Chapters Transcript Disparities in Obesity Care and Outcomes Course: The Impact of Obesity and its Comprehensive Management: From Prevention to Treatment Thank you so much. This happens to be the same room that we have our departmental M&Ms, so, uh, forgive me if I'm a little nervous. I may get attacked. All right. Um, so I'd like to thank, um, Doctor, Doctor Ron Fielding, Doctor Holly Lofton for inviting me to speak with you today about disparage in obesity care and outcomes. I have no disclosures, but I'm looking forward to getting some. So if you know of anybody, I have my email at the end. Anyway, today, um, what I'd like to focus on is really Talk about, I want to focus on, on just a few things. As Doctor Mascio outlined, the social determinants of health. I mean, that's a, a, a multi-day conference in and of itself in which to address the things that specifically affect obesity. So, I'm gonna focus mostly on access. We'll talk about some internal barriers and external barriers. We'll touch briefly on utilization of obesity treatment, uh, among different populations, and then again, briefly on clinical outcomes. So I know later on this afternoon, we'll be hearing about all the modalities that are available to treat obesity, but I'm really just gonna focus mostly on surgical and uh interventions with medicines. Now, according to the NIH Institute for Minority Health and Health Disparities, uh, there's certain group categories that they often look at. They often divide people by race, ethnicity. We discuss medical insurance coverage, type of, uh, insurance coverage, whether it's public or private. and also look a little bit at the urban rural divide. Uh, other groups are sort of less studied within the obesity sphere, specifically sex, gender, and sexual minority status, and disability. So, there aren't that many studies to talk about and we're, we're gonna skip that today. No talk would be replete without having one of these maps in place. This is the latest, uh, survey done, um, that sort of, uh, uh, measures the prevalence of obesity and severe obesity in the United States. This is from August 2021 through August of 2023, um, and you can see that, you know, it's, um, sort of had a hold on us. Um. The prevalence of obesity is about 40%. It's highest within my age demographic. Uh, fortunately, it's lower than those with a bachelor's degree or higher. Um, but it's also the rate of severe obesity is about 9.4%, and it's higher for women in every single age bracket. So if it's not obvious from the heat map, you can see that this table sort of clearly summarizes the characteristics of the obesity epidemic in the United States, and you can see that the prevalence of obesity is higher in the black population. It's higher if you have a lower household income level, and it's also higher in those people who have not completed college or have only done a few years of college. So we'll talk about access. Uh, I wanted to break it down into two different parts. So I think we talk a lot about the external barriers, and that's primarily insurance and what insurance is willing to cover and the kind of hoops that people have to jump through in order to get coverage for obesity treatment. But I want to take a step back and look a little bit more at some of the internal dynamics, uh, that may impact patients' access to obesity treatment. Uh, there's often some discordance between the healthcare providers and the patients on any number of factors. One is what the patients actually want to discuss with their provider, what are providers comfortable discussing with their patients, uh, what is the knowledge level of both the patients and the providers about the effectiveness of the various obesity treatments that are available. Um, so we'll get into that. So the observed trial, even though it was sponsored by Eli Lilly, uh, was actually, I think it was interesting. It was basically trying to assess what the perception was of the more modern anti-obesity medications and it was also trying to assess what the barriers were to wider adoption. Now, this was an electronic survey that was sent out to about 1500 participants, 1000 of which were, um, patients and about 470 which were healthcare providers. The healthcare providers were physicians, uh, nurse practitioners, PAs, and all of the patients were patients with obesity. So they had a BMI extending from 27 to 29.9 with a comorbid illness or their BMI was higher than 30. We're really trying to figure out what their current perceptions were of obesity management and the treatment. It was a pretty good demographic spread both amongst the healthcare providers as well as the patients, and they were asked various questions that they had to, uh, comment on and respond to and agreed on a five-point Leger scale. So, um, Because also what's interesting is because of the way that this um survey was advertised, it was more likely to attract people who had an interest in obesity and of note, about 40% of the healthcare providers self-identified as obesity treatment experts. So this question here, at least for the patients, were, to what extent does each of the following items prevent you from successfully keeping weight off over the long term? And the providers were asked, to what extent do the following contribute to the inability to maintain weight loss amongst your patients with obesity. And I think what's most striking is one, you can see there's a wide discordance, uh, between the provider's answers, which were the dark line and the patient's answers. And 2, for the providers, there was quite a few who thought that the lack of exercise, a lack of willpower, a lack of self-control, mindless eating were really the levers that determined whether or not someone was going to be successful with long-term weight loss. Then this question was, um, asking people to sort of, um, To, uh, rank the effectiveness of a single modality in terms of its ability to bring about long-term weight reduction. And again, amongst this group of self-proclaimed obesity treatment experts and patients, it's incredible to note that again, they felt that lifestyle or behavior changes were actually the most effective forms of treatment, while bariatric surgery and anti-obesity medicines were not. So I think what this demonstrates to me is that it hints not only at um a knowledge gap, both for patients and also for providers, but um it also may hint at a little bit of um Some discomfort and and a recognition that there's a lack of