In the U.S., the prevalence of adult obesity is extremely high: 41.9% as of 2020. Obesity is a chronic disease that is characterized by “excessive fat accumulation or distribution that presents a risk to health”; it is a known risk factor for diabetes, cardiovascular disease, and certain cancers. Unfortunately, the current handling of the disease is drastically mismanaged. Below, I explain how we’ve gotten to this point, and what to do about it.
1) Stigmatization of people with obesity.
Unfortunately, there exists in our society a pervasive stigma around obesity — which in turn may actually promote the disease. According to a 2021 study, the stigmatization of obesity can worsen disordered eating (e.g., eating for comfort), reduce activity, and reduce engagement with the health care system. In a disheartening twist, studies report that physicians and other health care workers are common sources of weight shaming, whether explicitly or implicitly: A 2022 study found that 70% of patients with obesity feel stigmatized by their doctors, and there is an inverse relationship between a patient’s weight and a physician’s willingness to treat the patient. If we want to tackle the obesity epidemic in this country, we will not get far if the people tasked with helping to manage it have a weight bias that can not only reduce patients’ willingness to come for care but also affect physicians’ effectiveness in treating it.
2) Under-reliance on preventative care.
Beyond individual clinicians’ inefficacy, we must also contend with a society that prioritizes disease management over preventative care. Reducing obesity is a powerful treatment (and potential preventative therapy) for diabetes, hypertension, and hyperlipidemia, which are among the top risk factors for cardiovascular disease and death. And yet, the U.S. does not invest adequately in preventative care, as it has the highest health care cost per person compared to other comparatively wealthy countries ($12,318 compared to average $5,829); that is over two times what other wealthy countries spend). Further, the amount the U.S. spends on administrative costs is higher than it spends on preventative care. And despite all this spending on “health care,” the U.S. performs worse in health metrics like life expectancy and unmanaged diabetes compared to other wealthy countries. If our society is to be pro-health, there needs to be a bigger focus on (and investment in) preventative care, not just disease management.
3) High cost of weight loss treatments.
Obesity is a disease that’s as real as diabetes, and it can lead to diabetes. It is not a personal problem or failure, as we know social determinants of health are strong contributors to obesity and that there are different causes of obesity (including iatrogenic and genetic obesity). Too often, the people who need treatment the most (because they have food insecurity or are low income) are the ones with the least access to it. So, if we are going to fight the obesity epidemic, our society must make treatments available that are conscious of these environmental and social barriers to weight loss.
An example of our inadequate prioritization of obesity treatment or cure is clear in the cost of anti-obesity medications. Semaglutide (brand name Ozempic, Wegovy) is a drug that was FDA-approved years ago. The FDA approved it presumably because it deemed it sufficiently safe and effective in improving glycemic control and causing weight loss. However, I have observed that a patient who has diabetes is more likely to have the medication covered by their insurance than if the patient is on the medication for obesity. A patient doesn’t pay more for rosuvastatin if it is for hyperlipidemia versus for secondary prophylaxis for stroke or MI, after all. We need to prioritize obesity management by making anti-obesity treatments affordable and requiring coverage by health insurance companies.
I have heard statements from some people that anti-obesity medications are just quick or temporary fixes to an underlying (unsolved) problem. That may be true, but it doesn’t change the fact that treatment is beneficial. It would be unethical to withhold evidence-based treatment because we are waiting to address the underlying cause. It is not a rational statement that if there are affordable medications for obesity treatment or cure, then people will no longer work on lifestyle management, so it is best to limit access to treatment. That would be like saying we will not offer treatment for melanomas or lung cancers because patients may then decide to forgo sunscreen use or smoking cessation! The best health care system focuses on preventative care AND excellent disease management because sometimes prevention is not enough for a variety of reasons.
Our health care system gatekeepers (FDA, health insurance companies, and even some clinicians) are not treating obesity with the urgency of the potentially dangerous medical condition it can be. This needs to change. As six leading U.S. organizations focusing on obesity said in a 2022 consensus statement, “Every person with obesity should have access to evidence-based treatment.” Stigmatization of obesity is counterproductive and costly. Effective obesity management is one of the major ways that society can reduce the risks of diabetes, cardiovascular disease, and premature death. It is worth the money we need to spend.
How do you talk to your patients about obesity? Share in the comments!
Dr. Eseh-Logue is a Nigerian-American Texan physician, writer, and self-proclaimed patient and physician advocate. She spends some of her time at www.paradoxicalchamelon.com.
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