On this episode, four guests joined to discuss the nearly 40% of the U.S. population that is living with obesity and how state policies can help with the prevention and treatment of the disease.
Nearly 40% of the U.S. population is living with obesity, and it is estimated that obesity costs the U.S. economy billions every year in medical costs, lost productivity and other costs. While people living with obesity were often seen as lacking the willpower to lose weight, the condition has been classified as a medical condition for more than a decade.
On this episode, our guests discuss the issue from different perspectives, all of which bear on state policy decisions that aim to prevent and treat obesity. They include Tim Dall, executive director of Life Sciences Consulting at GlobalData Plc and an expert of the economic effects of chronic diseases; Representative Ed Oliver, a Republican of Alabama and chair of the Chronic Weight Management and Type 2 Diabetes Task Force; Representative Marjorie Decker, a Democrat from Massachusetts and chair of the Public Health Committee; and Dr. Tracy Norfleet, is a physician specializing in obesity medicine.
Dall explained what the research tells us about the cost of obesity to the economy and how it affects the nation’s workforce. Dr. Norfleet offered her perspective on the rise of both prevention and treatment strategies for obesity as well as the stigma that still exists toward those living with obesity both in society generally and in the healthcare field.
Representatives Oliver and Decker discussed how their states are grappling with what type of health insurance coverage to offer both state employees and those in their state’s Medicaid programs.
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ES: (00:12):
Hello and welcome to “Our American States,” a podcast from the National Conference of State Legislatures. I'm your host, Ed Smith.
TD: (00:21):
One key finding from our research is that if you only look at a subset of the benefits such as what does it mean in terms of medical cost savings and you ignore improvements in quality of life and reduce mortality and labor force implications, that as a society we will underinvest in obesity treatment or any other treatment.
ES: (00:46):
That was Tim Dall, executive director of Life Sciences Consulting at Global Data PLC, and an expert on the economic effects of chronic disease. He's one of my guests on this podcast examining how states are dealing with obesity. My other guests are Representative Ed Oliver, a Republican of Alabama and chair of the Chronic Weight Management and Type two Diabetes Task Force; Representative Marjorie Decker, a Democrat from Massachusetts and chair of the public health committee; and Dr. Tracy Norfleet, a physician specializing in the treatment of obesity.
About 40% of the U.S. population is living with obesity and it's estimated that obesity costs the U.S. economy billions every year in medical costs, lost productivity and other costs. While people living with obesity were often seen as lacking the willpower to lose weight, the condition has been classified as a medical condition for more than a decade.
On this episode, Dall explained what the research tells us about the cost of obesity to the economy and how it affects the nation's workforce.
ES: (01:56):
Dr. Norfleet offered her perspective on the rise of both prevention and treatment strategies for obesity, as well as the stigma that still exists toward those living with obesity, both in society generally and in the healthcare field. Representatives Oliver and Decker discussed how their states are grappling with what type of healthcare insurance coverage to offer both to state employees and those in their state's Medicaid programs. Here's our discussion starting with Tim Dall.
ES: (02:26):
Tim, welcome to the podcast. Good to have you.
TD: (02:30):
Great. Nice to be here.
ES: (02:32):
Well, Tim, very interesting topic we're going to discuss here today. And you have spent a lot of your career studying the economic and workforce implications of chronic disease. And I wonder if you could tell listeners a little about your research focus and how you came to study obesity and its impact on health systems, employers, and even state budgets.
TD: (02:54):
I have about 30 years of experience in looking at chronic disease prevention and treatment. With my background in economics, the focus of my work is the economic implications. And one thing that's interesting about obesity is it's always been an important topic, but only in recent years as new treatment options have become readily available has it become so important in terms of a topic for discovery. And part of it is that there's a lot of unknowns. When we think about people with obesity, how many of them actually need treatment? If they do receive treatment, what will it cost and what will the benefits be and who will incur the cost and who will experience the benefits? And this is important for policy makers, for employers, for others that are considering legislation or policies that would affect people's lives, in this case through their obesity treatment. So, my background is really in disease management and prevention, but recently it's been obesity and the medical conditions for which obesity is a risk factor.
