If current trends hold, the world is heading for a heavy future. By 2050, almost 60 per cent of adults and one in three children will be overweight or obese, according to a stark projection from The Lancet.
Statistics like these, along with new clinical guidance and the powerful marketing of new weight-loss drugs, have medical professionals scrambling to keep up with best practices and patient demands.
“Not a day goes by that I’m not asked by a patient or a health-care provider, ‘So, what about this Ozempic?’” — Dr. Sonja Reichert, Associate Professor, Department of Family Medicine, Schulich School of Medicine & Dentistry
Adding to the explosive mix are new definitions of obesity that downplay the widely used body-mass index (BMI) and reframe clinical obesity as “a chronic systemic illness characterized by alterations in the function of tissues, organs, the entire individual.”
In April, the Canadian Medical Association Journal updated its guidance for treating children with obesity—supporting the use of GLP-1 medications like Ozempic and Wegovy in those aged 12 to 17.
The Journal of the American Medical Association has hailed the medications as transformative. “Health systems across the globe now may be able to offer a treatment response that, integrated with lifestyle changes, opens the possibility of an end to the obesity pandemic,” JAMA said in an editorial in February.
While Reichert welcomes the new emphasis on metabolism as opposed to lifestyle habits when diagnosing obesity, and considers the new medications “game-changing,” she cautions that they should only be used in conjunction with full medical assessment and careful follow-up. She recently served as the clinical lead for an online training module for primary caregivers in Ontario on how to prescribe and supervise the use of GLP-1s. Launched last October, the module has been downloaded more than 2,600 times and already needs updating, she says.
“For our [module-writing] team it was really important that we don’t just present ‘these are the drugs,’ but include how to assess for comorbidities, how to decide is this medication right for the person or not, because you can do harm with this medicine,” says Reichert, who holds the endowed Brian W. Gilbert Canada Research Chair in Primary Care Research. “You have to know what you’re doing.”
“Where things go awry is when people take the medicine without proper assessment and follow-up.” — Dr. Sonja Reichert
Used properly, GLP-1s are a great tool for breaking the shame-based vicious cycle of obesity, she says, because they offer patients a chance to experience success in their efforts to lose weight.
In her diabetes clinic, she prescribes Ozempic as part of a broad program that includes dietary and exercise counselling, extensive conversations with patients, and psychological counselling if needed. “Those are the pillars of care,” she says. “Where things go awry is when people take the medicine without proper assessment and follow-up.”
Social media is teeming with stories from people who got their hands on Ozempic, tried it without proper support or supervision, felt sick, and broadcast their experience on Instagram or TikTok.
Now, her patients are hit by all this misinformation. “I’ve had patients come to me and say, ‘Oh my gosh, Dr. Reichert, you put me on Ozempic. Are you trying to kill me?’”
GLP-1s mimic a natural hormone that works in the gut and the brain to reduce feelings of hunger and balance blood sugar.
Semaglutide is sold as Ozempic for Type 2 diabetes and as Wegovy for obesity. Though identical, they are marketed under different names and both are taken by weekly injection.
Another GLP-1, Saxenda (liraglutide), is a daily injection. Health Canada is also expected to soon approve a related drug—tirzepatide, known as Zepbound in the United States—that contains both GLP-1 and another hormone and is reported to be even more effective for shedding weight.
Dr. Marina Ybarra, an assistant professor of paediatrics and head of the Pediatric Healthy Eating, Activity and Lifestyle (HEAL) Program at London Health Sciences Centre’s Children’s Hospital, has high hopes that the teens with obesity she treats with Saxenda or Wegovy will avoid one downside of GLP-1 drugs—the need to stay on them long-term or risk gaining most of the weight back.
“We are in a different scenario than for adults,” Ybarra explains. “We believe that children are not on their own lifestyle yet; they’re under the parental or familial lifestyle. So, if we are able to get them where they want to be, I think we have a higher chance of them keeping the ball rolling on their own without the medication.”
At her clinic, the focus is on helping kids feel healthier and better about themselves, not just lowering numbers on a scale.
“We try to offer guidance to help them change their lifestyle at a very slow pace, so that they feel they are successful in the things they are doing,” Ybarra says.
If the child is aged 12-17 and has severe obesity, or if Ybarra thinks it will be too hard for a patient to reach their goal, she offers the medication.
The paediatric endocrinologist is preparing to launch new research alongside her clinical work, with plans to study the outcomes from the clinic through retrospective analysis.
She’s also interested in studying genistein—a compound found in soybeans known to reduce inflammation in adults—to see whether it could benefit children with obesity. Funding, she notes, is a major barrier, especially when it comes to studying costly medications like GLP-1s.
Since the potential of GLP-1s was recognized in the late 1990s by Canadian scientist Daniel Drucker, who found it was the reason that desert lizards known as gila monsters didn’t need to eat frequently, Canada has been at the forefront of obesity research.
“Why are we hesitant around treating something that’s been defined as a medical condition?” — Dr. Sonja Reichert
In a lab at Schulich Medicine & Dentistry, physiology and pharmacology professor Nica Borradaile, PhD, studies compounds from nature that can improve the metabolism of fat and could be synthesized in the future as obesity medications.
She has seen what happens inside vascular and liver cells when they’re exposed to too much fat.
“When fat is in the bloodstream, whether from a high-fat diet or your body making a lot of fat on its own, it ends up in tissues like the liver, the muscles, the pancreas, and causes toxicity that impairs function,” she says.
This malfunctioning can lead to diabetes, heart disease and fatty liver disease.
Borradaile’s team recently discovered that a compound from sea squirts (marine tunicates) can help clear fat from liver cells by inhibiting the action of a protein within the cells. Her research team would like to move on to testing the compound in animal models to see if it will slow the progression from liver cell damage to liver cancer.
Her team is also working with the Mushroom Growers of Canada on how components of mushrooms, such as niacin and ergothioneine, might help promote good lipid levels.
As the pharmacological battle against obesity unfolds, money remains a central problem. At about $400 per month for Ozempic/Wegovy, with insurance largely unavailable, these medications are out of reach for many Canadians. Running clinical trials is also expensive.
“Why are we hesitant around treating something that’s been defined as a medical condition?” Reichert says. “No one says, ‘You gave yourself hypertension, I’m not going to give you medicine.’”
She understands the concern that people who don’t need them are seeking medications simply to lose weight without dieting, but she doesn't see gatekeeping as the answer.
“That mindset shift, toward care and not blame, may be the real game changer.”
