Obesity is not your fault nor just for the affluent – Prof Carel le Roux, World-leading SA Diabetes expert

Obesity is not your fault nor just for the affluent – Prof Carel le Roux, World-leading SA Diabetes expert

A recent Lancet study reveals that over one billion people worldwide are living with obesity, equating to one in eight individuals. In South Africa, where obesity is likened to a tsunami or epidemic, 43% of adults were overweight in 2022, with a significant portion of women, men, and children with weight-related issues. Professor Carel le Roux, a global authority on obesity and diabetes from South Africa, who is the Chair of Experimental Pathology at University College Dublin, told Biznews in an interview that there has been a shift in treating obesity as a disease rather than a personal failing. Regarding semaglutide drugs for the treatment of obesity, he said they are able to turn back the clock on Type 2 diabetes, but he cautions against viewing them as mere weight loss aids. “You’re going to regain all that weight, probably be worse off after you have stopped the treatment than before you started,” he said. For people with obesity and diabetes, it is a lifelong treatment. Referring to the cost of obesity drug treatment in South Africa, he said the cost of the drugs will fall over time as it happened with HIV treatment.

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Extended transcript of the interview 

Linda van Tilburg (00:01.343)

I am Linda van Tilburg for BizNews. A study released by The Lancet shows that in 2022, more than a billion people in the world are now living with obesity. That is one out of eight. In South Africa, the statistics show that 43 % of adults were overweight in 2022, with over two-thirds of South African women 30 % of men and a significant proportion of children facing obesity or overweight problems. So how do we address this global problem that has a link to diabetes? One of South Africa’s own, Professor Karel Leroux is a leading global voice on obesity and diabetes and we have him in the business studio to discuss his work on obesity. Hi, Professor Karel Leroux, how are you?

Carel Le Roux (00:54.509)

Very well and thank you very much for having me.

Linda van Tilburg (00:57.919)

Well, we want to ask you, you were at the University of Pretoria, how did your path lead you to Dublin in Ireland?

Carel Le Roux (01:04.812)

Yes, so I graduated from the University of Pretoria and then went to the UK to do my postgraduate training. I was very fortunate to work at St Bartholomew’s Hospital, and the Hammersmith Hospital. I completed my PhD at Imperial College in London and then set up the first obesity clinic at Imperial College. That’s really where I started to learn about obesity as a disease and we had these amazing treatments, bariatric surgery,

We started to get medications, we had diet and exercise approaches, and really understanding how it worked is what triggered my interest. Later on, I moved to Dublin for a chair in Metabolic Medicine, and I’ve been here for more than 10 years and having great fun.

Linda van Tilburg (01:52.735)

So given that you were born and raised in South Africa and received your medical training there, how does that influence your approach to obesity?

Carel Le Roux (02:01.738)

Well, I think it’s changed my viewpoint because I understand that the disease of obesity is not necessarily a disease that’s just driven by affluence, and we see this in the rural parts of South Africa. We see this in the wealthiest areas in Europe. Therefore, I’ve come to realise that probably obesity isn’t one disease. It’s probably multiple diseases and what we need to do as doctors is get smarter so that we can diagnose it better, so we can have personalised treatment. T

his idea about getting the right treatment to the right patient at the right time. But certainly having grown up in Africa, and having trained in Africa, it gives me this perspective, a global perspective, both of the developing world, but also the developed world, and how, of course, we share far more than what makes us different.

Linda van Tilburg (02:56.671)Could you give more details on how your treatment and methodology differ from what is out there?

Carel Le Roux (03:06.282)

I think what has happened in the very recent past is that people that had obesity were first of all thought to be their own fault and therefore, healthcare professionals, rightly or wrongly, said to patients, ‘What you need to do is eat less and move more. So, our strategy now is completely different. We understand that eating less and moving more is what’s called a weight loss treatment. But if you treat the disease of obesity as you would treat any other disease,

then you are doing an obesity treatment. Probably the biggest and easiest way to differentiate it is if you go on a weight loss treatment while you are losing weight, you will feel hungry. But if you have an obesity treatment while you’re losing weight, you will feel less hungry and more satisfied. So, we are thinking about the symptoms of the disease of obesity and weight loss makes it worse, but treating obesity actually makes the symptoms better and hence we are now moving to these obesity treatments which could be nutritional therapy, pharmacotherapy or surgical therapy.

