Harry Rakowski: Dealing with the obesity epidemic: New drugs could be a gamechanger

Trials have shown semaglutide and tirzepatide produce significant reductions in weight
An obese man sits on a park bench with two others in Calgary, Alta., Monday, May 17, 2021. Jeff McIntosh/The Canadian Press.

Weight gain has been a common occurrence during the pandemic. Many people felt that the virus infected their clothes and made them “shrink in their closet” as they exercised less because of social isolation and ate more due to stress. 

The trend of gaining weight is not new. Obesity rates started climbing in the late 1970s and corresponded to the rise of eating out and consuming fast foods and high-carb meals. The Centers for Disease Control and Prevention estimated that in 2000, about 30.5 percent of Americans were obese and by 2018, about 42.4 percent had reached that weight level. Interestingly the greatest weight gain occurred in people’s mid-20s to mid-30s with an average weight gain of 17.6 pounds in that decade of life. Subsequent weight gain averaged a pound a year. 

The epidemic of obesity was also driven by an addiction to supersized portions of foods with high fat, salt, and sugar starting in childhood. We continue to have more sedentary work and spend more time on devices and less on exercise. It is not surprising that this trend has been associated with growing rates of diabetes along with its health risks and complications. 

You can determine your own ideal weight by calculating your body mass index (BMI) using the calculator from BMI represents your weight indexed to your height and provides a measure of whether you are in a healthy range of 18.5 to <25. A BMI of 25-<30 indicates being overweight, over 30 is in the obesity range and over 40 defines severe obesity. 

Obesity is now recognized as a disease with very negative and expensive public health outcomes. In addition to diabetes, it leads to a much higher risk of hypertension, stroke, breast and colon cancer, and degenerative arthritis. 

Obesity is caused by an interplay of genetic and environmental causes. Brain imaging studies have shown that there is an important genetic link in obesity affecting parts of the brain involved in impulse control, reward processing, and how we determine whether we are full when we eat. Physicians who simply advise and shame obese people by saying “all you have to do is eat less and exercise more” aren’t providing ideal advice. Managing obesity is challenging and requires a combination of eating better, exercising more, reducing stress eating, and when necessary using newer, safer medication. 

Diets often simply lead to yo-yo-ing with alternating weight loss and weight gain often due to the feelings of deprivation when on a “diet”. 

While not overeating remains important, eating “healthy” is superior to dieting. A Mediterranean diet of fruits, vegetables, beans, nuts, fresh fish, and olive oil has been shown to control weight and increase life expectancy. 

Exercise combining 30 minutes of cardiovascular exercise, resistance training, and stretching will also increase wellness and prevent frailty. 

It is of course tempting to just be able to take a pill to fix the problem. In the 1990’s Fen-Phen, the combination of two drugs, was approved with excellent weight loss benefits. The drug worked by increasing brain satiety and reducing appetite through its effects on brain chemicals serotonin and dopamine. Unfortunately, the drugs rarely caused life-threatening high pressures in the arteries to the lungs by constricting blood vessels. They also could stimulate receptors in heart valves leading to scarring resembling the effects of rheumatic valve disease. This led to the withdrawal of the drug and over $20 billion in lawsuits in the U.S. alone. Other drugs such as rimonabant also had to be stopped because of excessive side effects, such as depression and suicidal thoughts. 

That often left bariatric surgery as the best way to reduce stomach size to tell the brain that you were full earlier. The surgery could be done by an abdominal incision and stomach stapling or bypass, or by placing a stomach constricting band laparoscopically. These operations while useful, again had risk and the laparoscopic version was not always covered by insurance. 

The hottest current treatment is the use of drugs such as semaglutide and tirzepatide that treat diabetes and have very few serious side effects. While they have been popularized by stars and influencers posting about taking them inappropriately for minor weight loss, their greatest role is in managing true obesity. The drugs were approved for use in diabetics to reduce blood sugar and were found to have the additional benefit of significant weight loss.

Newer randomized trials focusing on weight loss alone showed about a 17 percent reduction in weight with semaglutide (Ozempic/Wegovy) and more than 20 percent with tirzepatide (Mounjaro), levels typically achieved by bariatric surgery. Only about 5 percent had to stop the drugs for intolerable side effects such as nausea, compared to 1-2 percent of the placebo control group. Rare, more serious side effects include pancreatic inflammation. 

The drugs work by mimicking gut hormones (GLP-1 and also GIPR for tirzepatide) that are secreted after eating food. While the mode of action for both drugs is different, they both increase insulin production, reduce insulin resistance, delay stomach emptying, and fool the brain into thinking you are full faster. 

These drugs have become so pervasively popular in reducing weight that overuse by those not obese has led to shortages of the drugs for diabetics who need them most. Access to those truly obese has also been limited by cost. While in the U.S. insurers will pay for the drug when used for diabetics, too many continue to not pay for obesity use, falsely arguing that obesity is simply a lifestyle choice, rather than a true disease. Since the U.S. drug cost is about $12,000 per year, few uninsured people can afford it. The drug price is about 1/3 of that in Canada. 

Obesity remains an all too common disease with multifactorial causes and is often resistant to intervention. For those with a BMI over 30 new drug use can help jump-start a comprehensive plan for successful, long-term weight loss. It shouldn’t be abused as a social drug. Insurers need to pay for its use when the level of obesity creates long-term risks and treatment will save both lives and downstream costs. Pharma companies have to also reduce their level of greed and lower cost and provide free drugs to clinics caring for those who are under-serviced and often need it most. 

The treatment of obesity requires compassion, education, better lifestyle choices, and affordable new drug therapy. Complex problems require thoughtful integrated solutions. Taking an important new drug can help break the frustration of not being able to overcome obesity. It isn’t a magic bullet and the effect wears off when you stop the drug. Its use needs to be complemented by eating less unhealthy addictive food that damages your microbiome and impairs gut health.

While obesity is a disease and genetics plays a role in its development, our behaviour modulates the effects of genetics. We often use food as an anti-anxiety drug. While we now have drugs that can safely help treat obesity, they won’t work without also working on our emotional health and what drives our addiction to the wrong foods. 

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