THE PROFITABILITY of obesity
Ozempic can’t fix what our culture has broken
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 (GLP1) receptor agonists are lifesaving drugs, created to help hundreds of millions of people with Type 2 diabetes and clinical obesity.
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? Viagra or Botox in the 2000s? Each had amazing hype cycles, but none as explosive as Ozempic. 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.
Thinness is a way to perform moral discipline, even if one pursues it through morally ambiguous means. 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 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.
There’s something seductive about a weekly shot that fixes the body while skipping past improving the way people have to live. 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 we should. Under these conditions, telling people to change their lifestyle to lose weight or prevent diabetes is cruel.
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, 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.
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.” Ozempic offers patients light and hope.
The problem with these drugs, he said, “is that they cost an enormous amount of money.”
Ozempic and 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 can regular people afford it?
It’s easy to assume that the nonwealthy use health insurance to pay for these drugs. 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 Ozempic can be more difficult. As Kahn says, “The vast majority of insurance companies refuse to pay for it no matter what the degree of obesity is. “
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 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.
That says nothing of the 27 million Americans who do not have health insurance—typically low-income and 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?
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 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.
Philosopher Kate Manne says that the fear of being fat 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 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.