Linda van Tilburg (04:17.311)

Let’s look at these treatments. Well, one of them is semi-glutide drugs that’s become so popular. So could you elaborate on the advantages of those medicines?

Carel Le Roux (04:26.858)

So actually this drug is based on a natural hormone that you have and I have. But people that have the disease of obesity don’t have enough of this hormone and actually the centre where I trained at London Imperial College, they were the first ones to inject this natural hormone into humans and show that when you do that, people felt less hungry. So, now what the companies have done is, they’ve changed that natural hormone so it lives in the bloodstream for almost a week and when you give that back to people, the same thing happens.

Patients come back and they tell us five things. They say, one, I feel less hungry. Two, when I eat, I feel more full. Three, I’m thinking about food less often. Four, I’m eating less food. But the fifth one, which is the most important one, is I enjoy the food that I’m eating and that is what the hormone is doing because it’s treating the disease of obesity in the middle part of the brain.

This is the part of the brain that is affected by the disease and by treating it, patients respond to the treatment. Now, it is true to say not everybody responds in the same way and there are people with the disease that don’t respond at all and that’s incredibly frustrating. So, we must find more treatments to actually help more people.

Linda van Tilburg (05:46.879)

So what are the potential effects, long-term effects of these drugs and use of – they’re all injectables, aren’t they?

Carel Le Roux (05:53.578)

Correct, so the first one of this class of medications was approved in 2005. So, we actually have more than 19 years of data on these drugs. Over the 19 years, the long-term effects of these medications are that they reduce the risk of developing diabetes by 90%, they reduce the risk of heart attacks by 20%, and we’ve recently learned they’ve reduced the risk of chronic kidney failure by 25%. So, those are the long-term effects.

What are the short-term effects? The side effects may be that people may feel a bit nauseous in the beginning, but the nausea goes away. Other people may have constipation. Now the constipation comes and stays in the long term and that’s why we have to be on top of it. We have to give people more water to drink, we need to give them more fibre to eat, we need to help them with their bowel habits, so that we need to really be on top of.

Of course, anything that makes you lose weight, whether or not it’s a nutritional approach, a medication approach or a surgical approach can cause gallstones. It’s very rare, about three in a hundred, but if it happens, we need to be able to manage it. So, these drugs are not magic, they are biology and we understand the side effects, we understand the benefits, and what we now need to do is use them as we would any other medical treatment for any other chronic disease.

Linda van Tilburg (07:18.367)

Well, the catchword there, of course, is medical treatments. What about this trend of celebrities using it for weight loss, and you hear these reports of Ozempic faces –  people’s faces become thin very quickly. So are you worried about the abuse of this drug?

Carel Le Roux (07:37.13)

So I’m saying this facetiously, but celebrities are people too. Of course, people who are celebrities may also have the disease of obesity and if we treat the disease in people who are celebrities, that’s a good thing. But, if you use this medication because you want to fit into another dress or the summer is coming up and you’ve got a couple of weddings to go to if you use it and you stop the medication, you will actually harm yourself because what would happen is you take the obesity treatment and the minute you stop it, you are in a weight loss state.  Therefore the body is gonna push back, you’re gonna regain all the weight and you probably will be worse off after you’ve stopped it than before you started. 

So, when we are saying to people we’re treating the disease of obesity, we say to them the most important decision they have to make is if this works, will they take it for the rest of their life? I think if you are prepared to take a treatment for the rest of your life because you have an understanding of how the complications of obesity are driving down the quality of your life, then that’s a good thing. Now, of course, there are very few people who become underweight because of this treatment, but there are some people who will lose half of their body weight. It’s rare, but it happens. 

