Episode 5: A Shot at Weight Loss: Should I Take It?

Rebecca Morrison 

If my doctor said you need to be on this, I would get on it. My doctor has not said that. I do need to probably lose some weight. I keep saying that, but my blood work is good. I’m more or less healthy. My stats are positive. I’ve gone to a cardiologist to make sure I don’t have a risk of heart disease. I don’t. So many women are in this middle place. We are not obese in the way that is dangerous for our health. We are just visually bigger than the ideal that is portrayed in the media. How do we deal with that?

Lauren Arora Hutchinson 

That’s Rebecca Morrison. Like so many people today, she is struggling with a decision about a new class of weight loss medications called GLP-1s.

Rebecca Morrison 

I mean, I’m just a person that is trying to determine something for my own health. What is the responsible thing to do as a human being, as a woman, as a mother, as a wife, as a daughter, as a person. Should I do it? Do I need to do it? Do I have to do it?

Lauren Arora Hutchinson 

Rebecca’s question isn’t just about medication, it’s about something many people are quietly wondering right now. When a medical intervention is promoted as both a public health revolution and a way to achieve a cultural ideal, how does that shape the choices we make about our bodies? I’m Lauren Arora Hutchinson. I’m the director of the iDeas Lab at the Johns Hopkins Berman Institute of Bioethics. I’ve spent years working on stories where medicine and science show up in people’s everyday lives, and in this episode we’re looking at GLP-1s. This is playing god?

Rebecca Morrison 

Being in my 50s now, and having children of my own, I understand my mother’s story much better than I did when I was 13-14. She thought, at the time, that being thin equaled being beautiful equaled having power, having worth as a woman. This came from her own experiences in Iran, where before the revolution, Iran was very Western. We were seeing the fashion of the world and European fashion, American fashion, and maybe culturally that beauty of a woman was very important. It determined a lot about how her life was going to end up, what kind of husband she would get, what kind of attention and respect she would get. So she comes to America. She thought I was very beautiful when I was young. I was tall for my age. I could be a model, or I was this statuesque woman, and I hit puberty, and I was eating, and she was shocked by the change in my body. In her mind, that dream of hers for me was shattered, and the more she fought to get me back to that thin ideal, the more I fought against it. Maybe it’s just who I am, maybe it’s genetics of my body. After 13-14, I never got back to my pre-puberty body. I was never thin again. So, binging for me was always this feeling of freedom, along with the sensation of all these foods that I wasn’t allowed to eat. I was bulimic for decades into my 40s, so that’s, you know, that’s a long time of keeping a secret, of closing the bathroom door and putting on the shower, so nobody can hear you. I felt like I was so broken or wrong, and I would not be loved. I would not be accepted if I didn’t try to lose weight, and those were the times where I really fell into the eating disorder.

Lauren Arora Hutchinson 

For Rebecca, food and body size were never just about health; they were tied up with identity, emotions, expectations, family, and what it meant to be valued.

Rebecca Morrison 

When I got married, that helped, because it was a man who I loved and respected enormously. It confirmed all my beliefs, all my fight, my whole life, that I am worthy of everything that anyone else is at a different size. I’m really proud that in my 40s I was able to look at myself in the mirror and say, never again. I’m not going to hurt my body for that reason. I settled into an average American-sized body. I think I had read a couple times throughout the years that the average American body was maybe size 14 or 12 or something.

Lauren Arora Hutchinson 

But as Rebecca worked to rebuild her relationship with food, unbeknownst to her, to most of us, there was a medical revolution occurring.

Mara Gordon 

My name is Dr. Mara Gordon. I am a very busy primary care doctor. The vast majority of my patients are publicly insured, meaning Medicaid or Medicare, and I have prescribed GLP-1 agonists since I graduated medical school in 2015. They’re not new medications, I’ve used them for years. We had a couple, I believe, versions of GLP-1 agonists that were used exclusively in patients who had a diagnosis of diabetes, and they were really helpful medicines. I mean, I pretty proactively recommend them for people who have a diagnosis of diabetes, heart disease, metabolic dysfunction associated steatotic liver disease, sleep apnea, they can all be useful for. So, I’m so grateful for their existence. They really, really helped my patients.

