John Donvan
We’d like to provide a brief note ahead of today’s episode. This discussion will touch on topics related to weight and dieting and body image, and the use of medications like Ozempic for weight management. These subjects may be triggering for individuals who have experienced or are currently dealing with eating disorders, so please take care as you listen.

This is Open to Debate. I’m John Donvan. Hi, everybody. Today we are having a debate about these medications that everybody’s been talking about because they are proving so powerful in helping people to lose weight. You probably recognize these names, Ozempic, Wegovy. There are others. Technically, they’re all known as semaglutides or GLP-1 agonists. And they have been used to treat people with diabetes for years, but it was discovered they also help people drop weight without a lot of dieting, without added exercise. And that has made them a hot topic, and it’s also won them approval from the FDA for people diagnosed with obesity, especially when it comes with other complications.

But some are saying, “Why stop there? Why require a diagnosis of anything when people might have lots of reasons to wanna lose weight fast?” Say there’s an actor up for a job in Hollywood and he wants to take off a few pounds. Or what if the Army wants to make sure that soldiers can go undistracted by hunger on a dangerous mission? Because these drugs do tend to suppress hunger. And just in general, if people want to get thinner because they like the look or the feeling, should they be able to do that without a lot of obstacles?

Well, there are arguments for that, but there are also strong arguments against it. And that’s what we are gonna be debating in this program, and that’s because the debate is out there. Today we have two exceptional panelists who are taking on this question. Prescription weight loss drugs for all, question mark? Let’s introduce them now. Answering yes to the question mark, who believes the prescription weight drugs for all should be made available, I wanna welcome David Allison. He’s an obesity researcher and dean and distinguished professor at the Indiana University School of Public Health in Bloomington. David, welcome to the program. Thanks so much for joining us.

David B. Allison
Thank you, John. Truly a privilege to be here.

John Donvan
And answering no to our question, which again is prescription weight loss drugs for all, we have Dr. Stuart Flint, who’s an associate professor of psychology, the psychology of obesity at the University of Leeds in the UK. Stuart, welcome to Open to Debate.

Stuart Flint
Hi, John. Thanks for having me.

John Donvan
Um, now since both of you are involved in medicine and in research, I, I just wanna give you each an opportunity to make any disclosures that our listeners and viewers should know in keeping with the ethics around research. So, uh, David, why don’t you take that first?

David B. Allison
Sure. I receive either through my university as grant support or as individual consulting, uh, fees and, uh, funds from multiple organizations, including Eli Lilly and Company, Novo Nordisk Foundation and other organizations, other pharmaceutical companies than, and companies that have interests in obesity treatment, including GLP-1 agonist drugs.

John Donvan
Thanks very much, David. And how about you, Stuart?

Stuart Flint
Yep, likewise. I, I also apply for and receive grant funding, uh, from research councils, uh, from a range of different organizations, including pharmaceuticals, soci- uh, organizations such as Novo Nordisk, past from Johnson & Johnson. So organizations who are involved in obesity-related treatments. Um, I haven’t specifically received any funding, uh, relating to GLP-1, uh, products themselves.

John Donvan
Thank you very much, both, for those disclosures and let’s get on to our opening statements. We wanna give each of you a few minutes to tell us why you’re taking the position you are. David, you are up first and again, you are arguing yes to the question, prescription weight loss drugs for all, question mark? Please tell us why.

David B. Allison
Thank you, John. Well, this is a simple matter. It is about choice. It is about the choice of what one does with own, one’s own body. It is about autonomy, liberty, freedom, and the right for adults to choose what is in their interests as long as it doesn’t harm others. It is about respecting the values of others and not telling them what their values should be. The United States Declaration of Independence proclaims, “We hold these truths to be self-evident that we are endowed with certain unalienable rights. That among those are life, liberty, and the pursuit of happiness.”

In this light, should we deny individuals access to tools that society has created, these tools being anti-obesity drugs, including created with their taxpayer money? They pay NIH and others to pay us to find these drugs that can be powerful, effective medications for them. This is not an issue of cost or payment. The question of who pays, how it’s paid, when it’s paid, that can be addressed another day. This is simply a question of should we make things available.

This is not about allow, uh, availability. The supply limits that do exist will come to an end. That will be solved eventually. This is not about the uncertainties of long-term health effects. We know those uncertainties exist. We don’t know everything. We will be surprised on occasion by things. That is true in our everyday life. There is no decision-making without risk. As long as we know those risks upfront, as long as we are honestly told what is known and what is not known, we can make informed and intelligent decisions. If we are honestly informed that the information’s incomplete, we should be free to make decisions.

Individuals might wish to take anti-obesity medications for many reasons. John, as you said at the opening, it can be the FDA approvals, approved conditions of diabetes and obesity, but it can be the other conditions for which it appears these drugs sa- can be effective, such as fatty liver, sleep apnea, uh, addictive disorders, and even some forms of cancer. So these are powerful effects. Now, one might say that those are standard off-label uses and physicians have the right to prescribe them, and they do.

