AT A GLANCE…
- World Health Organization’s says Wegovy and other weight-loss drugs are ‘…not a silver bullet.’
- A seeming shift in the narrative this week toward multimodal, whole-person, and multi-year strategies of care; challenging current direct to consumer, medication-first approaches.
- Benjamin Chavis Jr., an African-American civil rights leader, writes in The Miami Times on ‘Obesity is not a hopeless fight for Black America.’
- Researchers in Scotland find that COVID-19 results in an increased likelihood of death in people with severe obesity, and the effect of the COVID-19 vaccine is less durable over time in such people too.
EVENTS
- Happy Mothers Day to all our mothers, grandmothers, wives, daughters, aunties, sisters and everyone else that I may have missed!
- The STAT Breakthrough Summit in San Francisco convened a panel of obesity experts recently, with a theme of concern on ‘…the drugs’ costs – both to patients’ finances and to their health.’ The discussion topics were centered upon the effects of weight loss on reduced lean mass, the exacerbation of health disparities due to drug costs, over-prescribing of medications to those who might not have a clinical need, and ‘…Fix the food first…’ from Dr. Robert Lustig, emeritus professor of pediatrics at the University of California, San Francisco.
NEWS
- I am both intrigued and surprised by the suggestion, or hope(!), that diabetes drugs (including Ozempic) may be effective in the fight against neurodegenerative diseases.
- The biological mechanism is theorized to be ‘…improving glucose utilization and tamping down inflammation in the entire body – including the brain….”, which could in turn “….slow (the) progression of debilitating diseases like Alzheimer’s and Parkinson’s…’. The caveat is that ‘…Results are years away and success uncertain.’
- Dr. Suzanna Craft, at Wake Forest University School of Medicine, is ‘…running an Alzheimer’s trial evaluating intranasal insulin in combination with another diabetes drug.’
- I am all for opportunistic and expansive research, but also wary of the commercial hype around GLP-1 medications as a ‘cure-all’ …. and the subsequent rabbit holes that might be futile at best, and cause undue harm, at worst.
- ‘Boehringer shows its hand in obesity’ is the description for new data on a glucagon/GLP1 agonist drug, codename BI456906. The study reports almost 15% total weight loss ‘…after 46 weeks of adults living with obesity or overweight without type 2 diabetes…’ and thus ‘…meeting its primary endpoint.’ A follow-up study is focused upon patients with NASH, or non-alcoholic steatohepatitis, which affects about 1 in 20 Americans, and is a pre-cursor to end-stage liver disease, necessitating liver transplant.
- The World Health Organization’s director of nutrition and food safety, Francesco Branca, says ‘…This is not a silver bullet…’ in reference to Wegovy and other weight-loss drugs, in the WHO’s ‘…first review of obesity management guidelines in more than 20 years.’ The first draft is expected by the end of the year, in the face of ‘…obesity as a “rising epidemic”.’
- The UK’s Daily Mail leads with ‘…Weight Watchers and other legacy brands could go bust this decade due to success of Ozempic and Wegovy — after Jenny Craig shut its doors’, with a follow-up note that ‘…They’ve [obesity medicines] eaten into the profits of major players Jenny Craig and Weight Watchers’ (emphasis added). Don’t you just love British punnery! In reference to WeightWatchers, the newspaper notes ‘…a decision of self-preservation earlier this year when it bought up telehealth prescribing company Sequence for $106 million…’ I do hope that we do not see more of a transition from lifestyle, nutrition and behavioral approaches directly to medication; rather a complementary and integrated mode of care delivery.
OPINION
- Dr. MaryAnn Dakkak, Assistant Professor in Family Medicine at Boston University School of Medicine, begins her article in JAMA this week with an anecdote describing a visit to a pain specialist, with the doctor asking her ‘“Do you always…always look like this?”… waving both his hands in a circle in front of my body. I knew what he was asking. Was I always this fat?’
