Obesity is an epidemic. Obesity, the predispositions for obesity, and the medical consequences of obesity are a major, if not the major, contributing factors to most medical conditions that plague American society. This is true for everything, including cancers. For instance, how many people smoke in the mistaken belief that smoking controls appetite, and how many cancers have obesity as a risk factor? There are genetic predispositions for medical conditions that are aggravated by obesity or predispose to obesity. Just because these are risk factors does not preclude that obesity is inevitable.
Society is obligated to promote a lifestyle that avoids cultural factors that produce obesity; hence, there is the requirement for physical education in schools. Society is also obligated to avoid medical factors that predispose to or are associated with obesity; hence, there is the emergence of a pharmaceutical industry that develops appetite suppressants and other anti-obesity medications.
Physicians are obligated to manage conditions that predispose to or are associated with obesity, as well as with any other medical condition that plagues society, including such things as drug addiction. Physicians are trained to know how they can best manage these conditions while remaining faithful to their prime directive, “primum, non nocere,” from Hippocrates’ treatise, “Of Epidemic.” Only physicians have this prime directive. All physicians have the obligation of informed consent, and all patients have autonomy to either follow directions from a doctor or not. All treatments for obesity by physicians are designed to basically maximize the modalities of lifestyle and the use of pharmaceuticals. The use of pharmaceuticals for medical weight loss is essentially off-label because they are customized for a particular patient as per the standard of care. All patients are unique biologic systems. In reality, there are several million years of evolution behind the metabolisms of each biologic system, which is a patient. Regardless of what a patient may want as the “perfect weight,” all systems strive to achieve equilibrium.
In medical weight loss, equilibrium corresponds to a BMI of 25. Any weight below 25 is not sustainable. Any weight above 25 is too high; above 30 is obesity, and above 35 is morbid obesity. The ultimate goal of medical weight loss by a physician is not to achieve a patient’s perfect weight, but it is to prevent obesity, to avoid dehydration and malnutrition, and to prevent a complication from the treatment of obesity. The enemy of good is perfect. In other words, “primum, non nocere.” Hence, patients must be encouraged to eat three meals per day, to avoid excessive snacking, to exercise regularly, to have adequate fluid intake, to control appetite, to find a remedy for major medical conditions such as insulin resistance, and, when seeking a doctor’s help, to have regular follow-up visits with the doctor to avoid complications from any medical intervention embarked upon. Doctors have an obligation to maximize factors that prevent obesity and to stay within the prime directive, meaning the standard of care. In keeping with this obligation, they must obtain a complete history and prescribe appetite suppressants and semaglutide or tirzepatide as indicated.
Most recently, Wegovy, the only oral semaglutide, has been approved for medical weight loss. Start with 1.5 mg per day and titrate to 4 mg, 9 mg, and 25 mg per day over 4 months. The cost of Wegovy may be covered by insurance and Medicare if there are associated cardiovascular risks from obesity or fatty liver, such as steatohepatitis. Also, as of July 2026, the cost may be as low as $50 per month. Wegovy can be prescribed in association with other regimens for appetite suppression. Ultimately, this will become the standard of care, especially since there are no empiric data suggesting that this combination is unsafe or ineffective. I fully understand and appreciate concerns about affordability. I am convinced that this regimen is affordable and will increase the number of patients seeking medical weight loss while, at the same time, decreasing pharmacy expenses. As of now, other primary care providers do not regularly manage obesity. After all, if primary care providers are participating providers, why should they care about obesity if they are not paid because obesity is uncovered? As oral Wegovy gains popularity, physicians will join the band. I prefer to be the band leader.
As this occurs, there is more competition in the marketplace. Also, as demand for Wegovy increases, so will supply, and prices will come down according to the rules of supply and demand. As for medical malpractice risks, physicians who presently decline medical weight loss management for no better reason than insurance reimbursement are already taking them by not treating obesity to comply with factors that are beyond their control, as determined by the health plan or the accountable care organization, which considers obesity as an uncovered diagnosis. Until now, a lawsuit depends on a patient’s satisfaction and on the doctor’s refusal to comply with the standard of care in order to remain in the favor of the health plan rather than the patient.
Howard Smith is an obstetrics-gynecology physician.
