Ozempic: A Plastic Surgeon’s Perspective

We are all just a tap away from a never-ending social media parade of aspirational bodies, and as it turns out, just a quick few injections away from readily losing 15-20 lbs. This isn't the American Dream, it’s the new American reality.

A cultural fear of fat has been with us a long time, and remains the fuel that drives the “get skinny at any cost” movement. The full figure and voluptuous body trend championed by none other than Kim Kardashian has come to a screeching halt. 2-3 years ago, body positivity was trending. Body shaming was almost a thing of the past. That is, until celebrities and influencers got a hold of Ozempic, and big pharma realized they had the next big thing. Skinny is back!

What is Ozempic? 

Ozempic is based on a naturally occurring human hormone called glucagon-like peptide 1(GLP-1), which plays an important role in regulating appetite and blood sugar levels. Its active ingredient is a molecule called semaglutide, which mimics the structure of GLP-1 hormone and activates GLP-1 receptors. Ozempic is typically injected every 7-10 days, and it “tricks” the body into feeling full, even after consuming a small amount of food. It actually slows the passage of food through the digestive system. In doing so, Ozempic (or any semaglutide) makes one less hungry and therefore less likely to overeat. 

Ozempic and other GLP-1 agonists differ in a keyway from the natural molecule they’re meant to mimic: They last a lot longer! Natural GLP-1 released in our gastrointestinal tract has a half-life of just minutes in the bloodstream, whereas semaglutide (and tirzepatide, another new medication) have half-lives measured in days.

Ozempic is approved by the Food and Drug Administration ONLY for the treatment of Type 2 diabetes—a condition that accounts for ninety per cent of all diabetes cases—and has been available since 2017. Novo Nordisk, the Danish company that supplies the US with most of its insulin, developed Ozempic to control blood sugar levels in Type 2 diabetics. What happened next? Well, one side effect of treating diabetes with Ozempic is weight loss. And Ozempic has now become shorthand for the entire category of injectable weight-loss medications (Wegovy, Mounjaro, and 10 -12 others).

Obesity: A significant problem 

Roughly 40 percent of American adults and 20 percent of U.S. children are obese (BMI over 30) according to the CDC (Center for Disease Control and Prevention) and the WHO (World Health Organization). Also estimates show that there are more than 1 billion obese people globally. Furthermore, 38 million Americans have diabetes. The obesity epidemic has taken a horrible toll on the United States, and not just our citizens health. It costs the country about $200 billion a year through health-related problems such as diabetes and heart disease. 

Both obesity and diabetes involve metabolic dysfunction: Type 2 diabetes is characterized by resistance to insulin, a trait that tends to develop as a person gains fat. Insulin resistance leads to elevated blood sugar levels, which increases ones’s risk of stroke, heart disease, nerve damage, and more. Obesity is correlated with, among other things, higher rates of cancer, sleep apnea, and liver disease.

Remember the Treat and Reduce Obesity Act? I didn’t either. It has been introduced in congressional sessions annually since 2012, and if passed would require Medicare (and most likely commercial insurers) to cover, among other treatments, chronic weight management drugs. Anticipating the passage of this bill within the next few years has led the pharmaceutical industry to shift into overdrive to try and capture the billions of dollars at stake. Seeds have been planted; they just need the correct conditions to germinate.

A critical point came amid the COVID-19 pandemic, which underscored obesity as a medical risk. The CDC estimated that obese people were three times as likely to be hospitalized for COVID as others. This heightened the importance and interest in how society (cultural and medical society) deals with obesity. Obesity has been seen as a personal lifestyle choice, a self-inflicted result of bad habits. Our mindset was about to be challenged. To Novo Nordisc, this was a call to action. The pandemic began just two years after the FDA approved Ozempic for Type 2 diabetes, and Wegovy was approved for obesity at the height of the Covid crisis. (Wegovy has the same active ingredient as Ozempic but comes with a higher maximum dose). Now Novo Nordisc could justify bringing Wegovy to market by considering obesity a chronic, life-threatening disease NOT a self-inflicted, stigma-inducing result of unhealthy habits. Obesity became a treatable disease. That in itself was a game changer!

Ozempic and Wegovy are groundbreaking drugs. There was good reason for the hype around these medications. Studies show that Wegovy results in patients losing up to 15% of their body weight, a level researchers long considered humanly impossible. Ozempic and Wegovy help produce greater weight loss and more effectively decrease blood sugar levels than any previous treatments and, unlike many other medications for such conditions, they actually reduce cardiovascular risk factors! 

What happened next?

