Hoping to go down a few dress sizes, a 16-year-old girl cuts her daily calorie consumption by a third. She loses almost a fifth of her body weight in the three months leading up to her prom. She weighs herself daily, going giddy with pride as the numbers go down. She is nauseated almost all of the time, and if she eats a meal of the size she formerly consumed regularly, she throws up. She started declining social invitations a few weeks into her weight loss and has become increasingly obsessive about calorie counting. She feels lethargic, often overcome by an amorphous melancholy she never struggled with before. But as she walks her high school hallways, gazes that were once averted catch on her skin, compliments accumulate, and all the angst starts to feel worth it. Before she began shrinking, her body weight landed her in the “obese” range according to BMI charts, and by the big dance, she’s clocking in at the upper edge of “normal.”
Depending on how you tell this story, she either started out sick or ended up that way. The hypothetical girl starring in the story above might be suffering from a dangerous eating disorder. The symptoms are there: obsessive weighing, food restriction, vomiting, calorie counting, a conflation of her value with her body size. Or she may be on a doctor-directed weight loss journey and have been prescribed a semaglutide weight-loss drug like Wegovy, which is approved for children as young as 12. The medical establishment classifies her body as “obese,” so a doctor prescribes her a drug that may make her look “healthier” to the average observer but in fact is sending her spiraling into anorexia, a condition that is chronic or fatal in 20 percent of patients and incredibly difficult to treat. The obesity epidemic and the eating disorder epidemic are imagined to strike separate populations: fat people positioned against emaciated ones. But in reality, many fat people suffer from eating disorders, which are often missed by their doctors and worsened when medical professionals prescribe them diets.
The risks of thinness are rarely considered newsworthy
Fatphobia is insidious, encoded in medicine and media, even our imaginations. We shouldn’t underestimate its impact on our understanding of health and nutrition. Eating disorders kill over 10,000 Americans annually and are the most fatal mental illnesses other than opioid addiction, yet they receive far less attention than either the obesity or opioid epidemics — a status quo that reveals the depth of our devotion to the belief that thinness is healthy and fatness fatal. In our zeal to “cure” the obesity epidemic — which is likely less fatal than the fearmongering pharmaceutical companies want us to believe — we are potentially exacerbating another epidemic, one proven to kill. This country is afflicted by epidemics positioned as dueling that are in reality intertwined, a double helix at the core of our body politics.
False alarms, failed trials, dashed hopes. Bodies buckling under the weight of beauty, breaking in the pursuit of “health”: This is the wreckage of America’s appetite for thinness. But perhaps all that is in the past, detritus of an earlier era of diet culture and pseudoscience. Maybe today’s doctors have finally found the “cure”: GLP-1 agonists semaglutide and tirzepatide under the brand names Wegovy, Ozempic, and Mounjaro (Wegovy and Mounjaro are approved by the Food and Drug Adminstration, or FDA, for weight loss, while Ozempic remains approved only to treat diabetes, though it is often prescribed off-label for weight loss). Soon after Wegovy’s approval for weight loss in 2021, the eager, exclamatory articles arrived, announcing that “this is what a miracle drug looks like.” Multiple outlets heralded semaglutide as a “game changer.” The Financial Times applauded: “A new miracle weight loss drug really works,” while The Mirror hoped a “Holy Grail Weight Loss Jab” was here at last, and Rolling Stone wondered “Who Deserves the New ‘Miracle’ Weight Loss Drugs?”
But wildly optimistic coverage of under-studied weight-loss drugs is nothing new. In 1996, Time and CNN each salivated over new “miracle drugs” for weight loss, and NBC announced “a new weight control silver bullet” in 2004. These headlines refer to Redux, Fen-Phen, and Belviq, three weight-loss drugs that, like semaglutide, were greeted with hero’s welcomes. All three were eventually banned by the FDA after dangerous and often fatal side effects began afflicting patients.
