Given the current 42% US obesity rate and powerful results from the new anti-obesity medications (AOMs), employers and others responsible for healthcare benefits decisions are feeling pressure to add coverage for these expensive AOMs to employee health benefits plans. However, with a recent study showing 65% weight regain after patients stop taking their AOM meds, we need a programmatic way to first uncover and then tackle the underlying obesity-related behavior and psychosocial barriers to prevent regain.
AOMs on their own will fail as a national solution. Employees must gain new knowledge and develop new skills to lose weight and then keep the weight off. To derive value from their spend, employers must deploy multi-pronged, whole-person care programs that start by unlocking the reasons for obesity and then once unlocked, offer services to help address those barriers and teach people new skills to successfully navigate modern life.
There are good reasons why employers, and anyone footing the bill for healthcare costs today, are focused on AOMs.
- The obesity crisis is real! The National Health and Nutrition Examination Survey (NHANES) shows that since the 1960s, the average US man has gained 30 lbs. and the average US woman 27lbs. Today, ≈130 million Americans are obese (BMI >30) and 50% are predicted to become obese by 2030. Obesity is now defined as a medical condition by the American Medical Association and not surprisingly many Americans are highly focused on finding ways to lose weight and be freed from obesity-related sickness.
- Historical weight loss results are very disappointing. Unsuccessful attempts at weight loss and deteriorating health outcome trends have persisted despite repeated weight loss efforts by American citizens over the past 50 years with 80% typically regaining lost pounds in longer term follow ups.
- People taking the new AOMs are demonstrating significant weight loss. Clinical trials of Semaglutide GLP-1 RA, (Novo Nordisk’s Wegovy), and Tirzepatide, a new GLP-1 RA/GIP combo drug (Eli Lilly’s Mounjaro), show average weight losses of 18% and 22%, respectively. Also, Novo Nordisk’s lower dose GLP-1 RA (Ozempic), approved in 2017 for diabetes, is now being prescribed “off label” for obesity and achieving weight loss also.
The AOM benefits coverage question is complex
AOMs are expensive! Wegovy, first to market, is priced from $15,624 to $17,976 per year and others about to enter the market are also expected to be high priced.
Weight regain is a significant issue. While the clinical trial results are impressive, in a recent study patients taking GLP-1 RAs for one year were found at 1 year follow up to have regained 2/3 of their lost weight. Also, statistics show that 50% of patients stop taking their prescribed AOM medications at around 6 months for several reasons. These include loss of benefit coverage, side effects (diarrhea, nausea, vomiting, muscle loss), and the need to inject an AOM medication weekly (versus the convenience of taking a pill).
So what’s going on here? Why is the obesity rate so high in the US?
For the majority of people, obesity results from a combination of influences. Cultural environment and norms regarding the quality and quantity of the food we eat, societal pressures and influences, personal genetics, and our personal daily behaviors all factor into our health outcomes. For those wishing to understand the new insights into the biology of obesity and the negative impact of modern ultra-processed foods in more depth, please click through to our supporting blog on this issue.
In addition to paying attention to the quality of our food supply and daily eating habits, it is critical we assess and actively manage the psychosocial challenges people face today, including depression, anxiety, social determinants, loneliness, emotional burnout, poor sleep, and in many communities where disparities exist, limited healthy food options. These are root behavioral and psychosocial factors that strongly influence personal choices and health motivation around obesity. Assessing and understanding these human issues and providing practical solutions and support will be critical for long-term obesity program success. Prescribing AOMs alone will not be enough.
Why, after losing 18%–22% of body weight, do people regain weight?
The new AOMs act biologically through GLP-1 RA and GIP gut hormones that slow stomach emptying with meals that gives a feeling of fullness earlier, reduce hunger and food cravings by acting on GLP-1 receptors in the gut and brain, improve insulin sensitivity, and allow for new insulin signaling in the body to tell the body to burn fat reserves. However, when AOMs are discontinued, these powerful effects go away, and the old hormonal and metabolic problems return as does the hunger, cravings, and weight. AOMs do not address the root human causes of obesity (culture, environment, behavior, and lifestyle) but treat the symptoms and should be understood as only one component of a comprehensive obesity program.
The billion-dollar question around AOMs today is:
How can employers satisfy employee demand for benefit coverage,
ensure sustainable and positive health results, and control the
high ongoing costs associated with these new medications?
Actions to develop a best-in-class approach for obesity treatment
First, it is important to highlight that Wegovy is indicated by the FDA as an adjunct to diet and physical activity support. In other words, it is recognized that it is unrealistic to expect sustainable weight loss from AOMs alone, unless employees or patients are to take these medications for life – a very expensive proposition and likely to be suitable for the right candidates only.
