Like an endangered species, preventive medicine and chronic disease management—the US primary care system—face extinction. With nearly 30% of American adults lacking a source of care and 28 percent reporting delaying or not getting care due to cost, the consequences are far-reaching.  The focus on chronic disease prevention and addressing its root causes demands greater attention, as the health of the system—and the people it serves—depends on it. If we are frustrated about something, this is worth the outrage.

It has been almost impossible for elected officials, who too often look for singular villains, to grasp the extent of this system-wide dysfunction. This crisis extends beyond consumer comfort with technology or the cost of medicines. Primary care medicine—the basis for health delivery—is marginalized as an honored medical discipline. Somehow, we opt for a national health system prioritizing sick care over healthcare.

Primary care providers are grappling with burnout and inadequate compensation compared to their specialist counterparts, and the system often prioritizes paperwork over quality of care. Economics drives health delivery and access, and it’s simply not working to the advantage of consumers and primary care physicians.  

Finger-pointing and Senate HELP Committee photo ops cannot solve this nation’s care crisis. What’s needed is a fundamental shift in our approach to illness, prevention, and access—one that addresses the root causes of our failing primary care system and ensures that quality healthcare is accessible to all Americans, regardless of zip code or digital literacy. That will reduce our total health costs.

Obesity and Heart Disease: A Multigenerational Threat

America’s waistline is changing—we are adding notches to the nation’s belts. Obesity rates among younger Americans are climbing, creating an abundance of chronic diseases that once seemed confined to older generations. Alarmingly, heart disease, which had been in decline for decades, is creeping back up.

The invention of new weight-loss drugs like GLP-1 receptor agonists helps many struggling with chronic weight issues and mitigates some health risks. Yet, these drugs are not a complete answer to the challenge. They do not adequately address the underlying risks—heart disease, diabetes, and other chronic conditions—that require ongoing, consistent engagement with health professionals. Without this, even those who benefit from these medications – looking trim – may still end up battling old health challenges.

The persistent challenge of obesity across various age groups in the US, which hovers at +/- 40 percent, reinforces worrisome trends that impact people by age, race and region. A rate stable at 40 percent is not something to celebrate – it requires action. It’s a tipping point for illness.

Prediabetes: A Perfect Public Health Storm

Prediabetes is the nation’s silent epidemic. Close to 90 million adults—more than 1 in 3 Americans—have it, and 90% don’t know they do. Left unchecked, some 20 percent of these people “graduate” to Type 2 diabetes and other complications annually. The rise in obesity among younger populations only exacerbates this issue, setting the stage for an earlier onset of chronic diseases that worsen over time.

Prediabetes demands a dedicated behavior-focused treatment plan. Without significant lifestyle changes, individuals are on a fast track to diabetes and its life-altering complications. And yet, the primary care system—our first line of defense—is buckling under pressure, unable to provide the consistent support patients need. It’s not just the use of medications – it’s understanding that obesity is a multi-system condition and a unique disease that transcends more belt notches.

The Limitations of GLP-1 Drugs:

GLP-1 drugs do reduce weight and lower the risk of diabetes and heart disease. But they are not a substitute for comprehensive care. The underlying dangers—poor cardiovascular health, insulin resistance, and other metabolic issues—don’t disappear with weight loss alone. Without engagement with allied health professionals trained to address the complexities of obesity to monitor and address these risks, consumers will face new challenges despite these drugs’ initial success in losing pounds.

We live in what Katherine Saunders, MD, DABOM, a Weill Cornell Medicine’s Comprehensive Weight Control Center and co-founder of FlyteHealth, calls the “Obese-a-genetic” era.  Her efforts at FlyteHealth leverage the latest in science, technology, patient support, and a range of medications to individually tailor weight treatment based on a person’s unique biology alongside the complexity of obesity treatment:

“Overweight and obesity are misunderstood medical conditions that are more complex than calories in and calories out. The advice many patients receive—to eat less and exercise more—often fails to address the problem.”

Saunders and her colleagues are at the cutting edge of results-oriented care, but she is among the handful who have dedicated their careers to this pressing clinical discipline.

Walk-In Clinics are about Convenience

Convenience of care is essential to people’s well-being. Entrepreneurial internists have recognized this, creating “pop-up” vaccination and care centers to bring services closer to those in need and better work/life balance. But convenience alone isn’t enough. Urgent care clinics underscore one of the nation’s most pressing public health threats—the erosion of primary care—has reached a retail-like inflection point.

Walk-in clinics and telehealth check-ins are helpful but do not offer dedicated follow-up. They are geared to address the consumer’s immediate need and are not structured for the longitudinal engagement for the hard-to-tackle considerations that call for comprehensive support.

We are stuck between a system that focuses on its self-preservation and what is in our and national long-term interests – protecting our most important asset – our health.

The Rise of the Make American Health Again Movement

Primary care physicians, the cornerstone of preventive health, are becoming extinct as a medical profession species. The reasons are many: medical school debt driving doctors to higher-paying specialties, they are paid by the number of patients seen daily burnout, and the rise of retail clinics offering quick, transactional care.

While these clinics improve access, their focus is not on a long-term patient-physician relationship. This shift leaves a dangerous gap in the medical safety net, particularly for chronic conditions like obesity, prediabetes, and heart disease. Without a trusted health provider to guide them, patients are left to navigate their health journeys solo—often with devastating consequences.

Many are aghast at Robert F. Kennedy Jr.’s nomination to the Department of Health and Human Services as Secretary of the nation’s key organization setting national health policy. This justified anxiety centers on his stated positions on vaccines and his off-hand comments dismissing the importance of medicines in preventing more serious illnesses. However, his thoughts about America’s poor health report card grades deserve attention regardless of the outcome of the Senate confirmation hearings.

His Make America Healthy Again movement has an approach that deserves consideration: the need to tackle the chronic disease epidemic, which has become the leading cause of death in the US and, later, drives massive costs in hospitalization.

“There are some things that RFK Jr. gets right,” says Resolve to Save Lives CEO Dr. Tom Frieden, who was appointed Director of the Centers for Disease Control and Prevention during the Obama Administration. “We do have a chronic disease crisis in this country, but we need to avoid simplistic solutions and stick with the science.” Frieden made his comments in an NPR interview on the RFK Jr. nomination.

We need (much) more than medications and pop-up clinics to address America’s growing health crises. The health ecosystem must be reimagined to center around people’s health outcomes – not a one-size-fits-all approach to keeping them well. We must foster long-term patient-provider relationships, ensure easy access to understandable health data, emphasize nutrition and physical education in schools, and make care accessible to people across racial and generational lines.

As the ticking time bombs of obesity, prediabetes, and heart disease continue to warn, the urgency for change cannot be overstated. The frustration over the current complexity of access underscores what happens when we prioritize the system over prevention. Access to care isn’t just a convenience—it’s a matter of survival. To prevent the collapse of this fragile house of cards, we must act decisively and collaboratively to build a health system that sustains us all.

