By now, you may have heard about Wegovy, the first weight loss medication approved by the FDA since 2014. According to outlets who’ve gobbled this news up with unsurprising zeal, Wegovy (semaglutide) is being discussed as a “game changer” for the field of “obesity medicine”. A repurposed diabetes medication, Wegovy works by triggering insulin production and slowing the rate at which food leaves your stomach, creating a sense of fullness and satiety. Wegovy resulted in an average weight loss of 15% of participants’ initial weights in a recent study, more than double the effectiveness of other available weight loss drugs.
For those who have been struggling to lose weight, this feels like amazing news. One study participant quoted in many articles about Wegovy says that she dropped 65 pounds over the course of 16 months after a lifetime of weight cycling. Once the study was over, she regained half of that weight back, but is considering going back on Wegovy once it’s available. With these promised results, and an estimated price of $1,300 per prescription, the manufacturer Novo Nordisk stands to make a killing off Wegovy while bringing relief to people who have been discouraged in their weight loss efforts. It is a win-win situation if there ever was one.
And yet, like many of the stories we’re told, this one is incomplete.
I started with the study published in the prestigious New England Journal of Medicine that’s been cited in many of the news articles I’ve seen this week. If you scroll all the way down--past where NEJM reminds us that free, accessible science ends at 2 articles a month--you will see the words “Supported by Novo Nordisk” in a serif font. It is followed by a block of text that describes how each author has received money from pharmaceutical companies, like Novo Nordisk, Eli Lilly, and AstraZeneca, as well as weight loss companies, like WW International (Weight Watchers’ weird rebranding). One author, Niels Zeuthen, is a stock-owning employee at Novo Nordisk. (EDIT: Three authors, Marie T.D. Tran, Salvatore Calanna and Niels Zeuthen are Novo Nordisk employees; both Zeuthen and Calanna ALSO own stock.)
Financial disclosures like these are standard procedure, but that doesn’t make them any less jarring, nor does it make it any less infuriating to see that these companies don’t just bankroll the work of these individual authors, but they often do so through grants to their respective universities. Advisory board fees from Novo Nordisk and WW International were paid to the University of Pennsylvania for Dr. Thomas Wadden, former director for the School of Medicine’s Center for Weight and Eating Disorders. Another author, Dr. Ildiko Lingvay, had various forms of support paid to UT Southwestern from Merck, Mylan Pharmaceuticals, Pfizer, and Novo Nordisk. Under this block of text, the authors thank Lisa von Huth Smith, another Novo Nordisk employee, for “data representation of participant-reported outcomes and critical review of an earlier draft of the manuscript”, as well as a medical writing and editorial assistant who was funded through the generosity of, you guessed it, Novo Nordisk. It takes a village, indeed.
While prestigious peer reviewed journals are easy to please when it comes to things like conflicts of interest, we’d be foolish to let them set the tone for what is ethical. I have learned to be much less preoccupied with whether or not a medication works (which is what journal editors seem to care about) than I am with details like where people are getting their funding from and how likely it is they’d sell out their own mother for “advisory board fees” to their institution. And, from what I could tell, Dr. Robert Kushner ranked pretty high on the likely scale.
For those of you not super familiar with the politics of authorship order on papers like these, there is usually a good chance that the guy with the most clout or the one who owns/runs the lab that did the research will list his name last. First or second authorship comes with its own clout, but after a certain point in your career, it’s customary to take the backseat, so to speak. Dr. Kushner is clearly in this stage of his career. A full professor of medicine and medical education at the Northwestern University Feinberg School of Medicine, he is one of those physicians, I think, that could probably fill a NASCAR jumpsuit with sponsorship patches.
The Centers for Medicare & Medicaid Services’ Open Payments website has data on payments made by drug and medical device companies to physicians and teaching hospitals from August 2013 to December 2019. When I searched for Dr. Kushner’s profile, I found that he received 60 general payments totaling $125,005.06 and 4 associated research funding payments totaling $16,878.16 in 2019 alone.
According to the website, general payments are payments not associated with a research study. Things like consulting fees, covered travel and lodging, food and beverage, education (such as continuing education required to stay licensed), and “services other than consulting”, like speaking engagements, are covered by general payments. Research and associated research payments are both, of course, for research studies, but associated research payments are specifically for studies where the physician is named as a principal investigator (the person in charge). In the span of 6 years, Dr. Kushner received $448,239.47 in general payments and $150,980.14 in associated research funding from various pharmaceutical companies; almost $400,000 of those general payments came from Novo Nordisk.
