The End of Diabetes: The Eat to Live Plan to Prevent and Reverse Diabetes

This pleased originally appeared on Everyday Health. Republished with permission.

By Ross Wollen

Medically Reviewed by Adam Gilden, MD, MSCE

Drugmakers are struggling to keep up with the demand for weight loss drugs semaglutide (Ozempic, Wegovy) and tirzepatide (Mounjaro, Zepbound). The limited provide is forcing doctors, public health experts, and insurers to confront an unpleasant question: Who “deserves” these life-changing therapies the most?

“Right now, it’s 1st come, first served,” says Neda Rasouli, MD, an endocrinologist and professor at the University of Colorado in Aurora. “But it should be based on maximizing the benefit and prioritizing men and women who do worse without this intervention.”

GLP-1 drugs were originally developed to alleviate type 2 diabetes and are still considered a game-changing therapy in the field. In recent years, they’ve been widely recognized as the most effective weight loss drugs ever developed, and researchers keep discovering new benefits, too. GLP-1s also appear to prevent or alleviate kidney disease, sleep apnea, and cardiovascular disorder.

Doctors wish these drugs were universally accessible and affordable, but shortages continue as demand rises. Instead, health practitioners are debating how these drugs would ideally be distributed so that a limited supply can have the biggest possible health impact.

GLP-1 Drugs Are Not Distributed Equitably

“In our system, Americans can buy whatever they can afford,” says William Herman, MD, professor of epidemiology at the University of Michigan in Ann Arbor.

“We really require to believe about health equity,” says Dr. Herman. “Allowing wealthy individuals to purchase GLP-1s that are in short supply denies access to individuals who are more likely to benefit.”

High prices and unequal insurance access have caused disparities in GLP-1 use along familiar racial and socioeconomic fault lines. Among adults with type 2 diabetes, white patients in America are substantially more likely to use GLP-1 drugs than nonwhite patients, including folks from Black, Asian, Hispanic, and American Indian/Alaskan Native backgrounds.^[1] GLP-1 users also have higher income, more education, and are more likely to live in affluent urban areas.^[2] It is possible that the disparities are even starker for folks without diabetes, as insurers (including Medicaid) are less likely to cover the use of GLP-1 drugs for weight loss.

Dr. Rasouli believes that the situation ought to be reversed: “I crave to prioritize … underrepresented minorities, because they are not getting medication and they’re at even higher danger of comorbidities.” Several nonwhite communities have higher rates of obesity and diabetes complications, such as cardiovascular and kidney disease, and might therefore reap even greater benefits from GLP-1 drugs.^[3]

Herman points to research suggesting that Novo Nordisk could manufacture and distribute a single Ozempic pen for as little as , even at the same time as turning a 10 percent profit.^[4] And yet the sticker price for Americans is still around ,000. Meanwhile, an analysis published in 2023 found that in peer nations, a month of semaglutide was priced between (France) and 9 (Japan).^[5]

Timothy Garvey, MD, professor of medicine at the University of Alabama in Birmingham, calls the situation, with sky-high prices causing American insurers to revoke coverage, “untenable.”

“These are life-saving medications,” says Dr. Garvey. “To deny them to patients who would benefit is unacceptable.”

Who Benefits the Most From GLP-1 Drugs?

In order to maximize the public health benefits, it’s necessary to understand who responds best to these drugs. That is a difficult question to answer, because assorted folks take GLP-1 drugs for different reasons. While one adult may choose Ozempic for type 2 diabetes to assist control their blood sugar, one other might choose Wegovy, essentially the same medication, to lose weight and manage heart affliction risks. There’s no easy way to compare the importance and cost-effectiveness of the benefits across conditions.

