Obesity:A Misunderstood and

Undermanaged

Workforce Disease

• A Chronic Disease

• A Costly Disease

• An Undertreated Disease

• Treatment Benefits

• Employer Action

Obesity6

Obesity:A Chronic Disease

2008“the Council concludes that it is the official position of The Obesity Societythat obesity should be declared a disease.” 1

May 2013“RESOLVED, That our American Medical Association recognize obesity as a disease state with multiple pathophysiological aspects requiring a range of interventions to advance obesity treatment and prevention.” 2

July 2016“ …obesity is a complex, adiposity-based chronic disease …” 3

1The Obesity Society. Obesity as Disease: The Obesity Society Council Resolution, 2008. Available at: http://www.obesity.org/publications/position-and-policies/obesity-as-

disease. Accessed March 24, 2017. 2AMA. 2013 Annual Meeting of the American Medical Association House of Delegates. Resolution 420. Available at:

http://www.npr.org/documents/2013/jun/ama-resolution-obesity.pdf. Accessed March 24, 2017. 3Garvey WT, et al. Endocr Pract. 2016;22(suppl 3):1-203.

Obesity Is a Medically Recognized Disease

8

Obesity: Fact or Fiction?

9

?

?

?

?

Obesity? Say What? FACT?

Willpower alone is enough to fight obesity1

Obesity specialist society says it is imperative to manage the weight-related complications of obesity2

Obesity is not a complex condition with numerous causes, including many factors that are largely beyond individuals' control3

Obesity is a personal choice and primarily a cosmetic concern4,5

?

?

?

?

FICTION?

1The Obesity Society. Eradicating America’s Obesity Epidemic. April 2018. Available at http://www.obesity.org/obesity/publications/position-and-policies/eradicating-epidemic.

Accessed April 17, 2018, . 2Garvey WT, et al. Endocr Pract. 2016;22(suppl 3):1-203. 3The Obesity Society. Obesity as Disease: The Obesity Society Council Resolution. April

2018. Available at: http://www.obesity.org/publications/position-and-policies/obesity-as-disease. Accessed April 17, 2018. 4Ibid. Obesity and Disability. Positon Statement. April

2018. Available at: http://www.obesity.org/obesity/advocacy/obesity-care/obesity-disability. Accessed April 17, 2018. 5Mayo Clinic. Obesity Overview.2017. Available at:

https://www.mayoclinic.org/diseases-conditions/obesity/symptoms-causes/syc-20375742?p=1

?

?

?

Obesity? Say What? FACT?

Willpower alone is enough to fight obesity1

Obesity specialist society says it is imperative to manage the weight-related complications of obesity2

Obesity is not a complex condition with numerous causes, including many factors that are largely beyond individuals' control3

Obesity is a personal choice and primarily a cosmetic concern4,5

?

FICTION?

1The Obesity Society. Eradicating America’s Obesity Epidemic. April 2018. Available at http://www.obesity.org/obesity/publications/position-and-policies/eradicating-epidemic.

Accessed April 17, 2018, . 2Garvey WT, et al. Endocr Pract. 2016;22(suppl 3):1-203. 3The Obesity Society. Obesity as Disease: The Obesity Society Council Resolution. April

2018. Available at: http://www.obesity.org/publications/position-and-policies/obesity-as-disease. Accessed April 17, 2018. 4Ibid. Obesity and Disability. Positon Statement. April

2018. Available at: http://www.obesity.org/obesity/advocacy/obesity-care/obesity-disability. Accessed April 17, 2018. 5Mayo Clinic. Obesity Overview.2017. Available at:

https://www.mayoclinic.org/diseases-conditions/obesity/symptoms-causes/syc-20375742?p=1

Obesity: Fact or Fiction?

10

2016 Prevalence of Obesity (BMI ≥ 30) in U.S.1,a

aPrevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2016

1Figure adapted from: Centers for Disease Control and Prevention. Obesity Prevalence Maps. https://www.cdc.gov/obesity/data/prevalence-maps.html. Accessed March 13,

2018. 2 Ibid. 3Finkelstein EA, et al. Am J Prev Med. 2012;42(6):563-570.

