Ozempic Killed Diet and Exercise
Doctors might be slow to admit it, but Ozempic and other GLP-1 drugs are making dieting and exercise obsolete.
DECEMBER 9, 2024
Robert F. Kennedy Jr. has some thoughts about Ozempic. According to the nominee to run the Department of Health and Human Services, the government should not provide the drug for millions of Americans, but instead address obesity and diabetes by handing out organic food and gym memberships. Like many of RFK’s statements, these ideas have elicited some outrage. Their basic premise, though—that Americans should control their weight by eating better and getting exercise—could not be more mainstream.
But this commonsense philosophy of losing weight, as espoused by RFK, the FDA, and really almost any doctor whom you might have asked at any time in recent memory, has lately fallen out of step with the scientific evidence.
Lifestyle interventions have been central to the nation’s decades-long attempt to curb its rates of chronic illness. Eat less, move more: This advice applies to almost everyone, but for those who have obesity or are overweight—about three-quarters of the adult population in the U.S.—dieting and exercise are understood to be among the most important methods to improve their health. Even now, when doctors have access to Ozempic and related GLP-1 medications, which deliver lasting weight loss and a host of life-extending benefits without the need for surgery, changes to behavior still take precedence. Formal treatment guidelines for obesity have affirmed RFK’s approach, more or less, and argued that “lifestyle therapy remains the cornerstone of treatment.” And according to the government, the drugs themselves are fit for use only “as an adjunct” to a reduced-calorie diet and increased physical activity.
This insistence on the status quo has begun to seem a little strange. It’s long been known that prescribing dieting and exercise simply isn’t that effective as a treatment for obesity. People may slim down enough, at least initially, to prevent or help control type 2 diabetes, said Tom Wadden, an obesity researcher at the University of Pennsylvania who has been involved in clinical trials of both lifestyle modifications and GLP-1 drugs as treatments for obesity. But he told me that amount of weight loss will not reverse sleep apnea or prevent heart attacks or strokes.
For people with severe obesity today, even the modest benefits of dieting and exercise seem moot. Over the past few years, clinical trials of Ozempic and related drugs have shown that the “cornerstone” of treatment adds almost nothing to these medicines’ effects on people’s body weight.
The mere possibility that dieting and exercise no longer matter like they used to has produced its share of awkwardness within the field. “I’m going to answer carefully,” David Saxon, an obesity specialist at the University of Colorado’s Anschutz Medical Campus, said when I brought this up with him last spring. “I don’t want you to quote me saying, ‘He doesn’t think lifestyle is important.’” For older anti-obesity drugs, he said, the evidence in favor of prescribing dieting and exercise first (and in addition) is very clear: In clinical trials, patients who received a lifestyle intervention in addition to the drugs lost twice as much weight as those who didn’t.
But the data tell a different story for the newer drugs, Saxon and other doctors told me. In most of the clinical research on GLP-1s, patients get the medicine in combination with a modest lifestyle intervention: monthly, 15-minute check-ins with a counselor, for example, and advice to cut back on calories and do a couple hours’ worth of exercise, like walking, every week. In one of the large trials of Wegovy, called STEP 1, this approach produced a weight loss among participants of about 15 percent of their body weight. Another trial of Wegovy, called STEP 3, tried something more: Participants were offered biweekly check-ins with a registered dietitian, and they spent their first two months on the drug consuming very-low-calorie meal replacements. Evidence suggests that, in the absence of Wegovy, all of this extra coaching would make a major difference to people’s health. But for people on Wegovy, the benefits were negligible: Those enrolled in the STEP 3 trial lost an average of 16 percent of their body weight, just a hair more than the people in STEP 1 lost. “That speaks to the point that maybe the intensive lifestyle program is not necessary with these new medications,” Saxon said.
He’s seen this play out within the Veterans Affairs system, where he also works. Patients on the older, less potent anti-obesity drugs were expected to participate in an ongoing lifestyle-modification program with monthly check-ins, Saxon told me. Now that he and his colleagues are prescribing GLP-1s, “we don’t really mandate that anymore,” he said, “because we see that even without it, people are maintaining their weight loss with these newer meds.” Eduardo Grunvald, the medical director of the weight-management program at UC San Diego Health, told me that he had the same impression. “The bottom line is that you don’t necessarily need intense lifestyle intervention for these drugs,” he said when we spoke in March.
