The future – or not – of bariatric surgery; access disparities in GLP-1 medications (and taking second jobs to pay for them); cost per avoided cardiovascular death; and, are bacteria the new Ozempic?

Hello everyone,

Welcome to September; I hope you are well on this long Labour Day weekend in North America. [And I will note, Labour Day is celebrated in many more places around the world than just the US and Canada, though it is more commonly celebrated on May 1st and alternately or also known as International Workers’ Day].

Good articles this week on a variety of topics, ranging from the the exploration of the future of metabolic / bariatric surgery in the face of GLP-1 medications, to the disproportionate utilization of these medications by wealthier neighborhoods creating a new disparity in treatment access for obesity. Also, more cost analysis on the GLP-1 medications, including total costs for treating everyone with obesity in Denmark, and the total cost for avoiding a single heart attack, stroke or cardiovascular death: $1.1 million. And, ‘Are Bacteria The New Ozempic?’

Also: this past week saw the annual conference for the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), held in Naples Italy. [IFSO is composed of 72 National Societies of Bariatric Surgeons and Integrated Health Professionals around the world: “The aim of the Congress is to educate on all the bariatric and metabolic surgery topics, as well as to unite across country borders health care professionals from different specialties, in our fight against the adiposity epidemic”].

twenty30 health advisors Shanu Kothari of Prisma Health, and David Sarwer of Temple University, were in attendance, and by all reports it was a terrific event this year. Of particular interest, there is a movement to refer to ‘adiposity based chronic diseases’, or ABCD,  rather than obesity. From my perspective, I like moving away from terms like, ‘the fight against obesity’, which is a legacy of a different mentality with respect to treating this chronic disease.

Kind regards, Raj

AT A GLANCE

• Novo Nordisk has acquired Embark Biotech, a ‘…a 2017 spin-out from the Novo Nordisk Foundation Center for Basic Metabolic in ‘…a three-year research and development collaboration…’ valued at up to 456 million Euro.
• Wealthier, whiter and healthier neighborhoods are taking Ozempic, Wegovy or Mounjaro at double the rate of city neighborhoods where where diabetes and obesity are far more prevalent; based upon a New York Times analysis, in reporting by Joseph Goldstein.
• Simar Bajaj at STAT News seeks to focus upon the ‘…existential questions about the future of bariatric surgery.’
• Airfinity, a UK-based data and analytics company, has sought to perform a cost-effectiveness analysis based upon ‘…data from the Wegovy trial on cardiovascular outcomes [that] it will cost $1.1m to prevent one heart attack, stroke or cardiovascular death.’
• ‘Are Bacteria The New Ozempic?’ Hiroshi Ohno at the RIKEN Center for Integrative Medical Sciences in Japan found certain bacteria ‘…to be more common in the poop of people with higher insulin resistance, according to an analysis of fecal samples provided by more than 300 adults at their regular health checkups…’ as per Robert Hart at Forbes.

NEWS

• Novo Nordisk has acquired Embark Biotech, a ‘…a 2017 spin-out from the Novo Nordisk Foundation Center for Basic Metabolic Research (CBMR) at University of Copenhagen…’ based upon a ‘…novel target that suppresses appetite, increases energy expenditure and enhances insulin sensitivity.’
  • The deal is a ‘…a three-year research and development collaboration…’ valued at up to 456 million Euro, based upon ‘…development, regulatory, and commercial milestones.’
  • Zach Gerhart-Hines, Chief Technology Officer at Embark Laboratories, commented ‘…We are thrilled to pass on the baton for our lead metabolic program to Novo Nordisk.’
  • This comes on the heels of Novo Nordisk’s recent acquisition of Inversago Pharma, and Eli Lilly buying up Versanis Bio. Embark Biotech is yet another example of the lucrative commercial market that pharma companies are setting their sights upon, and charged to exploit, over the next decade and beyond.
• The Danish health minister stated that treatment with semaglutide of Denmark’s 900,000 people with obesity would run to as much as $4 billion per year, as per Reuters News this week. This amount comes in at about 1% of total GDP for the Danish economy.

