Note: This transcript has been created with a combination of machine ears and human eyes. There may be small differences between this document and the audio version, which is one of many reasons we encourage you to listen to the episode!

Dan Gorenstein: Obesity is a serious problem in the United States. 42 percent of adults — more than 100 million people — are considered obese. It’s linked to heart disease, diabetes and various cancers … and the CDC says obesity costs the U.S. health care system $173 billion a year. Now a new crop of weight loss drugs are helping people lose up to a fifth of their body weight and manage their serious health conditions. But this medical breakthrough is forcing the nation to grapple with some hard questions.

Elaine Chen: Because there’s already such a value placed on thinness in society, there is concern that this message that obesity is a disease could be taken too far.

DG: Today, we talk with reporter Elaine Chen to understand the impact and fallout from these drugs. From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.

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EC: I’m Elaine Chen. I’m a cardiovascular disease reporter at STAT, so I cover heart disease, but I also cover metabolic conditions like diabetes and obesity.

DG: STAT is a national health and medicine media outlet, and Elaine has written several articles for their new series, “The Obesity Revolution,” including a 5,000-word piece that looks at the impact these new injectable medications are having on our health care system. Only one of these drugs — known by the brand name Wegovy — is FDA-approved to treat obesity. But two other similar diabetes medications — Ozempic and Mounjaro — are also being used for their weight loss effects.

Elaine, you touched on so much in your article the price of these new obesity drugs, stigma, drugmakers funding medical school curriculum. What stands out to you most?

EC: I think these new drugs are ushering a new societal understanding of what obesity is. I would compare it to what we’ve seen with previous big blockbuster drug classes like in the field of mental health illnesses. When SSRIs came onto the scene, they really ushered in a new understanding of mental illnesses as a biological condition that requires treatment. 

DG: And those are antidepressants like Prozac and Zoloft.

EC: Right. And then when statins came onto the scene, that made people care a lot more about their cholesterol levels. And I think in a similar way, these new obesity drugs are changing people’s understanding of obesity being a chronic biological disease rather than just a result of, say, a person’s own willpower.

DG: Why is that so important, do you think? This shift in perspective on what obesity is?

EC: On one hand, there has been a lot of stigma against people with obesity, blaming them and saying you eat too much or you don’t exercise enough. There have been a lot of studies showing that oftentimes changes in diet and exercise alone aren’t enough to help people keep weight off. So it’s important that I think society realizes that there’s more to obesity than what was traditionally understood. And there needs to be new ways of addressing it. This is also a huge opportunity for pharma companies making the drugs. And so for them, this message that obesity is a disease and we have medical drugs to treat them is what really will help the pharma companies get really big sales of the drugs.

DG: So to you, the emergence of these drugs is a game-changing moment because it’s changing the conversation around obesity. It’s putting front and center a message drugmakers and many medical professionals have been saying for years, that simply obesity is a health problem, not a moral failing.

EC: Yeah, exactly.

DG: So to better understand what’s actually happening for people and some of the tensions around that conversation, I was hoping you could tell us the story of one of the people you interviewed, Gabriela Gonzalez.

EC: Yeah, Gabriela has a genetic heart condition that can make it harder for her heart to pump blood. And after she caught COVID, the condition of her heart worsened, and she was prescribed higher doses of medications that made her sluggish and she had difficulty exercising. So she gained weight. 

Gabriela Gonzalez: I was trying intermittent fasting and I hired a nutritionist and just nothing was working.

DG: You can hear Elaine typing in the background as she interviews Gabriela.

GG: It got to a very frustrating point last year. So I talked to my cardiologist at the time and he recommended Wegovy.

EC: Initially, she actually took an earlier obesity drug because Wegovy was in shortage, but she eventually was able to get a hold of Wegovy, and since then, she’s been steadily losing weight. 

GG: So far it’s been great. I feel like it’s right now, it’s a blessing.

