A counterpoint to the argument for denying effective anti-obesity therapy during a time of medication shortage.
In response to criticism about previous statements that were directly stigmatising of persons with a lived experience of severe obesity, the Therapeutics Goods Association (TGA) and others have appropriately altered their language regarding the use of GLP-1 agonists which have clinical effectiveness for the management of Type II Diabetes as well as clinically significant obesity. They have now asked clinicians prescribing these medications to consider delaying prescription unless other suitable alternatives are not available, rather than seeking to deny patients with severe obesity the opportunity to receive treatment.
While the best of these agents are only approved for use in Australia for the treatment of Type II Diabetes, ample research data and clinical experience are showing excellent results when used for severe obesity, which has subsequently led to widespread “off-label” prescription by Obesity Practitioners in Australia. Some versions of these drugs which are approved as obesity therapies are clinically inferior and more expensive than the newer and potentially scarcer agents.
The widespread success stories of people living with severe obesity who have lost weight with these medications have subsequently been shared on social media support groups set up by patients, which has then led regulatory agencies and the press to be aware of the potential contribution of these prescriptions to medication shortages. Unfortunately, this has potentially trivialised the importance of providing effective anti-obesity therapy to those in need, and it denies the validity of their experiences and health as being important.
While it is obvious that a poorly available therapy should not be used for frivolous purposes, appropriate consideration should be given to the needs of people living with severe obesity before denying them the opportunity to receive appropriate care. Overweight and obesity have skyrocketed in prevalence over the last 40 years and is Australia’s second largest cause of fatal disease and the largest contributor to non-fatal disease.
While substantial increases in the prescription of diabetic and cardiovascular therapies over this time have blunted the effects of obesity on mortality rates, little has been done with regard to managing obesity itself. No one is going to argue about the importance of lifestyle changes in obesity prevention as part of the suite of interventions for those living with obesity-related diseases. However, we have overwhelming evidence that lifestyle change as sole therapy is universally inadequate for those with severe disease, even though its effects in so-called multi-modality or combined therapies are important.
We know enough about obesity to predict, before treatment, the likely outcomes for an individual depending on the treatment prescribed. Patients requiring health improvement and weight stability should therefore be prescribed differing obesity therapies than those presenting with poorly controlled medical conditions, disabilities or diseases likely to become life-threatening soon.
While offering obesity therapies to patients has been made more difficult by the relative scarcity and complexity of treatments until reasonably recently, those treatments that are suitable, successful and cost-effective are rarely offered. The cost of therapy is often cited as a reason, but there appears to be a double standard applied to those seeking or who are eligible for obesity treatment. Therapies for obesity that are known to be more cost-effective than what we currently offer other patients with chronic disease (such as renal failure, osteoarthritis etc) or which are even potentially health-cost neutral, are consistently denied to patients by Federal and State healthcare systems.
Clinically severe obesity is the only major health condition where all healthcare costs are expected to be covered by the person with the disease. Most successful medical therapies for obesity are not approved for use by the TGA and are prescribed “off-label”, and even those that are TGA approved receive no government subsidies, which somewhat negates the point of seeking TGA approval in the first place. Patients presenting for treatment in public hospitals with life-threatening or disabling obesity-related conditions will have their condition treated but are virtually guaranteed to receive no obesity directed care other than documentation of their body mass index (BMI).
It is beyond the scope of this opinion piece to discuss the many complexities of obesity stigma, but for those who are interested, The Obesity Collective provides succinct and easily readable information for the public and lay-press, and the Weight Issues Network, a person-centred support group created by those with a lived experience of obesity, for those with a lived experience of obesity, have created an excellent position statement detailing the experiences of seeking health care when one has obesity. It’s unlikely that anyone reading these documents would come away without increasing their understanding and empathy for those negotiating their lives and the healthcare system with obesity as a front and centre issue.
A more nuanced way of managing the potential conflict between the requirements of those with severe diabetes or obesity is to make decisions based on the clinical needs of the patient. There are multiple drugs known to improve diabetes and prolong survival approved for use in Australia. If a diabetic patient does not require significant weight loss and is being prescribed one of the new GLP-1 agonists that are in short supply, alternatives could be prescribed without sacrificing their care.
