Pamela Malo, MHS, RD, Arivale Coach
Most people who are or have been significantly overweight know how much hard work it takes to get the weight off. While lifestyle changes are effective at reducing weight for many, preventing regain takes concerted effort and, over time, the pounds tend to come back on. There are a variety of biological and neurochemical reasons for this, but generally it can be said that having a BMI over 30 changes both the body and brain to make them resist weight loss.
This begs the question asked in a recent NBC News headline: “Weight-loss pills can help. So why don’t more people use them?”
The answer is likely rooted in pervasive bias and stigma toward obesity.
There are currently five FDA-approved weight-loss medications for long-term use. The fact they are FDA approved means they’ve been shown in large randomized trials to be more effective at producing weight loss than a placebo/lifestyle intervention and have good safety profiles.
The approved weight-loss medications have a variety of mechanisms. For example, Xenical (orlistat) is a “fat blocker” that acts within the gastrointestinal tract, Contrave (bupropion-naltrexone) acts on the brain to block cravings, and Belviq (lorcaserin) acts on the brain to suppress appetite.
Unfortunately, in the past there have been weight-loss medications approved by the FDA that were pulled off the market due to safety concerns. The most well-known of these in recent history was “FenPhen” (fenfluramine-phentermine), which was found to cause heart problems.
As a result, however, the FDA now requires a more stringent assessment of safety in weight loss trials prior to approving a drug. Recently, a three-year study of lorcaserin in 12,000 overweight or obese patients with cardiovascular disease found no safety issues.
However, despite the good safety profiles of current medications, many physicians remain reluctant to prescribe them.
This is where weight bias comes in. There are two primary issues:
One, many physicians still don’t understand that obesity is a complex genetic and neuroendocrine disorder that may require medical treatment.
Bias against people with obesity is well-documented in healthcare providers. Many conclude and, sadly, sometimes overtly state to patients that they should just “push away from the table.” This reflects a lack of understanding of the complex biological and neurological mechanisms involved in perpetuating the overweight state.
As a result, physicians may be uncomfortable bringing up discussions about medical weight loss or will make things worse by making shaming or inaccurate statements. Often patients themselves, sometimes buying in to the same mistaken beliefs about being overweight being a “failure of willpower,” won’t bring weight up in discussions with their doctor either. This means that finding a well-qualified and understanding provider is paramount.
Two, we still don’t have enough effective drugs to treat obesity. As noted in the NBC story, there are over 100 different medications for hypertension and 10 different therapeutic categories. This gives providers a wide range of options that can be tailored based on patient response, insurance coverage, and other factors. Although there are considerably more people with obesity than with hypertension in the US, we still only have five approved drugs, and many times their cost is not covered by insurance.
Drug companies, federal regulators, and insurance companies are complicit in the same weight stigma that can affect providers – believing that “simple” diet and exercise changes will solve the problem of obesity, so why should they invest significantly in medical options?
Just like high blood pressure and type 2 diabetes, obesity is a disease that has physiological causes but can be influenced by our lifestyle and behavior. Diet and exercise are foundational treatments for high blood pressure and diabetes, yet no one suggests that individuals with these conditions shouldn’t be offered effective medications if lifestyle alone is not controlling their condition. Why do we think this is acceptable for obesity? This is especially ironic since weight loss, in many cases, can help prevent or control high blood pressure and diabetes.
There are clear national guidelines regarding the treatment of obesity put out by clinical experts at the American Heart Association and the Obesity Society, and appropriate use of weight-loss medication for people with a BMI over 30 (or lower if other weight-related conditions are present) is part of the picture.
While intensive lifestyle interventions, including long-term coaching support, are effective for achieving the targeted 5 percent to 10 percent weight loss in more than half of the individuals who complete such programs, for some people adding an approved weight-loss medication to their lifestyle regimen can be the tipping point for long-term success. Talk to your doctor if you believe weight-loss medications might be helpful for you.
[Arivale Hot Topics address health stories currently in the news. The Arivale Clinical Team’s commentary on these news articles is not a review of the scientific evidence, nor an endorsement of a specific study, and is not meant as official medical opinion.]