Ozempic, Obesity, Hyperbole, and Hope

Ozempic, Obesity, Hyperbole, and Hope

David Katz 26/06/2023
Ozempic, Obesity, Hyperbole, and Hope

Concerns have been raised due to reported cases of stomach paralysis from Ozempic, despite its effectiveness in managing diabetes.

Berberine (a botanical extract taken as a supplement) is not “Nature’s Ozempic,” nor is it useless; the truth, as so often, is in betweenOzempic, for that matter, is not a panacea, has known liabilities now, while the full scope of costs attached to its apparent benefits will likely only be known in the fullness of time. Obesity is a dysfunction of the body politic, which turns a blind eye as entities profit both from its propagation and its treatment, far more than it is a dysfunction of our individual bodies. Thus, if obesity is any kind of “disease,” it is a social disease, a malady of cultural apathy, and worse.

If you would like to walk away with punch lines only, our work here is done. Elaboration follows for those with a few more minutes to spare.

There is, as we all know from the famous aphorism “missing the forest for the trees,” a native human ineptitude for seeing the big picture. This liability is, from my perspective, compounded by the reductionism native to the advancement of science. I am by no means impugning reductionism, let alone science – much has been gained from scrutiny directed to the smallest parts of small parts. But one size does not service the needs of all perception, and where reductionism fails, it fails spectacularly.

The topics of nutrition in general, and obesity in particular, reside at the interface of science and society, and are thus subject to the visual deficiencies of both. 

The prevailing cultural view has focused- for literal decades now- on a sequence of silver bullets and scapegoats, and has systematically failed to aggregate learnings over time into a big-picture understanding. We act as if every rogue hypothesis or hyperbolic headline obviates the sum total of all prior knowledge in a redundant display of supreme gullibility. As a result, having failed ever to see the forest, we remain lost in the dark wood of a rather dismal epidemiology. Obesity rates in the United States, and much of the world, are worse than ever, and worsening still.

As for science, its reductionistic impulses have invited a blinkered choice between obesity as a will-power deficiency state, and obesity as a disease. The latter has advanced in part as a remedy for the former, since the “legitimacy” of a disease ostensibly alleviates the taint and stigma attached to character flaws. The goal of un-blaming the victims of pandemic obesity is laudable, essential, and even urgent. The notion that only a disease state offers the requisite exoneration is an absurd, if profitable, concoction of the healthcare-industrial establishment.

What’s the problem with the “obesity as disease” rebuttal to obesity as character flaw? Let’s start with this: obesity simply isn’t a disease. A disease occurs when the body’s native functions are disrupted and misdirected; Oxford begins its definition with “a disorder of structure or function…”. By way of analogy, fever is not a disease; it is an adaptive response of the body that helps it defend against many pathogens. Fever may be a symptom of disease, but it is not the disease.

Malaria, in contrast, is clearly a disease because it is no part of normal physiology for a parasite to take up residence in red blood cells, replicate itself there, and then burst those cells upon exit. A rather glaring “disorder of function” results.

As it is normal and adaptive for the body to mount a fever in self-defense, so, too, is it normal for the human body to store a surplus of calories today against the advent of famine tomorrow. The functional conversion of surplus energy to body fat depots is normal; the structural accumulation of that fat is normal as well. Normal function plus normal structure do not equal disease.

Obesity results when the energy surplus recurs every day, and the famine is never- but not because the body has done anything “wrong.” A perfectly normal, perfectly functioning human body will store enough surplus energy as fat to qualify as obese given a sufficiency and constancy of appetizing calories. We live amidst the evidence of this; some 70% of all adults in the United States are overweight or obese. Either we are all diseased, or none of us is. 

I hasten to add that obesity can, of course, cause disease; in fact, it is implicated in almost the entire expanse of chronic diseases- from heart attacks to dementia, cancer to diabetes- that plague modern societies. But just as the canary in the coal mine is not the befouled air, neither is obesity the “disease.”

Diseases generally invite “medical,” not cultural advances. The current fixation on Ozempic and related drugs is emblematic of this, as is a shift in the policies of the American Academy of Pediatrics inviting drugs and bariatric surgery as recourse at ever younger age. So, too, the quest for some natural supplement with supernatural powers. When the body is the problem, drugs (or nutriceuticals) and surgery tend to be the solution.

The implications are ominous and protean. There is the financial cost of pharmacotherapy for all, with massive profits to Big Pharma. There is the potential for side effects and unintended consequences of drugs and surgery alike, as we have seen rather calamitously before- and to which some early worries about Ozempic are already directed. There is the possibility that pharmacotherapy might compound, rather than alleviate, the stigma of obesity. There is the utter neglect of prevention, a crucial concern since nearly everyone in America (and many peer countries) not yet overweight or obese is at risk for becoming so- children especially. Will our next great “advance” be pre-emptive bariatric surgery, or prophylactic pharmacotherapy?

Our societal desperation for easier leanness, and our seduction by the medical model have corrupted our reason and our morality alike. As for our morality, we apparently are prepared to sanction- or at least overlook- a willfully booby-trapped food supply that all but ensures our children will succumb to obesity, with wonder drugs or surgical rerouting of their GI tracts awaiting them to remediate. We are a society that, stated bluntly, engenders profit from the propagation of both obesity’s causes and treatments, even if it means sending legions of our kids to the OR for a condition they need never have acquired. I protest that as an abject moral failure.

As for our reason, we renounce it each time we fail to learn from the follies of history and start seeing panaceas in the vacant spaces where their predecessors died. Do you remember the hyperbole surrounding rimonabant (Accomplia)? That’s a precautionary tale if ever there was one.

