Medicalizing obesity is Big Pharma’s biggest and most disturbing heist of all time
Their plan is to inject people with hormones, starting as children, and charge them $1000 per month, forever, because... profit?
Over the past few decades, Big Pharma has developed a playbook for establishing new markets for its products: Take a complex condition with multi-factor causes and rebrand it as a chronic disease that afflicts individuals, then target it with a pharmaceutical intervention that can be heavily promoted and distributed via medical sales channels.
In tandem with lucrative payoffs to the right people — regulators, doctors, academics, politicians, the press — plus huge ad budgets to carpet-bomb public awareness, the playbook aims to bring about a new orthodoxy. Once the orthodoxy is established, the new and simple solutions to stubborn problems open up huge profits, hooking millions on medical subscriptions they can never give up.
You can see how this playbook was used with drugs for depression (Prozac and other SSRIs), acid reflux (Prilosec), cholesterol (statins), high blood pressure (ACE inhibitors), and, more recently, erectile dysfunction (Viagra). Now the Big Pharma vampire octopus (vampire squid was taken) is extending its tentacles to grab and consume its biggest target yet: obesity.
In late December, after just 18 days of consideration, on the basis of a single trial funded by the drugmaker itself, the FDA approved Novo Nordisk’s semaglutide as an injectable anti-obesity drug aimed at children aged 12 years or older. The company’s press release calls teenage obesity “a chronic disease … that can start in childhood or adolescence” and speculates that “90 percent of teenagers with obesity may continue to live with obesity into adulthood.”
This new class of obesity drugs are known as GLP-1 agonists, because they mimic the presence of a hormone in the body called GLP-1. Injecting this daily or weekly helps control blood sugar levels and slow stomach emptying, typically making people full more quickly, and for longer, so they consume less food in total. Because it works better than the old, useless advice of “just eat less and exercise more”, Big Pharma is pushing this as a “revolutionary” new system. A key point: it works only as long as patients continue to inject it. The weight tends to return afterwards. But staying on it forever is very pricey: costs range from around $900 to $1300 per month.
Multiply that number by the potential customer base — a total addressable market of almost 1 billion people — and you can see why the vampire octopus is so excited. Where Purdue Pharma’s blockbuster drug OxyContin sold around $35 billion over twenty-something years on the market, Morgan Stanley estimates that these GLP-1 meds will grow to sales of $50 billion per year. With so much money at stake — and so many lives potentially affected — we need to ask how the drugmakers are balancing their concerns for one against the other.
The first step is to rebrand a condition into a Disease™️
The signature move in Big Pharma’s playbook is to take complex conditions with roots that are biological, environmental, psychological, and social (“BEPS” for short), and rebrand them as simple, purely biological “diseases,” with a straightforward biological remedy. They tend to focus on mitigating the end result — the symptoms — of a condition, rather than understanding and tackling the root causes that brought about the symptoms. Because they sell drugs, and drugs cannot address the “EPS”, only the “B”, they write the EPS out of the story. If all you have to sell is a hammer, you tell people that everything is a nail.
In the case of obesity, rebranding it as a disease has three critical effects: First, it negates the agency of obese people and the control they have over choices they make. After all, they would not choose to have a disease; it is presented as misfortune or fate. Hence the second effect: Obesity is recast as an outside enemy, like a virus or an unlucky gene, that attacks a person out of the blue. That is, until the heroic pharma company scientists leap in to arm doctors with “medicine.” That is the third effect: Obesity is brought under the purview of MDs and their limited toolbox of treatments rather than nutritionists or trainers or educators or therapists, among others. And in today’s healthcare system, pressured for decades by Big Pharma to work as their sales arm, that toolbox is overwhelmingly full of pharmacological products, rather than lifestyle, educational or therapeutic interventions.
But obesity is clearly not a disease in the conventional sense, like a flu you might pick up haphazardly from a stranger’s sneeze. It’s the product of sociocultural conditions and the thousands of small choices we make in our daily lives, which so often compound over time into obesity. Obesity is also not, as Novo Nordisk would have us believe, “chronic.” It is not with you forever; it is connected to choices we make and fully reversible. While it’s not easy to lose weight unassisted, it is possible and millions have done it.