The post Conceptually, the “Make America Healthy Again Movement” Needs a Nod appeared first on Medika Life.

Considering that over 40% of U.S. adults have obesity and there are fewer than ten thousand obesity medicine specialists, PCPs are a critical part of the solution as we tackle this epidemic. While PCPs have extremely limited time to delve into the complexities of obesity and provide support between visits, it’s wonderful when they are knowledgeable about evidence-based obesity treatment so that they can at least initiate the conversation and refer their patients to an obesity specialist.

But the collaboration doesn’t stop there. Obesity is not only a chronic disease in its own right; it is also associated with more than 200 other conditions that can affect all body systems. According to data from IQVIA, people ages 40-64 with obesity have 2.4 comorbidities on average. That figure rises to 4.9 for individuals 65 and over (and 7% of people in the latter age group have 10 or more comorbidities). Effective treatment requires taking these comorbidities — and the medications often prescribed for them — into account and communicating with other members of the patient’s care team throughout treatment.

The following are just a few of the subspecialties that obesity touches.

• Cardiology: The impacts of obesity on cardiovascular health — raising the risk of high blood pressure, heart attack and stroke, among other conditions — are among the best known and most thoroughly studied. In fact, the anti-obesity medication, Wegovy, was recently approved specifically to reduce the risk of adverse cardiovascular events in individuals with obesity and established cardiovascular disease.

• Endocrinology: Adipose tissue is an active endocrine organ that produces more than a hundred different hormones, so it’s no surprise that endocrinologists are frequently involved in treating obesity-related conditions — Type 2 diabetes being the most familiar, but also polycystic ovarian syndrome and infertility, among many others.

• Orthopedics: Obesity is a risk factor for the development of soft tissue damage and osteoarthritis in load-bearing joints, particularly the knees, due to both inflammation and mechanical stress. Joint pain then inhibits physical activity, which worsens obesity, creating a vicious circle — while also increasing the risk of complications associated with orthopedic surgery.

• Oncology: Obesity is a risk factor for the development of many types of cancers, including breast, colon, rectal, pancreatic, kidney, esophagus, ovarian, skin, liver, thyroid, gallbladder, brain (meningioma) and endometrial cancer. Researchers believe that excess body fat leads to hormonal and metabolic changes that trigger inflammation and promote tumor growth.

• Gastroenterology: Obesity is associated with many digestive system diseases, including gastroesophageal reflux disease, esophagitis, gallstones, metabolic dysfunction-associated fatty liver disease and cirrhosis, and various related cancers.

• Pulmonology: Individuals with obesity face a higher risk of asthma, obstructive sleep apnea and other respiratory conditions (including, as we observed with COVID-19, potentially worse outcomes from viral infections).

• Psychiatry: Obesity and depression are closely linked, with a bidirectional association, and it’s worth noting that many antidepressants can promote weight gain, so prescribers should be prepared to consider weight-neutral or weight-loss-promoting alternatives for patients with obesity when possible. Other common mental health comorbidities include anxiety and eating disorders.

For many of these obesity-related health complications, losing weight can be the first line of treatment, and the relationship is often dose-dependent, meaning that these conditions worsen as obesity worsens and improve as obesity improves. This correlation may lead us to instinctively reach for GLP-1 medications as the most effective option, since we want to help our patients lose as much of their excess weight as possible and experience the greatest benefit. But especially considering significant cost, coverage and supply constriants, other anti-obesity medications can still bring measurable health benefits and might even be preferable for many individuals. Losing just 5% to 10% of body weight can lead to clinically significant improvements in markers such as blood glucose, cholesterol and blood pressure.

Improving patient health — not just reaching an arbitrary number on the scale — is the ultimate goal. Obesity touches everything, and treating obesity can have a positive, cascading effect on other conditions. If we can help a patient achieve Type 2 diabetes remission, reversal of sleep apnea or improved fertility, we’ll have made a real difference in their life.

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More than 1.6 million New Yorkers are diagnosed with diabetes, and some 11 percent of the State’s almost 20 million residents may already have prediabetes. Diagnosis and intervention are complicated by the fact that only 20 percent of the population is aware that without a lifestyle change and medical oversight, they will “graduate” to a Type 2 diagnosis.

This crisis is hidden in plain sight, waiting to overwhelm the health system.

Diabetes and New York, Imperfect Together

Prediabetes is among the more worrisome health comorbidities. Consider that:

• Diabetes disproportionately affects racial/ethnic minority populations. Compared with white adults, the risk of having a diabetes diagnosis is 77 percent higher among African Americans, 66 percent higher among Latinos/Hispanics, and 18 percent higher among Asian Americans. New York’s diverse population positions the State as an epicenter for diabetes risks.

• Diabetes prevalence is approximately 17% higher in rural areas than in urban areas, with studies showing that adults in rural America were more likely to report a diagnosis of diabetes than their urban counterparts. Approximately 21.5 percent of New Yorkers live in rural regions, with about 4.2 million residents.

• Type 2 diabetes is a pressing public health concern in New York State, affecting individuals of all ages and backgrounds. According to the New York State Department of Health, approximately 10.3% of adults in the State have been diagnosed with diabetes, with Type 2 accounting for most cases. This prevalence translates to over 1.6 million adults living with diabetes, a figure that continues to rise.

• There are 5,228,000 people in New York, 33.5% of the adult population, who have prediabetes. Their blood glucose levels are higher than usual but not yet high enough for them to be diagnosed with diabetes.

• Some 33% of adults aged 65 or older have Type 2 or prediabetes. This age group is at higher risk than younger people of developing diabetes-related complications such as nerve damage, kidney failure, or heart disease. In New York, nearly one in six people are 65 and older, and this population is growing faster than in any other State.

Raising awareness of prediabetes is one challenge; preventing diabetes is another. Addressing the urgent needs of people unable to afford essential treatment is yet another.

Without consistent treatment, blood sugar levels in individuals with diabetes fluctuate uncontrollably, risking hyperglycemia or hypoglycemia, both life-threatening conditions. Prolonged neglect escalates health complications, including cardiovascular diseases, kidney failure, blindness, and nerve damage, significantly reducing life expectancy. The emotional toll of diabetes is also profound; diabetes burnout is real, resulting from the stress and anxiety of constant monitoring every day, all year long, which often leads to depression.

Tackling Access to Care Saves Costs and Lives

The already considerable healthcare costs of diabetes also continue to mount, causing intensifying economic strain as emergency treatment, hospitalizations and repeat hospitalizations climb due to the disease. According to the National Institutes of Health, care for people with diabetes accounts for 1 in 4 healthcare dollars in the U.S. On average, people with diabetes shoulder annual medical expenditures of $19,736, of which approximately $12,022 is specific to diabetes management.

