Obesity: How do we treat America’s silent killer without breaking the economy?

Joe Murad Courtesy of Vida Health

There's a healthcare crisis raging in America that results in nearly 500,000 excess deaths per year. It disproportionately impacts poor communities and communities of color and its downstream effects cost the US economy over a trillion dollars annually. The killer is obesity — and it's set to afflict a staggering 50% of the US population in the next eight years.

Given the prevalence and danger of obesity, it would be easy to assume the US healthcare system is pouring time and attention into helping those with the disease. Instead, massive amounts of money are spent on its downstream effects — and not enough money is spent on addressing the cause. For example, Medicare covers few obesity treatments. And only 22 percent of commercial insurers are willing to cover game-changing weight loss medications like Wegovy that lead to 15% weight loss and 20% reduction in cardiovascular risk.

Soaring demand for GLP-1s like Wegovy, Ozempic, Mounjaro, and now Zepbound highlight thorny problems of unequal healthcare access across the US, particularly for chronic diseases like obesity. A recent report showed that in New York City, residents of wealthier neighborhoods are almost twice as likely to take GLP-1s as those in poorer neighborhoods, even though more people struggle with obesity and diabetes in those low-income areas.

At the same, handing out GLP-1s (at their current price) to everyone who wants or needs them is a quick way to bankrupt the entire healthcare system. Health plans are cracking down on prescriptions to hedge that risk. And even drug companies are limiting supplies, yielding fewer drugs for fewer people.

The result? A major new health inequity issue has arisen in our time — one that pits low-income communities in need of meaningful obesity treatment against higher-income communities with varying interests in the drugs, and health plans against patients deemed too expensive to treat.

We can do better to thread the needle between opening access to clinically appropriate obesity treatment and keeping run-away costs in check. After all, obesity already costs $250 billion in US healthcare expenses and is linked to over one trillion dollars spent on chronic diseases every year. Investing in obesity treatment makes more than enough sense for the health of our country. But that doesn’t mean we should hand out GLP-1s to anyone needing treatment for obesity — especially at a list price of $16,000 a year per person. We can take a much smarter approach to prescribing GLP-1s by first embracing proven alternative treatments for obesity in a medically appropriate manner.

The clinical approach to the treatment of obesity should be holistic. That is, it should include both behavior change and, as appropriate, the full suite of medications that have been medically proven to treat obesity.Here’s what this approach could look like in practice:

Registered Dietitians administer Medical Nutrition Therapy

The American diet — high in sodium, saturated fat, and added sugars — greatly contributes to the obesity epidemic. While we desperately need a major overhaul of our food system to provide more access to healthy food in low-income and rural areas, there are some stopgap measures we can take in the meantime. For one, we should provide equitable access to registered dietitians who can develop nutritious eating plans that work for people’s lifestyles and budgets. Studies show that dietary modification is central to obesity treatment.

In our current food environment, medical nutrition therapy is as essential as vaccines and other preventive care strategies to help people manage chronic conditions like diabetes and obesity. Medical nutrition therapy can bring a host of additional advantages, with research showing that some mental disorders are actually metabolic disorders — promising relief for diabetes patients who suffer from related depression, among other benefits like weight loss, reduced cholesterol, better bone health, and more.

The first step in obesity step therapy is helping people shift their relationship with food, offering supportive, evidence-based interventions that help them lose weight safely and sustainably.

Self-directed cognitive behavioral therapy for behavior change

While a healthy diet is integral to weight loss, it’s not the only thing that matters. Reducing stress, improving sleep, reducing food noise, and exercise all contribute to better outcomes. Self-directed cognitive behavioral therapy can work to shift thinking patterns and solidify healthy behavior changes to help people lose weight and keep it off.

For many people, however, dietary and behavioral interventions won’t go far enough. These people have often tried various new lifestyle changes for years but keep coming back to a frustrating set weight point. Just like any other disease, obesity sometimes requires pharmacotherapy to treat.

Less intensive anti-obesity medications (AOMs)

With all the fanfare around the arrival of GLP-1s, it's easy to forget that there are other effective anti-obesity medications that are more affordable, and better tolerated.

Drugs like Contrave (bupropion/naltrexone) and Topiramate, when prescribed alongside moderate behavioral change and nutrition regimens, can lead to 5-10% weight loss. Zonisamide, originally designed as an antiepileptic drug, is now commonly prescribed for weight loss. Metformin can help with insulin insensitivity and promote weight loss in some people.

These medications cost a fraction of the price of GLP-1s and can be very effective for most people. When combined with behavior change support like self-directed cognitive behavioral therapy and access to registered dietitians, they can be game-changers for millions of Americans who might otherwise jump straight to expensive medications like Wegovy and Ozempic.

GLP-1s like Wegovy, Mounjaro, or Ozempic for a smaller number of people

If nutritional support, behavioral interventions, and less potent medications either alone or in combination don't help with obesity, it makes sense to use more potent medications like GLP-1s to see success. In particular, people with comorbidities like diabetes, chronic kidney disease, or heart disease may need quicker, more intensive support. Others who have not succeeded with behavior change and are eager for more assistance shouldn’t be denied on so-called moral grounds that behavior change is "better" or more "virtuous." Just like any other disease brought on by a combination of genetics, environmental factors, and lifestyle, obesity should be treated with the best medications if that’s what it takes to see success.

But we should also be careful to define what success looks like and acknowledge that it doesn't always mean getting to the lowest number on the scale. In fact, just 5% weight loss can reduce cardiovascular risk and improve biomarkers like A1C for diabetes and blood pressure for hypertension. Given the costs of this new generation of medications — not to mention the side effects, which range from nausea and diarrhea to rare but serious complications like pancreatitis or kidney failure — it's best to use them cautiously.

When it comes to managing obesity, a step therapy approach gives people access to what can be life-saving care without unnecessary costs or risks. It guides people through a supportive process that provides the best, most effective, and least costly interventions for each individual person while still giving the people who need it access to GLP-1s. With step therapy, only about 10-20% of the population would likely end up on GLP-1s — not the nearly half of the American population currently clamoring for them now. When it comes to cost, efficacy, and sustainability, obesity step therapy is the best thing for patients — and the economy.

Joe Murad is President and CEO of Vida Health. He is a seasoned digital health executive and entrepreneur. Previously, he led WithMe Health, pioneering personalized medication guidance. As CEO of PokitDok, Joe played a pivotal role in healthcare interoperability before its acquisition by Change Healthcare. His impact extends to Willis Towers Watson, Extend Health, and eHealth, where he reshaped the health benefits landscape. Joe holds a BA from the University of Southern California and resides in the San Francisco Bay Area.