Sufferers in search of new weight reduction medicine discover ‘wild west’ of on-line prescribers

Briana Lawson was ready to knock her diabetes into remission. For years, the 47-year-old health care consultant had treated her high blood sugar with metformin. But to avoid a lifetime of medication, she knew she’d need to lose weight. She’d tried fad diets, Weight Watchers, Nutrisystem, and had even considered surgery when the results didn’t stick. When she started reading about GLP-1 receptor agonists — which, last year, became the first new FDA-approved chronic weight management drug since 2014 — she was ready to give them a try.

“Once I was ready to consider the GLP-1s and did a lot of research,” said Lawson, “then I had to figure out, how do I get it?”

She didn’t have to look far. With enthusiasm for a new class of drugs has come dozens of telehealth companies ready to prescribe them. Online searches surfaced an ad for Found, a virtual weight loss coaching program that can be paired with a drug prescription for $149 a month. Another pointed to Calibrate, a $1,650, year-long online program that guarantees 10% weight loss with coaching and the prescription of an oral or injectable GLP-1, including Novo Nordisk’s recently-approved Wegovy.

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Others ads tease quick prescriptions: “Weight Loss Shots Online – Rx After 15 min Dr. Consult,” one says. “$99 Weight Loss Pills Near You – No Diet or Exercise Required,” reads another.

Tens of thousands of people have gotten online scripts from telehealth companies. On the surface, that’s not a bad thing: Good weight loss support is hard to come by. But experts are growing deeply worried that the rise in direct-to-consumer platforms could harm patients. They see two causes for concern: First, that even well-intentioned companies that pair prescriptions with weight coaching aren’t designed to provide long-term support, leaving chronic disease patients in a lurch. And even more troubling, they say, are the platforms that have seemingly cropped up just to churn out prescriptions for a profit.

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“The world of obesity and weight loss treatments and products have forever been a wild west,” said Scott Kahan, director of a weight management clinic in Washington, D.C. “While there’s a legitimate core of the field, far more that surrounds it is bogus and nonsense and predatory. And a lot of these telehealth companies, from what I’ve seen, are sort of toeing the line between them.”

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Virtual weight loss platforms, obesity physicians acknowledge, are the product of a broken system. There are more than 100 million people in the United States with obesity, and only 5,000 specialists. At one Boston-based weight center, the wait list is 4,000 people long. Another is booking appointments out until November.

For patients who could benefit from anti-obesity medications, the path to a prescription can be truly odyssean. The shortage of specialists means most patients turn to their primary care office for help. But non-specialists can struggle to navigate a complex web of prescriptions, medication shortages, and insurance coverage for the many classes of weight management drugs.

“Telemedicine at least gives an opportunity to mitigate some of those access issues,” said Kahan.

Online companies dedicated to prescribing the drugs could offer an appealing option to get care without the stigma that’s all too common. “It is such a willpower and shame-focused industry,” said Sarah Jones Simmer, CEO of Found, which also offers a non-medication program. “PCPs are saying, ‘Just go lose weight and then come back. Try harder, eat less, exercise more.’”

For Lawson, her primary care doctor was never an option. “Absolutely not,” she said. “I don’t want to go and have that conversation. It doesn’t always go well when you’re like, ‘So, I’ve been on the internet.’” So she took out a loan to join Calibrate, and began taking a GLP-1, Ozempic, last month after a brief virtual appointment with one of its doctors. “The urge to snack, the urge to overeat, any of that, it immediately goes away,” she said. “I feel like this must be how ‘normal’ people relate to food, and it feels pretty freaking awesome.” In three weeks, she’s lost six pounds.

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The proliferation of prescription-writing startups — many of which emphasize GLP-1s, if not prescribe them exclusively — mirrors the growing enthusiasm patients and some obesity doctors have expressed for the drugs, which were first designated to treat type 2 diabetes and can be prescribed off-label for weight management. “We were most excited about the way that it shifted consumer and doctor perception around medication for obesity treatment and medication for metabolic health more broadly,” said Calibrate CEO Isabelle Kenyon.

Calibrate’s business increased 20-fold after the FDA’s greenlight for Wegovy, and at least one startup, Sequence, was founded explicitly on the back of the drug’s approval. Their competitors’ business models vary widely, making money from a combination of coaching, insurance navigation, and clinician services, paid through subscriptions or one-off fees. Others profit directly from medication sales.

John Buse, an endocrinologist and former president for medicine and science at the American Diabetes Association, went from a BMI of 32 to 24 while on Wegovy, in line with the 15% weight loss clinical trial participants saw over 68 weeks. “It’s a miracle,” said Buse, who has received consulting fees and grants from GLP-1 manufacturers. “It was in a way so easy, you almost feel guilty about it.”

But that perception of a simple, guaranteed fix can pose a risk to vulnerable patients searching for solutions. The most dangerous and predatory online weight loss services, experts agree, are those that begin and end with a prescription.

Online ads and search results are often dominated by these types of services, frequently offered by telehealth sites that don’t focus exclusively on weight management. They tout same-day appointments, easy prescriptions, and the promise of losing weight easily without diet or exercise. “A lot of these [companies], unfortunately, hold the GLP-1s up and sort of dole them out like candy,” said Kahan.

