The medical story about Ozempic is straightforward and satisfying. A drug designed to treat diabetes had a game-changing application for weight loss. But it has plenty of caveats: You have to take it indefinitely. It doesn’t work for everyone. It has side effects. It’s at the moment unbelievably expensive and rarely covered by insurance. But it works. People can lose a significant percentage of their body weight and keep it off—safely. In the history of spotty and dubious weight-loss drugs, this one is a genuine medical breakthrough.

But the cultural story is more complicated. In the last few years, the culture has finally started making a little bit of progress with fat-shaming. For example, WeightWatchers downplayed the word “weight” in its name and started talking more about health and wellness and developing a positive mindset. Ad campaigns started using models of all shapes and sizes. A lot of women find these models beautiful and are finding their own bodies beautiful too.

This progress is new, and fragile. And the introduction of a miracle weight-loss drug could easily upset all of that. In this episode of Radio Atlantic, science writer Olga Khazan and I imagine it’s 20 years from now. Insurance covers Ozempic. It’s affordable. It’s pretty widely available. In this future, have we become a lot less judgemental about obesity? Or does the decision to have whatever body you want come to be seen as a problem?

Listen to the conversation here:

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Here is a full transcription of the episode:

Hanna Rosin: There’s a story about the new drug Ozempic that people like to tell. It’s a story of a once-in-a-generation medical breakthrough, of how a drug to treat diabetes became a game-changing new drug for weight loss. Now, there are plenty of caveats. You have to take it indefinitely. It doesn’t work for everyone. There are side effects. It’s, at the moment, unbelievably expensive and barely ever covered by insurance. But it works. People can lose a significant percentage of their body weight and keep it off. And they can do it safely.

This medical story is straightforward and celebratory and satisfying.

But there’s another story: the cultural story, which is way more complicated. In the last few years, the culture has finally started to make a little bit of progress with fat-shaming. For example, WeightWatchers downplayed Weight in its name and started talking more about health and wellness and developing a positive mindset. Models who were not rail thin started showing up everywhere, not just in Dove ads. And a lot of the young women I know make a point to talk about how beautiful these models are and how beautiful their own bodies are.

This whole thing feels new, and it’s delicate. And now here comes this miracle weight-loss drug that could upset all of that. And the more I try and imagine a future where Ozempic is commonly available, the more I wonder how this medical miracle and our recent progress around body image live together, and if they can live together.

So as I was thinking about all that, the first person I wanted to talk to was Olga Khazan. She’s a rare writer who can see where medicine and culture clash. And she’s reported on Ozempic for The Atlantic.

Hi, Olga.

Olga Khazan: Hi, Hanna.

Rosin: So I am excited to have the cultural conversation. But first, some basics. What is Ozempic?

Khazan: Ozempic is a brand name for a drug called Semaglutide, which basically just mimics the digestive hormone that we all have, which slows digestion. And it also tells you that you’re full.

Rosin: And what makes it so revolutionary? Why do people say, Oh, this is a game changer?

Khazan: The idea of, like, a magic pill for weight loss has been with us for a while, but they’ve always been not effective or dangerous. This is really the first one where the side effects—usually like nausea and diarrhea and things like that—people feel like they can tolerate for this benefit of weight loss, and they’re really effective. People lose a substantial percentage of their body weight, and they’re able to keep it off as long as they keep taking it. And we really haven’t had those two magic ingredients so far in the weight-loss space.

Rosin: Two magic ingredients, meaning (1) people lose weight, and (2) they keep it off.

Khazan: That’s right. Yeah, I mean, a lot of people have lost weight on diets, and I’m not trying to minimize that, but it’s pretty widely known that with dieting, you only lose a small percentage of your body weight, maybe something like 5 percent or so. And a lot of people end up gaining that back. And for a lot of obese people, they actually find that their metabolism changes, so their body kind of fights the weight loss. So they tend to hold on to this excess weight, and it just becomes more and more difficult the further you get into obesity. Of course, weight-loss surgery is effective, but this is something that, it’s not a major procedure. You don’t have to go under. You don’t have to eat these tiny meals for the rest of your life. You do have to inject it for now, but people would prefer that.

Rosin: I mean, really, you describe it—it does kind of sound too good to be true. I understand it is true, but it is interesting that they suddenly swept in this thing that clears out all the problems that people have been struggling with for so long.

Khazan: Yeah, and I mean, I don’t want to minimize the fact that there are side effects, and a lot of people can’t tolerate them. And according to this one obesity doctor that I talked to, they don’t work for everyone everyone. Like, I think there’s always some percentage of the population that’s not going to respond. And of course, the big, huge caveat with these is that they are super-duper expensive if your insurance doesn’t cover them. So in a sense, they’re a magic pill, but only if you can afford it.

Rosin: Is it reasonable to assume that sometime in the near future it will be more widely accessible?