ES: (04:07):
Let me ask you about your research again, that you've looked at the workforce implications of obesity and what do we know about how obesity can affect the workforce participation and productivity as well in the workplace?
TD: (04:21):
Well, there's a couple components to that. One is when we have looked at national data on people's labor force participation and their risk factors such as obesity and the conditions associated with obesity, we find that it's mostly among women that there seems to be a lower labor force participation for women with obesity compared to women with a more healthy weight. We don't find that same pattern in men. And in women, we found that the pattern seems to be declining over time, that maybe a decade ago, the impact in terms of being out of the workforce was larger than it is today. And I think part of it is because of economic conditions that when the economy is doing well, then there are more opportunities for people. And to the extent that there might be biases or discrimination on the part of employers during economic good times, they have less ability to discriminate because they need all the workers they can get.
TD: (05:27):
So, we do see it mostly for women and not for men, and this is consistent with other countries.
ES: (05:34):
So, what you're saying is some of the workforce participation is not that the person with obesity is choosing not to work, it's that they're having a more difficult time getting employment because of inherent prejudices against people with obesity.
TD: (05:50):
It's probably a combination of things and the data are not granular enough for us to know the full implications. There is research that suggests there is some bias in terms of body weight bias, but it's difficult to quantify that. But we do know that people, for example, especially those that are maybe nearing retirement, if their health is deteriorating, they might be more likely to retire earlier than they otherwise would have if their health were in better shape.
ES: (06:22):
We're of course talking with state legislators, legislative staff, others interested in state policy. And for some of them, maybe many of them, prevention is a priority as opposed to treatment of people who already are living with obesity. What does the evidence tell us about the most effective strategies for preventing obesity and what levers have the greatest potential levers that legislators would have to improve health outcomes before obesity develops?
TD: (06:49):
To understand the value of different types of prevention, either programs or interventions or policies, it's important to understand why obesity has been increased in prevalence and what are the causes of obesity. For some people it's genetic that they're just predisposed to hold that excess body weight. There's also a cultural component and that includes the food that we eat, the amount of physical activity that we have. And this can differ geographically, it can differ by urban and rural areas, it can differ by socioeconomic status.
ES: (07:29):
We talked a little bit about how treatment options have changed and that certainly happened pretty significantly recent years. And I should probably note that the cost of some of those treatments has come down pretty significantly and maybe because more people are using them, I'm not sure what the dynamics are there. I'm wondering about how policymakers should think about this. States, of course, we're right now in a period of kind of tight budgets in many places. And when they think about balancing the cost of expanding access to obesity treatment with the potential long-term health and economic benefits, what would you tell legislators about that? How should they think about that? There may not be a definitive answer, this is exactly how you can calculate this, but how should they think about that?
TD: (08:18):
Each person is unique in terms of what might be effective treatment for them. For example, a large portion of people that meet the definition of obesity based on their body mass index, which is just one measure of obesity, they might only need to lose a little bit of weight, whereas others need to lose a lot of weight. And so, for some people, the most cost-effective intervention might be lifestyle intervention where they get some counseling on appropriate diet and physical activity. Maybe they get a medical device where it counts their steps or does something that will motivate them. Other people at the higher extreme, they might need surgery, bariatric surgery, which is very effective, both cost effective and effective in terms of losing weight. A large portion in the middle could benefit from medicines and there's a variety. And when we think about GLP-1s, there are injectables and there's oral pills.
TD: (09:21):
The injectables, usually you lose more weight, but they're more expensive than the oral ones. And then there's low, medium, and high doses, and each of those has different prices and different effectiveness in terms of losing weight. I think the key is that when a person meets with their healthcare provider, that they and their healthcare provider can determine what does this person need given not just their body weight, but the presence of other maybe complicating factors, whether those are clinical factors or things going on in their life, what would most effectively work with this person? And they try it. If for some reason it's not effective, then they try another option. And so, I think that's what I would tell policymakers is there's not just one approach, there's multiple approaches. And so, the idea is to give people and their providers the option to choose what evidence-based medicine would work best for them.
ES: (10:21):
So, if we were talking say more specifically in the Medicaid area, having state policy that would encourage that sort of treatment options would be something for state policymakers to consider.
