Clinical FeaturesEndocrine/MetabolicGastroenterology

Transforming the Obesity Landscape

Ask the Expert with Professor Carel Le Roux – Transforming the Obesity Landscape

A leading clinical scientist and expert on how the gut and brain communicate, Professor Carel Le Roux was named at the Irish Research Council Researcher of the Year for 2023. He was awarded the prestigious prize for his work on developing safer and more effective treatments of obesity.

Director of the Metabolic Medicine Group affiliated with the UCD Diabetes Complications Re-search Centre (DCRC) in the UCD Conway Institute, his research has focused on the impact of diet, exercise, medication and surgery, including bariatric surgery, on enhancing gut-brain signalling for the management and treatment of the disease of obesity.

Professor Le Roux was the recipient of a ¤600,000 IRC Laureate funding award in 2018, which he credits with enabling him to lead the development of the ¤16 million European project SOPHIA (Stratification of Obesity Phenotypes to Optimise Future Obesity Therapy)which is addressing obesity and its complications such as type 2 diabetes and chronic kidney disease.

We recently spoke to Professor Le Roux to find out more about this important work.

Professor Le Roux studied medicine at the University of Pretoria in South Africa and completed his PhD at Imperial College London before becoming Faculty, which is where he started the first obesity clinic.

He explains, “The clinic was really a combination of looking at obesity, type 2 diabetes and hypertension. But it brought the field from which I was able to drive my understanding.”

When he moved to University College Dublin, Professor Le Roux established a research unit at St Vincent’s, at which many clinical trials have taken place. He says, “It was really in this period from 2012 until now that we have witnessed an incredible increase in powerful treatments that offer the opportunity to change the disease of obesity.”

You recently won Researcher of the Year Award: Tell us more about this research

“I was very fortunate to win this accolade, which was really based on our translational research. We were able to show in the basic laboratory, animal house and with clinical research that we can treat the disease of obesity by using signals in the gut and we can enhance the signal through nutritional therapies, through pharmacological therapies and surgical therapies.

“If we treat this disease, it becomes under control and can therefore remain under control in the long-term, provided the treatments are sustained. However, if we are able to control the disease of obesity, that disrupts other diseases such as diabetes or disrupts cardiovascular disease or disrupts chronic kidney disease. So, our work went on to show that you can also reverse the complications of obesity. You can put type 2 diabetes into remission, you can put early chronic kidney disease into remission, and we can now see that we can prevent cardiovascular events as well.

“My research started from studying the pathophysiology of the disease, understanding the treatments, and now using the treatments, not for weight loss but for health gains.

“This research takes us back to where we started, now we have so much more insight into the disease, we are understanding the pathophysiology of the disease, and we are now understanding how to approach it.

“So the next steps for us lie in understanding that it is not one disease but a cluster of diseases. Now we are deconstructing obesity and if we can define it then we can be more effective at targeting patients who are at the highest risk, while also targetting those patients who will benefit the most from different interventions.”

Tackling Challenges

In looking ahead and what the biggest challenges are in this field for 2024, Professor Le Roux told us, “Our biggest challenge is people that are living with obesity don’t think they have a disease. If people don’t think they have a disease, they do not treat it like a disease. They believe that this is their responsibility, and they need to do something about it. But if you have, for example, hypertension, you would go to your doctor and ask for help.

“Furthermore, as an equivalent, many doctors don’t think it is a disease. There still exists an approach and belief that patients need to try harder and get ready for change instead of treating them like we would treat anyone with other conditions. We give people lifestyle treatment; we know that is important, but we treat them with biological treatments so that we can get the disease of hypertension under control, and I hope that we get the disease of obesity under control.”

So what advice would he give to doctors who accept that obesity is a disease and want to prescribe treatment?

“My advice would be that you need to listen to the patient; the proof is in the patient. When we have the effective treatments, we need to get beyond weight loss and think about the health benefits. The first thing that improves is the change in symptoms, they should start feeling less hungry and more full.

“The second thing is to shift the patients’ expectations away from weight loss to health gain, especially functional gains. So, it will be someone who is able to play with their children, or grandchildren, or go out with their friends, or put their socks and their shoes on. The activities of daily living without problems. These are the real benefits of these interventions. Ultimately it is about reducing symptoms and reducing complications.”

How do you view the role of the Pharmacist in treating patients with obesity?

