Why obesity must be treated as the root of cardiometabolic disease

The global prevalence of obesity has nearly tripled since 1975, but research demonstrates that calories and willpower are not the problems. Obesity is an underlying pandemic with profound effects on global health. In addition to contributing to the cardiometabolic disease burden, it is a leading risk factor for COVID morbidity and mortality.

In 2011, the United Nations General Assembly met to discuss the global burden of noncommunicable disease (NCD). It identified obesity as one of the most important risk factors for NCDs. As a result, World Health Organization (WHO) member states were tasked with developing a set of goals and strategies targeted at curtailing the expansion of the global obesity pandemic.

In 2013, world leaders agreed on goals to reduce obesity and set 2025 as the deadline for meeting these targets. We’re ten years in, the 2025 deadline is two years away and we still have a long way to go. World Obesity Federation President, John Wilding, recently declared that the global community is “catastrophically off track” to meet the WHO’s obesity targets. In fact, projections from the World Obesity Federation indicate that 1 billion people will be living with obesity by the end of the decade. The negative health outcomes associated with obesity are serious and impose a significant financial burden on healthcare systems worldwide.

Without a solution, the global economic costs of overweight and obesity are projected to increase from just under $2 trillion in 2020 to $18 trillion by 2060. And, people with obesity face a heightened risk of progressing further on the spectrum of cardiometabolic disease, from obesity to diabetes to liver disease, cardiac events, kidney disease and premature death. We must intervene and begin treating obesity as the root of all cardiometabolic diseases or this underlying pandemic will bankrupt healthcare systems around the world.

Obesity is a deeply misunderstood and highly stigmatised disease. We have long viewed obesity as a willpower failure, only recently beginning to acknowledge the complex interplay of underlying genetic, hormonal, biological and environmental causes for the physiological imbalance that causes obesity. We blamed physical inactivity, overconsumption and poor dietary choices as the primary drivers of the condition’s prevalence, a phenomenon that closely mirrors the ways we misunderstood diabetes, until it had become the most expensive chronic disease to ever challenge most developed countries, including the US.

Stigmatisation has not been and will not become an effective tool to treat obesity. In fact, stigma negatively impacts health outcomes: people with obesity are less likely to seek medical treatment if they fear stigmatisation at their doctor’s office and healthcare providers are less likely to effectively treat people living with obesity if they perceive the condition to be a lifestyle choice.

If we recognize obesity as upstream of all other cardiometabolic diseases, we recognize that we can’t afford not to start treating obesity as a chronic disease. Treating obesity as a chronic disease, however, requires a new standard of care to meet the unprecedented scale of the problem.

Today’s medical advancements make it possible to treat the underlying causes of obesity, addressing biological factors critical for weight loss and metabolic health. New, highly effective glucagon-like peptide 1 receptor agonist medications (GLP-1s) have been approved for obesity treatment around the world, with a robust pipeline of other brain-gut hormones regulating metabolic systems to follow.

Today’s technological advancements push us closer to healthcare’s elusive 'iron triangle' — balancing quality, cost and access. This Calibrate Health study demonstrates the real-world outcomes of a scalable obesity treatment model that could finally be cost-effective.

GLP-1s and other emerging combination therapeutics have been heralded as game-changers. Not only do they demonstrate weight-loss efficacy, their mechanism of action targets the underlying root cause physiology behind downstream chronic metabolic conditions, including diabetes and cardiovascular disease. These medications are expensive, however. With the backdrop of a $1.4 trillion global pharmaceutical market, manufacturers are on track to seek approval for another 5-10 obesity medications indicated for long-term, chronic use, with analysts projecting individual molecules could see sales over $100 billion (e.g. Eli Lilly’s tirzepatide).

However, research demonstrates that GLP-1 medications combined with intensive lifestyle intervention can alter the underlying biology that contributes to obesity. This could drive significant weight loss (15+% in obesity patients) and improve metabolic health markers and, ultimately, downstream health costs.

Access to care and obesity stigma pose significant barriers to treatment. Socioeconomic status, race, geography and education are not only critical contributors to the development of obesity and obesity-related diseases, but these social determinants of health are known factors limiting access to effective treatment. Healthcare systems are fundamentally misaligned to serve those with obesity: a review of clinical services for obesity treatment in 68 countries, spanning all income groups, found the majority of countries lack adequate services for treating obesity.

We need better public-private commitment on prevention, but right now we are in crisis. We need solutions that enable sustainable, cost-effective programmes specialising in the treatment of obesity to be delivered at scale. If we can provide access to effective treatment for people living with obesity and give them the tools to sustain their weight loss, especially after medication, we have the opportunity to help billions of people improve their metabolic health and halt their progression on the spectrum of cardiometabolic disease at a total cost of care that works.

How can we deliver this care at scale? Increasingly, technology plays an important role in expanding access to care and enabling us to measure the relative impact of obesity medication and lifestyle intervention in the real world. By using a combination of GLP-1s and interventions in food quality, sleep, exercise and emotional health, we can treat root case biology, overcoming the set point, the body’s natural defense against losing weight. While patient adherence in the real world is never perfect, technology allows us to respond to individual needs and customise lifestyle changes to maximise efficacy; this can multiply, extend or even replace the effects of medication over time to reduce the total cost of care while sustaining outcomes. Once physiologic changes have been established, patients can be thoughtfully transitioned off these medications with the shifted biology and tools they need to sustain their progress going forward.

At this critical moment, we have the opportunity to control the spiralling costs of obesity and reduce its prevalence during our time and for future generations. By expanding access to effective care through the utilisation of telehealth services, novel GLP-1 medications and holistic intensive lifestyle intervention, we can change the way the world treats weight and secure better economic and health outcomes worldwide.