Ozempic or Bust

Illustration by Vartika Sharma

1

In the early spring of 2020, Barb Herrera taped a signed note to a wall of her bedroom in Orlando, Florida, just above her pillow. NOTICE TO EMS! it said. No Vent! No Intubation! She’d heard that hospitals were overflowing, and that doctors were being forced to choose which COVID patients they would try to save and which to abandon. She wanted to spare them the trouble.

Barb was nearly 60 years old, and weighed about 400 pounds. She has type 2 diabetes, chronic kidney disease, and a host of other health concerns. At the start of the pandemic, she figured she was doomed. When she sent her list of passwords to her kids, who all live far away, they couldn’t help but think the same. “I was in an incredibly dark place,” she told me. “I would have died.”

Until recently, Barb could barely walk—at least not without putting herself at risk of getting yet another fracture in her feet. Moving around the house exhausted her; she showered only every other week. She couldn’t make it to the mailbox on her own. Barb had spent a lifetime dealing with the inconveniences of being, as she puts it, “huge.” But what really scared her—and what embarrassed her, because dread and shame have a way of getting tangled up—were the moments when her little room, about 10 feet wide and not much longer, was less a hideout than a trap. At one point in 2021, she says, she tripped and fell on the way to the toilet. Her housemate and landlord—a high-school friend—was not at home to help, so Barb had to call the paramedics. “It took four guys to get me up,” she said.

Later that year, when Barb finally did get COVID, her case was fairly mild. But she didn’t feel quite right after she recovered: She was having trouble breathing, and there was something off about her heart. Finally, in April 2022, she went to the hospital and her vital signs were taken.

The average body mass index for American adults is 30. Barb’s BMI was around 75. A blood-sugar test showed that her diabetes was not under control—her blood sugar was in the range where she might be at risk of blindness or stroke. And an EKG confirmed that her heart was skipping beats. A cardiac electrophysiologist, Shravan Ambati, came in for a consultation. He said the missed beats could be treated with medication, but he made a mental note of her severe obesity—he’d seen only one or two patients of Barb’s size in his 14-year career. Before he left, he paused to give her some advice. If she didn’t lose weight, he said, “the Barb of five years from now is not going to like you very much at all.” As she remembers it, he crossed his arms and added: “You will either change your life, or you’ll end up in a nursing home.”

“That was it. That was it,” Barb told me. Imagining herself getting old inside a home, “in a row of old people who are fat as hell, just sitting there waiting to die,” she vowed to do everything she could to get well. She would try to change her life. Eventually, like millions of Americans, she would try the new miracle cure. Again.

2

In a way, Barb has never stopped trying to change her life. At 10 years old, she was prescribed amphetamines; at 12, she went to WeightWatchers. Later she would go on liquid diets, and nearly every form of solid diet. She’s been vegan and gluten-free, avoided fat, cut back on carbs, and sworn off processed foods. She’s taken drugs that changed her neurochemistry and gotten surgery to shrink her stomach to the size of a shot glass. She’s gone to food-addiction groups. She’s eaten Lean Cuisines. She’s been an avid swimmer at the Y.

Through it all, she’s lost a lot of weight. Really an extraordinary quantity—well more than a quarter ton, if you add it up across her life. But every miracle so far has come with hidden costs: anemia, drug-induced depression, damage to her heart. Always, in the end, the weight has come back. Always, in the end, “success” has left her feeling worse.

In the United States, an estimated 189 million adults are classified as having obesity or being overweight; certainly many millions have, like Barb, spent decades running on a treadmill of solutions, never getting anywhere. The ordinary fixes—the kind that draw on people’s will, and require eating less and moving more—rarely have a large or lasting effect. Indeed, America itself has suffered through a long, maddening history of failed attempts to change its habits on a national scale: a yo-yo diet of well-intentioned treatments, policies, and other social interventions that only ever lead us back to where we started. New rules for eating have been rolled out and then rolled back. Pills have been invented and abandoned. Laws have been rewritten to improve the quality of people’s diets and curb caloric intake—to make society less “obesogenic” on the whole. Efforts have been made to reduce discrimination over body size in employment settings and in health care. Through it all, obesity rates keep going up; the diabetes epidemic keeps worsening.

The most recent miracle, for Barb as well as for the nation, has come in the form of injectable drugs. In early 2021, the Danish pharmaceutical company Novo Nordisk published a clinical trial showing remarkable results for semaglutide, now sold under the trade names Wegovy and Ozempic. Thomas Wadden, a clinical psychologist and obesity researcher at the University of Pennsylvania who has studied weight-loss interventions for more than 40 years (and who has received both research grants and fees from Novo Nordisk), remembers when he first learned about those findings, at an internal meeting at the company the year before. “My jaw just dropped,” he told me. “I really could not believe what we were seeing.” Patients in the study who’d had injections of the drug lost, on average, close to 15 percent of their body weight—more than had ever been achieved with any other drug in a study of that size. Wadden knew immediately that this would be “an incredible revolution in the treatment of obesity.”

[Radio Atlantic: Could Ozempic derail the body-positivity movement?]

Semaglutide is in the class of GLP-1 receptor agonists, chemicals derived from lizard venom that mimic gut hormones and appear to reshape our metabolism and eating behavior for as long as the drugs are taken. Earlier versions were already being used to treat diabetes; then, in 2022, a newer one from Eli Lilly—tirzepatide, sold as Zepbound or Mounjaro—produced an average weight loss of 20 percent in a clinical trial. Many more drugs are now racing through development: survodutide, pemvidutide, retatrutide. (Among specialists, that last one has produced the most excitement: An early trial found an average weight loss of 24 percent in one group of participants.)

The past four decades of American history underline just how much is riding on these drugs—and serve as a sobering reminder that it is impossible to know, in the first few years of any novel intervention, whether its success will last.

