Today, Explained - Life after Ozempic
Episode Date: January 15, 2025Americans were told “diet and exercise” was the key to better health, but lifestyle changes were never that life changing. Medication is. This episode was produced by Miles Bryan, edited by Jolie ...Myers, fact-checked by Laura Bullard, engineered by Patrick Boyd and Andrea Kristinsdottir, and hosted by Noel King. Transcript at vox.com/today-explained-podcast Support Today, Explained by becoming a Vox Member today: http://www.vox.com/members Semaglutide (GLP-1) weight-loss drug Wegovy, made by pharmaceutical company Novo Nordisk -- designed to treat type 2 diabetes, but widely known for their effect on weight loss. Photo by James Manning/PA Images via Getty Images. Learn more about your ad choices. Visit podcastchoices.com/adchoices
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During the 2024 Olympics, a player on the U.S. women's rugby team, Alona Marr, got
a ton of attention for talking about her body mass index.
I do have a BMI of 30.
Well, 29.3, even more exact.
I've been considered overweight my whole life.
I remember vividly one time in high school, I did turn in a physical to the office, and
right at the bottom of the page, it said overweight.
Ms. Ma'am went on to win a bronze medal and also to illustrate the absurdity of BMI, but
doctors and insurance companies still use this number to make judgments about your health.
And then just yesterday, a global panel of experts advised that we measure obesity differently.
The relationship between diet and weight and health seems like it should be
clear and knowable by this point, but it's really not. Coming up on Today Explained,
why the gospel on weight loss is always being rewritten and how medications have added a brand
new chapter. Amazon One Medical presents Painful Thoughts. I could catch anything sitting in this doctor's waiting room.
A kid just wiped his runny nose on my jacket.
And the guy next to me, sitting in a pool of perspiration, insists on sharing my armrest.
Next time, make an appointment with an Amazon One Medical provider.
There's no waiting and no sweaty guy.
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You're listening to Today Explained. Sumita Mukhopadhyay is a writer and editor
who was very anxious when she was hired as the executive editor of Teen Vogue
back in 2018. Like everyone else, Sumita had seen The Devil Wears Prada and she knew that the fashion
industry was unforgiving. But not long after she started there, she realized that things were
changing. You know, I entered the fashion industry at a really unique moment where there was an increased interest
in plus fashion, you know? And so when I got the job at Teen Vogue, I started having all
these fashion brands reaching out to me to be like, wow, we're so excited. We're launching
a plus collection. We'd love to like talk to you about it. We'd love to send it to you.
How does it feel to be a fat fashion editor? And at the time, I had kind of newly gained the weight. And so I wasn't totally embracing it.
I wasn't, I didn't, it didn't feel empowering.
It was almost felt like something that was happening to me,
where I was like, oh wait, I'm fat.
Like, you know, where I had to kind of get over that first step
before being like, I'm fabulous.
I love being fat.
Okay.
So you're in a period where Teen Vogue has become more accepting.
It is okay to be a person in a larger body.
And in fact, there's even some sort of advocacy or activism around the fact that there is
more than one body type.
And then you get some news that, again, changes how you see and experience all of this.
What happened?
While I was at Teen Vogue and kind of as I was leaving Teen Vogue, I had had a series of stressful
family-related things happen. My father passed away of diabetes-related complications.
My mother was diagnosed with breast cancer. I had this really hectic job and I was managing all of it.
And my stress response was eating.
And it was not just eating, it was like really not taking care of myself ultimately, right?
It was taking Ubers, it was getting takeout, it was kind of not really having a lot of
time for myself.
And that did lead to some unwanted weight gain on my part and I was having some
mobility issues. I was having trouble kind of, I just thought it was because I was exhausted
because I had never had these experiences but I was having trouble getting up and down
the stairs on the subway and I would just chalk it up to like, oh, I'm just so busy,
you know, like I have to take Ubers because I'm like busy and I'm exhausted. And I was having trouble keeping up on walks and I was having trouble sleeping.