Khazan: I have asked this question of every expert I talked to, like, When will it be covered by insurance? Generally, things tend to move from not covered to covered. So I do think it’s reasonable to expect that soon these will become covered by insurance.

Rosin: I guess I’m just trying to imagine if there is a future where these are widely available, and then the way we talk about weight loss kind of changes in the culture.

Khazan: Yeah, I mean, this is super sensitive and also hard to predict. And it’s something that these weight-loss companies that I’ve been talking to tiptoe around because their whole thing is helping people who want to lose weight. But there was sort of a period of time where expressing a desire to lose weight was not—how do I put this? Expressing a desire to lose weight was not—

Rosin: Cool.

Khazan: It was not cool. Yeah, I guess, cool. But it was also just kind of frowned upon. Like, there was just this era—I want to say, like, 2017 to 2020—where it was seen as gauche to be, like, I’m on a diet. People stopped dieting. You know, the CEO of WeightWatchers around that time was like, Healthy is the new skinny.

Rosin: This is what I want to talk about. Let’s back up.

Khazan: Sure.

Rosin: I think I want to start at the founding of WeightWatchers.

Khazan: Okay. (Laughs.)

Rosin: 1963. Because it happened in Queens, and I grew up in Queens. And Queens has so few moments of glory. Back in the early WeightWatchers era, what was the talk or idea around weight loss?

Khazan: So WeightWatchers really started as America was still partly in this era of shame around being overweight. Things kind of transitioned from Being thin is morally good to Being fat is shameful. You had these, like, support groups that held public weigh-ins, and they would force their members who hadn’t lost weight to stand in what they called a pig line. So according to a 1963 Life magazine story, during meetings, women would pin cardboard pigs on the non-losers, meaning people who didn’t lose weight, and serenade each other with ”We are plump little pigs who ate too much fat, fat, fat.”

Rosin: Oh, my God.

Khazan: Yeah.

Rosin: And this was like a sisterly, support-group situation?

Khazan: This was a support group. It’s, like, truly, deeply offensive.

Rosin: Wow. Okay. Wow.

Khazan: So we get to the ’60s, and this is when this housewife named Jean Nidetch invites six friends to her house and they talk about their weight struggles. She finds this to be really helpful, to just, like, have this informal group where you can share your experiences. She eventually loses 72 pounds, and so she kind of establishes this idea of having a real support group, not a mean, shamey one, where people encourage each other and help each other to lose weight in this more supportive environment.

Rosin: Was the underlying idea there still a kind of value or moral judgment around weight, so that even if it wasn’t quite so mean, there was this idea that fat is ugly or bad or something? Like, what was the language like in that era?

Khazan: Yeah, it was, I would say, less mean. But definitely she was not like, I just want wellness or I’m happy with my body. She wanted to lose weight.

Rosin: Right.

Khazan: And she would carry around a photo of her, like, former self when she was heavier. And she would be like, I pray that I never forget where I came from—

Rosin: Oof!

Khazan: Because it was, like, so bad to be overweight.

Rosin: Yeah.

Khazan: So definitely in this WeightWatchers era, people were still losing weight, and they were not just, like, doing yoga and being body-positive. So that’s kind of where it all originated.

Rosin: Okay, so what happens next?

Khazan: So because dieting isn’t very effective, I think a lot of people got frustrated with this encouragement to diet and exercise. And, I mean, there was a time when I was reporting a lot on obesity, and I would actually go to doctors’ appointments with people. And the doctor would tell them to lose weight, and they would be like, I don’t know how or I can’t. And they would be like, Well, have you tried diet and exercise?

Rosin: Also, Doctor, like, do you think I didn’t think of that?

Khazan: Right. Right

Rosin: Like it’s a novel idea you just came up with?

Khazan: Yeah, it’s, like, a little bit condescending. And so I think people kind of were like, I’m not going to put up with this anymore. And then the industry took a cue, I guess, from the general population. And so you had magazines who were like, We’re going to stop using phrases like “bikini body.” Lean Cuisine—this was a weird one—started offering a browser extension that actually blocks the word diet from your web pages.

Rosin: Interesting.

Khazan: Which is weird because it’s Lean Cuisine.

Rosin: Right? It is, kind of, diety food.

Khazan: Yeah, and you really had body positivity take off. And the idea of a diet really just seemed kind of outdated.

Rosin: So if dieting fell out of fashion, what new things sprung up?

Khazan: Yeah, so it’s very interesting. Right around this time in 2018, WeightWatchers starts calling itself WW. But, at the same time, you still have people who want to lose weight. So you have things starting up like Noom, which is this weight-loss app. And it does show you how to diet and how to eat foods that will keep you full longer, and helps you track your food and count your calories and things like that. But it also took this psychological approach where it would tell you, like, There’s no such thing as good and bad foods and You should move joyfully and Just because you mess up one day doesn’t mean that your diet is ruined. So it does a lot of, like, therapy coaching alongside telling you that grapes are healthier than raisins. And I know a lot of people who lost weight on Noom, and it seems to be pretty effective.

