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Journalism of Courage
With weight-loss drugs like semaglutide and tirzepatide taking the world by the storm — the World Health Organisation (WHO) has, for the first time, released guidelines on using these therapies for the treatment of obesity — defined as a chronic, relapsing disease.
While weight-loss has been treated as a cosmetic issue for years, the entry of these effective medicines has created a shift towards recognising obesity as a medical condition, which needs to be treated and managed to reduce risk of other chronic conditions like diabetes and heart diseases. Earlier this year, the inter-government agency had included these drugs in their list of essential medicines — a list that forms the basis for many country’s health systems ensuring access to them, government procurements, and medical reimbursements.
What are good practices and recommendations in the guidelines?
First, the therapies may be used for the treatment of obesity in all adults, except pregnant women, for long-term — meaning six months or more. This recommendation, however, remains conditional. This is because of limited data on the health impact of discontinuing these medicines.
Two, the guidelines suggested intensive behavioural therapy as a co-intervention in people prescribed the GLP-1 medications for obesity. The scientific review found other possible co-interventions such as lifestyle counselling, meal replacement and a lead-in phase with lifestyle changes. These recommendations were conditional, considering the low certainty of the evidence.
There are two good practice statements. One, treating obesity like a lifelong, chronic disease that requires holistic care including these therapies, surgeries, and other lifestyle interventions. Two, people living with obesity should receive counselling on behavioural and lifestyle changes as a first step to intensive behavioural therapy to support the use of GLP-1 medicines.
Dr Anoop Misra, chairman of the Fortis CDOC Hospital for Diabetes, says, “The guidelines are necessary for providing consolidated evidence to general physicians across countries, who may still not be well-versed in selecting appropriate candidates, providing proper doses, and managing complications. No one, other than the drug companies, are currently working on raising awareness about the use of GLP-1.” He added, India has now started looking at its own guidelines for diagnosing and treating obesity.
What are challenges of drug access?
First, and most important, was the equitable access to the drugs. Shortage of supply, unequal availability across the globe, and high prices are the challenges to access these medicines. The current production capability of GLP-1 therapies can cover only around 100 million people, which represents only 10% of the people currently living with obesity across the world. The availability can be improved with compulsory licences, a distributed network of manufacturers, and the entry of generics once the patent expires.
The medicines are also costly, prohibitively so for many people who need it. The inclusion of the medicines in the essential list also means more and more governments and insurance providers are likely to cover the cost. Dr Misra says, “In India, most private health insurance plans do not cover GLP-1 therapy for obesity unless prescribed for diabetes. Public schemes such as Ayushman Bharat and the government’s chronic disease management programme do not reimburse for anti-obesity therapies. Clearly, only a small percentage of patients who need these therapies can afford them. Significant gains in access will require efficient procurement, price negotiations or partial reimbursement. But these may be difficult to achieve in the near future. Low-cost generics remain a viable future option.”
Second, the health systems have to be geared towards life-long treatment of obesity by creating systems for screening, early diagnosis, referral, maintaining patient registries, and regular follow-up to check progress. And, there is a need to integrate it at the primary health centre level.
What’s needed for a new obesity management ecosystem in India?
For India to create a chronic care model as suggested by the WHO, Dr Misra says, there is a need to embed screening, diagnosis and follow-up of obesity at the Ayushman Bharat Health and Wellness Centres. These centres already screen for chronic conditions such as diabetes, hypertension, and the three most common types of cancers.
India, he felt, must build secure procurement and regulatory systems to prevent falsified and fraudulent GLP-1 products and to ensure uninterrupted, safe supply for patients. “This requires strict regulation and surveillance.”
Why do myths need to be busted?
Dr Misra points out that while specialists increasingly view obesity as a chronic disease, many clinicians and much of the public still consider it a lifestyle issue. “People often label an obese person as ‘healthy’ and someone with normal weight as ‘weak’. These misconceptions must change. Since GPs see most of the patients in India, a greater awareness in these physicians helped by continuing medical education is required.”
Who are high-risk patients who should be given medicines first?
When it comes to India, Dr Misra says, “The highest priority should be adults with BMI over 35 or those with BMI over 30, who also have severe obesity-related co-morbidities such as uncontrolled type 2 diabetes, established cardiovascular disease, advanced fatty liver disease or severe sleep apnoea. Such prioritisation will allow proper and efficient use of these medicines.”
