The Best Way To Lose Weight?

By Jill Tyrer | Nov. 20, 2024

If you’re carrying a few too many pounds, one of the best things you can do for your arthritis pain is to lose that extra weight. But that’s easier said than done. Even if your genes have not set you up to be chronically overweight, losing weight can be a struggle, especially in rich countries like America.

Stephen Messier, PhD, professor and director of the J.B Snow Biomechanics Laboratory at Wake Forest University, discussed the problems with obesity in a debate at the American College of Rheumatology’s 2024 annual scientific meeting, Convergence, in November. Obesity rates have skyrocketed in the past decade, with only about a dozen states with less than 30% to 35% obesity rates, he said. The richer the country is, the higher the obesity rates are, especially among women and wealthy people. And in rich countries, lower- and middle-income people are driving a steady increase in obesity.

As obesity continues to surge, Dr. Messier said, “The prevalence of obesity-related diseases, including osteoarthritis [OA], will continue to rise.”

Much of the problem revolves around our easy access to carbohydrate-rich foods and our lack of physical activity, said Martin Englund, MD, PhD, professor in the Department of Clinical Sciences, Orthopaedics, at Lund University in Lund, Sweden.

“Our genes have not adapted to our modern sedentary life, leading to obesity and other conditions strongly related to obesity, like diabetes type 2 but also osteoarthritis,” he said.

It’s well established that obesity leads to and worsens osteoarthritis in knees and other weight-bearing joints. We also know that weight loss eases OA pain and reduces the risks of numerous other health conditions, from type 2 diabetes and cardiovascular disease to premature death. But biological changes that come with obesity make it even harder to lose: The body works to prevent weight loss by slowing metabolism and increasing hunger.

In their presentation, “Weighing In: A Debate on Medical vs. Behavioral Lifestyle Interventions for People with Obesity and Osteoarthritis,” Drs. Messier and Englund agreed on most of those points. Where they diverge is on the best approach to weight loss: diet and exercise or using one of the popular blockbuster weight-loss drugs known as glucagon-like peptide-1 (GLP-1) receptor agonists, such as semaglutide (Wegovy, Ozempic), tirzapetide (Zepbound, Mounjaro) and liraglutide (Saxenda).

Weight-Loss Drugs

“Trials have found that they are vastly superior above placebo to reduce weight,” said Dr. Englund. People lose 10% to 15% more weight using the drugs along with diet and exercise than with lifestyle changes — diet and exercise — alone.

In one recent study, he continued, people with both obesity and knee OA received either semaglutide or placebo. Both groups reported less OA pain, but the semaglutide group had about 14% more pain relief than the other group, and their knee function improved 41.5% compared to 26.7% in the placebo group. Other health conditions, including cardiovascular deaths, heart failure hospitalization, stroke and others decreased far more in the semaglutide group than the placebo and lifestyle-changes group.

Lifestyle Changes

“It’s pretty clear that weight loss with GLP-1 is pretty successful. At least initially,” Dr. Messier countered. But there are plenty of drawbacks, beginning with the costs: More than $16,000 per year for semaglutide compared with about $3,400 per year for diet and exercise, including fitness facilities and personnel, meal replacements and more, he said. And given the popularity and demand for the drugs, insurance companies are increasingly reluctant to cover them.

Furthermore, once you start a GLP-1, you may have to take it for life. Trials have shown that, within one year of stopping the drug, people regain two-thirds of the weight they lost — and it’s not lean muscle that they regain, but fat, and it’s even harder to lose again, Dr. Messier added. With that added fat come cardiovascular and metabolic risks, including diabetes, heart disease, stroke and more.

In addition, GLP-1s do have some side effects, including nausea, diarrhea and vomiting, although Dr. Englund argued that they are short-term.

Dr. Messier, well known for his decades of research in treatment programs for OA, has established that community programs of diet and exercise help support people in their weight-loss efforts. They are designed to build people’s self-confidence in their ability to succeed at weight loss. Taking a pill does nothing to help in that regard, he said.

Or Maybe Both

It is likely that people would need to continue the drugs throughout their life, Dr. Englund agreed. But lifelong medications are not uncommon for other chronic diseases, like hypertension, he said, adding the costs would likely drop as patents run out and competition increases.

“Many obese knee osteoarthritis patients who do not succeed in losing weight and reducing knee pain with lifestyle changes would benefit from GLP-1 receptor agonists,” he said.

But there’s no question that Americans’ health is suffering overall from our unhealthy diet choices, easy access to unhealthy foods and lack of — or avoidance of — physical activity, both agreed.