America’s Obesity Crisis: Dr. Explains Problem Plaguing 75% of U.S. Adults

CHRISTIANE AMANPOUR, CHIEF INTERNATIONAL ANCHOR: And as we said, it’s streaming live now — or no, it’s streaming now on Apple TV. We turn next to a health crisis in the United States. A new Biden proposal to get obesity drugs covered by Medicare and Medicaid. It comes as a recent report found that three quarters of American adults are obese and it’s a worrying rise since 1990. Our next guest is an expert on this topic. Dr. Fatima Cody Stanford is an obesity medicine physician and professor at Harvard Medical School. And as medications like Ozempic become household names, Stanford joins Hari Sreenivasan to discuss the most effective treatments.

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HARI SREENIVASAN, CORRESPONDENT: Dr. Fatima Cody Stanford, thanks so much for joining us. As we’re recording this conversation, there is some news out that the Biden administration is proposing that Medicare and Medicaid cover this category of anti-obesity drugs called GLP-1 medications. How significant is that?

DR. FATIMA CODY STANFORD, OBESITY MEDICINE PHYSICIAN, MASSACHUSETTS GENERAL HOSPITAL AND PROFESSOR, HARVARD MEDICAL SCHOOL: Well, I think it’s tremendously significant and I can tell you that I have spent a lot of time at the White House and with CMS discussing this issue. I’ve taken several trips to D.C. to propose this as a significant area of coverage. What we do know is that these issues have disproportionately affected the Medicare population and those that are of lower socioeconomic position, the Medicaid population. And I can tell you that I am tremendously enthusiastic about this shift to cover these populations that have disproportionately been affected by obesity.

SREENIVASAN: You know, before we talk a little bit more about the drugs, I think that the thing that most people are going to think about right now is sort of the sticker shock. Look, these are expensive drugs that a lot of private insurers or employee health plans don’t even cover. What are the costs associated with this if we were to increase the numbers by 3 or 4 million people who might qualify under Medicare or Medicaid?

DR. STANFORD: Well, you know, the costs up front may be quite large for, you know, the Biden administration or, you know, for the government. But what I want to think about is the downstream impacts. What we do know is that obesity causes over 200 complications of, you know, cardiometabolic diseases, but other disease processes, everything from diabetes to hypertension to hyperlipidemia, which we know is high cholesterol to osteoarthritis to rheumatologic conditions, really everything across the board. And what we do know is that if we treat obesity, we can treat these downstream disease processes. What I have the pleasure of doing as an obesity medicine physician is actually removing diagnoses from people’s charts. What I have the pleasure of, you know, working with patients across the lifespan, most of my patients have been with me for 10 years or more. And, you know, when we’re doing this work is we actually find that over that decade plus is they get healthier, you know, at 70 years old, they’re healthier than they were at 60 years old. It’s a match, actually amazing. And they are living healthier lives. Actually, just this past weekend, I spent time with a family that are immigrant — an immigrant family. They’re in their 70s. They’re living healthier lives than they did in their 60s. You know, what does this say for the population? This is exactly the population that you’re speaking to. They are actually able to do things that they weren’t able to do when they were in their 60s. This is exactly the population and target of this actual change. Several of them are on pharmacotherapy. They are actually benefiting from this shift. They are getting this from private insurance, but as we make this shift and looking at Medicare enrollees, Medicaid beneficiaries, this is exactly the type of shift that we’re expecting to see as we see things coming out from the Select and Surmount trials, that Semaglutide and Tirzepatide trials, seeing the benefit of reducing major adverse coronary events, seeing benefits and improvement from obstructive sleep apnea, liver disease, et cetera. I mean, that’s exactly what we’re hoping to get from, you know, covering individuals that have not been able to get coverage thus far.

