There is a tremendous amount in the news lately about weight loss medications – so much so that it is tough to interpret all of the information. We get the following questions from our patients all the time:
- Is having excess weight really a big deal? Shouldn’t I just be happy with my weight?
- What is the best diet for losing weight?
- Can you prescribe me semaglutide (Ozempic®, Wegovy®) or tirzepatide (Mounjaro®)?
- Those medications seem effective, but are they safe?
We will discuss some of the most recent evidence on this topic and our approach at Paradigm Health for safe, effective, healthy, and maintained weight loss.
Framing the Conversation
We (Dr. Matt and Dr. David) want you to know that we have used semaglutide for weight loss personally. This resulted in losing >15% of total body weight for each of us and moving both of us from the obese category to normal weight. Our blood pressure is better, our glucose is better controlled, and our backs and knees feel better!
There are a lot of opinions around these medications and an inexcusable amount of shaming that can occur. If patients have hypertension, high cholesterol, diabetes, etc., we desire them to be compliant with a health optimization strategy, which often includes using medications to help control these diseases and prevent harmful outcomes like having a stroke or heart attack.
We almost never hear about anyone being shamed for needing to take blood pressure, cholesterol, or diabetes medication. In fact, just the opposite! Doctors complain that patients are not compliant with the medications that can help. But somehow with a disease that we can see (excess body weight), some people, including some physicians, are shaming patients “who take the shot.” This is wrong and should not happen and it is not tolerated by the Paradigm Health team.
There has also been increased availability of weight loss medications. Many people use them without benefiting from a therapeutic relationship with a supportive physician. In many cases, there is sub-optimal evaluation before starting medication, little to no monitoring as weight loss and side-effects occur, and no plan implemented that considers overall health. We take issue with this approach.
We are both board-certified in Obesity Medicine by the American Board of Obesity Medicine (ABOM) and thus know and apply the latest evidence concerning healthy, safe, effective, and lasting weight loss. So, let’s get to the discussion!
The Risk: Is Being Overweight Really a Big Deal?
The answer to this is unequivocally ‘yes’ if the goal is healthspan. In our practice we use the terms “excess weight” or “unhealthy weight” rather than the word “obese” because we want to avoid terms that shame people and stigmatize health issues. However, for the sake of this article we will use terms as they have been used historically.
The degree of excess body weight is typically defined by body mass index (BMI). This is not a perfect metric, but for the overall discussion it is helpful to know how it is used by healthcare providers.
The figure above shows how BMI is used to classify the level of excess weight. These standard definitions are used in research studies to understand the level of risk corresponding to weight. You can easily calculate your BMI by using the calculator here.
Shaming someone for their size is never okay; but this does not mean that we should avoid discussing the risks of excess body weight. The table below shows a list of conditions for which individuals with excess weight are at increased risk; the risk for many diseases is often several fold higher. In our clinic we focus on optimizing lifespan and healthspan and excess weight shortens both of these.
The 5 major causes of death in the United States are:
- Cardiovascular disease
- Cancer
- Neurocognitive disease, including dementia
- Pulmonary disease
- Metabolic disease, like diabetes
For those with goals of lifespan and healthspan, weight loss is one of the greatest ways to reduce or delay the risk of these diseases.
So, let’s go – all I need to do is lose some weight?!
Yes and no.
Four Points to Consider
The 2024 weight loss landscape
First, it is clear that the GLP-1 (glucagon-like peptide-1) and glucose-dependent insulinotropic polypeptide (GIP) medications (e.g., semaglutide and tirzepatide, respectively) are game changers for weight loss. Numerous studies have demonstrated reductions in total body weight of ≥20%, with some patients losing >40% of their total body weight. No other weight loss medications to date (e.g., phentermine, orlistat) even comes close.
Second, there are many online options for getting a prescription for semaglutide or other weight loss medications these days, but there are some reasons that may not be best. These medications should not be given to people with certain medical conditions (history of pancreatitis) or family history of certain conditions (medullary thyroid cancer). While side effects of these medications are normally mild (nausea, constipation), having a local provider that you can see for those is best practice. Also, if you develop a rare but severe complication called pancreatitis, it is important to have a relationship with a local physician to help you get the acute and follow-up care you will need.
Third, one of the most important parts of a weight loss program is having a physician and team who knows how to help you lose the right weight. Our approach involves physicians, physical therapists, nutritionists, and health coaches to help you maximize results in the healthiest way while also monitoring your overall organ function – heart, lungs, liver, kidneys, and more. We start with a comprehensive assessment, lab work, and physical tests (e.g., CPET and DEXA scan) to make sure that we map your starting point and progress along the way.
The GLP-1/GIP medications are absolute game changers, but many reports have shown that unmonitored use of medication alone may not be healthy. If patients just stop eating due to the effects of the medication, they can have significant health problems such as vitamin and micronutrient deficiencies and severe muscle wasting. This can be associated with fatigue, mood changes, hormone changes (thyroid and sex hormones), hair loss, and other problems. Weight loss is great and can be done safely, but it takes a structured approach to maximize fat loss while minimizing muscle loss and maintaining healthy vitamin and hormone levels.
Fourth, it is important to think about what to do once you have reached your goal weight. This is where our approach continues to empower you. Medications are just one leg of a five-legged stool to support you as you maintain your weight loss and optimize your health. The five components are:
- a healthy diet
- an exercise plan
- a good sleep regimen
- a healthy approach to psychological wellness
- medications – using the lowest dose necessary for long-term weight maintenance.
With this approach you can reduce your risk for all of the diseases listed above, live for many more years (lifespan), and make those years as active and functional as possible (healthspan). The goal for all of this is to continue to be able to engage actively with family and friends, community and work, hobbies and all your life goals for as long as possible.
In it with you,
Dr. Matt and Dr. David