Terry Prone: Forget 'skinny jabs', these drugs are changing everything

The share-dumping in a sleep apnoea technology company is just one of the hundreds of unanticipated consequences of GLP-1 success.

It’s estimated that at least 15 million people in the US alone are now taking these medications, with brands such as Ozempic and Wegovy becoming household names. Such a volume of consumption means that in just a couple of years, this semaglutide medication has become the first legitimate prescription drug to seriously lift the economy of a nation: Denmark’s finances are flying because of it.

But — as the evidence across a wide range of human activities builds up — it is becoming clear that the social, healthcare, cultural and economic effects of the GLP-1 injections go further. Much further.

No previous medicine has ever challenged international culture, jolted the food industry into radical change, rattled the future prospects of the alcohol industry, threatened Big Tobacco or promised the possibility of cheaper air travel.

We’re seeing almost daily publication of clinical studies into the efficacy of the medication, which in itself is an oddity. What usually happens with a game-changing drug is that the years before its release onto the market are the period within which most of the relevant studies happen. 

Semagludite, as a remedy for obesity, didn’t follow that pattern, largely because it was on the market initially and for several years as a way to control erratic blood sugar in diabetic patients, rather than as a weight-loss solution.

Broadcaster and author Matt Cooper, in 2018, on an August holiday in New York, found himself needing to get up in the middle of the night to visit the toilet. His energy levels were collapsing, leaving him wanting to drop off to sleep in studio in front of the microphone.

What ailed him was Type 2 diabetes, despite walking 10,000 steps a day, doing tough workouts at least twice a week, drinking little alcohol. He was put on Ozempic.

“It did lead to considerable weight loss,” he said. “Within months the weight started to fall off. I’m four years on it at this stage and 12 kg lighter than when I started it.” 

Four years ago, when Cooper started on the prescription, Ozempic was seen as a diabetes medicine. Now, it is synonymous with weight loss. What it will be synonymous with, four years from now, is anybody’s guess. 

According to the New York Times, dozens of studies are now going on to investigate if GLP-1s “might help with Alzheimer’s, liver disease, polycystic ovary syndrome and even skin conditions. If these trials prove successful, the drugs may extend many lives by years, save billions in medical costs and divide public health into before-and-after epochs.” 

Understandably, the HSE is an interested observer, with Dr Siobhán Ní Bhrian, HSE National Clinical Director, Integrated Care, Office Chief Clinical Officer confirming to the Irish Examiner that the HSE is “monitoring closely the ongoing work and research in the field of GLP-1 based therapies”.

She says that to date, based on the clinical trials, the benefits that have accrued are confined to diabetes, complex obesity and cardiovascular disease in high-risk patients but that “as with any high use and new class of medication, there are signals of potential benefit in other areas”. These could include, in the case of GLP-1 medications, dementia and primary prevention of cardiovascular disease.

“It will take some time before more information emerges and the evidence base becomes stronger one way or the other,” she says. “The early signals have not been studied in sufficient detail to date to have a position about their use.” Those early signals, like the possibility of reducing the risk of dementia, were initially attributed to the weight loss facilitated by GLP-1s. Like sleep-apnoea reduction: if obesity drops, sleep apnoea drops, too. One is a consequence of the other.

However, it now seems the picture is more complex. The mechanism whereby the risk of dementia may be reduced does not seem to follow the “If A, then B” sequence. Some of the gains may be attributable to factors within the drug itself, rather than consequent on weight-loss.

Semagludite may, goes one line of thought, reduce inflammation in the body, and it may be that factor which generates other beneficial changes. Whatever the cause of the putative benefits, those benefits themselves are of breathtaking possible magnitude.

Reducing dementia, kidney disease, stroke and heart failure would radically change public health provision throughout the world. It might not do it speedily, and it may not do all of these things, but it puts the world on the cusp of a new way to manage aging populations and their illnesses.

Nobody, right now, can project with precision any diminution in waiting lists or reduction in trolley-occupation, but it is not naive to suggest that both will be measurably impacted — and for the better — by the wider benefits of these drugs, assuming the supply lines can be strengthened.

Nor are all the positive implications restricted to older people. The CDC, looking at the almost three quarters of a million people in the US who each year develop obesity-associated cancers, points out that the incidence of these cancers has been going up in the last few years, particularly in younger people.

Could this trend be reversed if more people in their 20s and 30s were prescribed the drug for weight loss? The World Health Organisation maintains that five million lives are lost every year to diabetes, cancer, cardiovascular problems, chronic respiratory diseases and disorders of the digestive system which are caused or contributed to by people being overweight or obese.