EC: I think that what’s important with her story on one hand is that obesity is not just the state of having excess weight, but it’s also something that heightens the risk of downstream complications like heart disease, like diabetes. And so for Gabriela, for her, this drug is not something that’s cosmetic. It’s something that really she’s trying to take to improve her health and try to essentially try to live longer.

DG: Then you quote Gabriela, though, and this was fascinating, Gabriela’s medical provider says to Gabriela, oh, I’m going to go on this, too. I need to go to a wedding in a couple of weeks and I need to lose a few pounds.

GG I was like, really? I’m, like, struggling here, and you’re just telling me, you’re just prepping for a wedding? So that’s not really the goal of that medicine. 

EC: I think it highlights the tension surrounding these drugs because even though, like I said before, they’re starting to change the narrative about obesity being a biological disease, we still exist in a society where there’s still a lot of value placed on being skinny and looking skinny. And so there’s a lot of potential for these drugs to be misused. I’ve already seen headlines of people saying, oh, people are abusing this diabetes drugs for weight loss purposes. And that frustrates a lot of patients with obesity and doctors that treat obesity because they’re trying to get people to see that it’s not that people are trying to use these for cosmetic purposes. The patients that really need them are trying to use them to address their medical issues.

GG ​​I don’t like to talk about it a lot with people because there is a lot of judgment out there. I’m not taking Wegovy to get a six pack. I’m taking Wegovy because I have an implant in my chest and I’m 44, so I want to last, you know, 30 more years at the least.

DG: When we come back, Elaine talks about the concerns some are raising about these weight loss drugs, including the aggressive tactics drug companies are using to promote them. 

MIDROLL

DG: Welcome back. I’m here with Elaine Chen, a cardiovascular disease reporter at STAT, who has reported extensively on this class of new obesity treatments as part of STAT’s special series, “The Obesity Revolution.”

Elaine, one of the cool things about your reporting, is that in addition to talking with people like Gabriela about the good these drugs can do, you also explore a lot of the downsides or unintended consequences. I’d like you to walk through a few of those in this half of the conversation. One that really stuck out to me was the idea that these drugs could stop doctors from trying to understand, “the root cause of each person’s weight gain.” What does that mean?

EC: Well, there are also environmental contributors to obesity. There’s not very heavy regulation of the food industry. There’s a growing prevalence of food deserts and lack of access to physical activity. These are all big structural issues that some people are concerned society is going to overlook now that we have these drugs. And if you think about it, it’s probably much easier to just roll out these drugs than to try to fix these big structural issues.

DG: Do you have thoughts on that based on your continued reporting here? Do you think that that danger is real?

EC: I did talk to one doctor who was presenting at a big obesity conference, and his presentation was purely about how can we disseminate behavioral interventions to help people in lower income communities address obesity? And he said that after almost each presentation, there was at least one question about how do we integrate the drugs? So I think that’s an example of the medical community already latching on to these drugs very heavily and thinking that these drugs have to be a part of the solution. 

DG: And these drugs are also super expensive. Wegovy, for example, costs $1,300 a month. And many insurers are currently not covering them. And that’s leading to concerns around access and exacerbating inequity. Do you have a good sense, based on your reporting, on the value of these drugs?

EC: There’s a big issue with cost here. Because there are so many people who meet the definition of obesity in the U.S., there are so many people who are eligible for these drugs. It’s almost half of the US population. And then Wegovy is also now approved for adolescents. So it’s going to be really hard for the health system to pay for even a small percentage of the eligible population to take these drugs. And so there’s discussion about what to do here. I mean, obviously premiums will likely have to rise. 

DG: Because if millions of people take these drugs, insurance company costs will go through the roof, and they’ll pass that onto all of us in the form of higher premiums.

EC: Right, and I think insurers are having a really difficult time trying to figure out how to cover these drugs. And I mean, just based on what I’ve heard, they’re placing a lot of barriers, like a lot of insurers are requiring prior authorizations or requiring potentially some people lose a certain amount of weight in a certain time period to maintain coverage of the drugs. 

