A diabetes drug is being used for ‘easy’ thinness. Is it as magical as it seems?

This story is part of the Good Weekend: Best of Features 2023 editon.See all 22 stories.

It is a sad truth that if you pinned me to a wall and offered me a magic pill to change my life – and you narrowed the choices to entirely selfish and superficial ones, rather than including options like “a pill that would reverse climate change” – I would choose one that would let me immediately lose five kilos. Or maybe 10.

I’m not proud of this choice – I am in the “healthy weight range” (just) for my age and height – but at least it’s truthful; an unhealthy hangover from a childhood filled with Kate Moss and heroin chic. But now I’m grappling with another truth. This so-called magic pill actually exists. Except it’s not a pill, it’s a weekly injection. And what’s more, people are actually using it – especially celebrities like Elon Musk (freely touting his use of its active ingredient) and perhaps the Kardashians (though they deny it). And they are actually losing five or 10 kilos, or a whole lot more. Curse them.

The name of this magic medication is Ozempic, and it’s the centre of a social media storm – #ozempic has more than 932 million views on TikTok and counting. Its use has become so rampant that last year, global supplies of the drug ran out in most places for most people. In November, Australia’s Therapeutic Goods Administration (TGA) issued a statement explaining that Ozempic would be unavailable to all patients until further shipments arrived in the country.

This may be the moment to say that – like most magic – Ozempic is not as simple as it sounds. There are three different groups of people who use it, for starters. Firstly, people with type 2 diabetes. These are the patients for whom the drug was originally developed, and the only group for whom it is approved for use in Australia. Secondly, there are people with obesity, or without it, who may be prescribed the drug by their doctors for valid weight-loss reasons, but who are using it “off label” – that is, for a purpose for which it hasn’t been officially approved. And thirdly, there are people who are neither diabetic nor obese, who have no other medical conditions requiring weight loss, but who have managed to get prescriptions for Ozempic and are using it because it offers the seductive possibility of losing relatively small amounts of weight easily and swiftly – five kilograms, perhaps. Or 10.

But why is a diabetic drug being taken to lose weight in the first place? The short answer is, it works. The long answer is that its active ingredient, semaglutide, not only increases insulin production (which is why it’s effective for diabetes) but also acts on receptors in the brain that govern appetite, and ones in the gut that slow digestion. So it promotes the sense of fullness associated with having just eaten, and it delays the release of food from the stomach. All of which aids weight loss.

It didn’t take Novo Nordisk, the Danish company that manufactures Ozempic, long to realise that they might have something more significant on their hands than just a good new diabetes medication. Even before its release in 2017, they noticed that participants in Ozempic trials were reporting significant reductions in weight. So they ran new trials of semaglutide – same ingredient, but at a new, higher dose – as a weight-loss aid. In 2021, these trials revealed that the mean weight loss of patients taking the higher-dose semaglutide was a whopping 14.9 per cent of their body weight over 68 weeks, compared with 2.4 per cent with placebo. People taking it reported freedom from cravings, loss of appetite – even an inability to eat without feeling sick.

Nobody in obesity medicine had seen anything like it since bariatric surgery began in the 1950s. Just months later, Novo Nordisk released this higher-dose semaglutide under the brand name Wegovy. As a weight-loss aid, in the two years since it was released, Wegovy has gone from strength to strength. At an obesity conference late last year reporting trial results on teenagers – a notoriously difficult group to treat for obesity – the room of sober researchers broke into wild cheers: after 16 months of injections, along with some lifestyle changes, more than a third of the 180 participants had reduced their weight by at least 20 per cent. As one scientist told the science journal Nature, the jubilation sounded “like you were at a Broadway show”.

And so we come to the Ozempic supply-crisis story – which is also a Wegovy supply-crisis story. In late 2021, manufacturing problems in Belgium, plus in 2022 the incredible demand of up to 40,000 new weight-loss prescriptions being written every week, led to Wegovy shortages. Doctors overseas – especially in the US – compensated by moving their obesity patients onto Ozempic. At around the same time, Instagram began lighting up with the news that celebrities were losing weight thanks to a dramatic new “diabetic shot” for weight loss.

