Kristel Foisy has been overweight since she was a child. The Peace River, Alta., resident is 160 pounds heavier than the weight recommended by her doctor, and it affects every aspect of her life.
Walking up stairs is a challenge. Travel for work, a regular occurrence for her job as a cosmetics manager, requires her to pack a seat belt extender for the airplane – and she worries about fitting in the seat.
Her dream of taking her 10-year-old son to Disneyland is on hold indefinitely, as she knows she won’t be allowed on any of the rides. She’s prediabetic and experiences heartburn and anxiety. “I’m at a point where I physically hurt all the time,” she said. “It’s not a fun life to live at 38.”
Ms. Foisy limits her food intake and she’s as physically active as possible, working hard to hit 10,000 steps a day. But no matter what she does, she can’t lose weight.
She’s been seeking help from an obesity specialist and has been on the wait-list for bariatric surgery – a procedure that reduces the size of a patient’s stomach – for about four years.
While she waits, her doctor prescribed Ozempic, a brand name of semaglutide, a medication originally released in Canada in 2018 to treat Type 2 diabetes. Semaglutide mimics one of the body’s own hormones to help people control their blood sugar – and also lose weight by promoting a feeling of fullness.
Semaglutide is not the first drug of its kind to hit the market, but it appears to work better for weight loss than previous iterations. Manufacturer Novo Nordisk has created a distinct version of it in a different dosage, called Wegovy, to target obesity.
In one clinical trial, people taking weekly injections of Wegovy lost 10 to 15 per cent or more of their body weight over a 68-week period, results that dwarf any previous anti-obesity drugs. In the real world, some are reporting even more significant losses.
After decades of bombardment by commercials, books and social-media ads making false promises about the secret to miraculously shed pounds, scientists have finally discovered a formula that actually works. People around the world have taken notice, with demand for Wegovy outstripping supply.
Health Canada approved Wegovy in November, 2021, and Novo Nordisk planned to launch the drug here in the fall of 2022. But due to overwhelming demand in other countries – particularly the U.S. – Wegovy’s entry in Canada has been sidelined indefinitely.
As a result, many people with obesity are left looking to the next best alternative – Ozempic – although for a number of them, insurance won’t cover the cost.
Prescriptions of the drug dispensed from community pharmacies in Canada accounted for about $26-million in 2018. By 2022, it was nearly $808-million, according to Iqvia, a health analytics firm.
While many of these prescriptions would have been written for people with Type 2 diabetes, a significant chunk of the growth is the result of people with obesity seeking access to it.
Now, Ozempic is in short supply, prompting some medical groups and professionals to call for a moratorium on prescribing the drug for obesity, suggesting that people with Type 2 diabetes get priority access.
The Canadian Medical Association officially recognized obesity as a chronic disease in 2015, and while millions live with it, many go untreated and there have historically been few effective medications.
Despite this, there’s been surprisingly little celebration of a drug that has potential to change how the condition is managed. Instead, people living with obesity and clinicians who treat it say the discussion around semaglutide has veered down a toxic road, exposing long-standing biases against people whose health is severely affected by carrying extra weight.
The Globe and Mail interviewed more than a dozen specialists, scientists, patients and advocates who say that, while it’s true access to the drug is impacted by continuing shortages, it’s also being limited by stigma and the widespread – but false – idea that treatment for obesity is about vanity.
News headlines, for instance, have blasted viral TikTok posts for fuelling a frenzy around these drugs and blamed celebrity culture – unfounded speculation suggests Kim Kardashian’s rapid weight loss last year was the result of Ozempic – for creating the shortage.
Some in the medical community agree that the popularity of Ozempic on social media is the driving force behind shortages they say could put the health of people with Type 2 diabetes in jeopardy. For that reason, last year, Australia’s Therapeutic Goods Administration, an agency similar to Health Canada, issued a statement urging doctors not to prescribe Ozempic for obesity.