When people require insulin, the price can be a significant obstacle, and failure to access therapy has downstream costs. According to the American Diabetes Association (ADA), people with diabetes have medical expenses that are 2.3 times higher than people who do not have diabetes, and the impact is even more significant for communities of color, which face disproportionately high diagnosis rates.

To fight the disease and its costs in reduced health and mental well-being, as well as runaway treatment and hospitalization costs, addressing the barriers to accessing insulin is paramount. For decades, data has demonstrated that tighter control of insulin blood glucose levels corresponds to fewer medical complications, keeping people out of the hospital and helping to prevent amputations.

People with Medicare Part B and D have a one-month supply of each Part D- and Part B-covered insulin, capped at $35, and do not pay a deductible. However, for the economically challenged, the cost of insulin often means that they are skipping or limiting doses. The impact on their long-term health can be disastrous.

New York State’s Governor Tackles Insulin Access

Governor Kathy Hochul has proposed eliminating insulin cost-sharing through legislation to tackle this public health challenge. The policy would cap an insured person’s cost at $100 out-of-pocket for each 30-day prescription supply.

This public policy effort is the most expansive stopgap against insulin cost-sharing in the nation, providing financial relief to New Yorkers and improving adherence to a life-saving medication that can prevent severe kidney disease that can even cascade to necessary dialysis. This proposal is estimated to save New Yorkers $14 million in 2025 alone.

By removing cost barriers, the program empowers individuals to manage their diabetes effectively. It tackles a key social determinant of health – the cost barrier to access medicine – potentially improving health outcomes. Since the insulin cap proposal was introduced in New York, other States have seen Governor Hochul’s program as a model to address their patient-care challenges.

“Access to affordable insulin is an essential need for those who require this life saving medication,” states Dr. Leon Igel, an endocrinologist and obesity medicine specialist at Weill Cornell and Chief Medical Officer for Intellihealth. Dr. Igel will be honored in May 2024 by the New York Metro Region of the American Diabetes Association for his equal commitment to patient care and research.

Insulin dependency and consistent access to diabetes care is a New York State priority.  Through public health Initiatives such as the Governor’s insulin program, progress is being made in addressing this escalating crisis. Addressing social determinants of health and ensuring that people can affordably access healthy food will also help reduce risks – these steps can address obesity, a critical preventive measure.

Relationship Between Obesity and Health Inequities

Obesity is among the primary risk factors for Type 2 diabetes, and its prevalence in New York reflects the national trend. The Centers for Disease Control and Prevention (CDC) reports that nearly 30% of adults in New York have obesity, with specific communities showing disproportionate risk. Minority populations, low-income individuals, and those residing in underserved neighborhoods are particularly vulnerable to obesity. Limited access to nutritious foods, inadequate healthcare services, and socioeconomic disparities contribute to the heightened risk faced by these groups.

Obesity also leads to prediabetes, a stepping-stone to Type 2 diabetes. Alarmingly, more than 35% of adults in New York have prediabetes, placing them at an increased risk of developing the full-blown disease if left unchecked. State health officials note that 15-30 percent of people with prediabetes without intervention will develop Type 2 diabetes within five years, leaving them vulnerable to heart disease and stroke.

The trajectory from prediabetes to Type 2 diabetes underscores the importance of early detection and comprehensive management strategies – including, if necessary – access to insulin. Moreover, addressing the underlying factors driving prediabetes, such as obesity and health inequities, is essential in stemming the tide of diabetes-related complications.

 “Treating obesity to prevent progression to Type 2 diabetes is critical” according to Dr. Katherine Saunders, an obesity medicine expert at Weill Cornell Medicine in New York City and co-founder of Intellihealth. “Once individuals develop Type 2 diabetes, it can be harder to treat their obesity and the other weight-related comorbidities they likely have as well.”

Government Action Can Save Lives

With access programs like the Governor suggests, New York State is taking bold, preemptive steps toward a future where diabetes no longer casts a dark shadow on the health and well-being of its citizens. Being insulin-dependent and having consistent access reduces a pivotal barrier to care.  As patients, care providers and insurers struggle to navigate the complexities of diabetes management, Governor Hochul’s policy efforts are paramount in shaping a healthier tomorrow for Empire State residents. This proposed legislation, if passed, may encourage other States to follow her lead.

Now, if States also recognize that preventive care – addressing access to healthy food and keeping waistlines down is a public health priority issue, our healthcare system might begin to shift from sick care to well-care.  That would be a significant cost- and life-saving advance.

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Obesity care goes beyond mere body weight reduction in a number of ways, all of which tie back to an unwavering focus on improving patients’ health:

Comprehensive, individualized treatment

Obesity is a complex, multifactorial, relapsing chronic disease that requires a highly individualized treatment approach. Before starting a patient on an anti-obesity medication, we must develop a comprehensive, personalized education and treatment plan that takes into account all the specific factors contributing to that individual’s weight gain and those preventing weight loss (from physical activity and nutrition, to sleep patterns and stress, to previous weight loss experience, to other health conditions and medications). Treatment may include GLP-1 medications, but there’s no one-size-fits-all solution.

Careful prescribing

We call the medications anti-obesity medications rather than weight-loss drugs for a reason: they’re designed for long-term treatment of the chronic disease of obesity. We can’t just prescribe Wegovy or Zepbound and send patients on their way. These medications are generally well tolerated when prescribed appropriately, but not all patients with obesity are good candidates. We need to support those who are with dietary strategies and personalized titration schedules to minimize side effects, as well as education to identify early warning signs way before more serious adverse events occur.

Addressing comorbidities

Obesity leads to dysregulation in a variety of physiological pathways that can affect virtually every body system. Obesity is associated with more than 200 health conditions, including heart disease, hypertension, type 2 diabetes, osteoarthritis, sleep apnea and certain types of cancer, to name just a few. Treating obesity includes addressing these comorbidities. While it’s true that weight loss itself can lead to improvements in many of these weight-related health conditions, it’s not always a straightforward process. Individuals with obesity often have multiple comorbidities, and many are already taking multiple medications — creating additional variables and potential interactions to manage.

Health-related goals

Patients with obesity may present with specific weight goals they’d like to achieve, but as providers, we emphasize instead the importance of health outcomes, such as measurable improvements in metabolic health markers. The healthy lifestyle habits incorporated into the treatment plan underscore this focus, and a patient’s ability to decrease or discontinue other medications — for hypertension or diabetes, for example — often depends not only on the amount of weight lost, but also on these complementary lifestyle changes.

Support for long-term weight maintenance

Patients need to be aware that the initial weight loss period is only the first stage in a lifelong journey. Obesity is a chronic disease — one that we don’t yet have a cure for — which means that weight management requires long-term commitment. As clinicians, our job isn’t finished when our patients bring their weight down; we need to provide ongoing support to help them sustain the healthy behavior changes they’ve made, avoid medication discontinuation, and make adjustments and get back on track when they encounter the inevitable challenges along the way. Weight maintenance is often more difficult than weight loss, and patients frequently underestimate how much ongoing support they’ll need.

