An internet search of “anti-obesity medications (AOMs)” will land over 63+ million hits in under a second. The surge in the popularity of AOMs is fostered by various media outlets (news, social, marketing, research) adding to increased patient demand. Trilliant Health/STAT reported that in 2022, ~3.6 million Americans were taking an AOM and estimate that this will increase by 35% by the end of 2023.
After spending a combined 50+ years researching and translating lifestyle recommendations into obesity practice, we weren’t surprised when the public appetite for “Ozempic-like” medications exploded. Putting the costs, celebrity endorsements, and supply chain issues aside, let’s break it down, talk data and what this means for the physical activity profession.
You may hear these therapies referred to by several different names — second- or third-generation AOMs, incretin-based hormone agonists, or nutrition-stimulated hormone-based therapies (NuSHs). But these agents are not all “Ozempic®,” as people regularly refer to them. This likely happened because semaglutide was the first of these new agents that took the diabetes (Ozempic®) and obesity (Wagovy ) worlds by storm. With FDA approval for weight loss in 2021, semaglutide 2.4 m.g. demonstrated over double the weight loss compared to previous medications. The STEP-3 trial boasted a weight reduction after 68 weeks of -16.0% compared to -5.7% with lifestyle only, and semaglutide resulted in 86.6% achieving a clinically meaningful weight loss of >5%.
While the impact of these medications for weight reduction brings new excitement, the base mechanism of action is not new. In fact, glucagon-like peptide-1 (GLP-1), has been around for years, there are several positive clinical trials, and numerous trials are underway to continue exploring the safety and effectiveness of these agents.
Next up and under FDA review for weight loss is tirzepatide, which is a dual agonist (GLP-1/GIP) that has demonstrated ~20% weight loss after 72 weeks. More agents are in the pipeline, with STAT reporting ~70 promising single, dual, and triple NuSHs and other therapies in clinical testing and development.
It is hard to ignore the impact of these agents for weight loss compared to prominent behavioral lifestyle interventions like Look AHEAD and the Diabetes Prevention Program which have demonstrated a 5-10% average reduction in weight at one year. Yet, the benefits of the medications aren’t just about the number on the scale. Already mentioned was their impact in diabetes care, and recent pre-published evidence from the SELECT trial demonstrates a positive influence on cardiovascular health.
We are not denying that lifestyle interventions, which include physical activity, can be effective for weight loss. However, there are still challenges that we must recognize. For example, not all individuals respond to lifestyle interventions, there is variability in response, and for the people that do respond, long-term maintenance of weight loss and prevention of weigh recurrence remains difficult.
How do we move forward in this rapidly changing landscape that includes these powerful new therapeutic agents for weight loss? It begins by being honest about challenges and opportunities for physical activity professionals.
The Challenges:
On these agents, patients:
- Will lose significant weight without engaging in activity,
- Will improve many health parameters without engaging in activity, and
- May not see the value of activity specifically for weight loss.
Despite these challenges, this may open the door for new physical activity opportunities.
The Opportunities:
We can now:
- Pivot from doses and intensities of physical activity for weight loss and prescribe based on improving health in patients using AOMs,
- Target physical activity for the independent health benefits not realized with weight loss alone, and
- Support patients on their holistic weight loss journey as a part of an integrated team of healthcare professionals.
This is a redirect for many of us who realize the powerful benefits of physical activity. We must step away from positioning it as “physical activity vs. medication.” This type of thinking puts the method first rather than the patient.
It is important for exercise professionals to recognize that excess weight and adiposity are due to the complex collision of biology, environment, and behavior. Obesity is not from an absence of willpower; thus, the basic premise to eat less and move more is difficult for many patients, and this may partially explain the variability in weight loss response. These medications help patients gain better control over their eating behaviors; however, they don’t magically improve physical activity engagement. In fact, our group recently presented data at Obesity Week 2023 demonstrating that the majority of patients taking these medications don’t initiate physical activity, and of those who do, most are not engaging in levels consistent with public health guidelines.
Just as obesity is a multifaceted and complex disease, our group is taking the position that approaches to obesity care in this new age cannot be one size fits all — and this includes exercise prescriptions. We are using a bio-behavioral approach that prioritizes patient and clinician perspectives and biological responses to develop programming that may impact clinical implementation and guidelines. It may not be enough to just assume that the same physical activity and lifestyle approaches layered onto AOM therapies will have the same impact as previously demonstrated. After all, our recent data indicates that the majority of patients already know and have been told repeatedly by health care professionals that it is “important that they exercise.” There are likely deeper behavioral factors that continue to keep these patients from engaging in physical activity.
Exercise professionals must ensure that they are not contributing to the stigma that many patients taking AOMs report, which includes feeling like or being told that they are “taking the easy way out.” For physical activity counseling to be effective, it is going to require appropriately trained and certified exercise professionals that want to work with patients taking AOMs and clinicians prescribing these agents.
The profession has embraced physical activity as a complement to treatment for other chronic conditions, such as with cardiac rehabilitation. Now that AOMs provide effective medical treatment for obesity, it is time to embrace this opportunity as the next frontier in integrated patient care.
Learn more from Drs. Rogers and Jakicic, along with their board-certified obesity clinician colleagues, at the IDEA & ACSM Health and Fitness Summit and at ACSM’s Annual Meeting.
Related CEC Courses:
Rethinking Obesity Treatment with Fitness Pros (1 CEC)
Training the Adult with Obesity (3 CECs)
Dr. Renee J. Rogers, PhD, FACSM, is a senior scientist at the University of Kansas Medical Center and also works as an independent healthy lifestyle consultant and strategist. She chairs ACSM’s Strategic Health Initiative on Behavioral Strategies and Summit Program Committees. Dr. Rogers is an expert in bio-behavioral intervention design with a focus on relevant engagement approaches that blends her 20+ years of experience working in exercise physiology, behavior change, and weight management.
Dr. John M. Jakicic, PhD, FACSM, is a professor of internal medicine in the Division of Physical Activity and Weight Management at the University of Kansas Medical Center. He is the chair of the ACSM’s Strategic Health Initiative on Obesity. Dr. Jakicic is an internationally recognized expert on body weight regulation and obesity treatment, with a particular expertise on the role of physical activity, and he has authored or co-authored over 300 peer-reviewed papers and book chapters.
