Will the WHO Declare Dangerous Diet Drugs Globally Essential? Part 1

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Starting in 1977, the World Health Organization (WHO) began publishing a list of essential medications. Beginning in 2007 they began publishing a second list for children. They define these medications as

“those that satisfy the priority health care needs of a population. They are selected with due regard to disease prevalence and public health relevance, evidence of efficacy and safety and comparative cost-effectiveness. They are intended to be available in functioning health systems at all times, in appropriate dosage forms, of assured quality and at prices individuals and health systems can afford”

They are:

“intended as a guide for countries or regional authorities to adopt or adapt in accordance with local priorities and treatment guidelines for the development and updating of national essential medicines lists. Selection of a limited number of essential medicines as essential, taking into consideration national disease burden and clinical need can lead to improved access through streamlined procurement and distribution of quality-assured medicines, support more rational or appropriate prescribing and use and lower costs for both health care systems and for patients”

The list is updated every two years based on the recommendations of The Expert Committee on Selection and Use of Essential Medicines. The current list can be found here. The committee will meet April 24-28 to decide on the next list of essential medications for adults.

A request has been submitted to “add the incretin based therapy of glucagon-like peptide 1 receptor agonists (GLP-1 RAs) to the core list of the WHO Model of Essential Medications (EML) under a novel section of ob*sity with the indication of weight loss.”

The request specifically discuses liraglutide (Novo Novdisk’s Victoza,) but the class of drugs also includes Novo Nordisk’s Wegovy and Eli Lilly’s Tirzepatide. The request is 20 pages that I read so you don’t have to.

I’m going to do this in three parts. In part one, we’ll talk about who is making the request, and some of their justifications for doing so. In part two we’ll starting digging into the evidence they are using to support their case, and in part three we’ll look at the studies they are using around effectiveness and harm as well as cost effectiveness.

Let’s dig in. The request has four authors:

Sanjana Garimella
Yale New Haven Health

The request lists “Yale New Haven Health.” A search of their website including “YM-YNH doctors” and “all affiliated doctors” did not include her. Through a Google search, I found her page at the Yale School of Medicine indicating that Dr. Garimella is a resident physician (a doctor who graduated from medical school and is now completing their training by practicing under supervision.) She graduated from the University of Colorado School of Medicine in 2021. I couldn’t find much information about her. Her page on the Yale site currently doesn’t include a bio and I can’t find a LinkedIn profile. A profile from her medical school said that she is interested in internal medicine and global medicine. I found a study she co-authored about mRNA methylation in mouse embryonic stem cells, and another about Modified Fatigue Impact Scale in Parkinson's disease but I can’t find anything to suggest that she has any specialized knowledge when it comes to these weight loss drugs or the care of higher-weight people.

Alyssa Grimshaw
Yale School of Medicine

Grimshaw is a Clinical Research and Education Librarian. Her page on the Yale website lists her  “Research & Liaison areas” as “Allergy and Clinical Immunology, Cardiovascular Medicine, Digestive Diseases, Endocrinology and Metabolism, Infectious Diseases, Internal Medicine, General, Nephrology, OBGYN, Pulmonary and Critical Care Medicine, Rheumatology and Urology” Again, I can’t find anything to suggest that she has any specialized knowledge around these drugs or the treatment of higher-weight people in general.

Micah Johnson
Brigham and Women’s Hospital

Johnson is another resident physician (a physician with a medical degree who is completing his training under supervision.) I found a lot of work that he’s done on universal healthcare, but couldn’t find anything to suggest expertise in these drugs specifically or the treatment of higher-weight people in general.

Sandeep P. Kishore
University of California, San Francisco

Kishore is an Assistant Professor of medicine who completed his residency at Brigham and Women’s Hospital and his internship at Yale. He lists his interests as “global health, pharmacoepidemiology, cardiovascular prevention, hypertension, disparities, health policy, equity, clinician well-being” While he is listed as an author in a number of published studies, none that I found have anything to do with these drugs specifically or the treatment of higher-weight people in general.

To me this seems like an odd group of people to make a request that these drugs be considered essential by the WHO. Two are still in residency, one works in the Yale Library and none of them seem to specialize, or have published, anything about treatment of higher-weight people in general or these drugs specifically. That said, none of them have taken payments from pharma companies associated with these drugs as of 2021 (at least as far as I can tell from openpayments.cms.gov)

I’m unclear how this group of people got together to write this recommendation. Given (what seemed to me to be) the odd nature of this group of people, I decided I also wanted to dig around for other possible connections.

