A Holistic Approach to Weight Loss and Illness

Weight-loss drugs, like GLP-1s, are shown to be effective, but there are several barriers to their use including high cost and side effects. More than half of people quit taking GLP-1s before they hit their goal weight, correct?

There was recently an obesity forum held by The Obesity Society. One of the big focus areas was providing more equitable obesity care in our current treatment landscape. For GLP-1s, accessibility is the biggest factor for discontinuation because of cost, shortages, and finding providers who feel comfortable prescribing them. I think the medications are fantastic for the many people who have not been able to manage their weight in the way that they would like through lifestyle change. And some people have seen weight loss of about 20% or more, which is clinically meaningful for obtaining better control of a variety of additional disease states, from sleep apnea to arthritis, diabetes, heart disease, and hypertension.

But, you know, [GLP-1s] are not a treatment in a silo. Accessibility, affordability, and side effects are problems. I, and other providers, have had patients who have had to go to the ER for things like vomiting, diarrhea, and constipation, which is never an outcome that we want to see. And so, we have to ask, “What do we do before, during, and after using these medications to try and support patients to maintain their weight another way?”

How do you talk to patients about setting realistic treatment goals when they are taking these medications, and how do lifestyle changes fit into those goals?

The patient and provider have to set realistic expectations for what any of these treatments do. I also talk to my patients up front about lifestyle change and dietary changes as being very viable pathways for some people to lose 5% to 10% of their total body weight. There’s research that shows that people respond differently to different treatments for both medications and for dietary change. Some people respond really well to the high-protein, high-plant-based diet, and some people respond really well to a more ketogenic dietary pattern, to the point where they may not need medication.

But some people may need more and the newer weight-loss drugs, like semaglutide, can help lose 15% to 25% of a person’s body weight. The most recent ones, like tirzepatide, can be 20% to 25%-plus weight loss. But with modest weight loss that can be achieved via lifestyle changes, it could be enough to prevent diabetes, high cholesterol, or hypertension. If your goal is to treat cardiovascular disease, or put Type 2 diabetes into remission, you need to be thinking more about 15% or more weight loss.

You are a proponent of Food is Medicine programs, which emphasize using nutritious food to promote health and lower disease burden. How do they work for someone seeking to lose weight?

In primary care, we don’t have the resources, time, or tools at present for really making meaningful shifts to a more health-promoting dietary pattern for our patients. And the reality is, it’s very challenging in our current food environment and the cost of health-promoting foods are barriers for a lot of people. This is where I think Food is Medicine has the potential for a lot of growth. Some of the research that I do now is looking at ways to leverage Food is Medicine therapies. One of these is having a food prescription that can be purchased through an electronic benefit card, which would be like a fresh fruit and vegetable version of the SNAP program. It allows folks to purchase food from their local grocery store with an electronic card. There are also medically tailored groceries or direct food provisions that are usually produce-forward, but can be shelf-stable, nutritious foods to promote a healthy diet. And the last, and most intensive, would be medically tailored meals, where individuals are prescribed meals. But this kind of program can be challenging for patients who may be homebound or can’t prepare their own food.

Are there components, other than dietary prescriptions, for people in Food is Medicine programs?

Yes. The Diabetes Prevention Program model was quite effective for creating lifestyle change and preventing progression to diabetes. And part of that used shared medical appointments [group doctor visits for people with similar health concerns], which can be supporting and encouraging for people wanting to shift to a healthier eating pattern. The American College of Lifestyle Medicine is really a proponent of group-based visits for lifestyle change. Culinary medicine is also a new, growing field to help people learn to prepare these healthy foods in a way that is palatable and exciting. There are places, like Tulane’s Goldring Center for Culinary Medicine, that are really leaning into the culinary medicine space, as well as with the Teaching Kitchen Collaborative through Harvard, which has a number of teaching kitchens across the U.S. that are doing a lot of these interventions. All of these are sort of the kitchen-sink approach, but if we are really going to think about addressing obesity and these diet-related chronic diseases, it may take that intense level of treatment.

What about payment options for these kinds of services? A lot of this sounds like it would be outside the realm of traditional health insurance coverage.

Some insurers have worked with different healthcare institutions to provide these benefits. With the lifestyle medicine group-based visits, some are reimbursed by insurance and some are self-pay. There are varying cost models for these clinical care types of environments.

What about the cost of these programs? The insurance industry tends to be more open to paying for treatment than prevention. Is there a proven return on investment for some of these lifestyle interventions?

We will know more in the coming couple of years on modeling the cost of things. We know the costs of these new obesity medicines are potentially $12,000 to $16,000 a year.

But everybody is already spending money on food, whether or not it’s health-promoting food. We’re looking at the right dose of produce for a prescription benefit. I think for these different therapies, you’re probably looking on the order of $80 a month for Food is Medicine direct provision of foods. It will also vary, based on the type of intervention that you’re providing. But we are going to have to think about investing in some of these alternative therapies to potentially offset this really high cost per year, which could be $6,500 per year direct cost to patients for some of these medications. If you’re looking at around $80 a month, or, let’s even say, $100 a month, that’s, conservatively, about $1,200 a year. So, if we can think about offsetting some of these [drug] costs with really precise nutritional interventions, then I think we can start moving that forward. And we’re going to have to move it forward, because the reality is, we can’t pay the billions of dollars per year for our U.S. total healthcare expenditures for GLP-1s and these novel obesity medications.

Is a Food is Medicine program something that an employer, through its insurer, could put into place?

An insurer could put this into place. And I think the reason why they should do it is because the direct provision of nutritious foods fits into the context of value-based care that promotes health and well-being, rather than increasing the burden of medications, which have their own challenges and limitations.

We need more of these programs integrated into healthcare settings that encourage behavior change for our people so they may not need the medication, or they may not need medication for as long.

Where should employers look if they think this may be something they would like to implement in their workplace?

There are companies that exist specifically for employers to provide lifestyle-focused care for their employees. There are also specific clinics providing services for employers and insurers. There are health clinics that have obesity medicine clinics. Large health systems in many regions are focusing on this as an important topic and many have these types of programs available; it just takes a little bit of online research to find them.

Tackling obesity is difficult. If it weren’t, we wouldn’t need these medications. What has been your biggest takeaway as a provider in this space?

In our current food environment, the availability of calorie-dense, lower-nutrient foods is high. There’s a lot of ultra-processed foods out there that are readily available, highly palatable, highly advertised, and individuals have a large barrier to overcome these pressures that we have in our everyday food environments. Making those changes is hard.

We need to reframe our entire culture to think more about whether we should be focusing more on overall well-being, rather than treating specific diseases. We have developed a very good medical system to treat disease and find disease states, but the medical system in the U.S. has not done a great job of thinking about large-scale solutions to prevent disease and promote well-being. As we think about new payment models with insurers and think about how to rein in some of these high costs, there’s a big appetite for value-based care and changing the way that we’re working in our health systems to promote health and prevent disease, rather than just treat chronic conditions.

The focus for obesity management really should be on promoting health at every size and reducing stigma in the way we talk about weight management. Our focus should be on the goal of getting patients to their desired state of well-being and health. There is a lot of excitement with these new drug therapies, but they are mired with challenges. I think that integrating them into a non-traditional Food is Medicine program should help us make the change that we couldn’t attain up to this point. Very few disease states have just one approach to treatment. Hypertension’s first line of treatment is lifestyle change, but some people need medication, and they may even need multiple medications. In the coming years I think we will be managing weight loss similarly, and we need to make sure part of that is supporting healthy dietary patterns and increased mobility.