For decades, people with obesity have been told, “Eat less and move more.” While those are undeniably helpful behavioral changes, they’re rarely sufficient to help people with obesity lose significant amounts of weight. That’s because, contrary to popular belief, obesity isn’t about a lack of willpower, and it doesn’t always neatly follow a Calories Consumed < Calories Burned equation.
Startling numbers: 42% of the US population lives with obesity. And 30% more is overweight. That means more than 70% of Americans are carrying excess weight, a risk factor for more than 200 chronic diseases including hypertension, type 2 diabetes, heart disease, sleep apnea, several cancers and, more recently, increased severity of COVID-19.
In 2013, the American Medical Association officially recognized obesity as a disease. This was an important leap forward, helping to open the public’s and the medical community’s eyes to the fact that obesity is not a choice but rather the result of complex factors, including genetics…socioeconomic status (which impacts access to healthy food)…medications a person may be taking for other conditions…sleep…and more.
A NEW MEDICINE THAT WORKS
There has been a renewed call by specialists to reshape how we view weight management. A healthy lifestyle that includes whole, nutrient-dense foods, exercise, stress management and restful sleep is at the foundation, but for many people, this isn’t sufficient to achieve a healthy weight. They need a more aggressive approach— and that can mean medication.The Food and Drug Administration recently approved the anti-obesity medication (AOM) semaglutide (Wegovy)— the first such treatment to receive approval since 2014. Originally used to treat type 2 diabetes under the brand name Ozempic, this drug works in the brain to reduce hunger and cravings. Like other AOMs, semaglutide is for patients with a body mass index (BMI) of 30 or higher…or for those with a BMI of 27 or greater who have at least one weight-related condition, such as high blood pressure, high cholesterol or type 2 diabetes.
Recent study: In a 2021 New England Journal of Medicine study, 1,961 adults were injected weekly with 2.4 mg of semaglutide or received a placebo for 68 weeks. All the participants also received individual counseling on diet and physical activity every four weeks. On average, those in the semaglutide group lost 15% of their body weight (for example, someone who started at 230 pounds lost 34.5 pounds.) One-third of people on semaglutide lost 20% or more of their body weight—a loss approaching that typically experienced after a sleeve gastrectomy, in which the majority of the stomach is surgically removed. Less than 5% of those in the placebo group lost 15% of their weight via diet and exercise alone compared with 50% for the semaglutide group. These results are far superior to those seen with other weight-management medications, which tend to lead to a loss of 6% to 11% of one’s body weight. This means semaglutide is about 1.5 to two times more effective than other AOMs such as Contrave (naltrexone/ bupropion) and Qsymia (phentermine/ topiramate ER).
The fact that so many of the study participants taking semaglutide lost 15% of their weight is noteworthy because that benchmark is where we often see obesity-related conditions such as high blood pressure and type 2 diabetes begin to reverse or even go into remission. And despite what weight-loss companies and gyms claim, it is very difficult to achieve this degree of weight loss with diet and exercise alone.
TREATING OBESITY AS A DISEASE
People who struggle with their weight have historically resisted using AOMs and surgeries for a variety of reasons…
Stigma. There’s ample stigma surrounding obesity in general and medication for obesity specifically. People trying to lose weight feel as if they should be able to “do it on their own” by working out and cutting calories. These tactics are important, but they’re often no match for a genetic tendency toward obesity and they can’t undo the impact of living in an area with limited access to fresh food or gyms. There’s no shame in needing chemotherapy to treat cancer, but many individuals with obesity feel shame over needing medication.
A person with obesity doesn’t just take medicine and instantly lose weight. It needs to be combined with regular physical activity and a healthful, calorie- controlled diet. Most AOMs help dampen appetite…reduce cravings and thoughts about food…and make you feel more content between meals. With those reinforcements, people are better able to adhere to a healthy lifestyle.
Lack of coverage. Medicare explicitly rules out coverage for AOMs. But Medicare Advantage plans provide Part A and Part B coverage along with extra benefits and may offer expanded coverage for weight-loss treatment plans. Medicaid may cover them, depending on the state in which you reside. Coverage from private insurers varies from no coverage at all to limited coverage, meaning there still is a substantial copay. Insurers may not cover these drugs the way that they cover other medications because they do not view obesity as a chronic disease (as opposed to an aesthetic and thus elective issue)…and/ or perhaps they realize that with millions of potential candidates, the cost could be astronomical. Certain drugs may be affordable for some people—Contrave and Qsymia (see page five) may cost about $100 a month after insurance if you work with a mail-order pharmacy. Semaglutide costs about $1,000 a month, rendering it out of reach for most patients.
SHOULD YOU TRY AN AOM?
If your insurer covers semaglutide or you can afford the $12,000 out of pocket annually, ask your primary care provider if you are a candidate. Many doctors don’t mention AOMs, primarily because they haven’t been trained to do so. Semaglutide comes in two versions. The 2.4-mg version, used in the NEJM study, is branded Wegovy and is approved for chronic weight management. The lower, 1-mg dose, Ozempic. is approved for type 2 diabetes. Important: If you have diabetes, the lower dose of semaglutide likely will be covered by insurance.
Semaglutide is self-administered via a weekly injection in the belly, just under the skin. You will start at a lower dose and gradually build up to the full dose over four months. You should notice a reduction in appetite more or less immediately. Side effects include nausea and/ or diarrhea, but these tend to dissipate with continued use. The medication should not be used by patients with a personal or family history of medullary thyroid cancer or in patients with the rare condition multiple endocrine neoplasia syndrome type 2 (MEN-2). Your health-care provider will be able to tell you if you are a candidate for its use.
There are several other AOMs on the market. Two of them, both taken orally and costing about $100 a month, are…
Contrave. This combination of the drug naltrexone used to treat alcohol dependence and prevent relapse of opioid addiction and the antidepressant bupropion leads to an average weight loss of 8% of one’s weight. Side effects can include headaches, constipation, insomnia and dry mouth. People with uncontrolled hypertension, a history of seizures or a history of opioid use or dependence should not use Contrave. Smokers may experience an added benefit, though—bupropion assists with smoking cessation by reducing cravings in the reward center of the brain.
Qsymia. This is a combination of the stimulant phentermine and topiramate ER, commonly used to treat migraines and epilepsy. Patients can expect to lose 7% to 11% of their body weight. Side effects include dizziness, insomnia, constipation, dry mouth, tingling of the fingers and altered taste. People with hyperthyroidism, uncontrolled hypertension, coronary artery disease or glaucoma should avoid Qsymia, as should those who are sensitive to stimulants.
AOMs need to be taken long term. Be sure you have reasonable expectations about how effective the medicine will be. Work with a counselor or registered dietitian to understand these medications and craft a nutrition and exercise plan.
If cost is a barrier: Semaglutide and other AOMs are costly. Ask your doctor for a referral to an obesity medicine specialist, who can determine if you are a good candidate for any of them. Some are available in generic form, which increases affordability.
If you are employed, contact your human resources department to encourage your employer to include AOMs as part of its group health insurance plan. You also can join the Obesity Action Coalition (ObesityAction.org), a national advocacy group composed of like-minded people that provides educational resources and advocates for more access to treatments.