My brain on Ozempic

So when I realized I suddenly didn’t care about stepping inside, I didn’t trust it. I forced myself to visualize that first perfect bite, waiting for my mouth to water and jaw to ache … but nothing. When it dawned on me that I could win my daily battle without even fighting it, I felt like I’d learned how to breathe underwater, as if I’d lost enough weight to levitate.

I was skeptical about last year’s glowing articles about Ozempic and other GLP-1 medications. Like so many chronically overweight people, I’d seen it all and then some: stimulants, supplements, low-carb, low-fat, intermittent fasting, even laxatives. But these medications are nothing like what I expected. They’re not really “weight-loss drugs” at all. They’re something far more powerful and surreal: injectable willpower.

GLP-1s’ increasing popularity won’t just mean that millions of us who’ve beat ourselves up for being overweight will be able to win that lifelong battle. It will mean fundamentally reevaluating our conception of free will and human agency — and reckoning with our tortured relationship with shame.

So much of diet culture, of our culture writ large, belittles the choices we make about food. What happens, then, when a drug reveals that eating, gambling, and so many other behaviors aren’t choices at all? Just like when Prozac dismantled the myth that depression is a choice, or when earlier scientific advancements disproved the idea that illnesses like cancer were moral indictments, GLP-1s and similar medications are changing our shared sense of what is blameworthy and what is biology.

For those fortunate enough to never have struggled — seriously struggled — with weight, you have to understand just how futile most weight-loss strategies are. Though people can “succeed” in a diet for months, maybe even a year, many dieters eventually regain weight. Most of the dozens of diets and health schemes I’ve been on over more than 30 years have helped for a time, but they all set me up to fail. For a long time, the only evidence-based strategy for safe, long-term weight management was surgery. But gastric surgery is expensive and painful, and many patients end up regaining weight.

They’re not really “weight-loss drugs” at all. They’re something far more powerful and surreal: injectable willpower.

Moreover, weight often has no bearing on health. For decades the fat-acceptance and fat-rights movements highlighted how size discrimination affects hundreds of millions of people around the world. Anti-fat bias costs people jobs, relationships, access to public spaces, and more. Fat-shaming and size discrimination also fuel eating disorders that affect tens of millions of people and kill more than 10,000 Americans annually. But even as diet culture is deadly for some and discriminatory for countless more, many of us have a medical need to lose weight.

In 2017, everything changed during my physical — shocking cholesterol numbers turned into specialist visits, then a grim warning that I was cutting my life short. So I started on a massive project of weight loss, exercise, and lifestyle change. I set up a tracking sheet with a friend; we concocted a set of prizes for weeks when we were healthy and punishments for when we did badly. Having read so many studies about the failure rate for dieting, I decided I needed something that would truly terrify me if I seriously slipped. So I wrote out a check for $10,000 to the organization I hated most in the world, the National Rifle Association, and sent it to my friend. Through the combination of incentives, accountability, social pressure, and the mental image of Wayne LaPierre gleefully cashing my check, I lost 70 pounds and even ran a marathon.

But I couldn’t outrun the statistics, and during COVID-19 isolation I lost so much of the progress I’d made. (No, the NRA never got a penny.) Even after the lockdown era, as I went running and lifted weights every week, I couldn’t really make a dent.

My friend’s experience after our health challenge was very different. In early 2022, he began taking Ozempic. The injectable drug simulates GLP-1, a hormone regulating metabolism. Soon after, my friend switched to Mounjaro, which also simulates a second hormone called gastric inhibitory polypeptide, or GIP. The results were staggering. While I went from one gimmicky diet to the next, giving up carbs and then intermittently fasting, my friend was losing weight week over week with seemingly no rules or restrictions. By last summer I felt so stuck, enervated, and even desperate that I gave Mounjaro a try.

Miraculously, in less than a week I got a script from my doctor. My insurance would help cover the cost; I didn’t need preauthorization. The clerk at my CVS said it was the first time they’d see someone spend just $20 for a drug that usually retails for $1,000 to $1,200 a month. I was extremely lucky. Many health plans have refused to cover GLP-1s for weight loss, citing limited approval from the Food and Drug Administration. But prescribing GLP-1s “off label” for weight loss is legal, and the surge in popularity has led to drug shortages. Sadly, many of those most at risk from obesity-related illness and diabetes have had a hard time accessing the medication. And as with every other aspect of American medicine, the impact is most acute for those from low-income communities of color.

It felt like I was pointing a loaded gun at the oversized belly I despised.

I felt squeamish holding the glow-stick-sized autoinjector, still cold from the fridge. It felt like I was pointing a loaded gun at the oversized belly I despised. I took a breath, pressed a button, braced for the pain, and … felt almost nothing. It was so underwhelming that I called my friend to make sure I hadn’t screwed it up. Then I went about my day.

The change began the next morning. In the frantic deluge of emails and Zooms, I forgot about breakfast. By 2 in the afternoon, I realized I’d been going since 6 a.m. without a bite and still wasn’t hungry. When I went into the kitchen, I was even more startled to see the coffee pot almost untouched. As a young lawyer I’d learned to exist off coffee, going through two, sometimes three pots of stovetop espresso a day. I never thought of my coffee habit as an addiction or poor impulse control — just as what my body wanted to keep up with the pace of work. But suddenly my choices were changing.

And when I walked out of my building to grab lunch, passed Levain, and still felt nothing, the enormity of my changed decisions hit me.

The thing about a lifetime of shame is that you have no idea how heavy a burden it is until the moment you set it down. If you’d asked me what I thought about weight pre-Mounjaro, I would’ve said it was frustrating but generally no big deal. Sure, I struggled with diet and impulses, but didn’t everyone? Only a day after the first injection, I realized just how much pain I’d carried with my pounds, and how the humiliation of obesity had become central to how I defined myself.

