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South Asian physician Hamayle Saeed says she was screened for diabetes at a BMI of 23 under guidance that recognizes higher risk at lower weights, but could not meet U.S. GLP-1 eligibility thresholds at BMI 26.5 without diabetes or another qualifying condition. Her MedPage Today opinion argues that clinical guidance, drug labels and insurer rules use different definitions of obesity; the policy implications and individual coverage decisions remain unsettled.
South Asian physician Hamayle Saeed says her doctor began diabetes screening once her body mass index reached 23, but she was denied a GLP-1 medication at a BMI of 26.5 because she had neither diabetes nor another qualifying condition. In an October 31 MedPage Today opinion, Saeed argues that the contrast exposes a policy gap: diabetes-risk guidance recognizes lower thresholds for Asian patients, while U.S. drug coverage rules often use higher BMI cutoffs.
Saeed writes that the American Diabetes Association’s approach prompted screening at a lower BMI because Asian Americans can develop diabetes at lower weights. She says she did not qualify for the GLP-1 she requested: the thresholds she describes are BMI 30, or BMI 27 with a weight-related condition. At 26.5, without diabetes, she fell below both criteria. These are details from her account; the source does not identify her insurer or provide a coverage decision letter.
The article points to reductions in public coverage for weight-loss GLP-1s: Medi-Cal dropped coverage in January, followed by MassHealth in July, according to Saeed. It also says the ADA issued Asian-specific waist and BMI thresholds for diagnosing obesity in June. Saeed argues that these moves leave a widening difference between how clinicians may assess risk and how payers decide who can obtain treatment.
Her supporting evidence includes a study of nearly 1.5 million adults in England, which estimated that South Asians reached the diabetes risk associated with a BMI of 30 among white adults at a BMI of 23.9; the corresponding estimate for Chinese adults was 26.9. Saeed also cites a 2026 analysis of 352 GLP-1 trials: using a BMI-30 inclusion cutoff, 41.5% of non-Asian American adults, 13.5% of Asian Americans and 7.2% of Koreans would have qualified. These findings describe study populations and trial eligibility, not an individual’s diagnosis or coverage entitlement.
How BMI Rules Shape Drug Access
The account matters because screening thresholds and treatment eligibility serve different purposes, yet patients and clinicians may encounter them as conflicting rules. A lower BMI can prompt closer assessment of diabetes risk without automatically establishing obesity under a drug label or meeting an insurer’s prior-authorization criteria. Saeed’s case illustrates how that distinction can affect access for people whose health risks may be underestimated by BMI cutoffs developed around other populations.
The issue also has implications beyond one prescription. Saeed cites evidence that Asian populations can carry more visceral fat at a given BMI and can experience diabetes and cardiovascular disease at lower weights. She also reports that eight cardiovascular outcome trials found major cardiac events prevented among 2.9 per 100 Asian participants and 1.4 per 100 white participants. The article does not establish that those findings determine the benefit for a particular patient, but they add to the debate over whether coverage rules should account for population-specific risk.
Changing an eligibility threshold could affect who receives treatment and how coverage is rationed. But the opinion does not provide a cost-effectiveness analysis, a payer response, or evidence that all Asian patients would benefit from a lower threshold. Those questions matter when clinical guidelines are translated into insurance policies.
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Different Rules, Different Purposes
In the account, three systems use BMI in different ways: diabetes screening guidance, clinical definitions of obesity, and drug access criteria. The World Health Organization set lower action points for Asian populations at BMI 23 and 27.5, Saeed writes. She says the ADA’s 2026 Standards of Care call for confirming excess adiposity with cutoffs appropriate to ethnicity, including for South Asian patients. A screening or diagnostic threshold, however, does not itself require an insurer to cover a medication.
Saeed says the U.S. GLP-1 thresholds reflect earlier pivotal trial criteria, which generally relied on Western definitions of obesity. She points to the 2025 STEP 11 trial in South Korea and Thailand, which enrolled participants using a local obesity definition of BMI 25 or higher. The study reported average body-weight loss of 16% with semaglutide compared with 3.1% with placebo. In a post hoc subgroup of 68 participants who began below BMI 30, the 45 who received semaglutide lost 17.6%, compared with 4.4% among 23 placebo recipients. Those results are from a subgroup analysis and do not, on their own, establish U.S. coverage policy.
The opinion also says the 2026 U.S. labels for Wegovy and Zepbound describe indications using obesity or overweight with a weight-related condition, without stating a numeric BMI in the indication language. Saeed says 30 and 27 remain common in trial criteria and payer forms. She contrasts this with guidance from Britain’s NICE, which, despite setting a higher starting BMI for tirzepatide, lowers the threshold by 2.5 units for several populations, including South Asian and other Asian people.
“The ADA guideline that flags me for annual diabetes screening and the prior authorization form that denies me the drug are describing the same 26.5.”
— Hamayle Saeed, MD, in her MedPage Today opinion
Coverage Rules Still Vary
The article is a physician’s opinion and personal account, not a report of a formal insurer appeal or a nationwide review of coverage decisions. It does not name Saeed’s insurer, say whether she appealed, or establish whether every U.S. payer applies the same BMI rules. Individual coverage can depend on the drug, indication, plan terms, medical history and documentation.
It is also unclear whether the label language Saeed discusses will lead insurers to revise prior-authorization forms, or whether regulators and professional groups will recommend a single adjusted threshold. The evidence she cites includes trial results and subgroup analyses, but it does not resolve what BMI criteria should apply to every Asian subgroup or how those criteria should be used for prescribing. A screening threshold should not be read as an automatic treatment recommendation.
Whether Payers Revise Their Criteria
The next practical developments will be any changes to insurer prior-authorization policies, clinical guidance and reimbursement rules in response to revised labels and population-specific evidence. Saeed’s opinion does not announce a policy change or give a timetable for one. Patients seeking GLP-1 treatment will still need to check their plan’s current criteria and discuss their individual risks and options with a clinician.
Further research may clarify how well results from Asian trial populations apply across different groups and whether adjusted BMI criteria improve access without creating new inconsistencies. For now, Saeed’s case presents a documented policy question rather than a settled national change: the screening threshold she describes is lower than the drug-eligibility threshold she encountered.
Key Questions
Why was Saeed screened for diabetes at a BMI of 23?
Saeed says her doctor followed guidance that recognizes diabetes risk can arise at lower BMI levels among Asian Americans. Screening recommendations identify who may warrant assessment; they do not automatically determine medication eligibility.
Why did she say she did not qualify for a GLP-1?
In her account, the relevant thresholds were BMI 30, or BMI 27 with a weight-related condition. At BMI 26.5, without diabetes or another qualifying condition, she said she met neither threshold.
Do the thresholds apply to every insurer?
The opinion does not establish one rule for all plans. Coverage can vary by insurer, plan, medication and indication, so patients need to check their own policy and discuss it with their clinician.
Does a lower screening BMI mean someone should receive a GLP-1?
No. A screening threshold is not a prescription or coverage decision. Treatment depends on clinical assessment, the medication’s approved indication and applicable coverage criteria.
What evidence does the opinion cite for lower BMI thresholds?
Saeed cites population-level diabetes-risk research, a 2026 analysis of trial eligibility and the STEP 11 semaglutide study in South Korea and Thailand. The trial subgroup results provide evidence for the debate, but do not by themselves set U.S. coverage policy.
Source: medpagetoday.com
