I want to address some headlines that I’ve seen in the past couple of weeks regarding Ozempic, the diabetes (and, now, weight loss) drug that’s already been the subject of a lot of sensational coverage this year.
Clearing up some confusion about the weight loss drugs.
Nutrition Diva is hosted by Monica Reinagel. A transcript is available at Simplecast.
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Hello and welcome to the Nutrition Diva podcast. I’m Monica Reinagel and in this show, I take a closer look at nutrition headlines, research, and trends, to help you put that information into perspective, and decide how it might apply to you.
Today I want to address some headlines that I’ve seen in the past couple of weeks regarding Ozempic, the diabetes (and, now, weight loss) drug that’s already been the subject of a lot of sensational coverage this year.
For example, there’s been a lot of press over a recent study showing that people who lose weight on Ozempic lose a fair amount of muscle mass. Another article addressed the fact that people on Ozempic eventually stop losing weight and hit a plateau.
These news stories suggest some confusion, not just about how these drugs work but about how weight loss in general works.
Before I go any further, let me clarify that I’m not making a case for or against these drugs. My goal is to add some missing perspective to some of the conversations that I’m hearing and reading about this.
Ozempic and Wegovy are brand names for the same drug (semaglutide), depending on whether it’s being prescribed to treat diabetes or obesity. And these are the names that you’ve been hearing so much about. But semaglutide belongs to a larger class of medications called GLP-1 agonists, which are generally given by regular injection. These drugs were originally developed and approved to treat Type 2 diabetes—and they are quite effective in improving blood sugar control.
But it turned out that they were also quite effective in promoting weight loss. People taking these drugs can experience weight loss similar to what we might see with bariatric surgery—and well beyond what people suffering from overweight and obesity are typically able to achieve with lifestyle modification alone.
I want to be clear: This is not a drug that you take in order to drop a dress size for your class reunion, or hollow out your cheeks in preparation for your next movie role. It is not “willpower in a pill.” This is a serious medication that can be used to treat serious medical indications. And like any medication, it has risks and costs as well as benefits.
Sometimes, losing weight really is a matter of changing habits and learning to make better choices—and not just for a short time in order to lose weight, but on an ongoing basis, in order to maintain a lower weight. I personally have worked with hundreds of people who have achieved lasting weight loss through behavior modification alone. So I know this path is possible.
However, some people appear to have a physiological dysregulation of their metabolism and appetite-signaling mechanisms. They are constantly hungry and cutting back on portion sizes in order to lose weight proves extremely difficult. Ironically, these folks are often exercising far more restraint and willpower than those around them who don’t struggle with their weight. I say “ironically” because there’s a very damaging and inaccurate belief that people who are overweight are that way because they are lazy or less disciplined.
In any case, for people with dysregulated appetite or metabolisms, these drugs seem to level the playing field somewhat. People taking these medications often describe that it “turns down the food noise” in their heads, reducing their appetite and desire for food and making it possible to reduce their food intake enough to promote significant weight loss–leading to improvements in their health and wellbeing.
Newer research shows that the potential benefits extend beyond weight loss and blood sugar regulation to include a significant reduction in cardiovascular risk as well. This class of medications is truly a game changer in the treatment of conditions that affect the majority of our adult population.
Frankly, if I were a bariatric surgeon, I think I might be looking around for a new specialty. It’s hard to imagine why you would undergo highly invasive surgery, with all of the side effects and possible complications, when you could achieve similar results and benefits with a far less invasive treatment.
That’s not to say that these drugs have no side effects or risks. They absolutely do. One of the ways that these drugs regulate appetite and promote weight loss is by slowing down the rate at which food moves the digestive tract. For some people, this can cause nausea and even vomiting. These side effects often abate with time, but many people find the side effects so troublesome that they choose not to continue taking it. In a small number of cases, that slowing of digestive transit time can lead to more serious problems, such as intestinal blockage. (You may have seen in the news that this has now been added to the label as a possible complication.)
