the diabetes diet

how off-label drugs are changing the landscape of weight loss

Before the COVID-19 pandemic, the only time most of us heard the term “epidemic” being thrown around was in relation to the obesity crisis in North America. The paradigm has never been constant, always affected by new research, new social movements, and new diets (fad or otherwise). It felt like everyday we heard about Atkins, keto, intermittent fasting, or some other way to lose weight as a “shortcut” to a balanced intake of food and regular exercise. Then, in the 2010s, there was a new cultural shift that had been brewing for decades which rejected “fatphobia” and promoted body positivity; at the extreme end, there was (and is) the oft-touted and misleading statistic that “95 percent of all diets fail” and so we should essentially give up, accept ourselves as we are, and argue that the promotion of weight loss is equivalent to eugenics. 

The body-positive attitude to obesity always rang somewhat hollow. While it became impolite in more progressive circles to openly signal admiration for thinness or a desire to lose weight, the eternal fascination with the latest and greatest innovations in “wellness” — Crossfit, hot yoga, pilates studios, and trendy spin classes — in those same progressive circles made it hard to believe that their inhabitants had actually given up their desire to become or stay thin. 

The tug-of-war between fat acceptance and liberal “wellness” is in full swing today, but a new entrant into the space has changed the paradigm in a heretofore unseen way: drugs formulated to treat diabetes that happen to have a huge positive effect on weight loss. Suddenly, a decades-old promise associated with shady supplements and dangerous pills — weight loss without diet, exercise, or lifestyle changes — seems to some to have been brought into reality by modern science. 

Three drugs — Ozempic, Wegovy, and Mounjaro — as well as other similar drugs becoming household names have upended the weight loss industry as we know it. Originally formulated to treat type 2 diabetes, the first two of these drugs, both developed by Danish pharmaceutical company Novo Nordisk, slow the passing of food out of the stomach and into the intestines. This makes you feel full longer, which reduces your appetite, thus leading to lower calorie intake and subsequent weight loss. The mechanism is fairly simple, but it comes with side effects and complications that have had a terrible impact on the lives of some users of the drugs. Mounjaro, formulated by American company Eli Lilly and awaiting FDA approval to treat weight loss, has an additional mechanism that has the same effect at a higher intensity and could therefore have the same detrimental effect on the unlucky patient. While these drugs have been a godsend for many, the social, medical, and financial implications of their effectiveness and rocketing popularity throughout the world and especially in the West shouldn’t be ignored. 

Let’s start with the social effects: for one thing, many celebrities openly admit to using the drug to lose weight, which, while it may perpetuate problematic beliefs about the moral value of thinness, is at least a step in the right direction. Celebrities being honest about the steps they take to pursue modern ideals of beauty, which the average person does not have the financial means to go through with, will hopefully encourage people to correctly see them as extravagant luxuries rather than goals attainable for the average person (to be clear: we are not saying weight loss is unachievable for the average person, but that a face and figure like a Barbie doll or GQ model take time, effort, and money to maintain and these are in short supply for most). From svelte figures to small noses, expensive procedures and regimens like cosmetic surgery, personal trainers, and now off-label prescriptions for weight-loss drugs are largely responsible for the perceived beauty gap between the celebrity and the average layperson. Without insurance, a one-month supply of Ozempic, Wegovy, or Mounjaro costs about $900. Considering that these drugs must generally be taken indefinitely for weight loss to be maintained, a drug-assisted weight loss regime can easily cost hundreds of thousands of dollars over a person’s lifetime. 

Although private insurance can help bring these costs down, not all plans are willing to cover use for weight loss, particularly off-label use of Ozempic (which is technically meant to aid with type 2 diabetes). And in countries where prescription drug costs are publicly paid, the huge demand for drug-assisted weight loss is threatening to wreak havoc on healthcare finances: massive demand for newly available weight loss drugs was nearly single-handedly responsible for a 10% increase in prescription costs for the United Kingdom’s NHS in the 2022/23 fiscal year, and Canadian authorities were forced to ban export of the drug after a wave of Americans seeking to order the drug at cheaper Canadian prices (roughly C$300 per month’s supply) contributed to local shortages. Denmark, on the other hand, has had its economy boosted by these drugs — its GDP grew by almost two percent in the first quarter of 2023. This was almost single-handedly due to Novo Nordisk, which is expected to have a 37 percent increase in profits this year; without the pharmaceutical sector, the Danish economy would have shrunk almost half a percent. 

There are side effects of these drugs: the most common is gastroparesis, which is the delay or halting of food passing from your stomach into your bowels. While to some extent this is the intended effect of these drugs, it can become too intense for some, causing them to suffer from nausea and acid reflux, vomiting of food eaten hours earlier that remains undigested, inability to eat because of the blockage in their stomach, abdominal pain and constipation, and weight loss more extreme than is healthy to endure in a short time with the consequent malnutrition that occurs from understandable loss of appetite. This can mess with blood sugar levels, which is especially dangerous for those who are suffering from diabetes and are taking the drugs for their originally formulated purpose. There is also hair loss, known as telogen effluvium, which is not necessarily a side effect of taking these drugs but of the rapid weight loss that results; sudden weight loss is a stress on the body, which can cause all your hair to go into resting phase at once rather than the usual varied cycling of resting and growing. A very small number of patients have reported suicidal thoughts after beginning their semaglutide/dulaglutide regimen, though this has not been reported in clinical trials and may be related to comorbidities. 

These comorbidities are hard to put numbers on — some of the same conditions that may be directly treated by these drugs may also benefit from them indirectly by way of weight loss. Excess weight puts pressure on organs and joints, and indicates a less-than-ideal diet and exercise regimen, which impacts overall health in multiple ways. If weight is lost through reduced calorie intake alone, it may be the case that patients taking Ozempic and similar drugs without altering their lifestyle are still unhealthy.

That’s something we agree with the fat activists on — that being thin does not mean you are healthy. On everything else, we disagree: the success of these drugs for weight loss proves that simply eating less (whether from willpower and intention or from chemical suppressors of appetite) is enough to lose weight. Yes, it’s biology; but biology is not fate. Now, not having the fortitude to “just eat less calories” on one's own is not a moral failing; but clearly, even if 95 percent of all diets fail, it is people who are responsible for their own health and their own weight.