AT A GLANCE…
- Calibrate, a telehealth GLP-1 prescription machine, reports an 18% reduction in workforce, with a move to employer-based contracts.
- Legacy weight loss companies focused upon behavior change, counting calories and low-carb diets are in a quandary whether to embrace anti-obesity medications.
- Prediabetes currently affects 1 in 3 adult Americans and is projected to impact over one billion people across the globe by 2045. More screening please, for the 80% who don’t know that even have it.
- Bariatric surgery in patients with obesity and non-alcoholic fatty liver disease drives a 40-50% reductions in heart failure, heart attacks, stroke, and death.
EVENTS
- A quiet week.
NEWS
- Founded in 2020, Calibrate was an early mover in the telehealth direct-to-consumer [D2C] weight-loss medication market. Elaine Chen, in STAT News, reports of a 18% reduction in the Calibrate workforce, with a move from the D2C business to partner with employers. The Company statement reads ‘…Calibrate is accelerating our transformation into an Enterprise-first business, shifting internal resources and restructuring our team.’ with a tagline on the ‘For Employers’ page of the Calibrate website that reads ‘The metabolic health platform driving sustainable outcomes and reducing total cost of care.’ I am intrigued by this move, which seems defensive and offensive at the same time; and how competitor D2C companies offering GLP-1 medications will act on this news. Are we seeing the start of a major shift in the design choices made by technology platforms dedicated to metabolic and obesity care? Certainly, a space to watch closely and keenly…
OPINION
- The Wall Street Journal begins with a commonly heard story… Annick, a lawyer from Durham, NC has struggled with her weight since adolescence, had tried Atkins and keto, and spent thousands of dollars on Noom, Nutrisystem and Weight Watchers. The total U.S. weight loss industry in terms of the aforementioned companies and others like them, encompassed over $76B in sales in 2022, with the global market at $175B. Then, Annick started on Ozempic and lost around 30 pounds in weight. The so-called industry shift for the old guard of weight-loss companies is ‘…whether to embrace the drugs, stick with pushing diet and lifestyle changes, or find a middle ground.’ The recent acquisition of Sequence – a company that prescribes GLP-1 medication via telehealth – by Weight Watchers is conveniently mentioned, together with Noom’s GLP-1 launch of a pilot program earlier this year. The opinions from leaders at such companies are mixed, from the ‘…I did it the hard way’ through to ‘…an alternative and adjunct to the new drugs’ on to ‘…a “good partner” for the drugs.’ My suggestion is not to have to choose one from the other – imagine if we asked a person who had recently been diagnosed with breast cancer to choose between radiation therapy, chemotherapy, hypnotherapy, and surgical excision. Sounds crazy, but that is the approach we are taking here with obesity. This is not a winner-takes-all situation in terms of nutrition, behavioral therapy, medication, or surgery; we can provide optimal care interventions to our patients in a chronic disease model, that is longitudinal and dynamic, based upon clinically valid metrics of success.
- Writing in The International Journal of Obesity, Amber Olson, a medical student at Case Western Reserve University, partners with highly regarded clinician researchers Dr. Stanford in Boston and Dr. Butsch in Cleveland, to recount the ‘…apparent paucity of obesity content in both the preparation materials and the exam itself…’ in reference to the USMLE, or the United States Medical Licensing Examination. The authors continue ‘…the lack of obesity coverage on USMLE Step 1 is consistent with the lack of obesity education at every level of medical training, leaving physicians unprepared to treat a disease that affects more than 40% of adults in the U.S.’ They propose smaller, more realistic changes to the use of person-first language, learning how to counsel patients with obesity, and a discussion about obesity as a disease. I applaud the narrative, though would take it further and much sooner – to currently practicing physicians in their Board certification and recertification examinations, with a focus upon cardiologists, orthopedic surgeons, diabetologists, sleep physicians, and infertility care. The patients these physicians care for are more likely to suffer with obesity, as contributors to their chronic disease, and should be fully educated and engaged in the multitude of interventions available, their risks and outcomes, and make them available to all who can benefit.
- A nicely done review on diagnosis and management of prediabetes is published this week in JAMA (the Journal of the American Medical Association). First off, prediabetes is most commonly diagnosed with a HbA1c blood level of 5.7% to 6.4%. And second, 10% of the 1 in 3 adults affected with prediabetes in the US, progress to a full-blown diagnosis of diabetes every year. By 2045, prediabetes will affect a whopping one billion people across the globe, aligned with the major risk factors of overweight and obesity, older age, physical inactivity, unhealthy diet and genetic predisposition. Within the US, more than 80% of those with prediabetes are overweight, with a BMI greater than 25, with greater risks of not only developing diabetes, but also higher rates of cardiovascular events and mortality. Though the ‘…American Diabetes Association recommends universal screening every 3 years for prediabetes among all adults aged 35 years or older…’, more than 80% of the almost 100 million US adults with prediabetes are unaware they have it.
