Thomas Goetz (2:43)

This is Drug Story. I'm Thomas Goetz. I loved talking to Miranda. She was so straightforward and honest about her weight loss. And I was surprised at how downright, blase, almost indifferent she was about this miracle drug. Yes, Ozempic helped her lose half of her body weight, but it didn't change what she thought about herself.

Miranda (3:06)

One thing that I also in my wildest dreams did not think about or foresee the kind of fatphobia that you would experience being on a GLP1 medication. People say that you're cheating. They say that you're taking the easy way out. I love when stuff is easy. I don't know why people are so interested in hardship.

Thomas Goetz (3:27)

As you can tell, Miranda is confident and self assured and that's not because she lost the, the weight. She has always been like that. She liked herself before Ozempic. She had fun. She liked margaritas.

Miranda (3:41)

People knew that I was just like the fun drink girl and she likes herself now. Now I'm like the fun diet Coke girl. I don't want to sound like ungrateful. I just want to like be clear that losing 144 pounds, your life might not be any better. It might be, you know, the same

Thomas Goetz (3:59)

as it was before, just 144 pounds less.

Miranda (4:04)

Yes.

Thomas Goetz (4:05)

Miranda is one of about 30 million Americans who have taken a GLP1 drug. That's the name for the class of drugs that includes Ozempic. Today's drug story is about these GLP1 drugs. Amazing new compounds that just seem to make the pounds disappear. Or rather they just seem to make it easier for people to stop eating. Ozempic is the most famous of these, the one that changed how everyone thinks about obesity. Ozempic is the brand name for the drug Semaglutide. Officially, it's only approved for diabetes. When a doctor wants to prescribe semaglutide for obesity, then they're supposed to prescribe a drug called Wegovy. But it's the same drug and there are several other GLP1 drugs available. More than 100 other GLP1 drugs in development. There has been a lot of talk about these GLP1 drugs. They are the biggest phenomenon in medicine since statins hit the market in the 1990s. These drugs bring in billions of dollars a year to their companies. And what interests me about these drugs, these GLP1s, is, is how they have turned our assumptions about obesity upside down, why obesity happens and what is responsible and who is responsible, because there is a lot of stigma around obesity, as Miranda said. So. Well, there's a common idea that obesity is a problem of personal responsibility, that it's not a real medical problem, and that these drugs, as amazing as they are at improving people's health, well, they're somehow a cheat. In today's episode, we're going to break down that thinking about self control and responsibility and we'll explore how one of the greatest humanitarian and scientific feats in history, the green revolution in agriculture, well, it led directly to today's obesity epidemic. So even if you've heard all About Ozempic and GLP1s, I think this episode will offer some new perspective. And first, to set the mood, here's a word from a company that is not in any way sponsoring this podcast. It's McDonald's commercial from 1990.

Dr. Fatima Cody Stanford (6:25)

Food.

Thomas Goetz (6:26)

We got hot food, huge food, happy food, and dude food.

Commercial/Advertisement Voices (6:31)

We got lunch food, munchity munch food.

Thomas Goetz (6:34)

Not in the greatest mood Food. We got the right food, pure delight food.

Commercial/Advertisement Voices (6:38)

Morning food and night food to make a wish.

Dr. Fatima Cody Stanford (6:41)

Food.

Commercial/Advertisement Voices (6:42)

Not this food.

Thomas Goetz (6:43)

All right. Food. We got food.

Commercial/Advertisement Voices (6:46)

Get it to go.

Thomas Goetz (6:47)

Food. Get your own food. Drug Story is sponsored by GoodRx. Every prescription has a story. And for many patients, affordability is a defining chapter. Goodrx makes it easier to find lower prices on prescriptions from GLP1s to flu meds, so cost isn't a barrier to care. Trusted by nearly 30 million Americans and over 1 million healthcare professionals each year, Goodrx offers savings at more than 70,000 pharmacies nationwide, helping people start and stay on the therapies that keep them healthy. To start saving, go to goodrx.com that's goodrx.com GoodRx is not insurance. Welcome back to Drug Story. This is part one, the Diagnosis, where we explore the underlying condition and causes of obesity, the disease that can be treated by ozempic and other GLP1s. That McDonald's commercial we just heard, it's a great example of how food hasn't just been something that sustains us. It's something we consume for fun. It's sold to us as entertainment. It's a way to indulge our appetites. But food as entertainment only exists because the ingredients, the grain, the meat, the sugar, they're all so cheap and abundant now. For centuries, though, and as recently as the 1970s, food was not abundant at all. This all changed in large part because of one man, one American Norman Borlaug. You may have never heard of him, but you can argue that Norman Borlaug did more to create the modern diet than any other human being in history. He did this for all the right reasons, but with some unintended and unimaginable consequences. Borlaug was born in Crezco, Iowa, in 1914, just a few miles south of the Minnesota border. He was the child of Norwegian immigrants, and he grew up working on the family farm. In his youth, Iowa and the Great Plains were becoming known as the Breadbasket of America. A land with exceptionally rich soil, a stable climate, and a hardworking and proud farming culture. But farming was hard work. As a young boy, Orlog picked a quarter million ears of corn a year with his own hand. Hands. By the time he enrolled at the University of Minnesota in 1933, the Great Depression was in full effect. The once fertile Great Plains of North America had been overgrazed and over plowed. Then drought hit and the crops failed. This created the Dust bowl. And amid the environmental disaster, it brought a scale of human misery that Borlaug was terrified to witness. One day in Minneapolis, where Borlaug was a student in agriculture school, he got swept up in a food riot over the price of milk. He realized that when food was scarce, life could grow. Desperate, and he started to consider whether there was something he could do. Here's Norman Borlaug himself.