But let us go even further. Let us talk about, as you intimated, the Hollywood star who wants to get the next role, and for whom that might mean several million dollars of additional income or an important career opportunity that’s meaningful for them. And we might say, what’s 10 pounds or something for that person? But for them, it makes a difference. That’s for them to judge, and that’s the world they live in. It may be for cosmetic reasons for other needs and individuals. We regularly provide people cosmetic surgery. It’s approved. Uh, why shouldn’t this be different? Many of us choose to do many things to look younger or different. We put in hair dye, we put in teeth caps, uh, and so forth. Put, people put on makeup. You’re still gonna be the same at the cellular level. If you’re old, you’re still old whether you have hair dye or not. But if some people want it, we don’t say, “You can’t have it.”

We can think about the issue of chronic hunger. There are many people, and I happen to be one of them, who maintains a fairly lean body composition or a lean body shape, but does so at the expense of chronic hunger and thinking about food. Might people say, “This is a quality of life issue. I would like to not think about that”? And let’s even think about the, the athlete who is not a professional athlete, but it just is meaningful to them, who says, “I could perform better if I were thinner and lighter, and I’d like to take this drug to help.” Should those people not have the right to make decisions about their own lives? I believe we should all have the right to make decisions about our own bodies. Thank you.

John Donvan
Thank you very much, David. So Stuart, you’re taking the position of disagreeing with, uh, David’s position. You believe prescription weight loss drugs should not be available for all, at least at, not at this point. Uh, here is your chance, please, to make your case.

Stuart Flint
Thank you, John. And uh, David, some great points there. Um, and I think, uh, your, your last point there is really important, John, not at the moment, uh, because that is my stance. My stance is ultimately that, uh, these products have not been tested, approved, uh, and deemed to be safe for use outside of people living with diabetes or obesity. That’s where the clinical trials have, uh, focused. That’s where the evidence base is in terms of their use. And therefore, to open them up to be available for anybody would mean that there are people and, and, uh, parts of the population who we ultimately don’t know what’s the clinical effect of, uh, using these products would be. And we need to do those tests before we, uh, open them up to be widely used as, as suggested in the title of this show.

Um, the second point is, is that there is no guidance currently, of course, therefore, uh, for use by the general population. These products have been developed for significant weight loss, uh, if we’re talking about obesity, uh, significant weight loss. So the clinical trials are showing 15 to 20%, uh, weight loss, uh, in some instances, um, more. And of course, there’s new products that are being developed and there is intentions to have even greater weight loss. So, um, you know, this level of weight loss is clearly not relevant for many people within the population. And it opens them up to be potentially used, uh, by people who, for instance, may be, uh, experiencing eating disorders, body image concerns or other. And therefore, this may, uh, increase or maybe even exacerbate other concerns that we have across the population if they were to be opened up to be used by anybody at all.

Um, there is a mention there, and I think David also alluded to, um, them potentially being used for cosmetic reasons. Again, uh, we, we don’t have any evidence that these could be used for comet- cosmetic reasons at this, at this point. Um, and actually one of the manufacturers, um, Eli Lilly also, um, released an open letter earlier in, uh, 2024, uh, stating that these should not be used for, uh, cosmetic use, but they should only be used by the population groups that they’ve being clinically tested and approved to be safe and effective for. Um, so you actually have the manufacturer, one of the manufacturers, who are also calling for them not to be used by people outside of, uh, obesity and diabetes, the two, uh, clinical population groups that they’ve been approved for.

We also know that when people, uh, use these medications and then stop using these medications, again, this is only based on people living with obesity because that’s where the trials are focused, that people regain weight. Um, and actually there’s a, a nice study that was conducted by Professor John Wilding, um, and many colleagues across the globe, um, who, um, showed that, um, where people stopped taking, uh, one of the products, semaglutide, which is produced by Novo Nordisk, and people regained the weight. So after a year, um, people regained the weight that they had lost when they were using this product. So again, this is in a clinical population. We don’t know what the potential impacts of, um, losing weight, regaining weight would have on, uh, a lower, uh, weight, uh, status, uh, a group with a low weight status. Um, and this may even, uh, encourage or promote weight cycling, which we know has again, um, some, some quite detrimental consequences for people.

Now, my f- my final point would be that again, these dosage are, do- dosages are designed for significant weight loss. So it may well be that in their current form that either they’re one, not appropriate for people looking to lose, uh, a lower amount of weight, which is what’s suggested, um, by David as the, the other person debating this, uh, this topic, and even the potential risks and side effects, which, um, I totally agree with David. Of course, we have to accept these. There are risks that are associated with any medication. Um, but these risks might be very different for a different population group. We need to do the clinical testing to be sure, uh, and to, um, make sure we have the evidence about their potential safety for different parts of the population. Thank you.

John Donvan
Okay, thank you, Stuart, very much for, uh, for making your argument. Uh, we’re gonna take a quick break and when we come back, we’ll get deeper into our question. Prescription weight loss drugs for all, question mark? I’m John Donvan. This is Open to Debate and we’ll be right back.

Welcome back to Open to Debate. I’m John Donvan and we’re taking on this question, prescription weight loss drugs for all? Question mark. I’m here with David Allison and Stuart Flint. We have heard their opening arguments, but gentlemen, I’d like to just share what I think I heard each of you say. David Allison, you’re arguing yes to our question and you’re saying it’s a question of personal choice and freedom and respecting the values of others. Um, you also point out that at this point there’s indications that not only will these, um, medications help with weight loss, but they might have other benefits in terms of cancer and, and other issues as well. There’s, you mentioned fatty liver and cancer, and you also said if somebody just wants to look better or feel like they look better because of losing a few pounds, they should have that right. That sh- they should, that should be okay.

