Dear Dr. J: What should I know about weight loss medication?

A women’s health expert answers top questions about prescription weight loss medication.

If you’ve struggled to manage your weight successfully through lifestyle changes, healthy eating, and physical activity, then you might benefit from adding a prescription weight loss medication to your suite of health-supporting tools. Hello Alpha’s Chief Medical Officer, Dr. Mary Jacobson (affectionately known as Dr. J), answers all your questions about weight loss medications.

When should someone consider prescription weight loss drugs?

It’s simple: clinical guidelines state that medications for weight loss are appropriate for patients with excess body fat. People with chronic illnesses like diabetes or high blood pressure can also benefit from additional support from weight loss medication.

It’s important to note that obesity or excess body fat is a chronic condition, not a lifestyle choice or a weakness of willpower. According to the Obesity Medicine Association, obesity is defined as “a chronic, relapsing, multi-factorial, neurobehavioral disease, wherein an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass physical forces, resulting in adverse metabolic, biomechanical, and psychosocial health consequences.” In simpler terms, obesity is a medical condition that affects different body systems that impact our health and wellbeing.

One way that healthcare providers screen for overweight and obesity is with Body Mass Index, or BMI. BMI is calculated by taking a person’s weight and dividing it by the square of their height. (You can use our calculator to determine yours.) A high BMI can indicate a high level of body fat, but it doesn’t necessarily reflect body fat percentage.

Your provider may prescribe a medication to treat your overweight or obesity if you are an adult with:

• a BMI of 30 or greater
• a BMI of 27 or greater, plus you have weight-related health problems such as high blood pressure or type 2 diabetes

While it’s a common metric in many healthcare settings, BMI is not the only measurement for diagnosing overweight or obesity. A trained provider will take into account your individual health history, race, ethnicity, and other factors to evaluate your health condition.

How do weight loss medications work with healthy habits?

Even with medications, it’s important to eat healthy and exercise regularly. Consuming healthy foods and drinks, along with getting regular physical exercise, may help you reach and maintain a healthy weight. Maintaining a healthy weight, getting adequate sleep, and managing stress may also help reduce risk for some health conditions like type 2 diabetes and heart disease.

There are different ways that weight loss medications work alongside lifestyle habits to help you reach a healthy weight. Some medications may reduce your appetite or help you feel full sooner. Other medications reduce the amount of fat your body absorbs from the foods you eat.

What are the benefits of using prescription medicine to lose weight?

Losing 5–10% of your starting body weight, which may be more easily achievable with the support of a prescription weight loss medication, may improve your health by:

• Lowering blood sugar, blood pressure, and triglycerides
• Regulating ovulation and menstrual cycles
• Improving fertility
• Improving pregnancy outcomes
• Improving sleep apnea
• Decreasing joint pain
• Facilitating management of eating behaviors
• Slowing the progression of weight gain or regain
• Improving your general quality of life
• Providing improved outcomes versus just lifestyle intervention alone
• Preparing potential candidates for bariatric surgery and/or improving its results afterwards

What are the common types of weight loss prescriptions available today?

There are different categories of prescription medications to support weight loss. Every body is different, so your provider may prescribe medication depending on your desired results, side effects, and health condition. Here are the most commonly prescribed, and how to decode acronyms like GLP-1, GIP, and more:

• Semaglutide, known by the brand names Wegovy or Ozempic. Semaglutide medications are in the GLP-1 class of drugs, which mimic the action of a hormone called glucagon-like peptide-1. This medication acts on several systems to decrease appetite by producing feelings of fullness. It affects the appetite centers of the brain and slows down how quickly the stomach empties, which leaves you feeling full for longer. Semaglutide also acts on the pancreas to increase insulin secretion and decrease glucagon. (This reduces blood sugar levels after you eat.) Another way semaglutide works is by converting white fat-storing cells into brown fat, which increases energy expenditure. Semaglutide medications are taken once weekly via injection.
• Tirzepatide, known by the brand name Mounjaro. Like semaglutide, tirzepatide mimics GLP-1 but also includes GIP (glucose-dependent insulinotropic polypeptide). Tirzepatide works similarly to semaglutide medications to reduce appetite and increase feelings of fullness. It is also taken once weekly via injection.
• Liraglutide, known by the brand name Victoza. Like both semaglutide and tirzepatide, it mimics the GLP-1 hormone to slow down the process of stomach emptying. This medication is taken via a daily injection.
• Orlistat, known by the prescription name Zenical or the over-the-counter in a lower dose under the brand name Alli. This medicine reduces the amount of fat your body absorbs. It’s known as a gastric and pancreatic lipase inhibitor.
• Phentermine is similar to an amphetamine. It stimulates the central nervous system (nerves and brain), which increases your heart rate and blood pressure and decreases your appetite. This medicine is for short-term use only.
• Phentermine/Topiramate, known by the brand name Qysmia. This is a combination drug that can help you feel fuller, make foods taste less appealing, and help your body burn more calories.
• Naltrexone/Bupropion, known by the brand name Contrave. Naltrexone, typically used to reduce cravings for people with substance use disorder, can also curb hunger and food cravings. Bupropion is an antidepressant medicine that can also decrease appetite.
• Gelesis-100, known by the brand name Plenity. This pill (considered a medical device) is composed of cellulose and citric acid to absorb water and expand in your stomach and small intestine. This creates a feeling of fullness and increased satiety.

What are some of the drawbacks of using prescription medicine to lose weight?