- The publication is titled ‘Fat Shame – Inside and Out’, and expands on the stigma and bias felt by Dr. Dakkak and many many others, expressly from their own clinicians, saying that ‘…obesity is the cause of all evil things, all pains, all ailments. And it went further: Why go to the physician if they will just point at your weight? May as well stay home and just deal with it…’ and ‘…Every time I go to a physician’s appointment, I want to apologize for my body.’
- The bias that exists when a person with obesity seeks medical care, to then be told that it is simply a function of their obesity, is dire, upsetting, and plain wrong. And the internalization of such bias is a direct result of these experiences; Dr. Dakkak proceeded with bariatric surgery and wrote a note to herself the week prior to surgery, which in my mind is just so powerful ‘…I will not post before and after pictures. I won’t shame my body before. I will not glorify my body afterwards. My body is amazing. Any shape or size it is.’
- The approach to ‘…peel away stigma and pain the patients have experienced from our health care system…’ and to ‘…focus on function and goals…’ is exactly how I have treated my patients, including an objective to ‘…frame shame, depressed mood, and low self-esteem as symptoms of stigma, not obesity.’
- The author concludes with ‘…The data on medical stigma of obesity are damning. A survey of medical students published in 2018 reported that 74% thought obesity resulted from ignorance, and 28% thought people with obesity are lazy…’ We can and must do better, right away – that’s intended for all of my medical colleagues who see patients with obesity and associated chronic conditions. The article reminds me of when we started the bariatric surgery practice back in London, UK almost two decades ago, and similarly the adolescent bariatric practice at Children’s Hospital of Philadelphia a decade ago – many of my surgeon colleagues were aghast that we were getting operating room slots for our patients, let alone developing a clinical practice to treat severe obesity.
- Dr. Disha Narang, endocrinologist and director of obesity medicine at Northwestern Medicine Lake Forest Hospital, and a new connection for me at the recent Fortune Brainstorm Health conference [thank you Chrissy Farr], says ‘…it’s been fantastic. This is a game changer…’ in reference to GLP-1s, in Fierce Healthcare. The 2,082% increase in prescriptions for Ozempic, Mounjaro (tirzepatide), Rybelsus (semaglutide) or Wegovy is dramatic – from 230,000 in 2019 to over 5 million in 2022.
- In a more measured tone, Dr. Narang continues, ‘…There’s not a quick fix, there’s not a magic wand. We have to approach this as we are treating a long-term chronic disease.’
- Heather Landi continues her article with ‘In the past year, many telehealth and digital health companies have jumped into the market, offering prescriptions for GLP-1s as part of an existing weight loss or chronic condition management program, or creating a new service line targeting obesity care.’ I reference the greater than 10% jump in market value for Teladoc after its announcement to offer GLP-1 medications, and the almost astounding 48% increase in stock price of WeightWatcher’s following their acquisition of Sequence Health, a GLP-1 online prescription business. The Ro Body program is mentioned, as more than just a GLP-1 business, rather ‘…a combination of GLP-1 medication, high-touch provider chronic condition care management, insurance concierge service, at-home lab testing, RN coaching and specific educational curriculum’, from Dr. Melynda Barnes, chief medical officer at Ro.
- The article also notes that Hims & Hers, a direct-to-consumer healthcare business, ‘…has not yet dipped its toes into weight loss and obesity medications…’ though plans are afoot as it ‘…added five new members to its medical advisory board including specialists in obesity medicine and menopause.’
- Patrick Carroll, M.D., Hims & Hers chief medical officer, states ‘…When we offer a program, it’s really going to be holistic and will include evaluation, counseling and medications but not just GLP-1s as there are generic medications out there that have been very successful in managing weight loss.’
- Dr. Avlin Imaeda, a gastroenterologist at Yale Medicine has it spot on with ‘…My impression is that some of these sites are really pushing the GLP-1 agonists and they may not be offering multimodal treatment, including counseling on diet and exercise.’
