Robert F. Kennedy Jr. has some thoughts on Ozempic. The nominee for Health and Human Services secretary says the government should not: provide medicine Millions of Americans, but instead, to address obesity and diabetes. Organic food and gym membership. Like many of RFK’s statements, these ideas caused some anger. But their basic premise, that Americans should control their weight by eating better and exercising, is unlikely to become more mainstream.
But this common-sense philosophy of losing weight, espoused by RFK, the FDA, and in fact just about every doctor you’ve asked recently, no longer fits with the scientific evidence.
Lifestyle interventions have been central to the nation’s decades-long attempts to curb the incidence of chronic disease. Eat less and exercise more: This advice applies to almost everyone, but for people who are obese or overweight, who are about three-quarters of the U.S. adult population, diet and exercise can improve health. It is understood to be one of the most important ways to health. Ozempic and related GLP-1 drugs are now available to physicians and still provide sustained weight loss and sustained weight loss. Many benefits that extend lifespan Even if surgery is not required, behavioral changes are a priority. formal treatment guidelines Obesity researchers have more or less endorsed RFK’s approach, insisting that lifestyle therapy remains the cornerstone of treatment. And according to the government, the drug itself is only suitable for use. ”as an accessory” A reduced calorie diet and increased physical activity.
This insistence on maintaining the status quo has always seemed a little strange to me. It has long been known that diet and exercise are not very effective treatments for obesity. Tom Wadden, an obesity researcher at the University of Pennsylvania who has been involved in lifestyle modifications and clinical trials of GLP-1 drugs as a treatment for type 2 diabetes, says people should at least initially try to prevent or control type 2 diabetes. It is possible to achieve sufficient weight loss. obesity. But he told me that no amount of weight loss would improve my sleep apnea or prevent heart attacks or strokes.
For today’s severely obese people, even the modest benefits of diet and exercise seem to be meaningless. Clinical trials of Ozempic and related drugs over the past several years have shown that the “base” of treatment adds little to the effect these drugs have on people’s weight.
There is considerable awkwardness in this area simply because diet and exercise may not be as important as they once were. “I’m going to be cautious,” David Saxon, an obesity expert at the University of Colorado Anschutz Medical Campus, told me when I discussed this last spring. “I don’t want you to quote me saying, ‘He doesn’t think lifestyle is important.'” For older anti-obesity drugs, diet and exercise came first (and in addition). He said the evidence supporting prescribing it was: Very obvious. In clinical trials, patients who received lifestyle interventions in addition to medication lost twice as much weight as those who did not.
But the data tells a different story about new drugs, Saxon and other doctors told me. In most clinical studies on GLP-1, patients receive the drug in combination with modest lifestyle interventions. For example, a monthly 15-minute check-in with a counselor and advice to cut calories and exercise for a few hours. Do some exercise, such as walking, every week. In one of Wegovy’s large-scale trials, Step 1this approach resulted in participants losing about 15 percent of their body weight. It’s called Another Trial of Wegovy. Step 3tried something more: participants were provided biweekly check-ins with a registered dietitian and spent the first two months consuming very low-calorie meal replacements and taking medication. There is evidence that all this additional coaching would make a huge difference to people’s health if Wegovy didn’t exist. But for Wegovy participants, the effect was minimal. Those enrolled in the STEP 3 trial lost an average of 16% of their body weight and lost just one hair more than the STEP 1 participants lost. “This tells us that perhaps these new drugs don’t require intensive lifestyle programs,” Saxon says.
He’s seen this play out within the Department of Veterans Affairs system, where he also works. Patients on older, less effective anti-obesity medications are expected to participate in an ongoing lifestyle modification program with monthly check-ins, Saxon said. Now, he and his colleagues are prescribing GLP-1, but “we’re not really mandating it anymore, because even without it people are losing weight with these new drugs.” “Because we know we’re maintaining that,” he said. Eduardo Grunwald, medical director of the Weight Management Program at the University of California, San Diego, told me he had the same impression. “The bottom line is these drugs don’t necessarily require intense lifestyle intervention,” he said when we spoke in March.