For people living with diabetes and obesity, Ozempic and Wegovy were set up to be manna from heaven. However, this alone wasn’t enough to set off the wildfire that soon followed. What happened is a tale of innovative science meeting a cultural craving mixed with changing attitudes and the power of social media. That’s right, an unexpected side effect helped fuel a cultural shift, a monumental movement and potentially profound advancements in medical care and behavioral sciences. 

Celebrities and Social Media: Adding fuel to the fire

Comedienne Chelsea Handler recently joined Alex Cooper on her podcast: Call Her Daddy. She opened up about being prescribed Ozempic, unknowingly. “So, my anti-aging doctor just hands it out to anybody," Handler revealed. “I didn't even know I was on it.” Her physician told her: “If you ever want to drop five pounds this is good.” This may not be ground zero or the flash point, but it gives us insight into how the sparks of the Ozempic wildfire may have been fanned. A new Hollywood drug is born, and a cultural trend begins.

So, Ozempic, which seems to have entered my professional orbit roughly 2 years ago, had actually been around for 8 years! People who knew about it knew about it and started using it as early as 2017. It’s quite ironic that Chelsea Handler’s physician didn’t reveal that he had given her Ozempic or what it actually did. 

They say celebrities are impatient beings, they don't like to wait for anything — whether it’s a private car or the champagne that takes a few extra minutes to arrive, or even worse, the diet that takes forever to help them achieve their desired weight. Now they had a new weapon in their quest for “fitness”. Ozempic was the best-kept secret for a little while. If you were fortunate enough to get it, you were in the know.

Scarcity definitely fueled the buzz around Ozempic and Wegovy.

And at $1,000 - 1,300 for a month’s supply, so did the out-of-pocket price tag. Shortages of Wegovy soon followed, leading doctors to prescribe Ozempic as an off-label alternative for weight loss. This off-label use triggered a shortage of Ozempic among Type 2 diabetics, who wanted the drug for its true FDA-approved purpose — lowering blood glucose levels.

Suddenly influencers who had been promoting body positivity messaging were sharing their newly trimmed and thinner bodies. Elon Musk, Whoopi Goldberg, Sharon Osborne, Amy Schumer, and Oprah Winfrey are just some of the familiar names who have spoken about their experiences with taking Ozempic. More than a third of people taking Ozempic type drugs for weight loss have stated an influencer, celebrity, or a personal recommendation is why they got started. Ozempic quickly gained popularity and went viral due to one sought-after side effect: weight loss! Let’s get cut! Let’s get “pharma-cut”! 

In October of 2022, the Wall Street Journal reported that “Everyone is taking it” (Ozempic). One of my patients, who shall not be named, told me she actually stopped taking Ozempic in December of 2022! She had signed up via a Facebook post starting in March of that year and was immediately encouraged by the weight she quickly shed. However, she did share with me that the behavioral portion of the program is what helped her go on to drop over 70 pounds and keep it off. She’s now ready to undergo a mommy makeover — tummy tuck and breast augmentation. So as an aside, it looks as if Ozempic will not decrease the number of people requesting plastic surgery, it may very well increase it.

“Everyone is suddenly showing up 25 pounds lighter,” said Andy Cohen, the TV producer and creator of the Real Housewives franchise. At the Academy Awards ceremony in March of 2024, host Jimmy Kimmel gazed out at the audience of actors and movie people and aroused plenty of laughter when he said: “Everybody looks so great. When I look around the room, I can’t help but wonder: Is Ozempic right for me?” 

Ozempic has since been promoted on countless social media posts (some by plastic surgeons), television commercials, billboards and even Costco. The endorsements by celebrities and influencers are overwhelming with #ozempic reaching over 1.4 billion views on TikTok. A day doesn’t go by without my news feed putting out 2-3 new stories/articles about Ozempic. It’s as if Ozempic has been branded like Kleenex, Qtips or Polo shirts, a product with a label for an entire class of medications. These days it’s hard to not go out and not meet someone who’s taking these drugs. 

If I look past this as a celebrity-weight-loss headline story and try to see this for what it really might be, it’s revolutionary. As Chelsea Handler predicted: “In the future it might be like taking vitamins. Everyone’s going to be on it.” Losing 15% of your body weight over 3-4 months is remarkable. For the average 170 pound individual, that’s over 25 pounds! Walmart has just claimed that shoppers who use Ozempic and Wegovy are buying less food.

Downside? Is there one?

Well, what’s the down side? While the vast majority of people —almost 85% — have a positive experience, what about the 15% or so that don’t respond to Ozempic or have unwanted side effects?