We’re thrilled to have so many new anti-obesity medications in our armamentarium — medications that are extraordinarily effective at helping individuals lose weight. But weight reduction is just part of the obesity treatment story. As clinicians, we need to make sure we’re looking beyond the number on the scale and delivering holistic, empathetic, evidence-based care tooptimize our patients’ overall health and well-being.

** I’m honored to be a member of the International Obesity Collaborative (IOC), a global initiative to address obesity internationally. Comprised of 12 leading obesity organizations, the IOC aims to raise awareness, share best practices, and implement effective interventions to treat obesity around the world.  We recently published the consensus statement: “Obesity Care vs. Weight Loss.” Stay tuned for more publications by the IOC.

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Thanks to viral social media posts and constant press coverage, Ozempic and Wegovy have become almost household names, and many primary care providers face questions — some based on social media misinformation — from patients eager to give these new medications a try. The following are common questions I’m asked, and suggested context to frame a response.

• “Can you write me a prescription for Wegovy?”

Patients should understand that it’s not just a matter of writing a prescription. Obesity is a complex, chronic disease, and many interrelated factors, including genetics, environment, sleep patterns, stress, medications, hormonal imbalances, and other health conditions, need to be considered to determine the best treatment. Wegovy isn’t suitable for everyone who has obesity; there may be other, more appropriate medications. It’s also important to provide education and ongoing support for sustainable dietary, physical activity, and behavior changes. Lifestyle interventions are rarely sufficient on their own, but they’re always essential components of any effective weight management plan. A successful weight loss strategy needs to address all these factors comprehensively and in a personalized way as part of a long-term care plan. There’s no quick fix for obesity.

• “I don’t want to resort to medication. It feels like cheating. Why won’t diet and exercise work for me?”

Most people with obesity cannot lose significant weight and keep it off long-term with lifestyle changes alone. This is because weight loss triggers the body’s physiological “anti-starvation” mechanisms, leading to increased hunger and cravings and a lower metabolic rate. With obesity, the area around the hypothalamus (the energy regulatory center in the brain) becomes inflamed, interfering with feedback signals from the gut and fat cells. Anti-obesity medications address these underlying dysregulated hormonal and metabolic pathways. Semaglutide, for example, mimics the GLP-1 hormone, which helps people feel full sooner after eating and slows the passage of food through the gastrointestinal tract. It targets areas of the brain that control appetite and influence eating decisions. Other anti-obesity medications work differently, but they all help the body overcome its anti-starvation responses to enable weight loss and weight maintenance.

• “Are the horror stories about Ozempic’s side effects — abdominal pain, constipation, diarrhea, and vomiting — typical? I don’t want to feel miserable.”

These are known adverse events associated with semaglutide, and it’s to be expected that as more and more people take these medications, we hear more about the side effects, including the rare ones. Symptoms may be worse when the medication is not used appropriately — if the dose is too high or it’s escalated too quickly, if the medication is prescribed without adequate screening (for example, to identify people who have risk factors for these symptoms), or if patients aren’t given the necessary education and support (dietary and behavioral modifications can minimize symptoms). When best practices are followed, patients generally tolerate semaglutide well.

There’s a risk-benefit calculation when prescribing any medication, of course, but for people with a high BMI, who face elevated risk of many serious weight-related conditions, the benefits may outweigh the risks.

• “What about aesthetic changes? I’ve heard about ‘Ozempic face.’ Will my skin get saggy?”

Loose skin is common with major weight loss, regardless of how it’s achieved, especially if the weight is lost rapidly. But this aftereffect is highly variable, with age, diet, and genetics among the factors that play a role. Some people lose 100 pounds and have no loose skin, and others develop a significant amount of loose skin after losing much less weight.

It’s important to note that weight reduction involves the loss of muscle as well as fat, so I always recommend and regularly encourage  patients to incorporate strength training into their weight management program in order to maintain as much lean body mass as possible.

• “How long will I need to take Wegovy?”

Patients should expect to take the medication for the foreseeable future. Obesity is a chronic disease., We don’t counsel patients with other chronic illnesses about weaning medications once their condition is controlled. When a person with diabetes stops taking an antidiabetic medication, we expect blood sugar to increase. And when someone with high blood pressure stops taking an antihypertensive medication, we expect blood pressure to rise. Obesity is the same. The FDA has approved these medications for long-term use for this reason. Weight gain isn’t just possible after stopping an anti-obesity medication discontinuation, it’s expected.

• “Why doesn’t my insurance cover Wegovy?”

For years, weight loss was considered strictly “cosmetic,” and obesity was attributed to individuals’ poor lifestyle choices. Today, most industry players — including insurers — recognize that obesity is a complex, chronic disease. But the new anti-obesity medications are extremely costly, especially considering the huge number of potential users (more than 42% of U.S. adults have obesity).

Access needs to improve, and it needs to improve dramatically, but simply handing out GLP-1 prescriptions left and right isn’t the answer either.

A comprehensive approach to weight management can improve health outcomes for more than 200 other conditions that obesity causes or worsens, from high blood pressure and type 2 diabetes to sleep apnea and certain types of cancer. It makes more sense — in terms of both patient health and economics — to treat the underlying obesity directly rather than waiting for these preventable obesity-related diseases to develop.

Now that we have a critical mass of patients taking these new, highly effective medications, we will have more comprehensive data demonstrating the mortality benefits of anti-obesity medications. For example, results from Novo Nordisk’s landmark SELECT trial, a five-year cardiovascular outcomes trial of Wegovy compared to placebo in individuals with overweight or obesity, recently found that semaglutide reduced the risk of major adverse cardiovascular events (heart attack, stroke, and cardiovascular deaths) by 20 percent. With this evidence from the SELECT trial, improved insurance coverage should be next.

• “If my insurance doesn’t cover semaglutide, are there alternatives?”

Semaglutide is an important part of our anti-obesity armamentarium, but we don’t automatically prescribe it to everyone who qualifies. Other options include Contrave, Saxenda, and Qsymia, for example. Any anti-obesity medication needs to be selected in the context of a comprehensive individualized evaluation and prescribed as part of a personalized treatment plan. Depending on a patient’s specific situation and risk factors, I prescribe many medications that are considerably less expensive than semaglutide, and individuals on these medications are still able to lose a significant amount of weight. Everyone’s situation is different, and individuals respond to different medications in different ways. Obesity is not a simple disease, and there’s no one medication that’s right for everyone.

• “What about supplements like berberine? Some people are calling it ‘nature’s Ozempic.’ Is it worth trying?”

I caution my patients about dietary supplements for weight management because we don’t have high-quality evidence demonstrating efficacy. Worse, the lack of regulatory oversight in the supplement market makes it challenging to know exactly what’s contained in any given product. The actual amount of berberine could be different from what’s claimed, and other undisclosed ingredients could be included as well. For example, some dietary supplements have been shown to contain amphetamines or anti-obesity medications that have been withdrawn from the market.

