Opinion | Can obesity drugs transform Americas health?

correction

An earlier version of this column gave an incorrect annual cost estimate for the use of obesity medications. Their use is upward of $12,000 a year per person. This version has been corrected.

This week Post Opinions columnists are writing about the biggest questions on their beats for 2024 and beyond.

On the surface, the argument seems simple: More than 4 in 10 Americans have obesity, a chronic medical condition that is second only to smoking as the leading cause of preventable death in the United States. The class of drugs known as GLP-1s appears highly effective in reducing weight and decreasing negative health outcomes including diabetes and heart disease. Therefore, widespread adoption of these drugs must improve the public’s health.

The reality is more complicated. For many individuals, GLP-1s such as semaglutide (known by brand names Wegovy and Ozempic) and tirzepatide (Mounjaro and Zepbound) can certainly be transformative. But it’s less clear whether this individual benefit necessarily translates to a societal one.

Studies have shown an average loss of 14.9 percent of total body weight after just over a year of once-weekly semaglutide injections and as high as 20.9 percent with tirzepatide. Anecdotes abound of such weight loss resulting in reduced chronic back pain and sleep apnea and increased energy and confidence to socialize and go to the gym.

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But such medications are meant to be taken in perpetuity, and by some estimates, less than 1 in 3 people who start GLP-1s for weight loss still take them a year later. Those who stop appear to quickly regain the lost weight. For those who are able to continue the medications, the long-term effects are not known, including whether effectiveness will wane over time.

There is also the legitimate concern that those who receive the treatment will conflate weight loss alone with good health. It’s possible to have normal weight or be underweight and still be metabolically unhealthy. People should not start GLP-1s believing that the drug allows them to eat whatever they want and forgo fitness.

One entity that understands the need for a holistic approach is WeightWatchers. Though the company recently acquired a telehealth platform and shifted its approach to embrace obesity medications, chief executive Sima Sistani is clear that WeightWatchers’ long-standing food points system and support groups are not going away.

“Our commitment to behavior change remains the same,” she told me in an interview. She equates weight loss for someone with obesity to treating cardiovascular disease. “You absolutely need to make changes in your life — for instance, eat low-fat foods, move more, drink less and don’t smoke. But there are some people who are also going to need medications.”

Sistani calls these lifestyle changes “habit-stacking.” I like that terminology as well as another phrase she uses: “Weight health.” The goal of weight health is not solely about shedding pounds; it also requires adopting sustained habits that lead to overall well-being.

In fact, lifestyle changes were a cornerstone of the seminal GLP-1 drug studies. Clinical trial participants who took semaglutide and tirzepatide were asked to adhere to a reduced calorie diet that had a 500-kilocalorie deficit per day. They had assistance from a coach and increased their physical activity to at least 150 minutes per week.

“Read the fine print,” Sistani said about the studies. She is passionate about making clear to people that there is no “magic pill” that can address obesity. But if used as a tool along with diet and fitness regimens, GLP-1s can help them achieve weight health that they otherwise couldn’t with behavioral changes alone.

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This holistic approach also offers a blueprint for what must be done on a population level. The well-placed enthusiasm around GLP-1s should not distract from the urgent need for policy reform to reduce consumption of ultra-processed food and sugar-sweetened beverages. Moreover, far more can be done to increase access to nutritious food such as fresh fruits and vegetables, especially for people in low-income communities.

Plus, there needs to be a thorough reckoning of cost trade-offs with weight-loss drugs. Prices for these medications are very high — upward of $12,000 a year per person. If only 10 percent of people on Medicare who have obesity take semaglutide, the annual cost would be up to $26.8 billion.

Would these drugs prevent enough downstream medical costs to justify the enormous tax-dollar expense? What other provisions would have to be cut to pay for them? What societal benefits could we generate by instead investing an equivalent amount in walking paths, recreational programs and school meals?

I see the debate over GLP-1s as emblematic of the tension that sometimes exists between medicine and public health. These drugs represent a true medical advance that will help many individual patients. But whether they are a net positive for society depends on what other policy changes come with them. Ultimately, improving America’s health will not be accomplished by pharmaceutical interventions alone, but rather through comprehensive investments that promote and sustain a culture of good health.

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