The drugs don’t work for everyone. Their major side effects—nausea, vomiting, and diarrhea—can be too intense for many patients. Others don’t end up losing any weight. That’s not to mention all the people who might benefit from treatment but don’t have access to it: For the time being, just 25 percent of private insurers offer the relevant coverage, and the cost of treatment—about $1,000 a month—has been prohibitive for many Americans.

But there’s growing pressure for GLP-1 drugs to be covered without restrictions by Medicare, and subject to price negotiation. Eventually they will start to come off patent. When that happens, usage is likely to explode. The drugs have already been approved not just for people with diabetes or obesity, but for anyone who has a BMI of more than 27 and an associated health condition, such as high blood pressure or cholesterol. By those criteria, more than 140 million American adults already qualify—and if this story goes the way it’s gone for other “risk factor” drugs such as statins and antihypertensives, then the threshold for prescriptions will be lowered over time, inching further toward the weight range we now describe as “normal.”

How you view that prospect will depend on your attitudes about obesity, and your tolerance for risk. The first GLP-1 drug to receive FDA approval, exenatide, has been used as a diabetes treatment for more than 20 years. No long-term harms have been identified—but then again, that drug’s long-term effects have been studied carefully only across a span of seven years. Today, adolescents are injecting newer versions of these drugs, and may continue to do so every week for 50 years or more. What might happen over all that time? Could the drugs produce lasting damage, or end up losing some of their benefit?

Athena Philis-Tsimikas, an endocrinologist who works at Scripps Health in San Diego and whose research has received ample funding from Novo Nordisk and Eli Lilly, says the data so far look very good. “These are now being used, literally, in hundreds of thousands of people across the world,” she told me, and although some studies have suggested that GLP-1 drugs may cause inflammation of the pancreas, or even tumor growth, these concerns have not borne out. Exenatide, at least, keeps working over many years, and its side effects don’t appear to worsen. Still, we have less to go on with the newer drugs, Philis-Tsimikas said. “All of us, in the back of our minds, always wonder, Will something show up?  ” Although no serious problems have yet emerged, she said, “you wonder, and you worry.”

The GLP-1 drugs may well represent a shocking breakthrough for the field of public health, on the order of vaccines and sanitation. They could also fizzle out, or end in a surge of tragic, unforeseen results. But in light of what we’ve been through, it’s hard to see what other choices still remain. For 40 years, we’ve tried to curb the spread of obesity and its related ailments, and for 40 years, we’ve failed. We don’t know how to fix the problem. We don’t even understand what’s really causing it. Now, again, we have a new approach. This time around, the fix had better work.

3

Barb’s first weight-loss miracle, and America’s, came during a moment of profound despair. In 1995, while working in a birthing center, she’d tripped on a scale—“the irony of all ironies,” she told me—and cracked her ankle. When she showed up for the surgery that followed, Barb, then 34 and weighing 330 pounds, learned that she had type 2 diabetes. In a way, this felt like her inheritance: Both grandparents on Barb’s father’s side had obesity and diabetes, as did her dad, his brother, and two sisters. Her mother, too, had obesity. Now, despite Barb’s own years of efforts to maintain her health, that legacy had her in its grip.

The doctors threatened Barb (as doctors often have): If she didn’t find a way to eat in moderation, she might not make it through the end of 1997. Then she got some new advice: Yes, Barb should eat better food and exercise, but also maybe she should try a pair of drugs, dexfenfluramine and phentermine, together known as “fen-phen.” The former had just received approval from the FDA, and research showed that a combination of the two, taken several times a day, was highly effective at reducing weight.

[Read: The weight-loss-drug revolution is a miracle—and a menace]

The treatment was a revelation. Even when she talks about it now, Barb begins to cry. She’d tried so many diets in the past, and made so little progress, but as soon as she started on the weight-loss medication, something changed. A low and steady hum that she’d experienced ever since she was a kid—Where can I eat? How can I eat? When can I eat?—disappeared, leaving her in a strange new state of quiet. “The fen-phen turned that off just within a day. It was gone,” she told me, struggling to get out the words. “What it did was tell me that I’m not crazy, that it really wasn’t me.”

At the time, Wadden, the obesity researcher and clinician, was hearing similar reports from his patients, who started telling him that their relationship with food had been transformed, that suddenly they were free of constant cravings. Over the course of a small, year-long study of the drugs that Wadden ran with a colleague at Penn, Robert Berkowitz, participants lost about 14 percent of their body weight on average. That’s the same level of success that would be seen for semaglutide several decades later. “Bob and I really were high-fiving each other,” Wadden told me. “We were feeling like, God, we’ve got a cure for obesity.”

The fen-phen revolution arrived at a crucial turning point for Wadden’s field, and indeed for his career. By then he’d spent almost 15 years at the leading edge of research into dietary interventions, seeing how much weight a person might lose through careful cutting of their calories. But that sort of diet science—and the diet culture that it helped support—had lately come into a state of ruin. Americans were fatter than they’d ever been, and they were giving up on losing weight. According to one industry group, the total number of dieters in the country declined by more than 25 percent from 1986 to 1991.

“I’ll never diet again,” Oprah Winfrey had announced on her TV show at the end of 1990. Not long before, she’d kicked off a major trend by talking up her own success with a brand of weight-loss shakes called Optifast. But Winfrey’s slimmer figure had been fleeting, and now the $33 billion diet industry was under scrutiny for making bogus scientific claims.

Rejecting diet culture became something of a feminist cause. “A growing number of women are joining in an anti-diet movement,” The New York Times reported in 1992. “They are forming support groups and ceasing to diet with a resolve similar to that of secretaries who 20 years ago stopped getting coffee for their bosses. Others have smashed their bathroom scales with the abandon that some women in the 1960’s burned their bras.”

