Worries about Semaglutide

The UK’s health service has just approved the miracle weight loss drug Semaglutide for NHS use. I know 99.99% of things called a ‘miracle weight loss drug’ are duds, but Semaglutide seems to be the real deal. Here’s one summary of the evidence:

Of six major weight loss drugs, only two - Wegovy [Sam’s note: This is one commercial name for Semaglutide] and Qsymia - have a better than 50-50 chance of helping you lose 10% of your weight. Qsymia works partly by making food taste terrible; it can also cause cognitive issues. Wegovy feels more natural; patients just feel full and satisfied after they’ve eaten a healthy amount of food. You can read the gushing anecdotes here (plus some extra anecdotes in the comments). Wegovy patients also lose more weight on average than Qsymia patients - 15% compared to 10%. It’s just a really impressive drug.

Until now, doctors didn’t really use medication to treat obesity; the drugs either didn’t work or had too many side effects. They recommended either diet and exercise (for easier cases) or bariatric surgery (for harder ones). Semaglutide marks the start of a new generation of weight loss drugs that are more clearly worthwhile.

This is really, really promising. One person on the EA Forum (citing relevant and reliable data) claims that high BMI contributes to 5.02 million deaths (95% CI 3.22 to 7.11), with obesity being responsible for about 60% of the burden. Being fat is bad for you, who knew? And Semaglutide is much more effective than your standard diet and exercise routine. 

As Stephan J. Guyenet writes in Works in Progress: ‘Even intensive diet and lifestyle interventions have historically struggled to exceed a sustained 5% loss of body weight, and most weight loss drugs are no more effective’. Most weight loss drugs, but not Semaglutide. Guyenet notes that Semaglutide is ‘the leading edge of a wave of new obesity therapies in development that reflect our deepening understanding of the human body and that promise to fundamentally change the lives of people with obesity’.

Browsing the Semaglutide subreddit makes for compelling reading. There’s story after story from users who have never been able to lose weight until they got on Semaglutide. Here’s an example that’s fairly typical, from a post titled ‘This drug is normalcy’:

I CANNOT BELIEVE THAT THIS IS NORMALCY. I wake up and I don’t crave a cigarette or a big breakfast with bacon and hash browns. I go through the day needing tea or coffee but never a thought that I should get a snickers or a mars bar at 3pm. I go to the supermarket and walk past the chocolate aisle and my stupid brain goes ‘maybe you should try that new one’ but 30 seconds later I can firmly tell myself that I don’t need it and most importantly, I do not want it. It’s utterly fascinating that this is how regular people feel.

Incredibly, it seems like we might be at the point where obesity will soon be optional: as long as you’re willing to inject yourself with Semaglutide, you’ll lose weight. And as these drugs get more effective, you likely won’t have to inject them if you don’t want to - there’s already a (less effective) oral form of the drug called Rybelsus. If it gradually becomes more effective, I suspect people will switch from injecting Semaglutide to taking pills for easy weight loss.

So, what’s the problem? Well, for the most part, there isn’t one. There aren’t horrible side-effects from the drug for most people, as users of the subreddit are keen to point out. You inject Semaglutide and you lose weight, and you keep injecting it to keep the weight off. But I do worry about people with eating disorders.

Sometimes, I think, ‘what about people with eating disorders?’ is invoked too often in a way that’s counterproductive. The ED objection is wheeled out in response to any policy or campaign that is intended to help people lose weight. Want to put calorie counts on menus? Sorry, that won’t have any positive impact but will harm people with EDs, says Guardian op-ed writer. That isn’t to say that we shouldn’t take the point seriously, just to point out that I think it’s become almost a reflexive response to any policy intended to help people lose weight.

But when it comes to Semaglutide, I think it’s a point worth taking really seriously. Calorie counts on menus are one thing, but a drug that means you can go for days without feeling hungry at all is another. Here’s an account of an experience taking Semaglutide by LindyMan (note - a known plagiarist, so I can’t be 100% certain this is actually his experience rather than someone else’s):

LindyMan @PaulSkallas

As I move into week 2 i sometimes forget to eat for the entire day. I get physically weak. So I have to remind myself to eat even though I don't want to. I have constant burps. Which come from deep into my stomach. That is unpleasant. I notice my energy level is lower

Here’s another account from the Semaglutide subreddit:

I’ve been on Wegovy for five weeks and as I was lying in bed last night I was replaying everything I ate for the day and felt gleeful that it was so little. I was proud that it was very little.

Obviously, these are just anecdotes, and we shouldn’t take anecdotes as seriously as we should take research showing the impact of Semaglutide on disordered eating patterns. But there doesn’t seem to be much research on the link between Semaglutide and eating disorders! I think we can have a reasonable intuition here that a drug that makes it extremely easy not to eat anything might make things worse for people who struggle with disordered eating, or even cause people who haven’t previously struggled with eating disorders to develop them.