Point of view: Weight loss drugs
Do medications like Ozempic, Wegovy, and Mounjaro have a role to play in lifestyle wellness journeys?
In October 2023, Goldman Sachs came out with an alarming prediction: 15 million U.S. adults will be on anti-obesity medication by 2030. The market for these drugs is likely to grow from $6 billion last year to $100 billion six years from now, according to the same research report.
With such bold predictions, an abundance of favorable pharma-funded studies, and plenty of glowing media coverage, you might think the only obstacle preventing us from solving the obesity epidemic is a supply shortage of semaglutide, the industry’s most popular solution to date.
How did an injectable drug that suppresses appetite and slows the emptying of the stomach become the talk of the town? And what role could it play in achieving optimal long-term health?
As advocates for improving health through food and lifestyle change, we wanted to understand how medications like Ozempic and Wegovy work, who can benefit from them, and what’s known so far about the benefits and downsides of this kind of intervention. Read on, for a summary of key facts that we discovered through several months of research and surveying our own health-seeking community for a personal perspective.
Semaglutide for beginners
To appreciate the current wave of attention on weight loss drugs, we needed to get familiar with the history of anti-obesity medications and what’s different about the newest invention. Ozempic, the name you’ve likely heard most, is one of three products based on a drug called semaglutide, which is made by Danish company Novo Nordisk. Semaglutide belongs to a class of drugs called Glucagon-like-peptide-1 (GLP-1) receptor agonists.
What does that mean? Let’s break it down:
GLP-1 is a hormone that gets released in the gut when you ingest food. This hormone signals the pancreas to release insulin, which in turn lowers blood sugar. GLP-1 also signals the brain to reduce appetite and slows the emptying of the stomach after eating.
An agonist is a synthetic substance that binds to the receptor in a cell and mimics the action of the natural hormone.
Ozempic and other semaglutide medications essentially trick the body into releasing insulin and reducing hunger signaling, even when food is not present.
Before the invention of semaglutide, the most recently approved weight loss drug had been liraglutide, approved in 2014 and marketed (also by Novo Nordisk) as Saxenda. In 2017, the U.S. FDA approved semaglutide for blood sugar control in Type 2 diabetics, and Novo Nordisk began marketing the new product as Ozempic. The main breakthrough for semaglutide was changing how often a patient needs to administer the drug. One only needs to inject Ozempic once a week, compared to a daily injection with Saxenda.
As word spread about the effectiveness of Ozempic for chronic weight management, doctors began prescribing it off-label as an anti-obesity medication. Meanwhile, Novo Nordisk, which holds all U.S. patents to semaglutide until 2032, set its sights on FDA approval for a higher dose to be prescribed for weight management under the brand name Wegovy. The green light for this product in the U.S. came in 2021.
Eli Lilly has since developed its own GLP-1 drug, marketed as Mounjaro, which the FDA approved for Type 2 diabetes only (not for weight loss) in 2022. In November 2023, Japan became the sixth country to approve Wegovy, after the U.S., UK, Germany, Norway, and Denmark. Also in late 2023, Novo Nordisk started rationing its Ozempic starter kits to manage supply chain constraints for manufacturing semaglutide.
Why does all of this backstory matter to the health-seeking public? It provides important context to explain the mixed messages we are hearing about the safety and efficacy of these interventions. And it is a good reminder that companies like Novo Nordisk and Eli Lilly may not have your individual best interests in mind. As publicly held entities, they will prioritize profits and shareholder value whenever they are making key business decisions.
Semaglutide and metabolic health
To date, most of the evidence for semaglutide effectiveness comes from pharma-funded studies and the occasional individual patient success story. For example, a January 2023 review of the clinical trials program for semaglutide use in the higher 2.4 mg dose (Wegovy) reported the following:
Mean weight losses of 14.9%-17.4% in individuals with obesity without Type 2 diabetes from baseline to week 68
Mean weight loss of 9.6% for individuals with obesity and T2D from baseline to week 68
Improvements in cardiometabolic risk factors, including high blood pressure, atherogenic lipids, and benefits on physical function and quality of life
This is one of many similar write-ups in which the authors concluded, “The magnitude of weight loss reported in the Semaglutide Treatment Effect for People (STEP) trials offers the potential for clinically relevant improvement for individuals with obesity-related diseases.”
Put another way, in an April 2023 article in ScienceDirect that was written by authors who disclosed serving on industry advisory boards and consulting with Novo Nordisk:
Semaglutide has demonstrated the largest weight loss of any obesity medication to date with reductions of approximately 15% of initial weight at 68 weeks, accompanied by improvements in cardiovascular risk factors and physical functioning.
For comparison, in the Senza community, we’ve seen hundreds of thousands of users reach their health goals by implementing lifestyle changes such as keto and fasting. We’ve also had the opportunity to support a number of wildly successful keto’ers, who’ve lost more than 50% of their starting weight, and kept it off for years. For example, Senza user MrLowCarb lost more than 200 lbs by following a ketogenic diet and shares his experience with others on Facebook.
