Background

Type II Diabetes Rates and Impacts

As of 2021, 38.4 million people within the United States (11.6% of the population) are affected by diabetes mellitus (1) This is an increase of 2.16% or 7.15 million people from 2016 (2). Type II diabetes conservatively represents 90% of all diabetes cases, amplifying the need for treatments tailored specifically to people who have insulin resistance. Type II diabetes disproportionately affects marginalized groups. Impoverished communities suffer from type II diabetes at rates nearly 10 times that of their non-impoverished counterparts (20.4% and 2.2% respectively), and adult Black Americans are nearly twice as likely as adult White Americans to develop type II diabetes (5), (6).

The demand for type II diabetes medications in American markets has reflected the increase in prevalence. The prescription rates for Metformin, an oral medication that helps regulate blood glucose levels and the most used type II diabetes medication, have more than doubled from 40.89 million prescriptions in 2004 to 91.15 million in 2021 (7). In addition, new types of medications are being manufactured to meet the demand. The injection, Semaglutide, known by its brand name Ozempic, is leading the way as the most prescribed (65.4% of GLP-1 prescription by volume) of a new family of type II diabetes medication, known as GLP-1 medications (8). Below we describe Ozempic, its medical, pharmaceutical, and cultural impact within the United States, and how the misuse of Ozempic has led to an ethical issue of an unjust distribution of healthcare resources.

Ozempic

Ozempic prescriptions have risen exponentially from under a million prescriptions at its introduction in 2017, to almost 7 million prescriptions in 2022, with a 300% surge in under 3 years (2019-2022) (8). Ozempic prescriptions rates reflect both its effectiveness as a type II diabetes drug, and its side effect, weight loss. Ozempic has been shown to lead to an average of a 15-20% body weight reduction in obese patients (3). As stated by its parent pharmaceutical company Novo Nordisk, Ozempic is not a “weight loss drug”, but weight loss due to Ozempic is included in its “Power of 3 in the Ozempic® Tri-Zone” on the official “Why Ozempic?” tab of ozempic.com (4).

The high demand for Ozempic has led to a shortage of the medication since 2022 (9) Due to its popularity, and relative scarcity, the price of a 1-month supply of Ozempic injections in 2023 was $936 in the United States (10). The shortage and high cost have resulted in many people suffering from type II diabetes having to either go without their medications, or they may be taken advantage of by people selling “fake Ozempic” in both Europe and the United States (10). People who use Ozempic for weight loss are often wealthier (as insurance does not cover Ozempic when prescribed for weight loss), and due to the extraordinary means of their treatment, are less affected by the shortage of Ozempic (11). However, the people suffering from type II diabetes who desperately need Ozempic to control their condition have no place to turn during this shortage, creating an ethical issue around the just allocation of this medical resource. 

Medical

Diabetes mellitus is a chronic metabolic condition related to derangements in insulin secretion leading to persistent hyperglycemia. Insulin is a hormone produced by the beta cells of the pancreas that helps transport glucose from the bloodstream into the cells for metabolic use. Type I diabetes mellitus (T1DM) accounts for about 10% of total cases of diabetes while Type II diabetes mellitus (T2DM) accounts for roughly 90% of total cases (12). The two conditions differ in their pathophysiology, clinical presentation, and treatment.

Type I Diabetes Mellitus

Type I diabetes mellitus is characterized by the inability or reduced ability to produce insulin due to the autoimmune destruction of pancreatic beta cells. T1DM presents with low serum insulin levels alongside the presence of autoantibodies against some or all of the following: islet cells (ICA), insulin (IAA), glutamic acid decarboxylase (GAD) and protein tyrosine phosphatase (ICA2)(13). These lab markers can vary widely just as the clinical presentation varies. Often, T1DM presents during childhood with symptoms including polyuria, polydipsia, weight loss and hyperglycemia. However, it can also present in adulthood depending upon the level of beta cell involvement. The hallmark of treatment of T1DM is lifelong insulin replacement which involves much patient education. Patients with T1DM may also benefit from nutritional counseling in conjunction with learning the proper dosing and timing of insulin injections. Automated insulin delivery devices are also available to patients who require insulin replacement therapy.

