Calling Obesity a Disease is a Classic Move in Pharmaceutical Profiteering
And Oprah, characteristically, is jumping on the bandwagon
By now you may have seen it: the much-hyped Oprah special entitled, “Shame, Blame, and the Weight Loss Revolution,” which aired last night on ABC. So passionately did Oprah feel about making and airing this special that she resigned from the board of Weight Watchers to avoid any perceived conflict of interest, since Weight Watchers is now peddling weight loss drugs, after buying the Telehealth platform Sequence last year. (Weight Watchers’s tanking profits surely also had something to do with her resignation.) And to be fair, the special did read like an hour-long paid infomercial for the much-hyped new class of weight loss drugs, Ozempic, Wegovy, Zepbound and Mounjaro (GLP-1 receptor agonists), down to prominent branded shots of the injections and their packaging, to the instructions on how to use them (“wait for the second click”), to the “before” and “after” shots of patients. There was the obligatory canned science from the obesity doctors in white lab coats, and the final segment featuring the CEOs of the drug manufacturers, Novo Nordisk and Eli Lilly.
Oprah, of course, has a long and troubling history of jumping on weight loss bandwagons and using her incomparably large platform to a launch a string of problematic figures, including Dr. Oz and Dr. Phil. She’s also, as she pointed out in the opening of the special, been shamed and blamed for her weight more than almost anyone in the media. A potent combination of misogynoir and fatphobia has made her body fodder for tabloid headlines, media speculation, and the “national sport” of belittling her.
That’s partly why this special was so disappointing, even by the standards of the genre. Its message can be summarized in two lines. “You’re not to blame for your weight. Obesity is a chronic disease and you need a drug to treat it.” As someone who just wrote a book on fatphobia, and the moral ills of diet culture, I agree wholeheartedly with the first point. The second is harmful and wrongheaded.
As Oprah’s special mentioned, obesity was designated a disease in 2013 by the American Medical Association (AMA). What it neglected to mention, unfortunately, is that the AMA made this call against the explicit advice of a committee it convened to advise them on this matter, which held that the measure so-called obesity is based on, the BMI, is hopelessly flawed and simplistic. The likely reason that the AMA ignored these worries and deemed obesity a disease anyway can be gleaned by following the money: the new weight loss drugs Belviq and Qsymia had been introduced to the market just prior, and were not selling as well as predicted.
In fact, the labelling of obesity as a disease did not truly take off in the public discourse until the advent of Ozempic and related drugs as popular weight loss medications last year. In this vein, the trajectory follows a standard one in this space: a pharmaceutical company has a new drug to sell, which treats a circumscribed or even non-existent problem. Hence a more sweeping condition that the drug treats is branded, in a process known in the sociology of medicine as “condition branding” or “disease mongering.” “Testosterone deficiency” became a widely-diagnosed disease when testosterone became widely available as a treatment; “idiopathic short stature” became a thing when human growth hormone needed peddling; “hypoactive sexual desire disorder” was invented thanks to the availability of medications that promised to increase female libido. Time and time again, we find that the advent of the “disease” follows the supposed cure to what are overhyped and inflated medical (non)-problems. All to drive a tidy profit for profiteering drug companies.
It’s disappointing but predictable that Oprah has fallen for this hype when it comes to weight and weight loss. Her special never presented the question of whether to consider obesity as a disease as a question to begin with. It was billed as an insight, a discovery, a classic a-ha moment. But the truth is, the science on this topic is anything but definitive. To begin with, obesity would be a very unusual disease, in having no specific symptoms. Moreover, meticulous and well-replicated research by Katherine Flegal at the CDC showed nearly twenty years ago that being overweight (having a BMI between 25 and 30) is the lowest-risk category of the—hugely problematic—BMI charts to be in, in terms of all-cause mortality. That’s right: despite the seemingly new consensus according to Oprah that being overweight (as well as obese) is a disease state, it’s actually associated with the lowest risk of dying prematurely. Moreover, being “moderately obese” (having a BMI between 30 and 35) is not statistically riskier than being “normal-weight” (with a BMI between 18.5 and 25). True, being heavier than “moderately obese” is correlated with increased health risks; but so is being underweight. And we don’t tend to see expensive, potentially risky solutions to being underweight touted on Oprah specials in primetime. Moreover, it’s not clear whether the correlations between health problems and being very heavy are due to the weight itself, or whether it is mostly explained by the fact that these are the people subject to medical fatphobia, grossly inadequate health care, subsequent health care avoidance, the health risks of weight stigma, and the health harms of weight cycling.
