When people come to my office as a primary care doctor, one of the first things I assess is what we call their BMI—basically the ratio of their height and weight. There are many different ways to quantify body weight. One is just to look at oneself in the mirror. What I must decide is whether someone is underweight, a healthy weight, overweight, obese, or morbidly obese. These are medical terms that describe what everybody already understands. Obesity is not healthy. It is the main cause of the epidemic of illness in America.
Diabetes and obesity go hand in hand. Our average life expectancy has actually begun to decline. People seem to have a confused idea about what they ought to weigh to be healthy. TV newscasters and the people on the front of magazines tend to be anorexic-looking or super-muscular. Not long ago, companies like Victoria’s Secret were showing overweight women in their lingerie ads. We witnessed a Madison Avenue attempt to normalize obesity.
When I have to deliver the news that a patient should lose weight, the conversation differs depending on the patient I’m talking to. With most men, I am usually blunt: “George, you are fat.” That typically produces a smirk or a laugh. With most women, it is a much more delicate (and potentially hazardous) discussion. A woman once threatened to find another doctor after I described her as “plump.”
That was a tactical blunder I’ve never repeated.
I recently asked several women (those who have a sense of humor) to give me a series of safe adjectives to describe overweight women. I have been offered a bunch of creative alternatives. My favorite is “Rubenesque.” For those of you unfamiliar with art history, Peter Paul Rubens was a painter famous for classical scenes including lovely ladies who, by modern standards, might qualify as “overweight.”
Destined To Be a Decade-Long Experiment
What has happened in the last few years is the advent of a whole new class of drugs, originally devised for diabetes. They mimic hormones normally made in the gut and have significant effects on the hormonal response to food, blood sugar levels, satiety, and how long food takes to transit the gastrointestinal tract. An interesting fact is that the basic structure of these drugs traces back to a chemical originally found in the saliva of the Gila monster. I keep a picture of a Gila monster in my exam room just for the purpose of discussing these new drugs.
They were initially approved to manage diabetes and can be a game-changer for this condition. The weight-loss “side effect” has now become the main reason people ask for Ozempic, Mounjaro, and other similar drugs. The problem with any new drug—particularly one that is heavily advertised and promises significant weight loss—is that people rush to take it, not realizing they are participating in a very large experiment whose full results may not be known for a decade or more.
I hand every patient what I call an informed-consent sheet when we agree to try these drugs. It lists the known benefits and hazards of these drugs. One would think that after reading it, people would be hesitant to begin taking these medications with such uncertain long-term side effects. The most common side effects are gastrointestinal: nausea (which can usually be overcome by slowly advancing the dose) and constipation. One of my patients ended up in the emergency room with stool approaching the consistency of concrete. He had to be digitally disimpacted by a not-so-thrilled nurse. Other side effects, which are not so obvious, include significant loss of muscle as well as fat. It is now becoming apparent that these drugs may affect all parts of the body, including the bones and even the brain.
Even though they are quite useful for diabetes, many people who are mildly overweight but do not have diabetes have given up on lifestyle changes and simply want the drug. It should be noted that for people who are seriously obese and contemplating bariatric surgery, these drugs can make a huge difference. Another recently approved indication for them is sleep apnea, often seen in the obese.
Intermittent Fasting Works for Some Patients
Having struggled with my own weight for years, I have settled on intermittent fasting. I do a thirty-six-hour fast - only water, tea, or coffee, from 8 pm every Sunday to 8 am every Tuesday. This throws me into a fat burning state called ketosis. It has generally helped me keep off most of the 40 pounds I lost some years ago.
I tell nearly everyone who comes to see me the benefits of intermittent fasting. People nod and appear to get the idea. Only a few will make it part of their lifestyle. Sadly, most come back six months later looking apologetic and saying that they are still trying, blaming the holidays, stress, or whatever. After several cycles of this, depending on their blood sugar, cholesterol, blood pressure and BMI, I am more likely to throw in the towel and suggest Ozempic or Mounjaro.
Price Is An Object
One major issue is that these medicines are very expensive. Unless a person has diabetes or sleep apnea, the cash price can be $800–$1,000 a month. With the new TrumpRx pricing, it is still about $350 a month. Even if insurance covers it, there is often a very high co-pay.
The biggest issue, above and beyond all this, is what happens when you stop taking the drug. About half the people who start these medications have stopped within a year, and even more have stopped by two years. Cost, side effects, and not losing as much weight as they expected are common reasons for discontinuing the drug. Studies now show that patients regain, on average, two-thirds of the weight they lost within a year of stopping—and most of the cardiometabolic benefits fade as well.
These are powerful tools, but they are not magic. They work best when paired with real changes in how we eat, move, and live. In my office, the mirror still tells the truth—and so does the conversation that follows.
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Dr. Paul Aijian is a primary care physician practicing in Santa Barbara. This column reflects his personal observations and is not medical advice. Always consult your own physician before starting or stopping any medication.
If you have enjoyed this article or Dr. Aijian’s prior contributions to SBCurrent, you will probably appreciate his upcoming book, “Laughter and Tears: A Doctor’s Stories”. He is close to completing it. Stay tuned!
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