Obesity Isn’t a Willpower Problem - It’s a Chronic Disease | Marc-Andre Cornier MD, The Obesity Society & MUSC

🧠🍽️ Obesity and being overweight are often talked about like personal failures, but the science tells a very different story. In this episode of The Health Curve Podcast, Dr. Jason Arora and Dr. Marc-André Cornier (Past President of The Obesity Society, Professor of Medicine, and Director of the Division of Endocrinology at MUSC) explore obesity as a chronic, progressive disease shaped by biology 🧬 and an “obesogenic” environment.

Together, they unpack why obesity rates have risen so dramatically worldwide, how risk and complications vary across populations 🫀, and why low socioeconomic environments and “food deserts” can quietly stack the odds against health 🏙️. They also discuss why childhood obesity is so concerning 🧒📱, and what it means for long-term health systems, productivity, and society.

They also explore what evidence-based obesity care actually looks like today, walking through the full toolbox - from lifestyle foundations 🥗🏃 and medications (including GLP-1–based therapies) 💉 to bariatric surgery 🏥 , plus the hard truth that long-term disease often requires long-term treatment ⏳. They also tackle common fears and criticisms: side effects, cost and access 💸, direct-to-consumer “quick fixes” 🧪, and the tension between prevention and treatment.

If you’ve ever wondered why weight loss can feel like your body is fighting you - and what a smarter, more compassionate, science-based approach looks like - this episode is for you 💙.

Chapters"

00:00 – Introduction and guest background
01:10 – Why obesity is rising: genes × “obesogenic” environments
03:15 – Why obesity risk differs across populations and regions
04:20 – Visceral vs subcutaneous fat: metabolic vs mechanical health impacts
05:50 – The environmental drivers: food deserts, safety, inactivity, marketing
06:55 – Why childhood obesity is accelerating
08:20 – The societal and economic spillovers of obesity
10:50 – Why obesity meets the definition of a chronic disease
13:05 – Patient archetypes: cosmetic vs health vs “not on the radar”
14:30 – The obesity treatment toolbox: lifestyle, meds, surgery, teams
20:00 – Who should get what? BMI limits, waist measures, risk staging
23:35 – Expected weight-loss ranges: lifestyle vs GLP-1s vs surgery
26:10 – Long-term challenges: cost, coverage, adherence, access
29:15 – Side effects and safe prescribing: why supervision matters
31:35 – Direct-to-consumer risks, compounded meds, and regulation
33:45 – Prevention vs treatment: why it’s not either/or
36:30 – “Big food vs big pharma” concerns and stigma
39:50 – The future of obesity care: primary care, centers, virtual models
43:20 – What’s next in meds: multi-agonists, longer-acting options, muscle preservation

Transcript

Meet Mark And His Mission

SPEAKER_00 0:03

Mark, thank you so much for joining me. It's great to have you here. Can you start by telling us a little bit about your background?

SPEAKER_01 0:09

Yes. So again, thank you for inviting me. I'm trained as an endocrinologist and have had an interest in the obesity field since my training when I got involved in research in the area of metabolism and obesity. It was a time when there was significant new developments and how we approach body weight regulation and how you know how obesity is caused by alterations and genetic and biologic causes. You know, we in 1994 a hormone called leptin was discovered, and that really set the field forward. So that my interest has been in that for a long time, and I've cared for patients with obesity since my endocrinology training. Not quite 30 years, but getting close and have continued in that space during that time. I've also been highly involved in the US, the Obesity Society. And this year I'm the current president of the Obesity Society, and I've had a privilege of being involved and really taking the lead. And this year we've really focused on obesity as a chronic, serious

Framing Obesity As Chronic Disease

SPEAKER_01 1:11

disease.

SPEAKER_00 1:12

Right. And that's what we're going to talk about today, really. It's about obesity as a chronic disease and an increasingly relevant problem today and in the future.

Prevalence And Global Trends

SPEAKER_00 1:21

So it might make sense to start with how common obesity is and the trends. So in 2022, I believe we had recorded two and a half billion adults globally being overweight, and that included about 400 million children. And these are just estimates, of course. Today, I believe it's around about a billion people who may have obesity. It's a two-fold increase since 1990. And in children, I believe a fourfold increase since 1990. How do we explain this trajectory?

SPEAKER_01 1:47

Well, we don't have the exact science behind this, but what we believe is that there is a genetic and biologic predisposition to overweight and obesity in certain individuals in a certain environment that we call the obesogenic environment. So the same individual who would have that same genetic predisposition 100, 200, 500 years ago in an environment that was not promoting increased food intake and reduced activity, those individuals wouldn't have obesity. But today, because of our inactivity due to changes in the job force, due to new technologies, cars, computers, et cetera, and the setting of food being abundant, our biological signals can't handle that environment. And so that is the general rule of thumb of what we believe is happening, is that it's an interaction between our genetics and our environment. And yeah, like you mentioned, people with overweight and obesity, so excess body fat, that's the terminology we use. There are more than two billion people as of 2021 on this earth who meet those criteria. And it's expected to increase dramatically. And in the United States, for example, over 70% of our population has overweight or obesity. But you can go to other parts of the world where those are over 90%, like in the Middle East, for example, or some of the South Pacific Islands. So it's really is dependent on the region, but it's a global pandemic.

