6: Anti-Obesity Medications: Part 2

Following on from last week’s blog which focused on the pros and cons of certain anti-obesity medications, we are going to continue the topic by diving into some of the most commonly asked questions with regard to these medicines.

One of the questions I get asked the most is:

Does the weight come back on if I stop the medications?

The answer to this is not unique to any single one of the anti-obesity medications but applies to all of them. If you use a medical intervention with the medication on the way down, the randomized controlled trials show us that you need to stay on the medicine for the weight to stay off.

And remember that this is not about keeping the weight off for a year or two.

I want you to think about the long term, because I have doubts that the weight will stay off in 5 or 10 years without the medication if you used it initially. 

Based on the studies, we tend to see the weight slowly creep back up to the weight set point where you started. This is why I really like to stress that these medicines are not a quick fix. 

It's a chronic medical condition that we're treating, and it makes sense that you wouldn't necessarily stop them.

If you have to come off of it, for example for affordability or insurance reasons, there are strategies which can be implemented to support you. You can change to a different medicine or an oral option, and there are a lot of other things we can do in terms of the diet which will also help. Generally however, I see people struggle a lot more compared to people who stay on the medications.

Can these medicines stop working after losing a certain amount of weight?

A lot of patients tend to say that they have lost 20 pounds, for example, and they don’t see the medicines working anymore. So I would encourage all of you, if you're on a weight loss journey, to stop thinking about pounds lost, and instead focus on the percentage of body weight that you've lost.

There is great power in a 5% body weight loss. We see tremendous health benefits for you, and this does not matter where you start.

So how do you calculate the total percentage of body weight loss? 

The following formula determines percentage of weight loss:

(Starting weight minus current weight) / (starting weight) x 100= % of body weight loss

For example, If I was 200 pounds to begin with and I lost 20 pounds, my percentage of body weight loss would be 10%.

(200-180)/200 x 100 = 10%

This will help you to realize that if you think the medicine's not working anymore, you may have actually reached what that intervention is able to provide.

For example, a 15% body weight loss is what we typically see from the randomized controlled trials for the weekly medication Wegovy, which is the same as Ozempic. As people start to approach that percentage, they will notice that the weight loss starts to slow down or stop.

However, this does not mean that the medicine has stopped working. It just means that is as far as it's able to take you in terms of weight loss.

If the medicine stops working, what are the next steps? Can I add another medication to it? 

The first thing I look at is whether everything is optimized before we start to make other changes.

For example, I like to look at protein intake or if a patient is malnourished. If a physician has no idea how to titrate the medication and so every month it goes up, that can lead to the person’s appetite being very suppressed and them feeling sick. They may be eating just 800 calories a day, making them extremely malnourished and leading to weight loss stopping.

It’s also important to look at if you are eating enough, what your fiber intake is like, what your hydration is like, and what your movement is like.

If everything is optimized and we've taken the medication as far as it can go, then yes you can add on another medication. This is actually extremely common in obesity medicine because remember, it's a chronic medical condition. 

If we do add something on, it's not another medicine in the same class. So for example, if you're already on a GLP-1 medication, that's helping with satiety. Then if you notice more urges and cravings coming back and these things are very hard to control for you, then something like Contrave (which we talked about in part one) could be added in.

Keep in mind though that the whole point of this is not to eradicate food urges or cravings completely. A lot of these things have to be worked through on a cognitive behavioral level, through practices like thought work. 

Long-term weight management is almost like a chess game in the sense that there's an anticipation of what's coming up next. This is why it's so helpful to work with an obesity medicine physician because we’re doing this all day long. 

People often work with me for around six months to a year. And then if you're stabilized and you're doing great things, then we move into the maintenance period, with checks as needed. I always make sure that if a certain amount of weight comes back on or if a patient notices certain changes, they call me. We don't wait for 30 pounds to come back on to re-look at things. 

Why are anti-obesity medicines often written for off-label?

A lot of people shame the obesity medicine world for writing for medications off-label.

It is in fact extremely common to write for these medicines off-label and about one quarter of medications is written for off-label. This is common because when a medication comes through and is approved for one reason, we often then find it's helpful for something else. 

