Are lower- and middle-income countries ready for the roll-out of anti-obesity medications?

The rise of non-communicable diseases (NCDs) in lower- and middle-income countries (LMICs) has been described as “the next pandemic”. It is one that is happening right now, without generating the headlines of infectious disease outbreaks such as mpox and Marburg. The lack of profile belies the seriousness of the challenge: The WHO estimates that 17 million people die from NCDs prematurely – that is, before the age of 70 – every year and that 86% of these premature deaths occur in LMICs. Most of these deaths, led by cardiovascular disease and including diabetes in the top four by mortality, are preventable and treatable with public health measures and existing off-patent medications.

Beyond the societal burden of premature deaths, morbidities associated with cardiovascular conditions and diabetes are severe, life-limiting and expensive, including blindness from retinopathy, diabetic ulcers, limb loss, stroke and chronic kidney disease. Overweight, obesity and physical inactivity sit at the heart of this rising NCD challenge as 79% of people with a body mass index (BMI) of over 30 could be located in LMICs by 2035.

In addition to public health interventions focused on lifestyle changes, effective new anti-obesity medications (AOMs) have started to be available in high-income (HICs) and some middle-income countries. This phenomenon, alongside learnings from early adoption of AOMs in HICs, raises an important question: Can these new therapies be used in LMICs to effectively fight against obesity and overweight and their associated consequences, as a complementary approach to current national public health programmes?

Two new AOMs, sold under several brand names, are currently approved for obesity: the peptides semaglutide and tirzepatide. However, IQVIA analysis suggests that over 140 potential therapeutic solutions are in discovery or have entered clinical development for the treatment of obesity. There are also at least 30 small molecule agents in the pipeline; one of which, orforglipron, could see first global approval between 2026 and 2027. Semaglutide could also lose exclusivity in some middle-income countries, expected to happen in China in 2026.

As in HICs, out-of-pocket payment for AOMs will run ahead of any healthcare system coverage, even if insurance reimbursements are a possibility in the future. Nonetheless, the predominance of private market funding does not reduce the importance of AOMs as valid public health interventions in LMICs. The coverage of these therapies by national insurance schemes, particularly when more affordable and accessible formulations become available, has the potential to reduce obesity and downstream comorbidities.

First, health systems would need to develop obesity care pathways and address access hurdles, which continue to be severe for essential medicines; and second, hype and social media profile of AOMs as “vanity drugs”, encouraging their use for weight loss in the absence of genuine overweight, comorbidities or medical supervision, could fuel a parallel market of falsified and substandard medicines, threatening the safety of millions of patients. So it is important that health systems safeguard the use of these agents, ensuring they serve their intended purpose, and that they are also employed as additional tools in the promotion of healthy diets and exercise.

There are currently over 1 billion adults with a BMI over 30, but only a tiny fraction of them have access to modern AOMs, even in HICs. Evidence from trials shows that AOMs can significantly reduce risk of cardiovascular events and the progression of obesity-linked pre-diabetes into type-2 diabetes. Similarly, positive findings in obese patients with heart failure, steatohepatitis and chronic kidney disease, including the potential slowdown of Alzheimer’s, are a clear indication that AOMs are not simply weight-reducing agents. These medicines act to lower the risk of a broad range of cardiometabolic conditions and beyond. Health systems, especially those in LMICs with rising obesity rates despite public health measures, could benefit from keeping these facts in mind. AOMs can be a very powerful preventive measure for the treatment of many diseases or, in many cases, to avoid their progression.

In terms of AOMs’ inclusion within healthcare plans in HICs, the US is leading the way, covering semaglutide for obesity on Medicare plans for population over 65 with relevant risk factors. As per IQVIA’s data, European countries have been more cautious, even with hundreds of thousands of patients paying out of pocket for prescribed AOMs in the likes of the UK, Germany and Denmark. Regardless of this trend, a playbook for healthcare system-funded coverage of AOMs is emerging, targeting the most obese patients with multiple comorbidities as a priority, and then undertaking real-world evidence studies on a range of outcomes, including socio-economic ones, to evaluate true value. The UK’s NHS established an agreement with tirzepatide’s manufacturer, Eli Lilly, to roll out the AOM Mounjaro for up to 220,000 patients in three years, starting with those with a BMI of over 40 (reduced for ethnic minorities) and three or more weight-related health conditions.

For LMICs, people with obesity paying for prescription AOMs out of pocket will undoubtedly be necessary, but will it ensure the required level of coverage, especially for the most vulnerable and underserved populations? AOMs will become more affordable as they go off patent, with semaglutide at the forefront from 2026 onwards, or possibly when small molecule oral agents are developed and approved. Yet they could still represent an unaffordable long-term medicine cost for patients enduring financial or other forms of socio-economic hardship. The experience of HICs in addressing obesity in underserved groups may be considered as points of reference to inform strategies in LMICs: Manchester’s SURMOUNT-REAL study for tirzepatide could serve as a good model.

NCDs will be the leading cause of morbidity and mortality in all continents by 2030. Preventing the escalation of obesity to cardiometabolic and other diseases should be a prime objective of any health system strategy. Again, existing measures promoting healthy diet, exercise and regulating unhealthy foods are critical, but reality shows that they are falling short. LMICs should consider adopting AOMs to diversify the tools at their disposal to support a more impactful response to obesity and associated diseases.

More importantly, this diversification could potentially reduce the impact and cost of acute conditions on severely strained health systems. As for any healthcare intervention of this nature, multisectoral efforts will be necessary to produce more affordable and accessible formulations, encourage integrated approaches that incorporate screening and treatment of NCDs in primary care settings, and provide the necessary conditions to remove access barriers, especially for those with the greatest unmet needs.