Breaking the obesity cycle: A call for comprehensive care

Obesity is a chronic condition: ©Nito - stock.adobe.com

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 comorbidities 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.

Consequently, patients with obesity are confronting negative outcomes that affect not only their physical and mental health but also their quality of life. In fact, the number one cause of mortality in the US is cardiovascular disease, which is strongly associated with an increased weight, and metabolic conditions such as diabetes and dyslipidemia, all of them preventable and manageable with the right comprehensive health care approach.

A new approach to an old problem: Treating obesity first

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, 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 appropriate treatment. Those suffering from obesity avoid health care 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.

Now that we understand better the mechanism of obesity and the complexity of the physiopathology involved in it, and we have better resources available for diagnosis, the simplistic idea that obesity is the result of eating too many calories and not doing exercise is not only outdated but also inaccurate. Ignoring genetic components that are related to this medical condition could be related to delays in management, more frustration, and more medical complications. Studies have estimated the heritability of obesity to be between 40% and 70%. In addition, about 5% of obesity cases are caused by mutations in specific genes, also known as monogenic obesity.

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.

But let's be fair, how is a physician expected to educate patients about healthy lifestyles, and at the same time manage all their medical concerns and conditions in just 15-minute appointments? How are physicians able to offer nutritional management when the visits to a nutritionist are not covered by insurances? How are physicians expected to treat a condition for which they didn’t receive appropriate training?

Barriers to obesity care: Limited access and inadequate coverage

There is a shortage of professional professionals 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 health care professional professionals to specialize in obesity medicine. The associated stigmatization around obesity can deter doctors from specializing in this area.

In fact, the ABOM reported that only 8,263 physicians were certified in obesity medicine in the United States and Canada in October 2023. This number accounts for just 1% of all physicians.

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.

Leading insurance carriers have not covered the treatment of obesity using medications, referring to them as 'vanity drugs'; nor do they cover behavior counseling or any emotional support protocols. Practitioners don’t offer resources to their obesity patients like Overeaters Anonymous, Celebrate Recovery, or TOPS (Taking Off Pounds Sensibly). Even when preventive services like counseling are mandated, access can be restricted – only allowing a couple of sessions in a year.

Medications: The high cost of obesity care

Overall, there's a growing recognition of the need for insurance coverage in obesity treatment, and significant improvements are needed to make these treatments accessible to a wider population. Some insurers may consider obesity a pre-existing condition, and therefore exclude it from coverage. Surprisingly today, there continues to be 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 first line of treatment for obesity and may not cover medication or surgery until those options have been exhausted. Obesity treatments can be expensive, and insurers may be reluctant 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.

Beyond medication: The importance of comprehensive obesity care

With the FDA approving some drugs for treating obesity comes the need for behavioral support and emotional counseling. Medication can be a powerful tool to jumpstart weight loss, but behavior change is key to keeping it off long-term. Support groups offer a space to develop healthy habits, navigate challenges, and stay motivated. For instance, Overeaters Anonymous, a community of people who support each other to recover from compulsive eating and food behaviors is free to attend and designed as 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 carrying the message of recovery to others.

For weight loss sustainability, groups like Overeaters Anonymous can deliver 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 to provide a different level of support. Medication doesn't address unhealthy eating patterns or lack of exercise. Therapy can help identify and modify these behaviors, but peer support can be powerful in achieving long-term success.

In conclusion, addressing obesity requires a multifaceted approach that encompasses medication, behavioral modification, and emotional support. While the emergence of effective anti-obesity drugs offers promising results, it's crucial to recognize that they are most effective when combined with comprehensive care. Insurance coverage remains a significant hurdle, but ongoing advocacy and research are essential to expand access. Ultimately, sustainable weight loss and improved overall health and wellbeing depend on a comprehensive and multidisciplinary approach that empowers individuals to make lasting lifestyle changes.

Dr. Miriam Zylberglait, MD, FACP, daBOM, is a triple Board-Certified Physician in Internal Medicine, Geriatrics, and Obesity Medicine with more than 20 years of clinical and academic experience. Dr. Z is interested in the areas of well-being, burnout, mental health, and leadership development. She practices in Florida and Texas for Aventura Primary Care.