Q. I am very overweight and know I am putting myself at risk to get many medical conditions such as high blood pressure, diabetes and heart disease. I have tried losing weight on my own but find it very difficult. Can you let me know all of the options available to me?
A. There is much discussion around the fact that we are living in an obesity epidemic. In fact, the prevalence of obesity in Canada has risen 3-fold from 1985 to 2016. Though it may not seem like a bad thing to carry around a few extra pounds (let’s face it, some of us lived in an era where too much pressure was put on being skinny), the extra weight we carry on our body is leading to many other health issues that you hinted at in your question. We best measure our risk by using a body mass index (BMI) which is a calculation of your weight in kg divided by the square of your height in meters (kg/m2).
Underweight = BMI <18.5
Normal or Moderate weight = BMI 18.5-24.9
Overweight = BMI 25-29.9
Obese = BMI 30-39.9
Severely obese = BMI 40+
Let’s take a look at what 175 pounds (79.5kg) would look like for various heights.;
- For a person who is 6ft 2in (1.85m) their BMI would be 79.5kg/(1.85m)2= 23.2kg/m2 which is considered moderate weight.
- For a person who is 5ft 10in (1.75m) their BMI would be 79.5kg/(1.75m)2=25.9kg/m2 which is considered overweight.
- For a person who is 5ft 2in (1.55m) their BMI would be 79.5kg/(1.55)2=33kg/m2 which is considered obese.
As you can see, BMI takes into account your height and weight but does not take into account your sex, level of fitness or the proportion or distribution of body fat or muscle mass. Many experts agree that although BMI is not the best measure of obesity, it is still the measurement that is best available for the majority of us. The health concerns that are associated with being overweight and obese are;
- Cardiovascular conditions
– heart failure
– atrial fibrillation - Metabolic conditions
– Gout
– Type II diabetes
– non-alcoholic fatty liver disease - Mental health disorders- depression
– anxiety - Cancer – colon – kidney
These heath concerns are putting a strain on our health care dollars, money the government does not really have. Everyone benefits from being physically active and eating a well-balanced diet. Unfortunately, for some of us, adopting this healthier lifestyle may only reap benefits of a 3-5% reduction of our body weight. Let’s put that into perspective.
- Our 175 pound person 3% reduction = 5.3 pounds
5% reduction = 8.75 pounds - If you weigh 250 pounds 3% reduction = 7.5 pounds
5% reduction = 12.5 pounds - If you weigh 200 pounds 3% reduction = 6 pounds
5% reduction = 12 pounds
Though this does not lend itself to drastic weight reductions, even these small weight reductions can show improvement in health outcomes. To reduce the risk of health concerns further, many may require the help of psychological interventions such of cognitive behavioural therapy, pharmacotherapy and/or bariatric surgery.
In this column, we will delve into the various medication options available to help with weight loss. All of them require a prescription so a consultation with your health care provider will be necessary.
Orlistat (Xenical): Orlistat is a potent pancreatic lipase inhibitor and in effect reduces the absorption of dietary fats by 30% which is then excreted from our body through our stools. This explains the side effects that are associated with orlistat such as loose, oily stools and flatulence (gas). The less fat you have in your diet, the less side effects you will experience. This helps you stay true to your healthier lifestyle you have adopted. It is taken orally three times daily with each main meal unless you miss a meal or have a meal with zero fat. Since orlistat does not allow for the absorption of fats, you may find your fat-soluble nutritional foods are not absorbed and need to take a supplement away from the orlistat.
This also interferes with levothyroxine, cyclosporine, oral anticoagulants and anticonvulsants. The percentage of weight loss at 1 year is 10.2%.
