Slim Pickings: Finding Cost-Effective Obesity Solutions
During the Middle Ages and Renaissance, a full figure was a symbol of status, indicating one’s wealth, fertility and power in an environment of food scarcity. Today, it has a different and ambiguous connotation. Faced with antiquity’s unreliable resources, humans were hardwired to prioritize calorie-dense, energy-rich foods. To reinforce this behavior, evolution gave a boost of dopamine when consuming calorie dense fare. Those who failed to feast during times of plenty might starve when food ran out. While abundant consumption was an advantage in early societies, the ingrained drive to stock up has led to growing rates of obesity as access to food has become more reliable.
Exhibit I – Venus of Willendorf [1]
Abundance to the Masses
With the industrial revolution and the use of fertilizers and machinery to dramatically improve the productivity of agricultural land, food has become abundant and its price has declined. Efficient food processing, transportation improvements and broad distribution to grocery stores delivered this plenty to the masses. The never-ending drive to stimulate demand engineered salty and fatty processed alternatives with addictive qualities that were widely available and easily consumed.
Food as Pleasure
The human brain has been trained to seek foods with high energy content. High fat foods are packed with calories, which keeps a person full, satisfied and happy. As humans evolved, we learned to stock up on these treats, anticipating scarcity. While this behavior improved survival during times of food instability, constant consumption of energy dense nourishment now contributes to obesity, along with numerous associated disorders.
More Food, Less Activity
Beyond food availability, other changes have taken place that add to weight gain. For many, a shift away from manual labor towards office work has reduced our energy use. Other trends over the last 50 years have also detracted: technology advances, automation, greater urbanization, greater use of motor vehicles and other energy-saving changes. A study authored by Church et al. found that during the 1960s, half of all jobs required moderate intensity physical energy expenditure, whereas 50 years later, fewer than 20% did. Church further estimated that over the same period, occupation-related daily energy expenditure decreased by 142 calories in men. [2] The combination of more calories and less energy use has led to a dramatic increase in the rate of overweight and obese individuals.
Exhibit II – Trends in Obesity: 1963 to 2018 [3]
Obesity is the result of consuming more calories than you burn. A diet high in processed foods, sugar, refined carbohydrates and unhealthy fats combined with a sedentary lifestyle has shifted the balance for many towards greater weight. We’ve fattened up from a combination of evolved genetics, psychological factors and socioeconomic influences.
Corpulent Costs
Obesity not only increases health risks and reduces quality of life and mobility; but also produces a significant economic impact. Two primary areas behind this cost burden include incremental medical care and productivity.
A 2021 study [4] found that obese adults were burdened with medical costs $2,505 greater than individuals of normal weight and double the comparison group. Costs were positively correlated from low to high level obesity and included contributions from many categories of care including inpatient, outpatient and prescription drugs. The same study found that obese individuals covered by public health insurance programs incurred more costs than average, adding $2,868 per year.
Exhibit III – Annual Health Spending: Obese Diagnosis vs. No Obese Diagnosis [5]
Other studies have found even greater differences in health care costs for obese persons of almost $5,000 per year [6] and lower earnings. [7] Overall health care costs attributed to obesity in the United States were an estimated $261 billion in 2018 8 and 2.2% of gross domestic product (GDP) in 2019. [9]
Obesity can lead to fatigue and low energy, low self-confidence, absenteeism, cognitive effects and motivation issues, all contributing to reduced productivity. This can lead to less output, lower wages, lower living standards, reduced competitiveness and lower living standards among other challenges.
In particular, obesity is associated with lower work productivity and absenteeism. [10] Health related productivity losses of 5% have been observed as measured through additional time needed to complete tasks. [11] Obese workers are overall less likely to be employed [12] and suffer from a host of other indirect costs that impair work productivity. There is also an association between obesity and reduced motivation. Depression, self-image, loss of enjoyment and other related factors are all more common in obese persons compared to normal-weight counterparts. [13],[14] Depression is particularly tied to weight gain and many anti-psychotics used to treat it are associated with adding pounds. [15] Cravings for comfort food and physical inactivity are other characteristics of depression that underpin obesity.