Belviq, approved in 2012, was pulled off shelves in 2020 after it was found to spike patients’ cancer risk. Redux, approved in 1996, was banned just one year later after causing heart valve problems in patients. Meridia, approved in 1997, was pulled in 2010 after increasing heart attack and stroke risks. Fen-Phen, once imagined as a “magic pill” for obesity according to the New York Times, was approved based on a single study of 121 patients and was taken off the market in 1997 after causing heart valve problems in up to a third of the people who took it. These are just recent examples; this country has long been willing to risk fat people’s health in an attempt to slim them down, rushing weight-loss drugs to market before long-term data on their side effects are available. In the 1930s, a diet drug called DNP blinded over 2,000 American women and killed unknown numbers before it was banned in 1940. It is still sold illegally and has killed 33 women in the past three years.
The 1960s saw a slew of deaths due to “rainbow diet pills,” and multiple heart-attack deaths in the 1990s were attributed to the Fen-Phen craze. These drugs were far more dangerous to people’s health than obesity itself: Taking phenylpropanolamine (Fen-Phen) is associated with a death risk over 10 times higher than that associated with an obese BMI. The antidepressant Wellbutrin, now contraindicated for eating disorders, was advertised for its weight-loss side effects when it was first released. Despite exacerbating eating disorders and causing seizures in bulimics while still in clinical trials, eating disorders were initially not listed as contraindicated conditions, so doctors prescribed the drug to many disordered eaters whose diseases worsened as their appetites declined.
Instead of mental healthcare, fat people with eating disorders are often suggested diets that worsen their disorders
Back in the rainbow pill days, an intrepid Life journalist decided to see how many pills she could get prescribed in a two-week period. Ten appointments later, her bedroom was filled with pill bottles while a coroner claimed he saw a death due to diet pills every other month –– a congressional investigation and eventual drug ban followed. This year, the New Yorker conducted a modern version of Life’s experiment; writer Jia Tolentino successfully received syringes of semaglutide in the mail without ever meeting a doctor in person. When I logged onto a telehealth site I found through a simple Google search, its diagnostic quiz asked about contraindicated conditions like cancer but did not ask me if I’ve ever been diagnosed with an eating disorder. I closed the tab before I made it to the final page and immediately started receiving daily texts promising me discounted first doses.
Amid all the #OzempicJourney TikToks, the Semaglutide Success Story Facebook groups, and the buzzy, breathless reporting, there has also been a steady drip of unpleasant news: stories of severe side effects and scientists pointing out the dearth of long-term studies, which leaves the effects of these drugs over time shrouded in mystery. When they began being widely used for weight loss, the lengthiest studies for these drugs clocked in at two years. Since then, one study published in 2024 followed patients for four years. Still, none have followed patients over the long term despite the fact that prescriptions are often intended to be lifelong at a maintenance dose. Executives at Novo Nordisk, Ozempic’s manufacturer, readily admit that avoiding weight regain requires remaining on the drug indefinitely, possibly for life.
Short-term side effects include but are not limited to severe gastrointestinal distress (causing almost 5 percent of patients to drop out of one study), both fatal and non-fatal pancreatitis, gastroparesis (stomach paralysis), suicidal ideation, fatigue, and depression. According to NPR’s pharmaceuticals correspondent Sydney Lupkin, the FDA Adverse Event Reporting System has received at least 489 reports of patients experiencing anxiety, depression, or suicidal thoughts while taking drugs like Ozempic that contain the active ingredient semaglutide. Though we do not have long-term data on humans, long-term animal studies link semaglutide drugs to increased rates of thyroid cancer. We are treating fat adults and children as young as 12 like lab rats, sticking syringes of chemicals proven to cause cancer in actual lab rats in their bodies.
Yet most of the discussion around semaglutide across mainstream media, medical journals, and social media alike ignores all this, earnestly embracing the promise of a future with far fewer fat people. Of course, the buzz emphasizes curing obesity as a disease, not eradicating the people who suffer from it, instead envisioning those fat people transformed into “healthier” and, incidentally, smaller people.
Overweight and obese adolescents are actually more likely to practice disordered eating behaviors than “normal” weight people.
