Why is “Guilt” the First Line of Therapy for Obesity?

It is widely recognized that Canadians are less healthy than they have ever been, with an increasing proportion being overweight, obese, or morbidly obese. According to Statistics Canada, almost two-thirds of Canadians aged 18 and over are classified as overweight or obese. Realistically this situation is unlikely to change any time soon.  Healthcare practitioners generally agree that there is a direct link between obesity and other serious health risks, including but not limited to, diabetes, cardiovascular disease, stroke, chronic pain, certain cancers, and mental health conditions such as anxiety and depression.   

Despite this, obesity is often treated differently from other chronic diseases. Healthcare practitioners acknowledge that obesity is a chronic disease, yet it is rarely given the same level of medical attention and treatment as other chronic diseases.  As such, shouldn’t it also be put on even footing with other better-known chronic diseases in terms of first line medical treatments?  Unfortunately, that just isn’t the case.  Many still believe that obesity is a “lifestyle issue” or believe that “individuals brought it upon themselves through poor choices around diet and exercise”.  We would never consider guilt as an acceptable approach for other chronic diseases, nor should we approach obesity with the same perspective.

The good news is that the new class of GLP-1 agonist medications are showing that obesity can be medically treated, yielding tangible results for many people.  New data in 2024 from the U.S. National Health and Nutrition Examination Survey reveals that the U.S. adult obesity rate decreased by about 2% from 2020 to 2023, and researchers attribute this decline in part to the increasing use of GLP-1 drugs. It appears that these medications may be helping to reverse the long-standing rise in obesity rates in the U.S. and the same trend could likely be expected in Canada.

Ozempic, is arguably the most notable GLP-1 agonist drug. It is a drug that few knew about a couple of  years ago, but it has since become a household name, particularly within the employee benefits industry. However, its rapid rise in prominence has brought both praise and controversy. While Ozempic and similar GLP-1 drugs have proven highly beneficial for diabetics, their use for weight loss has sparked significant debate, highlighting the stigma surrounding around obesity and the potential benefits of weight loss drugs .

Many have argued that the problem is cost.  Unfortunately, there is no comprehensive data, that I am aware of, around the effectiveness of these drugs in reducing utilization for other items currently covered by employee benefits plans:

•          Prescription drugs for blood pressure, cholesterol, and depression
•          Medical supplies for CPAP machines, knee braces, and wheelchairs
•          Paramedical practitioners for massage therapy, physiotherapy, chiropractic care, and mental health support

On a positive note, some Canadian insurers are developing proactive prior authorization protocols for GLP-1 weight loss drugs.  These protocols restrict eligibility to individuals meeting certain BMI levels and/or have obesity-related comorbidities.  Additionally, they require individuals to engage in nutrition and fitness programs.  Most importantly, they specify that coverage will end if specific weight loss targets are not achieved.  Note that specific requirements vary by insurer.  These proactive protocols should be applauded, especially given  that many high-cost medications do not have similar protocols, nor do they have criteria to end coverage.

Beyond the healthcare perspective, there is also potentially a legal dimension to consider. While obesity is already recognized as a chronic disease by the health care community, many may be surprised to learn that obesity, in certain cases, might also be classified as a disability under Canadian law.  There are growing discussions that making employment or benefits decisions based on weight, particularly in cases of  obesity, could be found to be discriminatory.  Could that mean that excluding GLP-1 weight loss drugs from benefits plans would be seen as indirect discrimination? While no discrimination claims related  to GLP-1 drugs have surfaced yet, similar legal challenges arose when medical marijuana became widely accepted and legally recognized  as a treatment for various ailments.

There is no doubt that Ozempic, and the broader class commonly known as GLP-1 agonist drugs, have had a profoundly positive impact on the health of diabetics, with many of them losing weight.  While it is still early days, there is growing evidence that GLP-1 weight loss drugs can lead to positive health outcomes, when accompanied by nutrition and exercise support.  The key for plan sponsors is to have some confidence that the right employees are getting the right drugs at the right time, ultimately improving health outcomes and reducing overall benefits plan costs.  The new proactive protocols being implemented by some insurers appear to provide this reassurance and we hope all carriers adopt similar programs.

The vast majority of plan sponsors believe in supporting employee wellbeing, although the definition of wellbeing might vary.  However, in general, they share a common goal in ensuring employees feel valued and cared for by their employer.  They now need to determine if their definition of wellbeing includes helping employees dealing with obesity.  Currently most plan sponsors in Canada do not cover weight loss drugs.  If they do want to cover these drugs and their current insurer does not cover them or does not have proactive protocols, should they look at changing insurers?

Ultimately these decisions will likely be driven by different factors over time:  in the short term by moral considerations, in the mid-term by financial grounds (once more data becomes available), and quite possibly in the long term by legal grounds.  All that said, I hope we can agree that “guilt” is not an acceptable first line therapy for those dealing with obesity, arguably the most prevalent chronic disease in Canada.