By Heather Landi

Disha Narang, M.D., has been focused on diabetes and obesity treatment for more than a decade and has seen the transformative impact of next-generation weight loss drugs for her patients.

“It’s really helped our patients with Type 2 diabetes really get their disease under control, decrease their weight and then improve their overall health and metabolic health,” said Narang, an endocrinologist and director of obesity medicine at Northwestern Medicine Lake Forest Hospital.

“As we’ve gotten more approvals for weight management, it’s been fantastic. This is a game changer. In the world of weight management and as an obesity medicine specialist, I think it’s absolutely essential for patients who struggle with obesity to have this as a resource for weight loss,” said Narang, speaking about weight loss drugs like glucagon-like peptide agonists, or GLP-1s.

The effectiveness of drugs like Novo Nordisk’s Wegovy and Saxenda, which are approved for weight loss, as well as the diabetes drug Ozempic has created sky-high demand while off-label use of the drugs also has driven supply challenges in recent months. Pharma giant Eli Lilly also is pushing to get FDA approval for tirzepatide, a diabetes medication, to be added to the weight loss market in the US.

In 2022, more than 5 million prescriptions for Ozempic, Mounjaro (tirzepatide), Rybelsus (semaglutide) or Wegovy were written for weight management, compared with just over 230,000 in 2019—a 2,082 per cent increase, according to data from Komodo Health.

Prescriptions increased by 259 per cent between 2021 and 2022 alone.

As a physician, Narang is concerned that the buzz around GLP-1s is shifting attention to medication rather than treating diabetes and obesity as chronic conditions that require long-term, holistic care and medical follow-up.

“There’s not a quick fix, there’s not a magic wand. We have to approach this as we are treating a long-term chronic disease,” she said in an interview. “I think one of the things that needs to be understood is that a GLP-1 agonist, whether it’s for weight loss or diabetes, it is meant to be on for a while, this is a long-term therapy. If it took somebody 50 years to gain a certain amount of weight, taking this medication for like a month or two isn’t going to change that outcome. For these weight loss clinics and various online platforms, ‘OK, you’ve got this drug that’s in high demand, but what is your plan for the next 20 years?’ This is a long-term therapy that we’re looking at.”

This trendy new class of weight loss drugs is gaining attention as public health officials and the pharmaceutical industry target a growing obesity epidemic. Obesity has nearly tripled worldwide since 1975, and about 42 per cent of US adults are estimated to live with obesity, according to Centers for Disease Control and Prevention (CDC) data. The toll is physical and financial, with the medical cost of obesity hitting nearly US$173 billion in 2019 in the US.

Analysts project that the global obesity therapeutic market could be worth US$100 billion by around 2030, and Barclays estimates the burgeoning weight loss drug industry could reach as high as US$200 billion within the next decade.

GLP-1 medications support weight loss by sending signals to the brain and body that help regulate metabolism and help patients feel full and satiated longer. Based on clinical trials, with the use of GLP-1 medications and lifestyle adjustments, patients can anticipate losing 10 per cent  to 18 per cent of their body weight, based on the average weight loss in three 68-week clinical trials.

In the past year, many telehealth and digital health companies have jumped into the market, offering prescriptions for GLP-1s as part of an existing weight loss or chronic condition management program, or creating a new service line targeting obesity care.

Telehealth giant Teladoc recently expanded its provider-based care service for employers to include weight management and prediabetes programs. The programme is designed to help members lose weight and prevent and manage diabetes by safely optimizing medications, such as GLP-1 agonists, working in conjunction with solutions and tools that address the foundational pillars impacting cardiometabolic health, the company said.

Everly Health is building out its virtual care services combining diagnostic testing, treatment and ongoing condition management. As part of this service, the company is offering GLP-1 drugs to qualified patients in its weight management programme.

WeightWatchers also is moving into the obesity drug market with its recent acquisition of telehealth company Sequence for US$132 million.

In January, direct-to-consumer health and wellness company Ro launched a weight loss program that provides access to GLP-1 medications. Members of the Ro Body program also get access to a personalized provider care plan, diagnostic testing with at-home sample collection and 1:1 coaching from nurses.

“Weight management and weight loss are not new to Ro. We have over 160,000 patients who have partnered with us on their weight loss journey for the past couple of years. But we’ve been watching the GLP-1 space and just always thinking about what new effective treatments and solutions we can launch for our patients,” Ro’s chief medical officer, Melynda Barnes, M.D., said during an interview on the sidelines of the ViVE Conference in Nashville, Tennessee. “The Ro Body Program is a comprehensive program that is anchored on GLP-1s as the medical therapy but it’s a combination of GLP-1 medication, high-touch provider chronic condition care management, insurance concierge service, at-home lab testing, RN coaching and specific educational curriculum. I think the thing that’s really important about GLP-1s is that medications are highly effective, but the highest likelihood of success for treatment is really partnering the medication with high-touch provider care.”