The new orthodoxy Big Pharma wants to install goes something like this: “patients” (people) have a “disease” (obesity); and diseases are not your fault — who would choose to get a disease, right?; so if you happen to be unlucky enough to have the disease of obesity, you should go see your doctor; your doctor will look up the “approved medical interventions” (products) rubber-stamped by regulators, and pull one from their toolbox. Hook, line and sinker.
Alongside this cynical and self-serving rebrand of obesity as a biological disease, Big Pharma is shifting the goalposts to present its hugely-expensive drugs as the “cure.” But GLP-1 meds are not that at all. They are a temporary intervention that mitigates the condition, but stops working once you stop ponying up the $1000 per month. Just like providing a crutch to help a person walk is not a real fix for a broken leg, and covering up an open wound with a bandage is not the same as healing it, these injectables only cover up the symptoms, temporarily. When you go off the meds, the weight comes back.
The sinister reality is that the medicalization playbook only co-opts the language of disease and treatment and “cures”. Those are simply a cover story, hiding the true goal and motivator: new and highly profitable revenue streams. People complain about how their Netflix and Hulu and HBO costs mount up. But if Big Pharma succeeds in rebrand, they’ll condemn a huge population to the mother of all subscriptions: a “life-as-a-service” monthly subscription fee that you can never give up.
The “open plot” to medicalize obesity
With the playbook developed, and the rebranding process mapped out at vampire octopus HQ, the coup is in motion. Scott Alexander notes how the pharma companies are now “openly plotting” their coup: Everywhere you look, you’ll find the tell-tale talking points of “obesity as a disease,” a message crafted by Novo Nordisk and Eli Lilly, then handed off to highly respected proxies along who get hefty consulting fees — not always disclosed — to launder the propaganda into the respectable public sphere.
For example, the New York Times profiles Dr. Fatima Cody Stanford, a Harvard professor and obesity expert, in a podcast teased with this line: “Why one doctor believes obesity should be treated like any disease — with medication.” Big Pharma-approved messaging relabels an obese person as “a person of size,” neatly drawing a line between access to GLP-1 meds and social justice, while downplaying the role of individual choices.
Dr. Stanford notes that “we haven’t recognized obesity for the disease that it is,” and instead suppose that “people that have obesity did this to themselves. And that is, indeed, a fallacy.” By positioning obese people as helpless victims in need of pharmaceutical rescue from an outside enemy, it tees up the idea that not giving these drug therapies is a form of cruelty and discrimination. In this piece, to the Times’ credit, it is at least disclosed that she “has received consulting fees from the companies who make these drugs“.
Also in the Times was this op-ed last year on people fighting with their insurers to get the costs of injectable weight loss drugs like Wegovy covered. It cleverly equates their struggle with other battles fought by patients to get their insurers (the greedy villains of the story) to pay for life-saving new therapies. But there’s a huge difference. Where breakthrough drugs for diseases like cancer may be the only hope to save a patient’s life, the weight-loss injectables are just one option among many, and a very expensive one. These relatable ordinary individuals effectively serve as soldiers in Big Pharma’s PR war to extract more money from the insurance industry, who then pass the costs on to us.
Even the Guardian, generally hostile to Big Pharma spin, seem to have been fallen for their PR tricks here. In a 2015 article headlined, “Obesity is an incurable disease. So why is the government intent on punishing sufferers?” George Monbiot lays out the case made in this article in The Lancet that argues that “the mere recommendation to avoid calorically dense foods might be no more effective for the typical patient seeking weight reduction than would be a recommendation to avoid sharp objects for someone bleeding profusely.” But… read down to The Lancet’s disclosures, and you’ll see that three of the four article authors are on the payroll of Novo Nordisk. This “Comment” article is in reality The Lancet’s equivalent of a puff piece — a delivery mechanism to sneak Big Pharma talking points into a usually skeptical mainstream publication.
Alongside the press push, the vampire octopus uses its tentacles to grab for the hearts and minds of “key stakeholders” through their wallets. Thus, we see the president of the Royal College of Physicians declaring that obesity “is not a lifestyle choice caused by individual greed, but a disease.” At academic and medical conferences where the top agenda item is “to recognize obesity as a serious disease,” four out of six panelists disclosed funding from Novo-Nordisk. In The Lancet (again), an academic — also a paid consultant for Novo Nordisk — calls for “access to timely, quality health care” (i.e. drugs) and places obesity alongside cancer. Another professor on the payroll writes an op-ed (“Why it’s difficult to control our expanding waistlines”).
