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In this column, Katherine Saunders, MD, of Weill Cornell Medicine, provides perspective on the approval of tirzepatide for chronic weight management and what it might mean for patient access in the future.
With the Food and Drug Administration’s recent approval of tirzepatide (Zepbound) for the treatment of obesity, we are poised to take a significant step forward in combatting the nation’s obesity epidemic. The question is, will we seize this opportunity to turn the ability to treat into actual treatment?
Like semaglutide (of Ozempic and Wegovy fame), tirzepatide was originally developed as a treatment for type 2 diabetes (marketed under the Mounjaro brand), and it is what’s known as a GLP-1 agonist: it activates receptors for glucagon-like peptide-1, which stimulates insulin production and creates a feeling of fullness. But unlike semaglutide, tirzepatide also activates the receptors for a second nutrient-stimulated hormone, glucose-dependent insulinotropic polypeptide (GIP). This combination has proven highly effective, helping trial participants on the highest dose of tirzepatide lose an average of 22.5% of their body weight, compared to the highest dose of semaglutide’s average of about 15% in studies evaluating individuals with obesity and without type 2 diabetes.
The mere fact that these medications exist won’t be enough to overcome the obesity crisis. People need to actually access the treatment, and that will require broader change driven by the recognition that obesity is in fact a disease and not merely a lifestyle issue.
For most people with obesity, the standard advice to just eat less and exercise more doesn’t work. It’s not simply a matter of needing to try harder, or of balancing calories in versus calories out. The human body has evolved many mechanisms to actively resist weight loss. While some people are able to find success with lifestyle changes alone, obesity activates a range of physiological changes that make it extremely difficult for the vast majority of individuals with obesity to achieve clinically significant weight loss without medical guidance and, often, pharmacotherapy. Medications like Zepbound — used as part of a comprehensive, long-term weight management plan — can help override some of the hormonal, metabolic and neurobehavioral mechanisms preventing weight loss.
Major national and international health and medical organizations — including the World Health Organization, the American Medical Association, the American Heart Association, the American College of Surgeons, the Food and Drug Administration, and the National Institutes of Health — have acknowledged that obesity is a complex, chronic disease, but the U.S. health care industry continues to lag when it comes to putting that recognition into practice
Considering that 42% of American adults have obesity, medical schools devote remarkably little attention to the disease. As a result, many practitioners continue to maintain outdated ideas about obesity being simply a lifestyle issue, allowing stigma and weight bias to persist in healthcare settings. Many people with obesity avoid seeking care because of negative experiences with providers who rush to judgment. If we want to meet the magnitude of the obesity challenge, we’ll need to encourage more practitioners to treat obesity like the disease it is and spur more people with obesity to seek care.
Insurance coverage, or the lack thereof, also continues to reflect the stigma surrounding obesity. Although obesity is associated with more than 200 (expensive!) medical conditions such as heart disease, high blood pressure, type 2 diabetes, osteoarthritis, sleep apnea and certain types of cancer, many insurers and health plans don’t cover obesity treatment because they consider weight management to be nothing more than a “cosmetic” concern. Or they limit their coverage to nutrition counseling at one end of the spectrum or bariatric surgery at the other, ignoring the middle ground represented by comprehensive, evidence-based medical care.
Many health plans (most notably, Medicare) explicitly exclude coverage of medications for weight management. This needs to change if we want to extend the benefits of advances in the field of obesity medicine beyond the wealthy and those who already have serious weight-related complications. Now, with new medications and greater industry interest in conducting large-scale studies, we need to provide conclusive evidence to insurers that treating the underlying obesity is more cost-effective than trying to treat all the resulting complications separately. Yes, treating obesity is expensive, but not treating obesity is even more costly in terms of increased medical expenses, reduced economic productivity, and lost quality of life.
Because obesity has many causes and contributing factors that interact in complex ways, treatment needs to be highly personalized. Zepbound likely won’t be the best choice for everyone, but it provides individuals with the most effective anti-obesity agents yet — and others are on the way.
To make these innovations widely accessible, we need to let go of the idea that taking anti-obesity medications is somehow “cheating.” These new medications aren’t a magic bullet, and a healthy diet and physical activity will always be a critical part of any weight management plan. Let’s acknowledge that obesity is a chronic disease that requires medical care, and support those interested in exploring whether anti-obesity medications are right for them.
Editor's Note: This work reflects the views of the author and are not necessarily reflective of the publication or its owners.
Katherine H. Saunders, MD, DABOM, is the Co-Founder of Intellihealth (software and clinical services company democratizing access to medical obesity treatment), and Clinical Assistant Professor of Medicine at Weill Cornell Medicine