Rethinking Weight Loss in the Age of GLP-1 Medications

GLP-1 medications like Ozempic continue to dominate the zeitgeist. As I scroll, I see headlines about a new Wegovy pill, followed by red carpet images of dramatically slimmer celebrities. These medications are no longer just a medical breakthrough, but a cultural phenomenon. They have reshaped the weight-loss industry, but questions remain. How do we prevent misuse? What does their long-term impact look like? I recently attended the World Obesity Day Conference in London and had the opportunity to speak with one of the leading experts in the field, Dr. Scott Butsch. Here’s a portion of our conversation.

You’ve been working in obesity care for over 20 years. How have you seen things change over the last few years with this explosion of GLP-1s?

What we see is that there are simply more effective therapies available today. When I started in 2005, we didn’t have a lot of armamentarium (tools or methods available to doctors). There were very few effective options. There wasn’t a standard of care. In the last five years, new, innovative therapies have emerged, and with that effectiveness comes more awareness, which leads to more excitement.

I have often encountered patients with obesity who begin taking GLP-1 medications and lose weight but don’t change their diet and continue eating unhealthy foods. Should patients on these medications be required to see a dietitian?

Dietitians used to focus primarily on calorie deficit, but obesity is a physiological, pathological disease. We have to understand all the things that happen when we lose weight. We used to think about medications as appetite suppressants. Let’s suppress appetite in individuals with obesity, who are often stigmatized and struggling with control over what they eat, and give them an appetite suppressant. That’s how stimulants came into use. The focus was on eliminating hunger, rather than treating the disease of obesity.

Now we understand obesity as a much more complex system, so integrating a dietitian is essential. But what is that dietitian going to do? Are they focusing on weight loss, or on nutrition? We now have surgical and medical therapies that produce a greater magnitude of weight loss. Where the dietitian’s role can evolve is in focusing on health and nutrition, rather than weight loss alone, which has historically been difficult to achieve through nutrition therapies alone.

These medications change the reward pathways of our brains. People report less interest in addictive behaviors such as alcohol. Others report a loss of joy. Is this a similar pathway?

It’s a difficult question because it’s not that simple. I talked about food noise 15 years ago. In speaking with patients, you begin to understand how this might relate to the hedonistic part of the brain. We see changes even with dietary shifts. People think differently and may prefer different foods. These medications can influence that hedonistic pathway.

Mood changes are another facet. There are many psychological factors at play. People with obesity face stigma, and as they lose weight, their self-perception and how they are perceived by others can shift. Anhedonia, or loss of the ability to feel pleasure, can be part of that process. It’s more complex than simply calling it a side effect of the medication. It also reflects social, internal, and psychological pressures. At the same time, when appetite is strongly affected, there can be a temporary sense of disinterest.

Some of the anhedonia you’re describing relates to how someone is losing weight and where they are in that process. As they reach a new set point, those feelings and interests tend to return. New providers don’t always understand this, and part of our role is to educate them.

Why do you think people are resistant to staying on these medications long-term?

That reflects how stigma and weight bias are embedded in our system. There is a lot of internalized weight bias among people with obesity. Another challenge is that we now have a new group of providers who may not yet be fully equipped to manage obesity. We don’t stop blood pressure medications arbitrarily once someone reaches a goal. Obesity is also a chronic condition. There can also be a lag in understanding just how effective these medications are.

How do we respond to people like Hollywood celebrities using these medications that don’t need them?

That’s difficult, because who are we to judge what someone needs? It’s easy to look at a public figure and assume they don’t need treatment, but I’ve treated people in Hollywood, politicians, and former athletes. People may not fit the image we associate with obesity and still require treatment.

What you’re really pointing to is recreational use, and that’s something we need to push back on. There is an alternative wellness industry that has rebranded itself as a medical weight-loss space. I don’t mean to disparage it entirely, but there is clearly a money-driven aspect to it.

This often stems from barriers to accessing proper medical treatment. People turn to alternative routes that are not grounded in science, yet are widely trusted. At a critical moment in obesity treatment, we risk moving away from evidence-based care. We need to be careful about who we trust.

If someone wants to lose 10 pounds, should they use this medication?

It depends on many factors. We should question whether focusing on numbers is helpful in a condition this complex. 125 lbs. may not be meaningfully different from 131 lbs., even if it feels significant. We tend to be overly focused on scale weight. A better question is: what is it about someone’s weight or health that concerns them?

We need to reframe the conversation. What is their quality of life like? How would losing that weight affect it? We also need to consider the quality of the weight being lost, as some of it may be muscle. As we age, weight distribution changes, and concerns such as abdominal fat become more prominent. There are many factors involved. Some people may benefit from medication, while others may need to focus on physical activity, nutrition, or sleep. Our role is to look at the full picture and understand what is driving their current state and how to support meaningful change.

Is obesity going to disappear in 10 or 20 years? Won’t everyone be on these medications?

No, regardless of treatment. What we are seeing globally is that more children have obesity than are malnourished. This is a global disease that has not been taken seriously enough. We are also seeing increasing severity. This is not going to disappear. Over one billion people globally are living with obesity, and it’s something we need to take seriously.