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The Shifting Landscape of Obesity Treatment Models
Tampa—Despite national guidelines and practice tools, only one-third of obese patients report receiving an obesity diagnosis or weight-related counseling. A panel of speakers discussed the treatment therapies for obesity and the burden of comorbid conditions and risks during a satellite symposium at the AMCP meeting. This satellite symposium was supported by an educational grant from Takeda Pharmaceuticals International, Inc., US Region and Orexigen Therapeutics, Inc.
Robert F. Kushner, MD, MS, FACP, professor of medicine, clinical director, Northwestern Comprehensive Center on Obesity, Northwestern University Feinberg School of Medicine, Chicago, Illinois, opened the session by discussing the medical and economic burden of obesity, pharmacological agents for treating obesity, and models of care.
“We need to get away from just [body mass index (BMI)], and think about the patient,” said Dr. Kushner. He noted that 2 out of 3 patients coming in for treatment are overweight or obese. And while a study from JAMA found that the prevalence of overweight individuals has “flattened out,” Dr. Kushner said that it is not necessarily optimal that we have flattened out at these high rates [2012;307(5):491-497].
Obesity Impact
“Obesity affects essentially every organ system,” said Dr. Kushner, noting that obesity has largely contributed to the increased risk of cardiovascular diseases, type 2 diabetes, certain cancers, and musculoskeletal pain.
In addition to comorbidities, obesity contributes to sizable healthcare cost burdens. In terms of 2006 dollars, yearly per capita healthcare and productivity costs due to obesity among full-time US employees was $6087 for men with a BMI of ≥40 kg/m2, and $7092 for women with the same BMI range. Dr. Kushner noted that the costs associated with that would be even higher in 2014 dollars.
By 2030, if the obesity trend continues, healthcare costs attributed to obesity could reach $956 billion, representing $1 in every $6 spent on healthcare. “The numbers are scary,” said Dr. Kushner. The major driver of rising healthcare spending is the increased prevalence of obesity, according to the presentation. In 1998, 9.1% of US annual healthcare spending was attributed to obesity. It is projected that in 2020 that number reaches 15.6% and by 2030 could reach 17.6%.
Models of Care and Treatment
According to Dr. Kushner, there is “woefully little intervention,” for overweight and obese patients. The durability of weight loss is challenging, and obesity is a chronic condition to manage. Dr. Kushner noted that treatment should start with a foundation of lifestyle management, including diet and exercise, and then intensify to pharmacologic therapy and bariatric surgery. Only 3% of obese/overweight patients are prescribed weight loss drugs, and <1% of obese patients undergo surgery due to the perioperative risks and potential long-term complications.
Dr. Kushner noted that prior to the 2012 FDA approvals of phentermine/topiramate ER and lorcaserin for obesity management, pharmacologic options were not much considered for this condition. He also mentioned that 2 additional medications submitted New Drug Applications to the FDA last year and are awaiting approval: (1) naltrexone sustained release (SR)/bupropion SR; and (2) liraglutide.
The SEQUEL study of phentermine/topiramate ER was discussed, and Dr. Kushner noted that if patients do not lose 3% of their body weight in the first 3 months on the medication, the dose should be increased or stopped altogether. “If you do not see a response in that timeframe, it is not going to happen,” said Dr. Kushner. Rapid weight loss on obesity medications can be expected in the first 6 months, though weight tends to maintain after this point. However, a significant proportion of patients in the study taking phentermine/topiramate ER achieved ≥5% and ≥10% weight loss versus patients doing lifestyle medications alone.
A 104-week study of lorcaserin therapy was also presented during the study, and Dr. Kushner noted that when a portion of the study participants originally receiving lorcaserin were randomized back to receive placebo instead, they gained weight back. “This shows the drug works,” said Dr. Kushner.
While BMI has always been an indicator of overweight and obese diagnoses, Dr. Kushner said that the medical model may be giving way to what he considers the complications-centric model (See Table 1 and Table 2 below). The medical model is based in BMI classifications, while the complications-centric model considers patients as a whole, taking into account comorbidities. The complications-centric model “stages obesity like you would stage cancer,” clarified Dr. Kushner.
Obesity Prevalence and Healthcare Costs
William J. Cardarelli, PharmD, director of pharmacy revenue and supply, Atrius Health, Harvard Vanguard Medical Association, Watertown, Massachusetts, continued the session, saying, “We have a mammoth problem in the United States [with obesity] reaching epidemic proportions.”
More than one-third of US adults (35.7%) are obese, and the estimated annual medical cost of obesity in the United States was $147 billion in 2008 dollars. The medical costs for individuals who are obese were $1429 higher than those of people within a healthy weight range. Dr. Cardarelli continued, “We cannot talk about obesity without discussing childhood obesity,” noting that approximately 17% (12.5 million) of US children and adolescents aged 2 to 19 years are obese. Since 1980, the childhood obesity prevalence has almost tripled.
Managed Care Implications
Dr. Cardarelli noted that the recently approved drugs and additional drugs currently awaiting approval have introduced the need for more managed care involvement. There is a potential to increase drug utilization with these recent drug approvals, and managed care will need to be ready to address this. Dr. Cardarelli spoke in favor of the “more rational” complications-centric approach to care, noting the benefits of this model: (1) identifies patients who will most benefit from treatment; (2) improves the benefit/risk ratio by prioritizing treatment; (3) informs targeted therapy of obese/overweight patients with metabolic syndrome and prediabetes; and (4) limits off-label use of medications.
There is also an opportunity to save on costs and more efficiently treat the disease with pharmacologic agents available. “People who lose 5% to 10% of their body weight will take less medications overall,” because there will be less comorbidities once weight loss occurs, according to Dr. Cardarelli. He did note that medication adherence is a complication for any disease state, and that will be a cause for concern here as well.
HEDIS® Quality Measures
Jaan Sidorov, MD, MHSA, Sidorov Health Solutions, Harrisburg, Pennsylvania, concluded the session by discussing the National Committee for Quality Assurance’s (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) obesity measures. It is estimated that 51% of the US population will be obese by 2030. Obesity already contributes to 1 in 10 deaths in the United States each year due to complications of the condition. Keeping obesity rates from rising could save nearly $550 billion in medical spending.
Dr. Sidorov noted, “BMI is the first step in the process of addressing the patient. It is necessary, although it may not be sufficient” as the only evaluation of obesity. BMI should be documented during a visit to a doctor’s office, and the patient should be counseled on their classification. He said patients of children who are not overweight or obese should still be counseled, according to the NCQA, to make sure healthy, active lifestyles are being developed in growing children.
He concluded by noting that monitoring BMI can help healthcare providers identify at-risk adults and children, healthy eating and physical activity can lower the risk of becoming obese and developing comorbid diseases, and performance on obesity-related HEDIS measures can continue to be improved.
