Weight-loss drugs aren't a magic bullet. Lifestyle changes are key to lasting health

The headlines are compelling, with phrases like, "The Obesity Revolution," and "A new 'miracle' weight-loss drug really works." The before-and-after pictures are inspiring. People who have struggled for decades to shed pounds are finally finding an effective strategy.

The last few years saw breakthroughs in treatments for obesity, with new weight-loss medicines dominating recent news reports. The medicines, semaglutide (Ozempic, Wegovy) and tirzepatide (Mounjaro, Zepbound), work by slowing stomach-emptying and decreasing appetite. They're usually administered by weekly injection.

Clinical trials boasted success comparable to surgery. Celebrities like Oprah Winfrey shared encouraging personal stories.

The scientific literature behind the headlines is impressive as well. Those taking the medicines lose, on average, 10% to 20% of their body weight. Originally developed for Type 2 diabetes, the drugs are well known to improve control of blood sugar. In December, we also learned that in people with cardiovascular disease who are overweight or obese, semaglutide appears to reduce major adverse cardiac events by 20%.

For primary care doctors like me, who have counseled thousands of patients — often unsuccessfully — about their weight, this news is welcome. For many of those living with obesity, these medicines can feel like a game changer.

Excess body weight is tied to a range of medical problems, including diabetes, heart disease, osteoarthritis, sleep apnea and many types of cancer. It's linked to shorter life expectancy and higher rates of disability. With about 40% of U.S. adults now classified as obese — and another 30% considered overweight — many doctors and patients are embracing the new drugs as a solution.

Drugs don't address root causes of America's health crisis

Yet even as many may adopt the newest medications, we need to recognize and address their limitations, including a lack of long-term safety data and potential side effects like nausea, vomiting and, rarely, pancreatitis and gallbladder disease. Poison control centers are reporting an increase in calls due to medication overdoses, which can lead to low blood sugar and associated symptoms, like dizziness, irritability and — in severe cases — confusion and coma.

The high price of the weight-loss medicines — usually over $1,000 per month for each patient — is especially troubling in a nation that already far outspends the rest of the world in health care costs and faces major disparities in care. The cost concerns are amplified by studies showing that the drugs usually need to be taken long term to prevent weight regain.

"While these drugs are powerful and wonderful tools, they are not a panacea," said Jonathan Bonnet, a board-certified obesity, lifestyle, family and sports medicine physician who serves as program director of medical weight loss at the Palo Alto VA's Weight Management Center Clinical Resource Hub.

He is seeing positive results among his patients but recognizes cost as a significant barrier. "Treating everyone with obesity in the U.S. with medications will bankrupt the country and still not cultivate the type of health and vitality we actually want," he said.

More than half of employer insurance plans in the United States, as well as Medicare, don't cover the medicines for weight loss.

Medications also fail to address the root causes of the problem. Rates of obesity have increased substantially over the last few decades and have continued to climb since the COVID-19 pandemic. A Gallup survey released in December showed the obesity rate increased by 6 percentage points from 2019 to its current level of 38.4%. The prevalence of Type 2 diabetes — a known consequence of obesity in many individuals — increased from an estimated 10.3% of U.S. adults in the 2001-2004 time period to 13.2% in the 2017-2020 time period.

Our society's easy access to ultraprocessed, calorie-dense foods and our high levels of inactivity contribute to excessive weight gain and related health impacts. A health care system designed for "sick" care — supported by a multibillion-dollar pharmaceutical industry that stands to benefit when we fall ill — does not prioritize disease prevention.

And while we should embrace a culture of acceptance of all body types, we also can't ignore the fact that rising rates of obesity are part of a growing health crisis.

True health is not just a number on a scale

Enter lifestyle medicine. This burgeoning field focuses on prevention and treatment of chronic disease through adoption of healthy habits including a minimally processed diet rich in vegetables, fruits and whole grains; regular physical activity; restorative sleep; stress management; positive social connection; and avoidance of harmful substances.

