Science
'Miracle' weight-loss drugs could have reduced health disparities. Instead they got worse
The American Heart Assn. calls them “game changers.”
Oprah Winfrey says they’re “a gift.”
Science magazine anointed them the “2023 Breakthrough of the Year.”
Americans are most familiar with their brand names: Ozempic, Wegovy, Mounjaro, Zepbound. They are the medications that have revolutionized weight loss and raised the possibility of reversing the country’s obesity crisis.
Obesity — like so many diseases — disproportionately affects people in racial and ethnic groups that have been marginalized by the U.S. healthcare system. A class of drugs that succeeds where so many others have failed would seem to be a powerful tool for closing the gap.
Instead, doctors who treat obesity, and the serious health risks that come with it, fear the medications are making this health disparity worse.
“These patients have a higher burden of disease, and they’re less likely to get the medicine that can save their lives,” said Dr. Lauren Eberly, a cardiologist and health services researcher at the University of Pennsylvania. “I feel like if a group of patients has a disproportionate burden, they should have increased access to these medicines.”
Why don’t they? Experts say there are a multitude of reasons, but the primary one is cost.
Ozempic, which is approved by the Food and Drug Administration to help people with Type 2 diabetes control their blood sugar and reduce their risk of serious cardiovascular problems like heart attacks and strokes, has a list price of $968.52 for a 28-day supply. Wegovy, a higher dose of the same medicine that’s FDA-approved for weight loss in people with obesity or who are overweight and have a weight-related condition like high blood pressure or high cholesterol, goes for $1,349.02 every four weeks.
Mounjaro is a similar drug approved by the FDA to improve blood sugar levels in Type 2 diabetes patients, and it comes with a list price of $1,069.08 for 28 days of medicine. Zepbound, a version of the same drug approved for weight loss, has a slightly lower price tag of $1,059.87 per 28 days. For now, at least, all the new drugs are meant to be taken indefinitely.
Few health insurance programs cover the medications when prescribed to help people reach and maintain a healthy weight. Federal law requires that weight loss drugs be excluded from basic coverage in Medicare Part D plans, and as of early 2023, only 10 states included an antiobesity medication in the formularies for their Medicaid programs.
“If everybody had equal access, then this would be a way to help,” said Dr. Rocio Pereira, chief of endocrinology at Denver Health. “But without equal access — which is what we have now — it’s likely this is going to increase the disparity we see.”
U.S. obesity rates have been rising for decades, and they’re consistently higher for Black and Latino Americans. Among adults 20 and older, 49.9% of Black Americans and 45.6% of Hispanic Americans have a body mass index of 30 or greater, compared with 41.1% of white American adults and 16.1% of Asian American adults, according to age-adjusted data from the Centers for Disease Control and Prevention.
Obesity rates are also associated with income. In 2022, the age-adjusted rate was 38.4% for adults with household incomes between $15,000 and $24,999, compared with 34.1% for those with household incomes of $75,000 or more.
The two are related, said Pereira, who studies health disparities in diseases related to obesity. Black and Latino Americans are more likely to live in lower-income neighborhoods, where fast food is usually cheaper and more convenient than grocery stores.
“If you look at a map of the U.S. and plot out the neighborhoods where there’s no grocery store within a mile and there’s a high percentage of people who have no car, those are the areas where there’s the highest rates of obesity,” she said.
There’s also the time factor, she said: “Can you afford to cook your own meals, or do you have to work two jobs?”
An unusual experiment by the Department of Housing and Urban Development demonstrated the degree to which physical surroundings can influence obesity risk, Pereira said. In the 1990s, hundreds of mothers who were living in public housing were offered housing vouchers they could use only in wealthier neighborhoods. Ten to 15 years later, the women randomly assigned to receive the windfall had significantly lower rates of severe obesity (14.4%) than women in a control group who weren’t offered vouchers (17.7%). They were also less likely to have a body mass index of 35 or higher (31.1% vs. 35.5%).
The American Medical Assn. recognized obesity as a disease in 2013. People with the chronic condition are at heightened risk of cardiovascular disease, Type 2 diabetes, 13 types of cancer, osteoarthritis, asthma and other health problems. Researchers have pegged the annual medical costs associated with obesity at $174 billion in the U.S. alone.
