For a Step Change to Curb the Obesity Epidemic

Authors: Christian Frois PierreYves Cremieux

Publish Date: 2015/06/12

Volume: 33, Issue: 7, Pages: 613-617

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Abstract

Rising obesity levels worldwide have been of increasing public concern since the late 1990s and are now responsible for over onequarter of total healthcare expenditures in the USA 1 This special issue of PharmacoEconomics examines a particularly challenging set of issues with an economic focus why is the obesity epidemic and its unique burden still growing uncontrolled how have past efforts to curb it fared and what other actions are needed to succeed in controlling the epidemic Contributors to the issue cover a broad range of topics experience and perspectives related to obesity Taken together these articles give some sense of the urgency challenges and opportunity for action in this fieldA number of articles in this special issue examine the obesity epidemic and its burden from different perspectives to better explore the magnitude and complexity of the problem Hruby and Hu 2 provide a review of the epidemiological characteristics and trends of the disease and its burden eg in terms of prevalence of obesity risk factors morbidity mortality and economic costs Corica et al 3 review evidence on the impact of obesity and age on quality of life highlighting the lesserstudied effect of obesity on the elderly Cawley et al 1 and Li et al 4 use different approaches and data sources to estimate the medical care costs and savings associated with weight/body mass index BMI—and potential weight loss—for patients with and without diabetes Allen et al 5 highlight the impact that obesity has had on Medicare expenditures for certain chronic conditions—such as diabetes heart disease hypertension and hyperlipidemia—over nearly a quarter century 1987–2011 Finally Gaudette et al 6 examine the impact of statins on life expectancy and the costs of obesity and conclude that despite improvements in life expectancy statins do not significantly reduce the costs of obesityTogether these articles highlight the unique burden and challenge that obesity represents to healthcare systems worldwide First the prevalence of obesity is extremely high with one in three adults worldwide being overweight or obese 1 2 In the USA alone 80 million adults 35  and 127 million children 17  suffer from obesity 2 7 8 Second obesity comes with a large comorbidity burden and is the key underlying driver behind four of the top ten most deadly 2 5 and expensive 9 10 11 diseases ischemic heart disease cerebrovascular disease eg stroke hypertension and diabetes Notably obesity accounts for 423 309 224 and 98  of the increase in the number of cases of diabetes heart disease hypertension and hyperlipidemia respectively in the past quarter century 5 Finally obesity has a large impact on patient wellness productivity 12 13 14 and quality of life 2 3 and is associated with significant costs to healthcare payers and society 1 4 5 15Since the first alarm signals were raised about obesity in the early 1990s 16 various interventions have been attempted to curb the epidemic 17 These interventions have included both prevention and treatment approaches 18 To date most of the efforts have focused on prevention interventions including personal responsibility and awareness eg physical exercise/lifestyle interventions counseling of individuals at risk in primary care 19 education eg schoolbased interventions mass media health promotion campaigns and environmental control efforts eg food portion/intake control worksite health promotion interventions regulation of food advertising to children compulsory food labeling tax markups/price promotions 17 18 19 In addition a few treatment options have been introduced including both pharmacological and surgical approachesYet as evidenced by Cecchini and Sassi 18 Baum et al 20 Chawla et al 19 and Chawla et al 21 in this issue and others 17 elsewhere interventions have faced and continue to face significant challenges and to date have failed to curb obesity While many interventions appear to have provided some benefits the gains have often been marginal 18 22 In large part this appears to be caused by the frequently small scale of the interventions the complex—and still poorly understood—nature of the disease with genetic biological and environmental factors at play and significant barriers and challenges facing interventions eg in terms of perception access/funding etc 23 Misperception of obesity as a cosmetic or lifestyle issue rather than a serious health problem has been a significant hurdle to mobilizing patients communities and payers to embrace prevention and treatment initiatives 19 20 Many researchers including those in this issue note the need for 1 more comprehensive multifactorial interventions 17 22 24 and 2 treatment as opposed to purely preventive approaches to both address the needs of the already obese and the limited effectiveness of prevention 25 as key learnings from past failed experience in obesity prevention/managementThe challenges for new treatment options have been particularly acute As reported by Baum et al 20 Finkelstein et al 26 and Chawla et al 19 many patients face inadequate access to treatment—pharmacological and surgical—with poor health insurance coverage/reimbursement even in rich nations such as the USA and European countries particularly when patients do not yet experience comorbidities As noted by Baum et al 20 and Chawla et al 21 pharmaceutical innovation in the obesity field has been limited A poor safety track record of initial pharmaceutical interventions has resulted in cautiousness on the part of regulators in reviewing/granting new drug applications 20 Current studies assessing the economic benefits/cost effectiveness of obesity treatments 18 26 suffer from limited available data As a consequence modeled benefits typically understate the full benefits of obesity reduction Even clinically effective medications which result in 5–10  loss in body weight the necessary threshold to achieve clinically significant improvements in most risk factors for cardiovascular disease 27 28 have not been fully embraced by patients as patient expectations for weight loss are generally much more ambitious while patient adherence can be low 20 These multiple challenges explain in part the underwhelming success of past interventions 19 20 and their disappointing impact on the obesity epidemic 2Despite significant obstacles there has been progress in the search for effective obesity treatments Bariatric surgery has emerged as the first and so far only technology associated with significant success against severe obesity 29 30 31 and its associated comorbidities 32 for a large proportion of treated patients The procedure has demonstrated significant cost savings and return on investment for patients with class 3 obesity ie BMI ≥400 patients 33 34 35 36 37 38 39 40 41 and may be of benefit for other categories of patients 19 However its use remains largely confined to the morbidly obese and limited by various obstacles 19 42Another promising development in the fight against obesity comes from the new wave of approvals for pharmaceutical innovations four new drugs lorcaserin phentermine/topiramate extended release and naltrexone/bupropion extended release and liraglutide were approved in the past 3 years after over a decade without any approvals for drugs targeting obesity by European and US regulatory agencies 21 All four drugs hold promise for clinically meaningful weight loss in excess of 5  particularly if the intervention is focused on early responders as recommended by their FDA labels 43 44 45 46

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