Even so, obesity specialists, including Saxon, haven’t given up on dieting and exercise. But the field has begun to reevaluate the nature of such guidance. “We need to figure out what it’s going to look like,” Sue Yanovski, who co-directs the Office of Obesity Research for the National Institute of Diabetes and Digestive and Kidney Diseases, told me. Since last year, a series of reviews, editorials, and perspective papers, mostly published in obesity journals, have explored this very question. One paper, for instance, argued that instead of aiming to produce a “quantity” of weight loss, obesity specialists should now emphasize its “quality.” A co-author on that paper, the Wake Forest University obesity doctor and epidemiologist Kristina Lewis, told me that GLP-1 drugs don’t make dieting and exercise irrelevant at all; in fact, they free up patients “to focus on lifestyle intervention in a more refined way,” by clearing out cravings and tabling the need for counting calories. People on Ozempic, she said, and their doctors, too, can start to think about switching to a wholesome diet, being more active, getting more sleep. All of these interventions will be beneficial regardless of your weight.
This all sounds very reasonable, but in a broader context, it also feels like a concession. For decades now, the most ardent critics of the weight-loss industry and of its associated doctors have been saying something similar: Healthy behaviors can and should be decoupled from the single-minded goal of making people smaller. Now, ironically, the tenets of this movement, which came to be known as “Health at Every Size,” are being adapted for the treatment of obesity.
But if lifestyle interventions are meant to have the same benefits for people diagnosed with obesity as they would for anyone, how special is their role in treatment? Lewis and other doctors told me that people on Ozempic might still need some tailored dieting and exercise advice, because rapid weight loss can create specific health needs. For instance, clinical trials found that people on GLP-1 drugs were losing lots of muscle and bone as their bodies shrank in size; in fact, these and other fat-free tissues accounted for 25 to 40 percent of their total weight loss. To mitigate any added risk of weakness or fractures that might result, some experts now suggest that people on these medications should eat more protein and engage in more resistance training than they might in a traditional lifestyle intervention.
Advice on muscle-building diets and workouts could end up as part of standard care for people on Ozempic. “On a rational basis, I would say that we should be doing this,” Wadden, who was a member of the research team for the STEP 1 and STEP 3 trials, told me. Still, he acknowledged that the evidence for this approach isn’t yet complete. Wadden has been studying lifestyle interventions for people with obesity for decades. Some of that work found that adding resistance training and aerobic exercise to very strict diets did nothing to prevent the disappearance of lean body mass. The people who did these workouts were “really swimming against the current” of the effects of rapid weight loss, he told me. Other obesity researchers have contested the very idea that muscle loss is a problem to begin with. A recent paper from the Journal of the American Medical Association argues that the link between physical frailty and GLP-1 drugs is not supported by the data, and observes that if more than half the weight someone on Ozempic sheds is fat, then they’re sure to end up with a higher muscle-to-fat ratio than they had before.
Doctors still don’t fully understand why people on GLP-1s lose so much weight to begin with. Ozempic may be working, on its own, to foster different ways of eating, Wadden told me. “The drug changes your diet dramatically without a lot of conscious effort,” he said. “How does it change? We don’t know.” People on the drug may end up eating less across the board, while sticking to whatever diet they had before: One Pop-Tart for dinner, let’s say, instead of five. (In that case, meetings with a dietitian would be very helpful.) But the drugs might also work to shift people’s tastes. “So all of a sudden you like more fruits and vegetables,” Wadden said, “and you like lean proteins.” Similar questions may apply to exercise: The mere fact of losing lots of weight could lead someone to engage in more physical activity, regardless of their access to a gym or time spent with a trainer. The studies that might sort this out haven’t yet been run.
Wadden, like many other doctors, remains convinced that dieting and exercise should continue to be the standard therapy for people who are overweight or who have moderate obesity. But for people with more weight to lose—the tens of millions of Americans whose BMIs are higher than 35, let’s say—he now believes the rules are changing. For this group, he said, “I don’t think lifestyle modification is any longer the cornerstone of obesity treatment.”
Man Was Murdered in Cold Blood and You’re Laughing?
What the death of a health-insurance C.E.O. means to America.
December 7, 2024
As you know, the C.E.O. of UnitedHealthcare, fifty-year-old Brian Thompson, was murdered on the street in midtown Manhattan, on Wednesday morning, twenty minutes before sunrise. He was in town for an investors’ convention, and had worked for UnitedHealthcare for more than two decades—a company that is part of UnitedHealth Group, a health-insurance conglomerate valued at five hundred and sixty billion dollars. UnitedHealthcare had two hundred and eighty-one billion dollars in revenue in 2023, and Thompson, who became C.E.O. in 2021, had raised annual profits from twelve billion dollars to sixteen billion dollars during his tenure. He received more than ten million dollars in compensation last year. Andrew Witty, the C.E.O. of UnitedHealth Group, remembered Thompson in a video message to employees as a “truly extraordinary person who touched the lives of countless people throughout our organization and far beyond.” Thompson lived in a suburb of Minneapolis, where UnitedHealthcare is based, and he is survived by his wife and two sons.
