GLP-1s are making headlines and are in high demand for their ability to help people lose weight, with five million prescriptions written in 2022. For many people who’ve struggled with obesity, they represent a transformational clinical advance. But what happens if the meds are no longer taken, whether due to high cost or side effects? The weight often comes back, sometimes with a vengeance. Any siloed approach to weight loss – whether it’s medication, behavioral changes, or surgery – is not the answer. Instead, what’s needed is a multimodal and holistic approach. Such a sustainable weight loss model does what an injection alone cannot do – keep the weight off and support a person’s overall health.
A shocking 42% of the adult U.S. population is obese, and that figure is projected to rise to nearly half by 2030. There is a laundry list of health issues associated with obesity, including an increased incidence of arthritis, cardiac disease, stroke, diabetes, sleep apnea, clinical depression/anxiety, orthopedic issues, and even some cancers, plus a shortened life expectancy. Of the 100 million Americans suffering from obesity and related diseases, less than 1% undergo bariatric surgery, which is appropriate for some with a BMI of 30+ based on factors like comorbidities, Type 2 diabetes status, and inability to lose weight through other means. The number and severity of associated medical issues contribute to $480.7 billion in healthcare costs and $1.24 trillion in lost productivity each year. Consumers will spend an anticipated $160 billion on weight loss treatments this year, but 97% will not achieve sustainable, long-term outcomes. Will GLP-1s change that?
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As a practicing bariatric surgeon and PhD scientist, I wholeheartedly support GLP-1s and applaud their development. I have been working to advance the obesity management field for over two decades, and GLPs-1s are doing that. But they are not a solitary or comprehensive solution.
GLP-1s: The golden drug?
GLP-1s, or glucagon-like peptide 1 receptor agonists, were developed to treat Type 2 diabetes. In a person with obesity, GLP-1s delay gastric emptying and increase insulin sensitivity, ultimately reducing a person’s desire to eat. People with diabetes have successfully lost weight with GLP-1s, leading to use by people who are not diabetic. There has been such demand for GLP-1s that the U.S. has seen shortages and the drug companies delayed introducing the treatment abroad.
Currently the medications are cost-prohibitive for most individuals, at up to $1,200 per month. And they are unsettling employers and health plans, as costs and premiums could increase drastically if there is widespread coverage of GLP-1s, especially if not coupled with lowered medical costs and improved health. A recent announcement about the SELECT trial shared that Wegovy decreased cardiovascular disease risk by 20% in obese individuals over age 45, who did not have Type 2 diabetes. Data is not yet public and additional confirmatory studies are needed, but if accurate, this is groundbreaking.
A Personalized Approach to Medication Nonadherence
At the Abarca Forward conference earlier this year, George Van Antwerp, managing director at Deloitte, discussed how social determinants of health and a personalized member experience can improve medication adherence and health outcomes.
Without enough data on GLP-1s adding that value, employers are pushing back. Recently, Ascension and the University of Texas System put their feet down on paying for them, saying the drugs will sink their budgets and increase healthcare premiums. Even if most people initially lose weight, employers and plans don’t want to pay for a drug only to see the patient regain that weight if and when they stop taking it. The rate at which patients halt GLP-1 usage is high. The UT System noted that less than half of those on the medications continued them, with a separate claims analysis showing about one-third of those taking Wegovy staying on it a year later. That rate of adherence won’t solve the problem. Additionally, the UT System said it’s not seen lower health costs from the 3,100 individuals using GLP-1s in its plan.
A new lens into obesity
At the same time as the GLP-1 rise, the medical community and society as a whole are coming around to understanding obesity as a disease, not as a character flaw. There’s greater awareness that calories in/calories out is not a hard-and-fast weight loss rule. Researchers and clinicians are still trying to understand the complicated genetics and microbiome affecting a person’s weight. Even the American Medical Association is acknowledging the complexity behind obesity, noting that BMI is only one factor in assessing whether a person is obese. The disease’s multitude of contributing factors should be our therapeutic guide for a comprehensive approach.
The medical system is increasingly recognizing a multimodal approach as the most effective means of achieving lasting outcomes. The recent annual American Society for Metabolic and Bariatric Surgery (ASMBS) conference theme was Enhancing Outcomes Through Combined Therapies. Experience tells specialists like me that treatment should be tailored to the individual, which can include GLP-1s for some. Select individuals may benefit from it long-term, while others may progress to needing bariatric surgery. Some people may be able to manage their weight exclusively through lifestyle and behavioral changes.
I look at oncology care as a useful model. Individuals with cancer are offered chemotherapy, radiation and surgery as appropriate to their tumor, and the multimodal approach has saved millions of lives. People with obesity should be offered a range of suitable treatments as well: behavioral, nutrition, exercise, medication and surgery, through a coordinated and holistic approach under one roof, with a care coordinator. Like cancer, obesity is a heterogeneous disease and recommendations and responses to all treatment modalities will be heterogeneous as well.
A bigger arsenal of weapons
As with so many aspects of healthcare, it’s not easy to change the system to offer a different treatment model. There is an urgent need to integrate the structural elements of obesity therapy – patient awareness, clinical validation, provider education, therapeutic intervention for whole-person needs, and streamlining the bureaucracy of care – into our healthcare system so that the multimodal approach can build on the attention GLP-1s have brought to obesity disease management.
No single treatment approach is a solo solution. There is no quick fix for obesity. It is a sophisticated disease and it needs a comprehensive and ongoing treatment model. GLP-1s may be part of that equation, but they, alone, cannot solve the problem.
Photo: Peter Dazeley, Getty Images
Rajesh Aggarwal, MD, PhD, FRCS, FACS is the Founder and CEO of twenty30 health, a care coordination platform for metabolic and obesity management for individuals and providers. He is also a practicing physician. Dr. Aggarwal has practiced in the United Kingdom and in the US as GI and bariatric surgeon. Dr. Aggarwal was an early adopter of robotic/VR technology. After 20 years of practicing medicine, he transitioned to a new role as a partner in a digital health start-up and also serves as an investor and advisor for early-stage companies. While at Thomas Jefferson University, Dr. Aggarwal spent nearly 4 years building and running its venture arm to co-develop, validate and scale early-stage digital health start-up companies, including Livongo, Commure, Neuroflow and DinaCare. He received his medical degree from Royal Free Hospital and University College London Medical School.
