A popular, growing class of drugs for obesity and diabetes could, in an ideal world, help us see that metabolism and appetite are biological facts, not moral choices.
March 20, 2023
Dana Omari, a registered dietitian and an Instagram influencer https://www.instagram.com/igfamousbydana/ in Houston, Texas has accumulated a quarter of a million followers by documenting the blepharoplasties, breast implants, and Brazilian butt lifts of the rich and famous. Recently, she noticed that the human weathervanes of the social-media beauty standard were spinning in a new direction. The Kardashians were shrinking. Having previously appropriated styles created by Black women, they were now leaning toward a skinnier, whiter ideal. Kim dropped twenty-one pounds before the Met Gala, where she wore a dress made famous by Marilyn Monroe; Khloé, who has spoken in the past about struggling with her weight, posted fortieth-birthday photos in which she looked as slim and blond as a Barbie. All over Instagram, the wealthy and the professionally attractive were showing newly prominent clavicles and rib cages. Last spring, Omari shared with her followers the open secret behind such striking thinness: the Kardashians and others, she insisted, were likely taking semaglutide, the active ingredient in the medication Ozempic. “This is the ‘diabetic shot’ for weight loss everyone’s been talking about,” she wrote. “Really good sources have told me that Kim and Khloé allegedly started on their Ozempic journey last year.” Omari was about to start taking a version of the medication herself.
“Everyone is suddenly showing up 25 pounds lighter,” Andy Cohen, the TV producer who created the “Real Housewives” franchise, tweeted in September. “What happens when they stop taking #Ozempic?????” Celebrities have generally denied the accusation. “I get up 5 days a week at 6 am to train,” Khloé Kardashian wrote on Instagram. “Please stop with your assumptions.” Dana stifled a giggle when I asked her about such denials, which tend to be, subtly or otherwise, less than categorical. One can, and should, exercise in addition to taking GLP-1 drugs. And you can say you’re not taking Ozempic if you’re actually taking Mounjaro—a newer, similar drug, manufactured by Eli Lilly & Co., that is producing even more drastic results in clinical studies—or if you’re getting an off-brand version of the medication from a compounding pharmacy. Such pharmacies, which offer custom medications, often make drugs for people who have allergies to common ingredients, or who need commercially unavailable dosages, or who can swallow a liquid but not pills. But they are also allowed to compound drugs that are on a list kept by the F.D.A. of drugs that are in short supply, as low-dose Ozempic now is. (The shortage is not of the medication but of the devices used to inject it, which Novo Nordisk has not been able to manufacture fast enough to meet demand.) “I’m on compounded semaglutide, and I will tell you, I eat like a toddler,” Dana told her followers in January.
The ideal female body of the past decade, born through the alliance of Instagram and the Kardashian family, was as juicy and uncanny as a silicone-injected peach. Young women all over the Internet copied the shape—a sculpted waist, an enormous ass, hips that spread generously underneath a high-cut bikini—and also the face atop it, a contoured hybrid of recognizably human mannequin and sexy feline. This prototype was as technologically mediated as the era that produced it; women attained the look by injecting artificial substances, removing natural ones, and altering photographic evidence.
GLP-1 drugs effectively inject a sense of satiety, and also slow the rate at which food empties out of the stomach.Illustration by Yadi Liu
Ozempic, which is manufactured by Novo Nordisk, is part of an expanding class of drugs called GLP-1 receptor agonists, which have dramatically altered the treatment of diabetes and obesity. Ozempic is approved by the Food and Drug Administration only for the treatment of Type 2 diabetes—a condition that accounts for ninety percent of all diabetes cases—and has been available since 2017. Its name is now shorthand for the entire category of weight-loss injections. In 2021, Novo Nordisk received approval for Wegovy, which has the same active ingredient as Ozempic but comes with a higher maximum dose, as an anti-obesity drug. On a year-end earnings call in 2022, Novo Nordisk cited worldwide market growth of fifty percent, with almost forty thousand new Wegovy prescriptions being written every week.
The drugs mimic a hormone called glucagon-like peptide-1, which stimulates insulin production and suppresses the production of glucagon, which raises blood sugar. The body naturally releases GLP-1 after a meal, and the hormone travels to the brain, triggering the feeling of fullness. GLP-1 drugs effectively inject that sense of satiety, and also slow the rate at which food empties out of the stomach; patients generally report freedom from cravings and an inability to overeat without becoming ill. “I’m convinced that this basically replaced a signal my body has been missing my whole life,” a commenter in a Reddit group for people using semaglutide wrote recently. “All I can say,” a member of an online group called Lose the Fat wrote, “is that it is no wonder that skinny people think heavy people have no willpower. Their brains actually do tell them to stop eating. I had no idea.”
More than forty percent of Americans are obese, and eleven percent have been given a diagnosis of Type 2 diabetes. Both conditions involve metabolic dysfunction: Type 2 diabetes is characterized by resistance to insulin, a trait that tends to develop as a person gains fat; insulin resistance leads to high blood sugar, which increases the risk of stroke, heart disease, nerve damage, and more. Obesity is correlated with, among other things, higher rates of cancer, sleep apnea, and liver disease. For people living with these risks, the new medications may be a godsend. “These drugs are groundbreaking,” Dr. Cole Barfield, an internal medicine specialist in Nashville, told me, noting that they can spur greater weight loss and more effectively decrease blood-sugar levels than previous frontline treatments—and, unlike many other medications for these conditions, they do not put patients at risk of major cardiovascular events.
There are, however, complications. Initial side effects (diarrhea, vomiting, constipation, dizziness, nausea) can be gnarly enough to send people to the E.R. Patients can also experience hair loss, a result that—like the gaunt look that has been termed, not without Schadenfreude, “Ozempic face”—is caused by rapid weight loss rather than by the drug itself. In rare cases, patients might develop renal failure, pancreatitis, or intestinal obstruction. Also, GLP-1 drugs are expensive—often more than a thousand dollars a month out of pocket—and insurance companies frequently refuse to cover them. (Weight-loss drugs are not required to be covered by Medicaid.) Still, about a year ago, Barfield noticed an influx of patients who came in asking for Ozempic by name. “I’d guess this was probably when people started posting TikToks about the celebrities being on it,” he said.
It is possible to imagine a different universe in which the discovery of semaglutide was an unalloyed good—a powerful tool to untangle the knot of genetic tendencies, environmental forces, and behaviors that conspire to make more and more Americans gain weight. We might recognize metabolism and appetite as biological facts rather than as moral choices; rising rates of Type 2 diabetes and obesity around the globe could be reversed. In the actual universe that we inhabit, the people who most need semaglutide often struggle to get it, and its arrival seems to have prompted less a public consideration of what it means to be fat than a renewed fixation on being thin.
In the Renaissance and for centuries afterward, the Platonic ideal of the female body in the West was defined by proportionality: Rubens’s expressive fleshiness, the gentle undulations of Botticelli’s Venus. Then the Industrial Revolution produced increasingly sedentary lifestyles and easier access to food, not to mention standardized dress sizes. The diet industry roared to life: thyroid extract was packed into pills and sold under names such as Corpulin and Frank J. Kellogg’s Safe Fat Reducer; there were “reducing salons” where women could have their flesh rolled and squeezed by machines. Women’s magazines enshrined the idea that high-class whiteness could be expressed through a thin body, and articulated a horror of fat and of cultures that valued it. An essay published in Harper’s Bazaar in 1897 refers to fatness as a “crime” and a “deformity,” and argues that a fat woman “will not be a social success unless she burnt-cork herself, don beads, and then go to that burning clime where women, like pigs, are valued at so much a pound.”
