He’s starved in a spa, avoided junk food – but every time David Aaronovitch sheds weight, he puts it back on again. So what was the result when he tested the new ‘wonder’ drug the A-list is injecting?
It was a year ago, before the whole thing went mad, that my friend Bill told me about the injections. His NHS GP had recommended him to a private doctor who had prescribed a new drug that was causing a stir in the States. You injected it, Bill explained over breakfast, and it suppressed your appetite. You felt full all the time; no need for dieting, no need for calorie counting, just a once-a-week jab into a body part of choice and a perpetual feeling of fullness. He’d just started taking it and (Bill looked at my eggs with sourdough) so should I, if we’re being frank.
For reasons I’ll explain in a moment, I was attracted to the idea, but when it comes to something like this I have always adopted what I’ll call “the penguin protocol”. In waters that penguins are forced to share with penguin-eating sharks, but where the birds need to fish for food, lacking anti-shark warning devices the penguins crowd closer and closer to the water until eventually one of them falls in. If the unfortunate bird surfaces intact, in they all go. If, on the other hand, there’s a thrashing about and the water turns red, the survivors shake their beaks sadly and shuffle off inland. I decided to wait and see what happened to Bill.
We’ve been dieting in this country since 1863 when the undertaker William Banting published his short book Letter on Corpulence. In the past half-century since Robert Atkins hit us with his eponymous dietary regime, vast amounts of money have been expended by the unhappy tubbies of the developed world on tens of thousands of diets. We’ve cut out carbs, fats, wheat — you name it, we’ve cut it out. We’ve eaten only celery, only onions, only steak — if you can pronounce it, we’ve eaten only that. We’ve fasted for one day, for two days, for a week. We’ve lost between us amounts of fat so prodigious you could fuel an intergalactic expedition with it. We’ve done it to reduce our blood pressure, to avoid the risk of diabetes, to make ourselves look more attractive and — all too often — to try to avoid the stigma and shaming that is attached to being fat.
And it hasn’t worked – not for us. It has for the diet inventors and their armies of media publicists, of course, and it continues to work as one of the great cash cows of the modern age. Not for the dieters though. There are exceptions, but the general pattern has been that people will lose weight initially on the myriad diets and exercise regimes, almost all of which share the basic principle that if you starve yourself for a while you’ll get thinner. After which around 90 per cent of them, according to a University of Michigan study, will revert to a version of their previous situation and put back on most of the lost weight, or all of it, or all of it with interest. They would then hate themselves all over again.
There are, alas, too many people — mostly thin — who still think that this is essentially a problem of willpower, like giving up smoking. They also believe, in essence, that fat people are greedy and incontinent and that shame plays a useful role in persuading them to change their habits. If you loathe yourself enough, that’ll motivate you to go cold turkey, suffer a bit, run a weekly 10,000m and sort yourself out. Usually less judgmental, doctors are forced to repeat endlessly to their hypertensive patients the advice about eating less and exercising more. As if those patients didn’t already know and in many cases hadn’t already tried.
But the science is changing, not least as obesity becomes a widespread public health problem rather than an individual one. As we have learnt more about heritability and endocrinology, it has become evident that people absolutely do differ in their metabolisms (mostly their capacity to produce insulin), in the way in which they digest what they consume and in what their bodies are urging them to do. One newish theory is that we are in effect programmed to achieve a certain body mass and that our appetites will direct us accordingly.
But whatever combination of factors is involved, I think we can now safely say that the willpower/calorie-driven model is dying. In me, it died some time ago. I have been starved in Austria, lectured in Florida, taught new ways of cooking in South Carolina, run a marathon and still exercise far more than the average man my age: 68. And every time I lose weight, eventually it comes back on again. The business of policing my intake after a while becomes too tedious and, although I eat no junk food whatsoever, eschew desserts and drink little alcohol, eventually I will end up at about 18st 5lb/117kg (but never any more than that). So, I had been wondering, is there a way to establish a new equilibrium? And then along comes Bill with his magic pill. Or rather, his fab jab.
So what is it? It’s a substance called semaglutide, which the literature tells us is a “glucagon-like peptide-1 receptor agonist”. Its effect is to mimic a natural substance produced in the body after eating to suggest that no more food is needed. But the semaglutide response lasts longer than that of the natural receptor, causing, for example, the stomach to digest more slowly. The drug was originally developed and trialled for the treatment of diabetes because it helps regulate insulin production. Semaglutide in its current form has not been around long, only having been developed in 2012 and licensed for diabetes-related use in the US in 2017. We are talking about a relatively new drug, and one that has been shown to be very well tolerated in diabetics.
