A new World Health Organization (WHO) guideline recommending GLP-1s for obesity treatment along with recent efforts to reduce the drugs’ costs are unlikely to change US obesity practice — but actions that change the US healthcare system might, clinicians told Medscape Medical News.
After the two recent and widely heralded events, Medscape Medical News sought feedback from specialists on the potential impacts of the new guideline and price reductions on their practices and patients. While generally appreciating that the guideline helps normalize obesity as a chronic, relapsing disease, our interviewees felt it would have little impact on prescribing the drugs and lifestyle interventions, given the constraints of the US healthcare system.
While price reductions may give more patients access to GLP-1s, even with the projected reductions, costs will still be out of reach for many patients, they said. And WHO acknowledged when it released the guideline that “even with rapid expansion in production, GLP-1 therapies are projected to reach fewer than 10% of those who could benefit by 2030.”
Here's how our interviewees reacted to the changes.
Anne Peters, MD, director of the University of Southern California’s Clinical Diabetes Programs, Los Angeles: “The WHO guideline won’t change my practice because I’ve been prescribing GLP-1s for years and I already incorporate a chronic model of care when using these medications in my practice. Patients have frequent follow-up and targeted lifestyle and behavioral interventions.
“However, a potential benefit of the guideline is it can help take away stigma and bias by defining obesity as a complex chronic disease and stating that the drugs should be available to anybody who has this disease. Now we can say something to patients like, ‘the drug we need to give you is a hormone. Your body is lacking it or lacking receptors or whatever it needs [to work properly], and that’s why we’re prescribing it.’
“When it comes to my prescribing it here, though, we're still slaves to formularies and insurance coverage. I have a friend whose BMI is about 44, and he has heart failure and edema — all reasons to lose weight. But his insurance won't cover the drug to treat his obesity because he doesn't have an indication like fatty liver or sleep apnea. We keep sending him for sleep apnea tests, but he doesn't flunk them because his sleep apnea is mild.
“So, a big barrier to prescribing the newer weight-loss drugs has been the prior authorization process. I've been trying like crazy to help my friend get on Zepbound (tirzepatide). Now that it's cheaper, he can potentially afford to buy it, and that would get him on it. If the barrier of prior authorization didn't exist, or someone can pay out of pocket, then prescribing would be easier for all of us. Nevertheless, many people won’t be able to afford these drugs, even at the reduced prices.”
Sriram Machineni, MD, director of the Fleischer Institute Medical Weight Center at Montefiore Einstein in the Bronx, New York: “I am disappointed by the statement that ‘intensive behavioral interventions’ should be part of the treatment with GLP-1s. The guideline authors did not appear to consider that intensive behavioral therapy is resource-intensive and even in the clinical trial setting, it did not improve outcomes.
“The term ‘intensive behavioral therapy’ is very specific and should not have been used. Instead, the authors should have outlined the details of the interventions that should be included based on evidence that they change outcomes.
“I was an investigator on the STEP 3 study. The intensive behavioral therapy used in that study was 1000-1200 Kcal a day with meal replacements for 8 weeks followed by 60 weeks of a 1600-1800 Kcal diet, and every 2 weeks one-on-one counseling with the dietitian every 2 weeks with a sole focus on calorie reduction and increasing aerobic physical activity from 100 min a week to 200 min a week.
“Despite all this intensive intervention, the final weight loss in STEP 3 study participants was no better than individuals in the STEP 1 study who did not do an intensive behavioral regimen; instead, they had q 4 week counseling session based on a 500 deficit Kcal diet and were asked to do 150 min of physical activity weekly.
“Semaglutide and tirzepatide reduce the appetite so significantly that putting limits on calories to be consumed is meaningless. This is like bariatric surgery and the focus, as per more recent recommendations, is to maintain adequate nutrient intake to prevent vitamin deficiencies; protein intake of 1-1.2 gm /Kg body weight; and perform resistance exercises to maintain muscle and prevent bone and muscle loss.
“GLP-1 drugs should be used as a part of a program that includes frequent and regular medical follow-up to monitor patients for response and manage side effects; a targeted [not intensive] behavioral intervention to maintain good nutrition despite reduced hunger; increased physical activity, and particularly resistance exercises to keep muscle and bone healthy during treatment.”
