Helen Salisbury: Weight loss treatment—available in theory but not in practice

In general practice, some of the most challenging and frustrating consultations we have are those where a treatment does exist but, despite our best efforts, our patients can’t get it. Medication to aid weight loss comes into this category.

It’s hard for patients to ask for help with excess weight. They often experience a sense of failure and are all too aware of how they’re seen and judged by a society that celebrates thinness and regards obesity as a visible sign of weakness and sloth. They often fear that their doctor will share this view.

Many patients come to us having tried dozens of diets, typically losing a little weight only to regain it shortly afterwards. Some have had success with weight loss groups—shown to be more effective than lone dieting—but the loss is often modest, brief, or both.1 Meanwhile, the toll of excess weight on their bodies is considerable, contributing to multiple physical problems, including hypertension and diabetes. Joint problems are a major issue and play a role in an unhappy cycle of inactivity, weight gain, and then worsening arthritis.

The health problems associated with obesity make it expensive for the nation, and it causes both long and short term sickness absences that keep people out of the workforce.2 We clearly need far reaching, government led strategies to regulate unhealthy food and the obesogenic environment, but in the short term we must look to medication.

Medication that helps people to reduce their weight safely has been the holy grail of drug companies for generations. Injectable GLP-1 agonists, which were developed to treat diabetes but have an additional effect of suppressing appetite, are now filling this role. Though not perfect, they’re better than anything we had before. Semaglutide is widely prescribed in diabetes care, and in March the National Institute for Health and Care Excellence approved its use to aid weight loss where there are comorbidities related to obesity, but it stipulated that this must be prescribed in a specialist clinic.3

The problem is that access to these specialist clinics is almost impossible. The waiting lists are very long, and when patients do finally have a consultation they’re unlikely to get a prescription for the medication that could help them.4 A patient who ticked all the boxes for severe complications of extreme obesity, apart from diabetes, was told by the service commissioned for our area that it was prescribing only for patients who needed transplants or chemotherapy.

So, we have a ridiculous situation where relatively well but overweight patients with diabetes can get a prescription for semaglutide (marketed as Ozempic for use in diabetes), but patients with obesity and multimorbidity but not diabetes can’t get the same drug when it’s marketed for weight loss as Wegovy. This makes no sense, economically or medically: we could prevent so much cost and future suffering if we could help people with obesity to reduce their weight.

Meanwhile, patients who have money to spare can easily get this medication in the private sector, and many are doing so. The prevalence of obesity is higher in deprived areas, and by limiting the most promising treatment to people with the ability to pay—which is the effect of current arrangements—we’re further exacerbating health inequalities.5