By Joan Tupponce

Turn on the television any time of the day or night and within minutes you’ll probably see a catchy commercial for an injectable weight loss drug. Some people might believe these drugs are the “magic bullet” they have been waiting for. But, only time will tell.

According to 2017–18 data (updated in 2021) from the National Health and Nutrition Examination Survey, (NHANES), using measured heights and weights, indicate that an estimated 42.5% of U.S. adults aged 20 and over have obesity, including 9.0% with severe obesity, and another 31.1% are overweight. 

“Obesity is a chronic, progressive and relapsing disease and needs to be treated as such,” said Susan Wolver, M.D., clinic director of the VCU Health Medical Weight Loss Program. “In 2018 only one-half percent of everyone eligible to be on weight loss meds were on them.”

Weight loss medicines aren’t new. They have been available since the 1950s. The recent surge of interest and subsequent advertising frenzy revolves around the newer anti-obesity injectable medications — Ozempic® (which is not FDA approved for obesity, just diabetes), Wegovy®, and the newest, Zepbound®.

“All of the injectable medications were initially used for diabetes, and they found that people were losing weight on them,” Wolver said. “The earliest one that was approved for obesity, Saxenda®, was actually 10 years ago.”

The injectables are glucagon-like peptide-1 receptor agonists, known as GLP-1 RAs, that mimic the actions of the natural GLP-1 hormone, which is released by the gut after eating.

“It tells the brain that you’re no longer hungry,” Wolver said. “It makes you feel full.”

Results from the injectables have been notable. People in a study on Wegovy showed a more than 15% weight loss at the maximum dose. A study on Zepbound showed a more significant weight loss of 21%, “which is substantially more than you can expect to get from lifestyle alone,” Wolver said. “These medications help people lose weight and help them keep it off.”

The drugs have many positive effects, everything from a reduced appetite to benefits to the heart, kidneys and liver. Other potential benefits are being studied for things like polycystic ovarian disease, depression, Alzheimer’s, Parkinson’s disease and substance use disorders.

But they also come with side effects. Many people will experience gastrointestinal issues that can include nausea, vomiting, constipation, diarrhea and heartburn. The medicines can also cause other side effects including gallbladder disease, an increased risk of fracture and possible pancreatitis. Women also need to be on reliable birth control if they’re taking these medications.

People can’t go on the drugs for a short amount of time, lose weight, and then promptly stop taking the medication. These drugs are long-term drugs, meaning you may have to be on them the rest of your life.

“When you stop the meds, you can rapidly regain weight,” Wolver said. “Also, the drugs are not covered by many insurances including Medicare and the cost is $1,300 a month if you are paying out of pocket. However, Wegovy and Zepbound now recently have cash pay options which are about half the retail price.”

Because these drugs don’t have a long history of usage Wolver said: “we don’t know what we don’t know”.

Many insurance companies require that patients be monitored to ensure they are incorporating proper nutritional and exercise behaviors into their lifestyle.

Eligibility for weight loss medications

Not everyone is a candidate for weight loss drugs. People have to have a body mass index (BMI) of 30 or more than 27 if there is a comorbidity, meaning another condition related to obesity like high blood pressure. However, because of the cost of these medications, some insurance companies are introducing their own criteria for eligibility or requiring step therapy with the oral drugs.

When Wolver works with patients, she performs an extensive evaluation of all the factors that may contribute to their weight issues.

“People usually don’t come to me with normal BMI’s. I treat the disease of obesity,” she said. “Our main goal is to get people healthy and not necessarily to lose weight. We use lifestyle modification which includes teaching them how to eat a nourishing diet, along with exercising and behavior modification. We talk about their sleeping habits and managing their mental health,” she said. “If they are eligible, we discuss medications or surgery.”

She explains that our bodies are not programmed for weight loss, especially extreme weight loss. That phenomenon goes back to the metabolism of our caveman ancestors when weight loss was a danger.

“Our internal systems tell us to push against weight loss. We call that metabolic adaptation,” Wolver said, adding that when someone starts to lose weight, hunger increases, and metabolism slows over time. “No matter what your goal, whether it’s weight loss, surgery, weight loss medications or just changing your diet, all of those things eventually, over time, become less effective because of metabolic adaptation.”

She advises that anyone taking weight loss drugs should try to keep up their muscle mass and metabolism as much as possible by eating enough protein, exercising, and doing strength training.

Shedding a light on societal issues through education

One of the positive aspects of everyone talking about the newer weight loss drugs is that they have helped people who have been shamed and blamed about their weight speak out about the disease.

“Obesity affects every facet of a patient’s life, so when you help them get healthy and lose weight, it changes lives,” Wolver said. “I feel like I cure cancer every day because I watch my patients transform in the way they’re able to manage their everyday lives and the joy they get from getting healthy and feeling better.”

On the other hand, the success of the drugs puts a renewed spotlight on body image and the desire to be thin at a time when there has been an emphasis on body positivity at any size.

“A long time ago you only saw thin people in magazines and on television before the movement that emphasizes body positivity. I am all about body positivity,” Wolver said. “I love seeing so many more people represented in color of skin and body type.”

The desire to be thin may set some people who do not have obesity on a path to alternative ways and means of attaining weight loss drugs. Because these drugs are on the FDA shortage list, they are able to be compounded. There can be less than optimal oversight of this process and some people have been hospitalized.

Most of the patients who have obesity tell Wolver that they have tried everything they can to lose weight.

“Oftentimes, they have been told by their providers to eat less and move more. Although exercise is critically important to good health, especially as you age, it doesn’t help much with weight loss,” Wolver said. “We try to look for root causes and help them with that, whether that be challenges with understanding a healthy diet, being able to implement it, barriers to exercise, mental health issues or disordered eating. Nearly one in four people who come to our program has undiagnosed disordered eating.”

Patients who turn to VCU Medical Weight Loss program are desperate for help and Wolver cares deeply about helping them.

“That is what I am passionate about,” she said.