Wellness as work ethic

4 April 2024

This essay was originally published in Vol VI Issue 2 of the RUMS Review magazine. You can read the full issue here

Modern medicine has put health back into the hands of the individual. A slew of evidence over the past few decades has established exercise, mindful eating, and other such lifestyle interventions as necessities for the maintenance of good health. This evidence base has spawned public messaging campaigns, legislation such as the Soft Drinks Industry Levy and the proposed phased ban on cigarettes, and (perhaps most conspicuously) a 5-billion-dollar behemoth of a wellness industry. 

Much of this intensity is warranted! As little as three hours of exercise a week is associated with around a 42% decrease in all-cause mortality. But therein lies the rub — going from zero to three hours of exercise a week does exponentially more for your health than going from five to fifteen (1). I find that my conception of good health often neglects this harsh law of diminishing returns that governs all lifestyle changes, and I end up descending into a kind of “discipline essentialism” in which optimal health is at my fingertips if only I can muster gulping down a protein shake and heading out for a 5k. If Nike advertisements are anything to go by, the collective societal conception of wellness is not far off this either. This sort of aspirational mindset is relatively harmless when it comes to hawking over-engineered running shoes, but it becomes dangerous when it percolates into healthcare provision.

Semaglutide is a good example of this phenomenon. Branded as Wegovy in the UK and available as a medication for type 2 diabetes (T2D), it is a glucagon-like peptide-1 (GLP-1) receptor agonist which stimulates the production of insulin. In America it is branded as Ozempic and is available for both T2D and as a weight loss drug. In the UK (as of March 2024) it is only available as a weight loss treatment for those with or at high risk of getting T2D. As with all pharmaceuticals, there is a need to evaluate risk against benefit and cautiously monitor the longitudinal effects of chronic use, but this is by no means an untested drug. It has been used since 2017 to manage diabetes, and it has remarkable efficacy: it works in 84% of the tested population and it outperforms all previous weight loss drugs in outcomes(2). 

It almost seems too good to be true, and that could well be the problem. Previous weight loss treatments have always had a cost of some variety — Qsymia (phentermine/topiramate) is another weight loss pill and, put simply, it works by making food incredibly unappetising, along with a battery of unpleasant side effects (3). For severe morbid obesity, bariatric surgery is the last-line intervention. It is an incredibly invasive procedure and carries all the risks and trappings of any surgery (4). This can easily lead to an implicit belief that any pharmacological “easy solution” for weight loss is a Faustian bargain, and thus necessitates some sort of enormous sacrifice or negative consequence if someone does not “earn” a healthy body through diet and exercise.

The argument for the restriction of Wegovy, then, is a motte-and-bailey: the motte is concern for the precautionary principle, but the fact that the drug is widely available not just as a treatment for T2D but specifically as a weight loss drug for those with T2D reveals the bailey – that restricting the drug for weight loss alone is motivated by a fundamentally unscientific impulse. It seems as if a relatively consequence-free shortcut to weight loss contravenes some natural law. Perhaps it is a subconscious sense that high-status indicators of good health, such as physical fitness, must be earned through a high effort lifestyle.

You don’t need to look far to find this kind of thinking in other areas of medicine. The flavouring agent monosodium glutamate (MSG) has been plagued with unwarranted scrutiny since the 1960s. It is used for its umami (savoury/meaty) flavour, and therefore can reduce the need for sodium. Today, it is widely recognised as entirely safe for consumption, but for decades it has been seen as toxic. This perception has somewhat racial origins: it is used widely in Asian cooking and was used as a scapegoat molecule for “Chinese restaurant syndrome”. This was later laundered into medical literature as the “MSG symptom complex” (5). I think the enthusiastic adoption and propagation of this baseless view was also enabled by an incredulity towards the idea that it is possible to enjoy food that tastes stereotypically unhealthy without incurring an associated health cost. Here, too, the presence of an inviolable natural law is felt. 

There is an urgent need to do away with this quasi-religious tendency in healthcare. Not only does it deter people from embracing the rather marginal lifestyle changes that have outsized impact, but it clouds our ability to be scientifically objective about the risks and benefits of potentially life-changing therapeutics. Precaution is laudable, but we must ensure that it comes from a place of empirical enquiry and not a vague unease about “taking shortcuts”. We must embrace progress for the sake of our future patients. And when progress arrives in the form of a pill, prescribe judiciously and without judgement; leave the penance to the pastor.

1. Lee DH, Rezende LFM, Joh H-K, Keum N, Ferrari G, Rey-Lopez JP, et al. Long-Term Leisure-Time Physical Activity Intensity and All-Cause and Cause-Specific Mortality: A Prospective Cohort of US Adults. Circulation. 2022 Aug 16;146(7):523–34.
2. Singh G, Krauthamer M, Bjalme-Evans M. Wegovy (semaglutide): a new weight loss drug for chronic weight management. J Investig Med. 2022 Jan;70(1):5–13.
3. Rothman RB, Baumann MH. Neurochemical mechanisms of phentermine and fenfluramine: Therapeutic and adverse effects. Drug Dev Res. 2000 Oct;51(2):52–65.
4. Livingston EH. Complications of bariatric surgery. Surg Clin North Am. 2005 Aug;85(4):853–68, vii.
5. Williams AN, Woessner KM. Monosodium glutamate ‘allergy’: menace or myth? Clin Exp Allergy. 2009 May;39(5):640–6.