By the ’90s, diet and exercise trends had changed. The workout video “Steel Dumplings” is all the rage, and Snackwells is taking over US supermarkets. I remember picking out those fluffy, low-fat devil’s food cookies from the plastic tray. They remind me of chocolate, but only a little.
In the late 1990s, the obesity rate was as high as 30%.
In the early 2000s, spinning classes took the country by storm as a great way to work up a sweat and burn calories efficiently. Dieters are split, with some embracing the low-carb Atkins diet and others opting for Dr. Dean Ornish’s vegetarian, low-fat diet.
Yet, somehow, all those bread basket cuts, Diet Coke drinking, and hip toning don’t add up to much. Today, obesity rates exceed 40%. More than 70 percent of Americans are at least overweight.
“Obesity, to me, is the epidemic of the 21st century,” said Andrew Greenberg, director of the Obesity Metabolism Laboratory at the Center for Human Nutrition Research in Aging at Tufts University.
But now we are at an important inflection point. Hunger-suppressing drugs including Novo Nordisk’s Wegovy and Eli Lilly’s Mounjaro are expected to help Americans lose a lot of weight.
On average, studies show that patients lose 15 to 20 percent of their body weight about a year after injecting the drug. But we don’t yet know their long-term side effects — or whether paying for them will disrupt the health care system.
So how did we get here? How can our diet be so wrong? Can indefinite capital injection reverse the situation? Or are we at risk of abandoning prevention and turning to prescription?
What we misunderstand about fat
Dr. Robert Lustig, a pediatric endocrinologist at the University of California, San Francisco, believes we’ve been giving people the wrong food advice for the past 50 years, which is why our efforts to tackle obesity have failed.
Back in 1977, the Senate made a series of recommendations on how Americans should change their eating habits, emphasizing, among other things, reducing fat intake.
“We’re told fat is the problem,” Lustig said. “It turns out that’s the worst dietary advice we’ve ever had. … People still think low fat is important, including the USDA.”
It turns out that fat can help fill you up, replace other foods (often refined carbohydrates), and—depending on the fat—can have a range of biological benefits.
Lustig, who directs the Healthy Weight Assessment Program in Adolescents and Children at UCSF, thinks the real problem is insulin.
When we eat sugar and refined carbohydrates, insulin spikes — but not fat, he says. In turn, this promotes insulin resistance and increases the risk of cardiovascular disease. And we’re eating far more carbs than we used to be. Between 1980 and 1997 alone, Americans ate more than 400 calories a day of carbohydrates, many of them from a single source: corn syrup.
Dr. Dariush Mozaffarian, a cardiologist and professor of nutrition at Tufts University’s Friedman School of Nutrition Science and Policy, agrees that emphasizing low-fat diets is a huge mistake.
“For 30 years, we’ve had the wrong dietary advice,” he said. “The food industry is still aggressively marketing low-fat foods.” He points to polls showing that many Americans — 50% in a 2018 Gallup poll — say they try to avoid fat.
Mozaffarian said that over the long term things have gotten so bad — including avoiding fat and embracing highly processed foods — that we may have “changed our physiology as a nation. We’ve changed our gut microbiome. We’ve changed epigenetics passed from mother to baby.”
Surprisingly and frighteningly, Americans don’t seem to be eating any more calories now than they were in 2000. Over the past 20 years, obesity rates have continued to rise. This leads Mozaffarian to wonder whether some fundamental — but poorly understood — changes have created a “self-sustaining, irreversible cycle.”
So will drugs like Wegovy and Mounjaro turn things around?
Every doctor I spoke to said they might work. For obese patients — especially those with problems like type 2 diabetes, sleep apnea or heart disease — these drugs appear to be very effective at reducing weight, with undeniable benefits. Both Wegovy and Mounjaro increase insulin production, building on the knowledge that Ozempic — a drug that diabetics have used for years to lower blood sugar — has been prescribed off-label for weight loss. (Wegovy is essentially a more powerful version of Ozempic.)
Greenberg thinks this is a very exciting time, largely because obesity is proving to be difficult to tackle. His own research on obesity was inspired by his mother’s death from a stroke caused by obesity-related type 2 diabetes. He says the evidence now supports what every dieter knows: Losing weight and keeping it off is very difficult.
Still, he acknowledged that there are many unknowns about these new drugs, one of which is how patients respond to them years later. Studies have shown that you have to inject the drug indefinitely to maintain your weight loss. “There are unanswered questions about long-term safety,” Greenberg said.
Another unknown is how effective these drugs are at reducing disease. Here, Lustig is particularly skeptical.
“I’m not against shots,” he said, noting that he already prescribes the drug for children with insulin resistance. But he worries that adopting newer weight-loss drugs — rather than fundamentally changing our diets — will “bypass the problem, not solve it. That’s why all of these drugs only lose 16% of our body weight and don’t heal the heart.” disease or Alzheimer’s or whatever. … You can’t get rid of a bad diet and you can’t treat a bad diet with medicine.”
Finally, there is the considerable cost issue. Wegovy is priced at about $16,000 per year, so if 100 million people (less than a third of Americans) wanted it, the cost would be $1.6 trillion (43,000 for the entire healthcare system in 2021) One hundred million U.S. dollars). “We’re going broke,” Mozaffarian said. “It’s impossible to give medicine to everyone.”
Of course, despite production shortages and huge demand, many wealthy patients still have access to them. Even though wealthier Americans tend to be thinner, that hasn’t stopped some clamoring for prescriptions.
For kids, lifestyle interventions — including the provision of healthy foods, nutritional counseling, and guidance about physical activity and getting enough sleep — have many advantages over drugs, said Dr. Lauren Fiechtner, director of the Center for Pediatric Nutrition at Massachusetts General Hospital. They can deliver long-lasting weight loss, reduce costs, and have positive spillover effects for siblings and parents. About 20 percent of children in the United States are now obese.
But we have a system for drug approval, not wraparound services. “To expand those [lifestyle interventions] To a very large level, we need insurance reimbursement,” Fiechtner told me. “It’s a real struggle. “
It doesn’t make sense. Our current solution to the epidemic of poor eating is to pay outrageous sums of money — through taxes and insurance premiums — to address one symptom of the epidemic: weight.
Of course, new drugs will play a role. But actually tackling the problem will mean investing heavily in prevention.
Sessions with dietitians and community health workers should be affordable and very accessible—especially for kids. So should fruit and vegetable prescriptions, which make produce cheap (or free) to get. It is far better to avoid obesity, heart disease and type 2 diabetes than to treat them later.
According to Fiechtner, research shows that having children spend 20-30 hours a year with their healthcare team (dietitians, community health workers, and pediatricians) can lower BMI and improve other health markers.
But Massachusetts’ Medicaid program won’t pay community health workers, she said. In rural Mississippi, where she’s on another comprehensive plan, Medicaid doesn’t reimburse dietitians or community health workers.
Why should we save a penny on prevention if it costs a fraction of what diet pills cost? What if prevention has benefits that drugs can’t touch?
For 40 years, we’ve been postponing the inevitable. It’s here now. Plowing money into lifestyle changes is our only hope – oddly enough, it’s the cheapest option.
Follow Kara Miller on Twitter @Kara Miller.
