Weighing up the options

A flood of weight loss injectables is on its way, which may aid pharmacists in helping to stem the obesity crisis.

Growing numbers of Australians are overweight or obese, increasing their risk of ill-health, including heart disease, type 2 diabetes and some cancers.

According to the Australian Institute of Health and Welfare, 2 in 3 Australian adults are overweight (34%) or obese (32%), and 1 in 4 children aged 2–17 have overweight or obesity problems.¹

Associate Professor Neale Cohen, head of the Diabetes Clinical Research laboratory at the Baker Heart & Diabetes Institute, stresses that ‘obesity is not a lifestyle choice, it’s a chronic disease’, with weight problems often genetically based.

Pharmacists can play a significant role in helping people manage their weight by providing informed advice on the many weight loss options now available, both pharmacological and non-pharmacological. 

These range from encouraging changed behaviour patterns, such as increased exercise and a reduced calorie intake; advising on the new wave of injectable weight loss medicines; explaining the pros and cons of meal replacements and other non-prescription products; and social prescribing.

In addition, says A/Prof Cohen, pharmacists have a role in offering sympathy and understanding and sometimes referrals to dietitians.

In the Australian Pharmaceutical Formulary and Handbook (APF) the weight management treatment guideline describes obesity as a ‘chronic relapsing condition requiring long-term multidisciplinary care’.² People struggling with weight may require intensive interventions, including very low energy diets (VLEDs), pharmacotherapy, gastrointestinal devices or bariatric surgery, in addition to lifestyle interventions.

Improving diet and increasing physical activity can boost health even without weight loss, the guideline says, adding it should be recognised that weight loss prompts compensatory physiological weight gain responses, while VLEDs should be prescribed and supervised by a healthcare practitioner with appropriate VLED training. Weight loss in older people requires different treatment, according to the APF treatment guideline. It notes that ageing has been linked to muscle mass reduction, loss of height and an increase in abdominal obesity – and there are no clear BMI targets for patients aged over 65.

Certain medicines, such as corticosteroids, can cause weight gain, and the guideline notes other treatments that promote weight gain include beta-blockers, mirtazapine, SSRIs and sodium valproate.

Motivations are important

Kristian Ray MPS, Pharmacy Development and Health Services Manager at the Pharmacy 777 network, says ideally pharmacists should take care to understand the motivations driving patients who want to lose weight – to determine whether the patients are primarily seeking cosmetic changes, better sleep, more energy, or blood sugar or blood pressure improvements.

‘You can encourage them to take charge of their health by co-creating solutions aligned with their individual goals,’ he says. ‘For successful and sustained weight loss, optimising their adherence to any program or recommendations is the most important factor.’

Pharmacists can educate patients about the health benefits of small changes in weight, diet and daily activity, he adds, noting that even a 5% weight loss reduces the risk of type 2 diabetes, decreases blood pressure, improves sleep and reduces the risk of breast cancer, as well as alleviating tiredness or pain and reducing reliance on certain medicines.

Some people want a more supportive approach from their pharmacists with regular pharmacy visits for weigh-ins and health measurements to track progress, Mr Ray says. Others prefer a self-guided option for weight loss. ‘Their pharmacist can support them in making the best choice for them and their lifestyle, whether that be meal replacement programs, supplements or referrals into other health programs,’ he adds.

Asking permission to begin a conversation about weight management is important, he adds, as well as using ‘positive, health-centred language’, as overweight or obese individuals may have faced negativity, bias or bullying about their size.

Demi Pressley MPS, Chief Pharmacist at the Alive Pharmacy Group, says standard pharmacist care includes lifestyle advice such as information about diet and exercise, advice on meal replacement use, and advice on how individuals should best use their prescribed weight management medicines.

Pharmacists, she adds, can use motivational interviewing techniques with patients to develop weight management plans that are suited to their individual circumstances.

‘Pharmacists’ ability to provide over-the-counter weight management products is limited,’ she says.

