Medications such as semaglutide and tirzepatide are now recommended as a first-line treatment for managing cardiovascular disease risk among patients with obesity, marking continued clinical momentum for modern weight loss drugs.
The American College of Cardiology recently published the new guidelines, which square off those who support the use of these medications to deal with the ticking clock of heart attacks, stroke, and heart failure, against doctors who favor a traditional approach of lifestyle changes before drugs. This represents a major pivot in the treatment of obesity as it relates to heart disease risk.
The committee’s intent in changing its recommendations is that patients will no longer have to fail lifestyle interventions before they are able to try medication. Additional weight loss was minimal when lifestyle interventions were added to semaglutide and tirzepatide usage in clinical trials, according to the guidelines.
However, the guidelines aren’t intended to devalue the importance of healthy eating, exercise, and support systems that play a role in weight loss, according to Dr. Olivia Gilbert, a cardiologist at Atrium Health Wake Forest Baptist Medical Center and chair of the Concise Clinical Guidance panel that authored the recommendations.
“I think really they work in tandem and need to be emphasized and encouraged, as it already is by standard recommendations within the cardiovascular space,” Gilbert said.
She emphasized that patients no longer need to try and fail with lifestyle changes before starting medication, as these drugs are more effective and should be used as a first-line option alongside physical activity.
Drug-1st Approach
The new guidelines stem from a 2024 panel discussion about how cardiovascular doctors could best incorporate weight loss drugs into patient care, Gilbert said. Guidance is specifically for those with cardiovascular disease and heart failure to mitigate heart attacks, stroke, and death.
Anti-obesity medications are associated with 5 percent to 20 percent average weight loss, compared to about 10 percent weight loss with diet and exercise, according to data accompanying the new guidelines.
These peptides are in a class of drugs called nutrient-stimulated hormone therapies that mimic a natural hormone called glucagon-like peptide-1, which regulates blood sugar, appetite, and digestion.
Tirzepatide has the highest effectiveness for weight loss, followed by semaglutide, though factors such as availability, affordability, and insurance coverage may dictate prescriptions.
The guidelines further state that drug treatment is associated with a reduction in cardiovascular death, heart attacks, and stroke—especially in those with Type 2 diabetes and higher cardiovascular risk factors. Decreased weight also lowers the risk of chronic kidney disease and metabolic dysfunction-associated steatotic liver disease.
Doctors have fewer concerns about peptides because they work more naturally. Nevertheless, these drugs are new; the longest trials to date have been monitored for less than four years. Common adverse effects include nausea, vomiting, diarrhea, and constipation.
“When used appropriately and in the right patients, I think this offers a lot of hope and promise in the cardiovascular space,” said Amy Doneen, owner and medical director of the Heart Attack & Stroke Prevention Center in Spokane, Washington. She wasn’t involved in the new guidelines.
Doneen stated that more research is needed to understand the long-term safety of these drugs and whether people regain weight after stopping them, which is why a strong multidisciplinary care approach is essential.
Role of Lifestyle Support
Gilbert said that patients who stop taking weight-loss medication do tend to regain weight, and that’s one reason the guidelines emphasize a multidisciplinary support system to help patients combine the best of medication with diet, exercise, and medical accountability.
Doneen added that she supports the guideline’s approach of combining peptide medications with clinical support, which can help patients at risk of cardiovascular disease better recognize hunger cues and thereby maintain weight loss.
Specifically, the guidelines call for a multidisciplinary care approach that would:
- Provide personalized reports about what is contributing to patients’ cardiovascular disease, how to reduce those risks, and what other health issues may be involved.
- Refer patients to behavioral therapists and support groups.
- Partner patients with registered dietitians and exercise physiologists.
- Ensure pharmacy support to monitor medication use, side effects, and progress.
“The ideal state would be that these medications could provide people the fresh start perspective to increase physical activity, to make dietary changes, and have a new lease on life to be able to come off of them,” Gilbert said.
Shift in Thinking
A possible outcome of the new guideline that can’t be overlooked is that patients may become reliant on a lifetime of costly medications and come away no less educated about how to prevent disease, stated Dr. Ellie Campbell, a board-certified family medicine physician who describes herself as a cardiovascular risk reduction expert.
“Removing self-care as a primary tenet of wellness sets a dangerous precedent in my opinion,” she said in an email to The Epoch Times. “Too often, if a provider mentions therapeutic lifestyle changes at all, it is a one-page handout on ‘better choices,’ and when the patient comes for the next follow-up visit, the impression is, ‘Well, that didn’t work. Let’s use drugs.’”
The medical system is not currently designed to coach patients, Campbell said. She described the guidelines as an admission that a lifestyle approach for patients is hard work that is not in the wheelhouse for most doctors. She said some of the reasons lifestyle counseling is often overlooked are:
- Lack of time during appointments for in-depth counseling
- Lack of insurance reimbursement
- Lack of education in metabolism, nutrition, genetics, and the microbiome that influence risk factors
- Lack of training in motivational interviewing or behavior change science
- Lack of support to prevent burnout, which can allow patients to fall through the cracks
Argument for Coverage
Drugs like semaglutide are often covered by insurance for those with Type 2 diabetes, sleep apnea, and obesity. One goal of the guidelines is to gain greater patient access to the medications, Gilbert said.
In some cases, obesity alone is not sufficient for insurance coverage. The medications can cost anywhere from $8,126 to $15,738 per year in the United States, whereas the cost in other countries is much lower.
The guidelines show that low access to these drugs has led to patients seeking unregulated versions that can raise the risk of complications. Gilbert said that she has observed this firsthand.
“There are dangers with patients going out buying medications online if they aren’t being as well regulated by providers. There are concerns about patients having severe side effects,” she said.
On the other hand, the closely monitored use of anti-obesity medications can improve life expectancy, which is curtailed on average by 9.1 years for men and 7.7 years for women with severe obesity, according to data presented in the guidelines.
Doneen said the bigger shift with the new guidelines involves viewing peptides as different from other medications, not just as weight loss drugs but as part of a broader treatment approach for complex conditions such as fatty liver disease and insulin resistance.
