Episode Overview

Podcast: Endocrine News Podcast
Episode: ENP109: Anti-Obesity Medications
Host: Aaron Lohr
Guest: Dr. Geetanjali Srivasta, Professor of Medicine and Medical Director of Vanderbilt Obesity Medicine
Release Date: January 7, 2026

This episode provides a deep dive into the evolution, efficacy, and clinical considerations of anti-obesity medications. Dr. Geetanjali Srivasta shares insight from her clinical experience and recent presentation at the Endocrine Society's Obesity Fellows Conference, emphasizing the changing landscape, cutting-edge pharmacotherapies, and practical strategies in treating complicated obesity.

Key Discussion Points & Insights

Defining "Complicated Obesity"

• Obesity as Root and Amplifier of Disease:
  Dr. Srivasta describes complicated obesity as the form where obesity not only exists but leads to or worsens numerous comorbidities, making patients sicker overall.

  "This is referring to the sickest of the persons who actually have obesity, and hence the 'complicated obesity.' So this is referring to obesity causing the complications."
  — Dr. Srivasta [01:57]

• Obesity Impacts Every Organ System:
  Obesity contributes to diseases across all organ systems, including neuroinflammation, which can impair executive function and clarity of thought.

  "Obesity affects us from head to toe. It affects every single organ in our bodies... not only the heart, lungs, kidneys, but... neuroinflammation and meta-inflammation as a whole."
  — Dr. Srivasta [02:49]

Challenges in Managing Obesity

• Persistent Bias and Stigma:
  Both the public and medical community have historically maintained biases against discussing and treating obesity as a disease. This is gradually changing due to awareness efforts.

  "Initially, there was significant bias and stigma... but we've done so much background grassroots campaigns to recognize obesity as a disease process, and people are beginning to understand."
  — Dr. Srivasta [03:26]

• Equity and Access:
  High cost and insurance coverage remain significant barriers. The landscape is expected to shift as more medications enter the market, potentially reducing costs.

  "Cost of obesity medications have risen significantly. However... cost of these medications is expected to go down as new medications enter the market and it's a more competitive landscape."
  — Dr. Srivasta [03:26]

Evolution of Anti-Obesity Medications

• Past vs. Present:
  Early anti-obesity drugs were mostly repurposed from other indications, with modest efficacy (5–7% weight loss). Now, new drugs achieve higher efficacy, nearing surgical outcomes (up to ~30% loss).

  "Before, we were happy if we could get 5 to 7% weight loss. But now... we are striving towards more than 10%, 15%, 20%. And the even more novel medications are able to surpass that and effectively almost reach 30%."
  — Dr. Srivasta [05:41]

• Bridging the Gap to Bariatric Surgery:
  Modern pharmacotherapies are closing the efficacy gap with bariatric surgery (which typically results in 25–35% body weight loss).

  "In terms of medicines, we are definitely bridging the gap to bariatric surgery."
  — Dr. Srivasta [06:16]

Efficacy and Safety of Anti-Obesity Medications

• Robust Evidence for Novel Agents:
  Recent medications such as semaglutide and tirzepatide show high efficacy and additional cardiometabolic benefits, including reduced major adverse cardiovascular events.

  "These medications are effective and... they can actually benefit patients with cardiovascular disease. For example, the results of the SELECT trial show... a 20% major adverse cardiovascular risk reduction is significant."
  — Dr. Srivasta [06:42]

• Organ Protection:
  In addition to weight loss, new drugs can have protective effects on the heart, kidneys, and liver.

  "They can protect the heart, they can protect the kidneys, they can protect liver... help heal organs... having dysfunctional metabolism."
  — Dr. Srivasta [07:23]

• Tolerability and Monitoring:
  Most patients tolerate new medications well, but careful monitoring for side effects is essential, just as with any medication.

  "Patients are able to tolerate well these medications, but... a small cohort of patients... will need closer monitoring and adherence and supportive and symptomatic care."
  — Dr. Srivasta [07:41]

Clinical Strategies and Decision-Making in Anti-Obesity Therapy

• Patient-Centered Approach & Mental Algorithm:
  Dr. Srivasta applies a methodical, individualized assessment considering:

  • Side effects and contraindications
  • Prior patient experience with medications
  • Comorbid conditions (e.g., migraines, heart disease, diabetes)
  • Patient preferences (injectable vs. oral, prior family experience)
  • Cost and insurance coverage

  "You have to keep the patient first. There's a mental algorithm... You're also looking at side effects and contraindications... Then you're also looking at double benefits (e.g., medications treating two issues), patient preferences... and finally cost considerations."
  — Dr. Srivasta [08:21]

• Start Low, Titrate Up:
  Always begin with the lowest effective dose and adjust as needed.

  "We always start at the lowest effective dose... That's true for any medications that are started on a patient."
  — Dr. Srivasta [10:27]

Medication Selection — First and Second Line Guidance

• Potency and Individualization:
  Potent agents (GLP-1 agonists and GLP-1/GIP combinations) are first-line, but individual patient factors (side effects, access, contraindications) may necessitate use of other agents.

  "The best medication to use is going to be the one that actually is the most efficacious... Your first line is always going to be... the most potent in terms of efficacy... But we shouldn't necessarily negate the other medications... If you can't do your first line because of cost... what is your second line and third line..."
  — Dr. Srivasta [10:50]

Notable Quotes & Memorable Moments

• On Shift in Attitudes:
  "The tides are changing in both directions. Physicians are recognizing it and providers and so are patients."
  — Dr. Srivasta [03:26]

• On New Evidence:
  "The data is very robust. These medications are effective and... can benefit patients with cardiovascular disease."
  — Dr. Srivasta [06:36]

• On Holistic Patient Assessment:
  "There is a mental algorithm that we go through for each patient and I think that that's the best way to strategize."
  — Dr. Srivasta [09:52]

Important Segment Timestamps

• [01:40] — Defining complicated obesity
• [02:49] — Multisystem impact of obesity
• [03:26] — Challenges: stigma, access, and shifting attitudes
• [04:36] — Comparison: past and current drug development
• [06:33] — Efficacy & safety of newer medications
• [08:21] — Dr. Srivasta's decision-making "mental algorithm"
• [10:50] — Selecting the right medication

Conclusion

This episode offers a comprehensive view of the shifting landscape in anti-obesity pharmacotherapy, highlighting not just remarkable medicine advances, but a more nuanced, patient-centered decision-making process. Dr. Srivasta provides both detailed clinical framework and hopeful perspective on future access and therapeutic possibilities.

For additional resources and in-depth conference material, listeners are encouraged to check out the episode description for links mentioned.