SREENIVASAN: And we should point out a couple of things. One is that this is a proposal by the Biden administration. Obviously, there’s a new administration, new sheriff coming into town in January. Now, they might have different views on this. So, this is still up to the next administration to figure out whether they want to run with this proposal or not. But regardless of who is in the White House, you would suggest that this proposal go forward?

DR. STANFORD: Absolutely. You know, this is something — like I said, I’ve spent a lot of time advocating for in conjunction with the Treat and Reduce Obesity Act, which was initially introduced in the House in 2012. As you know, we’re in 2024. This would seek to do exactly this, cover the Medicare population with anti-obesity medications. We have seen that we — these medications are covered for individuals that have diabetes, but disproportionately not covering those that have obesity. We know that obesity is the most prevalent chronic disease, yet we somehow don’t seem to cover those individuals and preferentially cover only those with diabetes. But we must acknowledge that those with diabetes, about 80 percent, particularly with type 2 diabetes, concurrently have obesity. So, we have this preference for covering one population, not covering another population, and it seems a bit unfair. And so, I would, you know, be a strong advocate for covering this population, a population that I exclusively treat in the practice of medicine that I render to patients at Mass General Hospital.

SREENIVASAN: OK. So, you literally — this is the bread and butter of what you focus on, on a daily basis, and you’ve been working with patients for so long about this. I mean, is there something wrong with the thinking? RFK Jr. famously on the campaign trail, has said, look, I mean, we could fix all of this stuff if people just ate better. I mean, is there something else that we should be thinking about in the context of obesity, whether it’s on a chemical level in our brain or how our bodies react to extra weight? What are things that make this more complex than just saying eat right?

DR. STANFORD: Absolutely. I’m so glad that you asked me this. And you know, what we do know is that obesity is a complex multifactorial relapsing remitting disease where genetics, development, environment, and behavioral play a role. You know, as a part of the U.S. Dietary Guidelines Committee, I can tell you that food does play a role, but I want us to acknowledge that while food plays a role, all of these other factors that do indeed play a role. Let’s look at the role of medications in the fact that many of the medications that we prescribe is doctors are weight promoting. They influence the biochemical factors in the brain that actually influence weight control. And so, a lot of people ask me, so what are some of those medications that can influence weight regulation? And I’d like to spit off this list, medications like Lithium, Depakote, Tegretol, Celexa, (INAUDIBLE) Prozac, Ambien Trazodone, Lunestic (ph), Avitentin (ph), Glyburide, Glibenclamide, Parivital (ph), Metoprolol, Atenolol, Propranolol, long-term insulin, long- term prednisone, just to name the ones I wanted to say at that moment. But these medications can affect weight and weight regulation. And so, those are medications that can influence weight control. I’ve seen upwards of 200 pounds of weight gain associated with medications that we prescribe for other conditions. So, that’s important for us to know. Trauma can influence, stress can influence the storage of adipose. Adipose is this fancy word that we use, but actually, adipose is a metabolically active organ. Fat is a metabolically active organ. And some of us store excess adipose because of trauma or stress that we’ve experienced in our life and/or generational trauma or stress. Different things have implications. If you’re a night shift worker because — let’s say you’re a doctor or let’s say you have a night job, that destroys the super chiasmatic nucleus. That’s a fancy word, you guys couldn’t go look that up, but that affects how we store adipose or fat. There’s a variety of factors that have happened in our society that actually influence why we, at this time, in society, have more adipose or more fat mass than we’ve had at previous times in society. And it’s not just here in the U.S. We have over 1 billion people worldwide that have obesity. And the United States currently is ranked number 10 in the world in terms of countries with obesity. So, while we’re not ranked number one, we can recognize that this is an issue that is affecting the world and it’s something that we must acknowledge on a worldwide basis.

SREENIVASAN: In the interest of full disclosure, you have advised different drug companies about GLP-1s. Explain kind of how they work in combating obesity.