TD: (10:36):
Right. And many states are already actively participating in maybe nutrition type programs for low-income households, whether it's pregnant mothers, whether it's children, addressing what we sometimes refer to as food deserts where maybe they don't have access to fresh fruits and vegetables and healthy foods close to where they live. And there are many programs that states are currently implementing that are effective. Medication is just one more component to this kind of holistic approach to treating obesity.
ES: (11:14):
So, looking ahead, as we try to do on this podcast and try and give legislators sort of how to think about this in the future, what are the key considerations would you suggest to them to keep in mind as they develop policies related to both prevention and treatment, particularly given the potential implications for health outcomes, state budgets and the workforce? Big huge question, but it's kind of, we've got this audience here as we close out the podcast. Share with them what you'd like them to have in mind as they think about this issue.
TD: (11:49):
There are many groups of people that benefit from obesity treatment. Clearly there's the person with obesity that their improved health, quality of life, and because they have improved health, what that means is they can live longer. They're more productive in terms of being active in the labor force, missing time off from work, which are benefits to employers. So, we look at things from the perspective of the individual. We can look at things from the perspective of the employer where an employer, again, has a larger labor force, maybe higher productivity among their workforce because people aren't missing time off or reduced productivity due to poor health. Then there's government. And from the perspective of government, that might include lower Medicaid costs in the future. It could include state employee benefits plans because many people are employed by the government. But then there's the other economic implications that if treating obesity among their population improves labor force participation, reduces premature mortality, improves productivity, that their economy can grow faster, and then that has implications for tax revenues and so on.
TD: (13:05):
Then you can look at things from a societal perspective where you pull all these benefits together. One key finding from our research is that if you only look at a subset of the benefits such as what does it mean in terms of medical cost savings and you ignore improvements in quality of life and reduce mortality and labor force implications, that as a society we will underinvest in obesity treatment or any other treatment.
ES: (13:35):
Well, fascinating conversation, Tim. I really appreciate you taking the time. Take care.
TD: (13:41):
Great. Thank you.
ES: (13:44):
I'll be right back after the short break with Representative Oliver.
Speaker 3 (13:54):
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ES: (15:10):
Representative Oliver, welcome to the podcast. Thanks for coming on. Appreciate it.
EO: (15:15):
Glad to be here.
ES: (15:16):
So Representative, you chair Alabama's Chronic Weight Management and Type two Diabetes Task Force, and I wonder what made you interested in getting involved in this and what you're hoping the task force might be able to accomplish?
EO: (15:32):
In my first four years in the Alabama legislature, I was vice chair of the health committee, and from there developed an interest in insurance and health outcomes and that sort of thing. And obesity became one of the issues that just kept floating to the top. So, the task force was a natural progression to see if indeed there was a way we can improve health outcomes and save money at the same time.
ES: (15:58):
So, when it comes to obesity, certainly the interest is in prevention and treatment. These are things that come up. It's not just an issue for treatment, even though that has become sort of front of mind for a lot of people with all the GLP-1 drugs and that kind of thing. And so, I'm wondering through the task force, what you've learned about both those topics, both prevention and treatment and addressing obesity and related chronic diseases, type two diabetes, cardiovascular disease, that sort of thing?
EO: (16:27):
Well, obviously lifestyle choices make a significant difference in general health, but what we've discovered about obesity, particularly in Americans that are over 50 years old, is you don't move the needle without the drugs in any meaningful way. So that's sort of where we sit with the task force. We believe in the efficacy of the drugs. The issue of course becomes cost and once again, health outcomes. Obviously, the expense is great. Alabama is not a rich state. We have a high Medicaid population, and we are also one of the most obese states. So, our challenges here are many, but the task force itself is trying to develop enough data and we get it from people like you and all sorts of people that are doing research. And as soon as we can make the numbers work, we intend to improve our access to GLP-1s for as many citizens as possible.
ES: (17:29):
Let me ask you about the nature of a task force itself. You bring together a lot of different stakeholders, people coming with different perspectives, and I wonder what you've learned from that, listening to all these different things that maybe you didn't know before.
