Caroline Apovian

Caroline M. Apovian, MD, FACP, FTOS, DABOM is co-director of the Center for Weight Management and Wellness (CWMW) in the Division of Endocrinology, Diabetes and Nutrition. She is also a nationally recognized expert on nutrition, metabolism and obesity medicine. Levels of obesity have been increasing globally, resulting in reduced quality of life and increased risk for diabetes and heart disease. Apovian studies metabolism, conducts research on access to obesity care, and helps patients find the right treatment for them. She has spoken to CNN about weight management techniques during the pandemic and was interviewed, along with her patients, for a 60 Minutes episode discussing the blockbuster obesity drug Wegovy.

In this Q&A, Apovian describes her research, the effectiveness of different forms of obesity treatment, and her hope for a future in which obesity management is integrated into primary care.

Q: What motivated you to study obesity and disparities in obesity care across different populations?

My interest in obesity started 35 years ago when I did a fellowship at the New England Deaconess Hospital in Nutrition and Metabolism after internal medicine residency. I studied under George L. Blackburn, MD, PhD, who is considered the father of nutrition and obesity medicine. Then I transitioned to Boston Medical Center, where I was the Director of Nutrition and Weight Management from 2000 to 2020. Here, we were among the first to discover that the there’s an association between immune cells in human adipose tissue and insulin resistance, or hyperinsulinemia, which leads to weight gain. Now my lab focuses on metabolism in the mitochondria and how the body chooses to either store excess calories as fat or burn them off.

I also do a lot of work on disparities in bariatric surgery outcomes across different demographics. For example, my colleagues and I have found that Black patients have increased risk of insulin resistance and diabetes compared to white patients. We are now working to better characterize and ultimately reduce health disparities so that we can provide better care for all patients.

Q: How are GLP1 agonists like Wegovy being used currently?

We are utilizing as much of the GLP1 agonists as we can since they are analogs of naturally occurring gut hormones that can be helpful in reducing body weight by up to 20%. Unfortunately, insurance companies and the government haven’t kept up with the science and don’t believe obesity is a disease, so these drugs are not ubiquitously covered, and they are certainly not covered by Medicare or Medicaid.

It is important to note that while Ozempic was marketed and approved by the FDA for diabetes and Wegovy was marketed and approved by the FDA for obesity, they are the same drug. Both are in short supply, so people are worried about using Ozempic for obesity when it’s reserved for those with diabetes, but that is treating obesity as a second-class disease. Obesity causes diabetes, and it is right to use Ozempic for obesity.

Q: How do these weight loss drugs affect patients’ decisions to have bariatric surgery?

Bariatric surgery is underutilized in the United States, and only 1% of patients eligible for the surgery get the procedure done annually. If the same thing happened with cardiac surgery, we would find it negligent, but the problem is overlooked with obesity. Many patients don’t see obesity as a disease. They think their weight is under their control, and they tell me that they don’t want the easy way out.

Now, weight loss drugs are helping patients understand that they have a disease, because they take the medication and feel full for the first time in their lives. And if they want to continue feeling that way and lose more weight, they should consider bariatric surgery. For example, an orthopedic surgeon that I take care of told me he understands how feeling full changes your whole life since you are not thinking about food all day long.

Q: How can we support patients as they make decisions about obesity treatment?

We need to change the way medicine is practiced by empowering primary care providers to treat obesity. Right now, the patient has 10 minutes with the doctor, who will take their vitals and prescribe antihypertensives, antidiabetic medications, medications for pain, and then evaluate the patient’s weight, often through their BMI. Primary care providers need to treat obesity first, before they treat these other conditions. They can discuss diet and exercise, prescribe GLP1 analogs and other similar agonists, or discuss the possibility of bariatric surgery. Such efforts will allow us to treat the 42% of Americans who suffer from obesity and who will likely go on to develop diabetes and heart disease.

The SELECT trial results that were recently announced by Novo Nordisk looked at 5-year cardiovascular outcomes for semaglutide (Wegovy) in patients with obesity and cardiovascular disease risk and showed a 20% reduction in cardiovascular events. These results will be presented at American Heart Association’s annual meeting for further discussion but demonstrate how semaglutide in obesity care can be lifesaving. The striking reduction in cardiovascular disease mortality is similar to that shown for bariatric surgery.

Q: Where is obesity care headed in the future?

Many people think fighting obesity is a matter of willpower and that people with obesity must simply stop eating and exercise more. But anybody who has tried to lose weight with diet and exercise alone understands that their bodies force them to gain the weight back. After the 1997 discovery of leptin, we understand why that is the case. Leptin regulates your body weight, and genetic defects can predispose people to have higher risk of obesity.

We will continue to do our work until the world realizes that we are treating a disease, and if we treat it early enough, we can avoid diabetes, hypertension, heart disease, stroke and reduce the healthcare burden in the United States. We are fighting a battle, and we are going to win.

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