Treatment for obesity is changing. Ozempic is a drug used to treat diabetes; now, millions of people are using it to lose weight. We talked to bariatric surgeon and Chief of Minimal Access/Bariatric Surgery Marc Bessler, MD, about how drugs like Ozempic and Mounjaro work, the differences between medical and surgical treatment for obesity, risks, benefits, and all the questions in between.
There is a positive impact of Ozempic and similar drugs
- Drugs like Ozempic may help shift societal perceptions in understanding obesity as a disease, from blame to medical treatment.
- Previously, effective medical treatments for obesity were limited, with most medications offering modest weight loss. Ozempic and similar drugs now yield an average weight loss of 15 to 20 percent, significantly higher than previous options. About one-third experience around 10 percent loss of body weight.
Challenges and limitations of medical obesity treatment remain
- Treatment with drugs like Ozempic requires life-long commitment, as discontinuing the medication often leads to weight regain.
- Patients may face side effects, including nausea, reflux, abdominal cramping, delayed gastric emptying, and constipation, which might affect their ability or willingness to continue treatment.
- The high cost of medications like Ozempic, approximately $1,200 a month, poses a financial barrier for many individuals, potentially limiting access to this treatment option.
Bariatric surgery remains the most effective treatment for severe obesity, but treatment will likely evolve to include a new combination of approaches in the future
- Ozempic, Mounjaro, and other drugs are not a solution for those who need to lose a significant amount of weight.
- The future of obesity treatment may involve a combination of drugs targeting multiple hormones, similar to managing conditions like diabetes or hypertension.
Greater Weight Loss for More People
There are still a lot of wrong assumptions about medical obesity, and a lot of blame. It is often not seen as a disease. That can make it harder for patients to seek treatment. Is it reasonable to say that Ozempic and similar drugs are having a positive impact on how medical obesity is addressed?
Yes. It's opened up people's eyes to obesity as a disease now that there's effective medication for it. The vast majority of obese patients never got effective treatment because there wasn't effective treatment, or the treatment had more significant side effects. There was nothing that caused dramatic weight loss. You could get 5 to 10 percent of your weight loss on some of these other medications. Now we're looking at averages of 15 to 20 percent.
You have Ozempic and Wegovy, which is just a double dose of Ozempic. Same drug, just marketed under a different name, and actually has FDA approval for weight loss indication, whereas Ozempic doesn't.
Then Mounjaro, which is a different drug from a different company that actually not only has GLP-1 agonist effects, but also GIP gastrointestinal polypeptide, which delays stomach emptying a little bit and has been shown to be more effective for weight loss. It's only approved for weight loss, not diabetes.
There's also Rybelsus, which is the oral version of Ozempic, not quite as effective, but a pill. And there will be other drugs coming out at some point.
Wow. So there's good reason to be optimistic that many more people with medical obesity might achieve positive outcomes because of these drugs.
I'd say when you average losing 20 percent of your starting weight—and no drug has 20 percent as the average, Mounjaro is a little under that, about 17 percent–that leaves half of patients doing really well, right? They're losing 20 percent and more, with a percentage losing up to 30 percent.
But then you have your third of patients on the lower end of the scale who are only losing in the 10 percent range, and they'll say 90 percent of patients lost at least 10 percent of their weight. But if you're 250 pounds, that's 25 pounds. It's nice, but it's not going to get you the 60, 70 pounds that you would get with bariatric surgery. Though bariatric surgery was only available to about 2 percent of the population that was eligible for it. The other 98 percent basically had no effective treatment.
It's big. It's a change we’ve not had in obesity care since sleeve gastrectomy started in 2007.
Does that mean for the vast majority of people, these drugs can’t have lasting effects, and put obesity into remission?
I think obesity is with you forever. If you have bariatric surgery and your obesity is in remission, does that mean you don't have the disease? I think you do. It's just the symptom of your disease, which is the excess weight that has been managed, treated, whatever you want to call it, by the operation.
Same thing with the drug. So maybe if enough people are on these drugs with enough effect, you could start seeing a decrease in the number of patients with the weight qualification to now meet that diagnosis if they were going to be a new patient. I could definitely imagine that.
But how many people would have to be on the drug to really change it? 30 percent of the US population is obese. That's 100 million people. I don't know how many people are on these drugs, but my guess is there are only a few million on it.
Has there been an uptick of people who are seeking treatment, opening up to the conversation about how to treat their medical obesity?
We will be offering primary medical obesity treatment with medications this fall.
Previously, we have been mostly prescribing it for our patients who either need significant weight loss before surgery or those who are post-surgery and struggling, either not having lost enough or gaining back weight. So we've been using these drugs but, for the most part, not as primary treatment.
We're seeing easily 25 percent of patients who are coming in for surgery have tried and failed or don't want to stay on these medications. Either they took it and had bad side effects or took it and didn't lose much weight. Or, “I took it, I lost a bunch of weight, but I don't want to stay on it.”
