On a beach in San Sebastian, Spain, Aditi Juneja strutted around in the beige sand wearing a red bikini top with colorful bottoms, her mop of curly hair blowing in the breeze. A close friend and travel companion trailed behind snapping photos.
In the years before the Spain trip, Juneja, 32, a lawyer, had put on 50 pounds. She called it the “Fascist 50” — much of it gained during the Trump presidency, when her work dealt with the era’s democracy abuses.
Diagnosed with clinical obesity, she had come to embrace her larger body size. She’d been steeping herself in literature on fat acceptance and learning about the “Health at Every Size” movement, which seeks to demedicalize obesity and promote an understanding that body size is not necessarily correlated with health. On that beach day, she remembers wanting to document how far she’d come, “to celebrate this beautiful body.”
But around the same time, she was also coming to terms with health issues related to her weight. “I was experiencing the physical effects of being in a heavier body,” she says. First there were pain and mobility issues: Her back was regularly going out, and she was frequently rolling over her ankles.
Then she learned that her cholesterol levels had soared to 10 times the normal range. It was the result of a genetic predisposition and had to be treated by cholesterol medication, her doctor told her, but weight loss could help, too. Juneja was also growing concerned about how her weight would heighten her risk of Type 2 diabetes, for which she has a strong family history, and potentially complicate a future pregnancy.
When her doctor broached medication to treat the obesity — such as semaglutide, currently sold by Novo Nordisk under the brand names Wegovy and Ozempic — Juneja refused. The fat acceptance literature she’d been studying opposed weight loss as a means to health. Using an obesity drug also felt like an admission that her body was something to be ashamed about at a moment when she’d come to embrace it.
The new class of obesity drugs — referred to as “GLP-1-based,” since they contain synthetic versions of the human hormone glucagon-like peptide-1 — are considered the most powerful ever marketed for weight loss. Since the US Food and Drug Administration approved Wegovy for patients with obesity in 2021, buzz on social media and in Hollywood’s gossip mills has erupted, helping drive a surge in popularity that’s contributed to ongoing supply shortages. While celebrities and billionaires such as Elon Musk and Michael Rubin praise the weight loss effects of these drugs, regular patients, including those with Type 2 diabetes, struggle with access, raising questions about who will really benefit from treatment.
But there’s another tension that’s emerged in the GLP-1 story: The medicines have become a lightning rod in an obesity conversation that is increasingly binary — swinging between fat acceptance and fatphobia.
“It feels like you have to be like, ‘I love being fat, this is my fat body,’ or, ‘Fat people are evil,’” Juneja told me.
While many clinicians and researchers hail GLP-1-based therapy as a “breakthrough,” and one deemed safe and effective by FDA, critics question its safety and usefulness. They argue the drugs unnecessarily medicalize obesity and dispute that it’s an illness in need of treatment at all. They also say the medicines perpetuate a dangerous diet culture that idealizes thinness and weight loss at all costs.
At the same time, many of the patients currently on treatment tell a story that seems to fall somewhere between “miracle” and “useless” diet drugs. Despite all the TikTok videos decrying obesity medication as the easy way out, progress is not always straightforward. Navigating side effects, dosing, weight plateaus, and access issues are frustrating features of many patients’ journeys. Patients also told me it’s hard to know if and when to come off the drugs, or that a healthy end goal has been reached. A minority don’t respond to the drugs at all.
One thing they had in common: wanting medical help to lose weight, despite the cultural conversation around fat acceptance. Even Juneja, who eventually started using the GLP-1-based drug tirzepatide, sold as Mounjaro by Eli Lilly, argues that the medicines are part of a more nuanced story, one society needs to internalize. Rather than viewing obesity as the result of personal failing or emotional issues, easily reversed with diet and exercise, patients like Juneja say they’re beginning to see it as medical researchers long have: as a condition that arises from complex interactions between our biology and our environments. Like other complex illnesses, such as diabetes, this means it can also benefit from medical treatment.
And some patients, including those who accept their larger bodies, may want to try obesity medication for help losing weight. “You can be healthy at every size,” Juneja summed up. But “I was not healthy at the size that I was.”
