Oh, oh, oh, Ozempic! The catchy jingle from Novo Nordisk’s 2018 TV commercial helped to popularise Ozempic and cement its name as a generic term for an entire category of drugs, now prescribed to millions of people to treat diabetes and obesity.
An earworm, however, can go only so far in explaining why these drugs are all the rage. Semaglutide (sold under the brand names Ozempic and Wegovy), and related GLP-1 receptor agonists, such as tirzepatide (sold as Mounjaro and Zepbound), wouldn’t be as popular as they are if they did not have dramatic results. For example, those who regularly inject themselves with these medications lose, on average, about 15 per cent of their body weight. This has led some commentators to hail a potential ‘Ozempic revolution’, in which the obesity epidemic – ‘a problem that our high-tech society invented’ – also has a high-tech, pharmaceutical solution.
GLP-1 medications mimic glucagon-like peptide-1, a hormone that triggers the release of insulin, which lowers blood sugar levels. In addition, they moderate appetite and slow the movement of food from the stomach to the small intestine, prolonging satiety.
These drugs also seem to quiet persistent, intrusive thoughts about food (so-called ‘food noise’) and may reduce cravings in general. Although scientists are just beginning to study food noise as a concept, individuals who have taken a GLP-1 drug often report that it significantly reduces this distracting, ruminative thinking about food – a near-constant background hum of unwanted food-related thoughts, feelings and desires that may contribute to making poor food choices.
If Ozempic and its siblings end up revolutionising the treatment of obesity, it will primarily be through its powerful physiological mechanisms of action. However, when drugs become blockbusters, they can have equally profound indirect effects on public consciousness, changing the way we think about the conditions they are designed to treat. Consider, for example, how the popularity of antidepressants such as Prozac has changed how we think about depression and other mood disorders – helping to destigmatise these illnesses, but also catalysing broader conversations about how personality and the self relate to neurophysiology.
On this score, GLP-1 medications have yet to live up to their full potential. Or, rather, since the cultural impact of novel medications is determined by our reactions to them, not by the medications themselves, we have yet to live up to our full potential in reflecting on them and unpacking their implications. (If anything, in our current media environment, the widespread use of GLP-1 drugs has reinforced the cultural obsession with being thin.) Thinking carefully about how these medications work can help us develop a more accurate understanding of appetite and self-control – and thereby improve the way we see obesity and people affected by it.
Overweight people are often stigmatised as lazy, with no willpower or self-discipline. On this view, those who want to lose weight should simply try harder to eat well and exercise. When these additional efforts fail, as they often do, overweight individuals might feel shame or guilt. This emotional response can exacerbate unhealthy eating behaviours, discourage people from seeking medical advice, and create a vicious cycle in which weight stigma and weight gain reinforce each other.
Ozempic’s effects on those who use it suggest that weight management may actually have little to do with raw willpower. Taking the drug does not help you lose weight by strengthening your will to overcome cravings for high-calorie, nutrient-poor foods. Rather, it weakens those cravings, and silences ‘food noise’, so that you don’t even need willpower to resist them in the first place.
Based on this, it seems likely that a person’s weight is more strongly determined by the intensity of their desires and appetites than by the strength of their will. If this is right, thinner people shouldn’t be valorised for supposedly being strong-willed, and overweight individuals shouldn’t be disparaged for being weak or feckless. Someone who is overweight may have just as much willpower as a thinner person but need to deploy this willpower against stronger desires for food. In effect, thinner individuals might be getting credit for winning a battle that they never had to fight. As one member of an online weight loss group wrote after taking a GLP-1 medication, ‘it is no wonder that skinny people think heavy people have no willpower. Their brains actually do tell them to stop eating. I had no idea.’