Lauren Arora Hutchinson 

But also, Dr. Mara Gordon says…

Mara Gordon 

Patients often lost a little bit of weight on them, so I sort of thought of it as like a side effect of these medications, but over time researchers have started experimenting with using much higher doses, and they found that when you used much higher doses, often four times the dose that I was using in my patients to treat their diabetes a decade ago, people tended to lose weight, and often quite a lot of weight, 10 to 15, upwards of sometimes 20% of their body weight, and that was sort of the moment I pinpoint, like, ooh, everything’s going to change. This is going to be a big deal. Somebody is going to get really rich off of this.

Lauren Arora Hutchinson 

Scientists are still learning about the full range of effects of these drugs designed to treat diabetes, but it appears that GLP-1s work on a number of our systems simultaneously. I asked Mara Gordon what a drug like this does…

Mara Gordon 

Basically, it regulates glucose. It causes weight loss through several mechanisms. The primary one is that it slows gastric emptying, so what that means is the stomach is basically fuller longer. It sort of empties at a slower pace. People, when they’re taking these medications, have a sensation of satiety that lasts longer. It also enhances insulin secretion from the body, which can help with glucose levels in the bloodstream. They also promote satiety through the central nervous system, so they act centrally on the brain to sort of suppress appetite in ways that are not fully understood.

Lauren Arora Hutchinson 

But despite ongoing questions about short and long term effects, since this weight loss side effect became widely recognized, interest and demand for these GLP-1 drugs has been enormous.

Mara Gordon 

I would say people started asking about them, maybe in like end of 2021 beginning of 2022. It sort of started to enter the public consciousness, and I would have people sort of specifically coming in saying, “Hey, I heard about this weight loss medication, do you think I should try it?” It has just sort of reached a fever pitch. In my primary care clinic, I would say have conversations about GLP-1 agonists maybe five to seven times a day. Often patients who have no comorbidities, no diagnoses, often will say, “Hey, you know, I feel really fat, should I try Ozempic?” People are pretty desperate to lose weight.

Lauren Arora Hutchinson 

For decades, losing weight has been framed as a matter of willpower. Now, for the first time, that may not be true, and that shift has implications not just for health, but for how we understand responsibility, pressure, and choice. What happens when control comes from a medication instead of from within?

Alex Brewis 

I’m Alex Brewis. I’m a social scientist at Arizona State University.

Lauren Arora Hutchinson 

Professor Alex Brewis describes herself as a bio-cultural anthropologist. Her work combines social science and human biology, and she studies body image across different cultures.

Alex Brewis 

I have been working for a number of years, since about 2007 on cross-cultural views of body image, and we’ve now worked in many different countries, and we’ve established that negative attitudes towards fat have been expanding and have become really a globalized phenomenon. We have these clinical definitions that were set up actually in the 1930s or so for what constitutes obesity? There’s just a single number that’s height by weight that gets used a lot. You are so-called normal weight at 24.5 body mass index, and then at 25 you become technically overweight, or at 30 you become technically obese. People hate those labels because they are so laden with all sorts of feelings of judgment, and they re-categorize you within society. You feel now like a kind of a different person because you’ve had these labels applied. These are arbitrary labels, in the sense that there’s plenty of people that have as technically overweight or obese body mass index that have great metabolic health, and there’s plenty of people that have so-called normal or ideal body mass that have all sorts of metabolic issues.

Lauren Arora Hutchinson 

Taken together, the messages people receive from medicine, from media, from culture all point in the same direction: lose weight. And now, there’s a drug that makes it feel possible.