Some people with obesity are able to lose weight by changing their diets and burning more calories through exercise. But that doesn’t work for people who have developed resistance to leptin, a hormone that suppresses appetite.
“If you try to lose weight with diet and exercise, your body is going to fight you,” said Dr. Caroline Apovian, co-director of the Center for Weight Management and Wellness at Brigham and Women’s Hospital in Boston. “Your leptin levels go down, and when leptin goes down, a signal goes to the brain that you don’t have enough fat to survive.” That prompts the release of another hormone, ghrelin, that triggers feelings of hunger.
Leptin resistance also makes exercise less worthwhile.
“Your body fights you by decreasing your total energy expenditure,” Apovian said. “When your muscles work, they work more efficiently. If you want to lose 10 pounds, you’re going to get really, really hungry. And you can’t fight that. Your body thinks it’s starving to death.”
The “breakthrough” drugs counteract this by impersonating a hormone called glucagon-like peptide 1, or GLP-1, that’s involved in appetite regulation. Inside cells, the drugs bind with the same receptors as GLP-1, reducing blood sugar and slowing digestion. They also last longer than their natural counterparts.
The first so-called GLP-1 receptor agonist was approved in 2005 to treat diabetes, and early versions had to be injected once or twice a day. Ozempic improved on this by requiring an injection only once a week. After clinical trials showed that the drug helped people with obesity achieve substantial, sustainable weight loss, the FDA approved Wegovy as a weight management drug in 2021.
Mounjaro and Zepbound also mimic GLP-1, along with a related hormone called glucose-dependent insulinotropic peptide, or GIP.
Linda Morales credits Ozempic and Mounjaro for helping her lose 100 pounds and drop from a size 22 to a size 14. The 25-year-old instructional aide at Lankershim Elementary School in North Hollywood said she started to become overweight in middle school and carried 293 pounds on her 5-foot, 5-inch frame when she was referred to the Center for Weight Management and Metabolic Health at Cedars-Sinai two years ago.
She is no longer breathless when she climbs stairs, has an easier time when she goes bowling and fits comfortably into the seat on the Harry Potter ride at Universal Studios. Thanks to the medications, she is no longer on a path toward Type 2 diabetes.
Her job with the Los Angeles Unified School District comes with health insurance that covers the pricey drugs and charges her a copay of $30 a month for her Mounjaro prescription. She said she could swing a monthly payment of up to $50, but beyond that she’d have to stop taking the drug and hope the lifestyle changes she’d made would be enough to sustain the weight loss she’s achieved so far.
“It would definitely get hard for me, for sure,” Morales said.
Indeed, even when the drugs are covered by insurance or patients qualify for discounts from pharmaceutical companies, researchers have found that they often remain out of reach.
In one study, Eberly and her colleagues examined insurance claims for nearly 40,000 people who received a prescription for GLP-1 copycats. Patients who had to pay at least $50 a month to fill their prescriptions were 53% less likely to get most of their refills over the course of a year compared to patients whose copayments were less than $10. Even patients whose out-of-pocket costs were between $10 and $50 were 38% less likely to buy the medicine regularly for a full year, the team found.
In another study of insured patients with Type 2 diabetes, those who were Black were 19% less likely to be treated with these drugs than those who were white, while Latino patients were 9% less likely to get them, Eberly and her colleagues reported.
In some parts of the country, Black patients with diabetes are only half as likely as white patients to get GLP-1 drugs, according to research by Dr. Serena Jigchuan Guo at the University of Florida, who studies health disparities in pharmaceutical access. The disparity was greatest in places with the highest overall usage of the medications, including New York, Silicon Valley and South Florida.
“In those places, the drug is actually widening the gap,” she said.
Researchers have spent years documenting racial disparities in the use of effective treatments for obesity, such as bariatric surgery. Newer drugs like Ozempic simply bring the problem into sharper focus, said Dr. Hamlet Gasoyan, an investigator with the Cleveland Clinic’s Center for Value-Based Care Research.
“We get excited every time a new, effective treatment becomes available,” Gasoyan said. “But we should be equally concerned that this new and effective treatment reduces disparities between the haves and have-nots.”
