What is obesity?
Some people will tell you it’s a fancy word for being fat; others might say it’s a slur that pathologizes bigger bodies. And yet others will insist it’s a moral failing—one of laziness and poor willpower.
For the past decade, however, the medical community has recognized that obesity is a chronic disease, much like cancer, diabetes, and high blood pressure. Obesity triples the risk of hospitalization due to COVID-19, is linked with hundreds of medical complications, and accounts for 4 million preventable deaths every year.
Obesity is also heterogeneous, with manifold different causes, clinical presentations, and responses to treatment. The astronomical rise of GLP-1 drugs such as Ozempic, Wegovy, and Mounjaro has glossed over such nuance, with bold promises that medication is the “holy grail,” “silver bullet,” and “miracle” to the obesity problem, a one-size-fits-all solution. If only it were that simple.
The truth is that Ozempic can’t solve the obesity crisis in America. Although medication can help some individuals lose weight, obesity is not a simple disease of inactivity or overeating. A myriad of factors, including genetics, mental health, socioeconomic status, and environmental influences, contribute to the development and progression of this disease. As such, how patients present inside the clinic varies widely, from a mutation in the MC4R gene being linked to an 18% higher odds of obesity to some antipsychotic medications causing 75-125 pounds of weight gain. While GLP-1 drugs could help many of these patients, they also target only one factor—hormonal imbalances— and can’t solve for all the other problems.
This overly reductionist approach is mirrored in the diagnostic criteria for obesity—a body mass index (BMI) of 30 or higher—because patients can be perfectly metabolically healthy above this cutoff, or develop obesity-related comorbidities within the “normal” range. In fact, designed for white European men, BMI underestimates obesity among Hispanic and Asian Americans while overestimating it among Black Americans, so the American Medical Association has asked doctors to de-emphasize the use of this flawed, discriminatory measure.
A Lancet Commission of 60 international experts from high, middle, and low-income countries is currently working to redefine obesity, moving away from a height- and weight-based metric to a clinical diagnosis rooted in specific signs and symptoms.
Beyond these complexities in origin and diagnostic criteria, patients with obesity also respond differently to treatment. On average, the GLP-1 drug Wegovy helped patients reduce their body weight by 16%; in other words, a 300-pound person might have lost 50 pounds. But some patients in this New England Journal of Medicine study only lost 5% of body weight while others lost up to 30%. This variability highlights the importance of individualized treatment plans to address patients’ unique needs instead of relying on any one drug.
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With the current state of obesity care, however, that’s nearly impossible. In the U.S., there are 115 million people living with this disease, but just over 100 doctors who are fellowship-trained in obesity. Since 2003, federal law has also prohibited Medicare from covering obesity medications because they are seen as “lifestyle” drugs instead of real medicine. Correspondingly, our research shows that only 1% of eligible patients get treated with anti-obesity drugs, with most simply relegated to following the oft-quoted advice of eating less and moving more. While diet and exercise are certainly important, the most effective treatments for obesity are interdisciplinary, where this regimen is combined with behavioral therapy, medication treatment, and sometimes metabolic and bariatric surgery.
With so few doctors to help so many Americans in need, it’s no surprise that diet scams and products preying on people’s insecurities have filled the void — the U.S. weight loss market is estimated at $160 billion in 2023. When we similarly treat GLP-1 drugs as the proverbial magic bullet, we open this genuine medical advance to spurious critiques and attack campaigns. For example, the widely reported critique that patients gain weight when they stop taking GLP-1s only matters if they are seen as an obesity “cure.” After all, for insulin and hypertension drugs, it’s hardly news that glucose and blood pressure shoot back up when you discontinue medication.
With obesity costing the U.S. $1.7 trillion, or 9% of our GDP, we need to celebrate progress against this chronic disease and how GLP-1 drugs can help some patients live longer, healthier lives while also significantly reducing healthcare costs. But we must also recognize that much work remains to be done, from promoting social empathy to training more specialty physicians to implementing policies that ensure affordability and access to treatment. Although drugs like Ozempic, Wegovy, and Mounjaro holds great promise, it is not the panacea the media has made them out to be, and we must resist the temptation to oversimplify the issue.
Instead, let us celebrate the potential of GLP-1s as part of a comprehensive, individualized, and compassionate approach to treating obesity—one that not only considers individual’s unique needs and circumstances but also focuses on improving overall health and well-being.