• “What about compounded semaglutide? Is it safe?”

When patients present to me on compounded semaglutide, I recommend that they stop. As with dietary supplements, these drugs are not regulated. We have no idea what the products contain, what the actual dose of the active ingredient is, or whether the product has contaminants. The FDA has issued a warning about compounded semaglutide.

• “I’m having surgery next month. Is it true that I need to suspend my Wegovy?”

Because GLP-1 receptor agonists are associated with increased risk of nausea, vomiting, and delayed gastric emptying, the American Society of Anesthesiologists recently issued guidance suggesting that individuals who take these medications daily should stop the medication the day of the surgery, or, if they take them weekly, hold the dose the week before surgery. People who are taking these medications for diabetes in addition to weight management may need to consult with their endocrinologist to identify an alternative diabetes medication to bridge the gap.

Wegovy and the other anti-obesity medications in the pipeline that are even more promising are and will be extremely important agents in our armamentarium, but successful weight management requires more than just one medication in isolation. Media coverage of these new medications sometimes creates the impression that obesity is a simple disease that can be treated with a one-size-fits-all, short-term approach. In reality, however, obesity is, a complex, multifactorial, relapsing chronic disease, and treating it requires a comprehensive evaluation and a customized treatment plan with education and long-term support.

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I worked with Allison to develop an individualized treatment plan that addressed nutrition (she wanted to adopt the Mediterranean diet since it seemed sustainable), exercise (we identified several forms of physical activity she enjoyed that fit her schedule) and behavior modification (for example, we shifted her meal timing earlier and discussed techniques to avoid stress-eating). As part of this plan, we also started on metformin, a great option in cases like hers, because it can help with weight loss, it can help restore ovulation, and it is generally considered safe to take during pregnancy.

After a few months, Allison had lost 20 pounds and she began to ovulate; however, she had not yet conceived so she elected to start fertility treatment.

This meant her weight management program would be even more critical.

Weight gain associated with fertility treatment

Since hormones affect weight, hormonal therapy to enhance ovulation (whether pills or the multiple shots that the in vitro fertilization process entails) often leads to weight gain. This gain can be significant, especially for patients with insulin resistance and patients who, like Allison, have overweight or obesity.

While we don’t want to add to patients’ anxiety during the stress of fertility treatment, it is important for us as providers to be mindful of the potential for weight gain. Fertility-treatment-related weight gain can have a long-term impact because successful treatment means pregnancy — and thus pregnancy weight gain — and it’s often difficult to lose the cumulative excess pounds afterward. For women with multiple pregnancies, the extra weight can add up quickly. One of my patients, for example, gained 70 pounds with her first pregnancy and then lost only 20 pounds before conceiving again. She presented to me during her second pregnancy, and we’re working on strategies to avoid excessive weight gain this time.

Excess weight is associated with various health complications during pregnancy, including hypertension, diabetes, obstructive sleep apnea and preeclampsia, as well as an increase in the child’s risk of congenital anomalies. Women’s healthcare providers often hesitate to bring up the topic of weight, but both mother and baby could benefit significantly if more fertility specialists and OB-GYNs (nonjudgmentally) asked patients’ permission to discuss the issue — and then monitored their weight at appointments and took appropriate action as needed.

Managing weight during fertility treatment

Cases like Allison’s are extremely common, so it’s important for women’s healthcare providers of all kinds to be aware of the options and limitations of weight management during fertility treatment. Most anti-obesity medications are off the table for patients during this time, but there are still a number of steps practitioners can take to help their patients avoid excessive weight gain:

• Optimize lifestyle interventions. Dietary strategies, physical activity and recommended behavioral modifications may be more effective when tailored to the patient’s specific lifestyle. Referrals to outside resources, such as a dietitian or behavioral therapist, for instance, can be great options if additional support is needed.

• Address other contributors to weight gain. Stress, lack of sleep and many factors unrelated to the conventional diet-and-exercise combo contribute to weight gain, and all of these contributors may be in play during fertility treatment. Patients benefit from a personalized plan that addresses these as well.

• Assess for drug-induced weight gain. Many medications are known to promote weight gain, so consider pausing these medications or reducing the dose during fertility treatment, if possible, when substitution with weight-neutral agents isn’t an option. Critical medications obviously need to be maintained, but a risk-benefit analysis might suggest that others should be discontinued.

• Consider prescribing metformin. Some gynecologists and reproductive endocrinologists may be comfortable prescribing the diabetes medication, metformin, for patients with overweight, obesity or insulin resistance, or for those at high risk of weight gain. In addition to improving insulin sensitivity and helping to balance hormones, metformin is a weight-loss-promoting medication and can thus help decrease weight gain associated with fertility treatment.

• Refer to an obesity medicine specialist. While we generally can’t use anti-obesity medications during fertility treatment, patients may benefit from a comprehensive medical evaluation and a personalized treatment plan. A thorough plan is particularly important when a patient is unable to conceive quickly and undergoes fertility treatment for a prolonged period. (I currently have one patient, for example, who has gained 40 pounds over the course of seven months of fertility treatments and still isn’t pregnant.)

Supporting better outcomes for mother and child

Women with overweight or obesity who plan to become pregnant are often counseled to lose weight before trying to conceive, both to enhance fertility and to reduce the risk of health complications for themselves and their babies. This recommendation often becomes more explicit before a woman begins fertility treatment — and obesity medicine specialists like me receive many referrals at this juncture.

The more time we have to treat a patient’s obesity beforehand, the more we can do, of course, but we can still help even after treatment begins. While managing weight during fertility treatment is a challenge, it’s not a lost cause. Taking steps to counteract the potentially weight-promoting effects of hormone therapy can significantly impact the health of the woman and her future child. This is a challenge that impacts many generations to come. We can do this together!

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The discovery that Ozempic (semaglutide) supports weight loss is not new, but the unexpected spotlight on weight loss as a side effect of a diabetes medication serves as a good reminder to healthcare providers (or a wake-up call, for some) that all medications’ potential effects on weight should be taken into account, because the opposite result — drug-induced weight gain — is more common than most practitioners realize.

A typical case

A 33-year-old woman, Jill, recently presented to my obesity medicine practice because she had suddenly started to gain weight — 32 pounds over the previous six months. Through my evaluation, I learned that she had received two Depo-Provera injections during that time. She had previously used oral contraceptive pills, but she often forgot to take her pills and wanted a lower-maintenance form of birth control. Although progestin injections work well for many women, weight gain is a known and fairly common side effect, and the timing of Jill’s weight gain suggested a causal link. As part of her weight-management plan, we discussed birth control alternatives, and she ultimately chose to switch to a nonhormonal IUD.

