Beyond the scale, obesity in the age of GLP-1s

(upbeat music) - Hello and welcome to Inside EMA, a podcast about medicine regulation and the science behind it and the people making it happen. My name is Julia Gabrieli, I'm a communication officer at the European Medicine Agency, and I'm joined today by Dr. Bart van der Schuere. Dr. Bart, as we call you in this building, is an endocrinologist and a obesity specialist working out of K.U. Lurva in Belgium. And honestly, but I cannot think of a better person to have here today because the topic that we're going to discuss is obesity and weight loss medications. And I know that you have plenty to say on the topic. So welcome Bart. - Thank you. - Maybe we can start with a look at the number. So we know that over half the population in the U now is either overweight or living with obesity. Some countries support us as one in five children in four children with the same issue. Why do you think this is? This is a massive question for one person, but why do you think this is? - Yeah, it's a very good question, and there are several reasons. So currently in most of the European countries, the incidence prevalence of the disease obesity is at about 20%, so one of the out of five adults, that's a huge number. The number of people living with overweight is over half of the population in the adult population. And even in children where the figures are relatively small, so to say, because it's only 7%, also depending a bit on the country, even there it's a problem, because we know that if children are living with obesity, the chances that they will have a lifelong struggle with that disease is very likely, it's up to 80%, 85%. So there is a multitude of reasons. The first reason is that we live in a very, in a surrounding that when you have a tendency of having a problem controlling your weight, this will come out. So it's what they call a zogen environment. - So we are talking here about the kind of availability of easily, prepareable, palatable food about sedentary lifestyle, this kind of. - Exactly, it's all the commercial determinants, we're constantly reminded of food. The food industry knows very well how to make food, it's really palatable for us, that's also a very high in calories. But it's much wider than that, there is also the fact that a lot of people don't have time to not have a sedentary lifetime. I think if you live in the Netherlands and have to travel from far away to Amsterdam, you lose an enormous amount of time that you could be moving and you're not moving, and by the way, the Netherlands is not the worst country, because they cycle quite a lot. - We won't name and shame. (laughing) But that's also the fact that a lot of our, the way we spend our free time or hobbies are often sedentary as well. So we see a move away from football, et cetera, to online elements, but it's even more complicated than that, in the sense that people are also often taking medication for other issues, such as antidepressants or antipsychotic medication, but it can be really any kind of medication. The easiest example is cortical steroids, but also insulin, for example, very difficult to control your weight when you're using these medications. So depending on the person, the reason why someone is struggling to maintain their weight at a healthy weight can be very different. But overall, and this is maybe the most important thing to emphasize, when half of your population is struggling to maintain a normal weight, something is going wrong in your society, and that cannot be fixed by just a drug. And we are, I mean, there is a good side to this in a way. We understand obesity much better than we used to. There are countries who are now like enshrining it in regulation that obesity is a disease. And kind of what do we know about the condition now that maybe we didn't know, say 10 years ago? Well, I think when I was in medical training, which is more than 10 years ago, we don't have to know. But what we basically were learned is, well, move more, exercise more, and eat less. And that's the sole advice you're going to give your patient. What we know now is that this is very far from what you should be doing as a physician. You should, first of all, look at root causes, like look at someone's medication's list. Is there any medication in there that's actually increasing their weight? But also you should understand that weight is a heavily regulated characteristic of someone. So in normal circumstances, people will not lose weight when they don't really try to lose weight. So if somebody says, I'm without doing something, I'm losing weight, every physician knows something is wrong with that person. And we should investigate what exactly is wrong. So on the normal circumstances, your body is very able to defend its body weight. And this is because of a complex interplay of hormones, neuronal circuits, which is all about maintaining weight even in periods where the food is not readily available. And that system has worked great for the human species. We are slightly-- Not so much now. But it's not great when you live in a surrounding that's full of food noise. Thank you. And do you think that part of the understanding, or even part of the awareness that we have now around obesity, is linked to the fact that maybe for the first time, we have these medical treatments for it. And I'm obviously talking about G.O.P.1 medicines, medicines like ozampic, wagovi, mongaro, zapbound. Do you think there is a link now with the awareness here? Yeah, of course, because that has meant that in order to make a drug, you need to know what to target. So in making that drug, we needed to understand the hormones, the gut hormones that regulate weight, the satiety hormones, the hunger hormones. And so that's how all the developments came along of the G.O.P.1 receptor reginists. But what I find a bit disappointing is, first of all, the preconceived conceptions that people have about people using this kind of medicinal products. Sometimes you hear very negative comments like they don't have the willpower, so they're going on a drug. Also from people themselves saying, I don't want to do a diet, so I'm going on the drug. And that's a completely wrong use of this medication. Let's talk about G.O.P.1 medications, and since you bring them up, could you explain what they are and kind of also maybe how they've impacting your role as a physician, kind of how is your job changed with them? So in essence, G.O.P.1 medications are just analogs of human endogenous hormones. So everybody makes G.O.P.1. We make it one cells of the intestine coming to contact with food. And it's actually to signal towards the insulin-producing cells in the pancreas that they should make insulin because food is coming. And on the other hand, it's to signal to the brain, well, stop eating because there is food present in the intestine that still needs