The Ozempic Era, Part III: The Deal with the Devil

Our Sickcare System May Be Luring GLP-1 Patients into a Health Trap

This is the third of our three-part series on The Ozempic Era. This series explores how the Food Industrial Complex engineered an addiction crisis, how Ozempic emerged as its apparent antidote, and why millions of desperate patients betting their health on GLP-1 drugs may be making a deal with the devil.

Read The Ozempic Era, Part 0: Preview
Read The Ozempic Era, Part I: Craveware
Read The Ozempic Era, Part II: The Miracle Drug

The Price of Hope

The true cost of anti-obesity medications extends far beyond their hefty price tag. Up to one-third of patients’ weight loss comes from lean muscle tissue rather than fat ¹, severely impairing their metabolic “furnace.” When treatment ends – whether from patient fatigue, insurance denial, or unmanageable costs – the body is thrown off balance. Patients experience a perfect storm of metabolic maladaptation:

Junk food cravings return with a vengeance,
Diminished muscle mass means a lower resting metabolic rate and reduced calorie burning potential, and
Weight rebounds as their bodies, unable to cope with the sudden excess of junk calories, store this energy as fat.

The toll is brutal: this cycle often leaves patients not only heavier than before but metabolically and psychologically damaged.

Their bodies, having lost critical muscle mass and gained proportionally more fat, are even less equipped to maintain a healthy weight.
Their confidence in medical interventions is shattered.
Their financial resources are depleted.
And perhaps most cruelly, their brief taste of freedom from food addiction makes their return to old patterns all the more painful.

Why are the alluring promises of miracle weight loss drugs failing to manifest for so many patients?

The Terms of the Deal

The Seductive Promise

For eight years, Rachel had tried everything. After her first pregnancy left her struggling with gestational diabetes and stubborn weight gain, she cycled through all the standard interventions: nutritionists, personal trainers, specialized diets. Nothing seemed to touch her body’s newfound resistance to weight loss. Three different primary care physicians dismissed her postpartum weight gain concerns with bland advice about exercise and portion control.

When her doctor finally suggested GLP-1 medication, Rachel spent two months researching before agreeing to start treatment. “There’s so much stigma around these drugs,” she shared with me. Her hesitation reflected a common tension: the desperate desire for change tempered by fear of both the medication’s physical risks and the social implications of relying on pharmaceutical drugs for weight loss.

Nevertheless, the transformation, when it came, was profound. The “food noise” that had plagued her for years – particularly during stressful business travel – simply vanished. Previously irresistible treats became unpalatable. Her longtime love of wine gave way to a complete disinterest in alcohol. The siren song of modern processed foods suddenly seemed to lose its allure.

Millions Scramble to Sign on the Dotted Line

Rachel isn’t alone. Mass media and social media alike are filled to the brim with tales of GLP-1 medications’ unprecedented results: 15-20% ²^,³ total body weight reduction, greater impulse control, and – most remarkable of all – a fundamental reset of patients’ relationship with food. Stories like Rachel’s serve as a siren call for the millions of Americans who have endured decades of failed diets and relentless weight regain. These medications promise to restore something they once thought lost: hope.

The emergence of compounded anti-obesity medications, available at a fraction of branded drugs’ costs, has further democratized access to effective weight loss treatments. Over one in eight American adults have now tried these medications ⁴, an unprecedented adoption rate that speaks to both their effectiveness and the desperation of a population where nearly 75% struggle with excess weight ⁵.

But beneath the alluring promise of rapid weight loss lies a more complicated reality. As the first wave of patients progresses through treatment, concerning patterns have emerged – patterns that suggest these miracle drugs may extract a steeper price than anyone initially realized.

Read the Fine Print

Most patients view GLP-1 medications as a silver bullet for obesity – just pull the trigger to reclaim your body. And why wouldn’t they hold this belief when they are constantly bombarded with articles ⁶, advertisements ⁷, and testimonials ⁸ touting Ozempic and similar drugs as miracle cures?

Yet the pharmaceutical industry’s position, while quietly stated, is clear: these medications are designed for chronic disease management, not short-term intervention. Just as a diabetic patient requires ongoing insulin treatment, manufacturers maintain that sustained weight management requires continuous GLP-1 treatment ⁹.

This reality conflicts sharply with both patient expectations and physician hopes. While on the medications, patients experience unprecedented control over their eating habits. This dramatic shift can create an illusion of permanent change, masking the critical need for fundamental lifestyle modifications. Many physicians, observing this positive progress, attempt to wean patients off these medications after reaching their target weights.

