Recognizing and treating obesity as a disease

Almost half of American adults have obesity, a condition that was a fraction of that just 40 years ago and scientists don’t agree on what’s caused the dramatic increase. What everyone does agree on is that it’s a major health crisis, because obesity can cause type 2 diabetes, hypertension, stroke and more than a dozen cancers.

Now there’s a medication that leads to dramatic weight loss. But it’s wildly expensive. Hollywood celebrities take it to flatten their tummies, but few can afford the thousands of dollars it costs a year.  

And very few insurance companies will cover it, even though in 2013 the American Medical Association, some would say, finally recognized obesity as a disease.

Dr. Fatima Cody Stanford: It’s a brain disease. 

Lesley Stahl: It is?

Dr. Fatima Cody Stanford: It’s a brain disease. And the brain tells us how much to eat and how much to store.

Dr. Fatima Cody Stanford, an obesity doctor at Mass General Hospital and associate professor at Harvard Medical School, says common beliefs about obesity are all wrong 

And diet shows like “The Biggest Loser” are snookering people.

Lesley Stahl: If you diet, you lose weight, right? 

Dr. Fatima Cody Stanford: For many of us, we can go on a diet. Something like “The Biggest Loser,” right?  You go and you restrict people.  You make them work out for 10 hours a day and then you feed them 500 calories.  For most people, they will acutely lose weight. But 96% of those participants in “The Biggest Loser” regained their weight because their brain worked well. It was supposed to bring them back to store what they needed or what the brain thinks it needs.

Lesley Stahl: So willpower?  

Dr. Fatima Cody Stanford: Throw that out the window. My last patient that I saw today was a young woman who’s 39 who struggles with severe obesity. She’s been working out 5 to 6 times a week, consistently. She’s eating very little.  Her brain is defending a certain set point.

A set point, says Dr. Stanford, is a range of weight your brain is in charge of maintaining by controlling how much food you eat and how much of it you store. One theory is that it’s an evolutionary survival mechanism that helped retain fat during famines.  

Lesley Stahl: So we had COVID. Lots and lots of people gained weight. Did those people have a new set point that’s higher now?

Dr. Fatima Cody Stanford: Absolutely. So when you have a chronic stressor and you get to a certain weight and maintain that weight for, let’s say, at least 3 to 6 months, then you recalibrate that set point to a different set point. 

Lesley Stahl: I’ve always heard that it’s the fast food. That it’s the Diet Cokes, that kinda thing, that is the instigator. Is that true?

Dr. Fatima Cody Stanford: So I think we have to look at the different causes of obesity as a big pie. And that’s one factor. But notice how I’m using this part of the pie, right?

Dr. Fatima Cody Stanford: But the number one cause of obesity is genetics. That means if you were born to parents that have obesity, you have a 50-85% likelihood of having the disease yourself even with optimal diet, exercise, sleep management, stress management, so when people see families that have obesity, the assumption is, “Ugh. What are they feeding those kids? They’re doing something wrong.” Actually do you know this? 79-90% of physicians in the United States have significant bias towards individuals that are heavier. Now, doctors listening to me may say, “Oh, it’s not me.” Hold your horses, because has that patient come to you and told you, “Look, Doc, I’m eating well.” “Look Doc, I’m exercising.” And the doc says to them, “Are you sure? I don’t believe that that’s really what you’re doing.”

Lesley Stahl: Wait, are you saying that doctors don’t understand obesity? Doctors?

Dr. Fatima Cody Stanford: Doctors do not understand obesity.

In one of her published studies, Dr. Stanford found that most medical schools don’t teach that obesity is a disease and in fact don’t even offer courses on it, even though it’s the second leading cause of preventable death in the country after smoking. 

Nicole Sams, mother of five from Rhode Island, spent years going to doctors who all had the same message.

Nicole Sams: “Well, you just have to go see a dietician.” And I did. I did everything I was told to do: I went to a dietician; you know, I sat, had the rubber foods come in front of me, “Oh, you’ll only eat this portion,” I’m like “Oh.”

Maya Cohen went on her first diet when she was 13. At her heaviest, at 5 feet tall, she weighed 192 pounds.

Lesley Stahl: Did you feel that people looked at you and said “Why doesn’t she stop eating? She’s eaten her way to that”? 

Maya Cohen: You know you look at someone and you internalize, “Oh, they must think I’m eating too much.” So it’s just, after a while you just personally think that, “Okay. Everyone’s telling me that I’m — that this is a flaw in my character;” therefore, it must be true. And so you start believing this.

Dr. Caroline Apovian: Don’t you think if people walking down the street with obesity, stigmatized as they are, shunned, don’t you think if they could lose weight and keep it off they would?

Dr. Caroline Apovian, co-director of the Weight Management and Wellness Center at Brigham and Women’s Hospital in Boston who sees both Maya Cohen and Nicole Sams, is relieved that at last she has a highly effective medication to offer her patients that’s safe, according to the FDA.

It’s part of a new generation of medications that brings about an impressive average loss of 15% to 22% of a person’s weight and it helps keep it off. Drs. Apovian and Stanford have been advising companies developing drugs for obesity, including the Danish company Novo Nordisk, an advertiser on this broadcast. It makes the drug Wegovy that you inject yourself once a week with, something like an epipen. It’s not easy to get. The drug is currently in short supply. And it costs more than $1,300 a month. 

