The COVID-19 pandemic has revealed many health-related inequalities and concerns, among them the relationship between obesity and COVID-19 severity. The Centers for Disease Control and Prevention has reported that the risk for more severe COVID-19 increases with higher body mass index (BMI). A BMI of 18.5-24.9 kg/m2 indicates a normal or healthy weight, whereas a BMI of 30kg/m2 or more indicates obesity.
The relationship between obesity and severe COVID-19 disease has been much discussed and investigated during the pandemic. In Connecticut, state legislators recently took the issue a step further when they heard testimony in March regarding a senate bill that would require private insurers and Medicaid to cover bariatric surgery and FDA-approved anti-obesity medications for individuals who have a BMI of 40 or more.
“We need to treat obesity as we would any other disease, because obesity is a chronic treatable disease,” said Ania Jastreboff, MD, PhD, associate professor in the Department of Internal Medicine (endocrinology) at Yale School of Medicine, who testified on March 17 before the Connecticut General Assembly’s Insurance and Real Estate Committee. “If these anti-obesity medications are affordable and accessible to all, we can help patients with obesity reach their health and weight goals,” Jastreboff said.
Obesity, she explained, is physiologic dysregulation of a person’s body fat mass setpoint, which is determined by genetics and impacted by other factors such as the obesogenic environment. “Everyone's body wants to carry a certain amount of fat, or adipose tissue,” Jastreboff said. “The reason for this is because we need to store energy, and the natural way our body stores energy is in fat.”
However, by 2030, one in two Americans are projected to have obesity, Jastreboff said. “That’s half of us. Half of us in our country will have obesity in just nine years.” She confirmed what many of us experience: it’s really hard to lose weight and maintain weight loss. “Basically, when we lose weight, our body sends hormone signals to our brain, and our brain thinks we are starving and tries to do everything it can to make us gain the weight back -- this is obesity,” she said.
“Until recently, obesity was not understood to be a chronic disease and patients were deplorably blamed and shamed for having obesity; obesity was considered to be a personal choice,” she said in her testimony. “If a patient could not achieve and maintain a healthy weight, it was tragically considered to be the failure of the patient. We now know that obesity is not a choice, it is a chronic metabolic disease with complex underlying neurobiology,” she added. “It is not the patients who failed, we failed them, medicine failed them.”
After struggling with her weight for most of her life, Nancy Kravitz made an appointment with Jastreboff, whom she had met at a holiday work party at Yale School of Medicine. Jastreboff created an individualized weight-management plan for Kravitz that included several medications. Kravitz lost 50 pounds in just over a year; her blood pressure and cholesterol levels improved, and her obstructive sleep apnea resolved.
Losing weight also enhanced Kravitz’s mental health.
“I was very depressed because I didn’t feel good about myself, and I didn’t feel comfortable in my own skin. And that affects everything in your life,” said Kravitz, who is the manager for the Office of the Chair in the Department of Internal Medicine. “I think dealing with depression is just as important as managing the other health issues.”
Kravitz said her weight fluctuated throughout her life – she lost weight in her 20s but then gained weight after the birth of her daughter. According to Jastreboff, this is a familiar pattern for people with obesity.
“It's not as if your body always wants to weigh exactly 180 or 200 pounds throughout your life,” Jastreboff said. “Let’s say, in your 20s, your body wants to weigh 160 pounds, then you go through pregnancy, and your body now wants to weigh 175 pounds,” she said. “And then you lose weight to 170 pounds, and your adiposity setpoint is in a new place. But then you go through a significant life event, such as a divorce, and that stress drives up your adiposity setpoint to 180 pounds. So, there are different things that can cause that setpoint to go up or down.”
Just as there are safe and effective surgical interventions for patients with obesity, FDA-approved anti-obesity medications also are safe and effective, Jastreboff said. She gave the example of another patient who lost more than 100 pounds with anti-obesity medications.
The woman, who was in her late 50s, weighed more than 250 pounds when Jastreboff first saw her two years ago. The woman’s BMI was greater than 42 and she was classified as having severe obesity. She was also being treated for hypertension, hyperlipidemia, obstructive sleep apnea, and pre-diabetes.
“I started her on medication one, and within eight months she lost nearly 20 pounds,” Jastreboff said. “I added medication two, and over the next eight months she lost 42 pounds. I started her on medication three, and over the next year she lost 41 pounds. In total, over the course of one and a half years she lost more than 100 pounds, her BMI decreased from 42 to 25, her weight decreased from 253 pounds to 151 pounds. Overall, she achieved 40% total body weight loss with anti-obesity pharmacotherapy.”
“The woman’s pre-diabetes has resolved, and she no longer has obstructive sleep apnea,” Jastreboff said. “With three FDA-approved medications, she was able to achieve her weight and health goals, and is now living a healthier life.”
“If these medications are affordable and accessible, we can help patients with obesity achieve their health and weight goals and make America a healthier place for all,” she said in her testimony.
Senate Bill 1007 was voted favorably out of the Connecticut General Assembly’s Insurance and Real Estate Committee, and was sent to the Appropriations and Human Services Committees for further review.