We have become fluent in the new language of pharmacology, diabetes, and weight loss. Ozempic, Wegovy and Mounjaro are part of our public lexicon. Glucagon-like peptide-1 (GLP-1) receptor agonists are lifesaving drugs, created to help the hundreds of millions of people with Type 2 diabetes and clinical obesity.They promise to rid the United States of obesity, if our country can figure out how to make the pricey fix affordable.
But these wonder drugs are also a shorthand for our coded language of shame, stigma, status and bias around fatness. Untangling those two functions is a social problem that one miracle drug cannot fix.
It is hard to recall the last time a drug so excited the general public. Fen-phen in the 1990s, maybe? Viagra or Botox in the 2000s? Each had amazing hype cycles but none as explosive as Ozempic. Market watchers have flagged Novo Nordisk, the Danish pharmaceutical giant that makes Ozempic and Wegovy, as a contender for most valuable company in Europe. With better drugs still in various stages of development, the anti-obesity gold rush has just begun.
If GLP-1 drugs only treated diabetes and did not promote weight loss, they would still be medically groundbreaking. But Ozempic, Wegovy and Mounjaro probably would not have social media hashtags. These drugs are blockbusters because they promise to solve a medical problem that is also a cultural problem — how to cure the moral crisis of fat bodies that refuse to get and stay thin.
That many people don’t even question that eliminating fat people is an objectively good idea is why it is such a powerful idea. Thinness is a way to perform moral discipline, even if one pursues it through morally ambiguous means. Subconsciously, consciously, politically, economically and culturally, obesity signals moral laxity.
Any decent cleric will tell you that there is no price too high for salvation, so an entire class of people — the roughly three in four adult Americans who are overweight — is a target for profit-seeking. Medical weight loss interventions have, over the years, led to heart damage, strokes, nerve damage, psychosis and death. But under this moral code, it’s the social policies that promote, subsidize and profit from obesity that are cleansed of their extractive sins. It’s as if fat bodies, by housing slovenly people, do not deserve the protections of good regulations and healthy communities.
There’s something seductive about a weekly shot that fixes the body, while skipping right past the messiness of improving the way people have to live. Both diabetes and obesity are conditions that are as much about social policy as they are about what people eat. Studies show that the crops the U.S. government subsidizes are linked to the high-sugar, high-calorie diets that put Americans at risk for abdominal fat, weight gain and high cholesterol. Sprawling communities, car-centered lives and desk jobs make it hard for many Americans to move as much as medical guidance thinks that we should. Under these conditions, telling people to change their lifestyle to lose weight or prevent diabetes is cruel.
It should be no surprise that near-guaranteed weight loss — big, rapid weight loss in many cases — drives millions of people to take the drugs off label, creating consumer demand like the gold nugget that lured miners out West.
The cultural conversation around Ozempic is as obsessed with celebrities as the celebrities are obsessed with themselves. Rumors of which A-list star was on Ozempic peaked with the pejorative “Ozempic face,” a sign that someone was taking a shortcut right to skinny’s spoils. Social media users became adept at finding clues that a celebrity cheated, purchasing obesity absolution through pharma indulgence.
At the top of the status hierarchy, the rich, famous and near famous were getting skinnier. But in the same span of years Ozempic took hold of those buzzy sets, I began noticing that regular people like my friends were being reclassified as insulin-sensitive, insulin-resistant, and the utterly terrifying “prediabetic.”
Most of them are highly educated, self-made successes, with no family wealth or other cultural endowments. They handle their health with the same ferocity they brought to college admissions and career planning. One friend began blowing into a device that told her if she had reached a “fasting” state; another was prescribed metformin, a diabetes medication. So many of them seemed to be on a crash course with a medical liminal state that associated them with diabetes even though none of them were diabetic.
Although it was unknown to me at the time, my friends were swimming with a public health tide that would mark them for medicalization, even though nothing about their physiology, behavior or medical profile had changed. They may have needed drugs, they may not have, but “prediabetes” is not a precise enough predictor of whether anyone will become diabetic to warrant the fear the term provokes.
The American Diabetes Association developed the term “prediabetes” to bring attention to slightly elevated blood sugar levels in some Americans in 2001. Over the next two decades, the organization expanded the definition of the condition, so that by 2019, as Charles Piller reported for Science magazine, 84 million Americans had prediabetes, “the most common chronic disease after obesity.”
