Behavior Change and Medications: A comprehensive approach to tackling obesity

Obesity is a global epidemic, affecting millions worldwide. Over 40% of US adults have obesity — and the numbers keep growing. A 2020 Milkin Institute report estimated the cost of obesity to be upwards of $1.4 trillion dollars, up from $976 billion in 2014. Organizations everywhere are wondering how to get a better handle on treating it without blowing their budgets.

For too long, society chalked up obesity to simply a lack of willpower — even after the American Medical Association recognized it as a disease in 2013. In reality, obesity is a highly complex condition caused by socioeconomic, behavioral, genetic, hormonal, environmental, emotional, and metabolic factors. There’s nothing simple about it. That’s why it’s so tough to tackle. 

The complicated nature of obesity calls for a comprehensive approach to treatment. We need to come at the disease from all angles — addressing behavioral patterns, mental health, and SDOH factors, as well as hormonal and metabolic issues. 

One single solution will never be enough for handling obesity at the population level.

Trying to solve obesity on a wide scale through restrictive diets or exercise alone is a fool’s errand. The multi-billion dollar wellness industry tried that already without success. On the other hand, prescribing new glucagon-peptide agonists (GLP-1s) and other medications for every person in the US with obesity would cost over $150 billion a year and put many people on intensive medications they didn’t need to get results. We have to have a more nuanced approach.

When designing a strategy for obesity at the population level, it’s important to recognize the integral role of behavior change, the supplemental role a suite of medication options can play, and how a step therapy approach can responsibly manage access to control costs while achieving more meaningful outcomes than can be achieved with too restrictive an approach.

Behavior Change: The foundation to any obesity treatment

Behavior change is crucial for treating obesity because it addresses some of the root causes and contributing factors of the condition, making weight loss more sustainable. Unlike fad diets or other quick-fix solutions, gradual and accessible changes to eating patterns, physical activity levels, and overall lifestyle make weight loss outcomes actually last. 

Registered dietitians are uniquely qualified to help people develop healthy eating patterns that impact outcomes. Through medical nutrition therapy, they can set individualized calorie and macronutrient targets to help people lose weight in a healthy, sustainable way. At their best, dietitians tailor their guidance in ways that account for each person’s cultural preferences and life circumstances. 

Obesity is strongly linked to depression and anxiety. People with obesity have a 55% increased risk of developing depression, while those with depression have a 58% increased risk of developing obesity. Cognitive behavioral therapy (CBT) is a well-established intervention for people with binge eating disorders or other mental health treatment issues that induce weight gain. Even self-directed CBT, in which one goes through sets of self-guided readings and exercises structured around the same CBT principles used by therapists, can be very useful for recognizing destructive thought patterns and body dysmorphia. It can also help motivate people to adopt healthy habits including medication adherence.

Behavior change is the foundation to any lasting obesity treatment. But for some, it alone is not enough. For those who have not seen enough meaningful improvement through behavior change, there are many anti-obesity medications (AOMs) that can help.

Medications: Tools to boost the benefits of behavior change when needed

Medications alone cannot solve obesity long term. Yet dismissing medications altogether when tackling obesity at the population level is equally misguided — medications have a growing place in lessening the obesity epidemic. That’s why so many employers and health plans are starting to think about what role AOMs should play in managing obesity in their populations. In the last few years, more highly effective AOMs have been coming to the market and public consciousness than in the last couple decades combined. How should organizations design an approach that accounts for the many medication options, their efficacy, and their costs?

Medication can play an important supplementary role for people who don’t see enough improvement with behavior change alone, or when the results of behavior change stall out. While GLP-1s have seized the media’s attention for their impressive 15% to 20% weight loss outcomes, there are several much less expensive AOMs that also get strong weight loss results. Solutions that focus solely on GLP-1s miss the benefits of offering a fuller suite of options.

Step Therapy: Responsibly managing access to anti-obesity medications

Organizations should take a clinically rigorous step-therapy approach in managing access to AOMs to avoid unnecessary costs while achieving meaningful outcomes. That starts with doctors administering full medical assessments including labs, medical history intake, surgery history, and weight loss history to get a full picture of a person’s health and past efforts to combat obesity. It means organizations should ensure behavior change is always the foundation of obesity treatment, and medications can be layered on when needed. For many, behavior change will be enough. For some of those who need more support, lower-intensity, lower-cost AOMs will get the needed boost in outcomes to reach their goals. Still, for some with severe obesity or multiple cardiometabolic conditions, higher-intensity AOMs such as GLP-1s may be appropriate to start right away. But many people can try a less intensive (and expensive) AOM to start. All should be closely monitored for side effects, titration, and progress when using an AOM. If one medication doesn’t work or spurs side effects, there are others to safely try in succession. 

Using this careful step-therapy approach, it may turn out that only 5-10% of any given population will end up on GLP-1s, while the majority of people will still get clinically meaningful results without such intensive treatment. Contrast this with more than half of an unmanaged population living with obesity who might otherwise jump right to using GLP-1s first without a step-therapy approach to medication

How behavior change and medication work together for population health

Ultimately, instituting behavior change and medications together is a more powerful approach to treating obesity in a whole population than either one in isolation. While behavior change is essential, medications can help speed progress and augment results. And that extra help can make a fundamental difference in sustaining behavior change. 

It’s easy for people to get discouraged when weight loss doesn’t come easily. That discouragement often leads to falling back into bad habits, especially since obesity and depression are closely tied. Medication can give that extra boost, like pedaling uphill on an electric bike. While weight loss still requires effort and persistence, anti-obesity medication gets people where they need to go with less resistance — especially for people with hormonal and metabolic disorders who really need biological assistance.

Organizations don’t need to take an either/or approach to anti-obesity medications. When it comes to population health, we need all the tools in the toolbox. A variety of interventions and methods can help people battling multiple related conditions, across different acuity levels, and for those with unique constraints and social determinants of health. By taking a more targeted approach — drawing on behavior change and anti-obesity medications when appropriate — we have a chance to quell the obesity epidemic and save costs in the process.