By RICHARD FRANK
Demand for GLP-1 medications soared last year and shows no signs of stopping in 2024. Employers and health plans are understandably anxious about how long they should expect to pay for these pricey drugs. They’re itching for an easy off-ramp.
Some solutions are cropping up to pave the way. Many of them claim they can help patients reap the benefits of GLP-1s within a short time frame, and get them off the drugs within 12 months to save costs. But the data doesn’t support that promise. In fact, studies suggest some patients may need to stay on the drugs indefinitely to sustain outcomes while other patients may be able to discontinue the drugs and at least maintain their cardiometabolic risk reduction even if they cannot maintain all of their weight loss.
A better strategy to control costs is to more accurately pinpoint those who really need the drugs—and keep those who don’t off of them from the start. Of course, there will be times when deprescribing is appropriate, and we need to clinically support patients through that process. But one-size-fits-all solutions centered on medication as a silver bullet to obesity are only setting up patients and payers for failure. Similarly, those whose sole promise is to deprescribe, don’t follow the evidence.
Prescribing GLP-1s with the goal to deprescribe is foolhardy
GLP-1s treat obesity, but they don’t cure it. GLP-1 agonists increase the body’s own insulin production and slow the movement of food from the stomach to the small intestine. The drugs help people eat less by curbing cravings and boosting satiety. Studies show that once people go off semaglutide, the cravings come back in full force—and so does much of the weight.
While GLP-1 medications produce nearly miraculous outcomes in some people, they’re no quick fix. Obesity is a complex chronic disease. Drugs alone can’t solve for genetic predisposition, behaviors, mental and emotional components, social determinants of health, and other compounding elements that contribute to obesity. In the right circumstances, drugs can give people a solid leg up in better managing those contributing factors—but they’re not for everyone.
Keto is not a sustainable replacement for GLP-1s
Highly restrictive diets like the keto diet aren’t for everyone either. Keto requires a drastic reduction in carbohydrate intake, which can be difficult to maintain long-term. Not to mention, the high-fat content of keto diets can also lead to other health issues and isn’t conducive to tapering off of GLP-1 medications. Side effects from the drugs can make a high-fat diet difficult to tolerate.
It’s good to be wary of solutions that promise an off-ramp by way of highly restrictive diets. While a keto diet may help people lose weight in the short term, studies show that weight loss is rarely sustained over the long run and may be detrimental to overhaul health. The diet is associated with many complications that often lead to hospital admissions for dehydration, electrolyte disturbances, and hypoglycemia.
Triage the right care to the right people at the right time
Obesity’s complex nature requires a personalized approach to treatment that delivers the right care to the right people at the right time. That takes a whole care team of specialized providers—like registered dietitians, health coaches, and prescribing physicians to help people at various stages of the disease. And since obesity often occurs alongside other cardiometabolic conditions like hypertension, diabetes, COPD, and more, patients need the help of specialists who understand how those different conditions interact.
Behavioral interventions that focus on eating patterns, sleep hygiene, and exercise routines can be highly effective for many people. Studies show that people who participate in behavioral weight loss programs for over 12 sessions, lose approximately 5-10% of their body weight. That might not seem like a lot, but just 5% percent of weight loss is associated with healthier biomarkers. If the goal is better health—and not just quick cosmetic fixes—behavioral interventions can work really well.
Others may need to supplement behavior change with proven weight loss drugs like Contrave or Topomax that have been around for decades. These will work for the vast majority of patients who need help losing weight. About 10-20% of a population may need even more intensive drugs like GLP-1 medications, but they’re the exception, not the rule.
Optimize results for those already on the drugs
Significant side effects impede the progress of many people on GLP-1s. In order to see the best results from the drugs, people need wraparound support from expert providers. Registered dietitians can help strategize ideal eating times and nutrition-dense food that patients tolerate well. In fact, the FDA only approves the use of GLP-1 medication when prescribed in combination with calorie restriction and behavior change.
If we’re investing in these costly, though life-changing, treatments, we should ensure their success with medical nutrition therapy and other personalized care.
Maximize success when deprescribing
No matter how much support is given, there will be some people who simply can’t tolerate the drugs or choose to go off them for a variety of reasons. Deprescribing may also be necessary when a patient has a change in their health circumstances: a pregnancy, major surgery, or other condition where going off the drug is advisable in their short or long-term care plan. But we shouldn’t forcefully encourage patients dependent on GLP-1s to go off of them simply to save costs. That’s not how ethical medicine is practiced.
We need to set patients up for as much success as possible even when deprescribing is necessary. Highly restrictive diets aren’t likely to work for the majority of people who go off GLP-1s. They’ll need more sustainable approaches to maintaining a calorie deficit and managing behaviors around eating, including emotional aspects, while still getting adequate nutrition. Supporting patients with dietitian-led medical nutrition therapy and health coaches can help ensure patients get the best nutrition and care as they manage this transition.
Richard Frank, MD, MHSA is the Chief Medical Officer of Vida Health