And this is why this drug is not (and probably shouldn’t ever be) available over the counter. You need to work with a physician who can assess whether these drugs are appropriate for your medical situation, whether the potential benefits outweigh any possible risks, and can monitor you and help you manage any side effects or complications that may occur. This is really no different from other prescription medications, such as those used to treat high blood pressure, high cholesterol, or a-fib.
And this brings me to another common but misinformed critique of these drugs, which is that when you stop taking them, you are likely to regain the weight. These drugs are not like antibiotics that you only take until the infection is resolved. They’re more like the medications used to treat chronic conditions like hypertension.
If your doctor puts you on blood pressure medication to treat hypertension, you are likely to achieve normal blood pressure. But if you were to stop taking the medication, your blood pressure would likely go right back up. It’s the same with medications that treat the chronic disease of obesity. Weight loss happens because the underlying causes are being treated. If we stop treating the underlying causes, that effect will likely be reversed.
And this reflects a common misconception about weight loss in general, even when it doesn’t involve medication. We go on diets or regimens in order to lose ten or 15 pounds. And then, having lost weight, we resume our previously scheduled programming. We go back to the same habits that resulted in us weighing ten or 15 pounds more. And guess what? We go back to that higher weight. So, whether we are talking about lifestyle modification for modest weight loss, or the medications used to manage obesity, any lasting solution will require a long-term intervention.
I also recently saw an article pointing out that people taking GLP-1 agonists don’t continue to lose weight forever. Eventually, they stop losing weight and reach a plateau. I don’t know why this surprises or confuses anyone.
Weight loss happens because we change the balance of energy. If we consistently start taking in fewer calories, we’re going to lose weight, because we’re expending more energy than we’re taking in. As we lose weight, however, we expend less energy, because smaller bodies require less energy to sustain. Eventually, we will we reach the weight where the amount of energy our body expends matches the amount of energy we are taking in. At that point, we’ll stop losing weight. Because we are in energy balance.
It doesn’t matter whether the reduction in energy intake is due to making different food choices (such as cutting down on soda, snacks, or desserts), observing a restricted eating window, or because we are taking a medication that helps us feel satisfied with smaller portions. When our energy intake and expenditure reach equilibrium, our body weight will remain stable. If we want to lose more weight, we’ll have to make additional adjustments in order to create an imbalance between our intake and our lower rate of expenditure.
And finally, I want to address the recent study showing that GLP-1 agonists caused people to lose lean muscle tissue. Virtually anyone who loses a substantial amount of body weight is likely to lose a certain amount of lean muscle tissue. And this is definitely a concern. When we are losing excess body weight, we want to be losing body fat, not lean muscle tissue. This is especially important for people over 50, who are already fighting against age-related loss of muscle tissue.
But the loss of lean muscle in people taking GLP-1 medications is similar to the changes in body composition that we’d see in anyone losing a similar amount of weight in a similar time frame, by any means. This is not an issue that’s specific or unique to these medications.
In my own work coaching people on sustainable weight loss, I focus on strategies that minimize muscle loss during weight loss. Part of that is calibrating the pace of weight loss to the pace at which we can actually lose body fat. Losing weight more slowly can preserve more muscle tissue. (And there are other benefits, as well.)
Another strategy for preventing muscle loss—whether due to aging or weight loss—is to optimize the muscle-building effects of dietary protein. In some cases, this means increasing the amount of protein you’re taking in. Or, it may involve increasing the quality of the protein in your diet. Often, it is a matter of distributing your current protein intake more strategically. But it always also involves challenging your muscles with exercise and strength training. (Protein alone isn’t going to do it.) To learn more about how I help people with weight management, please visit weighless.life.
I hope that this gives you a bit more context for everything you’ve been hearing about these medications—from both promoters and nay-sayers. Obesity is a complex disease process, involving physiology, psychology, genetics, environment, culture, and behavior. The GLP-1 agonist medications offer a potent new tool that addresses some but not all of those factors. And it’s one with significant issues—not least among them, high cost, inadequate supply chains, and spotty insurance coverage. I can’t fix any of those problems (although, they will probably ease somewhat over time), but I hope I have added a little more clarity around the media conversation.