(Long Shot)

Semaglutide: The Diabetes Shot Non-Diabetics Are Using To Lose Weight

More doctors are prescribing the drug for aesthetic purposes — but at what cost?

Written by Jolene Edgar
Francesco Carta fotografo / Getty
injection

It’s like something out of a modern-day Wonderland: Ozempic — the shot that makes you magically thinner. The coveted injectable — a form of the glucose-regulating drug semaglutide, which boasts weight loss as a (wildly lucrative) side effect — is technically FDA-approved for those with Type 2 diabetes (and, at a higher dose, obesity), yet it’s now being used by a vast collective of folks solely for aesthetic purposes.

“Literally every one of my friends here in L.A. is on it,” says Beverly Hills board-certified plastic surgeon Dr. Sheila Nazarian. “A few weeks ago, you couldn’t even find any Ozempic — it was all used up in town.” These friends aren’t diabetic or overweight, mind you — “they’re 40-something moms who want to lose 10 pounds,” Dr. Nazarian shares. “One of them told me that if anyone says they’re on a ‘meal plan,’ they’re really on Ozempic.”

Ozempic is, by all accounts, the talk of the town — make that towns, plural. While the buzz may have originated in Hollywood — with a provocative star, the usual speculation — it has since permeated nearly every locale where the wealthy and connected congregate, endeavoring to further elevate society’s already-towering beauty standards. But at what cost?

What Is Semaglutide?

Considered a next-gen weight-loss drug, semaglutide is a stable, synthetic version of a naturally occurring hormone called GLP-1, which sparks insulin secretion while also pinging select receptors in the brain to curb hunger. When injected weekly — either by the patient or their doctor — semaglutide “increases the activity of [this] hormone in our bodies, which is responsible for helping us feel full within a meal or in between meals,” says Dr. Beverly Tchang, a board-certified endocrinologist and obesity medicine specialist in New York City.

The shot goes by various names. Semaglutide is sold under the brand names Ozempic — FDA-approved in 2017 for the treatment of Type 2 diabetes — and Wegovy, a higher dose of the same medication, approved last year for weight management in people who are obese or overweight. While these medications, both from Danish drugmaker Novo Nordisk, are currently in short supply due to overwhelming demand, generic forms of semaglutide can be obtained from compounding pharmacies (though experts warn against purchasing “bootleg” versions of the drug due to lack of quality control).

How Do Semaglutides Like Ozempic Work?

As a diabetes drug, Ozempic’s primary purpose is to help the pancreas make more insulin to regulate blood-sugar levels. “But the insulin effect only occurs in a glucose-dependent fashion, so if blood sugars are normal, the semaglutide won’t trigger pancreatic insulin release — which is why it’s able to be used in patients who don’t have diabetes, with zero concern for low blood sugar,” explains Dr. Caroline Messer, a board-certified endocrinologist in New York City specializing in thyroid disease, diabetes, and weight management.

The drug’s other mechanisms of action occur regardless of one’s glycemic state, she adds, allowing almost everyone to capitalize on its unparalleled slimming powers. Semaglutide “works in two different areas of the hypothalamus — one to cause satiety and the other to lessen hunger,” Dr. Messer tells TZR. “It also causes a mild gastroparesis, or a slowing down of the transit of food, and that too leads to decreased hunger.”

More impressive still, semaglutide has been shown in clinical trials to burn harmful visceral fat and improve cardiovascular health, reducing the risk of stroke and heart attack.

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How Effective Is Semaglutide?

In the Wegovy clinical trial published in the New England Journal of Medicine in 2021, 1,961 overweight or obese adults receiving a once-weekly injection of 2.4 milligrams of semaglutide lost 15% of their body weight at 68 weeks. The treatment shrunk their total fat mass as well as regional visceral fat while upping their proportion of lean body mass.

The results of a two-year study were also just announced, proving Wegovy safe and effective for long-term weight control.

Dr. Ashley Gordon, a board-certified plastic surgeon in Austin, Texas, has seen first hand how semaglutide whittles away visceral fat, allowing her to “make the abdomen as tight as possible” during tummy tuck surgery. Even better, she adds, “for many people, it can change their relationship with food and shift their perspective on how much they actually need to eat in a day.”

Board-certified dermatologist Dr. Paul Jarrod Frank notes comparable perks in his patients. Semaglutide “affects the way people habitually reach for food; it rewires craving pathways,” he says. “I have patients who went on it for a month or two, and said, ‘It’s funny — I didn’t want to drink [alcohol] as much’ or ‘I didn’t have the sugar cravings.’” (The drug has been found to temper cravings and dampen our desire for fatty foods.) “I think we’re just at the tipping point of figuring out what these drugs can do,” he says.

