Recognition and treatment of obesity as a disease – 60 minutes
Nearly half of American adults are obese, a condition that was a fraction of that just 40 years ago, and scientists disagree on what has caused the dramatic rise. What everyone agrees on is that it is a major health crisis, as obesity can cause type 2 diabetes, hypertension, stroke and more than a dozen types of cancer.
Now there is a drug that leads to dramatic weight loss. But it’s terribly expensive. Hollywood celebrities use it to flatten their tummies, but few can afford the thousands of dollars it costs annually.
And very few insurance companies will cover it, even though in 2013 the American Medical Association, some would say, finally recognized obesity as a disease.
dr. Fatima Cody Stanford: It’s a brain disease.
Lesley Stahl: Is it?
dr. Fatima Cody Stanford: It’s a brain disease. And the brain tells us how much we should eat and how much to save.
dr. Fatima Cody Stanford, an obesity doctor at Mass General Hospital and an associate professor at Harvard Medical School, says common beliefs about obesity are wrong.
And diet shows like “The Biggest Loser” snooker people.
Lesley Stahl: If you diet, you lose weight, right?
dr. Fatima Cody Stanford: Many of us can go on a diet. Sort of like “The Biggest Loser,” right? You go and limit people. You make them exercise for 10 hours a day and then you give them 500 calories. For most people, they will lose weight quickly. But 96% of participants in “The Biggest Loser” regained their weight because their brains were working well. He should have brought them back to store what they needed or what the brain thought it needed.
Lesley Stahl: So willpower?
dr. Fatima Cody Stanford: Throw it out the window. My last patient I saw today was a 39-year-old young woman struggling with severe obesity. She practiced 5 to 6 times a week, constantly. She eats very little. Her brain defends a certain set point.
The set point, says Dr. Stanford, is the weight range that your brain is tasked with controlling how much food you eat and how much food you store. One theory is that it’s an evolutionary survival mechanism that helped preserve fat during famine.
Lesley Stahl: So we had COVID. Many, many people have gained weight. Did those people now have a new setting that is higher?
dr. Fatima Cody Stanford: Absolutely. So when you have a chronic stressor and you get to a certain weight and maintain that weight for, say, at least 3 to 6 months, then you recalibrate that set point to another set point.
Lesley Stahl: I always heard it was fast food. If Diet Coke is that kind of thing, that’s an incentive. Is that true?
dr. Fatima Cody Stanford: So I think we have to look at the different causes of obesity as a big cake. And that is one factor. But notice how I use this part of the cake, right?
dr. Fatima Cody Stanford: But the main cause of obesity is genetics. This means that if you are born to parents who are obese, you have a 50-85% chance of having the disease yourself even with optimal diet, exercise, sleep management, stress management, so when people see families who are obese, the assumption is , “Ugh. What are they feeding those kids? They’re doing something wrong.” Do you actually know this? 79-90% of physicians in the United States have a significant bias against individuals who are heavier. Now, doctors who listen to me can say, “Oh, it’s not me.” Calm down, because did that patient come to you and say, “Look, doctor, I’m eating well.” “Look Doc, I’m working out.” And the doctor says to them, “Are you sure? I don’t believe that’s really what you’re doing.”
Lesley Stahl: Wait, are you saying doctors don’t understand obesity? Doctors?
dr. Fatima Cody Stanford: Doctors don’t understand obesity.
In one of her published studies, Dr. Stanford found that most medical schools do not teach that obesity is a disease and in fact do not even offer courses on it, even though it is the second leading cause of preventable death in the country after smoking.
Nicole Sams, a Rhode Island mother of five, spent years going to doctors who all had the same message.
Nicole Sams: “Well, you just have to go see a dietitian.” And I did. I did everything I was told: I went to a dietitian; you know, I was sitting, when the gummy food came in front of me, “Oh, you’re only going to eat this portion,” I said, “Oh.”
Maya Cohen went on her first diet when she was 13 years old. At her heaviest, at 5 feet tall, she weighed 192 pounds.
Lesley Stahl: Did you feel like people were looking at you and saying “Why doesn’t she stop eating? She ate her way to that”?
Maya Cohen: You know you look at someone and think, “Oh, they must think I’m eating too much.” So that simply, after a while, you personally think, “All right. Everybody tells me that I’m–that it’s a flaw in my character;” therefore, it must be true. And so you begin to believe this.
dr. Caroline Apovian: Don’t you think that if people walking down the street with obesity, stigmatized as they are, were shunned, don’t you think they might lose weight and keep it off?
dr. Caroline Apovian, co-director of the Weight Management and Wellness Center at Brigham and Women’s Hospital in Boston, which hosts both Maya Cohen and Nicole Sams, is relieved to finally have a very effective drug to offer her patients that is safe, according to the FDA.
It is part of a new generation of drugs that lead to an impressive average loss of 15% to 22% of a person’s weight and help keep it off. dr. Apovian and Stanford advise companies developing obesity drugs, including Denmark’s Novo Nordisk, an advertiser on this show. This makes Wegovy a drug that you inject yourself once a week, kind of like an epipen. It’s not easy to get. The drug is currently in short supply. And it costs more than $1,300 a month.
