Care New England Health System recently hired Dr. Max Cohen as part of the Medical and Surgical Weight Loss Center at Kent County Memorial Hospital. Cohen spoke with Providence Business News about best practices and the popularity of weight-loss drugs.
PBN: How have you seen patients’ interest in weight-loss drugs change recently?
COHEN: With the emergence of highly effective injection weight-loss drugs such as Wegovy and Zepbound, interest in medication-assisted weight loss has surged with a simultaneous shift in societal views on weight management.
These advances in the treatment of excess weight have been accompanied by a much-needed evolution in the scientific understanding of the underlying processes being treated in this complex, multifactorial chronic condition. This has allowed us to start moving away from systems that stigmatize patients and attribute weight issues to a failure of willpower.
In recent years, I’ve found that both patients and health care providers alike have become more accepting of the concept that medications may play an important role in a person’s unique weight-loss journey. For many patients, these drugs are lifesaving, and people are taking notice.
I think this has also improved provider morale as we now have some highly effective tools in our toolbelts to better address one of the greatest health concerns of our generation. Unfortunately, interest has also been piqued by a large group of people who see these medicines as tools to meet some unrealistic aesthetic standard and many of these people have more to lose than to gain.
PBN: Who are weight-loss drugs right for?
COHEN: Weight-loss medications are currently FDA [Food and Drug Administration]-approved for people who have a BMI [body mass index] greater than 30 or a BMI less than 27 with a weight-related health problem such as high blood pressure, sleep apnea, or type 2 diabetes.
National organizations unanimously recommend comprehensive lifestyle modifications focused on nutrition and physical activity as the first line of defense for weight management. For many patients, and in the eyes of many insurance companies, this means waiting to trial a medication unless insufficient weight loss is found after several months of a good diet and exercise regimen.
Those who already have weight-related health problems, however, may have benefits that outweigh the risks to start a weight-loss medication concurrently while initiating healthy lifestyle changes.
It’s important to acknowledge that all medicines have a spectrum of risks and benefits, and just because somebody technically qualifies by the minimum criteria, it does not mean that the risks and side effects are justified in the context of their unique biology, goals and previously attempted interventions. At a higher BMI and with more weight-related problems, the decision becomes clearer.
PBN: What are some common myths related to weight-loss drugs you’ve noticed?
COHEN: The field of obesity medicine is advancing rapidly. This makes it hard for the average person to follow myth versus fact. I hear from a lot of people that they think these medications are easy or a silver bullet, but that is simply not true. Although these medications can reduce excessive hunger signaling in the brain and reduce calorie intake, they can’t force you to move your body and they can’t choose your next meal. A healthy lifestyle is still needed to have their maximal health benefit - eating nutrient-dense foods and getting regular physical activity. There are also several barriers to obtaining and succeeding on these medicines including pharmacy accessibility, generally poor insurance coverage with substantial cost implications, and side effects.
Similarly, I hear people speaking as if they could never see real results without an injection weight-loss medicine. For many people, dietary and physical activity modifications can produce meaningful weight loss alone, and in others, older and cheaper oral medications can help people reach their goals.
Plenty of research shows that even 5%-10% bodyweight loss can have significant health benefits, but one side effect of these new injection medicines has been that it has drastically moved the needle for expectations in what is considered an effective treatment.
On the other hand, the myth of a scary needle and a painful injection has also instantly turned away many people who would be excellent candidates. The reality is that the needle is hidden and spring-loaded in a pre-filled, user-friendly pen device and most people rate the injection pain around a 5 on a 100-point scale.
PBN: What are some of the benefits and risks of weight-loss drugs?
COHEN: These are potent drugs with tremendous healing potential, but they also tend to have significant side effects. The most obvious benefit of these medications is a weight loss of about 5%-20% body weight in conjunction with lifestyle modifications. Results are highly individualized, with some folks responding very well and others less so.
If a medication is effective for weight loss, it can help prevent and even reverse conditions such as high blood pressure; blood sugar problems such as prediabetes and type 2 diabetes; high cholesterol, one of the most common causes of liver damage; joint pain from arthritis; sleep apnea; certain cancers; and several other chronic conditions.
Ultimately, the goal is not just to die a skinny person with normal values on a blood test but to live a long, happy and healthy life, so it’s important to emphasize that addressing these factors helps prevent heart disease, the leading cause of death in the United States.
There is also a wide variety of other health benefits that can be harder to measure. These are different from person to person – increased confidence, self-esteem, energy, physical ability, decreased pain, improved sexual function, better sleep, etc.
It is also critical to acknowledge the very real risks and side effects that can come with these medications. Firstly, issues such as vitamin deficiencies, hair loss and gallstones can be associated with weight loss regardless of the method. Then there are several weight-loss medications, and each has its profile of risks, side effects and interactions with other medications. Generally speaking, the most common side effects are gastrointestinal, with a large portion of people experiencing symptoms such as nausea, reflux, constipation and diarrhea. Other common side effects are things such as fatigue, headaches, dizziness, fast heart rate and low blood sugar. For most people, side effects are greatest with starting the medicine and increasing the dose, and they tend to get better over time. Severe medication effects such as seizures are rare, and generally resolve with discontinuing the medication, but are always important to consider.
We also need to acknowledge that these newer injection medicines have only existed for 20 years, and we are still learning about possible long-term effects that may currently be unknown or are not clearly associated with the medicine as opposed to the underlying condition. There have been a few reported cases of a condition called gastroparesis, for example, in which there is a severe slowing of the gastrointestinal system and difficulty emptying the stomach, which may not resolve with stopping the medicine. Again, these are very rare occurrences, but patients need to make well-informed decisions about their treatment plans.
PBN: How can someone get a prescription for weight-loss drugs?
COHEN: There are many ways to get a prescription for weight-loss drugs. Many primary care providers feel comfortable managing these medications, which is often the ideal setting to have a risk/benefit conversation with a trusted provider who understands your long-term health picture. If that’s not an option, or if a patient has more medical complexity, patients can be referred to a specialist such as a board-certified obesity medicine physician.
If there are transportation or mobility barriers, several online programs are available, including telehealth services, some of which can be connected directly via drug manufacturers. The Medical and Surgical Weight Loss Center at Kent Hospital can be reached at 401-736-3731.
(UPDATE: Clarifies Dr. Cohen's view of myths to weight-loss drugs in 12th paragraph)
Katie Castellani is a PBN staff writer. You may contact her at Castellani@PBN.com.