Categories

Tag: Obesity

Is getting people off weight loss medications the right move?

By RICHARD FRANK

Demand for GLP-1 medications soared last year and shows no signs of stopping in 2024. Employers and health plans are understandably anxious about how long they should expect to pay for these pricey drugs. They’re itching for an easy off-ramp.

Some solutions are cropping up to pave the way. Many of them claim they can help patients reap the benefits of GLP-1s within a short time frame, and get them off the drugs within 12 months to save costs. But the data doesn’t support that promise. In fact, studies suggest some patients may need to stay on the drugs indefinitely to sustain outcomes while other patients may be able to discontinue the drugs and at least maintain their cardiometabolic risk reduction even if they cannot maintain all of their weight loss. 

A better strategy to control costs is to more accurately pinpoint those who really need the drugs—and keep those who don’t off of them from the start. Of course, there will be times when deprescribing is appropriate, and we need to clinically support patients through that process. But one-size-fits-all solutions centered on medication as a silver bullet to obesity are only setting up patients and payers for failure. Similarly, those whose sole promise is to deprescribe, don’t follow the evidence.

Prescribing GLP-1s with the goal to deprescribe is foolhardy

GLP-1s treat obesity, but they don’t cure it. GLP-1 agonists increase the body’s own insulin production and slow the movement of food from the stomach to the small intestine. The drugs help people eat less by curbing cravings and boosting satiety. Studies show that once people go off semaglutide, the cravings come back in full force—and so does much of the weight.

While GLP-1 medications produce nearly miraculous outcomes in some people, they’re no quick fix. Obesity is a complex chronic disease. Drugs alone can’t solve for genetic predisposition, behaviors, mental and emotional components, social determinants of health, and other compounding elements that contribute to obesity. In the right circumstances, drugs can give people a solid leg up in better managing those contributing factors—but they’re not for everyone.

Keto is not a sustainable replacement for GLP-1s

Highly restrictive diets like the keto diet aren’t for everyone either. Keto requires a drastic reduction in carbohydrate intake, which can be difficult to maintain long-term. Not to mention, the high-fat content of keto diets can also lead to other health issues and isn’t conducive to tapering off of GLP-1 medications. Side effects from the drugs can make a high-fat diet difficult to tolerate.

It’s good to be wary of solutions that promise an off-ramp by way of highly restrictive diets. While a keto diet may help people lose weight in the short term, studies show that weight loss is rarely sustained over the long run and may be detrimental to overhaul health. The diet is associated with many complications that often lead to hospital admissions for dehydration, electrolyte disturbances, and hypoglycemia.

Triage the right care to the right people at the right time

Obesity’s complex nature requires a personalized approach to treatment that delivers the right care to the right people at the right time. That takes a whole care team of specialized providers—like registered dietitians, health coaches, and prescribing physicians to help people at various stages of the disease. And since obesity often occurs alongside other cardiometabolic conditions like hypertension, diabetes, COPD, and more, patients need the help of specialists who understand how those different conditions interact.

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What could we do if GLP-1 weight loss drugs were free? Would our obesity epidemic be solved for good?

By CECI CONNOLY and SAMI INKINEN

Unless you have been living under a rock, you likely have heard the names Ozempic, Wegovy or Mounjaro. Or perhaps been humming the jingle. Rarely has a class of drugs (in this case, GLP-1s) achieved such widespread attention in popular culture and the media, which has people clamoring for them in every doctor’s office in the nation.

And for good reason. What we know is that the efficacy and safety profile of these medications is substantially better than any weight loss drug in the past, while our obesity epidemic has only ballooned. As organizations committed to sound science and holistic patient care, we are encouraged by the benefits of these new therapies for diabetes. The clinical evidence shows that GLP-1s are highly effective for controlling blood glucose levels among patients living with Type 2 diabetes and certain co-morbidities. GLP-1s may even improve heart health for high-risk patients.

To date, the biggest worry with these weight loss therapeutics has been the hefty price tag, ranging from $800 to $1700 per person, per month. Conservatively, these weekly injections could cost the nation more than $100 billion dollars annually. Already, state Medicaid budgets are sagging under the financial burden. In North Carolina, for example, officials dropped coverage of GLP-1s for obesity, noting that two drugs alone would cost about $1 billion over 6 years, and that’s with a nice discount.

As troubling as the cost is, what we don’t know is what should really worry us. Amidst the excitement over patients rapidly shedding up to 15% of their body mass, fundamental questions remain about who should be taking GLP-1s, at what dosages and what the long-term health and economic consequences will be for patients and society. Ultimately, the price paid to people’s long-term health may be more concerning than the price paid out-of-pocket.

