Adjusting doses, coping with gaps, and teaching nutrition show the difference non-MDs can make
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By Elizabeth Cooney
Jan. 3, 2025
Cardiovascular Disease Reporter
Life was getting better for Carlos Campos, 72, a retired machinist who lives with his wife and daughter in Tukwila, Wash. Diagnosed about 20 years ago with type 2 diabetes, he was delighted to see his blood sugar levels improve dramatically about a year ago, when he started taking Ozempic.
Every week, in hour-long appointments, he shared his improved numbers via his continuous glucose monitor’s app with Maureen Chomko, a diabetes educator who works with his primary care physician at NeighborCare Health in nearby South Seattle.
“I tried different kinds of medications, but the best control I got was when I started taking Ozempic,” Campos said.
Then Medicare stopped covering his Ozempic. His cost per vial ballooned from $47 a month to $239 — more than he could afford. In insurance jargon, he’d hit Medicare’s “donut hole,” a gap in prescription coverage during which people must pay thousands more of their drug costs out-of-pocket. His blood sugars rose dramatically and erratically — more highs and lows — because he needed to take more insulin in addition to the blood pressure drugs and blood thinners prescribed for other cardiovascular conditions.
The explosive rise of GLP-1 drugs like Ozempic has brought an accompanying challenge: logistics too knotty for a single physician to handle. Increasingly, practices are turning to a team approach to fine-tune prescriptions and ensure access for patients. This is not simple for the many patients who are dealing with multiple chronic conditions, and it’s even harder when patients also face food, housing, or employment insecurity.
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“When you talk about arthritis, sleep apnea, heart failure, kidney disease, heart disease, diabetes, weight loss, whatever they have touched, they’re like totally miracle drugs,” Dhruv Kazi, director of the cardiac critical care unit at Beth Israel Deaconess Medical Center, said about the GLP-1 drugs. But, he said: “For these drugs to have maximal impact in terms of population health, it’s going to take more than this molecular breakthrough. It’s going to take more than clinical trials. We’re going to have to figure out the implementation science that goes with this, the economic health economics that goes with this, so that the people who benefit from them can access these drugs and stay on them long term.”
Carlos Campos, whose GLP-1 drug suddenly became unaffordable.COURTESY
The Standards of Care in Diabetes 2025, published in December by the American Diabetes Association, endorse a team approach to diabetes care, a theme discussed at its scientific meeting in June.
“Obesity is a chronic disease and it requires ongoing care, just like high blood pressure, heart disease, or diabetes, and preventing weight regain is very, very important,” Nuha El Sayed of Joslin Diabetes Center told STAT. Also senior vice president for health care improvement at the American Diabetes Association, she oversees standards of care for diabetes and obesity. “Extending the team by having others participate to full scope of practice is something we very much believe in.”
Dietitians and nurse practitioners are stepping up to fill gaps in patient care, whether the goal is better control of diabetes or weight loss to improve other chronic conditions. The team-based model is gaining traction at independent practices that may not accept patients with Medicaid or Medicare coverage and at federally qualified community health centers like NeighborCare that serve mostly people covered by Medicaid or Medicare.
When Medicare’s bills put Ozempic out of reach for Campos, older diabetes medications weren’t up to the challenge. That’s when Chomko helped Campos apply to Ozempic maker Novo Nordisk’s patient assistance program to get the medicine for free. She calls it another benefit of having a diabetes specialist on his team.
“Primary care doctors don’t know about patient assistance programs, nor do they have the time to fill out a nine-page application, coordinate with the patient to get the documentation needed, call to follow up multiple times on the status of the application,” she said about her two Medicare patients whose coverage dropped. “When they hit the donut hole, everything fell apart and they needed a tremendous amount more insulin.”
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It’s easy to forget that the new class of drugs leading to stunning weight loss were originally developed and approved for type 2 diabetes before showing success not only in treating obesity, but potentially many other chronic conditions, from addiction to Alzheimer’s as well as heart failure and kidney disease.
When taken to control diabetes, the powerful treatments require particular attention to proper dosing and nutritional needs. Calibration is more urgent when insulin levels are critical, not just when shortages empty pharmacy shelves or patients fall afoul of the donut hole. If medical questions arise amid food, housing, and employment insecurity, the need for on-demand, team-based care intensifies.
Adjusting a patient’s medication regimen takes time. Obesity clinics with teams of specialists, from physicians to nurse practitioners to other advanced practice providers, aren’t available to every patient in the United States, precluded by geography or insurance coverage.
“In my population, they’re losing their housing and their blood pressure is out of control,” said Chomko, a registered dietitian nutritionist and certified diabetes care and education specialist. “I am there to help out my providers so that they can do everything else they need to do and I can take care of the diabetes in the clinic.”
When people with diabetes start on these medications, the dietitian, diabetes educator, or nurse practitioner has to take into account not just the initial dose but also how to titrate their insulin as GLP-1s decrease their need. Nurse practitioners have prescribing privileges and certified diabetes care and education specialists are trained to adjust medication regimens.