I wasn't feeling well.
And, you know, on top of that, my clothes weren't fitting.
And so I went to the doctor and, you know, this is after I had left Teen Vogue.
And like, kind of after the pandemic, I decided to start the process of figuring out if I was okay, and also what
I could do because I knew and I understood that diets don't work. I knew I could restrict
what I was eating, but eventually I'd gain the weight back and I really wanted a strategy
that would be more effective. And so I went in and got my blood work done. And you know,
pretty much every indicator was elevated. So I was had become pre diabetic, my cholesterol
was elevated. And so those scared me, right? Like I had just lost my father to exactly
the things that I'm now looking at in my blood report. And so I was like, you know, I think
it's finally time for me to really take this seriously and
figure out, you know, a strategy to move forward. And she suggested Manjaro.
It is a injectable that you take weekly. It slows your digestion, basically, is how it works.
And in doing so, it reduces the rate at which you can eat and how hungry you get. And so, you know, I decided to go on it.
What did that mean for you? Like, once you start taking it, what happens?
Do you mean emotionally or physically?
Both. Both. Entirely, I mean both. Thank you for asking.
Yeah, yeah, for sure. I mean, emotionally, it was really hard to make the decision to go on it.
I saw it as two things.
I saw it as a betrayal to the kind of body positivity and feminism
that I had ascribed to, of loving yourself at any size
and not trusting pharmaceutical interventions.
And also, there was another voice inside me that was like,
this is how bad it's gotten, girl.
Like, you couldn't control this and now you have to take a drug.
That's how not well you are.
And so a lot of self-judgment, a lot of shame came out with the decision to go on the medication.
Physically it is a bumpy road.
It was for me.
For me, I struggled with very intense nausea.
So you know, one of the ways that it works is since it slows your digestion,
if you overeat, you feel very sick.
And then a lot of digestive issues.
It is very hard to go to the bathroom when you're on it.
You have to take all kinds of laxatives.
They now have additional prescriptions they put people on that are taking it
to help support with, you know,
regular bowel movements, and so it was not the best physical experience.
And then, you know, at a certain point I got used to it,
but I think it was more that I just got used to managing the side effects.
They never really went away for me.
You have made, interestingly enough, being on Moonjaro sound absolutely horrible,
but I
appreciate you being honest about the side effects because I don't hear talk about the
side effects very often. What was the good in this? What kept you on it?
It does something, and I think it's physiological and a doctor can speak more eloquently to
this, but it does trigger something in your brain,
a hormone that suggests that you're satiated, right?
And so it started to help me feel satisfied with less.
One of my behaviors is I tend to compulsively eat
in the evening, whether it's stress or just fun or boredom
or binge watching TV,
whatever it might be, I will sit down with like an array of snacks and kind of eat mindlessly,
not always keeping track of how much I'm eating, not necessarily food that had good nutritional
value. When I was on Manjaro, I would finish dinner and I pretty much would not physically
be hungry in the evening and I just wouldn't have space to eat anything else.
And if I got the munchies,
I started to reach for healthier snacks
because I noticed that I digested them easier.
And so if I just like ate an apple or some grapes,
you know, like I ate so many freaking grapes.
Um, or you know, a handful of carrots
or whatever that might be.
And all the things we tell ourselves,
we were like, this is the healthy choice,
let's make the healthy choice.
The healthy choice all of a sudden became easier. And so that was part of why I stayed on
it, that it really gave me this release from this yearning that I always had where, and it wasn't a
challenging decision, I didn't feel a lot of strain around it. Whereas, historically, when I
would beat myself up for eating at night, I never felt like I could stop. And with the kind
of pharmaceutical intervention, I was able to stop.
Okay, so there are pros, there are cons. Here we are early in 2025. How is it going?
I guess when Manjaro hit the market, they had given a manufacturer's coupon to early
people, to
people that had first started taking the drug.