Then, in May last year, Kim Kardashian appeared, looking strangely reduced, at the Met Gala, wearing a gown once owned by Marilyn Monroe. The buzz was that she’d used Ozempic to lose seven kilograms to squeeze into it. Kardashian hasn’t commented on the rumours, but the rest of the world rushed to leap on to the already overloaded Ozempic bandwagon. Cue both massive earnings by Novo Nordisk, which reported a worldwide market growth of 50 per cent in semaglutide products in a year-end earnings call for 2022, and the global Ozempic drought.

Kim Kardashian’s appearance at 2022’s Met Gala, wearing a dress formerly owned by Marilyn Monroe showcasing a seemingly dramatic weight loss, sparked rumours that she was using Ozempic.Credit: Getty Images

All this was made more complicated in Australia by the fact that Wegovy is not actually sold here. Ozempic was approved by the TGA for type 2 diabetes in 2019, and became available to patients on prescription soon after. Wegovy was also TGA-approved here last year. But at the time of writing, it was still not available for sale: Novo Nordisk has not released it in Australia, perhaps due to ongoing global demand and supply issues. In a statement to Good Weekend, Novo Nordisk says only that it is “working hard to make Wegovy available for patients living with obesity as soon as possible. The timing of its availability in Australia is not yet confirmed.”

In the meantime, the only semaglutide option for obesity patients in this country is Ozempic. They can get this on a prescription, but because they’re using it off-label, they are paying at least $130 a month for it. Patients with diabetes, meanwhile, pay only $30 a month for the same supply, because their prescriptions are subsidised by the government’s Pharmaceutical Benefits Scheme (PBS).

The confusion about what Ozempic should be used for, and who should be using it, led to some ugly moments during the shortage (which is now easing). “There were cases, especially on social media, where people with obesity were vilified during the Ozempic shortage,” says Kelly Cooper, a dietitian and spokesperson for The Obesity Collective, a national advocacy organisation. “It was unjust, and I think it shows that people don’t realise that patients with obesity are taking Ozempic on prescription, for valid health reasons.”

The waters have been muddied further by the increasing number of people who have been managing to get Ozempic, one way or another, for minor weight loss. People who don’t exercise enough; who eat and/or drink a bit too much, and who wish for a magic wand to wave a few kilograms away. (Ahem.) I know of two women who took Ozempic all through the supply crisis, though I don’t know how they accessed it. Neither has type 2 diabetes nor obesity. One is a size 14; one is a size 8.

I am simultaneously disapproving and envious of these women. I sit right between them size-wise, and I’m all too aware that there, but for a neurotic fear of freestyling medications, and an irresolute moral stance about taking resources intended for others, go I.

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Ozempic shipments (it’s manufactured in Europe and the US) began to return to Australia in February. But it’s expected to be mid-year before normal service resumes, and the TGA has asked GPs not to prescribe it for weight loss until supply stabilises. But interest in its use for “cosmetic” weight loss has not slowed at all. If anything, its scarcity has increased its value and the desperation of people to get their hands on it.

So this may be a moment to wonder what the future holds. Will Ozempic move into mainstream usage? Will Wegovy ever be sold in Australia, and if so, who will use it? How will we resolve issues of access, when obesity disproportionately affects people on lower incomes, and no semaglutide product for weight loss is currently subsidised by the PBS?

Semaglutide appears to be a fantastic advance for the 1.2 million Australians with type 2 diabetes, and for the approximately 6 million – a full third of the adult population – who are living with obesity. But what the past year has proven is that nobody has considered – not doctors, not researchers, not even Big Pharma – how being able to lose weight via medication alone will impact everyone else. We’ve failed to understand what a voracious appetite exists for so-called “easy” thinness among people who may or may not be overweight, but are certainly not medically classified as obese.