Rosin: Yeah, I remember when I was first looking through Noom and being really surprised at how different the language was. You know, they talked a lot about health and wellness and body positivity, but it was really hard to tell if people who were going to Noom just still had those same old anxieties about being thin—and if these companies sort of knew that and maybe were just coloring it over in more acceptable language so people felt better using it.

Khazan: I think that’s for everyone to draw their own conclusion. So I will say that, like, WeightWatchers, they stopped requiring their members to have a weight-loss goal. They stopped doing the before-and-after photos that they were kind of very famous for. You pick goals when you sign up for WeightWatchers, and one of them was developing a positive mindset. Meetings started to be called “workshops.” I don’t really know why that’s better than “meetings,” but they did that.

Rosin: More professional, maybe.

Khazan: Right? But they were still offering a point system and ways for people to lose weight. It was still a weight-loss program. So I think they just picked up on this sentiment in the culture that dieting is sort of passé, and they were like, What can we do—we’re a weight-loss company—that fits with this new sentiment that people have around dieting, but still fundamentally helps people lose weight?

Rosin: And there were periods that were a genuine opening up in the culture, like a change in models, like catalog models, just general models. Like, there was a broadening of types of bodies that you would see on screen or in magazines that everybody would agree could be called “beautiful.”

Khazan: Oh, totally. Yeah, I mean, and you had, like, the Dove commercials. Those famously, like, included size-10 women, which was, like, revolutionary at the time. (Chuckles.) So, yeah, there was a lot of positive stuff that came out of that time. Some of the shame around being fat, thankfully, went away. But there is this enduring, fundamental problem, which is that obesity is associated with a lot of bad health effects, and doctors in particular were still working on that.

Rosin: Now you’re separating the cultural issues from the medical issues, the medical issues being that obesity specifically—not overweightness, but obesity specifically—is associated with certain health outcomes.

Khazan: Obesity was and continues to be a big problem. It can cause diabetes, liver disease, heart disease, cancers, sleep apnea. It can shorten your lifespan. I mean, it continued throughout this time of body positivity to be something that doctors consider to be a huge health risk.

Rosin: I understand. So you could think of it as a symptom that might lead to other symptoms, but there isn’t any moral value attached to it.

Khazan: Yeah, I mean, I think that’s where things got really twisted. It’s that obesity did acquire a moral valence because, I think, a lot of people wrongly saw it as something you could completely control with what you ate. And if you just swapped out your Big Mac for carrot sticks, you wouldn’t be obese anymore. But realistically, that’s not what a lot of obese people are doing. They’re eating right and exercising, but they can’t lose weight anyway. So in some ways it’s better to think of obesity in a medical way, because it’s a medical condition.

Rosin: What are the American numbers on obesity, and how have they changed over all these decades that we’ve been talking about?

Khazan: It went from 13 percent of Americans were obese in the ’60s to 42 percent are obese now. So it is a really big medical problem. And we somehow have to muddle through and find a balance between treating obesity and helping people lose weight, if they want to, without shaming people who are obese or making them feel fat or lazy or somehow “less than,” just because they’re obese. I do think that this era of Semaglutide puts a new focus on the fact that if you’re, you know, severely overweight or obese, there is something you can do about that.

Rosin: When we come back, what happens when these medical imperatives and cultural shifts collide?

[Music]

Rosin: Imagine it’s 20 years from now. Insurance covers Ozempic. It’s affordable. It’s pretty widely available, not just to treat diabetes and obesity. We don’t live there yet, but you can tell it’s coming because of what happened this spring with WeightWatchers.

Khazan: These same companies that are sort of like, There’s no good and bad foods and You haven’t messed up; you just had a slip up and Wellness is more important than weight and Healthy is the new skinny, are now saying, Do you want some Ozempic?

Rosin: Yeah.

Khazan: Yeah, so both Noom and WeightWatchers have launched these services where you can be paired with a doctor. And if you qualify, which means if you’re obese or you have diabetes or other conditions, you can be prescribed these weight-loss drugs. And it doesn’t cover the cost of them, of course, which is substantial. So you would sort of do your Noom and your psychological behavior change, but also you would be injecting yourself with Ozempic.

Rosin: And to you, what was the significance of that announcement?

Khazan: Well, it’s an awkward pivot, right? Because you’ve been saying, All you have to do is follow our guidelines. You just have to count your points and keep going to meetings, and it’ll work or You just have to follow Noom and, you know, log your meals, and it’ll work. And suddenly it’s sort of like, Well, but if you want a little something extra, here it is. And I think anytime there’s an admission that the old approach has failed, and Here’s actually what’s better, it is a little surprising.