Commercial/Advertisement Voices (10:11)

I experienced the economic depressions of the 1930s. And from this experience I felt that the families on the lands, the small pieces of properties around the world, needed help from scientists. And I dedicated my life to science and especially to food production.

Thomas Goetz (10:33)

Norman Borlaug went to Mexico in 1944 as part of a research project trying to improve the country's agriculture, especially wheat production. At the time, Mexico imported most of its wheat and flour. Borlaug was a gifted plant breeder, mixing different kinds of wheat to take advantage of certain traits. He was hoping to develop something that might thrive in Mexico's arid soil. The work was a struggle, and he spent years, more than a decade, making little progress. But eventually he adapted a Japanese variety of wheat that created short stalks that could germinate large seed heads, the grains of wheat. What's more, his new wheat could be harvested twice a year instead of just once a year. This was huge because in the decades after World War II, famine and starvation were common around the world. Agriculture was still a primitive industry in most countries. Often a harvest could not provide for a country's booming population. Population 30% of people worldwide were chronically malnourished, and half the world did not have a reliable source of food to meet their basic needs. By 1963, Mexico was producing six times the amount of wheat as when Borlaug arrived. And they actually began exporting wheat to other countries. And other countries where agriculture had been a constant struggle began to look to science for ANSWERS. Here's a 1969 film from the U.S. department of Agriculture.

Commercial/Advertisement Voices (12:07)

Three billion people today, six billion by the year 2000. A world that will need four times our present food production to avert famine and disaster.

Thomas Goetz (12:25)

Soon, scientists from around the world were coming to Borlaug to adapt what he had done for their countries.

Commercial/Advertisement Voices (12:31)

And it's been fascinating to me not only from what has been accomplished in wheat, but more important, in the training of young people. For example, in the last eight years, we have had 150 young wheat scientists from about 25 different countries of the world who have come to study and work with us.

Thomas Goetz (12:50)

This was the start of what would be called the Green Revolution. It was a remarkable transformation of agriculture with better breeding and better pesticides that allowed farmers to grow more crops that sustained growing populations worldwide. The production of food per acre, known as yield, it doubled. And as the method spread, one country after another saw the food that their farmers could extract from the land soar. Average daily calorie consumption worldwide increased from about 2,000 in 1965 to about 2,500 in 1990. Malnutrition and starvation ceased to be commonplace, even as the global population increased by billions. Today, where food insecurity persists, it's largely for political reasons or logistical challenges rather than a true scarcity of food. The Green Revolution was certainly one of the great accomplishments of human history. For the first time, billions of people were freed from the tyranny of wondering where their next meal might come from. Nations that experienced persistent and deadly food shortages now had reliable sources of grain and food. India, Pakistan, Morocco, Tunisia, Turkey, China. It's estimated that Borlaug was responsible for saving 1 billion lives. And in 1970, Norman Borlaug was awarded the Nobel Peace Prize for his work. But. And you knew a but was coming. In the United States, the miracle technologies of the Green Revolution launched the industrialization of agriculture. Production of grain crops. Corn, wheat, oats, potatoes, rice that all soared with bigger yields every year. And more grain meant a bounty of food on a scale that would have been unimaginable just a few decades earlier.

Commercial/Advertisement Voices (14:51)

The supermarket is the showplace of today's agriculture. Here is where the shopper benefits from the work of the scientist and the farmer and the marketer. These products come from farms and ranches. Despite distance and season, they are the result of a miraculous agriculture. Tremendous advances on the farm and in the marketing system have created this miracle. The miracle whereby American agriculture has advanced more in the space of a single lifetime than world agriculture had in more than 7,000 years.

Thomas Goetz (15:31)

The result? Food got really, really cheap. Lets use just one example. Oreos, that perfect American snack. In 1934, when the dust bowl was raging and Borlaug was in college In Minneapolis, a 1 pound package of Oreos cost 27 cents, or about $6.50 today. By 1970, when Borlaug won the Nobel Peace Prize, Those Oreos cost 45 cents, or about 4, $4 today that's 1/3 cheaper, thanks to the green revolution. Oreos are a good example also, because they're really just wheat flour and sugar and fat. Those are all basic food ingredients, common commodities. And when those commodities are cheap, well, you can make a lot of things from them. Different mornings he wakes up in different moods, so different mornings he likes different cereals. Your answer is Kellogg's Variety Pack. A new and bigger selection.

Commercial/Advertisement Voices (16:33)

Ten personal servings, America's favorites, the best to you each morning in Kellogg's Variety Pack.