Lesley Stahl: People in Hollywood can afford those expensive injections. And they take them.
dr. Fatima Cody Stanford: That’s right.
Lesley Stahl: And not necessarily obese people.
dr. Fatima Cody Stanford: Yes. We have a national shortage of these drugs. If those who have the funds can get them, the people who really need them cannot. Then that creates a bigger disparity, doesn’t it? The haves and the have nots.
The vast majority of people with obesity simply cannot afford Wegovy, and most insurance companies refuse to cover it in part because, as AHIP — the health insurance trade association — explained in a statement, these drugs “have not yet been proven to work well for long-term weight control and may have complications and adverse effects on patients.”
dr. Caroline Apovian: What we’ve seen so far is really nausea, vomiting, you know that’s why these drugs are dosed slowly and start with low doses.
Lesley Stahl: Oh, and build?
dr. Caroline Apovian: And build.
dr. Apovian says most side effects go away over time.
dr. Caroline Apovian: We are frustrated every day when we see patients who desperately need to lose weight to reduce diabetes, hypertension, stroke, heart disease, and we can’t give them this amazing, robust drug that is very effective and safe. And we can’t give it to them because insurance doesn’t cover it. I’m getting denial emails– saying we’re denying it because “the doctor didn’t counsel the patient about behavior change as part of this.” This is where the stigma of obesity comes into play, the idea that the patient can achieve it with diet and exercise. You would never do that to a patient with hypertension or heart disease or type 2 diabetes, you would tell them that “Just don’t eat sugar, you’ll be fine.”
Novo Nordisk also makes a type 2 diabetes drug called Ozempic, which is covered by most insurers and employers. What frustrates doctors is that Ozempic and Wegovy are exactly the same medication, although Wegovy is usually prescribed in a higher dose for obesity.
When Maya Cohen wanted a cure for obesity…
Maya Cohen: My insurance company told me they consider it a “vanity drug.”
Lesley Stahl: “vanity drug”.
Lesley Stahl: That means the insurance company doesn’t consider obesity a disease–
Maya Cohen: Right.
Nicole was also denied coverage. On its website, her health plan, through the state of Rhode Island, puts obesity drugs in the same category as drugs for erectile dysfunction and cosmetic purposes.
There are about 110 million Americans eligible for the obesity drug, making it an expensive investment for insurance, but if they did cover it, overall government and private health care spending would likely decrease. Just take diabetes, which in many cases is caused by obesity. Diabetes costs more than $300 billion a year, most of which is covered through Medicare and Medicaid. But University of Chicago health economist Tomas Philipson points out that there is actually a law preventing Medicare from covering weight loss drugs.
Lesley Stahl: You would think that the senior insurance program would benefit tremendously from these drugs?
Tomas Philipson: Yeah, a third of Medicare costs is diabetes, you know, which is heavily linked to obesity. And Medicare sort of sees all the health care costs when you get older when you have heart disease, etc., because of your obesity. I think what will drive it in the end is that they have evidence that this will actually reduce the overall cost of Medicare.
When Dr. Apovian told Maya Cohen and Nicole Sams that their obesity was not weakness of will, they were thrilled.
Nicole Sams: I looked at her and said, “I don’t believe you. What do you mean, ‘It’s not my fault?’ I’m guilty.” Because that’s what I’ve been hearing all my life.
Maya Cohen: I went home that day like– a rock fell off my shoulder. Like, “Okay, finally there’s hope. There’s hope.”
Lesley Stahl: Did you cry?
Maya Cohen: I did. A lots of. (LAUGHTER)
dr. Caroline Apovian: All those years of thinking that somehow you have no willpower and that this is your moral decline and that you are a glutton and why did you eat so much and– you feel ashamed. It’s a shame.
Lesley Stahl: Yes, yes. It’s a shame.
dr. Caroline Apovian: That’s a shame.
Maya was eventually able to get medication covered by her insurance because she has type 2 diabetes. She lost over 50 pounds. dr. Apovian says she must continue diet and exercise and, like most patients, will take the drug indefinitely to maintain her weight. Nicole does not have type 2 diabetes.
Lesley Stahl: Nicole, we called your insurance company and they gave us a statement.
Nicole Sams: Okay.
Lesley Stahl: “Earlier this year the state of Rhode Island, in agreement with the pharmacy benefit manager, decided that health insurance for the state of Rhode Island would cover an entire class of anti-obesity drugs.”
Nicole Sams: Oh– really?
Lesley Stahl: “This coverage change goes into effect in January”–
Nicole Sams: Okay.
Lesley Stahl: –“2023”
Maya Cohen: I’m so happy for you.
Nicole Sams: Yes. This is great. This is great. (APPLAUSE) Wow. Woof.
In a statement, the health insurance professional association said, “obesity is a complex disease and the evidence and clinical guidelines related to the treatment of obesity … are evolving rapidly. Health insurance providers will continue to review the clinical evidence.”
Produced by Ayesha Siddiqi. Associate Producer, Kate Morris. Broadcast Associate, Wren Woodson. Edited by Craig Crawford.