Ozempic killed diet and exercise

Robert F. Kennedy Jr. have some thoughts on Ozempic. According to the nominee to lead the Department of Health and Human Services, the government should not give the drug for millions of Americans, but instead addresses obesity and diabetes by handing out organic food and gym memberships. Like many of RFK’s statements, these have ideas caused some outrage. However, their basic premise—that Americans need to control their weight by eating better and exercising—couldn’t be more mainstream.

But this healthy philosophy of losing weight, advocated by RFK, the FDA, and indeed almost any doctor you may have asked at any point in recent memory, has recently fallen out of step with the scientific evidence.

Lifestyle interventions have been central to the nation’s decades-long effort to curb chronic disease rates. Eat less, move more: This advice applies to almost everyone, but for those who are obese or overweight — about three-quarters of the adult population in the United States — dieting and exercise are considered among the most important ways to improve their health. Even now that doctors have access to Ozempic and related GLP-1 drugs, which provide lasting weight loss and a range of life-extending benefits without the need for surgery, changes in behavior still take precedence. Formula guidelines for treatment for obesity has confirmed RFK’s approach, more or less, arguing that “lifestyle therapy remains the cornerstone of treatment.” And according to the government, the substances themselves are only suitable for use “as a supplement” to a low-calorie diet and increased physical activity.

This insistence on the status quo is starting to seem a little strange. It has long been known that prescribing diet and exercise is simply not as effective as treating obesity. People can lose enough weight, at least initially, to prevent or help control type 2 diabetes, said Tom Wadden, an obesity researcher at the University of Pennsylvania who has been involved in clinical trials of both lifestyle changes and GLP-1 -medicines as treatments for obesity. But he told me that amount of weight loss won’t reverse sleep apnea or prevent heart attacks or strokes.

For severely obese people today, even the modest benefits of dieting and exercise seem controversial. Over the past few years, clinical trials with Ozempic and related drugs have shown that the “cornerstone” of treatment adds almost nothing to the effect of these drugs on people’s body weight.

The mere possibility that dieting and exercise no longer mean anything like they used to has created its share of awkwardness within the field. “I would answer cautiously,” said David Saxon, an obesity specialist at the University of Colorado’s Anschutz Medical Campus, when I brought this up with him last spring. “I don’t want you to quote me saying, ‘He doesn’t think lifestyle is important.'” For older anti-obesity drugs, he said, the evidence for prescribing diet and exercise first (and beyond) is very clear: ​In clinical trials, patients who received a lifestyle intervention in addition to the drugs lost twice as much weight as those who did not.

From the June 2024 issue: Ozempic or Bust

But the data tell a different story for the newer drugs, Saxon and other doctors told me. In most clinical research on GLP-1s, patients receive the drug in combination with a modest lifestyle intervention: monthly, 15-minute check-ins with a counselor, for example, and advice to cut calories and take a few hours’ worth of exercise, like walking, every week. In one of the great lawsuits of Wegovy, called STEP 1this approach resulted in a weight loss among participants of about 15 percent of their body weight. Another lawsuit against Wegovy, called STEP 3tried something more: Participants were offered twice-weekly visits to a registered dietitian and spent their first two months on the drug consuming very low-calorie meal replacements. Evidence suggests that in the absence of Wegovy, all this extra coaching would make a big difference to people’s health. But for the people at Wegovy, the benefits were negligible: Those enrolled in the STEP 3 trial lost an average of 16 percent of their body weight, just a hair more than the people in STEP 1 lost. “It speaks to the point that the intensive lifestyle program may not be necessary with these new medications,” Saxon said.

He has seen this play out within the Veterans Affairs system, where he also works. Patients on older, less potent anti-obesity drugs were expected to participate in an ongoing lifestyle modification program with monthly check-ins, Saxon told me. Now that he and his colleagues prescribe GLP-1s, “we don’t really mandate it anymore,” he said, “because we see that even without it, people maintain their weight loss with these newer medications.” Eduardo Grunvald, the medical director of the weight management program at UC San Diego Health, told me he had the same impression. “The bottom line is you don’t necessarily need intense lifestyle intervention for these drugs,” he said when we spoke in March.

