Yesterday, the UK Government announced a plan to spend £40 million on a two-year pilot to explore ways to make obesity drugs accessible to patients living with obesity outside of hospital settings.
As readers may know, anti-obesity medications including semaglutide have already been approved for prescription in hospital-based obesity clinics in the UK (albeit its use is limited to just two years, which makes little sense for a chronic disease like obesity).
As noted in the announcement, however, this limitation to use in hospital-based clinics will only reach about 35,000 people living with obesity, a tiny fraction of the over 12 million people with BMIs >30 kg/m2 in the UK.
According to the release, “Obesity costs the NHS around £6.5 billion a year and is the second biggest cause of cancer. There were more than 1 million admissions to NHS hospitals in 2019/2020 where obesity was a factor.”
The pilot will explore how approved anti-obesity drugs can be made safely available to more people by expanding specialist weight management services outside of hospital settings. This includes looking at how GPs could safely prescribe these drugs and how the NHS can provide support in the community or digitally.
The hope is that wider use of these medications can help cut waiting lists by reducing the number of people who suffer from weight-related illnesses, who tend to need more support from the NHS and could end up needing operations linked to their weight – such as gallstone removal or hip and knee replacements.
These activities to improve access to anti-obesity medications, of course, also includes negotiating a secure long-term supply of the products at prices that represent value for money taxpayers.
Obviously, this is a step in the right direction, as I have previously noted that to have a discernible impact on population health, anti-obesity medications will ultimately have to be made available and properly managed by GPs, not unlike their management of hypertension, diabetes or other common chronic diseases.
It will be interesting to see how this pilot develops and if other countries in Europe and elsewhere will follow suit.
Disclaimer: I have received honoraria as an independent medical, research and/or educational consultant from various companies including Aidhere, Allurion, Boehringer Ingelheim, Currax, Eli-Lilly, Johnson & Johnson, Medscape, MDBriefcase, Novo Nordisk, Oviva and Xenobiosciences.
There is no doubt that we are currently experiencing the dawn of a revolution in our ability to better treat and manage obesity. Under these circumstances, predicting the future of obesity medicine is perhaps even more difficult than when things were plodding along at a steady pace.
Nevertheless, here are some of the trends we should watch for in 2023:
- With ever more safe and effective anti-obesity medications becoming available (assuming the supply issues can keep up with the demand), patients, desperate for treatment, will be running down their doctors’ doors demanding prescriptions. At the same time, doctors, seeing the success that their patients are having, will begin feeling far more positive and optimistic about obesity management than at any time in the past.
- While the benefits for patients with clear indications for anti-obesity treatment will become more and more obvious, so will the magnitude of misuse and abuse of these medications by folks who clearly do not have a medical need to lose weight. As the misuse of these medications will largely happen without the supervision of health professionals, we should expect increased occurrence of adverse effects and complications that could well be avoided when these medications are used as intended. This development will prompt increasing critical attention by the media with warnings about these medications and calls to restrict access even for people who meet the indications and stand to benefit from these treatments.
- As medical treatments are now approaching a level of effectiveness previously only seen with bariatric surgery, one may suspect that surgery rates will decline. The opposite is likely to be true. In fact, we will probably see pre- and post-surgical use of these medications substantially enhance the safety and long-term success of surgical procedures. Thus, for many (if not most) patients with severe obesity, the question will no longer be surgery or medication – in most cases it may well be both.
- As medical treatments become more effective and available, many treatment plans that have so far relied solely on behavioural interventions (including the use of devices and formula diets), will adapt to support and embrace medical options if they hope to stay in business. The same will apply to the many behavioural apps that are now crowding the eHealth space – these will need to incorporate some form of support for patients on anti-obesity medications – and this feature may well turn out to be their most valuable function yet.
- As with other chronic diseases, the greatest challenge will be to actually get patients to use these medications as prescribed and to persist with treatment in the long-term. Thus, the issue of proper adherence (without which there will be little long-term benefit, potential harm, and a substantial economic waste) will gain increasing attention.
With my best wishes for a Happy New Year!
While I am currently teaching at a Harvard Medical School course on obesity for obesity educators here in Las Vegas, I thought it may be appropriate to post a link to my recent Obesity Canada webinar (about 60 mins) on why obesity is a chronic disease.
The full video can be accessed by clicking here
Las Vegas, NV
If there is one thing for sure, when it comes to managing obesity, one size does not fit all. In the same manner as there are hundreds of paths that lead to obesity, predicting the treatment that works best for any given patient is almost impossible – what works for one, may do nothing for another (treatments fail patients, patients never fail treatments).
Thus, in our analysis of interviews with patients and providers, published in Clinical Obesity, the eighth theme that emerged, was the importance of experimenting and reevaluating.
“Participants experimented with different actions, arranged appointments with interdisciplinary providers, or tried out community resources. Some changed their action plan and implemented different behaviours inspired through the consultation. During follow-up interviews, people reflected on what worked, what did not and what needed adjusting. Participants found that having someone ask how things are going was helpful for accountability and motivation. These conversations also helped them develop solutions for barriers.
It became glaringly obvious that, as with any other chronic disease, obesity care needs creating a supportive long-term relationship in order to respond to emerging barriers, shifting experiences, illness and treatment burden – what works great at one point may stop working when situations change. Things that seem impossible at first may well become possible over time.
If there is one thing that I have learnt in my dealing with patients, it is modesty in professing to have the solution for every problem.
As I have said, people who think there is a simple answer to every question, generally don’t even understand the question.
Although many of the comorbidities associated with obesity are directly linked to excess body weight, and losing weight has been shown to dramatically improve overall health and well-being (at least in people living with obesity), it is always important to remember that the ultimate goal of obesity management is to improve health and not just move numbers on the scale.
In this context, it is important to help patients identify and focus on health rather than on weight goals – indeed, patients tend to do best when they focus goals that are important to them – independent of what may or may not happen to their weight.
Thus, in our recent analysis of patient and provider interviews, published in Clinical Obesity, we found that both patients and providers agree on the importance of orienting all actions on goals valued by the patient.
“Context integration and priority setting led into thinking about what actions, strategies and resources may be of interest for the patient. Providers and patients identified a functional or value goal that served as an overarching orientation for action planning. A majority of participants wanted to plan actions, some chose to first reflect on thenew understandings gained from the conversation. Possible actions emerged from the conversation and differed widely between patients. They included addressing mental health, pain, sleep, seeking financial and social supports, considering anti-obesity medication or bariatric surgery.”
This is where it is always important to remind ourselves that losing weight cannot be a behavioural goal, as it is not a behaviour (losing weight is something your body may or may not do in response to a behaviour – you can control your behaviour but not how your body responds to this behaviour). Also, healthy behaviours will always improve your health, irrespective of whether or not you lose weight.
“While helping with accountability and motivation, action planning was described as less decisive than the cognitive and emotional work that led to context integration and priorities. However, this perception shifted over time, andmany participants later reflected on the benefits of planning specific and achievable actions for outcomes.”
Again, obesity management is best done in a long-term therapeutic partnership (as with any other chronic disease), and reorienting patients away from weight to non-wieght goals is a process that takes time but reaps significant rewards.