Ozempic & Obesity

[MUSIC] What truly honest to God peaked my interest was when Kim Kardashian used those epic to fit into Marilyn Monroe's dress to get into for the Met Gala. So that is like what started every day. >> I remember that, I remember that. >> [LAUGH] >> This is Miranda. >> My name's Miranda. I live in New York City and I've lost 144 pounds on those epic. So my experience as a class three obese person for the first 32 years of my life, I have never needed to ask a doctor to prescribe weight loss to me. So when that to say, my doctor who I love, her first question was if I wanted weight loss surgery. And I said no, just because it's super invasive. Nothing against people who opt for weight loss surgery, but that was just not in the cards for me. But I said that I'd be interested in a GLP1 medication. And she said that I qualified and wrote the script. >> And how quickly did you start to notice that it was affecting you? >> Instantly, honestly, as soon as I took my first shot, it was like I was definitely a person who had constant food noise. Like I was always thinking about food, I was always planning my next meal. And so I feel like truly as soon as I had my first shot, it was complete emptiness of that thought. Like I was not hungry, I wasn't thinking about eating. I wasn't thinking about my next meal. I wasn't like on Instacart putting stuff in my cart that I was craving. It was truly like turning off silent humming in your brain. >> That sounds calming, almost. >> Yes, I had always sort of been an active fat person. Like I did kickboxing, I bought a peloton. I think when I started, my goal was to lose 135 pounds, because it was just half of my starting weight, I'm five three. So I'm a short person. So I was doing like a lot of strength, a lot of cardio to accelerate the weight loss. >> How long was it before you hit your goal? Like how long did that take? >> I started August 20th, 2023, and I hit my goal weight at January 19th, 2025, earlier this year. It was like wild, I never in my life thought that I would weigh 135 pounds. Now I've actually lost more weight, and I weigh 126 pounds. And so it's prescribed to me as a four-life medication just because I have insulin-resistant PCOS. I'll be on like some form of a GLP one medication for the rest of my life. Next steps are like working with my doctor to figure out what maintenance does I'm going to be on. So right now, like, it feels good. >> This is drug story. I'm Thomas Kets. I loved talking to Miranda. She was so straightforward and honest about her weight loss. And I was surprised at how downright blase, almost indifferent she was about this miracle drug. Yes, Ozembek helped her lose half of her body weight. But it didn't change what she thought about herself. >> One thing that I also, in my wildest dreams, did not think about, or like foresee the kind of fat phobia that you would experience being on a GLP one medication. People like say that you're cheating, they say that you're taking the easy way out. I love when stuff is easy. I don't know why people are so interested in hardship. >> As you can tell, Miranda is confident and self-assured. And that's not because she lost the weight. She has always been like that. She liked herself before Ozembek. She had fun. She liked Margaritas. >> People knew that I was just like the fun drink girl. >> And she likes herself now. >> Now I'm like the fun diet coke girl. I don't want to sound like ungrateful. I just want to like be clear that losing 144 pounds, your life might not be any better. It might be, you know, the same as it was before. >> Just 144 pounds less. >> Yes. >> Miranda is one of about 30 million Americans who have taken a GLP one drug. That's the name for the class of drugs that includes Ozembek. Today's drug story is about these GLP one drugs. Amazing new compounds that just seem to make the pounds disappear. Or rather, they just seem to make it easier for people to stop eating. [MUSIC] Ozembek is the most famous of these. The one that changed how everyone thinks about obesity. Ozembek is the brand name for the drug, semaglutide. Officially, it's only approved for diabetes. When a doctor wants to prescribe a semaglutide for obesity, then they're supposed to prescribe a drug called Bogovi, but it's the same drug. And there are several other GLP one drugs available, more than 100 other GLP one drugs in development. There has been a lot of talk about these GLP one drugs. They are the biggest phenomenon in medicine since statins hit the market in the 1990s. These drugs bring in billions of dollars a year to their companies. And what interests me about these drugs, these GLP ones, is how they have turned our assumptions about obesity upside down. Why obesity happens? And what is responsible and who is responsible? Because there is a lot of stigma around obesity. As Miranda said so well, there's a common idea that obesity is a problem of personal responsibility, that it's not a real medical problem. And that these drugs, as amazing as they are at improving people's health, well, they're somehow a cheat. In today's episode, we're going to break down that thinking about self-control and responsibility. And we'll explore how one of the greatest humanitarian and scientific feats in history, the Green Revolution in Agriculture, while it led directly to today's obesity epidemic. So even if you've heard all about ozemic and GLP ones, I think this episode will offer some new perspective. And first, to set the mood, here's a word from a company that is not in any way sponsoring this podcast. It's McDonald's commercial from 1990. Food. Not in the greatest mood food. We got the right food. Beauty, lie, food. Morning food and night food. Make a wish food. Not this food. All right food, we got food. Feltify. Get it to go, food. Feltify. Take it to go, food. [Music] Drug story is sponsored by GoodRx. Every prescription has a story. And for many patients, affordability is a defining chapter. GoodRx makes it easier to find lower prices on prescriptions from GLP ones to flumettes, so cost isn't a barrier to care. Trusted by nearly 30 million Americans and over 1 million healthcare professionals each year, GoodRx offers savings at more than 70,000 pharmacies nationwide, helping people start and stay on the therapies