In 2016:

• All states had more than 20% of adults with obesity2

• Five states (Alabama, Arkansas, Louisiana, Mississippi, and West Virginia) had an obesity

prevalence of 35% or greater2

By 2030:

• 40-50% of the US population

will have obesity (BMI ≥ 30)3

• 9-11% of the US population will

have severe obesity (BMI ≥ 40)3

Prevalence of Obesity in America

<20%

20%-<25%

25%-<30%

30%-<35%

≥35%

11

Obesity is Epidemicin the US …August 20094

An Epidemicof Obesity: U.S. Obesity TrendsAccessed: June 20172

Controllingthe Global Obesity EpidemicMarch 20033

Understanding the American Obesity EpidemicMarch 20161

1American Heart Association. Understanding the American Obesity Epidemic. Available at: http://www.heart.org/HEARTORG/HealthyLiving/WeightManagement/Obesity/Understanding-

the-American-Obesity-Epidemic_UCM_461650_Article.jsp#.WU1cGJLyupo. Accessed June 23, 2017. 2Harvard School of Public Health. The Nutrition Source. An Epidemic of Obesity:

U.S. Obesity Trends. Available at: https://www.hsph.harvard.edu/nutritionsource/an-epidemic-of-obesity/. Accessed June 23, 2017. 3WHO. Nutrition. Controlling the Global Obesity

Epidemic. Available at: http://www.who.int/nutrition/topics/obesity/en/. Accessed June 23, 2017. 4The Obesity Society. Eradicating America's Obesity Epidemic. August 2009.

Available at: https://www.obesity.org/obesity/publications/position-and-policies/eradicating-epidemic. Accessed November 10, 2016.

Obesity Is Now Recognized in U.S. and Globally

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1Garvey WT, et al. Endocr Pract. 2016;22 (suppl 3):1-203. 2Jensen MD, et al. J Am Coll Cardiol. 2014;63(25 pt B):2985-3023.3CDC. Cancers Associated with Overweight and Obesity Make-up 40 Percent of Cancers Diagnosed in the United States.

Available at: https://www.cdc.gov/media/releases/2017/p1003-vs-cancer-obesity.html. Accessed April 17, 2018

Obesity Has Many Serious Weight-Related Complications

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Obesity:A Costly Disease

Cawley J, et al. Pharmacoeconomics. 2015;33(7):707-22.

Population Distribution

BMI (kg/m2)

Medical Expenditure

Increasing BMIs Drive Up Medical Costs

$30,000

$25,000

$20,000

$15,000

$10,000

$5000

$0

15 20 25 30 35 40 45

15

To

tal

Med

ical Exp

en

dit

ures

per C

ap

ita

a

aPresented in 2010 US dollars; data from 2000-2010 MEPS

80

70

60

50

40

30

20

10

0

aPercentages are based on adult per capita medical spending attributable to obesity in 2006 (in 2008 dollars)1Finkelstein EA, et al. Health Aff. 2009 Sep-Oct;28(5):w822-31.

Percent Increase in Health Care Costs for Adults with Obesity1,a

Physician Visits and Outpatient Costs

Inpatient Costs Spending on Prescription Drugs

Obesity Increases Medical Costs

27%

46%

80%

16

Compared to employees of normal weight, employees with obesity have diminished productivity

1Howard JT, Potter LB. Obes Res Clin Pract. 2014;8(1):e1-15. 2Finkelstein EA, et al. J Occup Environ Med. 2010 Oct;52(10):971-6. 3Arena VC, et al. J Occup Environ Med.

2006 Nov;48(11):1118-24.

Obesity Increases Lost Productivity Costs

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Absenteeism: 21-57% more likely to be absent1,a

Presenteeism: 2.3 to 21.9 more days with presenteeism2,b

Disability: 76% increased risk of short-term disability3

aBased on 2010 databData representative of men only

Obesity:An Undertreated Disease

Q: Is obesity itself a disease—or is obesity a risk factor for other diseases, but not a disease itself?

