Obesity Care: Past, Present, and Future
How history can inform a more equitable future.
The Obesity Epidemic
It is no secret that the United States has a weight problem. Data from the National Health and Nutrition Examination Survey (NHANES) reveals that the prevalence of obesity (BMI ≥ 30 kg/m2) among adults increased from 30.4% in 1999–2000 to 42.4% in 2017–2018. For those with Class III or “severe” obesity (BMI ≥ 40), prevalence increased at an even faster rate, from 4.7% to 9.2% over this same period. It is estimated that by 2030, 80% of U.S. adults will be living with overweight (BMI ≥ 25–29.9 kg/m2) or obesity, while 50% of adults will have obesity.
Obesity appears to spare no one. Recent reports from the CDC indicate that obesity rates are increasing among children and adolescents, with the overall prevalence rising to approximately 20%. The rise in obesity rates is alarming and disproportionately impacts some groups. People in lower-income groups are more likely to live with obesity than those in higher-income groups and generally experience severe disease at higher rates. Even after controlling for income and other measures of socioeconomic status, the prevalence of obesity is higher among Black and Hispanic adults compared to their White counterparts. These findings are concerning because those with obesity are more likely to experience a range of obesity-related complications (high blood pressure, high cholesterol, type 2 diabetes, cardiovascular disease, stroke, gallbladder disease, osteoarthritis, psoriasis, sleep apnea, at least 13 types of cancers, mental illness, pain, difficulty with physical functioning, premature mortality, and much more).
While this paper focuses on care for people with obesity, there is an ongoing debate about the primary contributor(s) to the rising obesity rates.
An Epidemic of Inaccessible Care
While much of the public health attention has been on preventing obesity, the growing number of people living with obesity necessitates access to effective evidence-based treatments. Unfortunately, recent estimates suggest that only 2% of eligible people receive evidence-based obesity treatment.
With the development of more effective anti-obesity medications (AOMs), the lack of access to treatment is unacceptable. Not only are we failing to prevent obesity, but we are failing to provide appropriate treatment for those living with it. Why is this the case? Medicare currently does not cover anti-obesity medications due to a statutory prohibition of cosmetic “weight loss drugs” that predates the enactment of Medicare Part D in 2003. When Medicare Part D was finally implemented in 2006, there were no widely accepted FDA-approved anti-obesity medications on the market. Therefore, Congress excluded obesity drugs from Part D coverage. This action resulted in AOMs being excluded from most pharmacy benefit plans. In June 2013, the American Medical Association (AMA) House of Delegates voted to recognize obesity as a disease requiring treatment and prevention efforts. Since this declaration, and despite the availability of numerous FDA-approved anti-obesity medications, they remain an excluded benefit from Medicare Part D.
Currently, Medicare coverage for obesity treatments is limited to bariatric surgery (for beneficiaries with BMI ≥ 35 and comorbidities), intensive behavioral therapy (IBT) (for beneficiaries with a BMI ≥ 30), and the Medicare Diabetes Prevention Program (MDPP) (for beneficiaries with a BMI ≥ 25 and a diagnosis of prediabetes).
IBT must be provided by a primary care provider in a primary care setting, even though these professionals are not best trained to provide nutrition or weight management counseling. In addition, IBT does not cover the full range of obesity care specialists, registered dietitians, mental health professionals, or community-based programs. As a result, few medical practices provide IBT for Medicare beneficiaries with obesity, and fewer than 1% of qualified beneficiaries receive the treatment.
The Treat and Reduce Obesity Act of 2021 (TROA) is a bipartisan bill set to modernize obesity care at the federal level. If enacted, the bill would significantly improve coverage for obesity care services. Of note, while commercial coverage for obesity care services varies dramatically, many plans now include some obesity care benefits.
Telemedicine Creates Access
The coronavirus (SARS-CoV-2) pandemic forced most people to experience telemedicine for the first time. Telemedicine is the practice of medicine at a distance using telecommunication technology. Due to the public health emergency (PHE), the Centers for Medicare and Medicaid Services (CMS) authorized a waiver, which expanded telemedicine services to Medicare beneficiaries, with many commercial payors following suit. According to some estimates, the waiver helped accelerate the utilization of telemedicine services by a decade.
The historic level of telemedicine utilization is mainly possible due to the growth in broadband access and mobile technologies over the last two decades. It is estimated that 97% of Americans have mobile phones, with 85% being smartphones.
So it begs the question: could telemedicine provide more access to obesity treatment? Early returns suggest yes. Not only does remote obesity care demonstrate comparable outcomes to in-person obesity treatment, but it also appears to improve appointment adherence and equitable care delivery. However, questions remain regarding policy, regulation, and payment beyond the PHE. Additionally, there are concerns that tech-enabled care may widen societal inequities. We should study these concerns to ensure this is not the case. Regardless of your stance, it appears that telemedicine is here to stay.
The Future of Obesity Care
The broad acceptance of telemedicine as a standard for healthcare delivery has been a springboard for several obesity-specific digital health start-ups. Most of these offerings focus on providing obesity treatment via a virtual business-to-consumer (B2C) or direct-to-consumer (DTC) experience (i.e., direct patient acquisition and direct payment). Because of the current public health emergency and increased demand for obesity services, several start-ups have experienced tremendous growth, raising large early- and middle-stage funding rounds. However, the question remains: is B2C the solution to the epidemic of inaccessible obesity care?
While virtual-first B2C provides a novel care model for access to obesity treatment, monthly costs to receive the care (often $99-$129+ per month, which do not cover the costs of medication) preclude many from benefiting, such as those in disadvantaged neighborhoods who have higher rates of many common chronic diseases (diabetes, obesity, and cardiovascular disease), higher utilization of health services, and higher rates of premature death. Also, there is a genuine concern that profit incentives drive some B2C entities to overprescribe pharmaceuticals for patient recruitment and retention and to increase patient-to-provider ratios, which may dramatically compromise patient safety. Additionally, many of these B2C companies and providers exist in silos outside the healthcare system, leading to care coordination and integration concerns. For example, how is data shared with other providers? What if a medication needs a dose adjustment? How are referrals managed? Are people deterred and stigmatized by the expectation that they must pay a separate cost to receive obesity care? Is care fragmentation the best way forward?
Our answer is no. Obesity is a complex, relapsing, and heterogeneous chronic disease that requires multi-disciplinary management, incorporating a wide variety of treatment options for a person-centered approach. For obesity to be treated at scale and to address the mounting concerns regarding health equity and access, people need to interact with obesity care providers within the existing railways of the healthcare system, including access to medical therapies, pharmaceuticals, and surgeries that are safe, effective, and durable. Unfortunately, payors, purchasers, and Medicare have treated obesity as an enigma up to this point, preventing many from receiving appropriate evidence-based treatment for their chronic disease. The modernization of obesity care cannot result in the further isolation and siloing of obesity treatment from the healthcare system. Instead, we believe that modernizing obesity care can best occur through direct integration into the healthcare system by leveraging tech-enabled care delivery and focusing on partnering with existing stakeholders to deliver equitable, comprehensive, and coordinated obesity treatment. With the recent advancements in anti-obesity medications and the increasing demand for safe and effective treatments, now is the time to update the obesity care model.
- Disclosures: Drs. Albert and Brill co-founded a virtual-first, equity-focused obesity medicine practice, Accomplish Health.
- Special thanks to Dr. Joel Brill, who co-authored the post.
- Thanks to Dr. Elizabeth Taylor-Albert, who assisted with editing.