Physiology professor Michael Cowley believes a new weight-loss treatment era is emerging.

We do not know how many people in Australia are taking Ozempic for minor weight loss. “We don’t have any figures,” says Michael Cowley, professor of physiology at Monash University and former director of the Monash Obesity and Diabetes Institute. “In this country it’s only available on prescription, which should prevent inappropriate use.” But he acknowledges that GPs may well prescribe it to patients without obesity, “taking into account all the circumstances and what’s best for that patient”.

On the other hand, “It is not uncommon to get requests from patients who should not be taking it,” explains Dr Nicole Higgins, president of the Royal Australian College of GPs. “I’ve dealt with it personally, and it’s a challenging consultation. There’s a mismatch in expectations. As consumers, patients sometimes have this idea that if you want a drug, you just go to your GP and get it. That’s not our role. Our role is to prescribe it carefully and appropriately.”

Nonetheless, there are plenty of people who are prepared to ignore their doctor’s advice. “Both online prescribing services and compounding pharmacies have been heavily promoting their sale of Ozempic on social media,” adds Higgins. “There are varying levels of quality with both. There are certainly services where it is not a GP who prescribes it; where it’s seen as a business opportunity for companies, not a health solution for patients.” Cowley agrees: “There’s clearly a line being walked over.”

In recent months, the TGA has attempted to crack down on companies advertising the sale of Ozempic. (Advertising of prescription drugs to the public is illegal in Australia.) It has ordered the removal of almost 1000 online advertisements in the past nine months, mostly on social media. But the most cursory search today shows any number of companies still offering it, often from overseas, with no assurance about whether you’ll receive what you paid for; or whether, for that matter, you’ll receive anything at all. Nor, say experts, is there always proper medical oversight of such sales. “Often you just fill out a form, and that’s it,” says Cowley. Such forms theoretically constitute the examination on which a prescription is then written, but as Higgins points out, such prescriptions are not always written by a GP. As Cowley puts it: “An online form is not an adequate consultation on which to prescribe a medication – certainly not a medication like this.”

RACGP president Dr Nicole Higgins says Ozempic has to be prescribed “carefully and appropriately”.Credit: Rhett Wyman

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Today, roughly a third of Australian adults are medically classified as overweight, and a third as being obese. But though they’re often considered as one group, there are in fact significant differences between them. Being overweight – usually defined as having a body mass index (BMI) of between 25 and 29.9 – does increase the risk of developing health problems. But obesity can be a potentially serious medical condition. Defined as having a BMI of 30 or more, it can be accompanied by life-threatening comorbidities such as cardiovascular disease, various cancers, and liver and kidney disease, as well as osteoarthritis, sleep apnoea, and mobility issues. It is in this group, plus those with a BMI of more than 27 and at least one obesity-related comorbidity, that semaglutide was trialled and approved for weight loss.

There have been no such trials, however, for people using it who are just a bit overweight, or who’d like to lose a few kilos to fit into a really cool party dress. There’s no information for how semaglutide reacts in people of regular weight and metabolism. “In all likelihood it is safe,” says Cowley. “But the truth is, we just don’t know. We don’t have the scientific data. And because people in this category might not be being managed for their weight by a doctor, if there are any problems, it could take a long time to hear about them.”

What we do know is that it is no small matter to significantly alter your body’s metabolic process, food preferences and hormone production. Even in the people for whom it has been designed, semaglutide does have significant side-effects, and the potential for serious complications. Some 20 per cent of people taking Ozempic experience nausea, and gastrointestinal issues are common, including bloating, stomach pain, diarrhoea, vomiting and constipation. In at least one study, almost three-quarters of patients using higher-dose Wegovy reported some kind of gastrointestinal disorder. Beyond these common side-effects are more serious risks, including kidney failure, pancreatitis, gallstones and an increased risk of some cancers.