Thomas Goetz (16:42)

It all starts with cheap grain. Entire new categories of food products were invented. Frozen foods and convenience food and TV dinners and sugared cereals and savory snacks like Fritos and Tostitos and Doritos and Cheetos and Funyuns. Those are all corn based snacks from just one company, Frito Lay. Cheap grain also means cheap feed for livestock, particularly corn for cattle and poultry and swine. That means more animals and cheaper meat. And that created Slim Jims and chicken fingers and cheaper fast food and more kinds of fast food. Chicken sandwich chains and roast beef sandwich chains and Wienerschnitzel chains and Taco Bell selling well. Not just tacos, but chicken strips and nacho fries and everything else that Taco Bell sells. This started in the 1960s and 70s, but it reached a whole new level in the 1980s, especially after Philip Morris bought Kraft and RJ Reynolds bought Nabisco. That's right, Big Tobacco took over Oreos. Kraft and Nabisco were the biggest food companies in the world. Ever. And by 1989, they were both owned by tobacco companies. These companies brought all the tricks of marketing and development that they had perfected with cigarettes to food. Starting with the notion that individual freedom means doing what you Want indulging your desires. Just like they sold cigarette smoking as a matter of personal liberties, not addiction, the commercials for their foods made it all about fun and choice. And it wasn't just the marketing. It was also what was in the foods, the ingredients, the formulation. Remember, a cigarette isn't just shredded tobacco. It's a carefully engineered and designed product. In the 1950s, tobacco companies knew that nicotine gave smokers a buzz and was addictive. It kept them smoking. So the companies began to boost the levels of nicotine in every cigarette, so more was delivered into the smoker's lungs with every drag. In the 1980s, they took the same approach to food. A recent study in the journal Addiction by researchers from the University of Kansas looked at foods manufactured between 1988 and 2001, the period when big Tobacco owned Kraft Nabisco and also General Foods. These include many of the food products you probably grew up. Miracle Whip, Ritz, Planter's, Peanuts, Oscar Mayer. During this period, products from tobacco owned companies were free. Far more likely to have high levels of sugar, salt, fat and extra carbohydrates than comparable food products from other companies. And not just by a little bit. Tobacco owned foods were 80% more likely to be high in carbs and sodium than other foods. These ingredients, sugar, carbs, salt, fat, they each trigger cravings and emotions in our brain and bodies. We can't stop eating them. Millions of years of evolution primed our biology to want these things, especially these things. In primitive times, these were scarce and essential for life. But after the green revolution, they were much more common and cheap. And after the tobacco companies got into food, there was just more of them in our everyday food than ever before. Foods that are high in these ingredients are called hyper palatable foods or ultra processed foods. And these foods are everywhere. More than half of the calories consumed in the typical American diet comes from ultra processed foods. And most of these calories come from just five sources. Sandwiches, including burgers, sugared beverages, savory snacks, sweet bakery products, and pizza. It's controversial to say that these foods are addictive, that they are as manipulative and dangerous as cigarettes. But the truth is that these foods are designed and engineered to make us want more. And if you listen to the commercials, they actually admit that they are designed to be irresistible. They use it as a selling point.

Commercial/Advertisement Voices (21:18)

No one can eat just one.

Dr. Fatima Cody Stanford (21:20)

No one can.

Commercial/Advertisement Voices (21:22)

I can't.

Dr. Fatima Cody Stanford (21:23)

What makes honey bunches of oats cereal so irresistible?

Miranda (21:26)

Is it the crunchy oat clusters, Touch of golden honey, Perfectly toasted flakes made with whole grain. Yes, yes, and yes.

Commercial/Advertisement Voices (21:35)

When you get the urge for a delicious snack, have a Kit Kat. Kit Kat's irresistible. I got one word for Taco Bell. Irresistible.

Thomas Goetz (21:46)

