In town hall after town hall leading up to the launch of the Obesity Bill of Rights in January 2024, older adults were outspoken about their desire to receive comprehensive obesity care. And they made their voices heard loud and clear at the 2024 Age+Action Hill Day in early May when over 200 attendees held 139 congressional meetings and an additional 13,100 advocates sent 50,300 letters to Congress—all urging the passage of the Treat and Reduce Obesity Act (TROA).

What does comprehensive obesity care really mean? And what can the original TROA do to help create a landscape that is conducive to providing comprehensive obesity care? Read on to find out more.

Comprehensive obesity care defined

Obesity is a complex chronic disease condition requiring an approach that is science-based, individualized, and inclusive of the full range of treatment options available to help older adults living with obesity achieve their health and weight goals. In other words, obesity care is comprehensive when the four pillars of obesity treatment—healthful nutrition, physical activity, behavioral modification, and medical management—are accessible to all who are at different stages of their obesity journey.

Healthful nutrition: Nutrition counseling and medical nutrition therapy

Nutrition counseling is a process by which a health professional with special training in nutrition—such as a registered dietitian nutritionist (RDN) or an obesity medicine clinician—helps people make healthy food choices and form healthy eating habits. Nutrition counselors can show someone how to:

• Accurately track food
• Create a tailored grocery list
• Prepare a list of snacks
• Target specific lifestyle habits or food components to help achieve health goals

Medical nutrition therapy (MNT) for weight loss provides a more specific and detailed nutrition plan than the standardized approach offered in nutrition counseling. An RDN will  develop a personalized eating plan that takes into consideration other health conditions (e.g., diabetes, heart disease, cancer, etc.); dietary issues (e.g. food allergies); the latest science; and  cultural preferences. An RDN can help set realistic weight loss goals; make sure weight loss is steady and safe (for most people this is about 1 to 1.5 pounds per week); and equip people with knowledge and skills that can support their weight loss journey, such as limiting calories; reading food labels; watching portion sizes; and increasing physical activity—among many other things.

Physical activity

Combining physical activity with a healthy diet is a key treatment strategy to manage stage 1 obesity (i.e., no known weight-related complications or any psychological conditions / internalized weight bias that impacts quality of life in a major way). Exercise is a more effective way to lose weight than depending on calorie restriction alone: Not only does it help burn calories, but it can also improve body composition (i.e. increase lean muscle mass, which also helps burn more calories); improve balance and flexibility; and reduce the risk of injury from falls. Exercise may lower the risk of certain diseases (e.g. prevent a heart attack by lowering blood pressure and cholesterol) and contribute to mental health and well-being.

Any amount of exercise can benefit health, but experts recommend the following physical activity goals:

• 150 to 300 minutes of moderate-intensity aerobic activity per week or 75-150 minutes or more vigorous-intensity aerobic activity per week.
• At least two days per week of resistance training/muscle-strengthening activity that works all major muscle groups (i.e., legs, hips, back abdomen, chest, shoulders, and arms). Strength training builds muscle mass and is important for bone health as well.

A health care provider can give guidance on how much exercise someone can do, what types of activities are best, and what types of exercise to avoid because of physical limitations or other chronic conditions.

Behavior modification: Intensive behavioral therapy

Intensive behavioral therapy (IBT) is a treatment that targets poor eating habits and lack of physical activity which contribute to obesity.  Working with a therapist, people learn how to track eating; change their environment to avoid overeating; increase their activity level; create an exercise plan; and set realistic goals.

Some parts of behavioral therapy are often the same as those in other weight-loss programs. These include self-help groups and commercial weight-loss programs. For some patients where record-keeping and accountability may improve health outcomes, other potential interventions include fitness trackers, smartwatches, and use of social media.¹

Medical management: Anti-obesity medications and obesity surgery

Anti-obesity medications (AOMs) may be prescribed by a health care provider when someone has one or more mild to moderate weight-related health complications (stage 2 obesity) or has been unable to lose weight through other means. AOMs do not replace nutrition or physical activity; in fact, pairing these strategies with AOMs increase the latter’s effectiveness and may help minimize weight regain once someone stops taking them. According to the National Institutes of Diabetes and Digestive Kidney Diseases (NIDDK), people who combine prescription AOMs with lifestyle changes lose 3% to 12% more of their starting weight, on average, than people in a lifestyle program who do not take a medication.