Type II Diabetes Mellitus

While T1DM is an autoimmune condition, type II diabetes mellitus is a chronic condition related to metabolic derangements of serum glucose due to increasing insulin resistance (12). Normally, the body is able to make and secrete insulin in response to blood glucose levels. As resistance to insulin increases, the body loses its ability to adapt to higher levels of glucose, creating a cycle in which cells are starved for glucose, yet the body thinks that more insulin is needed. This perpetuates the cycle further, ultimately leading to destruction of the beta cells in the pancreas, impaired insulin secretion and hyperglycemia. Risk factors for developing insulin resistance include excess body fat, increased age, decreased physical activity and presence of comorbid medical conditions of which the most common are metabolic syndrome, heart disease, hypertension, and hyperlipidemia (14). The crux of diabetes management is glycemic control which is accomplished with dietary and lifestyle modifications in conjunction with a variety of pharmacological interventions (1). The goal of these treatments is to correct the metabolic imbalance that is causing beta cell impairment and destruction; thus, restoring the body’s natural response to insulin.

GLP-1 Receptor Agonists

One pharmacological intervention that has gained traction in the past several years for T2DM is the GLP-1 receptor agonist. GLP-1 is an incretin hormone that is secreted by enteroendocrine cells in the gastrointestinal tract in response to the presence of glucose (12). Receptors for GLP-1 can also be found in the stomach, pancreas, heart, and central nervous system. When GLP-1 binds to its receptors on the pancreatic beta cells, it stimulates the secretion of insulin to help lower postprandial plasma glucose concentrations (15). It also decreases glucagon secretion by inhibiting the pancreatic alpha cells thus preventing glycogenolysis and gluconeogenesis in the liver. Furthermore, the widespread nature of these receptors leads to slowed gastric emptying and increased early satiety which can aid in decreasing the total number of calories assumed. In this manner, GLP-1 agonists have had the added benefit of decreasing body weight in addition to its main effect of regulating glucose tolerance in patients with diabetes mellitus (12), (16).

In 2017, the FDA approved the use of a semaglutide (brand name: Ozempic), a GLP-1 analog, as an adjunctive treatment for adults with type II diabetes mellitus. Semaglutide is a molecule that shares 94% sequence homology to human GLP-1 which has been manufactured to be bound to albumin, a serum protein, in order to extend its half-life effectively allowing the medication to be taken once weekly (14). It is administered as a subcutaneous injection and dosing starts at 0.25 mg once weekly, to be increased up to 1 mg once weekly as tolerated (17). The goal of this medication is to normalize the glucose tolerance in patients with T2DM to be used in conjunction with dietary and exercise modifications in treating diabetes mellitus. Ozempic has been shown to be effective in lowering HbA1c in patients with T2DM when used as a monotherapy or in combination with more traditional diabetes medications such as metformin, dipeptidyl peptidase-4 (DPP-4) inhibitors, and/or sulfonylureas (15). Yet, it does carry several notable risks and side effects. Generally, the less serious side effects include nausea, vomiting, diarrhea, abdominal pain and hypoglycemia. More seriously, Ozempic can cause pancreatitis, complications of diabetic retinopathy and acute kidney injury. In addition, this medication is absolutely contraindicated in anyone with a personal or family history of medullary thyroid cancer or multiple endocrine neoplasia syndrome type II (MEN2) (15).

Clinical Trials

The safety and efficacy of this medication was evaluated in the SUSTAIN clinical trial program which were randomized, parallel-group, multicenter, controlled trials that followed over 8000 patients with type II diabetes (18). Seven trial groups were formed and were followed for either 30 weeks, 40 weeks, 56 weeks or 104 weeks. Across all 7 trial groups, participants who were on either 0.5mg or 1mg of semaglutide had a drop in HbA1c between -1.1 to -1.8% with 57%-78% of participants reaching the target HbA1c of <7% (5). Another parameter studied was weight loss. Weight loss greater than 5% of body weight is the widely accepted threshold for clinically significant loss (19). Among those taking 0.5mg, 37-46% of participants lost ≳5% of their body weight. Among those taking 1mg, 45-66% of participants lost ≳5% of their body weight (15). The study was not able to follow whether this weight loss was maintained after the end of the trial time.