We do be aware of a few things about average GLP-1 responses. Researchers have found that women tend to lose more weight than men, for example, and men and women with a lower baseline A1C tend to lose more weight than those with a higher baseline A1C.^[6]

Rasouli would like to see GLP-1 drugs made available first to patients with class 3 (“severe”) obesity — the heaviest classification of obesity, corresponding to a body mass index (BMI) of 40 kilograms per square meter (kg/m2) or higher.^[7] “We use to call this morbid obesity,” Rasouli says, explaining that the condition is associated with a high hazard of sickness and early death.

Clinical trials have shown that folks with class 3 obesity respond particularly well to GLP-1 drugs.^[8] “People with a higher BMI lose a higher percentage of their body weight. More interestingly, the pace of side effects leading to drug discontinuation is lower in people with class 3 obesity,” says Rasouli. “These people tolerate the medication better, and they have a better retort. ”

By contrast, people with diabetes tend to lose less weight.^[9] But that without a doubt doesn’t mean the medication is any less impactful. So far, insurers have been far more likely to cover the cost of GLP-1 drugs for people with diabetes, because the drugs almost certainly diminish the incidence of the disease’s dangerous (and expensive) long-term complications.

Revoking GLP-1 Access

Deborah Horn, DO, medical director at the University of Texas’ Center of Obesity Medicine and Metabolic Performance in Bellaire, is especially concerned with the plight of people who lose access to their drugs. In 2023, the University of Texas announced that it would halt covering weight loss drugs for its several hundred thousand employees, many of them Dr. Horn’s patients: “I’m helping manage all those patients who had huge success, but then had to figure out another way to manage their sickness. ” She has plenty of experience seeing what happens when patients stop taking Ozempic — the weight usually comes back while the other metabolic benefits disappear.

Other insurers and employers across the nation, faced with staggering drug costs, have also begun to tighten restrictions on access and reimbursements.^[10] Sometimes this means discontinuing coverage after a patient’s BMI falls below U.S. Food and Drug Administration (FDA) cutoffs, a practice which seems to conflict with established standards for the use of medicine to treat and prevent chronic illness.

“We would never do this with diabetes medications!” says Horn.

Pam Taub, MD, a cardiologist at UC San Diego Health, agrees: “No payer would ever tell you to stop a statin after your LDL [cholesterol] met your goal.”

Prioritizing Heart Disease

Dr. Taub has a different perspective. She believes that clinicians can’t be guided by an academic concept of maximum public health benefit. Instead, they need to engage with the true reality of the insurance industry that largely decides which Americans get to use which drugs. And she believes that it could be the GLP-1 family’s impact on cardiovascular health that allows them to become widely accessible.

In saunter 2024, semaglutide was approved to prevent heart attacks and strokes. The FDA’s decision came on the heels of a three-year study showing the maximum dose of semaglutide reduced the risk of cardiovascular disease and death by 20 percent.^[11] “We see incredible benefit from across the cardiovascular spectrum,” Taub says. A similarly large and rigorous cardiovascular outcome trial is underway for tirzepatide now, with analyses of earlier data suggesting that tirzepatide might boast comparable benefits.^[12]

Taub believes these cardiovascular benefits are the key to persuading insurers, employers, and governments to pay for these notoriously expensive drugs. “The harsh reality of our clinical practice is that it is dictated by what payers will cover and what we can get our patients access to,” she says. Emphasizing the cardiovascular benefits of GLP-1 drugs could be the best way of increasing access — and of allowing patients to enjoy the full range of cardiometabolic benefits, including weight loss, blood sugar reduction, and kidney protection.

Prioritizing Overall Cardiometabolic Health

In reality, the conditions that GLP-1 drugs treat are inextricably connected. While there are certainly people with obesity who do not have diabetes, and vice versa, the conditions share causes and risk factors. Heart disease, kidney disease, and sleep apnea are all comorbidities of obesity and type 2 diabetes, as are other conditions such as metabolic dysfunction associated steatotic (fatty) liver disease.^[13]

“All of our organs are intricately linked,” says Taub. “The dysfunction of one leads to the dysfunction of another.”