- Isabelle Kenyon, Founder at CEO at Calibrate, an online, direct-to-consumer weight management company, is driving toward an approach that is ‘…more holistic, and it involves longitudinal care…’
- Zachariah Reitano, CEO at Ro, gets the final word, with ‘…What we think about a lot at Ro is we don’t want to be the easiest or quickest place to get the GLP-1 prescription. We want to be the best place to get high-quality and ongoing obesity care.’
- The message here is that prescribing GLP-1 or other obesity medications alone, through the ease of online platforms, is at best a short-term strategy, and the industry needs to focus upon multimodal, whole-person, and multi-year strategies of care for people with obesity and associated chronic diseases. Simply said, we need to put our patients’ needs, desires and wants first; ahead of lucrative early revenue wins.
- Noting the repetitive nature of articles in the past few weeks… the sub-title from Oliver Wyman, an American management consulting firm, is ‘…Treating obesity is complex and requires a multi-pronged approach. Pharmaceutical companies can foster a more integrated strategy.’ Multi-modal, complex, integrated, long-term, and whole-person, are the pervading terms… and ‘…focusing solely on drug delivery misses the mark.’
- The article is a good general read, with focus on three challenges: 1. obesity is a serious and chronic medical condition; 2. Obesity care is complex and cannot be addressed the same way for all; and 3. coverage and reimbursement is limited.
- The five recommendations to pharmaceutical companies – though I would extend this to all who are involved in the care of people with obesity – is to: 1. develop and integrated and personalized approach; 2. align with policymakers; 3. offer affordable solutions; 4. communicate responsibly; and 5. to be clear about the market segment – from high-risk, to self-pay patients.
- The last time that Oliver Wyman deeply focused on obesity was a session at the World Economic Forum in Davos in January 2016 entitled Sugar, obesity and diabetes – the other global food crisis, followed up by Fighting Fat, ‘…a report that addresses the obesity crisis in the UK by positioning large supermarkets as health and wellness champions.’ I make the prediction that we will see more activity coming from Oliver Wyman in this space, very soon.
- With the greater preponderance of obesity in Black Americans, in terms of prevalence, severity, and inferior outcomes of care, I welcome the perspective of Benjamin Chavis Jr., CEO and President of The National Newspaper Publishers Association (NNPA), a trade association of more than 250 Black-owned community newspapers and media companies from across the United States, writing an op-ed in The Miami Times on ‘Obesity is not a hopeless fight for Black America.’
- He admirably suggests ‘…The public discourse around weight loss that has taken over recent headlines has entirely missed the mark…’ such that ‘…we are squandering a critical moment to focus on the deadly disease of obesity, and missing the opportunity to save thousands of lives, particularly Black lives.’
- I am thrilled to share with you this article, from a prominent civil rights leader, author, and journalist, inspired during his youth by Dr. Martin Luther King Jr., to shift the conversation onto deeper, more complex and challenging issues, above and beyond GLP-1 medication prescriptions per se. Dr. Chavis’ call to action is ‘…to elevate the conversation on the obesity crisis to one that clarifies the facts, shares reliable resources and advocates for impactful changes for the benefit of our community’s health and longevity.’
- This is underpinned by important messaging that ‘…obesity is a chronic disease and a long-term illness, with multiple contributing factors outside of a person’s control: environmental circumstances, inherently racist health care programs, poverty and genetics.’
- With particular reference to Black communities, ‘…food deserts and food swamps have become the norm…’ such that ‘…many people cannot access one of the key tools for combating obesity – a healthy diet – because of factors outside of their control.’
- The concluding statement calls to ‘…prioritize combating the obesity pandemic with the same energy we use to combat COVID-19 and racial injustice…’ and onward to ‘…Our lives depend on it.’ For me, having treated numerous Black Philadelphians who suffer with obesity, I have witnessed first-hand their challenges, and how we as care providers can best serve our patients, for the long term, in a holistic and culturally appropriate manner.