With the recent release of the SELECT trial data highlighting limitations of existing published studies of GLP-1s, it is now even clearer that the public isn’t getting the full picture.

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Out of Control Health Costs or a Broken Society

Flawed Accounting for the US Health Spending Problem

By Jeff Goldsmith

Source: OECD, Our World in Data

Late last year, I saw this chart which made my heart sink. It compared US life expectancy to its health spending since 1970 vs. other countries. As you can see,  the US began peeling off from the rest of the civilized world in the mid-1980’s. Then US life expectancy began falling around 2015, even as health spending continued to rise. We lost two more full years of life expectancy to COVID. By  the end of 2022, the US had given up 26 years-worth of progress in life expectancy gains. Adding four more years to the chart below will make us look even worse.  

Of course, this chart had a political/policy agenda: look what a terrible social investment US health spending has been! Look how much more we are spending than other countries vs. how long we live and you can almost taste the ashes of diminishing returns. This chart posits a model where you input health spending into the large black box that is the US economy and you get health out the other side. 

The problem is that is not how things work. Consider another possible interpretation of this chart:  look how much it costs to clean up the wreckage from a society that is killing off its citizens earlier and more aggressively than any other developed society. It is true that we lead the world in health spending.  However, we also lead the world in a lot of other things health-related.

Exceptional Levels of Gun Violence

Americans are ten times more likely than citizens of most other comparable countries to die of gun violence. This is hardly surprising, since the US has the highest rate of gun ownership per capita in the world, far exceeding the ownership rates in failed states such as Yemen, Iraq and Afghanistan. The US has over 400 million guns in circulation, including 20 million military style semi-automatic weapons. Firearms are the leading cause of deaths of American young people under the age of 24. According to the Economist, in 2021, 38,307 Americans aged between 15 and 24 died vs. just 2185 in Britain and Wales. Of course, lots of young lives lost tilt societal life expectancies sharply downward.

A Worsening Mental Health Crisis

Of the 48 thousand deaths from firearms every year in the US, over 60% are suicides (overwhelmingly by handguns), a second area of dubious US leadership. The US has the highest suicide rate among major western nations. There is no question that the easy access to handguns has facilitated this high suicide rate.

About a quarter of US citizens self-report signs of mental distress, a rate second only to Sweden. We shut down most of our public mental hospitals a generation ago in a spasm of “de-institutionalization” driven by the arrival of new psychoactive drugs which have grossly disappointed patients and their families. As a result,  the US  has defaulted to its prison system and its acute care hospitals as “treatment sites”; costs to US society of managing mental health problems are, not surprisingly, much higher than other countries. Mental health status dramatically worsened during the COVID pandemic and has only partially recovered. 

Drug Overdoses: The Parallel Pandemic

On top of these problems, the US has also experienced an explosive increase in drug overdoses, 110 thousand dead in 2022, attributable to a flood of deadly synthetic opiates like fentanyl. This casualty count is double that of the next highest group of countries, the Nordic countries, and is again the highest among the wealthy nations. If you add the number of suicides, drug overdoses and homicides together, we lost 178 thousand fellow Americans in 2021, in addition to the 500 thousand person COVID death toll. The hospital emergency department is the departure portal for most of these deaths. 

Maternal Mortality Risks

The US also has the highest maternal mortality rate of any comparable nation, almost 33 maternal deaths per hundred thousand live births in 2021. This death rate is more than triple that of Britain, eight times that of Germany and almost ten times that of Japan. Black American women have a maternal mortality rate almost triple that of white American women, and 15X the rate of German women. Sketchy health insurance coverage certainly plays a role here, as does inconsistent prenatal care, systemic racial inequities, and a baseline level of poor health for many soon-to-be moms.     

Obesity Accelerates

Then you have the obesity epidemic. Obesity rates began rising in the US in the late 1980’s right around when the US peeled away from the rest of the countries on the chart above. Some 42% of US adults are obese, a number that seemed to be levelling off in the late 2010’s, but then took another upward lurch in the past couple of years. Only the Pacific Island nations have higher obesity rates than the US does. And with obesity, conditions like diabetes flourish. Nearly 11% of US citizens suffer from diabetes, a sizable fraction of whom are undiagnosed (and therefore untreated). US diabetes prevalence is nearly double that of France, with its famously rich diets. 

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Beyond the Scale: How organizations should evaluate the success of obesity management solutions

By CAITLYN EDWARDS

Obesity treatment is often framed as a race to the bottom — how much weight can someone lose? Five percent? Ten percent? And with recent scientific advancements in anti-obesity medications such as GLP-1s, what about even 15-20%?

