The Current State of Obesity Care in the United States: The Need for Innovative, Evidence-Based Programs

Introduction

We’re in the midst of an unprecedented and exciting time in obesity care. It’s clear that obesity is a common, serious, and costly disease in the United States, affecting a significant portion of the population and imposing a heavy burden on the healthcare system. And despite advancements in treatment options, the prevalence of overweight and obesity continues to rise, highlighting the urgent need for innovative, evidence-based programs to improve access to care, optimize efficiency, reduce costs, improve outcomes, and enable healthier living.

Obesity Prevalence, Morbidity, Mortality, & Cost

According to 2017–2018 data from the National Health and Nutrition Examination Survey (NHANES), nearly 1 in 3 adults (30.7%) are considered overweight, more than 2 in 5 adults (42.4%) have obesity, and about 1 in 11 adults (9.2%) have severe obesity (1, 2). Furthermore, by 2030, it is anticipated that a staggering 1 in 2 adults will have obesity (3). Studies consistently show that increasing Body Mass Index (BMI) correlates with higher morbidity and mortality (4).

It’s therefore not surprising that the treatment of obesity and related conditions places a significant economic burden on healthcare systems. For instance, 19 studies from high- and middle-income countries in 2022 estimated that direct medical costs of obesity accounted for up to 18 percent of health system expenditures (5). Indirect costs, such as lost work productivity and reduced household income, were even higher. In 2017, obesity was estimated to have cost the United States approximately USD $1.4 trillion (6).

Barriers to Obesity Care

Clearly, our healthcare system is poorly equipped to help patients properly manage their weight due to a multitude of issues. Part of the problem is related to physician shortages, including limited physician bandwidth, availability, and obesity-specific training (7). In fact, fewer than 1% of physicians in the United States are certified in obesity medicine (8). Additionally, patients may experience numerous barriers to receiving timely care such as stigma, inconvenience of scheduling in-person visits, limited mobility, and the cost of treatment (9, 10).

Highly Effective Anti-Obesity Medications

Originally developed for managing type 2 diabetes mellitus due to their glucose-lowering effects, GLP-1 agonists have emerged as promising agents for obesity treatment owing to their additional benefits on weight loss and metabolic parameters. Currently, the FDA-approved GLP-1 medications for weight loss include Saxenda (liraglutide) and Wegovy (semaglutide). Zepbound (tirzepatide) is a newer agent that acts on both the GLP-1 receptor and Gastric Inhibitory Peptide (GIP) receptor. Patients can achieve up to 20% or more weight loss with these newer classes of medication (11, 12). In a recent study, Wegovy use was associated with a 20% reduction in cardiovascular mortality in patients with preexisting cardiovascular disease and overweight/obesity but without diabetes (13). 

But despite their efficacy, newer classes of anti-obesity medications are particularly costly. The Institute for Clinical Economic Review (ICER) found that GLP-1 therapies are twice as expensive as their expected value for weight loss-related health benefits (14). The high cost of these medications makes them unaffordable for millions of people who could benefit from GLP-1 therapies.

See post by Noom CEO Geoff Cook for more information on GLP-1 cost & accessibility barriers.

Treatment Persistence, Weight Cycling, & Sarcopenic Obesity

Real-world data on the persistence and adherence of GLP-1s also reveal significant challenges. An analysis of 4,066 commercially insured members with obesity and without diabetes who initiated GLP-1 therapy in 2021 found that only 46.3% remained persistent with the treatment at 180 days, dropping to 32.3% at one year (15). 

Non-persistence/adherence to anti-obesity medication and inconsistent lifestyle changes (e.g., restrictive dieting) can lead to repeated cycles of weight loss and gain throughout one’s life. This phenomenon in obesity medicine is known as “weight cycling.” Recent research highlights the risks weight cycling poses to cardiometabolic health (16).

Importantly, when losing weight through a calorie-restricted diet, approximately 20% of weight loss is due to loss of lean body mass (eg, muscle mass), with the remaining 80% due to loss of fat (17). During marked weight loss, such as with the use of GLP-1 agonists or after bariatric surgery, 30 to 40% of the weight lost may come from lean mass (18-20). This muscle loss can be more pronounced in individuals with predisposing catabolic conditions (eg, chronic diseases or aging), or in those with prolonged unbalanced diets (particularly low protein intake) and weight cycling (21). 

Loss of skeletal muscle with weight loss may predispose individuals to a greater chance of weight regain (22, 23). Regaining weight as fat can lead to a condition termed sarcopenic obesity, which is defined as the combination of excess fat and reduced muscle mass/function. Sarcopenic obesity has consistently demonstrated to be a strong and independent risk factor for frailty, comorbidities, and mortality (24). 

This underscores the urgent need for effective obesity programs to address treatment persistence, weight cycling, and the risk of sarcopenic obesity associated with GLP-1 agonist use. It is imperative that lifestyle and behavioral change programs focus on adequate protein intake and resistance strength training during medical weight loss.