Exhibit IV – Obesity Death Rate (per 100,000 Individuals) [16]
Policy Perspective
The rate of obesity has increased dramatically over the last 50 years. In 1970 it was about 15% rising to over 42% today. The rapid rise has prompted policy responses that recognize best practices; however, the proposals are controversial. Obesity is clearly tied to higher death rates, lower productivity, greater health care costs and increased risk of illness. [17] But consensus on addressing these problems is less distinct.
Many policy approaches [18] have been proposed including mandating access to healthy foods, taxes on sugary foods, food assistance programs, menu and package labeling and incentivizing physical activity. The study found that most policy prescriptions modified access, cost and disclosure. The appeals for additional taxes, cost burdens and liberty and rights restrictions from product bans have galvanized resistance, underlining the complexity of a policy response.
Kaiser Family Foundation provided a review of recently proposed legislation that would authorize Medicare coverage for weight loss medications. It acknowledges the considerable evidence that weight loss promotes health. However, using Wegovy’s estimated annual net price of $13,600, the cost to Medicare, even if only 10% of obese beneficiaries use it, would be $13.6 billion. [19] This would increase the burden on a strained government program and incentivize policymakers to find other, more cost-effective alternatives.
Obesity’s Health Impacts
Related Health Conditions
Two of the primary health burdens associated with obesity are heart disease and type 2 diabetes. Excess weight strains the heart and blood vessels, leading to high blood pressure, heart attack and stroke. Obesity is associated with high levels of low-density lipoprotein (LDL) cholesterol, which can adhere to artery walls and restrict blood flow contributing to heart disease and stroke. Inflammation is linked to obesity, which can damage the heart. The greater body mass and volume of blood increases the organ’s workload which can cause hypertrophy and weaken the muscle.
Obese individuals are significantly more likely to develop diabetes than those of normal weight. Fat cells release pro-inflammatory chemicals and excess fatty acids into the bloodstream. These cause insulin resistance and interfere with the insulin-signaling pathway. In response, the body produces excess insulin, gradually exhausting the insulin-producing beta cells. There is also a high correlation between diabetes and a poor diet high in refined carbohydrates, sugar and unhealthy fats which exacerbate blood sugar spikes and instability.
Medical Interventions
Medical costs extend to bariatric surgery, which is recommended for severely obese individuals who have failed to control weight using non-surgical approaches. Individuals who qualify for bariatric surgery generally have a body mass index (BMI) in excess of 40, or are obese with comorbidities such as premature heart disease. [20] They may also be functionally impaired and suffer from mental health disorders. There are several types [21] of bariatric surgery which can vary in cost from $20,000 to $30,000+ depending on type, geographical location and provider. Ancillary costs can also be substantial and include hospital fees, travel and follow up care. For those without insurance, the costs are usually higher.
Medication may be an alternative. Costs and effectiveness can vary widely with weight loss ranging from 5% to 20%. Available medications can range from oral pills such as Qsymia to periodic injections for Wegovy and Zepbound. The products can also be over the counter, such as Alli or require a prescription such as Saxenda. Pricing for these medications can vary widely from $40 per month for over-the-counter options to more than $1,300 per month for the most recently approved GLP-1 agonists. Side effects are another consideration and can be of varying severity depending upon the product. Nausea, diarrhea, vomiting and constipation are common. Dizziness, dry mouth, sleeping difficulty and infection are other considerations. The FDA label must be reviewed to identify the risks and incidence of each.
Reclaiming the Spotlight
The search for an effective weight loss product has followed a tortuous path throughout the decades. There have been a number of rejections, approvals and later withdrawals following awareness of unacceptable side effects. A trio of agents were approved in Europe [22] in the late 1990s and early 2000s, but two were later suspended by regulators due to a variety of unacceptable side effects including cardiovascular risk and serious psychiatric problems. Only orlistat persisted in the market, but the drug’s strongest year was its first, after which sales declined over the remainder of its patent life.
