​Many people want to try the new diabetes drug that helps you lose weight. It’s known to be effective, but there is no silver bullet to keep those kilos away.

The frenzy over Ozempic, the blockbuster diabetes drug that was found to have weight loss benefits, has made headlines around the world and even led to shortages. When I recently caught up with a friend who is based overseas, I learnt that she, too, is using Ozempic.

My friend A has been living with Type 2 diabetes for years, and her doctor prescribed the drug to her in 2023 to help her manage her weight as well as the disease. Several weeks after taking it, she noticed her blood sugar readings had improved and her weight had slipped from 72kg to 68kg. Her appetite became smaller, with no effort on her part. The drug has to be injected under the skin, but she said it’s not painful and she needs to do that only once a week.

Other people have gone on social media to say they have shed 5kg, 10kg or even more, with such drugs. This has sparked a global frenzy.

It’s not surprising when you think about how many of us have tried to lose weight at some point in our lives, even though the success may be limited or short-lived. Still, we try, especially when right after one festive binge of log cakes and roast turkeys we are now into another calorific extravaganza of bak kwa, tarts and cookies and other Chinese New Year fare.

The pressure to lose weight is not confined to seasons in a society that values thinness. It is not just a matter of vanity. Being overweight can lead to increased risk of a whole slew of problems – Type 2 diabetes, high blood pressure, heart disease, stroke, fatty liver disease, some cancers, breathing problems, fertility problems, mental health issues and more.

For some, there is an economic price too. Studies in the West suggest overweight women suffer lower pay and poorer promotion prospects.

What’s to be done then? In the battle against the bulge, there are broadly three weapons in the arsenal: drugs, surgery and a regimen of dieting and exercise. As with all weaponry, there is no need to go for the bazooka when a handgun would do. It sounds obvious, but the advice bears repeating because the recent excitement over weight loss drugs like Ozempic, fuelled by celebrity use, has had people with a couple of kilos to lose eyeing the drugs as some sort of silver bullet.

Understanding the drugs

First, the drugs. They apparently work like magic for a lot of people, including healthy ones. They are relatively safe and require little to no effort to administer.

What Ozempic does is to mimic a gut-released hormone known as glucagon-like peptide-1 (GLP-1), which stimulates the production of insulin to lower blood sugar level after a meal. It also interacts with the parts of the brain that suppress the appetite and tell you that you are full.

Ozempic is a brand name for semaglutide, which also comes in a higher weekly injectable dose (Wegovy) meant for those with obesity or as a once-daily pill (Rybelsus) for those with Type 2 diabetes.

And, semaglutide belongs to a class of drugs known as GLP-1 agonists, which was first developed to treat Type 2 diabetes, and is now considered a major breakthrough in the treatment of obesity and Type 2 diabetes. Another drug in the class, known as dulaglutide and marketed as Trulicity, is a weekly injectable prescriptive drug for those with Type 2 diabetes that has also been used off label to treat obesity.

For far too long, people struggling with obesity and other medical issues have mostly been told to eat less, exercise more, or opt for invasive surgery. Their treatment options have now been widened by these new anti-obesity drugs, particularly semaglutide, which has recently been shown to also protect heart health.

That Ozempic is a prescription-only drug that has been approved here for Type 2 diabetes and is meant for long-term use (the worry is that your weight will come back once you stop it) has not dampened the enthusiasm for it. Doctors in private clinics here have prescribed it off label for weight loss purposes. Common side effects include nausea, diarrhoea and stomach pain, but there can be serious ones such as inflammation of the pancreas or pancreatitis, though these are rare.

Dr Tan Kok Kuan from Dr Tan Medical Centre, a general practitioner clinic focusing on men’s health, has seen how semaglutide has helped him shed a lot of weight that was causing him problems, such as high cholesterol and fatty liver disease. Years ago, when he was controlling his diet and running 40km to 50km a week, he saw a grand weight loss of about 2kg after a few months.

“You cannot outrun your body’s hormones! I tried a once-daily injectable weight loss prescriptive medication but hit a new body set point after losing 6kg. When I was prescribed semaglutide, I lost 15kg in all, in a year, and became a healthier 61kg.”

The body set point theory states that the body has a preset weight range that it will adapt to hold onto.

The drug has been so popular that there is still a shortage around the world. “It’s been three years, and every day, we get inquiries (about Ozempic). And in the past year, I’ve had to turn away a lot of people due to supply constraints,” said Dr Tan.

Wegovy is not available in Singapore, nor is a newer and even more effective weight loss drug tirzepatide, which is sold under the brand name Mounjaro for diabetes, or Zepbound for weight loss.

These drugs are not cheap, with Ozempic or Rybelsus costing possibly around $400 or more for a month’s supply. You still have to do your part, as doctors say these drugs are meant to complement diet and/or lifestyle changes, not replace them.

