Obesity was formally recognized as a disease just a decade ago, in 2013. The medical designation was intended to distinguish excess weight as a complex, chronic illness, not a failing of personal willpower — though there was, and remains, some controversy around the term, with Latin roots meaning “to eat oneself fat.”

The misconception that obesity is caused mostly by a lack of exercise — or that people with obesity pay no attention to their diet — is still deeply entrenched. Contrary to popular belief, obesity and related diseases like diabetes and hypertension are complex and cannot always be cured by simply moving more. The environment we live in, the chemicals we’re exposed to, the stress we’re under, and our unique brain circuitry all play roles.

Dr. Beverly Tchang, an endocrinologist at Weill Cornell Medicine, has spent the past seven years working to help her patients — and the society they interact with — view it as a medical condition like any other, requiring treatment, attention, and empathy.pathy.

Until recently, the main problem was that there had never been an effective nonsurgical way for patients with obesity to lose weight and keep it off, especially a lot of weight. Doctors may recommend a diet or exercise plan for a patient who has high cholesterol, high blood pressure, or high blood sugar, but research shows it’s nearly impossible for someone to maintain a calorie deficit if their brain and body are against it. The patient inevitably ends up in a cycle of “yo-yo dieting” that doesn’t do their metabolism any favors.

For a time, a medication approved by the Food and Drug Administration called Belviq seemed helpful, but it was pulled from the market in 2020 after it was linked to an increased cancer risk. Phentermine, once used in a widely prescribed appetite-control drug cocktail called fen-phen, is now doled out sparingly because it was linked in 2011 to a higher risk of heart disease and damage to the heart valves.

But in 2023, Tchang’s work, and the entire world of obesity medicine, is completely transformed.

The moment everything changed
As is often the case in the slow moving world of medicine, the seeds of this transformation were planted several years earlier, in 2017, when the Danish drug manufacturer Novo Nordisk released Ozempic.

Ozempic is a once-a-week injection to treat type 2 diabetes. Its active ingredient, semaglutide, mimics GLP-1, a hormone that the gut produces naturally to help balance blood sugar. Whether produced by the body or by a shot like Ozempic, GLP-1 can help quiet the voice in your brain telling you to have just one more potato chip, another helping of dessert, or an extra treat between meals when your body doesn’t need the fuel. It slows down digestion too, meaning people who take the drug stay both physically and mentally fuller for longer.

It worked brilliantly for diabetes control. But as Novo’s researchers studied semaglutide, exploring higher and higher doses, they encountered a truly groundbreaking result: significant, lasting weight loss on a level that was once possible only with major surgery.

Ozempic was hardly the first medication of its class — GLP-1 agonists have been around since 2005. But this wasn’t like liraglutide (sold as Saxenda), which needed to be injected daily, or dulaglutide (sold as Trulicity),which was good for managing blood sugar but didn’t affect weight all that much. In Ozempic clinical trials, patients on semaglutide were losing previously unimaginable amounts of body weight — 10% in a matter of weeks or months.

The results supported the widely held theory among obesity specialists that “food noise,” the persistent urge to keep eating to the point of weight gain, might be a matter of mismatched signals between the brain and body, rather than a question of willpower.

Ozempic’s FDA approval in December2017 sent a ripple of excitement through the US medical community. It was approved only to treat diabetes, but doctors have discretion to prescribe drugs for unapproved, “off-label” uses if they see fit. Comforted by more than a decade of safety research showing GLP-1 agonists to be low-risk medications, doctors started telling their patients with obesity about this once-a-week shot that melted pounds off. Patients who were previously reluctant to take mediocre, daily weight-loss medications were intrigued by these more powerful, elegant weekly drugs.

For doctors like Tchang, it made their jobs both easier and harder.

The rise and rise of weight-loss drugs hit a crescendo in 2023
Doctors were liberally prescribing Ozempic off-label for weight control for years, and seeing great results. It was an open secret among MDs. In the summer of 2021, the FDA approved Wegovy, another Novo Nordisk drug. It is essentially the same substance as Ozempic but contains a higher dose of semaglutide. This new formulation was specifically approved for weight management.

That’s when these drugs started flooding into society. Prescriptions ticked up, and word spread far beyond the world of obesity medicine. By 2022, patients were starting to ask for Ozempic and Wegovy by name, citing TikTok videos describing “magical injections” that celebrities were thought to be taking to lose weight. The internet speculated (without evidence) that these shots were behind Kim Kardashian’s dramatic and rapid weight loss.

At the same time, the rest of the pharma world was racing to catch up with Novo, whose success has single-handedly transformed the Danish economy. Eli Lilly produced Mounjaro, containing tirzepatide, which mimics GLP-1 and GIP, another appetite-regulating hormone, for a potentially greater effect. Mounjaro was FDA-approved as a diabetes drug in 2022. Like Novo Nordisk before it, Eli Lilly also started working on a weight-loss-specific, high-dose version of Mounjaro: Zepbound, which raced through the FDA approval process last month. Lilly is now working on a third drug, jokingly referred to as “the King Kong of weight-loss drugs” because it contains retatrutide, which targets three hunger hormones.

As shortages hit, clinics started making their own copycat “compounded” medications. The FDA allows this when there is a shortage, but there is little oversight and not much transparency about what these knock-off versions of the drug contain.

Uniquely, this all coincided with the COVID-19 pandemic, which forced the US into a new, uncharted world of telehealth. That made all drugs much easier to access than usual. “All of a sudden you have the outcropping of virtual care, and you have some people who want to make a business out of it and don’t have that sort of evidence-based management style,” Dr. W. Scott Butsch, director of obesity medicine at the Cleveland Clinic, told Business Insider.

Suddenly, you didn’t need to ask your doctor to prescribe that weight-loss shot you’d heard about on TikTok; you could just go to one of those websites promoted on Instagram, fill out a cursory “exam” via Zoom, or even a Google form, and put in your credit card information. Within a few days, you would receive your medication.

This unofficial system perpetuated the weight-loss drug trend through the shortages of 2023, allowing people to use weight-loss drugs even if they couldn’t find or afford brand-name versions.

“I walk around telling people, ‘pinch me,'” Dr. Nadia Ahmad, the medical director of obesity-medicine development at Lilly, told Business Insider at the American Diabetes Association conference in June. “It’s a historic, monumental time. There’s so much hope for patients. There’s so much hope for people who’ve been struggling with this chronic disease.”

Talking to people who are taking GLP-1s, the hope and excitement are palpable. It is also tinged with some uncomfortable feelings and unanswered questions.

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