Many people experienced the benefits of weight management medications, only to find that all the pharmacies are out of them everywhere. Others used to have them covered, and then were "cut-off". Others never have had coverage, but have read online about how "good" they are. Some people are paying the $100-$1400 a month but are not sure how long they want to keep doing that, or they can not get them at any price anymore.
What do you do when you have heard that these medications are the "best"but you can not get them? Many people experience emotions such as anger, frustration, hopelessness, or depression, or simply are gaining the weight they lost back, or giving up on other options.
While I certainly have no good explanations for the machinations of health insurance or the supply chain issues still affecting healthcare, I can try to offer a path if you find yourself in one of these situations, since it seems the shortage is expected to last until at least the new year right now and coverage issues will likely last much longer. Less than half of people have coverage for these medications right now, even if they were in the pharmacies. I have patients who switch jobs, lose coverage, and experience weight regain.
These medications affect the two main “incretin” hormones in the body, GLP 1 and GIP. In the states of obesity and Type 2 Diabetes Mellitus, incretin hormone secretion and function have become defective. The exact cause of this is not perfectly understood, but it may be due to them “burning out” over time with excessive demand. Glucose in the small intestine causes incretins to be produced. In normal physiology, eating glucose causes incretins to be produced and control blood sugar. In Type 2 Diabetes, this stops happening; the incretin effect goes away. Taking these medications mimics the natural incretin effect, restoring it to normal. But, if we intervene early enough, is there another option to restore incretin function closer to normal? Or, are there other things one can do in addition to taking them to get the best health results?
The protein sparing modified fast protocol offered by Rainier Medical since 2015 shows an average of 20% weight loss, 10% of it from lean body mass. Using fortified medical foods to safely deliver 100% of the required nutrients, vitamins, and electrolytes in just 800 calories a day, a nutritional ketosis is achieved and many people experience a naturally enhanced satiety, satiation, and appetite control. This macronutrient content and nutrient timing (eating 5 times per day), causes dramatic changes in the metabolic hormones compared the typical state. With just 20 to 50 grams of carbohydrates a day, and less than 40 grams of fat, it is much lower in calorie and fat content than a "keto" diet, and therefore can produce more weight loss, improved lipid profiles and improved fatty liver compared to a "keto" diet, while "resting" the pancreas and allowing return of normal insulin secretion.
How does this compare to weight loss using semaglutide? The weight loss from semaglutide is slower (12% at 20 weeks and 18% at 68 weeks) and more of it was lean body mass (30% average). Weight recurrence is common whether someone loses weight with a medication or a protein sparing modified fast. The graph below shows the rate and pace of weight recurrence when people stopped semaglutide after 20 weeks through 68 weeks. The amount of weight loss sustained at that point (7.9%) is about the same as expected with intensive lifestyle modification alone, without a medication), at 2 years. Weight recurrence with a protein sparing modified fast is noted to happen over 5 years typically, which is actually longer. Other studies show that the more weight a person loses and the faster they lose it, the better. The cost of a protein sparing modified fast is about $600 a month for all of your food and supplements, plus the cost of medical supervision and blood work. Ideally, the food cost saves money from a typical food bill and may be eligible for HSA or flex accounts. The out of pocket cost of the medical services varies depending on coverage, but preventive counseling for obesity may have low out of pocket cost and blood work is typically rather basic and does not need to be done frequently if you are using medical food meal replacements unless you are on higher risk medications like diuretics or lithium.