Ozempic, and the GLP-1 agonists in general (i.e., stated simplistically, agents that stimulate insulin release from the pancreas), are seemingly drugs of genuine and important utility. They have proven a welcome addition to treatment options for diabetes mellitus, with the weight loss effect initially observed as an ancillary benefit in such context. Part of a larger class of drugs known as “incretins,” these agents restore the so-called “incretin effect” whereby sources of glucose by mouth trigger a brisk insulin response. Of historical interest, the first marketed incretin drug- exenatide- was originally sourced from the saliva of the gila monster. (File that exotic bit of trivia as the spirit moves you.)

Only time will tell if GLP-1 agonists fulfill every hope now attached to them, or- like their most promising predecessors, succumb to the law of unintended consequences and let us down. Among the reasons to fret about the latter, along with the precautionary history, is that defenses against starvation are both robust and redundant in human metabolism; such is the imprint of evolutionary biology. To date, addressing appetite, satiety, and energy balance via any given pathway has led, over time, to compensation by other pathways. Maybe GLP-1 agonists will prove to be the “one pathway that rules them all,” but also maybe—no such a one exists. Time will tell.

Even if they fulfill every hope now linked with them, they obviously cannot promote every aspect of health the way eating optimally and being physically active can. They cannot be shared with our children the way lifestyle can as a way to find health together. They are not known to reduce the risk of all major chronic diseases; to add years to life, and life to years- as lifestyle is. They are not indicated, and we can only hope never will be, to prevent obesity from developing in the first place- as healthy living is.

As for those seeking to eat a panacea and avoid drugs, too, the natural compound berberine is the current preoccupation (wait a minute, and there will be another). Berberine is not “Nature’s Ozempic” – on the basis of quantitative effects, that is stark exaggeration. However, it is known to exert a range of beneficial effects, on glucose and insulin metabolism especially, with some assist to weight loss among them. So berberine is by no means useless, as some have implied in their equally exaggerated and opposing reactions. The same deficit of perception that obscures the forest behind trees causes some to see baby where there’s bathwater, some to see bathwater where there’s baby. Hyperbole is harmful in either direction.

If hope is indeed a thing with feathers, it perches most reliably where candor and clarity prevail over hyperbole.

There is a place for drugs, supplements, and surgery in a rational, comprehensive response to the obesity pandemic we have propagated largely for profit – but it is a lesser place than our perennial quest for effortless panacea would have us believe. Drugs and surgery should be to obesity as resuscitation is to drowning: recourses reserved for when the routine practice of sensible prevention fails. There is no sensible prevention when scalpels are favored over schools; when pathology in the food supply is blamed on human physiology; when explanations are preferentially sought in genes that have not changed for an obesity prevalence that has, and drastically, over the same timeline. 

There is hope where treatments are directed to root causes, rather than merely the symptoms induced by effects. Obesity as disease mistakes effect for cause, allowing the true causes rooted in our culture to persist – while neglecting the enormous promise of effective prevention. How enormous? Think of obesity as a form of drowning- in hyperpalatable calories and labor-displacing technology rather than water- and then imagine the full array of analogues to our defenses against drowning (e.g., lifeguards at beaches, honest warning signage about water conditions, fences around pools, parental vigilance as default, swimming lessons for children, and so on). Medical resuscitation is reserved for the relatively rare case of drowning that occurs despite such efforts; we don’t simply wait for 70% of the population to drown and then ply resuscitation for all. Obesity, too, might be rare- and treated with competency and compassion when encountered among the most vulnerable.

As a quick addendum, the considerable advantages of treating obesity as a form of drowning (or, at least, as we treat drowning) include but are not limited to: legitimizing the condition, while not blaming on our individual bodies what the body politic is actually responsible for; allowing for treatment, while placing the far greater emphasis rightly on prevention; starting prevention strategies with children; emphasizing shared responsibility among individuals, families, industry, and government; evincing a whole array of relevant prevention strategies by means of the comparison.

One final, vivid lesson issues from the comparison of obesity to drowning. We drown for being ill adapted to spend much time in a given environment, namely- under water. We might instead label drowning a “disease” and blame it on our bodies, and their want of gills. Consider, then, how far we would need to push the frontiers of pharmacotherapy and surgery to remedy that particular “deficiency.” Imagine the allocation of vast societal resources to that goal- Homo sapien gills- while doing nearly nothing to prevent drowning in the first place. Then redirect your mind’s eye to obesity, and none of this is imaginary.

Time to sum up.

We can combat obesity as an important cause of quite dire effects, without blaming its victims for the plague in which they have been swept up. 

We all share in the responsibility to see past tidbits and titillation to a big picture that encompasses causes, effects, and remedies rightly directed to the roots of large problems. Hope for ameliorating a pandemic that has only ever worsened over my nearly four-decade career, and my lifetime for that matter, resides there.

Adjust your focus accordingly. Expect no help from the legions deriving big, fat profits from the status quo; they will do their utmost to block the view.

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David Katz

Healthcare Expert

David L. Katz, MD, MPH, FACPM, FACP, FACLM, is the Founding Director (1998) of Yale University’s Yale-Griffin Prevention Research Center, and former President of the American College of Lifestyle Medicine. He has published roughly 200 scientific articles and textbook chapters, and 15 books to date, including multiple editions of leading textbooks in both preventive medicine, and nutrition. He has made important contributions in the areas of lifestyle interventions for health promotion; nutrient profiling; behavior modification; holistic care; and evidence-based medicine. David earned his BA degree from Dartmouth College (1984); his MD from the Albert Einstein College of Medicine (1988); and his MPH from the Yale University School of Public Health (1993). He completed sequential residency training in Internal Medicine, and Preventive Medicine/Public Health. He is a two-time diplomate of the American Board of Internal Medicine, and a board-certified specialist in Preventive Medicine/Public Health. He has received two Honorary Doctorates.

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