That same Times story included a quote from Wadden, who cautioned that these changing attitudes might end up being “dangerous.” But Wadden’s own views of dieting were also changing. His prior research showed that patients could lose up to one-fifth of their body weight by going on very strict diets that allowed for no more than 800 calories a day. But he’d found that it was difficult for his patients to maintain that loss for long, once the formal program was over. Now Wadden and other obesity researchers were reaching a consensus that behavioral interventions might produce in the very best scenario an average lasting weight loss of just 5 to 10 percent.

National surveys completed in 1994 showed that the adult obesity rate had surged by more than half since 1980, while the proportion of children classified as overweight had doubled. The need for weight control in America had never seemed so great, even as the chances of achieving it were never perceived to be so small.

Then a bolt of science landed in this muddle and despair. In December 1994, the Times ran an editorial on what was understood to be a pivotal discovery: A genetic basis for obesity had finally been found. Researchers at Rockefeller University were investigating a molecule, later named leptin, that gets secreted from fat cells and travels to the brain, and that causes feelings of satiety. Lab mice with mutations in the leptin gene—importantly, a gene also found in humans—overeat until they’re three times the size of other mice. “The finding holds out the dazzling hope,” the editorial explained, “that scientists may, eventually, come up with a drug treatment to help overweight Americans shed unwanted, unhealthy pounds.”

Leptin-based treatments for obesity were in the works, according to the researchers, and might be ready for the public in five years, maybe 10. In the meantime, the suggestion that obesity was a biochemical disease, more a function of a person’s genes than of their faulty habits or lack of will, dovetailed with the nation’s shift away from dieting. If there was any hope of solving the problem of obesity, maybe this was it.

Wadden was ready to switch gears. “I realized that we had sort of reached our limits on what we could do with diet and physical activity,” he said. Now, instead, he started looking into pharmaceuticals. He’d already run one weight-loss study using sertraline, better known as Zoloft, and found that it had no effect. In 1995, he turned to fen-phen.

Fen-phen wasn’t new, exactly—versions of its component drugs had been prescribed for decades. But when those pills were taken separately, their side effects were difficult to handle: “Fen” would make you drowsy and might give you diarrhea; “phen” could be agitating and lead to constipation. By the 1990s, though, doctors had begun to give the two together, such that their side effects would cancel each other out. And then a new and better version of “fen”—not fenfluramine but dexfenfluramine—came under FDA review.

Some regulators worried that this better “fen” posed a risk of brain damage. And there were signs that “fen” in any form might lead to pulmonary hypertension, a heart-related ailment. But Americans had been prescribed regular fenfluramine since 1973, and the newer drug, dexfenfluramine, had been available in France since 1985. Experts took comfort in this history. Using language that is familiar from today’s assurances regarding semaglutide and other GLP-1 drugs, they pointed out that millions were already on the medication. “It is highly unlikely that there is anything significant in toxicity to the drug that hasn’t been picked up with this kind of experience,” an FDA official named James Bilstad would later say in a Time cover story headlined “The Hot New Diet Pill.” To prevent Americans with obesity from getting dexfenfluramine, supporters said, would be to surrender to a deadly epidemic. Judith Stern, an obesity expert and nutritionist at UC Davis, was clear about the stakes: “If they recommend no,” she said of the FDA-committee members, “these doctors ought to be shot.”

In April 1996, the doctors recommended yes: Dexfenfluramine was approved—and became an instant blockbuster. Patients received prescriptions by the hundreds of thousands every month. Sketchy wellness clinics—call toll-free, 1-888-4FEN-FEN—helped meet demand. Then, as now, experts voiced concerns about access. Then, as now, they worried that people who didn’t really need the drugs were lining up to take them. By the end of the year, sales of “fen” alone had surpassed $300 million. “What we have here is probably the fastest launch of any drug in the history of the pharmaceutical industry,” one financial analyst told reporters.

This wasn’t just a drug launch. It was nothing less than an awakening, for doctors and their patients alike. Now a patient could be treated for excess weight in the same way they might be treated for diabetes or hypertension—with a drug they’d have to take for the rest of their life. That paradigm, Time explained, reflected a deeper shift in medicine. In a formulation that prefigures the nearly identical claims being made about Ozempic and its ilk today, the article heralded a “new understanding of obesity as a chronic disease rather than a failure of willpower.”

Barb started on fen-phen two weeks after it was approved. “I had never in my life felt normal until after about a week or two on the medications,” she’d later say. “My life before was hell.” She was losing weight, her blood sugar was improving, and she was getting to the pool, swimming 100 lengths five or six days a week. A few months later, when she read in her local newspaper that the Florida Board of Medicine was considering putting limits on the use of fen-phen, she was disturbed enough to send a letter to the editor. “I thank the creators of fen/phen for helping to save my life,” she wrote. “I don’t want to see the medications regulated so intensely that people like me are left out.”

4

For another year, Barb kept taking fen-phen, and for another year she kept losing weight. By July of 1997, she’d lost 111 pounds.

Thomas Wadden and his colleague’s fen-phen study had by then completed its second year. The data showed that their patients’ shocking weight loss had mostly been maintained, as long as they stayed on the drugs. But before Wadden had the chance to write up the results, he got a call from Susan Yanovski, then a program officer at the National Institutes of Health and now a co-director of the NIH’s Office of Obesity Research. We’ve got a problem, Yanovski told him.

News had just come out that, at the Mayo Clinic in Minnesota, two dozen women taking fen-phen—including six who were, like Barb, in their 30s—had developed cardiac conditions. A few had needed surgery, and on the operating table, doctors discovered that their heart valves were covered with a waxy plaque. They had “a glistening white appearance,” the doctors said, suggestive of disease. Now Yanovski wanted Wadden to look more closely at the women in his study.

Wadden wasn’t terribly concerned, because no one in his study had reported any heart symptoms. But ultrasounds revealed that nearly one-third of them had some degree of leakage in their heart valves. His “cure for obesity” was in fact a source of harm. “That just felt like a crushing blow,” he told me. Several weeks later, a larger data set from the FDA confirmed the issue. Wadden worried to reporters that the whole fiasco would end up setting back obesity treatment by many years.

[Read: The Ozempic revolution is stuck]

The news put Barb in a panic. Not about her heart: The drug hadn’t caused her any problems, as far as she could tell; it had only solved them. But now they were taking it away. What then? She’d already spoken out about her new and better life to local outlets; now she did so again, on national TV. On September 16, the day after fenfluramine in both of its forms was pulled from the market, Barb appeared on CBS This Morning. She explained then, as she later would to me, that fen-phen had flipped a switch inside her brain. There was desperation in her voice.

A few days later, she was in a limousine in New York City, invited to be on The Montel Williams Show. She wore a crisp floral dress; a chyron would identify her as “BARBARA: Will continue taking diet drug despite FDA recall.” “I know I can’t get any more,” she told Williams. “I have to use up what I have. And then I don’t know what I’m going to do after that. That’s the problem—and that is what scares me to death.” Telling people to lose weight the “natural way,” she told another guest, who was suggesting that people with obesity need only go on low-carb diets, is like “asking a person with a thyroid condition to just stop their medication.”

“I did all this stuff to shout it from the rooftops that I was doing so well on fen-phen,” Barb told me. Still, all the warnings she’d been hearing on the news, and from her fellow Montel guests, started building up inside her head. When she got back to Orlando, she went to see her doctor, just in case. His testing showed that she did indeed have damage to her mitral valve, and that fen-phen seemed to be the cause.

Five months later, she was back on CBS to talk about her tragic turnabout. The newscast showed Doppler footage of the backwards flow of blood into her heart. She’d gone off the fen-phen and had rapidly regained weight. “The voices returned and came back in a furor I’d never heard before,” Barb later wrote on her blog. “It was as if they were so angry at being silenced for so long, they were going to tell me 19 months’ worth of what they wanted me to hear. I was forced to listen. And I ate. And I ate. And ate.”

5

The Publix supermarket chain has, since its founding more than 90 years ago in central Florida, offered “people weighers,” free for use by all. They’re big, old-fashioned things, shaped like lollipops, with a dial readout at the top and handlebars of stainless steel. By the time I visited Barb last fall, in a subdivision of Orlando, she was determined to go and use one.

She’d taken heed of what Ambati, the cardiologist, had told her when she went into the hospital in April 2022. She cut back on salt and stopped ordering from Uber Eats. That alone was enough to bring her weight down 40 pounds. Then she started on Trulicity, the brand name for a GLP-1 drug called dulaglutide that is prescribed to people with diabetes. (The drug was covered for her use by Medicaid.) In clinical trials, patients on dulaglutide tend to lose about 10 pounds, on average, in a year. For Barb, the effects were far more dramatic. When we first met in person, she’d been on Trulicity for 14 months—and had lost more than one-third of her body weight. “It’s not even like I’m skinny, but compared to 405, I feel like an Olympic runner,” she told me.

We arrived at the supermarket in tandem with another middle-aged woman who was also there to check her weight. “Okay, you first, jump on!” Barb said. “My dream weight. I love it!” she said, when the pointer tipped to 230 pounds. “Not mine,” the other woman grumbled. Then Barb got on the scale and watched it spin to a little past 250. She was very pleased. The last number of the dial was 300. Even registering within its bounds was new.

Some people with obesity describe a sense of being trapped inside another person’s body, such that their outward shape doesn’t really match their inner one. For Barb, rapid weight loss has brought on a different metaphysical confusion. When she looks in the mirror, she sometimes sees her shape as it was two years ago. In certain corners of the internet, this is known as “phantom fat syndrome,” but Barb dislikes that term. She thinks it should be called “body integration syndrome,” stemming from a disconnect between your “larger-body memory” and “smaller-body reality.”

She has experienced this phenomenon before. After learning that she had heart-valve damage from fen-phen, Barb joined a class-action lawsuit against the maker of dexfenfluramine, and eventually received a substantial payout. In 2001, she put that money toward what would be her second weight-loss miracle—bariatric surgery. The effects were jarring, she remembers. Within just three months, she’d lost 100 pounds; within a year, she’d lost 190. She could ride a bike now, and do a cartwheel. “It was freakin’ wild,” she told me. “I didn’t have an idea of my body size.” She found herself still worried over whether chairs would break when she sat down. Turnstiles were confusing. For most of her adult life, she’d had to rotate sideways to go through them if she couldn’t find a gate, so that’s what she continued doing. Then one day her partner said, “No, just walk through straight,” and that’s what she did.

Weight-loss surgery was somewhat unusual at the time, despite its record of success. About 60,000 such procedures were performed in 2001, by one estimate; compare that with the millions of Americans who had been taking fen-phen just a few years earlier. Bariatric surgeons and obesity physicians have debated why this treatment has been so grossly “underutilized.” (Even now, fewer than 1 percent of eligible patients with obesity have the procedure.) Surely some are dissuaded by the scalpel: As with any surgery, this one carries risks. It’s also clear that many doctors have refrained from recommending it. But the fen-phen fiasco of the late 1990s cast its shadow on the field as well. The very idea of “treating” excess weight, whether with a pill or with a knife, had been discredited. It seemed ill-advised, if not old-fashioned.

[Read: The science behind Ozempic was wrong]

By the turn of the millennium, a newer way to think about America’s rising rates of obesity was starting to take hold. The push was led by Thomas Wadden’s close friend and colleague Kelly Brownell. In the 1970s, the two had played together in a bluegrass band—Wadden on upright bass, Brownell on guitar—and they later worked together at the University of Pennsylvania. But when their field lost faith in low-calorie diets as a source of lasting weight loss, the two friends went in opposite directions. Wadden looked for ways to fix a person’s chemistry, so he turned to pharmaceuticals. Brownell had come to see obesity as a product of our toxic food environment: He meant to fix the world to which a person’s chemistry responded, so he started getting into policy.

