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
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?