With the development and expanded use of medications for the treatment of obesity, we are able to broaden the tools we can offer patients to treat this condition. Medications like Wegovy and Ozempic have become household names. These medications are classified as glucagon-like peptide-1 (GLP-1) receptor agonists. Glucagon-like peptides are hormones that are naturally produced in the gut (intestines) that help regulate blood sugars and hunger signaling. Since these natural hormones last in our bodies for only a few minutes, GLP-1 medications create longer lasting signaling to potentiate these effects. These medications were first studied for the treatment of type 2 diabetes (Ozempic, Mounjaro) and have been approved for the treatment of obesity under different brand names (Wegovy, Zepbound).
While this class of medications have been used since 2005 for the treatment of diabetes and since 2014 for the treatment of obesity (as reported by Prime Therapeutics), their popularity has grown exponentially in recent years. As clinicians and patients alike recognize the need for treatment, more patients have been seeking care for obesity and pursuing pharmacological options. With all this excitement and buzz, there have also been some concerns about treatments and obstacles to appropriate care.
The treatment options for obesity and number of people seeking treatment has expanded rapidly. As a clinician, it has been challenging to fight off the associated misinformation. Per CDC reports, over 40 percent of Americans have obesity, and the Kaiser Family Foundation reports 12.5 percent of Americans have tried a GLP-1. However, per the American Board of Obesity Medicine (ABOM), there are less than 9,000 physicians who are board certified in obesity medicine, termed ABOM Diplomats. At this point, there are not enough specialized clinicians to meet the demand for medication management of obesity. With more than 70 percent of Americans having overweight or obesity, it will not be possible for every patient to receive specialized care. The bulk of this care will fall to primary care clinicians, many of whom have not had the time, training, or support to provide this care. We have started to see this training percolate through residency programs, so there is hope that future physicians will begin to meet some of the demand.
High demand and exorbitant drug prices have led to the appearance of many telehealth companies and medical spas providing inadequately supervised care and compounded medications. GLP-1 medications are not without side effects and risks, and they are not universally safe for all. Additionally, compounded medications are not federally regulated and can have severe side effects, even leading to hospitalization.
With limited sources of reliable information, many patients have turned to social media to share their experience of utilizing GLP-1s and to understand that of others. This has created a shared community and has empowered patients to seek treatment. Social media has the power to be a positive tool, but it can be difficult for a patient to sort through correct and incorrect information. I urge patients to look at trusted sources; the Obesity Action Coalition has great patient-facing resources and the Obesity Medicine Association has a tool to help patients locate board-certified clinicians in their area.
As a primary care and obesity medicine physician, when a patient walks into my clinic, I am excited to treat obesity and see the benefits from a cardiometabolic standpoint. Most of my patients see improvements in blood sugars, cholesterol levels, blood pressure, and many other metrics used to assess cardiometabolic health. However, when patients come in asking for treatment for obesity, the most common reasons they share include “I want to look better,” or “I want to feel more confident in my body.” Initially, this used to frustrate me; I wanted patients to recognize the long-term benefits of treating obesity from a health perspective. However, I have come to realize that a unique feature of obesity is that it is one of the few diseases we can visualize. Because of that, there is often an associated stigma. Patients with obesity are often labeled as “lazy” or not having enough “willpower,” however this language is rarely used when we think about diseases such as diabetes and hypertension. This type of stigmatizing language is incredibly dangerous and also inaccurate—we know that patients with obesity struggle with hormonal and chemical imbalances in the hunger and satiety signaling between our gut and brain, making the sustainability of lifestyle changes incredibly challenging. Because of these factors, obesity not only affects physical health but several emotional components as well. At the end of the day, my perspective has shifted to supporting patients regardless of their motivations. Aesthetic reasons may bring patients to my door, yet I have the pleasure of supporting their aesthetic goals and my clinical goals, a win-win situation. In a larger context, we also know that patients with obesity are much less likely to engage with health care settings due to stigmatizing factors. If the development and expansion of more effective anti-obesity medications brings patients to the door to re-engage with health, I think this is the biggest win that we should celebrate.
The results from the trials for Semaglutide (Wegovy) and Tirzepatide (Zepbound) show an expected 14.9 percent of weight loss at 68 weeks and 26.6 percent of weight loss after 84 weeks respectively. This amount of weight loss results in clear improvements in cardiometabolic outcomes. It can also be life-changing: in my practice, not only are we seeing improvements in overall health, but most patients report improvements in mental health, mobility, and overall quality of life.
In the clinical setting, I see some patients surpass these averages while others do not achieve this level of weight loss. Many patients who do not achieve these results feel discouraged, especially when social media has popularized the efficacy of these drugs. It is important for clinicians to remember that not everyone will respond to these medications. This is why research into new treatments is important. While frustrating for now, hopefully in the near future we will be able to offer other effective medication options. In the subset of patients who do not respond to GLP-1s as expected, we need to emphasize that obesity is a disease, and that treatment and response is unique to each individual.
Success looks different for each patient. Currently, there are no clear guidelines for treatment targets. When working with patients, I consider improvements in cardiometabolic factors, body composition, and the patient’s experience. This can be a gray area to navigate, and hopefully, we will have better guidelines in the future. This can be frustrating for patients, especially when intentions are driven by aesthetics. I have patients who continue to set aggressive weight loss goals despite now having a “normal” body mass index (BMI). As we shift into the weight maintenance period, it is crucial to set expectations by continuing to emphasize lifestyle modifications for health and to focus on body composition instead of purely on weight. This can be challenging in the primary care setting. I am grateful to have access to body composition analysis in my clinic. I urge primary care physicians to look into community support for accessing this metric; for example, many gyms and fitness facilities have body composition capacity. In the clinic setting, waist circumference can be used to better assess visceral adiposity. Assessing these metrics can help us avoid sarcopenic obesity (when patients have excess adiposity/fatty tissue while having low muscle mass). Patients with sarcopenic obesity could have a “normal” BMI, but are at higher risk for metabolic disease and more likely to experience functional impairments.
As the future of obesity treatments continues to expand, we will have the opportunity to treat disease states with various modalities. We will be able to further customize treatment for patients to appropriately achieve sustainable outcomes. Our future hurdles include addressing the challenges of equitable care. The cost of these medications, lack of qualified providers, bias in receiving treatment, and treatment availability all continue to be significant barriers in a patient’s ability to receive adequate care. Success here will require a unified effort by individuals, health systems, pharmaceutical companies, and governmental policies.
Sreevidya Bodepudi, DO is an obesity medicine and primary care physician at knownwell, a health startup geared to provide weight-inclusive healthcare for every patient. She supports both clinical and research endeavors in her current role.
**Feature photo obtained with a standard license on Shutterstock.
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