App-Based Support Aids Weight Loss With Semaglutide, Studies Show

MALAGA, Spain—Patients with obesity treated with the glucagon-like peptide-1 (GLP-1) receptor agonist semaglutide (Wegovy; Novo Nordisk) can achieve weight loss in the real world similar to what has been observed in randomized, controlled trials, studies presented here at the European Congress on Obesity suggest.  

Managing treatment through two commercial online weight-loss programs (Embla and Yazen)—both of which include contact with a healthcare team, including nurses and physicians—resulted in weight loss comparable to what semaglutide-treated patients achieved in the STEP-1 trial, but with lower doses of the drug needed to achieve that reduction.

The programs, according to investigators, can help overcome some of the barriers to treatment in parts of Europe, as well as fortify care for a growing population with obesity.

“From where I practice on a daily basis, in Denmark, we’ve had a huge discussion initially around reimbursement for semaglutide,” Henrik Gudbergsen, MD, PhD (University of Copenhagen, Denmark), who led one study, told TCTMD.

While the Danish Medicines Agency is currently reviewing the reimbursement status of semaglutide for chronic weight management, public health organizations and medical councils have argued there is yet no framework for delivering care that includes dietary and lifestyle changes, said Gudbergsen. Specialized obesity clinics can provide that type of care, but it’s a challenge for clinicians treating patients in routine practice.

“If you want to do this seriously, it’s estimated you need to see a coach or have an interaction [with a healthcare provider] at least 26 times a year,” said Gudbergsen. “There’s no way I can ever do that as general practitioner.”

The app, on the other hand, provides “a scalable solution for counseling in relation to weight loss.”

Martin Carlsson, MD, PhD (Linnaeus University, Växjö, Sweden), who presented the results of the second study, said his team believes digital weight-loss programs “can minimize side effects, reduce costs for patients, which is very important, and may also improve long-term adherence.”

Obesity expert Jason Halford, PhD (University of Leeds, England), who wasn’t involved in the study, also emphasized the importance of prescribing semaglutide with a lifestyle plan in place.

“These drugs are an adjunct to diet and the activity component of obesity management,” he told TCTMD. “They should never replace it. First of all, they’re not going to be as effective because you’re not engaging in the behavior needed for lifetime weight management. Also, when people come off the drug, they’re going to quickly rebound. There is some rebound coming off the drugs anyway, but you risk rebounding where you basically go back to where you were without long-lasting behavioral change.”

The GLP-1 receptor agonists—as well as tirzepatide (Zepbound; Eli Lilly), which activates receptors for GLP-1 and glucose-dependent insulinotropic polypeptide (GIP) to mimic the actions of those hormones—are meant to put patients back in charge of their diet and lifestyle, said Halford. The problem is that the intensive weight-loss interventions aren’t available to everybody.

“One of the challenges we face is that, by and large, people are using these drugs in specialist weight-management settings, which is great,” he said. “They’ve got access to special care, but it’s not scalable considering the prevalence of obesity.”

Given the scope of the obesity epidemic, even the United Kingdom’s National Health Service (NHS) is testing digital weight-management technologies to address this unmet need. Right now, there are several that have been evaluated by the National Institute for Health and Care Excellence and can be used in the NHS while more evidence is being generated.

Mostly Using 1-mg Dose

Semaglutide was approved in Europe in 2022 as an adjunct to diet and physical activity for people with obesity or those with overweight who have weight-related comorbidities. It was approved a year earlier in the US with the same recommendation that it be used in combination with a low-calorie diet and increased physical activity. 

To mimic the holistic approach of specialized weight-loss clinics, researchers are testing different digital platforms that include behavioral therapy with a “health coach” focused on nutrition and exercise, in addition to treatment with semaglutide. The technology includes video calls and chats, as well as community groups, courses, health tracking, and recipes, but no in-person visits. Participants have online access to doctors, nurses, and psychologists, with the physician prescribing semaglutide when appropriate.

From where I practice on a daily basis, in Denmark, we’ve had a huge discussion initially around reimbursement for semaglutide. Henrik Gudbergsen

For the Embla program, the approach to weight loss is “treat to target,” said Gudbergsen, with physicians prescribing the lowest effective dose to achieve a weekly reduction of 0.5% or more of body weight with no or manageable side effects or hunger. Treatment continued until patients reached their desired weight or a body mass index (BMI) of 25 kg/m².

