Statements by Robert F. Kennedy Jr. and Elon Musk tap into a dispute over whether lifestyle changes or drugs are a better way to treat obesity.
For Robert F. Kennedy Jr., the activist whom President-elect Donald J. Trump will nominate to serve as the secretary of health and human services, the solution to obesity in America -- now at 40 percent of adults -- is straightforward: "The first line of response should be lifestyle," he told Jim Cramer in a Dec. 12 interview on CNBC.
Elon Musk, the technology billionaire who advises the president-elect, sees things differently: "Nothing would do more to improve the health, lifespan and quality of life for Americans than making GLP inhibitors super low cost to the public," he wrote on X, referring to the new class of drugs that cause weight loss, including Ozempic. "Nothing else is even close."
And there, with the contrasting views of two men in Mr. Trump's ear, lie two sides of an issue that is plaguing health and nutrition researchers. Is it even possible to change lifestyles and the food environment enough to solve America's obesity problem? And, if not, do we really want to solve it by putting millions of people on powerful drugs? What is the right balance between the two approaches?
Many people find that eating well is easier said than done. Food companies have saturated the United States and other nations with seductively cheap and tasty things to eat, available seemingly everywhere and around the clock. Obesity researchers suspect that the current food environment has allowed many Americans to be as overweight as they possibly can be.
But for the first time, there is an effective countervailing force -- powerful new obesity drugs like Wegovy and Zepbound that allow people to ignore the siren call of high-calorie foods and large portion sizes.
Those with views like Mr. Kennedy's believe it is wrong to use pharmaceuticals to manage obesity and related issues that are tied to unhealthy lifestyle and to a ruinous food environment. The makers of obesity drugs, Mr. Kennedy told Greg Gutfeld on Fox News before the election, are "counting on selling it to Americans because we're so stupid and so addicted to drugs."
But there are many like Mr. Musk, who says he has used Wegovy, applauding the power of the new drugs to improve health and treat the seeming intractability of obesity.
Many health and nutrition researchers say they would love for obesity to be treated through lifestyle changes alone, but they are not optimistic. They point to a history of attempts to teach people to change their diet and exercise habits. Multiple studies left them with dashed hopes and tempered their enthusiasm.
That happened with diabetes.
In 1996, the National Institutes of Health initiated a study involving thousands of people at risk of developing Type 2 diabetes. Researchers led these subjects through an intensive program of diet, counseling and exercise. It worked so well that the study was ended one year early. The intervention slashed people's chances of developing diabetes by more than half.
The result was so consequential that Tommy Thompson, then the secretary of health and human services under President George W. Bush, joined the study's principal investigator, Dr. David Nathan, a Harvard diabetes researcher, to announce it in 2001, telling the nation that the study showed diabetes could be conquered.
"Just walk around the block, walk down the street 30 minutes each and every day and we can lick this particular disease," Mr. Thompson said at the time. He also said "Prevention works."
Until it doesn't. Diabetes incidence has actually increased since those results were announced 23 years ago.
Permanent lifestyle changes, it turns out, are not easy.
"The problem, of course, is that people being people apparently find it difficult to maintain such changes over long periods," Dr. Nathan said in a recent interview.
Christopher Gardner, a nutrition researcher at Stanford, is a true believer in the power of a healthy diet. He has done study after study, funded by the National Institutes of Health, in which health professionals guided participants in their food choices or, in some cases, even delivered meals to them.
The studies succeeded -- participants' health improved. But when the studies ended, Dr. Gardner said, and when participants no longer had that guidance or food delivery, many, if not most, went back to their old eating habits and all those benefits of a healthy diet vanished.
"Yes, diet should be the answer," said Dr. Gardner, who was paid five years ago by a purveyor of meat alternatives to study its products. But, he added, diet will be insufficient "unless some major changes are made to the whole food system in the United States."
There's also the problem of genetics, said Dr. Jeffrey Friedman, an obesity researcher at Rockefeller University in New York. Some people have a genetic tendency to become obese, and they will gain weight as long as food is cheap and plentiful. Tweaks like changing portion sizes or food advertising are not enough -- if popcorn were sold in smaller bags, many would simply eat two bags of popcorn, he said.
That has led Dr. Friedman, like Dr. Gardner, and Dr. Nathan to conclude that the only practical way to improve people's health and allow them to lose weight is to rely on the new obesity drugs.
Dr. Charles Burant, a professor of internal medicine at the University of Michigan, is sympathetic to Mr. Kennedy's view that the problem is the food system.
He recalled an experience with one large food company that showed him how hard it could be to change what foods are marketed to Americans.
He had an idea for a palatable drink containing an amino acid that he thought might sate hunger.
So he went to the large food company and asked if it could make such a drink for him to test in a study. After a while, he received a reply: It was not in the company's business plan to develop products that reduced appetites. It was not interested in helping.
"It wasn't their business to sell less food," Dr. Burant said.
"If you can rein in corporations or try to use pressure to modulate what they do, I think that's great," he added. "But in the meantime, until the population learns to eat good things, we need to do something to help people."
Others, like Dr. Kevin Volpp of the University of Pennsylvania, worry about promoting the widespread use of obesity drugs. He worries about the idea of tens of millions of Americans injecting themselves weekly with drugs to curb their appetites.
"There is not enough money in the system to suddenly fund drugs for that many people," Dr. Volpp said.
He prefers to reserve the drugs for adults with the most serious diseases related to obesity.
Instead of handing out drugs to nearly all who qualify, Dr. Volpp said the country needed to consider other solutions, like marketing restrictions and taxes on sugary beverages.
He also would like health insurers to help subsidize the purchase of healthy food for those who can't afford it and have chronic medical problems, like diabetes, that are related to diet. Eleven states have secured permission to test the use of state Medicaid programs for pilot studies along those lines, he said.
"All this is like pieces of a jigsaw puzzle," Dr. Volpp said. "But we have to try everything that will help make our population healthier, given the rise in obesity from 12 percent to 40 percent in the past few decades."
It's not clear, though, how to put the jigsaw puzzle together, or whether to even try.
For Dr. Peter Lurie, the president of the Center for Science in the Public Interest, the situation is dire enough to try everything all at once.
His organization, he said, firmly believes that the food environment is an important factor driving high obesity rates, and he wants it to change.
He also describes himself as "something of a pharma skeptic."
But "when the pharmaceutical industry comes up with strong data that affects important outcomes," Dr. Lurie said, "it is irresponsible to turn your back on it."
That is also the view of Dr. Robert Califf, who has been serving as commissioner of the Food and Drug Administration under President Biden. Before he joined the F.D.A. in 2016, Dr. Califf, a cardiologist, ran a clinical trials center at Duke University that received funding from drug companies as well as from the federal government.
"While I am totally in favor of helping Americans have a better diet, these drugs are highly effective" for people with obesity, Dr. Califf said. "Not just for losing weight," but also for preventing heart disease deaths.
In the meantime, "we have to control the advertising," he said, and "we have to gradually change the agricultural system," and "we have to subsidize healthier foods."
"You can either be a cynical old vet and say this is impossible, or you could be optimistic," Dr. Califf said.