AT A GLANCE…
- WeightWatchers enters definitive agreement to acquire Sequence, a telehealth weight management program, with a focus upon GLP-1 medications; closely followed by Noom Clinical, a new offering to meet demand for weight loss medications.
- The UK National Health Service approved Novo Nordisk drug Wegovy for weight loss, though at higher BMI entry criteria of 35, and for a maximum two-year period.
- Cardiovascular risk factors in terms of obesity, diabetes, hypertension and hyperlipidemia are on the increase in young adults [aged 20 to 44 years], with growing inequities among racial and ethnic groups.
- Precision obesity medicine, based upon four subtypes of emotional hunger, hungry gut, slow burn and hungry brain.
EVENTS
- The 95th Academy Awards ceremony, also known as the Oscars, is this evening; will be interesting to watch the red carpet and consider how many of the celebrities have been on adjunctive GLP-1 therapy to meet the demands of their tailors and fashion designers?
NEWS
- In big news this week, WeightWatchers ‘…has entered into a definitive agreement to acquire Weekend Health, Inc., d/b/a Sequence, a subscription telehealth platform offering access to healthcare providers specializing in chronic weight management.’ Sequence is a self-professed ‘…comprehensive weight management program (that) pairs clinically-proven medications with access to board-certified clinicians, Registered Dietitians, fitness coaches, and a Care Coordinator – to help you lose weight,’ and is led clinically by Dr. Spencer Nadolsky. In the press release, Sima Sistani, who is celebrating her one-year anniversary later this month as CEO of WeightWatchers, says ‘It is our responsibility, as the trusted leader in weight management, to support those interested in exploring if medications are right for them…’ This is the first of many consolidation activities in the metabolic/obesity space, which may mirror what happened a few years ago with the Livongo roll-up of diabetes, hypertension and behavioral health technology solutions, eventually selling to Teladoc Health; thoughts welcome.
- With seemingly serendipitous timing, Noom Clinical was launched this week as ‘…a new program that offers some users access to prescription anti-obesity medications.’ Noom is one of many companies in the past few months who ‘…want to capitalize on a surge in demand for new weight-loss drugs.’ The leaders of corporate strategy at every start-up in the digital health space, and their counterpart analysts and bankers, are surely working overtime to keep ahead right now…
- Lakshmi Varanasi reports in Business Insider, ‘WeightWatchers is buying a company that lets you pay $99 a month to see a doctor on video and get a prescription to popular weight-loss drug Ozempic.’ Most of the article is a repeat of the above press release, though the two sentences that follow are telling of the real and present challenges in this area: ‘The news comes after a few tumultuous years for WeightWatchers. The company’s stock dropped almost 80% last year. However, the company’s stock is already up more than 12% in after-hours trading…’ and ‘…Tele-health startups have faced controversy in recent years for how they’ve prescribed medications. The mental health startup Cerebral put dozens of patients on questionable treatment plans in 2021 and even misdiagnosed certain patients.’
- The WW story is covered by Reuters with a reminder that ‘global obesity market to be worth around $50 billion in sales in 2030.’
- The Wall Street Journal leads with ‘…the diet company’s move into the hot market for diabetes and obesity drugs including Ozempic and Wegovy.’ Dr. Gary Foster PhD, chief scientific officer at WeightWatchers [and previously director of weight and obesity programs at UPenn and Temple University] is quoted, ‘…We have no interest in prescribing medications to those who are trying to lose 10 pounds for a reunion.’ Though I have little idea how to square this approach with the media and Hollywood hype that surrounds GLP-1 medication.