Mainstream medical wisdom would have you believe that being overweight or obese dooms you to cardiovascular disease, stroke, Mainstream medical wisdom would have you believe that being overweight or obese dooms you to cardiovascular disease, stroke, and earlier death, but long-term, large epidemiological studies actually reveal that only obesity at grades two and beyond (BMI greater than 35) conclusively carries significant mortality risks (though BMI is itself a flawed metric with a racist and misogynistic history). An International Journal of Epidemiology (IJE) review concluded that the “ideal weight for longevity was overweight,” and a 2013 Journal of the American Medical Association (JAMA) review found that “grade 1 obesity was not associated with higher mortality.” Nonetheless, Wegovy is approved for people with BMIs of 27 –– the midpoint of the “overweight” band –– and above, through all grades of obesity. Weight-related mortality risks follow a U-shaped curve, afflicting both the severely obese and the very underweight. And yet, the risks of thinness are rarely considered newsworthy, though “the relative risks associated with being underweight were greater than those associated with even high levels of obesity,” according to the IJE.
Falling into the overweight and obese BMI bands does harm fat people’s health, but it is impossible to know how much of that harm is caused not by their size but by fatphobia: Doctors miss many early-stage diseases in fat people, diagnosing them later than thin people, assuming fat people’s health problems relate to their weight and declining to screen them for other diseases. Forty percent of American doctors in one study had a negative reaction to the idea of treating a fat patient at all, while others found that fat women are less likely to be screened for cancer than thin women. This is especially true in the case of eating disorders, where fat people’s suffering is disbelieved by doctors and stigmatized in the rare cases it is diagnosed. Overweight and obese adolescents are actually more likely to practice disordered eating behaviors than “normal” weight people. This initially surprising statistic becomes unsurprising once you consider the fact that dieting is often the first prescription fat people are given when they go to the doctor with any kind of chronic complaint, even though 35 percent of diets become “obsessive” and a quarter of those evolve into full-blown eating disorders, according to the National Eating Disorders Association.
Low body weight is a criterion for diagnosing anorexia, so people who aren’t yet underweight who suffer all the disease’s cognitive, behavioral, and psychiatric symptoms are instead diagnosed with “atypical anorexia,” usually over 11 years after the onset of their disease as opposed to two years for those with typical anorexia. This decade-long span without a diagnosis is a dangerous era: Eating disorder recovery rates are dismal in general under half of people with anorexia and bulimia ever fully recover), but one of the few factors associated with long-term remission is early treatment. But instead of mental health care, fat people with eating disorders are often suggested diets that worsen their disorders. As fat activist Deb Burgard has eloquently put it, “We prescribe for fat people what we diagnose as disordered in thin people.”
This discrepancy pushes fat people onto a dangerous hamster wheel: weight cycling. Because the vast majority of dieters regain their lost weight — dieting’s failure rate is one of the reasons the race for effective weight-loss drugs is so rabid — people who embark on restrictive diets often experience weight cycles, wherein they lose weight on a diet and find themselves extremely hungry in its wake, prone to bingeing. Fearing another period of restriction in the future, the body overcompensates, leaving dieters extremely hungry, leading them to gain even more than they lost. “Dieting is actually a consistent predictor of future weight gain,” not loss, as obesity researcher Janet Tomiyama has pointed out.
“Isn’t [Ozempic] just making me starve myself and feel sick like any disordered eating would?”
This kind of consistent dieting is, for many people, a form of disordered eating: Bingeing has been observed in anorexic patients since at least the 1970s, and crossover between anorexia, bulimia, and binge eating disorder — a pattern that parallels the cycle of extreme dieting and bingeing that characterizes weight cycling — is extraordinarily common. A majority of anorexic patients eventually develop binge eating disorder or bulimia, while “eating disorder not otherwise specified,” in which symptoms of various disorders appear but the patient does not lose enough weight to qualify for an anorexia diagnosis, is by far the most prevalent eating disorder. The very restriction recommended to fat patients often leads them to binge eating: 36 percent of teens treated for anorexia symptoms were previously deemed obese.
