Do popular weight-loss medicines cause vision problems?

Answering your questions about premenopausal osteoporosis, weighted vests, and vision changes tied to GLP-1 receptor agonists

Time for a Q&A to answer your questions about:

· How to navigate a diagnosis of premenopausal osteoporosis

· Whether you need to add a weighted vest to your workout routine

· Two new studies that link GLP-1 receptor agonists and vision problems

Enjoy! And remember to e-mail your questions to gillian@thesavvypatient.com or leave them in the chat

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Q: I did a commercial DEXA scan about a year ago to see my body composition and was shocked to see my bone mineral density score was in the lowest percentile for my age range. I am 45, still have regular menstruation, am generally healthy and active, and have no history of fractures. I have a family history as my mom broke her hip at 65 and has osteoporosis at 83. I just validated the results through a DEXA scan from my doctor, and he confirmed osteoporosis. Should we be looking for another cause of the osteoporosis or is family history enough? And is Fosamax recommended for my age group? —Anonymous

A: One of the biggest challenges with medical tests is what to do when you get an unexpected result. People are increasingly able to access dual-energy X-ray absorptiometry (DEXA) to measure body composition. How the body absorbs the X-rays gives us useful information about fat and muscle. But DEXA is also the main way we measure bone density. Most women don’t have a DEXA scan for bone density until they are in menopause, so managing premenopausal osteoporosis is a special case.

Before menopause, bone density should be stable. It is low energy levels in menopause that lead to bone loss. If you are having regular periods, you have adequate estrogen, so you should not be losing bone. As a result, premenopausal osteoporosis is more likely to be caused by something else. Many other metabolic problems can lead to bone loss including kidney disease, liver disease, an over-active thyroid, too much cortisol, or diseases that affect the gut’s ability to absorb nutrients—like celiac disease.

The first step should always be to rule out all of these. If one of those problems is present, the best treatment for the osteoporosis is often to treat those underlying problems. It is important to rule them out before starting any osteoporosis medications, because the medication can affect the results of the tests for those other diseases.

Once other causes of osteoporosis are ruled out, then medications that directly treat low bone density might be appropriate. Which medication to choose will depend on just how low the bone density is. If osteoporosis is severe, medications that can build new bone like Forteo or Evenity should be at the top of the list. If the osteoporosis is less severe then a medication like Fosamax, which just helps prevent further bone loss, might be appropriate.

The Savvy Short: Women diagnosed with premenopausal osteoporosis should always have an evaluation for underlying diseases that may be causing bone loss before starting medication.

Q: All my friends have started wearing weighted vests when they exercise. When I asked them why, they had some vague answers about muscle mass and bone density. It all left me wondering, should I be wearing one too? —Unweighted

A: All the women I see on my running path wear weighted vests, too. It feels like overnight they have become quite the trend. Always interested in the latest trends, I was curious if I had missed the publication of some amazing study. So, I did a little digging.

Weighted vests have been studied for three main things. First, do they improve training performance for sprinters? I don’t think most of the people I am seeing are trying to improve their sprinting times. The other thing weighted vests have been studied for is for improving bone density both in post-menopausal women and in people with obesity who have lost a significant amount of weight.

Let’s start with postmenopausal women. In general these studies were small, like this one that enrolled 18 women in their 60s. Half the women were instructed to do jumping exercise wearing a weighted vest three times per week, 32 weeks per year, for five years. The other half were just told to do regular weight-bearing exercise. After five years there was an increase in hip bone density among the women who did jumping exercise while wearing the vest compared to the control group. It is hard to know if the jumping exercise or the vest made the difference.

A more recent study enrolled 150 older adults, both men and women, with obesity who lost at least 10% of their body weight. The participants were randomized to wear a weighted vest for eight hours per day during their most active part of the day, or to not wear a vest. The authors found no difference in hip bone density after 12 months.

The Savvy Short: The trials of using weighted vests to improve bone density are small and the results are mixed. There is no evidence regarding improved muscle mass with weighted vests. For now, I will be opting out of this trend.

Q: I have PCOS [polycystic ovary syndrome] and I have always struggled with my weight. For the last 9 months I have been taking Wegovy and it has really helped me with food noise and my periods are even more regular. But recently I started seeing reports of vision problems with GLP-1s. Do I need to worry? —Anonymous

A: The reason you a hearing a lot about this now is because of two recent studies that looked at different eye problems and associations with GLP-1 receptor agonists. The first reports about vision problems and GLP-1s surfaced about a year ago with a report that noted an uptick in a rare but scary sounding problem called nonarteritic anterior ischemic optic neuropathy (NAION) among people who took GLP-1s.

One of the recent articles that has people buzzing about GLP-1s and vision problems is a follow-up study to that report. The new study was huge; it comprised data from 14 different databases that included more than 37 million adults with Type 2 diabetes. While the study did find an increased rate of NAION among diabetic patients who took semaglutide (Ozempic/Wegovy). The effect was smaller than the previous smaller study reported. I have never seen a case of NAION, and I have written thousands of prescriptions for semaglutide. This is exceedingly rare.

A second study found an association between a specific type of macular degeneration and taking GLP-1s. There are a few notable details about this study. First, the study population was older with the average age of participants at 66 years old. The risk of macular degeneration in both groups was quite small; just one in 1,000 in the group that didn’t take GLP-1s and two in 1,000 of the people who did take GLP-1s. The study didn’t look at specific GLP-1s but at the entire class. But most importantly, this is not a randomized controlled trial, so important differences between the two groups may exist. And those differences may explain the increase in macular degeneration seen in the group that took GLP-1s.

But perhaps the most important detail to observe in both trials is that the study subjects were taking GLP-1s to treat Type 2 diabetes, not for weight loss. Type 2 diabetes itself can put people at increased risk for a few different vision problems. We cannot assume that there are similar associations between GLP-1s and vision changes among people who take GLP-1s to treat excess weight.

The Savvy Short: There is an association between taking GLP-1 receptor agonists and two specific eye problems among people with diabetes. But it is not clear the GLP-1s are causing these vision changes and both types of problems are very rare. It is also not clear that this association exists in patients taking GLP-1s who do not have Type 2 diabetes.

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