As part of our ongoing commitment to help our patients live their best life we are sharing the full USA Today series on “Rethinking Obesity”. The following is #5 in the series.
ILLUSTRATION BY TRACIE KEETON/USA TODAY; AND GETTY IMAGES
Karen Weintraub USA TODAY
Published 5:01 AM EDT Jul. 26, 2022 Updated
Editor’s note: Part 5 of a six-part USA TODAY series examining America’s obesity epidemic.
For two decades, Charleah Torres-Vega, 43, refused to donate her favorite dress – a blue strapless number – hoping it would someday fit again.
After giving birth to her fourth child, the 5-foot-4 Boston resident weighed 236 pounds, or 62 pounds above the cutoff for clinical obesity.
“It was a shocking number and also very frustrating,” she said.
For decades, medicine has had little to offer people such as Torres-Vega, even as the majority of Americans added extra pounds.
There’s no other common disease for which only 3% to 4% of patients can get evidence-based treatments that are actually helpful, said Torres-Vega’s doctor, Fatima Cody Stanford, an obesity medicine specialist at Massachusetts General Hospital and Harvard Medical School.
“It’s hurtful to me to see that this is how we treat patients with obesity,” she said.
Finally, that’s starting to change.
Despite decades fighting America’s obesity epidemic, it’s only gotten worse. To try to understand why, USA TODAY spoke with more than 50 experts for this six-part series, which explores emerging science and evolving attitudes toward excess weight.
As the scientific understanding of weight loss deepens, the tools for addressing it are improving.
A year ago, an injectable diabetes drug called semaglutide, from Novo Nordisk, won approval from the Food and Drug Administration. It offered three times the weight loss potential of existing drugs: 15% of a person’s body weight.
Another drug, tirzepatide, was approved in mid-May for the treatment of diabetes. A study released in June showed it’s also effective at helping people lose weight. Virtually all 2,500 trial participants lost at least 5% of their body weight over a year and a half. More than half lost 20%.
With mostly manageable side effects, these medications and more in the pipeline have the potential to transform the nation’s obesity epidemic, said Dr. Katherine Saunders, a weight loss specialist at the Comprehensive Weight Control Center at Weill Cornell Medicine in New York.
Dr. Katherine Saunders, a weight loss specialist at the Comprehensive Weight Control Center at Weill Cornell Medicine
It does feel like we’re at an incredibly exciting time where the medications we have available are helping so many people to lose very clinically significant weight.
“It does feel like we’re at an incredibly exciting time where the medications we have available are helping so many people to lose very clinically significant weight,” Saunders said.
The big question is whether people will be able to access them – or want to. The new medications are expensive and often not covered by insurance. Staying healthy also requires regular exercise and maintaining a balanced diet, Stanford and others said, so the shots aren’t a simple solution.
As with drugs to treat other chronic illnesses, anti-obesity medications are intended to be taken for a lifetime. Stop taking the weekly injections, doctors say, and biology will ensure the pounds return.
As a medical student, Stanford was taught all about rare diseases she has never seen in decades of practice. But her professors spent almost no time talking about a condition that now affects at least 40% of Americans.
She was drawn to the medical treatment of obesity in part because she can make a profound difference in her patients’ lives and in part because she’s Black.
“I could see the disproportionate impact,” Stanford said. Black women have the highest rates of excess weight in the United States: More than half are considered to have obesity, and 30% more meet the definition of overweight.
“I felt like I needed to be at the front lines of being able to address this,” she said.
Taking on the challenge
Torres-Vega is a rare exception. She was able to lose weight through force of will.
In 2019, her primary care doctor said her blood pressure was on the rise, so she went back on the Beachbody diet and exercise plan. She committed to make more time for herself and stay disciplined.
She fed her family chickpea protein pasta and cauliflower rice and switched to 99% fat-free ground turkey instead of ground beef for her spaghetti sauce.
“I still eat everything I love,” she said, even if it’s in a slightly different form. “I don’t believe in deprivation.”
