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Newer obesity drugs offer promise of lasting weight loss

ASHLAND, Mass — Over the years, Mynette Shifman has tried diets well-known and obscure.

“I think I’ve done one where you eat grapefruit every day and hard-boiled eggs,” Shifman said. “I don’t know what that name is. But I’ve done a lifetime of dieting.”

One thing all those diets had in common: they didn’t lead to lasting weight loss.

“It was such a slow return... often... that you could kind of ignore that it was happening initially,” Shifman said. “And then you’d be back where you were. And sometimes it was a couple of years before you’d be back where you were. And sometimes it was six months. It was frustrating.”

It is a frustration shared by the many dieters who find losing weight -- difficult as that is -- pales in comparison to the task of keeping lost weight off. And obesity experts say there’s a good reason why that’s true. Genetically, many of us are programmed to a weight ‘set-point’ that is higher than it should be. Limiting calories will cause weight loss. But the body seeks, inevitably, to return to the set-point.

“The key thing that we have to recognize is that obesity is a chronic disease,” said Fatima Cody Stanford, MD, MPH, an obesity medicine physician and scientist at Massachusetts General Hospital. “If someone just eats less and exercises more they should all be the size they want to be, right? Like that’s the going mantra. But we do know that obesity is a disease that’s regulated by the brain. If you don’t realize that obesity is a disease, which most physicians and other healthcare providers didn’t learn, then why treat it, right? It’s something that people just need to fix on their own. they just need to exercise and eat less.”

But Cody Stanford says patients who come to her for treatment of obesity are often exercising regularly and eating moderately.

“They are doing all those things and their bodies are storing more fat than someone else is,” she said. “That’s not their fault. That’s their biology.”

As with any chronic disease, obesity can and should be treated, Cody Stanford said. And in recent years, new medications have made that task easier for patients and doctors, alike. Specifically, the GLP-1 receptor agonists or glucagon-like peptide-1 agonists liraglutide and semaglutide, which go by the brand names Saxenda and Wegovy. These injectable drugs provide a hormonal boost that induces feelings of satiety or fullness.

“Patients are able to lose weight in a way that for some of them may feel effortless,” Cody Stanford said. “But not only that, they’re able to pay attention to their cues, internally.”

And for the drugs to work, paying attention to those cues is key. Neither Saxenda nor Wegovy takes weight off directly. Rather, they reduce food ingestion. Doctors also recommend that patients using these medications engage in regular exercise.

And there’s something else.

“We have these medications that are acting on different parts of the brain, or the fat tissue or the pancreas,” Cody Stanford said. “When we stop those medications we’re no longer acting on the brain, or the fat tissue or the pancreas. This is a chronic disease. So we have to use these medications accordingly.”

Which means medications for obesity have to be used in the same way medications are for any other chronic disease: potentially forever.

“People will come into me and they will never stop taking their high blood pressure medicine because it keeps their blood pressure normal,” Cody Stanford said. “But when we talk about medications to treat this disease of obesity, the audacity of continuing them long term.”

That reluctance to treat obesity with medications long-term stems from misperceptions about the condition within the medical community, Cody Stanford said.

“Most doctors, most NPs, most PAs -- and we can keep going -- think that this is really just an issue of willpower,” she said. “If we look at education in medical schools or nursing schools or PA schools, very few people are learning anything about this disease of obesity.”

Yet it is a disease that can trigger many other chronic -- and deadly -- diseases, including some forms of cancer.

“I can tell you that one of my greatest joys in treating patients with obesity is being able to delete diagnoses from their charts,” Cody Stanford said. “When I treat their obesity I’m often treating the other 200-plus diseases that were caused by their obesity.”

Mynette Shifman, a nurse practitioner, began using Saxenda 18 months ago before switching over to Wegovy. She’s lost about 40 pounds during that time.

“I feel like this medication has made it infinitely easier to be in control,” she said. “I don’t have as much interest in food.”

That is a big change for Shifman, who said she always loved to eat.

“Food was one of those things, my whole life, you were eating breakfast and thinking about what you would like to eat for dinner and maybe what you were going to have for lunch,” she said. “I’d be in the shower in the morning, planning all those meals. I just don’t have that feeling anymore.”

But, Shifman said it’s important to note that using the drugs hasn’t led, magically, to weight loss.

“I eat very, very carefully,” she said. “:But I just feel like I have a little bit more of the ability to do that without suffering. Diets shouldn’t feel like you’re suffering. Because then it’s not sustainable. Nobody’s going to suffer around their food. It’s something we have to do every day, multiple times a day. So I am not suffering. I eat carefully. I eat healthfully. But I’m not hungry. I’m not thinking about food all the time. I’m not craving things the way I might have in the past. It just takes it off the front-burner and puts it on the back-burner.”

Since losing weight, Shifman has seen her blood pressure go down and indicators for diabetes retreat.

“I have health risks and I want to do everything I can to put myself in the best case for my physical health,” she said. “And I was heading in the direction of diabetes. And at this point I’ve curtailed that.”

Despite America’s obesity epidemic (the CDC estimates more than 40 percent of U.S. adults have obesity) -- few seek medical treatment. And when they do, Cody Stanford said they can run into barriers -- most especially a lack of practitioners skilled at treating obesity.

“And that can be very frustrating,” she said. “There’s this chronic disease you finally decided, hey I want to get care. And then you go and you wait in line.”

Cody Stanford said medicine needs more doctors who can deliver care for obesity -- and thinks primary care doctors could play a useful role in that regard.

Another possible obstacle to care is cost of the newest medications, which can run $1,500 - 2,000 a month without insurance coverage. Fortunately, many insurance plans in Massachusetts DO cover obesity treatments -- though, often, extra paperwork is required.

So when should you seek out treatment for obesity?

“If you’re recognizing, look, I’m doing what I can,” said Cody Stanford. “I’m optimizing my diet, I’m exercising, I’m managing my stress, I’m managing my sleep. I’m doing all the things I need to do and I’m doing it consistently. And despite this my weight continues to go up and up and up, incrementally. It’s at that point I would seek out care for the treatment of obesity.”

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