Still, obesity experts including Saxon aren’t giving up on diet and exercise. However, the field is beginning to re-evaluate the nature of such instruction. “We need to understand what that means,” Sue Yanofsky, co-director of the Obesity Lab at the National Institute of Diabetes and Digestive and Kidney Diseases, told me. Since last year, a series of review, editorialand perspective paperresearchers published primarily in obesity journals, investigated this very question. For example, one paper argued that obesity experts should focus on the quality of weight loss, rather than the quantity. Christina Ruiz, an obesity physician and epidemiologist at Wake Forest University who co-authored the paper, told me that GLP-1 drugs don’t completely make diet and exercise irrelevant. In fact, they allow patients to “focus on lifestyle interventions in a more sophisticated way” by eliminating cravings and reducing the need to count calories. People in Ozempic and their doctors can also start thinking about switching to a healthier diet, being more active and getting more sleep, she said. All of these interventions are beneficial regardless of body weight.
This all sounds very reasonable, but when viewed in the broader context, it also feels like a concession. For decades, the most ardent critics of the weight loss industry and its associated doctors have been saying something similar: Healthy behavior separates people from the singular goal of getting healthy. can and should be separated small. Now, ironically, the tenets of this movement, which became known as “health at every scale‘ has been applied to the treatment of obesity.
But if lifestyle interventions are intended to provide the same benefits to people diagnosed with obesity as to others, how special is their role in treatment? Lewis and other doctors say Ozempic people may still need individualized diet and exercise advice because rapid weight loss can create specific health needs. Ta. For example, clinical trials found that people taking GLP-1 drugs lost more muscle and bone as their bodies became smaller. In fact, these and other lean tissues accounted for 25 to 40 percent of the total weight loss. To reduce the added risk of weakness and fractures that can result, some experts now recommend that people taking these drugs consume more protein than with traditional lifestyle interventions. and suggests that you should participate in more strength training.
Advice on diet and training to build muscle could become part of the standard of care for people with Ozempic. “On a rational basis, I think we should do this,” Wadden, a member of the research team for the STEP 1 and STEP 3 trials, told me. Still, he acknowledged that the evidence for this approach is not yet complete. Wadden is Lifestyle intervention research For people who have been suffering from obesity for decades. some of that work Found Even a very strict diet combined with resistance training and aerobic exercise did not prevent the loss of lean body mass. People who did these workouts were “really swimming against the current” due to rapid weight loss, he told me. Other obesity researchers dispute the very idea that muscle loss is the problem in the first place. a recent papers from American Medical Association Journal He argues that the link between physical frailty and GLP-1 drugs is not supported by data, and that if more than half of the person in Ozempic’s hut is fat, they will eventually lose muscle mass. It is certain that the price will rise even higher. The fat percentage is higher than before.
Doctors still don’t fully understand why people taking GLP-1 lose so much weight in the first place. Ozempic, in its own right, may be working to promote different ways of eating, Wadden said. “This drug dramatically changes your eating habits without much conscious effort,” he says. “How will it change? We don’t know.” People who take drugs may eat less overall, while continuing to eat the same way they used to. For example, have one Pop-Tart for dinner instead of five. (In that case, a meeting with a nutritionist can be very helpful.) But drugs may also have the effect of changing people’s preferences. “All of a sudden you start liking more fruits and vegetables. And you start liking lean protein,” Wadden said. Similar questions apply to exercise. Regardless of whether you have access to a gym or spend time with a trainer, just losing a lot of weight can encourage you to become more physically active. No research has yet been done that could resolve this.
Wadden, like many other doctors, continues to believe that diet and exercise should remain the standard of care for people who are overweight or moderately obese. But he now believes the rules are changing for people who need to lose more weight, including the tens of millions of Americans with a BMI of 35 or higher. For this group, “I think lifestyle modification is no longer the cornerstone of obesity treatment,” he said.