Louis J. Aronne, MD, director of the Comprehensive Weight Control Center at Weill Cornell Medicine in New York City: “The WHO recommendations won’t change my perceptions or those of my colleagues at the center, of the drugs' safety, efficacy, and accessibility. But it will change the perceptions of many insurers, employers and providers. The change in prices will definitely have an impact, since the biggest issue we encounter is the inability of our patients to afford the medicine. Right now, the decision of which medicine to prescribe is based primarily on insurance coverage. The price drop will affect our practice as more patients will have access to the medications. I also think insurers and employers who don’t cover the medicines will rethink it, if the cost is lower for them as well. Multiple health problems will improve as a result of treatment. “
Sara Ghoneim, MD, spokesperson for the American Gastroenterological Association and clinical fellow at Massachusetts General Hospital, Boston: “The ‘conditional’ designation is appropriate for the WHO recommendations. We still have gaps in long-term safety data, and from a GI perspective, we're seeing more patients with delayed gastric emptying, nausea, and gastroparesis-like symptoms. The WHO acknowledging these uncertainties while still recommending the drugs reflects a reasonable balance.
“As a gastroenterologist, I find the emphasis on behavioral therapy as a co-intervention particularly important. These medications work best within a comprehensive care model, not as standalone solutions.
“The price reductions are more likely to change my day-to-day practice than the WHO recommendations. I've had patients who would clearly benefit from GLP-1 therapy but couldn't afford $1000+ monthly out-of-pocket. If we're truly seeing prices drop to $350 or less through direct-to-consumer channels — and eventually Medicare coverage for severe obesity — I'll be discussing these medications with more patients, particularly those with metabolic-associated steatotic liver disease, where we've lacked effective pharmacologic options.
“While the new pricing agreements help, coverage remains patchy. Patients shouldn't have coverage for diabetes but not for obesity when the metabolic benefits are similar.
“I'm also preparing for increased referrals to manage GI side effects. Gastroparesis symptoms, while usually reversible with dose reduction or discontinuation, still require evaluation. I'm counseling patients proactively about what to watch for and coordinating more closely with endocrinology and primary care. The interdisciplinary approach WHO emphasizes isn't just aspirational — it's practical. Endocrinology, primary care, and gastroenterology should be communicating about these patients, especially as prescriptions increase.”
Amy E. Rothberg, MD, clinical professor of internal medicine and of nutritional sciences at the University of Michigan, Ann Arbor: “The WHO acknowledges that a prescription will not solve the obesity pandemic. Fundamentally, we must address all the social and environmental challenges including, and not least of which, is the food environment and poverty. We need real policy changes to provide equitable access to robust, comprehensive care that is fully reimbursed, and regulations around food marketing, particularly to children.
Medications are only one tool in the toolbox for helping patients manage their obesity. Clinicians should not prescribe a drug in the absence of assessing the patient's lifestyle factors, emotional and psychological status, complicating health conditions, and understanding that obesity is a chronic, relapsing and remitting disease. They also need to ensure that their patients understand that they may need to take the medication lifelong, [and] be willing to provide long-term behavioral and lifestyle counseling or refer to a comprehensive, structured program.”
Hanna Blaney, MD, MPH, assistant professor of medicine and transplant hepatologist, Virginia Commonwealth University, Richmond: “I would like to see further reductions in barriers to accessing appropriate and comprehensive care, including improved coverage of these medications without the need for prior authorization. I would also like to see the development of public health policy to encourage healthy behaviors, with a focus on preventing obesity. I applaud the WHO for publishing this guideline, which cements obesity as a chronic disease requiring treatment and I hope to see improved global access to these life-changing medications.”
Peters serve(d) on the advisory board for: Abbott Diabetes Care; Becton Dickinson; Boehringer Ingelheim Pharmaceuticals, Inc.; Eli Lilly and Company; Lexicon Pharmaceuticals, Inc; Livongo; Medscape; Merck & Co, Inc; Novo Nordisk; Omada Health; OptumHealth; Sanofi; and Zafgen; she received research support from: Dexcom; MannKind Corporation; and AstraZeneca; and serve(d) as a member of a speakers bureau for Novo Nordisk. Machineni reported being involved in semaglutide and tirzepatide clinical trials and being a consultant to Novo Nordisk, Eli Lilly and Company, and Rhythm Pharmaceuticals. Aronne disclosed being a consultant, speaker, and advisor for and receiving research support from Altimmune, Amgen, AstraZeneca, Eli Lilly and Company, IntelliHealth, Janssen, Novo Nordisk, Pfizer, Senda, UnitedHealth Group, Versanis, and others; he has ownership interests in ERX, IntelliHealth, Jamieson, Kallyope, Skye Bioscience, Veru, and others; and he is on the board of directors of ERX, Jamieson Wellness, and IntelliHealth/FlyteHealth; Ghoneim, Rothberg, and Blaney declared no conflicts of interest.
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