Most adults with obesity are not prescribed obesity medication
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Key takeaways:
- Obesity medications were prescribed to 8% of adults with obesity in a large health system.
- Black and Hispanic adults and those with public insurance were less likely to be prescribed medication.
Most adults with obesity were not prescribed an obesity medication from 2015 to 2023, and of those prescribed an agent, 55% had at least one prescription fill, according to study data published in Diabetes, Obesity and Metabolism.
In a real-world analysis of adults with obesity who attended at least one weight-management program or had an obesity medication prescribed from Jan. 1, 2015, to June 30, 2023, researchers observed several disparities with obesity medication prescriptions. Black and Hispanic adults were less likely to be prescribed a medication than white adults, men were less likely to receive a prescription compared with women, and people with public insurance had lower odds of being prescribed a medication than those with private insurance.
“Despite the increased enthusiasm around obesity pharmacotherapy, the real-world data demonstrates that it is underutilized and likely will remain so for the foreseeable future,” Hamlet Gasoyan, PhD, associate staff in the department of internal medicine and geriatrics, and investigator at the Center for Value-Based Care Research at Cleveland Clinic, and assistant professor of medicine at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, told Healio. “It appears that many of the barriers linked to the underutilization of metabolic and bariatric surgery apply to the limited uptake of obesity medications as well.”
Gasoyan and colleagues conducted a retrospective cohort study with data from 50,678 adults who had a BMI of 30 kg/m2 or higher during their first primary care visit and attended at least one weight-management program or received an obesity medication prescription from July 1, 2015, to Dec. 31, 2022 (mean age, 50 years; 54% women; 66% white). Data were acquired from electronic medical records at a large health system with locations in Ohio and Florida. Obesity medication prescriptions and fills were acquired from the Surescript dispensation record through June 30, 2023. Sociodemographic data were obtained from medical records. Area Deprivation Index was determined using U.S. Census Block Group neighborhood-level data.
Few adults prescribed medication
During a mean follow-up of 4.7 years, 8% of adults were prescribed an obesity medication. Of those receiving a prescription, 55% had at least one documented prescription fill. Among adults filling a prescription, 39% received naltrexone/bupropion (Contrave, Currax Pharmaceuticals), 29% received phentermine/topiramate (Qsymia, Vivus), 19% received semaglutide (Wegovy, Novo Nordisk), 11% received liraglutide (Saxenda, Novo Nordisk) and 1.2% received orlistat (Xenical, Roche).
Gasoyan said it was surprising to see how few adults were prescribed a medication.
“Given the major progress in the development of new and highly effective obesity medications in the past few years and the amount of attention toward these medications in the news and social media, one could expect a higher percentage of prescriptions,” Gasoyan said. “At the same time, similar to the case of bariatric and metabolic surgery, both contextual and individual barriers may lead to the limited uptake of obesity pharmacotherapy, such as patient views and attitudes, patient-physician communication, weight stigma, as well as cost and insurance benefits coverage.”
In a multivariable-adjusted model, Black adults (adjusted OR = 0.68; 95% CI, 0.62-0.75), Hispanic adults (aOR = 0.72; 95% CI, 0.61-0.85) and those from other racial-ethnic backgrounds (aOR = 0.7; 95% CI, 0.55-0.89) were less likely to be prescribed an obesity medication than white adults. Men had lower odds of being prescribed an obesity medication than women (aOR = 0.38; 95% CI, 0.35-0.41).
Participants receiving Medicaid (aOR = 0.44; 95% CI, 0.4-0.49), traditional Medicare (aOR = 0.35; 95% CI, 0.29-0.42), Medicare Advantage (aOR = 0.36; 95% CI, 0.3-0.44), adults who self-paid for medication (aOR= 0.65; 95% CI, 0.44-0.93) and those with other insurance types (aOR = 0.53; 95% CI, 0.33-0.81) were less likely to receive an obesity medication prescription than adults with private insurance.