that keep them healthy. To start saving, go to goodrx.com. That's goodrx.com. GoodRx is not insurance. Welcome back to Drug Story. This is part one, the diagnosis, where we explore the underlying condition and causes of obesity, the disease that can be treated by ozemic and other GLP ones. That McDonald's commercial we just heard. It's a great example of how food hasn't just been something that sustains us. It's something we consume for fun. It's sold to us as entertainment. It's a way to indulge our appetites. But food as entertainment only exists because the ingredients, the grain, the meat, the sugar, they're all so cheap and abundant now. For centuries, though, and as recently as the 1970s, food was not abundant at all. This all changed in large part because of one man, one American. Norman Borolog. You may have never heard of him, but you can argue that Norman Borolog did more to create the modern diet than any other human being in history. He did this for all the right reasons, but with some unintended and unimaginable consequences. Borolog was born in Cresco, Iowa in 1914, just a few miles south of the Minnesota border. He was the child of Norwegian immigrants, and he grew up working on the family farm. In his youth, Iowa and the Great Plains were becoming known as the bread basket of America, a land with exceptionally rich soil, a stable climate, and a hardworking and proud farming culture. But farming was hard work. As a young boy, Borolog picked a quarter million years of corn a year with his own hands. By the time he enrolled at the University of Minnesota in 1933, the Great Depression was in full effect. The once fertile Great Plains of North America had been overgrazed and overplowed. Then drought hit, and the crops failed. This created the dust bowl, and amid the environmental disaster, it brought a scale of human misery that Borolog was terrified to witness. One day in Minneapolis, where Borolog was a student in agriculture school, he got swept up in a food riot over the price of milk. He realized that when food was scarce, life could grow desperate. And he started to consider whether there was something he could do. Here's Norman Borolog himself. I experienced the economic depressions of the 1930s. And from this experience, I felt that the families on the lands, the small pieces of properties around the world needed help from scientists and I dedicated my life to science, and especially to food production. Norman Borolog went to Mexico in 1944, as part of a research project trying to improve the country's agriculture, especially wheat production. At the time, Mexico imported most of its wheat and flour. Borolog was a gifted plant breeder, mixing different kinds of wheat to take advantage of certain traits. He was hoping to develop something that might thrive in Mexico's arid soil. The work was a struggle, and he spent years more than a decade making little progress. But eventually, he adapted a Japanese variety of wheat that created short stocks that could germinate large seed heads, the grains of wheat. What's more, his new wheat could be harvested twice a year instead of just once a year. This was huge because in the decades after World War II, famine and starvation were common around the world. Agriculture was still a primitive industry in most countries. Often, a harvest could not provide for a country's booming population. 30% of people worldwide were chronically malnourished, and half the world did not have a reliable source of food to meet their basic needs. By 1963, Mexico was producing six times the amount of wheat as when Borolog arrived, and they actually began exporting wheat to other countries. And other countries where agriculture had been a constant struggle began to look to science for answers. Here's a 1969 film from the U.S. Department of Agriculture. Soon, scientists from around the world were coming to Borolog to adapt what he had done for their countries. And it's been fascinating to me not only from what has been accomplished in wheat, but more important in the training of young people. For example, in the last eight years, we have had 150 young wheat scientists from about 25 different countries of the world who have come to study and work with us. This was the start of what would be called the green revolution. It was a remarkable transformation of agriculture, with better breeding and better pesticides that allowed farmers to grow more crops that sustained growing populations. Worldwide, the production of food per acre known as yield, it doubled. And as the method spread, one country after another saw the food that their farmers could extract from the land soar. Average daily calorie consumption worldwide increased from about 2,000 in 1965 to about 2,500 in 1990. Malnutrition and starvation ceased to be commonplace, even as the global population increased by billions. Today, where food insecurity persists, it's largely for political reasons or logistical challenges rather than a true scarcity of food. The green revolution was certainly one of the great accomplishments of human history. For the first time, billions of people were freed from the tyranny of wondering where their next meal might come from. Nations that experienced persistent and deadly food shortages now had reliable sources of grain and food. India, Pakistan, Morocco, Tunisia, Turkey, China. It's estimated that Borlaug was responsible for saving one billion lives. In a 1970, Norman Borlaug was awarded the Nobel Peace Prize for his work. But, and you knew about what was coming, in the United States, the miracle technologies of the green revolution launched the industrialization of agriculture. Production of grain crops, corn, wheat, oats, potatoes, rice, that all soared with bigger yields every year. And more grain meant a bounty of food on a scale that would have been unimaginable just a few decades earlier. The supermarket is the show place of today's agriculture. Here is where the sharper benefits from the work of the scientists and the farmer and the marketer. These products come from farms and ranches despite distance and season. They are the result of a miraculous agriculture. Tremendous advances on the farm and in the marketing system have created this miracle. The miracle whereby American agriculture has