Stuart, you’re not really opposing the liberty argument. You’re fundamentally arguing that we just don’t know yet enough about the impact of, uh, long-term or even short-term use of these medications outside of the parts of the population that have been studied, uh, primarily people with, uh, diabetes or with obesity, and that, uh, you have severe concerns about what the risks would be for other parts of the population that may be interested in taking these drugs. You, for example, point out somebody who already has an eating disorder. Is it really a good thing for them to be able to, uh, have access to a drug that will make them lose even more weight?

And you, as far as the issue of, uh, cosmetic interest, you’re saying that there’s no evidence that they can or should be used that way. And you also say one thing that is known about these drugs is that for people who have been using them for weight loss in the long term, when they stop, they tend to put on weight. I, I wanna start the conversation then by going to you, David, and just, just to get your reaction to Stuart’s objections on the issue of safety. He conceded that always, there is always some risk with any kind of medication, and we all know that. But he’s saying that in this case, he just thinks that the unknowns are too many, too hi- too high and, uh, and, and too, too risky. And what is your response to that part of his argument?

David B. Allison
With respect to weight regain, this is true of virtually every anti-obesity treatment with the partial exception of bariatric surgery. When you put a treatment in, whether it’s cognitive behavioral treatment, lifestyle treatment, any medication, and you withdraw it, people tend to regain the weight. That doesn’t mean the treatment’s a failure. We give people with hypertension, diabetes, schizophrenia, many other conditions, you take your drug for life.

The statement that weight cycling leads to known deleterious effects in humans is simply untrue. We have associations but not causation. When we look at randomized controlled trials from Tom Wadden’s group in University of Pennsylvania, it seems that weight cycling is not associated with or does not cause negative psychological problems. When we look in our mice where we can look at longevity with rigorous experiments, my group has shown that weight cycling makes mice live longer, not shorter. So that’s just not true that we know that weight cycling is bad.

Now, with respect to the unknown, um, side effects, it’s true there is, there is some unknown. We don’t know in the long run how safe these will or will not be, but we have a lot of evidence for safety in general. And we have evidence for safety in a more clinically, uh, challenged population than, let’s say, a thinner, healthier, non-obese, non-diabetic population where safety is likely to be greater. And so we can inform people of this is what we know today. And then I think if, if we as a society and the FDA and so on invested more into helping physicians and other healthcare providers to better communicate information so that people could truly make informed decisions about their lives, given uncertainty, then I think we have to accept that there is uncertainty in life and people should be able to make their own decision.

John Donvan
Stuart?

Stuart Flint
Yeah, I mean, my, my, my brief, um, responses to David’s, uh, comments is of course there are several debates on whether these products should be used long term, uh, akin to, for instance, using medications long term for other health conditions. Um, the simple fact here is, is that we’re talking about, uh, clin- clinical testing of, um, you know, people with a, a significant health outcome, um, not the general population utilizing these products. So yes, I, I, I agree, they’re like any other medication, people will regain weight.

Um, in terms of the, uh, weight cycling points, um, uh, my point really was that, that, uh, uh, there are associations and that this, this can have, uh, detrimental impacts. Uh, we need to better understand the potential impacts. I think that is the, the key issue here. Um, and so the point around, uh, the risks associated with using the medications and informing people, that’s exactly what I would like to do as well. I’d like to inform people, but I’d like to inform people based on clinical trials with population groups that have been studied, rather than say to people, “These are the risks that are associated with a clinical population group that you’re not part of.” This is what we see with people living with obesity, people with diabetes.

Uh, so the risks that we know with this population group, we are telling you what the risks are here, but that might not be the risk for you because we’ve not tested it. We need to do the testing. We need to prove, uh, that they are potentially safe, and we need to understand what the risks are. Are they different? Are they the same?

David B. Allison
There seems to be a double standard here in terms of the idea of perfect evidence. I- interestingly, in the public health domain, I, I often question the strength of the evidence that a particular intervention or prevention strategy is effective. And some of my public health advocate colleagues will get angry at me and say, “David, we can’t wait for perfect evidence. We can’t wait for the perfect randomized controlled trial. We need to act.”

And I say, “I never said you shouldn’t act. I just said act, but tell people the evidence is not compelling.” Here, I feel like Stuart’s taking the opposite position of saying, “It’s not okay to just tell people the evidence is not as compelling as you might wish it to be. We must wait and… to act until there’s evidence directly in the population of interest, directly on the outcomes of interest, directly for the duration of interest.” And I think that’s an unreasonable standard.

Stuart Flint
Um, I’ll just come back in as well, John, there, because I, there’s no double standard. It’s simply that we need to run the tests and have the data and have some information. Um, it’s not to say that we need to wait. I mean, th- there’s plenty of, uh, opportunity to, to trial these pro- uh, these, uh, medications in people without obesity. Um, so let’s do the trials, let’s get the evidence, and, and then we can better inform people. So, there’s no double standard.

John Donvan
Stuart, let me ask you to compare the, the, this situation with something we’ve all lived through, was the, the, the rather rapid development of the COVID vaccines and the fact that the COVID vaccines were, uh, distributed on a mass scale without years and years of study because the justification being the emergency that was in place. In, in that case, were, were the, uh, kinds of barriers of concern that you’re talking about lowered? And if so, how is that different from this case?

