849. It is now easier than ever to get a prescription for powerful weight-loss drugs, thanks to a growing number of telehealth providers. But is this responsible care for obesity or something else?
849. It is now easier than ever to get a prescription for powerful weight-loss drugs, thanks to a growing number of telehealth providers. But is this responsible care for obesity or something else?
Find a transcript here.
Ted Kyle on Telemedicine for Obesity Care.
You've probably seen the buzz on social media and all the ads on TV. It is now easier than ever to get a prescription for powerful weight loss drugs thanks to a growing number of telehealth providers.
Now on one hand, they are making these medications and this type of healthcare more accessible to more people. But are they upholding the same standards of care?
Welcome to the Nutrition Diva podcast, where we take a closer look at nutrition news, research, and trends so that you can make more informed decisions about your health. I’m your host, Monica Reinagel.
The month of January has always been peak season for weight loss programs. In years past, that meant ads for programs like Weight Watchers, Jenny Craig, Nutrisystem, or Noom—programs that promised some combination of nutrition advice, behavioral coaching, special bars, meals or shakes, and in-person or online support.
But this year, while many of the company names haven't changed, the ads sound a lot different. Instead of points, habit-tracking apps, or pre-package meals, we’re seeing ads promising fast, convenient access to prescription medications—specifically GLP-1 drugs like Wegovy or Mounjaro—delivered right to your door.
These medications, as you know, have revolutionized the treatment of obesity–as well as our understanding of this complex, chronic disease. And the expansion of telehealth companies into obesity care has the potential to get these medications into the hands of people who would benefit from them but have either struggled to get them (or hesitated to ask for them) through regular channels.
Many people are embarrassed to ask their family physician about these medications for fear that they will be shamed for looking for a shortcut. Or they don’t want to go through their company-sponsored health plan. Or, perhaps they tried to get them and were denied access by their insurance company.
Telehealth companies, on the other hand, may feel more convenient and private. You can pay out of pocket if you want to, and perhaps get access to lower-priced compounded versions of these notoriously pricey drugs. And many companies are doing this very thoughtfully, combining medication, where appropriate, with nutrition counseling, behavioral support, and ongoing medical monitoring.
But there are also telehealth platforms that seem to be prioritizing easy access over comprehensive care. The onboarding is fast, with minimal friction. Nutrition counselling or behavioral support may be minimal or completely automated. There may not be a whole lot of medical oversight beyond writing those prescriptions.
So, are we really expanding access to high-quality obesity care? Or are GLP-1s becoming the new Botox–with telehealth prescribers essentially running online medspas? I fear the answer is a bit of both.
I recently spent some time talking about this with Ted Kyle. Ted is a pharmacist, the founder of ConscienHealth, and a passionate advocate for more informed, equitable, and respectful treatment of the disease of obesity. In addition to his work as a highly respected educator and advocate, Ted also serves as a paid scientific advisor to a number of companies, involved in various aspects of behavioral and pharmaceutical obesity care.
Here’s a bit of that conversation, in which we were discussing the potential rise of these antiobesity medications as lifestyle drugs:
Monica: I wanna explore with you. Something that I see happening that I'm not sure we're talking about. So what if I am not clinically obese? I don't meet the clinical criteria for that disease description or diagnosis. I'm not really suffering from severe health complications. But I just feel like I would be happier if I could lose 10 or 15 pounds, and I just don't seem to be able to do that on my own. Is there any harm in signing up with one of these telehealth providers who is willing to provide this medication to me, essentially as a lifestyle drug? Who gets hurt there?
Ted: Well, I guess what I would say is there is a vibrant medical spa business that really speaks to the vulnerability of consumers for something that sounds good and makes them feel like they're doing something for their health, and it's not really well founded, and I don't know that that's going to disappear. It's not something that I feel good about, not something that I would endorse, but it is something where people go and get all kinds of things that make them feel like it will make them look healthier and better. And so that's the kind of thing that unfortunately, given the frailties of the human condition will always be out there somewhere.
