Treating Obesity Should Be Our Healthcare Moonshot

On September 28, the White House held a Conference on Hunger, Nutrition and Health. Unfortunately, obesity was skipped as the main topic of the conference. Still, the day before the conference, the CDC reported that the number of states with high adult obesity rates has more than doubled in the past 4 years, and the pandemic has exacerbated this increase. While rates of food insecurity are stable or declining and obesity rates are on the rise, why was obesity not first thought of at a White House conference on health and nutrition?

Hunger arouses sympathy, while obesity arouses shame and hatred. Stigma and blame are often associated with the disease. As Susan Sontag pointed out Disease as MetaphorA disease, such as cancer or obesity, is not the result of moral failure or personality. In particular, the Biggest Loser study showed that patients with obesity are supremely motivated to lose weight through lifestyle changes, even under a national spotlight, but will often regain the weight.

Weight gain is a result of physiology, not psychology. The diet will raise the hunger hormone ghrelin, decrease the satiety hormone GLP-1, and literally lower the thermostat by reducing calorie expenditure by 15%. While dieting, the body will maintain its set weight and make it difficult to lose weight because maintaining weight is a biological imperative.

Surprisingly, the conference talked about obesity only temporarily and as a treatment in the context of prevention and dietary counseling. However, while current and emerging obesity treatments are available, it is important to consider these treatments in conjunction with other healthy lifestyle interventions.

Treatment Time

While prevention is laudable, it cannot cure the millions of obese patients currently at risk of diabetes, hypertension, heart failure, cancer and COVID-19. Of note, the two leading risk factors for COVID-19 outcomes are weight and age, and our national obesity rates may be responsible for worse national COVID-19 death rates compared to other countries. We cannot change our age, but we can change our weight.

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Although nutrition is important, patients with clinical obesity cannot be treated with nutrition alone. The current administration has medicalized nutrition consulting, and the Obama administration has “Let’s Act!” initiative — these interventions can be helpful, but not standalone for most obesity patients. Sometimes too much emphasis on nutrition or exercise can lead to delays in drug intervention in patients who would benefit. For obese patients, weight loss is achieved metabolically – often not motivationally alone.

Medical Inflation

The long refrain about the consequences of obesity must be coherently lined up by health professionals and government officials to focus attention. When our soldiers can’t complete basic training because of weight, obesity affects medical costs and complications, and even national security. Obesity is the medical equivalent of economic inflation. The value of medical advances will be eroded and diminished by obesity, which increases the prevalence and outcomes of multiple diseases while simultaneously undermining the effectiveness of their treatments. The primary example is type 2 diabetes, which is a strong contributing factor to obesity. If obesity in the diabetes setting is left untreated, diabetes management will remain difficult, similar to providing aspirin for a fever that requires antibiotics. A recent National Commission on Clinical Care report on diabetes barely placed emphasis on optimizing current treatment options for obesity. Historically, instead of strong medicine, people with obesity and diabetes were offered less sugary drinks, more breastfeeding, and weak teas on initiatives such as food label changes. While these may provide some health benefits, they alone do not go far enough.

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This makes the conference’s decision not to engage in obesity and its treatment discouraging obesity patients and healthcare professionals dedicated to their care. Relying on changing food labeling without adequately benefiting from the proposed voluntary labeling could result in greater regulatory burden and confusion for the public. Nutrition advice is notoriously contradictory and difficult to message, and even more so when the message changes.

The Treatment Has Arrived

With 900 hospitals providing accredited bariatric surgery and two new anti-obesity drugs (AOMs) showing breakthrough results, these legacy approaches are all the more confusing as obesity treatment is now innovative, safe and effective. In the long run, bariatric surgery can reduce overall mortality by 40%, cancer mortality by 52%, and even hospitalization for COVID-19 by 49% and increase the likelihood of type 2 diabetes remission. AOMs can cause up to 20% total body weight loss, and 5% total body weight loss is a measure of significant health improvement. If cost is an issue, please already pays a conservative estimate of $260 billion annually for the consequences of obesity; Obesity treatment can also be cost-effective, as noted in the bariatric surgery example.

What can we do?

Here are 10 key steps for government officials and healthcare professionals:

  1. Pass Congressional Treatment and Reduce Obesity Act
  2. Lead CMS to negotiate pricing of anti-obesity drugs
  3. Instruct CMS to promote bariatric surgery for selected populations as CMS promotes kidney transplantation for patients with chronic kidney disease
  4. Ensure Basic Health Assistance includes access to obesity counseling, medications and bariatric surgery
  5. Improve reimbursement for obesity services commensurate with other treatments
  6. Provide a quality measure to advise on all obesity treatment options for those affected annually
  7. Fund new “National Institute of Obesity” centers such as the National Cancer Institute centers as well as a new National Institute of Health dedicated to obesity
  8. Provide nutrition education at all education levels, especially in medical faculties
  9. Improve economic opportunities and public safety in food and exercise deserts with demonstration projects and grants
  10. Create an Obesity Czar to support prevention/treatment strategies and overcome bureaucratic hurdles
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Treating obesity is our most important point in terms of health. If we fulfill this mission, our goal will be to improve the quantity and quality of life with fewer cancer, heart disease, diabetes and even COVID-19 complications. To achieve this goal, we need to seriously treat obesity. This isn’t a democratic or republican issue – it’s an American issue. Obesity affects inner-city minorities in the north and rural communities in the south, and even meeting rooms. We need to give more than counselling. Obesity patients need treatment.

John Magaña Morton, MD, MPH, MHA, is professor and vice chair in the Department of Surgery at Yale School of Medicine.

Descriptions

Morton disclosed consulting payments from Ethicon (which makes surgical staples used in obesity surgery), Novo Nordisk (manufacturer of obesity drugs), and Olympus.

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