Of course, all we need to do is just reduce the dose of the medication. But I think it was dating back to the 1930s where the saying comes, you can never be too rich or too thin and I think that is what we also need to push back against, that these are not weight loss drugs. These are health-gain drugs. So, does the drug make you healthier and if it does, then how can you do this for the rest of your life?

Linda van Tilburg (09:29.759)

So are these, the bariatric surgery that you talked about and the drugs, are they a solution to the problem of diabetes as well? 

Carel Le Roux (09:38.57)

So, the impact of treating obesity on type 2 diabetes is incredible and we now think that we can disrupt the disease of type 2 diabetes with these medications and also with metabolic and bariatric surgery. So, if you use these medications or you have surgery and you are at risk of developing diabetes, we reduce your risk by 90%. That’s incredible.

Now, if you have type 2 diabetes and we use these medications or surgery, we can put your body in what’s called glycemic remission. So, effectively, we turn the clock back. Your sugar levels get to the same level as it was before you had type 2 diabetes and of course, if you have incredibly bad diabetes and we use these medications or we use surgery, we can control it and make you live longer. 

So overall, the impact on type 2 diabetes is tremendous and that’s a very good example of the health gains that we get. When we’re talking to patients about what’s the value proposition to you – even people who lose 25 % of their weight, they come back and they say,actually the weight loss is no longer so exciting or interesting to me, but the fact that I can now put my socks and my shoes on, or I can play with my children when I’m sitting on the ground. My diabetes has gone away, that is the value proposition of these treatments.

Linda van Tilburg (11:09.951)

You’ve also written quite a lot or said quite a lot about the brain’s influence on it, the brain and the gut. Can you just explain your approach about the brain and the gut?

Carel Le Roux (11:18.378)

Yes, we were very interested to understand how the gut talks to the brain and how this signals,  when you and I have a meal, say for example, you are really hungry and you drink two litres of water, you will feel quite bloated, but in a half an hour, you’ll be just as hungry as you were before you drank the water. But if you’re really hungry and you drink two litres of full-fat milk, you would be satisfied for quite some time. 

The reason is because the gut can sense how many calories you’ve put inside it and therefore it sends a signal to that part of the brain to allow you to feel satisfied. Now, what is happening with the disease of obesity, those signals are diminished and that’s what we now need to boost. If you boost it, what will happen is people will feel more satisfied and now with these treatments, be it bariatric surgery, or be it medication, that’s exactly what we do. We’re enhancing the signals, the natural signals from the gut to the brain.

Linda van Tilburg (12:25.695)

That’s also interesting. So there’s this whole stigma associated with obesity and also now with the use of these drugs from people saying, I feel guilty, that’s a shortcut.

Carel Le Roux (12:37.802)

Yes, exactly. We are now in the process of convincing the scientific and medical community that obesity is a disease. The hardest stakeholder to convince, in my view, would be patients themselves, because people have been blamed for having obesity since the age of six and when you say to people, look, this is a disease, this disease is not your fault but it is your responsibility and it is my responsibility to find a treatment. When you do that, you see grown men crying and they say, now that I understand it’s a disease, you’ve given me agency. You’ve allowed me to take control of this situation. It’s not nice to be diagnosed with a disease. It’s not a happy moment, but the fact that I now know how to treat it and not just blame myself, that makes a difference.

So, I think it’s important to say that identifying obesity as a disease and medicalising it, is what we do with all other diseases. And only when we do that do we start making it better. Of course, what we all want to do is we want everybody in the world to have a better diet and better exercise because a better diet and exercise will make you healthier. However, a better diet and exercise are not necessarily a treatment for the disease of obesity in the majority of people. So we need to differentiate that it works for a subset of obesity and it’s fantastic, let’s do it because it’s so low risk. But if it doesn’t work, then don’t blame people, rather escalate treatments. Try another nutritional approach or try pharmacotherapy or even surgical therapy. But not blaming people is the first step in successfully treating this disease.

