The Obesity Epidemic: A Call for Change

More Than Just Weight: A Comprehensive Approach to Obesity Care

By Dr. Miriam Zylberglait

Obesity has long been treated as a lifestyle issue rather than a complex chronic disease. Despite its prevalence and serious health consequences, the medical community has historically fallen short in providing adequate care and support for those affected. While patients with obesity often present with multiple co-morbidities such as high blood pressure and diabetes, traditional treatment focuses on managing individual conditions rather than addressing the root cause. This fragmented approach has left millions struggling with weight management, facing stigma, and limited access to effective care.

Beyond the Basics: Treating the Root Cause

The idea of treating obesity first is a departure from customary medical practice. When patients visit their doctor and come in with obesity and other related chronic conditions like high blood pressure, elevated blood sugar levels, and sleep apnea, etc., most doctors tend to prescribe drugs for each condition. They also may advise exercise as well as changes to their diet without any clear guidance or support resources provided. This is typical and common – with the majority of the 42% of American adults with obesity not being treated. Although the American Medical Association recognized obesity as a complex chronic disease in 2013, only 7% of people with obesity are diagnosed and recommended for treatment.

Those suffering from obesity avoid healthcare settings because they’re tired or afraid of being told to just eat less and exercise more when that doesn’t work for them. The popular belief that weight gain is all about calories-in versus calories-out — and that people with obesity lack willpower — isn’t supported by science. While some people with obesity can lose weight with diet and exercise alone, more than two-thirds can’t. This is because of the physiological mechanisms the human body has evolved to fight weight loss.

Physicians often shy away from talking to their patients about obesity due to the presence of a stigma. Some people might not realize they have obesity, or the health risks associated with it. Others realize there is a social stigma making people reluctant to seek help.

A Systemic Issue: Addressing the Barriers to Obesity TreatmentThere is a shortage of providers to treat obesity and only the specialists, who treat the conditions caused or worsened by obesity — high blood pressure, type 2 diabetes, sleep apnea, etc. — are eligible to be reimbursed. This unfortunately causes limited access to care. Many medical schools do not offer comprehensive training in obesity medicine. Doctors are often trained in specialties that do not directly address obesity, such as internal medicine or endocrinology. In addition, there’s a lack of reimbursement that makes it financially challenging for healthcare providers to specialize in obesity medicine. The associated stigmatization around obesity can deter doctors from specializing in this area. Unfortunately, in the medical field, obesity is sometimes not treated with the same seriousness as other chronic diseases, leading to a devaluation of the field. It has become obvious that the rising rates of obesity have outpaced the available number of specialists.

Many insurance carriers do not reimburse for obesity medications, dismissing them as “vanity drugs.” Additionally, they fail to cover behavioral counseling or emotional support services other than a handful of sessions, not more. Healthcare providers often overlook recommending resources such as Overeaters Anonymous to their patients struggling with obesity. Even when counseling is mandated as a preventive service, access can be restricted to a small number of sessions per year.

Medications: The High Cost of Obesity Care

In general, there’s a growing acknowledgement regarding the need for insurance coverage in obesity treatment. However, significant improvements are necessary to make these treatments accessible to a wider population. Some insurers may consider obesity a pre-existing condition, excluding it from coverage. Surprisingly, despite the current era, there remains a lack of scientific evidence to convince insurers that certain obesity treatments are effective and cost-effective. Many insurers prioritize lifestyle changes like diet and exercise as the initial treatment for obesity, potentially delaying coverage for medication or surgery until those options have been exhausted. Obesity treatments can be expensive, and insurers may be hesitant to cover them due to the potential financial burden.

The new classes of obesity medications—GLP-1 and GIP/GLP-1 receptor agonists—have approved uses for diabetic patients. But they’re being prescribed for obesity both on- and off-label, depending on the drug in question. It seems by starting with one of the powerful new drugs for obesity, like Wegovy from Novo Nordisk or Zepbound from Eli Lilly – in addition to diet and exercise – doctors hope that while they treat obesity, using just one drug, the related conditions like high blood pressure, high cholesterol, sleep apnea for example, will improve. However it’s important to note that GLP-1s are designed for long-term use. While they can induce initial weight loss, stopping treatment often leads to weight regain. Therefore, viewing them as a quick fix might not be realistic.

Wegovy was approved by the FDA for weight loss in June 2021. While Ozempic itself is not FDA-approved for weight loss, its key ingredient, semaglutide, supports weight loss. Due to these weight loss benefits, many healthcare providers prescribe Ozempic off-label for this purpose. Rybelsus, another medication containing semaglutide, is also approved for type 2 diabetes and may be prescribed off-label for weight loss. Recently, companies have started reducing coverage for these medications. For example, the private healthcare system Ascension discontinued coverage on July 1, 2023, stating that weight loss and anti-obesity drugs would no longer be covered in its pharmacy benefit for its nearly 140,000 employees due to the high costs associated with these medications.

Beyond Medication: The Importance of Comprehensive Obesity Care

Doctors anticipate that prescribing obesity drugs could lead to patients taking a single medication instead of multiple medications for various health conditions. This approach suggests that in addition to weight loss, many of the other health issues could also start to improve. Another potential benefit is that patients often continue taking obesity drugs, while many who are taking drugs for individual health issues, like statins, may eventually discontinue them.

The recent pharmaceutical push for weight loss drugs like Saxenda (liraglutide), Ozempic and Wegovy (two semaglutide-based agents), Zepbound (tirzepatide), and others is changing attitudes towards obesity treatments. There is now one law that extends Medicare coverage for obesity treatment. However, despite some progress in insurance coverage for obesity treatment, significant gaps still exist, and the need for greater emotional support remains substantial.

The FDA’s approval of certain drugs for treating obesity highlights the need for behavioral support and emotional counseling. Medication can be a powerful tool to initiate weight loss, but behavior change is essential for maintaining long-term weight loss. Support groups offer a space to develop healthy habits, navigate challenges, and stay motivated. For example, Overeaters Anonymous, a community of people who support each other in recovering from compulsive eating and food behaviors, is free to attend and follows a twelve-step program. Its focus is on admitting powerlessness over food, seeking a higher power for guidance, conducting a moral inventory, making amends for past wrongs, practicing ongoing self-reflection, and sharing the message of recovery with others.

For sustainable weight loss, groups like Overeaters Anonymous can offer emotional support and provide a safe space to share anxieties, celebrate successes, and connect with others who understand the process. While therapists can help address underlying emotional issues that may contribute to weight struggles, peer empathy and solidarity remain important for providing a different level of support. Medication does not address unhealthy eating patterns or lack of exercise. Therapy can help identify and modify these behaviors, but peer support can be a powerful tool in achieving long-term success.

Beyond the Pill: A Holistic Approach to Weight Management

In conclusion, it has become evident to address obesity that it requires a comprehensive approach that goes beyond medication. While effective anti-obesity drugs offer hope, they are most powerful when combined with behavioral modification and emotional support. While insurance coverage remains a significant barrier today, increasing advocacy and research will be essential to expand access. For the long run, sustainable weight loss and improved overall health will depend on empowering individuals to make lasting lifestyle changes.