Perspectives across metabolic and obesity care – 2/19

Dear Friends, gosh! I cannot believe that it is already a week ago that we had the Super Bowl extravaganza – the third most watched television show of all time, with 113 million viewers; which is almost as many adults in the US that suffer from obesity and related co-morbidities [100 million in 2016].

Anyhow, whilst we Eagles fans are laying low this week, here’s a round up of all things obesity and metabolic health.


  • The UK NHS is proposing the recommendation of semaglutide for management of obesity associated with chronic disease, at less than 10% of the US list price.
  • Long-term affordability of GLP-1 drugs is becoming a hot topic.
  • Multi-modal, long-term, individual care of obesity is optimal.


  • Please let me know if I missed an event of interest and value.


  • The UK’s National Health Service has ‘…issued draft guidance recommending semaglutide… as part of a specialist weight management service… for a maximum of two years.’ It will be interesting to see how many patients are offered the drug and how many stay on it for two years; and akin to real world evidence, what happens when these individuals come off the drug at two years – will they maintain their healthier weight and lifestyles, or will they revert to the pre-intervention state?
  • In addition to the above, a story in BBC News states that Wegovy will be prescribed and dispensed by Boots chemists, at a price of just under $100 per month. Wow – that is significantly lower than the $1,300 per month price in the US…
  • An article in AXIOS quoting the CEOs of Calibrate and Ro, similarly and briefly entertains the multiple topics of who should be on the GLP-1 drugs, supply issues, long-term effects of the drugs, off-label prescribing by social media hype, obesity stigma and bias, and the role of behavioral modification through coaching.


  • Karen Weintraub at USA TODAY writes on the challenging affordability of anti-obesity medications, with easing of shortages of current drugs, increased demand, and the need to take them indefinitely [‘…or risk the pounds creeping back’]. Quoting Dr. David Rind, chief medical officer for the Institute for Clinical and Economic Review, which estimates the value of different drugs, ‘Weight loss medications are currently overpriced based on the value they provide, but “not dramatically” so…’ though importantly John Cawley, a health economist from Cornell University adds ‘It’s in preventing extreme obesity where the cost savings lie.’ I think this is going to be a very hot topic in terms of insurance approvals, for what, and for how long the anti-obesity medications will be covered.
  • An article in WIRED this week reviews the ’silver bullet approach to Ozempic, Wegovy and Mounjaro; and aligns this with the challenges of successful and long-lasting weight loss with bariatric surgery too. Whilst the piece is rambling in nature, I think that the overall message the author is trying to convey is that just a drug is not the answer – there are personal, professional and societal factors at play in the obesity epidemic that need to be attended to in active measure.
  • The Wall Street Journal recounts the experiences of Malia Funk to test a number of services to garner a prescription for a GLP-1 drug; incidentally Ms. Funk weighs 55 pounds less than the FDA-indicated level for drug approval. ‘In her test, Push Health Inc. asked for little information beyond Ms. Funk’s preferred pharmacy, the medication she wanted and past medical issues, according to screenshots of the interaction reviewed by the Journal. She wrote that she wanted a GLP-1. Less than 12 hours later, she was notified that a nurse practitioner, whom she hadn’t met, had sent an Ozempic prescription to her pharmacy.’ The report also charts the denial of a prescription to Ms. Funk by a number of other digital health companies marketing weight loss through coaching and GLP-1 medications; though in addition brings to the forefront  ‘…social-media content that connects being thin with being happy.’ A lot to unpack here, in terms of the direct to consumer marketing of GLP-1 medications, the social stigma associated with overweight and obesity, and the interplay of behavioral, exercise and nutrition therapy in alignment with medication for patients with obesity and metabolic diseases.


  • An excellent review article was published in The Lancet journal this week, titled ‘Contemporary medical, device, and surgical therapies for obesity in adults.’ The authors summarize beautifully and in just three sentences an optimal approach to obesity and metabolic care, i.e. ‘Maintenance of weight loss is the major challenge of obesity management. Like all chronic diseases, managing obesity requires a long-term, multimodal approach, taking into account each individual’s treatment goals, and the benefit and risk of different therapies. In conjunction with lifestyle interventions, anti-obesity medications and bariatric surgery improve the maintenance of weight loss and associated health gains.’
  • study in JAMA Network Open from authors at the University of Pittsburgh, supports the role of fully remote patient evaluation in bariatric surgery. From a total of 1,182 patients, 257 were enrolled in a telemedicine pre-operative evaluation program; outcomes were non-inferior [i.e. a statistical nomenclature to identify them as ‘the same’] for clinical outcomes and hospital utilization. Despite the extensive statistical analysis, from a clinical perspective, the patients in the control [or usual in-person care] group were sicker from the perspective of pre-operative chronic diseases such as sleep apnea, type II diabetes and chronic kidney disease, also reflected in an almost 16-fold higher rate of Medicaid patients in the control group. And whilst outcomes were reported as non-inferior, the frequency analysis reveals that procedures took longer, with a higher rate of major adverse events and a higher rate of re-operation, in the control group. My big picture takeaway here is that patient selection is key to successful outcomes.

Kind regards, Raj


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