Linda van Tilburg (14:30.239)

So how do we do this in Africa? Because we talked about a drug, which is expensive. We talked about bariatric surgery, which is expensive. So how do we tackle this problem of obesity in Africa?

Carel Le Roux (14:41.578)

So, I think we need to always try to prevent the disease. So we need to have better prevention strategies. But remember, prevention is focused on people who are normal weight. So I would like normal weight people to remain normal weight. When you see a lot of the health messages of eating less and moving more, and when people are normal weight, they don’t think it pertains to them. So, we need to get the messaging right so that a third of South Africans that are currently normal weight, are the people we need to target to keep them normal weight. However, what we also need to understand is all medications become cheaper over time. Even if you think about the HIV medications, that was incredibly expensive and unaffordable 10 -15 years ago. Now, those medications are affordable and we are able to roll them out and we are able to make a difference.

This is going to be the same with these medications. They will be expensive for some time to come, but they will become affordable as time goes on and it’s at that time that we need to be able to roll it out in a larger way. Of course, we need to identify those patients that would benefit most and if we can identify people that are at very high risk of developing significant complications like type 2 diabetes or heart attacks, we can target those.

If we can take those patients and actually look at those that will be the biggest responders that will lose 20 -25 % of their weight loss, if we can match that, now we have a health economic case to treat the people that would benefit most and also at highest risk. So, that’s maybe a place to start and how to implement this.

Linda van Tilburg (16:29.759)

If you look at HIV drugs, there was a lot of pressure at the time on the drug companies, on the pharmaceutical companies. Do you think that’s going to happen to make it cheaper for countries in Africa, like South Africa?

Carel Le Roux (16:41.098)

I think so because there was one very good company that really was leading the way. But, now the five biggest companies in the world have all joined this race and of course, by having more competition, and better treatments, what will happen is inevitably there will be competition in the system and the medication prices will come down. The medication is so effective, that it’s far exceeded our expectations of the number of people that want to be treated. So, even with these mega companies, they can’t make the medications fast enough. Now, of course, what they are doing, like any industry, they’re just building more factories. And of course, as that actually plays out, we’re going to see more medications in the system and ultimately, this challenge that we have for not enough supply will eventually go away.

Linda van Tilburg (17:39.423)

And do you think the stigma of it being a skinny drug instead of a health drug, something that can actually make people healthy? Do you think that stigma would go?

Carel Le Roux (17:47.722)

I think we need to work on it. I don’t think it’s automatically going to disappear. But we also have to have sympathy with the system. One of my colleagues was recently saying to me, that if we discover tomorrow the best pain medication that takes the pain away from anybody that has cancer and the minute we discover that medication, about in one week, that same drug is going to be on the streets and it’s going to be abused.

That doesn’t make it a less important treatment for cancer pain. In the same way, we need to think here is this medication for the disease of obesity. We can do a massive amount of good things. Of course, there’s going to be use of this treatment that is ill-advised. But I think the key here is to make sure that people understand this is not a weight loss drug. This is a drug for the disease of obesity.

Equally so that if you stop the medication, you may be worse off than when you started and that’s not me threatening people. That’s what the data shows, because in the clinical trials, when we stop the medication, patients become ravenous. They become incredibly hungry. They eat vast amounts of food because sadly the disease of obesity is relapsing and that is exactly what’s going to happen if you get into your swimsuit, you stop the treatment, you will become hungry, you will have food noise and you are very likely going to regain all the weight and a little bit extra. But you’ll be heavier after than when you started and that’s what we don’t want to do. The first rule in medicine is always to do no harm. So when we are saying to people please don’t take this treatment if you don’t have the disease of obesity, it’s not because we are vindictive, or we don’t want people to fit into the swimsuit that they want, it’s because we genuinely don’t want people to be less healthy after they’ve used the treatment.

Linda van Tilburg (19:53.151)

Thank you, Professor Carel le Roux for speaking to us.

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