When I left primary care to practice Medical Weight Management full time in April of 2015, there were very few physicians in this specialty, high weight bias and discrimination, and low awareness that medical treatment existed. Most patients received no treatment for overweight/obesity within the healthcare system experienced weight bias, and had no alternative but to independently find options outside their usual healthcare team. Part of the training I received from the Obesity Medicine Association was the principle that we needed to bring the treatment of this metabolic disease into the healthcare system where it belongs, since most people were in non-evidenced based programs, “fad diets” or no FDA approved supplements. As for medication options at that time, we had Qsymia (phentermine/topiraramate), approved in 2012, Saxenda (the first GLP 1 injectable for weight loss) approved in 2014, Belviq approved in 2014 (removed from the market in 2020), and phentermine (approved in 1959). I employed these medications, as well as various nutrition programs, including the medically supervised very low calorie ketogenic diet using meal replacements, ketogenic diets, Mediterranean Diets, Intermittent Fasting, etc. I am grateful to still be working with established patients, as this metabolic condition benefits from longitudinal care, as well as with new patients, going on 10 years.
Finally, and far too late, this metabolic condition is being recognized as one that requires medical evaluation and management as part of an individual's comprehensive medical care. It is fantastic that we now have more medical treatment options, most recently in the form of Wegovy and Zepbound, and the healthcare system needs to get many more people on treatment. We need to reduce barriers to care, remove stigmas and biases, and be much more proactive and patient-centered in catching up on long overdue care.
The medical community, insurance reform, and society at large has a very long way to go, but we seem to at least all be on the same page, gaining momentum and working together in the right direction for the most part! Major roadblocks currently are, of course, the fact that insurance policies are still legally permitted to exclude coverage for FDA approved medications, the supply of these medications, the small number of treatment options, established comprehensive programs to treat the multifactorial and complex nature of this condition over time, and diverse treatment options when current ones do not work for an individual. We still have a long way to go. Semaglutide has been used to treat obesity for only about 2 years (it was approved in 2021 but not available for a year or so do to supply chain).
However, should we not "celebrate too soon" and include a few cautionary tales in our enthusiasm for the expanded use of weight management medications? This is not the first time I have heart that a new medication is going to be the "silver bullet." It is known that obesity is a very tenacious condition. Several treatment options have been effective, generating excitement (Saxenda, Qsymia, bariatric surgery, Phen-Fen), only later to have that enthusiasm tempered by something such as side effects, weight recurrence,or the epidemic of obesity worsening and failing to improve anyway. With the current class of GLP 1 RA/ GIP medications, they have been used for weight management (as opposed to treating Type 2 Diabetes) for a couple of years at best. I don’t think we really know what will happen to people after 10, 20,30, or 50 years on these medications. Byetta was the first GLP 1 RA approved in 2005 to treat Type 2 Diabetes. But, obesity is a heterogenous disease, and the physiology of diabetes is not the physiology that everyone with every type of obesity has. Concerns that have emerged already in the short term use so far of semaglutide are the higher loss of lean body mass and gastrointestinal effects. Other anecdotally reported things such as fatigue or tolerance, may not be significant issues. I do not think these things should prevent us from using these by any means, but I do think we should use these medical tools wisely and remember:
These medications are excellent tools to be used in the treatment of overweight/obesity.
Like any tool, knowing when and how to use them and what to watch out for puts you in the best position for the most ideal outcome.
In treating this complex, multifactorial, multisystem condition, these may not be the ONLY tool from which an individual would benefit
When using this tool, due to the unique characteristics of obesity, other things can happen physically, mentally, and psychosocially that may or may not have been expected and may or may not be positive. Being able to anticipate and address these can prevent barriers to long term success.
As with many things, proper training and experience can potentially make a big difference in the course of treatment. Buyer beware of overnight “pop ups” looking to “cash in” on short term opportunities without providing comprehensive care. I was driven to write this blog when someone forwaded to me a social media post with the headline "The first beverage for GLP - 1 users." It seems to be implying that there is something different about meal replacements to use with GLP-1RA that is different than other meal replacements. I am cocnerned about retailers "riding the coattails" or generating yet another non-evidenced based product that preys on dieters efforts to reach a healthier weight. In this medical specialty, part of the message is to bring treatment under the umbrella of licensed medical professionals and avoid the many products and fads. It is interesting how creative people an get when marketing is involved. It is very true that medical foods and meal replacements have an evidenced- based and powerful role in weight management. However, this science has not changed since the advent of GLP 1 RA. Rainier Medical continues to offer the same medical food meal replacements as another option and tool in addition to weight management medications, as we have been doing since 2015. To read more about how we use them with medications, read this blog and this blog from 2022 on our website from over the years. You can look for an obesity medicine provider in your area on the website for the Obesity Medicine Association. There is also a board certification in this specialty, so look for Diplomates of the America Board of Obesity Medicine. It is a secondary specialty, so look also for primary board certification.
As of a few days ago, Wegovy received a new FDA approval for a new indication: reducing the risk of heart attacks, strokes and cardiovascular-related death in adults who have heart disease and are overweight or have obesity. This is excellent news, and hopefully will result in expanded insurance coverage of the medication, especially for people on Medicare. However, the manufacturer still expects demand to exceed supply and the medication is still on the FDA national shortage list.
All this to say, this area of medicine is evolving but still has significant barriers to overcome. Be sure to advocate for yourself and have properly trained and licensed personnel on your team. As tempting as it is to believe, these medications are not a “silver bullet” that you can just “take it and forget it.” Even if it is just to consider micronutrient levels, preservation of lean body mass, adjusting other medications, what to do if your weight loss plateaus too soon, starts to come back, food noise recurs, side effects develop, or what to do if you want to try coming off of them, how to handle saboteurs, body image issues, or weight discrimination, many people find they have some unanswered questions or concerns. Managing weight is hard. Would you hire a guide to climb Mt Everest who was not experienced? This is very important and we want to do it right. Experience matters.
Take Back Your Expertise,
Valerie Hope-Slocum Sutherland, MD
Diplomate, American Board of Internal Medicine
Diplomate, Americam Board of Obesity Medicine