DR. STANFORD: So, these medications work in the brain. As you kind of have alluded to, or we actually have to recognize that when we’re storing excess fat mass, it’s actually a disease of the brain. So, there’s a part of the brain called the hypothalamus that actually governs how much fat mass we store. And these medications upregulate a part of the brain that tells us to eat less and store less. So, a lot of patients that are on these medications will tell you they actually receive signals that tell them that they’re not hungry and they never recognize that a lot of their brain was focused so much on thinking about what’s the next meal, what’s the next snack, and they are not really thinking about this. I don’t necessarily use this term, but a lot of them will refer to this as food noise. But this is something that you’ll hear a lot within this kind of kind of thinking of how people will recognize their influence of being on these medications. So, there’s this idea of food noise that seems to be the volume is turned down when they’re on the medications. And so, when they’re on the medications, it’s influencing that. But what I will tell you is that GLP-1, you and myself, we all have GLP-1 inside of us. Those of us that happen to be leaner have more GLP-1 on base. So, when we administer GLP-1 to you, we are giving you more of what your body would naturally make. And for those of us that don’t have as much inherently inside of us, we are giving you more of what your body should make it baseline. So, that’s an important piece of the puzzle also.

SREENIVASAN: I’ve also heard that as people gain weight, sometimes their brain almost resets to a new norm.

DR. STANFORD: Yes.

SREENIVASAN: And then, when they start to go on a diet or they exercise and they lose a bunch of weight, it’s like the brain is somehow giving them signals to put that weight back on, even though it might not be healthy for them. But I mean, is that true?

DR. STANFORD: That’s absolutely true. So, it’s this idea of set point. And so, the brain wants to defend its newest set point. And this is the set point theory that has been, you know, out in the — out and about for over 75 plus years. What the body does is it recognizes — the brain, it goes back to the brain. The brain is very smart. It wants to defend fat mass, and it thinks that once you get to a certain fat mass, it needs to do whatever it can to bring you back to a set point. And the key hunger hormone in our body is called Ghrelin, that’s spelled G-H-R-E-L-I-N. And what it does is it wants to bring you back. And so, without you trying to do something, you’ll notice that you’re hungry and you’re like, well, gosh, I don’t want to be hungry, but it’s going to bring you back to its set point prior to. So, this is that idea of like, when you go on a diet, you lose weight, and then you gain weight back to actually a higher point than where you were prior to whatever dietary intervention. This is why when, you know, we go into the new year, people say, hey, I’m going to go on X, Y, or Z diet. They lose weight, and then they recognize, wait a minute, I’m a little bit higher than I was prior to that dietary intervention, or you know, lifestyle modification, let’s say it was an exercise plan. Because the body is going to make different mechanisms happen to bring you back to a point a bit above it. It wants to defend whatever it can amass of what it thinks is normal for you, despite what you think is normal.

SREENIVASAN: This month a study was out in the Lancet Medical Journal, and it found that nearly three quarters of American adults are overweight or have obesity. Were you surprised by that?

DR. STANFORD: Not at all. You know, we’ve been following these trends for years and we’ve seen this gradual rise in overweight and obesity within the American population. And I think that what we have found is that we’ve been using the same strategies to address overweight and obesity, which is only addressing the food portion of this puzzle. You know, just looking at the food quality, looking at dietary strategies, and maybe addressing it by looking at exercise modifications. But, you know, what is the definition of insanity, trying the same thing and hoping, you know, different results will occur. We have found that these strategies are ineffective alone and addressing this overweight and obesity pandemic, which is here in the United States and frankly around the world. So, this rise in obesity that has happened over time is by no means surprising to any of us that have been doing this work for decades.

SREENIVASAN: It found that the prevalence of obesity rose, especially rapidly, doubling in the past three decades in both adult males and females. And I wonder like what is behind this rapid increase and are there subpopulations that, you know, if we overlaid socioeconomic data, is this more likely to in states that are — have greater amounts of poverty or less access to health care or food deserts? I mean, what are the other things that, you know, this overall kind of picture doesn’t point out to us?