EO: (17:43):
That obesity has long been a challenge for medical professionals, and they are breathing a sigh of relief at the number of GLP-1 choices that you have now to treat various cases of obesity. On our task force, we have 20 people from all different walks of life, but I think one of the most impressive we have is a doctor who runs an obesity clinic that sees over 700 referred patients, and that's a tremendous amount of data that we get locally about our fellow Alabamians. We learn about side effects, we learn about the amount of weight loss, we learn about the health outcomes for people that lose weight. Not really anecdotal, it is an encapsulated little population from Alabama that we get to watch with this, then we get to compare to the other data that we develop nationally.
ES: (18:37):
We're of course talking with your colleagues around the country here, other state legislators, people who work as legislative staff, and certainly other people interested in state policy. And I wonder, in the tradition of this podcast, which is to try to share information across borders, what would be one or two of the big takeaways you would share with policymakers about how to approach this, how to sort of grapple with this issue and begin to look at it in their state?
EO: (19:06):
Well, because we have to work with Medicaid and insurance companies, the first thing is you have to look at dollars, and you have to draw a circle where you're effective and you actually save money by using GLP-1s. That becomes the quest. And I think we've done a good job of that here. And as we go further into this podcast, I'm sure you'll ask questions that will lead us into how we're approaching that. But I would say that working with your insurance companies instead of against them is one way to do it, making sure you're all sitting at the table. And the other thing is having some sort of defined goal for what you want to achieve. Is there a percentage of people? Is there a certain BMI? Is there some goal that you can focus on so that you have milestones in your project?
ES: (19:58):
Well, where do you feel you are with it now? That's a really, really great point because as you get into it and you start to say, "We want to basically get the best bang for our buck here in helping people to grapple with this issue," how do you think about that? How do you think about... There's some people that maybe are farther outside that circle, but how do you think about that circle? How do you go about that?
EO: (20:24):
Well, it's a big circle if you let it be, and it will bankrupt the state the size of Alabama if you're not very careful. Now, the one thing we have to do is quantify what are these health outcomes, the fact that we don't use as many drugs, that people aren't as sick if they use the GLP-1. Those are numbers we have not done a very good job of putting together and presenting to insurance companies. And that's really where our focus is right now is how do we make this affordable? I would think that within this next legislative session, probably without any legislation, that we will include GLP-1s within Medicaid, within that circle I just described, and we don't know exactly what that's going to look like yet, but also within our state insurance pools, teachers and state employees.
ES: (21:16):
Have you seen a good model that can tell you if we do X, we'll be able to reduce type two diabetes, cardiovascular disease by X amount? Or is that kind of the holy grail still out there in terms of data?
EO: (21:28):
That is the holy grail. You're absolutely correct. And that's what I was saying. When we're drawing the circle, we need to know in dollar amounts if we prescribe to this many patients, will we save or will we lose? And I don't think you can develop that data without actually doing it. I mean, that's just where we are.
ES: (21:50):
Well, that's tough. That's a conundrum because as you say, Medicaid, everyone listening to this is very familiar with what a huge piece of money Medicaid is for every state, and I know it's significant in Alabama. So that's a real challenge. I wonder, you're looking to the next legislative session, but as you go forward with this task force, as we wrap it up here, what would you like to see? What would the next five years bring in Alabama as you and your colleagues look at this and try to decide how do we make more progress in this area?
EO: (22:27):
We continue to look at the efficacy of the various drugs, and of course they improve. One of the things I truly believe is that the prices will continue to drop, and the discussion we're having may be a non-issue. I look at other drugs that we've seen in the past that started off expensive and got cheaper. I do believe that within the next year, looking for that cost versus efficacy versus side effects, all of the above within the next year, I think we're at a point where we're starting to get something that's tangible. I'm very optimistic that Alabama will within the next year offer GLP-1s in most realms of insurance and to a fairly general population.
ES: (23:14):
Well, Representative, thanks so much for sharing the experience here in Alabama. I'll tell you, I think you've taken on one of the tougher public health challenges anywhere in the country. This is not anything that's going to go away soon for this country or for Alabama. So, I wish you the best in persevering in this. It's a tough one. You take care. Thank you.
EO: (23:36):
Thank you. I'll
ES: (23:38):
Be right back with Representative Decker.
