People don’t become obese overnight.

Given the negative impact obesity has on so many aspects of our lives - for the individuals affected, their families, all the way up to health and social care systems that pay for the care and the lost productivity resulting from obesity – it is not something we can ignore.

Bringing to market an obesity drug, however, such as the recently approved Novo Nordisk drug, will not offer a miracle cure despite what the marketers say; it may risk leading to worse health effects as set out below.

Obesity alone is responsible for 1.2 million deaths per year in Europe¹. This is just one figure that would automatically lead to a moral imperative to act. The World Obesity Federation has highlighted that obesity and overweight cost the global economy $1.9 trillion each year, and this figure is expected to rise to $4 trillion per year by 2035² if their prediction is correct that 50% of the world's population will be obese/overweight by then. 

Poor diet and lack of physical activity are two major causes of obesity, so can't people counteract this by eating healthier and being physically active?  Well, it isn’t so simple. Many of the people at highest risk of ‘developing obesity’ are in environments that predispose them to eating unhealthily and being more sedentary³. They often don’t have the financial means to buy healthier food and live in neighbourhoods where it isn’t safe to be physically active outside. In addition, their home environments might be very crowded and they may lack the time to prepare their own meals because they are working multiple jobs to make ends meet. Fast food and highly processed food items are then often the only rational and logical choice.
 

But all of these factors can be changed and modified before people become obese! Just to give a few examples:

• We can improve food environments for people in less well-off areas to ensure they have access to affordable food that is healthier.
• We can provide low-barrier group exercise opportunities for people at all ages.
• We can provide other support to ensure that people can gain the skills to prepare healthier meals on limited financial and time budgets.
• We can restrict marketing of unhealthy food and improve welfare standards, paying people fairly and giving more time off.
• And we can go beyond acknowledging that there are numerous systemic issues we can address to counteract obesogenic environments – we can start acting to drive change

But instead of supporting the types of measures that can sustainably help people manage their weight, especially when they start noticing they are becoming overweight (not when they are already obese!) governments across Europe have just approved the use of a new obesity medication from Novo Nordisk. Let’s look a bit deeper at this.

Effects

The very first thing to note is that the clinical trials that have been done indicate that this medication has to be given alongside active weight management services – the medication alone does not lead to weight loss. Furthermore, bold added by the authors: 

“Upon initiation of anti-obesity medication, we communicate several important messages to patients. First, not every drug works for every patient; individual responses vary widely. Second, when the maximal therapeutic effect is achieved, a plateau is reached and weight loss ceases. This does not mean the drug has "stopped" working. It simply means that additional strategies will be required to induce additional weight loss. Finally, when drug therapy is discontinued, weight regain can be expected.”⁴ 

The other key thing about this medication is that the weight loss (up to 10% of Body-Mass-Index - BMI according to the UK regulators) will likely still leave an individual overweight and at risk if they do not change their dietary and physical activity habits.⁵ 

And then there are the side effects as highlighted in Box 1.

Side effects

The content below is a summary taken directly from Novo Nordisk’s website for its drug Wegovy/Semaglutide:⁶ 

“What is the most important information I should know about Wegovy®?

Wegovy® may cause serious side effects, including:

• Possible thyroid tumors, including cancer.

Wegovy® may cause serious side effects, including:

• inflammation of your pancreas (pancreatitis). 
• gallbladder problems. 
• increased risk of low blood sugar (hypoglycemia) in patients with type 2 diabetes, especially those who also take medicines for type 2 diabetes such as sulfonylureas or insulin. 
• kidney problems (kidney failure). 
• serious allergic reactions. 
• change in vision in people with type 2 diabetes. 
• increased heart rate. 
• depression or thoughts of suicide.

The most common side effects of Wegovy^® may include: nausea, diarrhea, vomiting, constipation, stomach (abdomen) pain, headache, tiredness (fatigue), upset stomach, dizziness, feeling bloated, belching, gas, stomach flu, heartburn, and runny nose or sore throat.”

Costs

We couldn’t find exact costs for the 2.4 mg dose, which is the maintenance dose for this medication, but can get an idea of the costs based on some figures released in the UK. But let's assume in a hypothetical scenario that drug becomes a standard treatment. What would it cost us?  
The list price of semaglutide 2.4 mg and 1.7 mg is commercial in confidence and cannot be reported here. The list price of semaglutide 0.25 mg, 0.5 mg and 1.0 mg is £73.25 per pack (4 pre-filled pens; excluding VAT).⁵
 

* equivalent prices in Europe were not available but it is likely that this monthly cost is an underestimate because the recommended dose is 2.4mg and £73.25 is the cost for the lower doses
** it is important to note that semaglutide is recommended for people who are obese and have at least one other condition but given that many of these individuals already have another disease or are predisposed to developing these diseases, we have included all people who are obese in these calculations
 

Is spending the equivalent of around £66 billion, about €76 billion, a year across the EU on what is in many cases (not all) a preventable disease the best use of money?  What else could that money buy? A LOT OF REALLY GOOD STUFF that can keep people healthy! Some examples, in addition to the ones already mentioned earlier:

• Healthy foods in schools:  the EU spent less than 0.4% of that amount of money (€250 million) to ensure children at school have access to free milk, fruit and vegetables.¹⁰ We could provide subsidised healthy meals at schools.
• Strengthen capacity of health authorities to counter the influence of commercial interests and develop the necessary legislation to create an environment that promotes the health and well-being of the population.
• We could provide low-cost high-impact group exercise opportunities for people who are just getting overweight and before they become obese.
• We can spend that money to empower individuals with the knowledge, skills and motivation to take care of their health themselves rather than needing to rely on medications with all sorts of side effects.  

The fact that our governments have approved these obesity medications without trying much harder to support our citizens with healthier foods and food environments as well as better opportunities for physical activity is a missed opportunity to help our citizens stay healthy and well. 

As Ivan Illich pointed out several decades ago:

“The more time, toil, and sacrifice spent by a population in producing medicine as a commodity, the larger will be the by-product, namely, the fallacy that society has a supply of health locked away which can be mined and marketed.”¹¹

We do not say that this drug should never be used, but like all drugs, this one does not solve anything if the causes of the problem are ignored. There are many people who are already sick and need to be treated accordingly. However, we would like to stress that it is important to act when or where preventable illness is allowed to perpetuate.

In the next blogs we will also look at this topic from other angles.