Dr Marc-Andre Cornier Weighs Pharmacologic, Behavioral Interventions for Obesity

Medical therapy for obesity is always going to be an adjunct to lifestyle changes, said Marc-Andre Cornier, MD, endocrinologist, professor, and director of the Division of Endocrinology, Diabetes and Metabolic Diseases at the Medical University of South Carolina.


What are your thoughts on pharmacological vs behavioral interventions for weight loss?

So pharmacologic interventions, we call them anti-obesity medications. That’s the kind of terminology we use now, because we’re treating obesity, a disease, we’re not treating the weight, per se. And I think that’s a mind frame shift, you know, thinking about, we’re treating a disease here. And we’re using all the tools we have available. So medical therapy is always going to be an adjunct to lifestyle. So it doesn’t mean you do lifestyle or medical therapy, you do them together. And the medications do several things. One, is they alter, most of them, alter brain responses to appetite signals. And so we talked about the individual who’s prone to weight gain. Well it might be that they’re prone to weight gain because of altered signaling in the brain. And so we use a medication to alter those signals in a way that makes them less hungry, more full, so that they can adhere to a lifestyle change in a more positive way. So that’s really how we use these medications. And these drugs are approved for long term weight loss. And they have great data supporting their use, you get more weight loss than lifestyle alone. And you’re more likely to keep that weight off long term if you continue taking those medications. So we know with lifestyle programs, you get good weight loss over 6 months, but almost every intervention shows weight regain after that. And that’s because people can’t adhere to those weight loss programs over that period of time. If you look at the pharmacologic studies using anti-obesity medications, if you go out a year, 2 years, those individuals on medical therapy, they lose that weight over 6 months. They don’t keep losing weight, but they maintain that weight loss long term. And that’s telling us that the medications are still working. So the patient might say, well, I stopped losing weight, but the natural tendency would be for them to regain the weight. So that medicine is helping prevent that weight regain. So in fact, these medications are very effective for long term weight loss and weight loss maintenance.

And these newer therapies actually are associated with significantly more weight loss than what we’ve seen with some of the older therapies. So we’re talking 15% weight loss on average, which is potentially game changing in terms of improving weight related complications, things like diabetes, or preventing prediabetes towards diabetes, reducing blood pressure, improving sleep apnea, and many, many other weight related complications or comorbidities.

Unfortunately, these medications are underused, there’s been a number of studies that have looked at this and most are showing 2% at the most 3% of eligible patients are getting prescribed drug therapy. And if you look at another disease like diabetes, 80%, 90% of patients are being prescribed medications to treat the diabetes yet, for obesity, we’re not doing that. And there’s many barriers. One major one is lack of coverage from insurers. But that is changing. The federal government has just said any federal insurance must provide coverage for anti-obesity medications. And so we’re starting to see payers cover these on a more regular basis. But it’s still a major issue. And then there’s lack of buy in from providers from patients. There’s thoughts that these drugs are unsafe, when actually a drug like semaglutide, at lower doses albeit, but in patients with diabetes have shown reduced cardiovascular outcomes. So actually, not only weight loss, improved diabetes efforts, but cardiovascular benefit, potentially. So I think these drugs are underused, they should be used more, and I think we’ll see an increase in the near future hopefully. And but again, a reminder that it is an adjunct, it’s to be used in addition to lifestyle. And studies have looked at this where if you just prescribe a drug, you might get 5% weight loss. You prescribe the lifestyle, you get 5%. You put the 2 together, you get 10%, they’re additive, and so really, that is the way we want those medicines to be used.

In the past often people thought of medicines for weight loss as a short term treatment, a kickstart You know, ‘Oh, I need a Kickstart to help me lose weight.’ But as I mentioned before, these drugs work most effectively at keeping the weight off long term. And studies have been done where everybody in the study gets a weight loss medication, everybody loses weight, then at a certain time point, people get switched to stay on the drug versus get a placebo. And those on the placebo regain the weight. Those who maintain on the medical therapy keep that weight off.

We have to change the way we think about medical therapy for the treatment of overweight and obesity as a long term treatment, just like we would treat high blood pressure. So we treat hypertension with medications that lower blood pressure. They lower the blood pressure, do we stop those medicines at that time? No, we continue the medicine because the medicine is working. So we have to think about management of obesity in the same context. We don’t just [go], ‘Oh, you did a diet for 6 weeks, you lost 10 pounds? Great. Now you stopped the diet.’ No, what’s going to happen? You’re going to regain all that weight. Stop the medication. No, that doesn’t make sense. You’re going to regain the weight. So we have to think long term here.

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