I don’t know when I first became overweight, but I remember the moment I was taught to be ashamed of it. It was Halloween, and a group of us 8-year-olds went through the uniquely New York take on the holiday by pillaging dozens of walk-up apartments. We started on the top floor of the converted customs warehouse I called home in Greenwich Village before darting across town to the motherlode: my friend’s 20-story, 500-unit building. Hours later we had bags of candy almost as large as we were. I sat down on my friend’s couch to savor the first piece of the night — only, as I tore the red wrapper off the Kit Kat, a familiar voice behind me said, “No.” I stammered some confused question: Why couldn’t I start when everyone else was stuffing their face? “Because you’re fat,” the voice said, “and they’re not.”

The shame of that moment stuck with me for decades — a funhouse mirror that transformed me from a child into a pig. It became an unshakable part of what I conceived as my essential self. I was a “fat kid.” Once I internalized that label, it became indelible. No matter what my actual weight was, I viewed it through that lens of moral failure. Being overweight, obese, and eventually morbidly obese felt like destiny, the inevitable byproduct of my failure to prioritize my health over my appetite. Even when I dieted, went on health kicks, or even ran the New York City Marathon, I still thought of myself as a profoundly flawed person, because of the food choices I wanted to make. The fat-shaming I encountered as a child was a part of me no matter how far I ran or how hard I dieted. And with that first Mounjaro injection, it began to disappear. I saw that while grown-ups and doctors had blamed me for overeating, my own biology had set me up to fail.

When you define yourself by being overweight, by your sense of weakness and failure, it warps how you view every other aspect of life. By nearly any measure, I’m a very driven person. After graduating from Harvard Law School, I worked at one of the top law firms in the country before founding a civil-rights nonprofit. I’ve run dozens of long-distance races, appeared in hundreds of TV segments, vied at a dozen Moth story slams. But I still thought of myself as a lazy, undisciplined person. Sure, I ran 30 miles a week, but it was at a “fat-guy pace.” Sure, I played tennis for four, five, even six hours a weekend, but I was doing the “easy” clinic. At work, body image fueled the imposter syndrome that discounted what I built. And I don’t even know where to begin when it comes to the cacophony of chaos I call dating.

These drugs can reprogram not only how our brains make choices but how we view ourselves.

All those feelings didn’t disappear the instant I injected the first shot, but for the first time in my life I could see them at arm’s length, mapping the tenuous threads that tethered them to painful childhood memories. No matter how many times you’re told that everyone’s metabolism is different, you don’t truly believe it until the moment you feel it.

Others have noted the questions these drugs raise about free will, but many of these conversations have missed the role that shame plays in how we see weight. These drugs can reprogram not only how our brains make choices but how we view ourselves. They can stop the vicious feedback loop where our food choices and weight drive the shame that drives our food choices and weight.

After seeing my own response to Mounjaro, I wasn’t surprised to learn that researchers are investigating whether GLP-1s can treat addictions to drugs, alcohol, smoking, and even gambling. Some people have even reported that they’ve helped control compulsive behaviors like skin picking. The data is preliminary, and these drugs might not work for all these conditions. Still, it seems clear that these medications can help shape our behaviors in a way that wasn’t possible. That’s where the truly tough questions start.

GLP-1s highlights how often we blame, even punish, people for choices that aren’t truly their own. And this goes far beyond food. Most legal scholars think that punishment is unjust without blameworthiness, but so many of those in our prisons and jails are arrested because of an addiction. We pretend we can delineate the brain and the body, untangling what’s choice and what’s craving. But it’s a farce. Those with serious addictions (and their families) have long understood that biology and cognition are linked. GLP-1s will give millions more this crucial insight, bringing so much of our criminal system into question. Blameworthiness is the cornerstone of criminalization. It’s why (at least in theory) we don’t punish people for crimes they commit by accident, when incapacitated, or held at gunpoint. Viewed through the GLP-1 lens, so much of our legal system looks like Stephen Spielberg’s “Minority Report.” The film posited a bleak future where suspects were arrested for pre-crimes they had not yet committed, but would commit one day. Watching the movie, it feels so wrong to imprison people who haven’t even chosen to break the law. And that same feeling could impact how we view the prosecution of DUIs, drug offenses, and much more.

Other vexing questions — like how and when to administer GLP-1s to kids — will come even sooner. About 17% of 10- to 17-year-olds in the US are classified as obese. While many contest current body-mass standards, millions of children are already being advised to lose weight. Who should choose whether to use GLP-1s? Should it be an option at all? It’d be one thing if these medications were just weight-loss drugs, but altering a child’s mindset during development could have lifelong effects. The moral questions grow even thornier in cases where children and parents disagree. The ethics of consent become incredibly complex to navigate.

In just the past five months, Mounjaro has been bewilderingly life-changing for me: I’ve lost more than 40 pounds, started running again — finishing my first half marathon since Covid-19 started — and my cholesterol and blood pressure are the healthiest they’ve ever been. I’ve been freed from a growing list of medications doctors warned I might be shackled to for the rest of my life.

Shortly before writing this piece, I stopped taking Mounjaro for a month. I wanted to see what it’d be like to go back to the status quo. While many people who stop using GLP-1s start to put back on the pounds, I managed not to regain weight. It was a hollow victory, though, because it was a month of agony. I constantly forced myself to turn away from the things I wanted, to ignore the endless array of temptations. But no matter how heavy that burden was, one thing made it easier to bear: I wasn’t weighed down by my shame.

Albert Fox Cahn is the founder and executive director of the Surveillance Technology Oversight Project, or STOP, a New York-based civil-rights and privacy group.