capacity on the on the part of providers to offer the appropriate care to the patients for a various number of reasons. So here, the last question that was posed to both groups was, what factors would increase the likelihood of you using or prescribing a new anti-obesity medication? Here you can see that the discordance between the answers of the providers and the patients is a lot narrower, and of course, they want the cost to be covered by insurance. Uh, they also felt that if it was recommended by an obesity medicine specialist that they would be more successful with their weight loss in the long term, and they also wanted the medications to address other illnesses that were also associated with obesity. So That was that. There's another study that looked at his different cohort of patients, um, and we'll talk a little bit about more about that, that huge database. But what I wanted to highlight here was that even amongst, um, people, um, providers in different subspecialties, there is a different rate of initiation of treatment with anti-obesity medications depending on the subspecialty. So, uh, endocrinologists were by far the subspecialty that are most likely to prescribe anti-obesity medications for obesity itself, not necessarily just in patients with diabetes, which is what you would presume. And also if a patient was seen by a nurse practitioner or a physician assistant, they were also more likely to be prescribed a newer GLP1. So now let's move on to everyone's, uh, favorite, um, topic to, um, to talk about and bash, uh, insurance. Um, so, um, we'll talk a little bit about payers and, uh, some of the availability and also some of the restrictions that they put in place that provide additional barriers to people getting adequate treatment. So, I wanted to start with something that I think is universally proclaimed as something that needs to be treated, which is diabetes. And even amongst patients with diabetics, despite the dramatic increase in the amount of money that's being spent on GLP-1 drugs, you can see that the vast majority of this is covered by private insurance, and there's very little that's covered by Medicaid. You can see the proportion is increasing over time, but it's still really, um, uh, dwarfs. The need, specifically within the patient population that uses that as their primary insurance coverage. And then if you, these two slides basically show on the left-hand side, we're looking at the percentage of adults in the US who have type 2 diabetes and who use GLP-1 medications. And this is broken down into various subgroups, female versus male, different age categories, uh, race and ethnicity, uh, degree of college, um, degree of education, uh, presence or absence of diabetes. And you can see that for the vast majority of each of these subgroups, that there is a higher percentage of usage amongst them. Than there is amongst the total number of patients who are using this medicines for obesity. So again, I think this sort of alludes to a bias where uh providers are more likely and more willing to prescribe a medication to treat hypertension, for example, or or diabetes, but not necessarily obesity. Um, and then there was a nice review last year where Luau basically went to every every single state and looked at the list of drugs that were covered by Medicaid in that state. So, uh, the dark bar shows medications that are not covered, and here are the individual medicines. So these are all the medications that are typically used to treat obesity. Uh, the GLP ones are right here, and you can see that for patients who are obese, if you're on either Saxenda or Egovi, that the vast majority of states do not cover payment for that medication. Whereas when we jump to GLP ones, exact same medications that are being used for diabetics, you can see that there's a lot more use. In fact, even some uh increased unrestricted use. But again, these numbers, or these medications do not include the most effective uh GLP-1 on the market as of now. So, uh, Ron and all, uh, they had access to a database called the, uh, One Florida database, and it's basically this huge repository of healthcare information. Uh, it pulls in electronic health records from, um, academic medical centers, uh, private hospitals, uh, public health institutions, community health centers, as well as pulling in, uh, Medicaid and, uh, Medicare claims, um, tumor registries, and uh, Death registries as well, and they examined this database over pulled data from like a nine year period from 2015 to 2024, and they're able to get about 320,000 adults. Again, these are all adults who are over the age of 18 and qualified for treatment based on their BMI and or the presence of a comorbid illness. And they found that out of that huge number that only 2% were initiated on any anti-obesity medicine, and only 1.8% were initiated on a newer anti-obesity medicine within that time frame. And within that group, as they broke it down, you'll see that, um, sort of the, the, the, um, The, the treatment of racial and ethnic minorities was less like they were less likely to receive prescriptions for these medications. People who are uninsured, people who are on public insurance were also less likely to be prescribed and or to use these medications. So Gascien sort of did a similar study with a different database in a different part of the US, uh, and he looked at not just the prescription of the medications, so are patients receiving prescriptions, but he also looked to see are patients actually even going to fill the prescriptions. Um, and so black, Hispanic, and other racial and ethnic minorities compared to whites have lower odds of even receiving a new prescription for the medication. And then once given the prescription, Hispanics were found to have a lower odds of having the prescription filled. Again, there was a bias where people who saw an endocrinologist or some specialized nurse practitioner or a physician's assistant were more likely to have these medicines initiated. And then the last part is that, you know, patients who are diabetic and on other glucose lowering medicines that maybe were ineffective, were in a category that they were most likely to be prescribed these medicines. So, you know, the question is why just with diabetes as opposed to what we know about the impact of these medicines, the positive impact on other metabolic diseases, coronary artery disease and heart failure and arthritis. And the reason is that there may be some