Rae Woods (01:28):
From Advisory Board, we are bringing you a Radio Advisory. Your weekly download on how to untangle health care's most pressing challenges. My name is Rachel Woods. You can call me Rae.

(01:39):
In the last several decades, billions of dollars have gone towards programs aimed at curbing obesity in the United States. But despite these efforts, the prevalence of obesity remains high. More recently than that, patients, physicians, the entire industry, the entire world, is focused on new weight management drugs. In fact, we did a whole episode about those drugs a couple of months ago, and I can link to those in the show notes. But while coverage for those medications varies, in the meantime, most people, most patients, will continue to receive the industry's traditional approach to weight management. And I'm not sure that that approach is working.

(02:19):
So we need to have a broader conversation about how the industry approaches obesity and weight management. And to do that, I've invited two Advisory Board experts, health equity expert Darby Sullivan, and pharmacy expert, Chloe Bakst, to discuss our current approach and how we might actually be doing more harm than good.

(02:40):
Hey, Darby. Hey, Chloe. Welcome to Radio Advisory.

Darby Sullivan (02:43):
Oh my gosh, it's great to be here.

Chloe Bakst (02:45):
Happy to be back.

Rae Woods (02:46):
Darby, I'm going to admit something to you. I'm so sorry...

Darby Sullivan (02:50):
What?

Rae Woods (02:50):
... But this is the second time this week that Chloe and I are talking about obesity and weight loss drugs.

Darby Sullivan (02:58):
Oh, without me?

Rae Woods (03:00):
Yes. We did it without you.

Darby Sullivan (03:01):
Devastating.

Rae Woods (03:01):
We did it without you at an event earlier this week at Advisory Board office. And I'm so sorry we didn't include you.

Darby Sullivan (03:10):
I don't know if I'll recover.

Chloe Bakst (03:12):
That would've been fun. That would've been a great value add, for me at least, having Darby there.

Rae Woods (03:17):
Maybe it would've been too fun. Maybe it was a good thing. Well, no, we had 90 minutes and we still ran up at the end of time, because there's clearly so much to talk about, so many opinions, so many questions. And I think that we should just lean into those questions, and frankly, even some of the controversy, as we have this conversation.

(03:38):
So no one needs to be told that weight management drugs are popular. This is the conversation of the moment in healthcare business, and outside of it. And like I said, there's still a lot of questions.

(03:50):
And I know, Chloe, you came on the podcast, a couple of months ago now, to talk about the dawn of this new category of drugs. And we started to talk about what the ripple effects would look like for the healthcare industry. But that was a few months ago. What's changed since we last spoke?

Chloe Bakst (04:07):
I feel like a lot has changed, but also very little. The big pieces that have shifted is it just getting more and more popular, there's more and more conversation around it. I think I saw something on the news that Novo Nordisk now is raising the entire Danish economy by the force of US sales of Wegovy and Ozempic.

Darby Sullivan (04:29):
Wow.

Rae Woods (04:29):
Because Novo Nordisk is in Denmark.

Chloe Bakst (04:31):
Yes. Yeah, exactly. Outside of the economics of it, all the bigger pieces: new competition, we're waiting on studies to come out to see if this has impact on outcomes outside of weight loss, we're still in that stasis, hold pattern right now, on deck to see what's coming.

Rae Woods (04:53):
And more drug innovations are coming, right?

Chloe Bakst (04:57):
Yes.

Rae Woods (04:57):
Just more kinds of these GLP ones. We're looking at a pill version instead of an injectable. This is very much the beginning of the conversation about how these drugs are going to affect healthcare.

Chloe Bakst (05:10):
Yes. The next 2, 3, 5 years are going to see so many new weight loss drugs hit the market, and they're probably going to get better and better with each iteration, and we're going to see different versions, and oral, injectable. I don't know if they can make any other versions of pills, but if they can, they'll try. And it's going to be a brand new market.

Rae Woods (05:35):
And this is one of the reasons why we tried to push health leaders to have conversations about these drugs early. But if I'm honest, I also think that the industry as a whole is actually quite late to conversations about obesity, and about weight management more holistically. Do you think that these drugs have pushed us to a point where we can actually start to rethink our approach to obesity in healthcare?

