Living With Obesity in 2023: Diet and Exercise, Surgery, or Drug Therapy?

Human epidemiology teaches that there are three stages of disease transition, which are the ages of pestilence and famine (ended in 1875), receding pandemics (1875–1930), and degenerative and man-made diseases (1930–present).¹ Focusing on what has changed between the age of pestilence and famine to the receding pandemics and beyond, the obvious ones are the rapid increase in population growth, greater salt intake, and—potentially most importantly—increased mechanization of food production. The latter means more processed foods, which, when combined with a decline in physical activity, have led to a worldwide obesity epidemic. Currently in the US, 34% of adults and 15%–20% of children and adolescents are considered obese.²

Should we care? Yes; obesity often contributes to cardiovascular issues—specifically, to major cardiovascular events (MACE) (eg, acute myocardial infarction, stroke, cardiovascular mortality, heart failure, and hospitalization for unstable angina or coronary revascularization).³ MACE occurs in approximately 3%–7% of the population, depending on the extent of coronary artery disease involvement. The burden of coronary artery disease in the US is estimated at 616,900 cases, with first-year treatment costs totaling $5.54 billion.⁵

How can we overcome obesity? There are three options available in 2023 for individuals with obesity. The first is diet combined with regular exercise. Diet is defined by Oxford Languages as a special course of food to restrict intake, either to lose weight or for medical reasons. Exercise portends protection from metabolic disorders, cancer, osteoporosis, mental impairment, disordered sleep patterns, and weight gain.⁶ The American Heart Association and American College of Cardiology recommend that everybody engage in moderate-intensity aerobic activity (eg, brisk walking) for 30 to 60 minutes a day for 5 to 7 days per week, and an increase in daily lifestyle activities (eg, gardening) can help supplement that to further improve cardiorespiratory fitness.⁷ The second option is gastric bypass and other weight-loss surgeries. Bariatric surgery is recommended when diet and exercise are ineffective or if a person has serious health problems due to obesity.⁸

The third option is drug therapy. Glucagon-like peptide-1 (GLP-1) is a gut hormone released with food intake, stimulating insulin release, inhibiting glucagon secretion, and regulating gastric emptying.⁹ GLP-1 receptor antagonists (GLP-1 RAs) are the latest class of drugs to be approved for the treatment of obesity. Preliminary results of the SELECT trial report that semaglutide, a GLP-1 RA, reduced MACE outcomes by 20% in about 17,500 patients with obesity and heart disease,¹⁰ although the final results have yet to be published in the peer-reviewed literature. For example, we do not yet know if the cardiovascular benefits seen in the SELECT trial last if the patient does not maintain the weight loss. Initial estimates of the effect of this study are that 93 million patients would be eligible for treatment with semaglutide, resulting in approximately 43 million fewer US adults with obesity and a 1.5 million reduction in the number of total adverse cardiovascular events for this population.¹¹

The diet and exercise option to treat obesity has not proven effective and durable over time as the prevalence of obesity continues to rise. Gastric bypass has a limited population who meet eligibility requirements. The third option—GLP-1 RA—could be the most feasible and may change the obesity narrative for weight loss from a cosmetic choice to a medical treatment. The current preliminary results indicate potential major implications for society, health care, and cost to the US health care marketplace. There are several issues to warn patients about when seeking GLP-1 RA treatment. First, direct-to-consumer telehealth companies are marketing GLP-1 RA drugs. A recent study suggests that approximately 47% of patients may get these drugs without a traditional health care visit.¹² Patients are prescribed these drugs by psychiatrists to offset weight gain from atypical antipsychotics, which is not an on-label indication.¹³ Second, the adverse effect profile of these drugs is not without concern. GLP-1 RA drugs increase the risk of heart failure hospitalization in patients with heart failure with reduced ejection fraction.¹⁴ Suicidal ideation has also been reported.¹⁵ Aspiration has occurred during anesthesia with Wegovy and Ozempic because of full stomachs, even after not eating for 6-8 hours.¹⁶ Third, insurers are reluctant to cover the high cost of these agents, which is the reason patients seek direct-to-consumer options for these drugs. The choice of living with obesity or choosing different routes of treatment has never been better for patients than it is today, but pharmacists should discuss the risks and benefits of each treatment option with their patients.

