Ozempic—a drug developed to treat type 2 diabetes—also causes significant and speedy weight loss. It has become wildly popular and reignited a prickly debate over the very definition of obesity. Is being fat a ‘disease’ that needs a miracle cure?
Researched by: Rachel John & Nirmal Bhansali
Wait, what’s this Ozempic?
First, some background: In 1994, a molecular geneticist named Jeffrey Friedman accidentally discovered that a hormone called leptin is connected to obesity in mice. It is produced by fat tissue and induces a feeling of fullness. The real revelation: a person’s weight isn’t just about eating too much or exercising too little. It has a “biological basis” and can therefore be potentially “cured” using drugs.
For decades, scientists tried to develop medicines that could induce weight loss in obese patients—but to no avail. Drug cocktails like fen-phen either caused serious complications like heart disease or didn’t result in significant weight loss.
Enter Ozempic: Researchers searching for an effective diabetes drug were looking at hormones that control blood glucose levels. They found GLP-1 (glucagon-like peptide 1)—which increased insulin production and reduced blood sugar. By the 2000s, the US had begun approving drugs that mimicked GLP-1 as type 2 diabetes treatments.
But trials for these medicines also revealed that participants were losing weight. The most impressive was Novo Nordisk’s medication called semaglutide—which was first approved to treat type 2 diabetes as Ozempic in 2017. More importantly, further trials showed that those receiving weekly injections of semaglutide lost 14.9% of their body weight after 16 months of treatment.
Enter Wegovy: Its maker Novo Nordisk increased the dosage of semaglutide—the active ingredient in Ozempic—and released it as a prescription weight loss drug called Wegovy in 2021. The drug, however, is only prescribed for patients determined to be both obese—and suffering from at least one weight-related health condition. Example: high blood pressure, high cholesterol or type 2 diabetes.
Point to note: Until semaglutide came along, it hasn’t been possible to safely decrease body weight by more than 10% using drugs.
How semaglutide works: To put it simply, it makes you feel fuller faster—curbing the urge to eat:
After a meal, semaglutide stimulates the release of insulin, lowering blood sugar. It also appears to slow the emptying of the stomach, which reduces feelings of hunger. “There also seems to be an effect of these medications in the brain that affects food reward,” Yanovski said. “People on semaglutide report they’re not thinking about food all the time.”
So you lose interest in your favourite foods—like that tub of mint Haagen Daaz. It is, as The Guardian puts it, “A Clockwork Orange for junk food.”
Hashtag Ozempic: Most of the world did not discover the drug until it went viral on TikTok last summer—causing a shortage in the diabetes drug. In September, Variety revealed it as the worst kept secret on the Emmys red carpet:
Moguls, reality starlets, veteran film producers and, of course, actors are quietly singing the drug’s praises on Signal, the encrypted messaging app mostly used for confidential conversations. Hair, makeup and styling teams for celebrities have come to accept the injections as part of grooming rituals ahead of major events.
By December, medical spas in the US were offering Ozempic alongside shots of Botox and laser hair removal.
FYI: Wegovy is not available in most countries—including India—as it is still a new drug. Hence, the rush for its lower-dosage sibling Ozempic.
But it sounds amazing…what’s the catch?
For starters, these drugs have not been tested on people of average weight—so using it as a diet pill is highly inadvisable. That said, the downside of semaglutide as a prescription drug is fairly modest compared to other weight loss drugs that tend to affect the digestive system. One can experience either diarrhoea or constipation. Most common symptoms: nausea and dehydration. In rare cases, it can cause pancreatitis or gallstones—even thyroid tumours which showed up in rodent studies.
Point to note: The nausea may be a feature not a bug—as The Guardian points out. The hormone GLP-1 also affects how food tastes to us. So it isn’t an accident that folks on Ozempic complain that they feel like throwing up if they eat more than a couple of bites:
Simply put, Ozempic, and similar GLP-1s, may work because they make food (or at least certain types of food) taste disgusting. A 2012 paper in the journal Neuropharmacology found that this feeling of nausea was integral to reducing food take. “Whether food intake suppression,” the authors wrote, “occurs independently of nausea is unknown”. More recent research has shown that glucagon-like peptide-1 plays a key role in taste perception.
This shouldn’t be surprising since drugs to treat alcoholism or nicotine addiction work in the same way.
Also this: If you’re taking the drug for reasons of vanity, the unwelcome news is that it causes something called ‘Ozempic face’—“the sagging, gaunt look of the facial skin due to the loss of facial fat following drastic weight loss.” Cosmetic surgeons are now recommending fillers as the must-have for anyone on Ozempic.
