HEALTH
The Ozempic Era Is Distorting What We See as Healthy
Fat people are constantly told they have to shed pounds. What will weight loss–inducing medicines really cost us?
BY KC HOARD
ILLUSTRATION BY KEY BENNETT
Published 6:30, July 3, 2024
In March, Oprah Winfrey released a prime-time special titled “Shame, Blame, and the Weight Loss Revolution” on ABC to unpack why she and an estimated millions of others are using drugs like Ozempic and Wegovy to get thin.
“In my lifetime, I never dreamed that we would be talking about medicines that are providing hope for people like me who have struggled for years with being overweight or with obesity,” she said at the top of the special.
Throughout her decades of fame, Winfrey has been transparent about her efforts to get thinner and the weight gain that has always, inevitably, followed her diets and exercise routines. “I took on the shame that the world gave to me,” she said in the special. “For twenty-five years, making fun of my weight was national sport.”
We’ve all experienced, to some degree, the disdain for fatness knotted deep under the skin of our society. “Fat” and “obese” are two linked but distinct terms: “fat” is a social descriptor while “obese” is a medical category, but fatness remains the traditional measure of whether a person is obese. Because of this, the two words have grown so inextricably attached that the differences between them have blurred. Popular wisdom around obesity is predicated on the belief that it can and should be eradicated. By extension, many seem to believe that fatness should also be done away with.
Over the past couple of years, I’ve been skeptical about the rapid, staggering rise of the diabetes drug Ozempic, similar drugs like Wegovy (which, unlike Ozempic, is marketed as an obesity treatment), and other newly approved drugs like Zepbound and Mounjaro, which mark a turning point in the history of fatness and weight loss. Many laud them as a miracle obesity cure at a time when the World Obesity Federation has predicted that over half of the world’s population will be overweight or obese by 2035. If these drugs were to become as widespread as insulin or penicillin, they could make it easier than ever for anyone to become thin. Put another way, there would be no excuse for anyone to be fat.
I thought these drugs would end our right to inhabit any kind of body, including and especially a fat one, without judgment or duress. I feared we had trudged toward a medical solution to a problem that could more fully be solved by a cultural shift. I thought it was wrong to try to end fatness. But I was naive about what these drugs really offer: a way out of a hell of our own making.
Obesity has long been seen as a personal failing—big people are thought to be choosing to eat more than they need to and not exercising enough. But diet and exercise don’t capture the full portrait of how and why our bodies grow and shrink. Some people seem to be genetically predisposed to being large, while others are predisposed to thinness. The environment one lives in can limit or alter our access to and relationships with nutritious food and exercise. And research shows social determinants like class, race, and gender can increase one’s odds of being overweight or obese.
In 1998, some doctors put forth an alternative idea: that obesity was not a failure and not necessarily a choice. They argued it had the hallmarks of a chronic disease, meaning the condition requires lifelong treatment and can cause unfavourable health outcomes. Obesity can lead to damaging, long-lasting, and uncomfortable pressure on joints; it can create mobility issues; and it has been linked to an increased risk of developing heart disease, type two diabetes, high blood pressure, asthma, and fatty liver disease, among other health complications.
Some believed that classifying obesity as a disease would shift responsibility away from the individual and into the hands of the medical community, which could take an authoritative, scientific approach to shrinking overweight people down to what are considered healthier sizes. Calling obesity a disease could also temper anti-fat sentiment and give doctors and researchers more leverage to develop a safe and effective treatment.
In 2013, the American Medical Association recognized obesity as a disease; the Canadian Medical Association followed suit in 2015. But critics, including many fat activists, have serious issues with this classification. A disease, by definition, impairs the body’s normal functions, but there are plenty of people who are obese who lead long, healthy lives without developing high blood pressure or heart disease.
Medical associations contest that the benefits of calling obesity a disease outweigh the drawbacks. Yet this approach doesn’t account for the toll it can take on someone to be labelled “diseased” even when they may not be sick. Though our vocabulary around obesity has changed now that it’s officially a disease, our philosophy hasn’t: fat people are expected to rid themselves of their fatness at all costs.
There are critical flaws in the common definition of obesity, which is based on the body mass index. BMI is an estimate of body fat calculated based on height and weight measurements. In 1998, the World Health Organization issued international standards that determined, among other things, that if a person’s BMI landed above thirty, they were considered obese.
The BMI is controversial. In the 1830s, Belgian scientist and sociologist Adolphe Quetelet created what would eventually become known as the BMI to determine what body the socially ideal man would have. He based it on the measurements of white European men of his time, and didn’t intend for it to be applied to the bodies of women or people of colour. He also developed his system long before the contemporary stigma around obesity began to take root. Some doctors now apply additional measurements, like waist circumference, to determine whether a patient’s size is considered healthy. But size alone is not an effective measure of a person’s health.
