Corlee Morris has been on a diet throughout her adult life.
After her weight started to climb in high school, she spent years losing 50 or 100 pounds and then gaining it back. Morris, 78, was at his heaviest in his mid-40s, standing 5ft 10in and weighing 310lbs. The Pittsburgh resident has suffered from diabetes for more than 40 years.
Managing his weight was a losing battle until Morris’ doctor prescribed him type 2 diabetes medication, Ozempic, four months ago. It is part of a new class of drugs that are changing the way everyday people as well as medical experts think about obesity, a disease that affects nearly 4 in 10 people aged 60 and over.
The drugs include Ozempic’s sister drug Wegovy, a weight-loss drug with identical ingredients, which the FDA approved in 2021, and Mounjaro, approved as a treatment for diabetes in 2022. (Ozempic was approved for diabetes in 2017.) Several other drugs are in development.
The drugs reduce feelings of hunger, generate feelings of fullness, and have been shown to help people lose an average of 15% or more of their weight.
“It cuts your appetite right away. I wasn’t hungry at all and lost weight like crazy,” said Morris, who lost 40 pounds.
But how these drugs will affect older people in the long term is not well understood. (Patients must remain on medication permanently or risk regaining the weight they lost.)
Will they help prevent cardiovascular disease and other chronic diseases in obese older people? Will they reduce disability rates and improve people’s ability to move around and manage daily tasks? Will they improve people’s lives and alleviate symptoms associated with obesity-related chronic diseases?
Unfortunately, clinical trials of the drugs have not included significant numbers of people aged 65 and over, leaving gaps in the available data.
Although the drugs appear safe – the most common side effects are nausea, diarrhea, vomiting, constipation and stomach pain – “they’ve only been on the market for a few years and caution is still warranted,” said Mitchell Lazar, founding director of the Institute for Diabetes, Obesity and Metabolism at the University of Pennsylvania Perelman School of Medicine.
Given these uncertainties, how do experts approach the use of new obesity drugs in the elderly? As expected, opinions and practices vary. But several themes emerged in nearly two dozen interviews.
The first was frustration with limited access to medication. Because Medicare does not cover weight-loss drugs, and they can cost more than $10,000 a year, the ability of older adults to obtain the new drugs is limited.
There is one exception: Medicare will cover Ozempic and Mounjaro if an older person has diabetes, because the insurance program pays for diabetes treatments.
“We need Medicare to cover these drugs,” said Shauna Matilda Assadzandi, a geriatrician at the University of Pittsburgh who cares for Morris. Recently, she says, she tried to persuade a Medicare Advantage plan representative to authorize Wegovy for a patient with high blood pressure and cholesterol who was gaining weight rapidly.
“I’m just waiting for this patient’s blood sugar to reach a diagnosable level for diabetes. Wouldn’t it be a good idea to intervene now?” she remembered saying. Rep’s response: “No. We have to follow the rules.”
Seeking to change that, a bipartisan group of lawmakers introduced the Obesity Treatment and Reduction Act, which would require Medicare to cover weight-loss drugs. But the proposal languished amid concerns about huge potential costs to Medicare.
If all beneficiaries diagnosed with obesity took brand-name semaglutide drugs (the new class of drugs), annual costs would exceed $13.5 billion, according to a recent analysis in the New England Journal of Medicine. If all obese older adults on Medicare — a much larger population — took them, the cost would exceed the total spent on Medicare’s Part D drug program, which was $145 billion in 2019.
Laurie Rich, 63, of Canton, Massachusetts, was caught off guard by Medicare policies, which have applied to her since she qualified for Social Security disability insurance in December. Prior to this, Rich had taken Wegovy and another weight-loss drug — both covered by private insurance — and she had lost nearly 42 pounds. Now Rich can’t get Wegovy and she’s regained 14 pounds.
“I haven’t changed my diet. The only thing that’s different is a signal in my brain telling me I’m hungry all the time,” Rich told me. “I feel awful.” She knows that if she gains more weight, her care will cost a lot more.
While acknowledging the tough political decisions ahead of us, experts expressed considerable agreement about which older people should take these drugs.
Generally, the drugs are recommended for people with a body mass index over 30 (the World Health Organization’s definition of obesity) and those with a BMI of 27 or more and at least one obesity-related condition, such as diabetes, high blood pressure or high cholesterol. There are no guidelines for their use in people age 65 and older. (BMI is calculated based on a person’s weight and height.)
But these recommendations are problematic because BMI can underestimate or overestimate body fat in older adults, the most problematic feature of obesity, noted Rodolfo Galindo, director of the University of Miami Health System’s Comprehensive Diabetes Center.
Dennis Kerrigan, director of weight management at Henry Ford Health in Michigan, a system that has five hospitals, suggests doctors also look at waist circumference in older patients because abdominal fat puts them at higher risk than fat carried in the hips or buttocks. (For men, a waist circumference above 40 inches is concerning; for women, 35 is the threshold.)
Fatima Stanford, an obesity medicine scientist at Massachusetts General Hospital, said the new drugs are “best suited for older patients who show clinical signs of obesity,” such as high cholesterol or blood sugar, and people with serious obesity-related conditions such as osteoarthritis or heart disease.
Since going to Mounjaro three months ago, Muriel Branch, 73, of Perryville, Arkansas, has lost 40 pounds and stopped taking three medications as her health improves. “I feel really good about myself,” she told me.
When obese adults lose weight, their risk of dying is reduced by up to 15%, according to Dinesh Edem, Branch physician and director of the medical weight management program at the University of Arkansas for Medical Sciences.
Still, weight loss alone shouldn’t be recommended for older adults because it leads to loss of muscle mass as well as fat, experts agree. And with aging, the shrinkage of muscle mass that begins earlier in life accelerates, contributing to falls, weakness, loss of function and the onset of frailty.
Between the ages of 60 and 70, about 12% of muscle mass drops, researchers estimate; after age 80, it reaches 30%.
To preserve muscle mass, older people who lose weight should be prescribed physical activity — both aerobic exercise and strength training, experts agree.
Also, because older people who take weight-loss medications eat less, “it’s critically important that their diets include enough protein and calcium to preserve bone and muscle mass,” said Anne Newman, director of the Center for Aging and Population Health at the University of Pittsburgh.
Ongoing monitoring of older adults with gastrointestinal side effects is necessary to ensure they are getting enough food and water, said Jamy Ard, co-director of Wake Forest Baptist Health’s weight management center.
Generally, the goal for older adults should be to lose 1-2 pounds per week, with careful diet and exercise accompanying medication management.
“My concern is that once we put patients on these obesity drugs, are we supporting lifestyle changes that will maintain their health? Drugs alone won’t be enough; we’ll still have to address behaviors,” said Sukhpreet Singh, system medical director at Henry Ford’s Weight Management Program.
We look forward to hearing from readers about the questions you’d like answered, the issues you’ve had with your care, and the advice you need for dealing with the health care system. Visit kffhealthnews.org/columnists to submit your requests or advice.
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