Speaker 3 (23:47):
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ES: (24:44):
Representative Decker, welcome to the podcast. Nice to have you.
MD: (24:48):
Great to be here.
ES: (24:50):
We're talking today, of course, about obesity and some of related issues with that, and you're the chair of the public health committee there in the Massachusetts House. You've worked on a wide range of issues that shape health outcomes, and I wonder how you see obesity prevention and treatment fitting into that broader public health landscape.
MD: (25:13):
Yeah. I mean, obesity treatment is like any other health issue that we would want to treat. Obesity is a medical issue, medical condition, and we now have evidence-based research and medication that can effectively treat obesity. And we know that when you treat obesity, then you're also treating underlying root cause of many other health challenges that can arise in somebody. So, it's actually one of the most effective ways in preventative care for other diseases down the road.
ES: (25:47):
Excellent point. Obesity is certainly connected to other health conditions, including diabetes and cardiovascular disease, even behavioral health challenges. And I wonder, as you've talked with your constituents, providers, other people in the public health world, how's that shaped your understanding about what the challenges are and also maybe what the opportunities are when it comes to obesity prevention and treatment?
MD: (26:13):
I'd say first there still continues to be a real stigma around obesity. Whether it's my constituents or anywhere in this country, we reduce obesity to individual willpower and in a way that we would not blame somebody for having cancer or cardiovascular disease. So, the assumption is that it's someone's fault and therefore it's on them to figure out how to manage all the secondary issues and health issues that come with obesity. So, I would say that's the first. I think what's been amazing with the GLP-1s is that so many people, one, feel affirmed. I mean, most people are trying to do the best they can to take care of their health. They just are. And it's based on limited resources, opportunities, so much around privilege and economic security also plays a role and opportunity. And for the first time for so many people, they have found an effective treatment.
MD: (27:16):
We first started out with people not having access to that treatment. So, there was a real equity issue. I was with seniors who live in Cambridge Public Housing at a senior building, and listening to so many of them talk about how they wished their MassHealth, which is our state health insurance, provided access to coverage for them. And these are women who had many secondary other health issues that research had proven actually can reduce and eliminate a lot of those others. So, the fact is that we were still willing to put money into a variety of health issues that required treatment and provide medications and costs for those, but we weren't covering a drug that could actually be the primary elimination of some of the other diseases. So, for me, the issue of equity was really important. Who's accessing these life changing and for many life-saving medications?
MD: (28:09):
And then if you looked at even further the data around who really was accessing them, you were seeing that it was, particularly when it came to people of color, they were even less accessible. So, there's a real equity issue here, and I was able to advocate and successfully win so that MassHealth patients could continue to get coverage.
ES: (28:30):
To pick up on that comment about how we cover it and who's covered, this is the big challenge for legislatures, of course. I wonder, as these treatments have become more available and there's more access, what do you think policymakers should be thinking about? Particularly, this podcast wants to share your thoughts with your colleagues in other states, and how are you approaching it? How are you talking to your colleagues about this in terms of how they ought approach it? What kinds of decisions are critical for them to make?
MD: (29:05):
Yeah, I think, first of all, I approach it as it's about prevention for many people, so it's treatment and prevention. If we can prevent an escalation of other health issues that cost more money, so there's both the actual cost of care and treatment, and then there's just actually the quality of life, right? We have to care about both things for people, but as policymakers, when push comes to shove, we're looking at the numbers, it actually makes far more sense to invest in some form of coverage for these drugs than it does to take it all away. There's a lot of evidence out there that shows that people are coming off of other medications, and we know coming off those other medications mean a healthier life for folks, less healthcare, less need for treatment. So, I'm reminding people that it's a healthcare issue, that it's cost effective, and we now have enough data moving forward that This is just fact at this point with people whose secondary issues, whether it's high blood pressure, cholesterol, all off those things.
MD: (30:08):
And then I think the other part of this is that we also have a responsibility to remind people that obesity is a medical issue. And I've heard from some colleagues who said, "Well, I know somebody, everybody knows somebody who is using it for what they think is vanity reasons." And I remind people that people who don't need it for obesity don't get covered.