advanced more in the space of a single lifetime than world agriculture had in more than 7,000 years. The result? Food got really, really cheap. Let's use just one example. Oreos, that perfect American snack. In 1934, when the dust bowl was raging and Borlaug was in college in Minneapolis, a 1 pound package of Oreos cost 27 cents or about 650 today. By 1970, when Borlaug won the Nobel Peace Prize, those Oreos cost 45 cents or about $4 today. That's one third cheaper thanks to the green revolution. Oreos are a good example also because they're really just wheat flour and sugar and fat. Those are all basic food ingredients, common commodities. And when those commodities are cheap, well, you can make a lot of things from them. Different mornings, he wakes up in different moods. So different mornings, he likes different cereals. Your answer is Kellogg's Variety Pack, a new and bigger selection, 10 personal servings, America's favorites, the best to you each morning in Kellogg's Variety Pack. It all starts with cheap grain. Entire new categories of food products were invented, frozen foods, and convenience food, and TV dinners, and sugar cereals, and savory snacks, like fritos, and tostitos, and Doritos, and Cheetos, and fonions. Those are all corn-based snacks from just one company, Frito laille. Cheap grain also means cheap feed for livestock, particularly corn for cattle and poultry and swine. That means more animals and cheaper meat, and that created slim gyms and chicken fingers and cheaper fast food and more kinds of fast food. Chicken sandwich chains and roast beef sandwich chains. And venerous knitzel chains and taco bell selling, well not just tacos, but chicken strips and nacho fries, and everything else that taco bell sells. This started in the 1960s and 70s, but it reached a whole new level in the 1980s, especially after Philip Morris bought Kraft and RJ Reynolds bought Nabisco. That's right, Big Tobacco took over Oreos. Kraft and Nabisco were the biggest food companies in the world, ever, and by 1989 they were both owned by tobacco companies. These companies brought all the tricks of marketing and development that they had perfected with cigarettes to food. Starting with the notion that individual freedom means doing what you want, indulging your desires. Just like they sold cigarettes smoking as a matter of personal liberties, not addiction. The commercials for their foods made it all about fun and choice. And it wasn't just the marketing. It was also what was in the foods, the ingredients, the formulation. Remember a cigarette isn't just shredded tobacco. It's a carefully engineered and designed product. In the 1950s tobacco companies knew that nicotine gave smokers a buzz and was addictive. It kept them smoking. So the companies began to boost the levels of nicotine in every cigarette, so more was delivered into the smokers' lungs with every drag. In the 1980s they took the same approach to food. A recent study in the journal Addiction by researchers from the University of Kansas looked at foods manufactured between 1988 and 2001. The period went big tobacco owned Kraft, Nabisco, and also general foods. These include many of the food products you probably grew up with. Miracle Whip. Ritz. Planter's peanuts. Oscar Meyer. During this period, products from tobacco owned companies were far more likely to have high levels of sugar, salt, fat, and extra-carbohydrates than comparable food products from other companies. And not just by a little bit. Tobacco owned foods were 80% more likely to be high in carbs and sodium than other foods. These ingredients, sugar, carbs, salt, fat. They each trigger cravings and emotions in our brain and bodies. We can't stop eating them. Millions of years of evolution primed our biology to want these things, especially these things. In primitive times these were scarce and essential for life. But after the green revolution, they were much more common and cheap. And after the tobacco companies got into food, there was just more of them in our everyday food than ever before. Foods that are high in these ingredients are called hyper-palatable foods or ultra-processed foods. And these foods are everywhere. More than half of the calories consumed in the typical American diet comes from ultra-processed foods. And most of these calories come from just five sources. Sandwiches, including burgers, sugared beverages, savory snacks, sweet bakery products, and pizza. It's controversial to say that these foods are addictive, that they are as manipulative and dangerous as cigarettes. But the truth is that these foods are designed and engineered to make us want more. And if you listen to the commercials, they actually admit that they are designed to be irresistible. They use it as a selling point. What makes honeybunches about cereals so irresistible? Is it the crunchy old clusters? Touch of golden honey. Perfectly toasted flakes made with whole grain. Yes. Yes. Yes. When you get the urge for a delicious snack, have a KitKat. KitKat's irresistible. What's so insidious about these foods is the way they are engineered for rapid eating and rapid digestion. That's what ultra-processed means the ultra-part. They are softer and easier to chew, which makes it easier to eat faster and eat more. And the high processing of ingredients means that ounce for ounce, these foods contain more calories than regular food. What's more, bite for bite, our bodies just absorb more calories per serving than we do of low-processed foods. This is worth explaining. Consider two turkey sandwiches. One is made at home, with lettuce and tomato, whole wheat bread, and a couple of slices of leftover Thanksgiving turkey, maybe a slice of cheese. And the other is a Titan turkey sandwich from Subway. Now, your typical homemade turkey sandwich would have about 300 or 400 calories, fewer than the 500 calories in the Titan turkey, according to Subway's website. But even if both sandwiches had the same amount of calories in the ingredients, the Subway ingredients are just made differently. The roll is softer and has more sugar and processed flour. The honey mustard spread has eight grams of sugar. The turkey, it's cut from a processed loaf, and the lettuce is shredded. The result is that our body just absorbs more of these calories