Dr Kam Lally explains why setting up a non-compliant weight loss service could have serious repercussions
Prescription weight loss treatments are becoming an increasingly common offering in aesthetic clinics. A prime driver over the past 12 months is that these services can be started and continued remotely with direct-to-your-door delivery. This ‘subscription’ service has been a way for clinics to have some income trickling in (in the same way as clinical skincare) with recurrent lockdowns hampering the traditional business model.
However, advertising for such services needs to ensure it stays on the right side of the regulations and that prescription-only medicines (POMs) are not advertised directly to the public. A recent enforcement notice from the Advertising Standards Agency (ASA) highlights the importance of this and how often the rules are being ignored.1 This may feel like a case of déjà vu for practitioners and is certainly familiar ground for the ASA in their previous dealings with non-compliant neurotoxin advertisements.2 This article will give an overview of the expanding sector in the aesthetics market and how to keep your weight loss services compliant.
PANDEMIC. Even a year ago, this would have been a word that you could use more comfortably – without an acute sense of dread and an associated daily death rate. However, we were in the midst of a different pandemic at the time – a more covert one – an obesity pandemic. In the year between 2018 and 2019, 876,000 NHS England admissions had obesity as a contributing factor – an increase of 23% on the previous year. 67% of men and 60% of women were in the overweight or obesity categories.3
Unfortunately, the recurrent lockdowns and subsequent impact on the job market across a number of sectors has led to a significant proportion of the population turning to food and alcohol for comfort.4 Combining this with a disruption in routine and a more sedentary lifestyle gives you the perfect recipe for weight gain. This has been referred to as the ‘quarantine 15’ (pounds) in a New York Times article last year,5 but going into 2021, it is surely becoming the ‘COVID-19’ (pounds). According to the World Health Organization, obesity appears to be a global issue and is only getting worse.6
But hang on a minute, you’re reading the Aesthetics journal not The Lancet – what is the relevance? When you have the perfect storm brewing for weight gain, enquiries for fat-loss therapies rise in tandem as a number of patients seek help to battle the bulge. As you may be aware, non-invasive, energy-based treatments for body contouring and peripheral fat loss have been around for a number of years. Recent advances in the science behind energy-based devices are allowing for more focused fat targeting, often combined with skin tightening and increasingly with muscle-toning abilities too.
However, over the past couple of years there has been a rise in the number of pharmacological fat-loss methods being promoted by medical and non-medical clinics alike. Specifically, POMs traditionally used in the diabetic arena have been advertised up and down the country – sometimes overtly, sometimes under the guise of a ‘not-so-subtle’ moniker.
The main focus of this article is the family of medicines known as glucagon-like peptide 1 (GLP-1) receptor agonists (RAs). They work by mimicking endogenous GLP-1 that is normally released following the consumption of food and drink. GLP-1 belongs to the incretin family of hormones and regulates glucose levels by stimulating insulin secretion, inhibiting glucagon secretion and slowing gastric emptying. This leads to a feeling of satiety sooner after eating, thus resulting in an overall calorie reduction (whilst on treatment) and associated weight loss.7
This simple overview does not take into account the numerous other extrinsic and intrinsic factors that contribute to the prevalence of obesity. One thing that is for certain is that this family of medications are here to stay, as ongoing research shows the benefits of GLP-1 RAs are widespread: from offering cardiac benefits to neuroprotection, and not just restricted to controlling blood glucose levels and losing weight.7
As alluded to in the introduction, the trigger for this article was a recent enforcement notice issued by the Committee of Advertising Practice (CAP).1 This body writes the advertising rules that are then enforced by the Advertising Standards Agency (ASA) – an independent regulator.