Obesity treatment, though, isn’t just about the number on the scale. It’s about moving the needle on biomarkers that really matter to overall health. Seven out of the top ten leading causes of death and disability in the United States today are chronic diseases that have links to overweight and obesity. The metabolic benefits of just 5% weight loss can be life-changing for many people with obesity-related comorbidities. This means that for organizations looking to treat their chronic conditions, obesity care shouldn’t be all about striving for the lowest possible weight.

Indeed, consensus and practice statements from groups including the American Heart Association, the American College of Cardiology, the American Diabetes Association, and The Obesity Society, support weight loss programs that achieve clinically significant weight loss outcomes, defined as greater than or equal to 5% of an individual’s baseline body weight. This number is derived from decades of research demonstrating that even modest weight loss has impacts on physiological health including type 2 diabetes, dyslipidemia, hypertension, and many kinds of cancer.

People who attain just 5% weight loss see the following health improvements:

  • Reductions in systolic and diastolic blood pressure
  • Risk reductions of developing type 2 diabetes by almost 60%
  • Reductions in HbA1c and fasting blood glucose levels
  • Greater insulin sensitivity
  • Decreased need for newly prescribed diabetes, hypertension, and lipid-lowering medications

Understanding that obesity outcomes include more than just the number on the scale, how can benefit managers and health plan leaders measure success? Here are some things organizations should look for when evaluating an obesity management solution:

N-size of outcomes

While a high weight loss average may sound impressive, it doesn’t tell the whole story. A better measure might be the number of people in a program able to achieve greater than 5% weight loss. The fact is that weight loss averages are easily skewed by outliers.  An exceptionally high average may not be representative of what is actually taking place at the individual level. What matters is that a large percentage of people in the program are able to see clinically significant results.

Emphasis on behavior change

Another way to measure the success of an obesity management solution is by the sustainability of its outcomes — primarily through adopting healthier behaviors. Intensive behavioral therapy is crucial to obesity treatment and can reduce the risk of type 2 diabetes. Support from expert dietitians and coaches can help promote a healthy relationship with food for optimal weight loss.

Through medical nutrition therapy, dietitians create personalized calorie and macronutrient goals to foster weight loss in a healthy, sustainable way. Also, self-directed cognitive behavioral therapy can help people become more aware of underlying thoughts and behavior patterns around food.

Step therapy approach to treatment

Some obesity management solutions avoid medications entirely while others rely solely on expensive GLP-1s. But both of those methods fall short of providing the best care to the most people at the lowest cost possible.

The best obesity management solutions take a clinically rigorous step-therapy approach to treatment. This way, they carefully manage access to expensive anti-obesity medications while achieving meaningful outcomes. Many of their members will achieve clinically significant weight loss through behavior change alone. Some may need a boost from lower-intensity, lower-cost anti-obesity medications to reach their goals. Others, with severe obesity or multiple cardio-metabolic conditions, may require higher-intensity anti-obesity medications like GLP-1s. Treatment levels can be safely tried in succession with needs and costs in mind.

It’s likely only 5-10% of a given population would end up using GLP-1s with this step-therapy approach, while the majority of people would still get clinically meaningful results without such intensive treatment.

Address SDOH to personalize care

One-size-fits-all solutions — like those that insist on a highly restrictive diet — miss the mark on health equity. Not everyone can afford expensive meat-heavy diets and they don’t always line up with people’s cultural preferences. Similarly, a program that simply doles out GLP-1s without helping people manage side effects doesn’t work and will only drain budgets.

The key to unlock improved outcomes is by helping people address SDOH challenges like food insecurity, language barriers, cultural factors, physical environment, and more. A good obesity solution should expand access to bilingual registered dietitians who are trained in dietary considerations and eating patterns for many different cultures and ethnic groups. They can help folks plan meals around limited budgets and specific dietary needs.

Conclusion

Organizations have much to consider when evaluating obesity solutions for their population. It’s easy to be swayed by simple metrics that seem indisputable. But, in the end, outcomes like 5% weight loss and reductions in HbA1c for the majority of an eligible population are what counts. Sustainable outcomes rely on real behavior change, a careful step-therapy approach to medication, and personalized care when it comes to social determinants of health.

Caitlyn Edwards, PhD, RDN, is a Senior Clinical Research Specialist at Vida Health

Obesity is crippling the US, but there are solutions

By STEPHANIE TILENIUS

Well over a third of Americans are obese — and the percentage keeps growing at a staggering rate. Over the last twenty years, obesity prevalence grew from 30% to 42% of the US population and rates of severe obesity nearly doubled. If we don’t make serious changes to our healthcare system, it’s scary to think where we’re headed in a few short years.

