Tidings of great joy: a weight-loss revolution

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From the first snacks on Thanksgiving morning through the New Year's Eve spreads until the last leftovers of Super Bowl Sunday, gaining weight is a nagging concern for everybody during the holiday season. Obesity has become a major scourge in America, but new medications are now available, and although many questions remain, these drugs may revolutionize the treatment of obesity.

More than 40% of all American adults are obese, and nearly 10% are considered severely obese, National Institutes of Health data indicates. Because it increases the risk of heart disease, lung disease, cancer and diabetes, obesity is currently the most serious health hazard the country faces, as well as a major risk factor in those who die from COVID-19.

What causes people to get fat? For many years, doctors adhered to a simple equation: If you eat more calories than you burn, you will put on weight. While this is true, it's an oversimplification because calories are not all the same: Foods of equal caloric value have different effects on suppressing appetite and hormone release. Gaining weight is dependent on many factors including genes, hormones, metabolism and even personal gut bacteria. Some people develop a "set point," with their weight remaining in a narrow range so that they can eat prodigiously and gain little weight, whereas others will not lose weight even on a scrupulous diet. Greater portions in restaurants and fast-food emporia, ubiquitous food advertising and sedentary lifestyles also have driven the national rise in obesity.

Throughout most of the last century, the treatment of obesity consisted of low-calorie diets, greater activity and counseling. Various diets were often effective at the outset, but many patients regained weight later. Counseling that involved "fat-shaming" often had a counterproductive effect — chastising patients caused them to eat more. Several types of surgeries have proved reasonably safe and effective, but they are invasive and not always reversible, and they represent a major commitment by the patient. There has always been a demand for drug treatment for obesity.

In the past 10 years, new medications have arrived on the market, including six approved by the U.S. Food and Drug Administration. The newer drugs stimulate hormones that trigger insulin release and readjust fat storage. Currently, the most popular is semaglutide, known by the brand names Ozempic and Wegovy. The drug is a once-a-week self-administered injection with minor differences in doses between the two brands, because Wegovy is designed as a weight loss drug while Ozempic was originally a diabetes medication that has been shown to cause weight loss. The most recently FDA-approved weight loss drug is also an injectable, tirzepatide, which has a similar but slightly different mechanism of action.

While they are generally well tolerated, these medications have side effects, some of which are common and can be distressing, including nausea and bowel problems that cause some patients to abandon treatment. Serious eye, thyroid and pancreatic problems occur rarely. A further problem is the uncertainty whether these medications must be taken indefinitely. Some people have regained weight after stopping therapy. No one is sure about the long-term risks, benefits and complications of these drugs, which remain to be studied in patients on lifetime therapy.

Finally, there is cost. These medications are currently quite expensive, in the range of $1,000 per month, although this varies widely depending on drug company pricing strategies and the patient's insurance. Many experts anticipate the cost of these medications will drop as new competitors, some in pill form, enter the market. As insurers realize savings from preventing heart disease and diabetes, they may encourage Congress to have the government pay for these drugs.

The high cost of these medications represents a short-term threat to already overstrained health care budgets, but surgical weight loss procedures are already being performed less frequently. Consider how many knee replacements, sleep apnea masks and electric scooters might become unnecessary, to say nothing of actual reduced food budgets.

Semaglutides and related drugs represent a new vista for the treatment of obesity, America's fastest growing medical problem. There is still much to learn, and there will be refinements in therapy in the future. Considering the costs, complications and alternatives, these medications are not for everyone, and the standard tagline applies here: "Consult with your health care professional about whether you are a candidate."

Now, more than ever, obesity is a treatable condition. With the range of options available, patients need not suffer the health risks and indignities they endured in the past. But be forewarned. You might be able to lose weight on your own through diet and exercise, and it is a serious undertaking to commit to a medicine possibly for life, one in which the long-range effects are unknown. It is not a decision made lightly.