Is obesity a disease, a syndrome or a natural response to an abnormal environment, asks Terry Maguire
Ministerial announcement
In many quarters, there was unrestrained jubilation on the announcement by N Ireland’s Health Minister Mike Nesbitt that he was setting up a Regional Obesity Management Service (ROMS). The community-based service will allow health service access to Wegovy and Mounjaro — better known as the ‘skinny-pens’, as the headlines ran. Speaking to the BBC at the end of May, the Minister said it was a “very important day for public health”. Unfortunately, a superficial reading of the report would have informed the laziest of journalists that skinny pens will not be available on prescription anytime soon, and it was probably not an important day for public health by any stretch of the imagination.
What the Consultation Analysis Report on a Proposed ROMS for N Ireland is, is a skilful blocking tactic. It allows our DoH to say it’s doing something about obesity, when it has little intention of doing anything because it doesn’t have the money. With this report, it can duck accusations of denying access to life-saving medicines, as the lobbyists are claiming. The game however has changed, personal responsibility for health is out, mass medicalisation for obesity, it seems, is in and it is coming to the Health Service when budgets permit.
Abuse on the BBC
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 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. 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 Wegovy 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 of course mission creep remains a risk.
The fully-engaged citizen
It’s now over 20 years since retired banker Derek Wanless published his report for the then UK Chancellor of the Exchequer Gordon 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, stop smoking and reduce stress, 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 perhaps the wrong advice on diet. The obesity epidemic remains, with some 66 per cent of the population either overweight or obese. The incidence of type 2 diabetes increased by 10 per cent, from three 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, and the other group stayed as they were. He recorded significant weight loss at six 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 may be the main 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. Dr Hadden was right, we need to be eating more natural fats and we need improved and updated public messaging on foods with more regulation of processed foods that are disproportionately affecting the health of the less-well-off in society. In the US, Robert Kennedy Jr is, to his credit, doing this.
Dietary advice based on evidence
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. Excessive consumption of processed foods, which are based on simple sugars/ starches (carbohydrates) and vegetable fats, is the problem. This is the Western Diet. Seed-based vegetable fats (not olive oil) contain too many trans-fats and are too high in omega-6-fatty acids. We need a one-to-one ratio (1:1) in our diet for the essential fatty acids, omega-3 and Omega-6. In the Western Diet, it is 1:30.
Our body weight is certainly much more complex than calories-in/calories- out. We each have a ‘weight set-point’, or so the theory goes. The set-point is the weight our bodies aim to maintain and will do so with tireless determination by use of hunger and satiety hormones. Try interfering with your set-point by,
for example, going on a calorie-reducing diet, the set-point will kick back and you’ll end up heavier as a result. Dieting does make you fat.
The set-point is determined by our genes, our epigenes, and our environment. For example, the genes in people living in the Middle East who over recent centuries were subjected regularly to severe famines (and survived) have a genetically selected high set-point and when faced with a Western Diet, pile on the fat. More amazingly, a mother with a normal set-point who is subjected to famine during pregnancy will cause her foetus, by epigenetic processes, to raise his/her set-point because the environment they are about to enter is predicted to be a harsh place where calories are few and far between. This is what was recorded in the Dutch Famine in 1944.
In the Irish population, in common with other European nations, there will be roughly equal numbers of individuals with low, medium and high set-points. Faced with a Western Diet, these will manifest in the statistics that have emerged over the last 40 years, giving us the obesity problem we now face. One- third are unaffected and remain normal weight, one-third become overweight, and one-third become obese. Resetting our set points requires a significant shift in diet, back to how we lived and ate in the 1970s. That’s perhaps too great a challenge for public health.
A pharmacological solution?
Minister Nesbitt’s ROMS announcement brings N Ireland into line with other UK regions. For England, NICE has allowed NHS prescribing of GLP-1 agonists 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 should now allow us access to these drugs, but how many are we planning to treat?
In June 2023, the UK government announced 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 per cent, and that is really significant. However, when treatment is stopped, the weight returns, questioning the sustainability of this approach. This certainly means skinny pens do not lower the set-point as 50 per cent of weight loss of muscle tissue, which reduces basal metabolic rate.
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 of 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 to bother taking exercise.
A ROMS 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.
Terry Maguire owns two pharmacies in Belfast. He is an honorary senior lecturer at the School of Pharmacy, Queen’s University Belfast. His research interests include the contribution of community pharmacy to improving public health.