There were no drugs specifically designed for prediabetes, so doctors often relied on off-label treatments, a common medical practice. But because off-label drug interventions coincided with the wholesale expanded classification of millions of people with a novel condition, a new market boomed.
This shift broadened the consumer language for medicalizing weight loss as a preventive strategy to treat not only diabetes, but also supposed — though not always proven — diabetes risk. It armed a wellness machine with the medical terminology of “insulin resistance” and “insulin sensitivity,” without the medical expertise to screen for diabetes risk indicators. People could soon buy an astonishing array of apps and devices to self-diagnose insulin efficiency. Enter Ozempic and Wegovy, perfectly designed for our highly developed consumer palates.
Given all these changes, I wondered what Dr. Richard Kahn, the former chief scientific and medical officer at the American Diabetes Association, who helped establish “prediabetes” as a term, now thought about the phenomenon.
When we talked, Dr. Kahn told me that he regrets his role in developing “prediabetes” and its associated grift, but his giddiness about GLP-1 drugs was palpable. He said that encouraging weight loss through lifestyle changes was an “abject failure.” Now, Ozempic offers patients light and hope.
The problem with these drugs, he said, “is that they cost an enormous amount of money.”
Ozempic and all similar formulations are administered by injection, via a pen that lasts about 30 days and costs from about $900 to $1,300. A year of pens can run between $10,000 and $16,000; the median household income in the United States is around $75,000. How in the world can regular people afford it?
It’s easy to assume that the non-wealthy use health insurance to pay for these drugs. And yes, if they’re using Ozempic for diabetes, the health insurance claim is straightforward. But for weight loss, getting health insurance to pay for Wegovy (or even Ozempic) can be more difficult. As Dr. Kahn says, “The vast majority of insurance companies refuse to pay for it no matter what the degree of obesity is. ”
Dr. Kahn grasps the big picture of health economics and the insurance cliff we’re standing on. But in the doctor’s office, the cliff is more of a canyon. In 2021, I went to a fancy doctor for my annual checkup. I justify the steep subscription fee for my concierge medical care because I have moderate medical anxiety from years of being talked down to, ignored, dismissed, and victimized by medical malpractice. I consider the concierge fee a convenience tax to be treated like a person.
After two hours of getting to know my new OB-GYN, bloodletting, and internal spelunking, we sat down to talk about my lifestyle and health goals. As an overweight person with high verbal acuity, I was sure to describe my Peloton practice as well as my plan to eat more plants for ethical reasons. The doctor’s face lit up when I finally intimated an interest in, shall we say, size modification.
Glancing at my blood test results she began describing her professional interest in “metabolic medicine.” What followed was a 20-minute presentation on the advancements in weight loss drugs. Ozempic was the star, but there were other drugs, many of them prescribed off label. The seizure medication might curb snacking. Another might slow digestion if it did not ruin your kidneys. And then, of course, there were the “injectables,” the “gold standard” of weight loss medical interventions.
The only problem was that I was not diabetic.
I was not even medically prediabetic.
The doctor said this with great regret.
My A1C, the measurement of average blood sugar levels over the past months, was within the normal range. It was, in fact, bordering on low.
“But these tests malfunction. We can test it again,” she said hopefully.
My doctor was hoping for a higher A1C because it would classify me as prediabetic, as it would increase the odds of getting health insurance to pay for the off-label use of the pricey drugs she recommended to me that day.
I vacillated between wanting to show my doctor that I could afford to pay for Ozempic out of pocket, not even wanting Ozempic and wanting to prove to her that my A1C was no fluke. I took the A1C test again a week later. It was still low. She was still dismayed.
I switched doctors when I realized one of us was rooting for me to be sicker so I could afford to be skinnier. In her defense, that is exactly the equation that GLP-1 drugs present to the millions of Americans who need health insurance to afford them.
Of course, that says nothing of the 27 million Americans who do not have health insurance at all. People without insurance are typically low-income and are overexposed to the social policies that produced the obesity crisis. For them, the best-in-class drugs may as well not exist.
But, just for the sake of argument, if obesity is a public health crisis and it can be solved with one imperfect injectable, it should be possible to make it so that everyone can afford the solution. Right?
But so far we have done the opposite. To prescribe millions of Americans Ozempic at its current price would stress the health care system to its breaking point. Dr. Kahn did some rough math when we spoke. “If 80 percent of the people with obesity would start to take this drug,” he argued, “it would bankrupt the health care system.” He bases that on the Centers for Disease Control and Prevention’s finding that more than 40 percent of Americans are obese. “We’re hurtling quite rapidly to this game of chicken,” Dr. Kahn said, “where you have the manufacturers saying they’re not going to reduce the price. And you have the insurance companies saying it’s too much to pay.”