The OB-GYN who prescribed her Depo-Provera had not mentioned the possibility of weight gain. While it’s understandable that many practitioners don’t want to create unnecessary worry about a side effect that might never materialize, it can be extremely difficult to lose weight once it has been gained, particularly for those who already have overweight or obesity. Since many patients who don’t track their weight can gain significant amounts without realizing it, simply advising patients to monitor their weight and notify their provider if they notice an increase can prevent tremendous frustration.

Jill was on only one weight-gain-promoting medication, but I often identify two, three, or even four such culprits when taking a new patient’s history. In addition to injectable or implantable birth control, some of the most common weight-gain-promoting drugs include diabetes medications, blood pressure medications, and antidepressants. In many cases the effect is modest, but with long-term medication use for chronic conditions, even a small effect can lead to a significant increase in weight over time.

Prevention starts with awareness

What can healthcare practitioners do to help their patients avoid drug-induced weight gain? Essentially, four things:

1. Be aware. First, practitioners need to recognize how common the problem is and educate themselves about the weight profiles of various classes of drugs and different agents within classes. (The Endocrine Society’s practice guidelines for the pharmacological management of obesity include information on drugs that cause weight gain and recommended alternatives; see the original article in the Journal of Clinical Endocrinology and Metabolism, or a summary listing in Table 2 of our more recent best practices article.) As with most contributors to the multifactorial disease of obesity, the interactions are complex, and a medication’s impact on weight may vary based on a variety of physiological, genetic, and lifestyle factors. But despite some unpredictability, many medications do have a well-documented track record of promoting weight gain, and providers should be alert to this potential side effect.
2. Choose alternatives when possible. When prescribing any medication, providers should consider the drug’s weight profile in assessing the benefits and risks, and seek to avoid weight-promoting drugs when possible. Weight-neutral or weight-loss-promoting medications are available for many common conditions that are frequently associated with obesity, including type 2 diabetes, hypertension, and depression. These alternatives should be prioritized when appropriate as first- and second-line treatments — especially for patients with overweight, obesity, or metabolic risk factors. For example, for patients with type 2 diabetes, weight-loss-promoting medications such as metformin and glucagon-like peptide-1 (GLP-1) receptor agonists (semaglutide and liraglutide, for instance), or weight-neutral options such as DPP-4 inhibitors, are preferred over insulin and insulin secretagogues that promote weight gain. For patients with hypertension, weight-neutral angiotensin-converting enzyme inhibitors or angiotensin receptor blockers should be chosen over weight-gain-promoting alpha- or beta-adrenergic blockers if possible. Many antidepressants present a risk of weight gain, for example, but only one, bupropion, has been consistently shown to promote weight loss, though it’s not appropriate for all patients. When recommending changes to existing prescriptions, providers should either consult with the original prescribing physician or ensure that the patient does so. The topic of drug-induced weight gain needs to be discussed extremely carefully with patients, though, or they may feel alarmed and stop taking their medications before a plan for replacement is in place.
3. Use the minimum dose. Drugs in the same class often aren’t interchangeable, and if no appropriate alternative to a weight-gain-promoting medication is available, providers should aim to prescribe the lowest effective dose for the shortest possible duration needed to manage the patient’s symptoms. Too often, patients are started on a medication, and then the dose and duration of the drug regimen are never reevaluated.
4. Counteract the effects with anti-obesity medication. When weight-gain-promoting medications must be used, practitioners should consider adding an anti-obesity medication, in conjunction with appropriate lifestyle modifications, to counteract weight-promoting effects in their patients with obesity. Providers who don’t feel comfortable prescribing these medications can refer their patients to an obesity medicine specialist.

The challenge of reversing weight gain

Optimizing medication choices may seem like low-hanging fruit in the effort to help patients manage their weight, and in a certain sense it is: prescribing weight-loss-promoting instead of weight-gain-promoting drugs can be a relatively simple way to prevent unwanted weight gain. This is an important strategy because reversing drug-induced weight gain is not always simple.

Jill was disappointed to find out that weight gained due to medication is sometimes no easier to lose than weight gained due to any of the other myriad contributing factors. Although switching birth control stopped the increase, she didn’t immediately lose the pounds she had gained. This is such a crucial point: many patients aren’t alarmed when realize they’re gaining weight on a medication because they assume the weight will come off easily when the medication is discontinued — however, this is often not the case. Jill and I developed a comprehensive, personalized weight-management plan that is beginning to show results, but it will be a long-term effort.

There’s no silver bullet in the fight against excess weight; obesity is a chronic disease that requires lifelong management. While weight-loss-promoting medications are a valuable addition to our armamentarium, they are not a quick fix, and pharmacotherapy needs to be part of a multidisciplinary approach that also includes diet, physical activity, and behavioral modifications. So it won’t be a surprise if most of the people who recently flocked to Ozempic without proper medical supervision regain the weight as soon as they stop taking the medication.

The ratchet nature of weight gain (easy come, decidedly not easy go) makes it even more critical that healthcare providers be aware of the potential weight-related side effects of medications and adjust their prescription choices accordingly. Obesity has many complex and interrelated causes, and the more of these underlying factors we can eliminate — like weight gain secondary to medications — the more successful we will be in helping our patients move toward a healthier weight.

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She had never been diagnosed, but Jennifer’s symptoms immediately suggested polycystic ovarian syndrome (PCOS). PCOS is a common endocrine condition (affecting 4%–18% of women of reproductive age, depending on the diagnostic criteria used) involving changes in two types of hormones: androgens and insulin. Increased androgens can cause growth of excess body or facial hair, acne, and hair loss from the scalp, while increased insulin can lead to acanthosis nigricans and skin tags, weight gain (especially around the waist), and difficulty losing weight. Both hormones can cause menstrual irregularity, inhibit ovulation and reduce fertility. They can also increase risk of earlier onset type 2 diabetes, produce mood changes, and result in other negative psychological effects.

Naturally, not all women with PCOS experience every potential sign and symptom, but the wide variety of manifestations means that a range of health providers — primary care physicians, OB-GYNs, endocrinologists, dermatologists and obesity medicine specialists, for example — may care for patients with PCOS.

The condition frequently goes undiagnosed, though, especially in women who are on birth control and thus don’t have irregular periods. When PCOS is diagnosed, treatment often focuses on relieving specific symptoms (for example, regulating menstruation or eliminating excess hair) without addressing underlying or exacerbating factors — including, more often than not, excess weight.

The need for a weight-centric approach

While obesity’s role in the development of PCOS varies among patients, the two conditions are closely correlated. Some studies suggest that up to 80% of women with PCOS in the U.S. have overweight or obesity. Furthermore, obesity exacerbates many of the signs and symptoms associated with PCOS, as well as the underlying hormonal abnormalities. Obesity also impacts the progression of insulin resistance and development of metabolic syndrome. For this reason, treating the patient’s obesity is often an early step in managing PCOS.

