GPBCH Speakers Support Potential Benefit Design for Obesity

Data presented at the Greater Philadelphia Business Coalition on Health (GPBCH) outlined obesity epidemiologic and economic trends, treatment and lifestyle options, and how benefit design can help providers manage obesity as a chronic disease.

Niki Patel, PharmD, MBA, a medical accounts associate director at Novo Nordisk, started off by discussing factors of obesity and the effects weight loss can have on health outcomes.

Approximately 42% of US adults have obesity, and that percentage is expected to reach 50% within the next decade. According to Patel, the primary issue with obesity is that it is not managed as the chronic disease that it is. Also, social determinants of health are affecting prevalence of obesity, which is increasing along with the cost of the disease.

“Currently, 2 in 5 White adults have obesity versus 1 in 2 Black adults, and yet Black patients are less likely to receive a diagnosis or treatment of obesity compared to White patients, and even less people actually get treatment,” Patel said.

Patel further explained that dietary changes are a major reason why obesity rates are high in the United States, especially the increase in portion sizes over time and the accessibility of less healthy food. Between the 1950s and the 2010s, the average restaurant meal has quadrupled in size, and the average US adult is 26 pounds heavier.

Stress, sleep deprivation, and inactivity are also major lifestyle factors contributing to the obesity epidemic in America, as well as genetic factors such as epigenetic modifications. Neil Goldfarb, president and CEO of GPBCH, presented data from a study on weight changes during the COVID-19 pandemic, noting how the pandemic affected these lifestyle factors that, in turn, triggered undesired weight changes.

According to data from the American Psychological Association that stratified people by sex, race, and age, the percentage of people who reported undesired weight gain during the pandemic was higher across the board compared with people who reported undesired weight loss. In general, 61% of US adults in the study reported an undesired weight change during the pandemic.

“The impact of the pandemic on obesity—which was already an epidemic—is really pronounced and why we think this is such an important topic more than ever,” Goldfarb said.

Going more in depth on strategies and clinical outcomes, the speakers noted that people with obesity can experience substantial benefits even when they lose small percentages of body weight. Data showed improved outcomes in the following comorbidities by percentage of body weight reduction:

• 0%-5%; hypertension, hyperglycemia
• 5%-10%; polycystic ovary syndrome, dyslipidemia, type 2 diabetes (T2D) prevention, asthma, atopic dermatitis, nonalcoholic fatty liver disease
• 10%-15%; urinary stress incontinence, obstructive sleep apnea, gastroesophageal reflux disease, knee osteoarthritis, cardiovascular disease, nonalcoholic steatohepatitis
• 15% or more; T2D remission, cardiovascular mortality, heart failure with preserved ejection fraction

Anastassia Amaro, MD, medical director at Penn Metabolic Medicine and associate professor of medicine at University of Pennsylvania, explained ways to help people with obesity lose weight. One strategy is the stepwise approach, which starts with lifestyle changes and moves onto pharmacotherapy and bariatric endoscopy. She discussed at length the challenges of getting patients started on medication to treat obesity.

Obesity drugs are a tough sell with some doctors, she said. They may have “therapeutic pessimism” because they’ve tried therapies in the past that have later been pulled from the market. And just getting drugs approved by an insurance plan is a process.

“I have an assistant who calls the insurance company and finds out what's covered,” Amaro said. “What are the conditions on the prior authorizations to get that medication covered? So that work is done before we even start discussing the medications….So, these are hours of work for just one patient-physician intervention to occur.”

The patients at her center have access to clinical trials, some were able to take part in the trials for semaglutide 2.4 mg (Ozempic), the glucagon-like peptide-1 receptor agonist from Novo Nordisk that has since received FDA approval to treat obesity; she noted the average weight loss among her patients was on par or better than the overall weight loss in the trial, which was 12.4%.

“I am pretty sure that we can replicate that in real life if we have access to this medication,” she said.

If pharmacotherapy is ineffective for any reason, the patients then become candidates for weight loss surgery. However, weight loss surgery is not a permanent solution for everyone.

“At this point, we already know that about 30% of people who had a history of weight loss surgery will regain either a portion or the entire weight they had lost through the bariatric surgery treatment,” Amaro explained. “So then, a new type of patient that we are seeing in our clinic is post-surgical weight regain patients, and we have to prescribe medications and implement self-directed and professionally directed lifestyle changes and dietary and exercise counseling.”

Amaro also suggested a more cyclical approach, saying that a person with obesity could receive treatment at any stage and “enter” or “exit” the circle at any time. General phases within the circle include obesity assessment, intense weight loss intervention, weight loss maintenance intervention, and weight gain or regain prevention.

Goldfarb concluded the seminar by describing what a comprehensive benefit design for people with obesity should include:

• Prevention and healthy lifestyle promotion
• Case identification and data management
• Provider network support and referral
• Mental health service support
• Pharmacologic benefit, including coverage of anti-obesity medications
• Surgical benefit
• Recognition of social determinants of health and health equity
• Follow-up support

“We don't want physicians just prescribing and thinking they've cured obesity or they've done their part,” Goldfarb said. “We want to make sure physicians are actively monitoring the patients.”