with every bite. While with the homemade sandwich, our body just doesn't break down as much of it before it passes into our digestive system. So not only do our brains crave a Subway because of those carbs and extra sugar, but our bodies also pull more calories out of every bite. And here's the thing. The rise of ultra-processed foods tracks almost perfectly with the rise in obesity. In fact, experts pegged the start of the obesity epidemic in the US to around 1980 when consumption of sugar and high-process carbohydrates began to soar in America. And when the food industry began to develop foods we crave and can't resist. They wanted us to eat more and we did. Over the 50 years from 1970 to 2020, average calories consumed per American rose from 3,000 to more than 3,800 a day. That's an increase of more than 25%. So what happens when people consume more calories than they need? Our bodies turn the difference into fat. The result is, well, we all know what the result is. In 1970, less than 15% of Americans were obese. Today, more than 40% of Americans are obese. That's more than 100 million people in this country alone. Okay, so we've basically made an argument here, a chain of causation, cheap grain, cheap calories, irresistible food, soaring obesity. But, is the food actually irresistible? Don't we have willpower? Don't we have free will? After all, the food industry, they're just giving us what we want, right? We choose what to eat. Isn't that a fundamental part of being American? Living in a free society that we can buy what we want and live our lives how we want? This is what the food companies argue, that they are simply satisfying consumer demand and offering choices. This is the argument that the food company Conagra made when the FDA moved to restrict the use of the word healthy to only products that are actually, you know, healthy. This matter a lot to Conagra because they make the healthy choice line of frozen meals. And according to the FDA's proposed new rules, a lot of healthy choice meals would not be able to actually use the word healthy. They contained too much sugar or fat or salt. Well, Conagra argued against the rules saying that if the food does not taste good, people will not buy it. In other words, they had to have lots of salt and sugar. The FDA did not buy Conagra's argument and the new rules went into effect December 2024. So now Conagra and other companies have to reformulate their products if they want to use the word healthy. This matters because this idea of personal choice has two sides. First, it seems like an American right to eat what we want. That's freedom of choice. But the flip side of that is that when people do become overweight, well, that's on them too. That was their choice. For decades, obesity has been framed as a lifestyle issue, a matter of diet and exercise and a matter of personal willpower. That framing has long been the mantra of the diet industry, with companies like Weight Watchers and Nutra System and Jenny Craig. By the way, a bit of irony here. Heinz Foods bought Weight Watchers in 1978 for $71 million and they owned it for 20 years. And in 2006, Jenny Craig was acquired by Nestle for $600 million. So the companies that created the problem, well, they also looked to profit from it as well. But blaming individuals gets hard when we are on the brink of half of all Americans being obese. Clearly, it's something other than poor individual decisions. Obesity became a true public health concern, a population concern, in the late 1990s. But it was not considered a medical issue because obesity itself wasn't considered a disease, a treatable medical condition. Obesity clearly leads to bad diseases, type 2 diabetes, heart disease, stroke. But calling obesity itself a disease was just not something that a lot of medical experts were willing to do. In fact, it wasn't until 2013 that the American Medical Association finally decided to consider whether obesity should be a disease. We're going to dig in on that debate and on the emergence of drugs that suddenly seemed to work coming up in part 2. And to take us there, here's a 2015 commercial from Weight Watchers, which it doesn't actually say the words Weight Watchers, but it's just a really effective, well, just take a listen. Eat a snack. If you're sad and you know it, eat a snack. If you're sad because you're angry, feeling down or generally bad, if you're sad, eat a snack. If you're bored and you know it, eat a snack. If you're lonely and you know it, eat a snack. If you're sleepy and you know it, if you guilty and you know it, if you're stressed, eat a snack. If you're human and you know it, then your face will surely show it. If you're human, eat your feelings, eat a snack. This is part 2, the prescription. So is obesity a disease? That was the question facing the American Medical Association in 2013. Just a year earlier, an expert AMA panel had issued a report arguing that obesity was not a disease, but the science was moving fast and the problem was getting worse. Many doctors believe that the AMA, as the nation's leading source of medical expertise, they needed to do more than weight. So at the AMA's annual meeting in Chicago that year, as they considered the research and the evidence, they invited a young doctor to offer her perspective. This was Dr. Fatima Cody Stanford. I'm an obesity medicine physician scientist at Massachusetts General Hospital and an associate professor of medicine and pediatrics at Harvard Medical School here in Boston, Massachusetts. That's Dr. Stanford today. She's among the country's leading experts in obesity medicine. But back then, in 2013, she had just graduated from Harvard Medical School and she was in year 1 of a three-year fellowship in obesity medicine at Harvard. This was a brand new specialty. So she takes the stage in front of more than 600 delegates, the leading doctors in the country. And I introduced them to one of my patients named Twinkie. She was an 11-year-old. That was admitted to the pediatric hospital with an asthma exacerbation initially to the pediatric ICU. When she was transferred to my care when I was still in intern, one day as I was going in to do my rounds, which we do very early in the morning, I found her to be not breathing. When I walked in the room, I go to