Thanks to viral social media posts and constant press coverage, Ozempic and Wegovy have become almost household names, and many primary care providers face questions — some based on social media misinformation — from patients eager to give these new medications a try. The following are common questions I’m asked, and suggested context to frame a response.

• “Can you write me a prescription for Wegovy?”

Patients should understand that it’s not just a matter of writing a prescription. Obesity is a complex, chronic disease, and many interrelated factors, including genetics, environment, sleep patterns, stress, medications, hormonal imbalances, and other health conditions, need to be considered to determine the best treatment. Wegovy isn’t suitable for everyone who has obesity; there may be other, more appropriate medications. It’s also important to provide education and ongoing support for sustainable dietary, physical activity, and behavior changes. Lifestyle interventions are rarely sufficient on their own, but they’re always essential components of any effective weight management plan. A successful weight loss strategy needs to address all these factors comprehensively and in a personalized way as part of a long-term care plan. There’s no quick fix for obesity.

• “I don’t want to resort to medication. It feels like cheating. Why won’t diet and exercise work for me?”

Most people with obesity cannot lose significant weight and keep it off long-term with lifestyle changes alone. This is because weight loss triggers the body’s physiological “anti-starvation” mechanisms, leading to increased hunger and cravings and a lower metabolic rate. With obesity, the area around the hypothalamus (the energy regulatory center in the brain) becomes inflamed, interfering with feedback signals from the gut and fat cells. Anti-obesity medications address these underlying dysregulated hormonal and metabolic pathways. Semaglutide, for example, mimics the GLP-1 hormone, which helps people feel full sooner after eating and slows the passage of food through the gastrointestinal tract. It targets areas of the brain that control appetite and influence eating decisions. Other anti-obesity medications work differently, but they all help the body overcome its anti-starvation responses to enable weight loss and weight maintenance.

• “Are the horror stories about Ozempic’s side effects — abdominal pain, constipation, diarrhea, and vomiting — typical? I don’t want to feel miserable.”

These are known adverse events associated with semaglutide, and it’s to be expected that as more and more people take these medications, we hear more about the side effects, including the rare ones. Symptoms may be worse when the medication is not used appropriately — if the dose is too high or it’s escalated too quickly, if the medication is prescribed without adequate screening (for example, to identify people who have risk factors for these symptoms), or if patients aren’t given the necessary education and support (dietary and behavioral modifications can minimize symptoms). When best practices are followed, patients generally tolerate semaglutide well.

There’s a risk-benefit calculation when prescribing any medication, of course, but for people with a high BMI, who face elevated risk of many serious weight-related conditions, the benefits may outweigh the risks.

• “What about aesthetic changes? I’ve heard about ‘Ozempic face.’ Will my skin get saggy?”

Loose skin is common with major weight loss, regardless of how it’s achieved, especially if the weight is lost rapidly. But this aftereffect is highly variable, with age, diet, and genetics among the factors that play a role. Some people lose 100 pounds and have no loose skin, and others develop a significant amount of loose skin after losing much less weight.

It’s important to note that weight reduction involves the loss of muscle as well as fat, so I always recommend and regularly encourage  patients to incorporate strength training into their weight management program in order to maintain as much lean body mass as possible.

• “How long will I need to take Wegovy?”

Patients should expect to take the medication for the foreseeable future. Obesity is a chronic disease., We don’t counsel patients with other chronic illnesses about weaning medications once their condition is controlled. When a person with diabetes stops taking an antidiabetic medication, we expect blood sugar to increase. And when someone with high blood pressure stops taking an antihypertensive medication, we expect blood pressure to rise. Obesity is the same. The FDA has approved these medications for long-term use for this reason. Weight gain isn’t just possible after stopping an anti-obesity medication discontinuation, it’s expected.

• “Why doesn’t my insurance cover Wegovy?”

For years, weight loss was considered strictly “cosmetic,” and obesity was attributed to individuals’ poor lifestyle choices. Today, most industry players — including insurers — recognize that obesity is a complex, chronic disease. But the new anti-obesity medications are extremely costly, especially considering the huge number of potential users (more than 42% of U.S. adults have obesity).

Access needs to improve, and it needs to improve dramatically, but simply handing out GLP-1 prescriptions left and right isn’t the answer either.

A comprehensive approach to weight management can improve health outcomes for more than 200 other conditions that obesity causes or worsens, from high blood pressure and type 2 diabetes to sleep apnea and certain types of cancer. It makes more sense — in terms of both patient health and economics — to treat the underlying obesity directly rather than waiting for these preventable obesity-related diseases to develop.

