Medications offer more options than ever, but behavior and surgery can be keys to success.
At a time when two in five adults have obesity, weight-related illnesses are a major health issue. But what works best for sustainable weight loss—the new, FDA approved drugs, surgery or plain old willpower? We asked RWJBarnabas Health bariatric surgeons Karan Grover, MD, PharmD, and Claire Terez, MD, to help us sort it all out.
What’s the most important thing for people to know about weight loss?
Dr. Terez: Effective pharmaceutical and surgical options are out there today, and they continue to evolve. But when it comes to maintaining weight loss long term, diet and exercise will never go away. Patients need to have a lifelong focus on a healthy diet, reasonable portions and muscle-building activities to help maximize metabolism.
Why do people often fail to achieve sustainable weight loss through diet and physical activity alone?
Dr. Grover: When I consult with patients for the first time, they invariably have tried several diet and exercise programs without lasting success. They have become yo-yo dieters and are very frustrated. To find the reasons, you would have to look to evolutionary biology—to a time when humans had to forage and hunt for food, and bodies evolved to strongly protect against underweight and weakly protect against overweight.
How do the new weight loss drugs work?
Dr. Terez: There are a number of FDA-approved medications to treat obesity, and they work in different ways. Currently the injectable medications, like Wegovy (semaglutide) and Zepbound (tirzepatide), are all over the news and incredibly popular for their weight loss results.
In general, these medications work by mimicking naturally occurring hormones that occur in the GI tract. Normally, these hormones are released in response to eating, signaling the brain that you are feeling full and then going to the rest of the GI tract to tell everything to slow down. So, used as a medication, they have a similar effect: They tell the brain that a person is feeling full and also tell the GI tract to slow down so that the person physically feels full.
Both Wegovy and Zepbound are once-a-week injections that the patient would give themselves in the thigh or lower abdomen. To qualify for these medications, a person must have a BMI [body mass index] of 30 or higher, or a BMI of between 27 and 30 with an obesity-related medical problem such as sleep apnea, high blood pressure or high cholesterol. There are also a number of oral medications available for the treatment of obesity. To be clear, Ozempic, which contains semaglutide, and Mounjaro, which contains tirzepatide, are both FDA-approved for treatment of Type 2 diabetes.
What should a person consider before taking a weight loss drug?
Dr. Terez: While studies show that people who take these medications do lose weight, studies also show that they gain a significant portion of the weight back when they stop taking the prescription. That means a patient can expect to be on the medication for life.
In addition, the medications are expensive. Insurance coverage varies widely by plan. If you have to pay out of pocket, you can be looking at costs in the hundreds of dollars a month, even after manufacturer coupons.
Dr. Grover: Some patients will have moderate adverse effects from the drugs, such as nausea, vomiting or diarrhea, but these tend to improve over time.
None of these medications is a one-size-fits-all, so people should consult with a doctor who is board certified and has expertise in treating obesity. For example, patients who would need to think twice about the medications include those who have a history of endocrine problems, gallstones or pancreatitis.
Because weight loss drugs have been promoted so heavily, there is a shortage of them. That may lead some prescribers to seek out a compounding pharmacy to formulate a version of them, but there’s a risk that those pharmacies may not follow established standards. It’s critical to confirm with your prescriber that your medication is coming from proper distributors.
When should people consider bariatric (weight loss) surgery, and what should they know about it?
Dr. Grover: Weight loss surgery is an option for patients with a BMI of 35 to 40 and obesity-related conditions, or any patient with a BMI of 40 or higher.
With surgery, we know that the weight loss is quite durable at the five-year, 10-year and 20-year marks, and so are the benefits of reduced obesity-related comorbidities such as diabetes, sleep apnea and high blood pressure.
The surgeries are very safe. Some people may experience side effects afterward, such as dehydration, nausea or vomiting, but the overall complication rate is very low.
What kinds of bariatric surgery do you most often do in your practice?
Dr. Terez: We most often perform the gastric sleeve procedure or the gastric bypass. In the sleeve procedure, 80 to 85 percent of the stomach is removed. With a much smaller stomach, a patient eats less and feels full sooner. In addition, the surgery reduces the amount of the “hunger hormone” ghrelin that the body produces, so the patient feels less hungry. Surgery affects a number of other GI hormones as well.
In gastric bypass surgery, the stomach is divided into two sections. During surgery, the top section, known as the pouch, is connected to the small intestine, and a portion of the small intestine is “bypassed,” reducing the body’s ability to absorb calories.
Both gastric sleeve and gastric bypass are done laparoscopically using small incisions and a camera. Typically, a patient will have a one-night stay in the hospital. Surgery is covered by Medicare, Medicaid and many major insurance plans.
I explain to patients that medication will treat obesity, but surgery can cure it. However, every patient has their own boundaries, and that’s fine. Doctors need to respect that and work with people where they are.
Dr. Grover: Weight loss medications and surgery are both tools, not miracle cures, and there is no replacing a healthy diet, regular exercise and a strong support system.
Learn more about weight loss surgery at RWJBarnabas Health.
