Five Stories That Defined 2024 in Obesity and Health

The closing days of 2024 give us a moment to reflect on the stories that defined this year in obesity and health. It’s been a big year, with no shortage of news on this subject. But the major themes stand out very clearly.

Health Outcomes Beyond Weight Loss

This was the year that objective evidence made it undeniable. Treating obesity is about far more than losing weight. It started in 2023 with publication of the SELECT study. But the implications became plain in 2024 with a new indication for semaglutide to prevent heart attacks, strokes, and death – approved by FDA.

But heart health was just the opening. Stories flowed throughout 2024 about a whole range of chronic diseases for which obesity treatment could improve health outcomes. This includes liver disease, kidney disease, heart failure, and sleep apnea. We even got hints (observational data, mind you) that cancer outcomes were better with obesity treatment. If that’s not enough, we have the report of a 99% reduction in prediabetes progressing to diabetes.

Yes. This is the year when we turned a corner on the framework for thinking about obesity care. Weight loss is not the whole point anymore. The real point is a life of better health by bringing a whole range of chronic diseases under control.

Momentum on Access

With improved chronic disease outcomes as the primary theme of obesity and health in 2024, the setting was right for other stories to emerge. The biggest of these was access to obesity care. It started with CMS ruling early in the year that Medicare drug plans could start covering obesity medicines for people with heart disease. Throughout the year, we saw progress (in fits and starts) on coverage in employer-sponsored plans. Congress got serious about advancing the Treat and Reduce Obesity Act. And then CMS initiated rulemaking to open up both Medicare and Medicaid to covering obesity treatment.

Make no mistake, insurance coverage for obesity care will not cease to be challenging. But we are on the way to it becoming less daunting.

The biggest challenge that remains is equity. Right now, getting access to obesity care is mostly a function of wealth and privilege. This is wrong.

Supply, Demand, and Price

Almost from the beginning of the launch of semaglutide for obesity, Novo Nordisk has been unable to meet the demand for it. Three years later, with Eli Lilly in the market, the capacity of pharmaceutical companies to meet this need is still woefully inadequate. Yes, Lilly and Novo are making the argument that they are doing everything they can. Lilly even claims they are out of a shortage situation.

But the truth is that demand is tamped down by high prices and high copays. A basic principle of economics is that supply, demand, and price work in an elastic relationship. When supply is short, prices go up, and demand recedes. Because most people who need these medicines can’t afford them.

Something’s got to give.

Compounding

One thing that gave some relief to the sorry state of pharmaceutical supply and prices for obesity medicines in 2024 was compounding. We have mixed feelings about this. On one hand, the assurance of quality is higher with genuine Ozempic, Wegovy, Mounjaro, or Zepbound. FDA oversight of pharmaceutical manufacturing is strict. Unbranded and compounded versions of semaglutide and tirzepatide open the door to a host of problems ranging from quality control to outright fraud and counterfeiting.

But the fact is that many people are getting good clinical results from the products of high quality compounding pharmacies. Lilly and Novo don’t like it and FDA can’t quite figure out what to do about it.

An unmistakable solution would be for Lilly and Novo to meet demand in the market. Both prices and copays need to come down. Pharma, health plans, and government all have roles to play. This is easier said than done.

Ultra-Processed Foods

Everyone’s favorite blame game is point your finger at the bad foods. For two decades, starting in the 1980s, it was high fat foods. Then the finger turned to sugar with the rallying cry that it’s toxic. Now public sentiment holds that the real villain of the obesity epidemic is ultra-processed foods.

The incoming administration has a candidate for Secretary of HHS who has totally bought into this proposition. So this year it seems we reached peak vilification of UPFs. But scientists and policymakers can’t yet quite agree on what to do about it. The scientific advisory committee for new guidelines concluded that there is reason for concern, but the evidence is “limited.”

This is a story to be continued for sure.

Five Canoes on the Coast in South Africa, photograph by Dietmar Rabich, licensed under CC BY-SA 4.0

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December 16, 2024