Weight loss and obesity in MS: is Ozempic the solution?

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Jess: This is the MS Boost, the stuff you need to know from the people who know it.

Hi and welcome to the MS Boost. So, my name is Jess and today Jodi and I are going to be talking about something that has been in the media and a pretty hot topic of conversation which is the weight loss medication Ozempic.

And so, who better to speak with than what we would consider, you know, one of the leading experts in Australia. Associate Professor Priya Sumithran, who is an endocrinologist and clinical researcher. She's the head of the Obesity and Metabolic Medicine group in the Department of Surgery through Monash University, as well as the clinical lead for Obesity Medicine at Alfred Health. Priya has, so much knowledge. She has published over 80 papers and has even served on the council of the Australian and New Zealand obesity society for several years up until 2022. So, thank you so much for joining us today, Priya.

Priya: Thank you. Thanks for having me.

Jess: So, can you tell us just briefly what is Ozempic and how long has it been around?

Priya: Ozempic itself is a brand name of a medication called semaglutide. Medications within this group have been available on the market for the treatment of diabetes for nearly 20 years, so since 2005. And more recently, over the last 10 years or so, they've, some medications in this class, but not all have also been available for weight management or treatment of obesity. So, these medications are based on a hormone called GLP 1 that our gut normally produces when we eat, and it acts in the pancreas to control our blood sugar. But it also acts in the brain to help us feel full more quickly and to be less hungry and sometimes possibly to change the types of foods that we feel like eating. And so, these medications are based on that hormone that we already normally produce in our body, but it's modified to make it last longer in the body our natural hormone would.

Jess: I hear the term food noise a lot now when they're talking about these types of medications and it's interesting that it was originally indicated for diabetes.

How is it now being used for weight loss or the treatment of weight loss when it sort of was originally indicated for you know another condition?

Priya: There is quite a lot of medications that are developed for one condition and then it turns out they're useful for something else. In the case of this type of medication even during the time they were developed for diabetes because of the effect on blood sugar, it was known that they do have this effect on appetite and body weight. So, it does make sense to, and diabetes and excess weight are often found in the same sugar people so it did make sense to see if it would be useful for weight even in people without diabetes

Jodi: and what sort of research has been done in that space, in terms of researching the drug for weight loss? I, I'm so surprised that it's been around for such a long time and yet it feels so new and so I guess I'm kind of like, is that because the research didn't catch up or?

Priya: No, the thing is it's not new. And I think what's new is that this latest generation of medications Although they've been around for 20 years, they've been different types and different brands with slightly different, different effects. And this most recent type is more effective than the ones that came before it. And so, what's new is that people outside the field of medicine or science or diabetes have heard about it and are talking about it, and so it sounds like it's come out of nowhere and it's here all of a sudden, but actually that's not the case at all.

Jodi: Has it been used in clinical practice frequently over the, you know, for weight loss? And for obesity management, or is that a new element of it?

Priya: A medication, which is still available, called Liraglutide, which Is one of these types of medications and that was the first of this class that was approved for the treatment of obesity and that, it's been in Australia since maybe 2016, if I remember correctly, but it's been, it was approved in the US two years before, so at least 10 years it's been used for weight measurement.

Jess: That's such a long history.

Jodi: Yeah.

Priya: So maybe we should have had this conversation 10 years ago.

Jess: Yes, and so what are the considerations now for people who are maybe considering taking this sort of medication or who are hearing about it and thinking, you know, could this be something that would be appropriate for me?

What are the things that should be sort of considered?

Priya: They would definitely need to have a conversation with their doctor. So, all of these medications are prescription only medications and should be used only in consultation with a qualified medical practitioner. That doesn't need to be a specialist, so GPs can prescribe these medications and should. Not everybody who, is thinking about using these medications needs to see a specialist. So, any doctor can prescribe, obviously people with other chronic diseases like MS, for example may want to talk about it with their neurologist as well as their GP.

But it is an individual decision between the person and their doctor but it's a conversation that if you are thinking about it, it's worth raising it. It may or may not be suitable for you but that's worth talking about and understanding.

Jodi: What would be some of the things that make it unsuitable for somebody?

Priya: Like all medications that can be prescribed there are rules about who it should be prescribed for solely for excess weight those rules are that people should have a body mass index of 27 or above with a medical problem that's related to their weight, or a body mass index of 30 or above.

But that's just sort of where you're allowed to prescribe them. I Think if we're talking about management of weight or obesity, then there are a lot of things to consider in terms of what your situation is, what could be potentially contributing, what other things you need to change, what other things you've tried, what other treatments may be suitable, where medications would fit in amongst all those things, what your other medical problems are, what other medications you take ,whether there's anything that might potentially interact with these medications or whether you have any medical conditions or medications that would need extra monitoring if you were using something like this.

Those would be the sorts of considerations.

Jess: We've heard that people can have difficulty maybe accessing these medications. Are there any sort of barriers that, you know, that you see or that you hear of for people in accessing these medications?