But very few patients are prepared for the intensive lifestyle changes needed to maintain their progress once treatment ends. Even patients who understand this need face an unfortunate reality: their treatments are often interrupted before new behaviors can take root.

The result is a system that seems almost intentionally designed for failure: patients begin treatment without understanding the fine print, receive inadequate support during their brief – and expensive – window of opportunity, and very likely face financial or other pressures that force premature discontinuation. This combination of factors transforms what could be an effective strategy for fostering long-term healthy habits into a mere temporary reprieve.

Our Sickcare System Is Failing Patients

The Primary Care Brain Drain

In my recent conversations with physicians, a recurring theme became concerningly evident: physicians are tired. Really really tired.

“Medicine is incredibly stressful – we have the highest suicide rate of any profession,” Dr. Laurie Marbas tells me. After two decades practicing medicine, she’s witnessed the steady erosion of primary care on multiple fronts. Crushing medical school debt drives new doctors toward higher-paying specialties ¹⁰, while reduced health insurance reimbursement rates and increased denials put intense financial pressure on patients and physicians alike ¹¹. Doctors often bear the brunt of patient frustrations, increasing burnout risk ¹².

Dr. Courtney Younglove, who operates two obesity medicine clinics, describes watching talented colleagues abandon private practice for corporate positions that offer escape from the crushing financial and administrative burden. “Everyone wants out,” she says. The exodus leaves fewer front-line physicians available to manage the growing wave of patients seeking weight loss treatment.

Those who remain face impossible demands:

Profit-driven corporate pressure to see more patients in less time ¹³ has transformed doctors into “cogs in the wheel,” as one physician bluntly put it to me.
The standard fifteen-minute appointment barely allows time to check vital signs ¹⁴, let alone provide the comprehensive lifestyle guidance critical for long-term success on GLP-1s.
Increasingly, health systems plug these gaps with undertrained nurse practitioners who lack the medical expertise to manage complex obesity cases ¹⁵.

The Obesity Medicine Training Vacuum

The crisis extends beyond physician availability into the foundations of medical education itself. “I was never taught how to incentivize patients and motivate behavior change. I had to learn that on my own,” Dr. Marbas explains, describing a pervasive gap in obesity medicine training. Medical schools provide virtually no instruction in the complex interplay of nutrition, metabolism, exercise science, and behavioral psychology required for successful long-term weight management ¹⁶.

This knowledge gap becomes especially dire when prescribing GLP-1 medications, where the quality of lifestyle support can mean the difference between lasting transformation and devastating relapse. Many physicians lack the expertise to help patients preserve muscle mass during rapid weight loss or navigate the psychological challenges of diet change ¹⁷^,¹⁸. Without this guidance, patients lose their brief window of opportunity for developing sustainable habits before treatment ends.

The problem is systemic: medical education remains focused on treating acute conditions while chronic diseases like obesity require an entirely different skill set ¹⁹. As one specialist observed, “We have the best acute care system in the world. If you have an acute medical condition, there’s no better country than America for treatment. We have the most cutting edge medical technology on the planet. But you can’t use an acute care model to treat chronic diseases. Our system is designed for sickcare, not healthcare.”

The Missing Support Infrastructure

Despite billions invested in healthcare technology, the basic infrastructure for successful obesity treatment remains absent: coordinated cross-disciplinary care teams, consistent behavior modification coaching, and proven protocols for managing the critical transition off medication.

The consequences of this infrastructure gap become evident in treatment outcomes. Patient after patient describes receiving their prescription with minimal guidance beyond basic dosing instructions. Critical aspects of treatment – preserving muscle mass, managing side effects, preparing for eventual discontinuation – are left largely unaddressed. The assumption seems to be that the medication alone will somehow solve decades of disordered eating patterns.

And that’s for formal, in-person doctor appointments. Many online compounding GLP-1 sellers merely ask patients to fill out a short intake form in order to receive compounded anti-obesity medications. If patients are lucky, these companies will provide education materials regarding diet change, muscle preservation, and side effects management. But for the vast majority of compounded drug consumers, they are left to fend for themselves – relegated to consultations with Dr. Google or their local weight loss Facebook group.

One may propose that recurring telehealth consultations with medical or nutrition experts are the answer. However, attempts to augment patient care with digital education tools or remote coaching have thus far borne little fruit. “Digital health tools keep getting pitched as the solution,” Dr. Younglove tells me, with an air of mild annoyance. “But they’re just adding complexity without really moving the needle.”

Some weight loss clinics augment their care with lifestyle change coaches. However, many coaches’ strategies rely on the old weight loss playbook of calorie counting and motivation, which runs counter to physicians’ efforts to reframe obesity from an issue of poor willpower to one of biology. The behavioral element of weight loss – understanding trauma, addressing emotional eating, building sustainable habits – often gets lost in the rush to show quick results.