SPEAKER_00 3:18

And I just want to pull on that thread a bit. Can you tell us a bit more about how it varies around the world across different ethnicities, different social groups, economic groups?

SPEAKER_01 3:26

Yes. So I

Genes Meet An Obesogenic World

SPEAKER_01 3:27

mean, clearly, because there are genetic influences and individuals from different parts of the world have different genetics, there we we see differences. What's interesting is that obesity is not just one disease. It's uh we actually some people use the term obesities, uh, plural, that it's a very heterogeneous, meaning that it's not all the same. And for example, someone from India, so Southern Asia, with a less excess body fat can have significantly more diseases as a result, like diabetes, hypertension, cardiovascular disease, compared to individuals from European descent, where you may not see those complications arise until they have even more body fat. So you do see the differences regionally based on where body fat is distributed and how that has an impact on developing complications related to excess body fat.

SPEAKER_00 4:17

Not to go too deep into this for our audience, but can you explain a little bit more about the biology there and the differences between different folks? Like why is the risk different for them?

SPEAKER_01 4:25

So there's one is we have to understand that there are metabolic risk, but there's also mechanical quality of life risk that these things are different from a metabolic risk, meaning risk for diabetes and cardiovascular disease and fatty liver disease. It's this what we call central obesity or visceral obesity. It's obesity on the center part of your body in and around your organs that causes those metabolic disorders. And so in individuals from certain parts of the world have a predisposition to develop body fatness around those organs. And so they may not appear to have obesity, meaning they don't have a lot of body fat on their arms and legs and other parts of the body, but they do around their abdomen. Whereas other individuals can deposit excess body fat in the subcutaneous, so under the skin, not around the organs. That is not harmful metabolically. But if you have a lot of it, it can cause mechanical problems like arthritis, stretch of sleep apnea, impact your ability to do

Risk Varies By Ethnicity And Fat Pattern

SPEAKER_01 5:26

simple things in life, the you know, quot, you know, tying your shoes, you know, going to the grocery store, walking down the street. And so there are differences from that perspective.

SPEAKER_00 5:35

And so in in many ways, this is a defining problem of our time, our success in feeding people and making them comfortable and you know, creating technologies that people can access without having to run around and whatnot is created a new set of problems that we now need to solve. But just coming back to environment, we've talked a lot about the role of food systems on this podcast, you know, stress, activity environments, obviously socioeconomic factors, marketing. Can you tell us a little bit more about these environmental factors that play such a big role? Yes.

SPEAKER_01 6:04

So, well, it's clear that socioeconomic status, for example, is a risk bill. So low socioeconomic status is a significant risk factor for obesity. And there are many reasons why that might be. Might be that group has a genetically might be more prone, but where people live. So just based on your zip code, you might identify people at higher risk because they live in a food desert, meaning there's not grocery stores with fresh foods. There are no sidewalks. You can't walk from one place to the other safely. You know, so there's issues with safety. And we see that globally as well, where countries of lower economic status or even medium have much higher risk for obesity than the higher economic countries, which we always thought that obesity was a disease of the rich, but it actually turns out it's not anymore. It used to be, but it's not anymore.

SPEAKER_00 6:54

And I I want

Metabolic Versus Mechanical Risks

SPEAKER_00 6:55

to talk about children very briefly, in that we're seeing more and more obesity in children and teens. And the rise has been astonishing over the past few decades. What's driving that increase? Is it the same stuff or are there other things going on?

SPEAKER_01 7:07

Yeah, I'm not a pediatrician or an epidemiologist, but certainly it's still at the end of the day similar causes as in adults. The concern is that children with obesity become adults with obesity. But it's reduced that physical activity is a huge player. Many schools don't even offer physical activity. And children come home instead of playing outside, they go straight and watch TV or play on video games. So an inactivity is a major role. And also lots of, you know, highly processed foods available that are very tasty, very good, and abundant. So it's that kind of that balance of inactivity with too much available food. You know, I think it it's the same, but in the past, I think children were significantly more active and food was controlled more by the parents, the family, and that that is a major issue. So, and this is again happening across the globe. And the concern is, you know, at one point we saw a dip in obesity rates and but in adults, but there was a continued increase in children, and now that has reflected into an increased rate in adults. So, and that makes sense because obesity as a child, you know, is a significant risk factor for obesity as in in adulthood.

SPEAKER_00 8:22

And we talked earlier just about how common this is and how common it's going to continue to be globally. I have an interesting statistic. By the year 2035, obesity, the economic cost of obesity will be over $4 trillion per year, which is about 3% of global GDP estimated. You know, there are significant implications for already overburdened health systems. Again, not just obesity itself, but the associated cardiometabolic diseases, type 2 diabetes, heart disease, liver disease, kidney disease, disability, productivity. And then there are intergenerational effects. So can you talk a little bit more about some of the societal spillovers that we expect to see with this? We are going to talk solutions, but we always start on this podcast just by trying to paint a picture.