Stuart Flint
My assumption is that they probably, uh, they probably were because of the, uh, epidemic that we ultimately were experiencing. But certainly, uh, there, there should be, uh, proper clinical trials to be able to evidence the, the potential safety and of course, again, you know, to highlight the potential risks of, uh, of the COVID vaccinations for people who, who would’ve been in the, the early trialing.

David B. Allison
I think we’re always adapting to the amount of evidence available. Evidence is never complete. We will never have the clinical trial done on a sufficient number of people for their entire lifetime when we start breaking it down to every subgroup at every dose and say, “Well, what about people living below the equator, above the equator, black, white, old, young male, female with diabetes, without,” et cetera?

John Donvan
David, I, I’m not sure if you’ve just told us the answer to this question, but where is the line? If your argument is that people can make, uh, this choice based on freedom, individual liberty, why have a, any sort of safety regime in place at all if people just want to go ahead and try stuff?

David B. Allison
Yeah, I, I think this is sort of the slippery slope argument a little bit of, well, if you allow this, then don’t you allow personal choice for heroin or what have you? And I think that’s, those are largely questions for another day. Our current view is a very paternalistic one in which the FDA gets to decide how much risk is too much risk and which benefits get counted and for whom they get counted, uh, largely.

But you could imagine a different world. This is sort of a little bit more what we have in the case of dietary supplements, which many people understandably criticize because of the, the very light level of regulation they have versus pharmaceuticals, but where essentially, the FDA is more a controller of the messages that marketers can sen- send, as opposed to you can sell it or not sell it. And so people can get dietary supplements as long as they’re generally recognized as safe and, uh, not known to be harmful. We could imagine a world in which the FDA, as well as prescribers, have more control and more investment in sending clear messages that allow truly informed consent and helping people make, uh, understand data better and less restriction on the actual availability of the product.

John Donvan
Stuart, what would you think of a world in which that was the, the ruling paradigm?

Stuart Flint
Well, you know, it’s interesting that David said, you know, “As long as, uh, the people are aware and they’ve been tested, and, um, there is sufficient evidence, uh, that they, um, that the risk is lowered.” ‘Cause there’s a lot of reports that would suggest that there are different, uh, effects that people are presenting with. There was, um, very recently there’s a publication from the UK Parliament looking at medications for obesity in England, which highlighted people without obesity who have been using the products who are presenting with, uh, a range of different, uh, effects, including, um, now actually checking into different types of rehab to support different types of effects that have occurred as a result of, uh, of using medications.

(

):
Um, but these are reports, and what I would like to do is actually have, uh, a trial to test that potential, uh, impact in this population group because, you know, there’s gonna be reports that would say, you know, “People can use these medications and they’re fine.” There’s other reports that are gonna be, people can use medications and there’s different issues. Um, there is no reason why we can’t run this type of test. It’s not that this, there’s a population group that we’re struggling to, uh, to recruit, or there’s reasons why we need to, uh, rapidly scale out a medication, uh, with, with, uh, less potential evidence, then that might be a different question. This is not one of those questions.

(

):
This is one where we can, uh, deliver this trial and get the evidence that’s required. And if it means that these medications are appropriate for the population, then so be it. Uh, we’ve got the evidence to be able to prove that. If they suggest that it’s not and there needs to be other types of dosages or variations of the product, then again, maybe that’s something that needs to be invested in in the future.

David B. Allison
I wanna jump-

John Donvan
David-

David B. Allison
… in here.

John Donvan
Sure.

David B. Allison
I, I just wanna make crystal clear that Stuart and I are 100% in alignment on more data is better than less data. I too believe we can generate more data. My entire career has been devoted to seeking evidence and data for things, but there is, there’s an infinite amount of data one could wish for and one will never get at all.

John Donvan
So, David, let me, let me break in. You’re saying, “Where they are now.” In this case, we have, we have what we need to safely be, uh, having wider dispersal of these drugs, as I understand it. So my question to you is, if, if you are right, is there also a concern for individuals abusing the drugs? Do, and, and what, what about, how do you safeguard against that? For example, Stuart brought up the case of somebody who perhaps has a de- a, an eating disorder and taking this drug is gonna be harmful. Should that person have access to the drug?

David B. Allison
So without getting into the specific case, I would say harms are inevitable. Uh, there will be harms. There are harms from driving vehicles, but we don’t ban vehicles. We do our best. We make sure everybody has a license. We make sure they know at least, uh, by getting the license, understand the rules of the road, there’re informed, and then we accept that there are some risks. I think this is the same thing. We should try to mitigate risks through information, through monitoring. The very fact of a prescription, uh, requiring a prescription mitigates risks. But no, it will not eliminate risk. We cannot eliminate risk from life.

John Donvan
All right. What we like to do in these programs is bring in people who know these topics very, very well from, from one, uh, perspective or another and ask them to jump in with some questions for you as well. And I wanna start that process now by welcoming to the program Barry Sears. Barry Sears is a famous name in this field. He’s the founder of the Zone Diet. Um, Barry, thanks so much for joining us, and I know that you’ve been listening to the conversation, so we’d like to invite you in and can’t wait to hear what your question is for our debaters.

