From diabetes medication to weight-loss wonder drug: Ozempic’s popularity raises big questions

The most important thing to ask oneself when prescribing Ozempic for obesity is whether you are approaching its prescription as you would the prescription of any medication for any other chronic noncommunicable disease. If the answer is no, then I don’t think you’re doing a very good job because obesity is a chronic noncommunicable disease.

Obesity has major medical impacts on patients as far as health risks and quality of life. The suggestion that we need to think differently about its prescription is a position that is borne out of societal weight bias, implicit bias and internalized bias. What prescribers need to ask themselves is, “Does my patient qualify for its prescription on the basis of the medical criteria that has been laid out for it and approved by Health Canada?” If the answer is yes, then you should discuss this with your patients. You don’t need to prescribe it, but you should be discussing it free from bias to explain what it does and how it works.

The suggestion that we need to think differently about [Ozempic’s] prescription is a position that is borne out of societal weight bias.

What is getting in the way of prescribers using it like they do with every other medication for every other chronic medical condition: free from blame, free from stigma, free from auditioning to have to somehow qualify for it? Even though patients meet the medical criteria, now they have to qualify for it by jumping through behavioural hoops. The real question should be “What is wrong with medicine that we can’t let go of our bias around obesity to utilize this incredibly effective medication?”

There’s a wealth of research exposing the bias in medicine versus people with obesity. I see it in my practice all the time when I hear about the way other doctors are denying patients medications that can be useful or the way they discuss them. It would be mind boggling if we were talking about anything other than obesity.

It’s a really problematic position to suggest that there is something beyond medical need and criteria that should be applied to this drug or this condition alone. But that’s what we’re seeing.

When Ozempic is prescribed for weight loss, physicians reinforce the idea that being fat is not an allowable way to be in the world. Being fat is difficult because we live in a world that restricts access to fat folks from many aspects of social and cultural life. The examples of this are numerous – access to social spaces, travel, self-expression through clothing, etc. – and yet fat people still persevere even in the face of ongoing and systemic fatphobia.

When Ozempic is prescribed for weight loss, physicians reinforce the idea that being fat is not an allowable way to be in the world.

We live in an inherently fatphobic world, and now we’re being offered this miracle cure, which is not a cure because people will be on it for the rest of their lives. If they do come off it, their bodies will revolt against being restricted and, like many other weight-loss products and diets, they will likely regain the weight, oftentimes gaining more than they lost. We’re being offered a treatment plan that comes with significant physical and psychological harm, and it’s very seductive because we live in a fatphobic world.

Conversations about weight are also tied to conversations around race, class and gender. Thinness has been intimately tied since the Enlightenment to conceptions of male, white rationality. Thinness is access to whiteness, and with that, there is a social and cultural privilege that some individuals deeply desire. We cannot untie the connections between fatphobia and white supremacy. When people push back against being fat, it’s because fatness has been ascribed to ideas around dim-wittedness, laziness and conceptions of bodily incapacity, characteristics that have also been wrongly associated with Blackness.

It’s also incorrect to associate weight loss with health. Medical sciences invented a term called the “obesity paradox.” It’s a concept that helps explain why people with higher body masses are more likely to survive certain traumatic events. Whether it’s car accidents, diabetes or certain cancers, carrying more weight has been proven statistically to improve people’s health outcomes, especially in older people. That’s not to deny that people with excess adipose tissue are more likely to experience things like diabetes or heart disease. But these are multifactorial diseases. You cannot just say that obesity causes heart disease or obesity causes diabetes. Being fat, one’s genetic makeup and many other social and cultural factors produce these experiences, so it’s simply too easy to claim that having more weight causes disease and having less weight means one is healthier. And even if being fat meant worse health, it does not mean that fat, ill people don’t deserve access to care or access to full and complete lives.

Psychologically, hating your body is also not a healthy way to move around in the world. Thinking that you are in a fight with your body to the point where you’ll accept nausea, vomiting and diarrhea (common side effects of Ozempic) to excise parts of your body has consequences. We should instead focus on dismantling fatphobia, learning about body acceptance and fat liberation – fat joy and desire – and begin to teach young people that their bodies, whatever size or shape, are beautiful and whole. These efforts would have a much more profound impact on fat people’s lives than a drug that might help them become less of themselves, take up less space or be less abundant.

The first thing to understand is that semaglutide has been approved by Health Canada as an anti-obesity treatment. When this discussion comes up, it’s often because people think this is just an off-label diabetes drug and ask why we’re using it for weight loss. But if you take a step back and realize it’s actually already gone through the approval process and has been studied as an anti-obesity treatment, I think that can take the edge off people’s concerns.

