Is Everyone on Ozempic?

Weight is something that I’ve thought about every single day of my adult life,” says Jennifer Blackburn*, a 49-year-old public relations professional in Toronto. Following decades of trying different diets and medications—and finding little success—in fall 2022 she started taking Ozempic, the diabetes drug that has become synonymous with celebrity weight loss.

“It has been life-changing,” she says. US health-care providers wrote more than nine million prescriptions for Ozempic and similar drugs during the last few months of 2022, around the time Blackburn received her script. Some 890 million adults have obesity worldwide, and weight-loss drug sales are forecast to grow to as much as $100 billion by the end of the decade. No wonder obesity medications are a hot topic. But there’s still mass confusion around who should take them, whether the potential side effects are worth it, and whether people who truly need them can access—and afford—the limited supply. 

How do the new obesity drugs work?

Ozempic was approved by the FDA in 2017 for the treatment of type 2 diabetes. Once the manufacturer, Novo Nordisk, tapped into the drug’s added benefit of triggering substantial weight loss, it soon had another drug in the works: Wegovy, with a higher dose of the same active ingredient, sema-glutide, was approved in 2021 for the treatment of obesity. The company also makes an oral form of semaglutide called Rybelsus for type 2 diabetes.

In addition to semaglutide, there is also tirzepatide, which is prescribed as Mounjaro for diabetes and Zepbound for obesity. (Again, the active ingredient is the same, but the drugs are prescribed under different names with slightly different doses.) Another diabetes drug, liraglutide, is marketed as Saxenda for weight loss. And dulaglutide is sold as Trulicity for diabetes management.

Due to staggered release dates of these medications and fluctuations in their availability, some people without type 2 diabetes (such as Blackburn)have been prescribed the diabetes drugs for the treatment of obesity. The practice of prescribing drugs ‘off-label', which means for a use other than the one the medication is approved for, is not uncommon.

Semaglutide and tirzepatide work for people with type 2 diabetes by ­helping the pancreas produce more insulin when blood sugar is high and by preventing the liver from releasing too much sugar. And they provide a third action, the one that’s getting all the attention: As GLP-1 (glucagon-like ­peptide 1) receptor agonists, they mimic the gut hormone that communicates fullness to the brain. This false fullness cue helps patients eat less, which leads to weight loss—as much as 15 to 20 per cent of a patient’s body weight. (Tirzepatide has the added benefit of also triggering a hormone from the small intestine, which speaks to the fullness centre of the brain as well.) Other than Rybelsus, which is a daily oral tablet, they are all given as a self-administered injection just under the skin of the thigh, the abdomen, or the back of the upper arm. Saxenda is a daily jab, while the others are taken weekly.

For most people, the doses will need to continue indefinitely. Once someone stops taking the drug, their hunger cues are likely to return to their baseline and the weight comes back. “The first time I see a patient, I tell them this is meant to be a long-term treatment plan,” says Nidhi Kansal, an obesity medicine specialist at Northwestern Medicine in Chicago.

Whom can these drugs help?

According to the Centers for Disease Control and Prevention (CDC), more than 4 in 10 Americans have obesity. Defined as a body mass index (BMI) of 30 or higher, obesity puts a person at increased risk of a range of health problems, from heart disease to sleep apnea. (It should be noted that BMI is a screening tool and does not on its own determine a person’s fitness or health.) In obesity, metabolic hormones can be dysregulated, which means that for some people who are trying to do the right things in terms of diet and exercise, their bodies just won’t respond the same way.

“That’s where medication has been a game-changer,” says Dr Kansal. But since Oprah Winfrey and a slew of other influencers have raved about their slimming successes on these drugs, it seems everybody wants to try them. The overwhelming demand has led to shortages. Throughout 2023, people with type 2 diabetes struggled to access Ozempic. Periodic shortages are expected to continue this year. Novo Nordisk recently announced an earmarked $6.5 billion to boost production facilities to bolster its global supply chain.

Those who can access these drugs face a significant financial cost. “These medications are mind-blowingly ex­­pensive,” says endocrinologist Amy Warriner, director of the University of Alabama at Birmingham weight-loss clinic. A monthly supply of Wegovy or Zepbound will set you back more than $1,000 (`83,290). Some private insurers won’t cover the cost; some place strict restrictions on who is eligible.

Seniors face an added challenge: “Medicare blocks all of these medications,” says Fatima Cody Stanford, an obesity medicine physician scientist at Massachusetts General Hospital. She hopes that the Treat and Reduce Obesity Act, a push to lift Medicare’s ban on weight-loss drugs—a movement that has been underway for over a decade—will finally be passed, expanding and updating coverage. In the meantime, dozens more obesity drugs in development are certain to increase competition and eventually drive down prices.

Still, there is big money to be made. In spring 2023, WeightWatchers acquired Sequence, an online weight-loss coaching company that provides support for diet and lifestyle modifications—as well as for use of prescriptions. Earlier this year, Eli Lilly and Co., makers of Mounjaro and Zepbound, launched a telehealth service called LillyDirect, where patients can, in consultation with an online health-care provider, order the drugs directly to their door.

Some practitioners worry that people are basically working around seeing in-person physicians who would be unlikely to prescribe to them, or turning to unregulated private telehealth services and weight-loss clinics to get unapproved generic versions of the drugs without a prescription. “This is very concerning, as we are not sure what patients are actually taking,” says Dr Warriner.

How well do they work?