to be digested. And so in a way, it was an endogenous hormone that we have now produced, and that we can now give to correct for a lack of that hormone functioning in people but living with obesity. So people who have type two diabetes and who are living with obesity, we know that that's G.O.P.1 signal that should normally arrive to the brain and to the cells making insulin, doesn't arrive as well. And so you're giving higher pharmacological doses of that hormone. OK, and a little bit, I mean, you going back to the same question, how has this changed the way that you treat obesity, the way that you work with people living with obesity who are coming to you seeking? It's a dramatic change because it means that you finally have a tool to treat, to help people living with obesity. Previously, it was either saying, well, diet and exercise, quite honestly, most of people that are living with overweight and obesity have tried that, a multitude of times. We have embellished on a study in which we show that people have tried 10 to 15 diets before they even talk about their way to their physician, just to show, because they think, well, my physician is not going to be helpful here. So the fact that you have a tool is very good. And the other tool that we had was surgery, but surgery, of course, is a very drastic decision to make. Now, on the one hand, it has changed things in a very positive way. On the other side, we have. to admit that the implementation of these medications in clinical practice has been a bit dramatic, meaning that often countries don't have it in the reimbursement system until you actually develop a comorbidity and then the most common comorbidity is type 2 diabetes. But also there it's really a life changing drug because people that are treated with GLP1 agonists will lose weight, will see an improvement of the glycemic control, can go of insulin sometimes, can have a remission of that diabetes. So also for type 2 diabetes these are very very potent and good drugs and what you see is that in type 2 diabetes they have found their way to the patients, they have found their way to the reimbursement agency but with people living with obesity and with other comorbidities such as cardiovascular disease or such as osteoarthritis etc. way less it's often not reimbursed and therefore people find it expensive or when people choose to pay for it out of pocket they will often not pay the dietitian or maybe the physiotherapist that also needs to accompany this because you need to have an adapted diet for when you're using these drugs and you also need to move a lot because otherwise you risk losing muscle mass. Okay and I mean you talk about diet and exercise being the number one recommendation that you would have once given in the past but I guess this is still a recommendation that you give. So what differentiates people who eventually get recommended GLP1? I mean when would you consider this appropriate and also what does it look like then to be on a GLP1 treatment? Well to be on a GLP1 treatment is really something that the first and probably the most important misconception about being on a GLP1 treatment is that it's all not that fun. I mean it's a drug that really helps you but at the same time obliges you to adapt your eating behavior. Wait and that's a misconception? Well some people still think it's the easy way out but it's not so easy. It's not so easy because you should structure your meals. Everybody should do that but especially when you're on a GLP1 you don't feel your hunger sometimes but you should still be eating at a regular basis and also those meals should be of high quality because otherwise you risk having shortages of micronutrients vitamins etc. And is that why for example we see people talking about lots of muscles, sarcopenia when they're exactly also because you should eat enough protein. So you should slightly the way your meals or put together should change the composition of your meals should change a bit when you're on a GLP1 agonist. And for some people it's not that easy to adapt to that and one of the things we see is that people also eat very fast and if you eat very fast on a GLP1 agonist you feel nauseated you don't feel well because it also slows down the emptying of the stomach. So it's first of all something that's not so easy to manage although the side effects are of course manageable but you should be advised on them. So don't buy a GLP1 receptor agonist online and think you can plug and play but the second thing is that you should also realize that when you start taking these medicines these are medicines that are long-term medicines and this is also a misconception people think well I'm gonna take this for a while until I achieve my desired weight and then I'll stop them and this is not the way these drugs work because this interplay of hormones once you start interfering in it you really need to take it chronically and we know that when you use it chronically your weight will stay off but you will stop losing but you will find a new equilibrium you will find a new set point and you've mentioned I mean you mentioned buying these medicines online right I think between social media, internet, celebrity culture these are basically the most famous medicines in the world who hasn't heard about it and I imagine I mean this has implications it has implications on how we use them it has implications on the perception that you have these are prescription medicines right you should have them you should be contacting your physician to get them you should be supervised by a physician once you're getting them and also they're not for everyone right? No and I think like with every new drug there's a very nice thing in Latin which is Vestina Lente go slow hastes have a slow pace when introducing new medicines and also first treat the people that are suffering most and are in need most and I think this is a very important concept because if you would just looking at Belgium which has 11 million inhabitants if you would go along the official label of these weight loss drugs you would be treating over 4 million Belgians with these drugs and this is not a number that's feasible and it's also not a number that's desirable until we know more on the long-term effects and we are following by the way the long-term effects and everything looks good but still it's not something that should be introduced too rapidly into a very big group of patients so who's most in need that are those people who have the most severe cases of obesity and so very important is that people living with obesity are staged and that you look at what is the effect of the excess of the positive on their functionality, on their mental well-being and on their metabolism, on their other organs, on the liver for example, on the heart and that people who are most in need or those who are most severely impacted and there we still