“Obesity is a very complex neuro-behavioural, hormonal, and genetic disease that has a very high interplay between the patient’s body and the environment,” says Ashley White, an emergency physician with an obesity medicine practice in Oakville, Ontario. “To reduce that to height for weight really puts patients at risk of being poorly understood.”
Yet the mainstream treatment for obesity remains the same as what it was before it was called a disease, which is to lose weight. For some, reaching a so-called healthy BMI is untenable. No amount of dieting or exercise will change that. Yes, they might drop pounds, maybe hundreds of pounds, but they would likely regain them.
“The body has no idea that being in a large body is so wrapped in social turmoil.”
Arya Sharma, a leading obesity expert for over two decades and an emeritus professor of medicine at the University of Alberta, compares losing weight with pulling on a rubber band. “The minute I relax my pull, it’s going to go right back where it started,” he says.
He’s referring to something called set point theory. According to nutritional researchers William Bennett and Joel Gurin, who wrote a book about the theory in 1982, our bodies have a built-in control system that seeks to maintain a “set” amount of fat. You can lose weight through diet and exercise, but as soon as you stop your regimen, your body will do everything it can to snap back to what it was before. This is a survival tactic on the part of the body, which has evolved to protect us from starvation.
In the 1990s, a drug combination called fen-phen, short for fenfluramine and phentermine, exploded in popularity, promising easy, harmless weight loss. The pills suppressed appetite by encouraging the brain’s production of serotonin and dopamine, which are released during eating and digestion. Time ran a cover story in 1996 calling a version of it “The Hot New Diet Pill.” But shortly after doctors began prescribing fen-phen, an alarming number of its users developed heart complications. In 1997, the Food and Drug Administration ordered the removal of fenfluramine and a related drug, dexfenfluramine, from the market. By 2000, over 9,000 lawsuits, linked to the side effects, had been filed against American Home Products, a maker of fenfluramine. Although fen-phen was a catastrophe, its prevalence introduced to the American public the idea that the problem of obesity had a pharmaceutical antidote—a belief that haunts us to this day.
Unlike fen-phen, treatments like Ozempic mimic a hormone called glucagon-like peptide-1, or GLP-1, which the body naturally releases in response to eating. They trick the brain into feeling full. In many cases, that helps induce weight loss. But to maintain the reduced weight without making lifestyle changes, you have to take these medications indefinitely; research shows that patients tend to regain weight after stopping use. In the last three months of 2022, over 9 million prescriptions were written for Ozempic, Wegovy, and similar drugs in the US alone. It was reported in late 2023 that Novo Nordisk, the Danish company that produces both drugs, had a potential value of $418.1 billion (US)—well over the 2023 GDP of its home country.
There have been some reports of grave side effects. One particularly harrowing story published in Chatelaine last fall told of a woman whose digestive system effectively stopped working after taking Ozempic; she was vomiting uncontrollably and incessantly for years, and doctors found undigested food “fermenting” in her stomach.
Some critics of the rise of GLP-1 drugs argue there are more holistic ways to combat obesity. “Many obesity-related health problems are worsened by circumstances that could be helped through policy,” wrote The New Yorker’s Jia Tolentino last year, citing solutions such as raising the minimum wage for more people to be able to afford nutritious food and regulating junk-food additives.
But even this argument presumes that obesity is something we should aim to end. Doctors like White are advocating for a more expansive medical definition of obesity, one that allows for big but healthy people to avoid medicalization without alienating patients who might genuinely need treatment. White’s definition identifies obesity not as something that lives and dies by lifestyle choices but as a condition with many possible causes that are difficult to untangle from one another. Beating into people that they simply need to shed weight to become healthy comes with a slew of potential consequences—eating disorders, depression, anxiety. And rapid weight loss comes with its own set of potential symptoms, such as gallstones, malnutrition, hair loss, headaches, and constipation, to name a few.
This historic moment in the war on fatness can be defined by a condition other than obesity—not a biological disease but a cultural one. “The body has no idea that being in a large body is so wrapped in social turmoil,” says White.
In 2019, Harvard researchers published a study examining how various prejudices evolved among Americans from 2007 to 2016. They looked at explicit biases, which are intentionally expressed (“Gay people are disgusting” or “I hate Black people”), and implicit biases, prejudices we may not be aware of but which influence the way we treat and judge others.
The results were mostly reassuring. The study found that implicit stigma against gay people, Black people, and people with dark skin had decreased. The same was not true of the implicit bias against fat people, which the study found had increased by 40 percent over a six-year period.