Responses:1

• Obesity is only a risk factor: 61%

• Obesity is a disease: 38%

Q: Is obesity is a lifestyle choice resulting from a person’s eatingand exercise habits—or is obesity a disease resulting from many different genetic, environmental and social factors?

Responses:1

• Habits: 48%• Genetic: 50%

Q: When it comes to managing your weight, do you have completeor quite a bit of control?

Responses:2

• Respondents without obesity: 68% – complete/quite a bit• Respondents with obesity: 41% – complete/quite a bit

Results of a recent national survey

1American Society for Metabolic and Bariatric Surgery (ASMBS) /NORC at the University of Chicago. At:

http://www.norc.org/PDFs/ASMBS%20Obesity/ASMBS%20NORC%20Obesity%20Poll_Brief%20A%20REV010917.pdf. Accessed March 25, 2017. 2Ibid. At:

http://www.norc.org/PDFs/ASMBS%20Obesity/ASMBS%20NORC%20Obesity%20Poll_Brief%20B%20REV010917.pdf. Accessed March 25, 2017.

Public Bias Against Obesity Is an Obstacle

19

1Phelan SM, et al. Obes Rev. 2005;16(4):319-326. 2Schwartz MB, et al. Obes Research. 2003;11(9):1033-1039.

• Primary care physicians, nurses and other healthcare

professionals have been found to hold negative opinions about people with obesity1

• Even obesity specialists have been found to have very strong bias against patients with obesity:2

– They infer that patients with obesity are blameworthy and lazy

– They question the intelligence and personal worth of patients with obesity

Research findings…

Physician Bias Against Obesity Is an Obstacle

20

aSurvey question: Do you consider yourself now to be underweight, overweight, or about right? Do you consider yourself to be obese, or not? About how tall are you

without shoes? About how much do you weight without shoes?1

bFrom a nationally representative survey of 1,509 adults

Answers to a recent phone survey question about their weightby Americans whose BMI qualifies them as having obesity:1,a,b

47% say:“I am overweight but not obese.”

43% say:“I consider myself

to be obese.”

9% say:“I consider my weight

to be about right.”

Majority of Americans who have obesity are in denial about their condition

1American Society for Metabolic and Bariatric Surgery/NORC at the University of Chicago. At:

http://www.norc.org/PDFs/ASMBS%20Obesity/ASMBS%20NORC%20Obesity%20Poll_Brief%20A%20REV010917.pdf. Accessed March 25, 2017.

Patient Denial of Obesity Is an Obstacle

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1Glauser TA, et al. Obes Res Clin Pract. 2015;9(6):573-583. 2Salinas GD, et al. Post Grad Med. 2011;123(5):214-219. 3Fitzpatrick SL, Stevens, VJ. Prev Med. 2017;99:128-133.

• Many physicians have limited knowledge of obesity pathophysiology and

treatment guidelines1

• Many physicians lack full understanding of weight loss options1

• Less than 1/3 of physicians have confidence in treating obesity2

Physician Report Card on Obesity Treatment Skillsa

Underdiagnosis / Undertreatment of Obesity Is an Obstacle

Perc

ent

of Patients

Receiv

ing:

WeightReductionEducation

Exercise Education

Diet /Nutrition Education

ObesityDiagnosis

30%

25%

20%

15%

10%

5%

0%

During Physician Office Visits of Patients with BMI ≥ 303

~9%

~14%

~17%

~26%

22

aSurvey of 300 physicians

• More than 33% of people with obesity have not spoken with a physician or other healthcare

professional about their weight1

• Several issues may prevent people with obesity from seeking help:

– Shame and embarrassment about their weight2

– Potential for hearing hurtful comments about

their weight2

– Fear of being blamed for their weight problems3

People with obesity may not seek medical care for their diseasea

1American Society for Metabolic and Bariatric Surgery/NORC at the University of Chicago. At:

http://www.norc.org/PDFs/ASMBS%20Obesity/ASMBS%20NORC%20Obesity%20Poll_Brief%20A%20REV010917.pdf. Accessed April 17, 2018.2NIDDK;2011. NIH Publication No. 03–5335. 3Ruelaz AR, et al. J Gen Intern Med. 2007;22(4):518-522.

