GLP-1 drugs are “the most effective drugs we’ve ever invented for obesity treatment,” but they “aren’t going to cure the obesity epidemic,” says one public health expert.
Speaking at a panel debate hosted by the Food is Medicine Institute at Tufts University on Wednesday, Tufts professor of medicine Dr. Dariush Mozaffarian explained: “These are… the biggest blockbuster drugs ever invented. The numbers are astonishing, because on average, in randomized trials, they give weight loss of about 12-18% which is much larger than anything we’ve previously seen.
“If you look at 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 aren’t going to cure the obesity epidemic.”
‘The weight loss is not continuous, it plateaus at about 18 months’
First, he observed, these kinds of reductions, while meaningful, “do not 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 a lot of side effects and challenges around costs and access, and most people don’t stay on them even for a year, and then the weight is regained if there’s not a wraparound structure of support to help with the weight maintenance.”
Second, he noted, “The weight loss is not continuous, it plateaus at about 18 months. And so now you have 40-year-olds, 60-year-olds, 16-year-olds, who have met 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 maintain them like that?
He added: “I think a reasonable number of patients could come off the drug and be very successful for the rest of their life. Another proportion could come off the drug and be successful for three years, four years, and then may need to go back on the drug for a year or so, and then others may just fail and need to stay on the drug.”
“We have… an amazing drug that can really work wonders for some people that costs an arm and a leg to the healthcare system, isn’t accessible to many people, isn’t associated with long-term compliance in most people, and then weight is regained [when you come off it].” Dr. Dariush Mozaffarian
Weight cycling and metabolic harm
Asked by AgFunderNews after the event about the metabolic impact of cycling on and off GLP-1 drugs over a period of years, he said: “While we don’t yet have long-term direct experience with this class of drugs, experience with other weight loss efforts would certainly suggest that weight cycling [losing and regaining significant amounts of bodyweight multiple times] would cause both physical and mental harm.
“This is why a structured system of lifestyle support, including food is medicine, is critical to prevent weight regain and maintain lean muscle mass and metabolism both on and off the drug.”
Fellow panelist Dr. Steven Heymsfield, Professor, Metabolism & Body Composition at Louisiana State University, added: “We’re in the exuberance phase now, but what we’re learning is this is a lifetime condition that requires management, not just at the pharmacologic level, but at the lifestyle level.
“The cost is very high, and the side effects are appearing. For example, people don’t eat adequately when they’re on these drugs; they require improved vitamins and minerals and other components, and they lose muscle mass.
“That muscle loss can be prevented if you take adequate protein and you do an optimum amount of exercise. So we’re learning that this disease requires not just pharmacologic management, but lifestyle, and perhaps lifestyle only at some point, once you reach a maintenance stage.”
Ultimately, said Dr. Alka Gupta, clinical assistant professor at George Washington University, treatment will only be successful “if we’ve developed an ecosystem around the patient, around the [healthcare provider’s] practice, ideally involving community to help enable that. If it all hinges on one visit every three months with a doctor, we’re setting ourselves up to fail.”
The elephant in the room?
As for compliance with GLP-1 drug therapies, studies show that it tends to steadily drop off with patients who do not for the most part “receive any lifestyle modification or behavioral health programs or wellness programs,” said Pat Gleason, assistant VP health outcomes at pharmacy benefit manager Prime Therapeutics.
“We looked at over 3,000 individuals who started GLP-1 therapies for weight loss and after a year, we had less than 30% still on the 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 that this drug will save money, but right now it is so expensive that that’s just not anywhere close to the case.”
He added: “It would have to be probably one tenth the cost to even be cost effective… To be cost saving, it would probably have to be a 20th or a 30th of the price. If you just take the weight loss indication, 93 million Americans qualify. And even at discounted prices, if every American who qualifies were on this drug, it would cost at least $600 billion per year, which is more than we spend on every other [prescription] drug combined in the United States right now.”
“And then if eventually, most of the patients who come off the drugs regain weight, you’ve not only spent that money, you haven’t spent it effectively.”
By comparison, he said, “wraparound lifestyle services” such as food is medicine programs (produce and exercise prescriptions, nutrition counseling, medical meals delivery, etc.) are a “really cost effective approach.”
Food is medicine interventions and GLP-1 drugs: a combined approach
“If you wonder why healthcare… 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 don’t think anything about physical activity, and nothing about sleep or mental health. And yet those four things, poor nutrition, lack of physical activity, poor sleep and mental stress are the foundation of all disease in our country, by far.
“And so what I think would be remarkable is for GLP-1s to be prescribed with wraparound lifestyle programs [that are covered by health insurance].”
He added: “For drugs we prescribe, they [patients] have a prescription. They go to some place that is close to them to fill it at a pharmacy. Their insurance pays for it or for most of it.
“Imagine if we gave them that drug prescription and they didn’t have a pharmacy within 10 miles… and if they did get to a pharmacy on three buses, the drug wasn’t paid for? How effective would our drugs be?
“And yet, when doctors tell patients you need to stop smoking, you need to sleep, you need to exercise, you need to eat better, here’s your verbal prescription, there’s nowhere to fill it. And for most many Americans, it’s not paid for.
“So we have a crazy system where the most important things that we should be prescribing are not covered by healthcare.”
What does ‘food is medicine’ mean in practical terms?
When using the term ‘food is medicine,’ he said, “I’m not just talking about the broad concept that food is foundational to health. I’m talking about structured, food-based nutritional interventions that are integrated into healthcare prescribed by doctors or educators, covered within RDN [registered dietitian nutritionist] counseling, supportive nutrition and culinary education, and then covered by health insurance.
“What we really need is Congress to…. move these things forward through a series of policy actions.”
His comments were echoed by Senator Bill Cassidy, (R-LA), who told attendees about two pieces of bipartisan legislation he is attempting to push through Congress with colleagues in the Senate such as Cory Booker (D-NJ):
The Treat and Reduce Obesity Act, which expands Medicare coverage of intensive behavioral therapy and medications for obesity, and
the Medically Tailored Home-Delivered Meals Demonstration Act, under which hospitals would provide medically tailored, home-delivered meals and associated nutrition therapy for Medicare patients with a diet-impacted disease after they are discharged from the hospital.
Guest article: GLP-1 drugs: The effect on food systems is going to be profound… and relatively quick