As shown in the SUSTAIN clinical trials, Ozempic does lead to weight loss. However, it is important to note that the formulation of semaglutide that is approved to treat obesity is Wegovy (20). In the STEP 5 clinical trials, over 50% of patients experienced nausea in the semaglutide group, which was 30% more than the placebo group. Similarly, more than 30% of patients in the semaglutide group experienced vomiting (>25% compared to placebo) and constipation (~20% more than placebo)(21).

Pharmacy

Pharmacy: Impact and Overprescription

Since Ozempic (semaglutide) is FDA-approved for type 2 diabetes but widely used off-label for weight loss, pharmacies face unique challenges in dispensing it profitably. The demand for Ozempic and Wegovy (marketed for weight management) has surged, driven by pharmaceutical marketing and increased public interest. However, many pharmacies struggle to remain financially stable due to the high cost of stocking these medications, which often outweighs reimbursement rates, leaving pharmacies with thin margins. Additionally, the hype surrounding these drugs has spurred demand from patients who pressure their doctors to prescribe them for weight loss, even if it’s outside the primary indication (22),(23).

While prescribing Ozempic for weight loss may be seen by some physicians as a preventative approach for obesity-related health risks, it’s essential that alternative weight management strategies—like lifestyle changes, diet, and exercise—are discussed before initiating medication. However, due to high patient demand and the potential to lose patients to other providers, some doctors may feel pressured to prescribe Ozempic over other methods to retain their patients. This can lead to an over-reliance on medication rather than comprehensive, sustainable weight management approaches that address the root causes of weight gain.

Ozempic is a weekly injected medication that has been approved by the FDA for use in adults with type II diabetes and is not recognized as being used for weight loss (24). Although some physicians prescribe it off-label for weight loss, the FDA still has not approved Ozempic for this use. The FDA has warned consumers against buying off-brand versions of Ozempic and Wegovy for weight loss, drawing attention to the fact that these off-versions may not contain the same ingredients as the original Ozempic and may be unsafe or ineffective. In most scenarios, these “off-versions” that are being referred to are known as compounded semaglutide, which is the same active ingredient in Ozempic and Wegovy. The FDA has recommended that these Semaglutide-containing drugs should be with a prescription from a licensed healthcare provider and be distributed from state-licensed pharmacies or other FDA-registered facilities(25). The FDA expresses concern not with licensed compounding pharmacies but those illegally selling semaglutide products online(26).

Pharmacy Alternatives

In July 2023, researchers conducted structured searches on Google and Bing to identify websites selling semaglutide without a prescription, selecting those meeting specific criteria for test purchases. Six online vendors flagged as "rogue" by regulatory bodies were included, offering either 0.25 mg prefilled pens or lyophilized vials for reconstitution. Out of six products purchased, only three were delivered; the rest involved non-delivery scams demanding additional fees. Quality testing on the received products showed potential contamination and low semaglutide purity levels (7-14%), with dosages exceeding the labeled amount by up to 39%, suggesting falsification. The study highlights significant public health risks, as unregistered and potentially harmful products are accessible online without prescriptions (26).

With the demand for Ozempic and supply chain continuing to take a toll, healthcare providers should emphasize alternative interventions. Other weight management drugs besides Ozempic include drugs such as Orlistat (Xenical; Alli), which is a lipase inhibitor that acts by reducing the absorption of fat in the guts, thus making it ideal for people who consume fat-rich foods (27).  Phentermine-topiramate is a medication prescribed to adults and children aged 12 years and over to help them lose weight. Another combination treatment for weight management in adults is naltrexone-bupropion (Contrave)(28).

Alternatively, other GLP-1 agonists such as Saxenda (Liraglutide) and Wegovy (Semaglutide) belong to a class of drugs known as GLP-1 receptor agonists and are given to patients through injections. Wegovy has been approved specifically for weight loss in adults and children aged 12 years and older who have obesity and certain related medical conditions (29). Setmelanotide (IMCIVREE) is one of the few non-approved drugs in this category that is only given by injections to patients 6 years and older for genetic obesity disease. These FDA-regulated drugs are essential in dealing with weight loss when combined with dietary and lifestyle modification.

Pharmacy: Additional Pharmacology to Consider

Semaglutide treatment improves blood glucose control and reduces body weight over 12 weeks at steady-state dosing. It significantly lowers fasting and postprandial glucose, enhances insulin secretion, and reduces glucagon secretion in a glucose-dependent manner. During hypoglycemia, semaglutide does not interfere with counter-regulatory responses. It also slows gastric emptying, which affects glucose uptake but does not impact cardiac repolarization (no observable impact on QTc (30).

Pharmacokinetically, semaglutide is well absorbed, reaching peak concentration within days and achieving steady-state in 4–5 weeks. It has a half-life of about a week, is primarily metabolized and cleared via urine and feces, and is highly protein-bound. Body weight affects its exposure, but factors like renal or hepatic function, age, and sex have no significant clinical impact. No clinically relevant drug interactions were observed, and dose adjustments are unnecessary when administered with most other medications(30). Overall, from a pharmacological view, Ozempic shows a relatively safe profile with common adverse effects of nausea, vomiting, constipation, and GI complications. The long-term safety data is still limited but should be considered before prescribing Ozempic.

Prescription of Ozempic

Ozempic is a prescription-only drug. Like other prescription drugs, Ozempic can only be prescribed by licensed practitioners such as doctors, nurse practitioners, and physician assistants. Upon receiving a prescription, the pharmacist reviews it to ensure that all information is correct and that there are no contraindications for the patient receiving Ozempic. If the doctor has not already done so, the pharmacist will run the prescription through the insurance. In the case of using Ozempic for weight loss, this can be an issue for insurance coverage even if a doctor writes a prescription for Ozempic. Ozempic was FDA-approved and indicated for the use and treatment of type II diabetes. Although Ozempic has great weight loss capabilities, the use of Ozempic for weight loss is considered to be off-label. Insurance companies are strict when it comes to approving coverage for medication, as many follow the protocol of medications being used in patients who have a medical need for them and as indicated. In some cases, healthcare providers can submit a prior authorization to the insurance companies, which is a letter that explains the patient-specific medical need of that prescribed medication. However, insurance companies may not accept the prior authorization, especially for patients who are seeking Ozempic for weight loss and are not overweight, defined as a BMI of ≥27, or obese, defined as BMI ≥30. Patients who fall in this category of non-coverage may pay for Ozempic out of pocket, which discount cards and other discount programs can help mitigate the cost.

Prescription of Other Semaglutide Products

Semaglutide, the active ingredient in Ozempic, is also used in other FDA-approved drugs such as Wegovy and Rybelsus. Wegovy is also an injectable form of semaglutide. The only difference from Ozempic is that Wegovy is a higher dose and is indicated for weight loss rather than type II diabetes. Rybelsus is the tablet form of semaglutide and is indicated for type II diabetes. Saxenda, which has the active ingredient liraglutide, is the only other current GLP-1 agonist indicated for weight loss. Zepbound, with the active ingredient tirzepatide, is a recently approved medication for weight loss consisting of both a GLP-1 agonist and a GIP agonist. Semaglutide drugs are preferred over liraglutide drugs because they have greater efficacy, as shown in clinical trials where patients in the semaglutide trial had nearly double the weight loss compared to liraglutide (31). Both the cost of Wegovy and Saxenda are comparable in terms of price, but Ozempic has a lower cost than both (32).

Cultural

Society's preoccupation with idealizing a skinny body type as the epitome of beauty and desirability is a pervasive cultural phenomenon influenced by media representations, celebrity endorsements, and evolving trends in medication use for weight management (33). There is an intricate relationship between societal norms, media influences, and the rising occurrence of utilizing medications like Ozempic to attain the desired body image.

Body image encompasses perceptions of one’s personal self. The psychological ramifications of the societal pressures on body image (to be thin) are eating disorders and body dysmorphia (34). A person’s attitude and behavior around their body is developed as they become aware of appearances and look to gain acceptance from the society they live in (35). A negative body image means ones feels body dissatisfaction believing they are flawed in relation to their peers (35).  Social media has a significant impact on shaping unrealistic beauty standards through modified imagery, fostering comparison culture, and influencing disordered eating behaviors (35). As per sociocultural theories, media can exacerbate body dissatisfaction and ensue the internalization of unrealistic body types (35). Research has shown reducing the time spent on social media results in a positive effect on one's body image (36).

Heinberg et al. (2023) conducted a cross-cultural study assessing the internalization of thin-ideal standards among women in the U.S., Italy, England, and Australia, highlighting the heightened pressure for thinness in the American cultural landscape (37).  Media representations, especially on social media platforms, play a central role in perpetuating unrealistic body ideals. The use of digitally edited images portraying a narrow range of appearances has led to mass insecurities and dissatisfaction (33).

Social media acts as a catalyst for internalizing unattainable beauty standards, triggering appearance comparison (34). Objectification theory defines this circumstance as people are taught to view themselves through the eyes of others, leading to habitual body monitoring (38). This high amount of self-scrutiny results in increased feelings of anxiety and shame of a person's outward appearance, sometimes leading to decreased awareness of one's own internal body (38). Therefore, the theory suggests how repetitive exposure to objectifying content fuels self-objectification, contributing to increased body shame (39). Moreover, the use of gratification theory positions individuals as active consumers of social media, illustrating how differing motivations result in a personalized social media environment that either reinforces or mitigates appearance-related content consumption (39).

Additional studies address the alarming rise in disordered eating attitudes (33). This increase poses significant health risks, with alarming statistics revealing that 16% of individuals with disordered eating attitudes engage in overeating, 20% resort to purging through vomiting, and 61% practice food restraining (33). These patterns vary with age, with food restriction being more common among older women and purging through vomiting prevalent in adolescents, highlighting the evolving nature of disordered eating over the lifespan (33).

Not only are internalized beauty ideals propagated through media channels, but through celebrity culture as well. The phenomenon of celebrities endorsing weight loss drugs, despite potential risks associated with their usage, further perpetuates the urgency to attain extreme thinness in alignment with societal beauty standards (40). Public figures are flooding social media with numerous Ozempic before-and-after photos. Celebrities are advertising their use of Ozempic by mentioning the drug or openly discussing their journey on their social media platforms. Some celebrities, like Oprah Winfrey and Tracy Morgan, have shared positive experiences with using weight loss medications to manage their weight (41). In contrast, others, such as Claudia Oshry and Lauren Manzo, have expressed reservations about the potential abuse and misuse of these drugs (41).

Notably, Real Housewives of Salt Lake City star, Heather Gay, revealed that she has been taking Ozempic for a significant period and has observed noticeable weight loss, prompting reactions from others in her social circle (42). The star released a new docuseries IMPACT x Nightline: The Skinny Confessions: After Ozempic (February 29, 2024) to reveal more about her weight loss journey. She expressed disappointment with the criticism she is receiving about her use of Ozempic as a weight loss medication, conveying the role of societal pressure and calling the movement of body positivity a facade (42). Although several stars have stated they do not think the drug is sustainable for long-term use and have denounced its misuse, they are perpetuating the fact that Ozempic works for weight loss subsequently influencing their followers to look into the drug and later on use it (43)(41).

The increasing popularity of Ozempic as an off-label weight loss drug can be attributed to the profound impact of social influences on individuals’ healthcare decisions. Societal trends, cultural acceptance, and celebrity recommendations play pivotal roles in shaping the choice of medication, with Ozempic emerging as a favored option due to its endorsement.

Ethical Analysis

Society, in general, has always recognized that in our complex world there is the possibility that we may be faced with a situation that has two consequences--one good and the other evil. The time-honored ethical principle that has been applied to these situations is called the principle of double effect. As the name itself implies, the human action has two distinct effects. One effect is the intended good; the other is unintended evil. As an ethical principle, it was never intended to be an inflexible rule or a mathematical formula, but rather it is to be used as an efficient guide to prudent moral judgment in solving difficult moral dilemmas (44). The principle of double effect specifies four conditions which must be fulfilled for an action with both a good and an evil effect to be ethically justified:

1. The action, considered by itself and independently of its effects, must not be morally evil.
   The object of the action must be good or indifferent.
2. The evil effect must not be the means of producing the good effect.
3. The evil effect is sincerely not intended, but merely tolerated.
4. There must be a proportionate reason for performing the action, in spite of the evil consequences (45).

The principle of double effect is applicable to the issue of whether it is ethical for physicians to prescribe Ozempic to treat weight loss and obesity because it has two effects, one good and the other evil. The good effect is that Ozempic can treat weight loss for Americans who are overweight or obese and may be more effective than conventional therapies in helping patients overcome the devastating effects of obesity.