Patient Aversion to Treatment for Obesity Is an Obstacle

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aFrom a nationally representative survey of 1,509 adults

Comparison of treatment rates of diabetes vs. obesity

Thomas CE, et al. Obesity. 2016;24(9):1955-1961.

Example of Obesity UndertreatmentP

ercen

tag

e o

f U

.S.

Ad

ult

Po

pu

lati

on

for W

hic

h T

reatm

en

t Is I

nd

icate

do

rR

eceiv

ed

ObesityDiabetes

Diabetes TreatmentIndicated

Diabetes TreatmentReceived

Obesity TreatmentIndicated

Obesity TreatmentReceived

T r e a t m e n t Efficiency86% of those needingtreatment received it

T r e a t m e n t G a pOnly 2% of those needing

treatment received it

46%

0.9%7.2%8.4%

24

25

The Continuum of Obesity Treatment Options

1Jensen MD, et al. J Am Coll Cardiol. 2014;63(25 pt B):2985-3023. 2Dunkley AJ, et al. Diabetes Care. 2014;37(4):922-933. 3Yanovski SZ, et al. JAMA. 2014;311(1)74-86. 3Sjostrom L. J Intern Med. 2013;273(3):219-34.

Lifestyle/Diet/Exercise Pharmacotherapy Bariatric Surgery

Indicated for all, across allspectrums1

Indicated for BMI ≥ 30 or BMI ≥ 27with risk factors1

Indicated for BMI ≥ 40 or BMI ≥ 35with risk factors1

Low invasiveness Medium invasivenessHigh invasiveness

~3-4% mean weight Loss2~3-9% mean weight Loss3 ~23% mean weight loss at 2 years4

~ 15% mean weight loss at 15 years4

Answer:

• Newer types of anti-obesity medications

• Less invasive procedures

– e.g., vagal block therapy

Treatment Gap

Percentage Weight Loss

NOT EFFECTIVE ENOUGHfor many people

TOO RISKY for many people

Risk Factor

Diet, Lifestyle & Drugs

Lap Band or Sleeve Gastrectomyor Gastric Bypass

Question:How do we get more weight loss with less risk?

Arrone LJ. Medications: a new frontier. In: Arrone LJ. Change Your Biology Diet. New York, NY: Houghton Mifflin Harcourt;2016.

Treatment Gap Created by Trade-offs Between Effectiveness vs. Risk

0% 5% 10% 15% 20% 25% 30% 35%

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Obesity:Treatment Benefits

Reduction intype 2 diabetes1

Reduction inCV risk factors2

Improvements inblood pressure2

Improvements inblood lipid profile2,3

1Knowler WC, et al. N Engl J Med. 2002;346(6)393:403. 2Wing RR, et al. Diabetes Care. 2011;34(7):1481-1486. 3Dattilo AM, et al. Am J Clin Nutr. 1992;56(2)320-328.

Benefits of 5% to 10% weight loss

Even Modest Weight Loss Has Powerful Effects

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1Garvey WT, et al. Endocr Pract. 2016;22(Suppl 3):1-203.

aAmerican Association of Clinical Endocrinologists and American College of Endocrinology

AACE Recommends Evaluating Obesity and Its Weight-Related Complications

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• Prediabetes

• Type 2 Diabetes

• Dyslipidemia

• Hypertension

• Nonalcoholic fatty liver disease

• Depression

• Obstructive sleep apnea

• Osteoarthritis

• Female infertility

• Asthma/reactive airway disease

Final recommendations of AACE/ACEa recognize that obesity is a complex, adiposity-based chronic disease,

where management targets both Weight-related complications and Adiposityto improve overall health and quality of life.