The first few weeks can be rough. If the aim is not just to improve glucose control but also to achieve better health through diet, it can be tough for patients to imagine eating broccoli, salmon, and brown rice when their nausea makes crackers seem like the only food they can stomach.
At NeighborCare, every primary care clinic includes a dietitian and diabetes educator on its team, allowing for hour-long visits, frequent check-ins, behavioral counseling, and referrals to social workers if patients have trouble paying for utilities, for example, as well as medications. “We are able to really dive into the barriers and what’s making it hard for a person to manage their diabetes,” Chomko said.
After the move to regular doses, the drugs help insulin work better as they eat less — a life changer for patients if they no longer need to inject the hormone with every meal.
Until they lose access, that is, from shortages or insurance lapses.
Shortages undermine patients’ progress and contribute to discontinuation, but so do barriers to access. A JAMA Network Open study published in May reported disparities in who no longer took GLP-1 drugs. Odds of stopping after one year were significantly higher among people who were Black or Hispanic, male, and enrolled in Medicare or Medicaid enrollees, or people who lived in areas with very high levels of social needs.
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While affordability of these drugs is a challenge, it’s still not known why more than half of the people who start taking them quit after one year, regaining the weight they lost.
Low socioeconomic populations have a disproportionate burden of obesity and diabetes, so that population will have the hardest time obtaining these medications at current prices and staying on them, potentially exacerbating health disparities in the United States. Kazi is a co-author of a November paper published in JAMA Cardiology estimating that more than half of U.S. adults are eligible to take the GLP-1 drug semaglutide to lose weight, manage diabetes, or prevent recurrent cardiovascular events.
“These drugs have the potential to be transformative in their impact on population health, but only if we can figure out all of these pieces that are real barriers to access and affordability,” Kazi said. “I think the partnership with dietitians and exercise physiologists may be really helpful, not just in the process of starting and initiating and dose adjustment, but also if you stop the drug.”
To maintain control diabetes or obesity, people generally need to take GLP-1s indefinitely. For Carol Gordon, weight loss has been a lifelong mission. Back in the 1990s, she took fen-phen, the combination of fenfluramine and phentermine that produced the marked weight loss we now expect from newer obesity drugs. But phen-fen was pulled off the market in 1998 after a serious side effect emerged: dangerous heart valve damage. Carol Gordon, who consults with a nurse practitioner to maintain a healthy weight.Courtesy
Fen-phen was the first of many attempts to reduce her weight but one Gordon had no choice but to abandon. Since then, she’s had a lap band placed around her stomach to limit her food intake, but in a familiar pattern, she gained back the weight she lost. “I’ve been dealing with it my whole life,” she said.
It wasn’t until she started Ozempic that she reached her goals, losing weight gradually and keeping it off. Now 68 and retired from a career as a vocational rehabilitation counselor working with ill or injured people, she swims laps for an hour a day, landscapes her yard, and volunteers for the Humane Society in Seattle.
She also marvels that her trusted adviser, nurse practitioner Colleen Dawkins of Big Sky Medical Wellness, cautions her against losing too much weight as she grows older — words she’d never heard from a medical provider before.
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Dawkins’s patients start their care with an online meeting before treatment starts, to establish goals for health that aren’t necessarily a number on the scale. Education is key, anticipating a loss of appetite if not nausea at first, making nutrition critical. Is there a history of eating disorders? How do they feel about being on a lifetime medication? Do they hope to be more active and move out of pre-diabetes territory? What about other medications they’re taking?
“If we could find a way to give those resources to primary care, I think a lot more patients could benefit and then tolerate the medications better — and actually have better outcomes overall,” said Dawkins, who previously practiced at an obesity center but now works remotely with physicians and patients. Her patients have private insurance and submit monthly bills for reimbursement. She first trained as a dietitian and then became a nurse practitioner, working in clinics that offered metabolic surgery and non-surgical weight management.
Despite Gordon’s struggles, including rationing her doses to cope with sporadic shortages and high cost, she does not have to deal with multiple complications. Her blood glucose, blood pressure, and cholesterol are under control, unlike many people whose obesity is just one of the chronic conditions they endure. She feels like she has her energy back. She enjoys a treat, within limits.
“I still have a sweet tooth at night, but I’ll have like one salted caramel,” she said. “I know a little bit will do me.”
Campos, who has been back on Ozempic for two months now, wouldn’t call himself healthy, but he does allow he’s doing better. His daughter thinks he’s still recovering from the interruption in his Ozempic regimen. She’s also taking Ozempic, thanks to her employer-based insurance.
“I still get the medicine, but my dad, who for all intents and purposes I feel like needs it a lot more than I do, just was not able to access it until Maureen came across that program from Novo Nordisk,” Carla Campos said. “I’m also diabetic, and watching him lose access to that just felt really unfair.”
STAT’s coverage of chronic health issues is supported by a grant from Bloomberg Philanthropies. Our financial supporters are not involved in any decisions about our journalism.
cardiovascular diseasechronic diseasediabetesdrug pricingdrug shortagesObesity
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