The researchers suggested this rise in anti-fat prejudice could be attributed to a rise in the related beliefs that being large is unhealthy and that fat people have agency over whether or not to lose weight. In essence, people seemed to believe it’s wrong to be homophobic or racist because you can’t choose to be gay or Black, but many believe you can choose to be fat.
A vicious cycle springs from this bias: the stigma and shame baked into being fat results in an endless cycle of weight loss and gain. But research shows that many of the health risks correlated with obesity can be meaningfully reduced if a person drops just 5 to 10 percent of their body weight. It’s a reasonable goal; if met, it can help prevent heart disease or type two diabetes without pulling the rubber band too tight.
It’s not so simple to tell an obese person, who may have internalized any number of negative messages about their size, to stop losing weight. “These are people who hate themselves because of their body size,” says White. She says they may get validation and approval from others for the weight they’re losing, which in turn can boost their self-esteem and encourage them to lose more weight. But the weight loss could be hurting their health more than helping it. As White puts it, “Fit is not better.”
If we were to uproot our hatred of fat people, then perhaps some of the health risks associated with obesity could diminish too.
Deborah McPhail, an associate professor in the department of community health sciences at the University of Manitoba, says the quest to eradicate fatness is akin to “eradicating difference.” She is wary of any drug that promotes intolerance of a certain kind of body.
For decades, fat activism and the body positivity movement have tried to counteract anti-fat bias by spreading a message of radical self-love, where we can learn to accept the bodies of others no matter how different they are to our own. There’s evidence that discrimination, especially the potent kind levelled against Black and Indigenous people, is linked to the disproportionate levels of diabetes, high blood pressure, and heart disease experienced by those communities. It’s not a stretch to suggest that anti-fat bias, like any other form of discrimination, could similarly cause negative health outcomes for those on its receiving end. If we were to uproot our hatred of fat people, then perhaps some of the health risks associated with obesity could diminish too. “That would be my ideal utopia,” says McPhail. “But that’s not going to happen.”
I conceived of this essay to test a hypothesis of mine—that the harm of calling obesity a disease outweighs the benefits because it reinforces the contested idea that fatness is inherently unhealthy. I found it shameful that we were pathologizing people merely because they were bigger. I thought that we should just leave obese people alone and not coerce them into taking costly weight-loss drugs for the rest of their lives. Then I met Jean.
While Jean (not her real name) was undergoing treatment for stage three lung cancer eight years ago, she was told to eat excessively, to gain as much weight as she could and store excess energy as she weathered debilitating treatments. Forty-four rounds of radiation, twenty-three rounds of chemotherapy, and eighty pounds later, something miraculous happened: Jean’s tumours completely disappeared. Her oncologist couldn’t explain how the seemingly impossible had come to pass, but they said eating so much may have helped Jean, now seventy-one years old, survive.
Before she had cancer, Jean weighed 156 pounds. With her cancer in remission, Jean now had an unforeseen obstacle to face: she had become obese, and developed a new slew of health problems, including type two diabetes.
In 2023, Jean’s doctor prescribed her a very low dose of Ozempic. Almost instantly, Jean’s blood sugar levels evened out and stayed there. Within a few months, she had dropped twenty-one pounds. She’s careful to note that her priority is to regulate her blood sugar and remain on top of her health. But she admits she’d like to drop the pounds she gained while she had cancer. It would help her move around more easily. It would help her fit into her old clothes.
Jean’s is an exceptional case. Her weight gain was the product of a victorious bout with cancer, but her age and reduced state after falling into remission prevent her from losing weight through dieting or exercise. Just as we shouldn’t shame people for their size, it’s equally misguided to judge them for doing what they can to make their lives easier.
I met Jean in her apartment, a one-bedroom in Pickering with huge glass windows that let the sunlight flood in. She greeted me with homemade chocolate cupcakes, baked from scratch and iced with care. Jean used to have a sweet tooth and often bakes but ends up throwing a lot out or giving treats away because Ozempic limits her appetite. She seemed thrilled to be sharing her creations with someone.
After our conversation, she took me to her bedroom. She rifled through a large white box in her closet. She pulled several colourful dresses from the box—her pre-cancer clothes, which Ozempic might help her wear again.
She told me about her only grandson, an energetic toddler. He was born a few months after Jean’s cancer went into remission. She showed me a video of him crawling around her living room floor. She beamed as his little voice cooed from her phone. “I have so many blessings,” she said. She knows how close she was to never meeting her grandson. She wants to stay healthy for him. “I’m hoping the weight loss will promote that.”
KC Hoard is an associate editor at The Walrus.
Key Bennett (cmykeyz.com) is a Hamilton-based illustrator and art educator.
