I wish everyone a Happy Easter if you celebrate and happy weekend if you do not :)
AT A GLANCE…
- Beyond BMI – a high-profile academic committee gets together this week to debate and define the role of BMI as a measure of obesity and health.
- The U.S. military is struggling with recruitment and lost workdays of their soldiers due to challenges with managing obesity.
- Two NYC companies offering online GLP-1 meds are slammed for their billboard type adverts on the train station walls of the New York subway.
- Metabolic phenotyping for pregnant women to assist in identification of babies that might be at risk for obesity.
EVENTS
- A planning committee of the National Academies of Science, Engineering and Medicine held a workshop titled ‘BMI and Beyond: Considering Context in Measuring Obesity and its Applications: A First Workshop in the Series’ on April 4 as part of the ‘Roundtable on Obesity Solutions’ series. The focus was ‘on the strengths and limitations of body mass index [BMI] as a measure of adiposity and an indicator health’. The committee includes luminaries in obesity medicine from The Ohio State University, University of Minnesota, Harvard University, Cleveland Clinic, the U.S. Food and Drug Administration, the Frameworks Institute, and George Washington University. So good to see a national heavyweight policy organization see beyond BMI as a strategy to determine health; our current state is akin to defining the treatment to a liver tumor by virtue of its size alone, and ignoring its metabolic, functional, and systemic profile. BMI is a tool to simplify the possibility of metabolic disease, and without a clinical evaluation, is too weak to determine optimal treatment.
NEWS
- An article in USA Today from Karen Weintraub considers GLP-1 receptor agonists in terms of their side effects, the risk of weight regain after stopping medication, and big pharma’s influence on doctors and education, as a corollary to ‘…Everything we saw with the opioid epidemic.’ Wow – strong words; I think we are far from such a scandal in this space. Weight or BMI as a metric for prescribing medication is attempted to be clarified with a quote from Dr. Adriane Fugh-Berman at Georgetown University ‘…”It’s not clear you’re going to get improved health outcomes” from weight loss medications…’ I fervently disagree with this – we know, without a doubt from 40-plus years of academic research that increased weight and BMI lead to significant co-morbidities and reduced life expectancy; a reduction in weight can get people with diabetes off their insulin and render them non-diabetic, such that their life expectancy increases, and powers them with a 30-35% reduced risk of common cancers over the next ten years too. I do agree that solely focusing on weight loss as a metric for success is reductive and unsophisticated – our job as clinicians is to engage and partner with patients to live their healthiest and happiest lives, to extend the length of such lives, and to underpin the treatment of obesity as a chronic disease.
- New research, highlighted in Fortune by Jonel Aleccia ‘…found that obesity in the U.S. military surged during the pandemic. In the Army alone, nearly 10,000 active-duty soldiers developed obesity between February 2019 and June 2021, pushing the rate to nearly a quarter of the troops studied.’ From a pure workforce and economic perspective, ‘…The military loses more than 650,000 workdays each year because of extra weight, and obesity-related health costs exceed $1.5 billion annually for current and former service members and their families.’ Would be of interest to explore how the leadership at the U.S. Department of Veterans Affairs is contemplating the situation, and the various treatment regimens available to their beneficiaries.
- Rachel Cohen, in the Military Times, writes ‘The Air Force has loosened its restrictions on body fat for new recruits, one of the latest moves to grow the pool of potential applicants amid the military’s recruiting crisis.’ The benchmark for body fat percentage has been increased from 20% to 26% for men, and 28% to 36% for women, as per Air Force Recruiting Service spokesperson Leslie Brown. This is in light of ‘…the active-duty Air Force has brought in less than 50% of its goal of 26,877 new airmen for 2023. Around 11,200 recruits have come in so far…’ In view of the last two news stories, is the obesity epidemic contributive to a national security crisis, in terms of the availability and effectiveness of our military troops?
- STAT News, in continuance of its articles related to The Obesity Revolution, reports on ‘…splashy ads plastered on train station walls and turnstiles across New York by telehealth companies promoting controversial weight loss medications like Wegovy by name.’ Two companies, Ro and Calibrate are named, both with head offices based in New York City; a spokesperson from Ro is quoted: ‘Ro is not a health care provider… As a tech platform enabling healthcare services, we connect patients to a network of affiliated healthcare providers.’ Whilst I defer to others with expertise in regulatory and drug advertising requirements, it is my opinion that the pharma, prescribers, telehealth companies, and patients themselves are moving through the metaphorical subway turnstiles faster than regulators can replace or slow down the barriers to entry.