Science
Cluster of farmworkers diagnosed with rare animal-borne disease in Ventura County
A cluster of workers at Ventura County berry farms have been diagnosed with a rare disease often transmitted through sick animals’ urine, according to a public health advisory distributed to local doctors by county health officials Tuesday.
The bacterial infection, leptospirosis, has resulted in severe symptoms for some workers, including meningitis, an inflammation of the brain lining and spinal cord. Symptoms for mild cases included headaches and fevers.
The disease, which can be fatal, rarely spreads from human to human, according to the U.S. Centers for Disease Control and Prevention.
Ventura County Public Health has not given an official case count but said it had not identified any cases outside of the agriculture sector. The county’s agriculture commissioner was aware of 18 cases, the Ventura County Star reported.
The health department said it was first contacted by a local physician in October, who reported an unusual trend in symptoms among hospital patients.
After launching an investigation, the department identified leptospirosis as a probable cause of the illness and found most patients worked on caneberry farms that utilize hoop houses — greenhouse structures to shelter the crops.
As the investigation to identify any additional cases and the exact sources of exposure continues, Ventura County Public Health has asked healthcare providers to consider a leptospirosis diagnosis for sick agricultural workers, particularly berry harvesters.
Rodents are a common source and transmitter of disease, though other mammals — including livestock, cats and dogs — can transmit it as well.
The disease is spread through bodily fluids, such as urine, and is often contracted through cuts and abrasions that contact contaminated water and soil, where the bacteria can survive for months.
Humans can also contract the illness through contaminated food; however, the county health agency has found no known health risks to the general public, including through the contact or consumption of caneberries such as raspberries and blackberries.
Symptom onset typically occurs between two and 30 days after exposure, and symptoms can last for months if untreated, according to the CDC.
The illness often begins with mild symptoms, with fevers, chills, vomiting and headaches. Some cases can then enter a second, more severe phase that can result in kidney or liver failure.
Ventura County Public Health recommends agriculture and berry harvesters regularly rinse any cuts with soap and water and cover them with bandages. They also recommend wearing waterproof clothing and protection while working outdoors, including gloves and long-sleeve shirts and pants.
While there is no evidence of spread to the larger community, according to the department, residents should wash hands frequently and work to control rodents around their property if possible.
Pet owners can consult a veterinarian about leptospirosis vaccinations and should keep pets away from ponds, lakes and other natural bodies of water.
Science
Political stress: Can you stay engaged without sacrificing your mental health?
It’s been two weeks since Donald Trump won the presidential election, but Stacey Lamirand’s brain hasn’t stopped churning.
“I still think about the election all the time,” said the 60-year-old Bay Area resident, who wanted a Kamala Harris victory so badly that she flew to Pennsylvania and knocked on voters’ doors in the final days of the campaign. “I honestly don’t know what to do about that.”
Neither do the psychologists and political scientists who have been tracking the country’s slide toward toxic levels of partisanship.
Fully 69% of U.S. adults found the presidential election a significant source of stress in their lives, the American Psychological Assn. said in its latest Stress in America report.
The distress was present across the political spectrum, with 80% of Republicans, 79% of Democrats and 73% of independents surveyed saying they were stressed about the country’s future.
That’s unhealthy for the body politic — and for voters themselves. Stress can cause muscle tension, headaches, sleep problems and loss of appetite. Chronic stress can inflict more serious damage to the immune system and make people more vulnerable to heart attacks, strokes, diabetes, infertility, clinical anxiety, depression and other ailments.
In most circumstances, the sound medical advice is to disengage from the source of stress, therapists said. But when stress is coming from politics, that prescription pits the health of the individual against the health of the nation.
“I’m worried about people totally withdrawing from politics because it’s unpleasant,” said Aaron Weinschenk, a political scientist at the University of Wisconsin–Green Bay who studies political behavior and elections. “We don’t want them to do that. But we also don’t want them to feel sick.”
Modern life is full of stressors of all kinds: paying bills, pleasing difficult bosses, getting along with frenemies, caring for children or aging parents (or both).