Another GLP-1-based injectable called tirzepatide (or Mounjaro), which boasts an extra hormone, is being heralded as the next big thing in weight loss. With it, “we’re now capturing all of the receptors in the brain that signal satiety and lack of hunger,” says Dr. Messer, who calls Mounjaro “a more effective Wegovy.” Indeed, in the clinical trial, participants lost 20% or more of their weight at the beginning of the trial. Currently, Mounjaro is FDA-approved only for diabetes, but it could get green lit for obesity as early as next spring.

Since some doctors believe you don’t necessarily need to have insulin issues or have a BMI of 30 or higher to benefit from semaglutide, it’s now being prescribed more than ever. “I write 10 prescriptions a day for that type of patient — maybe they’ve just gone through menopause, or were doing egg freezing and they’ve suddenly gained a lot of weight and don’t feel like themselves,” says Dr. Messer. “Because there’s so much upside and so little downside when semaglutide is administered properly to appropriate patients, I have no moral qualms about prescribing it off-label.”

How Long Do Semaglutide Results Last?

With both drugs, however, there is a catch. Because these medications are not permanently changing your hormones, when you stop injecting them, your weight can creep back up, as “your threshold for feeling full returns to what it was before,” Dr. Tchang says. When treating chronic obesity, “we consider semaglutide a long-term medication similar to high blood pressure or cholesterol medications,” she adds. “If you're using diet/exercise/medication to get to a weight goal, you have to maintain those choices to stay there.”

But not everyone stays on Ozempic forever. Oftentimes, when treating non-obese patients — those who unexpectedly put on pounds due to stormy hormones or traumatic life events — Dr. Messer finds she can “bring them back to their baseline” with a short course of semaglutide, and then wean them off the drug and “leave them to their own devices.”

Likewise, many aesthetics patients use the drug for a limited stretch, according to the doctors we interviewed. And, for the record, not all recoup their losses: “I have many patients who’ve kept the weight off for months after discontinuation,” Dr. Gordon tells TZR.

Still, the potential for rebound weight gain has some doctors hesitant to offer the shot. Recently, when #Ozempic took over TikTok after allegedly downsizing certain celebs, board-certified Beverly Hills plastic surgeon Dr. Gary Motykie fielded a surge of inquiries from curious millennials. But with research showing that “the majority of weight tends to return when patients discontinue use [of semaglutide], I haven’t found it to be a good fit for my patients,” he says.

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Semaglutide’s Risks & Side Effects

Compared to weight-loss drugs of the past, like amphetamines and the now-banned fen-phen, which were addictive and caused scary complications, semaglutide is proving to be remarkably benign. The most common side effects are gastrointestinal troubles, like nausea, constipation, heartburn, belly pain, and diarrhea, which doctors are generally able to temper by starting patients on low doses and gradually building them up to a level that’s tolerable and effective. Some users also counter side effects with anti-nausea meds or fiber supplements.

Dr. Tchang points out that there’s a roughly 1% risk of gallbladder issues with semaglutide and less than a 1% risk of pancreatitis, so those with a history of pancreatitis or gallstone pancreatitis may not be candidates for the shot.

The drug also has a boxed warning about the possible risk of a specific type of thyroid tumor. While “this risk was observed only in rodent studies during drug development and has not been seen in humans, we always ask if the patient or any family member has had medullary thyroid cancer or Multiple Endocrine Neoplasia syndrome, which is associated with medullary thyroid cancer,” says Dr. Tchang. “These are absolute contraindications to the medication.”

While semaglutide has not been shown to be intoxicating or habit-forming, some wonder if the dramatic weight loss — and ensuing esteem boost — it begets could be hard to quit. “One can imagine a situation in which regular use of this medication, the accompanying slender body habitus that it confers, and the resulting rewards may lead to behaviors that are psychologically addictive,” says Dr. Evan Rieder, a board-certified dermatologist and psychiatrist in New York City. This is pure conjecture, however, since evidence of dependency doesn’t exist. On the contrary, Dr. Rieder notes, “there is a little bit of data showing that medications, like semaglutide, may actually help to prevent certain addictive behaviors in studies of rats.”

A greater worry voiced by physicians is that semaglutide is being doled out to thin patients who don’t need it, which depletes the supply for those who actually do. And, of course, how the rise of a drug like this will perpetuate damaging notions of diet culture and fatphobia. “There’s no doubt in my mind that it’s being abused out there,” says Dr. Frank. “My biggest concern is that doctors [who are not weight-loss experts] are recklessly prescribing it — and I can name 10 doctors in New York who are doing just that.”