And you know, I don't read the fine print, Noel.
Like I don't know.
Like no one does, girl.
I thought that was my insurance covering it.
Like I didn't understand that like the reason it costs that much was a coupon and not my
insurance.
And so the coupon is rescinded and overnight overnight, the drug becomes six to eight hundred dollars a month.
I think it was like, I think it was eight hundred.
And they were like, we can do this other coupon that will get you to like six hundred.
Like, I'm kind of like, these aren't the exact numbers,
but all I'm saying is like, it was an insane amount of money that I was like, what?
Like, I live in New York City. You can't just take on another payment like that.
That's crazy.
Yeah, exactly.
Exactly.
I think the combination of the cost and the side effects, and I had lost a lot of weight.
Like I think I lost 50 pounds about.
And I was feeling great.
And I was like, you know, let me just try without it.
Let me phase out of it.
And so I came off the drug at the end of 2023 and, you know, I will say like maintained the
loss for quite a bit of time.
I probably gained like 10 to 15 pounds within like two or three months.
And that was definitely not a great mental experience.
Like I definitely came back to that feeling of control of like,
oh my God, I'm losing control, I'm losing control. And, you know, but I was excited
because I had made some lifestyle changes that I was maintaining and that felt like
a really positive intervention. Now, this is like the first interview I'm doing about
this in like six months. And so I will say the last six months have been really stressful for me.
I launched a book, I got married.
Nothing like, thank you.
Nothing like gaining weight for your wedding.
But I started, you know, some of the things
that I had been committing to, like cooking
and getting enough, you know, my steps every day
and all of that like fell to the wayside a little bit. And so the weight started to creep on and creep on and creep on.
And now I've probably gauged back like 60 or 70 percent of what I lost, which has been really hard.
You know, it's hard and it's also feels like it's forcing me to really face my relationship with my health and my own body and to like,
it's like I understand the options that are out there, but the options are limited.
I wouldn't even say that I would necessarily go back on it because when I think about it,
I just get sick to my stomach again. I'm just like, oh, I just don't know if I can go through
that again. But you know, it's been a roller coaster, emotional roller coaster, having the
kind of high of like, oh, like the weight came off and then to like be feel like I'm back to square one, even though I know in my mind and my heart and my spirit, I am not.
Sumita Mukhopadhyay, writer and editor. Coming up, is the age of diet and exercise over?
Amazon One Medical presents Painful Thoughts.
I could catch anything sitting in this doctor's waiting room.
Ugh, a kid just wiped his runny nose on my jacket.
And the guy next to me, sitting in a pool of perspiration,
insists on sharing my arm rest.
Next time, make an appointment with an Amazon One Medical
provider.
There's no waiting and no sweaty guy.
Amazon One Medical, health care just got less painful.
You're listening to Today Explained. I'm Dan Bessison. I'm an MD by trainee. I'm an endocrinologist. I'm here at the University of Colorado in Denver and I do clinical work taking care of patients at our County Hospital Denver Health and I
do research here at the medical school. I'm also the director of this building
called the Anschutz Health and Wellness Center.
Dan, you have 47 jobs, man.
Haha.
Alright, let's talk about the beginnings of this sort of cultural and medical interest in obesity.
When did doctors start thinking of obesity as something that needed to be fixed, something
that needed medical attention?
I think there's always been people with really high weights that doctors thought, well, that's
probably a health problem. But I don't think
it entered the general public consciousness until sort of the late 80s to the mid 90s.
The disease is obesity. But obesity is just a symptom of the real problem we as a nation face.
Frances, you've been overweight since you can remember.
Since a child, about early teens.
Americans overeat. We are obsessed with food, and it's an obsession that's killing us.
And when Greta was one year old, she weighed 100 pounds?
Almost 100.
Almost 100. That's a lot.
I think people looked around and thought, what's going on here?
There seems to be more and more people at higher weights.
And NIH had an expert panel that defined obesity using BMI.