Chloe Bakst (06:03):
I'll answer, but I'm also very curious for Darby's thoughts here.

Rae Woods (06:05):
We're so good at talking without Darby at this point.

Darby Sullivan (06:08):
This is hurtful. This is bullying.

Chloe Bakst (06:11):
I feel like my answer is I hope so. I hope that these drugs are a catalyst that pushes healthcare leaders to really start asking themselves, "Okay, we as both payers, our health systems, are going to be spending or seeing increased demand for obesity care services. Now is the time to really think about our strategies in this space and assess if we're going to integrate these medications, how can we do it in a way where we're wrapping services around patients so that they can either adhere to these medications appropriately, or if they have to wean off, don't immediately get the weight regain that follows discontinuation from these drugs."

Darby Sullivan (06:56):
I wonder, with the rise of these drugs, if this is going to push our industry into a more introspective moment, where we think about what is it that we are actually trying to do here? Is our ultimate goal weight loss, period, in which case these drugs are the answer, or is our ultimate goal health in a more metabolic sense? In which case these drugs may or may not. As Chloe said, we're still waiting to hear. They may or may not be the one size fits all answer. So I'm hopeful that the industry will start to grapple with how it even thinks about weight management overall.

Rae Woods (07:39):
Yeah, that's a good push. I guess I want to ask the two of you, what kind of conversation should we have today? What kind of conversation should the folks listening to this podcast have? We know that our current approach to obesity isn't working, that's clear. But should we be talking about how to advise health leaders to take a different approach to weight loss and enable more weight loss? Or are we having the wrong conversation about obesity, in general?

Darby Sullivan (08:09):
Well, you set me up for at least my spicy take on the issue, and I'd be curious to hear Chloe's thoughts. I think it's almost impossible to disentangle those two things. So we can't extricate the broader societal stigma and discrimination that we have baked into our culture from how our own industry operates because we're in the same world. So we have these biases in our culture that we need to rethink, and we also have to assess how those biases have led to major missteps in our approach in weight management.

Chloe Bakst (08:43):
I think my response to that, and to your original question, Rae, if it's weight loss versus obesity, I think to Darby's point, it's very hard to disentangle those two things. But also for me, it becomes a question of what are we measuring? Because if the goal is to lower someone's BMI, then we're going by weight loss, and is that an accurate picture of somebody's health? Probably not.

(09:09):
So if we want to actually think about health outcomes and treating chronic obesity, chronic obesity, including metabolic conditions or comorbidities outside of just a number on a scale, then we need to have a different conversation, and these medications can't be seen as the solution to obesity, because they're a solution for weight loss mostly in the short term. What does that mean for population health?

Rae Woods (09:36):
So it sounds like we need to talk about both, and you're getting down a path that I think is important for us to explore, which is to interrogate the things that the current healthcare industry gets wrong when it comes to obesity. And I have to believe that the things we're getting wrong today aren't going to suddenly get better as weight management drugs enter the market. Or to Chloe's point, as new and better weight management drugs enter the market. Is that right?

Chloe Bakst (10:02):
Yes. Yeah. You can't put people into a system that's built on structural inequities and expect them to come out with all their health problems solved. It's like, what's the data allegory? Garbage data in, garbage data out?

Rae Woods (10:20):
So what do we need to correct then, in terms of the way that our system approaches obesity?

Darby Sullivan (10:24):
So I think there are three things in particular that our industry should take a closer eye on, especially as we're thinking about how much money do we actually want to be spending on a regular basis on these extremely expensive weight loss drugs?

(10:39):
So the first being, are we over-focusing on the power of individual choice and action as the key driver of obesity? And I use the term obesity, specifically, because that is the term that the BMI uses.

(10:55):
But my second point is, should we take a closer look at this population level tool that we've been using for individual patient identification, the BMI?

(11:05):
And thirdly, are we accurately estimating the impact that weight bias and this over focus, or maybe not over focus, but are we underestimating the impact that weight bias in a microscope on someone's weight has on their mental and physical health?

