World Obesity Day: let’s talk about drugs

There are many burning issues when it comes to obesity: government policies, marketing of unhealthy foods (particularly targeting children), the cost and quality of food, education, stigma, and access to psychology to support behaviour change to name a few.

But what keeps me awake at night is the role of drugs in managing this condition – and major inequalities of access. When the NHS was set up in 1948, a key principle (championed by the RCP) was that ‘services should be comprehensive and available to all, regardless of means to pay’. Yet it is clear that when it comes to weight loss medications such as Ozempic, Saxenda and Wegovy (the so-called glucagon-like peptide 1 or GLP-1 analogues), the global desire for a quick fix to lose weight has resulted in fairly devastating consequences for the supply chain and NHS services trying to deliver these drugs.

In simple terms, the manufacturer of Ozempic is unable to meet demand. People will pay significant amounts to obtain these drugs privately. Once Ozempic became hard to source, people became aware of other drugs with similar effects, which became the next ‘must-have’ drug … and so on, until no one could obtain any of these drugs on the NHS.

As a result, there is currently a National Patient Safety Alert in the UK – no new GLP-1 analogues can be prescribed. This has had a huge impact on patients with type 2 diabetes for whom this class of drugs has been available since 2007, long before any mention of its use for weight loss.

Patients with diabetes taking GLP-1 analogues were informed by their healthcare provider that due to supply issues, they would need to go on to insulin until further notice. This might seem a simple switch, but the consequences can be lifestyle altering and involve not just having to regularly monitor blood sugar but facing additional weight gain, which the drugs were supposed to treat. Those using insulin treatment must notify the DVLA and have 3-yearly driving suitability checks, which can impact employment status and independence.

Amid this blanket ban on prescribing ability, Wegovy appeared, also a GLP-1 analogue. Both Wegovy and Ozempic’s drug name is semaglutide. They are exactly the same drug but with a different licensed use. Ozempic is licensed for type 2 diabetes, whereas Wegovy is licensed for weight loss. So in December 2023, healthcare providers could prescribe semaglutide for weight loss, but not for type 2 diabetes.

To further complicate matters, while Ozempic has primarily been initiated by GPs, Wegovy could only be prescribed and managed in ‘Tier 3’ weight loss services. These are often delivered by hospitals, and teams include healthcare professionals like dieticians, psychologists, physiotherapists, physicians and surgeons. Referral rates have rocketed while workforce numbers have remained static, as has funding. Unsurprisingly, already long waiting times have become much longer and it is not uncommon for patients to wait around 2 years to be seen in some parts of the country. Given the significant evidence for complications associated with obesity and being overweight, waiting for so long before treatment could increase this risk.

An increase in weight management services has cost and workforce implications. We know people in this country are living longer and they are living with more long-term health conditions. Pharmaceutical companies have been at the forefront of these advances and invested billions of pounds in developing new treatments to enable us to live longer. There is no doubt that these drugs work, at least in the short term – evidence at present for obesity medications is based on the first few years’ research.

There is now also a ‘new kid on the block’. Tirzepatide has already been approved by the Medicines and Healthcare products Regulatory Authority for use in obesity in the UK, with average weight loss from clinical trials standing at around 20%. Further novel treatments are in the pipeline, and it is likely that soon weight loss from these drugs will be similar to outcomes from bariatric surgery. The responsibility for evaluating the evidence and recommendations sits with the National Institute for Health and Care Excellence (NICE) and, rightly, it recommends these drugs as they are effective. The problem lies in the high demand. Almost 75% of people aged 45–74 in the UK are living with overweight or obesity as well as over 20% of children before they leave primary school. There are also significant health inequalities in our country – those from lower income areas are significantly more likely to be living with obesity than those from more affluent areas.

Integrated care boards, which contract services locally, consider NICE cost calculators alongside the health benefits of providing certain medications and services in their area. To put this into context, Wegovy costs £2,000–3,000 per person per year including wrap around care. For Tirzepatide, up to 13 million people in England could be eligible and costs may be higher still.

So, really this blog is a plea. We need to have open discussions about how we fund novel treatments for long-term conditions like obesity and ensure equal access for all to weight management services. As a society we need to collectively think about how we tackle this rising problem.

In future we will be in a fortunate position of having several medications available alongside surgery. With time, drug costs will go down. But we still need to look at how we deliver them, workforce implications for the NHS, and ensuring equal access to the right treatments at the right time.

Ultimately, the best outcome would be removing the need for such drugs and interventions by focusing on prevention first.