Noom Med Solution

To address these challenges, Noom Med operates under a philosophy aligned with The Institute of Medicine’s (IOM) six aims framework for assessing healthcare quality (25): ensuring that healthcare delivery is safe, effective, patient-centered, timely, efficient, and equitable. 

Our innovative, technology-enabled obesity program is differentiated by the following key features: 

• Asynchronous telemedicine
• Optimized lab testing flow
• Expanded GLP-1 medication access
• Medication tapering
• GLP-1 Companion app

Asynchronous Telemedicine

At Noom Med, we leverage obesity-trained physicians to provide telehealth services to our members. Our members have unlimited access to their healthcare provider and care team through text-based messaging, allowing them to regularly send updates about their health status. Cases can be escalated to synchronous encounters when clinically indicated per physician judgment, ensuring high quality of care. 

Telemedicine helps address a number of barriers to receiving effective obesity treatment (26-29). Asynchronous telemedicine, also known as store-and-forward telemedicine, is a subtype of telemedicine that involves the transmission of medical information to a clinician for assessment at a later time (30). Our evidence-based lab requirements start with vetted intake and certification, which includes a photo ID and identity check. Patients answer questions about their symptoms and medical history through a structured questionnaire and by uploading photos or videos. This data is then reviewed by a clinician, who develops a diagnosis and treatment plan. 

Asynchronous telehealth can provide clinical outcomes that are comparable to those provided by in-person care and has been shown to reduce health care costs (31). 

There are numerous benefits to asynchronous care delivery. Firstly, it offers privacy and comfort, as patients may feel more comfortable sharing sensitive information in a non-face-to-face setting. It also provides flexibility, allowing patients and clinicians to communicate at their own convenience without the need for real-time scheduling. This can lead to reduced waiting times, as patients can send their medical information and receive responses without waiting for a scheduled appointment. Improved efficiency is another advantage, as clinicians can respond to medical cases during their available time, potentially making better use of their time and resources. Lastly, clinical documentation is enhanced by creating a detailed record of patient interactions that is useful for follow-up care and quality assurance.

Optimizing lab testing flow

At Noom Med, we appreciate the importance of laboratory results in evaluating and managing patients with obesity. Labs tests can help identify underlying medical conditions that contribute to obesity (eg, hypothyroidism), assess for comorbid disease (eg, diabetes, hyperlipidemia, fatty liver), evaluate organ function (eg, kidney function), and monitor treatment efficacy (33). 

At the same time, we aim to ensure laboratory testing does not pose a barrier to obesity care by gatekeeping treatment. Our data shows that the majority (~70%) of new members at Noom Med have completed basic laboratory work within the past year. We encourage our members to securely share their medical records and laboratory result history when available, to help reduce duplicate testing, improve decision making, and enhance care coordination. This includes leveraging the use of Health Information Exchange data when available (34). Furthermore, we are actively exploring validated at-home-diagnostic testing options to further promote safety and convenience for our members.

See this post by Noom CEO Geoff Cook for more information on our evidence-based lab requirements.

Expanded GLP-1 access 

The high demand for new weight loss medications has led to shortages, with drug manufacturers struggling to meet the need for their FDA-approved drugs. To address this, federal law allows compounding pharmacies to produce copies of medications listed on the FDA drug shortage list, including semaglutide and tirzepatide (35). While the industry has recently made progress increasing the availability of meds, these medications remain in shortage.

Historically, the medical community has criticized the use of compounded GLP-1 agonists, citing concerns over unregulated companies producing substandard or counterfeit versions. The FDA has issued warnings about fraudulent products containing incorrect or harmful ingredients.

In 2023, the OMA published a position statement advising that anti-obesity medications (AOMs), including compounded peptides, should undergo FDA-supervised clinical trials to ensure safety, efficacy, and purity (36). Since compounded drugs are not FDA-approved, there were concerns about their quality and potential risks. The OMA emphasized that if compounded peptides are prescribed, they must be produced by legally compliant, transparent manufacturers.

Legitimate compounding pharmacies, which adhere to federal (503b registered) and state regulations and dispense medications only with valid prescriptions, provide a regulated alternative for obtaining GLP-1 agonists (37).

A recent report indicates that from August 8, 2021 to March 31, 2024, the FDA received more than 20,000 adverse events reports for FDA-approved semaglutide (38). Comparatively, there were only 210 adverse events reported on compounded semaglutide products from 503b registered pharmacies. Many of the adverse events reported were consistent with known reactions in the labeling, like nausea, diarrhea, and headache. 

Understandably, patients are often drawn to compounding pharmacies for pricing-related reasons. Brand name GLP-1 agonists for obesity are often not covered by insurance and out of pocket costs for these medications typically carry an excessive monthly cost of $1000 or more. In comparison, compounded semaglutide costs closer to $150-$300 per month.

