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In the GLP-1 Era, Clinical Guidelines for Obesity Care Are Urgently Needed

While the attention GLP-1s are receiving is exciting for medical professionals like me who’ve specialized in obesity treatment for decades, with little fanfare, the ‘miracle drug’ message is misleading and harmful.

The anti-obesity and diabetes drug semaglutide — known by its brand names Ozempic and Wegovy — has taken the medical community by storm. Physicians who regularly dished out the go-to prescription of diet and exercise now have an effective and reliable medication to help patients with chronic weight management.

The problem is that celebrities and clickbait headlines are steering the narrative of this potentially game-changing medication to that of a fad drug that helps shed a few pounds for the upcoming beach weather.

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A Deep-dive Into Specialty Pharma

A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.

But semaglutide is not the latest juice cleanse or diet hack. It’s far from it.

As an endocrinologist who has been specializing in obesity care for over a decade, I can say with near certainty that this new class of anti-obesity drugs — also known as GLP-1s— promises to help countless people struggling to achieve a healthy weight. While the attention GLP-1s are receiving is exciting for medical professionals like me who’ve specialized in obesity treatment for decades, with little fanfare, the ‘miracle drug’ message is misleading and harmful.

Healthcare leaders must come to a consensus on best practices for treating obesity, including the use of anti-obesity medications. Establishing clinical guidelines involves creating a body of clinical consensus statements regarding how physicians prescribe medications as well as discouraging providers from prescribing the newest or most expensive medication as first line therapy. Failing to establish proper guidelines and oversight increases the risk of companies prioritizing profits over effective treatment, and patients receiving inadequate, inappropriate or even reckless care.

The risk of not defining guidelines

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The GLP-1 drugs craze is pushing patients to demand the drug from their doctors without proper diagnosis or addressing lifestyle factors. Outpatient weight loss clinics solely built around GLP-1 drugs are already popping up, promising quick fixes but setting patients up for failure. Relying only on a drug for weight loss is a recipe for disaster.

A well-rounded treatment approach incorporating lifestyle habits is needed to ward off the risk for dreaded metabolic adaptation — when the body adjusts metabolism to compensate for a decrease in calorie intake resulting in a slowdown in weight loss, reversing any gains.

Rapid weight loss is not only unhealthy but also dangerous, as it can result in muscle loss, a decrease in bone density and a severe drop in resting metabolic rate. There is even a phenomenon called “sarcopenic obesity” that can occur with this kind of rapid weight loss where a person’s BMI might be in the normal or even low range, but their levels of lean muscle are so low that fat and bones are the only metabolically active tissue. From a hormonal perspective, this condition looks like obesity. That’s why it is so important for people taking GLP-1s to engage in strength training and as well as increase the consumption of lean protein into their diet.

In addition, in the absence of strong habits around diet, exercise, sleep and mental health, patients will see rapid weight regain if they stop taking the medication versus a slower more controlled gain if lifestyle and behavior factors are in place. And medication plan disruption can be common given most health insurance does not cover GLP-1s.

While GLP-1s are relatively safe, a small percentage of people who use these drugs might be in danger of side effects, such as severe nausea, vomiting, pancreatitis or pancreas inflammation, especially those at increased risk for thyroid cancer.  Anyone considering GLP-1 must have a medical history screening before using it.

Obesity medicine is still in its infancy

Obesity medicine is still a relatively new field, especially when compared to well-established areas like cancer or diabetes. Because of this, most doctors are not trained in obesity care, and only 1% of physicians specialize in it, even though more than 4 out of 10 adults in the United States are obese.

The use of medication to treat obesity dates back to 1959 when the FDA approved phentermine for weight loss. However, it wasn’t until the discovery of the hormone leptin in 1995 by Jeffrey Friedman at Rockefeller University that the field gained clinical relevance. This groundbreaking discovery was the first time that fat cells were viewed as an endocrine gland rather than just a storage depot for fat.

Another significant turning point came in 2013 when the American Medical Association classified obesity as a disease. This recognition of obesity as a disease highlighted the hormonal dysregulation that occurs in people with obesity, and transformed obesity medicine into a legitimate and respected medical field.

In 2021 the FDA approved Wegovy, an injectable version of semaglutide and the first medication authorized for obesity since 2014. The federal agency indicated the drug is to be used for “chronic weight management in adults with obesity or overweight with at least one weight-related condition (such as high blood pressure, type 2 diabetes, or high cholesterol), for use in addition to a reduced calorie diet and increased physical activity.”

Despite this progress, there are still no established clinical guidelines for obesity care.

What should be the gold standard? Well, it’s complicated!

The challenges with treating obesity are that it’s a highly complex disease that varies from person to person.

Based on my clinical experience, any guidelines should treat patients comprehensively, inclusive of physical, emotional and environmental factors, and patients should be supported by a medical professional, preferably one who is trained in obesity medicine. When an individual is diagnosed with breast cancer, for instance, the patient doesn’t continue to get treated by a primary care doctor. No, the patient connects with a care team headed by a physician specializing in oncology.

That should be the same for obesity. A care plan needs to consider medical history, lab work, family history, eating behavior and in some cases, account for a patient’s insurance coverage. Medication can be appropriate, and indeed recommended, for some patients, but it should be coupled with a supportive community and health coaching to reinforce positive habits, healthy routines and lasting behavior change. A clinician should also consider a medication’s cost, accessibility and efficaciousness.

Patients interested in weight loss medication may also find that alternative drugs — many of which have been prescribed off-label for years — are more appropriate than a GLP-1. Some of these medications are often more affordable than a GLP-1, which isn’t typically covered by insurance and can cost hundreds if not thousands of dollars a month out of pocket.

Obesity is not a moral failing or a lack of willpower; I can’t emphasize this enough. It’s a treatable and preventable disease that requires a comprehensive approach. We must consider a person’s biology, genetics, sleep, stress, and overall lifestyle to combat this epidemic. Defining guidelines won’t be easy. We need standards to protect patients, legitimize obesity medicine, and shape the future of the field.

Photo: Peter Dazeley, Getty Images

Rekha Kumar, MD, MS is a practicing endocrinologist, obesity medicine specialist, and the chief medical officer of Found, an evidence-based weight care platform. She also served as the former medical director of the American Board of Obesity Medicine and has authored papers and textbook chapters on the medical management of obesity.

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