Whatever the case, you would never know from Oprah’s special that the vast majority of Americans who are classified as too fat—and who may be tempted to take weight loss drugs to improve their health—do not have elevated mortality risks based on their body mass. True, some of these same people may have an increased risk of certain kinds of morbidity (illness) such as type 2 diabetes—though whether weight is one cause of this disease, or whether early disease processes drive weight gain, remains controversial. But the thing about these weight loss drugs that you would barely learn from Oprah’s special (it was mentioned once in passing) is that they were originally intended to, and are now widely used, to treat type 2 diabetes. When her opening guest, Amy, touted the benefits of Mounjaro for her diabetes, that is tremendously unsurprising because she was taking an effective new diabetes medication. The implication that Amy’s blood sugars and other markers of health for type 2 diabetes improved purely because she lost weight on this drug is an irresponsible example of the post hoc ergo propter hoc (“after, therefore because”) fallacy—especially since weight loss alone is far from the magic bullet for type 2 diabetes it is frequently touted as being. Some longitudinal studies have even shown, to the surprise of the researchers, that it increased mortality risks for patients in this population.
There were many other irresponsible aspects of Oprah’s special too. Aside from the opening montage, no side effects of GLP-1 receptor agonists were mentioned until the 48-minute mark, by my watch, of the hour-long program. We then learned of a patient who had to go to the ER because of extreme and persistent vomiting. She, sensibly, stopped taking the GLP-1 receptor agonist prescribed to her. “Did you try another?” Oprah asked, hopefully. One of the doctors in a white lab coat pointed out that some of the concerns about pancreatitis, gall bladder problems, thyroid cancer have not played out so far for many patients. True—and great news—but what about the fact that around 1% of the population taking these drugs appears to be experiencing gastroparesis, a potentially life-threatening complication where the gut essentially becomes paralyzed? Never mentioned. (And remember, even rare side effects affect a lot of people when drugs become ubiquitous; with at least ten million Americans taking Ozempic and similar drugs, that is tens of thousands of people facing this potentially severe complication.) Even the manufacturers of these drugs had to add ileus (where food builds up in the intestine, sometimes causing bowel obstructions) to the boxed warning. Again, this was never mentioned in this unethical special-cum-advertisement. (At least drug advertisements have to rattle off a fuller list of side effects at hushed breakneck speed before the inevitable question of whether the drug du jour is right for the viewer.)
Oprah may not be on the board of Weight Watchers anymore, but the CEO of the now-beleaguered, ailing company, Sima Sistani, was still given a guest spot almost as long as the discussion of side effects to defend the company’s dubious relevancy. And I can only imagine how much “consideration” Oprah received from Novo Nordisk and Eli Lilly for featuring their CEOs in the closing segment.
It’s sad to see the discourse get to this point. Of course nobody should be shamed and blamed for their weight. Period. Full stop. But the way to usher in a world in which there is no more weight stigma is to end weight stigma and stop celebrating weight loss. (As I’ve said before, this is compatible with acknowledging that individuals have the right to pursue intentional weight loss, in the name of bodily autonomy, if they choose to.) It’s to stop medicalizing and pathologizing those of us who live in larger bodies, and are often happy and healthy—or would be, but for the fatphobic society which we have to navigate. And even if we aren’t healthy and happy, the supposed solution of weight loss fails to be evidence-based or sustainable, given that the weight almost always comes roaring back after the diet is over—or after people stop taking weight loss drugs, as have and will the vast majority. To its credit, the Oprah special did acknowledge this: but the doubling down on the rhetoric of obesity-as-disease means the necessity of keeping people on these drugs for life, whatever the costs and complications, now has a new justification. We as fat people are deemed deficient in a new way: not of willpower, perhaps, but of a very special hormone. A hormone to which very lucrative pharmaceutical companies conveniently hold the patent to artificially increasing. Oprah just gave them her blessing to wring yet more money out of us.
