Nearly a decade has passed since the American Medical Association first classified obesity as a chronic disease, one that may require medical interventions beyond diet and exercise.
As the blockbuster drugs Wegovy and Ozempic grow in popularity, they are bringing more attention and adding complexity to cultural and medical conversations about weight and weight loss.
Both drugs are brand names for semaglutide, a drug that can lower blood sugar and suppress appetite. Ozempic is approved to treat type 2 diabetes in adults, while Wegovy is approved for weight loss in two groups: those 12 years and older who are obese and those who are overweight who also have at least one weight-related health condition, such as high blood pressure or cholesterol .
Patients and doctors say the results they’re seeing from the drugs underscore the consensus that lifestyle changes alone are often insufficient for people looking to lose excess weight.
“Two-thirds of Americans didn’t wake up one morning and chose to be overweight or obese. This is not a behavioral choice or a behavioral disease. This is a chronic disease — a chronic, treatable disease — and we should treat it if we treat any other disease, with drugs and with interventions that target disease mechanisms,” said Dr. Ania Jastreboff, an associate professor at Yale School of Medicine. She serves on the scientific advisory board of Novo Nordisk, which makes both drugs.
Stacey Bollinger, an account executive in Maryland, said when she started using Wegovy last January, she exhausted most other options for improving her physical health. She had prediabetes, her joints ached, and her asthma flared up. But she had been working with a nutritionist for about a year, following a healthy diet and doing regular strength training and cardio exercises.
“I went for my physical and it’s one of those things where it’s like, I know the doctor is going to tell me I’m overweight. It’s not shocking,” she said. “I see it. I feel it physically. But I also just feel miserable. Let’s talk about what options I do have.”
On Wegovy, Bollinger said, she’s lost more than 26 pounds, up from 266. She said she feels more energetic, her asthma is better controlled, and her feet, ankles, and knees don’t hurt at the end of the day. At a recent checkup, her blood work showed she was no longer prediabetic.
“I really don’t think I would have had this loss without Wegovy,” she said.
Novo Nordisk describes Wegovy as a long-term treatment, noting that just as a patient with high blood pressure sees an increase after stopping medication, people taking Wegovy can gain weight again when they stop taking the drug.
“Obesity is a chronic, progressive and misunderstood disease that requires long-term medical treatment,” the ministry said in a statement.
“A major misconception is that this is a disease of willpower, when in fact there is an underlying biology that prevents people from losing weight and keeping it off,” the company added. “Like any other chronic disease, such as high blood pressure or high cholesterol, obesity should be treated as such.”
Why obesity is more common
Semaglutide is part of a class of drugs called GLP-1 agonists that mimic a hormone that sends a signal to the brain when a person is full.
“This particular drug stimulates the pathway of your brain that tells you to eat less and store less, and then it regulates the pathway of your brain that tells you to eat more and store more,” said Dr. Fatima Cody Stanford, an associate professor of medicine at Massachusetts General Hospital.
Read more about Ozempic and Wegovy
She said that more important than inducing weight loss, the drugs may lower the risk of health problems associated with obesity, including diabetes, heart disease, stroke and some cancers.
“A lot of people assume we’re pursuing a measure” when prescribing the drugs, Stanford added. “I never aim for a size on a patient. I focus on their health.”
Obesity rates have been on the rise in the United States since the 1980s. In the four years prior to 1980, the obesity rate was 15% for adults and 5% for children and adolescents. According to the Centers for Disease Control and Prevention, those numbers jumped to 42% and 20%, respectively, between 2017 and early 2020.
The reasons for that increase are complex, but medical experts generally attribute it to interactions between genetics and social and environmental changes.
An important explanation for obesity is that bodies try to maintain a certain baseline or set point of fat. At the population level, environmental and behavioral changes have increased fat set points over time, Jastreboff said.
On average, people now exercise less, eat more processed foods or larger portions, sleep less, and experience more stress than previous generations, which can prompt the body to maintain a higher baseline of fat.
That could explain why some people struggle to lose weight through lifestyle changes, or why others regain weight with dieting.
Individual genes can determine how the body responds to external factors, so they may cause obesity in some but not others. For example, a theory known as the “frugal genotype hypothesis” suggests that some people store more energy as fat thanks to genes inherited from ancestors who needed that storage to survive famines.
Ozempic and Wegovy can help lower a person’s fat set point, Jastreboff said. Semaglutide has been shown in studies to reduce body weight by approximately 15%. In contrast, a 2018 study found that, at best, diet, exercise, and behavioral therapy help people lose an average of 5% to 10% of their body weight.
“Some people can lose weight with behavior changes alone, but some people can’t. Why do we have a problem with that?” said James Zervios, vice president of the nonprofit Obesity Action Coalition. “How come we keep leaning one way and saying, ‘Well, we’re just going to tell someone to keep track of their food. We’re just going to tell someone to take a walk at night after dinner.’ If that works, you wouldn’t be dealing with the number of people who are currently overweight or obese.”
Debates over obesity drugs continue
However, the idea that obesity should be addressed through diet and exercise alone is still pervasive.
“Unfortunately, the public view is that if a person is taking a drug, they’ve taken the easy way out to lose weight,” said Rebecca Puhl, associate director of the University of Connecticut’s Rudd Center for Food Policy and Health.
Even some doctors don’t feel comfortable prescribing the new obesity drugs yet. Stigma may play a role in those decisions: Research has shown that physicians have similar levels of weight bias to the general population, and medical school programs rarely address stigmas around weight, Puhl said.
On the other side of the coin, some people active in the fat acceptance movement say that many of those considered “overweight” by medical definitions are healthy and don’t need intervention.
A 2017 study of 3.5 million medical records in the UK found that while obesity increased people’s risk of diabetes, high blood pressure or high cholesterol, about 15% of obese people did not have these conditions.
In a BuzzFeed editorial last month, Evette Dionne, a culture journalist and MSNBC columnist, suggested that the medical establishment is now more focused on weight loss drugs than on solving systemic problems related to obesity risk, such as food deserts.
“It is objectively a good move to decouple the idea of moral virtue from fatness. In these attempts to complicate our cultural understanding of fatness, the remedy remains the same: to lose weight rather than change the ways our society deals with and treats fat people,” she wrote.
Puhl said that while debates about obesity treatment are important, decisions about how to use the drugs should be between a patient and a doctor.
“We don’t want medication to be used as a default strategy and we certainly want the risks and side effects considered,” she said. “But we also have to respect that medication can be very helpful for some people.”