Resisting the Diet-Industrial Complex in Medicine: Family Physicians and GLP-1 Receptor Agonists

Mara Gordon, MD
Posted on October 15, 2024

Dr. Mara Gordon is an assistant professor of family medicine at Cooper Medical School of Rowan University and the communications chair of the Association for Weight and Size Inclusive Medicine. She is a frequent contributor to National Public Radio, where she often writes about the culture of medicine. You can find more of her work via her newsletter, Chief Complaint.

I recently saw a woman in her 40s for routine well woman care in my family medicine clinic. After I sat down and introduced myself, her first question was, “Can I get some of that weight loss drug I’ve seen on TV?”

“Let me get to know you a little bit better,” I replied and continued to review her medical history. She had normal blood pressure and no evidence of insulin resistance; she had no joint pain, and her lipid panel appeared to be the textbook definition of “normal.” Her only “abnormality,” if it’s even fair to call it that, was a body mass index (BMI) of 27.

“What makes you feel like you want to use a medication for weight loss?” I asked her.

“I feel fat,” she told me.

And there we were. With the advent of widespread glucagon-like peptide 1 (GLP-1) receptor agonist use for weight loss, doctors have been thrust unwittingly into the middle of a massive, multibillion dollar weight loss industry—and we should proceed with caution.

That’s why I was heartened to read the editorial  in the October 2024 issue of American Family Physician about the “philosophical angst” that Dr. Rao and coauthors feel about the mass adoption of GLP-1 receptor agonists used simply for the purpose of making our patients’ bodies smaller. It seems I’m not alone in feeling ambivalent about what role they can—and should—play in helping our patients live healthy lives.

To be clear: I prescribe GLP-1 receptor agonists for many indications and have done so since I graduated medical school in 2015. I’m grateful to the researchers who developed them. It’s clear the medications have many benefits, including lowering a patient’s A1C and improving cardiovascular outcomes.

Using these medications deliberately for weight loss can also help our patients. I have patients who report improved mobility and increasing physical activity since starting a GLP-1 receptor agonist. Condemning these medications outright is short-sighted and not aligned with patient-centered care. But when active, thriving patients without any evidence of cardiometabolic disease start requesting them simply for the purpose of moving their BMI from 27 to 25, I worry that we physicians have lost sight of our dictum to “do no harm.”

Instead, I fear we are complicit in a deeply fatphobic culture that profits off of our patients’ body shame. Often, my patients’ requests for GLP-1 receptor agonists have very little to do with preventing disease and instead are a highly medicalized bandage on a complex social phenomenon: a patient who tells me, “I feel fat.”

In the AFP editorial, Dr. Rao and coauthors suggest that medicine as a field is moving away from using BMI as a metric to assess an individual patient’s health, given its questionable history (it was invented by a 19th century Belgian astronomer to define “the average man”) and limited practical use in predicting risk of disease or mortality.

Still, BMI remains a cornerstone of medical care. Many of my patients see a visit to the family physician as synonymous with a check-in about weight. “I see I gained 5 pounds, Doc,” they say, even though as a physician who practices size-inclusive medicine, I rarely initiate conversations about my patients’ body size. Patients leave the office with auto-populated print-outs from the electronic medical record that implore them to lose weight. No wonder they’re coming to us in droves to be placed on the GLP-1 receptor agonist bandwagon.

I agree with Dr. Rao and colleagues that despite our shared philosophical angst, it’s usually not therapeutic to withhold GLP-1 receptor agonists from patients who are highly motivated to use them. But I encourage family physicians to dig a little deeper, to question the racist and misogynistic origins of our cultural assumption that any BMI over 25 is inherently pathologic. Let’s explore the reasons why our patients believe they want to lose weight and support them in finding holistic strategies to meet their goals.