All AOMs work differently in the body to achieve the same goal: weight loss. Some may reduce appetite; help you feel fuller faster after eating; or limit the amount of fat your body absorbs from food. The U.S. Food and Drug Administration (FDA) has currently approved six weight management medications for long-term use.

It is important to note that, like many medications, AOMs may cause side effects that may be minor, serious, or anywhere in between. Some of the common ones include: headaches, nausea, abdominal pain, constipation, dry eye, anxiety, depression, mood swings, dizziness, vomiting, increased heart rate, and insomnia. Additionally, people respond to medications in diverse ways, so side effects can vary from person to person.

A health care provider can help manage these as well as set realistic expectations about how much weight someone may lose while taking an AOM. Different drugs have different success rates, and people respond to drugs differently. In general, those who take an AOM may expect to lose 5% to 10% of their starting weight. But individual results will depend on many factors, including starting weight, age, activity level, eating habits, stress levels, and sleep habits.²

Weight loss or obesity surgery is also known as bariatric and metabolic surgery. These terms describe the effect of these operations on patients’ weight and metabolism (i.e., the chemical reactions in the body’s cells that change food into energy). This procedure may be recommended by a health care provider for those who have at least one severe weight-related complication that requires significant weight loss for effective treatment (stage 3 obesity) and are unable to lose weight through other means. On average, people who have obesity surgery lose 15%-30% of their starting body weight. Results vary from person to person and lost weight may be regained if long-term lifestyle changes involving healthy eating, physical activity and behavior modification are not followed.²

Obesity surgery works by changing the structure of a person's digestive tract, which in turn, may help limit the amount of food they can comfortably eat; lower the calories their body can absorb; and regulate hunger and appetite hormones. The most common types of obesity surgery are explained in greater detail by the American Society for Metabolic and Bariatric Surgery.

There are risks associated with the procedure: bleeding, infections, blood clots, diarrhea, nutritional deficiencies, hernias, scar tissue, severe hypoglycemia, peripheral neuropathy, osteoporosis, and risk of alcohol use disorder (especially with gastric bypass). However, the benefits of obesity surgery include improvements in weight-related health conditions such as type 2 diabetes, sleep apnea, high blood pressure, high blood cholesterol, and lower risk of cancer.

Existing gaps in coverage limit treatment options

Obesity treatments can be expensive: as of an October 2022 report from the Institute for Clinical and Economic Review, a month’s supply of Wegovy ran $1,300. Obesity surgery, on the other hand, can run from $15,000 to $25,000 or even more based on NIDDK estimates.³ High costs leave patients asking, does insurance cover obesity treatments?

Unfortunately, payers—both governmental and commercial—tend not to cover the full range of obesity treatments.

According to the Medicaid Obesity Treatment Coverage 2024 report from STOP Obesity Alliance, no state fully covered all four pillars of obesity treatment. For individual components of care, the coverage varied. Only four states covered surgery and AOMs without restrictions. Total exclusions were the most common for AOMs across 37 states. Nutrition counseling was excluded in 22 states.⁴

Medicare is prohibited from covering AOMs by federal law due to past safety concerns related to Fen-phen, a combination of fenfluramine and phentermine that led to rapid weight loss and was touted as a miracle drug—only to be found later to cause heart valve damage. As a result, Medicare Part D—which helps manage prescription drug costs—is barred from covering medications viewed as having the risks outweigh the benefits, namely “cosmetic” benefits.⁵

The Affordable Care Act of 2010 expanded coverage by governmental and commercial insurers to defray the costs of obesity surgery, but it still does not address AOMs. Medicare only covers certain types of obesity surgery, namely RYGBP, laparoscopic adjustable gastric banding (LAGB), and BPD/DS.⁶

Medicare Part B will cover IBT for obesity only when services are rendered by primary care providers (“PCPs”, including nurse practitioners, physician assistants, certified clinical nurse specialists as well as MDs). Even RDNs may not bill directly for this service; they can only provide the benefit “incident” to a PCP.⁷ This restricts access to other highly trained providers such as obesity medicine specialists, psychologists, and to evidence-based, community-based weight loss programs.⁸

As for private insurance, plans vary with respect to AOM coverage. Some will only cover certain AOMs. Some will do so with prior authorization. Others will not cover them at all.

