Lesa Walton struggled with rheumatoid arthritis for years. “I was getting sicker and sicker,” said Walton, 57, who lives in Wenatchee, Washington. She also had high blood pressure and was obese. Doctors advised her to diet and exercise, which she attempted without success.
Then she found a doctor who prescribed Wegovy, a new anti-obesity drug. Not only did she lose over 20 kilograms, she said, her arthritis disappeared, and she no longer needed medication to control her blood pressure.
Her doctor, Stefie Deeds, an internist and obesity medicine specialist, said Walton exemplifies a movement in medicine called “obesity first.” The idea is to treat obesity, and as it is controlled, proponents say, a patient’s other chronic diseases tend to improve or vanish.
As Caroline M. Apovian, an obesity medicine specialist at Brigham and Women’s Hospital in Boston, put it, “You get the weight loss and you get the treatment for high blood pressure, fatty liver, diabetes, high cholesterol and high triglycerides.”
Others are hesitant. The new drugs are expensive, and many of the other potential benefits have not been demonstrated through rigorous studies.
Gordon Guyatt, a clinical trials expert at McMaster University in Ontario, said the prudent approach is to use drugs — often cheap generics — that have been well-tested and shown to treat problems that often accompany obesity, such as high blood pressure, high cholesterol, arthritis, and sleep apnea.
Susan Z. Yanovski, co-director of the Office of Obesity Research at the U.S. National Institute of Diabetes and Digestive and Kidney Diseases, noted that when Novo Nordisk conducted a clinical trial of Wegovy in people with heart disease, heart complications declined early in treatment, before patients had lost much weight.
Participants who took Wegovy and lost very little weight also had the same improvements in kidney function as those who lost a lot. A recent study by Novo Nordisk that tested Ozempic in people with diabetes and kidney disease found the same thing: kidney function was better preserved in the group taking Ozempic, an effect that was independent of weight loss.
A big part of the effect may be the drugs’ ability to reduce inflammation, said Daniel Drucker, an obesity researcher at the Lunenfeld-Tanenbaum Research Institute at Mount Sinai Hospital in Toronto who was involved in discovering the new drugs and is a consultant to the companies that make them.
Novo Nordisk found in another clinical trial that Wegovy improved physical functioning — such as the ability to exercise — in people with diabetes and heart failure. Eli Lilly found that Zepbound can help with sleep apnea. Other trials underway are testing obesity drugs as treatments for depression, addiction, schizophrenia, Parkinson’s disease, and Alzheimer’s disease.
But some are urging caution toward “obesity first” treatments, including representatives from Eli Lilly and Novo Nordisk, saying it is prudent to wait for clinical results.
Scott Hagan, a primary care physician in Seattle, practices an “obesity last” approach.
If a patient comes in with obesity and obesity-related ailments, he starts by treating the related problems with medications he knows can work. Only if the related problems don’t improve will he discuss the possibility of trying obesity medications, Hagan said.
People with obesity, he added, tend to have a long history of strained relationships with doctors who blame them for their weight.
“My priority is to establish trust in a relationship,” he said.
Obesity First: A New Approach to Treating Chronic Diseases?
Lesa Walton’s story is not unique. For years, she suffered from rheumatoid arthritis, high blood pressure, and struggled with obesity. Despite doctors’ advice to diet and exercise, she saw little improvement. Then, a new prescription changed everything.
Wegovy: More Than Weight Loss
Walton’s doctor, Stefie Deeds, prescribed Wegovy, a new anti-obesity medication. To her surprise, not only did Walton lose over 20 kilos, but her arthritis disappeared, and she no longer needed medication for her high blood pressure. This remarkable result is prompting a shift in medical thinking, with some doctors embracing an “obesity first” approach.
Obesity First: Targeting the Root Cause
The “obesity first” approach posits that by treating obesity, other chronic diseases, often associated with weight, will improve or even disappear. This approach has its proponents, like Dr. Caroline M. Apovian, who argues that treating obesity effectively addresses multiple health issues simultaneously. “You get the weight loss and you get the treatment for high blood pressure, fatty liver, diabetes, high cholesterol and high triglycerides,” she explains.
Beyond Weight Loss: Potential Benefits
The new anti-obesity medications, like Wegovy and Ozempic, go beyond mere weight reduction. Evidence suggests they may also alleviate inflammatory conditions, improve cardiovascular health, and even impact kidney function. In clinical trials, Wegovy was shown to improve physical functioning in individuals with diabetes and heart failure, while Ozempic demonstrated positive effects on kidney function.
Some researchers believe the medications’ anti-inflammatory properties are key to their multifaceted benefits. A clinical trial by Novo Nordisk revealed that Wegovy improved physical functioning, such as the ability to exercise, in people with diabetes and heart failure. It seems the drugs might be altering the body’s inflammatory response, offering a new avenue for treating chronic diseases.
Obesity First: Raising Concerns
However, the “obesity first” approach is not without its critics. While the initial results are promising, many question the long-term implications and the lack of robust clinical data. The medications are expensive, and the broader impact on other diseases needs further research.
Dr. Gordon Guyatt, a clinical trials expert, advocates for a cautious approach, emphasizing the use of well-established, generic medications for specific conditions associated with obesity. He argues that until more conclusive evidence emerges, the focus should remain on treating the individual ailments rather than solely targeting obesity.
Obesity Last: A Counter Approach
Some doctors, like Dr. Scott Hagan, practice a contrasting “obesity last” approach. They prioritize addressing the specific health challenges first, using established medications for high blood pressure, diabetes, etc. Only if these interventions fail to achieve satisfactory results do they consider introducing anti-obesity drugs.
Hagan justifies his approach by emphasizing the historical mistrust between patients with obesity and medical professionals. He believes building trust and addressing individual health needs should be paramount before introducing new, potentially controversial medications.
Moving Forward: A Balanced Approach
The “obesity first” approach represents a paradigm shift in medical thinking. While it holds great promise for addressing the complex interplay between obesity and chronic diseases, cautious optimism is essential.
Researchers and healthcare professionals need to collaborate in conducting comprehensive clinical trials to establish the long-term effects and safety profiles of these new medications. Addressing the ethical concerns regarding cost accessibility and patient autonomy is equally crucial.
The “obesity first” approach should not be a one-size-fits-all solution. A balanced perspective that considers both individual needs and the evolving understanding of obesity’s impact on overall health is necessary. Further research and careful consideration are needed before fully embracing this novel approach to treating chronic diseases.