The real worry: is that anyone using semaglutide for weight loss has to stay on it for the rest of their life. Studies show that most of the kilos come right back soon after stopping the medication. That’s a problem given the hefty price tag for Wegovy, which costs $1,300 for a 28-day supply (Ozempic costs $892 per month). And no one knows the long term effects of using these drugs.
I still don’t get why the drug itself is controversial…
Because even doctors can’t agree whether high body weight is a ‘disease’ that needs to be ‘cured’.
The definition of obesity: Obesity is most often defined by Body Mass Index numbers—both by the WHO and US health authorities. This is the weight in pounds divided by height in inches squared, multiplied by 703.
But, but, but: This doesn’t take into account variations in terms of ethnicity. For example, the average BMI of Polynesians tends to be high but it doesn’t mean they are less healthy than the rest of the world. Similarly, studies have shown that Asian populations are at higher risk for diabetes, high blood pressure and high cholesterol at lower BMI thresholds. Also this:
An estimated 30% of those classified as obese are actually healthy in terms of their cardio-metabolic profile, including such things as circulating glucose, insulin, and cholesterol levels. In this group of “healthy obese,” prescribing weight loss may actually be harmful. Furthermore, in the most detailed analysis of data worldwide carried out to date, having a BMI of 30-<35 kg/m2 was not associated with a higher death rate… Those who are overweight (BMI of 25-30) actually have the lowest death rates.
More importantly: BMI pays zero attention to where the fat is located. Fat that accumulates around your digestive system is bad for your heart—even if your overall weight is low. So a big pot belly is a problem, but not a large bum. Hence, health authorities now say you are at greater risk if your waist is more than 40 inches for a man and 35 inches for a nonpregnant woman. Or you can measure your waist-to-hip ratio or waist-to-height ratio.
The fallout: Many doctors argue that no single weight-related number can capture a person’s health risk. It’s therefore wrong to treat body weight as a problem to be solved. OTOH, the medical establishment points to the escalating numbers around the world. According to the WHO, rates of obesity have tripled globally since 1975. In the US, the American Pediatric Association sounded the alarm bell for 14 million kids with obesity—recommending early and aggressive intervention. India has 27 million obese children—which is 10% of the global total. And all of them are at high risk for some of the most serious diseases—including cancer, diabetes and heart attacks.
Is obesity a ‘disease’? That’s the other thorny question. Supporters of medical intervention say that body weight has long been seen as a personal failure—lack of self-control, laziness etc. Therefore, it is liberating and de-stigmatizing to define obesity as a disease—such as blood pressure—that can now be controlled with lifelong medication:
Society has never had an effective intervention for people with obesity, aside from bariatric surgery. We can’t contemplate having hundreds of thousands of people suddenly having bariatric surgery. Whether we can contemplate hundreds of thousands being treated effectively with this obesity medication is a debate we’re having now.
This is, in sum, the argument for drugs like Welovy.
But, but, but: Its critics argue that medicines like this only strengthen fat-phobia: “The remedy remains the same: lose weight rather than changing the ways in which our society interacts with and treats fat people.” It’s hardly an accident that within months of Ozempic going mainstream, New York Post announced the return of ‘heroin chic’. And it dovetails neatly into an ongoing backlash to decades of hard-won gains of the body-positivity movement. That these new weight loss drugs are absurdly expensive and unaffordable makes them all the more ideal:
That’s because being thin in 2022 is about being part of a protected class. It’s about looking fit and healthy and rich and virtuous in a time when we’ve all seen what happens if you don’t have wealth or pretty privilege to protect you. It’s a pursuit of thinness out of the fear of being rejected by everyone from doctors to prospective dates. I think it’s a more desperate pursuit than we’ve seen before.
The bottomline: Human beings' relationship with their body and with what we put in it is more messed up than ever before. There is no cure for that far more insidious and poisonous disease. This isn’t about how much we eat, but why and what we eat. That said, we are glad that a person who needs to lose weight to save their health now has the same options as someone with diabetes or high blood pressure.
Reading list
The Atlantic has a good overview of the various aspects of Ozempic and Wegovy use. New York Times has an in-depth explainer on the drugs while Nature traces the history. The Guardian offers a first-person account of how these medicines make food repulsive. Read this report in Healthline for an overview of the debate on obesity. Forbes has an excellent read on why obesity should not be considered a disease.