Barry Sears
Well, it’s been a very interesting conversation so far. Uh, as pointed out earlier, these are forever drugs, yet the real data indicates that people taking these drugs for medical conditions basically stop taking ’em, by and large, at least have 50% to stop taking ’em after two years. And once they, the drugs are stopped, the weight comes back, but now primarily as fat. The second aspect that these drugs were originally developed to prevent diabetics from advancing to more severe conditions such as cardiovascular disease, in-stage kidney disease and mortality. And from that perspective, drugs like metformin are just as effective and far cheaper.

And finally, these are hormones. These are the most powerful drugs known to medical science. And as a consequence, there’s a lot of things we still don’t know what happens. In many ways, this reminds me of the fen-phen craze in the United States 30 years ago when they said, “It’s safe as could be.” And yet basically, it’s taken off the market because it caused primary pulmonary hypertension that required a heart-lung transplant to treat. So there are many questions. I think we basically want to basically focus on what they can do, what they were really designed to do, and not basically make it, uh, open season for everyone to lose weight now, ask me how.

John Donvan
Okay, so if I’m gonna sum up what you just said as a question, I think, uh, primarily you’re challenging David. Is open season a bad idea, and does open season characterize what you’re talking about, David?

David B. Allison
So first, uh, unrelated, but I want to point out that Dr. Sears is an, uh, an alumnus of Indiana University where I work. So, go Hoosiers.

Barry Sears
(laughs)

David B. Allison
Um, second, uh, I do not dispute that many people discontinue taking the drug after a year or two. I, I don’t see why that’s relevant. If anything, doesn’t that strengthen the argument that people are able to choose to stop it? If people find it’s not working for them or they don’t like it or it has negative side effects, they stop. I know of no evidence to support Barry’s statement that more of the weight is regained as fat, leading to a greater, a fattier body composition after weight regain when controlling for age than compared to any other method of weight loss or, uh, just to where people started out at.

[NEW_PARAGRAPH]Uh, the fact that there are other drugs like metformin that work well for diabetes, that’s great. Metformin causes barely about 4% weight loss. It, it’s not gonna rival a GLP-1 agonist drug, which can cause, current versions, 20% weight loss. So I don’t see any of the points Barry has made as reasons that we should not allow people to have GLP-1 drug access.

John Donvan
Stuart, do you see any point, uh, in, in Barry’s, in Barry’s, uh, suggestions that we should be, be more cautious about this?

Stuart Flint
Yeah, very much so. And I think m- m- I guess the, the, the additional point just to note is, is that it’s not just that there’s weight regain. Um, the, uh, the study that I, I referred to earlier by Professor John Wilding also showed that there was, um, you know, similar changes in cardiometabolic variables as well. So it, it’s not just the weight regain, but also, uh, any changes in cardiometabolic outcomes, um, uh, also seem to be, uh, evident when people come off the, uh, the products.

John Donvan
Okay, so we’re, we, we’re gonna hit just at this point a fundamental disagreement about what the evidence shows about this, the nature of this weight regain. And so I think we’re at an impasse at that point because we don’t have the studies in front of us. But Barry, before we take our break, uh, just wanna thank you for joining the program and ask you if an- any last comment.

Barry Sears
No, I think these are very fascinating drugs, but the fact is that, um, other things which have been proven over a lifetime, that is calorie restriction, lifestyle, exercise, they’re being thrown to the wa- to the winds saying, “They don’t work.” They do if you do them, use ’em. So it’s back to saying, are we taking the easy way out?

David B. Allison
Caloric restriction, exercise work to promote weight loss if one can do them. We have 50-plus years of trying to tell people to do them. People understand the message. It’s hard to do. When we say, “Taking the easy way out.” Or, “People just wanna look better,” it’s very pejorative. There’s tremendous stigma about weight and obesity. We would not say that about other medical conditions or other desired factors. We should stop that stigma.

Stuart Flint
John, I also wanna come in here as well. Um-

John Donvan
Yeah, go ahead.

Stuart Flint
Because actually now I agree with both Barry and David on this point, but certainly I also wouldn’t describe ’em as an easy way out. And, um, I work with people living with obesity and charities that support people living with obesity. You know, that certainly, uh, this is not an easy way out. They’re very diff… It is a very difficult route that people ultimately take, managing side effects that ultimately, you know, quite a lot of people will ultimately experience, um, but also being adhered to a, uh, to, uh, a treatment for a long period of time. And you do need the behavioral change with that as well, the diet, the exercise, and so on. So, I, I also wouldn’t see this as an easy way out.

John Donvan
Barry, thank you for your question and got into some interesting places. And when we come back, we’re gonna have some more questioners, more experts in this field. Our debate is around this topic, prescription weight loss drugs for all? I’m John Donvan. This is Open to Debate, and we’ll be right back.

Welcome back to Open to Debate. We’re taking on the question, prescription weight loss drugs for all? I’m here with David Allison and Stuart Flint. Uh, we are at the portion of the program where we have some experts come in and, uh, add to the conversation by bringing in some provocative and thoughtful and well-informed questions. And our next question comes from David Ludwig. David is an endocrinologist and a professor at Harvard. David, thanks so much for joining us in the program, and, uh, please come in with your question.

David Ludwig
Uh, greetings and hello from Denmark, which, where I am part-time.

John Donvan
Ah.