The retrospective analysis included 2,694 patients (mean age 46.6 years; 78.0% female) enrolled in the program. The mean body weight was 100.5 kg and BMI was 34.3 kg/m².

Average weight loss at week 26 and 52 was 12.2% and 16.2% of total body weight, respectively. By week 64, the average weight loss was 16.7%. This translated into reductions of 12.2, 16.3, and 16.8 kg at weeks 26, 52, and 64, respectively. In STEP-1, the mean change in body weight with semaglutide was 15% at week 68, making the results comparable, said Gudbergsen.

However, there is a notable difference: patients using the app achieved weight loss using a lower dose of semaglutide. In STEP-1, the recommended dose was 2.4 mg per week, whereas the mean dose used here was just 1.0 mg per week, with a little more than 28% titrated higher than 1.0 mg weekly. At doses of 0.25, 0.5, 0.75, and 1.0 mg, body weight was reduced from baseline 17.3%, 17.3%, 18.1%, and 17.6%, respectively. 

“What this showed us was that an intensive behavioral therapy within an eHealth weight management clinic can actually reproduce the results” seen in the randomized, controlled trials, said Gudbergsen.

The data also point to the importance of behavioral therapy in addition to semaglutide, he said, noting they achieved similar weight loss at a fraction of the dose used in other studies. Behavioral therapy “goes a long way when you want to lose weight,” Gudbergsen told TCTMD. “If we look back at some of the early liraglutide studies, we also saw that adding a very intensive behavioral therapy component boosts the weight loss and minimizes some of the effect driven by the compound itself.”

The Yazen application is similar and is available to support weight loss in several European countries. Like the Embla application, patients receive physician-directed care, including a prescription for a weight-loss medication, if necessary, while being supported by a multidisciplinary team. 

For this presentation, Carlsson focused on 2,008 patients (mean age 48.9 years; 77% female) enrolled in the program and treated with a GLP-1 receptor agonist, mostly semaglutide. The mean BMI at baseline was 33.5 kg/m².

After 12 months, 69% of people were still enrolled in the program and the mean reduction in body weight among these participants was 16.3%. By 18 months, 60% of people were still taking part in the online weight-management program and the mean weight loss was 16.6%. On average, women lost more weight than men (17.6% vs 13.4%). In addition to weight loss, there were improvements in liver enzymes, lipid profiles, and HbA1c levels.

Here again, most patients did not exceed 1.0 mg of semaglutide. During the study period, Carlsson said, there were significant challenges accessing semaglutide, forcing many patients to switch to a different GLP-1 receptor agonist. As a result, he believes the reduction in weight is probably on the conservative side.

Some Questions About the Program

These app-based support tools are not cheap, with a monthly membership costing €150 per month for Embla and starting at €70 for Yazen. On top of this, patients must pay for their own medication.

Donna Ryan, MD (Pennington Biomedical Research Institute, Baton Rouge, LA), who participated in a press briefing at which the results were discussed, noted that many of the Embla patients dropped out of the program over time. For example, at 26, 64, and 76 weeks, 1,580, 712, and 465 patients, respectively, were still taking part. As such, it wasn’t unlike a gym membership, with large numbers not continuing the program over time.

These drugs are powerful, potentially, both in their efficacy and in their side effects. Jason Halford

Gudbergsen said that after 1 year, roughly 40% of patients remained in the program, with some dropping out and others switching to the weight-maintenance program either with or without medication. He acknowledged that had the study been a randomized, clinical trial, the dropout rate would be considered “dreadful.”

During his presentation, Carlsson made a similar point, noting, however, that their discontinuation rates are much lower than has been seen in other real-world cohorts.

A digital solution, said Halford, could be one way to provide patients with feedback and support around their weight loss, but a concern with commercial apps is the type and quality of support people are receiving, particularly when it comes to medical supervision.

“These drugs are powerful, potentially, both in their efficacy and in their side effects,” he said. “It can be quite a challenge when first going on these drugs where you might have to, with supervision, stop escalating the dose, take it down, or say, ‘This is not the treatment for you.’ You need that interaction with a healthcare professional. You need that support initially to ensure you’re getting the most out of the medication while using it.”