SPEAKER_01 9:07

Well, I mean, I think it's clear that

Environment, Inequality, And Place

SPEAKER_01 9:10

obesity is causative to many health complications. Just so that from that perspective, an increased burden. So the more obesity, the more complications, the more diabetes, cardiovascular disease, cancers, mental health disease, mechanical disorders. So and the cost of those complications is really why these numbers are estimated to go so high. It's it's the downstream effect. It's similar in diabetes, but the cost of taking care of diabetes is really the cost of treating the complications. It's not treating the diabetes itself. And so I think it's a parallel with obesity. So there's the direct costs of obesity and its complications. And many of these complications are a direct result of excess body fat or adiposity, leading to either the metabolic or the mechanical issues. But then there's all the indirect costs, you know, missed time at work, and you know, inability to get to the doctor's office. And so then you get sicker, and then it costs more to take care of you. More expensive to, you know, the bigger we are, the more it uh costs for us to travel, for example, right? I mean, you don't think about that, right? The more weight in a car, the more weight on an airplane, the more fuel it uses. There's but the big ones are the missed time at work, the absenteeism, those are the factors that really are going to drive a lot of the cost downstream if we don't do something sooner than later. Now, there's one statistic that in North Africa and Middle East, by 2050, two-thirds of the population will have obesity, not overweight and obesity, just obesity. And in high-income countries, that's going to be over 40%. You know, where right now we're around 30%. So it's quite concerning if we don't do anything about this.

SPEAKER_00 10:53

And relatively recently, there's been this shift in the medical and scientific communities toward framing obesity as a chronic progressive disease. Can you tell us a bit more about that?

SPEAKER_01 11:05

Yes. So, you know, what is a disease? So, you know, a disease is an abnormality in some normal function of the body, right? So an impairment. And with obesity, we know people prone to obesity or who have obesity have biologic signals in their brain and in their bodies that are abnormal in terms of how that regulates your body weight, how it regulates how hungry you are, how full you are. And that's also associated with metabolic

Childhood Obesity’s Rise And Stakes

SPEAKER_01 11:34

and endocrine dysfunction. Now, a disease also has characteristic signs and symptoms. Well, obesity has a very characteristic sign, that's excess body fat, symptoms, you know, joint pain, altered metabolism, sleep apnea. And then a disease, not only does it associate with these things, but it causes harm and more primitivity. And we know that obesity directly relates or even causes diabetes, cardiovascular disease, cancers, reproductive disorders, liver disease, et cetera. So clearly it meets the definition of a disease. And I think where the science is really taken is that in the brain, the wiring of the brain is different than people prone to obesity. And people with obesity can't regulate in an environment where there's abundance of food and we're inactive. So that's really the you know the disease part of it. The other is we know that that fat cells produce all these chemicals and proteins that cause harm in our body, can lead to the metabolic dysfunction, but also to cancers and inflammation. So there's a direct relationship between excess body fat and all these complications. So it's pretty clear that this is a disease from any way we look at it. Now there's been some controversy about how you define it or diagnose it in the clinics, but I think most experts agree that this is a disease that that needs to be treated like a disease, meaning this is a long-term problem. It's not a weight problem per se. It's a health problem that needs a long-term solution.

SPEAKER_00 13:06

And you see patients in your clinic, of course. What are some of the different archetypes of patient that come in? And what are some of the trends there? Is that changing? It's yes.

SPEAKER_01 13:17

Yes and yes. So the types of patients we have patients, you know, I'm an I do obesity care. So patients come to see me because they want to do something. So that's different than the patient with obesity who goes to see their primary care provider who's and they're not looking to work on treating their obesity. They may not even think obesity is a problem or a concern. So I have that advantage of patients are already wanting to do something. So that makes it easier for me. So we have patients who come in because they're worried about obesity and their health because their parents have diabetes or heart disease, or already they might already have health concerns that they know are related. Some are still more on the it's a cosmetic problem. You know, I want to look and feel better. But that's also a legitimate concern for people, and we want people to feel well and feel healthy. And, you know, I think in the primary

