Empowered Health Course · Lesson 18 · 9:47
Let's talk medications. We've covered body weight, the appetite center and where it's seated, how the brain defends against weight loss, the concept of best weight, the weight plateau, and how weight loss can improve the signs and symptoms of the real, chronic disease of obesity. Sometimes, despite best efforts, the brain's defenses mean symptoms continue — and medications can be considered, either up front or down the road. The guidelines suggest a BMI over 27 with an obesity-related complication, or a BMI over 30.
There are three classes of medication. The first is orlistat, which inhibits fat absorption in the intestine. It has some unpleasant side effects and is rarely used now, though it can be effective for some.
The second class is GLP-1 agonists. GLP-1 is a hormone the intestine makes; it tells the pancreas to release insulin after we eat carbohydrate, slows the speed of digestion in the stomach, and signals the brain that we're satisfied and full. It turns down the homeostatic "thermostat" and can also affect wanting and reward in the mesolimbic system, so it's quite effective for weight reduction. One approved option is liraglutide 3.0 mg (brand name Saxenda), a daily injection. It's given by a tiny needle under the skin because, as a protein, it would be broken down if swallowed. It's well tolerated, even by people with needle phobia. Main side effects are nausea, occasional vomiting, a queasy stomach, diarrhea, or constipation — generally GI-related, and often improving the longer you take it. The dose starts low (0.6 mg daily) and increases weekly to a target of 3 mg, where we generally see about an 8% weight reduction long-term, on top of lifestyle changes. Cautions: avoid it with a family history of medullary thyroid cancer or a history of pancreatitis, and people on diabetes medications may need those adjusted — so work with your clinician.
There's also semaglutide, used for diabetes (brand name Ozempic), started at 0.25 mg and increased to 1 mg weekly rather than daily — sometimes used off-label for obesity, depending on your provider's comfort, your insurance, and your own understanding. A higher-dose version, semaglutide 2.4 mg (Wegovy) — about two and a half times the Ozempic dose — provides around a 17% weight reduction, which is remarkable. (As of this recording in September 2022 it wasn't yet on the market here, so that will likely change.) Another therapy in the United States produces even greater weight loss and is well tolerated, and we're waiting to see if it arrives in Canada.
The third class is Contrave — a combination of bupropion and naltrexone. Bupropion alone, often used for smoking cessation or mood, causes a little weight loss or is weight-neutral; naltrexone alone does little for weight; but together they synergistically affect the appetite center and reduce body weight, acting on the mesolimbic "wanting and reward" system. Picture a trigger in our environment — or internal hunger, or seeing an appealing food — followed by wanting, then the action of eating to relieve it, almost independent of whether we even like the food. Contrave can settle that "wanting" part — though GLP-1 agonists do too, so it's sometimes hard to say which drug is right for which person; there's trial and error. Contrave brings about a 7% weight loss and is fairly well tolerated, though it can cause stomach upset, nausea, diarrhea, constipation, headache, and some increase in blood pressure — but overall it looks heart-healthy.
I'll aim to link a document listing these therapies along with their DIN numbers, so you can check whether your insurance covers them. Under provincial Pharmacare, Contrave and Saxenda aren't covered for obesity — we don't yet have an obesity drug the province covers, though hopefully that changes. Ozempic can be covered for patients with diabetes who meet certain criteria. A few cautions with bupropion: avoid it with a history of, or risk of, seizures; a low-carb, high-fat diet can increase its absorption; and use care if you have headaches or high blood pressure. Always review potential side effects with your clinician or pharmacist.
When we get the right drug and treat obesity properly, the wanting for excess calories naturally subsides. People often say they feel full for the first time, or realize they're thinking about food far less — they hadn't noticed how much mental "real estate" food had occupied. One patient told me she had a dinner date with her husband and didn't think about food until they got in the car, whereas before she'd have spent the day planning what she'd eat. She described how relieving it was to have mind space for other things. That's the aspiration: to find therapies that are truly effective for each person, lowering the barriers to important changes in behavior and augmenting the lifestyle work.
This transcript has been lightly edited from the video for readability. For the complete experience, please watch the video above.