While the market offered a number of effective products balanced by side effects, patients were wary and wanted confirmation of safety before committing. As risk perception for the failed weight loss offerings faded, the unmet need for a medicinal solution persisted. The rapidly-growing obese population [23] demands new medicines. A recent Goldman Sachs report estimates that this market could reach $100 billion by 2030.
New Options
Glucagon-like peptide (GLP-1) agonists are a class of drug first approved for Type 2 diabetes in 2005 with Byetta, generically known as exenatide. They stimulate insulin production and inhibit glucagon release from the pancreas. The class also delays gastric emptying, which limits volatility in blood sugar levels.
Over the following decade a number of other GLP-1 agonists came to market to address type 2 diabetes including semaglutide, liraglutide and dulaglutide. Researchers found that patients on GLP-1s reduced food intake and lost weight. This led to sponsors conducting additional studies and the eventual approval of liraglutide in 2014. Liraglutide’s (Saxenda) effectiveness was limited and it provided mediocre results. However, in 2021, semaglutide (Wegovy) produced better outcomes demonstrating substantially greater weight loss in a clinical study, bringing attention to GLP-1s. [24]
Obesity Treatment
Obesity can be diagnosed by measuring weight, waist circumference, BMI and evaluating imaging tests. A general physical exam is performed which evaluates heart rate, blood pressure, high cholesterol and other problems. After diagnosis, the first prescription to achieve weight loss is a change in diet and exercise. Avoiding high-sugar choices and consuming fresh fruits and vegetables are primary interventions. Evidence shows regular physical activity can be an effective complement to maintain weight loss. 150 minutes of moderate-intensity aerobic activity is recommended each week.
For many, diet and exercise are not enough. Maintaining the discipline of a low-calorie diet and time-consuming exercise routines may be impossible and require alternatives. Heart disease, Type 2 diabetes, high blood pressure, stroke and other deadly disorders must be addressed. Medicines may be necessary for patients that cannot achieve weight loss using diet and exercise alone. These are generally recommended for people with a BMI over 30 (obesity) or a BMI over 27 (overweight) with weight-related health conditions like diabetes or hypertension. A persistent question is: Which patients will benefit most from the drug while taking into account side effects and cost?
GLP-1 agonists such as Wegovy and Zepbound have rallied interest in the whole group bringing attention to the many weight loss therapeutics offered. Other prominent options include orlistat, phentermine hydrochloride & topiramate, and deoxycholic acid.
A literature review by Mital and Nguyen [25] found that, of the four leading anti-obesity drugs approved for pediatric use, phentermine-topiramate (Qsymia) was the most cost effective. All [26] demonstrated similar, mild to moderate, adverse events. Of the four, only Qsymia generated an incremental cost effectiveness ratio (ICER) under the standard threshold used by payors. Over a 30-year horizon, Qsymia’s ICER advantage was even greater.
Exhibit V – Weight Loss Medications [27]
While the weight loss benefits of GLP-1s have attracted the eye of dieters, so has their burdensome cost which can range from $800 to $1,350 per month. Except for the occasional billionaire, most patients are not able to afford the product without insurance. And many insurers have been reducing coverage [28] for the class due to anticipated pressures on premiums. Combine this with the shortage [29], [30], [31] of GLP-1s, which were first approved as life-saving diabetes treatment, and the need for alternatives becomes even more distinct.
Summary
There is much to consider when addressing obesity. The health risks are well documented and can dramatically affect quality of life and health care costs. While obesity’s solution is sometimes simplified to exercising more and eating less, this is frequently inadequate and further interventions are needed. Surgery or medications can help achieve weight loss but may bear significant costs and side effects which must be balanced against outcomes. With the additional healthcare burden of obese individuals adding $2,000+ per year and treatment costs running $30,000+ for bariatric surgery and $10,000+ per year for the leading GLP-1s, these alternatives lack economic support to be broadly pursued. This reality requires alternative approaches with comprehensive efforts including cost-effective medications along with diet and exercise to reduce appallingly high obesity rates.