He adds, “My heart goes out to all Pharmacists this year because there has been a tremendous shortage of supply of treatments. Pharmacists were wrongly asked to prioritise the treatment of some diseases over others. Pharmacists are also a part of the public and can have the same preconceptions of the public.

“Pharmacists of course, will never knowingly hurt patients, but so many unfortunately have been asked to tell people in public, in the pharmacy that they are not eligible for treatment because the department of health have said that these treatments should be prioritised to patients with type 2 diabetes.

“From a hospital pharmacy point of view, it may not be as acute as in the general pharmacy and a public pharmacy but there is still a massive problem. Pharmacists have probably put the disease of obesity back by 5 years, not intentionally of course, but because the system created an environment and consequences where they were not adequately trained and supported.”

How do you pharmacists should move forward and move past that?

“I think we need to understand what caused the problem, and the cause is that the companies are not able to manufacture these treatments fast enough. Ultimately, if the manufacturing can be improved, the problem will go away. “The patients who are asking for treatment, are correct to ask for help. The doctors who prescribe the treatment, are correct to prescribe biological treatments for a disease. The pharmacists that provide the treatment are correct to provide good pharmacotherapy. But now the manufacturers have to provide more products. Instead of it becoming a circular firing squad where the patients are angry with the pharmacists, and the pharmacists are angry with the doctors what we need to do, is get the manufacturers to provide more medications.

“That is what happened with the Covid-19 vaccine. As many will remember, there just wasn’t enough vaccines available and people were really upset with each other and then suddenly there was enough, and the problem went away. I think we really need to focus on where we can make a difference rather than making problems. Until that point, we need to be honest and say there are not enough treatment options right now and we need to do that on a reasonable and rational basis.

“For the patients we are not able to provide treatments for, we need to treat them with empathy, like we would have done for those who were very anxious to get Covid-19 vaccines because they were at a very high-risk of dying. We didn’t say you are bad people for asking for it, we said this is a difficult situation and we are working as fast as we can while treating patients with empathy.”

How does Irelands obesity treatments compare to Europe and America?

Professor Le Roux recognises that due to Irelands healthcare system, public patients are under tremendous pressure, simply because there is not enough clinics to provide these treatments.

“Therefore, a lot of our public patients are not getting the treatments provided, because either they don’t have access to a doctor that can prescribe it, because there are not enough doctors that are trained and not enough clinics that can provide this to the public. We do have reimbursement of these treatments within our system, which is a positive.

“Those reimbursement processes are robust, but they are used as a budget impact tool rather than a facilitate access to the patients who would benefit most. I think the processes are there, but it is just a mind shift that we must do. We have to think about doing the right thing appose to blocking the wrong thing. We are almost there but not quite yet.

“I think from a private point of view, many patients in Ireland have a tradition, where people have bought medications and accessed care privately. This is unfortunate as people are genuinely spending vast amounts of money, very often money they don’t have and the problem with that is that patients are not able to sustain the treatment because the treatments are expensive, accessing private health care is expensive. My concern is that we need to make sure if a patient is successful, that they are able to sustain the treatments in the long term.

What are the three things we need:

1. More public access

2. Reimbursement process which are fair and reasonable, but it needs to be implemented to help people as appose to block people and

3. Thirdly, the private system is able to help but we need to make sure we are not overselling treatments., We should not say to people to have those treatments because they are going to look different or they are going to feel different, we need to say you need this treatment so you can be healthier, so that patients use it for health gains and not for other purposes.”

In concluding, Professor Le Roux states, “We should recognise at all levels: the patient, provider, and government’s perspective. We should understand that obesity is a biological disease that we need to treat biologically with nutritional therapies, pharmacological therapies and with surgical therapies.

“I think what we need improve equity. Right now, in Ireland, obesity treatment is not equitable and we need to say, ‘which are the patients who will benefit most from this treatment?’ This is not necessarily the patients who are the heaviest, it is the people who will benefit most from a health gain point of view where the evidence is pretty clear.

“We need to focus on achieving equity. If treatments for obesity are not equitable, it is going to develop a bad reputation and people are going to resent each other and create uncomfortable position for patients and providers. We have made most of the mistakes we could possibly make and at the moment obesity treatment is not equitable.

“The way to do that is to understand the science and if we understand obesity is a disease and how the treatment works and understand what the side effects are and how to minimise the side effects and how to optimize prescriptions then we will achieve most benefit. I think the science is going to be the underlying driver of a better society for us.”

Read the full magazine: March HPN

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