Hims & Hers, a competitor in the direct-to-consumer health space, has not yet dipped its toes into weight loss and obesity medications but has signaled that it plans to in the future. The company recently added five new members to its medical advisory board including specialists in obesity medicine and menopause.

The price tag on weight loss drugs like Wegovy, which can cost more than US$1,000 a month per person without insurance, is a challenge for a cash-pay business like Hims & Hers, noted Hims & Hers chief medical officer, Patrick Carroll, M.D.,.

“We really recognize that obesity and weight management are a public health challenge. We will offer a comprehensive program in the future. I think our challenge today is that the whole drug category is challenging in itself. There are long-term safety side effect issues and there are challenges with cost,” Carroll said. “There are significant supply chain issues and challenges with insurance coverage. When we offer a programme, it’s really going to be holistic and will include evaluation, counseling and medications but not just GLP-1s as there are generic medications out there that have been very successful in managing weight loss.”

Studies have shown that people who take blockbuster obesity drugs Ozempic or Wegovy will likely gain the weight back after they stop taking the medications. Research also has shown that a significant percentage of people stop taking the medications after one year due to side effects, Carroll noted.

“We just want to make sure that they are not only safe but effective,” he said. “I think the other challenge with GLP-1s is that you have to keep taking them. There are a lot of challenges in the space and it’s a fairly new field.”

Chronic conditions are the next chapter for digital health

Weight loss telehealth platform Calibrate launched in 2020, before new drugs like Wegovy entered the market. The company offers a digital programme that combines medication, including GLP-1 drugs, with behavior change delivered through a proprietary intensive lifestyle intervention to treat the underlying biology that contributes to obesity, according to Calibrate Chief Medical Officer Kim Boyd, M.D.

The startup recently released data that showed members had 15 per cent average sustained weight loss at 12, 18 and 24 months. The data also demonstrate overall metabolic health improvements, and, notably, the reversal of diabetes and prediabetes diagnoses in 81 per cent of members.

The company has raised more than US$125 million from investors Founders Fund, Tiger Global, Threshold Ventures, Forerunner Ventures, Optum Ventures and Redesign Health.

Calibrate’s founder and CEO, Isabelle Kenyon told Fierce Healthcare that the company is focused on demonstrating that its approach to obesity treatment is sustainable and scalable.

“What fundamentally differentiates Calibrate from anyone else on the internet is that we really believe that to increase access to obesity treatment, you have to find a way to use GLP-1s across a population cost effectively, which means some people are on and off of them. Some people are on them forever. Some people don’t get them at all, but you have to do that at scale at a population level. And then you ultimately have to find a way to incorporate lifestyle intervention so that people can be successful after medication,” Kenyon said.

With growing competition in the market, Calibrate recently cut 18 per cent of its workforce as part of a pivot to focus on its employer business rather than direct-to-consumer, Stat reported.

In the past year, many telehealth platforms have popped up to cash in on the multibillion-dollar weight loss drug market. Many of these sites offer prescriptions for GLP-1s after the user inputs some information including their weight without a virtual or in-person visit with a doctor.

A gastroenterologist at Yale Medicine, Avlin Imaeda, M.D., Ph.D., says virtual care can help open up access to specialists in obesity medicine as patients are facing long wait times to see doctors. Imaeda herself uses telehealth for some patient visits as part of her obesity medicine practice. But she is concerned that some telehealth companies are offering easy access to medications without appropriate follow-up care.

“My impression is that some of these sites are really pushing the GLP-1 agonists and they may not be offering multimodal treatment, including counseling on diet and exercise,” she said.

Narang also is concerned that online companies offering prescriptions for GLP-1 medications are presenting an easy solution to a complex problem.

“People want a quick solution. So they say, ‘Let me log into one of these things, pay a fee and get my medication quick and be on my way.’ I wish it were that easy. I’ve had patients who have engaged with some of these platforms but have ended up spending a lot of money and they’ve had difficulty getting appropriate counseling for long-term management of this. They still end up in my office because they still have questions or they’re not necessarily doing as well as they hoped,” she said.

She notes that telehealth can be part of a comprehensive obesity treatment plan that incorporates long-term counseling, education and a focus on lifestyle and behavior change.

“With some of these platforms, I don’t know if people are getting counseling about long-term weight management or are they just being prescribed a medication? Because the medication is a fraction of it. My successful patients who had long-term weight loss will tell you that their lives now are absolutely different than their lives were before they kind of embarked on this weight management journey. The way they live their day-to-day lives is absolutely different,” she noted.

Kenyon sees a long-term strategy for virtual care companies to focus on weight loss and metabolic health by offering holistic, high-quality care. She believes companies like Calibrate can usher in the next chapter of digital health by offering longitudinal care for chronic conditions.