Alex Brewis 

People are being much more proactive than we normally see around weight. You’re having people drive the conversations with doctors, so from a perspective of action orientation, people are definitely more, you know, they’re using more agency around these drugs. So they’re… they feel in some ways more in control of the ability to access tools to lose weight.

Jeffrey Kahn 

I think that’s really important, actually, as a point in that these drugs are a tool that are empowering people to take charge of their health in a way that they may have wanted to, but it was very difficult before, but there are many examples of social pressures where people feel like they really need to do something to conform. That feels like what’s happening with GLP-1s.

Lauren Arora Hutchinson 

Professor Jeffrey Kahn, our resident bioethicist and director of the Johns Hopkins Berman Institute of Bioethics.

Jeffrey Kahn 

At the same time, it’s not just about, you know, people need to look a particular way. Public health experts have been messaging for a long time, and physicians have been messaging for a long time, that the proportion of Americans, in particular, but it’s not true only in America, that are obese had been growing and was unhealthy. Unhealthy for the individuals, and it’s unhealthy as a matter of public health, and so, the messaging has been people need to lose weight. So, it’s a combination. This is what I think makes it a kind of unique moment. A combination of there’s this health problem that we’ve had a very difficult time addressing over decades, and there’s this ideal body image that are pulling in the same direction.

Rebecca Morrison 

So I am a curvy woman. I always have been. I’ve been size 12 to 14 most of my life, mostly 14. So I’m not… I’m medically obese for sure, but maybe on the street a person looking at me wouldn’t say that I’m obese, but I’m overweight for sure, nobody would not say that. My face is not bad, you know, I’ve got a good face, I’ve got good hair, but I have a, you know, bigger body. But the pressure is enormous. I feel like, am I, am I irresponsible if I’m not taking this drug as an overweight person? Am I hurting my body by not taking a drug for the rest of my life that would make me thinner?

Lauren Arora Hutchinson 

How do you balance loving yourself and doing your best to be healthy all while not giving in to societal pressure? This is the question Rebecca finds herself grappling with. It’s a question made all the more difficult by the marketing of these GLP-1 medications.

Rebecca Morrison 

You see it on social media all the time. I am bombarded with those commercials, Ozempic commercials. Maybe it’s just me. Articles, magazines, doctors, it’s everywhere.

Alex Brewis 

They are really playing on people’s deepest anxieties and telling them, you know, if you feel these anxieties, then you need these drugs. So, what we’re seeing very quickly is a shift into cosmetic use for people that don’t have a medical sort of pathway in, and it’s pushing a product that is making enormous profits for these telehealth companies.

Lauren Arora Hutchinson 

Pharmaceutical marketing is always fraught. It involves the uncomfortable coupling of science, which is slow, deliberate, and searching for the truth with salesmanship, an endeavor not known for any of the above. And in the case of these drugs, Jeffrey Kahn says the salesmanship seems especially out front.

Jeffrey Kahn 

The process of information and its delivery runs a continuum between, you know, here’s just information you decide at one end of a spectrum to something that’s more like persuasion all the way through to coercion. So, if you don’t do this, I will harm you. And then, when you’re going from persuasion on the way to coercion, there’s an in between, which is manipulation. The individual’s weaknesses are being taken advantage of by the person who has power or influence or information, and is using that weakness in a way that gets them to make a decision that the individual who’s got the power wants them to make, so that’s that’s less of a free decision than just being given information and having the individual decide for him or herself. It sort of feels like what’s happening in the context of GLP-1s is the inundation of advertisements, often by very well-known celebrities who are very fit people who are saying, I use this, so should you. It’s a kind of manipulation, right? You want to look and be like me, doesn’t everybody want to look and be like that person? And if you do, then it’s easy for you to do so. Just call this number or go to this website, and we’re standing by to provide you this drug. When what’s being marketed is ideal body image, it’s, it’s harder for us to resist, and in the context of something that has been deemed a public health epidemic, and so GLP-1 feels like it’s it’s in that combination of advertising, so that you will want to look like the celebrity spokesperson, but also so that you will be healthier and fitter, and that’s better for you and the public’s health. So these are together very, very strong messages that make I think it hard to say no.