kind of shake her to get her to start breathing again and she starts breathing again. I report this to my senior residence and my attending physicians. You know, I think that she's not breathing. I think she may have obstructive sleep apnea. I get a, you know, pat on the back of Dr. Stanford. Great job. That is likely true. They called her Twinkie because this was a young black girl in South Carolina that carried significant access out of adiposity. Otherwise known as very severe obesity, a likely contributor to her obstructive sleep apnea, which was not yet diagnosed. She was discharged home and she died three days later. The idea that this young 11-year-old is dying and the cause of death ended up being a obstructive sleep apnea, which was secondary to obesity, spits volumes to what we were not recognizing at the time. And what we are still reticent to recognize, which is a disease that we can treat if we just take a step back and think about what we can do for the patient. Yeah. I don't like going to funerals in general, but I can tell you, I don't like going to funerals for 11-year-olds, particularly ones that could still be living a fruitful life. And if we don't recognize and treat obesity, which was the root cause of issues, we're going to continue to lose people well before their time here should be done. And that was the story that I told in addition to a few others, but I think that one stood out the most. Wow. That is very compelling. Dr. Stanford's talk, it turned out, was right before the vote by the delegates. And having assessed the evidence and heard from Dr. Stanford, the AMA approved the resolution to reclassify obesity as a disease. I think a very pivotal point in my career, I didn't know that was the, I guess, task that I had been presented with, which was to convince the AMA that obesity was a chronic disease, but after taking on that task that was unbeknownst to me, it obviously played a large role in my leadership in the field. So now, finally, obesity was designated as a medical condition. This was a big deal, because it made it more likely that the FDA would approve medications to treat obesity, and it made it more likely that insurance companies would pay for those treatments. But what sort of medicines were there? Well, that's why in the clock back a little here, because over the years, there have actually been many drugs that promised to help people lose weight. In the 1970s, M. Fedamines were widely used for weight loss until the Food and Drug Administration banned their use in 1979. In the 1990s, there was Fenn Fenn, a combination of Fenn Fluoramine and Apatite Suppressant and Fenn Turmin, an AMFedamine-like stimulant. Millions of people took Fenn Fenn. Fenn Fenn clinics popped up in strip malls and storefronts, but unfortunately the drug combo caused serious side effects. The Food and Drug Administration today stepped up its warnings about the dangers of so-called Fenn Fenn diet drugs. The FDA said patients taking a combination of Fenn Fluoramine and Fenn Turmin needed to be aware of the risks of serious heart valve disease. Hundreds of women began to experience heart problems and damaged the valves in the heart. Fenn Fenn drugs were pulled from the market in 1997. Meanwhile, surgical solutions were being developed that seemed more promising and also more severe. In 1994, the first laparoscopic gastric bypass was performed. The surgery basically re-roots the digestive system. It reduces the stomach to restrict food intake, known today as bariatric surgery, about a quarter million people get the procedure every year. Many millions of Americans have undergone the procedure in the last 30 years with great success. But it is an intense and grave decision where you're basically removing human organs in order to lose weight. And then in 2005 came the first GLP1 drug, Exanatide, sold as Bayeta. Exanatide was approved to treat type 2 diabetes, which is often driven by lifestyle factors and associated with obesity. The drug helped reduce blood sugar levels, but it came with a side effect, a welcome one. People taking Exanatide lost a good amount of weight without even trying, typically 5 to 10 to 15 pounds. But there was one downside. The drug was delivered by injection and required two injections every day. So even though words started to get out that Exanatide worked for weight loss, the drug never became widely prescribed for obesity. By 2010, another GLP1 drug had come along, lyragletide, developed by NOVO Nordisk. Like Exanatide, lyragletide was approved by the FDA for the treatment of diabetes. But that didn't mean that doctors couldn't prescribe it for other reasons like weight loss. This is so called off label prescribing, and it's 100% legal. It's just not legal for drug companies to promote drugs for unapproved uses. Unlike Exanatide, which remember required two shots a day, lyragletide only needed one shot a day. So much easier. And in 2014, the FDA approved lyragletide for treating obesity. Studies showed that people taking the drug lost on average around 5% of their body weight, as good as anything else out there, far fewer side effects. If you were overweight, losing 5% of your body weight, it turns out, is a significant benefit. That 5% threshold is associated with lower rates of heart disease, lower blood pressure, better blood sugar, and less joint pain. 5% makes a real difference. But the trouble is, 5% doesn't look like a big change. It's not what most people are going for when they say they want to lose some weight. If you were 200 pounds, you don't want to lose just 10 pounds. You more likely want to drop 20, or 30, or even 50 pounds. And those first GLP 1 drugs just didn't do that, not yet. And so while there was excitement about the drugs, they were still pretty under the radar. They weren't yet a phenomenon. But NOVO Nordisk had another drug in the lab, semi-glutide. This one worked even better. It only required an injection once a week. It worked even better at lowering blood sugar levels. And, oh yeah, it caused the significant weight loss as much as 20% of body weight. That's a 40 pound weight loss if you started 200 pounds. In 2017, the FDA approved semi-glutide for the treatment of diabetes. And NOVO Nordisk began to sell it as ozemic. My ozemic tri-zone, I lowered