I learned that Brigham and Women’s Hospital, where Micah Johnson is a resident, has accepted $2,137,262.46 in general payments and $6,787,466.97 in research payments from Eli Lilly, whose weight loss drug Tirzepatide is in the class that this request aims to get on the WHO’s list. Novo Nordisk also has a separate, ongoing partnership with BWH.

UCSF, where Sandeep P. Kishore is an assistant professor, lists Novo Nordisk as a “sponsor” but without any details. They also started an “exclusive” partnership with Novo Nordisk in 2018.

In terms of a Yale connection, Dr. Ania Jastreboff is Associate Professor of Medicine (Endocrinology & Metabolism) & Pediatrics (Pediatric Endocrinology) at Yale University School of Medicine, Director of Weight Management and “Ob*sity” Prevention” at Yale Stress Center and  Co-Director of the Yale Center for Weight Management. She serves on the scientific advisory board of Novo Nordisk. She has also taken $139,259.05 in general payments from pharma companies, as well as $21,594.60 in research payments and $138,507.94 in associated research funding, predominantly from companies that manufacture these drugs (you can see the breakdown here.) She’s also been quoted extensively in the media shilling for these drugs.

Now, to be clear, I have no idea if these connections mean anything, it’s just what I found when I did some digging because Novo Nordisk has been repeatedly caught trying to influence approval and prescription of its drugs.  

Ok, let’s get into their justification for this request:

“At this time, the EML [Essential Medicines List] includes mineral supplements for nutritional deficiencies yet it is also described that most of the population live in “countries where overweight and ob*sity kills more people than underweight”[2]”.\

Here it seems that they might think that nutritional deficiencies and living in a higher-weight body are somehow mutually exclusive. This is, of course, not the case. The idea that if the WHO has a vested interest in making sure that people (of all sizes) aren’t suffering from nutritional deficiencies then they should also insist that everyone have access to drugs that purposefully disrupt normal digestion and ability to feel hunger to manipulate their body size, is not a scientific (or logical) conclusion.

Further, the quote “countries where overweight and ob*sity kills more people than underweight”[2]”.was of particular interest to me, especially since Bacon and Aphramor found that “Weight cycling can account for all of the excess mortality associated with ob*sity in both the Framingham Heart Study and the National Health and Nutrition Examination Survey (NHANES)” I immediately wondered how their data source had calculated the number of deaths? How had they controlled for the impacts of weight stigma, weight cycling, and healthcare inequalities experienced by higher-weight people? For that matter, how did they calculate the deaths “caused” by being “underweight?”

For all of these reasons, I was anxious to evaluate the source of this quote. It turns out their “data source” is just a “fact sheet” by the WHO that has this sentence bulleted, in bold print, and without a citation. Shame on the WHO for this. It does not have the ring of sound science, and would certainly create a drop of at least one letter grade in a 6^th grade science fair project, let alone a fact sheet from what is supposed to be a trustworthy global health organization. I would hope that at least one of the four people making a request that supports global spending of billions of dollars on diet drugs would have asked these basic questions, but it seems that they thought a bolded bullet point was good enough.

The WHO even state that ob*sity is preventable however the discrepancy is certainly highlighted when the EML does not include any medications to treat this chronic condition.

Wait, what? First of all, the WHO does “state” that ob*sity is preventable but, again, fails to offer anything even approaching evidentiary support for the statement. I would suggest that a look through history shows that body diversity, including at the highest end of the weight spectrum, has always and will always exist, and neither the request authors, nor the WHO, offer any evidence otherwise. Beyond which, even if the existence of higher-weight people was preventable (and, again, I don’t think body diversity can, or should, be targeted for eradication,) it does not necessarily follow that it is “treatable.” For example, people can be prevented from being tall through various means (I’m not making an argument here for this being an ethical practice, simply acknowledging that mechanisms for stunting growth exist,) but once someone is tall, their tallness is not “treatable.” Besides which, these medications aren’t even marketed as “prevention,” they are marketed as “treatment” so the argument here does not support their request.

In terms of their justification for the request, so far, I’m pretty thoroughly unconvinced. In part 2, we’ll take a deeper dive into the research they are using to support this request.

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More research and resources:
https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.