Lauren Arora Hutchinson 

When you put all this together, what will it mean? Not just for how we’ll see ourselves, but how we’ll see our neighbors, our family, our friends.

Alex Brewis 

I think the universal thought from all those teams that have talked to so many people in so many different places is that it’s just going to make the stigma around weight worse, because now it’s also a signal of failure to be able to afford or be able to access the solution.

Jeffrey Kahn 

When we say body image, it’s not just how you feel and look, but how others perceive how you look. There’s now a thought, how did that person lose weight, or if they aren’t of ideal body size, why are they not taking advantage of this miracle drug? It’s going in the direction that they’re becoming more available, easier to administer, lower in price. So, in every respect, I think those kinds of issues are only going to get more pronounced. The stigma around people who are overweight in a, in an era when, like, why would anybody be overweight? Will people feel like they can resist, and sort of, how do we even think about, you know, what it means to resist? Like, I don’t want to take drugs like that for the rest of my life. I shouldn’t feel like I have to, and I don’t feel like I should be shamed and stigmatized for what is a decision that I think is for my best interests, right? So, we don’t want that to be the environment in which people are making healthcare decisions. That seems wrong. It seems to be against individual autonomous decision making, and so how do we create a space for people to say that’s just not for me, and not have them feel like they’re, you know, shamed and shunned as a result.

Lauren Arora Hutchinson 

There’s still a lot we’re learning about these drugs, how their effects play out over time across large populations, and what happens when people stop taking them. One place those questions are starting to surface is around eating disorders. By suppressing appetite so effectively, GLP-1s can make it easier to restrict food in ways that resemble an eating disorder. There are concerns among some clinicians that in some cases people may develop new patterns of disordered eating, while in others, symptoms that have been under control for years might return, and because these drugs are often so easy to access, those risks may not always be recognized ahead of time. For Rebecca, it’s one more layer in an already complicated decision.

Rebecca Morrison 

I’ve spent my entire life, first fighting against my mother’s ideas, and then really fighting against society telling me that I’m anything other than worthwhile, lovable, and frankly beautiful. My goal is to live a healthy life and to live a long time. If my longevity is at risk because of my weight, I will consider GLP-1s, and I’m already considering them. That’s the truth. I’ve talked to my doctor about it numerous times. I’ve thought, yes, no, yes, no, I don’t know. I still am not 100% convinced that I have to take a drug for the rest of my life that I’m not sure supports my ideals as a woman of what it means to have worth and purpose the way I am.

Lauren Arora Hutchinson 

Coming up next week on playing god?

Ashley Womble 

The first doctor visit I had after I became pregnant… They were like, “Well, if that’s what you think you should do.” Why isn’t there any guidance around this?

Ruth Faden 

It’s sort of like a mass social experiment.

Lauren Arora Hutchinson 

Many thanks to our guests in this episode—to Rebecca Morrison for sharing her story with us, and to Jeffrey Kahn, Alex Brewis, and Mara Gordon. playing god? is a production of the Dracopoulos-Bloomberg iDeas Lab at the Johns Hopkins Berman Institute of Bioethics, made in association with Sea Salt and Mango Productions. This episode was produced by Lyric Bowditch, Irene Carter, and Redzi Bernard, with help from Brian Ricker.  Our Executive Editor is Tony Phillips. Music and sound design by Alexander Overington. iDeas Lab Producer, Lyric Bowditch. Researcher, Brian Ricker. Story Editor, Simon Adler. Show art by Barry Pousman and Shawn Carney. Our Production Coordinators are Leah Lord and Susan Snead. Our Executive Producers are Jeffrey Kahn and Anna Mastroianni.  I’m Lauren Arora Hutchinson, host and Managing Editor.  Come back next week for more playing god?