my A1C, CV risk, and lost some weight. Losing weight seemed like a welcome side effect, but still just a side effect of its intended purpose to improve blood sugar in people with diabetes. But some NOVO Nordisk executives saw that there might be a whole new market beyond diabetes. Obesity. If they could just convince the company's leadership that obesity was a real medical condition and not just a matter of self-control. The obesity was in many ways seen as a mental deficiency on the people that were getting heavy, social problems and associated with inability to control your food intake. Many, many people can eat and eat and eat and never put on weight. And then there are other people that if they eat just a little, they will put on weight. And this is unfair genetically. I had to spend half a year convincing my CEO and my head of healthcare that obesity is not just a lifestyle condition, and they were ultimately convinced. So we should always think about obesity treatment as a treatment for those that are medically challenged by being overweight. That was two NOVO Nordisk executives. Lars Ryben, Sorenson, and Mads Thompson, from a video produced by the farmer company about the development of GLP1s. The company began doing clinical trials to get the drug approved for obesity, and that approval came in 2021. Now, when semi-glutide is prescribed for that purpose, it's sold as wagovii, same drug as ozempic, different purpose, different name. The demand for these drugs has been enormous. So many people wanted to take wagovii and ozempic that NOVO Nordisk was caught by surprise, and the company simply couldn't manufacture enough semi-glutide to satisfy the demand. This meant that for nearly three years, the FDA let other manufacturers create semi-glutide and sell it, which explains why all those online weight-loss companies could sell their own versions of the drug for a lot cheaper than the NOVO Nordisk version. In early 2025, the FDA said the shortages were over, and NOVO Nordisk had their monopoly back, though some online shops are still pushing their own versions. Even so, despite the shortages, NOVO Nordisk has sold more than 40 billion dollars worth of GLP once. So, I haven't yet explained how these drugs work, what they actually do in the body, and the explanation is, well, it's pretty complicated. Having to do with hormone receptors and insulin levels and brain chemistry. I'll have Dr. Fatima Cody Stanford take this one. So, in very layman's terms, it will tell you to eat less and store less fat mass without you really having to do anything. So, patients will often use this term that I don't use, which is this concept of food noise. And this idea that the volume, if you were to turn of the volume on your radio or your iPad or whatever device that you're using, that food noise in many patients may be at a high volume prior to the utilization of the medication. And when on the medication, it may go to very low volume and/or goes to mute. So much so that these patients may forget not only to eat, but also to drink. So, there may be then counseling on this part of our dietitians to ensure that they're getting an adequate nutrition because the food noise, which means the desire to eat and/or to drink things such as simple as water no longer are there. And this is not them trying to do this. This is being influenced by a drug that is stimulating their anorexogenic pathway of their brain in such a way. This notion of food noise, it's important. It's what Miranda talked about at the beginning of the episode. If GLP ones turn off the signal, this unstoppable craving, well, that suggests that in some ways these drugs are giving people back the ability to say no to food. Whatever it was about that food that was so irresistible before, suddenly that's gone. The spell is broken. The very first time I took a GLP one was that all these years I thought that thin people, those people, were just had more willpower, they ate better foods, they were able to stick to it longer, they never had a potato chip. And then I realized the very first time I took the GLP one, then oh, they're not even thinking about it. That's right. They're only eating when they're hungry and they're stopping when they're full. That's right. That was Oprah, obviously. So maybe obesity isn't just about willpower. Maybe it's not about free will and personal responsibility at all. That's the thing about GLP ones. They work really well. Mozambique and Magovie offer a simple solution to a very big complicated problem. Get the shot once a week, lose the weight, it works. A different you is possible if you just do this one simple thing. In fact, it's so simple that it's created a new twist on the old stigma of personal responsibility. Before GLP ones, people with obesity face the stigma of perception, the idea that they make bad choices. That they are to blame for their condition. But now, with GLP ones, the stigma has morphed, it's pivoted a bit. It's like those final destination movies. You cannot outrun the stigma. This time, the stigma is that people who use GLP ones and successfully lose weight, they're cheaters. It's a hack. They didn't deserve this. They took the easy way out. Comedian Jim Gaffigan said it best. These people will come up to me and accuse me of being on an appetite suppressant. They're like, you're on ozepic, admit it, you're on ozepic. And I'm not. All right. I'm on a different one. I'm on Manjaro, which is better, right? Because it sounds like an Italian restaurant. Now, you understand some people are against the appetite suppressants. That's cheating. It's cheating. I'm not playing Major League Baseball. I'm just a fat guy trying to not die. Manjaro, by the way, it's a GLP one drug developed by Lilly, which had a hand in that first GLP one, by Edda 20 years ago. Now, Lilly sells Manjaro for diabetes and zepound for weight management. When you think about it, this complaint about cheating is just another version of the willpower argument that people should just handle it themselves. They should have enough strength not to rely on a drug. That stigma is a very hard thing to shake. Here's Dr. Stanford again. Absolutely. I don't think it's a new phenomenon that people would be seen as cheating if they go on medicines. It is deplorable and