This month marks the 10th anniversary of the American Medical Association’s decision to recognize obesity as a disease. As we reflect on this milestone, I took the opportunity to discuss the progress we’ve made, and the outlook for the future, with my mentor, colleague and one of the pioneers of the field of Obesity Medicine, Dr. Louis Aronne.
Katherine Saunders, MD: Let’s start with the big picture. What’s the greatest change you’ve seen in Obesity Medicine over the last 10 years?
Louis Aronne, MD: The biggest change is a change in the attitude of the public about taking medicine to treat obesity. And I think that’s come about because of the development of new, highly effective treatments and their increased use. It’s now clear that obesity can be treated, and doing so brings enormous benefit.
Saunders: How much of this willingness to take medication for obesity do you attribute to the growing recognition of obesity as a disease?
Aronne: I think it took having a treatment to really convince people that obesity is a disease. Before, even though obesity had been declared a disease by numerous organizations, people still didn’t believe it. People didn’t believe that there were medical treatments that would work. However, I also think that if we had the treatments but didn’t have the support of the major medical organizations like the AMA, we wouldn’t be where we are today. I believe it’s really the combination of the two that’s catalyzed this dramatic change in the way people view obesity.
Saunders: You’ve been arguing since the 1980s that obesity is a disease, but it took a long time for the rest of the medical community to come around. And now it seems like we’ve gone to the other extreme, with so many people taking these medicines whether they’re indicated or not.
Aronne: True, but in the future, we may treat people at lower BMIs. I like to use the analogy of blood pressure: maybe the right thing is to treat earlier. If we treat someone with a BMI of 25 and reduce it to 23, they’ll need less medication and they’ll end up with fewer side effects. There are a number of reasons why the treatment paradigm of using medications earlier could be a good thing.
Saunders: What do you think it will take for treating earlier — treating pre-obesity — to become the standard of care?
Aronne: The first step will be outcome studies showing that people live longer if they lose weight. Once we have that data, it will make sense for insurers and employers to cover these treatments. It will make more sense to treat people earlier to prevent them from having heart attacks or strokes or developing diabetes, which are all very expensive. We already know that losing weight makes people much less likely to develop diabetes, and that 15% weight loss can produce diabetes remission in the vast majority of cases. I think these dramatic health benefits will be apparent to insurers and employers.
Saunders: To improve access, we need better insurance coverage, and we also need medications to be less expensive at some point.
Aronne: We really need to make larger, systemic changes to bring down prices and improve coverage. These issues are not specific to anti-obesity medications — all new medicines are expensive when they come out, and most of them don’t have the potential benefit that an anti-obesity medication has. My hope is that the prices will come down, but the system will have to change as part of that effort.
Saunders: Let’s talk about the science of obesity. We’ve learned so much in recent years, but there’s still so much that we don’t know about this complex, chronic, heterogenous, relapsing disease. If you could snap your fingers and magically have the answer to one question, or clarify one aspect that we still don’t understand about the science of obesity, what would it be?
Aronne: One fascinating question relates to the heterogeneity of responses to treatment. You can use the same treatment on a thousand people, and some will lose 30%–40% of their body weight or more, and some won’t lose any weight. What causes that difference? What are the characteristics of someone who loses a lot versus someone who doesn’t? That would be incredibly useful to know.
Saunders: There’s been a great deal of progress in anti-obesity pharmacotherapy in the decade since the AMA’s decision to recognize obesity as a disease. What do you think we’ll see in this area in the next 10 years?
Aronne: I think we’ll see many more compounds affecting many more targets. Right now, we’re focusing on the hormone GLP-1, and now with tirzepatide we have GLP-1 plus GIP, but in the future there will be many potential targets. There is already evidence that the efficacy of some drugs will rival that of bariatric surgery. We already have compounds in the pipeline that will be more effective than the best current medications. We’ll also see oral agents that are as effective as injectables.
Another area of work will involve lean mass preservation. When you lose weight, optimally you lose three-quarters fat and one-quarter lean mass, but there’s evidence that preserving muscle may help in a number of ways. Now, we expect patients to start regaining weight right away when they stop taking a medicine, but if muscle mass is preserved, the weight doesn’t seem to go back up right away.
And finally, I think the model for pharmacotherapy for obesity will eventually be similar to what we see for hypertension. We’ll have a medicine that’s readily available, and you’ll have access to it as soon as your weight goes over a certain threshold, which could be based on weight, BMI, waist size, blood sugar, or other complication. We’ll be treating people with prediabetes and pre-pre-diabetes, which will dramatically reduce the need for diabetes medicines and prevent other health problems that we spend a lot of money on. Just imagine if we could stop 80% of people from developing diabetes! And it definitely looks like that’s possible.
Saunders: Now that we have more effective medications, we’ll need even more trained providers who understand obesity. How are we going to meet that need?
Aronne: Ultimately, obesity is such a large problem that treating it has to move into primary care. I’ve been around long enough that I remember hypertension being a disease that was treated by specialists. Hypertension medicines were hard to use, and they had a lot of side effects. You didn’t prescribe them lightly because it wasn’t clear how much benefit they offered. As it became evident that treating hypertension could prevent strokes, heart attacks and heart failure, interest grew. But it wasn’t until we had better medicines — medicines that had fewer side effects, were more effective and were easier for people in primary care to use — that treatment in the primary care setting really took off. Looking at that experience, I think that now that we have these treatments for obesity, it will move into primary care.
Saunders: We’ve made steady progress over the past 10 years, but recently developments seem to suddenly be snowballing. Is this the start of exponential growth? In another 10 years, will we be significantly further along?
Aronne: I think this is the very beginning. Remember that just a few years ago, only 2% of the population that qualified for anti-obesity medication was being treated according to guidelines. Now, as people see the benefits, they’re demanding these medications. The number of prescriptions has skyrocketed and the supply can’t keep up with the demand for them. We need to figure out the cost issue, but we also have to take into consideration how badly people want this. People don’t want to have the disease of obesity, and they will do what they can to avoid it. The demand is only going to grow from here.
A leading authority on obesity and its treatment, Dr. Louis Aronne is the Sanford I. Weill Professor of Metabolic Research at Weill Cornell Medicine and he directs the Comprehensive Weight Control Center (CWCC), a state-of-the-art multidisciplinary obesity research and treatment program. He is the Co-Founder & Chief Scientific Advisor at Intellihealth.