On GLP-1-based drugs, it’s easier to consume fewer calories
At first, Juneja took the cholesterol medicine prescribed by her doctor but resisted the obesity treatment. She hadn’t yet put in the time to really try to improve her health through lifestyle changes alone, she thought. So for the year after her doctor first suggested semaglutide, Juneja focused on eating healthfully — more protein and vegetables, fewer snacks — and exercising five days per week, thinking these measures alone would be enough.
A year later, her cholesterol had improved on her cholesterol-lowering drugs but her levels were still too high, and the pain and mobility issues hadn’t fully resolved either. She had also lost “zero weight,” she recalls, and remained “very much concerned about the diabetes and the pregnancy thing,” referring to the fact that pregnancies with obesity are associated with a greater risk of complications, such as preeclampsia and gestational diabetes, as well as a higher risk of bias from health care workers.
In September 2022, after Juneja returned to New York City from Spain, she filled her first prescription for tirzepatide, which was approved for diabetes in 2022 and is now being used off-label for obesity. “I no longer felt guilty about exploring medication assistance as an option for weight loss,” she says.
Right away, Juneja noticed it was suddenly easier to consume fewer calories. Her hunger between meals eased, and she felt fuller faster whenever she did eat. The weight also started dropping off — roughly two pounds per week, she said, to the tune of 37 pounds by January 29, after five months on treatment.
GLP-1-based drugs “weren’t initially developed for weight loss,” Daniel Drucker, a scientist and endocrinologist at the University of Toronto who helped discover GLP-1, says. Instead, they were used in patients with Type 2 diabetes, to help manage their blood sugar, and only in those clinical trials did researchers see how many patients were also losing weight.
Researchers still don’t know the precise mechanism by which the drugs work, but they believe it has to do with mimicking the actions of hormones and their impact on the brain. Hormones are the body’s traveling messengers: Manufactured in one area, they move to another to deliver messages through receptors. The gut makes dozens of hormones, including GLP-1.
When we eat, GLP-1 is unleashed primarily in the gut (in addition to the brain stem) and stimulates the pancreas to make more insulin, lowering blood sugar and sending a signal to the brain that we’ve had enough food, which then curbs appetite.
Drugs like semaglutide and tirzepatide contain a synthetic version of our native GLP-1, and appear to be safe. There’s more than a decade of safety data on the effects of the medicines in people with diabetes, many who also had obesity. “We’ve been studying [GLP-1] in animals for 30 years and in humans for more than 18 years,” Drucker, who has consulted with Novo Nordisk, says.
So far, both semaglutide and tirzepatide have led to weight loss results rivaling bariatric surgery — without the need for an operation. In clinical trials lasting more than a year, patients lose up to 20 percent of their body weight on tirzepatide and 15 percent on semaglutide. Many patients also see their fasting glucose or insulin levels improve and their blood pressure go down.
Though gastrointestinal side effects — nausea, diarrhea — are common, Juneja didn’t experience any during her first four months on tirzepatide. Things were improving. Her back pain went away, and she could move around with more ease. Her cholesterol levels finally fully normalized, prompting her doctor to raise the possibility that she could reduce her reliance on cholesterol medication. And the weight loss came with an unexpected mental health benefit: It changed how she thought about her obesity, reducing the shame she felt about not being able to control her body size.
“I realized that it wasn’t my fault that I couldn’t lose weight despite making tons of lifestyle changes,” she says. “I can see how much hormones are a part of it now.”
She added: “Being on these medicines, I was like, ‘Jesus Christ, I didn’t need to have any guilt around this. I didn’t need to have any big feelings around it.’”
Easing the food stress
If anyone has tried dieting and exercise for weight loss, it’s Tracey Yukich. While she was a candidate on the reality TV weight loss contest The Biggest Loser, she had to be airlifted to a hospital to be treated for rhabdomyolysis, a life-threatening condition often caused by overexercising. Still, by the end of the season, which aired in 2009, she had managed to lose 118 pounds. And she kept a lot of the weight off years after her Hollywood stint — by exercising regularly (she’s run the Boston Marathon three times) and eating well.
By 2016, Yukich’s struggle changed. No matter how hard she tried, the weight piled on. “I would revolve my entire day around my caloric intake, and when I did splurge or have a normal meal, I gained weight easily and rapidly,” she recalls.