“Let’s focus on overall cardiometabolic health,” Taub says. “We need to be selling these as more than just weight loss drugs. … By just focusing on obesity, we’re doing this field a disservice.”

Herman suggests that the people who will benefit the most from GLP-1 drugs are those who have been diagnosed with multiple cardiometabolic conditions: “I think the value is probably greatest in people with type 2 diabetes, obesity, and cardiovascular disease … and for people with type 2 diabetes and complications.”

Rasouli adds that the drugs may be especially valuable “in younger people.” The younger a patient develops obesity or diabetes, the more intense and serious their complications are likely to be.^[14][15] Younger people, therefore, may have more to gain from GLP-1 drug use; prioritizing younger patients could maximize the number of healthy years saved.

Is Hollywood Really Hogging GLP-1s?

Many people, both doctors and patients alike, assume that the intense demand for GLP-1 drugs has been substantially driven by people who want to slim down but who do not have a serious medical need to lose weight.

Rasouli says, “When we have scarce resources, and if Hollywood people or people who don’t really need it get it first, it means that we’re denying access to people who might need it more.”

“I think the least cost-effective approach is in the cure of … people who are obese or have mild obesity who want to fit into that fabulous gown by losing a few pounds,” says Herman. “This is what we’re really seeing in Hollywood, and unfortunately this is what we’re seeing fairly widely.”

But Leah Wigham, PhD, a professor of public health with the University of Texas in Houston, questions this narrative: “There are these stories of movie stars [using Ozempic], that’s, what, a couple dozen anecdotes? Do we have data that that’s actually contributing in a significant way to the supply chain issues?” A July 2024 study of real planet prescribing data found that only a tiny fraction of users, 0.37 percent, are not medically qualified to use GLP-1 drugs.^[16]

Nikhil Dhurandhar, PhD, a professor of nutritional sciences at Texas Tech University in Lubbock, says that he “wants to put in a good word for those who want to lose weight to fit into a dress.” Dr. Dhurandhar says that as long as users are medically indicated to use a GLP-1 drug, “motivation should not matter … your benefits are going to be the same regardless of what made you lose weight.”

Dr. Wigham worries that vilifying some GLP-1 users only contributes to the disapproval and discrimination experienced by people who are overweight.

“These kinds of comments about the dress just perpetuate this stigma that people don’t deserve the medication unless they’re trying really hard to lose weight on their own,” says Wigham. “We don’t do that for other ailments and we need to stop utilizing that language for obesity.”

Shortages May Persist

Semaglutide and tirzepatide shortages are projected to last through 2024, but realistically there’s no telling when manufacturers will be capable to catch up. There are likely well over a billion people worldwide who are medically eligible to take a GLP-1 receptor agonist, according to FDA criteria.^[17] The potential demand is almost unimaginably large.

Many different businesses are trying to meet the demand. Major drugmakers are racing to expand their manufacturing capacity and to develop additional GLP-1 therapies. Generics may soon be approved in India and China, and in the United States, compounding pharmacies operating in a legal gray area offer less expensive unbranded equivalents.

In a perfect world, everyone who stands to benefit from these blockbuster drugs would be capable to access them. At the moment, that possibility seems extremely far away.

The Takeaway

Demand for GLP-1 drugs like Ozempic has outstripped supply, sparking debates over fair access. Some health specialists recommend prioritizing these medications for those who might benefit most, especially patients with multiple cardiometabolic conditions, including type 2 diabetes and severe obesity.

Resources We Trust

• Cleveland Clinic: Overweight and Obesity: What They Mean and Why They Matter
• American Pharmacists Association: Compounding FAQs
• Johns Hopkins University: Weight: A Silent Heart Risk
• American Heart Association: What Is Metabolic Syndrome?
• University of Southern California: 6 Examples of Health Disparities and Potential Solutions

Editorial Sources and Fact-Checking

Diabetes Daily

The End of Diabetes: The Eat to Live Plan to Prevent and Reverse Diabetes