People have been pushing back against fat stigma since at least the nineteen-sixties, when activists staged a “fat-in” at the Sheep Meadow in Central Park. But the desire to achieve thinness by any means necessary—amphetamines, grapefruit diets, SlimFast—remains an almost foundational tenet of female socialization. When I was a preteen, in the heroin-chic nineties, pro-anorexia Web sites proliferated on the Internet; in the early two-thousands, teen girls puked or did obsessive sit-ups or took Hydroxycut in pursuit of abs like Britney Spears’s. In the twenty-tens, even as the Kardashians ostentatiously displayed their curves, they sold Flat Tummy Co. teas—laxatives—and waist trainers. And young women now are just a tap away from a never-ending social-media parade of aspirational bodies. A Harvard study, drawing on data from the Implicit Association Test, which asks people to sort words and images into “good” and “bad” categories, found that implicit bias against fat people actually grew from 2007 to 2016, with eighty-one per cent of people exhibiting it by the end of the study. Every other implicit bias in the study—regarding race, gender, sexual orientation, age, and disability—waned during that period.
The cultural fear of fat plays a role in the negative outcomes associated with it. Doctors—about a third of whom, in one study, reported viewing their obese patients as “sloppy” and “lazy”—frequently misdiagnose, undertreat, or shame fat people, who then accumulate reasons to distrust medical care. (In one notable case, a forty-six-year-old woman went to see an obesity specialist at Georgetown University, complaining of shortness of breath; he told her she should go on a diet. It turned out that she had life-threatening blood clots.) Obesity correlates with poverty, and Black and Hispanic adults are more likely to be fat than white ones; the general attitude toward fat people allows an aversion to poor people and nonwhites to be expressed as a moral concern. The belief that fatness in itself is neither ugly nor alarming is sometimes misinterpreted, ingenuously or otherwise, as a complete disregard for the connection between health and weight gain. I recently went to a doctor’s appointment in uptown Manhattan, during which it came up in conversation that I was writing about Ozempic. The doctor put down her stethoscope and turned to me. “You know, I love Lizzo,” she said immediately. “But it’s a shame that this whole body-positivity movement has made so many people think that it’s O.K. to be obese.”
A healthy body can generally signal to the brain when it has had enough food. But that signaling system can be faulty, or get injured. “One of the most important things about obesity, and something most people don’t understand, is that, in the process of gaining weight, the neural circuitry of the brain that regulates weight is damaged,” Dr. Louis Aronne, the director of the Comprehensive Weight Control Center, at Weill Cornell Medicine, told me. (Aronne, like many other prominent practitioners of obesity medicine, has consulted on trials conducted by Novo Nordisk.) “The hypothalamus shows signs of inflammation and injury,” he went on. The prevailing theory, he explained, is that “too many calories coming in too quickly damages nerves that respond to the hormones that control body weight.” One of these hormones is leptin, which is produced in body fat, and signals to the brain that it’s time to stop eating. But, if you gain fat, the oversupply of leptin can cause your body to be desensitized to it, making your brain erroneously believe that you are starving. “Your body tries to rebalance the system by slowing down the metabolism and increasing appetite,” Aronne said. After a person has gained enough weight to enter this cycle of metabolic misdirection, it becomes nearly impossible to lose that weight and keep it off long-term simply through diet and exercise. (About five percent of people manage to do it.) A well-known study followed contestants on “The Biggest Loser,” the weight-loss-competition show, and found that the contestants’ metabolisms slowed so drastically after their weight loss that nearly all of them regained what they’d lost. One contestant, who’d dropped an astonishing two hundred and thirty-nine pounds, soon regained a hundred and then began gaining weight whenever he ate more than eight hundred calories less than the average amount recommended for a man his size.
