GLP-1 receptor agonists for obesity: eligibility across 99 countries

Obesity is a complex, multifactorial condition defined by excessive adiposity and associated health risks.¹ The rising prevalence of obesity contributes to the increasing global burden of obesity-related diseases, such as type 2 diabetes and cardiovascular diseases, placing immense strain on health-care systems and economies worldwide. Behavioural interventions, such as diet and exercise, have long been the foundation of obesity management, yet many individuals face challenges in achieving and maintaining substantial long-term weight loss through these approaches alone, especially in current obesogenic environments.²

GLP-1 receptor agonists, including combination formulations with glucose-dependent insulinotropic polypeptide, have emerged as an effective therapeutic class for management of obesity and its complications.^3,4 Governments and international agencies, such as WHO, are creating guidelines and exploring policies and programmes to integrate the use of obesity management medicines, such as GLP-1 receptor agonists, into routine care for weight management and cardiometabolic risk reduction in individuals who are at high risk.⁵ Understanding the potential demand and socioeconomic implications of GLP-1 receptor agonists is important for the effective design of such policies and programmes. Thus, we aimed to estimate and characterise the adult population eligible for GLP-1 receptor agonists for weight management using nationally representative health surveys and key inclusion criteria from trials to guide such policies.

We analysed pooled, individual participant data from nationally representative, cross-sectional household health surveys conducted in 99 countries between 2008 and 2021 (appendix pp 2–67). Our sample comprised non-pregnant individuals aged 25–64 years with an available diabetes biomarker, blood pressure measurement, and BMI measurement, as well as complete data on hypertension and diabetes diagnoses (appendix pp 69–75). Eligibility for GLP-1 receptor agonists was determined by applying the inclusion criteria from key randomised clinical trials.^3,4 Individuals were defined as eligible for GLP-1 receptor agonists for weight management if they had a BMI of 30 kg/m² or more or a BMI of 27 kg/m² or more with hypertension or diabetes, or both—two common weight-related comorbidities. Hypertension was defined based on measured blood pressure and diabetes was defined based on glycaemic markers (HbA_1c and plasma glucose). We did not consider other obesity-related comorbidities, such as obstructive sleep apnoea or cardiovascular disease, because data were not consistently available across surveys. For countries in the south, east, and southeast Asian region, we adjusted the eligibility to a BMI of 28 kg/m² or more or a BMI of 24 kg/m² or more with hypertension or diabetes, or both, in line with regionally based clinical trials.⁶ All statistical analyses included sampling weights that we rescaled in proportion to the countries’ population sizes. This study was deemed exempt from regulation by the institutional review board at the University of Michigan (Ann Arbor, MI, USA; HUM00201307).

The overall pooled sample included data from 810 635 individuals from 99 countries. According to World Bank country-income group, 15 surveys were conducted in low-income countries, 34 in lower-middle-income countries, 30 in upper-middle-income countries, and 20 in high-income countries. All but 27 surveys were WHO STEPS surveys. The median response rate was 87%. The mean age of respondents was 38 years (SD 9·7), and 617 915 (48·9%) of respondents were women (appendix pp 76–78).

An estimated 27·0% (95% CI 26·2–27·8) of the total pooled sample were eligible to receive a GLP-1 receptor agonist. Incorporating age-stratified UN 2020 population size estimates, this corresponds to approximately 799·0 million individuals (appendix p 100). By country-income group, eligibility was 11·7% (95% CI 10·9–12·5) in low-income countries, 25·2% (23·6–26·8) in lower-middle-income countries, 26·2% (25·0–27·4) in upper-middle-income countries, and 41·8% (40·5–43·2) in high-income countries (figure). 34·6% (33·7–35·6) were eligible due to the presence of hypertension or diabetes, or both, for individuals with a BMI of 27 kg/m² or more (or BMI ≥24 kg/m² in Asia; appendix pp 101–103, 107). Eligibility for GLP-1 receptor agonists for weight management varied substantially across world regions. The highest eligibility was observed in Europe and North America (42·8%, 95% CI 41·4–44·2) and the Pacific Islands (41·0%, 39·0–43·1; figure). In south, east, and southeast Asia, although 23·1% were eligible for GLP-1 receptor agonists, this region accounted for the largest absolute number of eligible individuals (appendix p 100).

Figure: GLP-1 receptor agonist eligibility by country-level and individual-level characteristics.

All analyses included sampling weights that we rescaled by the size of each country’s 2020 population aged 25–64 years, using the 2024 UN Population Prospects. Country-income group refers to the World Bank per capita country-income categories in the year each survey was conducted. World regions are adapted from the Non-communicable diseases Risk Factor Collaboration classification. Education data was unavailable in the survey from Tokelau. Income data was unavailable in the surveys from Bangladesh, Barbados, Belarus, Burkina Faso, Costa Rica, Czech Republic, El Salvador, England, Iraq, Libya, Malawi, Malta, Nepal, Nigeria, Pakistan, Qatar, Spain, Tokelau, Turkmenistan, the USA, Venezuela, and Wallis and Futuna.

