The conversation around Novo Nordisk’s Wegovy and Eli Lilly’s Zepbound has shifted dramatically over the past year, Bloomberg reports.
Initially dismissed by some as mere shortcuts to weight loss, these GLP-1 drugs are now widely recognized for their broader health benefits, such as reducing risks associated with heart disease, diabetes, chronic kidney disease, and sleep apnea. However, as their societal value becomes clearer, a new set of challenges is emerging, posing ethical and logistical questions about their use and accessibility.
A major development on the horizon is the release of an interim report in early 2025 by an international committee of obesity experts. This report aims to establish criteria for diagnosing “clinical obesity,” focusing on cases where excess weight causes or elevates the risk of health complications. The goal is to differentiate between individuals facing serious health risks and those who, despite meeting the current BMI threshold for obesity, remain otherwise healthy.
This redefinition could help guide doctors and insurers in determining who should receive GLP-1 treatments.
“We need an evidence-based approach to identify those most in need of treatment,” says Robert Kushner, an obesity medicine specialist at Northwestern University.
The US Food and Drug Administration (FDA) has approved Wegovy and Zepbound for adults with a body mass index (BMI) of 30 or higher, or 27 or higher for those with weight-related conditions such as high blood pressure. This translates to a massive potential market, including nearly 57 million working-age Americans with private insurance and about 14 million retirement-age individuals.
However, medical professionals are divided on whether everyone within these criteria should be treated. Some argue for universal access, while others suggest prioritizing individuals already experiencing or at high risk for health complications.
Adding to this complexity are ongoing shortages and the high cost of the medications, forcing doctors to make difficult decisions about which patients to prioritize. Kushner asks:
“Are we going to treat everyone with obesity? How do we ensure these drugs reach those who need them most?”
Another challenge is the tension between doctors and insurers. Many patients lose coverage for GLP-1 drugs once their BMI falls below a certain level, despite the need for ongoing treatment to maintain weight loss and prevent related health risks. Addressing this issue may require redefining obesity to focus on disease risk rather than BMI alone.
The expectation that patients will need to take these drugs for life further complicates the conversation. Long-term use raises questions about affordability, access, and how to measure success in treatment.
As doctors navigate this new landscape, they face critical questions about treatment goals. Should they target a specific BMI range, focus on waist-to-height ratio, or prioritize health markers like blood sugar and cholesterol levels? How much emphasis should be placed on preserving muscle mass and ensuring adequate nutrient intake?
The broader health benefits of GLP-1 drugs, which can occur independently of weight loss, add another layer of complexity. For instance, some patients may experience improved metabolic health even if their weight loss plateaus.
Unlike other chronic conditions, obesity treatments often come with strong opinions from patients. Many have personal goals that may not align with medical guidelines, making it essential for doctors to balance data-driven recommendations with individual preferences.
