“Marketing works in a subtle, psychological way,” explains Dr Alice Fabbri, postdoctoral research fellow in the School of Pharmacy at Sydney University’s Charles Perkins Centre, and expert on corporate influence on health. Large pharmaceutical companies, she says, only spend money for one reason: “if there’s a return on investment”.

If Novo Nordisk is to fulfil the potential of its anti-obesity drug Saxenda, it needs more doctors to have a new understanding of how obesity really works. And for them to prescribe — again and again.

Novo Nordisk’s influence runs deep in the tight-knit world of obesity specialists. Inq’s investigation reveals a network of relationships in Australia that the company has nurtured.

How? By supplying financial support for professional research, conferences, and education for doctors. And by stumping up money to help the leading not-for-profit professional groups, Obesity Australia and the Australia New Zealand Obesity Society (ANZOS), advance their cause.

Drawing on data from a declarations register run by the pharmaceutical industry body, Medicines Australia, Crikey‘s Inq team has pieced together how the money flows to those working in obesity.

According to the register, Novo Nordisk has spent $3.2 million over three years on events, speaker fees and for experts to sit on the company’s medical advisory boards. The company’s declaration shows 1300 separate payments to Australian GPs, nurses, and specialists over three years, with recurring payments to a handful of prominent specialists.

In six months last year, the company sponsored 31 educational events for GPs, nurses and specialists. Cost? A shade under $500,000.

It’s given close to a quarter of a million dollars to ANZOS over three years, including just on $80,000 for the society’s annual scientific meeting at the Melbourne Convention and Exhibition Centre. Here the cream of Australia’s obesity specialists were able to rub shoulders with rock-star international experts with Novo Nordisk links, flown in from the USA and Europe.

And yet these declarations tell only part of the story. Under a code of conduct administered by Medicines Australia, companies don’t have to declare spending on food and drinks up to a cap of $120 per meal per person. Nor does a company need to declare how much it spends on research grants to individuals.

University of Sydney Associate Professor Barbara Mintzes, who specialises in pharmaceutical policy and advertising, points to severe limitations in the level of detail reported. “There’s less information provided on what the funding is for, and whether it’s linked to a specific drug or set of drugs,” she says.

One study Mintzes has co-authored found that food and drink equated to almost a third of all costs.

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“Some of the money for sponsored events is no longer publicly available because there are a lot of events where the only funding provided is food and drink,” she said.

Fabbri notes that the money won’t be spent in vain. She has spent years researching corporate influence on the agenda of academic and medical researchers. As a medical doctor with a specialisation in public health, she was drawn to the topic as a student after attending a conference on conflict of interest.

“No one in my medical curriculum had taught me how to deal with pharma promotion … no one had ever taught me to question it. These are profit making multinationals, not charities. They’re only going to spend money if there’s a return on investment,” she said. “As humans, we’re prone to reciprocate a gift.”

And it doesn’t need to be an expensive gift, either. A 2016 study of US doctors showed that even a single $20 meal paid by an industry representative led to increased prescription rates of a brand-name medication.

Novo Nordisk has been able to draw on its network of support when it matters. Gaining approval for its obesity drug from the Therapeutic Goods Administration (TGA) in 2016 is a case in point.

The TGA’s report on its decision revealed that Novo Nordisk had provided supporting submissions from “two Australian experts in the management of obesity” who were also members of the company’s advisory board. The TGA referred to this as an “obvious conflict of interest”, which would be taken into account in weighing the decision to approve. The TGA noted, too, that the company had included the support of the Australian and New Zealand Obesity Society and the Australian Diabetes Society, both of which argued for a drug as part of the mix to treat obesity. (Inq is not suggesting their expert views were influenced by funding from the pharmaceutical company.)

In a statement, the company told Inq:

Novo Nordisk partners with researchers, professional associations, practitioners and other groups involved in the fight against the obesity epidemic. We do so because we believe it will take a united, collaborative and multi-factorial approach to addressing the obesity problem.