How Does Semaglutide Factor Into Aesthetics?

Dr. Nazarian doesn’t prescribe the shot in practice, but a growing number of cosmetic doctors are starting to — not only for weight loss, but as a means of lowering patients’ BMIs to a range that clears them for surgery. Since most body contouring procedures alone are not weight-loss methods, but rather sculpting operations undertaken to tweak one’s proportions by tackling resistant bulges and lax tissues, plastic surgeons have long enlisted the support of nutritionists, trainers, and weight loss doctors to help improve patients’ prospects prior to having work done. Now, semaglutide is emerging as a valuable part of that pre-op equation — a novel way to make cosmetic procedures more attainable, and results, more dramatic and long-lasting.

After doing a deep-dive on semaglutide, Dr. Gordon began offering a compounded version of the medication to existing patients who are near their target weight, but still — despite clean eating and daily exercise — struggling to hit her BMI cut-off of 30. Though BMI is regarded as a controversial measure of body fat — obesity experts have deemed it a flawed and stigmatizing tool — when evaluating patients for elective surgery, “it can be medically unsafe to disregard BMI entirely, as patients with higher BMIs have a slightly increased risk of multiple complications, including wound-healing problems, infections, and thrombotic events or clots,” says Dr. Christian Subbio, a board-certified plastic surgeon in Philadelphia. Beyond safety concerns, excess fat — namely the visceral kind hugging our abdominal organs — can prevent plastic surgeons from delivering results worthy of the big bucks patients are plunking down.

Dr. Subbio doesn’t offer Ozempic (yet), but as a tummy tuck authority, he appreciates its appeal. “One of the most powerful moves in a tummy tuck is the muscle repair, where I take the [six-pack] muscles, which have become separated, and I stitch them back together,” he explains. He likens the process to tightening a corset, noting that when there’s significant visceral fat pushing out against the abdominal wall from the inside, it severely limits the cinching effect he can achieve. But if a patient “is able to lose five or 10 pounds, then I can tighten the corset maybe one more row of hooks over,” he says. In other words, the more fat one sheds prior to a tummy tuck, the more their surgeon can shrink the circumference of their abdomen. To this end, he says, “weight-loss medicine dovetails nicely with body contouring.”

Dr. David Shafer, a board-certified plastic surgeon in New York City, has been exploring this very synergy for years and even expanded his Fifth Avenue clinic to include a metabolic aesthetics center, staffed by specialists versed in weight management, hormone replacement, and peptide therapy. Dr. Shafer takes semaglutide himself and recommends it to overweight patients (who are otherwise healthy) as well as those who are generally fit but perhaps “need a little boost to lose the COVID 15.” The drug is always just one part of “a comprehensive and supervised treatment plan,” he insists.

With similar intentions, board-certified dermatologist Dr. Frank invited into his New York City practice an integrative medicine physician, Dr. Jake Deutsch, who prescribes semaglutide to patients trying to trim down. “It has really optimized the way I practice body sculpting,” says Dr. Frank, referring to the tumescent liposuction he frequently performs. “I do think these drugs are a part of that now.”

How Much Does Semaglutide Cost?

Unless you have diagnosed diabetes or obesity, your insurance won’t cover the drug — and it can be very expensive. Brand-name Wegovy reportedly costs $1,350 a month. Compounded generic forms are typically more affordable, but in Dr. Motykie’s experience, they can still run between $170 and $350 a week. Dr. Shafer shares a price range of $510 to $610 per month for what he calls their “comprehensive program.” “We are not an Ozempic mill,” he reiterates. “Our patients [on semaglutide] have to be part of our comprehensive approach to weight loss and metabolic management, under our medical supervision.”

To his point, all of the doctors we spoke to stressed that people should be carefully screened before taking semaglutide, and then routinely monitored to track their progress and side effects and to possibly adjust the dosing of weekly injections.

Our experts also hammered home the vital importance of eating well and working out when using Ozempic. “While semaglutide is felt to be this magic bullet — and it is very powerful and safe — it's just another tool that we have to help patients look and feel their best,” says Dr. Gordon. “It must be combined with healthy lifestyle choices with regards to food and exercise.” Ultimately, she adds, the people who are truly transformed by semaglutide are those “who really re-evaluate their relationship with food during this process.”

From there, there’s a special sort of ripple effect that doctors often see. Whether spurred by drugs, cardio, cosmetic surgery, or all of the above, weight loss — and its repercussions — can be a turning point for many. “My goal is to get patients looking great and wanting to protect their investment,” says Dr. Subbio. “So three months after surgery, when I tell them, ‘You look amazing, goddamn fantastic! Keep it up!’’ — that’s a feeling they want to hold onto.”