Rae Woods (11:23):
That first one really strikes a chord with me, because I feel like so much of the conversation about weight management is all about the individual. If you could just eat less and move more, then you could overcome obesity. And I want to be so clear, it is not that simple. If it was that simple, we wouldn't be having this conversation. Frankly, these drugs would not exist if it was merely that simple.

(11:50):
I think this misses a broader picture that when it comes to obesity, there's a huge, and frankly, confusing web of factors that influence weight. Not to mention some of the structural causes of weight gain, or of health outcomes, and the fact that those things to Chloe's point may be different. So what is the industry missing when we only overemphasize this idea that it's a personal choice? This incorrect idea that it's a personal choice?

Darby Sullivan (12:19):
I think we're missing the point entirely. We are pointing the finger at individuals without having a sense of what are the reasons why people have certain tendencies or enact certain behaviors. It's interesting because I think our industry has largely learned this lesson for years now around the social determinants of health. They impact folks' health outcomes a lot more than an individual's behaviors do. But there's still this hesitance, or this mental block, in applying what we know to be true about the social determinants of health to people with higher weights.

(12:53):
Even though if you live in a food desert, if you don't have safe outdoor space, if you have to work multiple jobs and you're back to back back, you're going to have less resources and less time to devote to the healthy behaviors that we know helps everyone, regardless of your body size.

(13:08):
So it's both a poverty problem, but it's also a policy problem. So when we look at which foods are heavily subsidized and more affordable and which are not, so when I look at a weight management strategy that an organization has, if it doesn't touch the social determinants of health, that's a huge missed opportunity.

Chloe Bakst (13:26):
In addition to what we're missing, I also want to think about what those beliefs are causing, because if you are a provider and you have a perception that, "If my patients just worked out a bit more or ate a bit healthier, they wouldn't have all of these health problems, and then I wouldn't have to maybe work so hard to get them to be healthy." It creates a tension between the patient and the provider, where the provider might be not even conscious of the fact that they're perpetuating bias onto their patient, and then that patient walks away from that encounter feeling terrible, and feeling like, "I'm never going back to the doctor again. I was just treated so terribly."

Rae Woods (14:06):
So what I'm hearing is that on the one hand, there is danger when the entire healthcare system, when the entire enterprise thinks of obesity as an individual choice, because then we invest in the wrong solutions or we ignore the root cause problems, which to be clear, is not going to help move us forward towards the goal of reducing obesity, if that is the goal.

(14:28):
But it also comes up when individuals, not whole organizations, not whole systems, interact with people and default to this false notion that it is only about individual choice.

(14:41):
And to Chloe's point, this shows up in the doctor's office a lot. Why do physicians, aside from the fact that they're humans, like all of us, tend to default to this idea that it's just individual choice?

Chloe Bakst (14:56):
Well, I think the first, to cut physicians some slack, they are people living in a society that is based upon these types of beauty ideals and false narratives around weight and health, just like anybody else. So that's just the reality of being human in this day and age.

(15:14):
But I think the second piece of it is really just, primary care physicians are busy, and they have no time to talk to patients about complex issues in a 10-minute visit to get into all of the... We talked about all these different factors that can impact obesity, and to try to dissect that in a visit where you're probably having to talk about a bunch of other health concerns as well, it's really difficult. And a lot of providers don't have access to training to help them get to a point where they feel comfortable even starting that conversation. So there's a fear and discomfort.

Rae Woods (15:53):
Especially if to do it correctly, we have to do all the things that Darby just talked about, which is talk about all of the social determinants of health. That is not a small conversation to have, nor necessarily a conversation that your average, not just PCP, cardiologist, endocrinologist, orthopedic surgeon, might be equipped to have in a way that actually results in behavior change.

(16:12):
In fact, I think they're having the conversation, but perhaps not in a way that exhibits behavior change, and might actually be more risky because it has a deeper effect on the patient. And Darby, I think this was one of the big missteps that you mentioned at the beginning.

