How weight-loss drugs ended the era of “lifestyle changes”

When drugmakers pulled the weight-loss drug fen-phen off the market in 1997, my mom was devastated. Not because the FDA warned that the drug could severely damage her heart or even possibly kill her, but because she’d been trying to lose weight since she was aware of having a body, and the only thing that had ever worked was being ripped out of her hands.

This is an extreme reaction. That my mom would rather take a potentially deadly drug than face life without it illustrates just how frustrating it can be to be told you need to lose weight over and over again, try your best to do so, but find it absolutely impossible.

For decades, the go-to prescription for weight loss was to eat better and move more — make lifestyle changes. But these changes were extremely hard to keep up long term. Even when people kept at them for years, they often yielded marginal results. Few people were treated with medication. Even fewer opted for surgical interventions.

Now GLP-1 drugs like Ozempic and Mounjaro have entered the chat. And they’ve changed the game entirely — how doctors talk to and think about patients. How we think about ourselves and what’s achievable. And why we’ve been locked into a “treatment” cycle that’s been so frustrating to so many for so long, all while obesity rates have continued to climb.

In the mid-’90s, public health experts were looking for ways to mitigate rising obesity rates, largely because obesity was linked with diseases like Type 2 diabetes and certain kinds of cancer.

The NIH launched a study in 1996 that would largely define clinical thinking around treatment moving forward. Researchers looked at how eating better and moving more affected instances of Type 2 diabetes. They found that lifestyle changes resulting in even a modest amount of weight loss had a major impact on Type 2 diabetes prevention. Participants who met the goal of losing just over 5 percent of their body weight reduced the incidence of Type 2 diabetes by 58 percent. To put that in perspective, if a person weighed 300 pounds, they’d need to lose about 15 pounds. These were not The Biggest Loser weigh-ins. These were supposed to be achievable results.

Government officials issued calls to action. Doctors had real evidence that lifestyle changes mattered. Diet and exercise became the prescription for managing weight.

“I’ve spent 20 years trying to sell the benefits of a 5 percent weight loss,” said Dr. Dan Bessesen, an endocrinologist and director of the CU Anschutz Health and Wellness Center at the University of Colorado. “It seems like a small change in weight, and yet it had dramatic benefits.”

The limits of diet and exercise

The culture, of course, took these findings and quickly reworked them to fit existing beauty standards and narratives about personal responsibility. The argument was no longer, Lose a little bit of weight to be a lot healthier. Instead, it became, If only a person with obesity could control themselves, they could achieve their goal.

But biology is more complicated than that.

“The body’s got its own idea about what it wants to weigh,” Bessesen said. Losing weight triggers all kinds of biological responses that undermine the loss. We get increasingly hungry and our body hoards energy (a.k.a. fat). This used to be helpful when we were living in caves. Now that we’ve domesticated wolves and work from home in soft pants, not so much.

And so the miracle cure became something of a disease in itself.

“Doctors especially have this idea that, ‘Well, Mrs. Jones, you ought to be able to handle [losing weight] on your own,’” Bessesen said. “We don’t do that with diabetes or high blood pressure.”

And maybe we’re about to stop doing it with obesity.

There have been medications to treat obesity for decades. But nothing that proved as effective or culturally alluring as the idea of just eating better and exercising. Until Ozempic.

Ozempic is one brand name of a series of drugs called GLP-1 agonists that have exploded in popularity in the last few years. These injectables mimic hormones that slow digestion and trigger satiety, which means you eat less and want to eat less. Predictably, you lose a lot of weight — around 15 percent on average. And, much like a cholesterol or arthritis drug, they do not rely on willpower to achieve desired results.

Which means the conversation has shifted. Patients come in asking for GLP-1s by brand name, something that just doesn’t happen with most other conditions, Bessesen told me. And doctors can write a quick prescription instead of making a person self-flagellate for months or years before they’ll consider medical intervention.

The existence of an effective medication seems to have snapped obesity from a perceived personal failure into the category of treatable disease.

There’s an irony worth mentioning here: People who take GLP-1 drugs often report a distaste for ultra-processed foods and a preference for fresh fruits and vegetables. And losing weight can help people move around more freely. These drugs don’t replace lifestyle changes. They seem to make them possible.

Not everyone who lives in a bigger body needs to lose weight. And the body positivity movement has helped many people dismantle their own internalized fatphobia and break out of a prison made of unreachable beauty standards.

But some people do feel the need to make changes to prevent Type 2 diabetes or manage other health conditions. If they opt to take GLP-1 drugs, there are some challenges and drawbacks.

Side effects can be gnarly: People have reported debilitating constipation and vomiting. The drugs are also cosmically expensive and most insurance does not cover them for the treatment of obesity. And there’s another aspect of taking these drugs he’s concerned about: the emotional toll they can take.

Eating is often a social activity, so drastically changing your relationship to food can change your human relationships too. Noticeable weight loss can spark uncomfortable conversations about a person’s private health choices that are difficult to navigate. And those who have put a lot of work into embracing their weight can feel deep conflict at being able to change the body they’d grown to love.

“When we have somebody go to bariatric surgery, we prepare them for that,” Bessesen said. “They see a psychologist; they see a nutritionist. They talk to other people who’ve had surgery and say, ‘How was that for you?’ Medications are going to give that kind of weight loss. But we’re not preparing people for that.”

A new era of thinking around obesity and treatment may be helping solve some issues from the last era. But there are plenty of new ones to consider now that we’re here.

Prices are expected to level off as more companies pump more GLP-1 drugs into the market. And there’s a compelling case for insurance companies to eventually cover the drugs. It’s expensive to treat Type 2 diabetes and cancer. Preventing those diseases could save money in the long run. It’s a little less clear when we’ll develop the systems to handle the psychological effects of altering one’s physical body. But as more people take this path, we’ll learn more about the unintended consequences of this treatment.