The most significant drawbacks of prescription weight loss medications are the potential side effects. Often, side effects are short-term and improve as your body adjusts to the medication. Not everyone will experience side effects. It’s important to check with your provider for guidance on how to manage any side effects you may experience.

The most common side effects for each medication are listed below:

• Semaglutide: gastrointestinal side effects such as nausea, vomiting, abdominal discomfort, bloating, gassiness, constipation and diarrhea
• Tirzepatide: gastrointestinal side effects such as nausea, vomiting, abdominal discomfort, bloating, gassiness, constipation and diarrhea
• Liraglutide: gastrointestinal side effects such as nausea, vomiting, abdominal discomfort, bloating, gassiness, constipation and diarrhea
• Orlistat: bowel urgency, frequent bowel movements, oily evacuation, oily rectal leakage and flatulence with discharge; potential malabsorption of vitamins A,D,E or K
• Phentermine: dry mouth, insomnia, heart palpitations, headaches, hypertension, constipation and anxiety
• Phentermine/Topiramate: dry mouth, insomnia, heart palpitations, headaches, hypertension, constipation and anxiety; distortion to your sense of taste, a prickling or tingling sensation on your arms, legs or feet, cognitive issues, drowsiness and kidney stones
• Naltrexone/Bupropion: insomnia, anxiety, irritability, suicidal ideation, nausea, headaches and hypertension

Another drawback of prescription weight loss medications is that you may stop losing weight if you stop taking them. There is also a strong possibility of regaining weight if you stop taking your medication, potentially leading to weight cycling. Weight cycling refers to repeatedly losing and regaining weight. Studies have linked weight cycling to a greater risk of diabetes, hypertension and gallbladder stones.

Are there people that should not take these medications?

Not everyone is a good candidate for every medication. The following people should avoid prescription weight loss medications:

• Individuals for whom weight loss would be contraindicated, such as patients with a history of anorexia or bulimia, patients who are a healthy weight, or patients who are healthy and overweight (BMI between 27–29.9).
• Patients with a personal or family history of medullary thyroid cancer or of MEN2 Syndrome should not take injectable medications like Mounjaro, Wegovy, Ozempic, Saxenda, and Victoza. (MEN2 Syndrome is a rare genetic disorder that affects the endocrine glands and can cause tumors in the thyroid gland, parathyroid glands, and adrenal glands.)
• Patients with a history of blood-pressure related stroke, “ischemic” (clogged artery) heart attack or narrow angle glaucoma should not take phentermine, phendimetrazine or diethylpropion.
• Clinical guidelines restrict the use to certain medications for children whose BMI are above the 95th percentile for their age and gender.

It’s important to note that clinical trials on the GLP-1s and tirzepatide excluded people with the mental health issues listed below. Researchers hypothesize that GLP-1s may improve depressive symptoms. In contrast, a few small studies show an association with unhealthy weight and risk of suicide and worsening depression. We cannot yet determine the impact of GLP-1s on people with any combination of the below mental health symptoms:

The mental health exclusion criteria for GLP-1 clinical trials are:

• History of major depressive disorder within 2 years before screening
• Diagnosis of other severe psychiatric disorders (for example: schizophrenia, bipolar disorder)
• A PHQ-9 screening score that indicates moderately severe or severe depression
• A lifetime history of a suicidal attempt
• Suicidal behavior within 30 days before screening
• Suicidal ideation corresponding to type 4 or 5 on the Columbia-Suicide Severity Rating Scale within the past 30 days before screening

Who is the best healthcare provider to speak with for support with weight loss medications?

There are many healthcare professionals that can support your weight loss journey — a registered dietitian, a physician, a nurse practitioner, a physician’s assistant, and more. It’s best to connect with a provider who has considerable experience with weight management, who recognizes excess body fat as a chronic medical condition, and is knowledgeable about weight loss medications. Losing weight is a physical journey but also a mental one. Ideally, you want a provider who is empathetic, compassionate, and aware of the mental impact of weight loss efforts.

It’s highly recommended that women interested in weight loss medications find a provider that is also trained in women’s health. This type of provider can:

• Identify and treat menstrual irregularities which are common in women and people assigned female at birth with higher weights.
• Counsel women and people assigned female at birth interested in conception about risks associated with weight to the pregnant person and fetus.
• Guide and advise women and people assigned female at birth about menopause, which is associated with an increased risk of obesity and a shift to an abdominal fat distribution.

What questions should someone ask a healthcare provider before starting weight loss medication?

Open communication with your provider is key to a trusting relationship and taking charge of your health. Be sure to share your own weight goals, medical history, and lifestyle details with your provider, plus asking these questions to start:

• What is a healthy weight for me?
• Will losing weight improve my general health or specific health problems I have?
• Are any of my medical conditions or medications potentially causing weight gain or making it harder for me to lose weight?
• Are there any types or amounts of physical activity I should not do because of my health conditions?
• What dietary approaches do you recommend I try or avoid?
• What weight loss medications may be right for me?

How much do weight loss medications cost?

You’ll also want to keep in mind the cost of treatment. If you do not use any insurance benefits to cover weight loss medications, treatment may be expensive. If you have health insurance, your out-of-pocket cost depends on what your insurance plan will cover. Unfortunately, many insurance companies don’t cover newer weight loss drugs, even when medically necessary (more about this). If you want to use your insurance plan to cover treatment, find a copy of your insurance company’s drug formulary to see what medications are covered. With this information, you and your provider can create a treatment plan that fits your needs.

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