Fat people don't need medical care for who they are

Even Jia Tolentino, with her seemingly infinite capacity for nuance and tact, can’t get it right. Ozempic is evidently a Fermat’s theorem of social existence. We will need a new kind of mind to make sense of it. 

Ozempic is, of course, the new diabetes drug. Like other diabetes drugs, Ozempic improves blood sugar in adults with type 2 diabetes. That’s great. But it has fairly extreme side effects. One of those side effects is that it causes patients to lose their appetites. 

In any other era, and nearly everywhere on earth, losing an appetite is very bad. Loss of interest in eating and drinking is a form of accidental suicidality. This is why animals who lose their appetites are considered profoundly unwell. This is why babies who won’t eat are rushed to the doctor. A “healthy appetite” is a big appetite.

But in the rich precincts of the US, as everybody knows, we consider our appetites for food a grave social liability, and our inability to browbeat our biology into food-refusal as a moral or at least pathological shortcoming. 

So Ozempic’s capacity to drain our interest in food, to turn life-sustaining nourishment into a matter of cold indifference, is somehow a reason for rejoicing. Why? Because we have found yet another highly aggressive way that medical doctors can temporarily shrink our bodies to sizes that might make other people like us more, or at least hate us less. 

Jia Tolentino, who is so skilled a writer that I read each piece of hers with a kind of held-breath admiration, has written a piece for The New Yorker about Ozempic and this culturally complicated side-effect. But she has unaccountably opted not even to note how strange it is, historically speaking, that we have made a disease of bigger body sizes and decided to “treat” that “disease” with a drug whose most notable side effect, a dramatically diminished appetite, can be lethal. 

The piece purports to say that fatness is not a moral problem; it’s a disease. Remember when liberals tried to do this with queerness? It’s a supposed virtue to say someone is not evil, they’re sick. This means they don’t need exorcisms; they just need CrossFit and ipecac. Or maybe conversion therapy. But the discourses around sin and disease have always been just about one and the same. (See: Foucault, The Birth of the Clinic.) To pretend that one model represents progress over the other is to ignore the two assumptions present in both of them: Fat is bad.

This doesn’t add up, even if you stick to the health vocabulary. According to the CDC, bigger-sized people live longer than normal-sized people. And while bigger body sizes do correlate with increased heart disease and sleep apnea, things like liver disease correlate much more closely with the practice of heavy drinking than with the fact of a person’s size.

Hunger, on the other hand, doesn’t just loosely correlate with disease; it causes the deaths of 9.1 million people a year. Thin people die more often than fat or very fat people, and, again according to the CDC, it’s the thinnest people in the US who are at the greatest health risk. 

So the idea that a certain class of people would choose to induce this risky malady of starvation with an injection—and pay $1,000 a month for the privilege—is a cultural perversion to beat the band. And it’s no less twisted for being mundane. 

The regime has elegantly exploited us, and especially women. If I were the Kaiser of the world and wanted to subdue half the population, I would absolutely set in motion a religion that would have them waste their lives trying to eviscerate their own flesh without quite dying, since it’s still important that they reproduce and punch the clock for the economy. 

You can never be too rich or too thin. You can never have too much or too little. Keep at it, folks. And—I’m the Kaiser again—how about I suffuse the culture with weight stigma, fatphobia, and social incentives to vomiting and anorexia, so you can squander your energies and police yourselves and I can save my cops and armies for subduing unruly men?

But this doesn’t concern Tolentino. That’s probably because when a bad thing that defeats the human spirit (like bullshit jobs or mass incarceration or virulent fatphobia) becomes business as usual, it’s both invisible as the air we breathe and too hard to question lest we fall into bottomless despair realizing we too have lost decades to doing PR for a corporate law firm or restricting calories. Better to hold fast to the belief that all those decades of working and dieting were serving a very real, very present, very punitive god — and thus we couldn’t and shouldn’t have done otherwise.

Let’s talk about the “air we breathe” for a second. This is not the place where I get into identity politics. It’s too much to address here the somehow still controversial fact that people of certain sizes are not intrinsically diseased. They’re like people of all heights, complexions, or cognitive styles; they don’t need fixing or curing or skin-lightening creams or brain probes. Like all of us, they need medical care if they get sick. They don’t need medical care for who they are.

But I’m not getting into that here because it evidently takes whole books to persuade the world that fat people have all the rights that thin people do, and deserve none of the ubiquitous governmental and cultural programs set up to torture them or encourage self-torture in the futile hope of making them into thins. There’s a place for that kind of robust political discourse, including on “Maintenance Phase,” and in the work of Aubrey Gordon, Ragen Chastain, and Christy Harrison. But, if the New Yorker piece on Ozempic is any indication, ideological analysis is simply too advanced for general-interest journalism on this topic.