As an innovative medicines company, we have a responsibility to use our clinical expertise and available resources to partner with, and empower, the broader healthcare community to tackle this significant challenge.

All partnerships are undertaken in full observance of the Medicines Australia Code of Conduct, TGA regulations and all other regulatory obligations. In the case of healthcare professionals, Novo Nordisk Oceania is compliant with the Medicines Australia Code of Conduct.

Dr Gary Kilov.

In Inq’s analysis of Medicines Australia data, Tasmanian GP Dr Gary Kilov emerges as a frequent recipient of Novo Nordisk funds for services provided. Kilov had been paid fees of $36,663 over 30 months. His travel and accommodation costs, also picked up by Novo Nordisk, nearly matched his fees, costing just over $34,000.

Apart from running his practice in Launceston, Kilov is the founder of the Royal Australian College of General Practitioners’ special interest group on diabetes, a disease that has been core to Novo Nordisk’s business. He has also co-authored a paper — funded by Novo Nordisk — which suggests GPs consider prescribing anti-obesity medications, such as Novo Nordisk’s Saxenda “to both assist with weight loss or to prevent further weight regain”.

In a 2017 research article published in the World Obesity Federation’s Obesity Review journal, Kilov presented an impassioned argument for medical professionals to accept obesity as a disease. The paper urged doctors to embrace chronic disease models of care, concluding that recognising obesity as a disease amounted to “a moral imperative”.

It’s standard practice for academics to declare conflicts of interest at the end of research papers. Kilov’s statement offered a glimpse into how central a role Novo Nordisk plays. It reported that the pharmaceutical company had paid Dr Kilov fees “outside the work”.  The company had also paid for specialists from a medical PR company to provide writing assistance. Finally, Novo Nordisk had been given the opportunity to review his manuscript to check for “scientific accuracy”.

Kilov’s aware of how bad that can look. He takes Inq’s question on whether or not he has a conflict of interest and reframes it: “If I work with pharma companies, which I do, you could either say that I am absolutely tainted ..or you could say I am scrupulously fair because I work with all of them. “I would very much like to think I am not doing this for the pharma company, I am doing this for my patient.”

“Pharma companies are in the business of selling pharmaceuticals and I don’t think we should attach any moral context to that. They are business people and we should not necessarily shy away from the fact that a driver is to make profit. So we understand that’s their raison d’être if you like and hopefully in their existence they also do good for the community.”

Kilov has been a GP for 30 years and now works exclusively in diabetes and obesity. His patients include tough cases referred by other doctors. Many of those sitting in Kilov’s waiting room struggle to get out of a chair.

“If I could achieve our goals for my patients without medication I would absolutely be delighted to do that. But the reality is if we look at the message we’ve been passing on for the last half century about moving more and eating less, I ask you: how well have we done? How did that go for us? It’s a catastrophe.

“So I don’t have a problem using pharmacotherapy to assist those achieving their goals. My motives in using those medications are very different to the motive I would think of the pharma companies selling them.”

But couldn’t Kilov prescribe as he wishes without also being paid by Novo Nordisk? “Yes I could stop providing peer-to-peer education and I could restrict it to organisations with whom there’s no connection with a particular drug. You’re quite right.”

“But,” he says, “much of the education in Australia is provided by pharma companies, [as is] much of the funding. So there’d be a lot of that that would disappear.”

Kilov is driven by a conviction that obesity is “unquestionably” a disease. He believes doctors have a moral duty to help patients in all ways possible. How, though, does he defend the arrangement where Novo Nordisk pays for a medical writer to “assist” with his articles but can also check for “scientific accuracy”, as the declaration puts it? Kilov maintains the writer’s brief was to help with the formalities of referencing and that he would have “bailed” had there been any changes. But the process was far from watertight.

“I guess the medical writer was obliged to run it by them [Novo Nordisk],” he said. “And as long as they didn’t change the article I was happy with that.”

“If I wanted their support then I had to accede to that but conversely if they wanted anything in the article changed then I would step away from that.”

“Unfortunately,” he said, “it’s the reality on the ground.”