What's so insidious about these foods is the way they are engineered for rapid eating and rapid digestion. That's what ultra processed means. The ultra part, they are softer and easier to chew, which makes it easier to eat faster and eat more. And the high processing of ingredients means that ounce for ounce, these foods contain more calories than regular food. What's more, bite for bite, our bodies just absorb more calories per serving than we do of low processed foods. This is worth explaining. Consider two turkey sandwiches. One is made at home with lettuce and tomato, whole wheat bread, and a couple of slices of leftover Thanksgiving turkey, maybe a slice of cheese. And the other is a Titan turkey sandwich from Subway. Now, your typical homemade turkey sandwich would have about 300 or 400 calories fewer than the 500 calories in the Titan turkey, according to Subway's website. But even if both sandwiches had the same amount of calories in the ingredients, the Subway ingredients are just made differently. The roll is softer and has more sugar and processed flour. The honey mustard spread has 8 grams of sugar. The turkey, it's cut from a processed loaf and the lettuce is shredded. The result is that our body just absorbs more of these calories with every bite. While with the homemade sandwich, our body just doesn't break down as much of it before it passes into our digestive system. So not only do our brains crave a Subway because of those carbs and extra sugar, but our bodies also pull more calories out of every bite. And here's the thing. The rise of ultra processed foods tracks almost perfectly with the rise in obesity. In fact, experts pegged the start of the obesity epidemic in the US to around 1980, when consumption of sugar and high processed carbohydrates began to soar in America. And when the food industry began to develop foods we crave and can't resist, they wanted us to eat more, and we did. Over the 50 years from 1970 to 2020, average calories consumed per American rose from 3,000 to more than 3,800 a day. That's an increase of more than 25%. So what happens when people consume more calories than they need? Our bodies turn the difference into fat. The result is. Well, we all know what the result is. In 1970, less than 15% of Americans were obese. Today, more than 40% of Americans are obese. That's more than 100 million people in this country alone. Okay, so we've basically made an argument here. A chain of causation, cheap grain, cheap calories, irresistible food, soaring obesity. But is the food actually irresistible? Don't we have willpower? Don't we have free will? After all, the food industry, they're just giving us what we want, right? We choose what to eat. Isn't that a fundamental part of being American, living in a free society, that we can buy what we want and live our lives how we want? This is what the food companies argue, that they are simply satisfying consumer demand and offering choices. This is the argument that the food company ConAgra made when the FDA moved to restrict the use of the word healthy to only products that are actually, you know, healthy. This mattered a lot to conagra because they make the Healthy Choice line of frozen meals. And According to the FDA's proposed new rules, a lot of healthy choice meals would not be able to actually use the word healthy. They contained too much sugar or fat or salt. Well, ConAgra argued against the rules, saying that if the food does not taste good, people will not buy it. In other words, they had to have lots of salt and sugar. The FDA did not buy Conagra's argument, and the new rules went into effect December 2024. So now Conagra and other companies have to reformulate their products if they want to use the word healthy. This matters because this idea of personal choice has two sides. First, it seems like an American right to eat what we want. That's freedom of choice. But the flip side of that is that when people do become overweight, well, that's on them, too. That was their choice. For decades, obesity has been framed as a lifestyle issue, a matter of diet and exercise and a matter of personal willpower. That framing has long been the mantra of the diet industry, with companies like Weight Watchers and nutrisystem. And Jenny Craig. By the way, a bit of irony here. Heinz Foods bought weight watchers in 1978 for $71 million, and they owned it for 20 years. And in 2006, Jenny Craig was acquired by Nestle for $600 million. So the companies that created the problem, well, they also looked to profit from it as well. But blaming individuals gets hard when we are on the brink of half of all Americans being obese. Clearly, it's something other than poor individual decisions. Obesity became a true public health concern, a population concern, in the late 1990s, but it was not considered a medical issue because obesity itself wasn't considered a disease. A treatable medical condition, obesity clearly leads to bad diseases, type 2 diabetes, heart disease, stroke. But calling obesity itself a disease was just not something that a lot of medical experts were willing to do. In fact, it wasn't until 2013 that that the American Medical association finally decided to consider whether obesity should be a disease. We're going to dig in on that debate and on the emergence of drugs that suddenly seem to work. Coming up in part two, and to take us there, here's a 2015 commercial from Weight Watchers, which it doesn't actually say the words Weight Watchers, but it's just a really effective. Well, just take a listen.

Commercial/Advertisement Voices (28:23)

If you're happy and you know it, eat a snack. If you're happy and you know it, eat a snack if you're happy and you know it then your face will surely show it if you're happy and you know it, eat a snack if you're sad and you know it, eat a snack if you're sad and you know it, eat a snack. If you're sad because you're angry, feeling down or jealous, bad if you're sad, eat a snack. If you're bored and you know it, eat a snack if you're lonely and you know it, eat a snack if you're sleepy and you know it if you're guilty and you know it if you're stressed, eat a snack. If you're human and you know it then your face flow surely show it if you're human, eat your feelings eat a snack.

Thomas Goetz (29:22)

Welcome back to Drug Story. This is part two, the Prescription. So is obesity a disease? That was the question facing the American Medical association in 2013. Just a year earlier, an expert AMA panel had issued a report arguing that obesity was not a disease. But the science was moving fast and the problem was getting worse. Many doctors believe that the AMA, as the nation's leading source of medical expertise, they needed to do more than wait. So at the AMA's annual meeting in Chicago that year, as they considered the research and the evidence, they invited a young doctor to offer her perspective. This was Dr. Fatima Cody, Stanford.

Dr. Fatima Cody Stanford (30:09)

I'm an obesity medicine physician, scientist at Massachusetts General Hospital and an associate professor of medicine and pediatrics at Harvard Medical School here in Boston, Massachusetts.

Thomas Goetz (30:19)

That's Dr. Stanford. Today, she's among the country's leading experts in obesity medicine. But back then, in 2013, she had just graduated from Harvard Medical School and she was in year one of a three year fellowship in obesity medicine at Harvard this was a brand new specialty. So she takes the stage in front of more than 600 delegates, the leading doctors in the country.

Dr. Fatima Cody Stanford (30:43)

And I introduced them to one of my patients named Twinkie. She was an 11 year old that was admitted to the pediatric hospital with an asthma exacerbation, initially to the pediatric icu. When she was transferred to my care when I was still an intern. One day as I was going in to do my rounds, which we do very early in the morning, I found her to be not breathing when I walked in the room. I go to, you know, kind of shake her to get her to start breathing again and she starts breathing again. I report this to my senior residents and my attending physicians. You know, I think that she's not breathing. I think she may have obstructive sleep apnea. I get a, you know, pat on the back. Dr. Stanford, great job. That is likely true. They called her Twinkie because this was a young black girl in South Carolina that carried significant axis adiposity, otherwise known as very severe obesity. A likely contributor to her obstructive sleep apnea, which was not yet diagnosed. She was discharged home and she died three days later. The idea that this young 11 year old is dying and the cause of death ended up being obstructive sleep apnea, which was secondary to obesity, speaks volumes to what we were not recognizing at the time and what we are still reticent to recognize, which is a disease that we can treat if we just take a step back and think about what we can do for the patient. I don't like going to funerals in general, but I can tell you I don't like going to Funerals for a 11 year olds, particularly ones that could still be living a fruitful life. And if we don't recognize and treat obesity, which was the root cause of issues, we're going to continue to lose people well before their time here should be done. And that was the story that I told in addition to a few others, but I think that one stood out the most.