Liraglutide (Saxenda): Liraglutide is also available under the brand name Victoza as an anti-diabetes medication. You may recognize that name from the previous few weeks of our Ask the Pharmacist columns when we thoroughly reviewed diabetes. Since Victoza is not indicated for weight loss officially, if you are prescribed liraglutide for this purpose, it is dispensed under the brand name Saxenda. Liraglutide is a glucagon-like peptide-1 (GLP-1) receptor analog that works by reducing gastric emptying which gives you a feeling of fullness and thereby reduce hunger. It is an injection given daily and titrated up each week, as tolerated, to a maximum dose of 3mg. The percentage of weight loss seen with liraglutide is 8.6%. The main side effects seen are nausea, vomiting, diarrhea and constipation. This reduced gastric emptying may affect the absorption of other medications.
Naltrexone/bupropion (Contrave): This medication is comprised of 2 active ingredients and its mechanism of action is not fully understood. Bupropion helps induce a feeling of fullness and naltrexone is an opioid antagonist. You might be wondering how naltrexone can help with weight loss but the thought is that it works in the area of the brain involved in food intake; more specifically the hypothalamus which can affect our appetite regulatory centre and mesolimbic dopamine circuit which is our reward system. With its affects on these areas, naltrexone can play a role on our appetite and our notion of using food as a reward to make us feel better. It is taken orally every day and titrated each week to a dose of 2 tablets twice daily. The percentage of weight loss seen with this combination drug is 6.1%. The side effects that may be experienced are nausea, dizziness, diarrhea, constipation, headache and dry mouth. Bupropion may lower your seizure threshold and therefore should not be used in anyone with a history of seizures or have risk factors for seizures. Bupropion should also not be used in anyone with uncontrolled high blood pressure. Also, since naltrexone is an opioid antagonist, this weight loss medication is not a good choice for anyone taking opioids.
Semaglutide (Wegovy): Interestingly, Health Canada has approved the use of semaglutide as a weight loss medication under the brand name Wegovy but it is not yet available in Canada as such. It is available, however, in a lower dosage form under the brand name Ozempic to be used for lowering blood glucose. Semaglutide is a GLP-1 receptor agonist (as is liraglutide) and is 94% similar to our own GLP-1 we have in our body. GLP-1 is a physiological regulator of both appetite and calorie intake. By activating GLP-1 receptors, which are located in many areas of the brain that are involved in appetite regulation, it helps to suppress your appetite and give you a feeling of fullness. Semaglutide is given once weekly as a subcutaneous injection with increasing doses every 4 weeks until the maximum dose of 2.4mg. The percentage of weight loss seen with semaglutide is 14.9%. That might explain the increase in the prescribing of Ozempic we have seen over the last year. The side effects most commonly associated with semaglutide are nausea, vomiting, diarrhea and constipation. As is the case with other GLP-1 receptor agonists, it may affect the absorption of other medications due to the slowing of gastric emptying.
It is interesting to note that not only do these medications help with weight loss, they are also beneficial at reducing other comorbidities. What is a comorbidity? Comorbidities are the presence of two or more medical conditions occurring at the same time within an individual. Obesity is the one disease state we are discussing here. It is not surprising that being overweight puts a toll on the body and the extra pounds increases the risk of other comorbidities such as diabetes, high cholesterol and high blood pressure. These medications have been found to also reduce your A1C (3 month average of blood sugar), cholesterol and blood pressure (with the exception of bupropion/naltrexone).
With the reduction of weight, your body will be able to function better, your mobility will improve and your sleep apnea score will see an improvement. With that comes a better quality of life score.
Unfortunately, many drug plans do not pay for medications specific for weight loss. Many of us will agree that by tackling the current obesity problem, we are saving health care dollars by reducing trips to see our health care practitioners and to the emergency room so it might make sense for the government to help out. That being said, we do not make those decisions.
You might ask us if it is worth putting forth the money for these prescriptions? The evidence is there to show the much-improved weight loss compared to the adoption of a healthier lifestyle alone. So, the question goes back to you. Are you willing to pay for a healthier, new version of yourself that will reduce your risk of heath concerns and be able to grow old perhaps with a loved one and see your grandkids grow up?
For more information on this or any other health topic, contact the pharmacists at Gordon Pharmasave, Your Health and Wellness Destination.
