The drug representative had a smug look; she knew she had a winner. She didn’t need to sell anything—the American public had already bought the story. There are very few drugs in history where patients are excited about the conversation and want to take a new medication. I am talking about the new class of diabetic drugs called GLP-1 (glucagon-like peptide) agonists. The particular drugs are Ozempic (semaglutide) and Mounjaro (Tirzpatide). Initially developed for the treatment of type two diabetes, they were found to have a significant effect on weight loss.
I had already heard the stories from my other patients. Most of them loved it. They had lost weight, got a better grip on their diabetes, and, most importantly, did not crave the foods that were unhealthy for them. In trials, the average weight loss in this class was between 5 to 11 kg. These drugs bind and activate the GLP-1 receptor, which causes insulin secretion and decreases glucose levels. They also decrease stomach emptying time, making you feel full. These drugs decrease appetite by acting on the brain’s GLP-1 receptors, causing satiety. There was one major complaint from all my patients—you could not find a pharmacy that had the drug; they were sold out. Yes, you heard that right—the drug companies couldn’t make enough, despite charging an arm and a leg. The cost of a month’s supply of these drugs is roughly one thousand dollars.
Obesity is a disorder of the new world. Back in the day (in the early part of the 19th century), obesity was linked to prosperity. With food being scarce, extra fat was insurance against dying from starvation. The adaptive process of energy storage became maladaptive and pathological as food sources increased, and the effort required to get food decreased. Obesity is now defined as a chronic disease with an increased risk of diabetes, hypertension, kidney disease, and vascular disease—not to mention a social problem with the myriad mental health issues accompanying our quest for looking good.
Our society, with all our technology, is pushing us more and more toward the obesity precipice. Technology has made everything easy—you can manage your finances, pay bills, meet your friends, and of course, order your favorite food now with the click of a button. The energy expenditure is clearly less than what we put in. Today, a BMI (body mass index—weight in kg/height in m^2) of greater than 25 is considered overweight. India, with the largest population in the world, along with other developing countries, has joined the developed nations in the weight issue, with cardiovascular mortality suddenly surging over the last 20 years. While there are many reasons at play here, the familiar suspects of obesity and diabetes are omnipresent. There is now data that Ozempic reduces cardiovascular outcomes in patients with diabetes. The FDA recently gave it the nod for additional labeling for the reduction of cardiovascular disease.
The South Asian population has a higher incidence of abdominal obesity. Compared to Europeans, we can have a normal BMI but increased abdominal obesity. Unfortunately, this is the worst form of obesity, with abdominal visceral fat having a higher degree of insulin resistance and hyperinsulinemia, a term called metabolic syndrome. None of this happened overnight, and there will be no easy cure, and that’s exactly where the drug companies move in—a cure for a disease caused by other capitalist companies.
The companies making these drugs, Novo Nordisk and Eli Lilly, have already seen their stock prices climb to new extraordinary heights. The irony is that Mounjaro has not even been approved for weight loss. This hasn’t stopped the weight clinics from prescription overdrive. The side effect profile of these drugs is nothing to be envious of. The fine print has a black box warning for thyroid cancer and everything else from pancreatic disease to kidney failure to gut issues. This isn’t stopping the 76-billion-dollar diet industry from going full steam ahead.
Health is an active process and requires a lot of discipline. There are no shortcuts to the daily grind of diet and exercise, and it gets progressively more difficult as we age. Like most relationships, we get back what we put in. There is now hope for people who cannot get healthy due to a weight issue, but it comes at a price. Welcome to the new world web—where we keep entangling ourselves in the pursuit of perfection.
This essay is cited in the KevinMD record on GLP-1 drugs.
Dinesh Arab is a cardiologist.