[1] Venus von Willendorf, Naturhistorisches Museum Wien. Dated to 25,000 – 30,000 years ago, Willendorf, Austria. Photo by MatthiasKabel - Own work, CC BY 2.5, https://commons.wikimedia.org/w/index.php?curid=1526553
[2] Church, T. et al. Trends over 5 Decades in U.S. Occupation-Related Physical Activity and Their Associations with Obesity. PLos One, May 2011.
[4] Cawley, J. et al. Direct medical costs of obesity in the United States and the most populous states. Journal of Managed Care & Specialty Pharmacy. January 2021.
[5] Kaiser Family Foundation analysis of Merative MarketScan Commercial Database.
[6] Statistic cited by the STOP Obesity Alliance.
[7] Statistic cited by the Obesity Action Coalition.
[8] Cawley, J. et al. Direct medical costs of obesity in the United States and the most populous states. Journal of Managed Care & Specialty Pharmacy. January 2021.
[10] Goettler, A., et al. Productivity loss due to overweight and obesity: a systematic review of indirect costs. BMJ Open. October 2017.
[11] Kudel, I. et al. Impact of Obesity on Work Productivity in Different US Occupations. Journal of Occupational and Environmental Medicine. January 2018.
[12] Tunceli K, Li K, Williams LK. Long-term effects of obesity on employment and work limitations among U.S. adults, 1986 to 1999. Obesity. September 2012.
[13] Atlantis, E., Baker, M. Obesity effects on depression: systematic review of epidemiological studies. International Journal of Obesity. April 2008.
[14] Plackett, B. The Vicious Cycle of Depression and Obesity. Nature. August 2022.
[15] Baptista, T. Body weight gain induced by antipsychotic drugs: mechanisms and management. Acta Psychiatrica Scandinavica. July 1999.
[16] IHME, Global Burden of Disease. Death Rate From Obesity, 2019. Premature deaths attributed to obesity per 100,000 individuals. Obesity is defined as having a BMI ≥ 30. BMI is a person's weight (in kilograms) divided by their height (in meters) squared.
[17] The CDC estimates that 30% of COVID hospitalizations were related to obesity.
[18] Fox, A., Horowitz, C. Best Practices in Policy Approaches to Obesity Prevention. Journal of Health Care for the Poor and Underserved. May 2013.
[19] What Could New Anti-Obesity Drugs Mean for Medicare? Tricia Neuman and Juliette Cubanski. Published: May 18, 2023.
[20] Some of the diseases associated with excessive weight include: Diabetes, High blood pressure, High cholesterol, Sleep apnea, Depression, Heart disease, Acid reflux, also called gastroesophageal reflux disease (GERD), Stress urinary incontinence, Arthritis, Fatty liver disease, Migraines, Increased cancer risk.
[21] Common types of weight loss surgery include gastric bypass, gastric banding, sleeve gastrectomy and biliopancreatic diversion with duodenal switch among others.
[22] This included sibutramine, rimonabant and orlistat.
[23] According to the CDC, the US obesity rate was 35.7% in 2009-2010 and 42.2% in 2020.
[24] For all of you who read the notes here is your easter egg. Ozempic Wegovy Mounjaro, no more sorrow.
[25] Mital, S., Nguyen, H. Cost-Effectiveness of Anti-obesity Drugs for Adolescents With Severe Obesity. JAMA Network. October 2023.
[26] Other medicines: orlistat, liraglutide & semaglutide
[27] Qsymia by Vivus
[28] GLP-1 drugs are still in demand. Insurers are cutting back coverage in response, Found study shows.
[29] Government declares ‘national shortage’ of GLP-1 receptor agonists for type 2 diabetes until 2024.
