Obesity is a growing public health problem for the entire planet. According to the 2023 Obesity Atlas published this week by the World Obesity Federation, 51% of the world's population will be overweight or obese (more than 4 billion people) by 2035, up from 38% today. At a briefing organised by SMC Spain ahead of World Obesity Day on 4 March, two experts discussed the role that drugs can play in combating a disease whose roots are social and linked to inequality.
Diabetes and obesity drugs such as liraglutide, semaglutide and tirzepatide have sometimes been advertised as near-miraculous products, capable of achieving weight losses of 20% and replacing alternatives such as bariatric surgery.
"There is no doubt that obesity is a chronic and recurrent disease, it is not solved by willpower and this idea has done a lot of damage because it has been stigmatised. The problem begins with epigenetics during pregnancy, then with genetics, the brain... Food is a very small point among all the causes", explained the endocrinologist and coordinator of the Obesity Unit at the Vall d'Hebron Hospital in Barcelona, Andreea Ciudin, in an informative session organised by the Science Media Centre España. The scientist pointed out that "there is no such thing as healthy obesity".
"We know that what determines obesity is not the individual approach, such as physical activity and diet, but the determinants that make some populations do more physical activity and eat better than others," explained Luis Cereijo, a researcher in social and cardiovascular epidemiology at the University of Alcalá. For this reason, he advocated "going to the root of the problems so that, instead of provoking changes in individuals, we can achieve major changes in the population". In this, he said, prevention strategies such as "people having access to quality physical activity" play an important role.
Drugs: for whom and at what cost?
Regarding drugs, Ciudin qualified their usefulness. "They are not a panacea, not all patients respond in the same way and before starting treatment, the type of obesity must be phenotyped because each person is different. In addition, they must be accompanied by diet and exercise. He also explained their conditions of use: "[Liraglutide and semaglutide] are approved for patients with a body mass index of 27 or higher, and funded for patients with diabetes of 30 or higher, so they are also suitable for overweight patients. This means that 60% of the population could use them, but in both cases a prescription is required.
"Semaglutide costs between 150 and 180 euros per month and liraglutide between 200 and 250 euros per month, but they are only funded when obesity is associated with diabetes and the body mass index exceeds 30," he said. In children aged 12 and over, they are also approved, but not funded. "If you think it's five euros a day and you stop having the doughnut and the cortado to invest in the drug, it's not so expensive, but if you think you have a disease and you have the right to a funded treatment, it's scandalous," he said.
"Obesity is not a disease of saying 'eat less and move more', you have to understand that eating too much is not the cause, but a symptom. Drugs help us to do something about that symptom, but they cannot be used alone," the endocrinologist added. She also clarified that there is still not enough evidence on how long they should be taken: "Right now it's trial and error, the same suit for everyone, and we have to make progress there.
A problem that requires political solutions
Cereijo argued that obesity should be tackled with a population-based approach that "can only be in the hands of politicians". However, he added: "We have accepted that physical activity has an unacceptable cost for the population. When there are municipal elections I look at the programmes and in many of them the word sport does not even appear". When as a society we opt for a drug, we are giving up a whole range of alternative benefits that go beyond obesity, because we deprive people of moments of happiness and socialisation," he said.
Both experts explained that blaming and stigmatisation are problems that do not help to tackle the root causes of the disease. "Tell a person who works too many hours to find the energy at 8 p.m. to go jogging alone in the park. We say no pain, no gain, but there are people who live their daily lives in pain and no gain. The only thing they are thinking about is making the can of soda more expensive, when it may be their only moment of happiness. We have to make them have better economic capacity and social conditions," Cereijo concluded. "Diet and exercise are associated with obesity, but also with inequality because they depend on time. It is having that time”.