Societal Costs And Downstream Burden

SPEAKER_01 14:10

care world, you have a lot of patients who are being seen who have obesity, but there are they aren't diagnosed or the patient's not asking about it. So it's really up to the provider to really bring this up and to initiate, you know, a discussion, which hopefully down the road leads to treatment. So I think that's you know, the different settings. You know, the patient who don't doesn't know it's an issue, the one who knows it's a medical issue, one who thinks it's more of a cosmetic issue. Those are some of the different types of patients I might see. So how do you treat obesity? What are the different approaches? So the treatment of obesity needs to be a comprehensive approach. It's not just eat less and move more. It's not just here's a prescription or here's a referral to surgery. It's a comprehensive approach. So at the end of the day, if we want to treat the disease obesity, we need all the tools available to us because it's very difficult to treat. So lifestyle change, behavior modification, this is at the core to all our therapies. Ultimately, if we're trying to help people lose weight, which again, weight is not the driver. We're not treating weight, we're treating obesity, but weight is a marker and it tells us that things are improving. We have to help people bring in less calories than they burn every day, or they need to burn more than they consume. That's the only way that people are going to lose weight. And losing weight then equates to hopefully treating their obesity. And so diet is critical, right? So you can cut your calories, or you can eat less carbohydrate, which ultimately leads to less calories and less coming into the system. You can move more. You know, we can't control our metabolic rates. That's part of our energy that we burn every day. But what we can control is our activity, so we can be more active. But it takes a lot of activity to burn calories. And so, but you can lose weight that way. One of the problems with lifestyle is that when you start losing weight, the biology that controls our body weight is triggered to want to compensate. And so people get hungrier, their metabolic rate goes down, and so that promotes weight regain. And so people can't stick to or you know, adhere to a long-term diet or to the increased physical activity very easily because their biology is trying to get them to eat more and move less. And so it's very difficult because the biology is fighting against people. Is it doable? Yes, it is doable, but it's extremely difficult. But it's still at the core. We also want from diet and exercise a healthy

Why Obesity Meets The Disease Test

SPEAKER_01 16:42

lifestyle. We want not people eating lard all day long, right? We want people to have eat vegetables and fruits and healthy foods, fresh foods if possible, healthy oils, healthy protein sources, physical activity, the more the better. So that is core treatment. Then we have medical therapy, and that's where things are booming, right? You know, we've all heard about all the you know these new injectable therapies, GLP1-based therapies, and they lead to significant weight loss. And how they work is they work on the brain in those centers to tell you to eat more and to move less. They're blocking that. And so you're not as hungry, you're more full, and you're gonna burn more calories. And so people lose a significant amount of weight. Unfortunately, though, those medicines only work while you take them. The studies are pretty powerful. You take a medicine, you lose weight, you stop it, boom, the weight comes back. And that makes a lot of sense. So that's where we really need to educate everybody, including our patients, but also the healthcare providers, the policymakers, and the people who pay for healthcare, that this needs to be a long-term treatment. Does that mean that once you start on a medicine for obesity, you have to be on it for the rest of your life? We don't know, not necessarily, or maybe we use one medicine for a period of time and then transition to something else, a different treatment option. But everyone's gonna need a long-term treatment because we know once the treatment's taken away or the individual can't adhere to that treatment, the disease comes right back. I mean, we see that with other chronic diseases. You know, let's take diabetes, for example. Your blood sugar is elevated, we put you on a medicine, nobody blinks an eye about doing it. That medicine for diabetes, it brings down your blood sugar. Many patients, six months, a year later, may stop that medicine because insurance didn't cover it or something happened. And what happens? Their blood sugars go back up. That's the reality. So we need to be thinking about obesity as a chronic disease. Lastly, is there procedures that help patients? So bariatric and metabolic surgery, for example, have probably the best evidence, you know, that you get the most weight loss, keeps it stays off the longest, improves all the complications and other health effects the most more than medical therapy, more than diet and exercise. So obesity metabolic surgery is still a very important treatment, even in the setting now where we have medications that might result in weight loss that might approach a surgical type of intervention. So all of these need to be looked at for patients and it needs to be individualized. We also need to look at the severity. The sicker someone is, the more aggressive we want to be. You know, if they have uh you know severe obesity with significant complications, that patient deserves aggressive treatment sooner than later. So, for example, using surgical interventions, not waiting one, two, three years, which is often what happens for patients. So all of these are important to work together. And it's not just the health care provider alone, it's also using nutrition counseling, whether it's from a dietitian and nutritionist. Can we get involvement from on the physical activity

Patient Archetypes And Motivation

SPEAKER_01 19:46

side with exercise physiologists, physical therapists? Counseling can be important. So mental health professionals and then obesity medicine specialists when needed, and then surgeons for those patients who are eligible. So it's a very much a team approach in the big picture.

SPEAKER_00 20:02

And we always have these diagnostic criteria for you know, for giving a therapy or for diagnosing a disease, you know, we have these thresholds. What's your take on people who are overweight versus obese and this toolbox we have of different things we can use? So lifestyle modifications, you know, incritin-based therapies like GLP ones, except you know, surgery. We'll talk about prevention in a moment, but just thinking about this as a continuous process, how do you apply that toolbox across what is you know a progressive pathway? Right.

