Radical Concept: Medical Care for a Medical Condition

The Veteran’s Administration runs the biggest medical care program for obesity in world. It’s the MOVE! program. Because 41 percent of veterans are living with obesity, this disease has enormous cost implications for the VA system. Not because providing obesity care is expensive. Rather, it’s because the health costs of so much obesity – both human and financial – is great. And it becomes even greater when it goes untreated.

But a new study in Obesity poses an important question. Why is it that 99 percent of the veterans in the MOVE! program never receive any medicine for obesity?

Mostly Orlistat

Dylan Thomas and colleagues analyzed medical records for 153, 939 patients enrolled in the program from late 2013 until late 2016. They found that only 1.1 percent of those patients ever received any prescription for an antiobesity medicine. Among those patients, most of them (70 percent) received orlistat. Prescribers seemed to favor its use especially for veterans who were older, black, female, having heart disease, or with back pain.

This reliance on orlistat stands in stark contrast with antiobesity meds used outside the VHA. By far, in that setting, phentermine is the most common medication for this purpose. That’s because cost is a big factor outside the VHA and phentermine is available as an inexpensive generic.

Why Such Low Utilization?

These data raise an obvious question. What’s driving such low use of antiobesity medicines in a medical care setting? Thomas et al correctly observe that their data can’t answer this question. It’s a question for future research. However, they note that it may well be due to subjective factors and informal opinions.

In a commentary published with the study, Ted Kyle and David Arterburn offer three possibilities to explain this situation. First off, they note that this study is important because it suggests that financial barriers are not the sole reasons – even though people frequently cite this issue. That’s because patients in the VA system have very little out-of-pocket expense for these drugs.

Instead, they suggest that outdated perceptions of antiobesity meds may play a role. The 60-year old experience with amphetamines for short-term weight loss still resonates. Problems 20 years ago with phen-fen helped to keep that idea alive.

Another factor might be a wish for greater efficacy. The currently available antiobesity medications bring modest weight loss. It’s enough for health benefits in most patients. But it’s clearly less than the efficacy that bariatric surgery offers. Add to that the inaccurate view that these meds are only for acute weight loss. Many people don’t realize that these are chronic meds for a chronic condition.

When you’re only looking for weight loss and not health improvement, the efficacy of antiobesity medicines is disappointing.

Misunderstanding Obesity

And that brings us around to the final issue – a misunderstanding of obesity itself. The dominant narrative is that obesity is merely a behavioral problem. For many people – including many physicians – using a medication makes no sense because they lack an accurate understanding of obesity physiology.

This is changing. Insight into obesity is growing. Newer antiobesity meds are finding more use – especially by the growing numbers of obesity medical care specialists. But right now, it seems like a long slog.

Click here for the study and here for the commentary.

Meds, photograph © Rob Ireton / flickr

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May 22, 2019