Obesity levels continue to rise in Europe. According to the WHO Regional Obesity Report 2022, excessive adiposity is complex and multifactorial and presents a serious public health challenge that significantly increases the risk of non-communicable diseases.1 The report states 60% of adults in Europe are obese, as are 7.9% of children under the age of five. A third of school-aged children live with overweight or obesity and, while the prevalence decreases temporarily to a quarter in the 10-19 year age group, this reprieve does not last long. Seemingly no European member state is on track to reach the target of halting the rise in obesity by 2025 because of two compounding mechanisms at play, namely: developmental programming based on preconception and gestational exposure to obesity; and unhealthy diet and physical inactivity driven by exposure to obesogenic environmental factors.
We are all aware of the effects of obesity on cardiovascular and other health issues. Diabetes is currently on the rise; worldwide, the number of people with the diagnosis rose from 108 million in 1980 to 422 million in 2014, with the prevalence rising more rapidly in low- and middle-income countries than in high-income countries.2,3 In 2014, 8.5% of people aged 18 or over had diabetes, with type 2 diabetes accounting for more than 95% of cases worldwide. Physical complications include visual impairment, renal failure, ischaemic heart disease, cerebrovascular accident and amputation of the lower limbs. The period from 2000 to 2016 saw a 5% increase in premature mortality from diabetes at a time when the probability of dying from cardiovascular diseases, cancer or chronic respiratory diseases actually decreased. According to the WHO, diabetes was the ninth leading cause of death in 2019, with an estimated 1.5 million deaths directly attributable to the disease. All of this is, of course, linked to obesity.
Obesity is of particular concern to patients with severe and enduring mental illnesses such as schizophrenia. According to the WHO, individuals with schizophrenia have a reduced life expectancy of between 10 and 25 years. Suicide only accounts for a small fraction of this. Heavy smoking is two to six times more common among people with schizophrenia, while 45-55% are obese and 10-15% have type 2 diabetes. In parallel, individuals with schizophrenia receive poorer medical care for their physical problems than do members of the general population. Diagnostic overshadowing frequently occurs and delayed diagnosis often prevents effective care. To combat the development of obesity in this population, metformin is increasingly prescribed alongside the antipsychotics olanzapine and clozapine, but it does little to reduce any weight that has already been gained. Thankfully, a more-recent game changer has emerged.
Glucagon-like-peptide-1 (GLP-1) agonists include injectable medications such as semaglutide, dulaglutide and liraglutide and have been used in diabetes treatment for years. They were seen to be effective at producing weight loss and have been further developed with new formulations licensed as weight loss medications. A significant demand has emerged worldwide driven by celebrities and influencers, leading to issues of affordability and access.4 Since the HSE approved the first lirglutide licensed for the treatment of obesity in Ireland (Saxenda), demand for it has increased dramatically. The HSE now anticipates spending more on anti-obesity medications in just one year than it had originally budgeted for five years. Around 30,000 patients already take these medications but, with around 60% or Irish adults either overweight or obese, the current expenditure on these medications (estimated at around €55 million a year) is expected to increase significantly. But only, of course, if supply can keep up with demand.
- WHO European Regional Obesity Report 2022 https://apps.who.int/iris/bitstream/handle/10665/353747/9789289057738-eng.pdf