She ate more fresh, organic vegetables and fruit, made sure she had lean protein, controlled her portions and started accounting for the bites she took as she cooked nightly meals for her family.
Her husband also has lost weight, and she’s teaching her children good food habits.
“Improving our healthy relationship with food has been a journey,” she said.
By late last year, the paralegal and Beachbody coach managed to reach her longtime goal of 160 pounds, her high school weight. The skinny jeans she had bought for her 30th birthday were so baggy she could fit her whole body in one leg.
But she was terrified it would all come back. Again.
Rebound is a concern after all forms of weight loss. Sometimes people bounce back and end up even heavier than when they started, said Dr. William Dietz, director of the Sumner M. Redstone Global Center for Prevention and Wellness at The George Washington University.
Someday, researchers may find a “switch” in the brain or the gut that can be reset so formerly heavy people won’t have to keep fighting those extra pounds forever. Until then, Dietz said, medications are probably a lifetime commitment.
The price of significant weight loss
Even at that price, Novo Nordisk hasn’t been able to keep up with demand.
The company put advertising and new prescriptions for weight loss on hold late last year. In a memo posted to its website, Novo Nordisk said it can supply maintenance doses for those already on the drug but has stopped providing low-dose ramp-up prescriptions. Shortages, it said, will “continue into the second half of 2022 when we expect to stabilize supply.”
Eli Lilly, which makes tirzepatide, hasn’t yet set a price for weight loss, though it costs about $1,000 a month for the same dose that treats diabetes. The company has pledged to make it accessible to treat obesity.
At the moment, most insurance companies and Medicare don’t offer coverage for obesity other than some nutritional counseling.
Stanford said she is battle-hardened after years of fighting insurance companies. Massachusetts now has some of the best weight loss coverage in the country, she said.
Thanks in part to her efforts, Blue Cross Blue Shield of Massachusetts offers visits with staff nutritionists for obesity without the need for prior authorization. Many of its plans provide reimbursement up to an annual cap for weight loss programs, according to spokesperson Amy McHugh.
But still, many Americans can’t get routine coverage even to see a nutritionist unless they’ve been diagnosed with diabetes or another serious weight-related problem.
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Medications are covered only for people with high BMIs or related health problems “consistent with evidence-based best practices,” said David Allen, a spokesperson for America’s Health Insurance Plans, an industry group. “In some cases, plans may require individuals to partake in a period of behavioral modifications, increased physical activity and dietary changes.”
Obesity costs the U.S. medical system about $173 billion a year, roughly four times the amount spent annually to fund the National Institutes of Health. Medical bills for someone with obesity run $1,861 more than for a person weighing in the “normal” range.
Fundamentally, there’s not much incentive for insurers to cover weight loss treatments, said Dr. David Rind, chief medical officer for the Institute for Clinical and Economic Review, a Boston-based nonprofit that evaluates medical procedures.
Most treatments for diabetes, high blood pressure and high cholesterol are inexpensive generics, so insurance companies would end up paying more if they replaced these with a costly weight loss drug, Rind said. He noted insurers are supposed to cover treatments that improve health, and “weight loss treatments can result in important health gains.”
Coverage isn’t needed for people with just 10 pounds to lose, said Dr. Louis Aronne, an obesity medicine specialist at Weill Cornell Medical Center in Manhattan, who helped lead the tirzepatide trials. But in less than 10 years, a quarter of Americans are projected to have a BMI of 35, well above the benchmark for obesity, and related diabetes rates will continue to rise, he said.
Those people deserve to have their medication covered by insurance now rather than having to wait to get sick, he said.
Older, inexpensive anti-obesity medications still have a role to play, too, Saunders said.
They don’t trigger anywhere near the kind of weight loss as the newer generation of drugs. Most can help people lose about 5% of body weight. But they can be useful for modest weight loss and in combination, as part of a comprehensive treatment plan.
Saunders provides the kind of intensive, personalized counseling that most Americans can’t access, but her company, Intellihealth, has launched a digital program called Evolve and a telehealth practice called Flyte that she hopes will spread her approach.