In 2021, Yukich decided she needed medical help. She had come to “despise diet culture” which “has consumed so much of my life,” she says, and instead of more calorie cutting and exercise, she sought the care of an obesity doctor in Boston. The doctor recommended semaglutide — Ozempic — which Yukich started taking that May. The drug helped her lose 40 pounds, she says. And, as Juneja experienced, it also took away the shame she felt asking for help and the blame she was placing on herself about her weight gain.
“It’s taken me a year to get that weight off” on semaglutide, Yukich says. “I’m still exercising the way I was a year ago. I’m still eating the same as I was a year ago. The only thing I’ve done differently is take prescription medication. Does that not prove medicine is needed for people that are obese? That they need help? I can’t think of any other proof.”
On semaglutide, Yukich experienced some dizziness and a worsening of existing constipation, but both side effects resolved. In addition to weight loss, the drug’s other major effect was that her stress around food eased.
Suddenly, she was no longer worried about whether she’d made the right choices in her last meal, or what she’d be eating next. “My day didn’t revolve around what I was going to have for food,” she says.
Clinicians who have worked with patients with obesity shared a similar view: People on these drugs don’t just shed pounds, they shed food-related anxieties, too.
“There is tremendous mental health benefits to no longer stressing around food, to no longer feeling like you’re out of control around food, and to no longer feeling like there’s something broken and wrong with you that prevents you from making those healthy choices you’d like to make,” says Yoni Freedhoff, an obesity doctor based in Ottawa who has also consulted with Novo Nordisk, which has hired many leading diabetes and obesity doctors and scientists as consultants. His patients are telling him this reduction in stress “is as valuable as the weight loss,” he says.
“For the first time in many of these patients’ lives, they have a more neutral feeling toward food,” Michelle Cardel, associate director for the Center for Integrative Cardiovascular and Metabolic Diseases at the University of Florida who heads research at Weight Watchers, observed. GLP-1-based drugs “reduce the chatter in their brain; they quiet obsessive food thoughts.”
Critics worry the drugs will only reinforce weight stigma
But not everybody embraces the new obesity medications.
Some of the most vocal opposition has come from Health at Every Size and weight-neutral health advocates, who criticize how the drugs medicalize obesity.
They point to the longstanding debate about whether obesity is in and of itself a disease state and argue that body size is not a good health metric. Some of obesity’s health consequences may also be caused by stigma and discrimination, including on the part of health care providers who under-treat patients with obesity, attributing medical issues to excess weight even when they have other causes. The situation is especially risky for people of color, who also have higher rates of obesity in the US and are less likely to be accurately diagnosed by body mass index, or BMI — the tool that’s most frequently deployed to gauge obesity and its risks.
“The idea of other health issues being ‘obesity-associated’ is scientifically questionable, since weight cycling [also known as yo-yo dieting], weight stigma, and health care inequalities are all correlated with the same health issues to which being higher weight is correlated,” explained Ragen Chastain, a patient advocate and writer focused on weight stigma and weight-neutral health, who, like many of her peers, believes weight loss should not be used as a medical intervention. Instead, she’d like health care providers to “stop calculating BMIs, stop pathologizing higher weight bodies, stop prescribing weight loss diets/drugs/surgeries, and give fat people the interventions we would give thin people with the same symptoms,” as she summed up on her blog.
This pushback has gained traction in a moment when weight discrimination has been holding firm or worsening — even while discrimination based on other factors, such as race or sex, has been declining, and obesity rates have been rising. In the US, obesity affects 42 percent of the adult population and 20 percent of children and adolescents. Globally, the World Health Organization estimates more than 1 billion people have obesity, including kids. There are legions who’ve struggled with their weight and share a history of failed weight loss attempts.
Alongside the cultural movement, there’s a growing pile of scientific evidence from obesity and diabetes researchers showing that the health risks of excess fat are more difficult to untangle than the public has been led to believe.
Some people develop complications linked to obesity, such as Type 2 diabetes, before reaching clinical obesity, while others manage to avoid obesity’s metabolic risks, including “metabolic syndrome” — a cluster of conditions that typically occur together, including high blood pressure, high blood sugar, cardiovascular disease, and high cholesterol.
