Dr Sean Wharton, Medical Director of the Wharton Medical Clinic in Toronto, speaks to HEQ about the treatment and care of people with obesity.
In May, Novo Nordisk announced the latest results of its STEP phase 3a clinical trial programme, which showed that the medication semaglutide 2.4 mg demonstrated potential benefits in the treatment of obesity – not just as a means of achieving and maintaining weight loss, but in improving physical function for people living with obesity and excess weight.
Dr Sean Wharton, Medical Director of the Wharton Medical Clinic in Toronto and an investigator on the study, speaks with HEQ about the study’s findings and the treatment and care of obesity as a condition.
What secondary health issues are commonly associated with obesity?
80% of people with Type 2 diabetes are overweight or living with obesity. This means that obesity is effectively responsible for up to 80% of Type 2 diabetes cases; and diabetes is one of the most significant conditions that we deal with on the planet. Every condition where there is inflammation that causes a problem is associated with elevated weight, from head to toe: that includes conditions such as Alzheimer’s, strokes, heart disease, fatty liver, COVID-19 and related lung manifestations, and cancers, which we should really highlight.
Cancer is an inflammatory condition: cells are damaged and they have to be repaired; the more you have to repair a cell, the higher risk you have of cancer developing. Obesity is a major factor in causing conditions associated with rapidly producing cells, such as colon cancer or breast cancer.
Is there commonly a mental health component to obesity as a condition?
If we look at all people living with obesity, there is not a higher level of mental health conditions associated with that entire population. If we then break it down to the people who are seeking care, however, whether that is at a dietary level, a pharmacotherapy level or at a surgical level, we see a higher rate of poor mental health than within the general population. The literature that pre-dated very effective pharmacotherapy treatment options showed, to a degree, that mental health was a major factor in the quest to seek care.
Whether the mental health is connected with a person’s obesity being worse – that is, people who are looking for surgical intervention have a higher level of mental health challenges – or whether it may be the case that people with mental health conditions seek more intense levels of treatments, we do not yet know the answer to that. It is a complicated issue.
How does semaglutide 2.4 mg work to improve physical functioning in people with excess weight or obesity? How can this in turn have a beneficial effect on people’s overall quality of life?
Semaglutide 2.4 mg works to prevent the hunger experienced by someone who is on a diet. You have to take in fewer calories to decrease weight, but as soon as you have fewer calories, your brain starts to trigger neurochemicals that say: eat more. This medication allows you to have less hunger so that you can use the energy stored in your fat cells for your daily calorie needs, and that allows you to continue to lose weight over the long term. That is what I tell my patients: they do not always understand the neurochemical and neurohormonal aspects, but they understand that when they are on a diet, they will get hungry; semaglutide relieves hunger, allowing them to use the energy stored in their fat cells for their daily calorie needs over the long term; and that is why they are able to lose weight in the long term with this medication.
Primarily, semaglutide 2.4 mg is able to improve physical function because it helps to decrease weight. When your weight decreases over the long term, you can move better; and semaglutide 2.4 mg is very effective at decreasing the weight and keeping it down for longer.
When we talk about ‘moving better’, people often think of things like going to the gym or exercising at an intense level, but really, for many people it involves being able to do everyday activities such as bending down and tying their shoes, getting up from a chair, or being able to climb stairs. Many people who are not living with obesity may not realise that those regular activities can be a struggle for somebody who is living with excess weight.
Long-term weight loss makes those people’s lives better by making their regular functioning throughout the day more plausible, and it also allows them to do more strenuous activities.
Are there any key side effects or contraindications for semaglutide 2.4 mg that patients should know about?
The good news here is that this medication has been used for a long time in the treatment of diabetes, so we know most of the side effects and we know that they are not overly concerning for the majority of patients. The main side effect is nausea, but that is a tolerable side effect which dissipates over time. The other predominant side effects are largely gastrointestinal, and again, they are tolerable for the majority of patients: only 4% of patients or fewer will actually discontinue the medication due to any side effects.
Semaglutide 2.4 mg recently received approval from the US Food and Drug Administration (FDA) and is now under regulatory review by the UK’s National Institute of Clinical Excellence (NICE) and the European Medicines Agency (EMA) among others. If it is approved as a treatment option for obesity by these agencies, what will be the next steps?
In my opinion, for an effective medication to be used in an appropriate way, healthcare providers, people with obesity and stakeholders have to recognise that obesity is a disease that is worthy of pharmacotherapy treatment, not simply the ‘lifestyle’ type of treatment revolving around diet and exercise – which has been proven over and over again not to be effective, because there is no way to maintain the diet and exercise due to neurochemical changes in the body which drive the weight back up. For people living with obesity who are looking for effective treatment, the most important thing is for their physician to recognise that their obesity is a disease and that they should assist the person with effective treatment options; and semaglutide 2.4 mg is one of those effective options.
