Analysis Shows GLP-1s Work Best with Behavior Change Support

GLP-1 prescriptions for weight loss have seen an exponential rise over recent years, with over 5 million prescriptions written in 2022—a 2000% increase since 2019. GLP-1s approved for weight loss show dramatic results: In clinical trials, once-a-week Wegovy® (semaglutide) for 68 weeks led to an average weight loss of 14.9% from baseline body weight, while 86.4% of all participants taking Wegovy® saw clinically significant weight loss—generally defined as losing 5% or more of baseline body weight during the trial. Similarly, once-a-day Saxenda® (liraglutide) over 56 weeks led to an average of 8% weight loss, with 63% of participants experiencing clinically significant weight loss.

These impressive results have led people to wonder: Do medications take the place of diet, exercise, and other lifestyle modifications?

Omada Health, a multi-condition virtual care provider with over 12 years of experience, partnered with Express Scripts by Evernorth to learn more. Express Scripts serves more than 100 million Americans as a pharmacy benefit manager (PBM).

Behavior Change: The Key to GLP-1 Success?

Historically, most medication treatment options for weight loss have shown limited efficacy along with increased cardiovascular risks and unpleasant side effects. Furthermore, some medications are only indicated for short term use (12 weeks or less).

In 2014, the chronic weight management market changed when the FDA approved Saxenda®, introducing GLP-1s as a new class of medications for the treatment of obesity. Since then, the landscape has continued to evolve. However, as new offerings enter the FDA approval pipeline to meet demand, one constant remains:

Per the FDA labeled indication for Saxenda® and Wegovy® (two GLP-1s approved for obesity treatment), both medications should be prescribed in conjunction with a lower calorie diet and increased physical activity, i.e. behavior change—arguably the hardest part of maintaining weight loss.

Omada studies have previously shown that individuals with chronic health conditions such as prediabetes, diabetes, and hypertension can lose weight and keep it off via lifestyle modifications, with support from data-empowered care teams. Thus, evidence- based behavior change programs like Omada are ideally positioned to support individuals actively using GLP-1s through their weight loss journey.

This led Omada and Express Scripts to theorize that with behavior change support through the Omada for Prevention program, individuals taking GLP-1s for weight loss would see greater success.
 

The Analysis

Omada conducted a retrospective propensity-score matched analysis using Express Scripts’ pharmacy claims dated October 2022 through May 2023. The sample included Evernorth SafeGuardRx® members participating in Omada for Prevention with a baseline weight and
at least one follow-up monthly weight.

The resulting cohort consisted of 1,884 members with ≥1 Wegovy® only claim, 384 with ≥1 Saxenda® only claim, and 281 with ≥1 claim of each medication. The analysis examined how engagement in the Omada for Prevention program impacted the weight loss of members in these cohorts. All SafeGuardRx® members in the Omada program were divided into groups reflecting “meaningful” and “limited” engagement using a median split of their Omada program engagement values.
 

Summary of Results

Our analysis showed that members who used Wegovy® and/or Saxenda® and were more engaged in Omada for Prevention lost more weight than those who used these medications and were relatively less engaged in the program. Meaningful engagement in the Omada program among members with at least one GLP-1 claim was associated with a 2.6x (95% confidence interval, 2.51x to 2.82x; P<0.001) relative increase in weight loss at month 12 when compared to a matched cohort of Omada members who did not have any GLP-1 claims. Furthermore, among Omada members with at least one GLP-1 claim, meaningful engagement was associated with a 1.7x (95% confidence interval,1.53x to 1.87x; P<0.001) relative increase in weight loss at month 12 compared with limited engagement. These differences in outcomes are visualized in Figure 1.

Interestingly, certain types of program engagement, such as sending a message to your coach, posting on a peer discussion board, setting a goal, completing a lesson, stepping on the scale, and tracking a meal, were particularly predictive of greater weight loss over time.