Darby Sullivan (16:29):
Yeah, which absolutely was one of our takeaways, which is that there is a risk that weight bias can actually be actively harmful to someone's mental and physical health, and it can sometimes be more harmful to focus on someone's weight and to focus on weight loss as a part of a clinical conversation than the alternative. Partly, this is because sometimes your mental health is just more important than your physical health, which maybe is a hot take. That definitely is just an opinion. But the point is that the toll that constant bias and exclusion and moral judgment can take and can have on someone emotionally is also not healthy.

Rae Woods (17:10):
I'm not sure that that's as hot of a take. As you think, Darby, correct me if I'm wrong, but I think just a couple of weeks ago, the AMA adopted the position that, "An overemphasis on body thinness is as deleterious," okay, that's a big word, AMA, "to one's physical and mental health as obesity." So they're saying that an overemphasis on being thin is as harmful to your physical and mental health as being obese.

(17:37):
Yeah, that was a big statement to come from the AMA.

Chloe Bakst (17:41):
But I think it's so necessary, because I think a lot of the unspoken reality of living in a larger body is that anytime you go to a doctor, and I'm just talking specifically about healthcare, if you go to a doctor for any reason outside of a weight loss conversation, like if you're going to the doctor because you have painful periods or something, the doctor is going to tell you that you need to lose weight, and that's going to become the focus of the visit, and you're going to walk out with a diagnosis to eat less, move more, and not any sort of resolution for the problem that you went in with.

Rae Woods (18:17):
And talk about physical health, that might mean that person doesn't come back to the doctor for any other problem, whatever it might be next, because they were told that they just need to lose weight and all of their health problems are going to go away. So perhaps what I'm hearing you say is that if you're going to invest in weight management, or if you're going to invest in a more holistic view of obesity, you can't do that successfully without also including mental and behavioral health.

Darby Sullivan (18:43):
Yes. And also realizing how sometimes the actions within our own industry are making mental and behavioral health worse. There are a lot of studies that emphasize what Chloe was just saying around how providers, many providers, hold either implicit or explicit negative attitudes towards people who are of higher weights. They spend less time with them, they build less of a rapport, and they misdiagnoses depression, anorexia, diabetes, and even cancer. So it's not just an individual battle to feel comfortable in your body and to take care of your mental health, but it's also what are the direct impacts that this bias is having on you, as a patient.

Rae Woods (20:23):
And I want to be clear that this is a problem that's not going to go away with these drugs. It would be incomplete for folks to think, "Great. We'll put everyone on GLP-1s, they are going to get smaller. Once they are smaller, they will not be experiencing fat bias in their life or in healthcare." And in fact, one thing that I'm not hearing enough about in the conversation about these weight loss drugs, about these GLP-1s, is the mental health toll that it takes when everyone suddenly starts treating you very differently when you're in a different body, especially when you're spending, Chloe, what's the list price for Wegovy? I think $1300 a month.

Chloe Bakst (21:03):
I think $1350? Yeah. Yeah.

Rae Woods (21:03):
So you're spending, and list price isn't the same as the actual price that an individual is going to pay, but you are paying a ton of money to access these drugs, knowing that just like every other drug, the impact of it is going to stop when you stop taking it, meaning that you will gain the weight back. And what that might mean for the mental health of a patient who's in a different body, who's treated differently, and who knows that they're going to gain, what? Two thirds of the weight back, at least is what the data shows, if they stop taking the drug.

Chloe Bakst (21:34):
And the reality is, I'm adding onto that, we don't know what these drugs mean in a real world setting. We have clinical trial data, but we're so early on for how these drugs exist in the world as people take them. People don't adhere to drugs perfectly, 100% like they do in a clinical trial. It's not reality.

(21:56):
And also, lots of people could be on an antidepressant or a birth control pill or a diuretic, and all these medications have weight gain as a side effect of the drug. So how does that interact with the person who's on Wegovy? We don't know how weight management medications necessarily, yet, in everybody, are going to create the same outcomes. So what does that mean from a mental health perspective? If you're a patient and in order to lose the weight, you have to go off of your antidepressant? This is a fictional scenario, but there's a lot of factors at play here that make leaning on these weight loss drugs as the solution for weight loss and obesity difficult to imagine successfully.

