Ozempic drug: the debate around obesity that’s dividing doctors
Mel Sexton weighed 163kg before she began using weight-loss drug Ozempic. The results were astonishing. It’s being hailed as the answer to obesity — but some doctors argue it’s an all-too-easy fix.
Mel Sexton learnt from a young age that the world does not account for size. In the uniform shop of her high school, it was clear there was no point trying on the largest school dress. The only thing to be done was for her mother to buy two, and sew the dresses together. “At school I never took my jumper off regardless of the weather,” Sexton says. “I didn’t want anyone to see that. It also hid the scars up my arms.”
Life in a larger body has never got easier. Shame and self-loathing are ever-present. The fear of judgment from strangers is so acute that going out in public is an act of considerable courage. Disordered eating has been an everyday reality, with days of starvation relieved only by binges that left Sexton feeling suicidal. “I felt like if I can’t do anything about my weight, why am I here? Nothing I do is working so why bother? Then it got to the point, just eat whatever I want and don’t go out.
“I would be at home and I would watch the reality show My 600-lb Life on TV and I swore I didn’t want to be like that. They’re bedbound. It’s scary. I’d rather be dead. Watching it was a bit like torturing myself, but I just don’t want that life.”
Last spring, with her weight having hit 163kg, life began to change for 39-year-old Sexton. She began taking the diabetes drug Ozempic, which has been widely prescribed by doctors off-label for weight loss, and has lost about 45 kg in in the past six months. “Food for me has been an addiction. Food has run my life. But now there’s no cravings. There’s no drive to eat. It’s like a blocker in your mind. It’s a tool that I can use that I’ve never had. I’ve been able to completely change my habits and my diet. I’ve gone from having burgers for lunch to making a salad with tuna or salmon.”
Doctors at the frontline of treating patients living with obesity are embracing the advent of effective pharmaceuticals as an enormous step forward in managing a condition that has proved intractable for millions of Australians. Though Ozempic has been prioritised for diabetics because of a supply shortage amid booming demand, a drug with the same active ingredient, marketed as Wegovy, has been approved for weight loss – but at a high price. It is used as an adjunct to a reduced-energy diet and increased physical activity for chronic weight management, including weight loss and weight maintenance, in adults with a BMI over 30, or over 27 if they have at least one weight-related comorbidity. The drug’s manufacturer, Novo Nordisk, has not yet confirmed when supply of the drug will be available in Australia, saying it is “working hard to make Wegovy available for patients living with obesity as soon as possible”. There is another similar drug on the market, Saxenda, and other drugs that have shown substantially greater efficacy are on the way.
“Food for me has been an addiction. Food has run my life. But now there are no cravings”
Ozempic was dubbed “the Hollywood drug” after US talk show host Andy Cohen tweeted that everyone was “suddenly showing up 25 pounds lighter” to his show and blamed Ozempic. It was widely reported that celebrities were paying $2000 a month for the drug in America. TikTok influencers picked up on the trend, as did tech moguls including Elon Musk. The drug proved so popular with consumers in Australia that diabetics who rely on it have been left unable to source it and have been forced to switch to other medications, prompting the Australian Medical Association is demanding that when supply returns, it be quarantined for diabetics.
Now some doctors are voicing fierce opposition to the use of pharmaceuticals as a routine treatment for obesity, insisting drugs are indicated for only a tiny minority of people who suffer metabolic or hormonal barriers to ordinary weight loss. They’re concerned that the enormous changes to food policy, our environments and our diets that will be necessary to turn the tide of the obesity epidemic will take a back seat to an easy fix. And they’re enraged at new guidance issued by the American Academy of Paediatrics urging aggressive treatment with medication for children with severe obesity from the age of 12.
The guidance is in conflict with the Australian Medical Association’s reluctance to recognise obesity as a disease — the doctors’ group officially says it has no position on this point, while cautioning against “an individual solution”. The AMA is adamant the focus must be on the prevention of obesity and rejects the idea that the dice is inherently loaded against a large number of individuals. “There is no conceivable way human genetics have changed in any meaningful way over just the last 50 years,” says AMA president Professor Steve Robson. “So the rising rates of obesity have to be about nurture. There is no other explanation.