Also important to note, reports estimate that 50% of employers are already providing coverage and payors are picking up 95% of costs. So, despite the anticipated costs, we clearly have crossed a critical tipping point of market adoption and the AOM wave has indeed arrived for obesity treatment in the US. Therefore, we need to take full advantage of the current AOM excitement and stakeholder focus to get things right in our national obesity response.
A Smart Option
A smart option is to provide a sustainable “whole-person” solution for employees that combines AOMs with medication taking support, unlocks and addresses key human barriers, and educates on the healthy life skills needed today.
If we expect people to achieve and then maintain weight loss, this solution must uncover the real behavior and psychosocial issues (that drive 60% of outcomes) and use those insights to guide people towards greater health. Based on our experience in this area, this practical help must include assessing key self-management behaviors around obesity, identifying what issues people are willing to work on, and unlocking for each individual the practical barriers they face as part of a personalized approach.
Employers must urge their benefits design consultants to develop and offer comprehensive obesity treatment program options. Critical to sustainable workforce change is for each employee to better understand their own personal drivers of obesity as part of programs that drive better long-term financial results for employers.
Employers need Comprehensive Obesity Programs to ensure value in AOM spend
Epidemic levels of obesity and the associated costs are powerful human and financial drivers pushing employers in 2023 to find effective solutions. The current emergence of AOMs provides a unique and valuable window to design comprehensive obesity programs. For success, it is critical to develop multi-pronged, evidence-based, clinically-grounded, stepped care strategies for eligible employees to help attract and retain talent and reduce use of specialist medical services.
We also need a strong data-driven approach to measure and address the root environmental, behavioral, and psychosocial causes of obesity, insist on clinical and lab testing that leverages the latest science in obesity, and create business incentives that bring all stakeholders together to ensure long-term business sustainability of these programs.
Silver Fern’s suggestions for a Best-in-Class, Comprehensive Obesity Program generating lasting value
- Set consistent protocols for program goals and metrics, clinical improvement, employee/patient satisfaction tracking, AOM adherence, employee retention, and financial tracking.
- Collect the right employee data that highlights the latest salient clinical metrics (including hyperinsulinemia and insulin resistance and liver functioning) and tracks clinical progress and diet quality critical to the understanding of hormonal drivers of fat storage, satiety and hunger, and metabolic functioning missing from traditional obesity programs. Repeat assessments at 6 months and annually to track individual and population level progress and allow for informed program adjustments.
- Leverage patient diagnostics to assess obesity self-management behaviors and psychosocial barriers, including social determinants that drive the majority of health outcomes but often missed from traditional obesity programs. Insist on accurate data and sufficient resources to achieve this critical goal.
- Provide patients with longer term ongoing support, offering a 3-phase model of: 1) onboarding and qualifying 2) active AOM program for a defined period and 3) off-ramping and maintenance of a low UPF diet and balanced lifestyle. Support long term AOM therapy and health tracking, if appropriate.
- Design programs that address health inequities around access to AOMs and healthy foods. The new AOMs have been mostly tested among whites (83.7%) and females (81%). Innovative programs will be needed to engage men – historically a group having low participation rates in obesity programs.
- As noted in our companion blog on the latest science of obesity, we must target hyperinsulinemia and insulin resistance and promote minimally processed foods and drinks (NOVA level 1 and 2) that replace highly refined (NOVA 4) options. Dietary programs must be tailored for cultural preferences and local needs. Commonly prescribed eating patterns (Mediterranean, Flexitarian, Vegetarian/Vegan, Low carb/Keto, DASH) are low in UPFs and are established options, but creativity and effort will be needed to create options that employees (and their families) will like and embrace over the long term.
- Augment AOMs with a multi-pronged, integrated program that includes precision nutrition meals, healthy produce delivery, cooking, meal planning, and shopping skills training, and effective medication taking support. Also, we must leverage scalable, cost-effective digital engagement tools (text messaging, social media, virtual support groups).
- Emphasize the value of using AOMs effectively but for a limited period as part of a multi-pronged, evidence-based program that moves employees to a life of healthy eating and more balanced living, thus reducing use of costly specialist and hospital services.
For further ideas on establishing obesity programs that leverage AOMs with the highest likelihood of economic and employee success, please feel free to reach out to me. Also, look for my next blog out this fall with further suggestions and commentary regarding successful Comprehensive Obesity Programs.
About the Author: Garry Welch, PhD, is the Co-Founder and Chief Scientist at Silver Fern Healthcare, a mission-driven, evidence-based, digital healthcare innovator helping employers, payors, providers, and care teams more effectively manage patient chronic conditions. Garry’s life’s work started in New Zealand and then moved to Harvard Medical School and NIH funded clinical research at Tufts University School of Medicine as a Research Professor in the Department of Psychiatry. He has focused on improving the quality of life and health outcomes of patients living with chronic diseases while helping front line clinicians provide better clinical solutions at lower costs. He is widely recognized as a global subject matter expert in behavior change and psychosocial issues in obesity and chronic conditions.