Women were more likely to be eligible (28·5%, 95% CI 27·6–29·5) than men (25·5%, 95% CI 24·6–26·4). Eligibility increased with age, ranging from 17·9% (17·0–18·8) among individuals aged 25–34 years to 38·3% (36·8–39·7) among individuals aged 54–64 years (figure). In the overall sample, GLP-1 receptor agonist eligibility was higher among households with higher income. When stratified by country-income group, eligibility increased with household income in low-income and lower-middle-income countries. In contrast, in high-income countries, eligibility was highest among households in the lowest income quintiles (appendix p 106).

A previous study reported that 129·2 million individuals in the USA are eligible for semaglutide for weight management.⁷ Building on this finding, to our knowledge, we provide the most extensive global estimates of GLP-1 receptor agonist eligibility for obesity to date, showing that a substantial population across all economic strata worldwide would also qualify for GLP-1 receptor agonists. Currently, only a few high-income countries are likely to afford coverage for GLP-1 receptor agonists for obesity management, and the allocation criteria differ considerably between countries.⁸ Data on the availability and use of GLP-1 receptor agonists for weight management in low-income and middle-income countries remain scarce.

Given the high levels of eligibility and the substantial costs associated with GLP-1 receptor agonists, their widespread implementation is unlikely to be feasible in many health systems at this time. Currently, the short-term and long-term budget effects of implementing GLP-1 receptor agonists for obesity treatment are unknown. Thus, the key implementation challenge to use these medications lies in the ability of individual health systems to integrate considerations of cost, need, potential benefit, and the underlying infrastructure to support rational, high-quality, and sustainable obesity care.⁸ Optimal implementation will require evidence-based, context-specific approaches. Our study provides the initial foundation to inform such policy decisions. Although our estimates show overall eligibility at the national level, countries might also want to identify patient subpopulations that could benefit most from GLP-1 receptor agonists, such as those with higher BMIs or multiple comorbidities. Moreover, the distribution of eligibility might have broader implications for how systems of obesity care should be designed and implemented. For instance, evidence suggests that patients with lower incomes, less health literacy, or access to fewer health resources who receive GLP-1 receptor agonists might require additional support for adherence.⁹

Lastly, as these medications are introduced at a larger scale, health systems must be prepared to monitor and mitigate potential harms, including adverse effects and off-label use, and to support long-term adherence when needed. GLP-1 receptor agonists may not be preferred for many people, including those who could potentially benefit from them. Addressing the global rise in obesity requires a more comprehensive, multifaceted approach that integrates medical treatments with sustainable strategies, such as multilevel agricultural and food policies related to production, procurement, pricing, marketing, and sales, as well as obesity prevention policies.

This study has several limitations. First, we did not account for all weight-related comorbidities for which GLP-1 receptor agonists could be indicated; however, diabetes and hypertension are common and likely encompass the greatest proportions of those eligible.⁷ Second, we did not exclude individuals on dialysis, those with previous bariatric surgery, or those with contraindications to GLP-1 receptor agonists, such as medullary thyroid carcinoma and multiple endocrine neoplasia syndrome type 2, which are rare. This overestimation of eligibility is likely offset by the underestimation resulting from the restricted number of obesity-related comorbidities considered. Third, the BMI adjustment for Asian populations involved assumptions regarding lower BMI thresholds, which might not fully reflect the diversity of health risks within Asia as well as various pre-existing BMI thresholds in select countries. Fourth, the surveys were conducted in different years, which might introduce temporal variability in obesity prevalence; however, as obesity prevalence has been steadily increasing over time, our estimates are unlikely to overestimate current eligibility.¹ Fifth, our results are not representative of all countries worldwide, although our dataset of surveys from 99 countries is, to our knowledge, the most comprehensive available empirical evidence for global comparison. Sixth, data were not harmonised across differing diagnostic criteria. Seventh, the population estimates did not account for pregnant women. Finally, our data did not permit us to distinguish between type 1 and type 2 diabetes, although over 95% of patients with diabetes globally have type 2 diabetes.¹⁰

In conclusion, more than one in four adults in the study population qualify for GLP-1 receptor agonists for weight management, with almost four-fifths of those eligible residing in low-income and middle-income countries. The scale of potential eligibility for GLP-1 receptor agonists, combined with their high costs, demands strategic, tailored policies and programmes to integrate GLP-1 receptor agonists in routine care that are based on clinical priority, cost-effectiveness, and health-care delivery capacity.