Medical weight management protects against weight gain during the COVID‐19 pandemic

Abstract Background American adults have gained weight during the COVID‐19 pandemic. Little is known about how patients who are medically managed for overweight and obesity, including patients who are prescribed antiobesity pharmacotherapy, have fared. Objective To assess the COVID‐19 pandemic's effect on weight, food choices, and health behaviors in patients receiving medical treatment for overweight or obesity. Methods Adult patients treated at an urban academic weight management center between 1 May 2019 and 1 May 2020 were electronically surveyed between 23 February and 23 March 2021. The survey assessed changes in weight, eating, behaviors, and the use of antiobesity medications (AOMs) following issuance of social distancing/stay‐at‐home policies in March 2020. Results In 970 respondents, median percent weight change for those taking AOMs was −0.459% [interquartile range −5.46%–(+3.73%)] compared to +2.33% [IQR −1.92%–(+6.52%)] for those not taking AOMs (p < 0.001). More participants achieved ≥5% weight loss if they were taking AOMs compared to those who were not (26.7% vs. 15.8%, p = 0.004), and weight gain ≥5% was also lower in those taking AOMs (19.8% vs. 30.3%, p = 0.004). Patients with pre‐pandemic BMI ≥30 kg/m2 taking AOMs experienced the greatest weight reduction, and there was greater weight loss associated with increased physical activity. Conclusions and Relevance Medical weight management protected against weight gain during this period of the COVID‐19 pandemic. Increased physical activity, decreased alcohol intake, and use of AOMs were factors that contributed to this protective effect.


| INTRODUCTION
For the first time since the Spanish flu pandemic in 1918 the majority of Americans were asked to practice social distancing and abide by stay-at-home orders, when possible, starting in March 2020 to slow the spread of COVID-19. Forty-five out of 50 states issued stay-at-home orders during this time, which led to widespread business closures and a significant increase in working from home. 1 Other countries issued similar mandates, leading to major disruptions in national and international supply chains. These disruptions, both nationally and internationally, led to closures of restaurants, changes in access to certain foods at grocery stores, and changes in Americans' mental health and overall health behaviors (e.g., food choices, eating behaviors, physical activity, and alcohol consumption). 2 During the COVID-19 pandemic, many individuals have experienced significant weight gain. [3][4][5] The American Psychological Association conducted a survey in February 2021 which found that 42% of American adult respondents reported weight gain since the start of the pandemic. Of this group, average reported weight gain was 29 pounds (with a median weight gain of 15 pounds) and 10% reported weight gain of more than 50 pounds. 6 The cause of weight gain amongst American adults appears to be multifactorial and varied.
While for some individuals weight gain was related to behavioral changes caused by stay-at-home orders, food scarcity, etc, for others the emergence of the global pandemic and the disruptions it caused also lead to changes in mental health which led to downstream behavioral changes.
Studies have highlighted a connection between stress and anxiety leading to negative effects on health behaviors and weight management during the COVID-19 pandemic. 7-10 One study conducted in Rhode Island and Massachusetts evaluated the impact of stay-at-home orders at the outset of the pandemic in 99 individuals participating in an internet-based weight loss program. This study found that greater stress was significantly associated with having less time to spend on weight-loss efforts. 8 Another survey study of individuals with overweight or obesity participating in two separate behavioral weight loss trials (n = 82) conducted during the stay-athome mandate in Colorado concluded that most individuals experienced increased anxiety or stress. These participants reported difficulties adhering to recommended physical activity (68%) and to a prescribed diet (81%). 9 Another survey study (n = 1198) of American adults found that anxiety, worry, and stress were associated with self-reported increased eating. 10 While studies have been published assessing the impact of COVID-19 on mental health, behaviors, and weight among patients with overweight or obesity, little is known about how patients who are medically managed for their weight, which includes use of antiobesity pharmacotherapy, have fared. This study evaluated how the pandemic has affected weight, food choices, and health behaviors in patients receiving medical treatment for overweight or obesity at a large, urban, academic weight management center in the northeastern United States. The study's hypothesis was that the pandemic would have a negative impact on food choices and health behaviors but that medical weight management, including the use of antiobesity medications (AOMs) would protect against weight gain.  <30 kg/m 2 vs. BMI ≥30 kg/m 2 ; Figure 1). To explore this relationship, the study population was divided into four analytical subgroups:  Patients with a pre-pandemic BMI ≥30 kg/m 2 taking AOMs experienced the greatest weight reduction. Greater weight loss was associated with increased physical activity, with a more pronounced effect at higher BMIs. For example, somewhat more physical activity was predicted to decrease body weight by 4.0% at BMI of 30 kg/m 2 and by 19.4% at BMI of 50 kg/m 2 ( Table 2). Weight loss was also associated with reduced alcohol consumption and white race (Supp Table 1, Table 2). Among individuals with a pre-pandemic BMI ≥30 kg/m 2 not taking AOMs, weight loss was associated with higher pre-pandemic BMI and increased physical activity (Supp Table 2, Table 2). Among individuals with pre-pandemic BMI <30 kg/m 2 taking AOMs, weight loss was associated with pre-pandemic BMI and decreased alcohol consumption, whereas age over 65, decreased physical activity, non-white status, and increased alcohol consumption were significantly associated with weight gain (Supp Table 3 and Supp Table 4). Decreased alcohol consumption predicted percent weight loss of 2.1% at BMI of 20 kg/m 2 and 6.0% at BMI of 28 kg/m 2 (Supp Table 4). Regression factors from Supp Tables 1-4 were modeled to predict percent weight changes ( Table 2 and Supp Table 4).