Mark A. Munger, PharmD, FCCP, FACC, is a professor of pharmacotherapy and adjunct professor of internal medicine, at the University of Utah, where he also serves as the associate dean of Academic Affairs for the College of Pharmacy.

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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of the Annals of Long-Term Care or HMP Global, their employees, and affiliates.

References

1. Rogers, RG, Hackenberg, R. Extending epidemiologic transition theory: A new stage. Biodemography and Social Biology. 1987;34:(3-4):234-243. doi:10.1080/19485565.1987.9988678
2. Mitchell NS, Catenacci VA, Wyatt HR, Hill JO. Obesity: overview of an epidemic. Psychiatr Clin North Am. 2011;34(4):717-732. doi:10.1016/j.psc.2011.08.005
3. Bosco, E, Hsueh, L, McConeghy, KW, et al. Major adverse cardiovascular event definitions used in observational analysis of administrative databases: a systematic review. BMC Med Res Methodol. 2021;21(1):241. doi:10.1186/s12874-021-01440-5
4. McGinnis HD, Ashburn NP, Paradee BE, et al. Major adverse cardiac event rates in moderate-risk patients: Does prior coronary disease matter? Acad Emerg Med. 2022;29(6):688-697. doi:10.1111/acem.14462
5. Russell MW, Huse DM, Drowns S, Hamel EC, Hartz SC. Direct medical costs of coronary artery disease in the United States. Am J Cardiol. 1998;81(9):1110-1115. doi:10.1016/s0002-9149(98)00136-2
6. Wang G, Pratt M, Macera CA, Zheng ZJ, Heath G. Physical activity, cardiovascular disease, and medical expenditures in U.S. adults. Annals of Behavioral Medicine. 2004;28(2):88-94. doi:10.1207/s15324796abm2802_3
7. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2012;126(25):e354-e471. doi:10.1161/CIR.0b013e318277d6a0
8. Public Education Committee. Bariatric Surgery Procedures. American Society of Metabolic and Bariatric Surgery. Published May 2021. Accessed August 8, 2023. https://asmbs.org/patients/bariatric-surgery-procedures
9. Madsbad S. The role of glucoagon-like peptide-1 impairment in obesity and potential therapeutic implications. Diabetes Obes Metab. 2014;16(1):15-30. doi:10.1111/dom.12119
10. Novo Nordisk. Novo Nordisk A/S: Semaglutide 2.4 mg reduces the risk of major adverse cardiovascular events by 20% in adults with overweight or obesity in the SELECT trial. Published August 8, 2023. Accessed August 18, 2023. https://www.novonordisk.com/news-and-media/news-and-ir-materials/news-details.html?id=166301
11. Walter M. Weight loss drug semaglutide could boost heart health up to 93M patients in US alone. Published August 15, 2023. Accessed August 18, 2023. https://cardiovascularbusiness.com/topics/clinical/heart-health/semaglutide-wegovy-heart-health-overweight-obese-cvd
12. Palmer K. Where are patients getting their prescriptions for GLP-1 drugs like Wegovy and Ozempic? Published August 10, 2023. Accessed August 18, 2023. https://www.statnews.com/2023/08/10/wegovy-ozempic-weight-loss-telehealth-prescriptions/
13. Welle E. Psychiatrists prescribe Wegovy to battle medication-induced weight gain. Medscape. Published August 7, 2023. Accessed August 18, 2023. https://headtopics.com/us/psychiatrists-prescribe-wegovy-for-medication-induced-weight-gain-41934293
14. Neves JS, Packer M, Ferriera JP. Increased risk of heart failure hospitalization with GLP-1 receptor agonists in patients with reduced ejection fraction: a meta-analysis of the EXSEL and FIGHT trials. J Card Fail. 2023;29(7):1107-1109. doi:10.1016/j.cardfail.2023.03.017
15. Yournshajekian L. Evidence weighed for suicide/self-harm with obesity drugs. Medscape. Published July 12, 2023. Accessed August 18, 2023. https://www.medscape.com/viewarticle/994266?form=fpf
16. Aleccia J. Popular weight-loss drugs like Wegovy may raise risk of complications under anesthesia. Published August 11, 2023. Accessed August 18, 2023. https://abcnews.go.com/Health/wireStory/popular-weight-loss-drugs-wegovy-raise-risk-complications-102232190