hesitancy. Again, alluding to a little bit of a knowledge gap, uh, a discomfort level with adding this medication to a list of medications that may be critically ill or, um, complex medical patients already on because they're concerned about drug-drug interactions and how they would manage that. You also have to understand that in these offices, it really does take an enterprise just that you have to develop to actually push through and get pre-authorization for these medications and whether or not they have the resources and or the time to deal with it is really um um unsure. And I doubt that that's, I, I think that that's the case as well. So we talked a lot about medicine and sort of the underutilization of medicine. Uh, but here, I just want to show that again, surgery, which is a well-documented track record in, uh, producing, uh, you know, really, uh, Excellent long-term outcomes in terms of weight loss, as well as comorbidity resolution is also underutilized in the United States. I'm having a little bit of deja vu because I remember when I first started in my bariatric career, all the barriers we talked about were barriers to surgery. Well, now those barriers, I think have been shifted off to the medications, uh, and now surgery barriers are a lot less than they used to, but it's still a, a dramatically underutilized resource. OK. Countdown. I still have time. OK. So here are just some classic papers that are trying to show, you know, what are the outcomes after some of our interventions. We'll talk about surgery first. Um, Um, based on, uh, you know, ethnicity and race. And so this was a study where they looked at about, uh, I think it was 5000 patients. Um, no, sorry, this is a Michigan Bariatric collaborative. They had about 7000 patients and they looked specifically at a cohort of black and white patients and had them undergo different operations and identified that the black patients had less weight loss across the board with all different types of procedures. On the next slide, you'll see here that they sort of stratified the outcomes based on income level as well. And that as the income level of the participants increased, that gap between the outcomes and weight loss actually narrowed. And also the gap between the overall complication rate at 30 days also decreased. There was a persistence in sort of a lower weight loss among black black participants, uh, and as well, there was also a persistence in higher resource utilization for black patients. So meaning that their lengths of stay in general in the hospital at the time of the initial operation were longer. They had more returns to the emergency room for treatment after being discharged. Um, this study looks specifically at, um, socioeconomic status as well, um, and try to match for income. But once, once these patients were actually matched for income, this is a single center study, so not much to take from it. But after matching for income, there's really no difference in the outcomes that were observed for up to 3 years after having had surgery. So there may be a slightly persistent, uh, um, a persistent, slightly lower amount of weight loss in black patients for up to the first year, but then after that, it all kind of washed out. So, this is the last uh study I'll talk about. It's more descriptive, more recent, and what it tried to do is take those categories that were defined by the NIH that we first talked about, race and ethnicity, socioeconomic status, and then rural versus urban divide, and then specifically looked at studies that addressed access and studies that addressed outcomes. So under race and ethnicity, no surprise, all of the groups that we typically identify, they all had disparities in access for all the reasons that I've elucidated in the past 10 minutes. Uh, in terms of medication, there was no difference in the outcome from medication, but there was a difference in surgical outcomes, and that's again alluded to the things that I just outlined before. Uh, in terms of socioeconomic status, people with decreased income, of course, had decreased access to the medications, but, uh, Interestingly, for the states that opted for a Medicaid expansion under the Affordable Care Act, there was actually an increase in access to surgery for this particular patient population that actually they had never had before. So I think that was sort of a very nice real life study showing what can happen when you have a change in legislation that now provides people with more access to this kind of treatment. Uh, in terms of the anti-obesity medicine outcomes, we really don't have any studies, uh, that are, that I can refer to right now. And in surgery, there were some mixed results. Uh, in terms of the rural versus urban divide, for access, there was no difference for people in rural areas getting access to medicine. There was a difference in them having access to surgery, and that may be related to their ability to sort of go to all the appointments that they need to perform all the tests and studies before their operation occurs. And then on the outcome side, there aren't any studies that have been done with the newer medications and there was no difference in surgical outcomes. So I think we have, um, sort of our our marching orders. I'm trying to focus on things that we as practitioners can, uh, influence, um, more so. Um, and so I think that, you know, disparities exist, as we all know, amongst educational groups, income groups, race and ethnicity groups, uh, people with different insurance providers, but I do think one of the surprising things I found was sort of this persistent. Um, uh, difference in access depending on the physician's subspecialty. So that's definitely something that I think that's under our control, uh, that we can either sort of, um, uh, change or push to change on a local level where we can increase access to people who specialize in obesity and offload that burden from our colleagues who don't have the time or the resources or the knowledge base to actually take care of these patients. Um. And then I think the other thing that we can continue to do is, you know, just because we're physicians, it doesn't mean that we lack um uh any political power. I think that continuing to lobby governmental agencies and legislatures about expanding treatment coverage will go a long way to helping us provide the care that our patients need. That's all I have. Published September 9, 2025 Created by
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