Many providers are aware of the nexus between obesity and PCOS, but they either don’t realize the extent to which weight loss can improve outcomes — restoring regular menstruation, enhancing response to ovulation-inducing medications, and improving androgen levels as well as metabolic markers — or they assume their patients have already tried to lose weight so there’s no point in bringing it up. Unfortunately, many providers don’t feel comfortable talking to their patients about their weight, let alone treating it.

This hesitancy to address obesity is a disservice to patients, though, and the benefits of weight management in the treatment of PCOS need to be more widely recognized, just as they are in the treatment of type 2 diabetes. Since weight loss can lead to significantly improved health outcomes for individuals with type 2 diabetes, weight management is incorporated regularly into diabetes and pre-diabetes care. There’s also a growing focus on substituting medications that promote weight gain.

“The push in the field of endocrinology is to practice weight-centric rather than glucose-centric diabetes management,” says my endocrinologist colleague Dr. Leon I. Igel. “While controlling glucose levels remains paramount, doing so via medications that cause weight gain should be avoided, as this can lead to patients not following the treatment plan, as well as worsening of obesity-related health complications. Practitioners are encouraged to prioritize weight-loss-promoting or weight-neutral medications as first-line treatment in type 2 diabetes. We should take a similar approach in PCOS management, where certain weight-gain-promoting oral contraceptives, for example, are sometimes prescribed.”

Pharmacotherapy steps up

Not all patients with PCOS have overweight or obesity, but for the many who do, the diabetes medication metformin can be an effective first-line treatment to promote weight loss (in combination with a healthy diet and physical activity) while helping to balance hormones. A glucagon-like peptide 1 (GLP-1) receptor agonist, such as liraglutide or semaglutide, can be considered as a second-line treatment if metformin is ineffective. We have a growing armamentarium of pharmacotherapy options to support weight management, including medications approved specifically for obesity treatment and medications that treat both weight and insulin resistance that can be prescribed off-label. Finally, I couldn’t be more excited about the promising new medications in the pipeline.

Jennifer expressed relief when I suggested a potential diagnosis of PCOS because it provided an explanation for all her signs and symptoms, and it allowed her to stop blaming herself for her inability to lose weight. She responded well to metformin, which we introduced together with a low-glycemic diet and increased physical activity. Within a few months, not only had Jennifer begun to lose weight, but her periods normalized and her skin conditions improved as well.

Weight loss for better patient outcomes

Obesity is a complex multifactorial disease, and the fact that it affects so many body systems and it is linked to so many other conditions (PCOS is just one of 200 medical conditions associated with obesity!) can feel daunting. But the flipside is that effectively treating obesity can have a tremendously positive impact on many of these correlated conditions, even if we don’t understand all of the physiological mechanisms or causal pathways in every case.

And sometimes it doesn’t take much, because even a small amount of weight loss can lead to better clinical outcomes. For example, we can see improved glucose tolerance with a loss of just 2.5% of body weight. Improvements in menstrual irregularities and a subsequent successful pregnancy are more likely with a loss of 2%–5%, with more weight loss leading to a greater benefit.

Jennifer’s story is not at all unusual. Weight loss, especially with the help of a medication that simultaneously combats insulin resistance and hormone imbalance, is one of the most effective ways to treat PCOS in women with obesity — though it’s not a silver bullet, of course.

Providers who don’t feel comfortable counseling about diet and exercise or prescribing metformin or other weight-loss-promoting medications can refer their patients to an obesity specialist. An important first step is to recognize the correlation between PCOS and obesity, and start thinking about weight loss as a way to help patients achieve the outcomes that matter to them — whether that means getting pregnant, alleviating distressing acne, or reducing the long-term risk of developing type 2 diabetes and cardiovascular disease.

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But some clinicians are also hesitant to discuss weight with their patients. Because obesity is so stigmatized and such a sensitive topic, many providers don’t want to offend anyone, so they don’t bring up weight at all, even when the patient’s long-term health is at risk. This is not uncommon as most providers receive inadequate training on what obesity is (a complex, chronic disease), how to treat it (medical intervention is generally indicated per guidelines) and how to discuss it appropriately with patients. Now that we have more effective treatments for obesity and access to care is slowly improving, however, patients in my obesity medicine practice have actually begun to lament that their primary care and women’s health providers are staying quiet.

Many women first experience difficulty losing weight in connection with pregnancy or menopause. But because obesity is associated with more than 200 health conditions (including type 2 diabetes, coronary disease, sleep apnea, urinary incontinence, breast cancer, osteoarthritis and depression, to name just a few), providers in virtually any context can find themselves wondering whether and how to talk to patients about their weight.

If the patient presents with an acute condition or a situation that’s not weight-related, it may not be an opportune time to bring up the subject; however, if weight is pertinent to the patient’s medical concern, gently raising the issue in the context of that condition could be appropriate and even welcome. The following are tips to help make that discussion more fruitful.

1. Ask permission

Address the patient’s concerns first, and then ask permission to talk about her weight, explaining why it’s relevant.

If the patient doesn’t want to address the issue, respect her wishes and simply let her know that you’ll be there to provide support when she’s ready.

• Think about language and tone

With regard to terminology, weight experts recommend putting people first, to avoid defining them by their disease. In the same way that we would refer to “people with schizophrenia” rather than “schizophrenics,” we say “people with obesity” rather than “obese people.” We also try to avoid euphemisms (like “people of size” or “curvy women”) as well as terms that suggest victimhood (“she suffers from obesity”).

Although obesity is widely recognized as a complex chronic disease, and many people find it extremely liberating to realize that their inability to lose weight is due to biology rather than a lack of willpower, the terms “obesity” and “disease” themselves can be off-putting. I find that most patients tend to respond better to “excess weight” and “medical condition.”

The essential thing, in every interaction, is to be empathetic and respectful. Individuals with obesity are more than pounds on a scale, and they are not lazy or lacking in willpower. They are fighting a multifactorial disease. Whatever their weight, they deserve the best in compassionate, evidence-based care — just like patients with any other condition.

• Assess without making assumptions

Always assess the situation before telling patients what to do. While it’s true that obesity can cause or compound a wide variety of health issues, excess weight isn’t always the source of these problems. Providers who immediately tell their patients to lose weight, without considering all the potential causes and conducting a thorough assessment, risk overlooking other serious conditions.

It’s also possible that the patient has already lost considerable weight; insisting she do more without acknowledging this achievement may be demoralizing. Relatively small amounts of weight loss (5%-10% of body weight) can bring significant health benefits over time, even if the individual’s BMI isn’t within the normal range, so knowing the patient’s weight history is key.

Or maybe the patient has already made all the recommended lifestyle changes but her efforts are being thwarted by medications that promote weight gain. Drug-induced weight gain is common with some forms of birth control and antidepressants, for example, and this issue should be taken into account when evaluating the risks and benefits of any medication. If a woman needs hormonal treatments for breast cancer, for instance, it’s obviously most important to treat the cancer first, but when equivalent weight-neutral medications are available in any given situation, they should be considered first.