Now that we have a critical mass of patients taking these new, highly effective medications, we will have more comprehensive data demonstrating the mortality benefits of anti-obesity medications. For example, results from Novo Nordisk’s landmark SELECT trial, a five-year cardiovascular outcomes trial of Wegovy compared to placebo in individuals with overweight or obesity, recently found that semaglutide reduced the risk of major adverse cardiovascular events (heart attack, stroke, and cardiovascular deaths) by 20 percent. With this evidence from the SELECT trial, improved insurance coverage should be next.

• “If my insurance doesn’t cover semaglutide, are there alternatives?”

Semaglutide is an important part of our anti-obesity armamentarium, but we don’t automatically prescribe it to everyone who qualifies. Other options include Contrave, Saxenda, and Qsymia, for example. Any anti-obesity medication needs to be selected in the context of a comprehensive individualized evaluation and prescribed as part of a personalized treatment plan. Depending on a patient’s specific situation and risk factors, I prescribe many medications that are considerably less expensive than semaglutide, and individuals on these medications are still able to lose a significant amount of weight. Everyone’s situation is different, and individuals respond to different medications in different ways. Obesity is not a simple disease, and there’s no one medication that’s right for everyone.

• “What about supplements like berberine? Some people are calling it ‘nature’s Ozempic.’ Is it worth trying?”

I caution my patients about dietary supplements for weight management because we don’t have high-quality evidence demonstrating efficacy. Worse, the lack of regulatory oversight in the supplement market makes it challenging to know exactly what’s contained in any given product. The actual amount of berberine could be different from what’s claimed, and other undisclosed ingredients could be included as well. For example, some dietary supplements have been shown to contain amphetamines or anti-obesity medications that have been withdrawn from the market.

• “What about compounded semaglutide? Is it safe?”

When patients present to me on compounded semaglutide, I recommend that they stop. As with dietary supplements, these drugs are not regulated. We have no idea what the products contain, what the actual dose of the active ingredient is, or whether the product has contaminants. The FDA has issued a warning about compounded semaglutide.

• “I’m having surgery next month. Is it true that I need to suspend my Wegovy?”

Because GLP-1 receptor agonists are associated with increased risk of nausea, vomiting, and delayed gastric emptying, the American Society of Anesthesiologists recently issued guidance suggesting that individuals who take these medications daily should stop the medication the day of the surgery, or, if they take them weekly, hold the dose the week before surgery. People who are taking these medications for diabetes in addition to weight management may need to consult with their endocrinologist to identify an alternative diabetes medication to bridge the gap.

Wegovy and the other anti-obesity medications in the pipeline that are even more promising are and will be extremely important agents in our armamentarium, but successful weight management requires more than just one medication in isolation. Media coverage of these new medications sometimes creates the impression that obesity is a simple disease that can be treated with a one-size-fits-all, short-term approach. In reality, however, obesity is, a complex, multifactorial, relapsing chronic disease, and treating it requires a comprehensive evaluation and a customized treatment plan with education and long-term support.

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The discovery that Ozempic (semaglutide) supports weight loss is not new, but the unexpected spotlight on weight loss as a side effect of a diabetes medication serves as a good reminder to healthcare providers (or a wake-up call, for some) that all medications’ potential effects on weight should be taken into account, because the opposite result — drug-induced weight gain — is more common than most practitioners realize.

A typical case

A 33-year-old woman, Jill, recently presented to my obesity medicine practice because she had suddenly started to gain weight — 32 pounds over the previous six months. Through my evaluation, I learned that she had received two Depo-Provera injections during that time. She had previously used oral contraceptive pills, but she often forgot to take her pills and wanted a lower-maintenance form of birth control. Although progestin injections work well for many women, weight gain is a known and fairly common side effect, and the timing of Jill’s weight gain suggested a causal link. As part of her weight-management plan, we discussed birth control alternatives, and she ultimately chose to switch to a nonhormonal IUD.

The OB-GYN who prescribed her Depo-Provera had not mentioned the possibility of weight gain. While it’s understandable that many practitioners don’t want to create unnecessary worry about a side effect that might never materialize, it can be extremely difficult to lose weight once it has been gained, particularly for those who already have overweight or obesity. Since many patients who don’t track their weight can gain significant amounts without realizing it, simply advising patients to monitor their weight and notify their provider if they notice an increase can prevent tremendous frustration.

Jill was on only one weight-gain-promoting medication, but I often identify two, three, or even four such culprits when taking a new patient’s history. In addition to injectable or implantable birth control, some of the most common weight-gain-promoting drugs include diabetes medications, blood pressure medications, and antidepressants. In many cases the effect is modest, but with long-term medication use for chronic conditions, even a small effect can lead to a significant increase in weight over time.