The fact is, obesity is far from a cosmetic condition. It can be a devastating disease and was classified as such by the American Medical Association in 2013. Obesity is the leading risk factor for deadly diseases like type 2 diabetes, heart disease, stroke, and at least 13 types of cancer.

If we don’t stop the obesity epidemic in its tracks now, we’re in for a world of hurt. People’s lives, the healthcare system, and, by extension, the US economy could be headed for collapse if we continue to ignore it. Cardiometabolic conditions like obesity, heart disease, stroke, and diabetes cost the US healthcare system upwards of $500 billion a year in healthcare costs and another $147 billion in lost workforce productivity for heart disease and stroke alone.

And yet private and government-sponsored health plans are dragging their feet to address obesity head on. They know most people jump from health plan to health plan every few years, so they’re willing to take the chance that their members with obesity won’t develop high-cost complications soon enough to justify treatment now. And yet treatment could reverse the effects of obesity and downstream chronic disease, saving lives and billions of dollars in the long run.

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Young People Need To Turn Out For Their Health

By MERCEDES CARNETHON PhD

This month, we saw historic turnout at the polls for midterm elections with over 114 million ballots cast.  One noteworthy observation regarding voter turnout is record rates of participation by younger voters aged between 18 to 29 years old.  Around 31 percent of people aged 18 to 29 voted in the midterms this year, an increase from 21 percent in 2014, according to a day-after exit poll by Tufts University.

Surely their political engagement counters the criticism that millennials are disengaged and disconnected with society and demonstrates that millennials are fully engaged when issues are relevant to them, their friends, and their families. Why, then, do we not see the same level of passion, engagement and commitment when young adults are asked to consider their health and well-being?

I have had the privilege of being a member of the National Heart, Lung and Blood Institute-funded Coronary Artery Risk Development in Young Adults (CARDIA) study research team. In over 5,000 black and white adults who were initially enrolled when they were 18 to 30 years old and have now been followed for nearly 35 years, we have described the decades-long process by which heart disease develops. We were able to do this because, in the 1980s when these studies began, young adults could be reached at their home telephone numbers. When a university researcher called claiming to be funded by the government, there was a greater degree of trust.

Unfortunately, that openness and that trust has eroded, particularly in younger adults and those who may feel marginalized from our society for any number of valid reasons. However, the results—unanswered phone calls from researchers, no-shows at the research clinic and the absence of an entire group of adults today from research studies, looks like disengagement. Disengagement is a very real public health crisis with consequences that are as dire as any political crisis.
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Obesity Training and Reimbursement Should be a Higher Priority

Don Bradley MD, MHS-CL
Anand Parekh MD, MPH
Nichole Jannah
Hannah Martin
Anne Valik MPH
William Dietz MD, PhD
Jenny Bogard MPH
Christine Gallagher MPA

 

 

 

 

 

 

 

 

By HANNAH MARTIN MPH, RD; JENNY BOGARD; WILLIAM DIETZ, MD; ANNE VALIK; NICHOLE JANNAH; CHRISTINE GALLAGHER; ANAND PAREKH, MD, MPH; DON BRADLEY MD

The United States has been facing a mounting obesity epidemic for over a generation, but our health care system has struggled to keep up. Given the complexity of obesity and the pace of curricular change, obesity education for our health-provider workforce is still lacking. There are wide disparities in quantity and quality among programs and disciplines. Similarly, public and private payers have taken vastly different approaches towards coverage for obesity treatment and prevention, which even leaves the most educated providers unsure of what services each patient can access. Because coverage decisions are based partly on what providers are prepared to provide and curricula are based partly on what services are typically covered, these problems reinforce one another. Despite these challenges, several important steps have been taken recently to tackle both sides of the problem. The steps include the development of new Provider Competencies for the Prevention and Management of Obesity and the launch of the My Healthy Weight pledge to standardize coverage for obesity counseling services.

Why We Must Act

In the US, more than one-third of the adult population and nearly one-fifth of the children have obesity. Adult obesity prevalence is projected to reach nearly 50 percent by 2030. Adult diabetes prevalence currently hovers around ten percent and is further projected to affect one-third of the adult population by 2050. Estimates for the total annual medical cost of obesity in the U.S. range from $147 billion to $210 billion, with billions more lost in productivity due to absenteeism and presenteeism. Obesity is also a national security issue. As of 2010, 27 percent of young adults were disqualified for military service due to obesity.

