20 years of obesity treatment: New guidelines, semaglutide among the biggest advances
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During the past 2 decades, Endocrine Today has reported on the latest developments in treating obesity. For its 20th year, the publication is taking a look back.
Two decades ago, evidence-based care for obesity was in its early stages. The field was less than a decade removed from the 1994 discovery of leptin, a hormone that regulates fat storage and has been connected with the development of obesity. At the time, obesity was not recognized by the wider health care community as a disease, and evidence-based care was extremely limited.
“There was little to offer patients beyond counseling,” Scott Kahan, MD, MPH, director of the National Center for Weight and Wellness, faculty member at the Johns Hopkins Bloomberg School of Public Health and an Endocrine Today Editorial Board Member, told Healio. “Even with the counseling we were doing, some of it was very good and some of it was not so good. We didn’t have the very strong evidence base that we have now to support the strategies that were being used back then.”
Today, the outlook on obesity has dramatically changed. Obesity is now viewed as a disease by most in the health care community, and guidelines are abundant, with multiple professional organizations having released recommendations on treatment. A new medication, once-weekly 2.4 mg semaglutide (Wegovy, Novo Nordisk), was approved in 2021 with superior efficacy when compared with its predecessors. The evidence supporting bariatric surgery is much stronger, and the procedure is now viewed as a more mainstream treatment option.
Despite all of these advancements, there is still work to be done. Although there are more tools in place to treat obesity, providers have struggled to help eligible patients to access bariatric surgery or to take medications, even as obesity rates continue to increase.
“The obesity epidemic has not declined at all,” Caroline M. Apovian, MD, co-director of the Center for Weight Management in the division of endocrinology, diabetes and hypertension at Brigham and Women’s Hospital, and an Endocrine Today Editorial Board Member, told Healio. “Medications, diet and exercise, obesity-medicine programs and bariatric surgery haven’t been adopted in a manner to halt the obesity epidemic.”
Treating obesity as a disease
Thinking of obesity as a lifestyle choice rather than a disease was more common in the health care community 20 years ago compared with today. W. Timothy Garvey, MD, FACE, MABOM, professor of medicine at the University of Alabama (UAB) at Birmingham and director of the UAB Diabetes Research Center, said there has always been a bias surrounding people with obesity, and while attitudes have improved in recent years, a stigma continues today within the health care community, policymakers and the general public.
“It not only affects health care professionals and regulators, but it also affects patients,” Garvey told Healio. “They internalize the disease, and they are stigmatized by it. They think it’s their fault and they have to take care of it, because they are to blame, and it’s not something they should take to their health care professional. That prevents their well-being because all of it together prevents access to treatment.”
Some of the prior attitudes toward obesity have changed in the past decade, with more policymakers, providers and researchers now viewing obesity as one of the top public health concerns in the U.S. A big part of this change came June 18, 2013, when AMA issued a new public health policy, stating, “Our AMA recognizes obesity as a disease state with multiple pathophysiological aspects requiring a range of interventions to advance obesity treatment and prevention.”
Apovian said the AMA’s recognition of obesity as a disease was a turning point in how the health care community as a whole viewed the condition.
“The fact that the AMA proclaimed obesity as a disease broke the wall so we could start treating it instead of thinking we could just put somebody on a diet and exercise program,” Apovian said. “We had known for quite a while that obesity was a disease, but the fact that the AMA recognized it meant that the rest of the physician community and stakeholders could start to recognize it as well.”
Semaglutide a game changer in obesity medications
Twenty years ago, there were few pharmacotherapy options for providers to offer people with obesity when counseling proved inadequate. Orlistat (Xenical, GlaxoSmithKline), approved by the FDA in 1999, was the only medication approved for long-term use in obesity management.
“Orlistat was the first medication approved for long-term use for obesity management,” Kahan said. “Until then, everything on the market was only approved for short-term use, and all of those medications had much lower requirements to prove efficacy and safety before they are approved by the FDA, whereas now, there’s a very high bar.”
Since orlistat’s initial approval, FDA has approved several other medications for long-term use in obesity treatment, including phentermine/topiramate (Qsymia, Vivus), naltrexone/bupropion (Contrave, Currax Pharmaceuticals) and liraglutide 3 mg (Saxenda, Novo Nordisk). However, Garvey noted, the efficacy of early medications was limited, with long-term weight loss of less than 10% with each agent.
