How Weight-Loss Drugs Are Rewriting the Playbook for Treating Obesity

Liz McCabe wasn’t a typical candidate for Wegovy, one of the popular new weight-loss drugs.

She is healthy and active. Her body-mass index this past spring barely put her in the category of obesity, a qualification for the medication.

It was her history of “yo-yo” dieting that made the difference. The 45-year-old vice president at a healthcare company had tried for eight years to lose weight since giving birth to her son. She always regained pounds after she lost them.

McCabe turned to the Transition Medical Weight Loss clinic in Salem, N.H. Joseph Zucchi, a clinical supervisor and physician assistant, suggested that she try Wegovy, as part of a program including nutrition and fitness guidance.

The new drugs have transformed scientific understanding of obesity and the marketplace for weight loss. Soaring demand and the drugs’ powerful effects have pushed doctors and researchers to a new frontier in medical science: a Wild West of online prescribers, erratic supplies and limited insurance coverage of the expensive medications.

Patients such as McCabe are helping them figure out in real time who most needs the drugs and how best to use them. “There is some level of feeling it out and doing things absent the experience,” Zucchi said.

Medical organizations including the Obesity Society are writing new standards for treatment and addressing dilemmas. Should the drugs be prescribed to patients who haven’t tried losing weight before or who don’t have health problems? How much weight should you lose? What is the best way to maintain a lower weight?

About half of the U.S. adult population technically qualifies for Wegovy, according to criteria in the drug’s label. That includes people with a body-mass index of 30 or more, or 27 and a health problem related to weight such as diabetes or high blood pressure. A BMI of 25 is the benchmark for normal weight.

“If you have a BMI of 32 but no major health consequences, do you need a drug that gives you an average of 15% to 20% weight loss?” asked Dr. Jamy Ard, the Obesity Society’s president-elect and an obesity researcher at the Wake Forest University School of Medicine.

Weight and BMI—the yardstick currently used to determine obesity—aren’t the only barometers of good health. Researchers want to find others, such as improvements in fitness or markers of inflammation. They want to examine how to shed pounds without losing too much muscle, how to maintain weight loss and how diet affects weight loss and health for someone taking the drugs.

Sarah Abdelaziz has lost more than 70 pounds since starting on Wegovy more than a year ago. She had regained weight after bariatric surgery and trying another drug. She doesn’t know what her goal weight is and is relying on her doctor to guide her.

“This is really uncharted territory for me,” said Abdelaziz, 44. “I’ve never been to this weight before.”

She is doing strength training and eating more protein to rebuild the muscle mass that she lost along with body fat. The primary care and obesity medicine practice she visits, knownwell in Needham, Mass., tracks patients’ body composition to help them achieve the right balance of muscle and fat.

“We want to be leaner, not lighter,” said Dr. Angela Fitch, Abdelaziz’s doctor and knownwell’s chief medical officer.

More research is needed on how best to maintain weight loss, said Fitch, who is president of the Obesity Medicine Association, one of the groups developing new standards of care. The work is urgent; even more powerful drugs are on the way.

“We’re going to have different treatments five years from now,” Fitch said.

The American Medical Association recommended in June that doctors consider body fat, genetics and other factors in addition to BMI to diagnose obesity. BMI doesn’t account for differences in body shape and composition across racial, ethnic and age groups or sexes, the AMA said. It said BMI shouldn’t be used as the sole criterion to deny insurance reimbursement.

A commission of experts convened by the journal The Lancet Diabetes & Endocrinology and King’s Health Partners in London plans early next year to publish a definition of “clinical obesity” that will refer to patients with excess body fat that is causing health problems. They want to distinguish that group from people with excess body fat who are relatively healthy.

“When we define obesity the way we do today, all these people are under the same umbrella,” said the commission’s chair, Dr. Francesco Rubino, chair of metabolic and bariatric surgery at King’s College London.

About half the patients at Transition Medical Weight Loss are on weight-loss medications as part of a program that includes nutrition and fitness, weekly body-composition analysis and psychological counseling. Some have lost more than half their body weight on the drugs, Zucchi said.

McCabe’s history of “weight cycling” suggested that she needed help making permanent changes, Zucchi said. The drugs reduce appetite and quiet the “food noise” that can derail weight loss.

She has lost about 35 pounds. She aims to lose another 10 to 15 pounds and eventually stop taking the medication.

“I feel I adopted those changes to my eating habits and could go off it without regaining the weight,” she said.


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