Thomas Goetz (32:48)

Wow, that is very compelling. Dr. Stanford's talk, it turned out, was right before the vote by the delegates. And having assessed the evidence and heard from Dr. Stanford, the AMA approved the resolution to reclassify obesity as a disease.

Dr. Fatima Cody Stanford (33:06)

I think a very pivotal point in my career. I didn't know that that was the, I guess, task that I had been presented with, which was to convince the AMA that obesity was a chronic disease. But after taking on that task that was unbeknownst to me, it obviously played a large role in my leadership in the field.

Thomas Goetz (33:28)

So now, finally, obesity was designated as a medical condition. This was a big deal because it made it more likely that the FDA would approve medications to treat obesity and it made it more likely that insurance companies would pay for those treatments. But what sort of medicines were there? Well, let's wind the clock back a little here, because over the years, there have actually been many drugs that promise to help people lose weight. In the 1970s, amphetamines were widely used for weight loss until the Food and Drug Administration banned their use in 1979. In the 1990s, there was fen phen, a combination of fenfluramine and appetite suppressant and phentermine, an amphetamine like stimulant. Millions of people took fen phen. Fen phen clinics popped up in strip malls and storefronts. But unfortunately, the drug combo caused serious side effects. The Food and Drug Administration today stepped up its warnings about the dangers of so called fen phen diet drugs. The FDA said patients taking a combination

Commercial/Advertisement Voices (34:31)

of fenfluramine and phentermine needed to be

Thomas Goetz (34:34)

aware of the risks of serious heart valve disease. Hundreds of women began to experience heart problems and damage to the valves in the heart. Fen phen drugs were pulled from the market in 1997. Meanwhile, surgical solutions were being developed that seemed more promising, if also more severe. In 1994, the first laparoscopic gastric bypass was performed. The surgery basically reroutes the digestive system. It reduces the stomach to restrict food intake. Known today as bariatric surgery, about a quarter million people get the procedure every year. Many millions of Americans have undergone the procedure in the last 30 years with great success. But it is an intense and grave decision where you're basically removing human organs in order to lose weight. And then in 2005 came the first GLP1 drug, Exenatide. Sold as Byetta, Exenatide was approved to treat type 2 diabetes, which is often driven by lifestyle factors and associated with obesity. The drug helped reduce blood sugar levels, but it came with a side effect, a welcome one. People taking exenatide lost a good amount of weight without even trying, typically 5 to 10 to 15 pounds. But there was one downside. The drug was delivered by injection and required two injections every day. So even though word started to get out that Axenatide worked for weight loss, the drug never became widely prescribed for obesity. By 2010, another GLP1 drug had come along, Liraglutide, developed by Novo Nordisk. Like Exenatide, Liraglutide was approved by the FDA for the treatment of diabetes. But that didn't mean that doctors couldn't prescribe it for other reasons, like weight loss. This is so called off label prescribing and it's 100% legal. It's just not legal for drug companies to promote drugs for unapproved uses. Unlike Axenatide, which, remember, required two shots a day, liraglutide only needed one shot a day. So much easier. And in 2014, the FDA approved liraglutide for treating obesity. Studies showed that people taking the drug lost on average around 5% of their body weight. As good as anything else out there, far fewer side effects if you were overweight. Losing 5% of your body weight, it turns out, is a significant benefit. That 5% threshold is associated with lower rates of heart disease, lower blood pressure, better blood sugar and less joint pain. 5% makes a real difference. But the trouble is, 5% doesn't look like a big change. It's not what most people are going for when they say they want to lose some weight. If you are 200 pounds, you don't want to lose just 10 pounds. You more likely want to drop 20 or 30 or even 50 pounds. And those first GLP1 drugs just didn't do that. Not yet. And so while there was excitement about the drugs, they were still pretty under the radar. They weren't yet a phenomenon. But Novo Nordisk had another drug in the lab. Semaglutide. This one worked even better. It only required an injection once a week. It worked even better at lowering blood sugar levels. And oh yeah, it caused a significant weight loss, as much as 20% of body weight. That's a 40 pound weight loss if you start at 200 pounds. In 2017, the FDA approved Semaglutide for the treatment of diabetes. And Novo Nordisk began to sell it as ozempic.

Dr. Fatima Cody Stanford (38:34)

My ozempic trizone.

Commercial/Advertisement Voices (38:35)

I lowered my a1cv risk and lost some weight.

Thomas Goetz (38:39)

Losing weight seemed like a welcome side effect, but still just a side effect of its intended purpose, to improve blood sugar in people with diabetes. But some Novo Nordisk executives saw that there might be a whole new market beyond diabetes obesity if they could just convince the company's leadership that obesity was a real medical condition and not just a matter of self control.

Commercial/Advertisement Voices (39:06)

Obesity was in many ways seen as a mental deficiency on the people they were getting heavy social problems and sort of associated with inability to control Europe food intake.