A darker side to drugs
Is there a gotcha to losing weight with semaglutide injections? You bet…
In the short-term, the gut has to get used to the presence of a synthetic substance. People cite constipation, diarrhea, dizziness, nausea, and irritation of the injection sites as some of the difficult side effects that can last for weeks or longer. Some people can persevere through these symptoms, while others understandably give up.
Another adverse effect is the loss of lean body mass while taking semaglutide. In this commentary about Ozempic, Dr. Jeff Stanley, Medical Director of Virta Health, says it is not uncommon for 60-70% of weight loss with the drug to be from lean body mass, instead of body fat. This means you may be losing muscle and compromising bone health for the sake of a lower number of the scale. Losing muscle actually slows your metabolism, which can drive weight regain. Micronutrient deficiencies also can arise from poor nutrient absorption when you’re manipulating the body’s natural processes.
Bottomline: Taking Ozempic doesn’t address the root cause of obesity, and it doesn’t appear to free you of the need to make lifestyle changes. Patients are advised to restrict calorie intake and add exercise, along with the weekly injections, if they want to maximize results of the protocol. Most will need to take the medication for life, or risk losing all the progress they’ve made.
Predictably, a wave of lawsuits has begun, claiming that GLP-1s cause severe GI damage that is not clearly explained by the manufacturers. Food Lies author Brian Sanders reported on this recently. Meanwhile, the capable team at Virta Health is positioning its medically supervised ketogenic diet program for Type 2 diabetes reversal as an alternative and off-ramp to GLP-1 meds.
Finally, there is the cost factor to consider: Ozempic runs $800-1000 per month without insurance; it’s only covered if you’re diagnosed with Type 2 diabetes and have tried other medications first. Few health insurance plans cover Wegovy at this time, and you need to meet specific obesity and metabolic disease criteria to be approved. We have to question the logic of those who say it’s too expensive to buy well raised, pesticide-free, whole food ingredients if they are willing to pay the high cost of prescription medications instead.
Individuals who struggle with extreme health conditions may find weight management drugs to be the only realistic way to begin restoring their metabolic health. But it’s worth remembering that the long-term outcomes are not well understood, and it may be difficult to get off the drugs once you’ve started. As with any serious health intervention, we would be inclined to proceed with caution.
What the Senza community says
Across Senza, we are hearing a balanced approach to the question of weight loss drugs. When we fielded a survey earlier this month, about half of respondents indicated they see a limited role for medication, alongside nutrition and lifestyle change. But an overwhelming majority believes weight loss drugs are not the answer.
Will semaglutide become the most successful drug in history? That depends on how you measure success. Novo Nordisk and its ecosystem of industry players stand to make a record profit. But if we’re judging the medication on its ability to solve root-cause health issues for the general population, well that’s an entirely different scale.
Learn more
ScienceDirect: Semaglutide for the treatment of obesity
PubMed: Semaglutide for the treatment of overweight and obesity: A review
UCLA Health: Semaglutide for weight loss - what you need to know
NEJM: Once-Weekly Semaglutide in Adults with Overweight or Obesity
Virta Health: GLP-1 Alternatives
Food Lies: There’s Actually a Free Version of Ozempic that Nobody Wants
Five Days to Keto Guide
If you are keto-curious, you may appreciate our new e-book, recently published by the Senza health coaching team. It will help you get into ketosis without experiencing common side effects and maximize the benefits of making the transition to a low-carb lifestyle. Subscribers can use the code FIXTHEFOOD for a 20% discount on the Five Days to Keto Guide.
I lost 140 pounds while on Mounjaro; I've been off for six months and maintained.
I think my success thus far was I viewed my use of this medication as a tool and not some magic fix.
While I was on this medication, I did a ton of work changing my lifestyle and working on the emotional/physiological aspects that led me to weigh over 300 pounds.
Now that I'm off, fitness and health are at the center of my life.
The analogy I like to use with other people I have engaged with who are using Mounjaro for weight loss is that it is like using the bumpers in bowling. It keeps the ball out of the gutter so you can learn how to play.
Sure, you can throw the ball randomly down the lane, and it’ll bounce off the bumpers. You might score an occasional strike or a spare - i.e., lose a lot of weight - or hit hardly any or no pins. Your results will be completely random.
If you don't take the time to learn to play when the bumpers get taken away, the ball will go back to going in the gutter most of the time - i.e.; you’ll gain the weight back.
An effective goal while using this medication is to give you the confidence to consistently get the ball down the lane and focus on your technique so that you are not touching the bumpers every time.
That way, when the medication goes away (which, for many, it does), you have mastered the emotional and physical (diet/exercise) things you need to do to continue to lose and eventually maintain your weight loss.
I know that all of the emotional work I did the year I was on Mounjaro around my relationship with food is helping me keep the ball going down the lane so I can continue to hit the pins, even without Mounjaro.