BMI is sort of controversial, but that
was the point at which we had this accepted standard.
And shortly after that, the CDC looked at data they had
and said, what's been happening with obesity?
And I think they were sort of shocked to find
there was just a dramatic increase
in the number of people with obesity.
And so in 1999, they published these maps,
these CDC obesity maps, maybe some people have seen those.
And they really brought a lot of attention
to what really looked like an epidemic.
If you had looked at those numbers and it was HIV or cancer, people would be quite worried.
And people said, gosh, something is happening here.
We should do something about this.
And what was the something that doctors decided they should do?
Yeah, I think that the NIH panel had thought about levels of weight and that
treatment or what intervention somebody did should be based on how serious the problem was. So people
with a modest increase in their weight might change their diet and increase their physical activity.
People with a more severe weight problem might take a medication, and those at the highest weight might benefit
from surgery.
For most Americans, lifestyle is what was suggested, and I think at that point we were
still early in understanding the biologic basis of weight regulation.
And we all eat, we all move, and it seems like we choose those things.
And so the obvious first step was to say, maybe people just don't know what to eat,
and if they just thought about it some more
and ate less and moved more,
that this problem might go away.
So that was the first thought,
and the Surgeon General had a call to action.
Obesity, a major problem
that has increased dramatically since 1990.
Based on these numbers rising of obesity, saying, you know, people ought to move more and eat
a healthier diet.
When it comes to physical inactivity, obesity, diabetes, the fact of the matter is we're
moving in the wrong direction in terms of these areas.
The advice seems obvious, change what you eat and move more.
Do diet and exercise prove to work?
Yeah, I think there's a couple ways to look at that. One is, around this same time, there was a
study published, the Diabetes Prevention Program, and what they found was that a modest weight loss, a 5% weight loss, could reduce the risk of developing
type 2 diabetes by half. It was a really dramatic study. And so it was really based on that, that
people said, gosh, this is achievable and it has clear health benefits of 5% weight loss.
I'm just doing the math in my head. If you weigh 200 pounds, that's take 10 pounds off.
Yeah.
300 pounds, take 15 pounds off.
That feels like nothing.
It seems like a small change in weight,
and yet it had dramatic benefits.
I got to tell you, I mean, I see people in clinic,
and so I've spent whatever, 20 years trying
to sell the benefits of a 5% weight loss.
Most people don't buy it.
Most people want more weight loss than that.
It's not a weight loss that most people see in the mirror or that their friends are going
to notice, but it has clear health benefits and has become a benchmark of what a clinically
significant weight loss is.
A little bit of weight loss helps.
So what happened after the study was over with these folks who lost 5% of their weight
and then saw their health improve?
Did they keep the weight off?
Most lifestyle studies show that most people regain much of the weight.
It's not like everybody regains all of the weight, but much of the weight is regained.
What has happened over the last 25 years is a real explosion in our
understanding of the biology that underlies weight regulation. I think now we think of
weight much like we think about blood pressure or glucose, that there's complex biology,
that the body's got its own idea about what it wants to weigh. And what it seems like
the body wants to do, it doesn't regulate around a set point.
It regulates around a trajectory of gradual weight gain across the life.
So the biology of weight really pushes back against efforts to change our diet.
And so that's why people regain the weight is when they lose weight, the body goes, this
is not good.
And the people become more hungry, their energy expenditure goes down, and these
things tend to push the weight back up to where it was before.
Were there, you mentioned two other ways that doctors saw of treating obesity, medications
and surgeries. How common was it for a doctor to say, you sir or madam, you're going to
need medication, you're going to need surgery? I don't remember so much of that like 20 years ago.
Only maybe one or 2% of people ever had that conversation,
ever got that medication.
And there are a number of reasons for that.
One is the older medicines had some side effects.
There were some bad stories about health problems
with Fen-Fen and other medicines.
Oh, Fen-Fen.