Ozempic also works differently for different people. A, my friend, discovered that it would not bring down her weight to below 68kg, but she is continuing with the same dosage to keep her weight from rising.

“Compared with the drugs we had in the past, these (new) drugs are better in terms of efficacy. But will it work for anybody who is obese? No,” said Dr Ravishankar Asokkumar, a senior consultant in the department of gastroenterology and hepatology at Singapore General Hospital (SGH). “There are some patients where it works better. There are some patients where it doesn’t work that much. There are patients where it doesn’t work at all.” 

Shrinking the stomach

Weight loss surgery, also known as bariatric surgery, refers to various procedures that work by reducing the amount of food that you can eat. The reduced food intake helps to normalise blood sugar, blood pressure and cholesterol levels.

But such surgery is only for people with a body mass index or BMI (an estimate of body fat based on height and weight) of more than 37.5, or those with a BMI of more than 32.5 and medical conditions related to obesity such as Type 2 diabetes.

An option for those who do not qualify or do not wish to go for bariatric surgery is endoscopic sleeve gastroplasty.

This procedure is reversible and can be repeated, said Dr Ravishankar, who was the first to perform it here, at SGH in 2019, for individuals with a BMI of more than 27.5.

The weight loss ranges from 15 per cent to 20 per cent, with the super responders registering a loss of up to 25 per cent, said Dr Ravishankar.

This compares well with the other options. On average, medications can bring on weight loss of 5 per cent to 10 per cent, with the super responders registering an upper limit of 15 per cent, while for surgery, the weight loss is around 25 per cent to 30 per cent, depending on the type of surgery, he said.

Again, these options are meant to complement diet and lifestyle modifications.

No magic solution

“When it comes to obesity management, the first thing we tell all the patients is that if you’re looking for magic, this is not the place,” said Dr Ravishankar.

“When we talk about weight management, we have to look at long-term goals. What is it that I want to achieve? Why is weight loss important for me? If I manage to lose weight, what are the things that will happen to me and how will my life change?”

Dr Tan Chun Hai, a surgeon at Gleneagles Hospital and the immediate past president of the Obesity and Metabolic Surgery Society of Singapore, said surgery could be an option for those who have obesity and other medical problems.

“Most people who come to me have already tried diet and drugs,” he said. “Dieting works in the short term, but there’s always a rebound the moment dieting stops because everyone has a body set point.”

Experts have said that those who are obese may have a genetic predisposition towards a heightened reward system associated with food. Sometimes, it gets so hard that they give up, eat even more and sink into depression.

One man whose severe obesity had brought on various problems, including Type 2 diabetes, high blood pressure and sleep apnoea, found that the bariatric surgery he underwent made him miserable as he could not enjoy his meals like before. He found a way to consume more food, by blending his food and drinking it. 

“Most people have the misconception that obesity is due to a person’s lifestyle, and they are not going for the correct treatment (but) the World Health Organisation has called it a chronic, relapsing disease,” said the surgeon.

Obesity is defined as having a BMI of 30 or more, but in Asia, the cut-off is 2.5 points lower because of differences in body fat and muscle mass, he said.

It is a growing problem here. According to data from the National Population Health Survey, in 2021 to 2022, about one in nine Singapore residents was obese, up from one in 10 in the 2019 to 2020 period. In addition, some 28.6 per cent of Singapore residents were overweight, which, for the purposes of the survey, was defined as falling within a BMI range of 25 to 29.9. 

To lose weight, one has to burn more calories than one consumes, and the new drugs may prove to be popular. But they won’t reduce the importance of diet and exercise.

Dr Tan Kok Kuan said: “Diet and exercise are important, not so much for sustained weight loss, but for good health. Skinny is not healthy.”

He added: “Going by the textbook, obesity treatments are for life, but in real life, nobody wants to be on obesity treatments for the long term, so we always work out a treatment plan for them that includes diet and exercise, so that they can get off it once they can hit the target weight.”

Dr Kalpana Bhaskaran, head of the Glycemic Index Research Unit at Temasek Polytechnic and president of the Singapore Nutrition and Dietetics Association, said that to achieve success with surgery or drugs, significant lifestyle changes, including dietary modifications and regular exercise, are needed.

She said that regularly monitoring and weighing oneself, consuming smaller meals, and incorporating portion-controlled meals into the diet are some behaviours linked to long-term success in weight loss.

Dr Tan Chun Hai said he works closely with a dietitian to manage his patients, who, like many of us, need constant reminders to eat healthy. For instance, you don’t eat five oranges in one sitting, but you can drink the sugar of five oranges in one cup, he said.

What you need is a healthy diet and lifestyle that you can sustain, with occasional indulgences.

So enjoy the pineapple tarts and love letters this festive season, but watch out for excessive snacking and the calories hidden in fruit juices.