Could WHO jumpstart widespread access to obesity medications?

Medications such as Ozempic and Wegovy are enjoying a moment in the spotlight — largely thanks to online speculation over which celebrities might be taking them to lose weight. But they were recently singled out for another reason: inclusion on the World Health Organization’s Essential Medicines List. Three United States doctors and a researcher submitted an application in March to include a class of anti-obesity drugs, known as GLP-1 receptor agonists, on the list, which holds outsized weight in helping governments determine which treatments they should make available to their citizens. Experts said their inclusion could catalyze a transformation in how low- and middle-income countries recognize and respond to obesity and the noncommunicable diseases to which it contributes. “It makes it clear that obesity is a driver of disease and a disease in its own right and there are people who would benefit from the drug,” Johanna Ralston, the chief executive officer of the World Obesity Federation, told Devex. Including the drugs on the EML would only be a preliminary step, though, given the limited availability and high prices of the treatments. Many countries also lack experts or the infrastructure to effectively treat obesity as a disease, much less the NCDs linked to the condition, such as type 2 diabetes and coronary heart disease. “Globally, this is not so much there,” Nitin Kapoor, an India-based endocrinologist and expert on obesity, told Devex. “If there is access to this medicine, people need to know how to use it right.” Obesity has long been on the rise in LMICs, leading public health officials to warn that many will be contending with a double burden of disease — both communicable and noncommunicable diseases. That moment has arrived. Between 2000 and 2021, for instance, the number of overweight children under 5 years old in sub-Saharan Africa rose by nearly 24%, according to WHO. An estimated 70% of the overweight or obese people in the world live in LMICs and related NCDs are rising among the leading causes of death in those countries. Kapoor said warnings about the dual burden have been effective, encouraging many governments to increase their investments in prevention and treatment of obesity and NCDs “even in countries that have high infectious disease burdens or dual burdens.” But not nearly enough. In India he said patients, particularly low-income patients, still struggle to get even minimal obesity and NCD treatment. The inclusion of anti-obesity drugs on the EML could go some way in helping to change that. The creation of the first EML in 1977 followed a “peaceful revolution” spurred by global activists. Outraged that crucial medicines were often unavailable, particularly to poorer communities, they pushed for a list of the bare minimum that should be available to all patients. The process has evolved to become far more technical. Organized around a biennial selection process, a WHO-appointed committee considers medicines based on factors that include disease prevalence and public health need, as well as the efficacy, safety, and cost of the actual drug. The result is a list divided into core medicines of the absolute minimum drugs every health system should offer and complementary medicines, which may require specialist diagnostics or care. There are currently no medications on the EML that specifically target weight loss for the ongoing global burden of obesity, the experts underscored in their recent proposal. The advisory panel is currently weighing all of the proposed medications and is scheduled to release an updated list in September. WHO did not reply to requests for comment on the current status of those discussions. The EML serves as a starting point for governments as they make decisions, weighing their national budgets and health concerns, about which medicines must be available to their citizens. And the list has offered activists targets as they campaign for lower prices and improved access. And as breakthroughs in treatments occur, their inclusion on the list is a way to signal that those drugs should not be restricted only to the populations that can afford to pay the high prices companies usually charge when the drug is still under patent. HIV treatments were added as the epidemic swelled, for instance, despite their relatively high cost at the time. Kapoor said a push to add an anti-obesity drug would send a similar signal. “As time goes by, I think it will become more affordable,” he said, particularly if activists push for lower prices. And as patents fall away, the inclusion of the medicines on the EML could assure generic manufacturers it would be worth producing the treatments. Liraglutide, the active ingredient in one of the medicines, is set to come off patent soon. If the drug is included in the EML later this year, it will not result in immediate availability in LMICs, though, not least because demand for the medicines already far outstrips supply. That doesn’t mean countries shouldn’t start preparing for their arrival, Kapoor said, beginning with expanding the medical curriculum on obesity management, which is practically non-existent in some settings. “If the WHO does put this on the essential list, there need to be the right kind of people in place to use it,” he said. For Ralston, even the proposal to include the medicines has jumpstarted an important debate. “It’s put to rest the persistent myth that this is really not a global concern,” she said. “It’s very much reiterated how much an impact obesity has, particularly on middle-income countries, and that systems are not in place to address it.” Alongside a global action plan to reduce obesity released at last year’s World Health Assembly, the increasing focus on the disease and linked NCDs might ultimately recalibrate thinking about how to approach them. Still, she is cautious about the conversation that has developed around the medicines. It is a rare moment where an intervention that could truly benefit people’s health globally has become ensnared in celebrity culture. And when famous people like Elon Musk tweet about using Wegovy, a commercial version of the anti-obesity medicine semaglutide, it raises global attention. Kapoor said he immediately had patients in his clinic asking where they could find the medicine. But Ralston worries that it trivializes the treatment and bleeds into dangerous conversations about how obesity reflects a lack of willpower, where ultimately “the individual is to blame,” rather than a focus on obesity as a disease.