Medicine for Weight Loss (including the Skinny on the Skinny Shots)

 Jennifer Morris

ABPN, ABOM

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There are a multitude of medicine options available for those who might benefit from pharmaceutical intervention for weight loss. Typically, these medicines are warranted for those with a BMI (body mass index) 30 or above with no weight-related medical co-morbidities (medical illnesses related to weight), or for those with a BMI of 27 or above and a weight-related medical illness.  By the way, the BMI is, in my humble (and weight-lifting) opinion, a rather imperfect indicator of healthy weight, but that's what the insurance companies use and at this point it's one of the better of the easily accessible measurements. BMI is simply weight in kilograms divided by the square of height in meters (using measurements that everywhere in the world except the United States, Liberia, and Myanmar.)

Here's a handy calculator for this (in metric and imperial) in case you are not able to do the math in your head or just want to double-check your math: 

https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm

Onward...medicine options typically available: 

1. stimulant type medicines: These are the classics. They work by lessoning appetite and making you feel less hungry. Among other side effects, they can raise blood pressure and pulse and should not be used with hyperthyroidism

2. Orlistat: works in your gut to reduce the amount of fat absorbed from food. Can cause gallbladder problems, vitamin deficiencies, and bowel changes

3.  contrave: naltrexone plus buproprion. It works to decrease appetite and help you feel full sooner. It can raise blood pressure, aggrevate seizure disorders, interfere with opiate medicines, and can cause seizures in those whoa bruptly stop drinking alcohol or abruptly stop benzos. 

4.  qsymia:  a mix of phentermine (as above) and topamax, which has an additional appetite supression impact. topamax can contribute to kidney stones

5. metformin: off-label can assist with weight loss, esp in those with insulin resistance. contraindicated in renal dysfunction, congestive heart failure, metabolic acidosis, and impaired hepatic funciton

6. glp-analogue meds: work to regulate appetite, delay gastric motility, and reduce insulin resistance. 

GLP-analogue medicines (semaglutide aka wegovy or ozempic, and tirzepatide aka mounjaro or zepbound) have taken the country by storm. As noted above, they work through three primary mechanisms, outlined here:

• reset the reward center of the brain, to decrease appetite and "food-reward" and reduce cravings "food noise"
• delay gastric motility, slow gastric emptying, and increase a person's sense of fullness after eating
• impact the endocrine system to impact blood sugar regulation and also prevent weight-loss endocrine adaptation (the weight loss plateau...this involves leptin) and improve GLP-1 impact, to reduce appetite via gut mechanism. 

Not surprisingly, based on these mechanisms, the most common side effects are GI, including nausea, reflux, and constipation. They can also impact the absorption of some medicines, including some psychiatric medicines and oral birth control. 

Recognize that these medicines do NOT work well in a vacuum; some of the more powerful options will reduce weight without exercise and nutrition input, but not in a healthy fashion.  Medicine without exercise and nutrition will lead to unhealthy muscle loss, and little overall improvement in health (barring some circumstances.)  The national health guideline for exercise is 100-150 min of aerobic exercise a week. Pairing this with judicious weight lifting will help to maintain muscle mass and improve health; weight bearing exercise also protects from osteopenia/osteoporosis.  More on exercise in a soon-to-come post.

Likewise, extreme weight loss is never healthy nor helpful. Tik-Tok notwithstanding, rapid weight loss (with a few exceptions) contributes to significant health concerns, and a reduction or lack of meaningful health improvement. We aim for a 0.5 to 2 pound a week weight loss. 

Medicine is a tool, but not the exclusive mechanism for healthy weight loss.