As the incidence of diabetes grows in the community, attention is turning to obesity as one of the causes and what weight-loss therapies can be applied.
By Eric Martin
Few people would argue that the limited supplies of the diabetes drug Ozempic should be directed firstly to people with that condition. However, the current shortage and the use of the drug to treat obesity raises important questions.
In 2020, an estimated one in 20 (almost 1.3 million) Australians were living with diabetes, including 48,300 people newly diagnosed with type 2 diabetes registered on the linked NDSS and APEG data, equating to 188 diagnoses a day per 100,000 population.
Numbers could be even higher, with the 2011–12 ABS Australian Health Survey, which collected blood glucose data, revealing that 20% of participants aged 18 and over had undiagnosed diabetes before the survey.
Yet of these, more than one million are estimated to have developed diabetes due to obesity.
The latest available data shows that in 2017-18, 31% of Australian adults were obese, 36% were overweight, and 25% of children aged 2-7 were also either overweight or obese. That is more than 9,266,000 people who were overweight, and more than 7,979,000 who were obese.
With the condition listed as one of the major contributors to the burden of disease in 2018 at 8.4%, just behind tobacco at 8.6%, and a 2% increase forecast for 2023, obesity looms as a healthcare crisis.
Globally, the World Obesity Federation just released a report which showed that at current rates over half the world’s population (51%) will be overweight or obese by 2035.
Medical Forum spoke with Dr Julie Manasseh, a practising GP who specialises in obesity management, on the stigma around the use of Ozempic and other weight loss drugs, as well as the implications of the failure to train more health professionals in this area.
“There was a huge demand for Ozempic when it was recognised and popularised on social media to prompt weight loss, people wanted a medication that would be effective at helping them to lose weight,” she said.
“This group of drugs, including Ozempic (semaglutide), are called JL P1 agonists and were originally developed for the treatment of type 2 diabetes, but as a result of noticing that they also produced weight loss, manufacturers have gone into the development and production of these drugs specifically for this purpose.
“For example, although Ozempic was originally developed as a diabetes drug, it has now been marketed and approved as Wegovy, which is just a higher dose of semaglutide, for weight loss.
“The difficulties we face, though, are to do with access to the medication for obesity.”
Dr Manasseh believes this is largely caused by the outdated attitude among governments and health departments, and even health professionals, that obesity is simply a lifestyle choice.
“There is a misguided belief that obesity can be fixed either by dietary changes alone or diet and exercise – the eat less, move more philosophy. Yet we know studies have shown that this is only a short-term intervention, and invariably, biological adaptations will lead them to regain any weight that they have lost,” she said.
“We are still stuck in that paradigm and not moving forward to accept the scientific, evidence-based model that obesity is not that simple, and once developed, it is a complex and chronic disease. In addition to the obvious weight gain, it changes the physiology of appetite hormones, cytokines, and inflammatory mediators – obesity is a pro-inflammatory state.
“We now have effective drugs for the treatment and control of obesity, but we don’t want to know about it because that could cost too much money on this side of the equation.
“There is this huge disconnect between constantly having these obesity summits and meetings, and pulling out all these dire statistics about how much obesity is costing the economy, and the reality of trying to lose weight under the current system.”
For example, in 2018-19, an estimated $3 billion of expenditure in the Australian health system was attributed to diabetes, representing 2.3% of total disease expenditure, yet according to the National Obesity Strategy 2022-2023, obesity cost $11.8 billion in 2018 and could cost an estimated $87.7 billion by 2032.
“However, more medication has been developed to target diabetes rather than obesity – even though being overweight is one of the best predictors of developing the disease,” Dr Manasseh said.
“The current model of thinking about health care is that we will treat a disease once it is established, but we are not really interested in funding medications for a condition that we know can lead to all of these.
“Governments are just not brave enough to envision a different model of health care where we consider prevention or reduction of future risks rather than just treating downstream complications.”
About 25% of Australian children are either overweight or obese, and multiple studies have demonstrated that childhood obesity is one of the major predictors of developing a wide range of serious comorbidities in later life.
“We are already seeing issues that previously would only have been found in obese adults –metabolic syndrome such as high blood pressure, high cholesterol and high blood glucose or diabetes,” Dr Manasseh said.
“The health trajectory for these children is not good at all, and the same physiological rules apply to children who have obesity – diet and exercise alone is not going to be enough.”
Dr Manasseh cited the American Paediatrics Association guidelines around the management of children with obesity, which strongly indicates the appropriateness of weight loss medications for children who have well-established obesity and may also have developing co-morbidities.
“But there has been a lot of controversy about this with people saying we shouldn’t be sticking children on drugs, but what about these children developing health problems and having a heart attack before they reach the age of 21?
“Early intervention is generally argued as the best possible step for almost any other condition, so why would obesity or overweight be any different?”