“We had the first generation of digital health companies attacking chronic disease, but it was very point of care. But we know that how we actually treat chronic disease in primary care settings or in specialist settings is much more holistic, and it involves longitudinal care, and digital health has never done a good job with longitudinal care,” she said. “What’s so interesting about this category is that people care about their weight in a way that they don’t care about their A1C or their hypertension. I think waking up in the morning and continuing to care about your weight means you’re biased to participate in a longitudinal programme and to continue to engage in a way that we haven’t seen before. And I think that’s a really powerful place for the digital health sector to be moving.”

Form Health is another obesity telemedicine company that launched three years ago before Wegovy hit the market. Founded by Evan Richardson, a member of the founding management team at Grand Rounds and an early employee of Castlight Health, the company built a team of board-certified medical weight loss specialists and registered dietitians specialized in weight loss. Form Health pairs patients with a physician and dietitian team for frequent check-ins that incorporate medical guidance and behavioral, nutrition and activity changes for lasting weight loss and improved health, according to the company.

Form Health executives say patients lose up to 15 per cent of their body weight at three months and up to 20 per cent at six months.

“It is a whole health treatment approach,” Richardson said in an interview. “Because we are treating that whole patient, we meet the standard of care for reimbursement and we are unique in that aspect of being an insurance-reimbursed American Board of Obesity Medicine-style programme.”

Obesity management requires oversight for patients to successfully keep the weight off, Richardson noted, and Form Health focuses on long-term treatment plans rather than just prescribing medications.

“We are very clear on how obesity works and the fact that it is a relapsing medical condition and one that is with the patient for their whole life. The patients we work with who typically have a significant amount of weight to lose, we work with them for the long haul. Typically after about two years, we’ve still got about 50 per cent of our patients on treatment,” he noted.

Form Health’s approach is to offer patients frequent touch points with clinicians to help support obesity management, noted Form Health’s chief medical officer and a Harvard Medical School-trained endocrinologist, Florencia Halperin, M.D.,. “When you lose weight, a lot of your biology changes. One patient had high blood pressure and at one point she had lost a lot of weight and she didn’t need the blood pressure medicines anymore. If you don’t adjust them down people can really get into trouble. Losing weight requires medical care along the way.”

Another patient had issues with insurance and prior authorization that led to her being without medication for two to three weeks but she was able to maintain her weight and not gain it back by using tools that Form Health provided her, like eating healthy meals, Halperin said.

Equity concerns with trendy new drugs

As the demand for GLP-1 drugs grows and some online companies make it easy for off-label use of the medications, some doctors are concerned about patients having equitable access to the meds.

“For folks that are coming in getting these medications because they want to lose a quick 10 to 15 pounds or it’s not clinically appropriate for them, it cuts down supply, and currently supply is an issue and the cost is also an issue,” said senior medical director for chronic care management at One Medical, Hemalee Patel, DO,. “It really hinders folks from getting the care that they need appropriately. We do think these drugs are very powerful and can be useful. But we also want to make sure it’s appropriately given and accessed equally.”

CDC data illustrate that obesity disproportionately impacts some racial and ethnic minority groups. Socioeconomic hurdles for these groups can limit access to these medications, given cost and supply issues, noted Patel, who is double-boarded in internal medicine and lifestyle medicine.

Patel shares many doctors’ concerns about some online platforms offering prescriptions for GLP-1 drugs without the appropriate standard of care for obesity treatment.

“One disappointing aspect is that a patient might get started on these drugs, then they might stop for a month or two and then they might find another company that pops up that might give them these medications and all the while, no one’s really addressing what’s going on holistically with these types of patients who actually probably need to get plugged in and need to get an appropriate workup and diagnosis to make sure it’s appropriate and get that kind of whole person care,” she said.

Patel helped develop and launch One Medical’s Impact program, a chronic care management program utilizing digital health technology and a team-based approach to help patients manage their chronic conditions. One Medical, now owned by Amazon, offers a weight management program that includes prescriptions for obesity medications combined with what Patel calls “lifestyle medicine” focused on diet and activity.

“I think that there are some companies that do a great job [with obesity treatment] and others where they are simply dispensing the medication, and there’s no follow-up or there’s no ability to monitor someone’s conditions,” she said. “These are meant to be a long-term drug that’s titrated slowly and appropriately and monitored effectively so that you are doing the best by the patient and setting them up for success for when you eventually do maybe want to take them off of it or titrate them down.”

While the lucrative obesity drug market is poised to only keep growing, many digital health companies see opportunities to address chronic conditions and support patients’ long-term health.

“You have a chronic disease that is associated with eight out of 10 leading causes of death and you have something that is deeply meaningful to patients and affects the majority of the US population. I think it’s understandable why you see the massive increase in the percentage of prescriptions,” said Ro CEO and founder, Zachariah Reitano,during a recent Fortune Brainstorm Health event. “How to get it into the hands of people who need it most? What we think about a lot at Ro is we don’t want to be the easiest or quickest place to get the GLP-1 prescription. We want to be the best place to get high-quality and ongoing obesity care.”