With the explosion in popularity of a new class of weight-loss drugs, more and more people are asking their doctors for prescriptions.
In a survey of 346 health care professionals conducted by the physician online community platform, Sermo, in fall 2023, 89% said they’d seen a recent increase in patients requesting weight-loss medications and 92% of primary care physicians (PCPs) said they’d actively prescribed the drugs. One analysis found that the number of Wegovy prescriptions in the United States increased sevenfold from 83,200 in January 2023 to 598,100 in May 2023, before dipping to 162,200 in June 2023 after the drugmaker limited supplies to the United States.
“Some patients come in already knowing exactly what they want to be on,” says Olubunmi Oladunjoye, MD, MPH, an Internal Medicine specialist and assistant professor of General Medicine at Baylor College of Medicine in Houston, Texas. “They’re interested in Ozempic or Wegovy [or another medication] because they know someone on it … or just because of what they’re seeing on social media.”
While the medications have the potential to improve the health of millions of people with obesity, they do come with limitations, including side effects, price, and availability. Oladunjoye and other obesity medicine specialists urge doctors and their patients to take a holistic approach to weight loss, including the use of medications, when appropriate, as one of many tools.
“As physicians, we do our best to match patients with the right treatment modality,” Oladunjoye says. “Lifestyle changes, medications, surgeries, procedures … having a variety of options for our patients is great.”
Ozempic and Wegovy are branded medications containing semaglutide, which mimics the glucagon-like peptide-1 (GLP-1) hormone that is released in the gastrointestinal tract in response to eating, prompting the production of insulin. The release of insulin reduces blood sugar and sends signals of satiety to the brain, thereby curbing one’s appetite. Ozempic is approved by the Food and Drug Administration (FDA) to treat type 2 diabetes and is given at a different dose than Wegovy, which is approved for weight loss. The FDA also approved another similar drug, tirzepatide, under different brand names — Mounjaro (for type 2 diabetes) and Zepbound (for weight loss) — in May 2022 and November 2023, respectively.
These weight-loss medications have received a great deal of media attention over the past several months, particularly as celebrities, such as Oprah Winfrey and Elon Musk, have gone public with their use of them. They’re also effective. In a 2021 double-blind clinical trial of nearly 2,000 adults with obesity, Wegovy helped patients lose an average of 15% of their body weight over 68 weeks, compared to the placebo group, which lost an average of 2% of their body weight.
“This is a very exciting time, the medical community should definitely embrace this time and all the developments that are happening,” says Mustafa Hussain, MD, a professor of surgery and director of the Center for Weight and Metabolic Health at the University of Chicago Pritzker School of Medicine.
Hussain, who specializes in bariatric surgery, says that the new class of weight-loss medications — for which Wegovy is leading the way — is a gamechanger in the treatment of a disease that affects nearly half of all people living in the United States. Obesity is correlated with a number of other health conditions, including diabetes, heart disease, cancer, stroke, and complications of COVID-19, all contributing factors to preventable, premature death, according to the Centers for Disease Control and Prevention (CDC). A recent trial also found that Wegovy reduced the risk of heart attacks in people with obesity.
“[Obesity is] not a condition of a lack of willpower. Obesity is a disease that the medical community should be taking seriously and should be treating,” Hussain says. “With these medications, we have an effective medical treatment.”
But this prescription is not a “quick fix,” warns Genna Hymowitz, PhD, a psychologist at the Stony Brook Bariatric and Metabolic Weight Loss Center and a clinical associate professor at the Stony Brook University Renaissance School of Medicine on Long Island, New York.
“This is a very exciting time, the medical community should definitely embrace this time and all the developments that are happening.”
Mustafa Hussain, MD, University of Chicago Pritzker School of Medicine
For one, Wegovy is intended to be taken long-term, as patients reportedly gain back the lost weight after ceasing the medication, and should be prescribed along with proper nutrition and exercise. Also, the medication is expensive (with a list price of $1,349 per month) and often not covered by insurance, including Medicare, and has faced ongoing supply shortages. It can have several contraindications and unpleasant side effects, including nausea, diarrhea, vomiting, stomach pain, and in rare cases, pancreatitis, kidney problems, and other severe complications. It is also not recommended for people who are pregnant or planning to become pregnant within three months.
In the Sermo survey, 77% of the responding physicians said that they believed the celebrity buzz had created unrealistic expectations for their patients, with 77% saying some of their patients reported experiencing side effects, and of those, 65% saying that those side effects had caused the patients to stop taking the medication.
Adding to the challenges with the drug are reports of providers at med spas or with telehealth weight management services prescribing semaglutide inappropriately, including referring customers to compound pharmacies that provide a version of the prescription that is not FDA-approved. The FDA has received reports of adverse events from people who took compounded semaglutide and warned consumers to be aware that some compounding pharmacies were using semaglutide sodium, which does not have the same active ingredients as the semaglutide used in Wegovy and Ozempic.
Of the health care professionals surveyed by Sermo, 75% said they were concerned that the prevalence of med spas and telehealth prescriptions was potentially problematic for patients.
The discussion of weight-loss drugs in the media can also perpetuate unhealthy beauty standards and trigger people who struggle with their mental health and disordered eating related to body image, Hymowitz says.