- Across the pond in the UK, the cost-effectiveness agency NICE has approved Novo Nordisk drug Wegovy, for ‘…adults undertaking an NHS-administered weight-loss programme – including a reduced-calorie diet and increased physical activity – who have at least one weight-related health issue and a body mass index (BMI) of at least 35, putting them in the obesity range.’ This is way more restrictive than the prescribing information for Wegovy at BMI of 30 or greater, or 27 or greater with at least one weight-related co-morbidity condition such as hypertension, type II diabetes or dyslipidemia. In the UK, duration of therapy is to be limited to two years with the broad intent from Helen Knight, director of medicines evaluation at NICE ‘…to ensure it remains value for money for the taxpayer.’ Wonderful to see one of my previous colleagues from Imperial College London, Professor Alex Miras now at Ulster University, on the two year duration being ‘…understandable based on cost effectiveness [but] makes no clinical sense, as we would not stop treatment for any other chronic disease…’ with a stance supported by Professor Nick Finer of the National Centre for Cardiovascular Prevention and Outcomes at UCL that the two year limit was ‘illogical’. It is going to be revealing how the narrative and actions between access, cost and long-term outcomes of GLP-1 meds plays out, both in the UK and the US alike.
- The Washington Post’s Andrea Petersen covers the JAMA study mentioned in the DATA section below, with a quote from Dr. Wadhera, one of the study authors ‘We’re witnessing a smoldering public health crisis…’ The more startling though well known sentence is ‘Young Black adults face the greatest risk’ with ‘The study’s authors pinpointed structural racial inequities in American society as a driver of the gaps.’ I think the reporting is terrific, but what are we doing about the situation? Descriptive is important, but prescriptive is where we need to drive impact.
OPINION
- In a new series from STAT News, The Obesity Revolution, Elaine Chen and Matthew Herper lead with ‘…Obesity is a chronic biological disease – and it’s treatable with a new class of medications,’ with historical reference to Valium changing views on anxiety in the 1960s, and Prozac on depression in the 1980s. But there is a warning for Eli Lilly, Novo Nordisk and others in that ‘Doctors who have watched other big launches of new medicines already worry that the drug industry’s excitement – and its focus on marketing – could backfire.’ The article draws attention to the Institute for Clinical and Economic Review [ICER] report from 2022 on cost-effectiveness and ‘…at the drug’s current average net price of around $13,600 a year, as soon as 0.1% of the eligible population takes the drug over five years, insurance companies and government payers may have to shift money or increase premiums.’ The article is certainly robust, with a great penultimate paragraph, ‘Even if they are not magic bullets, the incretin drugs are undeniably powerful new tools to use in society’s long, fraught relationship with obesity – and maybe, if the coming trials are positive, against the deadly problem of heart attacks and strokes.’
- Julia Belluz continues the focus upon obesity articles in STAT News on attempts to ‘…subtype obesity and tailor treatments,’ with an interview from Dr. Andres Acosta at Mayo Clinic stating that ‘uneven response holds for the best tools currently available to treat obesity – gastric bypass surgery and the new GLP-1 based drugs…’ and ‘…a subset of patients will only lose a small amount of weight, or have no response at all…’ such that ‘…one size fits all is not working…’ The four subtypes are defined as emotional hunger, hungry gut, slow burn and hungry brain – to prescribe ‘…combination therapy typically a lifestyle program and obesity medication, or even weight loss surgery – matched to one or more of four obesity phenotypes…’ Dr. Acosta’s approach was published in the scientific literature almost two years ago; more telling is that one of his patients who went through the ‘precision obesity medicine’ approach was quoted ‘…It is not fundamentally different from other programs.’ Though importantly of Dr. Acosta, his patient said ‘I felt that he really listened to me, and that he understood my specific issues. I am very optimistic and somewhat hardened in my resolve to lose weight after our conversation.’ I am for the move toward whole-person, individualized therapy for the complex, chronic disease of obesity, though think that we have plenty of tools right now – in terms of a multi-pronged approach to embrace medication and surgical therapy, all the while supported and underpinned by nutrition, behavioral and exercise therapy, and meeting the needs of the patient, which are likely beyond weight loss and toward healthier and happier lives, and interactions with their family, friends, and community.
- At risk of being too focused upon STAT News articles, Hyacinth Empinado published an informational video on the BMI formula at the individual level, versus the population level.
- FDA Commissioner Robert Califf, in reference to Novo Nordisk funding the development of obesity coursework for medical schools, was quoted during a meeting with STAT reporters ‘…it’s a shame that you would need to depend on a pharmaceutical company for an educational program about something that’s affecting half of Americans.’ I agree in broad principle, but in the real world and for many decades, pharmaceutical and medical device companies have developed, supported, and implemented extensive numbers of medical education programs for their areas of influence and focus, including medical school courses, academic conference panels, and hands-on training courses; many of which were further augmented by social events – certainly and appropriately less of the social activity nowadays.