Priya: Cost is a major issue because there are no medications that are purely for weight or obesity management that are subsidized by the PBS. And so, for all of them, the full cost has to be paid by the patient. And for most of these medications when I say these medications, I mean all medications for obesity, not just this type of medication of the GLD1 class. But in general, they cost in excess of $100 a month, most of them cost quite a lot more than that so cost is a major barrier.

More recently for certain types of medication, including, I mean I don't like to use the brand name Ozempic only because well, partly because it applies to a lot of different medications, but also because Ozempic is not the version of the medication that's approved for diabetes, but there are other medications that are approved for obesity, but nonetheless, this sort of medication over the last couple of years there's been a severe shortage. And there's a newer medication that also came for diabetes and which is also approved overseas for obesity which will be available here for obesity at some stage. But there's been a severe shortage of that as well. So, they’re hard to you know, availability in terms of, accessibility in terms of actual product it has been absent. And not all countries have been equally affected by the shortage and we've been quite affected. But hopefully that will be resolving over the next, I don't know, six months we've been hearing that for the last couple of years. So those are the practical issues.

I do think there is a reluctance to use medications or to think that weight is a legitimate use for medications across all of society, so not just in the media, among patients, among doctors there's a general reluctance and I think that does contribute to a lack of access just because if people aren't raising it, or if people are raising it, but that discussion is not progressing, then that is another reason why they are probably underused compared to what would be the situation if there were a medication without any sort of judgment attached.

Jess: Absolutely, and it's so true, you know, you often hear people refer to things, even historically, you know, when weight loss surgeries used to be the buzz and people referring to that as the easy way out. Now this wave of weight loss medications and how people choose to manage it is sort of getting the same treatment. So, it's sort of no wonder. There's almost that ingrained belief that it's cheating and it's not doing it the right way. Like, what do you sort of think about that? About, you know, how people have this opinion collectively that there's one right way to lose weight?

Priya: Yeah, I mean there's so much judgment of that nature and this perception that it's an easy way out really just there's so much stigma associated with not just having obesity, but also treating it, there's a stigma about both but are really for almost all people who struggle with their weight, there are so many reasons beyond their control that contribute to it, and for most people it has a biological basis, so a genetic basis that makes us particularly prone to putting on weight in a certain environment.

This environment that we live in is perfect for making it difficult for people with that tendency to gain weight to manage it and. Yeah, there's really good reasons why people find it difficult to lose weight and keep the weight off and it is a pity that science has advanced and there are so many avenues of help now but there's still such a stigma against using them.

Jodi: I think people with MS, living with MS have particular challenges in weight loss in terms of overall fatigue and levels of disability that mean that they can't sort of get, they can't as easily approach that whole picture of being able to do all the meal preparation plus the exercise plus all of those things and therefore easily get easily feel overwhelmed in my experience at the concept of losing weight and seem to strike medication side effects and the whole picture of why, you know, the challenges seems to be a little bit more in people living with women living with MS in particular. Particularly the people who were if I remember back into clinic who were entering menopause as well too and had that additional burden on weight gain.

So, how do you sort of see it being placed in people with living with other conditions, where the condition itself creates the barriers of, for weight loss?

Priya: Don't really see it differently, to be honest, because I think that I take your point that people with certain chronic diseases and conditions including MS do have these challenges that make it hard to do certain things, but no one with obesity, even if they don't have additional chronic diseases or is having an easy time of, doing it everyone has their own unique set of circumstances. But the underlying reason why people tend to gain weight and tend to find it hard to lose is almost universal amongst people that have that tendency. So, I think that the range of treatment options and the place of treatment options is probably similar. And the other thing that I would say about that is that the medications don't do anything that means that people don't have to make those lifestyle changes. And I think that that's part of what the stigma about using them is, is that people think you could change your diet and exercise, or you could use medications. And that's why medications are perceived as the easy way out. But actually, the medications really just help you to make those changes in your diet because they help you not feel as hungry, they help you get full more quickly they help when you're trying to do make various changes.

One of the normal responses of the body to reducing your food intake, even if you're trying on purpose to reduce your weight, your brain perceives that you're losing weight and lots of changes happen in the body. Including we tend to get hungrier, we tend to get more interested in food and so it's very hard for people to sustain changes in their diet, even if they want to, we often just get hungrier when we're trying to do that. So, the medications help keep that under control and help make it easier for us to do the things that we were trying to do anyway. But it doesn't do anything for us instead of those things that we were trying to do. So, all of those challenges still remain but it doesn't mean that medications wouldn't make it easier to sort of surmount some of those challenges.

Jodi: That's such a great way of looking at it, you know that it's not a replacement, it's not an endurance. Does that mean that people it's not necessarily a long term commitment for people? Does that mean that you know, if it changes the way that you are managing food that it's not necessarily.

Priya: It would be nice if that were the case, but I think it's a minority of people for who that would be the case, because it's not just about, I mean, I think there's a tendency to think, well, once we're in the habit of eating a certain way, or, you know, doing a certain type of meal preparation or, you know, in the habit of doing that kind of thing will find it easier to stick to, and to some degree that's true. But because by that time, if you have lost weight, the medication is still trying to, is still there keeping the natural increase in your appetite that would have happened had you, you know, if you were not using it. So even though you are in those good habits. If you stop that medication some people will be able to maintain those habits, but a lot of people will find it really hard not to have a like a creep up in the portion sizes, for example, because they won't be feeling as full with the smaller portions, it'll be harder to avoid snacking if that's something that you're doing.