“I think whatever we do, we’ve set up the world for modern Australians in such a way that it promotes obesity, and once it’s set in, it’s incredibly difficult to deal with and to shift. And so we have to recognise that we’ve had this profound change in the way people are, and we’ve got to get back to prevention.”
Robson references the Life. Be in It advertising campaign, which while widely discredited as placing the blame on individuals, contained the kernel of a message he says is still applicable today. “When I was a kid, we had Norm, who used to sit around and be a slob at home – the message was get up and move. I think we almost need to get back to that. I think the mere fact that we’re having to turn to society-wide use of drugs and things like that to try and control things is truly extraordinary.”
Yet broad society-based prevention strategies do little to assist those living with severe obesity, who frequently live lives of isolation, wracked with feelings of shame and failure. Around two-thirds of Australians are overweight or obese, with roughly one-third overweight and one-third living with obesity. It’s one of the highest prevalences in the world and despite a national obesity plan being in place for the past decade, the rates keep climbing. It is an epidemic that represents the second-biggest risk factor for burden of disease next to smoking and is associated with cardiovascular disease, 17 types of cancer, Type 2 diabetes, dementia, asthma and chronic kidney disease as well as disabling musculoskeletal conditions.
As people desperate for assistance flock to obtain weight loss drugs, detractors are raising urgent concerns. South Australia’s Lieutenant Governor and former Australian of the Year James Muecke AM, an ophthalmologist who was so disturbed by the numbers of his patients going blind from diabetic retinopathy that he has made improving the nation’s nutrition a personal crusade, is alarmed at what he says is the strong influence exerted by the pharmaceutical industry upon medicine’s approach to obesity. He insists the answer to managing obesity must lie not with pharmaceuticals but with eating “real food”.
“I think when obesity is considered a disease, this is when the pharmaceutical industry steps in,” Dr Muecke says. “You can imagine this will be an absolute coup for the pharmaceutical industry to have a potential quick fix, you know, people can keep on eating all their junk food and ultra processed food, and just take a tablet. The pharmaceutical industry is set to make a fortune out of weight loss drugs. They can see the dollar signs. I mean look at the statistics. The statistics are staggering.”
But doctors at the frontline of treating obesity point to evidence that fundamental hormonal and metabolic factors that kick into play when a person attempts to lose weight make sustaining long-term weight loss extraordinarily difficult. Those living with obesity invariably say they have tried everything and no matter what they eat, “real food” or barely any food at all, significant and sustainable weight loss remains elusive.
They all have their own story of a doctor who told them that losing weight boiled down to a simple equation: calories in, calories out. Eat less and move more. “Our old doctor when we first met him, he was like, ‘Look at the size of you, you need to lose weight’,” Sexton says. “They never gave you the tools to do that. You can get to the point of starving yourself and you’re still overweight. I would try to only eat 800 calories a day or only eating once a day. I’ve tried just not eating at all. I thought the less I ate, I’d start to lose weight. I’ve tried eating then vomiting. I would be constantly calorie counting. Nothing worked.”
For Andrew Wilson, aged in his late 40s, weight loss followed by gain was a constant cycle. “Once you get to a bigger weight, the constant yo yo-ing, losing 10 or 20 kilos and then going back up again, it’s very fatiguing mentally and physically,” he says. “The idea that you’ve done it to yourself is prevalent. I’ve been at the doctors when my son was sick, and the doctor took me aside and he said, ‘Mate, what are you doing to yourself?’ But we’ve tried everything. We know we’re overweight. We’ve tried everything we can find. To say that to me made me feel even worse, it made me feel very shameful. And I avoided seeing a doctor for many years after that.”
Like many people living with obesity, for much of his life Wilson has instigated periods of punishing exercise and diet routines, with the many treatments he attempted having limited success in permanent weight loss. In the past few years, he has been a patient at a multi-disciplinary metabolic clinic at a Western Sydney hospital, and has recently undergone bariatric surgery which has enabled him to reduce his weight and comorbidities significantly. For the first time he is feeling optimistic about his health, and the mental fatigue and struggle has largely been lifted.
