For some, their attempt to lose weight ended in intensive care, for dozens of others with at least worrisome symptoms: muscle weakness and difficulty swallowing, speech disorders, breathing problems and seeing double vision. All of these people had traveled to Turkey from various European countries to have Botox injected into their stomach walls. Her hope: the nerve toxin can be used to delay gastric emptying and keep the feeling of satiety longer than usual, so that in the end her weight will drop.
Instead, they suffered from some serious complaints after the treatment. What exactly triggered this is unclear. It is also unclear whether patients actually lose weight as a result of Botox. In Germany, the syringes are not recommended. However, the events show how desperate the desire for slimmer body shapes can be. By mid-March, 27 cases of Botox poisoning had been found among German patients in Turkey alone.
In fact, there are few ways to lose weight on a large scale. With weight loss programs, even those that are medically recommended and accompanied, with a lot of effort and discipline, patients manage to lose an average of three to six percent of their body weight, and often not permanently. At the other extreme of the possibilities are surgical procedures, which carry greater risks than traditional approaches but allow for sustained weight losses of around 25 to 35 percent. “For a long time there was a big gap between them,” says Sebastian Meyhöfer, director of the Institute for Endocrinology and Diabetes at the University of Lübeck.
This gap is expected to close further over the course of this year. Then the weight-loss drug Wegovy comes onto the market with the active ingredient semaglutide, which was originally developed to treat diabetes. According to studies, it enables an average weight loss of about 15 percent.
Patients have to pay for the new drug themselves
Wegovy is approved for adults with a body mass index (BMI) of at least 30. If there is already a concomitant disease, the new drug can be prescribed from a BMI of 27. The weekly injections, which patients can also give themselves, curb appetite by creating a feeling of satiety, among other things. The side effects, especially gastrointestinal complaints, are “manageable” according to the European regulatory authority EMA.
“This is a drug whose benefit-risk balance is clearly positive,” says Meyhöfer, who is also Vice President of the German Obesity Society. The doctor observes that the patients are already asking about it. Will the injection make all other therapy options obsolete?
“It can be assumed that the two drugs used to date will become less important,” says Meyhöfer. With the preparations called orlistat and liraglutin, patients managed to get rid of around five and eight to nine percent of their kilos, respectively. With these – but rather manageable effects – the funds were not very widespread anyway.
“On the other hand, weight loss of more than ten percent, as with semaglutide, is in a different league,” says Meyhöfer: “We know that from this value on, significant effects on complications of obesity can be expected.” The high blood pressure improved. Breathing pauses at night also decreased, as did joint problems. Diabetes is alleviated or can disappear completely. The drug also seems to be helpful for preventing or at least delaying diabetes. The German Obesity Society already recommends that semaglutid be preferred to other drugs.
But there are still open questions, for example how long the effects last if the drug is discontinued temporarily or completely. The biggest catch, however, is that according to the current legal situation, patients have to pay for the preparation themselves – and possibly permanently. The price has not yet been determined. But the less effective predecessor drug liraglutide alone costs around 300 euros a month in Germany. In Denmark, where Wegovy is already available, according to the Obesity Society, between 180 and 320 euros per month have to be paid for the injections.
And even those who can muster these sums shouldn’t expect an effortless kilo tumble. The EMA envisages the use of semaglutide as “a supplement to a calorie-restricted diet and increased physical activity”. The conventional programs that combine nutritional advice, exercise and, if possible, psychological counseling should continue to be used in addition to the injections.
Experts like Meyhöfer also think that makes sense: “It’s not about taking a miracle injection, and everything is fine,” he emphasizes. “We know that physical activity is particularly important in order to maintain success in losing weight.”
Surgical procedures are hardly used today
And what will become of obesity surgery? The procedures, although they have been in use for decades and are mostly financed by health insurers, are already hardly used. According to the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), an umbrella organization of 72 national professional societies, only one to two percent of patients worldwide who are eligible for the operation actually undergo the procedure.
In Germany, acceptance is even lower than in many other Western industrialized countries, says Arne Dietrich, who heads the area of obesity surgery at the Leipzig University Hospital and who coordinated the creation of the most recent guidelines for this form of therapy. In countries like Austria, Switzerland or the Scandinavian countries, the rates of obesity interventions are five to ten times higher than in Germany.
The reasons still include stigmatization, says Dietrich: “Obesity is not yet accepted by everyone as a disease, those affected are perceived as weak-willed.” At the same time, the positive effects of the interventions are probably not sufficiently well known to the public. In fact, studies show that people can benefit significantly from the interventions in terms of health. A meta-analysis came to the conclusion in 2021found that surgery extends patients’ lives by an average of six years compared to control groups who received other treatments. The life expectancy of severely overweight people with diabetes even increased by more than nine years. However, treatments with semaglutide were not yet included in the comparison.
In contrast, according to Dietrich, the dangers of the interventions are sometimes overestimated. The IFSO points out that today 90 percent of the worldwide interventions are minimally invasive. The risk of the most common procedures can be compared to that of laparoscopic removal of the gallbladder, says Dietrich. “The operation can be described as safe.”
Anyone who has an operation in Germany has an average body mass index of 51
However, those who have been operated on have to change their eating habits, not everyone can and wants to do this. Some minerals and vitamins may need to be taken in pill form for life. If patients lose a lot of weight, procedures to tighten the tissue are recommended. All this is not easy and completely risk-free.
Nevertheless, Dietrich thinks that surgery will retain its importance in the high BMI range. Anyone who has an operation in Germany has an average BMI of 51, says the surgeon. “These patients want to lose 50, 60 or 100 kilograms of weight”. Wegovy will not suffice for this.
In the lower BMI range, on the other hand, the weight loss injection could further push back surgery. In Germany, surgery is currently recommended from a BMI of 40, if there are concomitant diseases, from 35. However, Dietrich expects that the limit values will be lowered with the next guideline. In a consensus paper, the IFSO has already spoken out in favor of reducing the values. In her opinion, surgery should already be considered from a BMI of 30. But it is precisely in this area that drug therapy will probably play a greater role in the future.
And she hasn’t reached the end of the road yet. While the patients are waiting for semaglutide, an apparently even more effective drug is already in prospect. Tirzepatid, previously only approved for diabetes, had enabled average weight loss of around 20 percent in studies.