- An article this week titled in the current manner of hype-plus-plus-plus on ‘The End of Obesity’ and the first sentence ‘Americans are fat and getting fatter.’ The focus of the article is on GLP-1 medications, though I am pleased to see more open reporting of the durability of the effect and the need for lifelong treatment, which is not only an issue of economic challenges, but also of medication adherence, ‘…Chronic illnesses are generally thought of as long-lasting conditions that frequently can be controlled but not cured. Many medical practitioners and researchers regard obesity as just such a chronic illness. Consequently, as a chronic condition, obesity needs chronic treatment. When users stop taking the new weight loss drugs, their feelings of hunger return and they rebound, regaining about two-thirds of the weight that they had lost, according to a 2022 study.’ A noted reminder on the two-year maximum period of prescription in the UK…
DATA
- Rahul Aggarwal and colleagues [no known relation!] published in the Journal of American Medical Association with well-known policy researcher and Associate Editor of JAMA, Karen Joynt Maddox this past week. The original investigation focused upon the changing prevalence of cardiovascular risk factors for young adults [aged 20 to 44 years] from 2009 through to 2020. Apart from the fact that this article suggests that I am no longer a young adult(!), the findings on almost 13,000 adults with a mean age of 31.8 years, reveal 37% increase in prevalence of diabetes [from 3.0% to 4.1%] over the 11-year period, 25% for obesity [from 32.7% to 40.9%], and 23% for hypertension [from 9.3% to 11.5%]. Black adults had highest rates of hypertension [to 20.1% in 2017-2020], and there was an alarming 73% rise in rates of diabetes among Mexican American adults [from 4.3% to 7.5%] – which for both racial groups are almost double the rate than for the entire cohort studied. Three key takeaways – first, the data brings reality to rates of diabetes and hypertension as very real sequalae of the obesity pandemic, second, the impact on growing racial disparities, and third, not only are our most productive and highly resourced individuals are at risk in terms of their health and wellness, but as a society we also are at risk in terms of their productivity as the backbone of our current and forward economy.
- The accompanying Editorial piece from researchers at Northwestern University highlights ‘…the growing inequities in cardiovascular health across racial and ethnic subpopulations in the US.’ The final sentence of the article states ‘Multilevel interventions to promote cardiovascular health tailored to young adults are critical to stem the growing burden of cardiovascular disease,’ which is non-specific and vague. We are at a serious, and accelerating situation that demands urgent and proactive attention; public policy such as diet quality and exercise programs are weak at best, community-programs in terms of screening and early engagement are sporadic and rarely engage racial and ethnic communities, and individual treatments being generally inadequate at a primary care level – there is a need to promote and provide individualized, integrated and high-value behavioral, nutrition, pharmacologic and surgical therapies, supported with highly trained providers, advocates and peers.
- In a news article from Nature, a highly well respected medical journal, there is a report of ‘…rising rates not only of diabetes but also of high blood pressure and obesity-linked liver disease.’ with the tagline of ‘global metabolic trouble’ to describe ‘…the prevalence of type 2 diabetes grew more than 1.5% annually’ between 2000 and 2019, and 5 million deaths attributable to obesity worldwide, just in 2019. Mark Mutiah, an academic gastroenterologist in Singapore is quoted ‘…If we can improve access to care, we can limit the burden of metabolic diseases in the future.’ This needs to be categorized into primary prevention where we avoid overweight and obesity as a disease state, secondary prevention to limit development of the chronic diseases such as diabetes, hypertension, and sleep apnea as sequalae of obesity, and tertiary prevention to avert progression, such as chronic kidney disease and the need for dialysis treatment in people with diabetes. When greater than 50% of the population is deemed to be obese by 2030, and 75% overweight, I believe that the ship has sailed on primary prevention; we must focus the majority of our efforts on secondary and tertiary prevention – at least for the next many years.
Kind regards, Raj