According to physicians who treat obesity, the implied suggestion is that people with diabetes are more deserving of priority access to semaglutide while it’s in shortage, demonstrating another example of bias. For many with obesity, all of this means that, instead of getting access to one of the best treatments ever developed, they continue to receive outdated advice to “eat less and move more” – and that’s only if they can find a health provider who is willing to talk about obesity.
“I think a lot of it is actually related to deeply ingrained weight bias. In the general public and even health care professionals, there’s still very much this belief that obesity is a lifestyle choice, that people choose to live a certain way,” said Sabrina Kwon, medical director of the Alberta Obesity Centre North and physician at the adult bariatric surgical clinic at Edmonton’s Royal Alexandra Hospital.
She couldn’t disagree more. “Obesity is worthy of treatment,” she says.
Nearly 30 per cent of adults in Canada, or more than seven million people, are obese, according to Statistics Canada’s 2018 Canadian Community Health Survey. It’s a complex and often misunderstood condition that has roots in genetics, a patient’s medical history, and social determinants of health and behaviour. The so-called obesigenic environment we live in – easy access to processed, calorie-packed foods combined with sedentary jobs and reliance on cars – also plays a role.
In recent years, mounting research has shown that errant brain signals are a common factor in those diagnosed with obesity.
Ali Zentner, an internal medicine and obesity specialist and medical director of the Revolution Medical Clinic in Vancouver, explained that, in simple terms, obesity can occur when an individual’s brain and body urges them to consume more calories than necessary, and hold on to fat. “It’s an inappropriate starvation response,” he says.
In addition to the challenge of identifying the exact causes of obesity, even diagnosing the condition is a complicated endeavour. Body mass index (BMI), which used to be the standard but is now known to be inaccurate in many cases, is still used but in combination with other metrics – including waist circumference and the impact excess weight has on a person’s health and well-being.
Plenty of people with obesity go undiagnosed and many others go untreated, despite it being one of the most common chronic diseases in Canada – even more so than diabetes, which afflicts about 5.7 million Canadians. While primary care providers are in a position to broach the topic of obesity with patients and start on a treatment path, they may not due to a lack of education and awareness around the condition.
Stigma related to obesity also plays a part, said Helena Piccinni-Vallis, an associate professor and research director in the department of family medicine at Dalhousie University.
For instance, most health providers wouldn’t hesitate to discuss treatment options with a patient who has high blood pressure, but many avoid the complicated and often awkward conversation with patients who meet the clinical definition for obesity.
“Obesity is often not recognized as a chronic disease,” Dr. Piccinni-Vallis said. “When you think about the fact that well over a third of the patients we see in primary care are obese, we’ve got to get a handle on this.”
Many clinicians say the condition continues to be wrongly understood as something a person could change if only they had the will – similar to the way depression and other forms of mental illness were viewed a few short decades ago.
“This isn’t an individual moral failing,” said Heidi Dutton, assistant professor at the University of Ottawa and Ottawa medical director of Aroga Lifestyle Medicine. “We really need to be thinking about obesity the same way we think about these other chronic metabolic diseases and not blame people for looking for an effective therapy.”
To be clear, physicians like Dr. Dutton aren’t suggesting anyone over a certain BMI take medication, or that they must lose weight. Rather, they and members of the medical community are advocating for better acceptance of obesity as a disease and increasing access to treatment for those seeking help.
The burgeoning fat acceptance movement has worked to reduce the stigma of obesity and encourage the embrace of bodies in all shapes and sizes. And while much more work is needed to combat fat shaming and the prevailing fixation with thinness, medical professionals say the majority of individuals who live with obesity will, at some point, experience health problems as a result.
People who carry excess weight are more likely to experience high blood pressure, stroke and other serious heart-related problems, as well as various forms of cancer. Add to that a list of other conditions that can make life with obesity an increasing challenge, including mobility problems, joint pain and mental health issues.
“Society has never had an effective intervention for people with obesity, aside from bariatric surgery,” said Daniel Drucker, a senior scientist at the Lunenfeld-Tanenbaum Research Institute who helped discover the hormone that led to the development of semaglutide.
