As a child, I’d watch my grandmother give insulin injections to herself in her abdomen. When I was 14, she died from complications of diabetes. Her loss left a profound effect on me and is ultimately why I became a physician.
Diabetes and related health issues are prevalent on both sides of my family, as is the case with many South Asians. Later, as other family members were diagnosed, I watched them struggle with their health and wrestle with the belief that they were resigned to suffer from this condition for the rest of their lives. I grew frustrated watching them go to doctors and simply be prescribed medications.
Much of my family had relocated from India and Africa to England, where they adopted a more Western diet. This adjustment proved difficult and led to weight gain and health problems. I started learning about the positive effects good nutrition and physical activity can have on chronic conditions like diabetes and heart disease. I experimented by putting my family on whole-food diets tailored to their cultural background and watched as, one by one, they reduced the number of medications they were taking for their chronic conditions and became more empowered in and around their health.
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These experiences are why I decided to focus on lifestyle medicine and chronic disease management.
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I share this personal story because recent trends like the over-prescribing of GLP-1 medications for weight loss concern me. These drugs can be incredibly powerful and effective for patients but are designed for people with diabetes or for people who are obese and also have high blood pressure or cholesterol. But GLP-1s should not be used in a silo without full context of a patient’s health. Doctors are to prescribe the drug for patients with clinically appropriate conditions where weight loss would help in conjunction with a lifestyle program.
But that doesn’t always happen.
As a doctor who runs a chronic care management program designed to provide patients with multidisciplinary care that takes into account their whole health, I feel obligated to explain the benefits and concerns with using GLP-1s, and reaffirm the value of a treatment plan that doesn’t rely solely on medication.
More than 41% of U.S. adults have obesity. The U.S. spends more than $173 billion annually on obesity-related healthcare, and that cost is on the rise. A simple search for “medication for weight loss” serves up ads from point solution companies offering quick consults for a prescription and claiming people can lose significant weight without lifestyle interventions including exercise.
This is alarming for a couple of reasons. First, simply placing patients on GLP-1s and assuming all other health issues hold steady is not only hubris on the part of the prescriber, but also dangerous. Second, starting to take these drugs without having first tried to make changes in lifestyle does the patient a disservice. They will need to remain on the drug indefinitely, because without any lifestyle intervention in place, more severe weight gain is likely. The absence of long-term studies leaves the safety of being on these drugs for long periods a big unknown.
There is also an equity concern. Data shared by the Centers for Disease Control and Prevention illustrates that obesity disproportionately impacts some racial and ethnic minority groups. Socioeconomic hurdles for these groups can limit access to these medications, given cost and supply issues. When people who don’t fit the on-label requirements are prescribed GLP-1s, it creates an unnecessary shortage that exacerbates access issues. I have had patients with diabetes drive 50 or 60 miles to a pharmacy that carries their prescription.
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The solution to battling obesity and the chronic conditions connected with it is complicated. Patients seeking treatment show up, often to their primary care physician, with deeply rooted behaviors sometimes established over decades that can make it difficult to affect change. They may be lonely or depressed and could benefit from doctors in different specialties being involved in their treatment plan.
To make progress, there needs to be more emphasis on lifestyle medicine when addressing these chronic conditions. A focus on health literacy and healthy lifestyle choices in general, but especially starting at a young age, can make a big difference. Keeping care managed within the primary care setting, and having an individualized care plan with nutrition modifications that can be easily integrated into a patient’s unique environment can help them reach their goals. Giving patients a way to measure their progress with fitness trackers can also be a motivating factor. Last but not least, we need to educate more physicians on the benefits of lifestyle medicine and treat patients holistically, not just focus on one aspect of a patient’s health.
The good news is that we’re starting to see progress. New York City is offering free lifestyle medicine training at hospitals to educate doctors on the value of nutrition. President Biden has committed more than $8B as part of a White House conference on hunger, nutrition and health.
To be clear, I am not opposed to patients taking weight loss medication. But I want that decision to be made in an environment that takes into account the whole health of the person and gives them the best chance for improved health, especially as more of these drugs come onto the market.
I have seen in my own family and the hundreds of patients I treat in my practice how small-but-impactful lifestyle changes can help people become healthier. And that needs to continue to be a part of the conversation, or, I worry we will lose the very idea of what it means to be healthy and simply replace it with a pill.
Hemalee Patel, DO, is the senior medical director for chronic care management at One Medical and is double-boarded in internal medicine and lifestyle medicine. Patel recently helped develop and launch One Medical’s Impact program, a chronic care management program utilizing digital health technology and a team-based approach to help patients better take care of their chronic conditions in a way that is achievable, sustainable and forward-thinking.