Eating disorders are, as mentioned, one of the most fatal mental illnesses, and they are also correlated with osteoporosis, depression, heart problems, stroke, kidney failure, gastrointestinal disease, and high rates of suicidal ideation. In 2019, Columbia Medical Center researchers reported that weight cyclers “had more cardiovascular risk factors than those who maintained a consistent weight,” even if that weight fell outside of the “normal” BMI range. Weight cycling has also been correlated with hypertension, metabolic syndrome, cancer, insulin resistance, vascular injury, and cardiovascular disease. Unless they plan to stay on semaglutide for life, patients trying such drugs might be embarking on a treacherous trajectory, as even the drugmakers admit that going off the drugs leads to rapid weight regain.
In the r/Ozempic subreddit, someone posts what they call a “controversial” question: “Does anyone else feel like Ozempic is leading to medically induced eating disorders?” What follows is a story that many Redditors relate to. Upvotes and replies roll in rapidly. One poster turned to Ozempic, which was effective in decreasing their weight quickly but also pushed them back into disordered habits and beliefs, leaving them asking, “Isn’t this just another form of massively disordered eating wrapped up as some miracle medication? …Isn’t it just making me starve myself and feel sick like any disordered eating would?” Other Redditors chime in, voicing visceral fears of falling into their own disordered spirals. One person “can’t help but feel Oz is forcing me to have an eating disorder,” describing the vomiting Ozempic causes whenever they eat even a normal-sized meal as “forced purging.”
Forums like Reddit can be the first places people receive validation around their suffering and are often spaces that foster far more honesty from these patients than doctor’s offices. Under the blue light of a laptop at night, people in pain can trade symptoms and stories, including obsessive thoughts about food, pride in consuming increasingly small amounts, calorie obsession, body checking, fatigue, and depression. Online, people describe experiencing all of these on semaglutide: “I’m back to that feeling of loving the feeling of an empty stomach” and “constantly checking the scale.” Someone notices an eerily eating disordered “sense of pride when I take in such a small amount of food.” Another user “eat[s] one meal a day” as they did during their eating disorder. One person’s Ozempic lifestyle “really does feel like the extremely damaging diets I have been on before that have spiralled into obsessive disordered eating.”
Eating disorder experts are observing this phenomenon too and fear that semaglutide might incite eating disorders in new patients or retrigger dormant ones for people in recovery. Dr. Erin Parks, the chief clinical officer at the eating disorder treatment program Equip, recently said that the semaglutide discourse “glorifies using eating disorder behaviors” for weight loss and described the drugs’ effects as “really just eating disorder symptoms…the mechanism by which Ozempic helps people lose weight is by helping them restrict—helping them consume the number of calories that most people who struggle with anorexia consume, or helping them vomit daily similar to people who have bulimia.” Dr. Lauren Mulheim, who directs an L.A. eating disorder treatment center, wrote a blog on her program’s site in which she contended that “these medications replicate the conditions of an eating disorder.” These drugs are not creating a healthier relationship between our appetites and food — they are allowing us to treat food like the enemy.
Life in a fatphobic society can be made easier by losing weight, and so these considerations are not meant as judgments. But until we address our sick misunderstanding of health, semaglutide might not be a miracle cure for obesity but a symptom of our disordered relationship with food, bodies, beauty, and health. These drugs likely won’t be safely prescribed and might heighten both our obesity and eating disorder epidemics. As one Redditor explains, “It’s not my body I hate, it’s the way the world treats my body.” Is it worth the nausea, pain, fatigue, depression, and malnourishment, just to make it smaller? Humans are feral animals: Our hunger is a survival impulse, not a symptom.
Emmeline Clein is the author of Dead Weight: Essays on Hunger and Harm and Toxic (Choo Choo Press, 2024). Her writing has appeared in the Paris Review, The Nation, the Yale Review, the New York Times Magazine, and elsewhere.
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