From Works In Progress, Issue 5, September 14, 2021:
Heart attacks can be prevented with cholesterol and blood pressure drugs, bacterial infections can be eliminated with antibiotics, and even HIV is now treatable with antiviral drugs. But obesity remains a remarkably stubborn condition.
Losing weight is hard, with or without the help of a doctor. Two-thirds of American adults with obesity try to lose weight each year using every diet imaginable, yet the adult obesity rate remains at 43%. Even intensive diet and lifestyle interventions have historically struggled to exceed a sustained 5% loss of body weight, and most weight loss drugs are no more effective. Compounding the problem, primary care doctors often can’t deliver the best diet and lifestyle tools that are available. “I spent my career trying to get primary care providers to deliver effective weight loss interventions in their office,” says Donna Ryan, professor emerita at the Pennington Biomedical Institute and president of the World Obesity Federation. “It’s hopeless.”
Doctors understand the profound impact obesity has on their patients, and the remarkable benefits of even modest weight loss, but have historically been unable to do much about it.
That is changing.
“Our recent experience treating patients with obesity,” says David Macklin, MD, “is similar to the experience physicians have when they provide blood pressure drugs to patients with high blood pressure or asthma medications to patients with asthma. We finally have a drug that effectively treats the condition.” Macklin, an 18-year veteran of obesity medicine and coauthor of the Canadian Adult Obesity Clinical Practice Guidelines, is referring to his two years of experience treating over a thousand people with obesity using the relatively new drug semaglutide. [1]
In his hands, semaglutide causes an average of 18–20% loss of body weight when paired with diet and lifestyle advice. In other words, a person who walks into his office weighing 250 pounds and chooses semaglutide can expect to shed about 48 pounds.
Semaglutide is just the leading edge of a wave of new obesity therapies in development that reflect our deepening understanding of the human body and that promise to fundamentally change the lives of people with obesity.
Outcompeting the surgeons
Macklin’s account may sound like a tall tale, but it’s supported by rigorous randomized controlled trials. The STEP-1 and STEP-4 trials, published this year, report that semaglutide paired with diet and exercise advice caused an average of 15% and 18% loss of body weight respectively, over 68 weeks in people with obesity or overweight. [2]
At lower doses, semaglutide has been in use for type 2 diabetes since the US Food and Drug Administration (FDA) approved it in 2017 and the European Medicines Agency (EMA) and Health Canada approved it in 2018. This is how doctors like Macklin have been able to unofficially use it “off label” to treat obesity. The FDA was impressed enough by the safety and effectiveness of semaglutide that it approved a higher dose of the drug for the treatment of obesity on June 4 of this year under the brand name Wegovy, which requires one injection per week. If you live in the US, it’s currently headed to a pharmacy near you.
There is one, and only one, highly effective weight loss method that predates semaglutide: bariatric surgery. For the low, low price of $20,000, a person can have part of his digestive tract permanently excluded from food contact, altering gut-brain communication and durably reducing body weight by about a quarter for the most common surgery types. Bariatric surgery provides all the health benefits one might expect from the massive loss of body fat it causes. Yet it isn’t a scalable solution to the obesity epidemic, and many people don’t want to undergo a treatment that’s so invasive.
Semaglutide, and the drugs that will follow it, may soon replace most bariatric surgeries. “Slowly, slowly, slowly, we outcompete the surgeons,” predicts Macklin, who is already referring many fewer patients for surgery. “They know we’re coming.”....
....MUCH MORE
Previously from works in Progress:
