Opinion

I lost 40 pounds on Ozempic. But I’m left with even more questions.

To Dr. Neal Barnard, all of this is head-exploding. Barnard is founder of the Physicians Committee for Responsible Medicine, which advocates “prevention over pills” and sees pharmaceutical manufacturers such as Novo Nordisk as complicit in creating a “false narrative” that people can’t control weight on their own — that “you need this injectable drug and you need to pay us $15,000 a year. That is a deceitful marketing campaign.”

“I’m not suggesting there is never a role for medication or for bariatric surgery,” Barnard told me. “I’m saying those indications are rare.” In fact, he argues, “what people need to know is that a truly healthful diet allows for weight control without calorie counting or exercise.” Becoming vegan, Barnard says, has the same effect as injecting yourself with semaglutide. “You can inject GLP1 analog, or you can go buy beans and rice and salad,” Barnard says. “Not only do health measures improve, weight comes down automatically.”

But veganism is a tough sell to dent the nation’s obesity problem, especially in the very communities that are hardest hit, where there is less access to fresh produce and less education about proper nutrition. Barnard says this is precisely the point: that we would be better off spending scarce public health dollars on intensive nutrition counseling and healthy food environments.

Other physicians — and not just those with hefty consulting contracts from drugmakers — have a different response: relief. Before the new generation of medications, said Dr. David Rind, a primary-care physician in Boston, “All I could ever do was say, ‘Well, I think you should exercise more and diet,’ knowing perfectly well that never works. You know, it works in the short run — everybody can lose weight in the short run, and 95% of people regain weight. And so, you know, it is thrilling for me to have something that I could use that lets people lose weight.”

Rind has a distinctive perspective on the issue because he is also chief medical officer of the Institute for Clinical and Economic Review (ICER), which assesses the quality and cost-effectiveness of medications. Its analysis of obesity medications, released in August 2022, awarded Wegovy a B-plus for effectiveness — “a really good grade,” Rind said. “If we knew that you could keep taking this for 10 years and you’d maintain that weight loss, we probably would have given it an A. We just don’t have those data yet.”

But that analysis was less cheery when it came to the cost-effectiveness — and overall budgetary implications — of Wegovy. Its model is complex, but the bottom line was that the medication would be considered cost-effective only at an annual price of $7,500 to $9,700 — far below the current sticker price.

More daunting: Even at that reduced rate, the impact on national health-care spending — already close to 20 percent of gross domestic product (GDP) — would be enormous and unsustainable. Less than 4 percent of eligible patients could be treated within five years without exceeding ICER’S limits on affordability.

“Even at a fair price,” Rind told me, “they're going to make a huge amount of money — and the budget impact in the U.S. is going to be enormous.”

In the opening scene of the movie “The Whale,” a morbidly obese Brendan Fraser is teaching an online writing class. On his Zoom display, a black square, labeled “Instructor,” sits in the midst of a sea of student faces. This encapsulates the experience of obesity: the shame at being seen, an aversion to seeing yourself. For all the encouraging talk about body positivity, this is the reality for millions of people, myself included: You don’t have to look like a whale to feel like one. Obesity medications empower us to be seen in the Zoom square.

After a year and a half on Ozempic, I find myself both exhilarated and unsettled by this prospect. How amazing it is that millions of people who have endured the misery of struggling with their weight now have what appears to be a safe and effective way to address it. We are at the start of a brave new world when it comes to treating obesity; one sign of the new if-you-can’t-beat-’em reality came in March, when WeightWatchers bought a telehealth company that provides obesity drugs.

And that also leaves me unsettled. In a just society, with a rational allocation of resources, I would not be anywhere near the front of the line to obtain a medication that is prohibitively expensive and, at least until recently, in short supply. (Now, you have to go hunting for Wegovy.) Neither would the attractive folks in the Oscars audience — nor many of the other people I know who are taking it. If you can’t be too rich or too thin, it turns out, you might have to be rich to be thin. The racial disparities — in obesity and access — make matters even worse.

And we are only starting to consider questions about what constitutes appropriate use. For the seriously obese, the case seems clear. Leaving aside the important questions of cost, and prices will come down, certainly as patent protections expire, where to draw the line? If this medication is safe and effective, why not prescribe it for the merely overweight, even without an associated medical issue? And why not for the bride who wants to drop 10 pounds before her wedding day? She might gain the weight back, but would it really be so terrible?

Still, to take up the other side of that argument: What role does this leave for instilling habits of self-discipline, encouraging healthy eating and incorporating exercise? The experts can preach about the importance of accompanying use with a program of diet and exercise; we know what will happen in the real world.

But given cost considerations and the apparent need for long-term use, we need to study whether the medications can be usefully combined with low-carbohydrate diets, as Dr. David S. Ludwig and Dr. Jens J. Holst suggested in a new article in JAMA, the American Medical Association’s journal.

There is also much that remains unknown, about whether it is healthy to go off and on these medications, especially with the associated weight gain — and whether to try to adjust doses to a lower amount once weight loss has been achieved. “Medically, I would want some kind of reason for lowering the dose,” Dr. Jason Brett, executive director for medical affairs at Novo Nordisk, told me. Of course, Novo Nordisk has every financial incentive to want people taking its medication for as long as possible at the highest doses. Still, if Wegovy is working at the prescribed dose, why fiddle? If anything, it might be that effects wear off and dosage may need to be increased for the medication to remain effective.

This genie isn’t going back in the bottle, nor should she. We need to embark on a serious conversation — not about what these medications mean for celebrities on Instagram but what their arrival signifies for the rest of us, struggling and imperfect.