Lifestyle medicine practitioners partner with patients to understand their core values and help them achieve goals — whether it's to lose 20 pounds, control high blood pressure or boost mood and energy.

Lifestyle medicine is cheap and low risk. Its proven benefits extend far beyond weight loss and can be lifelong. Those who make positive lifestyle decisions, including exercising, eating well and not smoking, may reduce their incidence of coronary artery disease by over 80% and Type 2 diabetes by more than 90%. They take fewer medications. They live longer and experience improved mental health and lower rates of cancer, chronic disease and disability.

And a diet that emphasizes whole, plant-based foods is also better for our planet, reducing deforestation, air and water pollution and greenhouse gas emissions related to meat and dairy production.

Lifestyle medicine and the new weight-loss medications are not mutually exclusive. In fact, the package inserts explicitly state these drugs should be prescribed in combination with increased physical activity and a reduced-calorie diet.

Yet the lifestyle piece is usually glossed over. It's not a quick fix; it requires commitment and a reexamination of personal values. It encourages us to cut back on the ultraprocessed foods we like, high in added sugars and salt, that still raise the risk of heart disease, stroke and some cancers, even in those who aren't overweight.

According to the American Heart Association, fewer than 1% of U.S. adults and adolescents engage in all practices recommended to achieve ideal cardiovascular health, which include most tenets of lifestyle medicine.

New anti-obesity medicines are an important tool. But true health is not just about a number on the scale. Widespread adoption of the principles of lifestyle medicine would reduce health care costs, reverse recent declines in U.S. life expectancy and transform lives.

Opportunities for change

Because more than 82% of Americans see a health professional every year, incorporating lifestyle medicine into these visits is an obvious way to reach those who need support. But health care providers are often unprepared to offer the kind of intensive coaching that's required.

A 2017 survey indicated that 90% of cardiologists, for example, reported receiving minimal or no nutrition education during fellowship training.

Medical schools and residency programs need to teach the next generation of doctors to promote healthy behaviors — and to implement those practices in their own lives.

Time is another constraint. In my years working in community clinics, I was routinely expected to see patients in 20-minute increments, leaving almost no opportunity to address lifestyle changes in a meaningful way. I might encourage patients with heart disease to eat more fruits and vegetables, but I didn't have time to understand the underpinnings of their dietary choices, often influenced by a complex combination of culture, finances and personal preferences.

Nor could I refer patients to supportive colleagues, such as dieticians, behavioral health counselors and health coaches — my clinic didn't have them.

Doctors need time for difficult conversations to understand the drivers behind patient choices and what might motivate them to change. They need to be able to partner with other professionals who can offer support and expertise.

But even more important — and more difficult — is the need to adjust cultural norms and public policies to make it easier for individuals to adopt healthy behaviors.

For example, SNAP (Supplemental Nutrition Assistance Program), formerly known as food stamps, should be reformed to reduce taxpayer-subsidized consumption of sugar-sweetened beverages and ultraprocessed foods. Even small acts, like moving healthy foods to the front of the grocery store, can have an impact.

"Our environments are optimized for unhealthy living." Bonnet said. "Willpower will only get us so far." What we need, he told me, is to design communities that make healthy choices the default, less-expensive option.

Such communities would have more green space and walkable streets, easier access to fresh produce, plant-based entrées in restaurants and increased opportunities for face-to-face social connections. By removing the reliance on willpower and financial resources to live well, we can reduce health disparities and improve quality of life for everyone.

This story comes from Public Health Watch, a nonprofit, nonpartisan investigative news organization that focuses on threats to America's well-being.

Lisa Doggett is a columnist for Public Health Watch, a family and lifestyle medicine physician at UT Health Austin's Multiple Sclerosis and Neuroimmunology Center and senior medical director of Sagility. She is the author of a new memoir, Up the Down Escalator: Medicine, Motherhood, and Multiple Sclerosis. The views expressed in her columns do not necessarily reflect the official policies or positions of Public Health Watch, UT Health or Sagility. Doggett can be reached through her website.