Treating Obesity With GLP-1s — Finding the Way Forward

Using lessons learned from medicating mental and behavioral health conditions, Stephen Cook, MD, offers suggestions about how medications approved for adolescents with obesity should become part of care.

For most of the time in Western medicine, people have treated obesity like a choice — not a disease. Like other conditions now understood to be chronic conditions, such as substance use disorder, attention deficit hyperactivity disorder (ADHD), and mental health conditions, perceptions and stigmas around these diseases have begun to shift as scientific discoveries have rapidly emerged. The science of body metabolism and energy storage has led to the development of medications that target various metabolic pathways that can lead to the disease of obesity.

Having a medication to treat the disease changed what it meant to live with the condition. It also further emphasizes that the condition is medical — not moral.

While medication for obesity is not new, GLP-1 agonists including semaglutide and liraglutide have dramatically altered the obesity treatment landscape. As the medical community shifts care plans to include these new medications, there’s a lot to be learned about how best to move forward. According to Stephen Cook, MD, pediatrician and director of the Center for Healthy Weight and Nutrition at Nationwide Children’s Hospital, a lot can be learned from considering how medication for behavioral and mental health conditions has been incorporated into practice.

“Now that medications are available to treat obesity, some providers wonder if we should start prescribing them to everyone with an obesity diagnosis right out of the gate,” says Dr. Cook. “But that’s not what we (the medical community) did with ADHD medications.”

According to Dr. Cook, behavioral health experts led the way in prescribing and developing best practices with the use of medication for ADHD in a range of children. Then, once evidence-based practice recommendations were established, primary care clinicians used what they had learned from the specialists. Dr. Cook also points out that every doctor had whole didactic units on mental health as well as a psychiatry rotation during their clinical years of medical school. They also had rotations or electives in behavioral/mental health during residency. In comparison, most medical schools don’t have formal units or rotation in obesity medicine, let alone electives in residency.

“I think we should look at a similar model for obesity,” he says.

Further extending the analogy of drug therapy for mental and behavioral health conditions, Dr. Cook says medications for weight loss should not be used in isolation.

Stephen Cook, MD

“Most of the time drug therapy for mental and behavioral health conditions is recommended and most effective when combined with talk therapy and lifestyle supports,” Dr. Cook says. “Likewise, medication treatment for obesity should not be used alone or without lifestyle and counseling support.”

People with obesity often have mental health comorbidities, including possible eating disorders. Sometimes, Dr. Cook says, weight loss can trigger or worsen stress, anxiety and any comorbid mental health conditions.

“GLP1 medications can have dramatic effects,” says Dr. Cook. But the weight-loss is not limited to fat loss. They can also result in a loss of muscle mass.

“We’ve seen this in adults and are looking at the muscle mass decreases in teens,” he adds. “This is also an important reason for continuing behavioral health support to help with exercise and nutrition.”

Additionally, long-term weight loss requires balance, he adds.

“While we have to accept the limits of healthy lifestyle for weight loss, we have to remember that it is essential to long-term weight management and overall health,” Dr. Cook says. “Medications and bariatric surgery are additive approaches. Their effectiveness should not cause us to abandon healthy lifestyle and continued support for good nutrition and exercise.”

Notably, most research suggests that lifestyle changes, including diet and exercise typically result in a 5-10% weight loss, but users of GLP-1 agonists can expect 15-20% weight loss. A recent publication indicates that bariatric surgery results in up to 30% weight loss after 12 months.

With all of these options, individualized care for children and adolescents that involves shared decision makingt. According to the American Academy of Pediatrics, health care clinicians should consider health status, family support systems, community contexts and other factors when developing a treatment plan. It is also acceptable for a family or provider to say that this is not the time or place to consider treating obesity if there is too much going on.

“The AAP guidelines didn’t say that we must prescribe these medications they say we should consider their use,” says Dr. Cook. “I think the future state is for obesity experts to share the experience we gain over the next few years to help other providers know when and how to best use these new tools in the obesity toolbox.”