Making GLP-1 drugs accessible for Type 2 diabetes and weight loss at a cost that regular Americans could afford would be an achievement for our health care system. The Biden administration is rolling out its Medicare Drug Price Negotiation program. For now, none of these drugs are included. The Treat and Reduce Obesity Act would expand Medicare coverage for obesity. These are the kind of policy approaches that could be a game changer for obesity management and diabetes care, while this country continues to work on the bigger problem: our poverty of imagination for the ethical care of all bodies.
For now, cash-strapped American consumers are left to contend with a society in which the price of being fat is so high that there will always be a rational reason to pay an exorbitant amount to be thin.
There is weight loss for health. There is also weight loss for status and avoiding stigma. While both men and women experience greater discrimination if they are fat, women suffer more for failing to be thin enough. Study after study shows that overweight women are more likely to be unemployed than their thinner counterparts. When they are employed, larger women earn less, with smaller penalties for Black and Hispanic women, who already earn less, on average. Overweight white and Asian women experience the labor market discrimination that Black and Hispanic women already do.
Outside of the workplace, the trend of educational and economic elites marrying, befriending and socializing with one another — assortative matching and mating — is also a marked characteristic of our time. Elite homogeneity has a look and the look is thin. So when women say that it is better to be sick and thin than healthy and fat, they are perfectly rational.
Kate Manne, a philosopher, says that the fear of being fat — fatphobia — is structural and intersectional. In her forthcoming book, “Unshrinking,” she questions whether solving obesity is something that can truly be done by eradicating fat people. Ozempic mania is not just a perfect example of how self-defeating our health economics are in this country, as Dr. Kahn points out. It is also an example of how the American penchant for solving structural issues by fixing individual bodies is excellent at creating demand without solving social problems.
I was overweight before I entered the concierge medical office. But being overweight was incongruent with a person who could afford concierge medicine. My doctor assumed I would want to be thin. In many ways, she was providing exactly the service I didn’t realize I was paying for — acculturating me to the expectations of the right body for my station. Minimizing weight stigma was a health service, even if my health indicators did not require intervention.
The mere existence of Ozempic and the like encourages millions of people to self-diagnose in a way that stigmatizes. If they walk into doctors’ offices begging to be classified as medically vulnerable, it’s not for some provision from the state like housing or food. They want a drug that can help them manage an environment that works against their aspirations. That is a condemnation of our culture.
Ozempic’s implicit promise is that it can fix what our culture has broken. There aren’t breathless profiles of a pharmaceutical drug because it will help a diabetic manage her blood glucose level. They exist because it promises to democratize access to the holy grail of embodied privilege, that sexy sexism of “nothing tastes as good as skinny feels.”
Whether fatness is a problem for the millions of people whom these drugs are poised to leave behind depends on perspective. It’s perfectly normal to live a happy, full life in a body that is above the medically recommended healthy size. Plenty of people do it and have done it. But being overweight becomes a social problem when it’s a population level statistic with a status hierarchy attached.
When supply chain disruptions made it harder for diabetic patients to get Ozempic last year, wealthy people bought the drug at a premium for weight loss while people who needed it struggled to fill their prescriptions. Then, the grim picture of inequality was clear.
But as the supply rebounds, the inequality may get harder to see. That would be unfortunate.
Inequality of access to Ozempic and Wegovy is not between the deserving sick and undeserving obese. The inequality is in attaching any moral clause to why people use the drugs in the first place. As long as most Americans cannot afford the drug that democratizes weight, the stigma of obesity is still controlled by those who can afford to be thin. GLP-1 drugs — or any miracle drug that cures obesity on label or off — works only if people who need the drug can afford it.
But solving for obesity will require more than drugs. It will require solving for a culture that makes being fat a woman’s burden, a means test for dignity, work, social status, and moral citizenry.
Until we end that stigma, we can create drugs that help people lose weight, but the conditions for making some people undesirable — at a cost — will still be lurking in the shadows.
Tressie McMillan Cottom (@tressiemcphd) became a New York Times Opinion columnist in 2022. She is an associate professor at the University of North Carolina at Chapel Hill School of Information and Library Science, the author of “Thick: And Other Essays” and a 2020 MacArthur fellow.
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