The evil effect is that Ozempic’s use for weight loss limits its accessibility and increases the price for diabetics that need this life-saving drug. To determine if it is ethical for physicians to prescribe Ozempic for patients to treat obesity as a medical therapy, this issue will be examined in light of the four conditions of the principle of double effect.

The first condition allows for the medical use of Ozempic to treat obesity because the object of the action, in and of itself, is good. The moral object is the precise good that is freely willed in this action. The moral good of this action is to help treat obesity in the United States that according to a recent study in Lancet found that nearly three-quarters of U.S. adults are overweight or obese. These conditions can raise the risk of diabetes, high blood pressure and heart disease, and shorten life expectancy(46)(47). Premoral evil refers to the lack of perfection in anything whatsoever. As pertaining to human actions, it is that aspect that we experience as regrettable, harmful, or detrimental to the full actualization of the well-being of persons and of their social relationships (48).

The immediate goal is not to limit the accessibility of Ozempic for diabetics or raise the price. Rather, the direct goal is to help obese patients overcome the burden of weight-related diseases.  It should be noted that some might argue that smoking marijuana by itself, independently of its effects, is morally evil.  This implies that certain actions in themselves are intrinsically evil and to do them is always morally wrong. However, when one enters the realm of a “moral” action, one is speaking of an action qualified by intention and circumstances. So unqualified actions can only be called “premoral actions.” (49). The second condition permits the medical use of Ozempic for obesity because the good effect of helping obese patients limit the risks of diabetes, high blood pressure, heart disease and shorten their life expectancy is not produced by means of the evil effect.  The two effects happen simultaneously and independently. Even though using Ozempic off-label to treat obesity may lessen accessibility of the drug for diabetics and could drive up the price, there are ways to increase production of Ozempic and new drugs are under clinical trials, which will increase accessibility (50).

In addition, recently the Biden Administration issued a policy directive that Medicare and Medicaid will cover obesity medications, which will extend access of Ozempic to millions of Americans who are not covered now (51). The third condition is met because the direct intention of prescribing Ozempic to obese patients, even though it is off-label, is to give patients suffering from the devastating effects of obesity a viable option along with diet, exercise and life-style changes to prevent additional diseases. To deny a physician the right to discuss, recommend, and prescribe Ozempic to obese patients is a direct violation of the physician-patient relationship. To make an informed decision about their treatment, patients have the right to expect full disclosure and discussion of all available treatment options from their physicians. Failure to do this violates the patient’s right of informed consent. The direct intention of prescribing Ozempic for obesity is not to limit its access to diabetics or raise the price.

The direct intention is to provide obese patients with all the viable options needed to help them lose weight and avoid other medical risks like diabetes and heart disease. Finally, the argument for the ethical justification of Ozempic for obesity by the principle of double effect focuses on whether there is a proportionately grave reason for allowing the foreseen but unintended possible consequences. Proportionate reason is the linchpin that holds this complex moral principle together.

Proportionate reason refers to a specific value and its relation to all elements (including premoral evils) in the action(52). The specific value in physicians prescribing Ozempic for obese patients is to help them lose weight and avoid other serious medical conditions. The premoral evil, which can come about by trying to achieve this value, is the foreseen but unintended possibility of the potential harmful effects of lack of accessibility of Ozempic for diabetics, which is approved by the FDA and the possible increase in cost of the drug. The ethical question is: does the value of decreasing obesity and decreasing the growing burden of weight-related diseases outweigh the premoral evil of the potential harmful effects to diabetics? To determine if a proper relationship exists between the specific value and the other elements of the act, ethicist Richard McCormick proposes three criteria for the establishment of proportionate reason:

1. The means used will not cause more harm than necessary to achieve the value.
2. No less harmful way exists to protect the value.
3. The means used to achieve the value will not undermine it(53).

