying those risks, after approval.
My waiting room is not getting any less crowded, and the health risks my patients face aren’t diminishing. Right now, it’s not medical treatment that’s threatening my patients’ health. The truly grave risk comes from the lack of viable options.
The writer, a diabetologist and internal medicine specialist, directs the Nutrition and Metabolic Research Center and the Center for Weight Management and is a member of the Division of Diabetes and Endocrinology at the Scripps Clinic - Del Mar in San Diego. He has conducted clinical research in collaboration with multiple companies developing drugs related to treating obesity.