Physicians Are Caught between a Rock and a Hard Place

Healthcare providers face a profound dilemma. They witness the medications’ transformative potential: when patients aren’t constantly battling cravings, when their minds aren’t clouded by intrusive thoughts of food, they finally have the headspace to do the hard work of changing their dietary habits.

However, the protocols physicians know their patients need – comprehensive metabolic monitoring, regular lifestyle counseling, structured transition planning – are often impossible to deliver within the constraints of modern medical practice. Physicians are thus forced to watch as their patients cycle through predictable patterns of initial success followed by devastating relapse.

Some physicians also shared with me in private a growing frustration of the quick-fix mindset held by many GLP-1-seeking patients. Doctors increasingly find themselves cast as gatekeepers to medication rather than partners in health transformation.

As trust erodes between patients and providers, the fundamental doctor-patient relationship suffers. Our sickcare system’s failure to support preventative care or lifestyle change mutates what should be a healing partnership into an adversarial dynamic centered around prescription access.

Uncovering Ozempic’s Physiological Traps

During Treatment: Deteriorating Body Composition

When patients begin GLP-1 treatment, few understand the hidden cost to their body’s fundamental architecture. A substantial portion of patient’s weight loss comes not from fat but from lean body mass ²⁰, which consists of muscles, bones, organs, skin, and other non-fat components.

The loss of muscle mass creates changes in body composition that lead to accelerated biological aging, setting up conditions for a cascade of metabolic complications ²¹. Studies also show significant reductions in bone mineral density, which is particularly concerning for premenopausal women ²².

“For all weight loss, you’re losing both fat and muscle,” explains S.M., a dietitian who has spent her career working with eating disorders. “But when you regain weight, it comes back primarily as fat unless you’ve maintained adequate protein intake and resistance training throughout treatment.”

This asymmetric pattern of fat + muscle loss followed by fat regain progressively erodes patients’ lean mass. Even if patients successfully achieve their target body weight, they may experience “skinny fat” syndrome – a form of metabolic obesity where their normal weight masks a high body fat percentage and dangerous metabolic dysfunction ²³.

The physician oversight gap compounds these challenges. Many prescribers – particularly online providers – provide little information about avoiding muscle loss. Without proper guidance on nutrition and exercise during treatment, patients unknowingly sacrifice the very tissue they need most for health and longevity. More troubling still, this deterioration occurs silently, masked by the euphoria of watching the numbers on the scale decrease.

Post-Treatment: Metabolic Dysfunction

The consequences of muscle loss extend far beyond aesthetics into the realm of fundamental metabolic health. As metabolically active tissue diminishes, patients experience a permanent reduction in their resting metabolic rate ²⁴ – the calories burned while at rest. But this direct impact of muscle loss tells only part of the story.

The body, interpreting rapid weight loss as a sign of starvation, initiates a complex hormonal cascade that fundamentally alters how it processes and stores energy:

This hormonal rebellion begins with leptin, the body’s primary satiety hormone. As fat tissue decreases, leptin levels plummet ²⁵.
Calorie restriction leads to increased production of ghrelin – the hormone responsible for hunger signaling ²⁶.
Simultaneously, the body becomes more sensitive to neuropeptide Y, a powerful stimulator of appetite and fat storage ²⁷.

“When people lose weight, their bodies treat it like starvation,” S.M. explains. “The body lives compensates by requiring fewer calories to maintain basic functions.” This metabolic adaptation persists even after weight regain, creating a perfect storm of increased hunger, reduced calorie burning, and enhanced fat storage. These changes leaving patients fighting not just their habits but their own biology.

This disruption extends to core metabolic systems, affecting everything from glucose metabolism to insulin sensitivity ²⁸. Even while maintaining their target weight on medication, patients often show elevated inflammatory markers and disrupted cortisol patterns ²⁹ that encourage abdominal fat storage ³⁰. Without proper medical oversight, these changes can seriously harm a patient’s metabolism – a cruel irony for those who paid an exorbitant price to improve their health.

Post-Treatment: Weight Rebound – Mostly Fat

When treatment ends – whether from side effects, cost, or insurance denial – the body’s response is swift and devastating. Patients report what S.M. describes as “insatiable hunger,” wherein cravings return with unprecedented intensity ³¹ – particularly for high-carb, calorie-dense junk foods. “The food chatter returns – that’s what patients find most distressing,” explains Dr. Francavilla Brown.