David Ludwig
The country that has, uh, benefited enormously financially from these new drugs because, uh, Novo Nordisk, the company that has the patent on semaglutide, is based here. So, um, the FDA in the United States has a nearly century-old regulatory system to distinguish between drug category risk. There’s some drugs, like heroin, which are completely unavailable. Um, other drugs, many prescription drugs, uh, are available but with a prescription because they have safety issues or unique challenges to certain populations. And then other drugs, uh, who, which have proven very safe in practice are over the counter.

David, you made a, initially, a libertarian argument that adults should be able to do whatever they want with their bodies. Why not, uh, allow them to use these drugs and assume the risk? Um, but why is this drug class different from a whole other set of drug classes that, um, we re- realized that there are serious risks if we made them freely available, uh, Valium for anxiety, high-potency testosterone, uh, for physical fitness and muscle strength. Why, in fact, can’t people take, take cancer drugs if they wanted to? Where, where is the dis- where’s the distinction here?

David B. Allison
I think that the distinction, uh, the slippery slope sort of analogy is a good one in that like freedom of speech, for example, where we generally say in the United States, “You have freedom of speech and you can say what you want,” there are a few restrictions. You know, the classic, you cannot yell fire, uh, in a theater if there was no fire, um, because it’s just too dangerous. And I think there may be situations where we say, “This is just way too dangerous.” Each one of those has to be taken at a case-by-case basis, and maybe that’s where heroin is.

Uh, on the other hand, I think there are many things in which we are much more open. Uh, roughly 40% of prescriptions in the United States are off-label prescriptions. Those are by legitimate physicians working with patients who see some use of a medication that’s not the primary FDA-approved usage, and yet they think it’s in their patient’s interests and they prescribe it. I think when we’ve still got physicians involved who can help patients work through, or even if we don’t call them patients, people want to take the medications, work through the information so that they’re making informed consent when these are not deeply dangerous things, then I think it becomes a matter of judgment of saying, “This is reasonable.”

And I think that’s where we are with these compounds, these, uh, pharmaceuticals, uh, just as many other people are taking some of these other things. Rapamycin is a great example. Uh, rapamycin is, um, it’s a inhibitor of mTOR and it seems to promote greater longevity in most model organisms in which it’s been tested. And there are people taking it, uh, for human use, even though it’s really approved, uh, for people getting things like transplant surgery where they, they need to have some immune function modulation from it. Uh, and yet there are physicians themselves who publicly have acknowledged that they’re taking it with the hope of living longer and stronger lives.

David Ludwig
Uh, Right. But David, there’s a bit of a logical leap here. Anything that’s given off-label prescription drugs are still prescription. Uh, doctors are overseeing, they’re making judgments about risks and benefits. Wanna be clear, you are advocating a radical overturning of a regulatory system, um, that keeps a prescriber-

John Donvan
I, I think, I think, I think, David, you actually do believe that these drugs should remain under prescription. Is that correct?

David B. Allison
I think that’s very reasonable, yes. David is making an arg- claiming that I’m making an argument I didn’t make.

John Donvan
But why, why actually keep them under prescription then?

David B. Allison
Because you can get better informed consent. What you want, I mean, the libertarian argument works best when everybody has access to the same information, the information is truthful and it’s understood. The hope is that by making it prescription, you’ve got the physician and healthcare providers helping the potential recipient to make informed decisions that are truly informed by the best evidence and rationally understood.

John Donvan
Okay. We have to move along, David. Thank you for your question, but I wanna let Stuart also take a crack at it if you would like to, Stuart.

Stuart Flint
I, I think, um, Professor Ludwig has, has raised some important points there. And, and I too wanted to, I guess, ask the question around why the need for prescription as, as, as you have, uh, uh, there. And I think that’s really interesting as well, because, um, the reality is, is that, um, you know, for, for these, uh, uh, medications, uh, for surgery, you know, so what we typically describe as more complex, uh, obesities, uh, we require a multidisciplinary team, uh, that supports a patient through that journey. Now, that’s not gonna be the case if they’re gonna be available for all. And of course, we don’t know what types of support is ultimately gonna be needed for somebody who’s not living with obesity.

Um, so it kind of almost goes back to my original point again that we still don’t really know, not only whether they’re gonna be effective or safe for the population, but also what types of support and other is gonna be needed to support different parts of the population.

John Donvan
Okay, thank you very much, David. Our next question today comes from Dr. Lou Aronne. Lou, you are a professor of metabolic research at Weill Cornell Medical College, and you also direct the Comprehensive Weight Control Center. Lou, welcome to Open to Debate and please come in with your question. You know a lot about this topic.

Louis Aronne
Yes, I do. The question that I have is that, uh, you know, my, my belief from way back in the 1980s when we started looking at drug treatment of obesity, and by the way, I’ve done 70 trials of, uh, medical therapies for obesity, and only two of them have been blockbusters so far. So, you know, it’s been very difficult to figure this thing out. My, my view has been that obesity will be the new hypertension, the same way that hypertension was treated with behavioral interventions back in the 1950s. Uh, eventually once we understood, uh, blood pressure regulating mechanisms, we then started to use medication because the evidence was clear that people lived longer and healthier lives. And I believe that we’re gonna start treating people with, uh, obesity earlier and earlier to prevent the many complications that we see and also to minimize-

John Donvan
So Lou, loo- look, Lou, is, is your, what you’ve been talking about is it’s, uh, fundamentally a, a challenge to Stuart’s position about like, let’s wait and see?