Obesity UK bills itself as “the leading charity dedicated to supporting people living with obesity,” but seems more akin to a front group, producing marketing materials and lobbying NICE on Novo Nordisk’s behalf as they tried to push the NHS into paying for GLP-1 injectables. As of February 1, 2023, Obesity UK is 277 days late on filing their government-mandated charity report, but their 2020 filing notes income for the year of £8563, and their NICE submission acknowledges £6500 in 2021 funding from Novo Nordisk. (To save you the math, 6500 out of 8593 is about 75%.)
The charity is a reliable and enthusiastic cheerleader for Novo Nordisk, comparing their mission with the civil rights movement: “Just as we are born with the color of our eyes, we can be born with a tendency to put on weight. And just as we do not blame anyone for the color of their eyes, we shouldn’t blame people who are genetically predisposed to gain weight.” Again, obesity is presented as a biological reality that afflicts individuals seemingly at random, with no agency or participation on their part. “It’s just your biology.”
A drumbeat becomes a forced march
The playbook has succeeded many times before. It normalized the perception that conditions like cardiovascular disease and depression are more or less permanent and necessarily treated through neverending drug regimens, and is now on the path to victory in redefining obesity.
Seeing the tactics Big Pharma uses to forcibly establish a new orthodoxy reminds me of the way that consent is manufactured for wars, as satirized in Wag The Dog. With Iraq in 2003, for example, a big decision was made first — to go ahead with a “pre-emptive” invasion of a sovereign nation — and because that required an updated orthodoxy, it was after that decision that they marshaled massive resources across government, media, military, diplomatic and other fronts. The resulting “war drumbeat,” echoing in every sphere for months, eventually led to a majority public feeling that the war was inevitable and necessary, exactly as the “plotters” had decided.
As the new medicalized obesity drumbeat grows louder and more ubiquitous, Big Pharma knows that doctors will succumb to the pressure of the new orthodoxy, and from there it’s a forced march. Where they would once have recommended lifestyle change, they will likely gradually shift, “to gesturing at the lifestyle change before prescribing the medication, to mostly just prescribing the medication,” as Scott Alexander writes.
Since Prozac came onto the market a — a B solution to a BEPS problem — depression has gotten much worse, not better, increasing in incidence by 47% from 1990, just after Prozac launched, to 2017. But while medications didn’t solve the problem, they have made boatloads of money for Big Pharma. Medicalizing obesity is the next big “B not BEPS” issue, where we’re offered a stopgap “solution” that does nothing to address the complex roots of the issue, but generates huge sales.
To be clear: GLP-1 meds like semaglutide do have some near-term efficacy against obesity, for as long as you keep paying. But they do nothing to address the root issues — dietary patterns and choices and the social conditions that structure those choices. It’s patching a wall when the foundation is rotting. When the injections stop, the obesity returns, sometimes worse than before. This is not surprising given that the injections cover up and therefore alibi behaviors that drive obesity, creating a false sense of security and making the rebound even worse, when the artificial crutch is taken away, and the true impact of your choices is felt.
The real solution here is two-fold: arm people with a much better understanding of their bodies on a personal level, through technology and education, and; on a broader level – government, health industry, regulators — to must push back much more vigorously against the root cause of obesity and the people who lobby for today’s abysmal status quo. The biggest single root cause here is the constant availability and unfettered marketing of ultra-processed, energy-dense foods that dysregulate our body, putting many people into near-constant hyperglycemia, and short-circuiting our satiety systems. This is what drives incremental over-eating each day, and obesity in the longer term. (Incidentally, the UK government’s campaign against salt, fat, and sugar is a colossally terrible blunder, missing the actual primary driver of obesity, carbohydrates. I’ll write more on that separately.)
Only by addressing these two areas can we actually tackle the problem in a sustainable, effective, long-term way. What won’t work is allowing Big Pharma to succeed in their plot to medicalize obesity, then hand them hundreds of billions of dollars to inject kids with hormones from age 12 onwards, while ignoring all the root causes and providing the kids with zero understanding of how their choices impact their bodies. That would not be a solution, but the biggest and most disturbing Big Pharma heist of all time.
PS: I had to look at these nightmare-fuel DALL-E images, so now you have to as well:
Fascinating post! Looking forward to reading more Rurik.