Medical management of obesity 'viable' option, but 'not a magic wand'
For patients with obesity, medical management options offer a new opportunity for successful treatment.
“In my practice, I see many patients who are struggling to lose weight despite their best intentions and using maximum ‘willpower,’” Scott Isaacs MD, FACP, FACE, an obesity medicine specialist and medical director at Atlanta Endocrine Associates, told Healio. “They are working hard at diet and exercise, but seeing no weight loss, and they feel frustrated and hopeless.”
He explained that anti-obesity medications decrease “biological sensations of appetite and cravings and enhancing satiety and satiation,” which subsequently “allows patients to maintain a calorie deficit without as much hunger and without as much willpower.”
Isaacs added that “from a provider’s perspective, using an effective anti-obesity medication reduces the need for intensive lifestyle interventions and behavioral modification.”
Healio spoke with Isaacs and Disha Narang, MD, an endocrinology, diabetes and metabolism specialist at Northwestern Lake Forest Hospital, to discuss the recent advancements in the medical management of obesity, when other options are preferred and how to approach conversations about medical management with patients.
Isaacs explained that recent advancements in the medical management of obesity include a widespread “acceptance of obesity as a disease, not a lifestyle choice,” in addition to an increased understanding of biological factors affecting appetite, the neurobiology of obesity and appetite regulating hormones.
Additionally, he noted new anti-obesity medications that have emerged in the last decade and the concept of using these medications chronically have been important advancements in obesity care.
Isaacs stressed that understanding the biological mechanisms that lead to weight gain and hormonal and metabolic changes in weight loss are important in the treatment of obesity as a chronic condition.
For example, he noted that a new medication for obesity management —semaglutide (Wegovy, Novo Nordisk) — is a synthetic version of the satiety hormone GLP-1.
“When someone loses weight, GLP-1 levels drop, so giving a pharmaceutical version of this hormone replaces the missing satiety signal to allow continued weight loss,” Isaacs said.
This past year, the FDA announced the approval of semaglutide for weight loss. The approval followed results from four 68-week trials that evaluated the safety and efficacy of weekly semaglutide at 2.4 mg.
Narang noted that semaglutide had previously been used “with excellent results” in patients with diabetes for weight loss and blood glucose control.
“No other medical weight loss option has resulted in such significant and sustained weight loss,” Narang said. “This is similar to what we can expect with surgical weight loss as well. So, this is a non-invasive, sustainable option for long-term weight loss.”
When to use medical vs. surgical, lifestyle changes
While medical options are available, it is important to recognize that lifestyle changes are integral to treatment strategies among patients with obesity.
“Medical weight management becomes a viable option when combining lifestyle changes and medication,” Narang said. “Medical weight loss options are certainly not a magic wand. In all studies showing weight loss benefit following use of medications for weight loss, combining a conscientious lifestyle with medication has resulted in maximum weight loss.”
Isaacs explained that clinicians can consider anti-obesity medications for patients who do not achieve sufficient weight loss after 3 months of a reduced calorie diet and increased physical activity and who have a BMI greater than 30 or greater than 27 and accompanied by weight-related comorbidities like hypertension, diabetes and dyslipidemia.
“The cornerstone of any weight loss program will always be lifestyle change — diet and exercise,” Isaacs said. “Even when other treatment modalities are used, such as medications or surgery, they must be combined with lifestyle changes.”
Because weight loss medications alone are not sufficient to achieve adequate weight loss, he added, “patients must understand that medications can help them comply with a low-calorie diet, but they must have a plan and follow a diet.”
Patient discussions, advocacy
Narang said that because many patients come into the office having felt “shamed” by their peers and by medical professionals for issues with weight, it is important for clinicians to have a nonjudgmental approach to treatment discussions.
“Telling patients to eat healthy and exercise is often not productive,” she said. “It’s important to get to understand their lives — are there mental health issues that drive emotional eating behaviors, could there be another medical/hormonal cause for weight gain, have they had traumatic life experiences that prevented them from embracing long-term weight loss, what are the barriers to weight loss — it's not always a simple conversation,” she said.
When discussing obesity management with patients, Isaacs said that clinicians should use the five A’s: “Ask the patient’s permission to discuss their weight; Assess the patient with a full medical evaluation including BMI, waist circumference and evaluation for complications of obesity; Advise the patient about the health risks of obesity and the benefits of weight loss; Agree on a plan — present recommended treatment options; and assist the patient in identifying and addressing their home and work environments and other potential barriers to weight loss.”
Narang explained that while obesity affects “nearly every part of our bodies,” and is associated with increased risks for a variety of conditions — including diabetes, liver and heart disease, cancer and stroke — insurers often do not offer coverage for medical management options for obesity.
“This is a significant barrier to appropriate care,” she said. “While that is not necessarily future research, future advocacy is essential. In fact, it is required.”
“Future research on the medical management of obesity should focus on the scientific advances that have been made over the past decade,” Isaacs said. “Many medications are currently in development that are based on our understanding of hunger and satiety hormones.”
He added that there is ongoing research on brown fat regarding “ways to safely enhance metabolic rate.”
Narang said that there is also research underway to examine weight loss pathways that “may allow for combination therapy so that several areas of the hormonal pathway that causes weight gain can be targeted.”
She noted that research is needed on patient selection for current medical weight loss treatments, including optimizing patients with diabetes, CVD and fatty liver disease.
“There are several areas of ongoing research within obesity, from learning more about fundamental obesity physiology, to determining therapeutic targets,” Narang said. “It is imperative to emphasize, however, that these are all just resources to weight loss. It is also important to emphasize that more physicians need to become more comfortable with the use of certain medical weight loss agents as a chronic treatment for obesity.”