“That’s why it’s really important to take a multidisciplinary approach,” she says, adding that treatments for weight loss should include physicians, dieticians, physical therapists, exercise physiologists, and behavioral health specialists. “It can be really helpful to focus on the patient’s health overall rather than just shape and weight.”
To qualify for a prescription of Wegovy, a patient must have a body mass index (BMI) of 30 or higher, indicating having obesity, or a BMI of 27-29 and a weight-related chronic health condition, such as high blood pressure or high cholesterol.
And while BMI continues to be used as a common screening tool for unhealthy excess weight, many in the field of obesity medicine have cautioned that the picture of health that BMI paints is a limited one. BMI is calculated by dividing a person’s weight by the square of their height and multiplying by a conversion factor of 703. While this number is correlated with excess fat and related health issues, it does not directly measure a person’s body fat.
For example, a person who eats a healthy diet and is muscular could have a BMI that is considered overweight or obese, just as someone who has poor nutrition and high cholesterol could have a BMI that is considered a healthy weight.
“Everybody responds to excess weight in a different way,” Hussain says. “That’s what we refer to as metabolic health.”
Societal standards of what is perceived as a healthy weight can also be misleading and there is often stigma associated with higher body weight, Hymowitz says.
This stigma extends to the doctor’s office.
“We must recognize it is a very sensitive topic for many … The words we use definitely matter when we raise the topic of body weight.”
Olubunmi Oladunjoye, MD, MPH, Baylor College of Medicine in Houston, Texas
Some research suggests that people with higher BMIs avoid seeking health care due to anxiety around being weighed or being told to lose weight. Patients have also reported facing discrimination from their doctors who overemphasize weight and miss other health problems.
One 2023 study found that only 10% of 107 surveyed primary care physicians used evidence-based guidelines to inform obesity treatment decisions.
As someone who works in obesity medicine, Oladunjoye recommends all physicians take care when discussing weight with patients. In her own practice, she starts by asking the patient for permission to discuss weight and respects the patient’s wishes. With permission, she asks open-ended questions and is careful to avoid judgmental or stigmatizing language.
“We must recognize it is a very sensitive topic for many,” she says. “The words we use definitely matter when we raise the topic of body weight.”
The National Institute of Diabetes and Digestive and Kidney Diseases recommends doctors avoid using stigmatizing terms like “heavy,” “fat,” “overweight,” or “obese,” instead opting for “having too much weight for their health” or “excess weight.” It also offers questions to guide the conversation, such as, “What kinds of food and drinks do you consume on a normal day?” and “What barriers might keep you from having healthy food and drinks?” It further recommends asking the patient to set their own goals and reviewing a variety of treatment options, emphasizing that it is a shared decision-making process.
Hymowitz adds that it’s also important for clinicians to screen for eating disorders. She recommends the SCOFF questionnaire, which includes five questions about the patient’s relationship with eating and their weight. According to a report by the Academy for Eating Disorders, about 9% of the U.S. population will have an eating disorder at some point during their lifetime.
Rather than focusing on BMI and weight loss, Hymowitz says it’s helpful to approach the person holistically and center the conversation on how an intervention will improve and/or prolong a patient’s life.
“It can also be helpful to consider and continue discussing obesity similar to other illnesses — like high cholesterol and high blood pressure — as complex illnesses that are impacted by so many factors,” she says. “A lot of us do focus more on the superficial, [but we must] see an individual as a whole person rather than just as the number on the scale.”
Just a few years ago, the medical community at large had little understanding of the growing problem of obesity, Oladunjoye notes. That perspective has evolved and expanded as research has revealed that excess weight and weight-related health conditions have more complex causes than a poor diet and lack of self-control.
“Now we have a better understanding of obesity as a complex disease and we’re not just blaming our patients for their weight,” she says.
Within the last few years, several academic medical institutions have developed multidisciplinary centers focusing on metabolic and holistic health care and weight research, like the center at the University of Chicago that Hussain directs, the Joan and Sanford I. Weill Center for Metabolic Health at Weill Cornell Medicine in New York City, the University of North Texas Health Science Center Metabolic & Longevity Center in Fort Worth, and the Johns Hopkins Medicine Center for Metabolism & Obesity Research.
Hussain says that more and better medication options are on the horizon. The makers of Wegovy are testing an oral version of the medication and several other drugmakers are in clinical trials for additional medications that target metabolic hormones.
His main concern is that, as obesity disproportionately affects Black people, Hispanic/Latino people, and people with low incomes, those most affected will be the least likely to have access to the treatments.
“Access to these medications will be important — it’s the Achilles heel of how [the drugs] will impact population health,” Hussain says. “It’s exciting that surgery and medications are available, but from a population standpoint, we need to do better about preventing obesity, making large social changes, and addressing some of the underlying causes, like diet and environment.”
Still, the momentum in the field makes Hussain optimistic.
“We’re just excited that there are more people moving from [thinking], ‘I can’t do anything about my weight’ to [knowing] there is an option.”
Bridget Balch is a staff writer for AAMCNews whose areas of focus include medical research, health equity, and patient care. She can be reached at bbalch@aamc.org.