We’re at the very beginning of a new era in weight loss drugs that promise extraordinary results. But ultimately, their impact depends on a few things: how well they work, how much they cost, and whether doctors are willing to prescribe them.
So far, these treatments seem to work extraordinarily well. Patients on Ozempic and Wegovy lose on average about 12 percent of their body mass and even more effective drugs are coming through the pipeline. But the cost can be high because health insurers are reluctant to pay for these drugs, putting strict conditions on prescriptions if they are willing to cover them at all.
That has left doctors caught in the middle. Many of them are hopeful about the potential these new treatments hold while also trying to manage expectations with patients and convince health plans that the investment is worth it.
The ubiquitous ads for Ozempic and Wegovy, like all prescription drug ads, tell patients to talk to their doctor if they’re interested in the medication. So, how are those conversations going so far?
“Right now, I can tell you, if you’re a primary care provider, it’s probably overwhelming to think about starting to do what they need to do to prescribe these agents,” said Caroline Apovian, co-director at the Center for Weight Management and Wellness at the Brigham and Women’s Hospital in Boston.
The drugs also have arrived amid a long-overdue social and cultural paradigm shift around obesity in medicine. Doctors are increasingly treating obesity not as a failure of character or willpower but as a physiological disease in its own right. Some doctors are still themselves in the process of learning how to think about obesity that way, rather than focusing on the conditions that are often its consequences, such as hypertension or heart disease.
It is a fraught moment. The public health opportunity these drugs present is significant, but the US health system was not prepared to seize it. Too few primary care doctors are well-versed in obesity medicine. Health insurers are not incentivized to cover a costly medication that may take years to properly pay off — even if that payoff proves real. Patients risk being exploited by shady operators trying to take advantage of the hype and confusion around the new era of obesity treatment.
But the demand is real: A new STAT-Harris poll found half of Americans said they would spend up to $100 per month out of pocket in order to take them.
I spoke with three leading obesity medicine experts about the misconceptions they are often hearing from patients, the information they want patients to know when having these discussions, and what questions people should be asking their doctors when considering whether or not to try them.
1) These weight-loss drugs are not a short-term fix
Different patients will have different considerations before deciding to take one of these new treatments. For people with extreme obesity, bariatric surgery is an option. Others may want to exhaust attempts at diet and exercise. But once they have decided to try a weight-loss drug, obesity doctors say it is critical that patients grasp what is happening biologically with their bodies.
Marcio Griebeler, director of the Obesity Center at the Cleveland Clinic’s Endocrinology & Metabolism Institute, told me he starts these conversations by making sure his patients understand the physiological roots of their obesity and how these drugs treat that — and why that means, despite media stories about celebrities using them as a kind of crash diet, they can’t just take Wegovy or whatever for a few months to slim down and then stop.
In brief and in general (each individual is unique), it becomes more difficult for a person to lose weight as they become more obese. They experience what is called metabolic adaptation; their body begins to change, and they start to see a decrease in the hormones that signal they are full and should stop eating.
These new drugs stimulate those hormones. Ozempic and Wegovy target a single hormone, called GLP-1. The so-called “triple-G” drugs coming soon that appear more effective target multiple hormones. The effect is that people feel more full more quickly, which makes it easier for them to eat less.
“You have more control of the hunger, so patients can continue to make the right decision,” Grieleber said.
But take away those hormones and the body starts to work in reverse.
Grieleber said “95 percent” of his patients will ask if they could take the drugs for a few months and then stop. The answer, he tells them, is no. Patients must be prepared for the reality that they would need to take some kind of medication for the rest of their life if they intend to keep the weight off.
This is an especially big hurdle for parents. “That’s a big pill to swallow: My kid may potentially be on this medication for life,” said Claudia Fox, co-director of the Center for Pediatric Obesity Medicine at the University of Minnesota Medical School. “Probably not the same medication that we start today, but they will likely need some sort of treatment for life. We’re not curing it. We’re treating it. We’re managing it.”
2) Your health insurer might not want to cover these treatments
Without health insurance, these are expensive drugs. Ozempic costs about $900 a month without insurance, and Wegovy costs about $1,350. But health insurers are reluctant to cover them — and that has led to cost coming up very early in these conversations between doctors and their patients.