Improving Obesity Education for Health Care Providers

Despite these shocking rates of obesity, fewer than one in four physicians feel that they received adequate training in counseling patients on diet or physical activity. Obesity concepts are underrepresented on medical licensing examinations and substantial gaps in provider knowledge related to obesity care have been recently documented. This is not surprising considering that less than 30 percent of medical schools meet the minimum recommended number of nutrition-related content hours.

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Starvation: The Cure For the Obesity Epidemic. Or Will Esther Dyson Be My Next Mother-In-Law?

Screen Shot 2014-12-12 at 2.27.00 PMI was enjoying drinks last week with Jody Holtzman (AARP)Terry Booker (IBC), and Doug Ghertner (change:healthcare) at a wonderful conference sponsored by Oliver Wyman. Jody was waxing eloquent about how every start-up needs a strategy for the senior population, when – after a few too many drinks – I emphatically told everyone at the table that I had the senior market cracked. I had experienced first hand the ills of the American health care system for seniors and had identified the perfect solutions.

My father-in-law grew up on a small, Kosher dairy farm outside of Pennsylvania (insert Jewish farmer joke here). He is 72 years old, he was about 40 pounds overweight, he has been widowed for about four years, and, about 30 minutes after my mother-in-law passed away, he started dating a woman that my wife never quite accepted, which is akin to saying that Russia is watching events unfold in the Ukraine from the sidelines (and to be clear, I don’t condone either position).

In January of this year, he was jumping from a backhoe onto a helicopter pad (don’t ask), fell 6 feet, and shattered his heel. The heel is a terrible bone to break in general (poor circulation) and, in particular, for someone who is older and a bit overweight (my goal is to not use the word “patient” once in this article because we aren’t patients, we’re people).Continue reading…

Eat Less. Eat Less Crap.

flying cadeuciiEating advice in the United States has taken leave of its senses. It is no wonder that Americans are perpetually on diets.

It is only in the last 20 years that eating, a task we do quite naturally, has become so complex that you apparently need professional spin from nutritionists and dietitians, or worse, from doctors, on how to do it.

Spend a little time on the web (and especially social media) and your head will spin from all the contradictory healthy eating advice: eat organic…no, wait, don’t waste your money; eat less salt…wait, too little salt might be worse for you than too much salt; don’t eat fat…oh, sorry, eating too little fat will actually make you fat because you’ll eat too many poor quality carbs; eat foods that have a low glycemic index…wait, we meant a low glycemic load, er, well maybe eat foods that are both; eat breakfast every day because it will help you control your body weight except when it doesn’t.

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International Classification of Diseases Hampers the Use of Analytics to Improve Health Care

By ANDY ORAM

andy oramThe health care field is in the grip of a standard that drains resources while infusing little back in return. Stuck in a paradigm that was defined in 1893 and never revised with regard for the promise offered by modern information processing, ICD symbolizes many of the fetters that keep the health industries from acting more intelligently and efficiently.

We are not going to escape the morass of ICD any time soon. As the “I” indicates in the title, the standard is an international one and the pace of change moves too slowly to be clocked.

In a period when hospitals are gasping to keep their heads above the surface of the water and need to invest in such improvements as analytics and standardized data exchange, the government has weighed them down with costs reaching hundreds of thousands of dollars, even millions just to upgrade from version 9 to 10 of ICD. An absurd appeal to Congress pushed the deadline back another year, penalizing the many institutions that had faithfully made the investment. But the problems of ICD will not be fixed by version 10, nor by version 11–they are fundamental to the committee’s disregard for the information needs of health institutions.

Disease is a multi-faceted and somewhat subjective topic. Among the aspects the health care providers must consider are these:

  • Disease may take years to pin down. At each visit, a person may be entering the doctor’s office with multiple competing diagnoses. Furthermore, each encounter may shift the balance of probability toward some diagnoses and away from others.
  • Disease evolves, sometimes in predictable ways. For instance, Parkinson’s and multiple sclerosis lead to various motor and speech problems that change over the decades.
  • Diseases are interrelated. For instance, obesity may be a factor in such different complaints as Type 2 diabetes and knee pain.

All these things have subtle impacts on treatment and–in the pay-for-value systems we are trying to institute in health care–should affect reimbursements. For instance, if we could run a program that tracked the shifting and coalescing interpretations that eventually lead to a patient’s definitive diagnosis, we might make the process take place much faster for future patients. But all a doctor can do currently is list conditions in a form such as:

E66.0 – Obesity due to excess calories

E11 – Type 2 diabetes mellitus

M25.562 – Pain in left knee

The tragedy is that today’s data analytics allow so much more sophistication in representing the ins and outs of disease.Take the issues of interrelations, for instance.

These are easy to visualize as graphs, a subject I covered recently.

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