With shots like Wegovy, Ozempic, and Mounjaro, who needs a healthy diet? – The Boston Globe

By the ’90s, diet and exercise trends had shifted. The fitness video “Buns of Steel” was all the rage, and Snackwells took the American supermarket by storm. I remember picking those squishy, low-fat devil’s food cookies out of plastic trays. They reminded me of chocolate, but only a little.

At the end of the ’90s, the obesity rate topped 30 percent.

In the early 2000s, spinning classes swept the country as a sweaty, efficient way to burn calories. And dieters splintered, some embracing the low-carb Atkins diet and others opting for the vegetarian, low-fat approach of Dr. Dean Ornish.

Somehow, though, all that bread-basket-declining, Diet-Coke-drinking, and butt-toning didn’t add up to much. Today, the obesity rate is over 40 percent. And upwards of 70 percent of Americans are at least overweight.

“To me, obesity is the pandemic of the 21st century,” says Andrew Greenberg, the director of the Obesity Metabolism Lab at the Human Nutrition Research Center on Aging at Tufts.

But now we’re at a major turning point. Hunger-suppressing medicines including Wegovy from Novo Nordisk and Mounjaro from Eli Lilly promise to help Americans shed lots of weight.

On average, studies show that patients lose 15 to 20 percent of their body weight after injecting the drugs for roughly a year. But we don’t yet know their long-term side effects — or whether paying for them will break the health care system.

So how did we get here? How did our diets go so wrong? Can indefinite injections turn things around? Or are we at risk of abandoning prevention in favor of prescriptions?

Dr. Robert Lustig, a pediatric endocrinologist at the University of California San Francisco, argues that we’ve been giving people the wrong advice about food for the last 50 years, which is why we’ve failed in our efforts to tackle obesity.

Back in 1977, the Senate offered a set of recommendations for how Americans should change their eating habits, which emphasized — among other things — reducing fat intake.

“We were told fat was the problem,” Lustig says. “That turned out to be the single worst piece of dietary advice we could ever have gotten. … People still think low-fat is important, including the USDA.”

As it turns out, fat helps fill you up, replaces other foods (often refined carbohydrates), and — depending on the fat — can have an array of biological benefits.

Lustig, who directs UCSF’s Weight Assessment for Teen and Child Health Program, argues that the real problem is insulin.

He says that insulin rises when we eat sugar and refined carbohydrates — but not fat. That, in turn, promotes insulin resistance and increases the risk of cardiovascular disease. And we eat lots more carbohydrates than we used to. Between 1980 and 1997 alone, Americans added more than 400 calories a day of carbohydrates, many of which came from a single source: corn syrup.

Dr. Dariush Mozaffarian, a cardiologist and professor of nutrition at the Friedman School of Nutrition Science and Policy at Tufts, agrees that the emphasis on eating low-fat was a huge mistake.

“We had the wrong dietary recommendation for 30 years,” he says. “The food industry is still actively marketing foods that are low-fat.” He points out that polls show that many Americans (50 percent in a 2018 Gallup poll) say they try to avoid eating fat.

Mozaffarian says that things have gone so wrong for so long — including the avoidance of fat and the embrace of highly processed foods — that we may have “changed our physiology as a nation. We’ve changed our gut microbiome. We’ve changed the epigenetics that mothers transfer to their infants.”

Amazingly, and frighteningly, Americans appear to be eating no more calories now than they did in 2000. Though, during those 20-plus years, rates of obesity have continued to rise. Which has led Mozaffarian to wonder whether some fundamental — but poorly understood — change has created a “self-sustaining, difficult-to-reverse cycle.”

So will drugs like Wegovy and Mounjaro turn things around?

Every doctor I spoke to said they could be useful. For patients who are obese — particularly those who struggle with issues like type 2 diabetes, sleep apnea, or heart disease — the drugs appear to be extremely effective at reducing weight, which has undeniable benefits. Both Wegovy and Mounjaro increase insulin production, building on the knowledge that Ozempic — a drug that diabetics have used for years to reduce blood sugar — has been prescribed off-label for weight loss. (Wegovy is essentially a stronger version of Ozempic.)

Greenberg believes this is a very exciting time, largely because obesity has proved so difficult to address. His own research on obesity was inspired by his mother’s death from a stroke, caused by obesity-associated type 2 diabetes. And he says that evidence now backs up what every dieter knows: It’s incredibly difficult to lose weight and keep it off.

Still, he acknowledges, there are lots of unknowns with these new drugs, one of which is how patients will react to them over the course of years. Research indicates that you have to inject the medications indefinitely to maintain weight loss. And Greenberg says that “there are open questions about long-term safety.”

Another unknown is how effective the drugs will be at reducing disease. And here, Lustig is particularly skeptical.

“I’m not against the shot,” he says, noting that he has prescribed drugs for kids who were insulin-resistant. But he worries that embracing a new class of weight-loss drugs — rather than fundamentally changing our diet — will be “bypassing the problems, not dealing with the problems. That’s why all of these medicines only reduce weight by 16 percent and are not going to fix heart disease or Alzheimer’s or anything else. … You can’t outrun a bad diet, and you can’t outmedicate a bad diet.”

Finally, there’s the rather enormous question of cost. Wegovy is priced at about $16,000 a year, so if 100 million people — less than a third of Americans — wanted it, the cost would be $1.6 trillion (the cost of the entire health care system was $4.3 trillion in 2021). “We’re going to go bankrupt,” says Mozaffarian. “It’s just impossible to give the drugs to everybody.”

Of course, plenty of wealthy patients have been able to access them, despite production shortages and massive demand. Though richer Americans tend to be thinner, that hasn’t stopped some from clamoring for prescriptions.

Dr. Lauren Fiechtner, the director of Center for Pediatric Nutrition at Mass General Hospital, says that, for kids, lifestyle interventions — including providing healthy foods, nutrition counseling, and guidance about physical activity and adequate sleep — have lots of advantages over drugs. They result in long-lasting weight reduction, cost less, and have positive spill-over effects on siblings and parents. And about 20 percent of kids in America are now obese.

But we have a system geared toward drug approvals, not wraparound services. “To scale those [lifestyle interventions] to really large levels, we need insurance reimbursement,” Fiechtner told me. “And that’s been a real struggle.”

Which makes no sense. Facing an epidemic of poor diets, our current solution is to pay enormous sums of money — through taxes and insurance premiums — to fix one symptom of that epidemic: weight.

Sure, the new drugs will have a role to play. But truly addressing the problem would mean investing massively in prevention.

Sessions with dieticians and community health workers should be affordable and super easy to access — especially for kids. As should prescriptions for fruits and vegetables, which make produce cheap (or free) to obtain. It’s far better to avoid obesity, heart disease, and type 2 diabetes than to treat them later on.

Research shows that having kids spend a total of 20-30 hours a year with a health care team — a dietitian, a community health worker, and a pediatrician — reduces BMI and improves other measures of health, according to Fiechtner.

But she says that Medicaid in Massachusetts won’t cover the cost of community health workers. And in rural Mississippi, where she’s involved with another wraparound program, Medicaid won’t reimburse dietitians or community health workers.

Why are we sparing a penny on prevention, if prevention costs a fraction of what weight-loss drugs cost? And if prevention has benefits that those drugs can’t touch?

For 40 years, we’ve put off the inevitable. And now it’s here. Pouring money into lifestyle changes is our only hope — and, strangely, it’s the cheapest option around.

Follow Kara Miller on Twitter @karaemiller.