After bariatric surgery in 2014, Kristal Hartman still struggled to manage her weight long term. It took her over a year to lose 100 pounds, a loss she initially maintained, but then gradually her body mass index (BMI) started creeping up again.
“The body kind of has a set point, and you have to constantly trick it because it is going to start to gain weight again,” Ms. Hartman, who is on the national board of directors for the Obesity Action Coalition, said in an interview.
So, 2.5 years after her surgery, Ms. Hartman began weekly subcutaneous injections of the glucagonlike peptide–1 (GLP-1) agonist semaglutide, a medication that is now almost infamous because of its popularity among celebrities and social media influencers.
Branded as Ozempic for type 2 diabetes and Wegovy for obesity, both contain semaglutide but in slightly different doses. The popularity of the medication has led to shortages for those living with type 2 diabetes and/or obesity. And other medications are waiting in the wings that work on GLP-1 and other hormones that regulate appetite, such as the twincretin tirzepatide (Mounjaro), another weekly injection, approved by the Food and Drug Administration in May 2022 for type 2 diabetes and awaiting approval for obesity.
Ms. Hartman said taking semaglutide helped her not only lose weight but also “curb [her] obsessive thoughts over food.” To maintain a BMI within the healthy range, as well as taking the GLP-1 agonist, Ms. Hartman relies on other strategies, including exercise, and mental health support.
“Physicians really need to be open to these FDA-approved medications as one of many tools in the toolbox for patients with obesity. It’s just like any other chronic disease state, when they are thinking of using these, they need to think about long-term use ... in patients who have obesity, not just [among those people] who just want to lose 5-10 pounds. That’s not what these drugs are designed for. They are for people who are actually living with the chronic disease of obesity every day of their lives,” she emphasized.
On average, patients lose 25%-40% of their total body weight following bariatric surgery, said Teresa LeMasters, MD, president of the American Society for Metabolic & Bariatric Surgery. However, there typically is a “small” weight regain after surgery.
“For most patients, it is a small 5-10 pounds, but for some others, it can be significant,” said Dr. LeMasters, a bariatric surgeon at UnityPoint Clinic, Des Moines, Iowa.
“We do still see some patients– anywhere from 10% to 30% – who will have some [significant] weight regain, and so then we will look at that,” she noted. In those cases, the disease of obesity “is definitely still present.”
Medications can counter weight regain after surgery
For patients who don’t reach their weight loss goals after bariatric surgery, Dr. LeMasters said it’s appropriate to consider adding an anti-obesity medication. The newer GLP-1 agonists can lead to a loss of around 15% of body weight in some patients.
or even just to optimize their initial response to surgery if they are starting at a very, very severe point of disease,” she explained.
She noted, however, that some patients shouldn’t be prescribed GLP-1 agonists, including those with a history of thyroid cancer or pancreatitis.
Caroline M. Apovian, MD, codirector of the center for weight management and wellness and professor of medicine at Harvard Medical School, Boston, said in an interview that the physiology behind bariatric surgery and that of the newer obesity medications is somewhat aligned.
“In order to reduce ... body weight permanently you need adjustments. We learned that you need the adjustments of the hormones [that affect appetite, such as GLP-1], and that’s why bariatric surgery works because ... [it] provides the most durable and the most effective treatment for obesity ... because [with surgery] you are adjusting the secretion and timing of many of the hormones that regulate body weight,” she explained.
So, when people are taking GLP-1 agonists for obesity, with or without surgery, these medications “are meant and were approved by the FDA to be taken indefinitely. They are not [for the] short term,” Dr. Apovian noted.
Benjamin O’Donnell, MD, an associate professor at Ohio State University Wexner Medical Center, Columbus, agreed that the newer anti-obesity medications can be very effective; however, he expressed uncertainty about prescribing these medications for years and years.
“If somebody has obesity, they need medicine to help them manage appetite and maintain a lower, healthier weight. It would make sense that they would just stay on the medicine,” he noted.
But he qualified: “I have a hard time committing to saying that someone should take this medication for the rest of their life. Part of my hesitation is that the medications are expensive, so we’ve had a hard time with people staying on them, mostly because of insurance formulary changes.”