‘Orlistat is used less for weight loss currently in the light of the more effective agents available,’ A/Prof Cohen says.

The non-prescription medicine has only moderate weight-loss effects and can have adverse gastrointestinal effects, including fat malabsorption, diarrhoea and pancreatitis.³ There is also evidence of nutrient and drug absorption interference and sporadic cases of liver damage.⁴

Mrs Pressley says issues of weight and obesity have a large impact on the health of patients but the treatment options now available to pharmacists are restricted.

‘The Queensland Community Pharmacy Scope of Practice Pilot presented an exciting opportunity to further assist patients on their weight management journey,’ she adds. ‘However, it is unfortunately limited by current clinical guidelines and does not offer any further weight management options outside of standard pharmacist care.’

Current Therapeutic Guidelines, she says, don’t include a dedicated weight management guideline with evidence-based treatments that reflect the pharmacological management options used in contemporary practice.

It is important, she says, to fully understand a patient’s situation, their goals, and potential barriers to weight loss.

‘For example, if a patient has osteoarthritis in their knees, exercise advice should be tailored to suitable activities for their condition, such as swimming, rather than running or other high-impact exercise.’   

Pharmacists might consider how a meal replacement specifically benefits a particular patient, Mrs Pressley says.

‘Do they skip breakfast? Do they need a quick lunch on the run? Is meal replacement the best option for them? The patient may be eating balanced meals but consuming high-calorie drinks, requiring a different approach to management advice.’

Meal replacements can work for short-term weight reduction, A/Prof Cohen says, but the weight is usually regained, and fad diets – including those heavily promoted on social media – rarely work well. ‘The truth is most people have tried very hard and they can’t lose weight,’ he says. ‘It’s very hard to lose large amounts of weight. The body is designed to prevent that.’

But a new wave of weight management treatments is coming, he adds, beginning with semaglutide (Ozempic), which is indicated for diabetes management and available in Australia, and semaglutide (Wegovy), indicated for obesity in people who do not have diabetes.

These new injectable medicines will have an enormous effect, he says; obesity rates will definitely decline, and the risks of diabetes, heart disease, cancer and arthritis will be slashed.

‘To date, though, there are no drugs on the Pharmaceutical Benefits Scheme (PBS) indicated for obesity, and there is a shortage,’ he says.

‘People are prescribed Ozempic for weight reduction, which is absolutely fine, because it works and it’s safe and it’s effective.’

A third ‘even more powerful’ injectable weight loss pharmaceutical, Mounjaro (tirzepatide), is also indicated in Australia for diabetes management, but it has yet to be registered on the PBS.

‘There’s a whole range of injectables coming,’ A/Prof Cohen says. ‘It will be a flood in the next few years, which will be incredible. It’s the first time we’ve had really good therapies that we think are safe.’ 

References

1. Australian Institute of Health and Welfare. Overweight and obesity. 2024. At: www.aihw.gov.au/reports/overweight-obesity/overweight-and-obesity/contents/overweight-and-obesity
2. Sansom LN, ed. Australian Pharmaceutical Formulary and Handbook. 26th edn. Canberra. Pharmaceutical Society of Australia. 2024.
3. Kose M, Akpinar TS, Ilhan M, et al. An unexpected result of obesity treatment: orlistat-related acute pancreatitis. Case Rep Gastroenterol 2015:95(2):152–5.
4. Qi X. Review of the clinical effect of orlistat. IOP Conf Ser Mater Sci Eng 2018;301:012063
5. Chew HSJ, Achananuparp P, Dalakoti M, et al. Public acceptance of using artificial intelligence-assisted weight management apps in high-income southeast Asian adults with overweight and obesity: a cross-sectional study. Front Nutr 2024. Epub 2024 Feb 7.
6. Overfelt M. AI can coach you to lose weight. But a human touch still helps. Insights by Stanford Business. 2023. At: www.gsb.stanford.edu/insights/ai-can-coach-you-lose-weight-human-touch-still-helps