This is the kind of conflict of interest that a disclosure does nothing for. Researchers have enough trouble keeping their internal biases--the ones that have nothing to do with people throwing money at them--from corrupting the work we do. Some of us try, but there is no escaping the way we are fused to the work we produce. And then there’s those of us who don’t only forgo this effort, but who lean in to the influence of those who benefit from the status quo.
Dr. Kushner is far from the only one. Other articles mentioned Dr. Harold Bays, the medical director of the Louisville Metabolic and Atherosclerosis Research Center as well as the chief science officer of the Obesity Medicine Association, as someone who helped run studies for Wegovy. According to the Open Payments website, Dr. Bays received $816,301.95 in general payments from pharmaceutical and/or medical device companies, as well as $7,034,903.42 in associated research funds between 2013 and 2019. Novo Nordisk actually awarded $953,837 of those associated research funds and was the company that gave him the second highest amount of such funds (first place honors went to Pfizer Inc. with over $1.4 million in payments). However, Novo Nordisk, unlike Dr. Kushner, is not his main bag--at least where general funds are concerned. “Novo Nordisk AS” is the source he received the 16th highest amount of general payments from, totalling just 8,647.01. There is another source listed as Novo Nordisk Inc., which also sent him 4,998.58 in general payments (the 20th highest amount). On the other hand, Sanofi-Aventis, the company that gave him the most general payments in this six year span, sent Bays a total of $144,919.47.
While looking Dr. Bays up online, I realized that the Obesity Medicine Association, of which he is a trustee in addition to chief science officer, was coming up over and over again as proponents for Wegovy in the articles about its FDA approval. In my curiosity about the rest of its trustees, I looked up each of the board members on the Open Payments website as well. Here is some of what I found in that 6-year data:
- President Craig Primack, “co-director and co-founder of the Scottsdale Weight Loss Center in Scottsdale, AZ” received 49,547.73 from Novo Nordisk and 213,639.11 in general payments from various pharmaceutical companies in total.
- President Elect Ethan Lazarus, “a Diplomate of the American Board of Obesity Medicine, board-certified by the American Board of Family Medicine, and a Fellow of the Obesity Medicine Association”, received $258,730.34 from Novo Nordisk and 372,270.54 in general payments in total. He was also part of the original council that helped get ob*sity recognized as a disease by the AMA.
- Former President Wendy Scinta, “Clinical Assistant Professor of Family Medicine at SUNY Upstate, Diplomate of the American Board of Family Physicians and the American Board of Obesity Medicine”, received 137,760.33 in general funds from Novo Nordisk and 164,441.43 in total general payments.
- Vice President Angela Fitch received 32,725.75 from Novo Nordisk and 40,291.27 in general payments in total from 2014 to 2019.
- Trustee Larry Richardson, former “president, chairman of the board, fellow, and master fellow” for the Obesity Medicine Association, received $87,114.74 from Novo Nordisk and 97,902.74 in general payments from 2015 to 2019.
Like I said: This is the kind of conflict of interest that a disclosure does nothing for.
Of course, the issue of buying researchers by the dozen is not the main problem. It’s horrible and corrupt, but it is, undoubtedly, not the worst part of corporations acting with impunity to reach ever-higher levels of capitalistic achievement. When I say that the current narrative on Wegovy isn’t the full story, I’m not just talking about how screwed up research is. I’m also talking about the ease with which we forget that we have done this before.
I wish I could say that the diet industry has a squeegee that it deploys to wipe the slate clean every couple years, but that doesn’t fully explain it. While I believe the diet industry uses its massive cache of resources to force the public to digest its bullshit on an unending basis, I also know that they make use of the way we choose to forget. We choose to forget how the mountain of products we’ve tried to shrink ourselves with failed us not too long ago. No matter how much progress I think I’ve made with my own self image, whenever I hear about something, like Wegovy, it feels like someone’s jabbed me in the stomach. It’s small and it never lasts, but by the time it’s gone I almost miss it. For others, I can imagine the sensation of being hit by a train, of being overcome by lust while writhing in pain.
The diet industry, including the manufacturers of weight loss drugs, knows about these tendencies too damn well. And it makes use of our selective memory to make way for a new shiny story that can make everyone, but especially them, happy.