- Following on the news on Nov 29 2022 of Boston Scientific, a forty-year old medical device firm, to acquire Apollo Endosurgery, a technology firm with endoscopic solutions for gastrointestinal and weight-loss procedures, there were reports this week of the completed transaction. Dr. Brian Dunkin, Chief Medical Officer at Boston Scientific, and most recently Professor at Houston Methodist Hospital [who I have known well for almost twenty years in relation to our aligned academic and clinical work in laparoscopic surgery, and simulation-based surgical education] was quoted ‘…We’ve been calling it a measured entry into the bariatric space.’ In response to reporter Lizzy Lawrence’s mention of ‘effective obesity drugs like Wegovy’, Brian’s response to obesity is spot on: ‘…Treating it as a chronic disease, this starts to build out the portfolio of things that we can bring to treat a patient. You might want to start with lifestyle modifications. Maybe you add medications, maybe you then put in an endoluminal procedure. Maybe you still have to go to surgery at some point. It allows you to tailor treatment to the individual patient and what’s best for them.’ In terms of the competitive challenges posed by anti-obesity medications, Dr. Dunkin unapologetically states ‘…I don’t know if we look at it as competition, to be honest. Competition implies that this is a defined pie that has a certain size to it and it’s a no-sum game. If one thing is done, then another thing is not going to be done. That applies in a lot of areas but it doesn’t really apply in this instance.’ and further delineates ‘…I don’t think they’re going to cannibalize one another, we’re going to find out how they’re synergistic and work together.’ Thank you, Brian!
OPINION
- Eli Lilly, an almost 150-year old pharmaceutical company based in Indianapolis, is featured by Peter Loftus in The Wall Street Journal, on their anti-obesity drug tirzetapide, also known as Mounjaro. The drug is currently licensed to treat patients with type 2 diabetes, though is expected to follow rival Novo Nordisk’s approach to semaglutide to be made available for people with obesity [Wegovy] in addition to people type 2 diabetes [Ozempic]. The financial incentives for company executives and stockholders are not lost on the author, noting ‘…Mounjaro could be one of the highest-selling drugs of all time with annual sales exceeding $25 billion. Novo’s Ozempic and Wegovy brought in close to $10 billion last year, with prescriptions rapidly growing.’ The article nicely recounts Lilly’s innovative approach to drug development, testing and commercialization, led by Chief Executive David Ricks and Daniel Skovronsky, Lilly’s chief scientific and medical officer. I do like the comment from Mr. Ricks ‘…To me, tirzepatide in my career may be the most important drug Lilly’s been a part of… It is one of the rare ones that has a chance to move the life expectancy of the population.’ Nicely done Peter, and not full of Hollywood hype either.
- The Atlantic focuses upon the big opportunity for anti-obesity medications and leads with ‘…A “huge explosion” in obesity drugs is on the horizon.’ Writer Yasmin Tayag is spot on in the next two sentences to state ‘…For all its hype, semaglutide is the stepping stone and not the final destination of a new class of obesity drugs. Just how good they get, and how quickly, will go a long way in determining whether this pharmaceutical revolution actually meets its full promise.’ The article recounts newer medications in development from drugmakers Pfizer, Amgen, Viking Therapeutics, and Structure Therapeutics, in a move toward oral forms with similar or superior effectiveness, fewer side effects, and lower prices. The end of the article mentions Lipitor as a ‘cholesterol-busting drug… taken daily to treat long-term disease’ though fails to advise the reader that the drug is intended to be partnered with modifications to the nutritional, behavioral and exercise status of those on it, to achieve optimal results – let’s think about the multimodal approach and how we might consider the explosion in anti-obesity medications; not just in those taking and paying for them, but in the outcomes achieved.
DATA
- Researchers from the University of Colorado evaluated the concept of metabolic phenotyping in 1,325 pregnant women, and 727 of their offspring; the pregnant women had their glucose, insulin, cholesterol and additional blood markers measured at 17 weeks of gestation, and the data was compared to body mass index and fat mass percentage at age 5. Women with insulin resistance and higher levels of triglycerides had offspring with higher risk of fat mass percentage, that was higher than with those of just pre-pregnancy obesity or gestational diabetes alone. My bigger picture takeaway is that gestational diabetes, management of pregnancy in women with obesity, and concomitant higher risks during childbirth and beyond are likely to become more apparent in health policy, payor and provider circles. And that BMI as a metric of obesity and its complications is moderate at best; we can identify better tools to support our patients.
- A small study to test the efficacy of a virtually delivered, diabetes-tailored weight management program on 136 adults with type 2 diabetes was published this week. The researchers essentially modified the WeightWatchers program into one tailored for those with type 2 diabetes, to include weekly virtual workshops, weekly check-ins, the WW app combining the well-known SmartPoints system, and a private online community. At almost six months in the trial, the HbA1c reductions from a mean of 8.0% were reduced by 0.75% which is fairly reasonable, associated with total body weight loss of almost 6%. The research was funded by WW International, Inc. with Gary Foster PhD, Chief Scientific Officer, as one of the co-authors of the study; a question to Dr. Foster – how many of these patients, with a mean BMI of almost 37 kg/m2, should, would or could be advanced to higher value treatments in terms of anti-obesity medications and/or bariatric surgery?
Kind regards, Raj