Patients’ bodies, primed by months of restricted eating and a diminished metabolism, aggressively store this flood of calories as fat rather than rebuilding lost muscle tissue. While some patients maintain their progress through older, more affordable – and less effective – weight loss medications, many experience rapid weight rebound. The weight regain is particularly severe for those with insulin resistance who return to high-glycemic foods after ceasing treatment.

Patients regain on average two-thirds of their lost weight after ceasing GLP-1 treatment, often in the form of increased central adiposity. “If someone has lost 40 pounds but 15-20 pounds were muscle, the weight regained is most likely fat,” Dr. Francavilla Brown informs me. “And they’re likely worse off metabolically than if they’d never started the medications in the first place.”

This preferential storage of regained weight around the abdomen ³² carries particular health consequences, including increased risk of heart disease, stroke, type 2 diabetes, insulin resistance, and other cardiovascular and metabolic disorders ³³.

Long-Term Consequences: Weight Cycling

When patients rapidly lose a significant amount of weight – whether naturally or with medication – more than half of the lost weight returns within two years. By five years, more than 80% is regained ³⁴. This treatment discontinuation puts patients’ health in severe jeopardy.

This pattern of rapid loss and eventual regain appears to be accelerating the onset of chronic disease ³⁵. The implications become particularly clear in examining metabolic health markers ³⁶. Studies show that individuals who maintain stable weights, even if elevated, often demonstrate better biomarkers than those who cycle through periods of loss and regain ³⁷. A 2022 study found that the number and degree of weight cycles were positively associated with increased risk of type 2 diabetes and hypertension, particularly among women and individuals with normal BMI ³⁸.

More concerning still, recent research has challenged long-held assumptions about who faces the greatest risks. While weight cycling’s negative effects were historically thought most relevant to geriatric or normal-weight populations, new evidence suggests these impacts may be even more severe in individuals with obesity ³⁹. These findings suggest that our current approach to obesity treatment may be creating a new category of patients with complex, treatment-resistant conditions that manifest decades earlier than in the general population ⁴⁰.

It’s Time to Renegotiate the Deal

The Devil’s in the Details

The toll of treatment disruption extends far beyond metabolic damage. Dr. Younglove describes watching patients disappear from care entirely after discontinuing treatment, their brief taste of freedom from food addiction giving way to a sense of shame and resignation. This pattern of treatment abandonment leads to a broader concern: patients who attempt and fail GLP-1 therapy may become dejected and lose faith in the medical system.

The financial toll compounds this psychological burden. While systematic studies of the economic impact are still emerging, early analyses suggest that GLP-1 drug costs vastly exceed any potential long-term healthcare savings ⁴¹ – mostly due to premature treatment discontinuation. This calculation doesn’t account for the financial and emotional anxiety many patients experience during treatment, often depleting savings or incurring substantial debt just to maintain drug access.

This combination of factors – psychological trauma, financial strain, and post-treatment medical complications – transforms what could be a powerful therapeutic tool into a dangerous game of chance for their long-term health. As CRC Group’s analysis concluded, “If an untrained clinician prescribes GLP-1s without appropriate support, an individual could actually become sicker.” ⁴²

The promise of pharmaceutical intervention means little without the systems necessary to foster lasting change. The medical community now faces an urgent question: how can they meet patients’ urgent weight loss needs without putting their long-term metabolic health at risk?

The Bill Is Coming Due

Insurers Pulling Coverage

A financial crisis looms over the GLP-1 treatment landscape. And our broken health insurance system is exacerbating these challenges:

Major insurers are increasingly implementing coverage exclusions, arbitrary BMI thresholds, and strict treatment time limits that all but guarantee treatment disruption ⁴³.
Some private insurers ⁴⁴ have implemented sweeping obesity coverage exclusions, often citing poor patient adherence ⁴⁵.
Medicare’s continued prohibition of anti-obesity medication coverage ⁴⁶ gives private insurers permission to follow suit.
State health plans like Colorado’s ⁴⁷ and West Virgina’s ⁴⁸ are moving to eliminate coverage for obesity treatment.

The pattern proves particularly devastating when insurers revoke existing coverage. “Some insurance plans will cover medication for weight loss,” Dr. Francavilla Brown explains, “but after a year or two will decide it’s not cost effective and stop covering it.” This rug pull leaves presents patients with a hard choice: deplete their savings to maintain treatment or discontinue the medications and put their health in jeopardy.

No More Cheap Ozempic

Concurrently, the FDA’s recent decision to declare the tirzepatide (and soon semaglutide) shortage over will imminently eliminate access to affordable compounded versions of weight loss medications drugs ⁴⁹. While this may be a win for patient safety ⁵⁰, the timing couldn’t be worse.