You'll still be intending to do those things and some people are successful, but there's an additional level of control from medications that's helping remove some of that challenge, and so where they stop medications after weight loss and then look at what happens. Most people will put weight back on once you've stopped a medication that was working well.

Jess: It’s so interesting how the brain is almost sabotaging you can try build habits and you know we know building habits in itself is difficult to do, but like when you, the medication literally sounds like it's bypassing your brain's ability to sabotage your weight loss.

Priya: But that's actually exactly right and your brain is sabotaging your weight loss to protect you because, you know, that part of your brain that's doing that, it doesn't sort of realize or it doesn't appreciate that you're doing it on purpose or that you're in a situation where you're unlikely to starve to death.

Our brain is trying really hard to help us. It's trying to help protect us from famine and from going through periods where food is not available. It just so happens that now we're in this and most of us, are in this environment where we don't need that sort of help from, our brain it hasn't caught up.

Jess: That is fascinating. That is just fascinating. I'm sure evolutionary, you know, biologists or something are probably having a field day with this. Are there any sort of, I guess, risks to losing weight with Ozempic? You know, because I think we also hear that it doesn't always work for everyone.

Priya: Yeah, nothing works for everyone so if you look at all treatments for weight management or obesity being diet and exercise interventions, more intensive diets there are people that respond really well and people that don't respond at all. And obviously the proportions of people in each of those groups is different according to the treatment. So, for these, this latest generation of medications, most people would have a good response, but there are people that won't. That's not a risk as such, that's just a fact that there are, you know, you might try it and it doesn't work, but that's unlikely.

There are side effects of all things. Again, we've heard so much hype about how effective these medications are, but I think we've also heard far too much hype about side effects because everything has potential side effects and compared to older generations of medications most of the side effects are fairly minor with these sorts of medications. Some people have very severe side effects, and we do have to look out for that. But most people wouldn't, most common side effects are gastrointestinal upset kind of things, so nausea. Some people have vomiting or abdominal pain, constipation or diarrhea, those sorts of things. But they're usually not severe enough to, for people to want to stop the medication and they can be minimized by, we start with a very low dose of medication and then build it up gradually as tolerated.

Jodi: Do you see, because there's so much potential knowing that people struggle with in not just MS, like you said, everybody we're talking about people, our audiences, people with MS struggle so much with their weight loss. I think it's really exciting that there's an option for people that can be an add on.

So where do you go, you know sort of, how would you encourage someone to bring up the conversation or where should it fit? Would you say you need to do all the lifestyle things as well? Because in MS we used to just say, here's a great medication for it and it's a disease modifying therapy and it works really well. And more and more the conversation is shifting, but there's also keeping your brain healthy lifestyle. You also need to do the other stuff as well too. So, is it similar to that? That you can't just take the pill, just won't work alone. It's got to be part of a bigger picture.

Priya: Yeah, exactly it's definitely part of an overall plan for reducing weight and maintaining weight loss. And healthy lifestyle is always part of that plan. There is a risk with these medications for people who don't make, you know, for people who need to, not everyone actually needs to make changes in their diet. Some people are actually trying pretty hard and doing pretty well even if they're overweight.

If they are not, because the medications just often help people just not be as hungry and not eat as much. For those people, if you don't actually improve the quality of your diet, but you're just eating less of an unhealthy diet that's not good for you. it is important to still pay attention to those lifestyle factors. And also, as people are losing weight, it's inevitable that they will be losing both fat and muscle. And most people lose mostly fat and a little bit of muscle, but exercise is important to maintain physical function and general health.

Jodi: And do you think this will be in obesity management down the track a first line or will it always as an add on. An add on sort of to how obesity is managed?

Priya: I think, even if it were first line, it will always be an add on to yeah. Lifestyle interventions or lifestyle changes will never not be important. But, I think we will understand better that, you know, currently, or until recently perhaps, our approach has always been you have to try lifestyle interventions alone first and then only if you haven't been successful or found it difficult to maintain the weight, then you can try something else like medications and I think that's changing, certainly within this field, it's changing because we know that that's not always the right approach for everybody.

Many people have been trying lifestyle interventions their whole lives and the medications, you know, don't do away with the need for the lifestyle intervention, you know, as we've talked about. They help people you know, you can do both at the same time and I think that there will be people who use everything, who use medications and lifestyle and surgery and it's not necessarily sequential. We can use combinations of things depending on the person, depending on what they need to give them the best outcome.

Jess: Yeah, absolutely. Thank you so much for having a chat with us about this. It is just such a fascinating area. And I think in a way it is actually uncovering that weight loss isn't just what you eat alone. Given the fact that medication is showing this is helping in so many ways. So, I just think it's just so interesting and thank you so much for talking with us about this today.

Priya: You're welcome. Thanks for having me.

Jess: Thanks for listening to the MS Boost. Check out the show notes for more details, and you can catch up with the new episode of the MS Boost next fortnight.