If Semaglutide is the answer, what’s the question?

NICE’s view is that Semaglutide, originally proposed as treatment for diabetes, is a safe, effective and affordable intervention for weight loss. Semaglutide mimics a naturally occurring hormone glucagon which slows progress of food out of the stomach into the small intestine and makes people feel fuller for longer. NICE envisages that Semaglutide will be available by weekly injection only through specialist services and for 2 years maximum. It is already available on private prescription through private GPs and has been widely publicised by its use amongst celebrities. One further problem at the moment is that the pharmaceutical company that discovered Semaglutide isn’t producing enough of it. So, even if someone merits a trial, the drug might not be available. That fact may lie behind its likely limited availability through specialist NHS sources in England for the moment.

This new treatment option is not only good news for people with weight problems; the drug manufacturers are also looking forward to selling into a vast market, projected to be ten times its current size in 2031 (estimated at $150bn worldwide). We don’t know what the treatment costs to patients and the NHS in Scotland and across the UK will be – but we can safely predict that it will be a lot. Currently in the US, one such product costs $1,300 per patient per month (Wegovy).

These reports emerge at the same time as the World Obesity Federation’s forward look projects a further rise in overweight and obesity in the coming decade. Currently estimates of obesity prevalence worldwide are 1.1bn, with a further 1.6bn having overweight. That is projected to rise to 4bn in total by 2035, costing the world economy $4trn or 2.9% of global GDP – through working days lost to illness, healthcare costs and premature deaths. As The Economist comments: ‘That is the equivalent of another COVID-19 pandemic every year.’ 

So it is no surprise that countries will be willing to spend on a drug that reduces this burden on their populations, if they can afford it. As is the case with the inverse care law; ‘those who most need medical care are least likely to receive it’. Conversely, those with least need of health care tend to use health services more (and more effectively). This phenomenon applies for countries and communities the world over, including health systems such as the NHS. Reaching treatment and support that is in short supply, with thresholds such as access to specialist services and private GPs, suggests that those who might need treatment are least likely to receive a drug that is in short supply. More equitable ways of preventing and treating obesity are available, and we know measures we could design and deliver for that to happen.

We need to take urgent measures that could prevent obesity in the first place, and prevent obesity recurring when people stop taking the drug. There is no evidence so far that taking the drug stops people putting on weight when they stop it – indeed early data suggest that people regain two-thirds of the weight they lost one year after finishing Semaglutide treatment. The Economist quotes Fatima Stanford of Massachusetts General Hospital and Harvard Medical School saying that “attempts to lose weight through diet and exercise work for only 10-20% of the population…. for most people we don’t see a dramatic drop.” The downsides of both treatment approaches underline the difficulty of addressing higher weight once it has already developed. In the Guardian’s commentary, it quotes a professor of cardiovascular medicine who questions the approach to the structural influences of weight gain - “are you going to let the food industry go on feeding us this rubbish and promoting it… or stop the food industry doing this?” He goes on to say “it would be so much better to prevent in the first place.”

If Semaglutide is the answer, it seems the question is asking for quick, unsustainable solutions to systemic issues. If our leaders are serious about offering better health outcomes for citizens, they must start following the evidence on prevention.

• Weight loss drug semaglutide approved for NHS use. BBC News. 8 March 2023
• Big Shots: A new class of drugs for weight loss could end obesity. The Economist. 2 March 2023
• Inverse Care Law. Jon Appleby, The King’s Fund. 21 June 2001
• World Obesity Atlas 2023. World Obesity Federation. March 2023
• New diabetes drugs do not tackle root causes of obesity, experts warn. The Guardian. 5 February 2023.

Blog written by Dr Andrew Fraser, Steering Group Chair for Obesity Action Scotland

Image: EPCO Image Bank