Prevention starts with awareness

What can healthcare practitioners do to help their patients avoid drug-induced weight gain? Essentially, four things:

1. Be aware. First, practitioners need to recognize how common the problem is and educate themselves about the weight profiles of various classes of drugs and different agents within classes. (The Endocrine Society’s practice guidelines for the pharmacological management of obesity include information on drugs that cause weight gain and recommended alternatives; see the original article in the Journal of Clinical Endocrinology and Metabolism, or a summary listing in Table 2 of our more recent best practices article.) As with most contributors to the multifactorial disease of obesity, the interactions are complex, and a medication’s impact on weight may vary based on a variety of physiological, genetic, and lifestyle factors. But despite some unpredictability, many medications do have a well-documented track record of promoting weight gain, and providers should be alert to this potential side effect.
2. Choose alternatives when possible. When prescribing any medication, providers should consider the drug’s weight profile in assessing the benefits and risks, and seek to avoid weight-promoting drugs when possible. Weight-neutral or weight-loss-promoting medications are available for many common conditions that are frequently associated with obesity, including type 2 diabetes, hypertension, and depression. These alternatives should be prioritized when appropriate as first- and second-line treatments — especially for patients with overweight, obesity, or metabolic risk factors. For example, for patients with type 2 diabetes, weight-loss-promoting medications such as metformin and glucagon-like peptide-1 (GLP-1) receptor agonists (semaglutide and liraglutide, for instance), or weight-neutral options such as DPP-4 inhibitors, are preferred over insulin and insulin secretagogues that promote weight gain. For patients with hypertension, weight-neutral angiotensin-converting enzyme inhibitors or angiotensin receptor blockers should be chosen over weight-gain-promoting alpha- or beta-adrenergic blockers if possible. Many antidepressants present a risk of weight gain, for example, but only one, bupropion, has been consistently shown to promote weight loss, though it’s not appropriate for all patients. When recommending changes to existing prescriptions, providers should either consult with the original prescribing physician or ensure that the patient does so. The topic of drug-induced weight gain needs to be discussed extremely carefully with patients, though, or they may feel alarmed and stop taking their medications before a plan for replacement is in place.
3. Use the minimum dose. Drugs in the same class often aren’t interchangeable, and if no appropriate alternative to a weight-gain-promoting medication is available, providers should aim to prescribe the lowest effective dose for the shortest possible duration needed to manage the patient’s symptoms. Too often, patients are started on a medication, and then the dose and duration of the drug regimen are never reevaluated.
4. Counteract the effects with anti-obesity medication. When weight-gain-promoting medications must be used, practitioners should consider adding an anti-obesity medication, in conjunction with appropriate lifestyle modifications, to counteract weight-promoting effects in their patients with obesity. Providers who don’t feel comfortable prescribing these medications can refer their patients to an obesity medicine specialist.

The challenge of reversing weight gain

Optimizing medication choices may seem like low-hanging fruit in the effort to help patients manage their weight, and in a certain sense it is: prescribing weight-loss-promoting instead of weight-gain-promoting drugs can be a relatively simple way to prevent unwanted weight gain. This is an important strategy because reversing drug-induced weight gain is not always simple.

Jill was disappointed to find out that weight gained due to medication is sometimes no easier to lose than weight gained due to any of the other myriad contributing factors. Although switching birth control stopped the increase, she didn’t immediately lose the pounds she had gained. This is such a crucial point: many patients aren’t alarmed when realize they’re gaining weight on a medication because they assume the weight will come off easily when the medication is discontinued — however, this is often not the case. Jill and I developed a comprehensive, personalized weight-management plan that is beginning to show results, but it will be a long-term effort.

There’s no silver bullet in the fight against excess weight; obesity is a chronic disease that requires lifelong management. While weight-loss-promoting medications are a valuable addition to our armamentarium, they are not a quick fix, and pharmacotherapy needs to be part of a multidisciplinary approach that also includes diet, physical activity, and behavioral modifications. So it won’t be a surprise if most of the people who recently flocked to Ozempic without proper medical supervision regain the weight as soon as they stop taking the medication.

The ratchet nature of weight gain (easy come, decidedly not easy go) makes it even more critical that healthcare providers be aware of the potential weight-related side effects of medications and adjust their prescription choices accordingly. Obesity has many complex and interrelated causes, and the more of these underlying factors we can eliminate — like weight gain secondary to medications — the more successful we will be in helping our patients move toward a healthier weight.

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