The excitement about Ozempic blends well with the air we breathe, then, because it breezily agitates for the abolition of fat and fat people and because it contains completely unexamined fallacies about science. 

In Tolentino’s piece, much fun is made of kooky Kardashian types who get silicon molds of butts or breasts surgically implanted into their flesh. But when those same people, the literal Kardashians, start shrinking themselves with intravenous drugs, Tolentino’s eyes seem to light up. Last time, the doctors made you tacky and curvy; this time, they may be on to something.

But if one intervention (implants) is clearly different in status from the other (injections), is she willing to say what we’re all thinking, that thin is just morally better than fat, the way rich is morally better than poor? Well, no—that would be cruel. So Tolentino instead goes straight to Ozempic’s chief sophistry. It’s not a dangerous and optional cosmetic intervention like implants. Rather, it’s sorely needed treatment for a disease.

On this point, Tolentino is convinced. The first hint of it comes when she discusses one of the Kardashians’ use of Ozempic: “Khloé, who has spoken in the past about struggling with her weight, posted fortieth-birthday photos in which she looked as slim and blond as a Barbie.” 

The problem here is not her tacit approval of the Barbie look (“slim” rather than “ill-proportioned” or “emaciated”; “blond” as opposed to “plastic” and “expressionless”). The problem is the innocuous-sounding “struggling with her weight.” 

Khloé Kardashian may have spoken about the mass of her body as something separate from herself and worth struggling against, but that doesn’t mean the “struggle” with “weight” should be glossed over as a valiant conflict rather than itself a concerning mental obsession. A more compassionate and accurate way to talk about Khloé’s experience is to say that Khloé “has spoken in the past about her fixation on shrinking her body.” 

Then there’s the idea that Ozempic and similar drugs “have dramatically altered the treatment of diabetes and obesity.” This just doesn’t track with the medicine. Ozempic does indeed improve blood sugar in adults with Type 2 diabetes. But it was not intended for use as an appetite suppressant, even as it’s being promiscuously prescribed for that purpose. Moreover, “obesity”—which has no useful or stable definition, and is increasingly considered a slur—is simply not a disease and needs no treatment. 

As my friend and the fat activist Brianna Snyder has explained, “When a fat person and a thin person each present with heart disease, the thin person is treated for heart disease, and the fat person is told to diet.” Treat the heart disease. Leave body size be.

Instead of saying these drugs alter “the treatment of diabetes and obesity,” then, I’d make it “they alter the treatment of diabetes and introduce an aggressive way to medically alter body shape for people who want to shrink themselves.” Seen that way, Ozempic is indeed an option—a costly and risky and unproven one, but an option nonetheless—for people bent on self-shrinking. It’s just not a treatment for any disease other than diabetes. 

(In a better world, therapy would be offered to anyone seeking to use Ozempic for this purpose, just as it’s offered to people making other optional but significant alterations to their bodies, including elective amputation.)

To her credit, Tolentino cites a typical case in which a middle-aged woman was ignored by a doctor at Georgetown University when she complained of shortness of breath. Noting only the size of her body, he prescribed…calorie restriction. “It turned out that she had life-threatening blood clots,” Tolentino writes. 

Tolentino also complains about her own presumably educated but hopelessly dim doctor who says that the superstar Lizzo and “body positivity” have made people think “it’s OK to be obese.” Uh, no. To sound the depth of the not-OKness we assign to certain body sizes merely sit in a chair and think about how not-OK weighing 700 pounds seems to you. If you can get outside the culture and your history and feel OK about 700, I salute you: You are a Nietzschean galaxy brain and should move on to more experiments in radical freedom. 

Look, the whole article is about how people are wild to score an off-label injection they will have to take for the rest of their lives—for $1,000/month!—that can cause skull-rattling vomiting and extreme gastrointestinal distress in order that they might train themselves to shun food with more ease. 

These people don’t think fat is remotely OK. They think, as Tolentino is explicitly arguing, that it’s a terrible disease.

And the supposedly good news that Tolentino ends with is the saddest part of all. Just as fat people and the thins who love them have started to think that maybe fats could get regular medical care and not be a despised caste, or at least not a caste that despises itself, influencers beyond the Kardashians are out to make sure fat people stay self-hating. 

After all, there’s Ozempic. “They’re no longer going to accept that they should just be happy with the body they have,” a TikTok surgeon says.

We don’t have to be happy the way we are! How radical. Oh wait.

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Virginia Heffernan is a journalist, critic and author, most recently of MAGIC AND LOSS: The Internet as Art (Simon & Schuster, 2016). She is the host of This Is Critical on Stitcher, a contributing editor at WIRED, and a frequent contributor to the LA Times, the Atlantic, the New York Times, among others. This article was reproduced with her permission and can be found on her Substack, Magic + Loss.