The Novo Nordisk Obesity Awareness Campaign

NCGP June 2022

Staffan Svensson
Margrét Ólafía Tómasdóttir
Karin Mossberg
Oskar Lindfors
Hálfdán Pétursson

Outline of Novo Nordisk’s obesity campaign

Placeholder slide : instructions

Press “s”!

Placeholder slide : background

This is a rough translation of a presentation held by Staffan, David Gyll & Jonas Sjögreen at the SFAM2022 conference, march 31st, 2022. The original is here: https://pharm.nu/SFAM2022/

That presentation was 1/2 in a 60 minutes session where David also presented on patient organisations (not included here).

This is the full NCGP2022 abstract text:

Background

Obesity is a prevalent problem in most societies, a health hazard in its own right and a risk factor for cardiovascular disease and some common cancers. The worldwide prevalence of obesity has tripled since the 1970s. This massive increase has many causes, notably the wide availability of “hyperpalatable” foods and sedentary lifestyles, as well as cultural and societal changes that contribute to an obesogenic environment. The main modalities of obesity treatment on the individual level are lifestyle modification, pharmacotherapy and bariatric surgery.

Drug treatment for obesity has historically been marred by side-effects and limited, short-term weight loss. Recently, two drugs in the GLP-1 receptor agonist class – liraglutide (Saxenda) and semaglutide (Wegovy) – have been approved for weight loss. This approval coincides with a marketing campaign by the pharmaceutical company Novo Nordisk (patent holder of S & W) directed at the public and health workers. This campaign attempts to raise awareness and reshape society’s perception of obesity, arguably with the ultimate aim of achieving reimbursement status for S & W.

Aim and learning objectives

Better understanding of obesity and its causes. Pros and cons anti-obesity measures on the individual and societal levels. Description of the key rhetorical statements of Novo Nordisk’s campaign. Comparison of its roll-out in the Nordic countries. Discussion of consequences of S & W achieving reimbursement status. What action is needed from Nordic family doctors?

Methods and timetable

30 minutes presentation, inventory of participants’ experiences. 30 minutes discussion in break-out groups, authors as moderators. 30 minutes plenary, ways forward.

Conclusions

The launch of these two drugs for obesity, and its accompanying marketing campaign aimed at reshaping the public and professional perception of obesity, has potentially widespread ramifications for society. Nordic family doctors need to have a clear view of this situation and formulate a proactive stance.

Marketing components

Ads in newspapers
Ads in medical journals
Ads sent to physicians & nurses
Invites to lectures, seminars
Marketing surveys
Podcasts
Campaign webpages
Patient & professional organisations
Targeted (¿co-edited?) newspaper articles
Videos
Collected here: pharm.nu/novo

Campaign webpages

For public/patients [Swedish]
For health professionals

Patient organisations

Hälsa oberoende av storlek, Swedish PO “Health regardless of weight”, HOBS
Nordic Obesity Alliance, NOBA
- HOBS and Danish PO Landsforeningen for overvægtige
- Sponsored by Novo Nordisk, et al
behandlaobesitas.nu
- The report En tillräcklig och jämlik obesitasvård (A sufficient and equitable obesity care), 2019
- Sponsored by Novo Nordisk, written by HOBS and marketing firm Reform Society/Re-Think
European Coalition for People Living with Obesity, ECPLO
- Sponsored by Novo Nordisk, et al
Obesity Action
- Sponsored by Novo Nordisk, et al

Professional organisations

Svensk förening för metabol- och obesitaskirurgi, Swedish association of obesity surgeons, SFOK
- Sponsored by Medtronic and Ethicon
Svensk Förening för Obesitasforskning, Swedish association of obesity researchers, SFO
European Association for the Study of Obesity, EASO
- Mother organisation of SFO
- Sponsored by Novo Nordisk, mfl
European Congress on Obesity, arranged by EASO
- Sponsored by Novo Nordisk, et al
European Society of Endocrinology, ESE
- Sponsored by Novo Nordisk, et al
World of Obesity, WOF
- Sponsored by Novo Nordisk, et al

Co-edited newspaper articles?

