The Drugs Are Working

The first step toward fulfilling a New Year’s resolution just might be a class of prescription weight loss pills and shots. The next steps: Getting patients and doctors to trust them and insurers to cover them

By Emma Court. Illustration by Steffen Ullmann and Chris Philpot

Obesity is a disease. The American Medical Association said so almost a decade ago, and experts convened by the National Institutes of Health did the same when Bill Clinton was president. But it bears repeating, because the conventional wisdom still holds that obesity is a choice. From paleo to Pilates, get-fit-quick schemes revolve around willpower and the assumption that weight loss is entirely a function of diet and exercise. Successful weight loss is partly a function of behavior, yes, but research suggests that genetics and environmental factors can make it extremely difficult or even impossible for some people without outside help. Today, outside help often means surgery, but there’s a much less invasive option quietly sitting on the shelf.

That would be prescription drugs, especially a group of drugs known as GLP-1 receptor agonists, or GLP-1s. These compounds were designed for people with diabetes but have also been shown to cause patients to shed pounds. They simulate a hormone known as glucagon-like peptide 1, the chemical that helps people feel full after they eat. Many people taking a newer GLP-1 drug for weight loss known as Saxenda, for example, lose at least 5% of their body weight, according to one study by the manufacturer. Older generic medications can cost patients as little as $15 a month, while new, brand-name GLP-1s run about $1,400 for a month’s supply of weekly injections.

Over the past several months, pharmaceutical manufacturer Novo Nordisk A/S has twice increased its annualized financial estimates, each time citing high early demand for Wegovy, its next-generation weekly obesity shot recently approved by the U.S. Food and Drug Administration, among other factors. Clinical trials showed patients losing an average of about 15% of their body weight, and the company says the longer-term goal is to make drugs that can produce results comparable to surgical options, which generally yield weight loss of roughly 30%.

Many overweight people and all obese people are candidates for a prescription. Yet no more than 3% of qualifying Americans are taking weight loss medications, and most haven’t even heard of them. The American Board of Obesity Medicine has certified 5,242 obesity medicine doctors in total, up from 587 in 2013. So far, though, most doctors simply aren’t prescribing the medications.

Obesity Medicine Association President Ethan Lazarus, who’s worked with companies that sell such drugs, says part of the reason is that these shots and pills aren’t the miracle insta-svelte elixirs of our dreams. Patients still need to eat healthily, work out, and keep in touch with a professional who can monitor their progress and tweak their program. The U.S. medical system isn’t exactly set up for that kind of personalized medicine, and doctors aren’t immune from biases about weight gain. “I think you’ve got a multitiered problem where, at the end of the day, most doctors and most people with obesity still believe it’s just the person’s fault,” he says, “and you know, ‘if they could just eat a little bit less, it would solve the problem.’ ”

Absent a major influx of interested doctors, a handful of startups are offering an in-between option: apps that can coordinate remote patient visits and coaching and dispense prescriptions for on- and off-label meds regularly prescribed by obesity doctors. The question is whether these approaches can start to change the conversation around weight loss. Fatima Cody Stanford, an obesity doctor at Harvard Medical School and Massachusetts General Hospital who’s advising the startup Calibrate Health Inc., says the emerging models can help bridge the gap between the drugs and their potential beneficiaries. “Patients aren’t being made aware that medications are even an option,” she says. If she withheld such treatment information from her patients with diabetes or hypertension, she adds, “I would lose my medical license.”

Obesity is called a comorbidity for a reason: It raises the risk of diabetes, heart disease, Covid-19, and straight-up death from any cause. Drastic upswings in weight over the past 40 years of increasingly processed foods and sedentary lifestyles have left approximately 3 in 4 Americans, an estimated 245 million people, either obese or overweight. In that time frame, scientists have also learned a great deal about the whys.