Wegovy is only indicated for people with BMIs that fall in the obese category, or those with BMIs over 27 who have at least one other weight-related health issue, such as prediabetes or high cholesterol. Many virtual weight loss startups, including Calibrate, attempt due diligence before prescribing: asking patients a lengthy list of questions, conducting video intake visits, and ordering blood work to check for undiagnosed metabolic conditions before writing a prescription. And some companies emphasize that GLP-1s are a good fit for virtual prescribing because they have fewer side effects and contraindications than other weight management drugs.

But some services provide prescriptions based on nothing more than a glorified Google form, and without careful screening, patients could easily be handed medications that harm them. “When you create these conveyor belt treatment programs, I think that’s where you risk more blanket inappropriate care, or really stretching the bounds of what’s medically appropriate,” said Kahan. There are dangerous drug interactions with many weight management drugs. And experts said rapid online prescribing could put them in the hands of patients with histories of disordered eating.

Even when drugs are doled out more carefully, obesity experts question the underlying model of companies putting prescriptions front and center. Providers for online weight loss platforms that advertise prescriptions are less likely to discuss non-pharmaceutical alternatives with patients, which experts consider a best practice in obesity medicine.

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“I think people should have access to all the options, or at least have all the options presented to them, in order for them to make an appropriate decision on what’s best for them,” said Angela Fitch, associate director of the Mass General Weight Center and president-elect of the Obesity Medicine Association.

That’s especially unlikely to happen when sites prescribe a single drug or drug class, or have a financial incentive to sell weight management products. Pharmaceutical manufacturer Currax runs a telemedicine platform that only prescribes its own drug, Contrave. Digital pharmacy Ro prescribes a single weight management product after buying up $30 million of the satiety-inducing capsule Plenity.

“When you have a hammer, everything looks like a nail,” said Kahan.

When she found Calibrate, Lawson was sold on the company’s combination of medication and coaching, which happens in 15-minute video visits every two weeks. “Their data is, GLP-1s can offer you this amount of weight loss, but if you do coaching with us, it creates this magical multiplier of potentially up to twice as much success,” said Lawson.

But the value of that support can vary widely between services, and with few virtual platforms specifying their coaches’ credentials and qualifications, it can be hard for patients to pick the right fit. “Different people have different needs for behavior change,” said Fitch. Some may do well with Found’s text-based coaching or Calibrate’s face-to-face accountability, while others want to pay for extra sleep therapy through the fee-for-service model of Mochi, another startup that launched in February.

For Lawson, Calibrate’s coaching strategy wasn’t a match, so she now pays even more for a personal trainer. “If I could just get the medication and drop the counseling now I would, but it’s not really an option, and I’m fearful of the interruption of medication availability,” she said. “You feel kind of suckered in.”

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Lawson was also surprised when the doctor she saw didn’t discuss her diabetes before writing her prescription. And while she’s allowed to message or make appointments with a doctor if she wants, Calibrate doesn’t require her to see a clinician for the rest of the year — which is “kind of crazy,” Lawson said. Other startups similarly prioritize clinician visits at the beginning of their programs, some providing the ability to message doctors on a time delay through online portals.

“The medications are powerful, but require, to me, a lot more monitoring than can be done via coach,” said Caroline Apovian, co-director of the Center for Weight Management and Wellness at Brigham and Women’s Hospital.

Weight-loss startups emphasize that they’re not built to replace primary or urgent care. But to obesity specialists, frequent clinical follow-up is critical to make sure conditions intertwined with obesity — like heart disease risk, diabetes, and chronic joint pain — are improving, as well as to manage any side effects from the drugs. Many patients enroll in these programs without a primary care doctor who could fill that role, and establishing those lines of communication is recommended, but often not required.

That gap becomes especially critical as patients come to the end of their online programs, whether they’re pay-as-you-go or part of a year-long subscription. Once patients stop taking GLP-1s, they usually gain back the weight they’ve lost.

“[These companies] don’t really understand that it’s not a matter of, ‘Just take this drug for three months and lose the 50 pounds and you’re done.’”

Caroline Apovian, physician

“[These companies] don’t really understand that it’s not a matter of, ‘Just take this drug for three months and lose the 50 pounds and you’re done,’” said Apovian. “They didn’t think down the line.”

Calibrate, for one, aims to build a path for members to transition off of medication; “long-term, chronic use of obesity medications would bankrupt the U.S. healthcare system,” a company spokesperson said. The company also says it passes prescriptions off when members leave the program, and transitions patients to other coaches when — as recently happened with the company’s layoffs of nearly a quarter of its staff — they lose access to a particular coach.

But some patients have grown so frustrated that they decided to leave the program, illuminating the risks of abruptly ending online care. Some are now seeking prescriptions from telehealth sites that provide no follow-up — the platforms that experts are most concerned about harming patients.

“I think it’s good people have access to treatment,” said Fitch. “I just hope it’s access that helps them treat long-term, not short-term.”

Obesity doctors expressed hope that over time, primary care physicians will become more comfortable with providing evidence-based obesity care — and that telemedicine in the right form can help patients gain access to both prescribing expertise and skilled follow-up care. “What I worry about is telemedicine that sits outside of the person’s normal care,” said Fitch, encouraging patients to try respectfully educating their primary care physician if they experience resistance.

And Buse counsels patience: With Wegovy’s approval still relatively recent, “your PCP isn’t very far behind the times,” he said. With the anticipated approval of another GLP-1 for weight management this year, he thinks it will soon be easier for patients to get evidence-based care that can be so difficult to find. Telemedicine has the potential to drive improved access, too — but only if it prioritizes patients over profits.

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