Stop Framing "Killing the Appetite" as a Medical Goal!

 

When I was growing up, gathering with the Italian-immigrant quadrant of my family meant that every meal began with the same ritual: everyone present wishing the rest of the family "buon appetit'!" May you have a good appetite! May you feel hungry, find this meal delightful and satisfying, and eat well.

This is a very common world practice. The French say "bon appétit;" in Finnish it is hyvää ruokahalua; and in Korean 맛있게 드세요.  Why? People wish one another pleasure in a meal as a social gesture of goodwill, just as you'd wish someone a good trip when they are about to travel. It's a gesture of hospitality. And it is also a wish for health, because we must eat well to survive, and traditional societies have always had a dread, not just of famines, but of the failing individual appetite that signifies that someone they care for is ailing.

Will someone please remind contemporary American doctors of this fact?

Recently, there's been a lot of reporting about drugs developed to treat diabetes that have the side effect of anorexia. Anorexia is the medical term for lack of appetite--for centuries considered a disease symptom doctors should make note of and attempt to treat. Today, when Western doctors treat anorexia with concern, they rarely mean "experiencing a lack of appetite." They mean instead "anorexia nervosa," an eating disorder characterized by self-starvation, because just as has always been the case, starvation is terrible for people's health. To see what WebMD has to say about the dangers of anorexia nervosa, you can follow this link if you wish. What I would point out is that WebMD states that anorexia nervosa is only diagnosed in people who are at least 15% below "their normal/ideal body weight."

Actually, self-starvation has been empirically proven to have the same dangerous effects in people of all sizes, including those deemed "overweight" by contemporary medicine. People substantially deprived of calories over time, whatever their weight, develop low and unstable heart rates, loss of menstrual cycles/fertility, impaired mental function, electrolyte imbalances leading to weakness, lack of coordination leading to patterns of injury, weakened bones, increased susceptibility to disease due to general poor health, and other negative outcomes.

But the contemporary medical profession remains wedded to an ideology that thin is good and fat is bad--and that the majority of people today are overweight and should become thinner by restricting their calories. Medical authorities go on endlessly about the "obesity epidemic," as if body fat was some kind of contagious germ. And researchers continue to pursue, as they have now for decades, "appetite suppressant treatments," despite their long history of doing more harm than good (probably because of an equally long history of being highly profitable during their initial honeymoon phase on the market). 

For example, there was the 1950s methamphetamine diet pill craze. Yes, meth, prescribed by doctors for weightloss.  Have a look at a meth diet pill ad:

It did indeed work as an anorectic killing the appetite, but the side effects and addiction issues eventually led doctors to look to other "treatments" for the fact that their patients could not "conquer their hunger," maintain a low-calorie diet indefinitely, and be thin. There was "fen-phen" in the 90s, which wound up damaging the heart valves of a third of the many thousands of patients prescribed it as an appetite suppressant to supposedly improve their health. The aughties had sibutramine, sold as Meridia in the U.S., which, again, did suppress the appetite, but also caused high blood pressure, heart attacks and strokes.

Those are just some of many examples of drugs created to suppress appetite so that patients would lose weight, which would supposedly protect them from developing problems like high blood pressure and heart disease, but which in fact caused the patients to develop those very problems.

And now we are at that juncture again, where another drug has been found to cause appetite suppression, and there is a tidal wave of interest, with doctors and patients scrambling and fighting over the supply. That drug is semaglutide, best known under the brand names Ozempic and Wegovy. It was developed to treat type 2 diabetes, and is fairly effective at doing so. It also has a lot of side effects, like GI symptoms, retinopathy of the eye--and loss of appetite. So now it is flying off the shelves, being prescribed off-label as a weightloss "treatment."

Off-label prescriptions are often enticing to clinics and pharmaceutical companies alike, because they are not covered by insurance, which means that the customer/patients must pay the full price, not the reduced one negotiated by insurance companies or Medicare, which in the case of Ozempic is as of this writing about $1400 per month. And this means not just more profit per injection (which drugmakers like), but more profit to clinics, because the patients who can afford this are well-to-do, and willing to spend on additional services. This has resulted in a situation in which the patients who have diabetes and a serious medical need for semaglutide have lost access to their supply, which is being redirected instead to the weightloss goals of a patient pool made up mostly by wealthy middle-aged white women (and younger celebrities) using it for cosmetic reasons.

Think about the irony here. Why is appetite suppression framed as a medical good? Because it leads to weight loss. And why is that framed as a good? Because being fat is believed to put a person at risk of developing medical conditions. Actually, many of these beliefs about negative health effects of being fat are bunk. The reason fat people are often diagnosed with more advanced cancers, for example, isn't because body fat is carcinogenic--it's because fat patients are treated with so much bias by the medical profession that their symptoms are ignored. And here we have a case of people who have an actual health problem, diabetes, not being able to access a treatment for it because it is being directed to people who want to lose weight, with doctors justifying this off-label use as possibly reducing the chance that they some day develop diabetes. That makes it really clear that what doctors are pursuing is not reducing diabetes harm, or they'd make sure all diabetes patients got the drug before diverting it to weightloss in people who don't have diabetes. It makes it clear that the real motivator is profit from medicalizing the desire of the privileged to be thinner than the masses, and "treating" them by killing their appetites.

And appetite "killer" is the right word: semaglutide doesn't just make people forget they need to eat. It can take the joy and pleasure we are supposed to find in eating good food and replace them with repulsion. For some, it causes nausea, vomiting, and disgust at the very idea of eating. And instead of treating this result as a negative, impacting quality of life, as doctors treat the loss of libido many people experience on anti-depressants, they celebrate this loss of pleasure. Over and over, the term you hear doctors saying the thing Ozempic "conquers" are "cravings." Patients must stay on the drugs, doctors warn, because as soon as they stop, "they feel cravings come back." 