If you took the diet drug combination known as Fen-Fen or the diet drug's pondimine or
redux, you may have heart valve problems and not know it.
Before Chicago area women are taking the makers of Fen-Fen to court, it's been one week since
the prescription diet drug was pulled off the market.
And I think too, doctors and patients, doctors especially have this idea that, well, Mrs. Jones, you ought to be able to handle this on your own.
This idea that weight is regulated, it's taken a long time to get any traction there.
Doctors would say things like, you know, if you show me you can stick to a diet, well, then I'll maybe talk to you about a medicine.
We don't do that with diabetes or high blood pressure. We're very quick to go to a medication in those conditions. So, I think there's a lot of maybe bias and stigma directed at people
living with obesity that we tend to blame them for their health problem. So, medicines that weren't
super effective and an environment that really thought that people could do this on their own.
How long have you been in this line of work, Dr. Dan?
this on their own. How long have you been in this line of work, Dr. Dan?
I'm an old person with kind of gray hair.
I prescribe fen-phen, and so I've been doing this for, gosh, whatever, almost 30 years.
You've been doing this for 30 years.
Sometime in the last 24 months, I became aware of Ozempic.
A lot of people became aware of Ozempic.
I'm just wondering what the conversation was like in the medical community among doctors
who do your type of work about the fact that there are these GLP-1 drugs that seem to work
magically, work for a lot of people, and are now widely available.
Yeah, I would use the term game changer.
There's never been anything like this.
We've done studies with older medications and you know the medications worked okay but
people weren't happy with them. These medicines just, not only the ones we have now which
are semaglutide and trisepatide, but the ones that are coming after that, that are in clinical trials.
We're in a time now that medications are likely to provide the kind of weight loss that we
used to only see with bariatric surgery.
I understand that there's more than a hundred medications in this anti-obesity medication
pipeline.
We've been doing studies with some of the next generation and they're even more effective
than the semaglutide and trisepatite are.
Oh, damn.
Yeah.
And, you know, when we have somebody go to bariatric surgery, we prepare them for that.
They see a psychologist, they see a nutritionist, they talk to other people who've had surgery
and say, how was that for you?
They think about it.
And then it's kind of a go-no-go.
You know, either you have surgery or you don't and you get what you get.
Medications are gonna give that kind of weight loss,
but we're not preparing people for that.
What does your life look like
when you're not interested in food?
I had a woman tell me,
you know, my husband took me out
to this fancy restaurant here in Denver for my birthday.
He was so excited.
I looked at the food and I thought,
gee, this is not gonna work for me.
So it makes changes in people's relationships
with other folks.
When people see someone losing weight,
they wonder, what are you doing?
Do you have cancer?
Who do you tell that you're out of medicine?
What do you tell them about why and what your goals are?
What are your goals?
How much weight do you want to lose?
And how will you know when you're done?
These are questions that we've never had to ask before.
And we don't have good data
and people are willing to pay.
So there's all these market forces with people just want a medicine, they don't want a doctor,
they don't want advice, they just want the medicine, but they don't really know what
they're getting into.
So it's a bit of a chaotic environment.
I think the key message I'd ask people to understand is this idea that weight is biologically
regulated and that it has some health problems for some people, maybe even many people.
And that ideally they find somebody that they can talk to, a doctor or a health care provider,
that they can get useful information from over time because it's a journey.
Dr. Dan Bessison, he's an endocrinologist. Miles Bryan produced today's show, Jolie Meyers edited, Laura Bullard
fact checked, and Andrea Kristen's daughter and Patrick
Boyd are our engineers. I'm Noelle King. It's Today
Explained. Amazon Pharmacy presents Painful Thoughts.
The guy in front of me in the pharmacy line is halfway through an incredibly detailed 17 minute story about his gout.
A story likely more painful than the gout itself.
Next time, save yourself the pain and let Amazon Pharmacy deliver your meds right to your door.
Amazon Pharmacy. Health care just got less painful.