Kara Mayes, MD

The through-line

Everything Kara Mayes says comes back to one claim: obesity is a medical condition, and the reason it is treated badly is that most of the system, including the people who write insurance benefit designs, still does not believe that. She describes decision-makers who "still think that obesity is not a medical problem and that people are just lazy or they just need to stop eating fast food," while the patients in front of her are "eating really healthy" and already exercising and still not losing weight, "because it's not just about the calories" [1]. That conviction has carried her from a family medicine faculty post, where weight management started as a couple of days a month, to running a dedicated clinic full time, to arguing publicly that obesity is a health equity issue shaped by socioeconomic factors and that it should be treated like any other disease [1][8][10].

The second constant is that treatment has to be measured in how patients live, not in the number. She named the program Mercy Weight and Wellness precisely because "we didn't want it to only be about weight," on the reasoning that patients "care about their weight um but it's not so much about weight as it is about their health and their happiness" [1]. Her later work at Ilant Health, on value-based obesity management and cardiometabolic health, sits on the same premise, and she has argued that tackling obesity is more than just a pill [8][10].

On how obesity medicine finds you

Mayes did not set out to do this. A patient asked about a new weight loss medication she had never heard of, two or three years into practice, and she went and read the approval studies and the FDA material herself to work out whether it was safe, effective, and appropriate for that particular woman [1]. Her gloss on it is that "sometimes we learn the most important things from our patients" [1]. Success with that one patient led to more conversations, then to referrals from her own partners, then to a deliberate build-out of knowledge about dietitians and exercise physiologists in her area so she "wasn't doing it all on my own" [1]. The pull was affective as much as intellectual: weight management follow-ups "became the part of my clinic day that i would look forward to the most," because those visits were about health and wellness "instead of just focusing on treating disease or diagnosing acute problems" [1].

She frames the pathway into the field as unusually open. There is a board exam from the American Board of Obesity Medicine, not an ABMS-recognised subspecialty, and no fellowship requirement, though roughly 15 to 20 optional one-year fellowships now exist; she took the CME pathway, which cost her "a conference and a half" plus online courses and self-study [1]. Her verdict on the exam is blunt: compared with USMLE, COMLEX and ABFM, "probably the easiest one i've ever taken" [1]. She also draws a line from an earlier interest in sports medicine, which she abandoned but sees echoed here, because in both cases patients arrive wanting to improve and get back to functioning, "but i think we're we're helping in an even bigger way" [1].

On why this belongs in primary care

Mayes is emphatic that specialists cannot absorb the volume: "there will never be enough obesity medicine specialists to take care of every patient with obesity just like there's not enough endocrinologists to take care of every patient with diabetes," and that, to her, is "the joy and the value of primary care" [1]. This is why the Mercy clinic was designed to be embedded in the primary care department, so that primary care physicians whose patients wanted more help had somewhere to send them without leaving the department [1].

The training gap is the other half of the argument. "we don't learn a whole lot about weight management anywhere in our training including a residency," so she learned it on her own [1]. At Mercy the obesity medicine elective is not required, yet she estimates at least two thirds of residents take a month with her, working alongside the dietitians and spending clinic days with a bariatric surgeon, and some come back for a second month "because they realize how big of a deal this will be in their practice" [1]. Her teaching goal for those residents is not to produce specialists but to make them comfortable managing obesity in their own panels [1]. That same instinct toward equipping generalists runs through her continuing education work on type 2 diabetes, where she has argued alongside Jay H. Shubrook for overcoming therapeutic inertia and intensifying treatment in a timely way to reach personalised glycaemic and weight goals, on the view that T2D is largely preventable and entirely treatable [2][3][4][11].

On coverage as the binding constraint

Asked how to get GLP-1s paid for, she calls it "the million-dollar question," then corrects herself to "the thousand dollar question" [1]. Her account of the asymmetry is precise: a new diabetes drug is covered by essentially every plan inside a year, while a new anti-obesity medication is treated as an easy exclusion because benefits consultants ask employers whether they want to cover obesity medicines and employers can simply say no [1]. Coverage therefore varies employer by employer rather than carrier by carrier, "it's not just blue cross covers it and aetna doesn't," Missouri state employees have it, Medicaid and Medicare do not, and, pointedly, Mercy's own staff do not get coverage for the medications her clinic prescribes, something she has repeatedly taken up with the people who make that decision internally [1]. She notes that others are lobbying CMS for anti-obesity medication coverage [1].