In her own practice, she starts with each new patient taking a detailed history of their weight gain and barriers to weight loss. She also runs a panel of labs to identify contributors to weight gain and ensure their kidney and liver functions are OK. Then she gives them feedback on lifestyle approaches they can try.
If they’ve already tried them all, she said, “then I’ll say ‘OK, you’re a good candidate for anti-obesity medication.'”
Why weight loss matters
Modest weight loss of 5% can improve some health metrics, like blood pressure and markers of diabetes, research shows. But even that amount of weight loss is difficult for most people to achieve through diet and exercise.
And it doesn’t always help. Famously, a trial of more than 5,000 participants with diabetes and either obesity or overweight was stopped after nearly a decade when weight loss of more than 6% failed to improve heart health.
Generally, though, more weight loss has been shown to lead to more improvements.
In a study of people with a BMI of 40, a 13% median weight loss led to a 40% drop in Type 2 diabetes and sleep apnea and a roughly 20% decline in rates of hypertension, high cholesterol and asthma.
Healthy weight tips
• Know that it’s not your fault if you’re carrying extra weight. The way the human body evolved, combined with easily available and low-cost processed food make weight gain likely and weight loss challenging.
• Fitness matters more for health than a number on a scale. Find physical activities you enjoy and commit to move a total of least 30 minutes a day, five days a week.
• Make sure to average at least 7 hours of sleep a night. Disconnecting from electronics for 90 minutes before bedtime can help.
• If you’re concerned about weight, prioritize not gaining more and the quality of foods you eat.
• Chose whole foods, like fruits, vegetables, nuts, healthy oils, fermented dairy products and fatty fish, which have a healthier mix of nutrients and make you feel fuller.
Reducing cancer risk requires people with obesity to lose about 20% to 25% of their body weight, according to a study in June. Until now, that kind of weight loss has been achievable only through surgery, though the new medications might get some people there.
(Studies of tirzepatide haven’t yet confirmed that weight lost with the drug leads to substantial health benefits, though “all of the metabolic parameters measured were improved,” Aronne said. Some research has found health benefits with semaglutide. About 75% of weight lost with both medications comes from fat and 25% from muscle, he said.)
Dr. Ali Aminian, who led the recent cancer study, was surprised to see that so much weight loss was needed to improve cancer risk.
This means it’s increasingly important for people to have a way to dramatically reduce their weight, said Aminian, a surgeon who directs the Bariatric and Metabolic Institute at the Cleveland Clinic. Until now, that has been possible only with surgery.
Just 1% to 2% of people who qualify for weight loss surgery actually go under the knife.
Surgery remains an option
“Why are we not using the thing that solves many of the disease processes that are affecting our country?” Stanford asked.
Some of that lack of use is because of fear. In the earliest days of bariatric surgery, death was a very real risk.
Though death remains a slim possibility, safety has improved substantially, Aminian said. Almost all surgeries are now done through “keyhole” openings rather than large incisions in the abdomen.
The lack of insurance coverage also keeps weight loss surgery from many who would benefit. It typically runs $15,000 to $20,000, Aminian said.
To qualify for coverage, someone must have a BMI over 40 or a BMI over 35 with a serious weight-related health problem, such as Type 2 diabetes, high blood pressure or severe sleep apnea. Someone 5-foot-5 would have to weigh more than 240 pounds and someone 5-9 more than 270 to reach a BMI of 40.
Although new medications are getting close, no other weight loss approach has proved as effective as surgically shrinking someone’s stomach and rerouting the small intestine. With surgery, people can quickly lose dozens of pounds and 30% to 40% of body weight, Aminian said.
They may regain some of that lost weight in the years after surgery, but unlike with dieting, the rebound is rarely complete, and fewer than 5% of patients end up heavier five to 10 years after surgery, Aminian said.
For most people, surgery improves obesity-related conditions such as asthma, hypertension, fatty liver disease, metabolic syndrome, diabetes, heart failure, polycystic ovary syndrome, menstrual dysfunction, excess hair, arthritis and sleep apnea, Aminian said. Often, these vanish within a few months.
