What older adults need to know before taking a GLP-1 medication to lose weight

By Brenda Goodman, CNN

(CNN) — For 35 years, Barbara Senich only owned black pants.

“I thought somehow, that would make me look less big,” said Senich, 69, who has struggled with obesity for most of her life.

At her heaviest, Senich, who is 5’11”, weighed 340 pounds. She lost at least 100 pounds twice on all-liquid diets but eventually regained the weight. Bariatric surgery helped her drop to 185 pounds, but the benefits turned out to be temporary, and the pounds began to creep back once again.

“I had like three or four sizes of clothes, in case I got fat again,” she said.

About five years ago, Senich finally felt confident enough to give all of her “fat clothes” away. Her weight has settled at around 137 pounds – a number she says she hadn’t seen on the scale since she was a teenager – with a combination of medications: the GLP-1 Zepbound; metformin, which treats insulin resistance; and a third drug that helps with binge-eating, called Contrave.

This summer, she’s enjoying wearing white pants and even a new pair in pale pink.

“This is the thing that’s been the miracle for me, is the maintenance,” she said.

While the medications have helped her stay lean, they have also taken a hefty bite out of her budget. She pays for Zepbound through the drugmaker’s LillyDirect program, which has helped a bit, but she’s had to shoulder that cost herself since her Medicare drug plan doesn’t cover weight-loss medications.

She hopes that may soon change, however.

Starting Wednesday, millions of Medicare-qualifying adults like Senich will have access to popular medications for weight loss at deep discounts through a temporary federal program called the Medicare GLP-1 Bridge.

Those who qualify will be eligible to get pill or injected forms of semaglutide (brand-named Wegovy), tirzepatide (brand-named Zepbound) and orforglipron (or Foundayo) for $50 per month.

To qualify, you must be 18 or older, participate in the Medicare part D drug coverage program and meet certain health criteria:

• Have a BMI that’s 35 or higher, the threshold for severe obesity
• Have a BMI between 27 and 34.9 and at least one of the specified obesity-associated health complications for your weight and height

Bridge is an experiment. By law, Medicare cannot cover medications that are solely used for weight loss. But because obesity drives many of the major diseases of aging, including heart disease, cancer, dementia, arthritis and diabetes, the US Centers for Medicare and Medicaid Services says it makes sense to pilot a test to see whether the medications might ultimately save the program money and improve health outcomes. The program will run through December 2027.

A new analysis by the nonprofit health policy group KFF found that 3.8 million Americans would newly qualify for the program, based on 2023 data, though it’s unknown how many people will actually participate.

Price has been a major barrier to access for these medications, especially for older adults who may live on fixed incomes. Bringing costs down may finally put them within reach.

But medical experts caution that price shouldn’t be the only consideration when deciding whether to use one of these powerful drugs.

“Just because you can doesn’t mean you should,” said Dr. John Batsis, a geriatrician and nutritionist at the University of North Carolina’s Gillings School of Public Health.

How well do weight loss drugs work for older adults?

Rates of obesity in older adults roughly doubled between 1988-94 and 2015-18, according to a report by the Population Reference Bureau. Today, about 2 out of every 5 seniors is obese based on their body mass index, or BMI, a ratio of weight to height, according to data from the US Centers for Disease Control and Prevention.

It’s hard to think of a disease of aging in which obesity isn’t a major contributor. Aching joints? Inflammation from too much body fat both triggers and worsens arthritis. Heart attacks, strokes, blood clots in the legs or lungs – all become much more likely if you’re obese, as do diabetes, dementia, kidney disease and a host of other life-limiting ailments.

Even a modest amount of weight loss can improve these risks, however. And on that front, there’s promising news: Recent studies show that the GLP-1 drugs do seem to work just as well in adults over 65 as they do for younger patients.