Prescription-only medicines or prescription-only medical treatments may not be advertised to the public
The Medicines and Healthcare Products Regulatory Agency (MHRA) can also become involved (as the statutory regulator for medicines and medical devices in the UK) ‘where a significant risk to public health has been identified from advertising to the public for unlicensed or prescription-only medicines’.8 This particular enforcement notice coincided with a relevant article by Wilding et al. in the New England Journal of Medicine.9 It summarises results from an ongoing randomised controlled trial involving newer members within this family of medicines that exhibit evidence of even better weight loss results. This led to the inevitable flurry of advertising activity via marketing email and social media posts – the vast majority (if not all) of which completely breached advertising guidelines.1
Rules and enforcement notice
The primary reason for the enforcement notice was breach of Rule 12.12 of the CAP Code that states: ‘Prescription-only medicines or prescription-only medical treatments may not be advertised to the public’.1,10 However, the enforcement notice was not just limited to this. Another reason for the notice was due to advertisements claiming that people can lose specific amounts of weight within a certain time, which breaches Rule 13.9 of the CAP code.1,11
In addition, some of the ads included testimonial claims about weight-loss which are not compatible with good medical and nutritional practice – such as losing more than 2lbs per week in an ‘overweight’ (as opposed to ‘obese’) person (CAP Code: Rule 13.10).1,11
There were also incidences where businesses were promoting weight-loss to people who do not qualify for treatment because they are not even in the overweight/obese categories!6 This clearly exploits any underlying insecurities about body image purely for financial gain and goes against social responsibility rules and ethics (see CAP Code: Rule 1.3).1,12 Finally, another problem area is promoting ‘off label’ use for a POM that has a license for a different indication.
The Enforcement Notice grace period ran out on February 12, 2021; therefore, any non-compliant advertisements on websites or social media are exposing the practitioner and their business to targeted enforcement. This can include fines, referral to the MHRA, referral to the practitioner’s relevant regulatory body and legal action.1
So, what does this mean practically and what can you do to promote your weight loss services without breaching any of the aforementioned rules?
The main thing you need to remember is that you are offering a service, therefore it is the service/consultation that can be advertised.13 The POM is one part of the service that the patient may, or may not, opt for after having a thorough consultation. The ensuing steps after that initial consultation with you may involve input from practitioners such as a dietician, psychologist, personal trainer, counsellor or physiotherapist. The journey the patient will be embarking upon may not need a POM, therefore this should not be at the forefront of any advertising or promotions. Any direct mention of drug names or brand names breaches the rules and there should not be any reference to the pharmaceutical manufacturer either.14
Even when promoting the service, realistic weight-loss parameters need to be used that comply with good medical and nutritional practice. You also should not promote targeted/regional fat loss if your service relies solely on pharmacological weight loss methods as opposed to energy-based devices.11
Appropriate imagery should go with the promotion of the service – for example, there should not be an image of a slim person next to the service advert as this would be seen as promoting the service to a cohort of people that do not need it.1,10 This also goes against the licensing guidelines for the medication – as a slim person would not fall within treatment parameters (BMI greater than or equal to 30kg/m2, or BMI greater than or equal to 27kg/m2 with at least one weight-related co-morbidity).
When promoting the service, you must avoid hinting at POMs indirectly by using suggestive emojis/GIFs/memes or images of patients carrying out treatments. This includes influencer marketing stories and posts. You can showcase the consultation and elements of the weight loss journey, but not show any POMs being administered or consumed. Also, hashtags that indirectly refer to the POM must not be used.1
A way of indirectly promoting weight loss services is by running a Disease Awareness Campaign (DAC). A DAC around the topic of obesity is ideal in the current climate and would be seen as an ethical yet effective way of promoting your services. Some key points for a compliant DAC are that it must be accurate, up-to-date, evidence-based, comprehensive, balanced, easily readable and with an identifiable source.9
Finally, we should take a step back here and think about the ethical implications of advertising POMs in this specific sector. As a doctor, I don’t want to encourage unnecessary POM use in my patients – this goes against the ‘Primum, non nocere’ or ‘First, do no harm’ part of the physician’s oath we adhere to in medicine. Also, inappropriate use could have significant implications – especially in those that are not overweight or obese. Body dysmorphic disorder is a real problem and unfortunately on the rise – particularly amongst the vulnerable adolescent group.15 Doctored images bombarding us over social media and self-proclaimed ‘experts’ offering fast-track ways to achieve ‘body perfection’ in impossible or unsafe time frames are rife. Therefore, illegal (and unethical) POM advertisements will only compound the issue further.
Setting up a weight management service needs to be done in an ethical way. Focusing on the patient journey through various aspects of the services one may offer should be the mainstay of any promotional material, rather than any particular POMs that are used along the way. Using the approach outlined in this article across all marketing platforms should keep you out of hot water and on the right side of the guidelines. Piece of cake, right?!
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