ES: (30:31):
Again, thinking about your colleagues around the country, obviously you need to collaborate with people in a lot of different areas on this kind of legislation and this kind of approach. And I wonder if you could talk a little bit about how you've approached that and maybe give people some ideas of who they ought to be talking to in their state if they're concerned about this issue.
MD: (30:51):
Yeah. So, we have been talking to a number of stakeholders. So, I've had conversations with the drug makers because I think they absolutely have a role and a responsibility in this conversation. The fact that we've seen such a range of drug pricing on the GLP-1s, and we've seen a significant drop on the GLP-1s, I will hold the drug makers accountable for thinking this is where they were going to... The gold rush was there. That drug that people knew that they wanted that worked and it was not okay. I think we're seeing the market actually play out right now and why the prices are coming down, also with more competition. But having those conversations with them and getting them to the table has been important. Talking to our administration and talking to here at our group insurance, we have the GIC, talking to all of them, having conversations with them about how could you make this choice and who's it centering?
MD: (31:49):
Because it's not patient centered and certainly in Massachusetts, the choice to walk away from state employees was really, I think, very disappointing. We're talking about people who work really hard and don't get paid a lot to do it. It's a passion, purpose, job to work in government. But also talking to advocates. So going out and talking to both patient advocates with lived experience and talking to providers who also... So, I would say in your state, that looks different in different states, but we have a coalition of people here who've been working, who are both providers and who are patient representatives and bringing them to the table. We're not done. We're still in the middle of this conversation. My goal is, if not sooner, but by next January to have changed the course of where we are in Massachusetts and to provide some form of coverage again for state employees.
MD: (32:43):
The issue of cost is not insignificant, but the fact is that we've made the issue of cost particular to one treatment and for obesity, that's problematic. There's ways to move forward that have different options than all or nothing. I think that's what we're moving. I'm hoping that that's where we're going to keep the conversation moving.
ES: (33:04):
Well, I think you're absolutely right that your state, like so many others, is in the midst of this. This is not something that other states, they've all solved it and figured out exactly what to do and that sort of thing. As we wrap up here, just take an opportunity to talk about what policy considerations your colleagues around the country ought to think about as they look at prevention, treatment for obesity, but also keeping in mind, of course, diabetes and other conditions. What would your closing thoughts be on that?
MD: (33:38):
Yeah. I think nationally we have a crisis when it comes to healthcare. We're really good at sick care and we're willing to pay for sick care in this country for many diseases, clearly not all. We're not really good at thinking about preventative care. And it's so reckless because when we do talk about how we're going to prioritize precious dollars and make investments, prevention is actually sometimes it feels like the most expensive, but in fact, in the long run, it's the most cost effective. I think we have to keep asking ourselves when we're making these decisions, one, who's being centered in the decision? I think we have to name it. And then who's being hurt by the decision? I would say here, who was not being centered were low-income residents or working middle class residents who just can't afford an extra $400 a month. There's nowhere to find it.
MD: (34:38):
We don't ask people to walk away from their asthma medication or their diabetes medication, although many patients are walking away from that because they can't afford that either. It comes down to who's being centered in these decisions? In answering that, you also have to have the follow-up question, you have to be able to label it and say, who's then not at the table? Who's not benefiting and who's being harmed? Those are, for me, the questions I ask with every policy decision I'm looking at, whether it's chair of public health or just the state rep from Cambridge. It's how are we making people's lives better and are our actions or inactions making people's lives worse? That's our job in government. It's really easy. We're either making people's lives better or we're not. We just have to keep asking those questions and then we have to name who's actually benefiting and who's actually not.
ES: (35:27):
Well, Representative, thank you so much for sharing your perspective and your experience there in Massachusetts. I know this is a subject of great concern to people all over the country, so thank you and take care.
MD: (35:39):
Thank you, Ed. Take care. Bye-bye. I'll
ES: (35:42):
Be back after this break with Dr. Norfleet.
Speaker 3 (35:53):
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Speaker 3 (37:06):
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ES: (37:28):
Dr. Norfleet, welcome to the podcast. Lovely to have you.
TN: (37:32):
Thank you. I'm so happy and honored to be here today.
