By RICHARD FRANK
The demand for GLP-1 drugs rose sharply last year and will not slow down in 2024. Employers and health insurance companies are understandably concerned about how long they will have to pay for these expensive medications. They long for an easy exit.
Some solutions are emerging that pave the way. Many of them claim they can help patients reap the benefits of GLP-1 in a short period of time and get them off the medication within 12 months to save costs. But the data doesn’t support that promise. In fact, studies suggest that some patients may need to continue taking the medications indefinitely to maintain results, while other patients may be able to discontinue the medications and at least maintain their cardiometabolic risk reduction even if they fail to maintain their weight loss can be fully maintained.
A better strategy for controlling costs is to more accurately identify those who really need the drugs—and keep those who don’t off them from the start. Of course, there will be times when deprescribing is appropriate and we need to clinically support patients through this process. But one-size-fits-all solutions that focus on drugs as a panacea for obesity only set patients and payers up for failure. Likewise, those whose only promise is not to prescribe are not following the evidence.
It is foolhardy to prescribe GLP-1 supplements with the goal of no longer prescribing it
GLP-1s treat obesity, but do not cure it. GLP-1 agonists increase the body’s production of insulin and slow the movement of food from the stomach into the small intestine. The medications help people eat less by curbing cravings and increasing satiety. Studies show that after stopping semaglutide, cravings come back in full force – and with them a lot of the weight.
While GLP-1 drugs produce near-miraculous results for some people, they are not a quick fix. Obesity is a complex chronic disease. Medications alone cannot address the genetics, behavior, mental and emotional components, social determinants of health, and other factors that contribute to obesity. Under the right circumstances, medications can help people better manage these factors—but they’re not for everyone.
Keto is not a sustainable replacement for GLP-1
Even highly restrictive diets like the keto diet are not for everyone. Keto requires a drastic reduction in carbohydrate intake, which is difficult to maintain in the long term. Not to mention, the high fat content of the keto diet can also lead to other health problems and is not conducive to stopping GLP-1 medications. Side effects of the medication can make a high-fat diet difficult to tolerate.
It’s good to be wary of solutions that promise a way out through highly restrictive diets. While a keto diet can help people lose weight in the short term, studies show that weight loss rarely lasts in the long term and can be detrimental to overall health. The diet is associated with many complications, often leading to hospitalizations for dehydration, electrolyte imbalances, and hypoglycemia.
Deliver the right care to the right people at the right time
The complex nature of obesity requires an individualized treatment approach that provides the right care to the right people at the right time. This requires an entire care team of specialized providers – such as registered dietitians, health coaches and prescribers – to help people at different stages of the disease. And because obesity often occurs along with other cardiovascular diseases such as high blood pressure, diabetes, COPD and more, patients need the help of specialists who understand how these different diseases work together.
Behavioral interventions that focus on eating habits, sleep hygiene, and exercise routines can be very effective for many people. Studies show that people who participate in behavioral weight loss programs for more than 12 sessions lose approximately 5-10% of their body weight. That may not seem like much, but only 5% of weight loss is associated with healthier biomarkers. When the goal is better health—and not just quick cosmetic fixes—behavioral interventions can work very well.
Others may need to supplement behavior modification with proven weight loss medications like Contrave or Topomax, which have been around for decades. These work for the vast majority of patients who need help losing weight. Approximately 10-20% of the population may require even more intensive medications such as GLP-1 medications, but this is the exception and not the rule.
Optimize results for those already taking medication
Significant side effects hinder the progress of many people taking GLP-1. To achieve the best results from medications, people need comprehensive support from expert providers. Registered dietitians can help develop ideal meal times and nutrient-dense foods that patients tolerate well. In fact, the FDA only approves the use of GLP-1 drugs when prescribed in combination with calorie restriction and behavior modification.
As we invest in these costly but life-changing treatments, we should ensure their success through medical nutritional therapy and other personalized care.
Maximize prescription success
No matter how much support is given, there will be some people who simply cannot tolerate the medication or choose to stop taking it for various reasons. Prescription withdrawal may also be necessary if a patient’s medical condition changes: pregnancy, major surgery, or other condition for which discontinuation of the medication is advisable in their short- or long-term care plan. But we should not forcefully encourage patients who rely on GLP-1 to stop taking the medication just to save money. This is not how ethical medicine is practiced.
We must give patients the greatest possible success, even if a prescription withdrawal is necessary. Highly restrictive diets are unlikely to work for most people who avoid GLP-1. They need more sustainable approaches to maintaining a calorie deficit and managing eating behavior, including emotional aspects, while maintaining adequate nutrition. Supporting patients with medical nutritional therapy and health coaches led by a nutritionist can help ensure patients receive the best nutrition and care as they navigate this transition.
Richard Frank, MD, MHSA is the Chief Medical Officer of Vida Health