Rae Woods (22:46):
I feel like the first two things that the industry gets wrong when it comes to obesity management are going to be hard to unwind. Unwinding this idea that it's individual choice, unwinding the fat bias that we all have and that exists in healthcare. Talk to me about this other one. BMI. I have to believe that moving off of BMI, maybe this is an easier one for us to do.

Darby Sullivan (23:09):
That's optimistic.

Rae Woods (23:10):
Does anybody think that BMI is a good measurement of health?

Darby Sullivan (23:13):
People do.

Chloe Bakst (23:14):
Yeah, that's a hot take. Is BMI a good measurement of health?

Darby Sullivan (23:18):
Well, you know who doesn't is the AMA.

Rae Woods (23:19):
Really?

Darby Sullivan (23:21):
So the AMA a couple months ago recommended that the industry move away from using BMI alone to diagnose obesity. So that was a major, major moment in the weight management space, because folks who studied the measure have long been raising the alarm that this is imprecise and sometimes harmful.

Rae Woods (23:43):
Wow. So what should they use instead?

Darby Sullivan (23:46):
Oh, well, isn't that the question? Well, at first it's probably helpful to unpack why the BMI has lost favor. So in the case of the BMI, it was supposed to be a population level statistical tool, and it was trained on white male bodies. I think they were specifically in the military, in the 1800s in Europe, and simply the ratio of weight to height. The AMA said this is a tool that has been used for historical harm and racist exclusion. And in addition, it's imprecise, because it doesn't account for muscle mass or bones or the different types of fat, and it is not a measure of any specific type of metabolic health metric.

(24:30):
There are two risks on either end of the spectrum. Using the BMI can underestimate health risks, most notably diabetes in Asian populations. And it can also sometimes overestimate health risks, because up to 30% of people who are overweight are still metabolically healthy. So if you are a health leader and you're using the BMI for your risk scoring methodologies, there's a risk that you maybe are misallocating resources or that your analyses are skewed.

Rae Woods (24:57):
And at the beginning of this conversation, I kind of asked you what should we be talking about? Should we be talking about how to enable more weight loss and reducing obesity, or should we be challenging the way that we look at obesity in general? And perhaps the better question that we should be asking is how do the structures that we have in healthcare, including the onset of these new drugs, enable better health, and health is different than merely obesity, or merely body size?

(25:27):
Chloe, do we actually know if these new drugs improve health outcomes and not just induced weight loss?

Chloe Bakst (25:33):
There are studies coming out. There are some studies that have shown that patients who take these drugs have lower cardiovascular risk and better cardiovascular health outcomes, but we're still waiting to see the full results. That the select trial will come out in November of 2023, so we're waiting on that right now.

(25:52):
But I think it's likely that they will demonstrate some pretty positive health outcomes. And so the question again goes back to what are we going to measure if we're moving past BMI? Realistically, I don't think we're ever going to be saying goodbye to BMI, wholesale. People are, it's such a cheap, easy way to measure a population, and it's part of the regulatory approval process for weight loss drugs in the first place. So it's really hard to untangle that web.

(26:27):
But I think we can move closer to a BMI/and approach where we are looking at BMI, but we're also looking at cardiovascular risk, or we're looking at what's your glycemic levels, or blood sugar levels, or how's your sleep apnea, or other health outcomes that can signify metabolic conditions or health risks beyond BMI or just weight alone.

Rae Woods (27:02):
I hear you, Chloe. But I mean, my question is, and this is not an advisory board research perspective, it's just mine, but if we're relying on this proxy that's imprecise, is it even helpful to use BMI as a proxy? The AMA did say it should be a BMI/and approach. So I think, best case scenario, that's where the industry will go, but it's not the best way, in my opinion to get to a really patient-centered and tailored approach.