But this use of GLP-1s to pursue what might be characterized as “nonmedical weight loss” really runs contrary to what we know both about the disease of obesity and about how these medications work. Obesity is a chronic disease that can be very effectively treated with this new class of medications. But those who expect to use them temporarily in order to lose some weight and then “taper off,” are probably going to be disappointed. At this point, the data are pretty clear that cessation of the medication almost always results in regaining of the weight.
Here’s Ted again:
A lot of people are thinking in terms of losing weight instead of managing a chronic condition. And so you have telehealth companies that are tempted to–and in the short term rewarded for– appealing to that short term weight loss mentality, which ultimately won't be satisfying. Because as much as people think they ought to be able maintain a lower weight after losing some weight, the truth is biology is working against them. It would be nice if we had treatments, and maybe one day we'll have treatments that will more permanently alter obesity. But for now, it is a chronic condition that has to be treated chronically.
Now there is one potential bright spot on the horizon. Earlier this month, a new oral version of semaglutide (better known as Wegovy or Ozempic) has just been approved–and the telehealth companies are already promoting it. This oral version does offer several potential advantages. First of all, it will likely be significantly cheaper than the injectable. And I think for a lot of people, taking a pill once a day will just feel more familiar and less intimidating than having to give themselves a weekly injection.
Perhaps that will make it easier for people to wrap their heads around the idea of taking this medication on an ongoing basis in order to manage a chronic condition. Here’s a little more of my conversation with Ted Kyle, where we were discussing these new oral medications:
Monica: Maybe this is our off ramp, maybe this is the maintenance protocol that people would feel more comfortable with on a long-term basis.
Ted: I think that's a very sensible way to think about it. There is another medicine that will probably come to the market when it gets approval later this year called orforglipron, and those two products will be in close contention to see who can gain a foothold in the maintenance market. I look at that as being a good thing because it will get people talking and thinking and changing their perception of obesity and start thinking about it in terms of that chronic disease.
//
Although some telehealth companies will try to work with your insurance company to get coverage, many are catering to people who are willing to pay out of pocket for these medications. And one of the ways that these companies can compete on price is by offering compounded versions of these medications. And you know what, this has become a bit of a gray market.
Here’s more from my conversation with pharmacist Ted Kyle.
Monica: Now, Ted, you have very specific expertise and training in pharmacology as a pharmacist, and so I want to take advantage of this opportunity to ask you to help me understand a little bit about the compounding that has been part of this conversation for a while now.
Some companies are still relying very heavily on compounded versions of these medications. I'm wondering why. Is it because it allows them to provide those medications more cheaply to clients than they would be able to provide brand name medications?
Is it about customizing dosages or formulas to make them more effective? Help me understand this whole compounding thing in this landscape.
Ted: FDA has provisions that allows for compounding pharmacies to manufacture medicines to fill the gap when there's a shortage on a wide scale basis. That ended, some sometime in the last year, and so that's no longer necessary or really legal.
That's not to say that there's anything, per se, wrong with compounding, but, it can introduce risks. Then there's another thing that's going on where all of these compounding pharmacies and all of these businesses, got kind of used to making a lot of money from compounded GLP-1s.
And some people just walked away from it and said, well, there's no more need for this and I'm not gonna participate. And others looked for a fig leaf to tell them that they're meeting a highly personalized dosage need for people. And I see some really absurd advertising on TV, actually getting bombarded by it, that talks about microdosing and makes all kinds of claims that are not grounded in any kind of science, but it gives them an excuse to continue making money from compounding on a much bigger scale than you would typically see.
Monica: I'm not a pharmacist, but I understand that these injectable forms of these medications are very technically complex to produce, much more so perhaps than the kind of tablet or pill that we may be more familiar with in oral medications. Is compounding a little bit riskier for that type of medication than it would be for a pill or a tablet?