All of the doctors I spoke to said they bring up insurance coverage almost immediately. “We have to make sure your insurer covers it,” Apovian said.
For patients on Medicare and Medicaid, those government programs generally will not cover weight-loss drugs, a longstanding statutory prohibition that physicians believe must be revisited if the US is to take advantage of these treatments. For private insurers, the picture is more mixed, but most commercial health plans also do not cover weight-loss drugs.
Even if they technically do, securing coverage can still be an administrative hassle. Apovian said her specialized practice has one employee managing prior authorizations and other paperwork for their eight practitioners and described the workload as “overwhelming.” That burden is going to be only greater for an independent physician practicing on their own.
In Minnesota, the Medicaid program does actually cover weight-loss drugs, but the conditions placed on prescriptions can still be cumbersome, Fox said. She recounted the story of one patient, a teenager who meets the eligibility criteria based on age and BMI. The state program also wanted to require the patient to eat a low-calorie diet, to meet regularly with a dietician, and to be enrolled in an exercise program.
Fox wrote an appeal letter, affirming that the patient was in gym class in school and also playing basketball outside of school. The Medicaid program wrote back: Not good enough. After several volleys with the plan, Fox sought the intervention of an independent arbiter who oversees the program.
“The challenge is how they implement those approvals. The stipulations are often not based on any scientific recommendation,” she said. “We face these delay tactics, even though this should be covered upfront.”
There are alternatives for patients who can’t get insurance to cover the drugs and can’t afford the $1,300 out-of-pocket price. Saxenda and phentermine were some of the options these doctors consider. But they come with the catch that they are not as effective as these new treatments attracting so much attention.
3) Your own experience with these drugs can vary significantly
Another thing patients should be aware of, obesity doctors say, is that their individual experience may not match the hype.
The headline numbers that patients may have seen showing people losing 10 to 20 percent of their body weight are only averages. Some people may lose 35 percent. Some people may lose only 10 percent. A small number of people may not lose any at all. At this point, obesity science does not fully understand how different patients are going to respond. There is still a lot of trial and error, Apovian told me.
“There are always gonna be patients who don’t lose a lot of weight with these drugs,” she said. “Patients need to know there’s a small chance that you’re not going to respond.”
Griebeler said he is also warning patients that it is normal to experience a plateau in weight loss after six to 12 months, as your metabolism begins to adjust.
That doesn’t mean a patient can stop taking the medication, for the reasons we covered. But a plateau can still be frustrating for somebody expecting extraordinary returns.
Then there are the side effects. Most people will experience some nausea, Apovian said. Some people experience such significant nausea that they end up in the ER. She has also had a small number of patients experience very severe constipation that had to be treated in the hospital.
The unpleasantness of side effects or the risks of more serious complications of the medications may be worth it for the potential benefits, in the view of an individual and the doctor. But it is important that physicians and patients confront them and prepare for them.
4) You need a holistic plan for weight loss and management
All of the doctors I spoke with lastly emphasized that patients need a comprehensive plan for weight management, including for their diet and to make sure they are getting exercise.
That’s not because weight loss is as simple as eating right and working out; all of these physicians wanted to break that misconception. But these drugs “are gonna work best in patients who also do diet and exercise,” Apovian said. “You can’t just prescribe these meds.”
Exercise has well-documented health benefits, particularly for the conditions associated with obesity, such as hypertension and diabetes. Building muscle makes it slightly easier for your body to burn calories. And being sedentary, even at a lower weight, brings health risks of its own. People may also start to notice a change in their palate after taking these medications, and so finding a diet that is satisfying and helps them manage their appetite in conjunction with the drugs is beneficial as well.
Strategies for achieving better sleep and managing stress can also help patients get the most out of these drugs and manage the other conditions that they may be contending with. Doctors and patients need to be thinking about how to treat the whole person, rather than count on the new treatments, promising though they may be, to act as miracle drugs.
“Obesity treatment is an ongoing treatment ... You can’t prescribe this once and not have a follow-up,” Grieleber said. “We have to use this medicine as a tool.”