A grave concern for all beneficiaries currently covered under private insurance for AOMs is that they will lose this benefit once they reach 65 under Medicare.

This includes Federal Employee Health Benefits and Tricare (for veterans) who receive coverage for treatment under Federal law. Approximately 4.1 million Americans are poised to turn 65 starting in 2024 and every year through 2027 (“Peak 65”). This means that thousands of older adults stand to lose AOM coverage over the next three years.

In summary, treatment options for obesity are limited due to gaps in coverage that make them unaffordable for many older adults. This creates health inequities, especially among communities of color.

How you can advocate for comprehensive obesity care

TROA in its original form is bipartisan legislation that provides Medicare beneficiaries with access to safe, effective, and life-saving treatments. This bill aims to effectively treat and reduce obesity in older Americans by enhancing Medicare beneficiaries’ access to health care providers that are best suited to provide IBT and by allowing Medicare Part D to cover FDA-approved AOMs. 

However, on June 27, 2024, a narrower version of this bill was passed by the House Ways and Means Committee, expanding Medicare coverage of AOMs only for older adults who have already been taking them for at least a year before aging into the program. It also requires Medicare to reevaluate its coverage of IBT. While this may not accomplish all the goals that were originally advocated for at the town halls and during Hill Day, this is just the starting point for working towards legislation that could provide broader coverage. Tell us what you think by filling out this brief survey.

You can also leverage the Obesity Bill of Rights, a set of eight patient-centered principles established so that people with obesity will be screened, diagnosed, counseled, and treated according to medical guidelines and no longer face widespread weight bias and ageism within the health care system or exclusionary coverage policies by insurers and government agencies. Launched on Jan. 31, 2024, the Obesity Bill of Rights is endorsed by 60 national obesity and chronic disease organizations. Find out more at right2obesitycare.org.

Sources

1. Fitch A, et al. Comprehensive care for patients with obesity: An Obesity medicine Association Position Statement. Obesity Pillars. September 2023. Found on the internet at https://www.sciencedirect.com/science/article/pii/S2667368123000165

2. American Association of Clinical Endocrinology (AACE). Journey for Patients with Obesity. Found on the internet at https://www.aace.com/patient-journey/obesity/diagnosis-staging

3. National Institute of Diabetes and Digestive and Kidney Diseases. Definition & Facts of Weight Loss Surgery. Found on the internet at https://www.niddk.nih.gov/health-information/weight-management/bariatric-surgery/definition-facts

4. ConscienHealth. Marginalizing People with the Greatest Need for Obesity Care. June 3, 2024. Found on the internet at https://conscienhealth.org/2024/06/marginalizing-people-with-the-greatest-need-for-obesity-care/

5. Obesity Medicine Association. Does Insurance Cover Weight Loss Medication? Dec. 18, 2023. Found on the internet at https://obesitymedicine.org/blog/does-insurance-cover-weight-loss-medication/

6. Medicare Coverage Database. Bariatric Surgery for the Treatment of Morbid Obesity. Found on the internet at https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&NCAId=160

7. Academy of Nutrition and Dietetics. Intensive Behavioral Therapy for Obesity. Found on the internet at https://www.eatrightpro.org/career/payment/medicare/intensive-behavioral-therapy-for-obesity

8. Obesity Care Advocacy Network. Medicare Must Reevaluate its National Coverage Determination for Intensive Behavioral Therapy for Obesity. Oct. 19, 2021. Found on the internet at https://assets.obesitycareadvocacynetwork.com/OCAN_Part_B_Memo_2c3a47daba/OCAN_Part_B_Memo_2c3a47daba.pdf