Rising obesity rates indicate the need for improved insurance coverage of proven effective treatment options, both medical and surgical

Mortality improvements in the U.S. have declined relative to other wealthy countries, and a new study points to obesity as the culprit.

“Rising levels of body mass index [BMI] have prevented the United States from enjoying the full benefits of factors working to improve mortality,” according to study author Samuel Preston, professor of sociology at the University of Pennsylvania, et al. The study is published in the Proceedings of the National Academy of Sciences, as noted in a recent article in HealthDay.

In addition, according to the article, rising BMI has “reduced the annual rate of improvement in U.S. death rates between 1988 and 2011 by more than half a percentage point—equivalent to a 23% relative reduction in the rate of mortality decline—a large amount by international standards.”

“Heart disease deaths had declined consistently for nearly 40 years,” the article notes. “These declines have slowed or stopped altogether” and “rates of decline in cancer deaths have also slowed,” the article says. “At the same time, rates of obesity have been rising in the United States. From 1976 to 1980, 15 percent of Americans were obese. By 2014, 38 percent of Americans were classified as obese.”

The study’s researchers evaluated how much of the change in the death rate trend could be explained by rising BMI, and found that the increase in BMI reduced life expectancy by 0.9 years, almost 11 months, at age 40, and accounted for 186,000 excess deaths in 2011.

Despite rising obesity rates, another new study finds that many obese patients are not receiving antiobesity medications – and patients who are being prescribed medicines may be getting them because of provider bias. 80 percent are women, although obesity rates are similar for men and women in the U.S.

Fewer than 1 in 50 people in the U.S. eligible for antiobesity medications are receiving them, according to an evaluation of electronic records conducted by University of Colorado endocrinologist David Saxon, MD. Patients above a specific BMI threshold are eligible for weight-loss medication, but only 1.3% had received any prescription from 2009 to 2015, a recent Medscape article notes.

In addition, among patients who had received a prescription, 85% of the prescriptions were for phentermine, as opposed to newer agents. Primary care providers were most likely to prescribe these drugs.

Patients want “more information from their physicians about these medication options but there’s rarely the conversation,” Saxon says in the article. “Patients are probably more interested in them than the 1.3% who are receiving them.”

My friend and colleague, Scott Kahan, MD, is the director of the National Center for Weight and Wellness, and the medical director of Strategies To Overcome and Prevent (STOP) Obesity Alliance at George Washington University. Kahan explains that physicians historically have received little training in obesity management, and may hold misperceptions about obesity medications, including that they are unsafe, ineffective, or not well-studied.

“These misconceptions are likely a legacy of older medications that had lesser requirements for approval and were likely misused,” Kahan says. Another issue is lack of insurance coverage.

Yet another successful obesity treatment option is surgery. Two recent studies published in the Journal of the American Medical Association (JAMA) compared Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy in morbidly obese patients.

First, researchers at St. Claraspital in Basel, Switzerland, conducted a randomized trial of morbidly obese patients to determine whether there are differences between the two surgical options, in terms of weight loss, changes in comorbidities, increase in quality of life, and adverse events, as noted in an article in The Clinical Advisor. Excess BMI loss was not significantly different at 5 years: 61.1%, with sleeve gastrectomy vs 68.3% with RYGB.

In the second study, researchers in Finland also studied morbidly obese patients to examine the clinical equivalence of the two surgeries. The trial found the estimated mean percentage excess weight loss at 5 years was 49% with sleeve gastrectomy and 57% with RYGB, with no statistically significant difference in quality of life between groups and no treatment-related mortality. At 5 years, the overall morbidity rate was 19% and 26%.

In an accompanying editorial, David Arterburn, MD, MPH, and Anirban Gupta, MD, state that “these and other studies suggest that sleeve gastrectomy and bypass are overall quite similar in terms of their effects on weight and comorbid conditions through 5 years.” They also note that “these procedures may be associated with improved long-term survival compared with usual medical care. Overall, it seems that both procedures are excellent options for surgeons and patients to consider in the treatment of obesity.”

With the slowing gains in life expectancy in the US linked to obesity, patients need their insurance plans to cover effective treatment options. If these options are going to be accessible for patients, insurers will need to have reasonable coverage and reimbursement policies in place; today, with FDA-approved drugs available to treat obesity and promising research showing that the sleeve and bypass surgeries are two excellent options, we need policies that encourage use of both drug and surgical approaches.