Ted: These are peptides, and these are complex molecules. And when you are talking about these complex molecules, having something that you can be sure is biologically equivalent to a reference product is a more complicated exercise than, say, getting a generic atorvastatin, which is a very specific molecule, and a small molecule.
Something that's manufactured in a GMP good manufacturing practice facility under FDA supervision for a major pharmaceutical company that is always gonna have a greater margin of safety than something that is prepared individually by a pharmacist. Even if it were being made by me, and I was a pharmacist working in a compounding pharmacy. I just have to recognize that the standards of production, and the quality assurance is at a higher level.
Monica: You mentioned microdosing, and this is also something that's getting a lot of play from online influencers. They are using tiny little fractions of the recommended doses of these. And I hear a lot of rationale for this, that it makes an expensive drug go a little bit further that maybe they don't experience, as many side effects for it, or they really only wanna lose a little bit of weight. So it makes sense to them to use just a tiny little amount of this extremely powerful medication. And I was actually surprised to see some of the telehealth companies that we've been discussing are actually promoting this, which seemed a little risky to me because this is not an FDA approved approach, and to my knowledge, there's not a lot of clinical data to validate this approach. So I'm not talking about modifying the standard dosage to manage side effects or maybe to accommodate a less than typical body size or something. But, you know, really using fractional amounts of the approved medications.
Is this just hype? have we lost the thread here?
Ted: So I, I think you make an important distinction. In some of these cases, it's becoming a pretext for pedaling compounded products inappropriately. For instance, I saw an advertisement that was in the New York Times this week, saying that we've got good science for microdosing. Well, show me the science.
Monica: Yeah, I'd like to see it too.
Ted: Please show me the science. Because in fact, in terms of actual clinical studies, the science has not, has not been published, has not been done. And as you say, this is very different from individualizing doses for a person.
Monica: I guess it is possible that in the fullness of time with more widespread adoption of these medications and more patient provider partnerships where people try and figure out what works–maybe we just don't yet know what the potential for these smaller doses are. But in my understanding, when you get drugs approved by the FDA, you do a lot of dosage studies to figure out which doses work. So had a lower dose been effective, they probably would have applied for that. Right?
Ted: That's right. One of the things that needs to be studied is for the longer term, will it be possible to maintain a clinical outcome with lower doses of a drug? I would suppose that for some patients that will prove to be true, and for other patients, it will not prove to be true. Understanding who that helps and who it doesn't, that's just part of a long list of questions
There’s another aspect of this that I think needs to be mentioned. These medications have become such a topic of conversation and speculation. It's gotten to the point where anytime someone we know (or perhaps a celebrity) loses a noticeable amount of weight, we are quick to assume that they must be using weight loss medications. And if it didn't seem to us that that person was particularly overweight, it might be tempting to conclude that they are using these medications simply to pursue vanity weight loss, as opposed to legitimate medical reasons. But as Ted points out, we need to be cautious about our assumptions.
Ted: Because of the nature of obesity as something, and metabolic diseases for that matter, that people can see and think they can make judgments about based on looking at a person, you have to be very cautious about what you assume and what somebody who is not a person's doctor assumes about whether or not somebody needs something. I'm thinking of one particular actress who recently started looking a lot more trim and svelte, and there was a lot of speculation about exactly what she was doing and why she's looking the way she's looking.
And bless her, she came out and said: “You know what? I have chronic health conditions that I'm managing the best way I can with my doctor, and I'm in a better place now than I was two years ago. Because I'm getting better care for this metabolic health issue, and we're not really gonna dive into the details of my medical records here. But trust me when I say I'm healthier than I've been in a long time, and that's all you need to know.”
