Beyond the scale: Society’s treatment of weight loss

First used as a diabetes intervention, GLP-1 agonist drugs for weight loss purposes are sparking a larger conversation about body image, health and social attitudes. Many of these GLP-1 agonist medications like Ozempic and Wegovy are becoming popular because they are now prescribed as a weight loss intervention due to their role in regulating blood sugar levels, appetite and digestion. One brand, Mounjaro, even garnered 5.2 billion in sales during 2023.

Simultaneously, the relatively new usage of these drugs for weight loss is emerging during an era of body positivity, a movement that promotes self-love, and fat liberation, which aims to eliminate weight discrimination. Some critics wonder if the popularity of GLP-1 agonist drugs nullifies the work of social movements that decrease weight stigma and shame – but the situation is much more complex, and even experts are divided. 

“It is about making sure that people have access, respect and dignity, which they don’t have if the constant push is ‘We have all these drugs now so what’s the problem? You could lose all that weight,’” which is not true, said Olivia Montgomery, fat liberationist and associate professor of practice in social work and practicum education specialist at Simmons University. Montgomery is referring to the situations where GLP-1 drugs are weaponized into denying bigger-bodied people of respect.

Obesity is a tense social and clinical topic of discussion. Clinicians focus on obesity as a medical condition which is associated with diabetes, hypertension, high cholesterol and sleep apnea. For them, GLP-1 drugs are just another tool in their toolkit to treat their obese patients. 

One of these tools is surgery, and it’s considered more of a last-resort approach. Surgeries’ purpose is to improve an individual’s metabolic health when lifestyle and behavior modifications are not enough, Dr. Thomas Tsai, a bariatric surgeon at Brigham and Women’s Hospital explained.

With these drugs, patients can potentially avoid bariatric surgery, which is highly invasive, because it permanently alters stomach size and digestive tract. Although obesity remains largely undertreated, Tsai said there was a drop of 26% of bariatric surgeries as GLP-1 medication use for obesity increased from 2022-2023.

 But, there are downsides. 

“My one worry is the focus away from a multidisciplinary treatment plan and overemphasis on a specific intervention,” Tsai said. He also acknowledges that medical treatment for obesity is a slippery slope: it can either destigmatize obesity or have the unintended consequence of stigmatizing obesity.

Cost is another issue as well, as these medications are expensive. But, social scientists like Montgomery who emphasize health as a socio-political construct don’t think that increasing accessibility of GLP-1 agonist drugs will solve the underlying stigma that people of larger bodies face.

“When we push these initiatives in public health, we are sending a message that, ‘hey, we have these options for you. So if you don’t go for it, it’s your fault that you’re fat,’” they said. “And that’s a terrible negative thing. That’s where we run into some trouble.”  

Montgomery and Lin emphasize that humans are the product of their genes and environment. The fear that GLP-1 drugs can increase the blame component of weight doesn’t come without consequences.

Movements like body positivity and fat liberation have given people the “permission to fight against weight shaming,” Lin said. But there is still a long way to go. “We receive a lot of societal messages that are focused around weight shame. When people feel shamed, they are less likely to exercise, make healthier food choices, less likely to go to the doctor.”

Is there room for both medicine and body-centric social movements to coexist? Tsai said yes. He doesn’t think of the two as mutually exclusive and believes we can be both body-positive while improving health outcomes. 

Keeping that in mind, GLP-1 agonists may be the only way that some are able to lose weight. 

Decisions surrounding one’s health are “incredibly personal,” said Matt Priven, registered dietitian nutritionist and owner of Oceanside Nutrition in Boston. “I hope that anybody navigating body image challenges with or without a weight loss drug is getting the support of a care team that includes a therapist as well as a registered dietitian,” said Priven.

Receiving the right support is crucial for GLP-1 agonist users because they may experience unpleasant GI side effects like nausea, vomiting, and diarrhea.

“These drugs encourage people to eat very little, but that doesn’t mean their body is well nourished,” he said. “They can experience weight loss from the undernourishment that results from those physiological changes.”

Over time, he can see loss of lean body mass, bone mineral density, vitamin and mineral deficiencies and lower fiber intake. Priven’s job as a dietitian is making sure his patients are adequately nourishing their bodies, even if they don’t feel hungry while on the medication.

Conversations surrounding body image are evolving for the better, experts said. “It’s really wonderful that when I’m talking to college students now, they know it’s not ok to comment on other people’s bodies,” Lin said.

Fat liberation has also been well received across generations, Montgomery said. One of its principles is that everyone, regardless of health status, is worthy of respect, dignity, and access.

“There is always going to be desires for effective weight loss. I would love to see an introspection for healthcare providers and scientists. What would it mean to treat someone who is unhealthy and wants to stay that way?” Montgomery said.