Semaglutide, a weekly injectable diabetes medication, is both complicated and controversial. The word is often used interchangeably with the word Ozempic, a brand of semaglutide (think copy machine vs xerox machine), and is the popular name for GLP-1 inhibitors which are a kind of diabetes medication. Semaglutide is a miracle drug for diabetics. It works in several ways, outlined in Semaglutides, Diabetes, and Fatness, Oh My! It also often causes weight loss which has made it an extremely popular medication. On this blog, I have published two different articles about semaglutide and my experiences with it. My first article Semaglutides, Diabetes, and Fatness, oh my! made an attempt to grapple with nuance, my second article Don’t Take Semaglutides for Weight Loss so I Can Get My Diabetes Meds, born of the frustration of trying to get my Mounjaro (a semaglutide medication I take to manage diabetes), had no nuance whatsoever. The first article acknowledged that patients taking semaglutide were not to blame for the current shortage, the second put the blame squarely on the patients. That was wrong.
In this article I aim to do a better job of articulating the problem of semaglutide shortages, the ways the medications and the shortages punish patients, and some of the players causing harm in this situation.
Semaglutide is tremendously valuable for diabetics. I’ve been on Mounjaro for more than a year and my a1c (a measure of the amount of sugar in your blood) has gone down from a level that is considered uncontrolled to a level that is right in the goal range for most diabetics.
Diabetes, when uncontrolled, can lead to organ damage, vision loss, infections that require amputation, dementia, and many more things that are frankly terrifying for me to imagine. This medication and thus my new a1c make it possible for me to delay or possibly even avoid some of these complications. When I call this drug a miracle, I mean it.
Semaglutide also often causes weight loss.
It causes weight loss and, as far as we know, doesn't cause dangerous or fatal side effects. It has side effects, which can be brutal, but none that are life threatening (that we know of– these meds haven’t been out for very long so it is possible there are undiscovered side effects) and for many the medical advantages make it worth it. Weight loss is something many people desperately want. People with the money to do so are often willing to pay out of pocket for semaglutide if their insurance won’t cover it. It is particularly popular with celebrities looking to maintain the Hollywood ideal of thinness. Some celebrities were said to throw “ozempic parties” where everyone would take their shots together. Actresses were sometimes said to have ‘ozempic face’ which is a particularly gaunt appearance.
Semaglutide is hard to get. It is expensive and the supply does not keep up with demand. I spend 45 min - 2hrs a month calling pharmacies and trying to track down my Mounjaro and sometimes even then can’t find any. The Hollywood elite are often blamed for the shortage, and when the drugs first came out this was a fair assessment. At this point the shortage has gone on long enough that it is clear that it’s not just the ozempic parties driving the lack.
Semaglutide is not just for the rich and for diabetics, there are many other folks for whom a doctor might prescribe it. The marketing for semaglutide done by the $93.8 billion a year diet industry and the pharmaceutical industry has very thoroughly repositioned fatness as a medical issue and posed semaglutide as the cure.
Most of my new doctors in North Carolina assume I’m on Mounjaro for weight loss not diabetes even though my chart very clearly says I have diabetes. One doctor, when I told her up front I was not willing to discuss weight at the appointment, looked at my meds list and said “we don’t need to discuss it because you are on Mounjaro so you are doing the right thing for it already.” Another doctor, looking at my meds list, said that I was lucky I was able to get a prior authorization (a necessary step to get some medications) for Mounjao since the clinic usually only did them for diabetics. Again, my chart very clearly says diabetes and my meds list contains three medications for it. Semaglutide has been positioned very effectively as a successful treatment for the terrible illness of fatness and prescribed in a wide variety of fat related circumstances so of course, if I, a fat person, am on it it must be for fatness.
Though it is not widely discussed outside the fat community, doctors routinely deny fat people surgeries. They usually cite issues with anesthesia or they bring out research that points to sub-optimal outcomes for folks above a certain BMI. Interestingly this includes weight loss surgery which puts people in the unenviable position of having to lose weight in order to get a surgery that will help them lose weight. This also includes most joint replacement surgeries and things like top surgery (top surgery is surgery to either remove chest tissue and masculinize ones chest or to augment breast tissue) or other gender affirming surgeries (GAS). This is a problem.
