American Heart Association. They are called “game changers.”
Oprah Winfrey says it's a “gift.”
Science magazine selected them as “Best Achievement of 2023”.
Americans are most familiar with their brand names: Ozempic, Wegovy, Mounjaro, and Zepbound. They are the drugs that revolutionized weight loss and raised the possibility of reversing the country's obesity crisis.
Obesity, like many diseases, disproportionately affects people from racial and ethnic groups that have been marginalized by the U.S. health care system. A class of drugs that succeed where many others have failed appears to be a powerful tool to fill the gap.
Instead, doctors who treat obesity, and the serious health risks that accompany it, fear that medications are making this health disparity worse.
“These patients carry a greater burden of disease and are less likely to get the medication that could save their lives,” said Dr. Lauren Eberly, a cardiologist and researcher at the University of Pennsylvania Health Services. “I feel that if a group of patients is bearing a disproportionate burden, they should have more access to these medications.”
Why don't they do that? Experts say there are many reasons, but the main one is cost.
The injectable drug Ozempic has revolutionized the treatment of obesity.
(David J. Phillip/Associated Press)
Ozempic, which is approved by the Food and Drug Administration to help people with type 2 diabetes control blood sugar and reduce the risk of serious cardiovascular problems such as heart attacks and strokes, has a list price of $968.52 for a 28-day supply One day. Wegovy, a higher dose of the same drug that's been approved by the Food and Drug Administration for weight loss in people who are obese or overweight and have a weight-related condition such as high blood pressure or high cholesterol, is priced at $1,349.02 every four Weeks.
Mounjaro is a similar medication that has been approved by the Food and Drug Administration to improve blood sugar levels in people with type 2 diabetes, and comes at a list price of $1,069.08 for a 28-day supply of the medication. Zepbound, a version of the same drug approved for weight loss, has a slightly lower price of $1,059.87 per 28 days. At least for now, all new medications are meant to be taken indefinitely.
Few health insurance programs cover medications when prescribed to help people reach and maintain a healthy weight. Federal law requires weight-loss drugs to be excluded from basic coverage in Medicare Part D plans, and as of early 2023, only 10 states included anti-obesity drugs in their Medicaid formularies.
“If everyone had equal access, that would be a way to help,” said Dr. Rocio Pereira, chief of endocrinology at Denver Health. “But without equal access — which we have now — this is likely to increase the disparity we see.”
Obesity rates in the United States have been rising for decades, and are consistently higher for black and Latino Americans. Among adults ages 20 and older, 49.9% of black Americans and 45.6% of Hispanic Americans have a BMI of 30 or greater, compared with 41.1% of white American adults and 16.1% of American adults Asians, according to age-adjusted data from the Centers for Disease Control and Prevention.
Obesity rates are also related to income. In 2022, the age-adjusted rate was 38.4% for adults with household income between $15,000 and $24,999, compared to 34.1% for those with household income of $75,000 or more.
The two are linked, said Pereira, who studies health disparities in obesity-related diseases. Black and Latino Americans are more likely to live in low-income neighborhoods, where fast food is usually cheaper and more convenient than grocery stores.
“If you look at a map of the United States and you plot the neighborhoods where there's not a grocery store within a mile, and there's a high percentage of people who don't have cars, those are the areas where there are the highest obesity rates,” she said. .
There's also the time factor, she said: “Can you cook your own meals, or do you have to work two jobs?”
Pereira said an unusual experiment conducted by the Department of Housing and Urban Development showed how much the surrounding physical environment affects the risk of obesity. In the 1990s, hundreds of mothers living in public housing were offered housing vouchers that they could only use in wealthier neighborhoods. Ten to 15 years later, women who were randomized to the windfall had much lower rates of obesity than women in the control group who did not receive vouchers (17.7%). They were also less likely to have a BMI of 35 or higher (31.1% vs. 35.5%).
Two women talking in New York.
(Mark Lenihan/Associated Press)
American Medical Association. Obesity was recognized as a disease in 2013. People with the chronic condition are at increased risk of developing cardiovascular disease, type 2 diabetes, 13 types of cancer, osteoarthritis, asthma, and other health problems. Researchers estimated annual medical costs associated with obesity at $174 billion in the United States alone.