Inspired by successful efforts to reduce tobacco use, Brownell laid out a raft of new proposals in the ’90s to counter the effects of junk-food culture: a tax on non-nutritious snacks; a crackdown on deceptive health claims; regulation of what gets sold to kids inside school buildings. Those ideas didn’t find much traction while the nation was obsessed with fen-phen, but they caught on quickly in the years that followed, amid new and scary claims that obesity was indirectly hurting all Americans, not just the people with a lot of excess weight.

In 2003, the U.S. surgeon general declared obesity “the terror within, a threat that is every bit as real to America as the weapons of mass destruction”; a few months later, Eric Finkelstein, an economist who studies the social costs of obesity, put out an influential paper finding that excess weight was associated with up to $79 billion in health-care spending in 1998, of which roughly half was paid by Medicare and Medicaid. (Later he’d conclude that the number had nearly doubled in a decade.) In 2004, Finkelstein attended an Action on Obesity summit hosted by the Mayo Clinic, at which numerous social interventions were proposed, including calorie labeling in workplace cafeterias and mandatory gym class for children of all grades.

As the environmental theory gained currency, public-health officials took notice. In 2006, for example, the New York City Board of Health moved to require that calorie counts be posted on many chain restaurants’ menus, so customers would know how much they were eating. The city also banned trans fats.

Soon, the federal government took up many of the ideas that Brownell had helped popularize. Barack Obama had promised while campaigning for president that if America’s obesity trends could be reversed, the Medicare system alone would save “a trillion dollars.” By fighting fat, he implied, his ambitious plan for health-care reform would pay for itself. Once he was in office, his administration pulled every policy lever it could. The nation’s school-lunch program was overhauled. Nutrition labels got an update from the FDA, with more prominent displays of calories and a line for “added sugars.” Food benefits for families in poverty were adjusted to allow the purchase of more fruits and vegetables. The Affordable Care Act brought calorie labeling to chain restaurants nationwide and pushed for weight-loss programs through employer-based insurance plans.

Michelle Obama helped guide these efforts, working with marketing experts to develop ways of nudging kids toward better diets and pledging to eliminate “food deserts,” or neighborhoods that lacked convenient access to healthy, affordable food. She was relentless in her public messaging; she planted an organic garden at the White House and promoted her signature “Let’s Move!” campaign around the country. The first lady also led a separate, private-sector push for change within Big Food. In 2010, the beverage giants agreed to add calorie labels to the front of their bottles and cans; PepsiCo pledged major cuts in fat, sodium, and added sugars across its entire product line within a decade.

An all-out war on soda would come to stand in for these broad efforts. Nutrition studies found that half of all Americans were drinking sugar-sweetened beverages every day, and that consumption of these accounted for one-third of the added sugar in adults’ diets. Studies turned up links between people’s soft-drink consumption and their risks for type 2 diabetes and obesity. A new strand of research hinted that “liquid calories” in particular were dangerous to health.

Brownell led the growing calls for an excise tax on soft drinks, like the one in place for cigarettes, as a way of limiting their sales. Few such measures were passed—the beverage industry did everything it could to shut them down—but the message at their core, that soda was a form of poison like tobacco, spread. In San Francisco and New York, public-service campaigns showed images of soda bottles pouring out a stream of glistening, blood-streaked fat. Michelle Obama led an effort to depict water—plain old water—as something “cool” to drink.

The social engineering worked. Slowly but surely, Americans’ lamented lifestyle began to shift. From 2001 to 2018, added-sugar intake dropped by about one-fifth among children, teens, and young adults. From the late 1970s through the early 2000s, the obesity rate among American children had roughly tripled; then, suddenly, it flattened out. And although the obesity rate among adults was still increasing, its climb seemed slower than before. Americans’ long-standing tendency to eat ever-bigger portions also seemed to be abating.

But sugary drinks—liquid candy, pretty much—were always going to be a soft target for the nanny state. Fixing the food environment in deeper ways proved much harder. “The tobacco playbook pretty much only works for soda, because that’s the closest analogy we have as a food item,” Dariush Mozaffarian, a cardiologist and the director of the Food Is Medicine Institute at Tufts University, told me. But that tobacco playbook doesn’t work to increase consumption of fruits and vegetables, he said. It doesn’t work to increase consumption of beans. It doesn’t work to make people eat more nuts or seeds or extra-virgin olive oil.

[Read: What happens when you’ve been on Ozempic for 20 years?]

Careful research in the past decade has shown that many of the Obama-era social fixes did little to alter behavior or improve our health. Putting calorie labels on menus seemed to prompt at most a small decline in the amount of food people ate. Employer-based wellness programs (which are still offered by 80 percent of large companies) were shown to have zero tangible effects. Health-care spending, in general, kept going up.

And obesity rates resumed their ascent. Today, 20 percent of American children have obesity. For all the policy nudges and the sensible revisions to nutrition standards, food companies remain as unfettered as they were in the 1990s, Kelly Brownell told me. “Is there anything the industry can’t do now that it was doing then?” he asked. “The answer really is no. And so we have a very predictable set of outcomes.”

“Our public-health efforts to address obesity have failed,” Eric Finkelstein, the economist, told me.

6

The success of Barb’s gastric-bypass surgery was also limited. “Most people reach their lowest weight about a year post-surgery,” Gretchen White, an epidemiologist at the University of Pittsburgh, told me. “We call it their weight nadir.”