The application of McCormick’s criteria to the off-labeling prescribing of Ozempic to obese patients supports the argument that there is a proportionate reason for allowing physicians to prescribe Ozempic to obese and overweight patients. First, while there are adverse side-effects associated with Ozempic use as discussed earlier in this paper and the FDA has not approved Ozempic for obesity, that does not mean that it could not be given on a short-term basis under close supervision to patients. Obesity is a complex issue. In the past many believed obesity was merely an issue of calories in and calories out and that people simply needed to eat less and exercise more to lose weight. We now know that “obesity comes from genetic, physiological and environmental factors”(54) The point would be that the benefit of the treatments outweighs the burdens, as is the case with any mediation that has potential side effects. In addition, the FDA could include Ozempic as a treatment for obesity. Second, at present, there does not seem to be an alternative medication that is as effective as Ozempic for patients who are overweight and obese. Studies have shown that newer GLP-1 drugs, like Wegovy and Zepbound, are promising but we need larger clinical studies to show their long-term effects. Unless we address the problem of obesity now, the long-term clinical and financial aspects will be devastating.

A Joint Economic Committee Republicans report released this year predicted that obesity will cost up to $9.1 trillion in excess medical expenditures over the next ten years. Obesity increases the likelihood of numerous metabolic conditions and their associated complications, including high blood pressure, Type 2 diabetes, liver disease, kidney disease, heart attack and stroke. 10 Studies are showing that to decrease obesity in the world will take a combination of lifestyle modifications, medication and surgery. Examining clinical studies, it appears that Ozempic is an effective way to assist patients struggling with obesity. Third, using Ozempic or the newer GLP- 1 drugs for medical reasons does not undermine the value, which is decreasing obesity and its medical consequences. Many of the patients who would use Ozempic off-label are struggling with obesity and its corresponding medical consequences. Since this seems to be the only medication to date for many patients that effectively decreases obesity, one can argue convincingly that it is a medical necessity. Therefore, it is ethically justified under the principle of double effect for the FDA to approve Ozempic and the GLP-1 drugs to treat obesity. The caveat would be that safeguards are put in place to address the side-effects of Ozempic and larger clinical trials are funded to address the long-term effects of these drugs. Seriously ill patients have the right to effective therapies. To deny them access to such therapies is to deny them the dignity and respect all persons deserve. The greater good is promoted in spite of the potential evil consequences.

Conclusion

Study limitations

The following limitations were encountered when completing the literature review of Ozempic: as the literature review deals with the intent of the patients when purchasing Ozempic, concrete data is limited and inferences must be made on general trends. Some polls have attempted to gain estimates on the reasons behind the usage of Ozempic an other injectable medications that could be used for weight loss and they found that 50% of US adult patients using semaglutide or semaglutide alternatives were using them specifically for weight loss purposes(3% of 6% total usage)(55). This was an online survey of 5,577 US adults and could be faulty due to the common errors found in online surveys such as non-response error, sample coverage error, or response bias. General trends and surveys support the increased misuse of Ozempic specifically for weight loss purposes, but these may not be representative of the intentions of the entire population of patients who use Ozempic.

Recommendations

There is strong evidence to support that the increased use of Ozempic had coincided with the misuse of Ozempic, as patients without type-II diabetes use the medication for its weight loss side effect. This misuse has made it challenging for the type-II diabetes patients who need the life saving medication obtain the drug due to limited access or price. This is a violation of the ethical principle of justice and its sub-principle distributive justice.

For Pharmaceutical companies

Novo Nordisk should remove weight loss from its “Power of 3 in the Ozempic® Tri-Zone” on its official website, and instead refer to its medication Wegovy when website goers look up questions about weight loss.

For Providers

Doctors are the primary contact in which a patient is able to gain access to Ozempic. Before prescribing Ozempic, especially in cases where the primary use of the drug would be to lose weight, extra educational steps should occur. Doctors should be proactive in addressing the patients weight concerns. Talking with patients about specific dietary changes and providing guidance on exercise planning instead of blanket statements such as “exercise” or “eat healthier”. Doctors should make more of an effort to understand their patient’s motivation for losing weight, and to then tailor their advice to match. When patients are insistent on using Ozempic for weight loss purposes, doctors should make sure that the patient is fully informed of the risks and unknowns that come with Ozempic as seen in the clinical trials. 

Educational

The use of Ozempic for weight loss must be addressed as a community as well as in the healthcare industry. Addressing weight issues might be difficult for some doctors, so education around addressing weight issues should become a focus of training in patient relations. Outside of the medical community, a focus on exercise and dieting is imperative in order to reduce the demand for pharmaceutical weight loss options. Finally, the use of community education around importance of using Ozempic for specifically for diabetics is imperative in order to solve this issue of distributive justice.