ES: (37:36):
Well, we're doing this podcast, of course, about prevention and treatment of obesity and how that intersects with state legislatures and what kind of policies states might pursue in order to address the issue. Let me ask you first, probably a lot of people think about lifestyle interventions, nutrition, physical activity, that sort of thing, as important components for people who are living with obesity, but I wonder what does the evidence tell us about the role of these approaches and how they fit into sort of the broader picture, if you will, of treatment for individuals living with obesity?
TN: (38:11):
Yeah, so evidence has shown, and our guidelines support this, that lifestyle and behavior intervention are the foundation of the treatment of obesity. We know that. But what we've found is that when we use lifestyle and behavioral interventions, in most cases we see about five to 10% of weight reduction. And in many cases, we need more weight reduction to affect clinical outcomes, because at the end of the day, the goal is not just weight loss. The goal is improvement and betterment of health, which ultimately improves health outcomes. So, we know that nutrition, lifestyle, behavior are our cornerstone and our foundation, but sometimes that's just not enough, especially when it comes to not just weight loss, but also weight maintenance. So, we know that when those interventions can't do everything that we needed to do alone, then we need to use everything in our toolbox to be able to really improve people's health, their quality of life, and that may require pharmacotherapy and our bariatric surgery.
ES: (39:21):
Obesity is really a fairly complex situation, as I understand it, whether it's biological, environmental, social, economic factors. I wonder how can a better understanding of these factors help us inform more effective prevention and treatment strategies?
TN: (39:40):
Yes. I think the first thing to recognize is obesity is a disease. Prior to 2013, we did not classify obesity as a disease, but science has come a long way. We recognize that there are a lot of now biological mechanisms in addition to environment, social and economic drivers that reframes how we think of obesity so that obesity is not just a failure of willpower, but it's complex, it's chronic, and it's multifactorial. So, we have to shift the blame from the patient and more work on helping the patient improve their health and their lives. So, we've been able to improve scientifically, recognizing that obesity is a disease, recognizing the signals that affect energy regulation and metabolism, and we have better mechanisms of helping patients improve their health. But at the end of the day, it's about recognizing that it's not just about willpower. 40 to 70% of BMI variance is based on genetics and you can't change your genetics.
TN: (40:46):
The way you're born is the way that you are born. I
ES: (40:50):
Think it's so interesting that the recognition of obesity as a health condition is pretty recent. I mean, that's 13 years ago. I would say just from a person who's not in any way an expert on this, that stigma has not disappeared from society. I would say in fact, it seems to be a pretty persistent stigma. I wonder if you could talk about whether it's in society generally or even in the healthcare field, how that stigma affects people and the ability for them to be able to deal with this. I guess as an addition to that, do you think that at least in the medical field, we're moving to a more sort of respectful or patient-centered view of this?
TN: (41:39):
I think we have to recognize that bias and stigma is not only within healthcare, but it's also in society. What happens is because we have weight bias and stigma, it impacts patient's care. It can result in a delay of care, and it can result in worsening or not an improvement certainly in health outcomes. Weight bias is the negative attitudes, beliefs, and judgements that we may have of others, and weigh bias can be internalized or externalized. Internalized means that you have bias against yourself, not that you want to. When you have that bias, it can be implicit or explicit, meaning implicit meaning that you don't even recognize that you have it there. Explicit means that it's shown outwardly. But what can happen is when we have this bias, it ends up turning into a stigma and that's the way that people are being treated. Now, the sources of stigma and bias, the primary sources are typically family and healthcare.
TN: (42:43):
When it gets involved in healthcare, it affects patients, it affects patients mentally and physically in a way in which not only do they not want to seek healthcare, but they avoid healthcare. And what this can result in is a worsening of clinical outcomes. There are ways that we can improve our environments and support patients as they are on their health journeys. There are certain things that we recognize in the Obesity Society and the Obesity Medicine Association have emphasized that some things that we can do to improve our environments, to decrease bias, to decrease stigma is number one, to recognize that obesity is a disease. Once we recognize that obesity is complex, it's multifactorial, and it's not just about willpower, then we can treat it like we treat other diseases. Another part of that is using person first language, not blaming the patient on the person for their illness.