Barb’s weight nadir came 14 months after surgery; she remembers exactly when things began to turn around. She was in a store buying jeans, and realized she could fit into a size 8. By then she’d lost 210 pounds; her BMI was down to 27—lower than the average for a woman her age. Her body had changed so much that she was scared. “It was just too freaky to be that small,” she told me. “I wasn’t me. I wasn’t substantial.” She was used to feeling unseen, but now, in this new state, she felt like she was disappearing in a different way. “It’s really weird when you’re really, really fat,” she said. “People look at you, but they also look through you. You’re just, like, invisible. And then when you’re really small you’re invisible too, because you’re one of the herd. You’re one of everybody.”

At that point, she started to rebound. The openings into her gastric pouch—the section of her stomach that wasn’t bypassed—stretched back to something like their former size. And Barb found ways to “eat around” the surgery, as doctors say, by taking food throughout the day in smaller portions. Her experience was not unusual. Bariatric surgeries can be highly effective for some people and nearly useless for others. Long-term studies have found that 30 percent of those who receive the same procedure Barb did regain at least one-quarter of what they lost within two years of reaching their weight nadir; more than half regain that much within five years.

But if the effects of Barb’s surgery were quickly wearing off, its side effects were not: She now had iron, calcium, and B12 deficiencies resulting from the changes to her gut. She looked into getting a revision of the surgery—a redo, more or less—but insurance wouldn’t cover it, and by then the money from her fen-phen settlement had run out. The pounds kept coming back.

Barb’s relationship to medicine had long been complicated by her size. She found the health-care system ill-equipped—or just unwilling—to give her even basic care. During one hospital visit in 1993, she remembers, a nurse struggled to wrap a blood-pressure cuff around her upper arm. When it didn’t fit, he tried to strap it on with tape, but even then, the cuff kept splitting open. “It just grabs your skin and gives you bruises. It’s really painful,” she said. Later she’d find out that the measurement can also be taken by putting the cuff around a person’s forearm. But at the time, she could only cry.

“That was the moment that I was like, This is fucked up. This is just wrong, that I have to sit here and cry in the emergency room because someone is incompetent with my body.” She found that every health concern she brought to doctors might be taken as a referendum, in some way, on her body size. “If I stubbed my toe or whatever, they’d just say ‘Lose weight.’ ” She began to notice all the times she’d be in a waiting room and find that every chair had arms. She realized that if she was having a surgical procedure, she’d need to buy herself a plus-size gown—or else submit to being covered with a bedsheet when the nurses realized that nothing else would fit. At one appointment, for the removal of a cancerous skin lesion on her back, Barb’s health-care team tried rolling her onto her side while she was under anesthesia, and accidentally let her slip. When she woke, she found a laceration to her breast and bruises on her arm.

Barb grew angrier and more direct about her needs—You’ll have to find me a different chair, she started saying to receptionists. Many others shared her rage. Activists had long decried the cruel treatment of people with obesity: The National Association to Advance Fat Acceptance had existed, for example, in one form or another, since 1969; the Council on Size & Weight Discrimination had been incorporated in 1991. But in the early 2000s, the ideas behind this movement began to wend their way deeper into academia, and they soon gained some purchase with the public.

In 1999, when Rebecca Puhl arrived at Yale to work with Kelly Brownell toward her Ph.D. in clinical psychology, she’d given little thought to weight-based discrimination. But Brownell had received a grant to research the topic, and he put Puhl on the project. “She basically created a field,” Brownell said. While he focused on the dark seductions of our food environment, Puhl studied size discrimination, and how it could be treated as a health condition of its own. From the mid-1990s to the mid-2000s, the proportion of adults who said they’d experienced discrimination on account of their height or weight increased by two-thirds, going up to 12 percent. Puhl and others started citing evidence that this form of discrimination wasn’t merely a source of psychic harm, but also of obesity itself. Studies found that the experience of weight discrimination is associated with overeating, and with the risk of weight gain over time.

Puhl’s approach took for granted that being very fat could make you sick. Others attacked the very premise of a “healthy weight”: People do not have any fundamental need, they argued, morally or medically, to strive for smaller bodies as an end in itself. They called for resistance to the ideology of anti-fatness, with its profit-making arms in health care and consumer goods. The Association for Size Diversity and Health formed in 2003; a year later, dozens of scholars working on weight-related topics joined together to create the academic field of fat studies.

[Read: Why scientists can’t agree on whether it’s unhealthy to be overweight]

Some experts were rethinking their advice on food and diet. At UC Davis, a physiologist named Lindo Bacon who had struggled to overcome an eating disorder had been studying the effects of “intuitive eating,” which aims to promote healthy, sustainable behavior without fixating on what you weigh or how you look. Bacon’s mentor at the time was Judith Stern—the obesity expert who in 1995 proposed that any FDA adviser who voted against approving dexfenfluramine “ought to be shot.” By 2001, Bacon, who uses they/them pronouns, had received their Ph.D. and finished a rough draft of a book, Health at Every Size, which drew inspiration from a broader movement by that name among health-care practitioners. Bacon struggled to find a publisher. “I have a stack of well over 100 rejections,” they told me.

But something shifted in the ensuing years. In 2007, Bacon got a different response, and the book was published. Health at Every Size became a point of entry for a generation of young activists and, for a time, helped shape Americans’ understanding of obesity.

As the size-diversity movement grew, its values were taken up—or co-opted—by Big Business. Dove had recently launched its “Campaign for Real Beauty,” which included plus-size women. (Ad Age later named it the best ad campaign of the 21st century.) People started talking about “fat shaming” as something to avoid. The heightened sensitivity started showing up in survey data, too. In 2010, fewer than half of U.S. adults expressed support for giving people with obesity the same legal protections from discrimination offered to people with disabilities. In 2015, that rate had risen to three-quarters.

In Bacon’s view, the 2000s and 2010s were glory years. “People came together and they realized that they’re not alone, and they can start to be critical of the ideas that they’ve been taught,” Bacon told me. “We were on this marvelous path of gaining more credibility for the whole Health at Every Size movement, and more awareness.”

