The trend is startling—within the span of just a single generation the rate of obesity among older Americans has nearly doubled, from 22% in 1988–1994 to 40% in 2015–2018. Equally concerning is that support and coverage of medical treatments for obesity in older adults have not kept pace with the research and remain limited.
Without intervention, older adults with obesity are at increased risk for many other health conditions, along with disability and reduced life expectancy. The bipartisan Treat and Reduce Obesity Act (TROA) can change that by providing Medicare beneficiaries with access to safe, effective and life-saving treatments. As an obesity medicine specialist for more than 15 years, I have witnessed first-hand the impacts of obesity and know the components needed to provide comprehensive obesity care. TROA needs to be passed, and a shift in mindset is essential to advancing such policies for quality and equitable obesity care in the United States.
Impacts of Obesity
Obesity is a chronic disease that is associated with higher rates of high blood pressure, heart disease, type 2 diabetes, some cancers, lipid disorders and many other medical conditions. Older adults with obesity also have greater disability and shorter lives than their peers without obesity. There is evidence that rising U.S. obesity rates may be slowing improvements in our country’s overall mortality and life-expectancy rates.
Older adults with obesity also have higher medical costs. It is estimated that older men with obesity spend over $190,000 more on lifetime healthcare expenses versus their normal weight peers; likewise, older women with obesity spend over $220,000 more compared to their peers. For the U.S. healthcare system as a whole, annual obesity costs are nearly $173 billion. Not surprisingly, costs are greater at higher levels of body mass index (BMI). One study found per-member-per-month total healthcare spending for Medicare beneficiaries at the highest BMI (of 40+) was 50% greater than beneficiaries with a BMI of 35–39, and more than double that of beneficiaries with a BMI of 30–34.
‘Nutrition is a part of lifestyle interventions that are a mainstay of effective obesity care and pivotal to the Obesity Medicine Association’s four pillars of obesity treatment.’
Obesity is a complex, multifactorial disease that also has been linked to health disparities and inequities. For example, individuals with higher BMI often may avoid healthcare visits because of their experiences with weight bias/stigma—discrimination or unfair treatment because of size or body weight. In addition, obesity disproportionately affects certain groups. Prevalence in Medicare fee-for-service beneficiaries is almost 30% higher among those who are Black/African American (24%) compared to those who are White (19%) or Hispanic (18%). Regionally, Medicare beneficiaries in Alabama have been reported to have the highest obesity prevalence rate (30%), with other states including West Virginia, Louisiana, Michigan and Ohio also having high rates.
Though there may be overlap in biased attitudes in frequently stigmatized groups (i.e. race, age, disability, sexual orientation), weight bias has persisted over the years and threatens to undermine the health of people with obesity through reduced quality of care, underutilization of healthcare, and misinformed or stagnant health policies that fixate on personal discipline or motivation as a barrier to comprehensive care.
Components of Comprehensive Obesity Care
Evidence-based, holistic approaches are critical to help prevent and treat obesity as a chronic disease. Throughout the spectrum of obesity treatment, access to a range of nutrition therapies is important, from diet and nutrition counseling to specialized oral protein supplements that can help meet targeted nutrition needs.
Nutrition is a part of lifestyle interventions that are a mainstay of effective obesity care and pivotal to the Obesity Medicine Association’s four pillars of obesity treatment: nutrition therapy, physical activity, behavioral modification, and medical interventions. Nutrition interventions also are included in the Strategies to Overcome & Prevent (STOP) Obesity Alliance’s core components of benefit design and the algorithm for the Complication-Centric Care Model of the American Academy of Clinical Endocrinology, both of which also include intensive behavioral therapy (IBT), pharmacotherapy and bariatric surgery.
Medicare provides coverage for some of these core components of comprehensive obesity care, but in a very limited way. Specifically, obesity screening (BMI of 30 or more) and IBT are only covered for Medicare beneficiaries if completed in the primary care provider’s (PCP) office and delivered by or in the presence of the PCP (physician, nurse practitioner, physician assistant or clinical nurse specialist). Because of such restrictions, very few medical practices—just 1.2%—provide IBT for obesity. Barely 1% of Medicare beneficiaries who qualify for IBT ever receive it, and marginalized communities can face access barriers, further limiting access and contributing to disparities in care.
In contrast, TROA expands access to IBT by including coverage outside the primary care setting for a range of providers: registered dietitian nutritionists (RDNs), community providers, obesity medicine specialists, endocrinologists, bariatric surgeons, psychiatrists, clinical psychologists and other specialists.
Medicare limits the coverage of anti-obesity medications (AOMs), in part because when the original Medicare Part D law was passed more than two decades ago the medications that were available lacked the safety profile or demonstrated effectiveness to justify coverage. Further, at that time there was no medical consensus that obesity was a chronic disease requiring medical treatment. Such circumstances and views have clearly changed. Importantly, some of the newer AOMs have added benefits based on recent evidence that they can lead to a 20% reduction in adverse cardiovascular events such as heart attack and stroke. CMS has recently issued guidance for coverage of AOMs that “receive FDA approval for an additional medically accepted indication.” This means AOMs approved for treating individuals with cardiovascular disease and overweight/obesity can be covered. Coverage is still lacking for all AOMs for other people with obesity.
TROA expands pharmacotherapy coverage to include anti-obesity medications.
Shift in Mindset Needed to Advance Policies Supporting Quality and Equitable Obesity Care
By 2030, it is estimated that 50% of the population ages 65 and older will be living with obesity. Every American with obesity, regardless of age, should have access to important treatment options. Yet people with obesity face bias and stigma from family, co-workers and even healthcare providers based on beliefs that obesity is due to laziness, noncompliance or lack of discipline. Even worse, some people—including policymakers—view obesity as a lifestyle issue and not a disease, either because they don’t know about the definition or don’t consider it as a disease. As a result, weight bias and stigma impact older adults with obesity on multiple fronts: quality of life; quality of healthcare; and access to healthcare due to health policy limitations—that is why TROA is needed.
A shift in mindset is urgently necessary to act on obesity as a public health crisis and ensure equitable access to evidence-based care. The first step to fostering an environment that is less stigmatizing is education. We must educate the public to increase awareness about the complexity of obesity and its impact on the healthcare system. We must educate healthcare professionals and medical students to diagnose and treat obesity as a chronic and complex disease. And we must improve formal medical obesity education, including acting as role models to medical and health professional students.
Next, healthcare professionals and constituents alike must move from awareness to advocacy—call, write, assemble to require a solution from their elected leaders. Passing TROA will help ensure all Medicare beneficiaries have access to the quality and equitable obesity care that they need and deserve. Let’s take action now!
Dominique R. Williams, MD, MPH, FOMA, Dipl. ABOM, is the adult nutrition medical director for the Nutrition Division of Abbott in Columbus, Ohio.