OPINION

• Wealthier, whiter and healthier neighborhoods were taking Ozempic, Wegovy or Mounjaro at double the rate of city neighborhoods where where diabetes and obesity are far more prevalent; all together, GLP-1 medications accounted for about 2.3 percent of all people living along a stretch of Manhattan that extended from the Upper East Side down to Gramercy Park. This is according to an analysis by Trilliant Health, a health care analytics firm, performed at the request of the New York Times, in reporting by Joseph Goldstein.
  • Goldstein quotes Upper East Side native, Jill Kargman who refers to it as the ‘…running game show of the 10021 ZIP code is guessing who is on “Vitamin O”…’ with access to these medications effectively becoming a new disparity in access to effective healthcare.
  • It is noted, ‘…obesity and diabetes…. disproportionately affect Black and Hispanic New Yorkers (and, in the case of diabetes, Asian New Yorkers) more than white New Yorkers.’
  • In reference to Covid vaccination and HIV prophylaxis post-exposure, the article claims ‘…New treatments often first benefit people who have higher incomes, top-notch health insurance or easy access to good doctors.’
  • In the South Bronx, ‘…about 73 percent of people on these medications had diabetes…’ whilst in ‘…the city’s wealthier enclaves, under a third had diabetes, Dr. Allison Oakes, Trilliant’s director of research, noted.’
  • It is of additional interest that this analysis was only based upon ‘…prescriptions that went through insurance…’ and as such ‘…did not capture people who were willing to pay the monthly cost of $1,300 for some of these medications, or people using imitation drugs.’
• Simar Bajaj at STAT News seeks to focus upon the ‘…existential questions about the future of bariatric surgery.’ More broadly, with ‘…only 1% of eligible patients receiving drugs or bariatric surgery…’ there may be an ‘…increase the number of patients seeking surgical treatment.’
  • The ‘…competing visions of harmonious medical-surgical integration [versus] potential obsolescence under the relentless pace of biotech innovation…’ are mostly powered by ‘…fierce turf wars over patients…’ in a fee-for-service health care model, that incentivizes well-meaning clinicians to deliver services in a transactional, silo-based manner, in counter to a whole-person, multi-modal care.
  • I am thrilled to see Bajaj quote several of my clinical colleagues over the past two decades, and one of my past trainees in this article. Dr. Marina Kurian, bariatric surgeon in New York City and president of the American Society for Metabolic and Bariatric Surgery, says ‘…bariatric surgery blows weight loss drugs out of the water, reducing major heart complications by 40%-50%, on top of various other benefits to every organ system in the body…’ and drops the microphone with ‘…these drugs are getting closer, but they’re not [yet] close.’
  • Dr. Dan Azagury, a Swiss-trained surgeon and now chief of minimally invasive and bariatric surgery at Stanford, says ‘…There’s three reasons why you might choose to not be on medications… One, you don’t want to be on it for life; two, there’s a cost equation; three, there’s some side effects.’
  • Michael Albert, an obesity medicine physician [and not a bariatric surgeon] corroborates Kurian and Azagury: bariatric surgery ‘…has a real advantage that medicine will never have, and that is a legacy effect…’ closing with ‘…in theory, it’s one and done.’ Albert believes weight loss drugs will be ‘…a sort of rising tides effect with surgery as well.’
  • Importantly, and to negate the aforementioned turf wars, Jenny Choi, a bariatric surgeon at Albert Einstein College of Medicine in New York, says ‘…I actually like the medications being around because I feel like I can offer patients more than just surgery…’ in a complementary, not mutually exclusive approach.
  • Zaher Toumi, a bariatric surgeon at Spire Washington Hospital in England pitches in that it ‘…will be almost impossible to get medications which are more effective than bariatric surgery.’
  • Indeed, the ‘…the future of obesity medicine might parallel that of cancer, where chemotherapy can be given before surgery to reduce tumor size and after surgery to kill residual cancer cells…’ where neither ‘…medication nor bariatric surgery will be the magic bullet.’
  • Over two decades ago, in patients with gastric cancer, we opted to remove the tumor surgically first, and then offered chemotherapy or radiotherapy to remove any residual disease; in 2006, the landmark MAGIC trial noted a 25% increase in overall survival for patients who received chemotherapy before surgery. This was groundbreaking, though seemingly counter-intuitive, with practitioners asking “shouldn’t we remove the cancer with a knife and then use the drugs?” The answer turned out to be no, not at all; we should shrink the tumor first with intravenous chemotherapy medication, and then undertake surgical excision.
  • In the care of people with obesity, I and many others strongly believe we are trending toward a similar model of multidisciplinary care, with surgery and obesity medicine extended to enlist nutrition, exercise and behavioral expertise, to achieve true whole-person, multi-modal care.
• In Health Affairs, William Dietz, Director of the STOP Obesity Alliance and colleagues review the ‘…major knowledge gap in the safety and effectiveness of drug therapy in people with obesity comorbidities.’ Their two-fold approach is to explore and understand ‘…how increased body fat can modify the effects of drugs commonly used to treat the comorbidities of obesity...’ and to ‘…consider the need to strengthen how drugs are evaluated in people with obesity to improve the effectiveness of their care.’
  • In people with ‘…excess body fat, fat soluble or lipophilic drugs may be distributed differently throughout the body…’ with common examples of such medications being painkiller ibuprofen, the SSRI sertraline, and emergency contraception drug levonorgestrel. The potential of pre-existing liver damage in people with obesity should also be considered, as the liver is a key organ in the metabolism of medications.
  • Currently, ‘…the pharmacokinetics of drugs in people with obesity are not currently assessed in the regulatory approval process.’ Indeed, drug companies ‘…are not required to include people with obesity in clinical studies, and the FDA has recognized that people with obesity are often excluded.’ In essence, ‘…studies must be done in people with obesity to assess the drugs’ clinical impact.’
• Stephanie Armour reports in The Wall Street Journal ‘…Patients report taking on second jobs, racking up credit cards and cutting back on travel or family expenses to… cover the full or almost-full price of popular drugs used for weight loss, after their insurance denied them coverage.’
  • This is a double whammy – first, insurers are denying coverage for weight loss, and second, drugmakers are charging the full list price of a drug instead of offering any of the discounts they give to health plans.
  • And third, likely most importantly too, ‘…Lower-income people who have higher risks for obesity might be left behind because they can’t as easily afford to pay out of pocket.’