SPEAKER_01 20:33

So, you know, historically we've used body mass index as a tool to or metric to diagnose obesity and to determine what treatments a patient should be on. It's a start, but it's not ideal. And there's many new guidelines that are saying we need to do more than just a body mass index or BMI. BMI takes your weight and your height in consideration. That's important. But what it doesn't tell you is where is the excess body fat? Is it centrally in your abdomen where we're more concerned? So, what's the distribution? What how much body fat there is there? Where we're most concerned is in people who have lower degrees of obesity or might have overweight. So their BMI is in a rate range that's considered overweight. But that individual potentially, depending on the genetic and their ethnic background, maybe they're at higher risk than someone who has a higher BMI that has less sensual obesity. And so that's why the BMI is not ideal, because we're potentially under-diagnosing certain high-risk groups. It's rare to over-diagnose obesity. You know, it's one concern would be, you know, a professional athlete who has a lot of muscle, that the muscle weighs more than fat. So their BMI might be elevated, but it's all muscle, not fat. So they don't really have obesity, but by BMI they do. That's rare. I mean, I can't remember the last time a patient walked into my room that had an elevated BMI due to just too much muscle mass. But so it's more concerned about underdiagnosing people. But with the BMI criteria,

Comprehensive Care: Lifestyle To Surgery

SPEAKER_01 22:05

we over the years we've said, okay, if your BMI is in the overweight range, let's really use lifestyle treatment as our primary mode of therapy. If you're in the obesity range, which means a BMI of 30 or higher, consider medicines. Unless you're overweight with obesity-related complications, then consider medical therapy. If your body mass index is over a certain threshold, 40 was the historical, more recently 35, then we consider surgery for those individuals. I think that the newer guidelines are saying, okay, we use a BMI, that's fine, but we want to confirm excess body fatness by doing things like a waist circumference or comparing the waist to your height or your waist to your hip. Can we measure percent body fat with different technologies? And so that there's a move towards that as well. And then also staging patients, meaning, do you already have complications? And so should we be more or less aggressive? So I think the landscape is changing there in terms of how we diagnose it and how we use those tools to decide who gets which treatment. I think we all are mostly in agreement that we wait too late. We wait till people have very elevated body mass indexes. They already have complications before we treat them. It is much easier to treat earlier and to prevent those complications. So we really believe that obesity should be treated, quote, first, end quote, you know, before we have all those other complications arise.

SPEAKER_00 23:35

We'll get back to this conversation in just a moment. But if you're finding this episode helpful, here's a quick ask. Take a second to follow or subscribe to the Healthcurve Podcast wherever you're listening. And if someone else in your life would benefit from this episode or any of the others you've heard, please send it that way. And we've talked about this toolbox. Just briefly, can you tell us what are the expected improvements that we would tend to see with lifestyle modifications, GLP1, surgery, etc. And how do they compare them?

SPEAKER_01 24:07

Yeah, so with lifestyle, typically we're going to see anywhere from 3 to 7% weight loss. So kind of, you know, the 5% is a rule of thumb number we often use as a goal. With more intensive diet therapy, with, for example, very low-calorie diets, that's often done using what's called meal replacements, so shakes or bars, those kind of things, where we put people on, you know, 800 calories, 1,000 calories. Sometimes we see upwards of 15% weight loss. But again, that usually lasts about six to 12 months. And then people start regaining because it's difficult to adhere to those diets and lifestyle changes. With medical therapy, we see anywhere from 3 to 5% weight loss with some of our older medicines. But now with our newer agents, with our GLP1-based therapies like somagalitis, we see 15 to 20% weight loss. So that's pretty dramatic. And even, you know, with some of these treatments, you know, 20 to 30% of patients might even lose 25% of their weight. You know, it's quite dramatic. With surgical interventions, we see somewhere between the 25 to 40% weight loss. And I usually use that rule of thumb number of about 30% weight loss. So you see more weight loss with surgery than you do with medications, more weight loss medications than you do with lifestyle.

BMI Limits And Better Staging

SPEAKER_01 25:25

And but that's those are averages. And not everyone follows the average. You know, we have responders and non-responders to all of these treatments. You know, I've there are good research studies that show, you know, some patients losing a lot of weight on a low-carb diet, but some patients gain weight on a low-carb diet. And even with medical therapies, you can see some patients lose a lot and some don't lose any, and some even gain some weight. So I think we we have to find the right treatment for the right patient. We don't have good ways of identifying that necessarily. So we're often trying different things until we find a thing that works for that patient, which can be frustrating, both for the patient and the healthcare professional who's working with that patient, because it might take some time to find the right tool for the right patient.

SPEAKER_00 26:11

What are some of the challenges with these therapies long-term? We've talked about the fact that this is a chronic long-term disease that needs chronic long-term treatment. We have a toolbox, there are different things. The core approach has to involve lifestyle and behavior, no matter what. And then you have some medicines now that are very effective. You have surgery that can be very effective. For the medicines specifically, the GLP ones in particular, what are some of the challenges at the moment?