We do not directly control our appetites; the heart (or stomach, in this case) wants what it wants
We can get clearer about the effects of GLP-1 drugs on self-control by drawing on a distinction between two different ways of acting moderately, which traces back to Aristotle. The first kind of moderate action lines up with how most people think of self-control: effortfully resisting doing something that you believe you shouldn’t do. The ancient Greek word for this form of moderation is enkrateia, which is usually translated into English as ‘continence’ (despite its contemporary associations with bladder control).
As we’ve seen, Ozempic does not seem to make those who take it more continent; it doesn’t help them resist strong temptations to eat more than they think they should. Rather, taking GLP-1 drugs brings people closer to the other form of moderation: sophrosyne, which is usually translated as ‘temperance’. While the continent person experiences many tempting desires and successfully resists them, the temperate person doesn’t face temptations in the first place. A temperate person’s appetites are in perfect harmony with her judgments about what it is best to do. If a temperate person believes that she should eat only a single piece of cheesecake after a big dinner, then she will want only that single piece, and will be satisfied once she’s eaten it, even when faced with a dessert tray full of other delicious treats.
We do not directly control our appetites; the heart (or stomach, in this case) wants what it wants. Simply deciding to be temperate is not likely to be effective. In part this is because both appetite and weight are highly heritable: in any given environment, a large fraction of their variance between individuals is attributable to genetics. Although environmental factors – an increase in sedentary lifestyles and greater availability of high-calorie, nutrient-poor foods – explain why average obesity levels have gone up worldwide, genetic differences partially explain why some individuals gain more weight than others in these ‘obesogenic’ environments.
Some researchers have argued that these gene-by-environment interactions are partly due to the genetically determined differences in appetite. Individuals who inherit a stronger appetite – those who are more responsive to food cues and less sensitive to satiety signals – are simply more susceptible to obesogenic environments. They are more likely to overeat in response to a food environment in which high-calorie, low-nutrient foods are readily available.
This theory meshes nicely with the idea that GLP-1 medications work in part by moderating appetite and promoting feelings of fullness. If you are not among the lucky few who are naturally temperate with respect to food, taking Ozempic or one of its peers helps you approximate temperance – bringing your appetite into line with your beliefs about what, and how much, you should eat.
The notion that willpower and resistance are overrated when it comes to weight is backed up by recent research on self-control. Surprisingly, being a highly self-controlled person seems mainly to involve using proactive strategies to avoid and manage temptations, rather than being good at directly and effortfully resisting them through sheer willpower. In this way, actual self-controlled humans don’t seem to fit the traditional picture of continence.
Self-controlled individuals don’t fit the traditional conception of temperance, either: their appetites aren’t automatically in agreement with their judgments about what’s best to do. Instead, they take indirect steps to nip potential temptations in the bud. For example, someone who might be tempted to eat an entire chocolate bar at once if they buy one in the grocery store checkout line might avoid this temptation by choosing a register where candy is not displayed, or by distracting themselves from the array of chocolate. Or, if they already have chocolate at home, they might reframe how they think about it – say, as a treat reserved for special times – to moderate their consumption.
In short, a more accurate picture of self-control reconceives it as flexibly organising our lives so that we are less likely to be in situations where strong temptations arise, and changing our patterns of thought so that the temptations we do encounter are easier to resist. Ozempic and similar drugs are a way of proactively managing temptation, and their effects lend further support to this reconceptualisation of what it means to be self-controlled. The success of GLP-1 drugs ought to shift the emphasis away from willpower and continence, revealing these forms of self-regulation to be burdensome and ineffective for many people.
GLP-1 medications do not work for everyone and, at least in the US, they are expensive, which raises concerns about equitable access. Injecting Ozempic may not be a panacea for obesity. But reflecting on why these drugs work, when they do work, can still reinforce valuable lessons about self-control. It can help us move beyond the myth that highly self-controlled individuals just use superior willpower to inhibit their impulses and cravings. It can remind anyone who has passed judgment on those affected by obesity that simply trying harder to eat differently is not likely to be effective. And it affirms that struggling with one’s weight does not make someone lazier or mentally weaker than anyone else.