A newly released study that compared the weight loss and side effects experienced by 358 adults 65 and older who participated in trials of the drug semaglutide, or Wegovy, confirmed that seniors lost 15.5% of their body weight on average, while younger adults lost 15.6%, nearly exactly the same. Study participants in the placebo group, who followed the same diet and exercise plans but got injections of saline solution, lost just 5% of their body weight, on average.

Similarly, a new analysis of seven randomized controlled trials testing the drug tirzepatide, or Zepbound, focusing on results in adults over 65, showed that on the highest dose of the drug, seniors lost about 23.3% of their starting weight on average, while younger adults lost about 22.6%. In contrast, those using a placebo lost between 2% and 4% of their starting weight.

An analysis of 64 studies of GLP-1 medications used for weight loss, published by researchers at the Johns Hopkins Bloomberg School of Public Health in March, came to the same conclusion: The benefits are consistent, no matter a patient’s age.

Although these conclusions are encouraging, experts caution that they’re based on trials that enrolled relatively small numbers of older people. Across the studies of semaglutide for weight loss, for example, just 358 participants were 65 or older, and 100 of those were in the placebo group. The tirzepatide studies included 575 adults over the age of 65 who didn’t have type 2 diabetes and 351 who did have diabetes, which tends to make weight loss more difficult.

“When you look at the trials, most trials either exclude older adults, or if they include them, very few are over the age of 65, and even fewer are over the age of 75,” Batsis said.

“An older adult is very different than a younger adult. Their physiology is different, their biology is different, and what is important from an outcome standpoint is different, as well,” making it important not to try to extrapolate data from younger to older adults, he added.

“I think GLP-1s, and what we really know about them, is still kind of in its infancy,” said Dr. Jennifer Schrack, who directs the Center for Aging and Health at the Johns Hopkins Bloomberg School of Public Health.

“Being obese is never healthy, and if these drugs help people lose weight, that’s a great thing,” she said. “But I think we just have to think about what are some of the other potential problems that could arise from these drugs.”

Schrack says older adults who may have issues with balance or bone mass should be mindful that the weight loss on these medications may cause the loss of muscle, not just fat, which may affect stability and fracture risk. That makes resistance exercise, or weightlifting, a must while using these medications.

What about side effects?

In the clinical trials, adults 65 and older on GLP-1 medications were more likely than those ages 18 through 64 to have certain side effects.

In the studies of tirzepatide, for example, seniors on the drug were about twice as likely to stop taking their medication because of adverse events compared with younger adults and other older adults who were in the same study but got a placebo.

Gastrointestinal side effects were cited by 7% of participants as their reason for coming off the drug. About 1 in 4 seniors using tirzepatide had nausea, about 1 in 10 said they vomited, and about 1 in 5 reported diarrhea or constipation.

While these percentages are close to rates of side effects like nausea, diarrhea and constipation experienced by younger adults, experts point out that the consequences can be more serious for seniors.

The sensation of thirst diminishes with age, making it harder for older adults to stay hydrated under the best of circumstances. Add a bout of vomiting or factor in slowed digestion, and dehydration can quickly turn into a medical issue, such as kidney problems or a bowel blockage.

Although hydration remains crucial, other fears about GLP-1 use in older adults may turn out to be more theoretical than real.

For example, doctors had worried that older adults, who are already losing muscle mass due to age, might be at greater risk for falls and perhaps fractures on weight loss medications. Research is limited, but so far, that doesn’t seem to be the case.

“When you lose weight, you lose fat, but you also lose muscle and bone,” Batsis explained. This happens with all kinds of weight loss, not just weight loss on GLP-1 drugs. “Just because you lose muscle doesn’t necessarily mean you’re losing function, though.”

In clinical trials, older adults taking tirzepatide were just as likely as those on a placebo to experience falls and were less likely to break a rib or hip, or an arm or leg. The picture was largely the same for those on semaglutide. Older adults using Wegovy were slightly less likely to have a bone or joint injury compared with those taking a placebo, although Wegovy users were slightly more prone to falls than those assigned to take a placebo (4.4% of the Wegovy group had a documented fall, compared with 3.6% of the placebo group).