The particulars of this murder are strange and remarkable: it occurred in public; the suspected shooter went to Starbucks beforehand; he got away from the scene via bicycle; he has not yet been found. But the public reaction has been even wilder, even more lawless. The jokes came streaming in on every social-media platform, in the comments underneath every news article. “I’m sorry, prior authorization is required for thoughts and prayers,” someone commented on TikTok, a response that got more than fifteen thousand likes. “Does he have a history of shootings? Denied coverage,” another person wrote, under an Instagram post from CNN. On X, someone posted, with the caption “My official response to the UHC CEO’s murder,” an infographic comparing wealth distribution in late eighteenth-century France to wealth distribution in present-day America. The whiff of populist anarchy in the air is salty, unprecedented, and notably across the aisle. New York Post comment sections are full of critiques of capitalism as well as self-enriching executives and politicians (like “Biden and his crime family”). On LinkedIn, where users post with their real names and employment histories, UnitedHealth Group had to turn off comments on its post about Thompson’s death—thousands of people were liking and hearting it, with a few even giving it the “clapping” reaction. The company also turned off comments on Facebook, where, as of midday Thursday, a post about Thompson had received more than thirty-six thousand “laugh” reactions.
What on earth, some people must be asking, is happening to our country? Are we really so divided, so used to dehumanizing one another, that people are out here openly celebrating the cold-blooded murder of a hardworking family man? That people are making jokes about how the assassin could’ve won the Timothée Chalamet look-alike contest in Washington Square Park? That when a journalist at the American Prospect called an eighty-eight-year-old woman who was aggravated by her poor Medicare Advantage coverage for comment, she wisecracked that she wasn’t the killer—she can’t even ride a bike?
There had been prior threats against Thompson, his wife told NBC News, motivated, she said, by, “I don’t know, a lack of coverage? . . . I just know that he said there were some people that had been threatening him.” There had been protests at the UnitedHealthcare headquarters, in Minnesota, in April and July; during the latter, eleven people were arrested. The group responsible for the protests, People’s Action, also confronted Witty, the UnitedHealth Group C.E.O., at a Senate hearing in May. In a statement, People’s Action leaders referenced endless hours on the phone trying to get medical care covered, and denials of coverage for lifesaving medication and surgery. A recent statement from the group, in response to Thompson’s death, read, “We know there is a crisis of gun violence in America. There is also a crisis of denials of care by private health insurance corporations including UnitedHealth.” They urged political leaders to “act on both.” UnitedHealthcare has the highest claim-denial rate of any private insurance company: at thirty-two per cent, it is double the industry average. And, though the shooter’s motive remains unknown, shell casings found on the scene had the words “deny,” “delay,” and possibly “depose” written on them, echoing the title of a 2010 book by Jay M. Feinman, “Delay, Deny, Defend: Why Insurance Companies Don’t Pay Claims and What You Can Do About It,” which by Thursday had leapt up one of Amazon’s best-seller charts.
To most Americans, a company like UnitedHealth represents less the provision of medical care than an active obstacle to receiving it. UnitedHealthcare insures almost a third of the patients enrolled in Medicare Advantage, a government-funded program facilitated by private insurance companies, which receive a flat fee for each patient they cover and then produce their own profits by minimizing each patient’s care costs. Reporting in the Wall Street Journal has found that these private insurance companies, which cover more than a third of American seniors on Medicare, collect hundreds of billions of dollars from the government annually and overbill Medicare to the tune of around ten billion dollars per year; UnitedHealthcare has used litigation to fight its obligation to repay fees that were overpaid. In 2020, UnitedHealth acquired a company called NaviHealth, whose software provides algorithmic care recommendations for sick patients, and which is now used to help manage its Medicare Advantage program. A 2023 class-action lawsuit alleges that the NaviHealth algorithm has a “known error rate” of ninety per cent and cites appalling patient stories: one man in Tennessee broke his back, was hospitalized for six days, was moved to a nursing home for eleven days, and then was informed by UnitedHealth that his care would be cut off in two days. (UnitedHealth says the lawsuit is unmerited.) After a couple rounds of appeals and reversals, the man left the nursing home and died four days later. The company has denied requests to release the analyses behind NaviHealth’s conclusions to patients and doctors, stating that the information is proprietary.
At the same time that news was breaking about the NaviHealth algorithm, the company was fighting—ultimately unsuccessfully—a court decision that it had acted “arbitrarily and capriciously” in repeatedly denying coverage of long-term residential treatment to a middle-school-age girl who repeatedly attempted suicide, and has since died by suicide. Several years ago, government investigators found that UnitedHealth had used algorithms to identify mental-health-care providers who they believed were treating patients too often; these identified therapists would typically receive a call from a company “care advocate” who would question them and then cut off reimbursements. Though some states have ruled this practice illegal, it remains in play across the country. There is no single regulator for a private health-insurance company, even when it is found to be violating the law. For United’s practices to be curbed, mental-health advocates told ProPublica, every single jurisdiction in which it operates would have to successfully bring a case against it.
