Will Ozempic Change How We Think About Being Fat and Being Thin?

“Let’s be honest,” she said. “I was not healthy at over two hundred and twenty pounds, being five-four.” She needed something to get her back to a state of equilibrium, and semaglutide appears to have done it. “If we get past this as a celebrity-weight-loss headline story, and we see this for what it really is, it’s revolutionary,” she said. “In the future it might be like taking vitamins. Everyone’s going to be on it.”

This past November, I created an account on a telehealth Web site that looked as though it had been designed in about forty-five minutes using stock images and a free template. I filled out a form that asked for my height, my weight, and my reason for wanting semaglutide. I entered a weight that gave me a B.M.I. of 3src. This was a lie, and I expected to be caught out during the Zoom appointment that I assumed was coming. Instead, a nurse practitioner named Nicole sent me a direct message laced with cheerful emojis. “My extensive experience allows me to provide a very wide range of services to you,” she said, adding prayer hands. She warned me that it was hard to get Ozempic covered by insurance; I replied that I would be happy to pay out of pocket.

“My patients, YOU, are suffering,” she wrote back. She said that she could connect me with a compounding pharmacy to get me three months’ worth of low-cost semaglutide. “This NEW alternate option I am providing is for ALL patients, even those with stubborn insurance, no insurance, or government insurance,” she wrote. It would cost two hundred and fifty dollars, and the fee for my “visit” would be a hundred and fifty dollars. She thanked me for my patience “during this time when it is very difficult to obtain weight loss assistance.” I asked if she would help me manage the side effects, but got no reply. I wrote again and asked to move forward with the prescription.

A few days later, I received a small cardboard box from Clearwater, Florida, in the mail. Inside was a baggie containing alcohol pads, orange-tipped single-use insulin syringes, and a vial of bacteriostatic water. Another baggie contained a two-inch vial of clear liquid—this was the semaglutide—plus a syringe with an alarmingly long needle and a single sheet of instructions for how to mix the semaglutide with the bacteriostatic water and inject myself.

The over-all vibe of this package did not inspire confidence. (Semaglutide is supposed to come in temperature-controlled packaging, and it did not.) Still, when I told people about my semaglutide stash, they were intrigued. “Should I take it and be your guinea pig?” a friend asked. I reminded him that he was already skinny. “I’m Gigi Hadid skinny,” he replied. “I could be Bella Hadid skinny.” He was kidding, sort of.

I became curious whether I could get a prescription without lying about my weight. I found the Web site of a telehealth clinic advertising semaglutide, and, this time, entered my real height and weight, that of a woman who wears a size 4. A practitioner called me the next morning; I told him that I’d had a baby in 2src2src and wanted to lose fifteen pounds. “Our program is meant for this exact kind of case,” he said. He discussed side effects—“the only one to really be worried about is mild nausea”—and told me that I wouldn’t need to do any blood work or visit a doctor. “It’s very mild, it’s a peptide,” he said. “It just balances everything out.”

Novo Nordisk has patented semaglutide, and the company has insisted that it does not sell the medication for compounding purposes, which raises the question of what compounding pharmacies are providing to their customers. These pharmacies have to comply with regulations set by state pharmacy boards and the F.D.A., and they are required to source ingredients from F.D.A.-registered suppliers, but the F.D.A. does not approve or verify compounded drugs, and the pharmacies—there are about seventy-five hundred in the United States—are primarily monitored through inspections. The rules that govern them are, a prominent figure in the compounding industry told me, “under-enforced.”

I wrote to the telehealth clinic and asked to be put in touch with its pharmacy. A co-owner of the clinic called me a few minutes later. He said that the pharmacy they used, which is also based in Florida, was selling semaglutide sodium—the salt form of the drug molecule, which is easily obtainable for bulk purchase online as a research chemical. Most drugs can be prepared in different chemical formulations, but the F.D.A. requires clinical studies of each formulation to prove safety and efficacy, and it has not approved semaglutide sodium for compounding. The Alliance for Pharmacy Compounding has suggested that semaglutide sodium “should not be used for human compounding,” and is “not a substitute for semaglutide base.” But the clinic owner insisted that, for the purposes of weight loss, semaglutide sodium was “the same thing,” and that the business with the F.D.A. was just politics. “Ozempic is so expensive here because our health-care system is capitalistic,” he said. “In socialistic health-care systems, in Europe, you can get a month’s supply for a hundred and fifty dollars.” (This is not far off—it costs about two hundred dollars in the United Kingdom.) He assured me that I could trust the Florida pharmacy and its products: it was, he claimed, where all the Hollywood celebrities got their stuff. He also said that semaglutide sodium was in such high demand that the pharmacy was testing semaglutide acetate, which hasn’t been approved for compounding by the F.D.A., either.

I asked the prominent figure from the compounding industry about the legality of compounding pharmacies using semaglutide sodium. He described it as a “gray area.” “When you dissolve semaglutide sodium in water, you end up with semaglutide base and sodium ions,” he said. He also insisted that “the F.D.A. knows this is going on, and they haven’t said a word.”