| METHODS
In the entire sample, 73.1% reported more home-cooked meals and 60.8% reported less physical activity. There was greater weight loss with self-reported increased physical activity, with a more pronounced effect at higher BMIs (

| DISCUSSION
This study illustrates that medical weight management, particularly use of AOMs and increased physical activity, protects against weight gain and can also lead to weight loss during times of stress and environmental change. Increased physical activity, decreased alcohol intake, and use of AOMs were modifiable factors that contributed to this protective effect. Interestingly, the predicted impact of physical activity on weight loss increased exponentially at higher BMIs in those taking AOMs. Both directions of change in alcohol consumption during the pandemic have been reported in the literature. 13,14 In this study, the majority of respondents across all subgroups reported about the same or reduced alcohol consumption, a finding that may reflect the impact of lifestyle counseling or use of AOMs. While the survey was anonymous, this does not preclude some bias in selfreported alcohol consumption.
This is the first study to investigate weight change in patients undergoing medical treatment including pharmacotherapy for overweight and obesity during the COVID-19 pandemic. These findings offer unique insight into the utility of antiobesity pharmacotherapy and its interactions with health behaviors. While morbidity and mortality associated with the virus has decreased there is still uncertainty, anxiety and stress surrounding the pandemic. There are also semipermanent to permanent changes in Americans' daily routines which continue to impact overall health behaviors. Addressing both the mental health and behavioral health components is important to mitigate weight gain and promote overall health.
Limitations of this study include single center design with participants at different stages of weight-loss/maintenance, and lack of a -685 control group. The anthropometry data was also self-reported and retrospective in nature. Intercurrent illness and unintentional weight loss could not be differentiated. Overall health and socioeconomic status of the participants were not controlled for.
Obesity is increasing rapidly in the United States and it has been projected that by 2030 nearly 50% of American adults over the age of 18 will have obesity. 15,16 While weight gain during the pandemic may seem trivial, research has shown that small changes in weight on vacations or during the holidays can lead to substantial and permanent weight gain over time. 17,18 It is therefore likely that weight gain during the pandemic may be lasting and may accelerate the rise of obesity in America. COVID-19 has further highlighted the critical need to treat obesity as individuals with obesity are at higher risk for COVID-19-related morbidity and mortality. 19,20 Weight loss of 5%-10% among patients with obesity has been shown to be sufficient for clinically significant improvements in health. 21