(27:32):
I will tell you the pushback that I hear about BMI is sure, it's imprecise when we talk about defining overweight versus quote normal weight people. It may even be imprecise when we're talking about obese people, so BMI over 30 and their health outcomes. But where we start to see a stronger correlation between health and body size is when BMI gets higher and higher and higher. And those are numbers that are used for things like, will insurance actually cover weight loss drugs? Will insurance cover other methods of weight loss, like bariatric surgery? That's where I start to hear folks go, "Yeah, BMI is not that precise, but above 40, 45 even, is that where we can start to have more confidence in the health outcomes in this metric?"

(28:13):
I don't know that we are going to perfectly solve the BMI question today, but I do think that we can push all health leaders to start moving away from this metric, at the very least to be thinking about BMI/and.

(28:27):
So if I'm honest, we've spent a lot of time talking about all the things that are wrong in the industry and the way that we're approaching weight loss, the way that we are approaching obesity, the way that we are approaching patient centricity when I look at this kind of population. Even the way that we're thinking about these drugs.

(28:43):
I want to talk about what we should be doing. What would it look like for the healthcare industry to more holistically look at and address obesity and support obese people?

Darby Sullivan (28:54):
So it sounds hard, but I actually don't think any of the solutions that we would point to are that new. So one of the aspects we always like to highlight is how are we implementing more patient-centered care models to meet the full range of patient needs? That's just population health 101, right? How do you engage a patient, learn their preferences and their health goals, but maybe keeping in mind that it's time to set weight aside? That's how the "Health At Every Size" movement is one example of this, that incorporates this weight inclusive approach, where we track metabolic metrics, we emphasize the importance of physical activity and nutritious eating, and ensure that folks can get there, but we're not at all interested in the number on the scale or whether that translates to weight loss.

(29:41):
That, paired with social services, behavioral health support, nutritionist support, that kind of wraparound care that meets those social needs we were talking about, that's stuff that we have already been building muscles to do in our population health departments and community health.

Chloe Bakst (29:58):
I think when we're thinking about how to integrate weight loss medications into what Darby is describing, it becomes a two-parter. The first is before a patient initiates these medications, if you're a provider recommending them, interrogate why you are recommending this drug, and whether there are other non-weight loss specific options that makes sense, similar to what Darby was describing.

(30:24):
And if a patient's coming in and asking for them, take the time to have a conversation about their health goals and why they think that being on a weight loss medication will get them there.

(30:38):
And also if it turns out that that patient does really want this medication, don't gate keep it, but be prepared to offer an intense level of wraparound services that will help patients to stay adherent to a medication that is a lifelong drug, and has significant side effects, and will require behavioral health, conversations with a pharmacist, talk about drug-to-drug interactions, conversations with nutritionist to make sure that if your appetite is depressed, are you getting the right nutrients? All of these things have to be a part of the greater care conversation when we're talking about managing obesity, and not just treating for weight loss.

Rae Woods (31:23):
I feel like we've only scratched the surface on the questions that a lot of folks have about these drugs and obesity, even though this is our second conversation about the onset of these drugs in the last few months. And this is going to be an area where we are going to continue to watch, especially as the innovations behind these clinical products evolve, and we start to learn what the impacts are like for patients.

(31:45):
So Darby, Chloe, thank you so much for coming on Radio Advisory. I do think that we're going to have to have another conversation.

Darby Sullivan (31:53):
You know I can't wait.

Chloe Bakst (31:54):
I feel like this flew by. I could keep talking about this for a very long time.

Rae Woods (32:00):
Look, this challenge, or at least the solution sets that we've described might feel new, but as Darby said, a lot of them are actually parts of best practice ways to think about population health, to think about social determinants of health, and to think about health equity.

(32:18):
I know that every one of you listeners has a commitment to health equity. You must think about how weight loss, obesity, fat bias fits into that strategic goal. And remember, as always, we are here to help.

(32:47):
Radio Advisory is a production of Advisory Board. This episode was produced by me, Rae Woods, as well as Julia De Georgeo, Katy Anderson, Kristin Myers, and Atticus Raasch. The episode was edited by Katy Anderson. With technical support by Dan Tayag, Chris Phelps, and Joe Shrum. Additional support was provided by Carson Sisk, Leanne Elston, and Erin Collins. Thanks for listening.