Eli Lilly and Novo Nordisk together have at least twelve more obesity medications in development. Novo Nordisk reportedly spent about a hundred million dollars advertising Ozempic last year, and the two companies are spending roughly ten million dollars annually on lobbying. A primary focus of that lobbying is the proposed Treat and Reduce Obesity Act, which has been introduced in congressional sessions annually since 2src12, and which would require Medicare to cover, among other treatments, chronic-weight-management drugs. Anticipating the passage of this bill within the next few years, Morgan Stanley has forecast that U.S. revenue from such drugs will increase four-hundredfold by the end of the decade. Obesity looks “set to become the next blockbuster pharma category,” it declared, in a report last year, which also predicted that social media and word of mouth will create an “exponential virtuous cycle” around the new medications: a quarter of people with obesity will seek treatment from physicians, up from the current seven per cent, and more than half of those who do will begin taking medicine. In March, WeightWatchers acquired the telehealth weight-loss company Sequence, which specializes in prescribing GLP-1 drugs.

Controversially, the American Pediatric Association recently included weight-loss medication and bariatric surgery as part of a set of treatments that physicians should consider for kids with obesity. (Bariatric surgery, previously the only medical intervention that resulted in lasting weight loss for more than a small percentage of people, works in part because it, too, increases GLP-1 levels, and does so before any weight loss has occurred.) In clinical trials, patients who go off GLP-1 drugs regain much of their lost weight within a year. I asked Dr. Aronne, from Weill Cornell, about the possible medical consequences of irregular lifetime use, which seems to be a likely outcome for many patients, especially those who are prescribed the drugs at an early age. “That’s a great question,” he said, “and we don’t have the answer.” He suggested that doctors might begin treating obesity the way they treat hypertension. “You could start people on a tiny dose per week, and they would never get to the place where they have catastrophic problems,” he said. Patients would still need regular blood work and other monitoring; it’s likely enough that, as these drugs come into use in a wider patient population than ever before, new risks and complications will arise. But to Aronne, who has treated patients with serious health complications related to weight for thirty years, a lifetime on Wegovy seems far less dangerous than a lifetime of severe obesity.

I had been wondering, I told Aronne, about the extent to which the excitement around this new class of drugs took the broader status quo more or less for granted. Many obesity-related health problems are worsened by circumstances that could be helped through policy—by raising the minimum wage high enough for people to afford fresh produce and high-quality protein, by investing in housing and community spaces that are conducive to recreation, by ending the billions of dollars in farm subsidies that go to junk-food additives, such as high-fructose corn syrup. “These things would work to prevent obesity, not treat it,” Aronne said. “It would be like trying to treat lung cancer through a smoking-cessation program.” This was the point I was trying to make—that we have an individual solution, but we need collective ones, too.

Omari, the Instagram-famous dietitian, is now off her compounded semaglutide, which she’d taken to shed some pandemic pounds. She was optimistic that she’d be able to maintain her weight, as she’d generally been able to do before. But, as I kept reminding Ozempic-curious friends, these medications were designed for chronic conditions, obesity and diabetes. For people who are dealing with those conditions, Ozempic appears to create a path toward a healthy relationship to food. For those who aren’t, it might function more like an injectable eating disorder. As the side effects make clear, it’s not a casual thing to drastically alter your body’s metabolic process, and there is no large-scale data about the safety of these drugs when taken by people who are mainly interested in treating another chronic condition, the desire to be thin.

Once Ozempic is off the shortage list, compounding pharmacies will no longer be allowed to sell semaglutide, but that doesn’t necessarily mean they’ll stop: the pharmacy in Clearwater that supplied my stash told me that they’d sold semaglutide before the shortage and would continue to do so after it ended. Jonathan Kaplan, who oversees the weight-loss program at Pacific Heights Plastic Surgery, in San Francisco, told me that he saw a “glimmer of hope” in tirzepatide, the active ingredient in Mounjaro: that drug is on the shortage list, too, and compounding pharmacies were already gearing up to sell it. In the meantime, Pacific Heights, which prescribes compounded semaglutide to patients who meet the medical criteria, and also provides blood-work monitoring and life-style coaching, has warned the members of its mailing list that compounded semaglutide may soon become unavailable. “You may want to join our program now so that we can reserve a 6-month supply of the medication for you,” the clinic added.

Kaplan, a plastic surgeon, is better known on TikTok as @RealDrBae—in his videos, he wears navy scrubs monogrammed “DR BAE” and talks to the camera as though it’s his partner in an absorbing conversation at an airport bar. He believes that more people—a lot more people—are going to start taking GLP-1 drugs soon. He didn’t have in mind thin people who want to be thinner, he added; he was thinking about fat people who had been struggling with discomfort, with inconvenience, with social pressure all their lives, who might have lately felt encouraged to try to accept their heavier weight. He predicted that the Ozempic era would put an end to all that. “They’re no longer going to accept that they should just be happy with the body they have,” he said. ♦