The email subject line read “Ozempic exposed the body positivity lie.”

Body positivity, wrote the fitness influencer, was really a consolation prize. He said, when given the choice of a GLP-1, people embracing the body positive movement would readily trade their “participation trophy” for the opportunity to be thinner.

These types of accusations have become pervasive across social platforms, increasing in both frequency and venom. Obesity specialists and psychiatrists have said it has become a topic, if not a primary theme during appointments and sessions. What do doctors need to do to counter these narratives?

“Social media is playing a very large part in what our patients are bringing up,” said Reema Dbouk, MD, obesity medicine specialist at Emory Health and assistant professor at Emory University School of Medicine in Atlanta. “I think that a lot of the increase in attention to GLP-1s empowered people to bring up their weight with their healthcare provider, which was good. But there’s also a lot more dangerous misinformation and shaming,” she said.

Unlike other chronic diseases associated with multiple comorbidities and lifetime treatment, obesity has long been tied to poor life choices such as lack of self-control and laziness. With the rise in use and soaring popularity of GLP-1s to help patients with obesity lose weight and improve overall health outcomes, weight bias and stigma have reached new heights.

“When it comes to patients I’m seeing in my office, I’m definitely having these conversations,” said Gregory Scott Brown, MD, psychiatrist, educator, and author, adjunct faculty member at the Tilman J. Fertitta College of Medicine in Houston, and American Psychiatric Association (APA) spokesperson. “Someone who’s struggled with obesity for years and years and loses a substantial amount of weight in a relatively short period of time, the automatic assumption is that this person took a shortcut, they cheated,” he said.

A Duality of Outcomes

Research has shown that more than 50% of US adults have experienced weight stigma. In turn, this stigma has been linked to an increased risk for disordered eating, diabetes, depression, and social isolation. The growing popularity of and access to GLP-1s has ushered in a new challenge to find strategies to help patients with obesity deflect and de-internalize messages that might derail any gains they make toward their health goals.

Stacy M. Post, PhD, applied social psychologist and postdoctoral scholar at Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, has been examining how weight stigma, including that related to GLP-1s, influences health behaviors.

In an experimental, randomized-controlled study using a 2x2 design, Post and her colleague randomly assigned 357 adult women to read about and view a photo of woman in her thirties who lost 15% of her total body weight after 3 months with diet/exercise or a GLP-1; participants had been informed that the woman either had a normal BMI or a BMI indicating obesity. They then completed a series of scales assessing negative evaluations, egocentric impressions, and motivations.

“We found that a woman who lost weight with a GLP-1 was judged significantly more negatively than a woman who lost weight with diet and exercise, despite body size,” said Post. “We then developed a short, four-item scale that assessed the extent to which participants felt the subject took the easy way out or cheated to lose weight, or the way they lost weight wasn’t fair, and found using a GLP-1 was thought to be a shortcut or cheating, and were driving the negative perceptions of GLP-1 weight loss.”

Post has since repeated the study several times. She said that subsequent findings in a sample of overweight and obesity demonstrated that having a larger body did not alter perceptions of weight loss with a GLP-1.

“It’s kind of a universal effect, at least in this country. Here, we really value effort, hard work, and willpower. So the idea that someone can just as easily (theoretically) take a pill and change their body size when someone else has to go to the gym for 6 months is not as well-received as it should be,” said Post.

A Multidisciplinary Challenge

The complexities of treating obesity cannot be overstated, especially when it comes to its impact on mental health.

Brittany Albright, MD, MPH, a dual certified obesity medicine specialist and psychiatrist, assistant professor at the Medical University of South Carolina in Charleston, South Carolina, and APA spokesperson, said patients mostly present to her for mental health issues, such as depression or anxiety disorders.

“Over 50% of patients with obesity have major depression,” she said. “We also know that patients with bipolar disorder are much more likely to relapse back into a manic or depressive episode if they have obesity; the same is true of schizophrenia and psychosis,” said Albright. “Most of the medicines we use in psychiatry are obesogenic.”

Behavioral management remains the pillar of successful obesity treatment, said Lauren Oshman, MD, family physician and clinical associate professor in the Department of Family Medicine at University of Michigan in Ann Arbor, Michigan.

In addition to a mostly toxic food environment, she said patients don’t only need behavioral health specialists to assist with behavior modifications but also strategies to address “mental health, internalized stigma, and all of changes that come with a change in weight, how patients perceive themselves, and how their family and the rest of the world perceive them.”

The medical community is not immune.

“Some people, based on qualitative data and anecdotal conversations, feel hesitant to approach their healthcare provider about GLP-1s because they don’t want to be judged, or told they have to exercise and diet for 6 months before their doctor will prescribe a GLP-1,” said Post. “This gatekeeping, keeping medications from people has been a problem.”

Dbouk underscored the importance of clinicians to shift their perceptions of obesity and validate patients’ weight struggles.

“We have to try to understand their lived experience, explain the complexities of obesity, establish a rapport with the patient that allows them to feel more open discussing their weight, and then offer tools that we have available to treat the condition,” said Dbouk.

“A lot of physicians hold GLP-1s hostage until a prerequisite is met with certain patients, to prove they’re determined,” she said.

The same sort of gatekeeping also prevents patients with obesity from being successful in their fitness prescriptions.

“When basic quality of life through movement patterns is being inhibited, GLP-1 tools can help people with obesity lose weight so they can move better. A critical piece is understanding the backstory, how we get to the point where we unravel the skills that need to be acquired or potentially be there for a person with obesity,” said Dani Dellarco, a fitness instructor and motivation coach based in San Francisco, who said that she encouraged doctors to partner with fitness coaches who can champion them to have the courage to take the necessary steps.

“There’s a lot of creation that needs to happen, whether it’s finding a walking pad that can hold their weight, finding a gym with equipment suited to their size,” she said, “or even walking into a gym in the first place without feeling shameful.”

“If they become discouraged in what they’re trying to achieve, it’s easy to give up,” said Dellarco.

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Weight Stigma Is Growing Across Social Networks, Do GLP-1 Prescribers Need a New Approach?