Obesity Disparities, Stigma, and the Case for Systemic Change: Fatima Cody Stanford, MD, MPH

In part 2 of her conversation with The American Journal of Managed Care^® (AJMC^®), Fatima Cody Stanford, MD, MPH, MPA, obesity medicine physician at Massachusetts General Hospital and associate professor of medicine and pediatrics at Harvard Medical School, turns to the systemic forces that shape who gets treated and who gets left behind.

She examines why minoritized populations carry the highest burden of obesity yet face the steepest barriers to emerging therapies. Stanford also explores what it will take for payers and policymakers to fund treatment with the same consistency they apply to other chronic diseases and why the health care system's own bias problem may be the hardest obstacle to overcome.

Read part 1 here, where she breaks down the brain mechanisms behind obesity.

This transcript has been lightly edited for clarity

AJMC: Your work has highlighted significant disparities in who actually receives evidence-based obesity treatment. What disparities concern you most, and what are the root causes?

Stanford: I think disparities are quite vast when we think about obesity as a chronic disease, and I think some of the key disparities really surround the epidemiology of obesity when we look at who this disproportionately impacts, and I think this is from a global perspective. We see minoritized individuals having a disproportionately greater burden of obesity.

A lot of this may have to do with genetic predispositions or allostatic load, i.e., stress and stressors, which can predispose to obesity. But we also see disparities when we look at who has access to therapies, because of the high cost associated with pharmacotherapy treatments, particularly as we get into the glucagon-like peptide-1 (GLP-1) receptor agonists; these medications can be cost-prohibitive for those who would glean the greatest benefits. So, not only are we seeing these individuals having the highest burden of disease, but they also have the least access to treatment.

This is problematic as we think about therapies, and this is what's leading to more disparate outcomes—the haves and the have-nots—which I think is a really important consideration as more and more tools become available. But we're seeing disparate treatment outcomes across who has access and who does not.

AJMC: What structural and policy changes would most urgently close that access gap for GLP-1 receptor agonists?

Stanford: Let's talk about what we should be seeing from both public and private payers for coverage of GLP-1 receptor agonists. From a federal legislation standpoint, we've seen the Treat and Reduce Obesity Act really try to pass since 2012. That's 14 years of trying to pass a piece of legislation that would give individuals with obesity access to pharmacotherapy. This piece of legislation hasn't passed as of yet, and I think it would really pave the way for more consistent coverage of GLP-1 receptor agonists. We know that public payers influence private payers, because if a public platform like Medicare or Medicaid consistently covers these medications, then private payers say, "Well, if the government's doing it, we should be doing it."

So, let's talk about what's being said and what I think will potentially happen: as of January 2027, we're hearing that Medicare may cover coverage for older adults, primarily because that's what Medicare typically covers, for the treatment of obesity. I am not from the Show-Me State, but I need to see this to believe it. I have yet to see coverage for older adults. I do believe that older adults have the most to gain from coverage, particularly as we see that these medications are effective for reducing heart attacks and strokes, improving kidney outcomes, and treating things like obstructive sleep apnea, which are all things that can lead to serious health outcomes. So, if we do truly see this happen in January 2027, then I do think that private payers will say, "If Medicare is covering it, we need to cover this also."

But let's look at those with the lowest socioeconomic position, which, of course, is Medicaid. If Medicaid covers this, we'll again see private payers step up to the plate, employer-sponsored insurance carriers like Blue Cross Blue Shield, Aetna, etc., saying, "We need to do this too if those 2 key public payers, Medicare and Medicaid, are doing the same." I think that's the story that needs to be told: if the government sets an example, we'll see the private payers fall in line. What we have seen instead is private payers step up and say, "We're going to cover this temporarily," and then pull back coverage. What they don't understand is that we're treating a chronic disease. It's just like treating high cholesterol. You can't put someone on a statin and then pull it back. Or, treating high blood pressure, you would never put someone on a medication and then pull it back. They would never do that for any other disease process. So why are we doing this for obesity?

There is a lack of equity for obesity compared with other disease processes. But the interesting thing is that obesity causes these other downstream diseases. So, if you treat the obesity, you could possibly pull back all of these medications, reduce costs across the board, reduce hospitalizations, improve presenteeism, and reduce absenteeism. We could keep going, but when we look at how the Congressional Budget Office does estimates on shortened time spans, we don't get to see the full benefit of these medications in the real-world population, and I think that's where some of the problems lie.

AJMC: How much of the disparity in obesity rates among minoritized populations is attributable to neurobiological factors vs social determinants of health? 

Stanford: I think it's more the interplay between those 2 that has led to the disproportionate rise in obesity within minoritized individuals, not 1 vs the other. When we look at genetics interacting with social determinants of health, that allostatic load that comes with being, for example, a Black woman who has to work 10 times harder to achieve the same thing that someone else achieves, it interacts with the genetics, with all of these things.

When you put that together, it's a perfect storm, and that leads to higher rates of obesity within that demographic. So, it's incumbent upon us to ensure that there are even more resources for individuals who carry a greater burden. I would say that, in the current climate, that's probably not the prevailing mantra, but as someone who's dedicated to this work, particularly as a member of a community that is disproportionately impacted, that is something I am still driven by.

AJMC: Many patients with obesity face stigma not only from society but from within the health care system. What changes would you like to see in medical education and clinical culture?

Stanford: I want our health care providers and clinicians to step up to the plate and do their job. Let's talk about what that means. Stop with all of the bias, the stigma, the inappropriate language. Just 2 days ago, I was in a lecture for obesity medicine physicians, taught by obesity medicine physicians, and the language I heard was deplorable. If we can't do it right in an obesity medicine setting, taught by obesity medicine physicians, how can I expect anyone outside of that space to do it right? I was so infuriated during this lecture that I literally was developing palpitations. That's how I feel as someone who is an ally to those who have obesity.

How do the patients who actually have obesity feel? I don't understand where the empathy is. What would you feel if you were sitting there as a patient, hearing words that are so stigmatizing, feeling like you do not belong here? And then we wonder why these individuals come in when they're so far gone; it makes total sense. And then we wonder why there's this internalized bias. It’s because we've been so externally biased toward them, because obesity is that disease that you wear.

We have to do better. From an education standpoint, we need to be treating it better. But we know that bias starts around the age of 3 or 4, so we need to go beyond just teaching it in the medical environment. This needs to start early in life, because by the time they make it to us in these professional settings, the bias is so deeply entrenched that you can't undo it.

AJMC: New pharmacotherapies achieve 20% or greater weight loss in trials. How do you think about balancing those developments with structural and social interventions that address root causes? How do we ensure those interventions don't fall through the cracks?

Stanford: I think these things can work in concert with each other. If we're looking at structural and social interventions alongside pharmacotherapy, I think we can combine these and ensure they are used side by side. I don't think we need to look at them as singular. That's where we've gone wrong in this work in the past.

"We're going to use this thing over here, we're going to focus on exercise, we're going to use this intervention." No. These things need to work in concert with each other. If you're using a GLP-1, you should be focused on nutrition, you should be focused on exercise, and you should be focused on the built environment. We should be focused on all of these things together to best optimize the health of that individual. It's not one or the other; it's all. That's what makes that person live the happiest, healthiest life for them.