Having any anti-obesity therapy available to patients who have traditionally struggled on their own to eat less, exercise more and do all the things that are recommended is really valuable. I do think that pharmacotherapy, whether it’s Ozempic or any other obesity medication, needs to be one tool in a toolbox for treating a very complex disease that has a whole lot of psychological and behavioural components.

My impression is that this is a medication like any other.

But we do need to have medical treatments available to address the changes in metabolic physiology that make it harder for some people to lose weight. My impression is that this is a medication like any other. It’s like asking me if I have any concerns prescribing Tylenol for someone who has a headache. Why shouldn’t someone with a headache have analgesia? Why shouldn’t someone with obesity have an anti-obesity medication? And I think that goes back to weight bias and how many people don’t really believe that obesity is a disease.

The challenge is that obesity is not under behavioural control. Weight is not a behaviour. What we know about weight management is that we have no idea how much weight any person will lose from any treatment. If you decide you’re going to go on a ketogenic diet, how much weight are you going to lose? Nobody can predict. It’s completely individual.

Ozempic is interesting because it’s almost like a false promise to the public. It’s challenging because it’s normal for people to want a “magic bullet” to solve their problems. Though Ozempic is quite groundbreaking, we have to be mindful about managing patient expectations.

Weight isn’t something you can turn up or down on a dial. It’s a function of biological, genetic and sociocultural determinants. Three people can do exactly the same thing, from bariatric surgery to medication to exercise, and they will all lose different amounts of weight. Excess weight is also not a moral problem – it’s not that you’re weak or lazy or all these biases that we’ve established against people living in larger bodies. Bodies come in all shapes and sizes.

We’re so weight obsessed in our society, my concern about this whole issue is it may appear to the public like Ozempic is a magic pill. While this new medication is proven to be very safe, we want to try to help people while not contributing to people’s bias against obesity.

We need to reframe obesity as a chronic disease where it’s not about weight, it’s about health.

My biggest fear is that we will lose the chronic disease part of the condition and it will just simply become a piecemeal treatment. That’s not likely to work when you just take a very simplistic attitude. In complex conditions like lifestyle-related diseases such as asthma, hypertension, arthritis, etc., you need a number of different interventions to manage them, including lifestyle changes. But we also know that only 10 to 15 per cent of people can actually change their behaviour significantly on their own to make those things happen.

We need to be compassionate toward people and support them, but we need to be careful about not falling into the trap of prescribing this drug to patients just to keep them happy for a period of time. That’s in part what’s happening now with the shortages of Ozempic.

We need to reframe obesity as a chronic disease where it’s not about weight, it’s about health, function and quality of life. But I’m happy these conversations about weight can start happening at a public level. I think people are sick and tired of being made promises that they can’t keep when they set out with the goal of changing their body shape.

The World Health Organization recognizes obesity as a chronic complex disease and a public health crisis. From 2015-2018, data showed that more than one in four adult Canadians (26.6 per cent) are living with obesity. Factors contributing to the obesity epidemic are complicated and wide-ranging and include system-level drivers like processed food and drinks with high caloric content; urban design and “food deserts” where residents have limited options for fresh food and groceries; and insufficient access to obesity management programs from the health care system. These drivers are also linked with disparities in social determinants of health. Much like all public health crises, addressing the obesity epidemic requires multilevel, cross-sectoral efforts.

While semaglutide, or Ozempic, appears to be effective for weight loss, it is not risk-free. The most common side effects are nausea, vomiting, diarrhea, abdominal pain and constipation. More serious adverse events are pancreatitis, hypoglycemia, cholelithiasis, acute kidney failure and diabetic retinopathy. Animal studies have reported thyroid cancer as a serious adverse event.

With news reports and social media promoting semaglutide for weight loss, Health Canada issued a notice to educate the public about the use of semaglutide to ensure sufficient supply for patients with diabetes are available. In the U.S., the (Food and Drug Administration) warned the public against unregulated production of compounded Ozempic, altered medications that may not act the same as the original, as well as the under-researched over the counter supplement, Berberine, or so-called “natural Ozempic,” both of which are risks to public health. Uncertainties of semaglutide include post-treatment weight management, especially in the absence of sustained lifestyle interventions. More importantly, post-marketing “real-world” data on efficacy and safety may take years to be recognized.

“Real-world” data on efficacy and safety may take years to be recognized.

Nevertheless, some jurisdictions outside of Canada, such as the U.K. NICE Guidance, have recommended to publicly fund semaglutide for weight loss, recognizing the significant health and economic burden of obesity, such as diabetes, hypertension, stroke, kidney failure and mental health issues, as well as the disproportional impact of obesity affecting those in lower socioeconomic groups.

The long-term benefits and risks of semaglutide remain to be fully understood. From a global health perspective, its high cost means it remains out of reach for many affected by obesity. It can be a welcome part of the toolkit to tackle the obesity crisis, though not the panacea, especially if the structural and system-level causes of obesity are not addressed.