The strongest association with weight loss was apparent between relationship-oriented engagement, including the relationship with the health coach and the relationship with fellow Omada members within the GLP-1 subgroup. The results are similar across both the GLP-1 subgroup as well as the whole population, which is in line with research that suggests the importance of social support in health behavior change. Specifically, greater relationship-oriented engagement was associated with 1.7x (95% confidence interval, 1.46x to 1.94x; P<0 .001) greater average weight loss relative to other types of in-app engagement, such as lesson completion and goal-setting. Similarly, tracking-oriented health behaviors were associated with 1.1x (95% confidence interval, 0.96x to 1.19x; P=0.35) greater average weight loss relative to other types of engagement. Overall, this demonstrates that more action-oriented engagement is an especially important predictor of weight loss success. These results are depicted in Figure 2.  

Overall, the results showed a dose-response relationship between months of medication claims and weight loss. As expected, members who took the medication for increasingly longer periods of time and at increasingly greater doses (according to standard medication titration prescription recommendations) experienced greater weight loss.

New Analyses Lead to New Questions

Are GLP-1s alone enough? The short answer is no—lifestyle modifications are an important component in obesity treatment. In fact, the Wegovy® and Saxenda® trials mentioned in the introduction of this article display the weight-loss effects of these drugs coupled with lifestyle interventions such as a reduced- calorie diet and increased physical activity.

While Omada and Express Scripts’ analysis saw a positive relationship between high engagement in the Omada for Prevention program and weight loss for those taking GLP-1s, a few points remain unclear:

• Should participation in a behavior change program be required alongside GLP-1s? If so, what does that look like?

• How do people taking GLP-1s without behavior change support fare following
usual care?

Future real world analyses may help answer some of these questions. Even more, future studies could benefit from participant input on medication adherence and side effects,
an understanding of the cause and effects of medication discontinuation, and the impact of medication dose and timing. The opportunity for future studies to enhance our understanding of obesity treatments is key in setting individuals up for success.

Current Challenges and the Path Forward

Unfortunately in medicine, there’s no one size fits all solution. In the case of Wegovy® and Saxenda®, people who have a fear of injections may not be good candidates. The medications also have side effects and people with a history of certain medical conditions should not take them. Lastly, and quite critically, is the issue of cost and insurance coverage. The listed cash
price for a month’s supply of Saxenda® or Wegovy® hovers around $1,300, which presents a cost challenge for payers and patients alike. One survey found that only 43% of employers and health plans cover weight loss medications in their formulary, while another 28% are considering covering the medications in the next two years.

Employers and health plans alike are balancing the efficacy demonstrated by these medications with the associated cost and unknown variables: What’s the ROI on these medications? Do people have to be on GLP-1s for life? What happens if they stop? Finally, what can plans do to ensure appropriate access while limiting abuse and misuse of these drugs? Omada and Express Scripts are excited to continue their investigation to help answer these questions. What we can examine today is the real-world impact of these medications coupled with a virtual behavior change program.

With the high price tag on medications like Wegovy® and Saxenda®, the employers and health plans paying for these treatments want to know how they can optimize their investments. As strategic partners, Omada and Express Scripts are here to help roll out these medications responsibly. Additionally, offering Omada along with a GLP-1 allows members to receive the support they need through their weight loss journey.

About Omada + Express Scripts

Omada Health has partnered with Express Scripts to offer Omada for Prevention, a digitally delivered individualized program for individuals with overweight or obesity who are at risk of developing type 2 diabetes. The program provides members personalized support in adopting healthy lifestyle behaviors through health coaching, digitally-delivered weekly lessons, peer support via topicbased communities, a cellularly-connected scale to make tracking weight easy, and more. Omada for Prevention is currently embedded in SafeGuardRx®’s Weight Management Care Value and Diabetes Care Value program with more than 28K members enrolled in 2022.

SafeGuardRx made Omada Health’s Prevention program available to all of its members in 2022. In Partnership with Express Scripts, Omada conducted an analysis to understand the relationship between engagement in the Omada for Prevention program and weight loss for individuals using GLP-1s. The use of GLP-1s was inferred from members’ having one or more Wegovy® and/or Saxenda® paid claims during the analysis period.