- Thomas E. Hubbard, from the The Network for Excellence in Health Innovation, a Boston-based nonprofit health policy organization, in partnership with obesity medicine clinicians and entrepreneurs Dr. Fitch and Dr. Halperin, together with Joe Nadglowski, CEO of the Obesity Action Coalition, write in Health Affairs ‘…It seems inexorable: About half of all US adults will have obesity by 2030, only seven years from now.’ The focus of the article is to develop ‘…a road map toward high-value obesity treatment delivered at scale.’ It elucidates three reasons for limited uptake of effective treatments: first, past unsafe medications and their disappointing results; second, the persistent stigmatization of obesity; and third, the focus upon behavior and lifestyle change interventions, such as the Diabetes Prevention Program. The authors ‘…envision four stages in the patient’s clinical journey around which specific care processes and parallel payment models might be developed’ based upon formal diagnosis and documentation of such, initiation of treatment or referral to more specialized care, treatment to individualized patient goals beyond BMI alone, and finally chronic obesity care for development and maintenance of long-term outcomes. The article states ‘…Value-based delivery of obesity treatment and support will rely on the capability to document and report patient results against validated process and health outcome measures, as is the case with other conditions that are targets of value-based payment models.’ It continues that ‘…obesity presents challenges for value-based provider payment…’ with the call to action for ‘…new thinking on how obesity treatment and support could be delivered effectively and efficiently, at the highest value to both patients and the health care system at large.’
- While I applaud the push for better policy around the treatment of obesity, the article lacks much of a real-world prescriptive approach. Quite frankly, there are tens of millions of Americans who are deserving of high quality obesity care, and we should provide it in alignment with data on payment models that already exist, and serve our population with treatments that work now and for the longer term – namely anti-obesity medications and bariatric surgery, underpinned by supportive nutrition, behavioral and exercise therapies.
DATA
- Dr. David Unwin, a general practitioner in north-west England, publishes in the journal BMJ Nutrition, Prevention & Health, the results of a program to engage 186 of his patients with type 2 diabetes in a lower carbohydrate diet and weight loss program. The doctor managed to sign up 39% of all eligible patients, which is a good capture rate – very much akin to the Livongo sign-up rate, when I worked with them over five years ago in my innovation role at the Philadelphia-based Jefferson Health system. After almost three years on Dr. Unwin’s program, his patients lost about 10% of their total weight, with just over half of the patients no longer being diabetic, i.e. having achieved remission of the disease. This might seem like a simple intervention to recreate, but the reality is that Dr. Unwin and colleagues maintained patient engagement through one-on-one consultations, weekly seminars and check-in appointments, group sessions, regular weight measurements and blood tests. So, it is less about the type of intervention per se, and more akin to the relationship Dr. Unwin had built with his patients, to develop trust, to drive engagement and to maintain results. We can do this for sure, but it takes time, commitment, and drive for the provider and patients, over a multi-year period.
- From a registry of over 150,000 patients with non-alcoholic fatty liver disease [NAFLD], the almost 5,000 who underwent bariatric surgery were compared in a case-matched manner to those who did not have surgery, over a five-year plus follow-up period. The published data in those having had bariatric surgery, revealed the risk of new-onset heart failure to be 40% lower, serious cardiac events such as a heart attack were fewer by almost 50%, stroke and related events were 40% fewer, and the need for coronary stents or bypass surgery was reduced by 50%. Even more so, mortality was cut by 44% in those who underwent bariatric surgery. WOW! And these are people who want to lead active lives – their mean age was 45 years, with a third suffering from diabetes, over half from high blood pressure, and half with obstructive sleep apnea. Imagine if we could achieve such game-changing outcomes for all patients who are eligible for bariatric surgical intervention – not just for those with NAFLD, but for anyone who meets the new criteria for bariatric surgery, i.e. a BMI of 35 or greater, or a BMI of over 30 with related co-morbidities such as sleep apnea, high blood pressure, type 2 diabetes, back pain, or depression. We intervene in the United States on less than one percent of the total eligible population – we can and should do better, certainly with supportive data akin to this publication, of which there are many hundreds and thousands out there – from over forty years of research. And to those that worry about the risks of surgery, bariatric surgery in general is safer than hip and knee surgery, and almost as safe as gallbladder removal surgery.
Kind regards, Raj
