Prescriptions of GLP-1 drugs to patients without diabetes have seen an increase of 700% since 2019. GLP-1 drugs like Ozempic and Mounjaro were originally used to treat Type 2 diabetes and to reduce the risks of heart attack and stroke. Now they are also prescribed off-label for the purpose of weight loss, especially for those with other weight-related medical conditions. According to one recent poll, approximately 32% of American adults have heard “a lot” about these drugs, and of those adults, 42% were told within the last five years that they were overweight or obese by a doctor. Thanks to celebrity influence, the use of GLP-1 drugs is becoming increasingly popular, but clinicians may have an unduly influence as well.
Recently, my gynecologist joked that she wished she could just write me an Ozempic prescription. I found this comment off-putting. Not only was this offer unsolicited, but also, such a prescription did not seem medically warranted in my case. Although my Body Mass Index (BMI) officially classifies me as obese, along the alleged “fat spectrum,” many may consider me to be “small fat.” More importantly, I did not have nor was I at risk of developing any weight-related morbidities. My blood pressure, cholesterol, and blood sugar levels were all well within normal range. Even her previous concern that I had Polycystic Ovary Syndrome (PCOS)—a gynecological condition that more commonly affects overweight or obese individuals with a uterus—was unsupported. Yet, I knew embedded in her joke was an order for weight loss that, as a clinician, she still had the institutional power to prescribe.
When a clinician recommends Ozempic to a patient who does not have a weight-related morbidity that would make prescribing Ozempic medically justified, what gets conveyed is not only an obligation to take the medication—which can come with a host of gastrointestinal side effects—but it also conveys an obligation to not be fat. In her book, Unshrinking: How to Face Fatphobia, Kate Manne addresses the implicit assumption that individuals have a duty to themselves and to society to be thin. Manne suggests that such a misplaced obligation stems from misguided ideas about fat people, including but not limited to, the idea that fat people necessarily incur a risk of poor health and are a burden to the healthcare system, that fatness is necessarily tied to overeating and a sedentary lifestyle, and that someone’s weight is ultimately under their control.
The misguided, unspoken obligation to not be fat becomes even more binding when legitimized by medical practice. Despite patients having a right to refuse medical treatments, the power granted to clinicians instills their medical advice with the moral force to ascribe an obligation or duty to adhere. This is especially evident in the response a patient can receive when they choose not to comply with a clinician’s recommendations for treatment or care. Patients will likely be described as non-compliant, non-adherent, or unwilling in their electronic health records—studies have shown that such language is stigmatizing, and it can negatively influence attitudes and clinical decision-making in subsequent clinicians who access the patients’ charts. I worried whether other clinicians would take, say, my pelvic pain seriously if my gynecologist noted that she offered me Ozempic and I declined?
Moreover, this obligation rests heavily on the assumption that fat people are necessarily unhealthy, and the converse, that thin people are necessarily healthy. Bioethicist Alison Reiheld argues that medicine utilizes an idealized conception of health that sets smaller bodies as the norm or ideal one ought to achieve. As a result, in encouraging patients to be healthy, clinicians are quick to advise weight loss. However, being smaller is not necessarily linked to better health. For example, about 15% of individuals with Type 2 diabetes are not overweight, but rather, are “metabolically obese, normal weight (MONW).” While such individuals present as thin, they accumulate visceral fat around their abdominal organs, which still results in lower insulin sensitivity. On the other hand, about 50% of obese people are metabolically healthy, or do not have conditions like type 2 diabetes, high blood pressure, or high cholesterol.
Instead, research shows that an active lifestyle is a stronger determinant of health than a person’s BMI. I had made drastic changes to my lifestyle prior to seeing my gynecologist. I started going to the gym twice a week, was cutting back on caffeine and alcohol, and was more mindful about my carbohydrate intake. I had even lost a few pounds. Still, within the first ten minutes of my appointment, my gynecologist strongly encouraged me to speak with my primary care provider about an Ozempic prescription. (Since, again, she jokingly noted that she could not write me a prescription herself.)
Clinicians’ voluntarily recommending a GLP-1 drug to patients in which weight loss is not a required course of treatment for a particular weight-related condition goes beyond the scope of their expertise. Having medical expertise does not give one the epistemic authority to prescribe normative judgments about one’s body. Although health lies within the realm of clinical knowledge, concerns solely about an individual’s fatness reflect mainstream beauty standards more than they express a genuine concern about the individual’s well-being.
To be clear, I am not arguing against the use of Ozempic per se. For many patients, especially those with Type 2 diabetes, Ozempic is a necessary part of their treatment plan. Moreover, I believe individuals have the right to do with their bodies as they wish, which includes using whatever weight loss means that they see fit, given that they are well-informed of the associated risks. I see no moral issue with a patient expressing interest in a GLP-1 drug and a clinician prescribing said drug if doing so does not go against medical judgment. However, it can be harmful when clinicians, for no other reason than patient weight loss, take an individual’s right to choose to be thin (or fat!) and transform it into an obligation to lose weight under the power of “medical advice.”
Jada Wiggleton-Little, PhD is an assistant professor of philosophy at The Ohio State University.