The FDA’s regulatory shift comes just as online prescribing services have reached a critical mass. Millions of patients have come to rely on compounded medications for obesity treatment ⁵¹, thanks in part to the loose prescribing practices of digital health companies ⁵².

These companies, which are operating in a regulatory grey zone and were quick to capitalize on the compounding loophole, typically lack contingency plans for patients who can’t afford branded medications or face treatment disruption. “It’s a concern with mass prescribing companies,” Dr. Francavilla Brown notes. “If cheap compounded medications go away, what other options can you provide patients if you’re a one-trick pony?”

Reimagining Obesity Care: Calls for Systemic Change

The rise of GLP-1 medications represents both a breakthrough and a warning. While these drugs have demonstrated unprecedented effectiveness in treating obesity, their implementation reveals fundamental flaws in America’s approach to chronic disease management.

The current system, built around short-term interventions and quarterly profit reports, systematically undermines patient health through fragmented care, arbitrary coverage restrictions, and inadequate support infrastructure.

Dr. Laurie Marbas’ Recommendations

Creating sustainable solutions requires a complete reimagining of obesity care. Dr. Laurie Marbas, who has spent 20 years in medicine and 8 years specializing in lifestyle medicine, suggests that sustainable change requires addressing both medical education and patient behavior.

First, medical training must evolve. Dr. Marbas shared her belief that physicians need training not just in prescribing medications, but in health psychology and behavior change. Incorporating lifestyle medicine into medical school curricula and board certification requirements would help prepare doctors to support lasting transformation.

Dr. Marbas also proposes employer-facing programs to orient consumers away from ultra-processed foods and towards more healthful, whole foods. She points to programs like Plantstrong and Metabite, which partner with self-insured employers to implement comprehensive lifestyle changes.

Dr. Marbas states these programs have achieved 5-9% body weight reductions through plant-inclusive diets while improving blood sugar and cholesterol levels. Crucially, their payment models align incentives with outcomes – they only get paid by employers when patients achieve specific health improvements.

Dr. Carolynn Francavilla Brown’s Recommendations

Dr. Carolynn Francavilla Brown’s practice offers another model for comprehensive care. Her clinic offers:

Regular body composition testing to monitor muscle mass preservation.
Specific, customized protein and exercise targets.
Ongoing lifestyle counseling.

This detailed monitoring helps prevent severe muscle loss, which is critical for long-term weight loss success.

The financial barriers to treatment also require systemic reform. Dr. Francavilla Brown notes that while insurance coverage for GLP-1 drugs remains wildly inconsistent, more stable treatment options exist. She points out that bariatric surgery, while more invasive, also tends to be more effective and durable. The procedure is also more affordable than GLP-1 medications due to wider, more consistent insurance coverage.

Dr. Courtney Younglove’s Recommendations

Dr. Younglove’s experience with employer-based solutions offers one promising path forward. She proposes a comprehensive model combining:

Obesity medicine protocols,
Clinical teams trained to handle basic care with experts available for consultation for complex cases, and
Dedicated behavioral health support.

This integrated approach acknowledges that sustainable weight loss requires addressing both physical and psychological factors.

Digital health tools, while fashionable, often add complexity without improving outcomes. “A lot of people throw money at easy things that don’t move the needle,” Dr. Younglove notes. Her clinics’ experiments with digital education platforms revealed low patient engagement, suggesting technology alone cannot drive behavioral change.

Upstream policy changes may offer the most leverage. “We need vegetables to be cheaper, not more expensive,” Younglove emphasizes. This requires policy intervention to realign food subsidies and market incentives toward promoting metabolic health.

The Path Forward

The story of GLP-1 medications reveals a healthcare system at a crossroads. These drugs have delivered life-changing weight loss for countless Americans but at a steep price: metabolic strain, soaring costs, and a healthcare system unprepared to provide meaningful long-term support.

It’s time for patients, providers, and policymakers to demand a healthcare system that treats obesity as the chronic disease it is – not as a series of quick fixes doomed by short-sighted insurance policies and profit-driven prescriptions:

Reforming health insurance to ensure obesity treatment is covered the same as that for any chronic disease
Pushing for transparent drug pricing from insurers and manufacturers
Integrating behavioral health and nutrition specialist support with medical care to promote sustainable behavior change rather than only short-term results
Putting greater emphasis on obesity care and lifestyle medicine practices into standard medical education
Implementing upstream policy changes that make healthy food and lifestyle choices more economically accessible
Comprehensive medical monitoring of body composition and metabolic health

The challenges are significant, but the consequences of not acting are dire. By learning from these models and implementing systemic changes, we can build a healthcare system truly capable of supporting lasting transformation in patients’ lives.