Similarly, if a patient is being prescribed a GLP-1 agonist for obesity and is at the weight maintenance part of their therapy, other alternatives are available. Those requiring a lesser degree or slower weight loss have other options as well. This would leave scarce agents available for those patients requiring reliable and consistent weight loss to treat significant illness, and for those diabetics where significant weight loss and lifestyle modification are part of the management of their complicated diabetes associated illnesses.
GLP-1 agonists are part of the first of a suite of anti-obesity medications being released which are effective and well-tolerated when appropriately prescribed. Whether or not these make it into the hands of those in need will depend on our Health system’s re-evaluation of the importance of the needs of those affected by severe obesity, as well as advocacy by patients, clinicians and healthcare institutions.
Dr Talbot is a surgeon working in a multi-disciplinary clinic that provides treatments to patients referred for management of severe obesity. He is a past president of the ANZ Metabolic and Obesity Surgery Society (ANZMOSS) and is on the Board of The Obesity Collective.
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This article is being shared around the Ozepmic community (both forums and Facebook groups) as it’s what so many of us have been saying for so long. I just want to add that the focus is primarily on weight loss, but not so much on weight management. Many GPs are poorly equipt to deal with the whole weight loss journey. With many sentiments and experiences within the community agreeing that the medication is prescribed when a patient is overweight or obese, once they reach their goal or healthy weight, the GP no longer prescribes the medication or recommends anything for maintaining that weight loss. So many go on to regain that weight back.
In your article, you state: “Similarly, if a patient is being prescribed Semaglutide for obesity and is at the weight maintenance part of their therapy, other alternatives are available.”
Which “other alternatives” are you referring to? Because like so many, when the weight is gone, all prescriptions for medication also end. The aspect of a patient’s therapy doesn’t seem to include a maintenance phase with any appropriate alternatives to maintain the loss, this is reflected by so many patients within these above-mentioned communities.
To me, this just indicates that understandings of weight loss and obesity as a whole are quite poorly understood, with patients not getting the full support and therapy they need to set them up for long-term success.
It’s a valid point that replacing an effective therapy (Ozempic) for a chronic condition like obesity with nothing other than good wishes is inappropriate. It would be like telling someone who feels good on an asthma puffer for a month that their asthma is now cured and they shouldn’t take it again.
There are a number of strategies that can be offered to people with significant obesity when they are tapering down from the rather intensive “weight loss” part of their journey to the rather more difficult “weight maintenance” part. I can’t detail them all, as what’s appropriate for some people won’t work for others, however, there are some obvious standouts that can be more-or-less universally applied.
Surveillance. A weekly weigh-in is probably mandatory, otherwise it’s easy to lose track and allow kg after kg to stack back on. Body composition scales (Withings makes nice ones, but there are other alternatives) that sync with your phone are excellent as they tell you about your fat and muscle levels, which is more important than weight, as your weight can fluctuate for a whole host of reasons but it’s your fat and muscle mass that you want to stay stable.
Exercise. Exercise isn’t great for weight loss but it’s been shown again and again to be great for weight maintenance, mental health and physical health. At least 3 hours a week of “proper exercise” including some aerobic and some strength work. Pilates, yoga, light weights, and aqua aerobics are all excellent. Making yourself a slave to exercise may not be sustainable, but aiming for that minimum should be.
Meal replacements (3-4 per week). Meal replacements are high protein, low carb meals. They can be Very Low Energy drinks or bars, but other meals are similar. They help keep you in the habit of “eating enough” while eating small and can be used as good alternatives when decent food is hard to find.
Ongoing medical therapy, or medications. Weight loss medications can be used at lower doses, they can be combined with other cheaper and easier to obtain medications or they can be replaced by other cheaper and easier to find medications. The list of medications “approved” for use is small and the PBS covers zero of them because of Obesity Stigma. Still, we actually have a number quite suitable for “off-label” prescriptions after assessment by someone experienced in the field. These meds include Topiramate, Phentermine (or both combined), Naltrexone or Bupropion (or both combined), some of the diabetic meds like Metformin or Trulicity, as well as the GLP1 agonists Saxenda and Ozempic. Some of these meds are available on standard prescription and some need to be made up by compounding chemists. Pretty much all of these require assessment by people who have decided to become very involved in this field and most GP’s simply have too much to do to feel confident in this area.
I hope this has answered some of the question. Thanks, A/Prof Michael Talbot.