ES: (43:48):
We're talking, of course, to state legislators, others working in state government here, and when we think about the treatment options for obesity, which of course have expanded in recent years, and I think have become much more part of the public conversation, behavioral intervention, nutrition counseling, but medications, which of course have become a rather high-profile aspect of this. How do you think policymakers should think about the tools here, which we have to deploy as they think about a comprehensive approach from a state policy perspective?
TN: (44:23):
Yeah, I think policymakers should think about obesity like they think about every other chronic condition or chronic disease. When we treat other conditions, the main component usually is lifestyle and behavioral intervention first, whether that is obesity, whether that is diabetes, whether that's high cholesterol, whether it's high blood pressure, the first intervention is lifestyle and behavioral intervention. We recognize that that is the foundation for obesity care as well. But we know, just like we know with hypertension and diabetes and cardiovascular disease, that unfortunately that does not do it in itself, and we need to add therapy and tools to help our patients achieve their goals, improve their health, make sure they have good quality of life, and that is pharmacotherapy and sometimes surgery. So, when we think about the care of patients with obesity, we must think about it just like we think about the care of any other chronic condition.
ES: (45:26):
Let me dive into that a little bit more. Pretty much anytime I've done a podcast dealing with health issues with state legislators, the calculation is if we spend more upfront now, are we going to save money on the back end? As you're addressing policymakers, how would you suggest that they think about things like coverage, utilization management, things like prior authorization when it comes to this issue in order to think in the larger sense? I mean, everybody wants a number. How do you talk to policymakers about that?
TN: (46:02):
The one thing that I would emphasize with policymakers is that, again, and you're going to hear me saying this over and over again, but again, treating obesity as if it is a disease. I know that we think about costs and we should. We should think about healthcare costs. It's important. A lot of times I will hear what is the cost savings? How will we know what the cost savings is? Well, we don't have that evidence right now as far as pharmacotherapy goes because we're in a new age where we've now have medications that can have significant amount of weight loss and improve health. But if we wanted to use an example of how does the improvement of weight affect clinical outcomes, we can look at the studies and the efficacy that we've seen with bariatric surgery. Now, that mechanism of weight reduction is different. It's a surgical intervention, but at the end of the day, the result is the same, which is a reduction in fatty tissue, a reduction in inflammation and improvement in clinical outcomes.
ES: (47:07):
Doctor, as we close up, I saw your TED Talk, and I wonder if you could talk a little bit about your own experiences, your own lived experience and your experience as a physician in this personal dimension of obesity. And from that perspective, can you talk about what you'd like policymakers and the public more generally to keep in mind about people living with obesity and the challenges that they have?
TN: (47:33):
Yeah. I mean, at my TED Talk, as you know, it's called Breaking Weight Bias in Healthcare and Society. I start off my talk in really talking about my own experience with my health and how I had internalized weight bias, negative thoughts about myself that really prohibited me from doing and being the best person that I could be because of how I felt about myself. And then when in the TED Talk, you'll see that I go further along to see how weight bias showed up for me in a clinical setting, not as a patient, but as a clinician dealing with how patients were speaking to me, along with witnessing how patients were treating our own staff just because of weight. So, for me, I've experienced weight bias not only personally, but I see it as well. The whole idea that I want legislators to recognize is that at the end of the day, we are treating people.
TN: (48:34):
This is about not just health, this is not just about cost, but this is about humanity as a whole. And it is important for us not only just to take care of ourselves, but to make sure that we are taking care of others. We're created to be social beings, right? We're supposed to have community, and it is important for us to not just think of ourselves, but to think of others when it comes to care.
ES: (49:00):
Well, doctor, I think you've given our listeners a lot to think about. Thanks for taking the time. Take care.
TN: (49:06):
Thank you. It's a pleasure being here, and I hope that this has some impact as we move forward with the comprehensive care and coverage of obesity.
ES: (49:19):
I've been talking with Tim Dall, Representative Marjorie Decker of Massachusetts, Representative Ed Oliver of Alabama, and Dr. Tracy Norfleet about strategies for dealing with obesity. Thanks for listening. Search for NCSL podcasts wherever you get your podcasts. This podcast, Our American States, dives into some of the most challenging public policy issues facing legislators. Also, check out our special series, Building Democracy, on the history of legislatures.