And then it went all Viagra on us. You will almost certainly know that sildenafil was a drug developed to allow people with pulmonary arterial hypertension to exercise without suffering dizziness and shortness of breath. It did this by increasing blood flow. Blood flow here and, it turned out, blood flow there. Eventually, a lot of happy male hypertensives were reporting that one of the side-effects was more of an in-front effect. The drug was repurposed and sold as Viagra and, instead of making its manufacturers millions, it made them billions. There are lots of drugs that, having been developed and used for one condition, are found to work with another. With semaglutide takers, one effect of the drug was the suppression of appetite — a physical desire not to eat. By the beginning of this decade the first trials were beginning of the use of semaglutide to control appetite in obese adults and adolescents.
The results were pretty amazing. In one recent US trial of adolescents whose body mass index was in the 85th percentile or higher and who had at least one weight-related health condition, 73 per cent of the group taking semaglutide lost 5 per cent or more of their body weight, compared with 18 per cent in the control group. In other adult trials, more than 30 per cent of those taking the drug lost more than a fifth of their body weight in 15 months. A fifth. Twenty per cent. A weight-watcher’s fantasy.
As you can imagine, Novo Nordisk, the Danish pharmaceutical company that developed the injectable drug under the brand names of Wegovy and Ozempic, began to look for regulatory approval for semaglutide use in treating obesity. And those approvals are beginning to come through. In this country, though not available on the NHS, semaglutide for weight management is permitted under certain conditions. In practice, this has meant prescriptions from private GPs at a not inconsiderable cost.
Which brings us to me. Or, in the first instance, to my penguin, Bill. Last autumn I stood uncourageously at the metaphorical water’s edge to see if he would resurface a thinner, better man, uncrippled by side-effects. And he did. Four to five months after having started on a low dose and having gradually increased it, Bill was looking different. His clothes were loose; cheekbones appeared in his face. His blood pressure was falling. He hadn’t died. I regarded him over his insubstantial breakfast and said to myself, as that woman did in the When Harry Met Sally diner, “I’ll have what he’s having.”
My GP referred me to a colleague in the private sector. After a full examination and an interrogation of my motivation for losing weight (“How serious are you, really?”), I got the prescription for Ozempic, starting with a 0.5mg dose to be injected weekly. Later that week I went to my local pharmacy, where they delved inside the fridge to find my gear. I paid 100 quid for a month’s worth, walked back home and prepared to shoot up.
Actually, that’s a bit overdramatic. No tourniquets or tapping of veins is necessary. When you open the cold little box, inside you’ll find a rather pretty sky-blue plastic pen and four capsules containing the needle and semaglutide. You screw the capsule onto the end of the pen, then load by turning the pen’s barrel. You take the top off the capsule, which reveals a tiny needle. That is pushed into a convenient portion of flesh and you press the plunger on the pen. A few seconds later you’re done. It doesn’t hurt in the least and there’s no mark. You do this once a week. In case you were wondering, I inject into my abdomen and I do it on Tuesdays.
From the beginning — and unlike Bill — I was determined to test it as an appetite suppressant, not as a supplement. The whole point for me was not to diet or have to spend my waking hours planning menus and obsessing about calories. I wanted to see if it would do what was claimed for it: reduce my intake by making me not want to eat. I wanted it to work its magic.
I hate writing this, because I sound like a PR agent, but from quite early on magic was worked. I’ve thought a lot about how to describe this, and every time I’ve tried I’ve failed. The nearest I can get is to say that I have felt a strange combination of being at all times mildly bloated and pleasantly full, as though someone has put a football where my stomach ought to be. Since I started on the semaglutide I have never, not for one second, felt hungry. I don’t have to try not to eat, or exercise any willpower. I can go without food quite happily for 16 to 18 hours. If it’s family pizza night, I’m happy with half a diavolo where before I wanted a whole one and then some. I pass some of the best bread shops in the country every day and I feel no need to enter. The other day we went to the theatre. I hadn’t eaten since breakfast, we arrived early and the others decided to have a light supper there. I said no thanks and saw them wondering who this person was.
Dear reader, you’re now wondering three things. First, how much have I lost? Round about a stone (6kg) in four months. The loss stalled for a while but, as the weather has improved and I’m more active, it’s picking up again.
Second, you want to know about side-effects, because I am your penguin. The literature gives the following as common or very common side-effects: “burping; cholelithiasis (small gallstones); constipation; diarrhoea; dizziness; fatigue; gastrointestinal discomfort; gastrointestinal disorders; hypoglycaemia; nausea; vomiting.” Some combinations — such as dizziness and diarrhoea together — could be very unfortunate.
