Obesity has become a major scourge in America, but new medications are now available, and although many questions remain, these drugs may revolutionize the treatment of obesity.
What causes people to get fat? For many years, doctors adhered to a simple equation: If you eat more calories than you burn, you will put on weight. While this is true, it’s an oversimplification because all calories are not the same: Foods of equal caloric value have different effects on suppressing appetite and hormone release. Gaining weight is dependent on many factors including genes, hormones, metabolism and even personal gut bacteria.
Throughout most of the last century, the treatment of obesity consisted of low-calorie diets, greater activity and counseling. Various diets were often effective at the outset, but many patients regained weight later. Counseling that involved “fat-shaming” often had a counterproductive effect — chastising patients caused them to eat more. Several types of surgeries have proved reasonably safe and effective, but they are invasive and not always reversible, and they represent a major commitment by the patient.
In the past 10 years, new medications have arrived on the market, including six approved by the U.S. Food and Drug Administration. The newer drugs stimulate hormones that trigger insulin release and readjust fat storage. Currently, the most popular is semaglutide, known by the brand names Ozempic and Wegovy. The drug is a once-a-week self-administered injection. The most recently FDA-approved weight-loss drug is also an injectable, tirzepatide, which has a similar but slightly different mechanism of action.
Studies have consistently demonstrated that these drugs are extremely effective in causing weight loss. Besides their hormonal effects, they suppress appetite and delay absorption of food. People who take these medicines for a year cut their caloric intake and lose roughly 15 percent of their body weight. Reports suggest that patients also reduce their intake of sugary carbonated drinks and alcohol. A recent study in the New England Journal of Medicine found an added benefit to some of these weight-loss drugs: an impressive reduction in heart attacks, strokes and cardiac deaths in obese patients with heart disease.
These medications have side effects, some of which are common and can be distressing, including nausea and bowel problems that cause some patients to abandon treatment. Serious eye, thyroid and pancreatic problems occur rarely. A further problem is the uncertainty whether these medications must be taken indefinitely. Some people have regained weight after stopping therapy. No one is sure about the long-term risks, benefits and complications of these drugs, which remain to be studied in patients on lifetime therapy.
Finally, there is cost. These medications are currently quite expensive, in the range of $1,000 per month, although this varies widely depending on drug company pricing strategies and the patient’s insurance. Many experts anticipate the cost of these medications will drop as new competitors, some in pill form, enter the market. As insurers realize savings from preventing heart disease and diabetes, they may encourage Congress to have the government pay for these drugs.
Semaglutides and related drugs represent a new vista for the treatment of obesity, America’s fastest growing medical problem. There is still much to learn, and there will be refinements in therapy in the future. Considering the costs, complications and alternatives, these medications are not for everyone.
Now, more than ever, obesity is a treatable condition. With the range of options available, patients need not suffer the health risks and indignities they endured in the past. But be forewarned. You might be able to lose weight on your own through diet and exercise, and it is a serious undertaking to commit to a medicine possibly for life, one in which the long-range effects are unknown. It is not a decision made lightly.
Dr. Cory Franklin is a retired intensive care physician. Dr. Robert Weinstein is an infectious disease specialist at Rush University Medical Center.
