The debate over obesity treatment: Drugs vs. lifestyle changes

The head of a company that helps brokers and employers manage obesity risk warned recently against assuming that Wegovy, Zepbound and their competitors will win the weight-control war.

“The main thing people are getting wrong is treating this space as one-size-fits-all,” Elina Onitskansky, the chief executive officer of Ilant Health, said via email.

She sees many people assuming that the GLP-1 agonists and related types of drugs will be the right treatment for everyone coping with obesity, or that GLP-1 agonists will be the wrong treatment for everyone.

“Some of that comes from this mindset of diet culture that we just can’t shake,” she said. “The persistent idea that we can ‘solve’ obesity if everyone just does keto, or paleo, or the grapefruit diet, or gets on a GLP. We need to get to a place that is much more individualized.”

Some plan enrollees may be able to control weight problems with intensive behavioral therapy, and others may need bariatric surgery, she said.

Ilant estimates that behavioral therapy can help many people lose up to 5% of their weight, but that anti-obesity medications and bariatric surgery can help people lose much more of their weight.

Ilant: Onitskansky is a former McKinsey consultant and Molina Healthcare executive who founded Ilant after fighting with her own problems with controlling her weight.

Ilant uses board-certified physicians, dietitians and mental health professionals to help provide, support manage obesity care. Its services include getting plan participants quick access to obesity care providers and determining which participants might benefit the most from specific types of care.

The backdrop: Onitskansky is in a field changed by the discovery that relatively new anti-diabetes drugs with an acceptable risk profile help people who are dealing with obesity lose a significant amount of weight.

Drug makers have responded by setting list prices of about $1,000 per month per patient.

People with obesity have wrestled with people with diabetes over access to the drugs.

Workers have sued employers’ health plans over lack of GLP-1 agonist coverage.

Employers have accused drug makers and pharmacy benefit managers of making it almost impossible for employers to cover GLP-1 agonists, by increasing net prices by about two-thirds for employers that try to use utilization management drugs to channel to the costly drugs to the patients with the most urgent needs for the drugs.

Related: Employer plans face GLP-1 anti-obesity drug rebate threats

Some people who are obese point to the success of the new weight-loss drugs as vindication of the idea that obesity is primarily a metabolic disorder and that drugs and other medical interventions are the only practical treatment strategies.

Onitskanky’s thinking: Onitskansky sits in the middle between the people who think that diet and exercise are the only acceptable responses to weight problems and the people who think that drugs, surgical procedures and other physical medical interventions are the only interventions that make sense.

“We actually have decades of research that shows that most people are not successful on diet and exercise alone,” Onitskansky said. “That doesn’t mean they don’t work for anyone, but we currently have about 50% of the U.S. population with obesity, and those levels of obesity are driving other chronic conditions, including diabetes, cardiovascular disease, musculoskeletal issues.”

The country needs to help people use effective strategies to control their weight, she said.

“However, that doesn’t mean that behavior change and movement and access to healthy food are not a part of the answer,” Onitskansky said. “They are.”

Most people who are coping with obesity also want help with improving their eating habits, exercising more and managing stress levels, she said.

“So, it’s really not an either/or,” she said. “It’s about providing people the tools and support to live healthier, longer, and more productive lives through a combination of medical support and lifestyle support.”

The psychology: Onitskansky also believes in the importance of emotional support for people with obesity, even if counseling does not do much to increase weight loss.

“Obesity is a disease you literally wear, and so much of it affects how we see ourselves and how the world sees us,” she said. “There can be a lot of self-perception and mental health wrapped into the experience.”

Because of those kinds of concerns, mental health support is part of the services Ilant provides for every patient in its programs, Onitskansky said.