Ozempic, Wegovy, Mounjaro, Zepbound – all drugs in the GLP-1 category – have become the topic du jour of healthcare conversations the way Chat GPT has monopolized technology talk this year.
And perhaps for a good reason, these drugs, whether FDA approved for treating diabetes or obesity, have shown remarkably strong weight loss results with better than before safety profiles. And one branded drug after another is trying to beat the previous ones with the highest possible headline weight loss result to market: from -10% to -15%, -20% and so on.
As a result, most of the popular press has centered around the benefits of these drugs, painting them as the “magic pill”, albeit expensive, that will solve our obesity epidemic, as long as everyone has access to them.
Little has been written about what’s happening in the ‘real world,’ outside of hyper-supervised pharma-funded drug trials. We and our collective organizations’ providers have treated 10,000’s of Americans, who suffer from obesity and/or Type 2 diabetes with these GLP-1 drugs. And we believe we have important observations to share.
First, while manufacturers promote -20% weight loss, real world effectiveness is more around -10%. This is what we’ve seen among our patients with obesity, as well as what has been published and peer-reviewed in studies. This is not unheard of, but important to keep in mind.
It is also important to ask – since these same GLP-1’s have been approved for use with people living with type 2 diabetes since 2005, why haven’t they solved obesity (and possibly T2D) in the last 18 years or at least become the one and only miracle drug? We have more people with T2D than ever before and the average outcomes are no better now than a decade or two ago.
Secondly, an alarmingly high percentage of the weight loss is lean body mass (LBM) i.e. muscle. It is not uncommon that 60% or even 70% of weight loss is muscle. So you might lose 40 pounds, but 25 pounds of that is LBM, making you more likely to regain weight and deteriorate overall health. Losing LBM is an issue for everyone, but particularly for older patients. For health and even aesthetic benefit, weight loss should be body fat loss.
Thirdly, many of our patients report such unpleasant side-effects, from nausea to vomiting and even pancreatitis, that they’re unwilling or unable to continue the GLP-1 therapy. Others have reported that 70% of patients come off of these drugs within the first 12 months.
Consequently, here’s the real dilemma: In the absence of something else that works after the drug, the weight comes back when patients come off of these drugs, and the great majority of patients that we have treated either can not or do not want to be on these drugs for the long-term.
In light of our experiences, these drugs seem more like an effective short-term patch – and expensive at that – than a systematic, long-term solution to our obesity epidemic. So the likelihood that millions of people would be successfully on these drugs forever and maintaining health and sustained weight loss, seems infinitesimally low.
This leaves us with the question: what comes after the drug, if you ever get on it in the first place? Coincidentally, Senator Cassidy who is on the Health, Education, Labor, & Pensions Committee (HELP) recently asked the very same question at the Milken Institute event – what comes after the drug? How can we use nutrition here? A very good question, indeed.
We have some experience with that too. Based on our data set treating patients over the last 7 years with Ozempic and other GLP-1 agonist medications, contrary to all other published evidence, it is possible to safely de-prescribe these medications and sustain achieved -10% weight loss at that level for a year or more (the period we tracked in this case). This is actually a remarkable outcome and the maintenance therapy was possible with nutrition, combined with intensive counseling and support, all virtually through telemedicine. We also used nutrition in such a way to mimic reported effects of GLP-1: feelings of reduced hunger and cravings, which reportedly made it sustainable and easy for our patients to follow. This is very good news.
Interestingly, contrary to the conventional wisdom that Americans are unwilling or unable to change their behavior and would rather just “take a pill” to lose weight, nearly all of our patients would rather be healthy without drugs. Unfortunately, most patients have been told that “all diets fail,” and that medications are the only solution. Doctors often don’t have the time to investigate the out-of-pocket cost to patients, ask about things like affordability, or assess patient goals and preferences around medications. So patients end up on meds they don’t want to be on, often spending large amounts of money.
The most common goal we hear in working with new patients is “to get off as many medications as I can” or “to stop spending $1000 a month on Ozempic.” Surveys of people across the country have shown that most people aren’t interested in taking obesity medications, and that interest in obesity medications decreases dramatically when they are told they likely must take them for life to maintain success. We have found that when patients are provided the tools and support and they see success in losing weight, they can’t wait to be off of any unnecessary pharmacological therapy.
So where does this leave us based on our real world experience treating 10,000’s of patients on Ozempic over the last 7 years?
We believe GLP-1’s for obesity can be a tool for a select group of patients, particularly those who’d otherwise be in line for an even riskier, even more invasive and even more (short-term) expensive treatment such as bariatric surgery.
But most importantly, given the evidence, we have to focus on deploying nutrition i.e. lifestyle modification based treatments with proper support because they can work and are likely the only real solution to our obesity epidemic as a better alternative to these drugs – and likely the only post-drug option for sustained weight loss. We now have the evidence to show it’s not only possible, but already deployed in the real world.
Photo: Jason Dean, Getty Images