Weight-Related Complications of Obesity According to AACE/ACE

Obesity:Employer Actions

When employers were recently asked to rank the importance of managing workforces disease…

Obesity was identified as

the Number 2 workforce health concern.

Benfield, a division of Gallagher Benefit Service, Inc. EMI 2016 Employer Market Overview & Trends.

Employers Are Highly Concerned About Workforce Obesity

31

Employers are

Generousin making weight-loss resources available to their workforce.

Employers Are Taking Action by Providing Obesity-Relevant Benefits

Percent of employers offering the following weight loss resources

Health screenings(e.g., BMI and weight-related

comorbidities)Weight loss programs

(e.g., Weight Watchers)

Insurance for bariatric surgery

Access to health coaches (live or by phone) to assist with behavior changes

like diet and exercise

Healthy food selections in the cafeteria and vending machines

Psychological counseling

Onsite fitness facilities or fitness center reimbursement

Insurance coverage for prescription weight loss medicines

Incentives for achieving a healthy or improved BMI

83%

79%

76%

75%

68%

67%

60%

55%

37%

Benfield, a division of Gallagher Benefit Service, Inc. EMI 2016 Employer Market Overview & Trends.

32

Good, but is it getting the job done?

Percent of employers offering the following weight loss resources

Health screenings(e.g., BMI and weight-related

comorbidities)Weight loss programs

(e.g., Weight Watchers)

Insurance for bariatric surgery

Access to health coaches (live or by phone) to assist with behavior changes

like diet and exercise

Healthy food selections in the cafeteria and vending machines

Psychological counseling

Onsite fitness facilities or fitness center reimbursement

Insurance coverage for prescription weight loss medicines

Incentives for achieving a healthy or improved BMI

83%

79%

76%

75%

68%

67%

60%

55%

37%

Disrupt the Status Quo to Have a Real Impact on Employee Obesity

33

Benfield, a division of Gallagher Benefit Service, Inc. EMI 2016 Employer Market Overview & Trends.

1. Coordinate employer-sponsored nutrition + activity + behavioral health coaching as an official WL program.

2. Target condition management programa participants for WL program.

3. Notify relevant PCPs and onsite clinic healthcare providers of targeted patients and WL program availability.

4. Add coverage for new generation anti-obesity medications to support PCPs and onsite clinic healthcare providers with treatment choices.

And…aE.g., blood pressure, cholesterol, diabetes, asthma

Expand and strengthen current efforts

Disrupt the Status Quo to Have a Real Impact on Employee Obesity(cont’d)

34

According to Benfield, a division of Gallagher Benefit Service, Inc., facsimile communication, June 21, 2017.

1. Meet with PBM during RFP or pharmacy benefit review process.

2. Request coverage of AOMs (with prior authorization) during annual review process.

3. During review process, remove non-coverage status of AOMs.

4. Request active coverage of AOMs and determine their status and PA process (BMI ≥ 30 or BMI ≥ 27 with comorbidities).

Ensure AOM coverage to give providers the tools they need to manage obesity

Disrupt the Status Quo to Have a Real Impact on Employee Obesity(cont’d)

35

According to Benfield, a division of Gallagher Benefit Service, Inc., facsimile communication, June 21, 2017.

“Lack of coverage for treatments for weight loss –

including medical visits for overweight treatment, behavioral health intervention, anti-obesity

medications and bariatric surgery – is the single biggest obstacle to dealing effectively with

overweight and obesity at the employer level.

Employers can play an important role by changing their messaging, increasing access to treatments via benefit design, and exerting their leverage with the delivery system to align with

evidence that obesity needs to be treated as a medical disorder.”

Northeast Business Group on Health. Tipping the Scales on Weight Control: New Strategies for Employers. August 2016.

— Louis J. Aronne, M.D.Director of the Comprehensive Weight Control Program at Weil Cornell Medicine

Chairman, American Board of Obesity Medicine

A Final Observation…

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Thank youQuestions?

© 2018 Novo Nordisk All rights reserved. USA18SAM00882 March 2018