Is there a need for wider acknowledgement of obesity, both at the policy level and at the medical level, rather than – as commonly appears to be the case – viewing it almost as a moral failing?
That is the most important step that we can make within medicine for a pandemic such as obesity. Obesity is a pandemic; and the lack of recognition of it as a disease, as opposed to a character flaw or a moral failing, has been the single biggest challenge to addressing it. There are a number of countries which are ahead of others in terms of recognising that obesity is a disease; there are medical associations recognising it; going past that level, there are doctors and patients who recognise it. Once that happens, there needs to be pressure on the stakeholders, such as the insurance companies and the government bodies which help to implement healthcare, to take notice; because their own voters, their own constituents and the people who live in their country are not going to be pleased that they are not recognising a disease when there are effective treatments out there. We have seen some countries step up to the plate, where all levels are actually working very well, but the majority of countries are still behind in terms of this recognition.
Biases at all levels, wherein people do not believe that obesity is a disease and believe instead that it is a character flaw, have been one of the biggest things that have stopped effective obesity intervention. This bias comes both from outside sources – from doctors, stakeholders and governments – and there is also an internalised bias, where many people living with obesity feel that it is their own fault. They have been fed this message for years, through stigmatising pictures and dialogue that they see every day, telling them that obesity is not a disease and that they themselves are the problem; and as a result, they have internalised that message. Therefore, they themselves do not believe that this disease deserves treatment beyond their own ability to be better, to use more willpower to correct their character flaw. And it is unfortunate that those stigmatising images and dialogues have been so pervasive, so intense, and so global that obesity has fallen to the wayside in terms of having effective treatment options. This is the main reason why obesity is not treated in an appropriate fashion: it is because of external and internal bias.
It must be quite demoralising to internalise that message that obesity is a personal failing on your part, and that you could fix it if you just tried hard enough, and then to try and fail. Is there a possibility that those internal biases could tie in with the mental health component?
We do see that people have something called learned helplessness. If you keep failing over and over again and nobody gives you an opportunity to fix the problem with an appropriate treatment option, you become helpless in your attempts and you stop trying. We certainly see that as an emotional challenge – it is not necessarily a mental health condition; when we talk about mental health conditions, we are talking about major depressive disorder, schizophrenia, medical and neurochemical conditions that cannot be easily fixed by somebody saying: you are a good person, I believe in you.
It is not so much the case that people living with obesity run into mental health problems as that they have a failure of the system believing in them, therefore they are stigmatised and stereotyped; and that is painful. We would not say that racial minority communities have a mental health condition, they are just treated poorly on a regular basis and they internalise that at times as well, making their daily life and their world very challenging. The same principle applies here: people living with obesity are demoralised all the time, by their family members, by doctors, by providers and stakeholders saying: we don’t care about you. That causes an inability to effectively help themselves until anger builds up and a resilience happens where there needs to be an actual change.
People living with obesity today are saying: we do not have a mental health disorder. We have a lack of care, a lack of recognition, a lack of being treated in an appropriate fashion. We are competent, bright people, we are not being treated well; and that is no longer OK. And we demand effective care.
There are three key pillars of effective obesity treatment: psychological intervention; pharmacotherapy; and bariatric surgery. Those three pillars are what upholds the diet and exercise element of losing weight. The only way to lose weight is to eat fewer calories, but the three pillars strengthen that diet to a much greater capacity than shaming and blaming a person or forcing them to rely on willpower alone. Shaming and blaming do not hold up a diet for very long; it will usually fall down very quickly.
Key to the psychological intervention is telling somebody that they need to work on self-love and self-efficacy, that you must love yourself at 350 pounds first or else you will never make it to 250 and actually stay there; the pharmacotherapy allows patients to keep that dietary aspect for much longer and to deal with natural hunger; and bariatric surgery may be needed for the people who have a significant elevated weight. Many people tend to think that obesity management begins with diet and exercise then moves on to something a little more intense and then we move on to something more attached – that is not the case. It is the ability to do the diet and exercise supported by these three pillars, which is a completely different paradigm. There is no one specific diet whether it is paleo, keto, intermittent fasting – the question is always what the support is for it, and that support comes from those three treatment pillars.
Dr Sean Wharton
Wharton Medical Clinic
This article is from issue 18 of Health Europa. Click here to get your free subscription today.