The field of gender affirming surgeons is small no matter what size you are. There simply aren’t enough doctors doing an adequate job with these surgeries. If you want to use your health insurance it narrows further. If you have a high BMI the field narrows even further than that. Last time I helped a fat client find a top surgeon there was only one doctor who would work with folks with their BMI. One. In the greater Boston area which offers some of the best medical care in the country. This client has a high BMI but not as high as mine or many of my other clients. Luckily that surgeon was willing and able to take them as a patient but if the doctor had a full caseload or there was some other disqualifying factor, this client would have no options. As it was, their wait was about 6 months. I have had two other clients who were straight sized (“normal” BMIs) who have found surgeons and gotten the surgery in the time that my fat client has been waiting. I now live in North Carolina and was recently told by a fellow clinician that there are no GAS providers in the STATE that do not have a BMI limit for patients.
I have several clients and some friends who have been put on semaglutide to help them lose weight for surgery. I have a friend who is currently refusing semaglutide despite the fact that the doctor refuses to do surgery unless she loses weight. For her, the side effects are not worth it and so she is in enormous pain but unable to get surgery. Prior to semaglutide the only “safe” medical option for weight loss was weight loss surgery which is not appropriate for most people (“safe” includes an enormous potential for life threatening complications with every weight loss surgery).
I said in my first article on the topic that I didn’t blame people for wanting to take semaglutide for weight loss and I didn’t. Somehow in between my first and second articles that changed. I became frustrated with the endless cycle of phone calls to pharmacies and my inability to consistently get the medication. I was looking for an easy villain. My second article placed the blame squarely on the people taking semaglutide for reasons other than diabetes.
I was aiming my frustration in the wrong direction. First, I was painting everyone who was prescribed semaglutide for things other than diabetes (or a few other conditions that are helped by the medication) with the same brush as the people throwing ozempic parties. The fact is there are many people who take the meds who are more or less forced to do so by doctors in order to get lifesaving or life improving care.
Second, I was ignoring the systems at play. The reach of the diet industry is incalculably large. The industry creates pressure for both doctors and patients to be invested in weight loss, to keep spending dollars in hopes of shedding pounds. Patients are not at fault for the intense and insidious impact of diet culture driven by the diet industry.
Within diet culture, doctors bear some responsibility for the overprescription of semaglutide that drives the shortages. People need prescriptions to get semaglutide even if they have the money to pay for them without using insurance. There are a large number of doctors who are prescribing them for weight loss, whether it be to keep up with Hollywood norms or to lose weight prior to surgery. Some doctors more or less force patients to go on them. The diet industry pushes people to try to be smaller, the medical system prescribes the meds to get them there.
Individual doctors, however, do not deserve the full blame for the prevalence of semaglutide being prescribed for weight loss. They are working in a system they did not create and are getting inaccurate and biased information from pharmaceutical companies and other sources they turn to for information. They live in a culture that tells them that fat is a disease and they want to cure that disease. Many of the doctors prescribing semaglutide genuinely believe they are helping people.
Perhaps the biggest, and least visible, systemic player in the game is Pharmacy Benefit Managers (PBMs). These are companies like CVS/Caremark that decide prices and supplies of various medications. They work between pharmaceutical companies and pharmacies who also have a financial stake in the semaglutide supply/demand/price puzzle. PBMs do most of the heavy lifting in terms of patient access. Contrary to the information provided places like on the Caremark and Express Script websites, PBMs are the major driver of drug shortages and high drug prices (cvshealth.com says “PBMs are one of the few parts of the prescription drug supply chain specifically dedicated to lowering costs.” which is so patently and brazenly false that I immediately started yelling about it to the poor people in the coworking session with me. Thank you J & K for not ejecting me for my ranting.) PBMs want supply low to keep demand high, they decide and enforce who can make each drug and how much of it they make. PBMs have enormous power and most people have never heard of them at all.
There is no single villain here, there are, in fact, multiple villains. I want to be clear that people who have been prescribed semaglutide for any reason are not one of those villains. Be mad at the PBMs, be mad at the diet industry, be mad at the medical system, but don’t be mad at consumers. Semaglutide is a miracle in many lives whether those people have diabetes or if they are trying to access necessary surgery.
I put the blame in the wrong place when I posted Don’t Take Semaglutides for Weight Loss so I Can Get My Diabetes Meds and I am sorry. I wanted a simple villain and a simple action to solve the problem when in reality it is not so simple. It would be easy if people could just choose to stop taking them unless they were needed for some very specific diagnosis but people do not always have that choice. And even if they did have that choice, even if they were taking a semaglutide purely for weight loss with no medical coercion the shortage would still not be their fault. Diet culture is real and it is destructive and we all exist in it. Who am I to judge someone else’s survival strategy?
There is more to say here about fatness and health and diabetes and medication but I’ll leave that for another blog.
For now, please walk away with this message: patients don’t create the systems that oppress them and there is usually more nuance if you look.
Want to work with me? Email meg@fatqueertherapist.com to schedule a free consultation today!
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