DR. STANFORD: Yes, if we look at — if we kind of drill in and kind of look a little bit with a finder tooth comb, we do see that this is more prevalent in the southeast. If we look at in the kind of the Midwest, we see a little bit less prevalence. Also see in the west, we see a little bit prevalence. Higher prevalence and racial and ethnic minority populations also. In the indigenous population, we see higher prevalence. This is coming out of some of the finer tooth information that’s coming out of the CDC and this — we also see this in lower socioeconomic position. So, you’re right, if we kind of look at this, if we’re looking at lower socioeconomic position, access definitely plays a role and, you know, this is not of any surprise to us. And this is really germane to some of the problems that we believe are behind this rapid rise in overweight and obesity in both populations, you know, regardless of gender, you know, and this is something that we’re paying close attention to. But this is something that we expected. And if we look at, like, the full picture, you can see that it’s affecting everyone, but disproportionately affecting certain populations.

SREENIVASAN: One of the things the study points out was that if we don’t take any immediate action, that by 2050, the prevalence of overweight and obesity in adults will exceed 80 percent nationwide. So, what are some of the kind of longer-term implications of how society functions, what kind of policies we need to be rethinking? And then I guess, I mean, that’s the sort of the downside, but on the positive note, like what are things that are working that we can actually do now to prevent this?

DR. STANFORD: Yes. So, you know, one of the key things that I think we’re not doing that we need to be thoughtful of is that we need to address parents prior to conception. What do I mean by that? If we address parents and their health and health status prior to conceiving, we actually have the best likelihood of addressing the next generation. So, studies have shown that if parents are in their optimal health prior to conceiving children, they actually have the best implications for the next generation to come. We know that maternal and paternal obesity increases the likelihood of a child having obesity themselves. And so, we’re kind of behind the eight-ball at that point. So, that’s the best likelihood or thought process, but we aren’t thinking in that way. So, that’s, I think, the best forward thinking. So, I think that’s a strategy that we need to be thoughtful about. So, that would start, you know, prior to conception. So, we need to be thoughtful in that way. Things that we need to be thinking about is actually treating overweight and obesity since it’s already here. We’re talking about 75 percent of the population. Let’s begin to actually treat this disease that’s actually here in the population, both in the pediatric and the adult population. This study focused on the adult population, but I can tell you as also a pediatrician, since I take care of patients across the age spectrum, we need to be treating this across the age course and we need to be thoughtful about that and thinking about how do we actually address this from a lifestyle factor — from lifestyle factors, using pharmacotherapy and also metabolic and bariatric surgery, which has had a significant decline over the last year. We’ve seen a 25 percent decline in the use of a bariatric surgery in the last year. But we’ve had a rise in severe obesity. This is something that we need to be thoughtful about. So, we need to be thinking about that. But we also need to be thinking about policies, which is how we started this conversation. How do we think about large scale policies, thinking about governmental policies intersecting with the healthcare sector and thinking about how do we also address the exorbitant costs of access, not just to pharmacotherapy, but thinking about how — what are we doing in our schools? How are we thinking about food and thinking about the quality of our foods? We need to reduce our ultra-processed foods. These do need to change within our society. We do know that that is still part of the problem. And so, we do need to make some reduction in that to make sure that overall, our society is healthier. But we have to also address all those other issues that we know are germane to increasing these obesity rates over time. And so, this is going to take a multisector, multi-pronged approach to really address this issue. It’s not going to be just health care. It’s not going to be just government. It’s really going to take every — all-hands- on-deck because there’s no way that one sector is going to be able to address this alone.

SREENIVASAN: Obesity medicine physician and professor at Harvard Medical School Mass General Hospital, Dr. Fatima Cody Stanford, thank you so much for joining us.

DR. STANFORD: Thanks so much for having me. It’s been a delight being here.