Patients complain that some obesity treatment startups offer pills and little else

Many Americans turn to the latest big ideas to lose weight: fad diets, fitness classes, questionable herbs and pills, and bariatric surgery, to name a few. They rarely turn out to be the magic solution people dream of.

Now a wave of startups are offering access to a new category of medicine combined with intensive behavioral coaching online. But already there are concerns.

These startups, spurred by hundreds of millions of dollars in funding from blue-chip venture capital firms, have signed up more than 100,000 patients and could reach millions more. These patients are paying hundreds, if not thousands, of dollars to get access to new drugs called GLP-1 agonists, along with online coaching to encourage healthy habits.

Startups initially positioned themselves in lofty terms. "This is the last weight-loss program you'll try," the Calibrate Health startup said in its 2020 marketing analysis, in a message aimed at one of its target demographic groups, "working moms." (Company spokeswoman Michelle Wellington said the document does not reflect Calibrate's current marketing strategy.)

But while doctors and patients are intrigued by the new model, some clients complain online that the reality is not true: They say they get "canned" advice and unresponsive doctors, and some report that they cannot get the latest drugs.

Calibrate Health, a New York-based startup, reported earlier this year that it had served 20,000 people. Another startup, Found, headquartered in San Francisco, has served 160,000 patients since July 2020. Calibrate costs patients nearly $1,600 a year, not including the cost of medications, which can reach nearly $1,500 a month without insurance, according to drug price savings website GoodRx. (Insurers reimburse GLP-1 agonists in limited cases, according to patients.) Found is offering a six-month plan for nearly $600, a spokesman said. (That price includes generic drugs, but not the newest GLP-1 agonists such as Wegovy.)

According to Crunchbase, a repository of venture capital investment data, the two companies have received more than $200 million in combined venture capital funding. The companies claim to be at the forefront of the fight against overweight, and both cite the influence of biology and other scientific factors as key components of their approaches.

There is potentially a large market for these startups. According to the Centers for Disease Control and Prevention, just over 4 in 10 Americans are obese, which increases their risk of developing cardiovascular disease and type 2 diabetes. Effective medical treatments are hard to come by.

Centers that provide such specialized care are "overwhelmed," says Dr. Fatima Stanford, an obesity specialist at Massachusetts General Hospital in Boston, a teaching hospital affiliated with Harvard. At her own clinic, the waiting list is 3,000 people.

Stanford, which said it has advised several such telemedicine startups, is positive about their potential.

Dr. Scott Butsch, director of the Division of Obesity Medicine at the Cleveland Clinic, says startups offer help with less judgment and stigma than face-to-face interactions with peers. They're also more convenient.

Butsch, who learned about the model through counselors, patients and colleagues, wonders whether startups are working "to strategically find out which patients are responding to a particular drug." They should coordinate well with behavioral health specialists, he said, because antidepressants or other medications can provoke weight gain. "Obesity is a complex disease and requires treatment appropriate to its complexity," he said. "I think programs that don't have a multidisciplinary team are less comprehensive and, in the long run, less effective."

The startups are marketing two products: first, a new class of GLP-1 agonists. Although these drugs are effective in inducing weight loss, Wegovy, one of two drugs in this class specifically approved for this purpose, is in short supply because of manufacturing difficulties, according to its manufacturer, Novo Nordisk. Other drugs in this category can be prescribed off-label. But doctors are generally unfamiliar with these drugs, Stanford said. In theory, startups can bridge some of those gaps: They offer more specialized, knowledgeable doctors.

There is another component: behavior change. Companies use TV shows and online communications with nutritionists or trainers to help patients adopt new eating and exercise habits. The weight loss achieved by participants in clinical trials of new drugs - up to 15 percent of body weight - has been linked to such changes, according to Novo Nordisk.

From podcasts to Instagram, social media sites are overflowing with ads from these startups. A search of Meta's ad library found 40,000 ads on Facebook and Instagram between the two firms.

Advertising complements people's posts on social media: Numerous Facebook groups are dedicated to the new type of medication - some even focus on helping patients deal with side effects, such as changes in bowel function. The hype is quantifiable: According to an analysis by investment bankers at Morgan Stanley, the number of mentions of the new GLP-1 agonists on TikTok tripled from last June to this June.

There is now a feverish, waiting appetite among startup customers for these drugs. Patients often complained that their friends got a drug they weren't offered, recalls Alexandra Coults, a former pharmacy consultant at Found. According to Coults, patients may have perceived this as some sort of substitution, when in fact, prescribing decisions are made for clinical reasons - such as contraindications.

Patient expectations affect the quality of care, Cults says. Clients come in with ideas shaped by a culture of fad diets and New Year's resolutions, she says. "Quite a few people signed up for one month and didn't continue."

In interviews with KHN and in online complaints, patients also questioned the quality of care they received. Some of them said that patient appointments that began with filling out a form and transitioned to an online doctor's visit were perfunctory. Once they started taking their medications, they said, requests for advice about side effects were slow to respond.

Jess Garrant, a patient at the Found Foundation, recalls that after she was prescribed zonisamide, a generic anticonvulsant drug that showed some ability to help with weight loss, she felt "totally weird."

"I stayed up all night and my mind was racing," she wrote on her blog. She developed mouth ulcers.

She sought advice and help from Found physicians, but their responses, she told KHN, "were not quick." Nonemergency messages are sent through the company's portal.

It took a week to change her medications and get a new prescription at home, she said. In the meantime, she said, she went to the urgent care clinic for mouth ulcers.

Found often prescribes generic drugs -- often off-label -- rather than just new GLP-1 agonists, company executives said in an interview. Found said older generics, such as zonisamide, are more readily available than GLP-1 agonists advertised on social media and on their own Web site. Both Butsch and Stanford said they have successfully prescribed zonisamide. Butsch says that rapidly increasing the dosage can increase the risk of side effects.

But Dr. Kim Boyd, chief medical officer of a Calibrate competitor, says the old drugs "just don't work."

Patients from both companies criticized online and in interviews the startups' behavioral approach, which experts say is integral to successful weight-loss treatment. But some patients believe they were simply given ready-made advice.

Other patients said they had had ups and downs with their coaches. Dana Krom, an attorney, said that with Calibrate she went through many coaches. Some of them have been good, effective helpers, others not so much. But, she said, when problems arose in the program, the coach couldn't help her navigate them. While a coach might report problems with medication or the app, those messages don't seem to be any more effective than messages sent through the portal, Crome said.

What happens when her annual subscription ends? Crome said she would consider continuing with Calibrate.

The relationship with coaches, given the need for behavioral change, is a critical element of the business model. Patient outcomes depend "on how committed they are to lifestyle changes," says Found's chief medical officer, Dr. Rekha Kumar.

While startups offer health care across a wider geographic range, it is unclear whether the demographics of their patients differ from the traditional "brick and mortar" model. According to the company, Calibrate patients are overwhelmingly white; more than 8 in 10 have at least a college degree; more than 8 in 10 are women.

And its early marketing strategies reflected that. The September 2020 "Segmentation" document outlined three types of customers the company could hope to attract: perimenopausal or menopausal women with incomes between $75,000 and $150,000 a year; working mothers with similar incomes; and "men."

Isabelle Kenyon, Calibrate's CEO, said the company now hopes to expand its reach and partner with large employers to help diversify its patient mix.

Patients would have to be persuaded that this model - more affordable, more acceptable - was right for them. For her part, Garrant, who no longer uses Found, reflecting on her experience, wrote on her blog that she had hoped for more follow-up and a more personalized approach. "I don't think it's a helpful way to lose weight," she said.

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