As the use of compounded peptides continued to evolve, especially during shortages of FDA-approved AOMs, confusion increased among clinicians and patients. In response, the OMA recently issued a call to action for collaboration among stakeholders (patients, pharmacists/pharmaceutical companies, clinicians/medical organizations, health insurance companies, and the government) to clarify the role of compounded peptides during shortages (39). Additionally, the OMA now provides clinicians with specific guidance to ensure ethical prescribing when FDA-approved AOMs are unavailable.

At Noom Med, we provide our members with options of both branded as well as compounded GLP-1 medications. Ethical prescribing of anti-obesity medication is of paramount importance. That’s why we adhere to the Obesity Medicine Association’s (OMA) guidance when offering compounded peptides to our members. Compounded semaglutide is manufactured by trusted and reliable compounding pharmacies that adhere to federal and state regulations in order to meet our members’ needs. This helps ensure due diligence when prescribing compounded peptides during shortages.

Weight Maintenance & GLP-1 Tapering

Emerging evidence suggests that weight loss can be maintained off GLP-1 medication. 

The STEP 1 trial extension and the SURMOUNT-4 trial, funded by Novo Nordisk and Eli Lilly respectively, indicate significant weight regain (65% and 67%) within a year of stopping semaglutide and tirzepatide (40, 41). Notably, they selected study participants to include only those who failed dieting in the past and favored participants at the highest decile for BMI.

However, real world data from the Epic Research Study, involving over 38,000 patients, found that more than half maintained their weight loss a year after stopping semaglutide or liraglutide (42). Substantial benefits have been seen at lower doses of GLP-1 medication: Studies suggest that 70% of the weight loss outcome can be achieved with 40% of the maximum dose. 

Furthermore, recent evidence shows that combining GLP-1 therapy with lifestyle interventions like diet and exercise results in better weight loss outcomes and sustainability post-medication (43, 44). In fact, some digital weight loss programs have been successful in achieving weight loss maintenance after a medication taper (45-47).

At Noom Med, we strongly advocate for less reliance on medication through behavioral change and lifestyle intervention. We’re confident that through our program, many members with overweight/obesity can achieve healthy weight and maintain their weight loss through our 9 month titration and 9 week taper protocol. Some members will successfully come off medication altogether.

Noom GLP-1 Companion 

Noom is rooted in behavioral change at its core, implementing principles of motivational interviewing and cognitive behavioral therapy in our program. The app is engaging and fun to use, promoting healthy behaviors by letting members earn Noomcoin. 

Members receive continuous support through the Noom GLP-1 companion app, which follows the 4 Cs principle: clinical, coaching, content, community. 

Members work 1:1 with health coaches to establish rapport, receive nutritional guidance, and gain additional support throughout their weight loss journey. They can also join community circles to connect with other members with similar interests, exchanging ideas, supporting and learning from each other. Studies suggest that relationship-oriented engagement, including the relationship with the health coach and the relationship with fellow members is associated with a 2.6x relative increase in weight loss at 12 months (48).

See this post by Noom CEO Geoff Cook for more information on how Noom Med’s psychological grounding drives sustainable weight loss.

Noom Med members also receive personalized educational content, with lessons about how GLP-1 medications work and their potential side effects. Educational modules also help our patients understand the psychology behind their lifestyle habits, increasing their self-efficacy  and encouraging them to implement healthier habits for sustainable weight loss outcomes. Members learn about the importance of protein intake and resistance weight training (eg, Muscle Defense™) to prevent sarcopenic obesity.

Last, but certainly not least, members also have the ability to track their metrics such as their weight, protein intake, meals, water intake, and activity levels.

Conclusion

The current state of overweight and obesity care in the United States presents numerous challenges, but innovative, evidence-based programs like Noom Med are leading the way in improving access to care, optimizing efficiency, and reducing costs. The prevalence of overweight and obesity continues to rise, highlighting the urgent need for innovative, evidence-based programs to improve access to care, optimize efficiency, reduce costs, improve outcomes, and enable healthier living.

By integrating asynchronous telemedicine, evidence-based risk stratification, optimized lab testing, expanded access to GLP-1 medications, a structured tapering protocol, and a comprehensive behavioral change companion app, Noom Med effectively tackles the multifaceted challenges of obesity care. The alarming statistics on obesity prevalence and its associated health and economic burdens highlight the need for such an innovative and holistic program.

Noom Med’s protocol is more than medication; it creates a supportive ecosystem that empowers patients to achieve and maintain their weight loss goals through comprehensive care. This innovative, evidence-based program improves access, optimizes efficiency, and reduces costs associated with obesity care. As we continue to face the growing challenges of obesity, Noom Med’s protocol offers a robust and scalable solution, significantly impacting public health outcomes and offering a healthier future for those affected by obesity.

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