Louis Aronne
I, I think we should be treating people earlier and earlier and we should be doing it now.

John Donvan
What is Stuart getting wrong so that he can respond to that?

Louis Aronne
Well, well, we have 20 years of experience with these medications for the treatment of diabetes. The first drug in this category, in the GLP-1, uh, category, was approved in 2005. So, you know, I think there’s ample safety.

John Donvan
So you’re saying, you’re saying we know enough?

Louis Aronne
I believe so.

John Donvan
Okay. I just wanna bring it back to Stuart ’cause Stuart, I’ve heard you say, “Yeah, if we know, we might not, we might know the impact on people with diabetes, we don’t know the impact on a lot of other people who might wanna use the drug.” I think that’s been your point. Um, and also as you study the psychology of obesity, I’m wondering if, if there’s a psychological aspect to this conversation that hasn’t come in yet.

Stuart Flint
You know, I think that the likelihood is that, that the products will be used, um, you know, in a, in a wider group of the population and, um, may even be used as part of the preventative actions relating to obesity amongst people, for instance, who fall into more of the overweight, uh, range, for instance, and, and so forth. I don’t think, I don’t foresee that that isn’t something that at least will be tested and maybe even will become the reality in the future. Uh, my point here is, is that as new medications, uh, are developed and we have more in the pipeline, for instance, uh, that that testing needs to be, uh, conducted before they are to be rolled out. So, uh, I probably see a a very similar future to Lou.

John Donvan
But I think, I think Lou is saying the future should be now.

Stuart Flint
Well, well, you know, the, of course, medications and products, uh, you know, uh, differ. Uh, and we need to be able to test, uh, new medications as they come forth. And that’s, you know, that is, that is the, the, the guideline that we have new medications, new products, they need to be tested for safety, for effectiveness, for, uh, economics and so forth.

David B. Allison
Lemme jump in here.

John Donvan
Even if… G- go… Yeah.

David B. Allison
I think that we, we really need to think about who’s gonna be part of this future and who’s gonna get to see it. So if we say, “Before we can lower the BMI criteria and use it for lifespan optimization, longevity promotion, prevention, we have to wait for a 20-year trial,” then we will all, not all, be gone. Many of us will be gone before we get the opportunity to even try these things. So I think at some point we have to recognize that just as with blood pressure drugs, with anti-cholesterol drugs, we keep lowering the level at which we think they’re useful. We start them earlier and we hope and believe that these can promote longer lives. And I think that’s what we can do here.

John Donvan
Lou, thank you very much for your question. I, I have to move on because we have time for only one more question, and I’m gonna welcome Dr. Jeffrey Singer, uh, to the program. Uh, Jeffrey, you are, your book is called, and it’s forthcoming. your book is called Your Body, Your Health Care. You’re a senior fellow at the Cato Institute. Uh, please join and, uh, let’s hear your question.

Jeffrey Singer
Thank you. And as you can tell from the title of my book, my views tend to align with, uh, David’s. And in fact, uh, I, I. I’m very pleased by his respect for patient autonomy, uh, informed consent, and it’s corollary, the right to self-medicate. My, my issue is that sort of comes to GLP-1s, especially with new evidence showing they may actually, uh, also be used to, to reduce cravings for illicit drugs, for tobacco, for alcohol. Um, why shouldn’t it be made over-the-counter? Uh, which also evidence has shown us that when drugs move to over-the-counter from prescription only, their price goes down considerably, and this increases access.

John Donvan
So interestingly, neither, neither of the panelists is arguing for over-the-counter access at that point, this point, but I, I wanna let each of you respond to that concept of this ultimately becoming over-the-counter. Um, Stuart, do you see a day when there would be sufficient safety proven that these things could be become available over the counter?

Stuart Flint
I, I, I’m not in a position where I would say that it couldn’t happen, but certainly it’s a long way from now in terms of where the clinical evidence is. Uh, and as alluded, you know, there are, uh, is evidence that’s coming forth that might suggest that they are useful, for instance, for people with alcohol or drug-related addiction and so on. And as that evidence is, is, comes forth and is proven, then, you know, potentially they could be used. You know, that’s not my, that, that’s certainly not my stance to suggest that they couldn’t be used in, in those instances.

Um, and the argument around autonomy, for sure, again, once they’re proven to be safe and effective, then they could be used by people across the population. It’s not in my will to say, “This group of the population should or shouldn’t use them,” if it’s been proven to be safe or that there’s a certain group of the population who, um, you know, has more right to access versus others. Uh, if they’re proven to be safe, then the autonomy, uh, point, uh, certainly can come into, in, into flow.

John Donvan
Okay. And David, same question to you because you, so far, you’ve said you think they should go prescription, but as Jeffrey points out, they could get a lot cheaper if they go over-the-counter. What would it take for you to feel more comfortable with moving to an over-the-counter regime?