Thompson’s murder is one symptom of the American appetite for violence; his line of work is another. Denied health-insurance claims are not broadly understood this way, in part because people in consequential positions at health-insurance companies, and those in their social circles, are likely to have experienced denied claims mainly as a matter of extreme annoyance at worst: hours on the phone, maybe; a bunch of extra paperwork; maybe money spent that could’ve gone to next year’s vacation. For people who do not have money or social connections at hospitals or the ability to spend weeks at a time on the phone, a denied health-insurance claim can instantly bend the trajectory of a life toward bankruptcy and misery and death. Maybe everyone knows this, anyway, and structural violence—another term for it is “social injustice”—is simply, at this point, the structure of American life, and it is treated as normal, whether we attach that particular name to it or not.
The Norwegian sociologist Johan Galtung coined the term “structural violence” in 1969, in a paper that offers a taxonomy of violence—ways to distinguish between the forms that violence can take. It can be physical or psychological. It can be positive, enacted through active reward, or negative, enacted through punishment. It can hurt an object, or not; this object can be human, or not. There is either—Galtung notes that this is the most important distinction—a person who acts to commit the violence or there is not. Violence can be intended or unintended. It can be manifest, or latent. Traditionally, our society fixates on only one version of this: direct physical violence committed by a person intending harm. The pretty girl killed by a boyfriend, the C.E.O. shot on the street, the subway dancer strangled by the ex-marine. You don’t even need a human object—people are generally more troubled by the Zoomers throwing soup at paintings in a weird bid to raise attention about climate change than by the more than ten thousand farmers in India who die by suicide every year in part because of the way erratic and extreme weather renders their debts insurmountable. If one were to, hypothetically, blow up an unoccupied private jet in protest of the fact that the wealthiest one per cent of the global population accounts for more carbon emissions than the poorest sixty-six per cent, this would be seen by many people—like Thompson’s murder, and unlike the tens of thousands of human deaths per year already caused by climate change—as a sign of profoundly alarming social decay.
On this point, though, everyone’s really in agreement. It’s just a matter of where you locate the decay—in the killing, or in the response to it, or in what led us here. The only way to end up in a situation where a C.E.O. of a health-insurance company is reflexively viewed as a dictatorial purveyor of suffering is through a history of socially sanctioned death. A person who posted on Reddit’s r/nurses forum, whose profile describes her as an I.C.U. nurse, wrote, “Honestly, I’m not wishing anyone harm, but when you’ve spent so much time and made so much money by increasing the suffering of the humanity around you, it’s hard for me to summon empathy that you died. I’m sure someone somewhere is sad about this. I am following his lead of indifference.” Reading this, I thought about the statistic, from 2018, that health-care workers account for seventy-three per cent of all nonfatal workplace injuries due to violence. Nurses, residents, aides, specialists—they are asked to absorb the rage and panic induced by the American health-care system, whose private insurers generate billions of dollars in profit and pay executives eight figures not despite but because of the fact that they routinely deny care to desperate people in need.
Of course, the solution, in the end, can’t be indifference—not indifference to the death of the C.E.O., and not the celebration of it, either. But who’s going to drop their indifference first? At this point, it’s not going to be the people, who have a lifetime of evidence that health-insurance C.E.O.s do not care about their well-being. Can the C.E.O. class drop its indifference to the suffering and death of ordinary people? Is it possible to do so while achieving record quarterly profits for your stakeholders, in perpetuity?
Thompson’s death resurfaced some unsavory details about his industry. We learned, for instance, that Thompson was one of several UnitedHealth executives under investigation by the D.O.J. for accusations of insider trading. (He had sold more than fifteen million dollars’ worth of company stock in February, shortly before it became public that the Department of Justice was investigating the company for antitrust violations, which caused the stock price to drop.) A new policy from Anthem Blue Cross Blue Shield also went viral: the company had announced that, in certain states, starting in 2025, it would no longer pay for anesthesia if a surgery passed a pre-allotted time limit. The cost of the “extra” anesthesia would be passed from Anthem—whose year-over-year net income was reported, in June, to have increased by more than twenty-four per cent, to $2.3 billion—to the patient. On Thursday, the company withdrew the change in response to the public outrage, if only in Connecticut, for now. It’s hard not to be curious about what, if anything, might happen to UnitedHealthcare’s claim-denial rates. I was at a show in midtown Manhattan on Thursday night, and when the comedians onstage cracked a joke about the shooter the entire place erupted in cheers. ♦