see a shortcoming now it's more the people that come to ask for it so they're well-informed people that usually also have the deepest pockets so to say that are on the drug and are profiting from the drug where is people that are less informed people that actually should be on them don't know about them and don't ask their physician about them and do you think about this do you think that there is a large, large number of people who are for example not overweight or not living with obesity who are using or seeking the medicines? I don't even know. I'm afraid, yeah, well actually the European Medicine Agency did a study on this, a Darwinian use study, on to look at the off-label use but sometimes we refer to as the cosmetic use, it's a very negative term I think of the GLP1 receptor reganist. We did that at the time of shortages because especially at that time it was important to make sure that there were big shortages of these medicines. We reviewed shortages up until last year right. Meaning that people for example with obesity and diabetes couldn't get them and so that was something we needed to intervene in and we have to say that from the results from these studies we were quite reassured so apparently doctors do behave and they too prescribe within the label. What you do see is that people and especially people that may not have the deepest pockets so to say they go and look for this drug online or even in foreign countries and that's very dangerous because there we see that people are actually injecting products that don't have the quality stamp on them they should have so you should really get these drugs on prescription from a pharmacy and not in foreign countries or also not online at least if it's not a source. And I mean the usual principle online if it looks to go to be true, it's probably not true. Also I mean the EU has done a lot to kind of identify authorized retailers online so even when you're buying online you can check whether you're buying from a pharmacy so definitely there is something to be said about this. But I mean is this in Europe I guess the situation is what you just described but there are definitely countries where this medicine is advertised by celebrities and so on who are not overweight and who are not and are we going to get to a point where everybody is going to be on the smite of the set? I honestly hope not I honestly hope that food industry will also use the knowledge that we have now generated to make food products that are actually helping us, helping us maintaining our weight so I think that's and there are moves in that direction by the way and Europe luckily also has a quite well regulated food industry so although often we get criticized, Europe gets criticized that it's slow and etc etc sometimes being slow is not so bad and definitely being able to work in a regulatory environment also for companies is actually often better because it gives you reassurance. But that's maybe not really on topic here. But I definitely hope that not everyone will need this drug because it's also very cynical. We're going to have a food industry that pushes us towards obesity. And then on the other hand, we're going to pay a pharmaceutical company to give us injections that makes us able to maintain or wait in that kind of environment. It doesn't make any sense. It's paying twice. But what I think is kind of dangerous with this framing of GLP1 agonists is first of all that people who need it now sometimes become afraid of it. So this is something we've seen with patients that they're like, "Yeah, but I don't want to be on that because I've read that you get an ozemic face." And so that's sad because they would benefit from the product. And so it takes away the credibility of the product. And I think it's important to emphasize that if a product is on the European market, it means that the benefit risk is positive and that it's looked at by people that are objective. And the second thing is, and this is also something that you will have seen, there is a lot of noise out there about food supplements that are claiming to be the new natural GLP one. And that's based on very thin evidence. It doesn't have, so there is a lot of noise around this class and I hope that kind of goes away. And I'm happy to see actually that lately I haven't been contacted so much by the Belgian press at least. And I haven't seen so many celebrities finding it necessary to give their experiences with this class of products publicly. OK, that's a reassuring message. Maybe we are moving towards a balance. I think we're moving towards stabilization yet. So we ask this to a lot of our guests. Is there a movie or a book that you've read recently related to the topic that has made you think and that you would like to recommend to our listeners? Well, one of the movies that I find a great movie is Ray Quillham for a Dream. Oh, I got it. Prasic movie in the world. It's not the most blifting movie. But in this movie, there is the mother of the lead character that is trying to get into a TV show and she wants to put her wedding dress when going on that TV show. And she starts taking emphetamines to lose weight. And this is something that we honestly see that people try everything to lose weight. And well, it goes, people should watch this movie. It goes completely sideways, put with sun and mother before-- Definitely puts you off using any type of drug, I would say, the movie. It just shows that it's not a good idea to use drugs that have not been true, a proper regulatory system. Thank you. Maybe if you find all words, if you're trying to lose weight, number one thing to do, contact your physician. Well, first of all, drop the shame and indeed contact your physician. Don't think he's going to be useless. If, however, your physician is useless, go to another physician. But that's the first thing. Talk to a physician. Have your hormones checked. Also, when you see that you are prescribed a drug for any other reason and you see that you're gaining weight, talk to your physician as well and tell your physician. And sometimes they will react like, yeah, but that's a side effect. But that you need help with that-- that he needs to switch to another alternative. Because once the weight is on, very difficult to get it off. And this is because of our physiology. And then also look at reliable sources for advice. And I still think there is some work to do also within the European Union to give people access to reliable sources. Because there is a lot of food noise, but there is also a lot of noise about the potential treatments and the potential diet. So not every diet is a good diet and it should really be a scientifically sound diet. Thank you. Thank you very much. But thank you very much to everyone listening. If you've enjoyed this episode, please check out our other episodes. 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