Most mornings I have a few seconds of nausea, which have never led to throwing up. However, I am not very German when it comes to enthusiastically discussing bowel matters, so if you look at the list above you can do the work yourself and put a tick against three, four and seven. But almost never to any extent that has become problematic. I am now on the maximum dose and I really don’t find it particularly troublesome.
Third, what happens when I come off the semaglutide, as eventually I will? Will my old appetite kick back in and I’ll put the weight back on again? And the answer is that we have no idea. Although we should bear in mind that I’m doing this without the recommended nutritional counselling, and maybe taking a bit more of a risk of reversion.
To find out what a prescribing GP is seeing with patients generally I talked to Daniel Gordon, a young doctor in north London who works both privately and with the NHS. He has a dozen or so patients on semaglutide but, for reasons I will explain, has temporarily stopped prescribing it to new patients. Gordon, I infer, got fed up with just giving “the talk” to people with obesity-linked conditions and watching them fail to lose weight. “I’d tried many strategies before,” he tells me, with patients who “often feel despondent and ashamed about their weight.” He saw how they would be afflicted with pre-diabetes, high blood pressure, sleep apnoea (much more dangerous than people realise) and, eventually, cardiovascular disease.
Until early 2022 the only appetite suppressant available was orlistat, which was rarely used because of its very unpleasant side-effects. Gordon was familiar, however, with a forerunner of semaglutide called liraglutide, used for controlling diabetes. Just over a year ago he saw that the properties of semaglutide were “causing quite a lot of noise” in the medical community. There had been a significant trial published in 2021 and more were taking place. The evidence convinced him that this was worth pursuing.
So he started prescribing “off licence” — ie giving a tested and safe drug to patients for whom it was yet to be licensed. This, he explains, is not an uncommon practice among GPs. And the results? “They have mimicked the trial,” he tells me. Patients have lost between 10 and 15 per cent of their body weight. “They have seen dramatic improvements in their quality of life, in their general happiness.” He adds brightly, “Their cardiologists have been pleased.” Clearly, in the medical profession, you don’t want to piss off the cardiologists. The caveat is that all his patients are still taking the drug and, as he reminds me, there have as yet been no long-term trials of semaglutide use for obesity management.
In any case, though I had never heard of semaglutide before Bill told me about it, that cat is well and truly out of the bag. US celebs and billionaires got to it first, with Elon Musk and Kim Kardashian said to be among early adopters. Now it’s hard to open a lifestyle supplement without some famous person like Jeremy Clarkson explaining how these days raiding the fridge for them means getting their Ozempic dose, not a hunk of cheese. That’s the frivolous side of the beginning of a mass market for semaglutide. The serious side was in evidence last month when the American Academy of Pediatrics — alarmed by the scale and seeming intractability of childhood and adolescent obesity in the US — issued new guidelines for treating seriously the estimated 14 million overweight youngsters. These amounted to a much more proactive approach to the problem and included the prescription of semaglutide to children.
The frivolous use of semaglutide as a kind of slimming aid and its more justified use for obesity management have had serious consequences for diabetics. In Australia, for example, supplies of the drug simply ran out for everyone. There are also shortages here in Britain and in the US. Except, of course, if you have the money. Then you can always find a supply, and that could easily mean rich slimmers getting hold of a drug effectively denied to poorer diabetics. It’s for this reason that Daniel Gordon has temporarily stopped prescribing it for obesity management to new patients, even though the people he sees also have a proper health need. Hopefully the manufacturers, who will be desperately looking to scale up production and make the really big bucks, will sort out the supply problem soon.
Oh, and finally there are two side-effects I didn’t tell you about. The first because I only twigged to it the other day and the second because it’s just not my problem. I think I suffer a little from hypoglycaemia due to eating less, because I have developed sudden and urgent desires for sweet things, from orange juice to chocolate. And so has Bill, he told me last week. It’s not a taste thing; it feels more like a need thing. So that’s one thing that can happen when you fool around with your endocrine system.
The other makes me laugh, though perhaps it shouldn’t. A series of articles have appeared Stateside about a condition they’re calling “Ozempic face”. As one woman put it, “I looked in the mirror and my body looked great, but my face looked exhausted and old.” The skin on her body was evidently elastic enough to shrink to the new size required of it. But upstairs, not so much. There was sag around the jowls, droop below the chin. The result, of course, has been a bonanza for cosmetic surgeons.
So why doesn’t it affect me? I just reset my beard trimmer from four to seven. All I have to do now is go and get that suit taken in — reminding me that some chores are more pleasurable than others.
Written by: David Aaronovitch
© The Times of London