For perspective, it helps to compare these drugs to the alternatives. “Only 5 to 10 per cent of patients seeking treatment for obesity are going to get significant weight loss with diet and lifestyle modifications alone,” says Dr Stanford. Bariatric surgery (where a large portion of the stomach is removed) has a high success rate (between 50 and 85 per cent depending on the type), but not everyone is a candidate, and many patients don’t want to go under the knife.

The third option is a class of oral weight-loss drugs. The ‘old generation’ of obesity medications, such as phentermine with topiramate (Qsymia) and bupropion plus naltrexone (Contrave), help most patients lose an average of 5 per cent of their body weight. These medications are much more affordable than the newer ones, but the results aren’t nearly as impressive.

By comparison, studies show that those taking Wegovy shed an average of 15 per cent of their weight. The results for Zepbound are even better, with patients losing 20 per cent or more of their body weight when the drugs are taken in conjunction with exercise and dietary changes. “These are results we’ve never seen before,” says Daniel Drucker, an endocrinologist at the Lunenfeld-Tanenbaum Research Institute in Toronto, who helped identify the hormone that gave rise to these medications. But that’s if, and only if, the medications work for you. “This is not talked about enough, but I do have patients—about a quarter of them—who are minimal to non-responders,” says Dr Stanford. “That’s why I don’t use phrases like miracle drug, because it’s only a miracle if it works for you.”

What else can they do?

The benefits extend beyond the number on your scale, says Daniela Hurtado Andrade, an endocrinologist at the Mayo Clinic in Jacksonville, Florida. The largest semaglutide study to date, published in the New England Journal of Medicine, found that the drug reduces the risk of heart attacks, strokes and cardiovascular death by 20 per cent. The patients in the study were all 45 years and older, overweight or obese, and had cardiovascular disease. Also, only 3.5 per cent of the patients taking semaglutide progressed to having diabetes, compared to 12 per cent in the placebo group. And a major new study published in the American Heart Association journal Hypertension found that people with obesity taking Zepbound experienced a significant drop in blood pressure.

“These medications are life-changing for so many people, allowing significant weight loss, but more importantly, leading to impressive health benefits including medical reversal of diabetes, improved mobility, reduced liver disease due to fatty infiltration and so many more,” says Dr Warriner.

Because we already know that GLP-1 drugs reduce inflammation in the heart, kidneys and liver, researchers are hopeful that this effect could be applied to treat inflammatory diseases of the brain and eventually Parkinson’s and Alzheimer’s diseases. Additional research is looking at the potential of these drugs to treat non-metabolic conditions related to the reward centre of the brain, such as drug addiction and alcohol abuse.

But are weight-loss drugs really the answer?

Despite all the benefits, there are some definite downsides. Mental health issues are not listed among Ozempic’s possible side effects, but in July 2023 the European Medicines Agency (Europe’s equivalent of the FDA) said it was looking into a risk of thoughts of self-harm and suicidal thoughts with the use of Ozempic and similar drugs. Wegovy comes with warnings for depression or thoughts of suicide.More common side effects include a range of gastrointestinal issues, including nausea, constipation and diarrhoea. As many as 15 per cent of patients experience side effects, says Dr Kansal. Ozempic’s list of possible serious side effects includes inflammation of the pancreas, kidney failure, gallbladder problems and thyroid cancer. In August 2023, Eli Lilly and Co. and Novo Nordisk were sued over claims that their drugs caused gastroparesis, a disorder that makes food move too slowly through the stomach on its way to the small intestine, which can cause severe pain, vomiting and dehydration. As of February 2024, over 55 personal injury lawsuits against Ozempic had been combined into a federal litigation that could grow to as many as 10,000 plaintiffs. The companies deny the claims. (At press time, all cases are ongoing.)

And a report published in the Journal of the American Medical Association has established a link between the use of GLP-1 agonists for weight loss and a risk of serious gastrointestinal conditions. Researchers looked at health insurance claims from more than 5,000 patients in the US and compared four gastro­intestinal problems, including gastro­paresis, in patients prescribed these drugs. Among people taking semaglutide, gastroparesis was seen at a rate of about 10 cases per 1,000.

“A rate of 1 per cent initially may seem small, but when you put it into the context of millions of people taking these medications, that could potentially affect tens of thousands, if not hundreds of thousands of people,” says the report’s lead author, Mohit Sodhi of the University of British Columbia Faculty of Medicine in Vancouver. With all this in mind, the experts we spoke with say we have sufficient data on the drugs to allow people—those who need them for medical use and have been prescribed under the care of a doctor—to feel confident taking them. But we don’t know how the use of the drugs might play out over decades, or what some of the side effects of rapid weight loss will mean in the long run. (There are already some concerns about decreases in muscle mass and bone density.)

Despite all their potential, what the new obesity drugs can’t seem to cure is the stigma of obesity. “It’s a myth that obesity is a choice,” says Dr Stanford. “The reality is that obesity is a disease.” And still, the world judges people with obesity harshly—and people often condemn themselves too. “They think they are failures, and they think they are cheating if they are using a drug to manage their disease,” says Dr Kansal. “We don’t think about any other medical diagnosis in this way.”

Jennifer Blackburn has discovered a new life on Ozempic. She has lost 35 pounds (and kept it off) and gained a new appreciation for her body. She no longer drinks, she is excelling at work, and she has started travelling, booking several walking trips in recent months.

“I feel happier, more confident, and I guess the word would be empowered,” says Blackburn. “It’s about so much more than size—it’s like the weight has been lifted off my shoulders.”