Eli Lilly and Novo Nordisk together have at least twelve more obesity medications in development. Novo Nordisk reportedly spent about a hundred million dollars advertising Ozempic last year, and the two companies are spending roughly ten million dollars annually on lobbying. A primary focus of that lobbying is the proposed Treat and Reduce Obesity Act, which has been introduced in congressional sessions annually since 2012, and which would require Medicare to cover, among other treatments, chronic-weight-management drugs. Anticipating the passage of this bill within the next few years, Morgan Stanley has forecast that U.S. revenue from such drugs will increase four hundredfold by the end of the decade. Obesity looks “set to become the next blockbuster pharma category,” it declared, in a report last year, which also predicted that social media and word of mouth will create an “exponential virtuous cycle” around the new medications: a quarter of people with obesity will seek treatment from physicians, up from the current seven percent, and more than half of those who do will begin taking medicine. In March, WeightWatchers acquired the telehealth weight-loss company Sequence, which specializes in prescribing GLP-1 drugs.
I had been wondering, I told Aronne, about the extent to which the excitement around this new class of drugs took the broader status quo more or less for granted. Many obesity-related health problems are worsened by circumstances that could be helped through policy—by raising the minimum wage high enough for people to afford fresh produce and high-quality protein, investing in housing and community spaces that are conducive to recreation, ending the billions of dollars in farm subsidies that go to junk-food additives, such as high-fructose corn syrup. “These things would work to prevent obesity, not treat it,” Aronne said. “It would be like trying to treat lung cancer through a smoking-cessation program.” This was the point I was trying to make—that we have an individual solution, but we need collective ones, too.
Omari, the Instagram-famous dietitian, is now off her compounded semaglutide, which she’d taken to shed some pandemic pounds. She was optimistic that she’d be able to maintain her weight, as she’d generally been able to do before. But, as I kept reminding Ozempic-curious friends, these medications were designed for chronic conditions, obesity, and diabetes. For people who are dealing with those conditions, Ozempic appears to create a path toward a healthy relationship to food. For those who aren’t, it might function more like an injectable eating disorder. As the side effects make clear, it’s not a casual thing to drastically alter your body’s metabolic process, and there is no large-scale data about the safety of these drugs when taken by people who are mainly interested in treating another chronic condition, the desire to be thin.
Once Ozempic is off the shortage list, compounding pharmacies will no longer be allowed to sell semaglutide, but that doesn’t necessarily mean they’ll stop: the pharmacy in Clearwater that supplied my stash told me that they’d sold semaglutide before the shortage and would continue to do so after it ended. Jonathan Kaplan, who oversees the weight-loss program at Pacific Heights Plastic Surgery, in San Francisco, told me that he saw a “glimmer of hope” in tirzepatide, the active ingredient in Mounjaro: that drug is on the shortage list, too, and compounding pharmacies were already gearing up to sell it. In the meantime, Pacific Heights, which prescribes compounded semaglutide to patients who meet the medical criteria, and also provides blood work monitoring and life-style coaching, has warned the members of its mailing list that compounded semaglutide may soon become unavailable. “You may want to join our program now so that we can reserve a 6-month supply of the medication for you,” the clinic added.
Kaplan, a plastic surgeon, is better known on TikTok as @RealDrBae—in his videos, he wears navy scrubs monogrammed “dr bae” and talks to the camera as though it’s his partner in an absorbing conversation at an airport bar. He believes that more people—a lot more people—are going to start taking GLP-1 drugs soon. He didn’t have in mind thin people who want to be thinner, he added; he was thinking about fat people who had been struggling with discomfort, with inconvenience, with social pressure all their lives, who might have lately felt encouraged to try to accept their heavier weight. He predicted that the Ozempic era would put an end to all that. “They’re no longer going to accept that they should just be happy with the body they have,” he said.
♦Published in the print edition of the March 27, 2023, issue, with the headline “The Ozempic Era.”
Read the original story in it’s entirety: https://www.newyorker.com/magazine/2023/03/27/will-the-ozempic-era-change-how-we-think-about-being-fat-and-being-thin