David B. Allison
I’d go very much to, back to my analogy of vehicles where we require a license to drive a vehicle, which shows some knowledge of the situation. Uh, but we don’t deny people the right to drive. And, and yet for bicycles, you don’t need a license typically to ride a bicycle and because the safety issues are much lower. And so I think it’s exactly the same here. When the safety issues are, as Stuart points out, somewhat unknown, these are still somewhat new, could be s- su- uh, serious as David Ludwig pointed out, then I think we wanna make sure everyone’s truly getting informed consent and that a prescription is a way of helping to do that. Uh, you’ve gotta go to the physician and show that you’ve heard the information and understood it.

Uh, eventually, if we get to the point where we say, “It’s so mild that even, you know, if you don’t understand it, it’s not a concern,” then let it go over the counter.

John Donvan
Okay. Jeffrey, thank you very much for your question. And we are now moving on to our final round in this debate. And in the final round, each of our two debaters makes a closing statement. Uh, David, you are up first. You have the first closing remark. Uh, one more time, your case for why you believe prescription weight loss drugs should be available for all.

David B. Allison
This is about having the best lives we can. This is about the freedom to choose what for ourselves we see as the best lives. And this is about equity. I have many, many friends, some of whom have been on the questioners, uh, today, who are physician scientists who are hackers, who wanna live longer and stronger lives. They don’t wanna just treat diabetes. They want to have the best, vital, active, energized, maybe best-looking lives they can have. They wanna live long and they wanna live strong. And they are hacking with rapamycin and metformin and acarbose and drugs that clear senescent cells. And their education and their wealth and their prescription pads let them have some of that.

The wealthy can get these drugs regardless of their conditions and do in many cases. This is an issue of equity, obesity, weight concerns, hunger. The, the social discrimination against people, uh, who are not as lean as somebody might wish them to be or they might wish themselves to be, are profound. They affect different groups differently. And I think all groups should have the opportunity to benefit from these drugs that we have brought to market through good science and good research, often at the earliest stages paid for by the general public. And so I think this is a benefit that people should be entitled to pursue as long as they pursue it with fully informed knowledge of the risks.

John Donvan
Thank you very much, David. And Stuart, you get the last word in this program. Uh, one more time to make the case why prescription weight loss drugs should not be available for all, at least not yet.

Stuart Flint
Thank you. And, and my stance remains that, uh, these medications should not be available until they’ve been clinically proven to be safe and effective for different groups of the population. They’ve only been tested for people living with obesity and diabetes. And until we’re in a position where they’ve been tested across the population, uh, with people, for instance, who are not living with obesity who may fall within the healthy weight range, then, uh, my stance is they shouldn’t be, uh, available for all.
[NEW_PARAGRAPH]Uh, I like David’s point that, uh, you know, in, in relation to, for instance, a license to drive, people, uh, should know and they should have the information. They should be fully informed about the risks. And again, that’s, that’s the issue. We don’t, we’re not, we can’t fully inform people about the risks because the, the tests and the trials have not been conducted. So I totally would agree with David. We need to be able to provide people with the right information, the evidenced information, and that means we need to conduct the research and the trials to be able to do that. And then I would agree, certainly if, uh, you know, they have been proven to be safe and effective and so forth, again, I agree with David, you know, allow people to live the best life, life that they potentially can.

Uh, and if that means that these medications can support, um, you know, a be- a better life, um, whether that’s to support people who, for instance, have, um, different types of addictions, if that’s where the evidence base is going, then, then again, uh, so be it. But I think until we have that evidence, um, there remains a potential danger of us allowing them to be freely accessible by people who are not looking to, uh, lose a significant amount of weight or who are looking to lose a significant amount of weight and it might actually pose a risk to them, a risk of injury, of illness, and potentially, uh, even worse. So that is my stance. It remains that people should only be able to access these medications once it’s been proven to be safe and effective for their use.

John Donvan
Thank you, Stuart. And, and actually to you, Stuart Flint, and you, David Allison, I wanna say thanks to both of you, uh, for being willing to have the conversation. Uh, I think we learned a lot from each of you, and part of what we learned from each of you is how two professionals can disagree and do so with respect and civility. So I wanna say once again, uh, Stuart Flint and David Allison, thank you so much for joining us on Open to Debate.

David B. Allison
My thanks to you all. It’s been good fun.

Stuart Flint
Thank you. Thanks for having me.

John Donvan
And, uh, I also want to thank, uh, everybody who took part, uh, by asking questions. Uh, thank you to all of you as well. And a big thank you to you, our audience, for tuning into this episode of Open To Debate. I wanna remind you that is, we’re a nonprofit that’s working to combat, uh, extreme polarization through doing what you just saw, which was a civil debate, civil disagreement. And I want to point out that our work is made possible by listeners like you and by the Rosenkranz Foundation and by supporters of Open to Debate.

Robert Rosenkranz is our chairman. Our CEO is Clea Conner. Lia Matthow is our chief content officer. Elizabeth Kitzenberg is our chief advancement officer. Michele Debreceni is director of, uh, marketing. And this episode was produced by Jessica Glazer, Alexis Pancrazi, and Marlette Sandoval. Editorial and research by Gabriella Mayer. Andrew Lipson and Max Fulton provided production support.

The Open to Debate team also includes Gabrielle Ianacelli, Rachel Kemp, Erik Gross, Linda Lee, Mary Regas, Tom Bunting, and Vlad Virtanen. Damon Whittemore mixed this episode. Our theme music is by Alex Clement. And I’m John Donvan. We’ll see you next time on Open To Debate.