disgusting that people still are in this thought process. But it really reflects a lack of knowledge with regards to the science. And I think that that's really important for us to stop the shame and blame game that's become inherent in our society, both here in the US and worldwide. Do you think GLP ones are changing that in any way? Is there a way that they're actually taking some of the shame or blame away? In some ways, yes, because we have at least 10% of the population that has been on these agents here in the US at some point. And for those that have been on therapy that can now speak to my goodness. Wait a minute. I've been dealing with this issue of obesity. I thought this was always my fault. I realized that I just didn't have one board something that someone else has if it's been explained to them in that way. Now, but we're talking about a glacial pace in terms of changing that bias and stigma that is pervasive in society from utilizing these medications. Because they are too villainized and a lot of it is because there are some misuse and abuse of these medications where these medications inherently gotten in the hands of people that may not necessarily need them. And so I think that that will help unfortunately set us back as we have been making some strides to improve the plight of those that that do actually have disease, particularly obesity and other cardiometabolic diseases associated with it. And the thing is, lots of people take medications for things that could also be reversed through lifestyle changes. But there's no stigma. Are people with high cholesterol cheating when they take a statin? Are people with high blood pressure cheating when they take a drug instead of cutting back on salt? Are people with insomnia cheating when they take a pill to help them fall asleep? At some point, it just gets absurd. But there's another thing about these GLP ones that make them a concern, and that's the cost. A year of Ogobi or Manjaro at the retail price costs somewhere between $10,000 and $17,000. Many people have insurance that will pay for that. But it's still a cost that somebody has to pay. That is a lot of money. Too much for many people if their insurance won't pay. And remember, there are 100 million people in this country with obesity. And if they start a GLP one, they may have to take it for the rest of their lives. Billions of dollars. Who in the world is going to pay for all of that? We'll get into the money in part three after the break. First, here's a commercial for Ogobi. I need to say they are not paying us for this. Change is never easy. There will be naysayers, doubters, and critics. You may even give up for a moment, only to start again another day, because you believe in moving to the beat of your own drone and passing down lifelong skills in your ability to lose weight and keep it off. And when you believe you can succeed, you already have. Ogobi is for adults with obesity. This is part three, side effects, where we discuss the social and economic consequences of using a drug to treat disease. In this episode, about ozampic and other GLP ones, we're going to dig into just one side effect. And it's not something that happens to people taking these drugs. This side effect occurs when you multiply 100 million. That's the number of Americans with obesity right now today. 100 million times $15,000. That's about the cost of one year of Ogobi or Manjaro. That equals $1.5 trillion. That's the price of treating everyone with obesity in the U.S. at the full retail price of the drug. That would be a very, very big side effect. That would be on top of the $5 trillion the U.S. presently spends on health care, a 30% jump in overall costs. Not every American with obesity is taking these drugs. As of May 2024, about 30 million adults, or 12% of the U.S. population had taken a GLP one drug. And most people are not paying out a pocket. Most, but not all, have health insurance that covers the cost of the drug. But still, that's money. And several insurance companies raise their premiums because of the cost of GLP ones. Nothing comes for free. I first did that math 100 million times $15,000, a couple of years ago. When GLP ones were starting to go gangbusters. At first, I couldn't believe the number. 1.5 trillion dollars on one kind of drug. I didn't think it was possible to pay for so many people to take such an expensive drug. Before starting my research on this episode, I thought it would be insanely wasteful to spend so much money on obesity. I thought it would be ruinous to our health care system. After all, it's not like a snake eating a gerbil, where the big gulp passes through the system. Most people would need to be on GLP ones for life. And I thought it would actually be dangerous for human health, a free pass for millions of people who had given up trying. But I don't think that way anymore. After researching this episode, I realized I was wrong. This is not a fair fight. It's not about self-control and discipline. I think there is something very wrong about the food system we've got and what it does to people. And I think that GLP ones will save a lot of people's lives. They will spare millions of people, many hundreds of millions of people worldwide, from some really horrible outcomes and experiences and diseases. Diabetes is a really hard disease to deal with. It is a lifetime of challenges and monitoring. And if we can spare people of that, end of heart disease, or chronic pain, or sleep apnea, or certain cancers, or the many other diseases that often result from obesity, well, that could be a wise investment. In fact, spending $15,000 a year to help someone avoid these other diseases, what medicine calls co-morbidities, it began to sound to me like money worth spending, a reasonable return on investment, even a great one in terms of how the U.S. might spend our tax dollars. But also, it's not money down the drain. The U.S. spends more than $400 billion a year on medical costs for diabetes, $400 billion on heart disease treatment and care, and billions more on osteoarthritis and obesity, etc, etc, etc. If we really were able to greatly reduce obesity in this country, some of all that expense would go away. Now, I'm not saying all those costs go away with GLP ones. Some people will still develop