In many quarters, there will be a warm welcome to this week’s announcement by Health Minister Mike Nesbitt to set up a Regional Obesity Management Service (ROMS). The community-based service will allow access to Wygovey and Mounjaro– better known as the “skinny-pens”.
The minister said it was a “very important day for public health”.
At the end of last year, I took part in a BBC radio discussion about “skinny-pens”. NICE had just published its direction on tirzepatide (Mounjaro), and although the drug is licensed for the management of obesity (BMI 30), in the UK, the NHS only funds it for patients with a BMI over 35 plus one weight-related condition: diabetes, hypertension or sleep apnoea. I suggested to my radio host that using these drugs for “cosmetic purposes” was impacting availability for patients with, for example, diabetes. An expert on the panel was having none of it. All obese patients would benefit from the drugs, he insisted, and the NHS needed to make it more widely available.
I was then attacked for suggesting there was “cosmetic use” of the drug as all obese people need all the help they can get to achieve a healthy weight. This would in turn reduce future treatment costs for; diabetes, hypertension or sleep apnoea. There were, after all, too many people living with obesity and obesity is as much a disease as diabetes and hypertension.
It is a seductive argument indeed. Skinny pens; Wygovy and Mounjaro are being positioned by vested interests as the solution to our obesity problem. Initially in the ROMS access will not allow “cosmetic use” but off course mission creep will remain a risk.
The Fully Engaged Citizen
It’s now over twenty years since retired banker Derek Wanless published his report for the then UK Chancellor of the Exchequer Gordan Brown. Wanless was asked to consider how the NHS might be funded in the future, given its escalating year-on-year costs. He was not the first to realise that unless individuals take more responsibility for their own health, lose weight, take exercise, and stop smoking, a time would come when the NHS would be bankrupted by demand. He predicted that by 2025 diabetes itself would most likely destroy the NHS. You could argue that it does feel that way now that we have arrived.
Wanless promoted the “fully engaged” citizen; actively adopting behaviours to keep healthy and, as a result, reduce NHS costs. It hasn’t really worked out like that mainly due to a lack of investment in primary prevention and the wrong advice on diet. The obesity epidemic remains with some 66% of the population either overweight or obese. The incidence of Type 2 diabetes increased by 10% from 3 million in 2017 to 3.3 million in 2021.
The Wrong Dietary Advice?
In his book Too Many Pills, doctor and journalist James Le Fanu details a research paper published in 1975 by Dr David Hadden and colleagues from the Royal Victoria Hospital, Belfast. Dr Hadden took 50 patients with type 2 diabetes, split them into two groups, placed one group on a high-fat/low-carbohydrate diet the other group stayed as they were. He recorded significant weight loss at 6 months in the study group and more importantly a reversal of some aspects of diabetes. The control groups showed weight increase and worsening of diabetic parameters. His study was ignored because in those days, fat was the enemy, it caused heart disease and there were no exceptions; everyone had to reduce fat. To reduce fat, we must increase calories from carbohydrates. This was, and still largely is, government dietary advice and ironically it maybe the major cause of the current obesity crisis. Low-carb/high fat diets were ridiculed by medical authorities and banished to the Fad Diet section of high street bookstores and promotional articles in fashion magazines. And I’m not talking about the Dr Atkins Diet which is too difficult to comply with.
In his book Why We Eat (too much), bariatric surgeon Andrew Jenkinson updates current scientific thinking on the mistakes in public health messaging on diet. The problem is excessive consumption of processed foods based on simple sugars/starches (carbohydrates) and vegetable fats. Dr Hadden was right; we need improved public messaging and more regulation on foods.
A Pharmacological Solution?
Yesterday’s announcement brings N. Ireland into line with other UK regions. For England, NICE has allowed NHS prescribing for patients in Tier 3 and Tier 4 weight management services, mostly specialist centres in hospitals and which covers about 35,000 patients – not very many given the 12 million who potentially need treatment. NICE guidance generally applies to N. Ireland so ROMS will allow us access to these drugs but how many are we planning to treat?
In June 2023, the UK government announce a pilot to add 40,000 patients to treatment by GPs and to determine Wegovy’s real-World effect. I’m not aware of any outcomes and I do wonder why?
When these drugs are used as recommended, patients reduce weight by 15% to 20%, and that is really significant. However, when treatment is stopped, the weight returns, questioning the sustainability of this approach.
On the wrong side of history?
Where debate will continue on whether obesity is; a disease, a syndrome or a natural response to an abnormal environment, there remains little disagreement on the causal link between obesity and illness. Yet for obesity, the question whether a drug or a lifestyle intervention is superior has been, up until now, in favour of lifestyle intervention; better diet and increased activity have been proved effective in reducing morbidity and mortality. To say it should be both drugs and lifestyle is naive and suggests we really don’t appreciate how these potent satiety drugs work.
Losing weight is difficult and perhaps too many people struggle to achieve meaningful targets. Individuals with insulin resistance, for instance, have been shown to lose weight only half as successfully as others by whichever means is attempted. I have no issue with using these drugs in patients with diabetes.
I might find myself on the wrong side of history in this debate but I do feel it perverse that “skinny-pens” are being positioned as a key solution to our obesity problem. I worry about mass medicalisation because moral hazard is writ large across this policy trend. With these drugs, there is no need to change, alter food intake, or bother taking exercise.
A service with an emphasis on satiety agonist drugs is a dystopian future and one that would have Derek Wanless and David Hadden turning in their graves.
I am a pharmacist in Belfast.
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