But that sense of unity proved short-lived; the movement soon began to splinter. Black women have the highest rates of obesity, and disproportionately high rates of associated health conditions. Yet according to Fatima Cody Stanford, an obesity-medicine physician at Harvard Medical School, Black patients with obesity get lower-quality care than white patients with obesity. “Even amongst Medicaid beneficiaries, we see differences in who is getting access to therapies,” she told me. “I think this is built into the system.”

That system was exactly what Bacon and the Health at Every Size movement had set out to reform. The problem, as they saw it, was not so much that Black people lacked access to obesity medicine, but that, as Bacon and the Black sociologist Sabrina Strings argued in a 2020 article, Black women have been “specifically targeted” for weight loss, which Bacon and Strings saw as a form of racism. But members of the fat-acceptance movement pointed out that their own most visible leaders, including Bacon, were overwhelmingly white. “White female dietitians have helped steal and monetize the body positive movement,” Marquisele Mercedes, a Black activist and public-health Ph.D. student, wrote in September 2020. “And I’m sick of it.”

Tensions over who had the standing to speak, and on which topics, boiled over. In 2022, following allegations that Bacon had been exploitative and condescending toward Black colleagues, the Association for Size Diversity and Health expelled them from its ranks and barred them from attending its events. (“They were accusing me of taking center stage and not appropriately deferring to marginalized people,” Bacon told me. “That’s never been true.”)

As the movement succumbed to in-fighting, its momentum with the public stalled. If attitudes about fatness among the general public had changed during the 2000s and 2010s, it was only to a point. The idea that some people can indeed be “fit but fat,” though backed up by research, has always been a tough sell. Although Americans had become less inclined to say they valued thinness, measures of their implicit attitudes seemed fairly stable. Outside of a few cities such as San Francisco and Madison, Wisconsin, new body-size-discrimination laws were never passed. (Puhl has been testifying regularly in support of the same proposed bill in Massachusetts since 2007, to no avail.) And, as always, obesity rates themselves kept going up.

In the meantime, thinness was coming back into fashion. In the spring of 2022, Kim Kardashian—whose “curvy” physique has been a media and popular obsession—boasted about crash-dieting in advance of the Met Gala. A year later, the model and influencer Felicity Hayward warned Vogue Business that “plus-size representation has gone backwards.” In March of this year, the singer Lizzo, whose body pride has long been central to her public persona, told The New York Times that she’s been trying to lose weight. “I’m not going to lie and say I love my body every day,” she said.

Among the many other dramatic effects of the GLP-1 drugs, they may well have released a store of pent-up social pressure to lose weight. If ever there was a time to debate that impulse, and to question its origins and effects, it would be now. But Puhl told me that no one can even agree on which words are inoffensive. The medical field still uses obesity, as a description of a diagnosable disease. But many activists despise that phrase—some spell it with an asterisk in place of the e—and propose instead to reclaim fat. Everyone seems to agree on the most important, central fact: that we should be doing everything we can to limit weight stigma. But that hasn’t been enough to stop the arguing.

7

Not long before my visit to Orlando in October, Barb had asked her endocrinologist to switch her from Trulicity to Mounjaro, because she’d heard it was more effective. (This, too, was covered under Medicaid.) A few weeks later, Barb blogged about the feeling of being stuck—physically stuck—inside her body. “Anyone who has been immobilized by fat and then freed, understands my sense of amazement that I can walk without a walker and not ride the scooter in the store,” she wrote. “Two years ago, all I could do was wait to die. I never thought I would be released from my prison of fat.”

In all that time when she could barely move, of all the places that she couldn’t really go, Disney World stood out. Barb is the sort of person who holds many fascinations—meditation, 1980s lesbian politics, the rock band Queen—but Disney may be chief among them. She has a Tinker Bell tattoo on her calf, and a trio of Mickey Mouse balloons on her shoulder. Her wallet shows the plus-size villain Ursula, from The Little Mermaid. “It’s just a place where you can go and be treated beautifully,” she said. “No matter who you are, no matter what country you’re from, no matter what language you speak. It’s just wonderful and beautiful.”

She’d been raised in the theme park, more or less: Her mother got a job there in the 1970s, and that meant Barb could go for free—which she did as often as she could, almost from the time that it first opened, and for decades after. She was at Disney when Epcot opened in 1982, just weeks before she gave birth to her first child. Later on she helped produce a book about where to eat at Disney if you’re vegetarian, and published tips for how to get around the parks—and navigate the seating for their rides—whether you’re “Pooh-size” or “Baloo-size.” She worked at Disney, too, first as an independent tour guide and photographer, then as a phone operator for the resorts. “They used to pull me off of the telephones to go test new rides to see how large people could do on them,” she told me.

But lately she’d only watched the park’s events on livestream. The last time she’d gone in person, in 2021, she was using a scooter for mobility. “I dream of one day walking at Disney World once again,” she’d written on her blog. So we called a car and headed over.

Barb was exhilarated—so was I—when we strolled into the multistory lobby of the Animal Kingdom Lodge, with its shiny floors, vaulted ceilings, indoor suspension bridge, and 16-foot, multicolored Igbo Ijele mask. Barb bought a pair of Minnie Mouse ears at the gift shop, and kibitzed for a while with the cashier. Before, she would have had to ask me to go and get the ears on her behalf, she said, so she wouldn’t have to maneuver through the store on wheels. We walked down the stairs—we walked down the stairs, Barb observed with wonderment—to get breakfast at a restaurant called Boma. “Welcome, welcome, welcome! Have a Boma-tastic breakfast!” the host said.