I agree with you that the Oprah special felt like an infomercial, and left me wondering if Oprah is planning to launch some new business that will capitalize on these meds. However, I do feel like nuance is needed on both sides. I'm on one of these GLP-1s and they have been absolutely life-changing for me. Obesity may or may not be a disease, but I do think that there are enough shared metabolic issues among a significant number of people with obesity that there must be some underlying biology/genetic link to it.
I've had high cholesterol since I was 19. Elevated blood pressure since I was in my early twenties. Elevated glucose levels since my teen years. Over the last five or six years, my weight had ballooned to the point where where basic movement (tying my shoes, bending down to pick things up, gardening) had become really difficult and uncomfortable. I was losing functionality and felt awful. I've been on these meds for 18 months now, and I will tell you that it's easier to move through the world as a smaller person, not only because of the way society looks at me, but because I have less pain and discomfort, and I can move my body more easily. I'm not out of breath going up the stairs, and I'm not drenched in sweat after a five minute walk. Although I am still obese, my life is so, so much better than it was 18 months ago. For the first time in my life, I have normal glucose, cholesterol and blood pressure numbers. I have less pain. I feel more in control of my body and my mind.
GLPs turned off my constant food noise. This is a concept hard to explain to those who haven't experienced it. But it's constant chatter and obsession about food that takes over your life. I can actually exercise and make healthy food choices without a constant internal battle on these meds. My brain has room for thoughts and ideas not centered on food. I tried therapy, journaling, self-help books, dieticians, medical health programs, health coaching...you name it...my GLP1 completely resolved my life-long food issues within an hour of my first shot. I read another one of your pieces about food noise, and while I appreciate what you are trying to do, I do wonder if you have an understanding of what food noise is, and how devastating it can be to a person's mental health.
I think of my life now as pre and post GLP1s. I have a lot more mental clarity. My moods are more stable. I don't have insulin-related crashes. I take joy in exercises and good foods. I'm less flaky with my commitments because I feel better. I have an easier time following through with tasks and completing my work on time. I believe all these mental health aspects were somehow linked to whatever underlying metabolic issues I was born with that eventually lead me to become morbidly obese.
Of course there are people who are going to be healthy at any weight. But I think there is a correlation between between disease and weight, especially for those of us at the highest and lowest percentiles. Yes, being underweight is a problem, but I think underweight-related conditions/diseases aren't highlighted as much because less than 2% of Americans are underweight and close to 20% of Americans are severely obese. At this moment, our country is seeing more problems related to severely obese individuals than severely underweight individuals.
I think it's far to be cynical about the drug companies' motives. Do I think they are driven by altruism? No. Of course they are driven by profits, and it's fair to question the safety of these medications and the ulterior motives of the pharmaceuticals. Of course I think the focus should be on creating an environment for health in our country where healthy foods are affordable and highly processed foods have warnings, and cities and neighborhoods are more walkable, and we have better social connections with our neighbors and supports, and everyone has health care and access to safe and enjoyable movement, etc. But from my own experience -- and the experience of friends and colleagues also taking these meds -- GLP1s have improved the lives of millions of people, and I don't think they should necessarily be villainized, or dismissed solely because some CEOs are making millions.
As a general rule, I try to avoid feeling sad for billionaires but, damn, Oprah makes me feel sad for her. She is so smart and talented and she has spent to much of her life/time/money on trying to fight her body. I really wonder if she's ever had a day where she wasn't thinking about her weight and was just content to live in the body she has? What a terrible waste of emotional energy.