This was exactly what happened with Viagra The medication was initially trialed as a heart medication but they ended up finding that men had unprovoked erections. So it is very common that a medication will come out for one thing, and we see it works for something else. But the company doesn't always necessarily get another FDA approval for the new indication.

I find it interesting that the weight community is so stigmatized and shamed for this, when it's truly done in every single other area of medicine. For example, it’s very common in neurology and with headache medications. Often it's not the things that a medicine was originally approved for that end up being helpful.  

Birth Control

If you are a woman of childbearing age and you are on these medications, you really need a solid birth control plan.

It's really irresponsible if someone's prescribing these medications and you don't have a solid birth control plan.  

One of the big concerns is that there's always a period where you don't know that you're pregnant for some weeks before you find out. And so if you're on some of these medications like Topamax (topiramate), there is the risk of babies getting cleft lip and palate. This is obviously something that we want to avoid and can avoid, as long as there is a good birth control plan in place.

Patients often say they have struggled with infertility and so they think it's not possible to get pregnant. What I want to stress is that fertility can potentially increase with weight loss. This is the reason why having a birth control plan in place is important for your safety, no matter how long you've had an infertility struggle.

Creating a comprehensive plan with your doctor

Not having a comprehensive plan with your doctor can leave you in a spot where you are actually worse off, compared to if you had never taken the medicine to begin with. 

The four main pillars for chronic weight management are nutrition, movement, (possibly) medications and behavior modification. Therefore, if you are just taking medications without working with someone who is coordinating everything else with you and questioning how you're doing, this can be hugely problematic.

If you are going to go down this road where you do use medications, make sure that you have someone that's checking in with you. This follow-up might look different for everyone. Fr some people, it might be physically in person in a clinic, whereas for others, it might be a virtual telehealth service where you do some video visits and can message the doctor in between.

It’s vital to have this accountability and professionals can find the problems before they become disasters. This is a health journey for you and not just “losing weight”. Doing medications in isolation and ignoring all those other areas, means it just won’t be effective.

Can someone who has a history of bariatric surgery take anti-obesity medications? 

For each individual case, it is of course vital to talk to your medical team, your doctor, and your surgeon, to get that advice from them. 

Generally speaking, the answer is yes. If someone's going to get bariatric surgery, a lot of the time there is an extensive pre-op period of time, even up to six months, where people need to have monthly dietician appointments and prove different things during that time.

This can be a really great time as they're learning to balance out their meals. It can be incredibly helpful to start the medications as you’re learning these healthier behaviors, because your weight's down a little bit and you can keep losing after the surgery. 

Sometimes years out of bariatric surgery, people start to experience some weight regain, and then it can be added in as well. 

Where can I find the right physician for me?

What’s so tricky about this space is that there's such variation, which can feel frustrating. Not every physician does things the same way. 

If you live in Indiana or Illinois and have been following my work and like my approach, you can check out my clinic by going to renteaclinic.com. I offer direct care obesity medicine practice and we don't involve insurance in this, so it’s a set rate monthly. You meet with me and the dietician and I have a course that we do, including weekly calls and lots of mindset work. My approach is very anti-diet culture, very supportive long-term, and comes from my own informed work having done this all myself. Right now it's a virtual telehealth clinic, and starting in June, I will have a location in Lincolnwood, Illinois.  

You can also subscribe to The Obesity Guide podcast list so you can keep informed and find out about episodes that are coming out, and if there are ever resources available for you.

Unfortunately, there's no comprehensive listing for physicians to work with, but you can go to 

abom.org, which is the American Board of Obesity Medicine. They list everyone that's board certified but the downside is that you know nothing about their philosophy and there are no links to clinics. 

One of the better resources is obesitycareproviders.com, run by the Obesity Action Coalition. What I love about this website is that you can search by medical provider, e.g. by dietician, psychologists or psychiatrists etc. 

Looking at different physicians on social media can also be useful to see if there are any local physicians around you. More and more physicians are realizing that they need a place on social media so that patients know their philosophy. There you can quickly see if you like how they describe certain things and you can gain a bit more background on them before potentially organizing a visit.