DG: Yeah and on the public insurer side, only 15 state Medicaid programs cover these drugs for low-income and disabled people, and the public insurer for older Americans, Medicare, does not cover them at all, right?

EC: Yeah, they’re currently prohibited from covering weight loss drugs. But there’s a bill that’s trying to change that, and it actually has bipartisan support. And I think with the arrival of these new weight loss drugs, that’s giving even more momentum to this bill.

DG: Right. And as we know, as Medicare goes, so go the private insurers typically.

EC: Mmhm.

DG: So Medicare coverage is one big question facing lawmakers. What other issues, Elaine, are lawmakers grappling with or should be grappling with?

EC: I think down the line, there’s also going to be issues of addressing the potential inequities here. If we do see widening health disparities within the realm of obesity, what are lawmakers going to do about that? 

DG: And that’s important because there are higher obesity rates among Black, Hispanic and Native Americans than white Americans, but those populations often have less access to treatment.

EC: Right. And then again, going back to what are lawmakers going to do about the structural factors that contribute to obesity? Because are obesity rates just going to continue to rise and more and more people will use these drugs and we’re going to have to continue paying for these drugs? I mean, that’s just the longer term concern that’s probably on the horizon.

DG: You talked about the role that the pharmaceutical companies are playing. And this is obviously a huge moneymaker. So it’s no surprise that drugmakers are super excited and really trying to push this and push this narrative that obesity is a medical condition that needs a medical intervention like a prescription drug.

EC: Yeah, so companies like Novo Nordisk are doing stuff like disease awareness campaigns. Novo has enlisted Queen Latifah in a big campaign that’s also on social media to change the way that we talk about obesity. 

Queen Latifah: Living without obesity isn’t about a lack of willpower. It’s not a character flaw. It’s bigger than that. Obesity is a health condition.

EC: Novo Nordisk is also funding the development of medical school curricula about obesity. 

Training Module: Let’s start off by defining obesity and the classifications of obesity.

EC: Novo Nordisk has put up slides online and also doctors who have helped review the curricula have recorded themselves giving lectures of the slides so medical schools can easily access these materials.

Training Module: Obesity is clearly a disease. It’s a progressive chronic disease of energy homeostasis resulting in excess adiposity or body fatness which then leads to negative or impaired health outcomes. 

EC: Some people say that’s a good thing, that someone is filling in the gap there, since there’s very little obesity education in medical schools. But some others are pretty concerned that that’s pushing the envelope too far, that pharma companies who have a vested interest shouldn’t be getting anywhere near medical students.

DG: Elaine, if you were going to sum up the messaging that drugmakers like Novo Nordisk are trying to convey in just one sentence, what’s the message?

EC: Obesity is a chronic biological disease, and we have medications to treat that.

DG: And if they do successfully drive home that message, what is the problem with that?

EC: The idea that obesity is a disease could be a really harmful message, these people say, if you’re really shoving it in people’s faces. You’re telling people that there’s something wrong with you, you need to fix it. You have a disease. I mean, being told that constantly could be really harmful psychologically for especially younger people.

DG: If I was going to push you to be reductive, when you distill 5,000 words down to the essence of how to really think about the pros and cons of this class of drugs, how do you think about them?

EC: I think I ultimately see them as a huge medical breakthrough. I mean, they really are having a positive impact on a lot of patients’ lives. And I think really it’s just about keeping tabs on how pharmaceutical companies are handling these drugs, you know, how they’re being used in society and the unintended consequences. But I think in general most people in the medical community do see them as a huge medical breakthrough.

DG: Elaine, thanks so much for taking the time to talk to us on Tradeoffs. I really appreciate it.

EC: Thank you so much for having me on.

DG: You can find a link to all of STAT’s Obesity Revolution series featuring reporting from Elaine and others on our website: tradeoffs.org.

I’m Dan Gorenstein, this is Tradeoffs.