Oprah kicked off a national conversation on obesity and GLP-1 drugs. Let’s have it

Oprah Winfrey, true to form, is forcing America to yet again grapple with a complex topic: weight loss. Her full-throated endorsement on national television last week for using GLP-1 drugs like Ozempic and Wegovy to treat obesity has opened the door for an important conversation about the use of these drugs for people struggling with their weight.

As a physician focused on obesity and metabolic disorders, I was troubled by Oprah’s support for these drugs. The show was framed as news, but sounded to me more like an hour-long infomercial. When it comes to GLP-1 drugs, there are some things prescribers know, more we’re just beginning to know, and plenty we don’t know yet.

People deserve to be happy and healthy in their weight loss journeys. They also deserve to be fully informed.

The introduction of GLP-1s has turned the obesity epidemic — more than 40% of Americans are obese, and another 30% are overweight — into a complicated and expensive landscape. Oprah’s show was just the latest development in a conversation that has so far been driven by pharmaceutical companies and their proxies, rather than practicing clinicians. The result is a trend that does not consider the needs of people; not just their health, but their joy as well. Suppressing the desire to eat robs people of the enjoyment that comes with it.

Obesity starts with a problem with metabolism and requires a precise, behavior-driven approach to treatment that is sustainable for people over time. GLP-1s are indeed a powerful new tool for combating unhealthy weight gain and are effective at suppressing the desires that drive unhealthy behaviors like overeating. But in the short time they’ve been on the market, they’ve demonstrated some serious issues that require further examination and study, specifically around how they are used, and how they affect overall health.

Here’s what’s known about GLP-1s: They are wildly expensive and most people need to take them forever. Worst of all, they don’t effectively address metabolic dysfunction, which disrupts the body’s ability to turn food into energy and get rid of waste. This has negative downstream effects for nearly every system in the body, and can lead to diabetes, obesity, and other metabolic diseases. The prices of these medicines are astronomical, costing more than $11,000 per year. That cost is increasingly unsustainable for payers in the U.S., and prohibitive for people whose insurance doesn’t cover the drug.

Many people can’t tolerate GLP-1 drugs, as made evident by the fact that two out of three people who are prescribed these medicines stop taking them within a year. Oprah’s hour-long special dedicated around two minutes to discussing disruptive side effects like nausea and vomiting. Mere seconds were given to a woman in the audience who described side effects that put her in the emergency room. And no direct mention was made of the immediate rebound in weight most people experience when they stop taking these drugs.

Oprah found something that works for her, and she’s excited to share it with the world. Coincidentally, it also works for the pharmaceutical manufacturers who, according to reports, pay many of the clinical consultants featured on her special.

The resounding opinion of the medical community is that weight loss is a poor measure of medication efficacy. Many weight loss experts are concerned about the effect of GLP-1s on body composition. The weight people lose when taking these drugs comes not only from fat but also from muscle. That’s not healthy weight loss, and it’s the wrong way to address this metabolic disease.

GLP-1s have helped people lose weight quickly, and studies have suggested there are broader health benefits. But in practice they often don’t help people with chronic metabolic diseases discontinue their other medications, like SGLT2s and insulin. It’s important to approach GLP-1 therapy judiciously, when it’s clinically appropriate, with the intent to eventually transition people away from perpetual dependence on these medications through lifestyle interventions such as healthy eating and physical activity.

As a physician, my point of view is that the obesity crisis and the stigma surrounding weight are real, but a monthly $1,000 injection for a lifetime isn’t a silver-bullet solution. GLP-1 drugs suppress the desire for food by influencing the neurons in the brain’s reward system. While this chemical interaction calms intense cravings, it may also quell more joyful and less harmful wants — a “quieting of the wanting mind” — like the joy of eating a meal with family. When the desire to eat does emerge, people taking GLP-1 drugs are not necessarily eating healthier foods, and so aren’t likely affecting the microbiome and root cause of metabolic dysfunction.

Everyone deserves to be able to sit down and share a meal with the people they care about. Food plays a central role in cultural identity and social health; it’s a focal point for connection, for belonging, and for happiness. To take food off the table is to remove an element of joy from life.

In the case of GLP-1s, that decision is a long-term commitment. Just as there have been advances in treating the symptoms of metabolic disease such as weight gain, clinical understanding of the biology and behavior behind metabolic health is improving. Both will play a role in treating metabolic diseases like obesity, but for most people, GLP-1 drugs aren’t sustainable. The lasting solution will be unique to each individual because no two people’s metabolisms, genetics, and preferences are exactly alike. That’s what makes many diets and medications fail — they’re one-size-fits-all solutions. GLP-1 drugs may work for some people in the short term, but they won’t work for anyone forever.

Lisa Shah is an internist and the chief medical officer of Twin Health, a health AI company using digital twin technology to reverse and prevent metabolic diseases.