Dr. Kaye Discusses his obesity treatment philosophy and thoughts on GLP-1 prescriptions.

Why do you prioritize lifestyle changes over medications or surgery as the first-line treatment for obesity?

As an internal medicine physician in primary care, I see several patients a day suffering from obesity and obesity related diseases. Lifestyle changes should be instituted first and foremost regardless of whether medications or surgery are being considered. First, we should define lifestyle changes as making sustainable and intentional shifts to your daily habits and inner monologue. In regards to obesity specifically, these shifts are focused on making different food choices and accurately monitoring your activity levels to change the delicate balance of energy within your body. Without these changes medications and/or surgery are destined to fail. For example, when bariatric surgery is being considered a patient undergoes extensive evaluations over many months by nutritionists, therapists and their primary care physician to ensure that they are able to make sustainable lifestyle changes prior to undergoing such a life altering surgery. If a patient is unable to sustain these changes they may end up regaining all of the weight lost or may  suffer other serious complications. With the popular GLP-1 injections becoming ubiquitous we also see similar results when these medications are prescribed without instituting lifestyle changes. For example, we have seen many patients not lose weight or even gain weight despite max dosages of these pharmaceuticals. This is why I personally prioritize changes in habits and thoughts regarding food, diet, and physical activity before utilizing pharmaceuticals.

 Do you see obesity primarily as a lifestyle-driven condition, a disease, or both—and how does that shape your approach?

Obesity is caused by multiple factors and is often mistakenly narrowed down to only one or two factors. Lifestyle habits, genetics/epigenetics, hormonal state, activity level and other comorbid conditions all contribute to obesity (or health!). I like to focus on addressing the variables that will have the biggest impact while evaluating for underlying contributing medical conditions. Lifestyle focused changes often have the greatest impact on overall health and longevity.

 How do you interpret or apply the current guidelines from the AHA/ACC/TOS and the Obesity Medicine Association, especially as they increasingly recommend medications and multimodal strategies?

Many professional societies including the American Heart Association, and Obesity Medicine Association are starting to recognize anti-obesity medications (AOMs) like GLP-1 as reasonable and often recommended adjunct to lifestyle changes. The changes to obesity treatment algorithms reflects the changing landscape of evidence as well as the success many patients have had by adding on medications. The important part to recognize is that these medications in addition to lifestyle changes and not a substitute. While it is an important step to recognize how medications can assist in obesity treatment it is crucial to understand that lifestyle changes are still the foundation of true transformational health change.

What kind of pushback, if any, do you get from patients who expect or ask for anti-obesity medications like GLP-1s? Do you ever prescribe those medications? If so, under what circumstances—and if not, why not?

The conversations around anti-obesity medications can vary wildly depending on a patient’s personal journey with weight loss and overall health. Medications like GLP-1s are mentioned almost everywhere including the media, pharmaceutical ads, and celebrity gossip. The bar for obtaining a prescription for these medications is also lower than ever with the ever-growing industry of pop-up online weight loss clinics promising affordable compounding options. Therefore, when a patient presents to my clinic and is asking for a prescription it is a perfect opportunity to really delve into the details of what these medications can offer and also the risks involved. Most of the time patient’s welcome an open discourse about options and strategies to achieve their goals. My usual practice is to discuss these medications as an option but only after a careful review of their food choices, activity level, health history and current medications. Without foundational lifestyle changes these medications are not always effective.

 Do you feel pressure from colleagues, patients, or payers to shift away from lifestyle-first care? How do you navigate that?

Oftentimes GLP-1 medications are viewed as a quick fix or a shortcut to achieve health goals. With new guidelines and recommendations also leaning towards medications as an option it can be tempting to start with a pharmaceutical approach; however, I often find that a candid discussion about my patient’s true health goals and the reality of the success and risks of medication usage I am able to develop a holistic strategy for weight loss.

What keeps you committed to this approach, especially in a system that increasingly rewards quicker or pharmacologic solutions?

After seeing many patients start down the pathway of pharmaceuticals and ultimately not reaching their goals reaffirmed my commitment to a more holistic approach. In my experience, without a strong foundation of lifestyle changes, the long-term success rate is low even with anti-obesity medications. Therefore, helping patients with true transformational health changes requires more than a quick fix.