In short, it’s critical to get the full picture and listen carefully to the patient’s story to understand what factors have contributed to her weight gain and what barriers might be preventing weight loss. Specific factors and barriers are associated with each weight-related health condition, and these factors depend on the woman’s stage of life, comorbidities and other variables. An effective individualized treatment plan requires a thorough assessment.

• Provide support

If the patient agrees that she’s ready to make changes, simply telling her to eat less and exercise more is unlikely to be helpful. Obesity is a medical condition that needs to be addressed with a comprehensive medical approach, with ongoing support and regular follow-up.

Lifestyle changes are the cornerstone of any weight-management program, so focus first on collaboratively setting realistic goals for healthy eating and physical activity. If you don’t have the time or expertise to provide the necessary guidance, you can connect your patients with outside resources such as dietitians, behavioral therapists, health coaches, and community or telehealth programs.

When lifestyle interventions have been optimized or aren’t working, consider referring patients to an obesity medicine specialist to discuss adding anti-obesity medications to the mix. These agents can help overcome metabolic adaptation (our bodies’ anti-starvation responses to weight loss that push weight back up) and allow patients to lose significant weight.

• Offer hope

Most women with obesity have tried to lose weight many times, only to gain it back. This pattern often leads not only to feelings of shame and personal failure, but also to a sense of futility. To give these women hope, it’s important to emphasize, first, that their inability to lose weight is not their fault — the body has evolved many complex hormonal, metabolic, and neurobehavioral mechanisms to actively fight weight loss — and second, that excess weight is a treatable condition.

Every day we’re learning more about this complex disease, and although only 2% of eligible patients are currently receiving medical weight management according to guidelines, telemedicine and data-driven tools are expanding access to evidence-based obesity treatment, new anti-obesity medications offer increasingly effective pharmacotherapy options, and insurance coverage of obesity treatment is improving. Now is not the time to give up!

If we as women’s healthcare providers can help our patients overcome the discomfort of bringing up a difficult topic, we can help more women with obesity achieve better health and well-being.

The post Hesitant to Discuss Weight with Your Patients? appeared first on Medika Life.

Many of the most common side effects, such as hot flashes and night sweats, for example, are caused by hormonal fluctuations and thus appear primarily during perimenopause; these symptoms usually decrease and eventually disappear at some point after a woman reaches menopause (defined as the absence of menses for more than one year). However, some of the symptoms caused by lower levels of estrogen and progesterone may continue.

One of these longer-term side effects may be menopause-related weight gain.

Some studies suggest that weight gain during menopause is due primarily to the normal aging process rather than the menopausal transition specifically, and many women do not gain weight at all. But menopause does cause a number of physiological changes that can affect weight, including increased fat mass (total body fat and especially visceral fat), decreased muscle mass, and reduced energy expenditure (up to an 8% decrease in resting metabolic rate).

These changes in body composition and metabolism can represent an unwelcome new reality for some women who never before had a tendency to gain excess weight. And for those already struggling with their weight, especially women with obesity, these additional challenges can further increase the risk of weight-associated health conditions.

Hormone- and weight-related physiological changes

Menopause leads to a decrease in the body’s production of both estrogen and progesterone. While the loss of progesterone affects weight partially through increased water retention, the decrease in estrogen levels has more widespread and lasting effects. For example, loss of estrogen can weaken the brain’s “fullness” signals, increase susceptibility to binge eating and reduce energy expenditure (calories burned both at rest and during activity).

“Normal” hormone-related metabolic slowing during menopause is sometimes compounded by the presence of subclinical hypothyroidism, which also decreases energy expenditure. Estrogen and thyroid hormones interact and affect each other in a variety of ways, and subclinical hypothyroidism often remains undiagnosed because many of the symptoms (such as fatigue, sleep disturbances and mood swings, for instance) are instead attributed to the menopausal transition. One study found subclinical hypothyroidism to be present in 18% of perimenopausal women. According to my endocrinologist colleague, Dr. Leon I. Igel, “Immediate treatment might not be warranted, but thyroid levels should be monitored closely, as subclinical hypothyroidism may be a precursor to overt hypothyroidism.”

Menopause-related hormonal changes are also associated with insulin resistance, which leads to higher levels of blood sugar and increased fat storage. This creates something of a vicious circle, as visceral fat promotes further insulin resistance — which in turn raises the risk of type 2 diabetes and cardiovascular disease, two of the most widespread and serious weight-related health issues.

Treatment options

So how do we treat menopause-related weight gain? Perhaps counterintuitively, hormone replacement therapy, one of the most common treatments for many menopause symptoms, has not been shown to affect weight significantly (causing neither gain nor loss). We do have other options, however, and weight gain is not inevitable.

Diet and physical activity are bedrock components of any weight management program, but to overcome the body’s resistance to weight loss — particularly when it comes to treating people with obesity — these lifestyle elements must be part of a comprehensive approach. This means not only providing ongoing support and assistance to foster sustainable lifestyle change, but considering the full range of underlying factors and potential treatment tactics, including medical interventions.

Insulin resistance can be counteracted with a wide variety of eating plans; low-carb and Mediterranean diets, for example, have proven effective. The most important strategy is to find a way of eating that is sustainable, so it becomes part of a long-term healthy lifestyle change rather than a temporary measure that will be abandoned at the first sign of difficulty. This means the food must be both tasty and satisfying, and the plan can’t feel too restrictive or rigid.

Physical activity also helps reduce insulin resistance and support weight loss. The ideal activity plan combines aerobic exercise, which burns calories and improves cardiovascular health, with resistance training, which builds muscle and reduces fat. Again, sustainability is key: physical activity should be enjoyable and fit in with the individual’s lifestyle and schedule constraints — it doesn’t necessarily need to involve traditional “exercise” or going to the gym.

Women whose weight doesn’t respond to changes in diet and physical activity and who have a BMI over 30 kg/m² or over 27 kg/m² with comorbidities may benefit from anti-obesity pharmacotherapy. On- or off-label medications — such as metformin, liraglutide, phentermine/topiramate, naltrexone/bupropion, and semaglutide — can help counteract the effects of insulin resistance. As an adjunct to lifestyle modifications, these medications can help surmount some of the hormonal, metabolic and neurobehavioral mechanisms (manifested as plateauing or the development of cravings, for example) the body has evolved to prevent weight loss.

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This important contribution by Medika author Dr. Saunders was co-authored by Leon I. Igel, MD, FACP, FTOS, DABOM. Dr. Igel is an Assistant Professor of Clinical Medicine at Weill Cornell Medical College, and an Attending Endocrinologist at New York-Presbyterian Hospital/Weill Cornell Medical Center. He is Director of the West Side division of the Comprehensive Weight Control Center, as well as the former Program Director for Weill Cornell’s Obesity Medicine and Obesity Medicine/Bariatric Endoscopy fellowships. Dr. Igel is board certified in Internal Medicine, Obesity Medicine, and Endocrinology, Diabetes & Metabolism.

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