Despite his internal positivity, stigma persists, and it leaves an indelible mark. “The general public and even intelligent friends of mine have that same opinion as that doctor, you can see straight away when you walk in the room, people are judging what they think might be going on, thinking this person is lazy, they’re stupid, they’re greedy. There’s bias and discrimination in the workplace, people living with obesity are looked over for roles because bosses think, ‘How can you manage this department or this company if you can’t even manage your weight?’
“I was invited to be best man a couple of times at weddings and I made excuses, I wouldn’t even go to family functions. Just negotiating going out, you’d think can I sit down in this chair? Will it break in front of everybody? I didn’t want to dress up and for people to see me in the state I was in so I’d just avoid it.”
Despite the celebration of the body positivity movement in popular culture, many people living with obesity say it has done little to combat society-wide stigma and that they feel disconnected from its philosophy. While the message that you can be fit and healthy when overweight does hold true, many of the role models of the movement are best described as curvaceous and do not face the disabling morbidity of severe obesity. “You should feel good about yourself, you shouldn’t have to feel ‘less than’, but I don’t think anybody would want those comorbidities,” Wilson says. “If you look at what actually happens to you it’s not a joyful thing. It’s the opposite.”
Sexton agrees. “I’d love to have that perception of myself, that it doesn’t matter about my size,” she says. “But I don’t. It’s hard when just moving around is still a bit difficult. I wish I could do more.”
One of the many psychologically devastating aspects of obesity is that despite the monumental force of will, discipline and organisation it takes to lose weight, for all but a vanishingly small proportion of people the weight loss is invariably temporary. The cycle that sees the body strive to maintain a weight “set point” – which for people with obesity is very high – is predetermined by genetics and then driven by a combination of powerful counter-regulatory metabolic mechanisms and hormonal processes within the brain that kick in during and following attempts at weight loss, radically affecting hunger and satiety.
“When a person actively loses weight, their metabolic rate drops, so the body burns less calories a day,” says Georgia Rigas, a Sydney GP who specialises in treating obesity. “And secondly, there are a number of hormonal changes that occur in the body. The hunger hormone ghrelin is elevated, and a lot of the satiety hormones are suppressed. We can’t use our free will to control our hunger. And as a result of that combination of increased hunger, decreased satiety and also reduction in metabolic rate, all those things encourage the body to go back to the weight it was prior to the weight loss.”
The scientific explanation for why an individual may be eating very little but remain overweight rings true for Tasmanian mother Katrina Maddigan, who broke down in tears in the consulting room of her doctor, associate professor Gary Kilov, when he explained the epigenetic reasons she could not lose weight.
“Every time I’d go to a doctor I’d tell them I struggle to lose weight,” Ms Maddigan says. “And they’d always say ‘watch what you eat and exercise’. I would sit there and say ‘I used to be in the army, I know what discipline is’. I can remember actually going to one doctor and she asked me to fill out a food diary. I brought it back and she basically said ‘you’re lying’. She said there’s no way this is all you’re eating because you haven’t lost any weight’.
“Over the years I’ve done Weight Watchers, I’ve done Michelle Bridges, I’ve done isogenics where you basically just drink shakes, I’ve eaten nothing but brown rice and salmon. I could do that for weeks and only lose a kilo. I don’t eat much sugary food, I’ve never been a sweet person. I don’t eat a lot of processed foods or bread.”
“When obesity is considered a disease, it’s a coup for the pharmaceutical industry”
Kilov, director of the Launceston Diabetes Clinic, says the “nihilistic approach of ‘blame the patient’” is changing but is still prevalent. And while he agrees pharmaceutical companies have a vested interest in pushing the view that obesity is a disease that requires a medical treatment, he also believes that position is supported by science.
“Of course pharma companies want to make a motza, and they’re going to do their best to do that,” Kilov says. “But by the same token, they have produced highly effective agents. Obesity can’t be cured any more than diabetes can be cured, or cardiovascular disease can be cured. There’s no cure.
