Obesity has long been viewed as a lifestyle disease, with the "eat less, move more" mantra dominating treatment recommendations for over half a century. However, the global prevalence and severity of obesity continues to rise, prompting the development of new anti-obesity medications (AOMs) like glucagon-like peptide-1 receptor agonists. Amid the media frenzy surrounding these "game changers," some may wonder if lifestyle-based treatments for obesity will become obsolete. However, the reality is that medical and behavioral approaches to obesity treatment are complementary and must coexist to make a significant impact on the obesity epidemic.
The Limitations of Behavioral Approaches
While lifestyle-based treatments have been the cornerstone of obesity management, they often yield modest weight outcomes with substantial variability in effectiveness and durability. These approaches do not address the physiology of obesity, including the gut-brain connection and other systems involved in weight and appetite regulation. When weight loss occurs, the body triggers counterregulatory physiological cues that persist well into the weight-maintenance phase. Instead of identifying this physiology as the culprit, the field has often blamed a "lack of behavioral compliance" for poor treatment response or weight regain, contributing to stigma and shaming of those with obesity.
Moreover, individually focused behavioral interventions cannot address the patient's external environment, such as economic stability, access to resources, social and community context, and the built environment. Without equitable environment-level changes that address the social determinants of health, reliance on individual behavior changes to treat obesity may contribute to further increases in prevalence and widening disparities.
The Role of Anti-Obesity Medications
Newer AOMs, boasting impressive safety and weight loss profiles, are increasingly viewed as attractive options for long-term weight management. For instance, the SURMOUNT trial demonstrated a greater than 20% mean reduction in weight at 72 weeks in a group of patients receiving a 15-mg weekly dose of tirzepatide, without a traditional intensive lifestyle intervention.
AOMs like tirzepatide and semaglutide impact physiological pathways and symptoms that otherwise make it difficult to initiate and sustain clinically significant weight loss. While they cannot change a patient's external environment, they may alter one's response to that environment, resulting in durable weight loss despite the persistence of external challenges.
A New Approach: Combining Lifestyle Changes and Medications
Even in this era of next-generation AOMs, lifestyle and behavior change still play a critical role in improving population health outcomes. Healthy lifestyle behaviors, including adopting healthful dietary patterns, reducing sedentary time, engaging in regular physical activity, and receiving sufficient, good quality sleep, have numerous benefits, from cardiovascular protection to improved mental health.
For patients with obesity, effective medical or surgical treatment should not be withheld pending a patient's behavioral "failure" or discontinued upon reaching a weight goal. The underlying disease of obesity, much like hypertension, has not been "cured" per se. For patients not interested in weight loss, lifestyle intervention may be a sufficient intervention for preventing additional weight gain.
Lifestyle behavioral therapy could also help achieve "quality" in weight loss, not just the "quantity" that is so appealing with modern AOMs. With weight loss substantially empowered by AOMs, lifestyle behavioral therapy could be refocused as a tool to optimize nutrition and physical activity to improve overall health during weight loss.
Conclusion
The future of obesity treatment will likely feature AOMs, but they will not address the widespread pathologies of our food and lived environments. Healthy lifestyles for all people, irrespective of body mass index, should be supported using individual, policy, systems, and environmental approaches that address the social determinants of health and are responsive to community needs. As a field, obesity medicine must move away from the toxic "lifestyle versus medical therapy" debate. Our patients will benefit most if we can learn to pair lifestyle interventions with pharmacotherapy to both optimize health outcomes and help them maintain lower body weights.
Frequently Asked Questions
What are the specific side effects associated with the mentioned anti-obesity medications (AOMs), such as tirzepatide and semaglutide, and how do they vary among different patients?
Common side effects of medications like tirzepatide and semaglutide include gastrointestinal issues such as nausea, vomiting, diarrhea, and constipation. These effects can vary among patients, with some experiencing mild symptoms and others having more severe reactions. Specific side effects depend on the individual's health condition, dosage, and other medications they might be taking.
How do lifestyle interventions and AOMs compare in terms of cost-effectiveness and accessibility for the average patient?
The cost-effectiveness and accessibility of lifestyle interventions versus AOMs can vary widely. Lifestyle interventions may require significant personal time and effort but minimal financial cost. In contrast, AOMs can be expensive and may not be covered by insurance in all cases, making them less accessible to some patients.
Are there any long-term studies or data on the effects of combining lifestyle changes with AOMs on obesity-related comorbidities, such as type 2 diabetes, heart disease, and certain types of cancer?
Long-term studies specifically addressing the combined effects of lifestyle changes and AOMs on obesity-related comorbidities are limited. However, both strategies independently have shown benefits in reducing the risk of conditions like type 2 diabetes, heart disease, and certain cancers. The synergistic effects of combining these approaches warrant further investigation.
