Weight-loss medications: The 5 most-asked questions

Obesity is a chronic disease – it doesn’t develop overnight, and it can’t be “cured” with a short course of medication. Take for example how high blood pressure is managed. Many people take medication to help them achieve a healthy blood pressure, and then they continue treatment to keep their blood pressure controlled. If they stopped the medication, their blood pressure would go back up.

Obesity should be managed in a similar way. GLP-1 RAs are approved by the FDA for long-term use and are started at a low dose, gradually increasing to a target dose or the maximum tolerated and effective dose for the patient. Once the weight loss and health goals are achieved, treatment can be tapered and discontinued but many studies show that chronic therapy is needed to maintain the weight loss and health benefits achieved with treatment.

The amount of weight people lose and the speed with which they lose it is highly variable. In clinical trials with semaglutide and tirzepatide, participants achieved weight losses of 15-22% over 68 and 72 weeks, respectively. Every patient has a unique history and health needs.

In clinical trials with semaglutide 2.4 mg (Wegovy), of the weight that participants lost, approximately a third of it was lean or muscle mass. Gradual weight loss gives people the opportunity to incorporate healthy eating and activity programs, with optimal protein and strength training, which decrease the risk of muscle loss. By improving muscle mass, people may also reduce the appearance of sagging skin associated with weight loss.

Additionally, loss of muscle, especially in older adults, can increase the risk of frailty and falls.

People who watched “The Biggest Loser” in the early 2000s might remember that several contestants who lost a significant amount of weight regained much or all of it after they left the show. This also happens when people lose smaller amounts of weight, which can be called weight-cycling or yo-yo dieting.

The body has a complex system of hormones and nerve reflexes that are designed to help us resist famines and stop us from starving to death. These systems cause the body to resist weight loss, which causes weight-loss plateaus and makes it easier for us to regain weight. We call this process metabolic adaptation to weight loss. It involves an intricate interaction between our fat cells, gut hormones, and certain centers in the brain that increase appetite and decrease the number of calories we burn with physical activity. When we are trying to treat obesity, this protective mechanism can make it difficult for people to maintain their weight loss without additional support or treatments.

GLP-1 is naturally released in the intestine when certain cells see that we have eaten. When we give patients GLP-1 RAs, it makes the body think we have already eaten. This decreases the sensation of hunger and cravings. In addition, our stomachs empty more slowly, which makes us satisfied with less food for longer.

To support a healthy weight and maintain weight loss, we recommend:

• Avoiding calorie-dense foods such as potato chips, which are easy to eat and can allow us to consume more calories than we need before we sense we’ve had enough.
• Prioritize lean proteins to support healthy muscles. Good sources of protein are lean meats, beans, peas, and lentils. Most patients require around 60-80 grams of protein per day, but this may vary depending on your health conditions. Consider meeting with a registered dietitian for more individualized advice.
• Consuming whole grains, non-starchy vegetables, and fruits as part of a balanced diet, and they are also great sources of fiber.
• Moving your body regularly. Make a plan for regular physical activity, which includes strength training and stretching to promote strength, function, and weight maintenance.
• Incorporating stress management, mindfulness, and a healthy sleep pattern to support mental well-being and restoration.

GLP-1 RAs were originally used as treatments for type 2 diabetes but won’t give you diabetes. In people without a history of diabetes, studies show that these medications can prevent diabetes and decrease the risk of heart attack and stroke in high-risk individuals.

Obesity is associated with an increased risk of type 2 diabetes and cardiovascular disease. For many people, avoiding these health complications may be more important for them than weight loss, and it is great that we have safe and effective treatments that can decrease health risks and body weight.

All medications have potential side effects. GLP-1 RA medications are generally well-tolerated with the main side effects being nausea and less commonly constipation, vomiting, and diarrhea. We decrease the risk of these complications by starting patients on the lowest dose of the medication and increasing it gradually based on how well they are doing.

In addition, we provide dietary advice on how to avoid foods and eating habits that can make the nausea worse – such as eating too quickly and consuming high-fat foods.

Losing a significant amount of weight by any method, including medications, can cause loose skin. “Ozempic face,” which has been in the news a lot, is sagging skin on the face following treatment with Ozempic but is not unique to weight loss with GLP-1 RAs. For many people who lose large amounts of weight there may be loose skin around the abdomen, chest, arms, and legs. In some cases, insurance may cover removal of the extra skin across the abdomen, which can improve quality of life and body shape.

Recently in the news, there have been reports of gastroparesis, or “paralysis of the stomach,” in people who have used GLP-1 RAs. These medications help us to be satisfied with smaller portions of food by decreasing the speed at which the stomach empties. The effects of the medication on stomach-emptying are transient and usually do not cause severe symptoms. The impact of GLP-1 RAs on stomach emptying and symptoms depend on many factors including the dose of the medication, how quickly the medication dose is increased, underlying health conditions (including pre-existing, diabetes-related gastroparesis), how quickly we eat, and other dietary factors such as fat content of meals. Symptoms of bloating, nausea, and (rarely) vomiting can be managed with diet modification, medication dose adjustment, and anti-nausea medications if symptoms are severe. People experiencing significant gastrointestinal side effects, including abdominal pain, should stop their medication and contact their health care provider to be evaluated.

When GLP-1 RAs for treating obesity are not covered by insurance, the out-of-pocket price is $900-1,400 a month. Unfortunately, this makes these effective medications unaffordable for many people who would benefit from obesity treatment. As more medications are approved by the FDA – for example, tirzepatide, which is already approved for diabetes under the brand name Mounjaro, could be authorized for weight loss soon – prices may decrease.

Many patients have sought alternative ways to get GLP-1 RA medications that are more affordable. Some pharmacies, medical spas, and health care offices are offering compounded preparations that are often combined with other substances such as vitamin B12. Unfortunately, it is unclear where the active ingredients are being manufactured and how the compounded drugs are being prepared. Recently, the FDA has received reports of adverse outcomes from patients taking compounded medications for weight loss and has provided guidance because the safety and effectiveness of these compounded drugs cannot be verified. In other words, patients should avoid using these unregulated versions of the medication as they may experience a bad or unintended outcome.

Patients should use GLP1-RA medications under the guidance of a health care provider who understands how to prescribe these medications and provide evidence-based advice on nutrition and physical activity. This will increase the chances that patients are meeting their health goals and avoiding unwanted and potentially dangerous side effects.

Unfortunately, some health care providers still view obesity as a patient’s personal failure rather than the multifactorial chronic disease that it is. I am the president and founder of the Dallas Obesity Society, which is a nonprofit organization dedicated to educating local primary care providers about obesity and tools to manage it. Our goal is to provide education and support to health care colleagues on how to treat obesity in a patient-centered and evidence-based way.

Improving awareness among patients and health care providers on the effectiveness of GLP-1 RA therapies, other effective medications, and bariatric surgery as adjuncts to lifestyle modification, can help us to overcome the inertia that exists in treating the epidemic of overweight and obesity that we are facing in the U.S.

Ultimately, treating obesity is not just about weight loss. It is about improving health, reducing and preventing obesity-related complications like diabetes, and improving quality of life.

To talk with a weight management sp­­ecialist, call 214-645-8300 or request an appointment online.