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!
A few days ago I posted an article with the tongue-in-cheek rhetorical title, “Is there a role for dietitians in obesity management?”, to which, as readers should note, my clear answer (or so I thought) was “ABSOLUTELY!”.
Interestingly, the response to this post from the dietitian community was both humbling and indeed an honour. Not only did the post receive an unusually large number of lengthy and passionate comments (both here and on social media), but I also received a most thoughtful letter signed by well over 200 dietitians, suggesting I reconsider or at least clarify my post.
This overwhelming response to my post was humbling, because, I do not believe that there is anything I could possibly have written that would have elicited an even remotely similar prompt and passionate response from my own medical colleagues – clearly dietitians care strongly about what they do. Apparently, they also appear to pay attention to what I have to say – which is an honour indeed!
That said, I agree very much that some clarification is in order.
For one, as stated above, the title of the post was indeed entirely rhetorical – if I did, for even a second, have any doubts as to the important role that dietitians have in obesity management, I would probably not have bothered writing the post at all.
Secondly, I would have thought that both my opening and closing paragraphs would have made it entirely evident just how much respect I have for the professional expertise that dietitians have with regard to their discipline and their essential role in obesity management. I truly believe that it would be entirely fair to say that dietitians’ knowledge of biochemistry, disease processes, counseling techniques, client-centred care, and clinical passion are second to none (and I happily include my own colleagues in the comparator).
Furthermore, nowhere did I state or imply that my comments apply to ALL (or even the majority of) dietitians – in fact, I thought I had made it clear that the issues I raised applied to a small minority (perhaps no more than a handful?) of dietitians. (I did not single out anyone by name, as I do not believe in, nor intended, any ad hominem attacks).
In my post, I touched on a few different but related issues:
1) The unequivocal endorsement of obesity as a chronic disease.
2) Potential gaps in specific obesity training.
3) Reluctance (of at least some practitioners) to consider weight loss as a realistic (and often necessary) therapeutic option.
Apart from the fact (as I have done in countless previous posts) that I have called out members of my own (or for that matter, any) medical profession on the exact same issues, I am also fully aware that within any health profession there is a wide range of expertise, experience, and opinion on virtually any issue.
But, I do believe that each of the above-mentioned issues is of importance (not just for dietitians), and I will happily clarify my stance and thinking on each of them in subsequent posts.
As to why, if my comments apply to all health professions, I decided to single out dietitians for this particular post, the reasons are simple:
1) This specific post happened to be prompted by actual conversations over the past few months with several dietitians from across Canada, who all (independently!) raised similar concerns about what they thought was perhaps amiss amongst some (younger?) members within their profession when it comes to obesity management (again, no names!).
2) Ten years of blogging have taught me that to initiate a lively discussion with any post, it needs to be opinionated, one-sided, strongly worded, and provocative – anything less, is a waste of time (sadly, balance is boring!). If nothing else, my post certainly achieved that.
3) I truly do consider the role that dietitians have to play in obesity management of the utmost importance. Dietitians are in fact “THE” profession, that other health professionals most often look to when it comes to obesity management. With that comes immense responsibility, which I know dietitians take very seriously.
I promise that I will attempt to do my utmost to clarify and expand on the specific issues raised in my previous post in subsequent posts.
Hopefully these “clarifications” will be taken in the respectful and constructive spirit in which they are offered – I am fully aware that nothing in medicine is black and white; we all happily operate in shades of grey (as I always emphasize to my patients). I’m also very aware that today’s certainties may well turn out to be yesterday’s follies – as our understanding of disease processes and treatments evolve, so do our clinical approaches (as they should).
All I ask of you, is to bear with me…
Metabolically Active Fat
Recent evidence suggests that brown adipose tissue (BAT) exists into adult hood and can, when present account for as much as 20% of daily resting energy expenditure. While the exact contribution of BAT (or lack thereof) to obesity remains to be determined, the presence and inducibility of BAT by cold exposure is inversely related to BMI, appears higher in women, and diminishes with aging. Given the role of cold exposure in the expression of BAT, it can be speculated that an increase in ambient temperature may promote weight gain by significantly reducing BAT and, thus, metabolic rate in some individuals. In rodents, increased production of neuropeptide Y in the hypothalamus can not only increase food intake but also reduce energy expenditure via a reduction in non‐shivering thermogenesis in BAT and facilitate triglyceride deposition through increased insulin levels.
A wide range of medications can affect metabolic rate. Notably, the use of beta‐blockers has been shown to significantly reduce thermogenesis, resulting in clinically relevant weight gain 34. Metabolic rates can also be reduced by the discontinuation of drugs that promote thermogenesis such as beta‐adrenergic agents, stimulants (including performance‐enhancing and illicit drugs like crack/cocaine), coffee or nicotine, resulting in weight gain.\
Finally, weight loss can markedly reduce energy requirements with a 5–10% reduction in body weight reducing resting metabolic rate by as much as 20% in some individuals, thereby substantially increasing the susceptibility to weight regain in the post‐obese state.
Commentary: In summary, any of the many factors that can reduce metabolic rate, can result in weight gain even with no change in energy intake or energy expenditure. In a clinical setting, this would apply to the patient, who tells you that they have not changed their food intake or their activity levels and, yet, have gained weight. Rather than simply discarding this information from a patient as being untrue or “delusional”, clinicians should give careful consideration to the factor that there very well may be factors that have led to a significant reduction in metabolic requirements.
I was recently, once again asked about my opinion on weight-loss challenges. So here is a repost of an article I wrote back in 2008 on this topic – apparently, it is still as relevant today, as it was almost a decade ago.
There appears to be a rather widespread notion out there that introducing a bit of competition into the affair may spurn people on to try and lose those “extra” pounds.
In fact, a quick google search on the term “weight-loss challenge” reveals an amazing array of challenges from voyeuristic and sadistic TV shows like the “Biggest Loser” to well-meant workplace wellness initiatives or fund raisers. I am sorry to admit that I recently even became aware of a weight-loss challenge within my own hospital – well intended, but useless in the fight against obesity.
So what’s wrong with this idea? Isn’t competition a great motivator?
Sure it is – and people will do anything to win a competition – including crazy stuff like starve themselves, exercise till they drop, or even (God forbid) pop diet pills, diuretics or laxatives just to win.
All of this is in direct contradiction to a fundamental principle of obesity management: you do not do things to lose weight that you are unlikely to continue doing to keep the weight off.
Most people seem to think that if only they could lose some weight, they will somehow be able maintain that lower body weight in the long-term with less effort.
The reality unfortunately is (and most dieters have experienced this over and over again) that no matter what diet or exercise routine you chose, no matter how slow or fast you lose the weight, no matter how long you keep the weight off – the minute you relax your efforts, the weight simply comes back.
As I have blogged before: obesity is a chronic disease for which we have no cure – only treatments! When you stop the treatment the weight (and any related problem) simply comes back.
By now you will already have figured out the problem with these challenges – unless you are very modest and reasonable about your weight-loss target and are carefully making changes that you can reasonably sustain forever, you are simply setting yourself up for failure.
If you are indeed modest and reasonable – you’ve already lost the competition to all the crazy folks who’ll do anything just to win.
My advise to anyone with a weight problem – the next time you see an invitation to a weight-loss challenge – simply ignore it!
If you really think you will benefit from obesity treatment – seek help from a trained and accredited health professional with experience in weight management – let’s put an end to weight cycling!