Advice by Silvana Pannain, MD Updated March 13, 2023 at 5:13 p.m. EDT|Published March 13, 2023 at 6:00 a.m.
Q. I am hearing good things about weight-loss drugs. Are they effective?
A. Jimmy Kimmel joked about widespread use in Hollywood of the weight loss drug Ozempic during his Oscars monologue, and now many people are searching for more information about prescription weight-loss drugs.
Injectable anti-obesity drugs and drugs for diabetes which induce weight loss such as Wegovy, Ozempic and Mounjaro are gaining in popularity among people with overweight and obesity. Research shows that they cause an average weight loss of 15 to 21 percent.
These medications have helped to change my patients’ relationship with food: “Suddenly food is not so important,” “I do not obsess about food anymore” or “Sometimes I forget to eat.”
They are also helping my patients drop medications used to treat the complications of obesity such as diabetes and hypertension, just two examples of the health benefits of maintained weight loss.
Here are answers to some other common questions about weight-loss drugs:
How were these weight-loss drugs developed?
When I began practicing obesity medicine — the specialty of treating obesity with medical interventions — obesity had not been declared a disease. It was designated as a disease seven years later in 2013.
I soon learned that being an obesity medicine specialist was, at that time, more like being an alchemist. There were no great, proven treatments.
We had to master the art of off-label prescribing and combining — a little of this drug, a little of that and maybe even a third one to try to help patients control hunger and craving. In some cases, the medications we offered were not approved for long-term use. I often wondered how a chronic disease could be treated with short-term medications.
The anti-obesity medications being developed today have come after years of failures and limited drug development. Research has begun to unveil the reason so many struggle to lose weight, and more importantly, to maintain weight loss; why simply eating less and exercising more does not work.
When we try to lose weight, there are biological forces which increase hunger and cravings, and decrease energy expenditure, ultimately limiting weight loss and promoting weight regain over time. With this new understanding of the dynamics of obesity, drug companies are now seeing new promising targets to modify energy balance and promote weight loss.
Drugs approved to control diabetes, such as Ozempic (semaglutide 1 and 2 mg), from Novo Nordisk, and Mounjaro (tirzepatide 5, 10 and 15 mg), from Eli Lilly, are being prescribed for weight loss off-label. And Novo Nordisk’s Wegovy, which is semaglutide with a different dosing regimen (up to 2.4 mg), was approved in 2021 to treat obesity.(Full disclosure: I consult for Novo Nordisk and Eli Lilly.)Eli Lilly is collecting trial data and is aiming for Mounjaro’s approval for weight loss by the end of this year.
How do weight-loss drugs work?
Anti-obesity drugs currently available are appetite suppressants. They modulate the activity of key brain cells to suppress hunger and cravings, and induce satiety.
What are the side effects of weight-loss drugs?
Wegovy approved for obesity and similar drugs approved for diabetes may cause nausea, diarrhea and constipation, but with a slow increase of the dose and doses that can be tailored to each patient, the side effects can be minimized and in most cases disappear over time.
Who would benefit from weight-loss drugs?
These medications are mainly targeted to people with obesity body mass index (BMI) greater than or equal to 30 kg/m², or overweight with BMI greater than or equal to 27 kg/m², and comorbidities.
But even those who do not meet FDA criteria for use of anti-obesity medications are hoping to get access to these treatments and any off-label version of them.
BMI is, arguably, just one measure of excess fat accumulation. Some individuals with a BMI below 27 kg/m² have a large waist size and manifest some of the complications of excessive fat around their abdomen, which is linked to a higher risk for metabolic and cardiovascular disease.
One other case where BMI does not tell the whole story is in people of Asian descent, who are more likely to develop fat around their abdomen. It’s partly why the World Health Organization has proposed lowering the BMI cutoff for Asian populations to consider anything 23 or higher as overweight.
These individuals could also benefit from effective weight-loss drugs to achieve sustained weight loss over time.
Your health questions answered
Are insurance companies approving weight-loss drugs?
With over 70 percent of the U.S. population suffering from overweight or obesity, many are asking their physicians for effective weight-loss treatments. Even those who do not need to lose much weight are seeking the new drugs.
These treatments are expensive — they cost about $1,300 per month — and insurance may not cover it. Many commercial insurers still view anti-obesity medications as poorly effective, lifestyle drugs or weight loss treatments as just a vanity.
Sixty to 70 percent of commercial plans do not cover anti-obesity medications. And almost two-thirds of those who offer coverage try to limit it by requiring prior authorization approval — getting approval from the insurance company for a covered treatment — which seems like nonsense and leads to more paperwork.
Few Medicare and Medicaid plans are covering anti-obesity drugs so far.
When it comes to state plans, the authors of “Obesity across America,” a research report published last year, say: “Fifteen Medicaid programs cover antiobesity medications in fee-for-service Medicaid, and only four additional programs cover antiobesity medications under at least one Medicaid managed-care plan. Only two states cover antiobesity medications in benchmark Marketplace plans, and 16 state employee plans offer such coverage.”
With some of the newest drugs, results are close to those achieved with bariatric surgery, yet surgery is more widely covered than medications.
We still have a long way to go before insurance plans consider weight-loss medications effective and not just vanity drugs, despite years of advocacy by medical societies for recognition of obesity as a serious, chronic, relentless and progressive disease. This disease, over time, affects the health, quality of life and life expectancy of our patients.
Do patients have to stay on weight-loss drugs indefinitely?
Many of my patients have struggled with their weight for almost all of their lives. Obesity is a chronic disease, and it needs chronic treatment. These treatments are to help people lose weight and maintain the weight loss, and yes, they should be taken indefinitely.
I remind my patients that it is their decision to stay on medical therapy long term. Very few of my patients have voluntarily stopped medication. Those who did have done so because of changes in insurance coverage or a shortage of the product.
Are weight-loss drug shortages affecting patients?
There is a supply problem for these medications because the companies that make them did not anticipate this unprecedented attention and demand. Also, the treatments were launched with a strategy to have as many patients as possible on them, even before insurance kicked in. Finally, the drugs approved for diabetes are being used off-label as a weight-loss tool, and that information has exploded across social media.
The shortage is also affecting patients with diabetes, who were the original beneficiaries of many of these treatments.
The days in the office when I have to tell patients that the drug they need is not covered by insurance, or they must stop it because of supply shortage are difficult days in my clinic. As doctors, we are looking forward to the day when all our patients in need will have access to effective weight-loss drugs.
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