“Currently, most state Medicaid programs, including the Medicaid programs in Ohio and Florida, as well as Medicare Part D prescription drug plans do not offer coverage for obesity pharmacotherapy,” Gasoyan said. “This was well reflected in our study by significantly lower odds of an obesity medication prescription and fill among Medicare and Medicaid beneficiaries compared with privately insured patients.”
Adults who lived in an area in highest deprivation quartile according to Area Deprivation Index had lower odds of receiving a prescription than those in the least deprived quartile (aOR = 0.81; 95% CI, 0.72-0.92).
Strategies needed to improve access
In a model examining medication fills, Hispanic adults were less likely to fill an obesity medication than white adults (aOR = 0.51; 95% CI, 0.37-0.7), but no difference was observed between Black and white adults. Lower odds for a prescription fill were seen for adults with Medicaid (aOR = 0.41; 95% CI, 0.32-0.51), traditional Medicare (aOR = 0.38; 95% CI, 0.26-0.57) and Medicare Advantage (aOR = 0.37; 95% CI, 0.25-0.55) compared with those with private insurance. Adults receiving phentermine/topiramate were more likely to fill their prescription (aOR = 1.27; 95% CI, 1.08-1.51) and those receiving liraglutide (aOR = 0.61; 95% CI, 0.49-0.75) and orlistat (aOR = 0.11; 95% CI, 0.07-0.17) were less likely to fill their prescription than adults receiving naltrexone/bupropion. There was no difference in prescription fill odds between naltrexone/bupropion and semaglutide.
Gasoyan said the study reveals a need for strategies to address barriers to obesity medication access.
“Recently, the Congressional Budget Office shared in a blog post that it is looking for new research into factors affecting obesity medications use, including their take-up rates, to enhance its analysis of policies affecting the use of obesity treatments — particularly obesity pharmacotherapy,” Gasoyan said. “That is an encouraging step forward. At the same time, as newer and more effective obesity medications become available, heterogeneity in patient preferences for obesity management would increase too. Increased awareness of the existing disparities, addressing weight stigma and promoting patient-provider communication about obesity treatment and pharmacotherapy in particular could help.”
For more information:
Hamlet Gasoyan, PhD, can be reached at gasoyah@ccf.org.
Perspective
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Katherine H. Saunders, MD, DABOM
Thanks in part to the Ozempic hype, there is increasing recognition of obesity as a complex, heterogeneous, chronic disease requiring medical treatment for most individuals to lose clinically significant weight and maintain weight long term. After decades of countless diets and programs, individuals present to obesity medicine specialists like me hopeless and blaming themselves for lack of “willpower.” Comprehensive obesity care, which may include anti-obesity medications, is life-changing and life-saving — when people have access to it.
Medical obesity treatments are not “cheating” or an “easy way out.” Any of my patients can describe in detail how anti-obesity medications finally allow their bodies to respond to their often unbelievably diligent lifestyle efforts.
But they still need to work hard to manage their disease. Medical treatment for obesity is like medical treatment for other chronic diseases like type 2 diabetes and hypertension. Evidence-based guidelines recommend considering anti-obesity medications especially if individuals with obesity have not had success with diet and exercise, especially if they have experienced years of weight cycling, and especially if they have weight-related health complications.
There are many barriers to access. Weight bias, stigma and discrimination are tremendous ones that cannot be underestimated. For example, providers are less likely to treat obesity appropriately if they view it as a lifestyle problem one can cure by eating less and exercising more. And patients are less likely to seek treatment if they blame willpower instead of dysregulated hormonal pathways that aggressively fight weight loss.
Effective treatment of obesity starts with clinicians validating their patients’ experiences, and then offering evidence-based, guideline-recommended treatments or referring to qualified providers. Obesity can and should be treated with a multifaceted strategy. Advanced medical options like anti-obesity medications may be the perfect complement to dietary intervention, physical activity and behavioral change for many individuals who have not yet received appropriate care.
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