The sudden popularity The use of weight loss drugs has been one of the biggest health stories of the year, and also one of the most controversial. While experts say drugs like Ozempic, Wegovy and Zepbound represent a major breakthrough in treating obesity, there are also growing concerns that people looking to lose a few pounds may be using them as a quick fix.
So, who are these medications for? And what are the potential health risks and benefits? Colombia Magazine I recently spoke to an endocrinologist Judith Korner ’92GSAS, ’93VPSprofessor of medicine at Columbia University Irving Medical Center and director of its Metabolic and Weight Control Centerfor answers.
First, can you explain how these new drugs work?
Ozempic, which hit the market in 2017, and Wegovy, released in 2021, contain a synthetic version of a hormone naturally produced in the intestines when you eat. This hormone, GLP-1, sends a signal to your brain that you have eaten enough. He announces: “You are full now!” Don’t take another bite! Ozempic was initially developed as a diabetes drug, because GLP-1 also tells the pancreas when to produce insulin and thus plays a key role in regulating blood sugar levels. Zepbound, which is the new kid on the block, received FDA approval this month as a weight-loss drug. It also contains GLP-1, as well as another hormone that modulates appetite. By increasing your levels of appetite-controlling hormones, all three medications reduce your hunger and make you feel full after eating less food. They are injected once a week, using a device similar to an insulin pen.
You have been treating people with obesity at the Columbia Metabolic and Weight Control Center for more than two decades. How has the availability of these medications influenced your practice?
Having these medications in our toolbox is an absolute game changer. Other weight loss drugs were available in the past, but they were either less effective or caused dangerous side effects, including cardiovascular problems, so we prescribed them less frequently. The new drugs have an excellent safety profile and are incredibly effective. There are still some open questions, as with any new therapy. For example, we do not know whether their effectiveness may decrease after prolonged use. And there are safety concerns for certain demographic groups, including older adults, some of whom may lose muscle mass. But so far, the drugs overall appear to be extremely effective.
Who do you recommend them for?
We consider body mass index, or BMI, which is a person’s weight adjusted for their height and general health. If a person has a BMI of 30 or greater, which is the clinical definition of obesity, and a history of unsuccessful attempts to lose weight through nonmedical interventions, we consider them a good candidate for medication. And if their weight already seems to be contributing to other health problems, like diabetes, hypertension, high cholesterol, or sleep apnea, we may recommend a medication with a BMI below 27 or higher. We will offer the medicine as part of a comprehensive clinical care package including personalized dietary and lifestyle advice, counseling and other support.
What types of results have you seen?
People who take these medications often lose 15 percent of their body weight, and we have patients in our clinic who have lost 100 pounds or more. As you can imagine, it’s a transformative experience, physically and mentally. Most of our patients have struggled with their weight for years, if not their entire lives. They have tried every diet imaginable and every kind of exercise program. The majority have managed to lose a lot of weight, several times over the years, only to gain it back, and then some. By the time they come to us, many have lost the ability to exercise or even move around. They feel defeated and hopeless. And then, after taking one of these drugs, the tide turns. Patients will tell us things like, “For the first time, I no longer think about food constantly. I eat normally and feel in control of my life. As chronic joint pain and fatigue disappear, they regain mobility.
Additionally, losing weight significantly improves long-term health. When excess fat accumulates in the body, it seeps into the liver, pancreas, intestines, heart and other organs, damaging them. This causes inflammation and increases our risk of cardiovascular disease and certain cancers. Studies show that people who take these medications can reduce their risk of heart attacks and strokes by 20%.
What are the potential side effects of medications?
The main problems are gastrointestinal side effects, including nausea, vomiting, diarrhea, and constipation, which can be minor or quite severe. In rats, the drugs have been associated with two rare diseases, medullary thyroid carcinoma and multiple endocrine neoplasia. People with a family history of these conditions are therefore advised not to take them.
Some health experts have expressed concern that people at a healthy weight are using these drugs to lose the last 10 pounds.
This appears to be a problem, although it is unclear to what extent. Obviously, people should not use these medications to lose a few pounds and look great in a bikini. Although these medications appear very safe, it is certainly possible that decades from now we will discover that these medications have long-term negative health consequences that we had not anticipated.
I must say, however, that the media attention given to the potential misuse of these drugs frustrates me, as I find that there is often an undercurrent in the public debate that seems to question whether these drugs are really necessary for anybody. Commenters often seem to imply, “Can’t overweight people just eat less?” Can’t they show more willpower and take better care of themselves? This ignores the fact that obesity is a chronic disease that often requires medical treatment.
Your own research has been instrumental in the recognition of obesity as a disease by the medical establishment in recent years.
I am a molecular biologist by training and have always been fascinated by how the body controls appetite. For example, I want to understand why some people feel satisfied after eating a 400-calorie meal, while others may need to consume 800 calories to feel the same feeling of satisfaction. Such differences may be based in part on genetics, which is believed to be responsible for at least 40 percent of a person’s risk of obesity. Additionally, research by my group and others has shown that excess body fat changes our metabolism and appetite in ways that make weight loss extremely difficult. The goal of new weight loss drugs is to compensate for metabolic and hormonal irregularities that may be causing a person’s obesity.
If someone loses a lot of weight on one of these medications and then stops taking it, will they keep the weight off?
It’s rare, unfortunately. I don’t want to say categorically that people can’t do this because I think if someone significantly improved every aspect of their diet and lifestyle while taking the drug and then stuck to those changes later, it is possible. But studies have shown that people who stop taking these medications usually regain weight, even if they also take better care of themselves.
If obesity is a genetically based disease, why does its prevalence vary widely across demographic groups and cultures? Doesn’t that suggest that this is driven by our behavior?
Of course, our food and lifestyle choices, our genes and our environment all contribute to obesity. But you are confusing the cause of the disease with the fact that it leads to chronic disease. A colleague once put it this way: “Smoking contributes to lung cancer. But no one is therefore suggesting that lung cancer is not a disease.” In our society, obese people are stigmatized and accused of having an illness. Even many doctors don’t realize how difficult it is for people to lose weight. If they talk to these patients about the prospect of losing weight—and they often avoid the sensitive topic—they will simply say, “Try to lose fifty pounds” without offering much advice.
What advice would you give to someone looking for a friendly provider to help them lose weight?
Find a doctor accredited by the American Board of Obesity Medicine. I also suggest seeing a dietitian or nutritionist regularly. However, their services are usually not covered by insurance and they can be expensive. An affordable option is to keep a food diary, which promotes mindful eating and is one of the most effective ways to lose weight. There are also smartphone apps that make it easier to track your meals.
Do medical insurance plans cover weight loss medications?
In recent years, private insurers have begun to cover the new class of weight-loss drugs more frequently, but Medicaid and Medicare still do not. This is troubling because obesity rates are highest among disadvantaged populations who rely on these diets.
What is your research focused on today?
My colleagues and I are studying how the effectiveness of different weight loss interventions, including medications and bariatric surgery, varies depending on people’s genetic profile and medical history. The goal is to bring more of a precision medicine approach to the care we provide. Currently, physicians in our field rely too much on trial and error to decide which interventions are best for particular patients. Over the next few years, many more weight loss drugs will come to market, targeting different molecular pathways, and we want to help doctors make more informed decisions when prescribing therapies.