Videofilmer

Den svenska sjukvården förlorar slaget, “Swedish healthcare fights a losing battle”
- Linked from behandlaobesitas.nu, “treat obesity now”
131 short films (counted Feb 2022)
Seminars arranged by Novo Nordisk with Reform Society/Re-Think, eg:
- Webinarium 2021-11 about National Board of Health & Welfare’s upcoming obesity guideline, with Petter Odmark
- Seminarium 2021-07 about obesity, with Göran Hägglund
- Seminarium i Almedalen 2019-07 about diabetes and obesity, with Mats Eriksson

GLP1-receptor agonists

The STEP programme

STEP 1–8 + SELECT

Studie/Reference
STEP-1 : Wilding JP, et al. Once-Weekly Semaglutide in Adults with Overweight or Obesity. NEJM 2021;384(11):989–1002.
STEP-2 : Davies M, et al. Semaglutide 2·4 mg once a week in adults with overweight or obesity, and type 2 diabetes (STEP 2): a randomised, double-blind, double-dummy, placebo-controlled, phase 3 trial. Lancet 2021;397 (10278):971–984.
STEP-3 : Wadden TA, et al. Effect of Subcutaneous Semaglutide vs Placebo as an Adjunct to Intensive Behavioral Therapy on Body Weight in Adults With Overweight or Obesity. JAMA 2021;325(14):1403.
STEP-4 : Rubino D, et al. Effect of Continued Weekly Subcutaneous Semaglutide vs Placebo on Weight Loss Maintenance in Adults With Overweight or Obesity. JAMA 2021;325(14):1414.
STEP-5 : NCT03693430
STEP-6 : Kadowaki T, et al. Semaglutide once a week in adults with overweight or obesity, with or without type 2 diabetes in an east Asian population (STEP 6): a randomised, double-blind, double-dummy, placebo-controlled, phase 3a trial. Lancet Diab Endo 2022;10(3):193–206.
STEP-7 : NCT04251156
STEP-8 : Rubino DM, et al. Effect of Weekly Subcutaneous Semaglutide vs Daily Liraglutide on Body Weight in Adults With Overweight or Obesity Without Diabetes. JAMA 2022;327(2):138.
SELECT : NCT03574597

STEP outcomes

Study	Patients, criteria	Duration	Weight loss	Weight difference S2·4–P
STEP-1	1961 obese BMI>30/27§	68w	S2·4 14.9%; P 2.4%	12.7 kg
STEP-2	1210 obese & DM2 BMI>27	68w	S2·4 9.6%; S1·0 7.0%; P 3.4%	6.2 kg
STEP-3	611 obese BMI>30/27§	68w	S2·4 16.0%; P 5.7%	10.6 kg
STEP-4	902 obese BMI>30/27§	20 + 48w¶	S2·4 -7.9%; P +6.9% (v20–68)	13.2 kg
STEP-5	304 obese BMI>30/27§	2 yrs	S2·4/P not published
STEP-6	401 obese/DM2 BMI>35/27§	68w	S2·4 13.2%; S1·7 9.6%; P 2.1%	?
STEP-7	~375 obese/DM2 BMI>30/27§	44w	S2·4/P not published
STEP-8	338 obese BMI>30/27§	68w	S2·4 15.8%; L3·0 6.4%; P 1.9%	13.8 kg
SELECT	~17 500 CVD BMI>27	2½–5 yrs	S2·4/P not published

Studies in the STEP-programme, all designed by Novo Nordisk and concerning injected semaglutide compared with placebo (in STEP-8 also liraglutide). Participants also got lifestyle counselling, typically every fourth week (more often in STEP-3). The SELECT study outcome measure is cardiovascular morbidity/mortality.

