This commentary is by Dr. Priscilla Carr, an internal medicine specialist with the University of Vermont Health Network who has practiced primary care in Barre for more than 20 years.
Lately it seems like everyone has heard of Ozempic or Wegovy, powerful medications being used for weight loss. As an internal medicine physician who works in primary care, I’ve been spending a lot of time talking about these medications. They seem to have all of the makings of a modern-day miracle offering safe, effective therapy — and hope — to a group of people who have spent their lives struggling with a chronic condition that is often extraordinarily difficult to treat.
Obesity is a disease. It is associated with 200+ chronic medical conditions and implicated in the development of many forms of cancer including breast, uterine and colon cancers. It keeps people from being able to tie their shoes, play with their grandchildren or walk down a long hallway to get to work. It shortens people’s lives; on average, severe obesity reduces life expectancy by 8-10 years.
With all the hype around these new drugs has come a steady stream of judgment. News reports of expensive health spas selling these medications would leave you thinking that they are for the exclusive use of the rich and famous. (In reality, many of my patients are essential workers and everyday members of our community.) Bizarrely, patients in need are ridiculed and blamed for medication shortages. Chemotherapy medicines are in short supply, yet patients with breast cancer are not publicly shamed for this. No patient should ever be blamed because the medication they need is in short supply.
Our culture has always taken a profoundly judgmental view of obesity. Now thanks to extensive scientific research, we understand the disease of obesity to be a complex problem of disordered regulation of fat mass. ‘Eat less, exercise more’ is no longer considered a valid approach as we now understand that it’s quite a bit more complicated. Diet and exercise, along with other lifestyle approaches, will always have a profound role to play in promoting health. What has changed is that there is an understanding that medications and surgery — interventions that change the brain’s regulation of energy balance — are often more effective at generating sustained weight loss.
Obesity rates are skyrocketing; the prevalence of obesity is 42% in the United States and 27% in Vermont. Why is this happening? No one knows for certain. We know there are 1,000+ genes associated with obesity. Ultra-processed food now makes up 57% of the food consumed in the U.S. Somehow, the interplay between genetics, the changes in our food supply and the modern built environment has led to exploding rates of obesity.
Medications such as Ozempic and Wegovy are powerfully effective. When given to patients with overweight and obesity, semaglutide (Ozempic/Wegovy) leads to an average weight loss of 14.9%. Tirzepatide (Mounjaro/Zepbound) leads to an average weight loss of 20.9%. In my experience, these medications really work. Patients tell me that they don’t feel hungry and don’t desire unhealthy foods. With these new medications, I’ve watched patients lose profound amounts of weight, feel better and work to make their lives healthier.
Yet bias and judgment that are deeply embedded in our health care systems limit access to treatment. Medicare does not cover any weight loss medications. Medicaid programs from many states, including Vermont, exclude coverage for weight loss medications. While many commercial insurance programs cover the medications, they have prior authorization requirements that are so complex that they prevent patients who clearly qualify for treatment from accessing medication.
Watching the effects of these barriers on patients is heartbreaking.
One patient of mine with severe obesity took Wegovy and had an excellent response but needed to stop when her insurance changed. After stopping the medication, she had terrible cravings and blamed herself for excessive hunger and weight gain. Another patient with severe obesity began taking Wegovy, but her work hours made it difficult to pick up the medication on time. She was told the prescription was canceled because she wasn’t taking it as prescribed (this is not how patients with other chronic diseases are treated). Yet another patient with severe obesity is contemplating purchasing semaglutide from an unregulated internet site. While the safety of obtaining medication from these sites is unproven, she knows the medication may help her, her insurance isn’t going to cover it, and she cannot afford the brand name version at the pharmacy.
These patients deserve better treatment. Never before have I had to look patients in the eye and tell them that there is a safe effective treatment available for the serious condition from which they suffer, and it’s not available to them.
Obesity disproportionately impacts women, people of color, and lower income people. Perhaps it should come as no surprise that there are systemic barriers to care for this condition — barriers that we do not tolerate for cancer or heart disease.
Vermonters with obesity deserve better access to treatment. Vermont Medicaid needs to update its policies and cover anti-obesity medications. The commercial insurance practice of making the prior authorization process so complex that many cannot access anti-obesity medications needs to stop. We need to make our food systems and modern lives healthier. And we can all try a little harder to understand each other’s struggles — and put equitable access to treatment for chronic disease ahead of judgment and blame.