The FDA’s approval of in June 2021 changed the outlook on pharmacotherapies for obesity. A GLP-1 receptor agonist, semaglutide produced weight loss that trumped previous medications, with half of participants who took the medication losing 15% or more body weight over 68 weeks, according to data published in The New England Journal of Medicine.
“It’s the first medicine for general treatment with between 10% and 20% of weight loss in the majority of patients,” Garvey said. “It allows us to actively manage weight loss in a range where we can improve people’s health by preventing and treating complications. That’s going to drive the public interest in the medicine, and when patients want something, health care systems tend to respond.”
Many experts have referred to semaglutide as “game changing,” but not everyone is looking to the drug to be a solution to the problem of obesity.
“I wholly disagree with calling semaglutide a ‘game-changer,’ but I appreciate others may disagree,” Kahan said. “It is a great medication, but simply an iterative step forward, not something that leads to miraculous weight loss. Indeed, we have several excellent medications already on the market, which have been shown to help patients achieve almost as much weight loss as semaglutide.”
Other recent medications, such as phentermine-topiramate ER, liarglutide 3 mg and naltrexone/bupropion ER, can approach 15% weight loss in the majority of patients, according to Kahan. Additionally, Kahan said access to obesity medications must be improved for any to be considered a game changer.
“If no one has access to these medications, then it doesn't matter how helpful they are,” Kahan said. “A game changer would be if policies changed such that those who have indications and could benefit from good obesity medications could actually get access to them.”
Bariatric surgery has also become a more common procedure for the treatment of obesity compared with 20 years ago. In 2013, the American Association of Clinical Endocrinology, The Obesity Society and American Society for Metabolic and Bariatric Surgery published updated practice guidelines that recommended bariatric surgery for all patients with a BMI of at least 40 kg/m2 and those with a BMI of 35 kg/m2 and at least one comorbidity, increasing the number of patients eligible for the procedure.
Improving access to care
There are more effective medications, procedures and evidence-based treatment available for obesity today than 20 years ago, but health care professionals are still struggling to get treatment to more people.
“Obesity treatment in general is very challenging, in part because it’s often not covered by payers,” Kahan said. “Up until 2003, Medicare had an explicit policy that said you could not consider obesity as a disease or a health condition. It was considered a cosmetic issue; it was explicitly excluded from any kind of Medicare treatment.”
Additionally, few private health insurers cover obesity treatments, creating disparities based on a patient’s ability to pay for care out of pocket.
“Some of the private insurers will cover semaglutide and liraglutide, but not all,” Apovian said. “It always has to undergo a prior authorization. A lot of primary care providers don’t have the time in their day to do the prior authorizations because it’s very labor intensive. Without insurance coverage, these drugs are very expensive.”
A lack of health care providers trained in obesity treatment is also an issue.
“We don’t get a lot of training for obesity as a disease in our medical schools or other schools for training health care professionals,” Garvey said. “That’s changing slowly, but what it’s going to take is people realizing that this is a disease and we’re paying for the complications of the disease anyway.”
Apovian said there are several ways for the health care community to improve access to obesity care, including fellowship programs to train health care professionals in obesity treatment, advocating for legislation to improve access to care and educating the public on obesity care. Perhaps the biggest change that needs to happen, however, is a shift in the way obesity is approached in primary care.
“It’s going to take years to create a paradigm shift because you’re trying to take the way medicine is practiced in the United States and turn it upside down,” Apovian said. “Primary care providers now deal with hypertension, type 2 diabetes, heart disease, sleep apnea, arthritis. All of these conditions are exacerbated or caused by obesity. Turning it upside down would mean having every primary care provider in the country treat the obesity first, and that’s not happening.”
References:
- AMA. Recognition of Obesity as a Disease H 440.842. https://policysearch.ama-assn.org/policyfinder/detail/obesity?uri=%2FAMADoc%2FHOD.xml-0-3858.xml. Accessed March 9, 2022.
- Mechanick JI, et al. Obesity. 2013;doi:10.1002/oby.20461.
- Wilding JPH, et al. N Engl J Med. 2021;doi:10.1056/NEJMoa2032183.
- Zhang Y, et al. Nature. 1994;doi:10.1038/372425a0.
For more information:
Caroline M. Apovian, MD, can be reached at capovian@partners.org.
W. Timothy Garvey, MD, FACE, MABOM, can be reached at garveyt@uab.edu.
Scott Kahan, MD, MPH, can be reached at scott.kahan@gmail.com.
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