Rosin: Because there’s nobody explicit about that.

Khazan: Well, yeah. And I mean, the WeightWatchers CEO, Sima Sistani, said, There are people who join this program and lapse from our program because it didn’t work for them. And we have to be honest about that. And we now know better. And so we should do better. And so they’re kind of saying, like, We have to admit that, for some people, just regular WeightWatchers doesn’t work. So it is—it’s a huge admission, and it’s a huge step for them to be offering these drugs.

Rosin: I mean, on the one hand, saying We know that our program doesn’t work for a lot of people feels liberating. Like, there’s a way in which it acknowledges that obesity is a problem completely separate from willpower—we all acknowledge that. It’s a little bit like the change in framework we had with Prozac.

Khazan: Yeah, Prozac is a really good analogy, because in this day and age, I don’t think people would really shame someone who’s like, I have depression and I take Prozac. You wouldn’t be like, Well, have you just, you know, tried to be happy?, you know, or whatever.

Rosin: But it was more that when Prozac was first introduced, it sort of switched the framework so that you didn’t necessarily have to think about psychodynamic therapy and sort of dig deep into your past. You at least had another model, which can be treated in this separate chemical way. So there’s kind of a bright line between you and it. It just externalizes the situation.

Khazan: Yeah, I mean, and that’s something the new medical director also pointed out to me, which is that, like, some people are just genetically predisposed to have insulin resistance. That can lead to abnormal fat storage and a dysregulated appetite. And there’s just not a lot that you can do when your body is actively working against you to keep you from losing weight.

Rosin: Let’s say Ozempic-like drugs are widely available. A lot of people start to know people who are taking Ozempic and think about it and talk about it in this way. Can you imagine a scenario in which that actually changes this underlying, lingering bias against fatness?

Khazan: I really hope so. I mean, because once you have a medication that works really well for something like obesity, and everyone kind of acknowledges that if you take this, you will lose a substantial amount of weight very quickly, I do think some of the moralizing around it will go away. Because the problem with diets is that they are very moralistic—like, forcing people to eat carrots or whatever instead of what they actually want to be eating, it has, like, a “should” and “shouldn’t” quality that is a little like telling people to just be happy. Like, I think that, you know, once these become more popularized, hopefully it will lead more people to see obesity as a medical condition, which, again, I think is a positive thing.

Rosin: So that’s the positive. The positive is that we move into a world where we have a completely different medical framework for obesity, and it slowly erodes the stigma around being fat. Now, maybe the difficult thing—like, one thing I wonder about is if it actually hardens our intolerance of fat if you just won’t get with this program.

Khazan: Yeah, I mean, I think there’s a real risk of that. To use an example of my own that’s not obesity, I do have anxiety, but I’m not on antianxiety medication. But every time I go to the doctor and check anxiety on the form, they’re like, Lexapro! Here you go. Like, Here, why don’t you take it? No, seriously, take it. And it doesn’t matter how many times I say, like, I want to try other things, like, whatever, I’m meditating. They’re like, Well, we have a pill. Like, you could just take it. And it’s very hard to push back against the medicalization of something. And I do think that there is a potential for that for people who don’t want to take it for whatever reason, can’t tolerate it—again, there are side effects. Maybe it doesn’t work for them. Maybe insurance doesn’t cover it. Maybe they just have other things they want to focus on than losing weight. I think there is a risk that we’ll get to be like, Well, you know, your biggest problem is obesity, and why don’t you just, you know, inject this into yourself already?

Rosin: Right. Right. I mean, and this—what you described about your relationship with doctors and anxiety, it is a discipline for you to maintain a complicated relationship with your anxiety in the same way as, I think, it might really take a lot of work and be a discipline to maintain a complicated relationship with your body.

Khazan: Yeah, I mean, right now the obesity doctor—or one of them that I talked to for this—he was saying he does not just, like, write a prescription for everyone who comes by. You really have to be obese, which is, like, above a certain BMI threshold. So if you were just a little overweight, that’s not really going to qualify you. But I think in the future it might come to a point where these drugs are so widely available that someone who’s just overweight, not obese, can get their hands on them and basically use them, probably.

Rosin: Mm-hmm.

Khazan: So you will not see as many people who are obese. And so, therefore, being a little overweight will start to look, maybe, a little more conspicuous among your social group, or whatever else, and that you might start to put some pressure on that endocrinologist to write that prescription already. I think there is the possibility of that happening, but at the same time, obesity is, like, such a huge medical problem that if we do have a way to get people to not be obese—and it’s relatively low-key and they can tolerate it well and it’s, like, widely available—I have trouble not seeing that as a good thing.

[Music]

Rosin: Well, Olga, thank you very much. That was very helpful in thinking through the future.

Khazan: (Laughs.) No, thanks so much for having me on.