Lesley Stahl: People in Hollywood can afford these expensive injections. And they’re taking them. 

Dr. Fatima Cody Stanford: Right.

Lesley Stahl: And they’re not necessarily people with obesity.

Dr. Fatima Cody Stanford: Yeah. We have a national shortage on these medications. If those that have the means, are able to get them yet the people that really need them are unable to. Then that creates a greater disparity, right? The haves and the have nots.

The vast majority of people with obesity simply can’t afford Wegovy and most insurance companies refuse to cover it partly because, as AHIP – the health insurance trade association – explained in a statement, these drugs “have not yet been proven to work well for long-term weight management and can have complications and adverse impacts on patients.”

Dr. Caroline Apovian: What we’ve seen so far is really nausea, vomiting, you know that’s why these drugs are dosed slowly and starting with low doses.

Lesley Stahl: Oh, and build up?

Dr. Caroline Apovian: And build up.

Dr. Apovian says most of the side effects go away over time.  

Dr. Caroline Apovian: We are frustrated every single day when we see patients who desperately need to lose weight to reduce the diabetes, reduce the hypertension, stroke, heart disease, and we can’t give them this fabulous, robust medication that is very effective and safe. And we can’t give it to them because insurance won’t cover it. I receive emails about denials– that state that we’re denying this because “the doctor has not counseled the patient on behavior change as part of this.” That’s where the stigma of obesity comes in, the idea that the patient can do it with diet and exercise. You would never do that to a patient with hypertension or heart disease or Type 2 diabetes, tell them that you “Just don’t eat sugar, you’ll be fine.”

Novo Nordisk also makes a drug for type 2 diabetes called Ozempic, which most insurers and employers do cover. What frustrates the doctors is that Ozempic and Wegovy are exactly the same drug, though Wegovy for obesity is usually prescribed at a higher dosage. 

When Maya Cohen wanted the medication for obesity…

Maya Cohen: My insurance company told me that they consider it a “vanity drug.” 

Lesley Stahl: A “vanity drug.”

Lesley Stahl: So that suggests that the insurance company does not consider obesity a disease–

Maya Cohen: Correct.

Nicole was also denied coverage. On its website, her health plan, through the state of Rhode Island, puts anti-obesity medications in the same category as drugs for erectile dysfunction and cosmetic purposes.

There are about 110 million Americans eligible for an anti-obesity medication, making it a costly investment for insurance, but if they covered it, overall government and private health care spending would probably come down. Just take diabetes, that is, in many cases, caused by obesity. Diabetes costs more than $300 billion a year, most of which is covered through Medicare and Medicaid. But University of Chicago health care economist Tomas Philipson points out that there’s actually a law that prevents Medicare from covering weight loss drugs. 

Lesley Stahl: You would think that that insurance program for older adults would see an enormous benefit to these drugs?

Tomas Philipson: Yeah, a third of Medicare spending is diabetes, you know, which is highly with– tied to obesity. And Medicare kind of sees all the health care expenses when you get older when you have heart disease, et cetera, from your obesity.  I think what ultimately will drive it is that they have evidence that this is actually gonna lower total Medicare costs.

When Dr. Apovian told both Maya Cohen and Nicole Sams that their obesity was not a weakness of willpower, they were blown away.  

Nicole Sams: I looked at her and I said, “I don’t believe you. What do you mean, ‘It’s not my fault?’ It is my fault.” Because it’s what I heard for my entire life.

Maya Cohen: I went home that day like– a boulder had come off my shoulders. Like, “Okay, there’s finally hope. There’s hope.”

Lesley Stahl: Did you cry?

Maya Cohen: I did. A lot. (LAUGH)

Dr. Caroline Apovian: All those years of thinking that somehow you have no willpower and it’s your moral failing and you’re a glutton and why did you eat so much and– feeling shame. It’s the shame.

Lesley Stahl: Yeah, yeah. It’s the shame.

Dr. Caroline Apovian: It’s the shame.

Maya was ultimately able to get the medication covered by her insurance because she has type 2 diabetes. She’s lost more than 50 pounds. Dr. Apovian says she does have to continue dieting and exercising and, like most patients, will be taking the drug indefinitely to maintain her weight. Nicole doesn’t have type 2 diabetes.    

Lesley Stahl: Nicole, we called your insurance company and they gave us a statement.

Nicole Sams: Okay.

Lesley Stahl: “Earlier this year the State of Rhode Island, in consultation with its pharmacy benefits manager, decided that health insurance for the State of Rhode Island employees would cover the entire class of anti-obesity drugs.”

Nicole Sams: Oh– really?

Lesley Stahl: “This coverage change goes into effect January”–

Nicole Sams: Okay.

Lesley Stahl:  –“2023”

Maya Cohen: I’m so happy for you.

Nicole Sams: Yes. This is great. This is great. (CLAPS) Wow. Wow.

In its statement, the health insurance trade association said, “obesity is a complex disease and the evidence and clinical guidelines related to obesity treatment… are evolving rapidly. Health insurance providers will continue to review the clinical evidence.”

Novo Nordisk Statement to 60 Minutes

Produced by Ayesha Siddiqi. Associate producer, Kate Morris. Broadcast associate, Wren Woodson. Edited by Craig Crawford.