Thomas Goetz (39:23)

Many, many people can eat and eat

Commercial/Advertisement Voices (39:25)

and eat and never put on weight. And then there are other people that

Dr. Fatima Cody Stanford (39:30)

if they eat just a little, they

Thomas Goetz (39:31)

will put on weight.

Commercial/Advertisement Voices (39:32)

And this is unfair genetically. I had to spend half a year convincing my CEO and my head of healthcare that obesity is not just a lifestyle condition. And they were ultimately convinced. So we should always think about obesity treatment as a treatment for those that are medically challenged by being overweight.

Thomas Goetz (39:54)

That was two Novo Nordisk executives, Lars Riben Sorensen and Mads Thompson, from a video produced by the pharma company about the development of GLP1s. The company began doing clinical trials to get the drug approved for obesity, and that approval came in 2021. Now, when semaglutide is prescribed for that purpose, it sold as Wegovy, same drug as Ozempic. Different purpose, different name. The demand for these drugs has been enormous. So many people wanted to take Wegovy and Ozempic that Novo Nordisk was caught by surprise and the company simply couldn't manufacture enough semaglutide to satisfy the demand. This meant that for nearly three years, the FDA let other manufacturers create semaglutide and sell it, which explains why all those online weight loss companies could sell their own versions of the drug for a lot cheaper than the Novo Nordisk version. In early 2025, the FDA said the shortages were over and Novo Nordisk had their monopoly back, though some online shops are still pushing their own versions. Even so, despite the shortages, Novo Nordisk has sold more than $40 billion worth of GLP1s. So I haven't yet explained how these drugs work, what they actually do in the body. And the explanation is, well, it's pretty complicated, having to do with hormone receptors and insulin levels and brain chemistry. I'll have Dr. Fatima Cody, Stanford take this one.

Dr. Fatima Cody Stanford (41:26)

So in very layman's terms, it will tell you to eat less and store less fat mass without you really having to do anything. So patients will often use this term that I don't use, which is this concept of food noise and this idea that the volume, if you were to turn up the volume on your radio or your iPad or whatever device that you're using, that food noise in many patients may be at a high volume prior to the utilization of the medication. And when on the medication, it may go to very low volume and or goes to mute, so much so that these patients may forget not only to eat, but also to drink. So there may be then counseling on this part of our dietitians to ensure that they're getting an adequate nutrition. Because the food noise, which means the desire to Eat and or to drink. Things similar, such as simple as water, no longer are there. And this is not them trying to do this. This is being influenced by a drug that is stimulating their anorexigenic pathway of their brain in such a way.

Thomas Goetz (42:41)

This notion of food noise, it's important. It's what Miranda talked about at the beginning of the episode. If GLP1s turn off the signal, this unstoppable craving, well, that suggests that in some ways, these drugs are giving people back the ability to say no to food. Whatever it was about that food that was so irresistible before, suddenly, that's gone. The spell is broken. The very first time I took a GLP one was that all these years,

Dr. Fatima Cody Stanford (43:11)

I thought that thin people, those people

Thomas Goetz (43:15)

were just had more willpower, they ate better foods, they were able to stick to it longer. They never had a potato chip.

Dr. Fatima Cody Stanford (43:23)

And then I realized the very first time I took the GLP one that, oh, they're not even thinking about it.

Thomas Goetz (43:30)

That's right.

Dr. Fatima Cody Stanford (43:31)

They're only eating when they're hungry and they're stopping when they're full.

Thomas Goetz (43:34)

That's right. That was Oprah, obviously. So maybe obesity isn't just about willpower. Maybe it's not about free will and personal responsibility at all. That's the thing about GLP1s, they work really well. Ozempic and WeGovy offer a simple solution to a very big, complicated problem. Get this shot once a week, lose the weight. It works. A different you is possible if you just do this one simple thing. In fact, it's so simple that it's created a new twist on the old stigma of personal responsibility. Before GLP1s, people with obesity faced the stigma of perception, the idea that they make bad choices, that they are to blame for their condition. But now with GLP1s, the stigma has morphed. It's pivoted a bit. It's like those Final Destination movies. You cannot outrun the stigma. This time. The stigma is that people who use GLP1s and successfully lose weight, they're cheaters. It's a hack. They didn't deserve this. They took the easy way out. Comedian Jim Gaffigan said it best.

Dr. Fatima Cody Stanford (44:55)

These people will come up to me

Thomas Goetz (44:56)

and accuse me of being on an appetite suppressant.

Commercial/Advertisement Voices (44:59)

They're like, you're on Ozempic. Admit it, you're on Ozempic.

Thomas Goetz (45:03)

And I'm not. All right? I'm on a different one.

Commercial/Advertisement Voices (45:08)

I'm on Manjaro.

Thomas Goetz (45:10)

Which is better, right? Cause it sounds like an Italian restaurant. Now I understand Some people are against the appetite suppressants. You know, that's cheating. It's cheating. I'm not playing major League Baseball. I'm just a fat guy trying to not die. Manjaro, by the way, it's a GLP1 drug developed by Lilly, which had a hand in that first GLP1 by ETA 20 years ago. Now Lilly sells Mounjaro for diabetes and Zepbound for weight management. When you think about it, this complaint about cheating is just another version of the willpower argument that people should just handle it themselves. They should have enough strength not to rely on a drug. That stigma is a very hard thing to shake. Here's Dr. Stanford again.