She said that another argument against the use of weight loss medication was what happened once the patient had achieved their target weight and treatment was stopped.
“Many studies have shown, including the step trials with semaglutide, that weight is regained over time after drug cessation. The question then arises, will people have to stay on weight loss drugs for the rest of their life to maintain their new lower weight?” she said.
“Many commentators say that this is too costly or offer other excuses. But if we view obesity as a chronic disease like we do diabetes or high blood pressure or someone with heart problems, then what do we do? Do we stop medication?
“Of course, we don’t, we continue them on their treatment in a lifelong manner to manage their underlying chronic condition. Obesity is a chronic disease and the concept that we cannot continue, or that it is too expensive to provide lifelong treatment, is flawed.”
Dr Manasseh explained that obesity is multifactorial, caused by a combination of genetic predisposition and our modern environment, which promotes a lifestyle with plenty of cheap, very palatable foods, high stress levels, and an increased risk of mental health conditions.
“It is very easy to become overweight and, in fact, it is the prevalent body type now,” she said.
“We only have one third of the population who satisfy the normal criteria for BMI and the irony is found in asking, ‘why is it then, that we are still holding on to this image that it is so important that you must have this specific look to feel like you are a worthy person?’
“People who are considerably obese can be afraid or feel ashamed to even step out of their homes because they immediately feel that just by looking at them, people are going to judge them negatively.”
WA-based research has shown that individuals who were on the receiving end of weight bias or discrimination had a 60% greater risk of mortality and were 2.5 times more likely to experience mental health disorders such as anxiety.
Dr Manasseh believes that the body positivity movement is an understandable pushback against the stigma that overweight and obese people face in our society.
“However, it is at risk of going too far the other way in a sense that there is a strong element of denial that obesity does carry health risks. It most definitely does. We cannot say ‘look, let us just not worry about our weight, let us just be happy about it,’” she said.
“But you can understand how that view came about because of enormous stigma that people have experienced in their lives, the amount of bullying and ostracism.
“And the fact that diet and exercise has failed them repeatedly, they are saying, ‘look, you are just telling us all the wrong things, you are telling us that we need to eat less and move more. We have done that, and we have ended up at a higher weight, and we are not going to diet anymore. We just want to live our lives’.”
Even health-care professionals are not immune from messaging. Curtin University-led research has found that Australian health-care students often hold negative attitudes and beliefs towards people living with obesity, which could lead to poor clinical care.
“Obesity management from a medical sense is a specialised area,” Dr Manasseh said.
“Aside from a knowledge of weight loss drugs, to work properly with a patient, we really must examine all the factors that have contributed to weight gain. We need to look at their mental health, stress management, sleep, eating behaviours and the contribution of any other medications.
“It is expected that a GP should know about everything and be able to help patients with everything, but the reality is that they have not received the training – they are playing it by ear themselves. Which is why attitudes can vary when discussing weight management with a patient, or whether they will even raise the issue.”
Doctors and other health professionals get minimal training, if any, in obesity management, she said.
“They know about the associated co-morbidities like high blood pressure, and they are quite comfortable in treating that, writing them prescriptions, and reviewing them. But they haven’t been taught how to address weight in a sensitive way with patients, and might struggle with the question of, ‘how do I help my patient with their weight?’,” Dr Manasseh said.
“This is a major disconnect. Two thirds of our population is overweight or obese and consequently present with all these health problems, but doctors and other health professionals are not trained to deal with it.
“One of the reasons why I took an interest in this exact area was that when I graduated from medical school over 30 years ago, obesity was not an issue, and it certainly was not in our curriculum.
“But in the 30 odd years that I have been practising as a GP, there were increasing numbers of patients carrying extra weight and I was telling them they have high blood pressure; they are getting diabetes – ‘you’ve got to go lose some weight’ – and then prescribing medications.
“That was all I could offer them, and I could not help thinking that from a first principle’s perspective, it did not make sense: why was I writing all these scripts for complications when I could help them with their weight, which might address those issues too.”
The impact of this lack of training is that many patients miss the benefit of sound medical advice from their GP.
“I have never done a survey, but just my impression from patients that I have spoken to is that when a patient thinks, ‘I need to lose weight and I need help with this’… who do they go to?” Dr Manasseh said.
“I would say that personal trainers are at the top of the list, along with commercial weight loss operators. Dietitians might be there somewhere at the third rung, but their GP is, in fact, not anywhere in the top five.
“Yet even dieticians receive little training in weight loss in a private practice situation. The curriculum for dietitians is very much geared towards prescribing specialised diets for hospital in-patients, such as people with kidney disease, and to develop that further, they too will need to do extra training after they graduate.
“We are all experiencing the same lack of education on obesity, and this is another major barrier for patients seeking help for their condition.”