Weight loss surgery improves quality of life, and the 10-year death rate after surgery drops by nearly 40%.
Aminian would like to see insurance cover surgery sooner, before patients reach extreme levels of obesity and suffer severe health problems. Just as it’s easier to treat cancer caught at an early stage, so the health consequences of obesity are more treatable or preventable if weight gain can be stopped.
“If a patient is 500 pounds, 600 pounds with all those complications, sometimes you feel like it’s already too late to intervene,” Aminian said.
How the drugs work
Once people gain weight, something changes about the way their body self-regulates that makes it nearly impossible to go back, Aronne said.
Consuming too many calories too quickly overloads the nerves in the brain that receive signals from hormones, he said.
“As you get more damage there, fewer hormonal signals are able to get through and tell your brain how much you’ve eaten and how much fat is stored,” Aronne said. “As a result, your body keeps expanding your fat mass.”
After decades of struggling to understand this process, researchers have finally figured out how to manipulate two of those naturally occurring hormones, called GLP-1 (short for glucagon-like peptide-1) and GIP (for glucose-dependent insulinotropic polypeptide).
GLP-1 is a fullness signal and GIP seems to amplify GLP-1’s effect, Aronne said.
Still, one medication alone is never going to be the solution to obesity, Saunders said.
Obesity is a complex problem with many factors contributing to weight gain and multiple barriers that prevent weight loss, she said. “It’s all about optimizing diet and physical activity, and then we need as big of an armamentarium of medications as we can get.”
As with any medication, they’re not for everyone. Some people suffer severe stomach problems, though doctors who use them routinely say they can help patients work through most of them.
Dr. Zhaoping Li, chief of the Division of Clinical Nutrition at the University of California, Los Angeles, said stomach discomfort is part of how the drugs work. “That’s how it makes you not want to eat,” she said.
Saunders said she had one patient who was vomiting every five hours after taking the drug. Clearly, it wasn’t a good fit.
But for most people, symptoms can be controlled by fine-tuning the dosage of the anti-obesity medication and adding or eating smaller meals. “Treatment needs to be personalized and complemented by close monitoring,” she said.
The coronavirus pandemic helped Torres-Vega lose weight. Instead of spending time commuting, she was able to work out at home early in the morning. She had more time to cook. And with that extra time and growing kids, she was finally able to prioritize her own needs.
“Being able to shut out most of the world,” she said, “helped me have much success.”
But she wanted something in addition to her new attitude to help her stay in control of her weight.
In January, under the direction of Stanford, Torres-Vega began taking semaglutide. She has been thrilled with the results. She no longer eats mindlessly and has been able to disconnect food from emotions such as happiness, sorrow and boredom.
Unlike many patients, Torres-Vega said she has no side effects from the medication. She doesn’t mind that she’ll probably have to take the medications forever to keep her weight where she wants it.
She just wishes she had learned sooner to think about obesity as a chronic disease to be managed rather than as a moral failing. “That would have helped me not be so hard on myself.”
Torres-Vega’s medication sits at the head of a long line of potential new approaches to weight loss.
“There are other advances to come that are going to continue to improve outcomes,” Aronne said.
Semaglutide acts on one biological pathway. Tirzepatide acts on two. The next-generation drug, now in animal studies, acts on three and could offer even more weight loss potential, he said.
Aronne said he went into weight loss research decades ago to address suffering. He didn’t think it would take this long to help people. But now that he has effective medications to offer, he finds it incredibly gratifying.
“It’s fantastic when you can help people who want to be helped,” he said.
As for Torres-Vega, the blue strapless is now a regular part of her wardrobe. “I’m having fun dressing the body I’ve always wanted and worked hard to achieve.”
Contact Karen Weintraub at firstname.lastname@example.org.
Health and patient safety coverage at USA TODAY is made possible in part by a grant from the Masimo Foundation for Ethics, Innovation and Competition in Healthcare. The Masimo Foundation does not provide editorial input.