As an NHS GP, I can now prescribe weight-loss jabs – but a quick fix for obesity is not what we need | Helen Salisbury – The Guardian

NHS England Initiates Controlled Rollout of Weight-Loss Medication Tirzepatide

Introduction to Tirzepatide and Its Availability

Tirzepatide (Mounjaro), a medication that suppresses appetite by inducing feelings of fullness and mild nausea, has been widely available privately. However, until recently, its prescription for obesity treatment on the NHS was limited to specialist clinics. As of this week, general practitioners (GPs) in England can prescribe tirzepatide, marking a significant development in obesity management accessible through primary care.

Eligibility Criteria and Initial Rollout Limitations

The initial phase of the NHS rollout enforces strict eligibility criteria, limiting the number of qualifying patients:

1. Body Mass Index (BMI) greater than 40 (approximately 102 kg for an average-height woman or 123 kg for an average-height man). The BMI threshold is slightly reduced for high-risk groups.
2. Presence of at least four out of five specific obesity-related conditions:
   • Type 2 diabetes
   • High blood pressure
   • Dyslipidaemia (abnormal blood fat levels)
   • Obstructive sleep apnoea
   • Blood vessel damage

These stringent criteria mean that only a small fraction of patients qualify. For example, in a GP practice with 12,500 patients, only two individuals met the requirements. The second phase of the rollout, anticipated next summer, will lower the BMI threshold but maintain the list of qualifying conditions, likely resulting in only a modest increase in eligible patients.

Implementation Challenges and Support Services

NHS England’s cautious approach aims to prevent overwhelming GP services. Key implementation details include:

• Mandatory six hours of training for GPs before prescribing tirzepatide.
• Monthly patient monitoring during dose escalation, followed by six-monthly reviews.
• Provision of “wraparound care” encompassing dietary and exercise advice.

Dietary guidance is critical, as many obese individuals suffer from malnutrition due to diets high in fat and sugar but low in essential nutrients. Appetite suppression may exacerbate nutritional deficiencies and dehydration risks. Additionally, rapid weight loss can lead to loss of bone and muscle mass, necessitating exercise to prevent frailty.

Cost Considerations and Long-Term Use

Tirzepatide costs approximately £122 per patient per month at the maximum dose, totaling £1,464 annually. While this may be cost-effective compared to treating obesity-related complications and improving quality of life, significant questions remain:

• Optimal duration of medication use.
• Management of rebound weight gain after cessation, which studies indicate can lead to patients regaining their original weight within two years.

Broader Implications for Obesity Management and Sustainable Development Goals (SDGs)

The current focus on pharmaceutical interventions addresses SDG 3: Good Health and Well-being by targeting obesity-related health complications. However, the widespread prevalence of obesity—affecting over a quarter of England’s adult population—demands comprehensive strategies aligned with multiple SDGs:

• SDG 2: Zero Hunger – Improving nutrition quality by addressing malnutrition despite obesity.
• SDG 11: Sustainable Cities and Communities – Enhancing urban environments to promote active transport through safe pavements and cycle routes.
• SDG 12: Responsible Consumption and Production – Regulating availability and marketing of calorie-dense, nutrient-poor fast food.
• SDG 4: Quality Education – Improving school meal quality and reclaiming school playing fields to encourage physical activity.

Effective obesity prevention requires policy measures such as:

1. Taxation on sugar and fat to influence dietary habits.
2. Restrictions on fast food availability.
3. Investment in public spaces and free exercise opportunities.

These interventions address the complex social and commercial determinants of health and support a sustainable, long-term reduction in obesity prevalence.

Conclusion

While the NHS’s controlled rollout of tirzepatide represents progress in obesity treatment, it is not a standalone solution. Integrating pharmaceutical approaches with broader public health strategies is essential to meet the Sustainable Development Goals and effectively combat obesity at the population level.

Author

• Helen Salisbury, General Practitioner, Oxford

1. Sustainable Development Goals (SDGs) Addressed or Connected

1. SDG 3: Good Health and Well-being
   • The article discusses obesity treatment, weight loss medication, and related health complications such as type 2 diabetes, high blood pressure, and obstructive sleep apnea.
   • Focus on improving health outcomes and quality of life through medical intervention and lifestyle changes.
2. SDG 2: Zero Hunger
   • The article mentions malnutrition among obese individuals due to poor diet quality (high fat and sugar, low essential nutrients).
   • Highlights the importance of nutritional quality and dietary advice as part of treatment.
3. SDG 10: Reduced Inequalities
   • References to high-risk groups with lower BMI thresholds for treatment eligibility imply concerns about health inequalities.
   • Access to treatment through NHS and potential barriers in availability.
4. SDG 11: Sustainable Cities and Communities
   • Calls for active transport, safe cycle routes, and pleasant pavements to encourage exercise and healthier lifestyles.
5. SDG 12: Responsible Consumption and Production
   • Discussion on regulating availability of calorie-dense, nutritionally poor fast food and taxing sugar and fat to alter diets.

2. Specific Targets Under Those SDGs Identified

1. SDG 3: Good Health and Well-being
   • Target 3.4: By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment.
   • Target 3.8: Achieve universal health coverage, including access to quality essential health-care services and medicines.
2. SDG 2: Zero Hunger
   • Target 2.2: By 2030, end all forms of malnutrition, including achieving targets on stunted and wasted children and addressing nutritional needs of vulnerable groups.
3. SDG 10: Reduced Inequalities
   • Target 10.2: Empower and promote social, economic and political inclusion of all, irrespective of health status or socio-economic background.
4. SDG 11: Sustainable Cities and Communities
   • Target 11.7: Provide universal access to safe, inclusive and accessible green and public spaces, promoting health and well-being.
5. SDG 12: Responsible Consumption and Production
   • Target 12.4: Achieve environmentally sound management of chemicals and all wastes throughout their life cycle.
   • Target 12.8: Ensure people have relevant information and awareness for sustainable development and lifestyles.

3. Indicators Mentioned or Implied to Measure Progress

1. Health Indicators
   • Body Mass Index (BMI) thresholds used to determine eligibility for treatment.
   • Prevalence rates of obesity and obesity-related conditions such as type 2 diabetes, high blood pressure, dyslipidaemia, and obstructive sleep apnea.
   • Number of patients prescribed tirzepatide and monitored for adverse effects.
   • Rates of weight loss and rebound weight gain after stopping medication.
2. Nutritional Indicators
   • Incidence of malnutrition among obese individuals (protein, vitamin, mineral deficiencies).
   • Quality of diet measured by intake of fats, sugars, and essential nutrients.
3. Access and Service Delivery Indicators
   • Number of GP practices able to prescribe and monitor weight-loss medication.
   • Availability and uptake of wraparound care including diet and exercise advice.
   • Training hours completed by healthcare providers for obesity management.
4. Environmental and Social Indicators
   • Availability of safe cycle routes and quality of public spaces for exercise.
   • Regulatory measures such as taxation on sugar and fat and their impact on consumption patterns.
   • Quality of school meals and access to physical activity opportunities for children.

4. Table of SDGs, Targets, and Indicators

Source: theguardian.com