Well. Here is a story I just remembered:
Victoza is another GLP-1, like Wegovy, sold for treatment of diabetes. It’s active drug is liraglutide, which is extremely similar to semaglutide, the active ingredient in Wegovy. Victoza is manufactured by, yes, Novo Nordisk, which rebranded it as Saxenda in the same way it rebranded Ozempic into Wegovy. Wegovy is Ozempic just at a higher dosage. Saxenda is Victoza just at a higher dosage. Consider it the earlier version of Wegovy for simplicity’s sake.
In 2017, Novo Nordisk was ordered to pay $58.65 million to the federal government and state Medicaid programs for misleading physicians about the potential risk for developing medullary thyroid carcinoma (MTC), a rare form of cancer, while taking Victoza. When the medication was approved in 2010, the FDA required Novo Nordisk to ensure that the potential risk of developing MTC was communicated clearly to physicians. Seven whistleblowers came forward alleging that some Novo Nordisk sales representatives downplayed the significance of the FDA’s requirement for disclosure, saying it was unimportant or in error.
According to the government’s complaint, Novo Nordisk actually provided the sales team with a training specifically intended for them to learn how to assuage any concerns about the FDA’s disclosure requirement during conversations with physicians. Following the training, sales representatives used tactics like claiming “physicians should not be concerned about MTC because it is easy to treat if a patient does get it” and stating that “the risk of MTC associated with Victoza is only applicable to rats and mice.” In 2011, Novo Nordisk was required to conduct surveys with doctors to measure their awareness of the risks of MTC associated with Victoza, which revealed that only about half of primary care physicians were aware that Victoza had a boxed warning (the most serious warning given by the FDA, which Saxenda also has) and awareness was even lower among endocrinologists. Novo Nordisk was then required to draft a letter to primary care physicians properly informing them of the risks, which the FDA worked with them on. But Novo Nordisk then directed its salespeople to pair the letters with a verbal message to physicians “intended to mislead them as to the purpose of the letter.” Even a recorded voicemail from Novo Nordisk’s Vice President of Marketing for Victoza was sent to the sales team, instructing them to “provide context”, “qualify with them that there are no new safety concerns”, and “transition to the promotional messaging”, ensuring that physicians were not aware of the risks of Victoza that the FDA had intended on being communicated through the letters. That year (2011), Victoza prescriptions generated more than $1 billion in sales.
In the aftermath of the 2017 settlement, Novo Nordisk continues to deny any wrongdoing. Litigation around Victoza continues due to possible risks of pancreatic cancer. Victoza continues to be sold in the US and UK.
The world of pharmaceuticals is a particularly torrid one. It is buoyed, first and foremost, by incompetent regulatory bodies that view the life-threatening antics of pharmaceutical corporations with the same tired disappointment a parent shows to their kid’s messy room. There are the pharmaceutical companies themselves, who need no introduction. And then there’s the insurance companies, who insure their own longevity by regularly refusing to cover services for the most vulnerable, followed by physicians who double as secondary salespeople by way of their prescription pads. And then, a few spaces down on the list, there are the ordinary, usually sick, people who need medication for many different reasons--all worthy of treatment. The thing about weight loss pharmaceuticals, though, is that fat people are not sick. We are not ailing by way of our fatness. We are just fat. And yet there is an entire industry dedicated to the pathologization of our bodies that is, at this very moment, rejoicing over this newest ode to our destruction that really could put our lives at risk because that is a possibility when you are increasing the dosage of a substance associated with serious adverse effects in much smaller doses.
I don’t write this, at least not intentionally, to discourage anyone from seeking out this medication. I would be lying if I said I didn’t care whether or not people took Wegovy, but I am not the arbiter of other people’s bodies. And fat people may not be sick, but, fuck, we hurt. I know I do. The weight of unwelcome is sometimes unbearable. So I would never begrudge someone for trying to find solace by hacking away at themselves. What I absolutely do begrudge is the notion that this--a pill they’d rather I choke on--will make this world safer for us. It will not. Taking a pill will not fix all of this shit, the shit that compels me to stay up all night hunched over a laptop while I sit on the floor in my underwear because my air conditioning is busted typing in the names of shitty MDs on a small laptop that I hate.
Anyone claiming the contrary is peddling an incomplete story.
If you want to learn more about these kinds of conflicts of interests in the world of pharmaceutical research, I recommend going to websites like OpenPaymentsData.CMS.gov and drugwatch.com, which are on a mission to make this incredibly opaque world more transparent for the safety of consumers.