Weight Loss Strategy: Starve, Shot or Scalpel?

Earlier this month, Weight Watchers announced that it has purchased a company that specializes in pharmacologic therapy for weight loss. For six decades, Weight Watchers has promoted weight loss through meticulous calorie monitoring and encouraging exercise. It now appears that the company is ready to embrace the fact that weight loss in America is now dramatically different than it was even just a few years ago. While most people agree that calorie counting and exercise should be encouraged, new medications that greatly help with weight loss such as GLP1-RAs and SGLT2-Inhibitors have markedly changed this landscape among both clinicians and patients.

I suspect that Weight Watchers believes that its future must incorporate pharmacotherapy or it may cease to exist. Certainly, consumer preference is a significant driving factor with this. Many Americans have found weight loss through lifestyle modifications to be difficult and ultimately unsuccessful. The option to take a pill or a weekly injection to facilitate weight loss is more appealing, especially as it is much more likely to be effective. Even in a monitored and structured program like Weight Watchers, weight loss in the short term is often less than 10% and long term is significantly less than that. Emerging data on medications like GLP1-RAs show much more robust weight loss in the short term - around 15%. Dual acting agents with concomitant GIP activity recently showed up to 22% weight loss. These medications can be used for long-term maintenance. 

We have a precedent in our society for favoring such an approach. When SSRIs were shown to be effective and safe for treating depression, cognitive-behavioral therapy became much less popular. When Chantix was approved for smoking cessation, many patients stopped trying to quit “cold turkey.” Certainly, “just” taking a pill can be an easier approach both for patients and treating clinicians.

We also need to consider the future role of the third option for weight loss: bariatric surgery. This is, of course, more complex than just prescribing a medication and patients have to go through many steps to qualify for the surgery. Yes, the surgery involves risk, but the surgical risk is less than the long-term risk of severe obesity. There is data showing decreased long-term morbidity and mortality with this approach, and current surgical interventions are associated with significantly fewer long-term adverse effects than earlier surgical approaches. Bariatric surgery is clearly more successful for many people than diet and exercise alone. We have had many weight loss medications in the past, but none were more effective overall than bariatric surgery.

 However, that may no longer be the case now that GPL1-RAs and SGLT2-Is are available. The downside of these medications is their high cost, hence insurers are hesitant to cover them for weight loss, especially in non-diabetic patients. As we know these medications were initially developed to treat diabetes, but in the last couple years a tremendous amount of data has shown their benefit for the treatment of ischemic heart disease, heart failure, and renal failure even in non-diabetic patients.  Despite FDA approval of some GLP1-RAs for this purpose, most insurers do not cover them for weight loss alone. If Medicare chose to cover GLP1-RAs for weight loss, the estimated cost would be around $14 billion annually.

Tirzepatide (a GLP1-RA and GIP dual acting agent) is under expedited review by the FDA for weight loss and likely will soon be approved for this purpose. With this medication showing up to a 22% weight loss in just over a year in several patients, it will be interesting to see how weight loss is viewed in the future by patients, bariatric surgeons, primary care doctors and programs such as Weight Watchers. Cost and convenience will remain significant factors in the decision for pharmacotherapy, but these medications will doubtlessly have a leading role in the future.

With its proven track record, bariatric surgery will still be a good option for many patients. I strongly believe that we should still encourage healthy lifestyle choices such as reducing calories and promoting exercise for all patients. I discuss this with almost every patient I see. Nonetheless, I suspect that the prior model of Weight Watchers to lose weight only through lifestyle modifications will be largely supplanted by pharmacotherapy for the majority of our obese patients.