Barb relished being in the lodge again, and had lots to say, to me and everyone. “My mom was a cast member for 42 years,” she informed our server at one point. Even just that fact was a reminder of how much Disney World, and the people in it, had evolved during her lifetime. When her mom started to gain weight, Barb remembered, her manager demanded that she go on a diet. “They didn’t even make a costume bigger than a 16,” Barb said. As Americans got bigger, that policy had to be abandoned. “They needed people to work,” she said, with a glance around the restaurant, where kids and parents alike were squeezing into seats, not all of which looked entirely sufficient. It was easy to imagine what the crowd at Boma might have looked like 20 years ago, when the restaurant first opened, and when the adult obesity rate was just half of what it is today.

“I feel smaller than a lot of these people, which is really interesting,” Barb said. “I don’t even know if I am, but I feel like it. And that is surreal.”

Things feel surreal these days to just about anyone who has spent years thinking about obesity. At 71, after more than four decades in the field, Thomas Wadden now works part-time, seeing patients just a few days a week. But the arrival of the GLP-1 drugs has kept him hanging on for a few more years, he said. “It’s too much of an exciting period to leave obesity research right now.”

[Read: How obesity became a disease]

His bluegrass buddy, Kelly Brownell, stepped down from his teaching and administrative responsibilities last July. “I see the drugs as having great benefit,” Brownell told me, even as he quickly cited the unknowns: whether the drugs’ cost will be overwhelming, or if they’ll be unsafe or ineffective after long-term use. “There’s also the risk that attention will be drawn away from certain changes that need to be made to address the problem,” he said. When everyone is on semaglutide or tirzepatide, will the soft-drink companies—Brownell’s nemeses for so many years—feel as if a burden has been lifted? “My guess is the food industry is probably really happy to see these drugs come along,” he said. They’ll find a way to reach the people who are taking GLP‑1s, with foods and beverages in smaller portions, maybe. At the same time, the pressures to cut back on where and how they sell their products will abate.

For Dariush Mozaffarian, the nutritionist and cardiologist at Tufts, the triumph in obesity treatment only highlights the abiding mystery of why Americans are still getting fatter, even now. Perhaps one can lay the blame on “ultraprocessed” foods, he said. Maybe it’s a related problem with our microbiomes. Or it could be that obesity, once it takes hold within a population, tends to reproduce itself through interactions between a mother and a fetus. Others have pointed to increasing screen time, how much sleep we get, which chemicals are in the products that we use, and which pills we happen to take for our many other maladies. “The GLP-1s are just a perfect example of how poorly we understand obesity,” Mozaffarian told me. “Any explanation of why they cause weight loss is all post-hoc hand-waving now, because we have no idea. We have no idea why they really work and people are losing weight.”

The new drugs—and the “new understanding of obesity” that they have supposedly occasioned—could end up changing people’s attitudes toward body size. But in what ways? When the American Medical Association declared obesity a disease in 2013, Rebecca Puhl told me, some thought “it might reduce stigma, because it was putting more emphasis on the uncontrollable factors that contribute to obesity.” Others guessed that it would do the opposite, because no one likes to be “diseased.” Already people on these drugs are getting stigmatized twice over: first for the weight at which they started, and then again for how they chose to lose it.

Barb herself has been evangelizing for her current medications with as much fervor as she showed for fen-phen. She has a blog devoted to her experience with GLP-1 drugs, called Health at Any Cost. As we stood up from our breakfast in the Animal Kingdom Lodge, Barb checked her phone and saw a text from her daughter Meghann, who had started on tirzepatide a couple of months before Barb did. “ ‘Thirty-five pounds down,’ ” Barb read aloud. “ ‘Medium top. Extra-large leggings, down from 4X’ … She looks like the child I knew. When she was so big, she looked so different.”

In November, Barb’s son, Tristan, started on tirzepatide too. She attributes his and Meghann’s struggles to their genes. Later that month, when she was out at Meghann’s house in San Antonio for Thanksgiving, she sent me a photo of the three of them together—“the Tirzepatide triplets.”

She’d always worried that her kids might be doomed to experience the same chronic conditions that she has. All she could do before was tell them to “stay active.” Now she imagines that this chain might finally be broken. “Is the future for my progeny filled with light and the joy of not being fat?” she wrote in a blog post last fall.

Barb’s energy was still limited, and on the day we visited Disney World, she didn’t yet feel ready to venture out much past the lodge. Before we went back to her house, I pressed her on the limits of this fantasy about her kids’ and grandkids’ lives. How could she muster so much optimism, given all the false miracles that she’d experienced before? She’d gone on fen-phen and ended up with heart damage. She’d had a gastric bypass and ended up anemic. And we hadn’t even had the chance to talk about her brief affair with topiramate, another drug prescribed for weight loss that had quieted the voices in her head for a stretch in 2007—until it made her feel depressed. (Topiramate is “the new fen/phen and I am blessed to have it in my life/head/mind,” she’d written on her blog back then. Ten years later she would pledge, in boldface: “I will never diet or take diet drugs again. Ever.”)

After all of these disappointments, why wasn’t there another kind of nagging voice that wouldn’t stop—a sense of worry over what the future holds? And if she wasn’t worried for herself, then what about for Meghann or for Tristan, who are barely in their 40s? Wouldn’t they be on these drugs for another 40 years, or even longer? But Barb said she wasn’t worried—not at all. “The technology is so much better now.” If any problems come up, the scientists will find solutions.

Still, she’d been a bit more circumspect just a few months earlier, the first time that we spoke by phone. “There’s a part of me that thinks I should be worried,” she told me then. “But I don’t even care. What I care about is today, how do I feel today.” She was making travel plans to see her grandkids over Labor Day, after not having been on an airplane for 15 years because of her size. “I’m so excited, I can hardly stand it,” she said. Since then she’s gone to see them twice, including Thanksgiving; the last time she went, she didn’t even need to buy two seats on the plane. She’s also been back to Disney since our visit. This time, she had more energy. “When I walked out the back door of the Beach Club and headed towards EPCOT,” she wrote on her blog, “I felt like I was flying.”

This article appears in the June 2024 print edition with the headline “Ozempic or Bust.”