“We don’t want to medicalise weight management, but at certain stages it is a severe disease. Somebody with severe obesity, with a BMI of 40, has a decade less life expectancy than somebody who has healthy weight. Not only are they losing 10 years of life, but they’re losing 10 more years of healthy life. It can be an awful condition that deserves the same level of care that any other serious medical condition attracts.
“The question then is how society and pharma companies can work together to make sure that everybody wins. But we do absolutely need these therapeutic agents to be much more cost effective and affordable to the individual and to the community.”
The reason the new class of weight loss drugs prove so effective for many people is that they directly influence the hormones that drive the hunger spikes associated with calorie restriction while also acting on the satiety hormones. The drugs slow the movement of food from the stomach into the small intestine and stimulate the body to produce insulin which lowers blood sugar, but they simultaneously also act on the hypothalamus.
“These drugs are actually affecting the biology of obesity, both in the gut and in the brain,” says Terri-Lynne South, medical director of Lifestyle Metabolic clinic in Brisbane and chair of the Royal Australian College of GPs Specific Interests Obesity Management group. “Ozempic is a glucagon-like peptide 1 agonist, this is a natural hormone that our body produces and the drug is an analogue of that. And that’s I think one of the reasons why it’s so powerful, we’re actually using the body’s physiology to help balance the hunger hormones versus the satiety hormones. It has been the best tool from a medication point of view that we’ve seen for some time.
“The medication is only one part of a broader holistic picture. We’re still looking at those lifestyle factors of eating patterns, eating choices, behaviour, sleep, mood, activity. So it’s just a tool that can often open up a little bit of space that’s needed to be able to make those changes easier.”
Kilov treats patients in his clinic with a multi-disciplinary approach that involves dietitians, nurses, exercise physiologists and psychologists and usually prescribes medication. He does not believe a purely dietary and exercise approach works for most people who are severely overweight.
“Absolutely eat real food, I agree with that entirely. But I would never, ever have the audacity to say to people ‘eat real food and that’s all you get as an intervention for obesity’,” he says. “This is an environmentally caused disease superimposed on a genetic predisposition. There’s no question at all that prevention is better than cure. It’s not inevitable that everybody will gain weight, and some people can lose weight sustainably, without any medication or surgery, but that’s a vanishingly small number, perhaps as little as one or two per cent. Suffice it to say that the vast majority of people will regain weight if all they’re doing is relying on lifestyle intervention because it’s incredibly difficult to fight the body’s drive.
“You’ll often talk to people who carry excess weight and they’ll tell you they’re hungry all the time. This is not about gluttony, this is about biology, and it’s about the body attempting to restore the lost weight. Most people who are trying to reduce their weight work really, really hard at it. It’s enormously demoralising when doing everything one can results in stagnation of the weight loss and weight regain, or just not being able to lose weight at all. And insult is added to injury when those individuals are not believed, when they are not understood, and particularly when they are discriminated against. There is lots and lots of evidence around the discrimination of people who carry excess weight being seen as slovenly, stupid, lazy, all sorts of terribly derogatory things. And to be the victim, and then to be blamed is awful. We don’t tolerate it in other situations, we don’t accept it. And we’ve been terribly slow in acknowledging and recognising this awful injustice.”
Dr Muecke has great compassion for those living with obesity but insists lifestyle is at the heart of the problem, not least at a society-wide level. He advocates a low-carb approach and is critical of the demonisation of fat. He points to the Australian Dietary Guidelines, which recommended a high-carbohydrate, moderate protein, low-fat diet, as one of the primary drivers of obesity, along with predatory marketing by the food industry and an abundance of ultra-processed foods in supermarkets. “The major components of ultra-processed foods are sugar, refined carbohydrates, and seed oils,” he says. “We should be minimising our consumption of all of those elements, and maximising our consumption of real foods. My feeling strongly is that diet change should be first-line management, particularly consumption of sugary drinks and added sugar in foods,” he says. “What we should be focusing on as medical practitioners is nutrient-dense real foods and bioavailable proteins.”
“Insulin resistance, which is the core element here, indicates that you as an individual are carbohydrate intolerant. So restricting your carbohydrate intake actually is very powerful in reversing the metabolic markers of obesity and type two diabetes.”