The stress that stems from politics isn’t fundamentally different from other kinds of stress. What’s unique about it is the way it encompasses and enhances other sources of stress, said Brett Ford, a social psychologist at the University of Toronto who studies the link between emotions and political engagement.
For instance, she said, elections have the potential to make everyday stressors like money and health concerns more difficult to manage as candidates debate policies that could raise the price of gas or cut off access to certain kinds of medical care.
Layered on top of that is the fact that political disagreements have morphed into moral conflicts that are perceived as pitting good against evil.
“When someone comes into power who is not on the same page as you morally, that can hit very deeply,” Ford said.
Partisanship and polarization have raised the stakes as well. Voters who feel a strong connection to a political party become more invested in its success. That can make a loss at the ballot box feel like a personal defeat, she said.
There’s also the fact that we have limited control over the outcome of an election. A patient with heart disease can improve their prognosis by taking medicine, changing their diet, getting more exercise or quitting smoking. But a person with political stress is largely at the mercy of others.
“Politics is many forms of stress all rolled into one,” Ford said.
Weinschenk observed this firsthand the day after the election.
“I could feel it when I went into my classroom,” said the professor, whose research has found that people with political anxiety aren’t necessarily anxious in general. “I have a student who’s transgender and a couple of students who are gay. Their emotional state was so closed down.”
That’s almost to be expected in a place like Wisconsin, whose swing-state status caused residents to be bombarded with political messages. The more campaign ads a person is exposed to, the greater the risk of being diagnosed with anxiety, depression or another psychological ailment, according to a 2022 study in the journal PLOS One.
Political messages seem designed to keep voters “emotionally on edge,” said Vaile Wright, a licensed psychologist in Villa Park, Ill., and a member of the APA’s Stress in America team.
“It encourages emotion to drive our decision-making behavior, as opposed to logic,” Wright said. “When we’re really emotionally stimulated, it makes it so much more challenging to have civil conversation. For politicians, I think that’s powerful, because emotions can be very easily manipulated.”
Making voters feel anxious is a tried-and-true way to grab their attention, said Christopher Ojeda, a political scientist at UC Merced who studies mental health and politics.
“Feelings of anxiety can be mobilizing, definitely,” he said. “That’s why politicians make fear appeals — they want people to get engaged.”
On the other hand, “feelings of depression are demobilizing and take you out of the political system,” said Ojeda, author of “The Sad Citizen: How Politics is Depressing and Why it Matters.”
“What [these feelings] can tell you is, ‘Things aren’t going the way I want them to. Maybe I need to step back,’” he said.
Genessa Krasnow has been seeing a lot of that since the election.
The Seattle entrepreneur, who also campaigned for Harris, said it grates on her to see people laughing in restaurants “as if nothing had happened.” At a recent book club meeting, her fellow group members were willing to let her vent about politics for five minutes, but they weren’t interested in discussing ways they could counteract the incoming president.
“They’re in a state of disengagement,” said Krasnow, who is 56. She, meanwhile, is looking for new ways to reach young voters.
“I am exhausted. I am so sad,” she said. “But I don’t believe that disengaging is the answer.”
That’s the fundamental trade-off, Ojeda said, and there’s no one-size-fits-all solution.
“Everyone has to make a decision about how much engagement they can tolerate without undermining their psychological well-being,” he said.
Lamirand took steps to protect her mental health by cutting social media ties with people whose values aren’t aligned with hers. But she will remain politically active and expects to volunteer for phone-banking duty soon.
“Doing something is the only thing that allows me to feel better,” Lamirand said. “It allows me to feel some level of control.”
Ideally, Ford said, people would not have to choose between being politically active and preserving their mental health. She is investigating ways to help people feel hopeful, inspired and compassionate about political challenges, since these emotions can motivate action without triggering stress and anxiety.
“We want to counteract this pattern where the more involved you are, the worse you are,” Ford said.
The benefits would be felt across the political spectrum. In the APA survey, similar shares of Democrats, Republicans and independents agreed with statements like, “It causes me stress that politicians aren’t talking about the things that are most important to me,” and, “The political climate has caused strain between my family members and me.”
“Both sides are very invested in this country, and that is a good thing,” Wright said. “Antipathy and hopelessness really doesn’t serve us in the long run.”
Science
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