These insights have led to the “personal fat threshold” hypothesis — that everybody has a different point at which fat heightens the risk of Type 2 diabetes, and that point isn’t always correlated with a high BMI. A related strand of research explores “metabolically healthy obesity,” a concept that’s been heavily debated since it can take decades for obesity’s complications to surface. People who seem “metabolically healthy” early in life may not be in the future, or they may develop obesity’s non-metabolic complications, which include sleep apnea and mobility problems.
Besides questions about the true health costs of obesity, critics also express concern that the published GLP-1 weight loss clinical trials to date have only followed up with people for up to two years and patients tend to keep off most of the weight only as long as they stay on treatment, meaning if they want to maintain their new body weight, they probably have to stay on the medicine for life.
Even the obesity clinicians and researchers who view the drugs as a major step forward acknowledge uncertainty. While it’s true that drugs containing synthetic GLP-1 alone, such as semaglutide, have been used for years in diabetes patients, some of the newer compounds — such as tirzepatide, which features both GLP-1 and a synthetic version of another similar hormone called GIP — have not. “When we add anything, it’s a very appropriate question to ask, ‘Are you going to take anything away from the safety of GLP-1 alone or maybe ideally add something to the safety,’” Drucker points out. “We cannot assume that [additional drug ingredients] have a neutral or beneficial effect.”
Still, like many of his peers, Drucker says he’s puzzled — and concerned — by how people treat obesity differently from other diseases, and downplay “the risks of leaving it untreated.” Of the long-term use of the drugs, he says, “I could give you a list of hundreds of chronic diseases that remit when treatment is discontinued — all forms of diabetes, hypertension, heart disease, atherosclerosis, arthritis. Yet somehow, we hold obesity therapy to a higher standard and ‘complain’ that chronic therapy is necessary.”
Tony Goldstone, an Imperial College London endocrinology clinician-researcher who treats patients with obesity and has previously monitored the safety data in GLP-1-based drug trials for Novo Nordisk, shared a similar view. “So we shouldn’t develop treatments for obesity, because there’s a risk that it might get abused by Hollywood celebrities who want to lose a little bit of weight?” he asked. “I mean, that isn’t how medicine works.”
Goldstone and others pointed out that there’s a mountain of evidence demonstrating that, as body weight increases, people’s health risks do, too, including problems that can’t be explained by discrimination alone, such as sleep apnea and cancer. Weight loss has also repeatedly been shown to improve health outcomes — in everything from rodent research to long-term controlled human studies of bariatric surgery.
Samuel Klein, the director of the Center for Human Nutrition at Washington University in St. Louis, who researches metabolically healthy obesity, noted that many weight loss studies include lifestyle changes, like diet or exercise, so it’s difficult to separate out the benefits of the weight loss itself from the benefits of the other changes — a point those skeptical of treating obesity as a disease make, too. “But it’s very unlikely” that weight loss is not the “primary contributor” to health improvements, he added, pointing to research that shows the more weight people lose, the more health benefits accrue.
Even with the unknowns, Klein says, people “need to get their heads out of the sand. We know very much that even moderate weight loss can prevent and improve obesity related-diseases. It improves medical health, quality of life, and the ability to be physically active and interact in activities with family and friends.”
As researchers try to untangle how all this works, and patients’ conceptions evolve, society’s “warped idea” about obesity remains stubbornly in place, journalist Evette Dionne, author of a“fat liberation” memoir, wrote recently. “It is objectively a good move to unlink the idea of moral virtue from fatness. However, in these attempts to complicate our cultural understanding of fatness, the remedy remains the same: lose weight rather than changing the ways in which our society interacts with and treats fat people.”
Caught in the middle of the debates are patients who would like to lose weight for myriad health and personal reasons, which may have nothing to do with how they look.
Those reasons can span medical conditions, such as diabetes, to simply wanting to play a sport or with their kids on the playground, to not feeling out of breath when bringing in the groceries, Marian Tanofsky-Kraff, a clinician-researcher at the Uniformed Services University in Maryland, says. But, she adds, “Many of my patients have told me their desire to lose weight due to reasons other than appearance is somehow slowing the fat acceptance movement and they feel invalidated and guilty.”
Juneja has come to her nuanced view by reconciling her embrace of body positivity with taking the drugs. Acceptance is not resignation; people can love and accept their bodies while also wanting the health benefits that come with weight loss, she says.