Monica: Well, right. We do make free with our assumptions and our judgments of people who are in the public sphere, but you make a really good point. We cannot know what a patient's medical realities are based on how they look on the outside, and there are clinicians who are getting good results or enthusiastic about the potential for these medications to help with other things that may not look on the outside, like somebody has a weight problem, but might still respond to this type of medication. She mentioned PCOS for example. And of course it has always been the case that clinicians have the latitude to use approved medications in ways that are not exactly perhaps the textbook application for that medication that was approved by the FDA, but which they are getting good clinical results for. We do grant medical professionals that latitude to use these medications off-label. And perhaps that's some of what might be going on here? Mm-hmm.
Ted: Well, yes, and the simple thing to remember is indeed, when it come do metabolic health, this is not a disease of appearance. This is a disease of impaired metabolic homeostasis. So someone might not look like they have a big problem with obesity might have a big problem with fat accumulating in their liver, and that affects their health status. That affects many other things. And a skilled clinician who's actually working in a shared decision making mode with a patient that has metabolic health needs has to figure out what's gonna get that person to the healthiest state they can.
That may mean that they lose weight when they were perfectly satisfied with the weight aspects of their appearance, but they had other things going on. And it might mean that somebody gets to a much healthier state without suddenly looking like a slender person. It's just the end goal does not look the same. And that's absolutely just fine if you're dealing with a good doctor who understands how to care for this patient.
Monica: Well, and I guess that's the underlying concern. I mean, what you described there sounds like excellent healthcare, shared decision making, informed in the context of someone's whole health. I guess some of us are worried that that might not be what's going on all the time, with some of these telehealth providers where there's not a lot of other medical history or monitoring going on. It really is a bit of a pill mill.
Ted: Right. Right. And that's where it's important to realize that with virtual care with telehealth, it's really important that it meet or exceed the standards of in-person care, not be an excuse for a pill mill.
A telehealth provider should be having mechanisms for an interface with someone's primary care provider to make sure that that care that they are delivering, which is specialized care for weight issues, is complimentary to the primary care relationship that the patient has.
Monica: Right, and as you and I both know, the treatment of obesity or healthcare conditions is not just about taking a medicine. There's a lot of other things that go into that: nutrition counseling, appropriate movement, lifestyle. And so I would imagine, that is also something that we should be looking for as part of these relationships–or at least as you say, evidence that there's a close coordination with other people on the healthcare team that are providing that wraparound service.
To sum up some of the key points that Ted and I have been discussing, these new anti-obesity medications are a true game-changer. And telehealth has the potential to break down barriers to care, which is a very good thing. But there is also the very real potential for irresponsible prescribing that is more about profit than about providing good healthcare.
If you or someone you know is considering using one of these online obesity programs, I suggest looking for a program that offers more than just a prescription. It should include nutrition counseling, behavioral support, and a commitment to helping you build healthy habits for the long term.
You also want to look for a program that ensures there is a serious process with a qualified clinician. Somebody who is taking a full medical history, who is offering ongoing monitoring, and ideally, who is coordinating with your primary care provider.
I also suggest seeking out a company that is not promising a quick fix followed by an "off ramp." These are medications are for a chronic condition, and the goal is to manage your metabolic health for life and not just to slim down for a class reunion.
I’d also really be wary of companies promoting “microdosing,” at least until there’s something beyond anecdotal data to support this practice.
And finally, you may wish to stick to companies that are prescribing brand-name medications, unless there is a legitimate rationale for requiring custom compounding.
I really want to thank Ted Kyle for taking the time to share his expertise and insights. (I’ll include links to his work in the show notes, if you’d like to follow him. He's a great follow)
If you have a question or topic you’d like me to tackle on the podcast, you can email me at nutrition@quickanddirtytips.com. If you’d like to find out about having me speak at your next in person or virtual event, you can learn more at wellnessworkshere.com
Nutrition Diva is a Quick and Dirty Tips podcast. Holly Hutchings is our Director of Podcasts. Steve Riekeberg is our audio engineer, Morgan Christianson heads up Podcast Operations & Advertising, Rebekah Sebastian is our Manager of Marketing and Publicity and Nat Hoopes is our Marketing and Operations Assistant. Thanks to all of them and thanks to you for listening!