Treating belly fat before it makes you chronically ill

‍Did you know the apple body shape that’s common in post-menopausal women can cause a number of serious health conditions? Here’s how the new wave of metabolic health drugs can not only help you lose belly fat, but prevent these conditions robbing your good health.

By Sabrina Rogers-Anderson 

Have you ever wondered why many women slowly transform from a pear shape into an apple shape as the years tick by?

The answer is simple, but the health implications are far-reaching.

During their childbearing years, women tend to store fat on their hips, thighs and buttocks to meet the high energy demands of breastfeeding. 

“But with the loss of oestrogen at menopause, any excess energy in the body gets deposited between the hips and the tip of the shoulders,” says Professor Katherine Samaras, endocrinologist and clinical scientist at Garvan Institute of Medical Research.

“Women feel their waists thickening up and they often feel it in their shoulder blades, which may start hanging over their bra straps. Some women have thickening in the upper arms as well.” 

The health implications of belly fat

So, we change fruit shapes as we get older. Does it matter?

According to Katherine, the apple fat distribution increases the risk of developing insulin resistance.

“Insulin resistance can lead to a number of health conditions, including type 2 diabetes, vascular disease and coronary artery disease,” she explains.

“It’s also associated with increased rates of cancer, specifically breast, uterine and esophageal. When you’re insulin resistant, you have much higher blood insulin levels, which promotes cell proliferation.”

A non-surgical breakthrough that’s changing lives

Until recently, the only option available to women with obesity and comorbid conditions such as type 2 diabetes was risky and costly bariatric surgery. 

But all that changed in 2022 when so-called “weight-loss drugs” such as Ozempic exploded onto the world scene. 

With Hollywood stars and TikTok influencers showcasing the astounding weight loss they’d achieved with a simple pill or injection, the demand skyrocketed and there was soon a worldwide shortage of Ozempic.

Despite going viral on social media as miracle diet pills, most of these drugs aren’t even approved for weight loss by the Therapeutic Goods Administration (TGA) in Australia. 

They’re TGA-approved to treat and manage type 2 diabetes, and weight loss is considered a side effect.

So, how are so many Australians who don’t have diabetes getting their hands on these medications?

Who can access metabolic health medications

For the government to subsidise part of the cost of the drug, it must have a Pharmaceutical Benefits Scheme (PBS) listing and you need to have the condition it’s approved to treat.

If you don’t have the condition but your doctor believes it would benefit you, they can write you a private script and you’ll have to pay the full price out of pocket.

“For women who have central [abdominal] obesity and are starting to show markers of other diseases, these medications can assist in optimising their metabolic health,” Katherine explains. “This is considered off-label prescribing because the indications for these medications are to wait until people get the disease and then treat them.

“But there's more and more evidence that we shouldn’t wait for people to get the disease. If they have weight issues and they're not able to manage them with lifestyle changes, we can enable people to do the hard yards required for weight reduction. The medications create space to create behaviour change, which takes time and repetition.”

Types and costs of metabolic health medications

The following medications are currently approved by the TGA:

GLP-1 agonists

In Australia, three glucagon-like peptide-1 (GLP-1) agonists are registered with the TGA: semaglutide (Ozempic), dulaglutide (Trulicity) and liraglutide (Saxenda).

Semaglutide and dulaglutide are TGA-approved and PBS-listed for the treatment of type 2 diabetes, but not for weight loss. Liraglutide is approved for both conditions, but isn’t subsidised at all.

Another semaglutide, Wegovy, has been approved specifically for weight loss, but it hasn’t yet been launched in Australia. It isn’t interchangeable with Ozempic because it isn’t approved for type 2 diabetes.

“For the government to subsidise semaglutide or dulaglutide, you have to have diabetes, be on at least one other medication and have poor glycaemic control,” says Katherine. “Then the price comes down from $130 per month for a private script to about $40.”

GIP/GLP-1 receptor co-agonists

A new class of drug combines GLP-1 with glucose-dependent insulinotropic polypeptide (GIP) to treat type 2 diabetes. Tirzepatide (sold as Mounjaro) has been shown to be highly effective at treating type 2 diabetes and inducing weight loss.

“Tirzepatide is approved for the treatment of diabetes, but it doesn’t have a PBS listing,” Katherine explains. “It's only available with a private prescription and it costs between $350 and $550 per month.” The TGA is reporting shortages of Mounjaro, as well as Ozempic, in Australia.

Biguanides

Sold as metformin, this class of drugs is only TGA-approved to treat type 2 diabetes.

“Metformin is inexpensive, so it’s no more than $12 a month whether it’s subsidised or not,” says Katherine. 

While some of these out-of-pocket costs may seem exorbitant, Katherine notes they may be well worth it for some patients.

“If you have a family history of diabetes, your glucose is going up and you’ve been trying really hard to lose weight without success, these medications could benefit you,” she says.

“Before contemplating bariatric surgery, it might be worth trying a medication that, even at full price, is still a small drop in the ocean compared to what surgery may cost.”

Many Australians have raided their superannuation savings to pay for bariatric surgery and other medical treatments.

How the shortages are affecting Australians 

Novo Nordisk, the pharmaceutical company that makes Ozempic, has advised the TGA that the Ozempic shortage is likely to continue throughout 2024.

The TGA has urged prescribers not to initiate new patients on Ozempic unless there are no suitable alternatives or there’s a compelling medical reason to do so, and has asked pharmacists to prioritise patients who are already stabilised on the medication.

And, as new medications such as Mounjaro become available to the public, they too are in short supply due to the high demand.

For patients like Amy, who has insulin resistance and three autoimmune diseases - underactive thyroid, coeliac disease and psoriatic arthritis - Ozempic has been a lifesaver when she’s had access to it.

“I was eating cleanly and exercising, but my insulin resistance was at a point that it just didn't matter what I did,” she explains. “I kept packing on the weight, which was so demoralising and made my pain and arthritis a lot worse.”

After starting Ozempic in 2022, Amy lost 10 kilos and felt great until she had to stop taking it due to the shortage.

She’s been back on it since early 2023 - though she’s taking 0.75mg instead of the 1mg she needs because she wants to stretch it out - and she’s never felt better. 

“I’ve lost 21 kilos so far and my body feels like it's functioning as it should,” she says. “I can't describe it, but it feels like something is different physiologically. I don’t think I’ll ever stop taking it.”

Connie also desperately needs Ozempic to help manage her health, but she’s currently unable to get her hands on it.

After battling leukaemia twice and developing serious complications from the stem cell transplants she needed to save her life, Connie takes a daily cocktail of medications to keep her alive.

Several of them, especially the steroids she’s had to take on and off for years, make her retain fluid and send her weight and blood sugar levels skyrocketing. 

“My endocrinologist prescribed me Ozempic in the past and I lost nearly 20 kilos in 6 months,” says Connie. “Being on Ozempic evened everything out. It was beneficial in so many ways.

“I had to stop taking it for a while, and now that I need it again, there isn’t any available.

“[The shortage] makes it difficult to live a full and healthy life. But I stay positive and keep going for my two kids. They’re my world.”

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