The Weight-Loss-Drug Revolution Is a Miracle—And a Menace

How the new obesity pills could upend American society

A bottle of pills acting as a stanchion, with two red-fabric tape measures hooked to it
Getty; The Atlantic

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About a decade ago, Susan Yanovski, an obesity researcher at the National Institutes of Health, held a symposium to discuss a question that bedeviled her field: Why was it so hard to develop weight-loss drugs that actually worked and didn’t harm the people they were meant to help?

For years, the most popular weight-loss pills had earned their stigma. For example, the drug cocktail known as fen-phen was taken off the market for causing heart disease almost as reliably as it promoted healthy weight loss. The only intervention that seemed to work consistently was bariatric surgery. Doctors sliced into patients’ digestive system to reduce stomach size and slow the absorption of nutrients to stave off feelings of hunger. But these operations were expensive and complicated, and in some cases posed serious risks.

Yanovski was looking for a breakthrough. She wanted the effects of bariatric surgery without the surgery. The symposium’s conclusion, however, was dreary. The miracle drug that everybody was looking for simply did not exist.

Except, maybe it did exist. Just not where most weight-loss researchers were looking.

In the early 2010s, the Danish pharmaceutical company Novo Nordisk developed a medication called semaglutide for the treatment of type 2 diabetes. It was approved by the FDA as an injectable called Ozempic. The company soon realized that patients on Ozempic reported significant weight loss as a side effect. Novo Nordisk ran further trials on the drug and discovered that it was, in fact, “associated with less hunger and food cravings.” They rereleased the drug for weight loss under a new name: Wegovy.

Ozempic, Wegovy, and similar drugs represent the vanguard of a weight-loss revolution. Last year, Yanovski attended a conference in San Diego on the results of a new Novo Nordisk trial for adolescents and teens with severe obesity. The hotel ballroom was standing-room only, according to the scientific journal Nature, and the results of the trial were met with cheers, “like you were at a Broadway show.” After a year, young patients on semaglutide said they lost nearly 35 pounds on average. Teens on the placebo actually gained weight.

Here was the breakthrough that Yanovski, the obesity-research community, and perhaps the entire world were looking for: the effects of bariatric surgery without the surgery.

In the past few years, use of new weight-loss medication has grown, putting the U.S. in the early stages of a drug boom. One story you could tell about these drugs is that they represent a watershed moment for scientific discovery. In a country where each generation has been more overweight than the one that came before it, a marvelous medication seemed to fall out of the sky.

But just months into this weight-loss-drug bonanza, a range of medical, cultural, and political challenges has materialized. Doctors are reporting rampant use of these new weight-loss drugs among the very rich. The surge of off-label use of Ozempic is already creating a shortage of the medication for people with type 2 diabetes. Now that celebrity skinniness is merely an injection away, online “thin culture” has returned, likely exacerbating Americans’ fraught relationship with body image. On paper, these drugs might be a miracle. In the real world, they’re also becoming a menace.

Before wading too deeply into skepticism, let’s reiterate the stakes. More than 40 percent of U.S. adults, including about 20 percent of children and teens, are considered obese. These Americans face elevated risks for type 2 diabetes, heart disease, liver disease, and various cancers, along with mobility issues associated with being overweight. During the pandemic, obesity may have tripled the risk of hospitalization with a COVID infection. Among women living in poverty, in particular, obesity rates are higher. Treatment for obesity would increase longevity, improve health, and possibly even save the entire health system hundreds of billions of dollars in the long run.

For years, doctors have encouraged overweight patients to begin with diet and exercise. This sounds like a levelheaded approach to health care. But it’s not always a useful suggestion. “There are lots of people who are very successful in every aspect of their life—in school, at work, and in their communities—and it’s just in this area of being able to control their body weight that they struggle,” Yanovski, who is now a co-director of the Office of Obesity Research at NIH, told me on my podcast, Plain English. “People who haven’t experienced it themselves often think, Just push away your plate! But we know it’s not that simple.” Even in NIH studies overseen by behavioral scientists working with extremely motivated patients, more than half of people with obesity can’t maintain their weight-loss goals, she said.

Where behavioral changes have failed, chemistry might succeed. The drug semaglutide mimics a protein in the gut that assists digestion. 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.”

Every drug has side effects. Patients on semaglutide and similar drugs have reported nausea and vomiting, which can be partly managed by starting patients on a low dose. The drugs can also produce gallstones, which are common among all patients undergoing rapid weight loss. Some people using Ozempic report accelerated “facial aging” when they lose fat in their cheeks.

Nevertheless, as a medical achievement, these drugs are stupendous inventions. But as I’ve written in The Atlantic, invention is one thing; implementation is another. And the current rollout of these weight-loss drugs raises questions about ethics, fairness, culture, and America’s berserk relationship with beauty.

Ozempic and Wegovy can cost roughly $1,000 or more a month for people trying to lose weight. Most insurance companies do not cover weight-loss medication. In the U.S., racial and ethnic minorities and low-income Americans have higher rates of diabetes and obesity. But because they cost $12,000 a year or more without insurance coverage—and that’s not even counting higher prices on the black market—the drugs’ first clientele is likely to be the richest Americans, not the poorest.

As demand rises, insurance rules and public policy might adapt. For the first time, the Federal Employee Health Benefit program agreed to cover some anti-obesity medication. Other insurance companies might follow. One Morgan Stanley model projected that semaglutide and similar weight-loss drugs could be a $30 billion market by 2030. That’s about 10 percent of all U.S. drug spending. This level of prevalence is inconceivable without insurance coverage, but coverage of these drugs could warp the cost of private and public insurance to an inconceivable degree. 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.

More likely is that influencers, celebrities, and millionaires will monopolize the market for weight-loss medication. In the past six months, Hollywood Ozempic stories have reached an obnoxious level of ubiquity. TikTok has become overrun with #myozempicjourney testimonials and week-by-week photo collages of disappearing waistlines. After years of magazines and advertisers grappling with the dangers of promoting unrealistic body images, New York magazine reports that “thin is in,” as the waifish “heroin chic” of the 1990s makes its medicalized return to the mainstream.

These drugs will also scramble our relationship with the basic concept of willpower in ways that aren’t cleanly good or bad. How long should doctors recommend that their patients press forward with “diet and exercise” recommendations now that pills and injectables may safely and more consistently keep off weight? Is the U.S. health-care system really ready to treat obesity like it’s any other disease? Obesity is not a failure of the will, Yanovski told me, again and again. “It is a complex chronic disease,” she said. “It affects almost every organ system. If you can successfully treat obesity instead of the individual conditions, it could have a positive impact on health.”

I think that’s right. But there is still something menacing in the rollout of these young miracles. Semaglutide seems to collapse the complex interplay of genes, environment, diet, metabolism, and exercise into a simple injection with a luxury price tag. I’m holding out hope that these drugs will soon augur a public-health revolution. In early 2023, however, they represent an elite cultural makeover more than a medical intervention.

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