“We can’t contemplate having hundreds of thousands of people suddenly having bariatric surgery. Whether we can contemplate hundreds of thousands being treated effectively with this obesity medication is a debate we’re having now.”
The history of the weight loss industry is littered with snake oil and dangerous medications, such as amphetamines, that caused numerous deaths before being banned. In the years before semaglutide, there were three drugs approved to treat obesity in Canada, but none are as effective.
Semaglutide is a glucagon-like peptide-1 (GLP-1) receptor agonist, which is a class of drugs that, to many doctors and obesity advocates, represent the future of obesity treatment. These medications mimic the body’s own GLP-1 hormone, found in the gut and used to control insulin and glucagon levels.
In the clinical trial where people taking the drug lost 10 to 15 per cent of their body weight – when combined with therapy, calorie reductions and other lifestyle interventions – participants who took a placebo and received the same lifestyle interventions lost only 3 per cent of their body weight.
“This class of drug opened the door to a better understanding of biology,” Dr. Zentner said. “It reinforced the idea this wasn’t an ‘eat less, move more’ phenomenon. People were taking this medication and their brain was no longer telling them they were starving.”
In a March, 2022, interview, Novo Nordisk president and CEO Lars Jorgensen told The Globe that Wegovy represents a pivotal moment in the way society views obesity.
“The fact that there’s now an efficacious treatment means that we are starting to actually acknowledge obesity as a disease,” he said. (By late last year, Mr. Jorgensen had stopped doing media interviews, explaining that it would be “irresponsible and unethical” to promote a drug that is not currently available.)
In November, Health Canada approved another drug in the same class, tirzepatide, for the treatment of Type 2 diabetes. But clinical studies show it may work as well or even better than semaglutide for obesity and it’s widely expected that its maker, Eli Lilly, will also seek separate approval for an obesity version. The drug, sold under the brand name Mounjaro, is not yet available in Canada.
In an interview, officials with Eli Lilly said, due to overwhelming demand elsewhere in the world, it’s difficult to say when the newly-approved medication will be launched in Canada.
Demand for Mounjaro is so high that Eli Lilly is investing $3.6-billion in five new manufacturing sites in the U.S. and Ireland, all of which will be largely dedicated to the new medication.
That’s not to say GLP-1 treatments are miracle drugs. They don’t work for everyone and people using them are supposed to monitor their calorie intake and stay active. Once people stop taking the drugs, they will likely regain the weight they lost. It’s not clear if there are any long-term issues linked to taking the drugs for many years.
And both semaglutide and tirzepatide come with side effects, including the risk of nausea, stomach pain, vomiting and pancreatitis. Some animals taking the drug developed thyroid cancer, and while it’s not yet clear if the risk is similar in humans, patients are advised to seek advice from a doctor and watch for any signs of tumour growth, such as difficulty swallowing.
Dr. Kwon said the risks need to be taken seriously, but that in her experience, many common side effects can be mitigated with guidance.
On the flip side, Dr. Kwon said many of the patients she has treated with Ozempic see a major boost in quality of life, including reduced aches and pains and an increased ability to do everyday necessities, such as shovelling snow, going for walks and cleaning themselves after using the bathroom.
Many clinicians interviewed by The Globe have worked with its manufacturer, Novo Nordisk, accepting payment for educational talks or consulting sessions. Financial relationships between doctors and drug companies, while common, raise concerns about a potential conflict of interest.
James Johnson, professor in the department of cellular and physiological sciences at the University of British Columbia, said he’s concerned about the near-universal praise for Ozempic and what he sees as a fleeting discussion about side effects and other options for weight loss. He said the proliferation of obesity experts who appear to be promoting Ozempic and other obesity treatments on TikTok is a major red flag.
“It makes me wonder about peoples’ credibility and motivation and conflicts of interest,” said Dr. Johnson, who used to work for Novo Nordisk. “Nothing is so good that it should be in the water.”
Yoni Freedhoff, a physician specializing in obesity who has developed a loyal following for his online takedowns of popular weight loss treatments, said he’s taken money from Novo Nordisk and other drug companies, but doesn’t prescribe drugs that don’t work.