"Craving" is not a neutral word. We all need to eat, like we need to sleep and breathe. But a person not getting enough air to breathe is called oxygen-deprived by doctors, not oxygen-craving. The desire of a hungry person for food is portrayed as greedy, excessive, and unnecessary by terming it a "craving"--something the strong-willed should be able to control. 

This is both wrong on the facts, and wrong in a larger sense. Our hunger for food is not weakness or a poor life choice, it is our bodies choosing life. Our bodies have evolved over millennia to keep us alive by giving us both pleasure in eating, and the lifesaving capacity to lay down fat stores to allow us to survive when we encounter social catastrophes like war, and personal catastrophes like contracting a serious disease. The reason 95% of all diets fail is not because we are weak--it is because nature has given us a remarkable strength to survive periods of want and illness.

Our historically-novel social bias against being fat today, however, makes us praise people who look sick, because they are gaunt. So many people with eating disorders suffer from the fact that the very behavior that is harming them is also getting them constant praise from others. Formerly-fat people with cancer in the process of declining toward mortality are praised by casual acquaintances for losing weight "and looking so much healthier." I myself had an antibiotic-resistant MRSA infection for a year and a half, and lost half my body weight, going from fat to emaciated, down to the same weight I was as a prepubescent child of 11--and I constantly ran into people who lavished praise on my extreme weight loss, including most of the doctors I interacted with.

What was my secret, people asked. My secret was that I nearly died, and was very very sick for a very long time. But I did survive--and the fact that I went into that medical misadventure well-padded may well have saved my life.

This is why people around the world have wished each other a healthy appetite before meals. 

But now the medical profession is fine with "overweight" patients feeling sickened by food. Some people on Ozempic feel revolted and gag just thinking about eating. Some experience ongoing nausea, and are happiest barely eating or skipping meals, leading to rapid and substantial weightloss. Mind you, that same rapid weightloss from skipping meals, extreme caloric restriction, and/or vomiting food are the central diagnostic criteria for eating disorders. It is disturbing that this is treated as a positive, healthy intervention by doctors when confronted by people who want to shed weight. In fact, while most of the influx of media stories about semaglutide is glowing and excited, there are a few pieces that critique it as "an eating disorder in an injection."

And the wealthy clientele that has been buying out the supply, leaving actual diabetes patients who need it unable to get their medication? They are discovering that starvation actually doesn't make you look good. It gives the users "Ozempic face, which the New York Times weirdly illustrates that like this:

This is not, of course, an accurate illustration. What "Ozempic face" looks like is the face of someone who has been enduring a serious illness, and lost their appetite as a result, and stopped eating much of anything. They look lean and haggard, with hollow eyes and cheeks, their skin sagging due to the loss of the body fat that had kept it plumped up and taut. 

You might expect doctors and patients to say, "Woah, feeling and looking sick is not a good outcome!" But instead, patients said, "OK, now I look thin which is great, but I also look old." And doctors have capitalized on that with a whole new medical boom, in plastic surgical treatments for "Ozempic face," using fillers and transplants of fat harvested from the buttocks to fill out the lost buccal fat and other facial fat padding, plus a wide range of plastic surgical lifting of eyes, "jowls", cheeks, etc., running anywhere from $25-100,000. And that's not to mention that the rest of the body also sags after substantial weight loss. Some patients are warned that in the future, they will "need" a "full body lift," which costs hundreds of thousands of dollars, and involves a great deal of pain and recovery time.

The thing is, even if the wealthy can afford the whole semaglutide-to-facial-reconstruction pipleline that has sprung up, they have to stay on the medication to continue their disinterest in eating. Stop the medication, and the body wakes up and recognizes that it has starved, and urges the individual to eat with a hearty appetite. The person's weight rebounds, their face rounding out again.

This is healthy--having an appetite is healthy. But just like any ordinary fatphobic American on the street, doctors speak in awed terms of how their patients on semaglutide can eat very little food and yet not "ruminate about it all the time," having some sort of detachment from the body's needs that is framed with the reverence mediaeval Christians reserved for ascetic hermit monks and nuns--celibate, owning no property, wearing ragged old robes, living off of nuts and fruits, and devoting their lives to prayer, with no fear of hastening their own deaths by their deprivations.

But we are not ascetics. Americans treat loss of libido as a terrible, perhaps intolerable, side-effect of antidepressants. And the people grabbing Ozempic-and-plastic-surgery combos from doctors are rich. They want to be thin so they'll look good in their designer clothing, going out to restaurants and traveling and enjoying the Good Life. 

Yet however svelte they look in their new, smaller clothing, going to those desirable restaurants will bring them little joy. Perhaps they'll spend the entire time there trying to control their gagging, eating a few bites that just nauseate them. Sure, they can see and be seen while traveling, but how much fun is travel when you can't enjoy the new tastes, and feel sick and worn down, like any starving person would?

What I see is a powerful example of our society's terrible bias against fatness, and intense privileging of thinness. These things are so potent that we will sacrifice our actual health for them, while mouthing a claim that we're acting to protect our health. And they are so puissant that we will give up the pleasure in our lives, the joy of actually living in our bodies, to avoid the shame our society heaps on the fat, and seek the praise it gives the thin. 

How much happier and healthier we would all be if we stopped viewing food as a sinful temptation to flagellate ourselves over! If we sat down to a meal of beautiful food, wished one another a good appetite, and enjoyed nourishing ourselves.