SPEAKER_01 26:36

Well, there are a number of challenges. Probably the biggest one is the financial challenge, the cost. You know, in some parts of the world, these drugs are not even available yet. So that's certainly so access to these medicines is a key issue. We have patients who are asking for it and their healthcare professional doesn't feel comfortable prescribing them or isn't trained or doesn't believe that obesity is a disease that should be treated this way. So again, so education is critical. So we have to educate our providers, but we need to educate our patients too about the long-term need for therapy. But the cost is high, and we generally don't have coverage for

Expected Results: Lifestyle, Meds, Surgery

SPEAKER_01 27:15

medical therapy. You know, here in the United States, it's fairly rare now. So we're dependent on people paying cash for these treatments often. The current administration announced cost reduction for cash-paying patients in agreement with some of the companies that make these drugs. And that's a nice first step because yes, $350 a month is less than $500, but $350 is a lot of money for a lot of people. A lot of people can't afford that. And it's the only disease that I know where the patients have to be the provider of care in terms of paying for it. So we need to get coverage universally for obesity. But there's a lot of concern from the payers of healthcare. That's going to bankrupt them because we're talking a lot of patients. Having said that, we already said that the cost of treating obesity in you know 10 years from now is going to be in the trillions and trillions of dollars. So if we don't do something, it's going to be unaffordable for us. So I think we ultimately have to invest and pay maybe more money now to save money later to prevent all those expensive complications. It's going to take years to show cost effectiveness, you know, and it's going to be always going to be difficult. We see it with surgery, you know, that, you know, it's a one-time payment, and so we get a benefit. And so that the cost savings actually occurs after a few years. With medicines, we haven't been able to show that yet, because we haven't, these medicines haven't been around long enough, nor have we been able to follow patients long enough. And so I think it's going to take longer-term therapy to really show that we can save money down the road. Competition will help. New drugs coming down the pipeline. We should have new, even in the next year, there should be some new therapies. The more therapies, the more competition, potentially the lower the cost. Therapies that are maybe not injectable therapies might be cheaper to make and produce. So at the end of the day, we need to get access for our patients. And so that includes educating our providers and our healthcare system, but also dealing with the

Access, Cost, And Coverage Barriers

SPEAKER_01 29:19

cost of these treatments.

SPEAKER_00 29:20

And of course, there's been a lot of talk about side effects with these therapies. Can you talk a little bit more about that?

SPEAKER_01 29:25

So that's certainly another issue. So if you but if you look at, and this has been studied in a number of groups, at least here in the US, less than 50% of people are still on obesity medicine after a year. And why do they stop? The most common reason is cost. The least common reason is side effects. Well, you know, we think that's the number one driver, but really it's it is important, but it's not the number one driver. So yeah, these newer therapies have side effects of nausea, vomiting, diarrhea, constipation. And maybe the rates of these side effects is uh towards 20, 25% of patients. But really, only about it seems like around 10% are not able to take these medicines. You know, we're actually, they cannot continue. These medicines, the side effects tend to be more significant early and improve over time as the likely the body is kind of gets used to them. And so there seems to be a time effect as well. So if you can get patients through those first number of months, you're they're more likely to be able to tolerate. So the hope is that in the future that we'll have you know medical therapies that will be effective, but maybe even better tolerated than what we have now. But again, I think the majority of people do tolerate these medicines, but we have to work with our patients. These medicines are typically titrated, meaning we start at a low dose and we slowly increase. And you know, there's I think we we tend to try to push too quickly because people want to lose weight fast, right? And so often if we go slower, we can get people to tolerate these treatments better. So I think that's another strategy is and but it requires that the healthcare professional has experience using these drugs, right? And that the patient's being monitored closely. And that's one of our concerns. We see we have patients going and getting these treatments through not real medical facilities, through health spas, medispas, or online, and there's no, there's little to no follow-up with patients and medical supervision. These are powerful medicines and they should, you should be supervised closely. And I think when we see bad outcomes, it's often because patients weren't being monitored very closely and weren't being educated on how to take these medicines correctly and safely.

SPEAKER_00 31:40

Right. And that's where I was going to go next, is this has almost become a bit of a street drug and in that you know, there is an industry spinning out around longevity and direct primary care, you know, these sorts of things. There are a lot of good things about that trend. But one of the challenges

Side Effects, Titration, And Safety

SPEAKER_00 31:55

is that these obesity treatments or medicines, as an example, are being used rather frivolously. And, you know, there are people talking about microdosing on them, all sorts of things. So you're saying, of course, these are powerful medicines. It's critical that they are administered by professionals who are trained in how to use them, how to monitor the patient. And the patient needs to be monitored and this needs to be part of a bigger treatment plan, not just used.

SPEAKER_01 32:18

Yes. And you know, I think one of the big concerns has been compounded versions of these treatments where not only is the active ingredient not legal, it's not the real medicine, it hasn't been studied, it's not generic. And so there's concerns about the efficacy and the safety, but then it's not, you know, uh not even monitored properly. You know, and you can go online and get whatever you want. And, you know, you theoretically it's prescribed by a healthcare professional, but you know, you're online, you're not even being examined, and so you can lie about your weight and your height so that your BMI is in a category that allows you to be eligible. I think direct-to-consumer care can be good and it can be done well, but it can also be done poorly and in an unsafe manner. So I think we need a little more regulation uh in that area, because not everyone can have access to a healthcare provider that is experienced in treating obesity. And so direct-to-health care to consumer care, I think, is a model that can be effective if it's done correctly. So that, you know, not everyone can go to a center of excellence. And so I think in the ideal world, we would have forced training for our healthcare professionals for using these medicines. And in some countries they do. And where to be able to prescribe these treatments, you have to have passed, you know, an exam, so to speak, to confirm that you have the expertise to use these properly.

