No Magic Bullet

As a nation, Americans – from teens through senior citizens – are less healthy than they’ve ever been, driven by lifestyle factors such as poor diet and lack of exercise.

More than 70% of Americans fit the new obesity diagnosis developed by the Lancet Diabetes and Endocrinology Commission where body mass index (BMI) is only a screening tool. The actual diagnosis is based on confirming excess body fat (using waist circumference, ratios or direct measures) plus identifying functional impairment (clinical obesity) or increased risk (preclinical obesity). More than 40% of Americans are pre-diabetic and nearly 15% have been diagnosed with type 2 diabetes.

It’s an epidemic, noted Thomas Collins-Pallett, MD, chair of Family Medicine at Washington Health Medical Group (WHMG), but one that can be managed by a combination of lifestyle modifications and medication.

He is quick to add, “Let’s be clear: there is no magic bullet in either controlling diabetes or weight loss. Dealing with type 2 diabetes and fighting obesity calls for a long-term management plan. I aim for slow weight loss that is consistent – and sustainable – over time. We’re talking changes over a lifetime, not just a few months.”

Plan of Action

Dr. Collins-Pallett’s strategy includes diet, exercise and the use of weight loss medications including GLP-1s (glucagon-like peptide-1 receptor agonists) and so-called dual-hormone agonists. GLP-1s, such as Ozempic, Wegovy and Rybelsus, were initially FDA-approved for management of type 2 diabetes. Dual agonists have both GLP-1 and GIP (glucose-dependent insulinotropic polypeptide) agonists and were FDA-approved for management of both type 2 diabetes and obesity. These include the medications Zepbound and Maunjaro. An agonist is a natural or synthetic chemical that binds to a specific cell receptor and activates it, mimicking a natural signal to trigger a biological response, essentially "turning on" the cell's function.

“Think of it as a key fitting a lock and opening the door,” he said. “GLP-1 and dual agonists mimic the natural hormones GLP-1 and GIP, stimulating the pancreas to release more insulin when blood sugar is high. They help get rid of the ‘food noise,’ slow digestion, reduce appetite and decrease glucose (sugar) production in the liver. I use both types in my practice depending on the patient’s unique diagnosis and comorbidities.”

Some patients come in seeking quick weight loss using these medications alone. Dr. Collins-Pallett is quick to tell them that’s not the way the medication, or his plan of care, works.

“Obesity is a chronic condition, so I tell my patients we’re looking at a long-term, two-year management plan at a minimum, with slow weight loss that allows their stomach to shrink,” he said. “We have great health data showing yo-yo dieting is actually worse than staying at the same weight. We work together to set reasonable expectations so when we start weaning them off the medication after two years, they have the lifestyle tools to keep the weight off. If you abruptly stop taking the medication without that plan, it will go right back on. This is a commitment and plan for life.”

Body System Health

In addition to being very effective at helping patients achieve significant weight loss and attain diabetes control, Dr. Collins-Pallett noted this class of weight loss medications can have positive effects on overall health. They can slow the progression of chronic kidney disease and reduce inflammation in the kidneys. They lower the risk of heart attack and help lower blood pressure. They also improve liver health by reducing fat, inflammation and liver enzymes, particularly for fatty liver disease.

But they also come with potential side effects. Dr. Collins-Pallett outlines the potential benefits and side effects of this class of medication for his patients and cautions them about looking for a quick fix.

“I think people understand they’re overweight, but being obese might not be on their radar,” he said. “Then they see Hollywood stars shed pounds virtually overnight on these medications, but that’s not an accurate depiction of how these medications work and what their purpose is. You don’t lose 40 pounds overnight. You need to work with your primary care provider to safely lose weight using any method, especially using these medications. There are short- and long-term side effects to consider and baseline lab tests to run before we even begin a course of medication. We want our patients to live long, healthy lives, not have their health compromised by a regime that isn’t right for them.”

Common short-term side effects are the same for the GLP-1 and dual-agonist medications. Most common are gastrointestinal and include nausea, vomiting, diarrhea, constipation, stomach pain, bloating and indigestion. Patients have also reported injection site reactions, fatigue, headache and dizziness. All short-term side effects generally occur when starting or increasing doses. There are also long-term side effects that are often tied to rapid weight loss, including increased risk of gallstones; dehydration, which can lead to severe kidney problems; hypoglycemia (low blood sugar); and facial changes (hollow cheeks, sagging facial skin and increased wrinkles).

Based on animal studies, the FDA has issued a black box warning for GLP-1s for potential thyroid tumors in patients with a family history of medullary thyroid cancer or multiple endocrine neoplasia syndrome type 2. Recent large human studies haven’t shown a clear causal link. Dr. Collins-Pallett noted GLP-1s don’t impact common thyroid conditions such as hyper/hypothyroidism and weight loss can improve thyroid hormone levels, but he monitors his thyroid patients on weight loss medication closely.

The most common long-term side effect is weight gain after stopping the injections. Many people regain up to half of the weight they lost within a year because the medication’s appetite suppressing effects are gone and old eating habits come back.

“This is why I work closely with my patients on these medications,” Dr. Collins-Pallett said. “It is possible to lose the weight with a combination of medication and lifestyle changes and maintain the loss after weaning off the medication by keeping up with the lifestyle changes. I work with each patient to set that as our goal, using gradual tapering and focusing on a sustainable, healthy diet and exercise, and a positive mindset to keep moving forward.”

For more information about WHMG Family Practice, go to mywtmf.com/services/family-medicine/.