GLP-1 drugs are “the most effective drugs we’ve ever invented to treat obesity,” but they “won’t cure the obesity epidemic,” says a public health expert.
Speaking in one panel discussion organized by Food is Medicine Institute at Tufts University on Wednesday, Tufts Professor of Medicine Dr. Dariush Mozaffarian explained: “These are… the greatest drugs ever invented. The numbers are surprising, because on average, in randomized trials, they give weight loss of about 12-18%, which is far greater than anything we’ve seen before.
“If you look outside the trials in real-life practice, they give weight loss of about 10%, and 10% is meaningful. But I want to emphasize that at the same time, they will not cure the obesity epidemic.”
The weight loss is not continuous, it falls off around 18 months.
First, he noted, these kinds of reductions, while significant, “don’t make obesity go away. One in 11 American adults weighs more than 300 pounds, and if you go from 300 pounds to 270 pounds, you’re much healthier, but you still weigh 270 pounds. There are also many side effects and challenges around costs and access, and most people don’t stay on them for even a year, and then the weight is regained unless there is a wrap-around support structure to help maintain the weight. “
Second, he noted, “The weight loss is not continuous, it comes off about 18 months. And so now you have 40-year-olds, 60-year-olds, 16-year-olds who have achieved their weight loss goals. Are you going to give them this drug for the next 40, 50, 60 years, at $8,000 a year just to keep them that way?
He added: “I think a reasonable number of patients can come off the drug and be very successful for the rest of their lives. Another proportion may come off the drug and be successful for three years, four years, and then they may have to go back on the drug for a year or so, and then others may just fail and have to stay on medicine.
“We have… an amazing drug that can really work wonders for some people that costs an arm and a leg for the health care system, is not accessible to many people, is not associated with long-term compliance in most people, and then weight has been regained [when you come off it]. Dr. Dariush Mozaffarian
Weight cycling and metabolic damage
Asked by AgFunderNews after the event regarding the metabolic impact of cycling on and off GLP-1 drugs over a period of years, he said: “While we do not yet have direct long-term experience with this class of drugs, experience with other weight loss efforts will certainly to suggest that weight cycling [losing and regaining significant amounts of bodyweight multiple times] would cause physical and mental harm.
“That’s why a structured lifestyle support system, including nutrition is medication, is essential to prevent weight regain and maintain lean muscle mass and metabolism both on and off medication.”
The other panelist Dr. Steven Heymsfield, Professor, Metabolism and Body Composition at Louisiana State University, added: “We’re in the phase of abundance right now, but what we’re learning is that this is a state of life that requires management, not just in pharmacological level, but at the lifestyle level.
“The cost is too high and the side effects are showing up. For example, people do not eat properly when taking these drugs; they require improved vitamins and minerals and other components and lose muscle mass.
“This muscle loss can be prevented if you get enough protein and do an optimal amount of exercise. So we’re learning that this disease doesn’t just require pharmacologic management, but lifestyle, and maybe lifestyle only at some point, once you’ve reached a maintenance phase.”
After all, said Dr. Alka Gupta, clinical assistant professor at George Washington University, the treatment will be successful only “if we have developed an ecosystem around the patient, around [healthcare provider’s] practice, ideally involving the community to help make this happen. If everything depends on a visit every three months with a doctor, we are setting ourselves up for failure.”
The elephant in the room?
As for compliance with GLP-1 drug therapies, studies show that it tends to decline steadily with patients who for the most part “do not receive any lifestyle modification or behavioral health programs or of wellness,” said Pat Gleason, assistant VP for health outcomes. in the pharmacy benefits manager Prime Therapeutics.
“We looked at over 3,000 individuals who started GLP-1 therapies for weight loss, and after one year, we had less than 30% still on therapy. After two years, we had one in seven.”
That said, the cost of GLP-1 drugs, he said, is the real elephant in the room. “People assume this drug will save money, but right now it’s so expensive that it’s nowhere near the case.”
He added: “It would have to be maybe a tenth of the cost to even be cost-effective… To save costs, it would probably have to be a 20th or a 30th of the price. If you take the weight loss metric alone, 93 million Americans qualify. And even at discounted prices, if every eligible American got this drug, it would cost at least $600 billion a year, which is more than we spend on any other drug. [prescription] drug combination in the United States now.”
“And if eventually, most patients who quit the drug regain weight, you’ve not only spent that money, you haven’t spent it effectively.”
By comparison, he said, “together lifestyle services” such as food and drug programs (prescription and exercise, nutritional counseling, medical meal delivery, etc.) are a “really cost-effective approach” .
Nutrition is a medical intervention and GLP-1 drugs: a combined approach
“If you’re wondering why health care… used to be 5% of the federal budget and now it’s 30% of the federal budget… it’s because we’re not addressing the root causes [of metabolic disease]”, said Dr. Mozaffarian.
“In my 11 years of training in medical school, internal medicine and cardiology, I got maybe an hour of food and nutrition. [training] and I think nothing of physical activity, and nothing of sleep or mental health. And yet these four things, poor nutrition, lack of physical activity, poor sleep and mental stress are the foundation of all diseases in our country, until now.
“And so, what I think would be tremendous is for GLP-1 to be prescribed with lifestyle programs. [that are covered by health insurance].
He added: “For the drugs we prescribe, those [patients] have a prescription. They go to a place that is close to them to fill it at a pharmacy. Their insurance pays for it or most of it.
“Imagine if we gave them that prescription drug and they didn’t have a pharmacy within 10 miles… and if they went to a pharmacy three buses away, the drug wasn’t paid for? How effective would our drugs be?
“And yet, when doctors tell patients that you need to stop smoking, you need to sleep, you need to exercise, you need to eat better, there’s your verbal prescription, there’s nowhere to fill it. And for the vast majority of Americans, it doesn’t pay.
“So we have a crazy system where the most important things we need to prescribe are not covered by health care.”
What does ‘food is medicine’ mean in practical terms?
When I use the term ‘food is medicine,’ he said, “I’m not just talking about the broad concept that food is fundamental to health. I’m talking about structured, food-based interventions that are integrated into care prescribed by doctors or educators, covered within the RDN [registered dietitian nutritionist] counseling, supportive nutrition and culinary education, and then covered by health insurance.
“What we really need is for Congress to…. take these things forward through a series of political actions.”
His comments were echoed by Sen. Bill Cassidy, (R-LA), who told attendees about two pieces of bipartisan legislation he is trying to push through Congress with Senate colleagues Cory Booker (D-NJ):
of Obesity Treatment and Reduction Actwhich expands Medicare coverage of intensive behavioral therapy and obesity medications, and
THE Medically Adapted Home Delivered Meals Demonstration Actunder which hospitals will provide medically tailored, home-delivered meals and nutrition-related therapy to Medicare patients with a diet-related illness after they leave the hospital.