In Australia, says RACGP president Dr Nicole Higgins, “It is not uncommon to get requests from patients who should not be taking [Ozempic] … There’s a mismatch in expectations.”Credit: Getty Images

None of this is prohibitive if you are already battling a serious medical condition. For both clinical obesity and type 2 diabetes (which can lead to conditions including heart disease, kidney failure and blindness), effective treatment is important for basic health – and in both cases, patients taking Ozempic are already under medical management.

But if you’re not officially overweight? Or by only a few kilograms? Effects may be more intense, or more damaging. Ozempic seems to alter your reaction to food, even before you eat it. Highly calorific, fatty food especially seems to bring on nausea; as does the prospect of alcohol. Changing food preferences in this way seems like a good thing but it may have unexpected consequences. Indeed, in rare cases, it’s been associated with malnutrition, and may function, as one writer puts it, like “an injectable eating disorder”, leading people ever further away from a healthy relationship to food.

Another consideration is that semaglutide must be taken permanently to maintain weight loss. In one trial, those who stopped regained up to two-thirds of the weight they lost within a year. And while it’s been licensed for continuous use in people who have obesity and in diabetic patients, the current long-term data spans just a few years, and is totally absent for non-obese, non-diabetic patients.

There’s also the question of overall health. Today, much of the received wisdom about weight loss centres around some variant of the “better food choices and more exercise” philosophy. Novo Nordisk also specifies that semaglutide for weight loss should be taken “as an adjunct to a reduced-energy diet and increased physical activity”. But anecdotally, it appears many people are losing weight without significant lifestyle changes – and if all you have to do is pop a pill (advances on semaglutide are slated to be available in tablet form by 2026), what are the chances you’re really going to eat salads and drag yourself to the gym? These drugs create an element of moral hazard in pursuit of beauty: the idea of weight loss without effort, or care, for your body.

And what about society’s perceptions? “There’s a really entrenched stigma in society about obesity,” says Cooper, “which stems from misunderstanding of the science. There are really powerful genetic and biological drivers behind obesity, but people just see it as laziness, or lack of willpower. Hopefully, the way medications like semaglutide work will help people realise that there are biological drivers of obesity for which people may need additional support, and which respond to evidence-based medical treatment.”

Dietitian Kelly Cooper says a stigma about obesity stems from a misunderstanding of science.Credit: Simon Schluter

But despite semaglutide’s success, there is a significant number of people for whom it doesn’t work. There is also a large group of obesity patients who can’t afford it. Will they be subject to even greater criticism and social stigma than they are already, now that there is something being touted as a “cure” for the way they are? Ozempic’s popularity seems to suggest that, despite all we’ve learnt about shaming those who diverge from the narrow range of conventional beauty standards, we’re still choosing exactly those standards if we get the chance.

There are also the economic costs. Unless drugs like semaglutide for weight loss are included in the PBS, they will remain unavailable to a portion of the population. And if they are included, what will that mean for the health budget? Though reducing weight-related diseases would be an enormous saving for health care, the costs of the medication itself would also be enormous. According to the American journal The Atlantic, if every currently obese American was taking semaglutide at a cost of $US15,000 a year ($22,100, the shelf price in the US right now), the total cost would be a staggering 10 per cent of the US economy, or $US2.1 trillion a year.

One thing does seem clear: our future will only contain more, not less, weight-loss medication. Spurred on by Ozempic and Wegovy, there is a raft of new drugs in the pipeline. One, called Mounjaro, is rumoured to be even more powerful than these two, with a mean loss of 22 per cent of body weight: The Wall Street Journal has suggested Mounjaro may become the “King Kong” of weight loss. “I think it’s true to say that we are entering an era of really profound treatment for weight loss,” says Michael Cowley.

What we have to face, however, is that neither Ozempic, Wegovy, nor whatever comes after them will solve the deeper issues involving weight in our society, and in our own heads. In my heart of hearts, I know I wouldn’t be happier if I was five kilos lighter, and I know this because I have been, and I wasn’t. Thanks to the world we live in, it’s incredibly difficult to be at peace with the way we look. That’s really the magic pill we need: being happy as we are.

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