type 2 diabetes, and some people will still get heart disease. But for many people, these drugs significantly reduce the risk of developing other conditions and diseases. Forecast now estimate that the U.S. will spend maybe $150 billion on GLP ones in four or five years. That's three times what was spent in 2024. That, of course, is a tremendous amount of money. But it reflects the reality that while these drugs are great and they help a lot of people, they don't entirely fix the problem of obesity in this country. There will still be a lot of people with obesity who are not taking these drugs. I'll let Dr. Stanford explain. No one thing is the solution to obesity. I think that we would be short-sighted to think that one thing is the answer. Bariatric surgery is the best treatment for patients with severe obesity. It is underutilized. It is not VC-lution. It still requires consistent follow-up, and many of those patients will need to go on medications ultimately. Medications are not effective for every single person that utilized them, particularly the GLP ones. They work at about 85% of individuals, but notice I didn't say 100% and even for those that aren't going on therapy, they need to remain on therapy consistently if they tolerate such therapy. There is no one treatment tool that is going to solve obesity. It's going to require a multi-bacterial multi-sector approach. The best treatment for obesity starts preconception. Let's treat the parents with obesity prior to conceiving so that the offspring then have a better chance once they arrive. That's not a strategy that we're talking about. That's the best public health strategy that hasn't been entertained. I think that we have to be thinking about a wide swath of potential treatments and prevention strategies. The prevention strategy I just mentioned, which is preconception, and recognizing that GLP ones are one tool in the toolkit, but will not solve our entire problem with obesity, but by any stretch. OZEMPEC and other GLP ones are not a cure all, but they are the first drugs ever that work safely for millions of people, and they're the first drugs that change how we think about obesity and why it happens and how to address it. And here is one more side effect. GLP ones are having a big impact already on the food industry. Remember how Miranda talked about how they turn off the food noise, how they stop cravings? It seems that these drugs don't entirely stop appetites. They just stop appetites for things that people used to find while irresistible. People start eating other things instead. Things that are actually good for us. Salads, carrots, Swiss chard, radicchio. So people aren't just eating less. They're eating differently. And that has food companies scrambling. Here's a recording from early 2025 of Ramon LaGuarta, the CEO of PepsiCo, talking to Wall Street analysts after the company reported first quarter earnings. PepsiCo, I'll just note, makes a lot more than just Pepsi. They own Quaker Oats, which makes Cappin Crunch and other cereals. They own Sabra Hamas, Gatorade, and yes, the whole Frito Lay empire. Now the other thing we're seeing in GLP consumers is that they're keeping our brands in their repertoire, probably in smaller portions. So they're going for, and that's the way they're actually eating across most other choices. They're eating less quantity. So our offerings in small portions and whether it's in multi-pack or some other options that we provide, keeps our brands in their repertoire and it's still relevant. Pretty much every food and beverage company, even grocery companies, are facing the same issues. They're having these same conversations with Wall Street. Calorie consumption is going down for people taking these drugs. They are spending less money on food and drink. People also report less appetite for alcohol. It so happens. And the more people who take GLP ones and its upwards of 10% of Americans right now, the less those highly processed, highly engineered foods sell. They break the spell. They seem to remove the addictive properties of those foods. Addiction, it's a strong word to use here, but it is not a stretch. A 2018 research review in the journal Nutrients found strong evidence that food could be considered addictive, given how it affects our brains, including withdrawal symptoms and relapse. GLP ones seem to liberate those areas of our brain that food companies have been exploiting for decades, just poking our cortex like dogs and Pavlov's lab. So food companies so far are talking about developing healthier foods and smaller portions, as part of their strategy for dealing with GLP ones like ozempic, which when you think about it is great, healthier foods, smaller portions, more options. Maybe we do have a choice. After all. That's it for this drug story about ozempic. For an annotated list of our sources for this episode, visit drugstorey.co. Drugstorey was created, written and hosted by me, Thomas Gets. Molly Warner is our research director. From reasonable volume, Rachel Swavy produced and sound designed this episode with assistance from Audrey Know. The least hue was the editor. Mark Bush is our engineer. Drugstorey was produced with support from the University of California Berkeley School of Public Health, special thanks to Claudia Williams and Michael Liu. Thanks also to Dr. Fatima Cody Stanford and Miranda, who shared her story with us. Drugstorey is an independent production. If you'd like to support our work, contact us at drugstorey.co. You can also subscribe to our sub-stack there and be notified when new episodes come out. And if you like this episode, help us spread the word. Rate us on Apple or Spotify or wherever you get your podcasts. Next up on drugstorey. It's all about Xanix, a medication that was considered a wonder drug. Because it works so well for anxiety and panic attacks. But it turns out it may work too well. We'll see you next time. Listening to this episode of drugstorey may cause you to eat more fruits and vegetables. Walk to the store instead of driving and regret all those late-night visits to subway back when you were in college. We recommend you think twice about that third helping. Stop blaming yourself and know that Tony the Tiger is talking straight to you and me when he says, [MUSIC]