Dr. Fatima Cody Stanford (46:00)

Absolutely. I don't think it's a new phenomenon that people would be seen as cheating if they go on medicines. It is deplorable and disgusting that people still are in this thought process, but it really reflects a lack of knowledge with regards to the science. And I think that that's really important for us to stop the shame and blame game that spread become inherent in our society both here in the US and worldwide.

Thomas Goetz (46:29)

And do you think GLP1s are changing that in any way? Is there a way that they're actually taking some of the shame or blame away?

Dr. Fatima Cody Stanford (46:39)

In some ways, yes. Because we have at least 10% of the population that has been on these agents here in the US at some point. And for those that that have been on therapy that can now speak to, my goodness, wait a minute. I've been dealing with this issue of obesity. I thought this was always my fault. I realized that I just didn't have on board something that someone else has if it's been explained to them in that way. Now we're talking about a glacial pace in terms of changing that bias and stigma that is pervasive in society from, from utilizing these medications because they are too villainized. And a lot of it is because there are some misuse and abuse of these medications where these medications inherently gotten in the hands of people that may not necessarily need them. And so I think that that will help unfortunately set us back as we have been making some strides to improve the plight of those that do actually have disease, particularly obesity and other cardiometabolic diseases and associated with it.

Thomas Goetz (47:49)

And the thing is, lots of people take medications for things that could also be reversed through lifestyle changes, but there's no stigma. Are people with high cholesterol cheating when they take a statin? Are people with high blood pressure cheating when they take a drug? Instead of cutting back on salt Are people with insomnia cheating when they take a pill to help them fall asleep? At some point, it just gets absurd. But there's another thing about these GLP1s that makes them a concern, and that's the cost. A year of Agovy or Manjaro at the retail price costs somewhere between $10,000 and $17,000. Many people have insurance that will pay for that, but it's still a cost that somebody has to pay. That is a lot of money, too much for many people if their insurance won't pay. And remember, there are 100 million people in this country with obesity, and if they start a GLP one, they may have to take it for the rest of their lives. That is a lot of money. Billions of dollars. Who in the world is going to pay for all of that? We'll get into the money in part three after the break. First, here's a commercial for Wegovy. And I need to say they are not paying us for this. Change is never easy. There will be naysayers, doubters and critics. You may even give up for a moment only to start again another day because you believe in moving to the beat of your own drum and passing down lifelong skills in your ability to lose weight and keep it off. And when you believe you can succeed, you already have. The gov is for adults with obesity.

Dr. Fatima Cody Stanford (49:33)

It shouldn't be used with sematrophil.

Thomas Goetz (49:35)

Welcome back to Drug Story. This is part three, side Effects, where we discuss the social and economic consequences of using a drug to treat disease. In this episode about ozempic and other GLP1s, we're going to dig into just one side effect. And it's not something that happens to people taking these drugs. This side effect occurs when you multiply 100 million. That's the number of Americans with obesity right now, today. 100 million times $15,000. That's about the cost of one year of WeGovy or Mounjaro. That equals $1.5 trillion. That's the price of treating everyone with obesity in the US at the full retail price of the drug. That would be a very, very big side effect. And that would be on top of the $5 trillion the US presently spends on health care. A 30% jump in overall costs. Not every American with obesity is taking these drugs. As of May 2024, about 30 million adults, or 12% of the US population had taken a GLP1 drug. And most people are not paying out of pocket. Most, but not all, have health insurance that covers the cost of the drug. But still, that's money. And several insurance companies raise their premiums because of the cost of GLP1s. Nothing comes for free. I first did that math 100 million times $15,000 a couple of years ago when GLP1s were starting to go gangbusters. At first, I couldn't believe the number. $1.5 trillion on one kind of drug. I didn't think it was possible to pay for so many people to take such an expensive drug. Before starting my research on this episode, I thought it would be insanely wasteful to spend so much money on obesity. I thought it would be ruinous to our healthcare system. After all, it's not like a snake eating a gerbil where the Big Gulp passes through the system. Most people would need to be on GLP1s for life. And I thought it would actually be dangerous for human health. A free pass for millions of people who had given up trying. But I don't think that way anymore. After researching this episode, I realized I was wrong. This is not a fair fight. It's not about self control and discipline. I think there is something very wrong about the food system we've got and what it does to people. I think that GLP1s will save a lot of people's lives. They will spare millions of people, many hundreds of millions of people worldwide, from some really horrible outcomes and experiences and diseases. Diabetes is a really hard disease to deal with. It is a lifetime of challenges and monitoring. And if we can spare people of that end of heart disease or chronic pain or sleep apnea or certain cancers or or the many other diseases that often result from obesity, well, that could be a wise investment. In fact, spending $15,000 a year to help someone avoid these other diseases, what medicine calls comorbidities, it began to sound to me like money worth spending a reasonable return on investment, even a great one, in terms of how the US might spend our tax dollars. But also, it's not money down the drain. The US spends more than $400 billion a year on medical costs for diabetes, $400 billion on heart disease treatment and care, and billions more on osteoarthritis and obesity. Etc, etc, etc. If we really were able to greatly reduce obesity in this country, some of all that expense would go away. Now I'm not saying all those costs go away. With GLP1s, some people will still develop type 2 diabetes and some people will still get heart disease. But for many people, these drugs significantly reduce the risk of developing other conditions and diseases. Forecasts now estimate that the US will spend maybe $150 billion on GLP1s in four or five years. That's three times what was spent in 2024. That, of course, is a tremendous amount of money, but it reflects the reality that while these drugs are great, that they help a lot of people, they don't entirely fix the problem of obesity in this country. There will still be a lot of people with obesity who are not taking these drugs. I'll let Dr. Stanford explain.