Some people with obesity can lose weight by changing their diet and burning more calories through exercise. But this doesn't work for people who have developed resistance to leptin, the hormone that suppresses appetite.
“If you try to lose weight with diet and exercise, your body will fight you,” says Dr. Carolyn Apovian, co-director of the Center for Weight Management and Health at Brigham and Women's Hospital in Boston. “Your leptin levels drop, and when leptin drops, a signal goes to the brain that you don't have enough fat to survive.” This leads to the release of another hormone, ghrelin, which triggers feelings of hunger.
Leptin resistance also makes exercise less important.
“Your body is fighting you by reducing your total energy expenditure,” Apovian said. “When your muscles are working, they work more efficiently. If you want to lose 10 pounds, you're going to feel very hungry. And you can't fight it. Your body thinks it's starving to death.”
“Advanced” drugs counter this by impersonating a hormone called glucagon-like peptide 1, or GLP-1, which is involved in regulating appetite. Inside cells, the drugs bind to the same receptors as GLP-1, lowering blood sugar and slowing digestion. They also last longer than their natural counterparts.
Oprah Winfrey credits the new generation of medications with helping her keep her weight under control.
(Chris Pizzello/Associated Press)
The first so-called GLP-1 receptor agonist was approved in 2005 to treat diabetes, and early versions had to be injected once or twice a day. Ozempic improved on this by requiring injections only once a week. After clinical trials showed that the drug helped people with obesity achieve significant and sustainable weight loss, the US Food and Drug Administration approved Wegovy as a weight management drug in 2021.
Mounjaro and Zepbound also mimic GLP-1, along with a related hormone called glucose-dependent insulinotropic peptide, or GIP.
Linda Morales credits Ozempic and Mounjaro with helping her lose 100 pounds and drop from a size 22 to a size 14. The 25-year-old instructional assistant at Lankershim Elementary School in North Hollywood said she began being overweight in middle school and carried 293 pounds on her frame, which She was 5 feet 5 inches tall when she was referred to the Center for Weight Management and Metabolic Health at Cedars-Sinai two years ago.
She no longer holds her breath when climbing stairs, has an easier time when bowling and sits comfortably in the seat on the Harry Potter ride at Universal Studios. Thanks to medications, she is no longer on the path to developing type 2 diabetes.
Her job with the Los Angeles Unified School District comes with health insurance that covers expensive medications and charges her a co-payment of $30 a month for Mongaro's prescription. She said she could make a monthly payment of up to $50, but then she would have to stop taking the medication and hopes the lifestyle changes she's made will be enough to maintain the weight loss she's achieved so far.
“It will definitely be difficult for me,” Morales said.
In fact, even when drugs are covered by insurance or when patients qualify for discounts from drug companies, researchers have found that they often remain out of reach.
In one study, Eberly and her colleagues examined insurance claims for nearly 40,000 people who received a prescription for a GLP-1 mimic. Patients who had to pay at least $50 a month to fill their prescriptions were 53% less likely to get most of their refills over the course of a year than patients whose payments were less than $10. The team found that even patients with direct costs between $10 and $50 were 38% less likely to purchase the drug regularly for an entire year.
In another study of insured patients with type 2 diabetes, those who were black were 19% less likely to be treated with these drugs than those who were white, while Latino patients were 9% less likely to get them, Eberly and her colleagues reported. .
In some parts of the country, black patients with diabetes are half as likely as white patients to get GLP-1 drugs, according to research by Dr. Serena Jigshuan Gu at the University of Florida, who studies health disparities in access to the drugs. The disparity was greatest in places with the highest rates of overall drug use, including New York, Silicon Valley and South Florida.
“In those places, the drug actually widens the gap,” she said.
Researchers have spent years documenting racial disparities in the use of effective treatments for obesity, such as bariatric surgery. Newer drugs like Ozempic highlight the problem more clearly, said Dr. Hamlet Gasoyan, a researcher at the Cleveland Clinic Center for Value-Based Care Research.
“We get excited every time a new, effective treatment becomes available,” Gasoyan said. “But we should be equally concerned that this new, effective treatment reduces the disparities between the haves and have-nots.”