“People are losing uniformly double digit percentages of their weight,” he said. “That is not cheerleading. That’s just fact.”
Dr. Freedhoff, medical director of the Bariatric Medical Institute, said the debate over Ozempic is a reflection of the stigmatization of obesity. He pointed to the fact that less-proven drugs are approved for use and covered by provincial insurance plans all the time with little public discussion.
He believes there’s a strong case to be made for public coverage of Ozempic and similar drugs and that better access to proven treatments will lead to better outcomes for many, not just those who have private insurance or can afford to pay out-of-pocket.
“Anybody pushing back on this, as far as I’m concerned, does not understand or work with patients with obesity,” he said.
Even though Kristel Foisy’s doctor recommended she take Ozempic, her insurance company won’t cover it because she hasn’t yet been diagnosed with Type 2 diabetes. Ms. Foisy can’t afford to pay the cost – roughly a few hundred dollars a month – so she is left to wait for surgery and live in a declining state of health.
What makes this even harder to take is that a colleague of Ms. Foisy, who has the same insurance provider, approved her Ozempic reimbursement, despite the colleague not having diabetes either. “There’s no real rhyme or reason to why I was denied for it,” Ms. Foisy said.
In the meantime, she describes how obesity robs her of the life she wants to lead. “I think I would be a totally different person if I didn’t have the extra weight. I feel like I’m stuck in somebody else’s body,’ she said. “I want to run. I want to play hockey like I used to play hockey. I want to take my kid to the park and not be out of breath.”
Those who manage to get access to Ozempic describe the striking effect it’s had, after years of suffering with a chronic illness.
In 2022, Darlene Harris-Williams reached her heaviest weight ever at 480 pounds. The 60-year-old Edmonton resident can’t leave home without her wheelchair or walker. Her husband has become her full-time caregiver and all of the things the couple once loved – travel, restaurants and nights at the theatre – are too cumbersome to attempt. She’s also suffered from urinary incontinence, high blood pressure and myriad other issues related to obesity. “I was struggling to get out of bed. I was struggling to walk,” she said in a recent interview.
Last March, after witnessing the impact her disease was having on her husband, she decided to make a change. She’s now a patient of Dr. Kwon, who prescribed Ozempic while she waits for bariatric surgery. Less than a year later, Ms. Harris-Williams has lost nearly 100 pounds. Her blood pressure is normalizing, the urinary incontinence has disappeared and her mobility is slowly improving. It’s all the result, she says, of her hunger being much more manageable. “There is an amazing difference between this and all the diets I’ve ever done.”
Ms. Harris-Williams can now imagine a future where she is able to regain some of her lost mobility and do some of the things she loves. She said she feels fortunate to have a physician who was able to prescribe Ozempic, and an insurance plan that covers it.
But experts say shortages and a lack of coverage means Ms. Harris-Williams’s story is the exception. Many, like Ms. Foisy, continue to struggle daily with no access to effective treatment for their chronic disease. This is particularly the case when it comes to low income and other vulnerable individuals who are more likely to experience obesity, lack private insurance and have challenges navigating the health system.
Obesity is not being recognized and treated at the primary care level often enough, Dr. Piccinni-Vallis said. Those lucky enough to get connected with a physician specializing in the treatment of obesity face long wait lists and other hurdles. For instance, there are nearly 4,000 people on the wait list for Dr. Kwon’s bariatric surgery clinic.
“The system is brutal,” Dr. Kwon said. “It’s just unconscionable from my perspective as a health care provider. They clearly need medical attention and they’re just not getting it in a timely fashion.”
The Canadian Medical Association officially recognizing obesity as a chronic disease was a good first step, said Dr. Piccinni-Vallis, but more medical groups and associations need to follow suit to help ingrain the recognition and treatment of obesity into primary care and other branches of medicine.
“As obesity becomes more recognized as a chronic disease,” she said, “it also then becomes more normal to address it.”