SPEAKER_00 33:45

Aaron Powell A couple of criticisms out there about this approach. I guess the first being that some critics say that medicating obesity or medicalizing obesity is giving up on prevention and that obesity is fundamentally preventable. How do you respond to that?

SPEAKER_01 34:00

Aaron Powell Prevention obviously is always better than treatment, regardless of the chronic disease, you know. And so intervening earlier certainly

The DTC Boom And Compounding Risks

SPEAKER_01 34:09

makes sense. And again, I think that's back to education at a public health level, at a you know, at the public level, but also at the health professional level, of when we see that someone's at risk, either genetically because of family history, et cetera, or we see that in their chart that their weight is going up over time, let's intervene sooner than later. That's, you know, we as I said earlier, we tend to wait till someone has obesity and/or they already have complications before we address it. So prevention certainly would be optimal. That's more of a public health level of treatment in terms of how we deal with the food environment, how we do with the physical activity environment around us. The issue is that we have, and that'd be great. Maybe we could prevent obesity down the road with certain public health initiatives. I don't think that's possible, to be honest, but let's say it is. We still have more than two billion people with overweight and obesity now that need treatment. And we know that just telling people to eat less and live more doesn't work long term. And so medical therapy can be very effective in many of those people. Not saying all of them need medical therapy, but many might qualify and many deserve treatment. So I I think that prevention is critical, but meanwhile, it's a problem today. And I don't know how far we're going to get with prevention 10, 15, 20 years down the road. So you know, one of the key changes in our society is our job force. You know, we went from labor-intensive jobs over the last hundred years to very sedentary jobs. I think it's highly unlikely that that tide will ever change, right? You know, I mean, look at us right now, we're sitting here at a computer, right? Many of us are doing that, or we're driving, or we're we're not all of a sudden going to go back to labor jobs for most of us. So that in of itself can explain a lot of the obesity epidemic. So that's a challenge. And telling people, oh, you just take more time to exercise. Well, that's easier said than done. And I tend to, it seems like I hear that from people who don't genetically have are prone to obesity. Or that they, you know, is you know,

Prevention Versus Treatment Debate

SPEAKER_01 36:25

so it's so it's easy for people to say, oh yeah, it's not a disease, it's a choice, what have you. But I think it's pretty clearly a disease from a biologic perspective.

SPEAKER_00 36:33

Yeah, I mean, I think the trend of people sitting for most of their day at a screen is one of the biggest problems for humankind right now. And I keep telling people, very soon I would like a job where I'm doing manual labor on my feet all the time, because I just think that that would be much better for me. Anyway, there are people out there who feel they're trapped in a system of intense profiteering between two industries, big food and big pharma. And some of these people are very reasonable and very intelligent, and they're not completely wrong. So, what would you say about that? Where, you know, we've not on purpose, you know, necessarily, but there are these systems that have been created where there's an obesogenic environment that has been allowed to happen. Let's just say that it continues to be propagated and encouraged, and you know, the pathway to okay, well, you need to now take a drug to solve that problem, and there are other entities that profit from this and you just have to deal with it. I mean, it's a complex question, but what would you say to those people who feel they're trapped in a conspiracy?

SPEAKER_01 37:32

Well, I think it really highlights the stigma and bias of obesity. I mean, if we take the same example for type 2 diabetes, much of type 2 diabetes is due to our environment. I mean, it there's been great research. You know, I've never heard of the Pima Indians. They're, I think, in Mexico, and there there's very little diabetes. And they moved in Arizona. There they have significant obesity and they have the highest rates of diabetes in the United States. Genetically, they're the same people, but they're in obesogenia. And so it's diabetes. And yet no one is criticizing that we need to treat diabetes and that it's a conspiracy, and etc. But so it really, I think, gets back to the people just don't believe that obesity has a biologic basis behind it and that it is a disease. It's a disease that comes out in the right environment. But so is type 2 diabetes. You know, if you were running every day and and fighting to keep your weight up because of your environment, even if you were prone to getting diabetes, you probably wouldn't get diabetes, you know, type 2 diabetes. So I think we can't blame everything on an industry or more than one industry. But yeah, it's a tough question in a tough situation. You know, we can try to alter the food system. Again, realistically, I'm not sure how to do that. You know, why do why does the food industry make highly processed foods that are taste really good and full of calories? It's because people want it. They want that food. It tastes good, it's cheap. It's calorically dense, so you can get the calories that your body needs, you know, pretty effectively. So it's they have

Food Systems, Pharma, And Stigma

SPEAKER_01 39:21

found the solution in a way. But I'm not sure how we change the activity side of it. And I think that the pharmaceutical industry who's developing all these treatments, yeah, I mean, certainly they're looking to make a profit and make money, but they're also trying to help patients and treat the underlying biology that predisposes people to obesity. And so I don't certainly see it that they're conspiring in any way.