Her practical sequence is to try the obesity-indicated products first, Saxenda and Wegovy, which are higher-dose versions of Victoza and Ozempic, and to submit the prior authorisation even when she expects denial, on the theory that "even simply the act of getting those prior auths even if they get denied" signals demand to insurers, "probably not a lot but maybe a little" [1]. If that fails she will try the diabetes-labelled GLP-1s off label for pre-diabetes, insulin resistance or PCOS, telling patients openly that the drug is approved for diabetes and they do not have it [1]. When plans refuse both, there is usually nothing left, since she has met exactly one patient willing to pay a thousand dollars a month and a two-hundred-dollar coupon is meaningless at that price: "900 versus eleven hundred dollars is not really enough of a coupon to to make that work" [1]. The fallback is metformin for insulin resistance, sometimes combined with phentermine or phentermine-topiramate, cheaper but delivering modest weight loss [1]. She connects this whole picture to bias and stigma against obesity treatment, and to the argument she has made elsewhere that obesity in America is a health equity problem driven by socioeconomic factors [1][8][10].

On the team and what is still missing

Weight management is, for Mayes, unavoidably multidisciplinary. The Mercy team includes dietitians, an athletic trainer, nurse practitioners and other physicians, and residents rotating through also spend time with a bariatric surgeon [1]. The one role she has never managed to fill is a behavioural health specialist, "on my wish list since we opened," which forces the clinic to refer out for a component she considers central [1]. Her broader position, carried into her work at Ilant Health, is that treating obesity together takes more than a pill [8][10].

She was also candid about the cost of specialising. Choosing to leave primary care in October meant saying goodbye to families she had cared for over ten years of practice, some of them continuity patients she had kept since residency, twelve or thirteen years in [1]. The reason was structural rather than sentimental: below a certain number of clinic days a week, "it's hard to be a primary care doctor in one day a week patients need you a little bit more than that" [1].

On what counts as success

Mayes is deliberate about not defining outcomes by pounds. She points to a patient who went from 80 units of insulin a day to none with an A1c in the pre-diabetic range, and notes that removing insulin also removes multiple daily injections and the hypoglycaemia that comes with them, trading them for a weekly shot [1]. Getting patients off blood pressure medication and improving A1cs is, in her framing, the good part of the job precisely because the journey usually starts by adding medicines: "it's so much more fun when we get to the point where we're we're taking all these things away" [1].

Even at around 10 percent body weight loss, she says, patients "just feel great," move better and can keep up with their children [1]. The examples she reaches for are deliberately small and concrete: a six-mile hike in Arizona that would have been impossible a year earlier, a first vacation for someone who had avoided flying because of airplane seats, someone whose stomach no longer touches the steering wheel [1]. She has patients who have lost 100, 120, 150 pounds and are delighted, "but i think it's it's not even the big successes that stand out to me," it is the daily details that are "even more fun to celebrate" [1]. She is equally clear that the clinic has "plenty of people who were we're not celebrating with" [1].

Takeaways

• Obesity is a medical disease, and the biggest obstacle to treating it is that benefit decision-makers still assume patients are "just lazy," when many are already eating well and exercising and not losing weight "because it's not just about the calories" [1].
• Anti-obesity drug coverage is decided employer by employer, not carrier by carrier; Medicare and Medicaid exclude it, and even Mercy's own employees lacked coverage for the medications her clinic prescribes [1].
• Her prescribing ladder runs from the obesity-indicated GLP-1s (Saxenda, Wegovy) to off-label use of the diabetes versions for pre-diabetes, insulin resistance or PCOS, to metformin with phentermine or phentermine-topiramate when nothing is covered [1].
• She files prior authorisations she expects to lose, on the view that the volume itself signals demand to insurers [1].
• Obesity medicine has no fellowship requirement; the CME pathway plus the ABOM exam is enough, and she found that exam easier than USMLE, COMLEX or ABFM [1].
• Specialists will never cover the need, so the leverage point is training every family physician to manage obesity: two thirds of Mercy residents take her elective voluntarily, and some return for a second month [1].
• Success is measured in function and deprescribing, getting a patient off 80 units of insulin a day, fitting into an airplane seat, a six-mile hike, rather than in pounds alone [1].
• A behavioural health specialist has been missing from her clinic since it opened, a gap she treats as unfinished business [1].
• She frames obesity in America as a health equity issue shaped by socioeconomic factors, and her work at Ilant Health applies a value-based approach to obesity management and cardiometabolic health [8][10].
• In type 2 diabetes she argues for overcoming therapeutic inertia and intensifying treatment promptly toward personalised glycaemic and weight targets, on the premise that T2D is largely preventable and entirely treatable [3][4][11].