The Semaglutide Debate: Prioritising lifestyle behaviours for overall health over medication

May 25, 2023

The current ‘war on obesity’ has directed a lot of effort and resources towards developing the next ‘miracle cure’ that will finally lead to permanent weight loss. But the truth is that this quest is not new, pharmaceutical companies have developed numerous ‘miraculous’ drugs for decades. Although most of those drugs have been pulled out from the market because of their serious side effects (remember when we didn’t know amphetamines were addictive?).

The latest ‘miracle drug’ in the market is semaglutide, more widely known as Ozempic. Ozempic has gained significant media attention in the last few months due to recent findings from a randomised controlled trial which show significant weight loss in people who received the drug compared to placebo. However, as with previous weight-loss drugs, there is some small print worth looking into.

What is Semaglutide?

Semaglutide, licensed under the names Ozempic, Rybelsus and Wegovy, has been approved for treating type 2 diabetes and obesity. While Ozempic and Rybelsus are not explicitly marketed as weight loss medication, Wegovy has been approved by The National Institute for Health and Care Excellence (NICE) in the UK and by the Food and Drug Administration (FDA) in the US for the treatment of obesity independently of type 2 diabetes, and will soon be available over the counter from pharmacists in the UK.

These drugs belong to a class of medications called glucagon-like peptide-1 (GLP-1) receptor agonists, which mimic the action of a naturally occurring hormone in the body that regulates blood sugar levels and appetite. The medication was originally used as a treatment for people with type 2 diabetes to manage blood sugar levels through a once-weekly injection pen. When it became noticeable that one of the side effects of this medication was weight loss (mainly through a reduction in appetite), Semaglutide was trialled and quickly approved as a weight loss drug.

Where Semaglutide falls short: a closer look

While Semaglutide has been approved for weight loss under various brand names, it doesn’t come without potential side effects. These largely include gastrointestinal complications, such as diarrhoea, vomiting, and nausea. In rare instances, people may also develop serious complications such as renal failure, gallbladder issues, pancreatitis, diabetic retinopathy (damage to the eye’s retina), and intestinal obstruction. The FDA also includes warnings for suicidal behaviour or thinking. And last but not least, the FDA has included a black box warning (the most severe warning for drugs and medical devices) to inform about the potential risk of thyroid C- cell tumours (though this type of cancerous cells has only been seen in mice so far).

Another frequently overlooked aspect is what happens after Semaglutide treatment is stopped. Results from the largest study investigating the effects of discontinuing Semalglutide treatment revealed that participants regained most of the weight they had lost within one year, and most metabolic and cardiovascular risk factors went back up to what they were before taking the medication. The conclusion from the authors of the study was that people need to take the medication indefinitely if they want to maintain their weight loss and cardiometabolic benefits. However, we don’t know the long-term side effects of taking this medication. This is why in the UK, NICE has recommended its use for a maximum of 2 years for weight loss purposes.

So the story goes like this: people take the medication for 2 years. During these two years, people will likely lose some weight but they may also experience some side effects such as feeling nauseous when they eat. After two years when they stop taking the medication, they will regain all the weight they had lost and will likely feel sad and dissatisfied with their body once again…Having all this in mind is not unreasonable to think, what is the point?

The hidden cost of weight-loss drugs

Aside from the risk of side effects (including the ones we don’t yet know about), relying solely on medication for weight loss is a costly approach. One Semaglutide pen contains 4 x once-weekly doses of Semaglutide and costs £73.25, making it a very expensive approach given the recommended 20 weeks of use. Plus, the widespread controversy and trends on the social media platform TikTok have led to shortages of Semaglutide, creating challenges for people who use the medication for the treatment of type 2 diabetes.

The price to pay goes beyond money

Physiologically, regaining weight after stopping the medication can in itself be detrimental to people’s health. Studies show that weight cycling (a.k.a. yo-yo effect) can have a negative effect on cardiovascular risk factors such as blood pressure, heart rate, and glucose levels. But also from a psychological perspective, purposefully manipulating internal signals of hunger and fullness can lead to a sense of distrust towards people’s own bodies, which arguably is one of the underlying causes of a problematic relationship with food. And of course, this problematic relationship with food paired with poor body image and low self-esteem (especially as a result of gaining back weight), can lead to the development of serious mental health conditions such as eating disorders, depression and anxiety.

Let’s prioritise health gain over weight loss

Obesity is a complex condition with multiple factors contributing to its development, including genetics, environment, and lifestyle behaviours. However, because our bodies evolved way before the industrialised era when food was not widely available, weight gain is perceived by the body as an advantage for survival. In contrast, losing weight would mean that we are less likely to survive in the face of food scarcity. This is why the body is programmed to gain back any weight that has been lost. As a result, losing weight through restrictive diets (even if this restriction is the consequence of taking a weight-loss drug), will inevitably be short-term.

But the good news is that research shows that focusing on health behaviours independently of weight can achieve the same health outcomes. For example, a large study showed that adopting four health-promoting behaviours (eating five or more portions of fruit/veg per day, limiting alcohol intake, not smoking and exercising 12 times per month) leads to a reduction in all-cause mortality risk no matter the BMI category (including “normal” weight people). Plus, focusing on health regardless of body size or weight (i.e. taking a weight-neutral approach), will help reduce the harmful weight stigma that comes with weight-centric approaches.

Slow and steady wins the race

Of course, behaviour change is hard too but with the right support (mainly psychological), long-term change is possible. Many great behaviour change techniques can empower people to take action through a change in mindset. For example, the small habits approach can increase people’s confidence in their ability to make a change because the actions required are small and achievable, which is completely different from an ‘all or nothing’ approach. The satisfaction of having been able to complete a simple but impactful task will then trigger a positive feedback loop that supports the adoption and maintenance of these new healthy habits.

Ultimately, supporting people to incorporate more health-promoting behaviours instead of sentencing them to a lifetime of medication is a more sustainable and cost-effective approach to improving overall physical and mental health.

By Daniela Beivide PhD, Chief Science Officer at Holly Health