Still, obesity specialists, including Saxon, haven’t given up on dieting and exercise. But the field is beginning to reevaluate the nature of such guidance. “We need to figure out what that’s going to look like,” said Sue Yanovski, co-director of the Office of Obesity Research for the National Institute of Diabetes and Digestive and Kidney Diseases. Since last year have a series reviews, editorial articlesand perspective papersmostly published in obesity journals, have explored this very question. One paper argued, for example, that instead of aiming to produce a “quantity” of weight loss, obesity specialists should now emphasize its “quality.” A co-author on that paper, Wake Forest University obesity doctor and epidemiologist Kristina Lewis, told me that GLP-1 drugs don’t make dieting and exercise irrelevant at all; in fact, they free patients “to focus on lifestyle intervention in a more refined way,” by eliminating cravings and accounting for the need to count calories. People on Ozempic, she said, and their doctors can also start thinking about changing to a healthy diet, being more active, getting more sleep. All of these interventions will be beneficial regardless of your weight.

It all sounds very reasonable, but in a wider context it also feels like a concession. For decades now, the staunchest critics of the weight loss industry and its associated doctors have been saying something similar: Healthy behavior can and should be decoupled from the single-minded goal of making people less. Now, ironically, the principles of this movement, which became known as “Health at any sizebeing adapted to the treatment of obesity.

But if lifestyle interventions are intended to have the same benefits for people diagnosed with obesity as they would for anyone, how special is their role in treatment? Lewis and other doctors told me that people on Ozempic may still need tailored diet and exercise advice because rapid weight loss can create specific health needs. For example, clinical trials showed that people on GLP-1 drugs lost lots of muscle and bone as their bodies shrank in size; in fact, these and other fat-free tissues accounted for 25 to 40 percent of their total weight loss. To reduce any increased risk of weakness or fracture that may occur, some experts now suggest that people on these drugs should eat more protein and engage in more resistance exercise than they could in a traditional lifestyle intervention.

Read: The science behind Ozempic was wrong

Counseling on muscle-building diets and exercise may end up as part of standard care for people on Ozempic. “On a rational basis, I would say we should do this,” said Wadden, who was a member of the research team for the STEP 1 and STEP 3 trials. Still, he acknowledged that the evidence for this approach is not yet complete. Wad has been study lifestyle interventions for people with obesity for decades. Some of that work found that adding resistance training and aerobic exercise to very strict diets did nothing to prevent the loss of lean body mass. The people doing these workouts were really “swimming against the current” of the effects of rapid weight loss, he told me. Other obesity researchers have disputed the very idea that muscle loss is a problem to begin with. ONE newer paper from Journal of the American Medical Association claims that the link between physical frailty and GLP-1 drugs is not supported by the data, noting that if more than half of the weight a person on the Ozempic sheds is fat, then they are sure to end up with a taller muscle -to-fat ratio than they had before.

Read: The illusion of ‘obesity’

Doctors still don’t fully understand why people on GLP-1 lose so much weight to begin with. Ozempic may be working alone to promote different ways of eating, Wadden told me. “The drug changes your diet dramatically without a lot of conscious effort,” he said. “How does it change? We don’t know.” People on the drug may end up eating less across the board while sticking to the diet they had before: One Pop-Tart for dinner, say, instead of five. (In that case, meetings with a dietitian would be very helpful.) But the drugs can also work to change people’s tastes. “Then all of a sudden you like more fruits and vegetables,” Wadden said, “and you like lean proteins.” Similar questions can apply to exercise: the mere fact of losing a lot of weight can lead someone to engage in more physical activity, regardless of their access to a gym or time spent with a trainer. The studies that can solve this have not yet been carried out.

Wadden, like many other doctors, remains convinced that dieting and exercise should remain the standard therapy for people who are overweight or moderately obese. But for people with more weight to lose — the tens of thousands of Americans whose BMI is higher than 35, say — he now believes the rules are about to change. For this group, he said, “I don’t think lifestyle changes are the cornerstone of obesity treatment anymore.”

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