§ BMI≥30 or BMI≥27 with at least one overweight-related risk factor.
¶ Data from STEP-4 relates to change after 20 weeks treatment with semaglutide 2.4 mg followed by the same, or switch to placebo.
S2·4 semaglutide 2.4 mg weekly; L3·0 liraglutide 3.0 daily, etc; DM2 diabetes type 2, CVD cardiovascular disease.

Participants STEP

Study	Locations§	Completion¶	% Women	% White	BMI mean
STEP-1	Asia, EU, NA, SA	94%/81%	74%	75%	37.9
STEP-2	Asia, EU, NA, SA, ME, SAfr	96%/87%	51%	62%	35.7
STEP-3	USA	93%/83%	81%	76%	38.0
STEP-4	USA, EU, SAfr,	98%/92%	79%	84%	38.4
STEP-5	NA, EU
STEP-6	South Korea, Japan	99%/94%	37%	0%	31.7
STEP-7	China, Korea, Brazil
STEP-8	USA	94%/80%	78%	74%	37.5
SELECT	Asia, EU, NA, SA, NAfr, Aust

§ NA North America, SA South America, ME Middle East, SAfr South Africa, NAfr Northern Africa.
¶ Completion of study/completion of treatment protocol.
Mean BMI at baseline.

Side effects STEP

Study	Adverse effect profile SAE§	Signals?
STEP-1	SAE S2·4 9.8%; P 6.4%	gallstones
STEP-2	SAE S2·4 9.9%; S1·0 7.7%; P 9.2%	retinopathy
STEP-3	SAE S2·4 9.1%; P 2.9%	gallstones
STEP-4	SAE S2·4 7.7%; P 5.6%	neoplasia
STEP-5
STEP-6	SAE S2·4 5.0%; S1·7 7.0%; P 7.0%	retinopathy
STEP-7
STEP-8	SAE S2·4 7.9%; L3·0 11.0%; P 7.1%	neoplasia
SELECT

§ SAE serious adverse events.

Main campaign messages

My interpretation

Obesity is a disease
- A chronic disease that needs life-long treatment
People with obesity are wrongfully depicted as having weak willpower
- The body is a fierce opponent
- Physiological mechanisms counter-act and over-compensate weight reduction
- … through hunger hormones and the body’s set-point of weight
Patients with obesity are blamed
- By themselves, health care and society

Interpretation 2

Health care staff are ignorant and prejudiced about obesity
- Patients are stigmatised by health care
- Particularly by primary care
- Health care does not assume responsibility for obese patients
Swedish authorities have a misguided view of obesity
- The coming obesity guideline from the National Board of H & W will change this

Goals of the marketing campaign

Inclusion in reimbursement scheme for liraglutide (Saxenda) and semaglutide (Wegovy) for obesity
Presently only reimbursed for diabetes type 2
- as liraglutide (Victoza) and semaglutide (Ozempic)
Monthly cost ~2600 SEK (~280 US$; ~250 EUR)
Semaglutide (Wegovy) was approved by the EMA in Jan 2022
Swedish pharma benefits agency TLV has not yet decided on reimbursement

Points of debate

Circumvention of ban on marketing of prescription-only drugs to the public, by marketing the diagnosis obesity?
Societal interventions vs. individually oriented interventions for obesity?
Involvement of ex highly placed health care politicians and functionaries in marketing?
Engagement of patient organisations in marketing?
Is reimbursement of of GLP1-receptor agonists for obesity a good idea?

I put questions marks on these statements for the sake of “debate”, but it looks a bit strange. The circumvention point is about the ads violating the Swedish ban on marketing of prescription-only drugs to patients and the public, here one could also include the promotion of a not yet approved (at least at the beginning of the campaign) drug indication.

The patient organisation point is difficult, as one does not want to come across as having a demeaning attitude towards patients. But the key representative of the Swedish PO is clearly very much aligned with Novo, as are a number of key opinion leaders among Swedish obesity researchers and clinicians. These health professionals figure in Novo’s marketing and are compensated economically for their efforts (see eurosfordocs.eu). The PO representative and the KOLs furthermore co-operate in publishing opinion pieces, etc.