In It for the Long Haul: Strategies for Sustaining Weight Loss

Key Takeaways

• Medications can be effective tools to support the lifestyle changes needed to achieve weight loss goals.
• Obesity management should be viewed as part of a comprehensive, chronic preventive care approach for metabolic diseases.
• The weight loss journey should be individualized, with clear expectations communicated to the patient.

Introduction
Obesity is tied to various disease states and has become a growing burden in the United States over the past few decades. At this time, more than 40% of the population is considered obese. Therefore, it is important to discuss obesity management as part of a comprehensive preventive care approach for metabolic diseases such as diabetes, hypertension, and hyperlipidemia rather than continuing siloed treatment of the effect of these diseases stemming from obesity. Weight management and weight loss are consistent concerns for patients and provide a great opportunity for healthcare professionals to provide accurate information and support. In our practice, weight management is a team-based engagement, including not only physicians and pharmacists, but also behavioralists, nurse practitioners, and physician associates/physician assistants. This approach offers the patient support in 4 different foundations: food, activity, medications, and behavior modification and mindset.

Medications
Unfortunately, the number of medications available to aid with weight loss is limited. These medications work on different pathways and can be used in combination, if needed, or as monotherapy. Some examples include bupropion/naltrexone, orlistat, glucagon-like peptide-1 receptor agonists (GLP-1 RAs), and phentermine/topiramate. 

Some of the most frequently used medications I see in my practice are GLP-1 RAs. Two GLP-1 RAs—liraglutide and semaglutide—have been approved for weight management by the FDA and have shown promising evidence. For example, according to a study published in the New England Journal of Medicine, overall weight loss with semaglutide over 68 weeks was 15%, which is outstanding. These results are exciting because we need to start thinking of obesity as a chronic disease state, rather than an acute presentation, and treating it like we would other disease states. Focusing on food and activity is important, but so is the medication component. Medications are a key foundation in the discussion of weight management and can help ensure that patients achieve their goals.

The Medication Journey
The medication journey in general should be individualized. Before prescribing weight loss medications, I discuss expectations with the patient. The typical minimum commitment recommended by studies is 3-6 months for weight loss medications, so individuals need to be prepared to incorporate the medications as tools to help maintain recommended lifestyle modifications, decrease appetite, or decrease cravings.

To achieve results, we need to make sure the patient remains on the medication long enough to  see a benefit. For some, 6 months produces incredible success, and we discuss with the patient whether we continue with the medication or stop once they have achieved their goals. However, for many individuals, long-term therapy is warranted. Some medications, such as phentermine/topiramate, are considered chronic medications and have been approved by the FDA for prolonged use. Although earlier medications such as phentermine are indicated for short-term use, newer medications provide value with their ability to be used chronically.

One caveat I’d like to mention is that although the medications are effective tools, when they are discontinued, their effect frequently stops. For example, GLP‑1 RAs slow gastric emptying. When we stop that medication, gastric emptying will start to speed up, and patients sometimes report increased hunger and may experience weight gain if we don’t have some of those concrete lifestyle habits in place.

To conclude, we should educate patients to not be afraid of considering these as chronic medications. Weight loss medications should not be considered different from other medications that may be lifelong therapy depending on the patient’s needs. If we had a patient with hypertension and started them on losartan, and they got down to their goal, would we stop the losartan? Absolutely not. That is a chronic medication. Obesity similarly needs to be viewed as a chronic condition with equal needs, time, and treatment in the healthcare setting.

Your Thoughts?
In your practice, what recommendations or suggestions do you provide to patients to achieve and maintain a healthy weight? Answer the polling question and join the discussion by posting a comment.