Opinion: We’ve accepted Wegovy and Zepbound. The next phase is harder.

This time last year, people were still debating whether Novo Nordisk’s Wegovy and Eli Lilly & Co.’s Zepbound represented a weight-loss shortcut or a medical breakthrough. But with a wealth of data on the health benefits these drugs provide beyond reducing obesity – including alleviation of heart disease, diabetes, chronic kidney disease, and sleep apnea – most appear to have finally accepted their enormous potential societal value.

Now comes the hard part. These highly effective drugs – GLP-1s – are changing the way obesity is viewed and treated. The changes are coming so quickly and can benefit so many that they have created new questions and ethical dilemmas for medical professionals, including who should get it.

The theoretical market for Wegovy and Zepbound is huge: The Food and Drug Administration has approved their use for anyone with a body mass index of 30 or more — 27 or higher for individuals with a weight-related condition like high blood pressure or sleep apnea. About 57 million working-age Americans with private insurance meet these criteria, as do nearly 14 million retirement-age Americans. It is expected that once started, medications will need to be taken lifelong to maintain results.

But does everyone who fits this broad description need medication? Opinions vary among doctors. Some feel strongly that everyone deserves treatment, while others distinguish between people who are at risk for or already have weight-related health complications and those who are healthy at a BMI that makes them eligible for the drugs.

Within both camps, shortages and rising drug prices are forcing doctors to come up with ways to prioritize which patients should get them. This is a necessary response to an ongoing problem and forward-thinking, says Robert Kushner, an obesity medicine specialist at Northwestern University Feinberg School of Medicine. “Are we going to put this in the water? Are we going to cure everyone with obesity? How can we leverage this powerful tool to get it into the arms of the people who need it most?”

This field needs an evidence-supported approach to help better identify the right candidate for GLP-1. To that end, an international panel of obesity experts will issue an interim report in early 2025 setting out criteria for diagnosing “clinical” obesity, or where excess weight causes or increases the risk of other health problems. Ideally, this would help doctors more easily distinguish between “who has true obesity and who we need to treat early,” people who have gained 10 or 20 pounds and crossed the BMI threshold into obesity and still remain healthy, as He says. Kushner, who led the committee.

These definitions are sure to anger some Americans and their doctors. No one wants more surveillance when many cannot find or afford these medications. But it could also be a good step toward a more critical assessment of the relationship between weight and health – one that could make it easier and more equitable for those most in need to access medications and provide guidelines for insurance companies to make it easier to cover them.

This may help resolve tensions between doctors and insurance companies. Obesity specialists have countless infuriating stories of patients losing their GLP-1 coverage once their BMI dropped below a certain number. The reality is that without consistent treatment, the weight will return — and with it, so will their patients’ risks of diseases like diabetes and high blood pressure. A way to define obesity that focuses on disease risk may clarify the need for long-term treatment.

This could also help doctors as they try to answer another important question: When is weight loss enough?

Not so long ago, obesity doctors would spend most of their time urging their patients to keep up, since if they could stick to their lifestyle changes, the health benefits would be within reach. “I’m spending more of my time trying to convince people to stop losing weight,” Louis Aron, an obesity expert at Weill Cornell Medical College in New York, said during a keynote address at a recent obesity medicine conference.

What is worrying is that these drugs cause loss not only of fat, but also of muscle, and that they can affect nutrient intake. All of this should take into account the patient’s weight loss journey.

But doctors still lack consensus on the correct way to manage a patient’s obesity using medications. Should they aim for a specific BMI range (widely considered a problematic measure) or look at waist-to-height ratio (an assessment of body fat distribution, which is linked to heart disease risk)? Or should they target specific health markers, such as low blood sugar or cholesterol levels? How much should they take into account muscle mass and nutrient loss during treatment? Complicating all of this is the issue of the broader health benefits of GLP-1, some of which accrue regardless of the amount of weight loss.

The need to set goals is not unusual. Transformational treatments for chronic disease have a way of setting standards for what doctors consider healthy. The advent of medications to lower cholesterol, blood pressure, and treat diabetes has enabled doctors to identify watermarks for treatment. But the difference with obesity drugs is that patients tend to have strong opinions about these goals, and may not match what the data (or their doctor) says is best.

“These are small issues now, but I think they will get bigger over time. We have to pay attention,” Aaron said.

Ultimately, data will be the best guide. But until then, doctors will still be feeling their way through this new era.

Lisa Jarvis is a Bloomberg columnist covering the biotechnology, healthcare, and pharmaceutical industries. She previously served as executive editor of Chemistry and Engineering News.

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