- An intriguing approach to obesity prevention is outlined by Hank Cardello in Forbes this week, with a PepsiCo initiative to ‘… gradually reduce sugar, salt and fat in its snacks lineup (without telling anyone).’
- PepsiCo CEO Ramon Laguarta’s intention is to ‘…make PepsiCo’s products less damaging by reducing those ingredients so gradually that people won’t notice.’
- Like Mr. Cadello, I too ‘…applaud Pepsi for taking this slower route and developing foods that over time can help people from becoming obese in the first place’. But, I cannot get out my head that it is also a way to get some airtime when the majority of the conversation is centered upon GLP-1 medications.
DATA
- Colleagues from County Kildare and Dublin, Ireland report on two lesser-known factors on obesity; namely ‘…Obesity is strongly associated with increased mortality from cancer and viral infection…’ and ‘…Peripheral blood natural killer (NK) cells are defective in people with obesity.’
- Natural killer cells, in case you did not already know, ‘…are a critical front line immune population tasked with protecting the host from invading pathogens and the development of malignancies…’ to ‘…rapidly kill infected or transformed malignant cells…’
- Think of NK cells as the good folks out there to combat bad actors, if I may. The short and sweet in three parts, for people with obesity: first, GLP-1 agonist treatment restores NK cell functionality; second, GLP-1 treatment boosts the cellular metabolism of NK cells; and third, these effects are independent of weight loss.
- So, I hear you call, does this mean that GLP-1 therapy can obviate viral infection and decrease cancer susceptibility? In short, yes. But in long form, this study only recruited 20 subjects, all of whom were on a GLP-1 agonist [semaglutide], without type 2 diabetes and obesity, defined as a BMI of greater than 30, before and after six months of GLP-1 therapy.
- Please also note that the authors ‘…declared no conflict of interest.’ which essentially means they are not supported with grants or consulting fees from pharmaceutical companies; indeed the research was supported by the Irish Health Research Board, with support and guidance from Irish Coalition for People living with Obesity.
- The research publication immediately above was picked up by Elaine Chen at STAT News, with the opening: ‘Drugs like Ozempic and Wegovy have become immensely popular for their ability to help people with obesity lose weight. A new small study suggests they may also be useful in fighting cancer.’
- In quote, Sagar Bapat, an assistant professor at University of California, San Francisco, states ‘…It’s becoming evident over the past few decades that obesity is not just an altered metabolic state, but perhaps is also an altered immunological state.’
- And to put the data in to context, the reporter does say ‘…The study is very small, and more research is needed to understand what this could mean for patients’ real-life health outcomes.’ Thank you for the real world approach and avoidance of onward, and inappropriate, hype.
- Professor Sir Aziz Sheikh, of the University of Edinburgh with a global focus on health information technology and data science to transform the delivery of care and improve population health, together with Professor Francisco Rubino and notable others, published this week in Nature Medicine, on ‘…waning of COVID-19 vaccine-induced humoral immunity is accelerated in individuals with severe obesity.’
- With BMI, hospitalization and mortality data on 3.6 million people in Scotland, the authors ‘…found that vaccinated individuals with severe obesity (BMI > 40 kg/m2) were 76% more likely to experience hospitalization or death from COVID-19…’ and second that ‘…that 55% of individuals with severe obesity had unquantifiable titers of neutralizing antibody against authentic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus compared to 12% of individuals with normal BMI, 6 months after their second vaccine dose.’
- The take home message is that COVID-19 kills more people with severe obesity, and the effect of the COVID-19 vaccine is less durable over time. Wow, a terrible double whammy for people with severe obesity. Professor Sheikh was quoted in a University of Cambridge press release: ‘…Our findings demonstrate that protection gained through COVID-19 vaccination drops off faster for people with severe obesity than those with a normal body mass index’, with the intent that more frequent booster shots will be needed to maintain COVID-19 protection for people with obesity.
Kind regards, Raj
