December 1, 2023
(Sol Cotti for The Washington Post)

“Well, if I gave it to you, you’d be the thinnest person I’ve ever prescribed it for.”

Thinnest was not a word I was accustomed to hearing in a sentence about me. I wasn’t fat, exactly, but I was awfully close — at 5 feet and 152 pounds, my body mass index was 29.7, just shy of the 30 that is considered obese.

More to the point, when I emailed my doctor on that day in October 2021, I was miserable. My clothes didn’t fit. Looking at myself in photos — on the unfortunate occasions when I was caught on camera — was painful. There were more than a few “fat pig” comments from readers, and while I pretended to shrug them off, those words hurt. The “slug” for this essay — what it’s called in The Post’s internal system — is “fat columnist,” but that suggests a level of breezy self-acceptance that I never actually attained.

I had been a skinny child. But Mrs. Whitman, my middle school home economics teacher — this was back in the day — was prescient when she caught me sneaking chocolate chips from the supply cabinet and warned that this kind of eating would one day catch up with me. It did. Puberty wasn’t kind to me, pregnancy was bad and menopause even worse.

Weight was a chronic issue but, for the most part, not an urgent one: I was always heavier than I wanted to be, but when I put my mind to it, I could shed enough pounds to look better — for a while. They say you always remember your first time, and I will never forget the slap-in-the-face sting of a 10th-grade boyfriend who offered, in response to what I had intended as a joking inquiry, “Everyone knows you could stand to lose a few pounds.” This was the day I became a person who worried about her weight, but his cutting remark wasn’t the last.

What is your reaction to the Ozempic boom? Post Opinions wants to hear from you.

Over the years, I tried a little hypnosis and a lot of grapefruit. I attempted Scarsdale and SlimFast, counted calories and cut carbs. At college, I packed on the freshman 15, then lost it. I was thin — or thin enough — when I met my husband a dozen years later, and thin enough at our wedding. When children arrived, so did the extra pounds and, like them, stuck around. WeightWatchers, with its sensible, balanced approach to diet, helped peel them off (the pounds, not the kids) — and then, after the scale inevitably crept back up, lose those same pounds again. Setting up shop at the kitchen table for remote work during the pandemic didn’t help.

So, at 63, I was stuck, and unhappy. This time, I just couldn’t seem to get my appetite under control, I told my doctor, Beth Horowitz. A close friend, another patient of hers, had been seriously obese. Since we met nearly four decades ago, my friend had tried everything — liquid diets, bariatric surgery, you name it. Nothing worked, or, more accurately, nothing worked for long. But now, with a diabetes drug called Ozempic, my friend had lost 75 pounds, slowly, over the course of more than a year.

“This may sound crazy,” I asked Beth, “but could this work for me?”

A few days later, I unwrapped my periwinkle blue Ozempic pen, screwed on the tiny needle, and turned the dial to .25. A tiny droplet of clear liquid appeared at the tip; I jabbed it into my abdomen. (Calling this an injection overstates things — it’s a teeny, painless pinprick, especially painless if you’ve got the body fat to justify it.) As I write this, I have lost 40 pounds, an astonishing quarter of my body weight. I weigh less than I have since high school — just about what I did when that high school boyfriend made his nasty crack, and while I’d still like to lose a few more, this goal is now in the realm of pure vanity.

My “thin clothes” — the pants that sat untouched in the closet for years, because I couldn’t zip them up — are falling off my body. I have more energy. Hikes that were punishing a few years ago felt easy last summer, without all that extra weight. People comment on the transformation, then pause to make sure — I’m at that age, after all — that there’s nothing life-threatening going on.

At this point I should interject: Novo Nordisk, the manufacturer of Ozempic, is clear that this medication has not been approved for weight loss — although the company’s ubiquitous cable ads (“Oh-oh-oh, Ozempic!”) happen to mention that topic (“Adults lost up to 14 pounds”) three times in the course of a minute, and physicians are free to prescribe Ozempic off-label — for a use other than its official purpose.

Insurers clamping down on doctors who prescribe Ozempic for weight loss

Indeed, Ozempic is just part of a new arsenal of medications being used to treat obesity. In June 2021, the Food and Drug Administration gave the go-ahead to an identical formulation, at higher doses and a higher price, under the brand name Wegovy. Another diabetes medication, tirzepatide (marketed under the brand name Mounjaro), has demonstrated even more dramatic weight-loss results — 22.5 percent on average vs. 15 percent with Wegovy — and the FDA is expected to formally approve its use to treat obesity.

“I think this is the turning point,” said Dr. George A. Bray, a veteran in the field of obesity research. “It’s the equivalent of bariatric surgery, but without the surgery.”

This is a remarkable development, given the astonishing prevalence of obesity, especially in the United States, where more than 40 percent of adults are obese and an additional 30 percent are overweight, and given the failure of measures less drastic than bariatric surgery to produce lasting results.

But with this accomplishment comes a complex tapestry of moral, scientific and economic questions. Among them:

  • Obesity, which has been linked to diabetes, stroke, heart disease and increased cancer risk, imposes enormous individual and societal costs. Yet these medications are hugely expensive; they can cost more than $15,000 annually. Given the extent of obesity, how can society afford to cover more than a fraction of those who might benefit?
  • Those who earn less and minorities tend to suffer higher levels of obesity; at the same time, they have less ability to pay out-of-pocket costs when insurance companies won’t pick up the tab, which is often the case. How can we ensure that those with the greatest needs have access to the best therapies, rather than entrenching or even widening existing disparities?
  • What are the consequences of long-term use, especially because evidence suggests that patients quickly regain weight once they stop using the medication? Semaglutide, the key compound in Ozempic and Wegovy, was developed in 2012 and has been around for 11 years, and widely used for diabetes, with no evident cause for alarm. Nonetheless, the question of staying on these medications for years remains, and became more pressing when the FDA in December approved Wegovy for ages 12 and up, and the American Academy of Pediatrics encouraged the use of obesity medication “as an adjunct to health behavior and lifestyle treatment.”
  • In an age of telemedicine and online commerce, how do we mitigate the risk that the new drugs will be used by large numbers of individuals who aren’t appropriate candidates? Even a rare side effect will be magnified if a drug is taken by a large-enough portion of the population. For specialists in obesity, the current situation carries unsettling echoes of the fen-phen disaster of the mid-1990s, when another promising medication had to be yanked off the market.

The emergence of this new class of drugs poses an even more fundamental issue: how society regards people who are overweight. In the 14th century, Dante condemned to the third circle of hell those who fall prey to “the pernicious sin of gluttony.” In the 21st, do we still think of obesity as a personal failing, evidence of lack of adequate self-control about how much to eat and self-discipline about how vigorously to exercise?

Or is obesity a disease, a chronic condition, much like high blood pressure or elevated cholesterol, whose prevalence and severity have underpinnings in genetics and brain chemistry and are largely outside individual control? The medical and scientific consensus has settled on the latter understanding, particularly since 1994, when Rockefeller University molecular geneticist Jeffrey M. Friedman identified leptin, a hormone secreted by fat cells that regulates appetite and body weight.

Still, as much as Friedman’s discovery demonstrated a biochemical basis for obesity, at least in some cases, there remains little doubt that being overweight continues to subject people to judgment and stigma.

I experienced this myself as I began taking Ozempic. Intellectually, I get it; I’m more disposed than many others to weight gain, and, after I lose weight, my body wants to return to a higher set point. Yet as my weight loss began to show and people started to ask how I was doing it, I realized that I had internalized the sense that being heavy was a failing for which I was personally responsible.

Sometimes, when I wasn’t up to being fully transparent, I would share a pallid version of the truth, saying simply that I ate less. That was technically true but fundamentally misleading. And why? No one with diabetes would balk at acknowledging that they treated it with insulin or high cholesterol with statins.

Other times, I would offer a fuller explanation, one even more revealing of my discomfort with the frame of obesity as disease. “I cheated,” I would confess. “I took this new medication.” Again, the diabetes analogy: No one thinks taking insulin is cheating; they recognize that it’s a treatment for a medical condition. But I had, and I suspect I’m not alone, a deep-rooted sense that losing weight should be accompanied by suffering, a reverse no-pain, no-gain mentality.

And I have to admit to some qualms, even now, about resorting to the easy way out. If America has a Puritan strain, which demands that we lose weight the old-fashioned, diet-and-exercise way, there is also something quintessentially American about the alluring prospect of the quick fix, the magic pill. In the realm of supersized sodas and sedentary lifestyles, what the experts call our obesogenic environment, does the availability of obesity medications offer too much license to ignore underlying causes? Should I have just tried harder, again, before turning to my 21st-century version of Mother’s Little Helper? Doctor, please, some more of these. More evidence underscoring the fundamental point: We assert that obesity is a disease more than we are fully convinced of it.

“People still believe that it’s a personal choice and a lifestyle choice that somebody makes, and this is at fault for their obesity,” said Dr. Scott Butsch, director of Obesity Medicine in the Bariatric and Metabolic Institute at the Cleveland Clinic. “And the problem is that people who have these beliefs are everywhere — physicians, dietitians, schoolteachers, people who work on policy issues. … So when you multiply the decision-makers and those who still have the belief that obesity is not a disease and it is a lifestyle problem, you realize what we’re up against when it comes to trying to make large changes in our health-care system.”

The search for a safe and effective weight-loss drug has been a century-long quest, mostly fruitless and marked by dangerous missteps.

In 1893, thyroid extract became the first modern drug of choice, used in patent medicines with names like “Dr. Gordon’s Elegant Pill” and “Frank J. Kellogg’s Safe Fat Reducer.” It boosted metabolism, but it raised heart rates and caused a loss of muscle mass. In the 1930s came dinitrophenol, discovered when workers in munitions factories where the chemical was used began to lose weight; it caused cataracts and hyperthermia, a dangerous increase in body temperature. The 1940s brought amphetamines, and the 1960s “rainbow pills,” a toxic medley of amphetamines, the heart drug digitalis, thyroid hormone and diuretics.

Then came fen-phen, a combination of fenfluramine and phentermine, which worked through different mechanisms but had the similar effect of suppressing appetite. Each had been approved separately for short-term use, although they weren’t terribly effective. But they turned out to be a blockbuster combination; a four-year study of 121 patients whose starting weight averaged 200 pounds found that they lost an impressive average of 30 pounds and suffered fewer side effects — or so it seemed — than if the medications were taken alone.

On April 29, 1996, fen-phen became the first obesity medication approved by the FDA for long-term use — a step taken only after an FDA advisory committee initially voted to reject the medication, warning that its safety hadn’t been adequately demonstrated. “People are dropping 20 lbs. or more in a matter of weeks,” Time magazine reported that September. “And it’s not through willpower or exotic diets or Olympian exercise routines, but largely because, for the first time in their lives, they have simply lost interest in eating.”

Then the bad news began to pile up. There had been cases of pulmonary hypertension, an untreatable and often fatal condition, associated with fenfluramine. Next came reports of valvular heart disease — faulty heart valves — in patients taking fen-phen; a small study suggested that up to 30 percent of patients could develop heart disease. On Sept. 15, 1997, less than 17 months after fen-phen was approved, manufacturers voluntarily pulled it from the market at the urging of the FDA.

New York Times medical reporter Gina Kolata wrote fen-phen’s damning obituary. “The tale speaks to the limitations of current methods of evaluating drug safety,” she observed. “It speaks to the willingness of some doctors, who see a quick flow of ready cash free from the constraints of managed care, to lure desperate patients, who will do almost anything to lose weight. It also raises questions about the Food and Drug Administration’s standards for approving diet drugs, as well as about the way that drugs are monitored after they are on the market.”

Now, especially with easy access to obesity medications over the internet, many experts, including those who are big believers in the drugs’ safety and effectiveness, are experiencing uncomfortable déjà vu.

“These pop-up online weight-loss programs that are just focused on doling out medications — they scare the heck out of me,” Dr. Scott Kahan, director of the National Center for Weight and Wellness in Washington, told me. “They’re the modern, high-tech version of the old-school pill mill. It was the pill mill 25 years ago that led to fen-phen coming off the market.”

The fen-phen debacle had predictable consequences for the development of medications to treat obesity. Patients, scared by the fen-phen episode, didn’t want to take them. And manufacturers weren’t eager to pour the necessary resources into finding promising drugs.

But for all of fen-phen’s ills, it also brought with it an important insight: that obesity medication could be understood not as a temporary jump-start to weight loss but as a long-term approach.

“If you looked at the drugs that had been approved for weight management by the FDA, it all said, ‘for short-term use,’ like up to 12 weeks, and people were saying, ‘Oh, well, you know, you could choose these, and it’s going to let you get a jump-start. And then you can learn the right ways to eat. And then you stop them. And you should be able to keep the weight off if you’re really motivated enough.’ And of course, that turned out to be totally wrong,” said Dr. Susan Z. Yanovski, co-director of the Office of Obesity Research at the National Institute of Diabetes and Digestive and Kidney Diseases, part of the National Institutes of Health. Fen-phen, she said, introduced the idea that “we may need to use these medications in the same way we do medications for other chronic diseases.”

The new class of anti-obesity medications didn’t come from the search for a weight-loss drug. Instead, it was the accidental byproduct of medication designed to help diabetics control their high blood sugar. In the 1980s, researchers discovered an appetite-suppressing hormone, which they named GLP-1, short for glucagon-like peptide-1.

Glucagon is a hormone made by the pancreas that prevents blood sugar from dropping too low. GLP-1 works in the opposite direction: It boosts the release of insulin and thereby helps lower blood sugar; it also reduces the production of glucagon. And that’s not all. GLP-1 also slows stomach-emptying, creating a sense of fullness, and acts on the appetite control system in the brain’s hypothalamus to reduce feelings of hunger. But in its natural state, GLP-1 lasts for only a few minutes in the bloodstream.

Scientists, prompted by, of all things, studying the saliva of Gila monsters, developed synthetic, longer-lasting forms of GLP-1, including semaglutide, the scientific name for the medications now being marketed by Novo Nordisk as Ozempic and Wegovy. As Novo Nordisk scientists studied the synthetic GLP-1, they noticed that the rats and mice on which they were testing the drug were losing weight — an enormously beneficial side effect because Type 2 diabetes is associated with being overweight or obese.

In 2014, Novo Nordisk secured FDA approval for a daily injection of a version of GLP-1 (liraglutide, marketed as Saxenda.). But Saxenda didn’t result in huge losses — just about 5 percent of body weight. The scientists kept going and came up with semaglutide, which produced more dramatic results, more than 12 percent of body weight. It was approved for diabetes treatment under the name Ozempic in 2017. Then, in June 2021, the FDA approved Wegovy, a higher dose of semaglutide, for individuals with obesity and/or those who are severely overweight (body mass index above 27) and have a weight-related health condition such as high blood pressure or elevated cholesterol.

Wegovy will not be the last word in weight-loss drugs, and perhaps not the most effective. A different diabetes medication, tirzepatide, manufactured by Eli Lilly under the brand name Mounjaro, has produced even more impressive results, up to 22.5 percent of body weight at the highest doses. The FDA has put tirzepatide on the fast track for approval, and, as with Ozempic, doctors are already prescribing it for weight loss off-label.

Mounjaro is intriguing because it contains one ingredient that, like Ozempic and Wegovy, mimics GLP-1, and a second that acts like a different hormone stimulated by eating, glucose-dependent insulinotropic polypeptide (GIP). The precise mechanism of GIP in producing weight loss is still unclear and somewhat puzzling, since GIP has been thought to encourage obesity, not reduce it, but the results are astonishing. The Wall Street Journal called Mounjaro the “King Kong” of weight-loss drugs, and more medications are under development.

The track record of the new class of anti-obesity medications is far more extensive, and comforting, than that of fen-phen. The most common side effects — nausea, vomiting, constipation and diarrhea — are tolerable for most patients and dissipate with time. The risk of more serious complications — pancreatitis, gallstones, thyroid cancer — appears remote. If anything, the developing evidence is that semaglutide protects cardiovascular health, based on the experience of patients with diabetes and a forthcoming analysis of semaglutide’s effect on those without diabetes. Because semaglutide reduces inflammation, which plays a role in dementia, researchers are studying whether it can slow the progression of those with early Alzheimer’s disease. At the same time, as some experts cautioned me, we don’t know what we don’t know: These new drugs last in the body and act on the brain in far higher concentrations than we have ever experienced.

After I emailed her about the possibility of taking Ozempic, my doctor and I talked about some of the downsides. I didn’t want to be the kind of patient who badgers a reluctant doctor into trying something against her better judgment. But if Beth was comfortable, and she is a cautious physician, I was comfortable, and, to be honest, I felt pretty desperate.

The biggest question — the known unknown — was what would happen if I stopped Ozempic. “No one really knows,” Beth said, although recent studies have bolstered what was then her surmise: The weight would come back. (One trial published in April 2022 looked at people who had taken semaglutide once a week for 68 weeks and then quit; they also stopped receiving diet and exercise counseling. Participants regained two-thirds of their weight loss.) But the risk of gaining back weight was the least of my problems at that point. After all, I had done that before.

Almost immediately after my first injection, I felt a bit queasy, like suffering from car sickness after a bumpy ride. I vomited several times after eating too much or too fast. Those effects mostly disappeared, but other gastrointestinal consequences remained (with apologies if this is too much information: constipation, sometimes followed by diarrhea). I learned to stay away from particularly fatty foods, such as the greasy pizza that arrives in the office every Wednesday; that, too, created gastrointestinal distress. But while some people experience severe and even intolerable side effects, mine were minor, manageable and, for the most part, fleeting.

What I also experienced, and what remains, is an unfamiliar feeling: satiety. My relationship with hunger, and therefore with eating, is transformed. I leave food on my plate, untouched and unlamented, and do not look at the food on yours with the same longing: “Are you gonna eat those fries?” I can, it turns out, stop after just a few Thin Mints. And my taste buds appear to have shifted: I would rather have the roasted Brussels sprouts than the burger, which isn’t going to sit all that well in my stomach. The thin women I once watched at dinner parties, as they waved away the dessert plate and plunged into the fresh berries brought instead — I can do that now.

The weight came off — slowly, which I knew was the best way to lose it, some weeks just a pound, some weeks nothing, rarely anything more. I gradually ramped up the dosage as suggested, from .25 to .5 milligrams weekly, then, in March 2022, when the weight loss had plateaued at about 15 pounds, increased to a higher-capacity pen, 1.0 milligram per injection. This seemed to nudge things back in a downward direction without any real change in side effects, and I’ve remained at this level since. (The recommended dosage with Wegovy climbs from .25 mg in the first month to a maximum of 2.4 mg weekly in month five. I can’t imagine tolerating — or needing — that amount.)

My appetite has returned, somewhat. At times, I am hungry again, and that feels oddly welcome, because it is controlled hunger, not insatiable craving. Somehow, I can stop myself from reaching for another piece of bread. My weight loss has slowed — depending on the day, I’m down a pound or two this year — and that’s fine. The critical question is whether, for the first time in my life, I will be able to maintain this weight.

I cannot claim to have done this for my health — certainly, appearance was my primary motivation — but the health impact has been impressive. My sleep apnea had been so severe that tests showed I was waking up an alarming 54 times every hour; new testing put it in the mild range, and my sleep apnea machine has been stashed in the closet. In November 2020, my LDL cholesterol — the “bad” kind, which raises your risk of heart disease and stroke — was at 146; it was down to 133 by March 2022 and, a year later, to 120. My A1c levels, measuring blood sugar, have fallen from on the cusp of prediabetes to safely in the normal range. My blood pressure is lower, and my C-reactive protein, an indicator of cardiovascular disease, has plummeted.

Then there is the emotional impact, harder to quantify but equally important. I understand the movement for body positivity and fat acceptance, and if you are heavy and content with your weight, that’s terrific. No one should feel externally imposed shame about how they look. But speaking for myself: I am so much happier being thinner. Shopping for clothes is no longer a humiliating ordeal. Ordering dessert does not feel like a contest between gluttony and shame.

This essay is one manifestation of that improved mental state. For years, I treated my weight as a state secret, hiding the real number even from my husband. Now, much to my astonishment, I feel brave enough to share that publicly, perhaps because I feel cautiously confident, for the first time, that I won’t find myself overweight again. So far, so good, and if that means Ozempic for life, I’m comfortable with that prospect, absent evidence of some as yet unknown risk.

There are two things that are important for readers to know: My response to the medication has been extraordinary, and my experience with insurance coverage has also been unusually positive. Most insurers do not currently cover medications for obesity alone. But my doctor was able to point to my risk of developing diabetes, and my insurer, thankfully, did not question the need for coverage. “Ozempic, $24.99,” the Walgreens website informs me when I look back at my prescription records. “Insurance saved you: $1,046.10.”

And forgive me for phrasing it this way, but that’s really the two-ton elephant in the room.

Obesity represents a national — indeed, a global — public health crisis, one that imposes huge costs both on individuals and society at large. It is prevalent and growing: From 1999 to 2020, obesity increased from 30 percent of the U.S. adult population to 42 percent. Severe obesity, defined as a body mass index of 40 or higher, nearly doubled, from 4.7 percent to 9.2 percent. Childhood obesity, which had been climbing steadily, surged during the pandemic, from 19 percent of children and teens in 2019 to 22 percent in 2020.

Those figures understate the magnitude of the issue: They don’t include people who are overweight but not technically obese. Taken together, that means 7 in 10 adults and 3 in 10 children in the United States are overweight or obese.

The phenomenon, moreover, is not distributed evenly through society. Almost half of Black adults are obese, compared with 45.6 percent of Hispanic adults and 41 percent of non-Hispanic Whites. Relatedly, obesity is generally correlated with both educational attainment and socioeconomic status: Men and women with college degrees are less apt to be obese than those with less education. Same for those with higher earnings.

So, if obesity is a disease, and if it now appears this disease can be effectively treated with medication, who should bear the cost — or is the price tag too high even to contemplate?

Consider, on one hand, the annual medical costs associated with excess weight — leaving aside lost productivity and other indirect costs — are estimated at $173 billion in 2019 dollars. That’s enormous — $1,861 in additional medical costs for every obese individual ($3,000 for those with severe obesity) and $600 per person for those who are overweight.

But the cost equation has another side. As the Atlantic’s Derek Thompson has pointed out, “If every obese American were on semaglutide at its current price of $15,000 a year, the total cost would be roughly 10 percent of the entire U.S. economy, or $2.1 trillion. That’s not going to happen.”

Of course not. But then again, not every person who might qualify is going to seek out help, is a good candidate for the medication or can tolerate it. Still, as a matter of public health economics, if obesity is a public health crisis (it is), and if these medications are an appropriate response for some patients (they are, but more on this debate later), doesn’t it make sense to figure out a sensible payment system?

Which is where our peculiar form of health care becomes a thorny obstacle. Unlike other countries, the United States has a system in which most people receive health coverage through their employers — an irrational artifact of World War II inflation-fighting policies in which employers were prohibited from raising wages so they competed for workers by offering them tax-free health insurance.

Because workers in the modern era shift jobs frequently, health insurers do not reap the benefit of paying for preventive measures. That is especially true when it comes to obesity, whose medical costs tend not to manifest themselves until later in life. So, most insurers have been balking at coverage, although the federal government instructed its insurance carriers to stop excluding anti-obesity medications from coverage, beginning this year.

“If this drug was $100 a month, I think every employer would cover it for everyone,” said James Gelfand, president and chief executive of the ERISA Industry Committee, which represents employer-sponsored health plans that cover about 110 million people. But at the current price, he said, covering these medications risks raising costs — not just for employers but also for other workers who would see their premium prices rise.

Even within Medicare, the system makes no sense. Medicare covers obesity screening and behavioral counseling. Good. In cases of severe obesity, it pays for bariatric surgery. Also good. But it is prohibited by law — the 2003 statute that created the Medicare prescription drug benefit — from paying for “weight loss” medications. This is nonsensical and antiquated; when the prescription drug benefit was enacted, these new anti-obesity medications didn’t exist. Indeed, the American Medical Association didn’t recognize obesity as a chronic disease until 2013.

Legislation has been introduced for years to fix this glitch, but it has so far languished — despite millions in lobbying expenditures by the drugmakers. And the outdated restriction doesn’t harm only those enrolled in Medicare; because insurance companies tend to follow Medicare’s guidance, it has ripple effects for private coverage.

And yet, expanding coverage would bring with it daunting fiscal implications for the Medicare program. According to an analysis published in the New England Journal of Medicine in March, if all obese Medicare beneficiaries were to be prescribed semaglutide, the cost would be nearly double the entire budget for Medicare prescription drugs.

No wonder other countries have chosen to limit the availability of these medications. Canada’s Drug and Health Technology Agency recommended against public reimbursement for semaglutide for weight management, while the United Kingdom’s National Institute for Health and Care Excellence said semaglutide use should be reimbursed, but only for a maximum of two years. But tellingly, as the New England Journal of Medicine piece observes, “In both countries, the prices of these medications are roughly one third the prices in the United States.”

And that brings us to the unavoidable point: This is big business, with billions to be made in selling obesity medications to a market that is enormous, growing and largely untapped. “Obesity is the new hypertension and looks set to become the next blockbuster pharma category,” Morgan Stanley research cheerily reported in July 2022.

Much as ACE inhibitors and calcium channel blockers supplanted pushing lifestyle changes to deal with high blood pressure in the 1980s, anti-obesity medications could take the place of encouraging diet and exercise alone.

To prime the pump, to change public perceptions about obesity, Novo Nordisk launched a campaign, separate from its branded advertising and featuring Queen Latifah, called “It’s Bigger than Me.”

“Obesity isn’t about lack of willpower. It’s not a character flaw,” she says in an online video. “Obesity is a health condition. It can make you feel like it’s your fault, but it’s actually because of your biology.”

Even based on conservative assumptions about what percentage of those eligible would sign up, and how long they would stay on the medications, the market could reach $54 billion in 2030, Morgan Stanley estimated, up from $2.4 billion today.

Already, the impact is quantifiable — and enormous. Komodo Health, which tracks health-care data, reported in February that in 2022 “more than 5 million prescriptions for Ozempic, Mounjaro, Rybelsus [semaglutide in pill form], or Wegovy were written for weight management, compared with just over 230,000 in 2019 — a 2,082% increase.” No surprise: These patients, with no prior history of diabetes, were also overwhelmingly female — 81 percent of those ages 25 to 44.

Morgan Stanley anticipated the explosion, and how it would be unleashed. “It’s a just a matter of time before the key bottleneck for obesity — the activation of patients to seek treatment and engagement with physicians — is addressed,” its report said. The solution, it suggested, was already in place: using social media to spread the word. “Our analysis shows that social media is already creating a recursive cycle of education, word of mouth and heightened demand for weight-loss drugs,” it noted.

Translation: Instagram and TikTok are already bursting with accounts of miraculously dropping unwanted pounds. “Hollywood’s Secret New Weight Loss Drug Revealed: The Hype and Hazards of Ozempic,” Variety reported in September. Elon Musk tweeted the next month that he had lost weight by fasting — “and Wegovy.”

Kim Kardashian might have used medication to help squeeze into a Marilyn Monroe gown for the Met gala — she denies it but told Vogue she had lost 16 pounds in three weeks. The truth doesn’t matter. Posts speculating on how she did it went viral, along with the query, “Where can I get some?”

The answer: If you have the cash, almost anywhere, and with very few guardrails to make certain that you meet the guidelines for eligibility.

According to the FDA, Wegovy is supposed to be used in conjunction with “a reduced calorie diet and increased physical activity.” That practice appears more aspirational than actual, because Ozempic, Wegovy and Mounjaro are just a few internet clicks away, with seemingly little medical supervision.

“Weight Loss Secret used by the Stars: Get a Wegovy Prescription in Minutes,” says one typical site. If you are willing to fib about your BMI, the dose is yours — and the fib might not even be necessary. New Yorker writer Jia Tolentino described finding a website, accurately relating her Size 4 height and weight, and saying she wanted to lose 15 pounds. “Our program is meant for this exact kind of case,” she was told — no bloodwork or doctor’s visit required.

“Everybody looks so great,” Oscars host Jimmy Kimmel said as he surveyed the audience and riffed off a line from Ozempic’s marketing. “When I look around this room, I can’t help but wonder, ‘Is Ozempic right for me?’”

To Dr. Neal Barnard, all of this is head-exploding. Barnard is founder of the Physicians Committee for Responsible Medicine, which advocates “prevention over pills” and sees pharmaceutical manufacturers such as Novo Nordisk as complicit in creating a “false narrative” that people can’t control weight on their own — that “you need this injectable drug and you need to pay us $15,000 a year. That is a deceitful marketing campaign.”

“I’m not suggesting there is never a role for medication or for bariatric surgery,” Barnard told me. “I’m saying those indications are rare.” In fact, he argues, “what people need to know is that a truly healthful diet allows for weight control without calorie counting or exercise.” Becoming vegan, Barnard says, has the same effect as injecting yourself with semaglutide. “You can inject GLP1 analog, or you can go buy beans and rice and salad,” Barnard says. “Not only do health measures improve, weight comes down automatically.”

But veganism is a tough sell to dent the nation’s obesity problem, especially in the very communities that are hardest hit, where there is less access to fresh produce and less education about proper nutrition. Barnard says this is precisely the point: that we would be better off spending scarce public health dollars on intensive nutrition counseling and healthy food environments.

Other physicians — and not just those with hefty consulting contracts from drugmakers — have a different response: relief. Before the new generation of medications, said Dr. David Rind, a primary-care physician in Boston, “All I could ever do was say, ‘Well, I think you should exercise more and diet,’ knowing perfectly well that never works. You know, it works in the short run — everybody can lose weight in the short run, and 95% of people regain weight. And so, you know, it is thrilling for me to have something that I could use that lets people lose weight.”

Rind has a distinctive perspective on the issue because he is also chief medical officer of the Institute for Clinical and Economic Review (ICER), which assesses the quality and cost-effectiveness of medications. Its analysis of obesity medications, released in August 2022, awarded Wegovy a B-plus for effectiveness — “a really good grade,” Rind said. “If we knew that you could keep taking this for 10 years and you’d maintain that weight loss, we probably would have given it an A. We just don’t have those data yet.”

But that analysis was less cheery when it came to the cost-effectiveness — and overall budgetary implications — of Wegovy. Its model is complex, but the bottom line was that the medication would be considered cost-effective only at an annual price of $7,500 to $9,700 — far below the current sticker price.

More daunting: Even at that reduced rate, the impact on national health-care spending — already close to 20 percent of gross domestic product (GDP) — would be enormous and unsustainable. Less than 4 percent of eligible patients could be treated within five years without exceeding ICER’S limits on affordability.

“Even at a fair price,” Rind told me, “they’re going to make a huge amount of money — and the budget impact in the U.S. is going to be enormous.”

In the opening scene of the movie “The Whale,” a morbidly obese Brendan Fraser is teaching an online writing class. On his Zoom display, a black square, labeled “Instructor,” sits in the midst of a sea of student faces. This encapsulates the experience of obesity: the shame at being seen, an aversion to seeing yourself. For all the encouraging talk about body positivity, this is the reality for millions of people, myself included: You don’t have to look like a whale to feel like one. Obesity medications empower us to be seen in the Zoom square.

After a year and a half on Ozempic, I find myself both exhilarated and unsettled by this prospect. How amazing it is that millions of people who have endured the misery of struggling with their weight now have what appears to be a safe and effective way to address it. We are at the start of a brave new world when it comes to treating obesity; one sign of the new if-you-can’t-beat-’em reality came in March, when WeightWatchers bought a telehealth company that provides obesity drugs.

And that also leaves me unsettled. In a just society, with a rational allocation of resources, I would not be anywhere near the front of the line to obtain a medication that is prohibitively expensive and, at least until recently, in short supply. (Now, you have to go hunting for Wegovy.) Neither would the attractive folks in the Oscars audience — nor many of the other people I know who are taking it. If you can’t be too rich or too thin, it turns out, you might have to be rich to be thin. The racial disparities — in obesity and access — make matters even worse.

And we are only starting to consider questions about what constitutes appropriate use. For the seriously obese, the case seems clear. Leaving aside the important questions of cost, and prices will come down, certainly as patent protections expire, where to draw the line? If this medication is safe and effective, why not prescribe it for the merely overweight, even without an associated medical issue? And why not for the bride who wants to drop 10 pounds before her wedding day? She might gain the weight back, but would it really be so terrible?

Still, to take up the other side of that argument: What role does this leave for instilling habits of self-discipline, encouraging healthy eating and incorporating exercise? The experts can preach about the importance of accompanying use with a program of diet and exercise; we know what will happen in the real world.

But given cost considerations and the apparent need for long-term use, we need to study whether the medications can be usefully combined with low-carbohydrate diets, as Dr. David S. Ludwig and Dr. Jens J. Holst suggested in a new article in JAMA, the American Medical Association’s journal.

There is also much that remains unknown, about whether it is healthy to go off and on these medications, especially with the associated weight gain — and whether to try to adjust doses to a lower amount once weight loss has been achieved. “Medically, I would want some kind of reason for lowering the dose,” Dr. Jason Brett, executive director for medical affairs at Novo Nordisk, told me. Of course, Novo Nordisk has every financial incentive to want people taking its medication for as long as possible at the highest doses. Still, if Wegovy is working at the prescribed dose, why fiddle? If anything, it might be that effects wear off and dosage may need to be increased for the medication to remain effective.

This genie isn’t going back in the bottle, nor should she. We need to embark on a serious conversation — not about what these medications mean for celebrities on Instagram but what their arrival signifies for the rest of us, struggling and imperfect.


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