Kilov says that approach may work for many people, but his patients are dealing with a severe disease. “I would love to have a clinic where nobody requires any medication, where I could talk all about the Mediterranean diet and the best diets, and chat about the various attributes of physical activity,” Dr Kilov says. “But that’s not the reality. The reality is I deal with people who struggle to get out of chairs, struggle to walk into my consulting room. What am I going to do for them?”
“The vast majority will regain weight if all they’re doing is relying on lifestyle intervention”
Meanwhile, doctors at the front line of treating metabolic disease are pushing for at least one weight-loss drug to be available on the Pharmaceutical Benefits Scheme to treat severe obesity. But an application by the pharma Novo Nordisk, which manufactures Wegovy, to have the drug listed on the PBS to treat severe obesity was rejected last year on the basis it would represent an “extremely high investment with very uncertain implications for the PBS and broader health budget”.
One of the reasons subsidising weight loss drugs could be such a huge burden on the public purse is because some doctors believe patients are likely to be unable to maintain weight loss without them. “Treatment has to be lifelong, just the same as treatment for diabetes, for cardiovascular disease, for chronic kidney disease, or any other non-communicable disease,” Dr Kilov says. “There is no disease for which we say you’ll have a short-term treatment, and you’re good to go. It’s just a nonsense. It flies in the face of our understanding of the biology.”
Even as rates of diabetes skyrocket and the waiting lists of the relatively few metabolic clinics in public hospitals balloon beyond two years, Australia is performing miserably on the prevention front too. While other countries introduce sugar taxes, binding food labelling policies and strict regulations on the placement of junk food in supermarkets and advertising to children, Australia has given extraordinary latitude to the food industry, allowing the roundly criticised health star rating labelling regime to be voluntary and granting tax breaks to companies for developing ultra-processed foods.
A scorecard of government performance on the Federal government’s National Preventive Health Strategy and the National Obesity Strategy by Deakin University’s Institute for Health Transformation found there had been zero progress in the past five years. “For the most part the government is relying on voluntary action from the food industry,” says Associate Professor Gary Sacks, co-director of Deakin’s Global Obesity Centre. “The food industry has successfully lobbied the government to allow them to have policies to make as much money as they can. Prevention policies in Australia are just on a wing and a prayer.”
Muecke also fingers the food and drinks industry for predatory sales and marketing tactics. “They target people with what in essence are addictive products, people who are vulnerable, children. And that’s why we’re seeing this huge shift towards ultra-processed foods. Ultra processed foods are becoming normalised and real foods, particularly nutrient dense animal source real foods, are being demonised, including in the dietary guidelines. It just totally makes no sense.
“And now you have this push to medicate patients, backed by prominent individuals in the obesity or the Type 2 diabetes space, being funded by the pharmaceutical industry. It’s a model that I’m trying to tell my colleagues that we should be rejecting. Once you get into that spiral of medicating, it’s very hard to get off. These drugs are phenomenally expensive, and there is in essence a way of reversing metabolic dysfunction by just simply using food.”
It’s a message that won’t deter Sexton from regularly injecting the medication that has helped not only radically alter her health but also change the small things that no one could ever see. “Getting in and out of the shower now, I don’t have to stand sideways,” she says. “Those little wins are starting to really show. I’ve never liked myself. But I can look in the mirror now.”
At least three times a week now, Sexton works out in the local gym. She goes for long walks every day. Walking into the gym for the first time was terrifying, but staff and fellow patrons have bent over backwards to help and support her and her confidence has grown with each passing week. “I feel amazing. I can box now for nearly five minutes without stopping and without needing Ventolin. Before, I would throw maybe 30 punches, and then have to sit down.”
Now she is planning to marry her partner Sam, something she has long wanted but hasn’t felt worthy of until now. “I want to stand at the altar where I’m centre of attention and feel proud, not feeling like I shouldn’t be standing there,” she says. “I would love nice photos that we can hang up and be proud of. And then maybe we could have a kid. I’ve always wanted to be a mum.”
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