SPEAKER_00 39:50

As we look ahead to the future, you know, the next few decades, we've already talked about the fact that we expect obesity rates to continue to go up in adults and children. We've talked about some of the spillovers that we're gonna see economically in society. What does the future of obesity care look like? How are we gonna meet this moment? That's a great question.

SPEAKER_01 40:13

And I think there are many people talking about this, many, many people meeting to try to understand how can we best address this pandemic that we are in. One is we believe that the care today and tomorrow and for the future for obesity should be a comprehensive care. It shouldn't that that's critical. That we have evidence-based medicine that's you know, studies that tell us that diet, exercise, medication, surgeries work to not only not just reduce weight, you know, again, that's not our goal. Our goal is to improve health and that these treatments improve health outcomes and that so our patients deserve it. So, how do we get that care and that access to care to our patients? There's not one right way to do it. And I think depending on where you are on the planet, you will receive that care in different ways. But if we just look at the United States, for example, or some of the European countries, I think care will come in probably in three different flavors. One will be primary care. You know, that's going to be the vast majority of people that their primary care will need to be involved, will need to lead the treatment paradigms that we have. Now we hope that the primary care providers will use resources around them because they won't be able to do it alone. So they'll need to refer to dietitians, to exercise physiologists, mental health experts, to surgeons and other specialists. But the primary care provider will be at the core. There'll be more complicated patients. And perhaps those patients are the ones

Future Care: Primary, Centers, Virtual

SPEAKER_01 41:50

that are should be seen by centers of excellence for obesity care. So in academic centers or in other hospital centers where you have dedicated obesity medicine providers with all the ancillary, all the ex other staff, the dietitians and others to support them. So we see is just too common. And then the third is the direct-to-consumer approach. And I think that will continue to occur. And as we talked about earlier, there are good direct to consumer organizations and there are bad ones. And so we need more regulation on this because patients need comprehensive care. They need close follow-up. So these virtual platforms need to be able to provide that comprehensive care. So I think to be able to reach all these patients, we're going to see that all of these areas are going to grow. And the big emphasis is going to be on primary care. I think what's exciting is the whole new pipeline of new medications. And, you know, we've had a boom just in the last few years with new medicines that are much more effective, that are associated with significant improvements in clinical outcomes like cardiovascular disease, sleep apnea, and fatty liver disease and arthritis. And we're going to get more of these. And that's very exciting.

SPEAKER_00 43:19

I guess we're going to have to appreciate that this is not going to go away. And we have to have a more comprehensive approach to this particular disease segment. Let's just call it that. Now, in the therapeutics area in medicines, there are there are lots of different types of medicine that are being developed that work in different ways. For our audience, can you just tell us a little bit about some of the different ways in which these medications work?

SPEAKER_01 43:41

Yeah, the science is fascinating and we're learning a lot. So the medicines that we have that are very popular, the cybaglotide throughzepitide, you know, known as Ozepicinwikovy and Monjaro and Zeppelin, these are GLP1 based treatments or incretin based treatments. These are, you know, they mimic a hormone that your body normally makes when you eat that causes satiety and makes you more full and less hungry before the next meal, leading to other effects in the brain to lead to less food intake and weight loss, and they're very effective. But the number of pharmaceutical

How New Obesity Drugs Work

SPEAKER_01 44:18

industry partners are combining multiple of these types of hormones together to have an effect on the brain, to increase appetite. And so there are, like trusepatide is a what we call a dual lactase. It impacts two types of hormone receptors. There's one that has three, and there potential for one that has four different hormone effects. And so when you know the brain, you shut down one part, another part might enhance. And so by using different mechanisms, you can potentially block things better. And that leads to bigger effects on the appetite and potentially more weight loss. I think these approaches are also being looked at to be not just injectable therapies once a week, but there's a couple that are once a month. There's even a therapy that where we have some early data where it impacts the RNA in your cells and it has an impact on appetite weight loss that lasts six to 12 months. It's a single treatment. So a lot of excitement out there in terms of the possibility. The other area where there's a lot of new research is on instead of trying to block appetite, let's block the loss of muscle that we see with weight loss. So the more muscle you have, the more higher your metabolic rate. As you lose weight, you tend you lose fat, but you lose some muscle. So if we can prevent loss of muscle, we could then keep metabolic rate at a higher level. That might lead to more weight loss, but also might help people maintain weight loss in a more effective way. So there's a lot of excitement there where there's different mechanisms to approach preventing that loss of muscle or even increasing muscle mass in people who have low levels, like people who are of older age, for example. And then there's some interesting treatments that are being studied that instead of impacting appetite and energy that you burn, it impacts inflammation, which we know is a downstream effect of excess body fat. And so to prevent the metabolic disorders. There's a lot of interesting and neat things that we hope to see in the next number of years. The good news is I think there's going to be many more treatment options, which is good for competitive in terms of competition that might help drive the cost down, but also give more options for us as healthcare providers to give to our patients. Well, thank you so much for joining me. You're very welcome. And thank you for inviting me to join you today.