It's not about the weight loss, it's about the maintenance. The majority of patients stop taking it. And then there's this thing about "I'll stop; if I gain the weight back, I'll go back on it." Which is not so crazy, but if you're diabetic, you're not going to stop your insulin and then watch your sugar go up and go back on it when your sugar comes down. That's a more immediate thing. You don't do the same thing with blood pressure, "Well, I'll come off my blood pressure meds or cholesterol meds, and see how I do.”
So people would need to take these drugs for the rest of their lives?
Yes. There's still this mindset, “Once I get this under control, I'll be able to keep it under control,” because it's not really a disease. They're willing to look at it a little bit more, but not fully understanding that this really isn't in your control. If it was in your control, it wouldn't be a disease, and you wouldn't be here.
Like once I get there, whatever there is, everything will be different.
It might be a little bit easier to exercise, but you won't like it more. It might be that you'll feel better, but feeling better doesn't make you eat less. And the hunger response to that weight loss is really what makes the weight come back. And these medications are pretty effective at reducing hunger.
What about side effects?
They also cause reflux. They also cause nausea. They also cause abdominal cramping. A very small percentage of patients get pancreatitis, that's one of the major side effects. Nausea, delayed gastric emptying. Constipation is pretty common too.
Does bariatric surgery have any similar side effects?
Bariatric surgery doesn't have nausea. Gastric bypass doesn't have reflux. A little bit of constipation, but not significant.
Some patients have sleeve gastrectomy, where they get bad reflux. They might have to take antacid medications, which is a pill a day.
Are some people stopping treatment with Ozempic because of these side effects?
With Ozempic, nausea is the biggest thing for patients. It's the most common reason for stopping. Some have a lot of discomfort from reflux. And some just didn't lose that much weight.
I have patients who didn't lose 30 percent of their starting weight and are not having symptoms and come to surgery. I have a patient for whom I did a lap band; she lost a bunch of weight, but then decided she wanted to lose more and went on Mounjaro and got down to the weight she really wanted to reach. She had like 20 more pounds to lose, so it's relatively easy to get there with these medications.
Bariatric Surgery vs. Medical Weight Loss: Similarities and Differences
These are pretty incredible results, but will bariatric surgery always have more significant outcomes?
When somebody's 350 pounds, they are not getting down to a weight that's healthy with medication. They might lose 50, but they're still going to be 300. I saw a patient recently who went from 320 pounds to 180 pounds on Mounjaro but got so badly constipated they ended up in the emergency room needing to be disimpacted. After that, they said, I'm done with these meds, and I'm going to have surgery so that I don't gain this weight back.
It runs the whole gamut, from people not losing enough weight to having too many symptoms, to being thrilled. And then it's medication for life. So, if it's covered by insurance because you're diabetic or maybe because you're morbidly obese, and they cover it, that's great. You still must inject weekly for life as of right now. There will eventually be either longer-acting meds or pills that are as good as the injections.
In what ways do these medications overlap with or mimic aspects of bariatric surgery?
Basically, these drugs were discovered from some of the research we did on how gastric bypass works. We discovered that gastric bypass releases many hormones from the gut shortly after a meal that usually comes way later after you've eaten.
In gastric bypass or sleeve, you get a blast of GLP-1 [glucagon-like peptide 1, a hormone produced in the gut that releases insulin and reduces hunger] once you start eating. It's there in a balanced way, so you don't have the nausea because it's not there all the time. As opposed to having GLP-1 around all the time, which is what these meds do.
That's a big part of how these operations work. You also get the release of other hormones along with GLP-1. It's more physiologic as opposed to having this drug that's in you all the time, that you don't really need in you all the time.
Now I've had patients who had gastric bypass and gained weight back, then went on these meds, and that's what they needed. It was more GLP-1 than they were getting from the bypass, and it led to weight loss again. But as soon as they stop it, that weight returns because it's the same thing. If the drug isn't there, the disease is.
What is the basic BMI [Body Mass Index] threshold to determine treatment?
A BMI of 27 is overweight, BMI over 30 is obese. We're probably not going to treat anybody below 30 in our practice, and we're probably not going to treat anybody below 35 if they don't have medical problems.
Usually, the insurance company would want you to have a BMI and a comorbid illness, whether it is high cholesterol, diabetes, sleep apnea, or hypertension. You can't just be ‘fat’ and have a BMI of 30.
Is cost a factor? How much do these drugs cost?
Ozempic costs about $1,200 a month, depending on the dose. There are some of these compounding pharmacies that do a generic version of it for a lot less money. I'm not so sure how comfortable we are with that. But what I do know is that people are taking the ‘generic,’ and it's not really generic; it's compounded. They're saying it's a different drug because it's compounded to get with some vitamins or something like that, but it's unregulated.