Many people talk about using them to lose weight but not wanting to be on them forever. Significant numbers of people are paying $1000 a month or more for them, and I am not sure they are fully aware of the rates of weight recurrence when stopping them in the studies. My concerns are that many people are not aware of the high rates of weight recurrence after stopping anti obesity medications and the potential high rate of lean body mass loss if not used with a specific diet and exercise plan. Losing more lean body mass can make metabolic adaptation to weight loss more pronounced, which is the decrease in resting metabolic rate seen with weight loss. This may make weight recurrence more likely, or lead to incomplete weight loss, or reduce the benefits of weight loss if the excess body fat percentage is not addressed. Don’t get me wrong, I am a proponent of the use of anti obesity medications to treat and manage excess weight over time. I recommend and prescribe them every day. But, if people use other strategies with them, perhaps the durability will be better. To that end, my goal is that people understand what they do, what they don’t do, how to get the most out of them, and how they can learn from the research to have a diet and exercise option without them if they want. Anti obesity medications are not the best comprehensive treatment plan for excess weight. They work best when used with a specific diet and exercise plan. Adequate protein and avoiding excess carbohydrates (especially processed ones) and avoiding excess calories are key. Medical foods are one option to reach those targets. Skeletal muscle mass reduces insulin sensitivity and losing weight with medications can cause a significant reduction in muscle mass as well as fat mass. A protein sparing approach to reducing calories and nutrient timing, and an exercise plan with the right amount, intensity, and timing of resistance exercise for your body type can help. Weight recurrence is common no matter how a person loses weight, whether it is with lifestyle modification, medication, or even surgery. Repeating a modified plan in response to small amounts of weight gain for 4 weeks may be a biologically sound way to manage weight “creep”. For example, if your weight goes up 10 pounds, doing a modified plan for 4 weeks each year may give your liver and pancreas a “rest” to avoid burnout and return insulin response to normal in a well tolerated manner. A protein sparing modified fast should not be discounted because of concerns about adherence or durability. There is ample opportunity to improve tolerability and be strategic with the right follow up.
Anti obesity medications may be more important to prevent weight than to lose it as losing weight can be the easier part with the right tools for some, but keeping it off can be harder. Semaglutide and tirzepatide are not “magic bullets” that will make the obesity epidemic go away, in my opinion. Liraglutide is a similar, albeit not as potent, injectable weight loss medication approved since 2014, and it was a hit at first, and now barely anyone has heard of it.
Importanly, also note that there are 2-4 other classes of medications used for weight management that are generic and inexpensive and still out there. They may not be the right fit for you, but they can be considered. Also, bariatric surgery is generally safe and effective and is an underutilized option that you deserve to be counseled on as it relates to you and your health individually.
Capitalizing on diet and exercise from the start as part of a comprehensive treatment plan are still integral to help you get the best results and maintain them, with or without medication or surgery. Medication can be helpful to improve adherence to lifestyle plans, as hunger, cravings, and lack of satiety are common physiologic responses to losing weight and reducing calories. Body composition analysis and blood work can help guide your plan. Food, healthcare, and medications can be expensive. Value in healthcare is important for a plan that is sustainable. If this all sounds like gibberish, read more here, or join our program to be your partner and guide. Managing weight is hard, getting the right information for you shouldn’t be.
There are many ways to reach a healthier weight. The plan that a person is most likely to follow is usually the one that is most likely to work.
Modest weight loss (as little as 3 to 5% of starting body weight), has important health benefits and should not be discounted as a success. Losing 10 to 15% can cause remission of many health conditions. Reaching an ideal body weight is not necessary to achieve the vast majority of health benefits. The law of diminishing returns applies here. Progress, not perfection, is a good mantra. Studies show that anti obesity medications need to be taken forever to maintain their weight. Like a blood pressure medication, if you stop taking it, it stops working. Obesity is not “cured” by these medications.
Even continuing to take them, “tachyphylaxis” or “immunity” to them is not uncommon over time
Taking an anti obesity medication without a specific diet and exercise plan that is right for you can lead to 30% of the weight loss being lean body mass
Loss of lean body mass can make the reduced metabolic rate seen with weight loss worse
A protein sparing modified fast can naturally control hunger hormones and lead to an approximately 20-30% weight loss over 3 to 6 months without any medications
Ironically, anti obesity medications can be more important for weight maintenance than weight loss- the exact opposite of what most people tend to think intuitively or based on prevalent news and advice
Weight recurrence over time is common without follow up and repeated intervention over time and is not considered a “failure”. The Obesity Medicine Association recommends a provider trained and educated in this disease.
Take Back Your Options,
Valerie Hope-Slocum Sutherland, MD