Ozempic and its extended family could possibly make a quantum leap in the reduction of those deaths, which is why the HSE's Obesity National Clinical Programme (NCP) is contributing to a World Health Organisation working group on the existing and potential future indications for the GLP-1 therapies.

This group is due to issue its report by the end of this year and the Obesity NCP will continue to advise other HSE national clinical programmes and strategies of the risks and benefits of these therapies, says Dr Ní Bhrian, adding that the impact of the muscle loss that occurs with weight loss and its potential to increase frailty is also an area that requires further attention.

At one end of the spectrum, what’s going into people’s supermarket trolleys has already measurably changed, at least in the US. At the other end of the spectrum is the boost for gyms and protein products designed to mitigate the muscle-wasting effects sometimes associated with medication containing semaglutide.

Some of the world’s biggest companies face a complicated future. One side of Nestlé, for example, brings us Rolo, KitKat, Smarties and Häagen-Daz ice-cream. The chief executive of Mark Schneider, has acknowledged the threat to food manufacturing companies. "In our case,” he said, “that will be the frozen food side of things, confectionery, and to some extent ice cream."

The other side of Nestlé is their Health Sciences Division, of which Anna Mohl is the CEO. Mohl told Bloomberg that they’re developing supplements to help in "preserving lean muscle mass, managing digestive upset and assuring an adequate daily consumption of micronutrients" in those taking ‘skinny drugs’. One woman’s "Ozempic face", in other words, is another woman’s marketing opportunity.

Walmart may have been the first major retailer to use its massive data-management capacities to measure the GLP-1 prescriptions issued by their pharmacies against the consumption by the individuals taking those prescriptions, and to come to a speedy realisation that the individuals were significantly changing their purchasing and consumption habits.

For starters, they were spending less. In addition, what they were buying with that reduced spend was changing, too. They were picking up less ‘junk’ food: ultra-processed, high fat, high calorie, high salt, high carbohydrate items, ranging from cookies to crisps. 

This was added to by a Morgan Stanley survey in April of this year, showing the users of these drugs were visiting restaurants less frequently and reducing their takeout orders.

It is, of course, possible to cast doubt on this threat to the purveyors of ‘empty calories’ by mentioning the numbers of patients who quit the drug in any given year, either because, like writer Stephen Fry, they suffer unbearable side effects from it, or because they don’t like the idea of being dependent on a pharmaceutical product for the rest of their lives.

Taking comfort from the dropouts might not be a great commercial strategy, according to the Morgan Stanley analysts who expect the market for GLP-1s to be worth $105 billion by 2030.

They go further, predicting that as many as 31.5 million people, or around 9% of the US population, will take GLP-1s by 2035. Extrapolate from the US figures to a nation with embedded obesity problems, like India, and the inevitable conclusion is that the direction of choice for food manufacturers has to be smaller sizes higher in protein, while the direction of choice for retailers is a greater emphasis on berries and vegetables.

Paradoxically, the new drugs may deal a near-fatal blow to many weight-loss products that have been around for a while. 

Sales of SlimFast, the meal replacement shakes, have plummeted from $300m in 2019 to half of that last year. That is not good for Ireland’s Glanbia, which owns the brand and now finds itself, in common with many food manufacturers, facing sudden change and the need to re-invent what it provides.

A largely unanticipated outcome of the new drugs is a reduction in alcohol consumption with almost a quarter of the users claiming to have either reduced their alcohol consumption or quit booze altogether.

If this pattern holds true as GLP-1 consumers exponentially grow, then this, too, carries inchoate but considerable benefit for public health and public health systems, worldwide. A reduction of even a couple of percentage points in hospital admissions resulting from alcohol abuse in Ireland would be a gift to the A&E in every one of our acute hospitals.

Progress comes with warnings, though, and the WHO last month issued a global alert about fake Ozempic. There were seizures of fake medication claiming to contain semaglutide in Ireland last year as well as Brazil, the UK and US.

But if, as seems inevitable, millions of people worldwide lose weight on these drugs, this is a step change. Knock-on effects could include the textile industry reducing the amount of fabric they use. A lighter load means a plane requires less fuel, so in theory airline tickets could be cheaper.

One thing is certain. That argument that people should lose weight by being disciplined rather than taking pharmaceuticals? Forget it. GLP-1 users have already moved on from that one. It’s not a moral issue any more.