And generally, people are not good about taking medications. We know that adherence to a medical regimen is not great. So as soon as you lose some weight and see you’re not losing weight anymore, a large percentage stop taking it. I wonder what's going to happen with insurance companies once they stop taking it, whether their insurance companies are going to allow them to go back on it. The bottom line is: will they go back on it? I don't know yet how this will work out on the medical versus surgical end.
In the treatment of obesity, there was basically nothing decent beforehand. And this is really a better tolerated, more effective drug than we've ever had. How it's going to impact bariatric surgery is not obvious, although I believe it will increase surgery over time.
Interesting, can you say more about that?
There's this large pool of untreated obese patients, some of whom will start thinking about treatment because of medication, and some of whom will not be happy with the outcome, but now they're thinking about treatment. Some of them will be happy with the outcome, recognize how wonderful it is to be 50 pounds lighter, but won't want to stay on the medications or have significant side effects they can't tolerate.
Stigma, Abuse, and Changing Perceptions about Obesity
Sounds like Ozempic and similar drugs may lower the barrier for people to begin addressing their disease as opposed to perhaps a sense of resignation.
Right. Which is what most people have. It's like, “Oh, I'll get this under control at some point. This is in my control. I could do this if I really decided to.” They blame themselves. They beat themselves up about why they can't do it. And really, it's not about that.
Now, there is a percentage of patients who are addicted. They don't just have the disease of hunger but have the disease of addiction. Usually those are carb abusers. Some people say that surgery turns that around for them. Some people with these meds say the cravings for sweets and stuff have gone away, but not for everybody. I have heard people talk about the quieting down or the food yearnings. Basically, that's how these work. They are satiety hormones.
Overcoming stigma/judgment and opening to the idea that there are treatments and help available seems profound and promising.
Or just having false beliefs about it. It's hard to fight what society has told you, which is that this is your fault. It's in your control. Just shut up and stop eating. I can't tell you how many medical professionals I've heard say that. They just don't understand this as a disease. Well, it is a disease, and just like suboxone for narcotics addiction shuts off the drive, this is similar. Maybe even a better situation because it's a natural substance that's in your body that we're just augmenting.
It can be hard for people to imagine things being different. We can get used to things that are pretty awful.
That's right. I think it's a complacency. The devil you know versus the scary thing you don't know.
And maybe being able to shift from being afraid to becoming hopeful.
Right. Or being afraid of intervention. The nice thing about medication is you can come off it. I've seen some patients get gallstones from the medication, but that's a common thing with weight loss in general. I've seen a few patients who've had pancreatitis as a result of medication. I haven't seen anybody with bad pancreatitis, but that certainly will happen. Some patients will get bad or lifelong pancreatitis from having taken the medication. But it seems to be a relatively small percentage so far.
In the press, it seems that there are a good number of people taking Ozempic who are not medically obese.
I don't think we know what percentage of patients taking the drug are obese versus not obese. I just don't think we have data on it yet.
You could call it a drug of abuse. Everybody wants to be 10 pounds lighter. I know a lot of people who are taking it just for 10 or 15 pounds. It doesn't make sense to me because we just don't know enough about these drugs and the benefits versus the potential risks long-term. They haven't been around for 10 years, never mind 20 and longer. We just don't know enough.
It's one thing when you have a severe disease, but we're still learning, and I think ten years from now it might be a reasonable thing to do. Right now, it's a fashionable thing to do.
Can you touch on what you envision the future of bariatric care might look like?
Bariatric surgery touches on the distension of the stomach and signaling fullness much sooner when you eat from nerve impulses to the brain, not just hormonal impulses to the brain. It causes the release of multiple hormones, not just one or two that we're able to touch.
Now, one of the big ones is PYY [a peptide released in the small intestine that reduces appetite], which has been shown to be one of the more powerful satiety hormones. But when used so far in clinical trials, it causes a fair bit more nausea than the GLP-1s do. So, it's not being used clinically yet.
But if that could be figured out, then we may be looking at a scenario where we can employ a system like what's used to manage blood pressure or diabetes, with multiple drugs. I think we're looking at a future where you may be taking multiple drugs or combination drugs, either injection or pill, that hit up on these multiple hormones. I think that's going to be in the future.
And in the short term, the bariatric surgery practice is expanding. What does that entail?
We’re going to start offering primary medical treatment within the bariatric program. The medical program already exists, they're just overwhelmed. So, we're adding to that.
If somebody calls the office that has a BMI over 30 with a comorbidity, or over 35 without a comorbidity, we will offer them both medical and surgical management depending on what they're interested in. Whereas before, we used to refer patients out for medical management.
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Learn more about The Center for Metabolic and Weight Loss Surgery.
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- A New Way to Think About Carbs, Weight, and Obesity