Must-dos when taking a GLP-1

First, talk to your doctor or nurse practitioner.

“Anyone, if they’re on these medications, should have very good medical care and be followed, especially when first starting,” said Dr. Melanie Jay, who directs the Comprehensive Program on Obesity at NYU’s Langone Medical Center.

Your provider can help determine whether you are eligible for coverage through the Bridge program. They can also advise if they think starting a GLP-1 will be a good idea, based on your individual medical circumstances.

“Older adults stand to gain the most benefit from the medicine, because for instance, if you already have heart disease, taking these medicines can prevent heart attacks and cardiovascular mortality. It can decrease it by 20% over a four-year period,” Jay said, “so they have the most to gain, but they also need to be followed.”

Jay said she’s seen patients who are prediabetic normalize their blood sugar on a GLP-1, but she’s also had some experience kidney failure after starting them, making good medical care, and follow-up blood testing essential.

Second, drink more water.

Dr. Alison Moore, a geriatrician and internist at the University of California, San Diego, says she counsels patients about making sure they are drinking enough water if they’re taking a GLP-1.

“I have many, many patients who live in a state of mild to moderate dehydration, because they don’t feel the need to drink, so I end up saying, ‘OK, drink a full glass of water with every meal, and ideally two or more,’ ” she said. She also advises that people try to drink most of their water early in the day so a full bladder doesn’t disrupt their sleep.

Water can also help with another significant side effect of GLP-1 medications that plagues older adults: constipation.

“Constipation was a huge problem for me. I know it doesn’t sound sexy, but it can kill you to get blocked up,” said Barbara Senich, who switched from Wegovy to Zepbound in part because of the constipation she was experiencing. Any GLP-1 medicationscan cause constipation, but how well they work and the side effects people have are highly individual. Senich said she found that constipation wasn’t as much of a problem for her on tirzepatide as semaglutide.

In the clinical trials of tirzepatide, 19% of older adults had constipation while using the drug, compared with about 6% of those on a placebo.

“You have to watch that like a hawk,” Senich said. “I tell everybody who goes on these things, ‘write down every time you poop. I mean, literally put it on your calendar.’ ”

Third, and this will help with constipation too: Seek nutritional counseling.

“Certain diets can make the side effects worse, so you want to make sure that you’re having good nutrition information, that you’re getting good counseling,” said Jay, of NYU.

Fatty, greasy foods and large meals can bring on bouts of nausea and vomiting, Jay explained.

Protein, on the other hand, is king. Getting enough protein can help preserve muscle mass, which helps people stay strong and active. Because it’s easy to feel full when using a GLP-1 medication, she advises people to start their meals with protein.

“Eating protein first and then eating fruits and vegetables, to make sure you’re getting enough nutrients from the fruits and vegetables, is really important,” Jay said.

Finally, set realistic goals.

There may be a decades-old number that you’d like to see again when you step on the scale, but you may need to reconsider whether that weight would be healthy for you now.

Instead of thinking about what you want to weigh, experts counsel that it’s a better idea to think about what you want to be able to do.

“We need to move away from a weight-centric approach to more of a function-centric approach” for older adults, said Batsis, at UNC’s Gillings School.

Losing weight can help people gain lifespan but also health-span, Batsis said. Joints are less painful. Moving is easier and more enjoyable after weight loss, too.

Just be careful not to overdo it.

With age comes the obesity paradox. Study after study has shown that older adults who carry a few extra pounds – even enough to kick their BMIs into the overweight category – tend to be healthier than those who are underweight.

Part of the paradox is thought to be explained by health. People who are very sick often don’t eat well and may become thin and frail as a consequence, rather than a cause.

But it also seems to be true that having a few extra pounds can help people weather illnesses and other health challenges a little better, too, said Moore, of UC-San Diego.

“If you’re too thin as you age, that’s no good,” Moore said.

CNN’s Tami Luhby contributed to this report.

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