“While I agree that there’s an obsession with thinness in our culture, some of us do have health challenges that losing weight helps with … which is hard to do with just diet and exercise,” Juneja told me. “And it’s such a gift to be able to get ahead of things like diabetes.”
Yukich sees the drugs as something entirely apart from the diet culture she was so steeped in. “What I seek is a healthy me and while I will never be 132 pounds weighing in on the Biggest Loser stage again, I am the healthiest version of myself today and am more happy than I ever have been.”
The bumpy road for patients
The multifaceted scientific-cultural moment the GLP-1-based medicines have entered into has an additional layer of complexity: Treating obesity as a chronic disease with what experts deem a safe and powerful weight-loss medicine is new — and can be difficult. Even if the drugs themselves continue to be as promising as they currently seem, this change scales up the medical treatment of obesity, bringing it into the realm of all the common conditions marred by the inequalities inherent to the American health system.
I’ve talked to many people on obesity medication, and the range of stories I’ve heard is stunning. There are people who report incredible progress and call the drugs life-changing. For others, side effects were unmanageable or weight loss on the drugs didn’t meet their expectations. Most people felt the drugs were helpful but also less of an “easy way out” of weight problems than an entirely new maze to navigate.
These patients in the middle — including Yukich and Juneja — have had to switch or add medications after their weight plateaued far from their goal at the highest doses, or they reported interruptions to their access due to changing insurance and coupon policies and other affordability issues — or all of the above.
After Yukich shed 33 pounds on her regimen of Ozempic plus diet and exercise, her weight plateaued, 25 pounds shy of her goal weight. Her doctor suggested she switch from Ozempic to the higher-dose version of semaglutide, Wegovy. But her insurer, Blue Cross Blue Shield, would not cover Wegovy. Yukich was able to access tirzepatide but had to stop it after a month because it had the opposite of the desired effect: Her cravings increased, and she gained 10 pounds. This January, after she wrote to her insurer twice a month requesting coverage, she finally got the approval for Wegovy.
In her first two weeks on the drug, her weight started dropping again. “I hope to reach my goal, and then slowly taper off and see how I manage without,” she says.
Juneja has faced similar disruptions — and now she’s wondering whether to continue with the drug at all. After her insurer, UnitedHealthcare, rejected her initial requests to have tirzepatide covered for obesity, she got access to the drug with a coupon from its manufacturer, Eli Lilly, for $25 per month — a fraction of the roughly $1,000 she would have had to pay out of pocket.
Then, last December, Juneja learned that Eli Lilly’s coupon policy changed, to only offer the discount to people who already have Type 2 diabetes. So she’s been paying out of pocket for a month while waiting to see if UnitedHealthcare might cover another GLP-1-based drug. So far, all of her prior authorization attempts were rejected. Because of the costs, and diarrhea that surfaced during month five on tirzepatide — which she’s not certain is linked to the drug — she’s contemplating stopping, just 14 pounds short of her goal weight.
If she does quit, she’s hoping she can maintain her current weight loss with her usual diet and exercise routine, but she knows there’s a risk her weight might creep back up, along with the mobility, pain, and cholesterol issues and other health risks. And she’s not sure how concerned to be.
“Even if I lose the next 14 pounds and I’m no longer obese, I’m simply overweight, does that actually stop me from having Type 2 diabetes?” she told me.
What’s more, she’d only ever planned to be on the drug for a year — she had been told by her prescribing doctor that the medicine would reset her body’s “set point,” so that she’d be able to maintain a lower weight without medication. Today, she feels she was misled. “I would’ve never gone on [weight loss drugs] if I thought I’d have to be on them forever.”
Apart from the confusion over her own case, she’s wondering about the potential societal effects of the new medicines, and how the gaps in GLP-1 access will play out in a country where states with some of the highest rates of obesity also have some of the lowest rates of health insurance coverage.
“I worry that because of the cost — and the marketing — it’s going to perpetuate us having people who are rich and thin, and people who are poor and fat, and it’s not going to change the culture or help people that most need it,” Juneja says. “So while it’ll make a difference for individuals who can access it, our ability to change population-level obesity is still determined by the ability to access healthy foods, access health care, have the time to think about your health. And all of that is not changed by these drugs. It’s exactly where we were before.”