Gastrointestinal complaints are the most common side effects — vomiting, nausea, gas, abdominal pain, burping, constipation — but half of patients don’t experience them at all. However, studies have demonstrated that nearly 17 percent of patients discontinued the medication because of side effects. Other possible side effects are loss of lean muscle mass; pancreatitis; rapid heart beat (tachycardia); hypoglycemia (too low blood sugar); dizziness; blurred vision; gallstones; diabetic retinopathy; and fatigue. There are several reports of psychiatric side effects, depression, low mood, and suicidal thoughts. In general these reports are very rare. The FDA recently stated that their ‘preliminary evaluation has not found evidence that use of these medicines causes suicidal thoughts or actions.

And what about loose skin? Weight loss of 15 -40 pounds potentially leads to lots of loose skin! “Ozempic face” is a thing: a hollowed appearance; more wrinkles and accelerated aging. I’ve got plenty of answers for loose skin.

To many people the most disturbing unwanted side effect is regaining the weight. A 2022 study funded by Novo Nordisk found that patients regained two-thirds of their lost weight a year after they stopped taking semaglutide medications. There are more studies coming and such data is required to fully understand the effects of these drugs. These drugs are not a silver bullet, but the risk-benefit ratio looks very positive. A lifetime on Ozempic seems far less dangerous than a lifetime of obesity. 

Ozempic and Wegovy were never intended for use as ongoing weight-loss aids. So how long do patients stay on them? How do they tamper off? Can they stop all together? What are the long term effects of prolonged use? Reports have detailed patients spreading out their weekly injections to 2-3 weeks apart or going off Ozempic for 2-3 months before restarting it. Weight management is the ultimate goal. Strategies for the long-term use need to be crafted and will be developed based on the monitored experiences of thousands and thousands of patients. 

Other Developments

Interestingly, doctors and patients have reported that Ozempic and Wegovy can decrease a range of dopamine-seeking behaviors, including smoking and online shopping. There are many GLP-1 receptors in the brain, and this GLP-1 system is largely separate from whatever is going on in the gut, and most likely responsible for the effects that extend beyond food. Anecdotally, people on these medications have reported to spontaneously quit drinking, smoking, shopping, and other addictive and compulsive behaviors. I have personally witnessed patients drastically reduce their alcohol consumption or quit drinking altogether months after stopping Ozempic. These weight-loss drugs may ultimately be drugs for the brain.

This fire is sure to keep burning.

This class of drugs — GLP-1 receptor agonists — is rapidly expanding. We’re currently only witnessing the beginning. There has and will continue to be a proliferation of GLP-1s. Mounjaro and Zepbound are newer versions made by Eli Lilly (American pharmaceutical company). An oral form of semaglutide is soon to be out that works about as well as Ozempic or Wegovy, so does another pill containing a drug called orforflipron. Other reports hint that shots containing tirzepatide or survodutide or retatrutide may produce even better results than semaglutide, and with significantly less side effects. There are many more in development as big pharma is trying to capture the ever expanding billion dollar diet industry, not to mention the potential profits to be gained from tackling addiction. There is so much more to come.

So the next rabbit hole is upon me: Should plastic surgeons be involved with prescribing or providing people with Ozempic or Ozempic like medications?

My answer is no, simply no. I don’t think plastic surgeons should be the ones selling or prescribing it. That should be left to an expert; an internist, family practitioner or an endocrinologist. Because at the end of the day people need baseline lab tests, monitoring and follow up. Weight management can be a deep dive with nutritional, lifestyle and behavioral aspects playing significant roles. Many techniques and medications exist, and for most people Ozempic may not be the best long term solution. Consider the message we are sending to children and teens, who are already very body-conscious. I can imagine both sides of that coin. Thousands of overweight and obese children benefiting from Ozempic-like medications, and plenty of normal weight children begging their parents for Ozempic to gain followers, influencer contracts or make weight for their next wrestling match.

Final Thoughts 

Right now, a lot of what GLP-1’s do is magic, and researchers are still trying to figure out how the magic happens. No one diet works for everyone, no one Ozempic medication works for everyone … more news is coming, and people need information, data, guidance and expertise.

In the realm of plastic surgery, the journey to achieving one's desired aesthetic goals is often multifaceted. While surgical and non-surgical interventions play a vital role, addressing underlying health concerns such as obesity and diabetes is equally important. Ozempic and other semaglutides represent powerful tools in this regard, offering significant benefits in weight management and overall health improvement. As a plastic surgeon, I am committed to providing comprehensive care to my patients, which includes referring them to clinics that offer these transformative medications. By embracing a collaborative approach to patient care, we can enhance outcomes and empower individuals to live healthier, more fulfilling lives.