Successful weight management is challenging for most people, as human biology is engineered by evolution to defend us against weight loss and to promote weight regain (see the Science of Obesity chapter for more on this). Lifestyle changes usually only achieve 3-5% weight loss, and for most people, this weight is eventually regained (though results can sometimes be better and more sustained with ongoing psychological support and guidance). The good news is that we now have three medications approved for weight management in Canada, that can help to improve weight and – most importantly – health; AND, help to keep weight off that has already been lost with hard work on behavior and lifestyle changes.
In the Pharmacotherapy chapter (in which I am the lead author) of the 2020 Canadian Adult Obesity Clinical Practice Guidelines , we recommend that medication for weight loss can be used for people with BMI ≥ 30, or ≥ 27 with an obesity-related health complication. There are three medications available in Canada for weight management: liraglutide 3.0mg (Saxenda), naltrexone/bupropion (Contrave), and orlistat (Xenical).
Importantly, we recommend that medication for weight management can also be used to maintain weight loss that has been achieved with lifestyle changes, and to prevent weight regain. This represents a big step forward from previous guidance, which really only talks about using medications for weight loss, and doesn’t take into account the context of the person’s journey before starting medication.
Remembering that weight management is about improving health more so than the numbers on the scale, we recommend weight management medication for people with type 2 diabetes and BMI ≥27 to improve weight and diabetes control, and for people with prediabetes and BMI ≥27 to delay or prevent type 2 diabetes.
Weight management medications haven’t yet been studied very much in regard to their ability to improve other health complications associated with obesity. Liraglutide 3.0mg has been shown to improve sleep apnea and fatty liver. There is a need to study weight management medications further for these conditions, as well as other health issues like osteoarthritis and polycystic ovary syndrome.
We have created a practical algorithm (see page 10 in the chapter) to help health care providers consider which medication might be best for their patient. Consider what health issues your patient has, as the goals of improving health and weight can often be achieved by choosing a medication that also benefits these health issues.
Other issues to consider include any potential side effects, safety, how they are administered (pill vs injectable), any possible interactions with other medications, how often they are given, and cost. (see Table 1, page 4 in the chapter).
If a medication is tried and not sufficiently successful, consider whether there is something standing in the way of success. Has a medication for another health condition been started that is favoring weight gain? Is there an emotional struggle creating a barrier to success? Was there weight loss prior to starting the medication, and medication is now actually successful because it is preventing weight regain?
Remember that weight management medications are intended to be long term treatments. Just like medications for diabetes or high blood pressure, weight management medications do not ‘cure’ obesity, they help to control it.
Medications that do not have data to show they actually work (or that they are safe) are sometimes used for treatment of obesity, and we have advised against any such treatments. This includes hormonal approaches (eg thyroid hormone, testosterone) and over-the-counter treatments and supplements (see more in the Commercial Products chapter).
Finally, as you see repeated in many chapters in the Guidelines, for people who need medications for other health conditions, medications should be chosen (where possible) that do not cause weight gain.
NOTE: This blog is not intended to be a full synopsis of the chapter. There is a wealth of information in this chapter that is beyond the scope of one blog post. I encourage everyone to read the recommendations and key messages in full, and to dig in to the entire chapter!
Disclaimer: I receive honoraria as a continuing medical education speaker and consultant from the makers of liraglutide 3mg (Novo Nordisk) and naltrexone/bupropion (Bausch). I have been involved as an investigator in clinical trials of liraglutide 3mg.
Stay tuned for much more on the Obesity Guidelines in coming weeks!
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