Dr. Fatima Cody Stanford (54:11)

No one thing is the solution to obesity. I think that we would be shortsighted to think that one thing is the answer. Bariatric surgery is the best treatment for patients with severe obesity. It is underutilized. It is not the C. Lucian. It still requires consistent follow up. And many of those patients will need to go on medications. Ultimately, medications are not effective for every single person that utilized them, particularly the GLP1s. They work in about 85% of individuals, but notice I didn't say 100%. And even for those that are going on therapy, they need to remain on therapy consistently if they tolerate such therapy. So there is no one treatment tool that is going to solve obesity. It's going to require a multifactorial, multi sector approach. The best treatment for obesity starts preconception. Let's treat the parents with obesity prior to conceiving so that the offspring then have a better chance once they arrive. But that's not the strategy that we're talking about. That's the best public health strategy that hasn't been entertained. So I think that we have to be thinking about a wide swath of of potential treatments and prevention strategies. The prevention strategy I just mentioned, which is preconception and recognizing that GLP1s are one tool in the toolkit, but will not solve our entire problem with obesity by any stretch.

Thomas Goetz (55:40)

Ozempic and other GLP1s are not a cure all, but they are the first drugs ever that work safely for millions of people. And they're the first drugs that change how we think about obesity and why it happens and how to address it. And here is one more side effect. GLP1s are having a big impact already on the food industry. Remember how Miranda talked about how they turn off the food noise, how they stop her cravings? It seems that these drugs don't entirely stop appetites. They just stop appetites for things that people used to find, well, irresistible. People start eating other things instead. Things that are actually good for us. Salads, carrots, Swiss chard, radicchio. So people aren't just eating less, they're eating differently. And that has food companies scrambling. Here's a recording from early 2025 of Ramon Laguarta, the CEO of PepsiCo, talking to Wall street analysts after the company reported first quarter earnings. PepsiCo, I'll just note, makes a lot more than just Pepsi. They own Quaker Oats, which makes Cap' n Crunch and other cereals. They own Sabra, Hummus, Gatorade, and yes, the whole Frito Lay empire.

Commercial/Advertisement Voices (57:01)

Now the other thing we're seeing in GLP consumers is that they're keeping our brands in their repertoire, probably in a smaller portion. So they're going for and that's the way they're actually eating across most of their choices. They're eating less quantity. So our offerings in small portions and whether it's in multi pack or some other options that we provide, keeps our brands in their repertoire and it's still relevant.

Thomas Goetz (57:31)

Pretty much every food and beverage company, even grocery companies, are facing the same issues. They're having these same conversations with Wall Street. Calorie consumption is going down for people taking these drugs. They are spending less money on food and drink. People also report less appetite for alcohol, it so happens. And the more people who take GLP1s, and it's upwards of 10% of Americans right now, the less those highly processed, highly engineered foods sell. They break the spell. They seem to remove the addictive properties of those foods. Addiction. It's a strong word to use here, but it is not a stretch. A 2018 research review in the journal Nutrients found strong evidence that food could be considered addictive, given how it affects our brains, including withdrawal symptoms and relapse. GLP1s seem to liberate those areas of our brain that food companies have been exploiting for decades, just poking our cortex like dogs in Pavlov's lab. So food companies so far are talking about developing healthier foods and smaller portions as part of their strategy for dealing with GLP1s like Ozempic, which when you think about it, is great. Healthier foods, smaller portions, more options. Maybe we do have a choice after all. That's it for this drug story about Ozempic. For an annotated list of our sources for this episode, visit Drugstory Co Drug Story was created, written and hosted by me, Thomas Goetz. Molly Warner is our research director. From Reasonable Volume. Rachel Swavy produced and sound designed this episode with assistance from Audrey Ngo. Elise Hu was the editor. Mark Bush is our engineer. Drug Story was produced with support from the University of California, Berkeley School of Public Health. Special thanks to Claudia Williams and Michael Lu. Thanks also to Dr. Fatima, Cody, Stanford and Miranda, who shared her story with us. Drug Story is an independent production. If you'd like to support our work, contact us at Drugstory. Co. You can also subscribe to our substack there and be notified when new episodes come out. And if you liked this episode, help us spread the word. Rate us on Apple or Spotify or wherever you get your podcasts. Next up on Drug Story, it's all about Xanax, a medication that was considered a wonder drug because it works so well for anxiety and panic attacks. But it turns out it may work too well. We'll see you next time. Listening to this episode of Drug Story may cause you to eat more fruits and vegetables, walk to the store instead of driving, and regret all those late nights visits the subway back when you were in college. We recommend you think twice about that third helping. Stop blaming yourself and know that Tony the Tiger is talking straight to you and me when he says they're great.