English Version | The miracle of subtraction

They call it "the hottest drug in Hollywood." However, the latest Holy Grail of weight loss is actually a diabetes drug. The cult of the skeletal body has returned, but it is precisely to those who wish to be (even) thinner that Ozempic is not intended. Obesity is one thing, a distorted mind is quite another.

 All over Instagram, protruding clavicles and overly prominent ribcages seem to be on the rise. In an article published by The Guardian, journalist Eva Wiseman raises the question: "Thinness is back in trend, but has it ever stopped being so? Dazed magazine, for its part, sounds the alarm: "Is fashion heading for a worrying return to size zero? On TikTok, we see a growing popularity of searches like "heroin chic body", suggesting that indeed "thin is in" - and low-waisted jeans or tiny T-shirts leave no room for doubt. A lot of ink has been spilled encouraging body positivity, the yes to self-acceptance, but that's how trends are, they dance to the wind, or, we might say, to the tune of what influencers and social media, in general, dictate. Dana Omari, a nutritionist from Houston, USA, who has amassed about 250,000 followers for documenting the blepharoplasties, breast implants, or buttock lifts of the rich and famous on the internet, noticed that the standard of beauty was moving in another direction: the Kardashian-Jenners were shrinking in size. The clan that had once been the symbol of defined, assumed curves was now leaning toward a slimmer body ideal. And it all started when Kim lost seven kilos to slip into a dress that had belonged to Marilyn Monroe as part of the Met Gala last May; sister Khloé, meanwhile, who had already mentioned her long and torturous battle against some extra weight, posted images of her 40s where she appeared noticeably thinner and as blonde as Barbie. "It marks a shift in tone, ushering in the end of an era that claimed to at least celebrate bodies with curves," points out Marielle Elizabeth, columnist for British Vogue. "If the woman who has most influenced and shaped beauty standards in the last 15 years is slowly disappearing before our eyes, it is because the plague of the white anorexic ideal (...) is back in our lives," writes El País in turn. Dona Omari then shared with her followers the secret behind that impressive thinness: the Kardashians - among other personalities -, she insisted, were probably taking semaglutide, the active ingredient in the drug Ozempic. "This is the 'diabetic injection' for weight loss that everyone is talking about," she declared. "Reliable sources revealed to me that Kim and Khloé supposedly started their Ozempic journeys last year." Manufactured by Novo Nordisk, Ozempic is part of a growing class of drugs called GLP-1 receptor agonists, which have come to dramatically change the treatment of diabetes and obesity. "We are living a very happy period when it comes to weight loss drugs," says João Jácome de Castro, Endocrinologist and President of the Portuguese Society of Endocrinology and Metabolism. "The active ingredient in the drug Ozempic, the so-called semaglutide, is fantastic for treating diabetes and an excellent cardiovascular protector. But in higher doses, it shows extraordinary effects on weight loss." He explains to Vogue that there are two trade names for semaglutide: the already mentioned Ozempic and, in the future, Ozempic used in doses to treat overweight and obesity, called Wegovi: "Wegovi is already approved in Europe, but it is not yet on the market in Portugal. There is hope that by the end of the year it will be available in pharmacies," he adds. Ozempic acts in two ways: on the one hand, by stimulating the production of insulin (fundamental in diabetes); on the other, by reducing appetite (fundamental in losing weight and also important in diabetes). On appetite, the drug acts through two mechanisms: acting directly on the appetite centers at the base of the brain, inhibiting them; and delaying the emptying of the stomach - by doing so it will, in turn, act on the appetite center at the base of the brain and promote satiety. João Jácome de Castro assures that this "new class has demonstrated an efficacy in weight loss safety like no other has been able to demonstrate in the past. Even to treat obesity this class already has a medicine in Portugal, whose substance name is liraglutide, a 'cousin' of semaglutide, already approved for both diabetes and weight loss. It has two names because the doses are different: for diabetes the doses are smaller than those [used] for weight loss. The dose used for diabetes is called Vitoza, while the one for weight loss is called Saxenda. Let's say that Vitoza is to Ozempic as Saxenda will be to Wegovi. Both are approved at different doses. And both are pharmaceuticals." I ask that endocrinologist about the rush to the pharmacies in search of this "magic" weight loss formula: "It's the most effective treatment available on the market", he hastens to clarify. It is true that with the COVID-19 pandemic and, currently, the war in Ukraine, the factories have not been able to keep up with the market's needs, but in Portugal the position adopted was to make sure there is no shortage of medication for diabetes patients and to wait for Wegovi to arrive as soon as possible, without forgetting that there is already a medication from the same family which, although not as effective, is the most effective of those available on the market. He also says that new drugs are expected next year that are "cousins" of these and even more effective: Terzipatide, whose commercial name is Mounjaro (this already exists for sale, for example, in the United States).

Let's see, obesity is a serious health problem: "In Portugal 67% of adults are overweight or obese (...) This is a chronic disease and is related to diseases that increase the risk of premature death. People with obesity live, on average, seven years less than those who are not obese. It is associated with diabetes, hypertension, hypertolerance, numerous cancers, stroke, and many more problems of the osteoarticular system," explains Jácome de Castro. The belief that fat itself is neither ugly nor alarming can sometimes be misinterpreted, naively or not, as a complete disregard for the connection between health and excess weight. In a text that can be read in The New Yorker on the subject, the author says: "I recently went to a doctor's appointment in upper Manhattan, during which it came up in conversation that I was writing about Ozempic. The doctor put down her stethoscope and turned to me. 'You know, I love [singer] Lizzo,' said immediately. 'But it's a shame that the whole body positivity movement has made so many people think it's okay to be obese.'" Both thinness and fatness can be the result of disordered eating, and both present dangers when taken to an extreme. In 1958, American physiologist Ancel Keys began a long-term study in seven countries about the relationship between diet and heart health; later, when he analyzed the data, he found that very thin or very fat people had the highest risks of heart disease. But Keys focused his concern on obesity, a condition he considered "disgusting" and "repugnant." At the time, he resurrected the so-called Quetelet index - invented in the 19th century by Belgian mathematician Adolphe Quetelet in an effort to identify the statistically average man ("the type of perfection," according to Quetelet) - and gave it a new name: the body mass index. In the 1980s, BMI became the standard method of assessing a person's health through their weight. In the July/August 2021 issue of Vogue Portugal, in a text about "chubbier" bodies, a nutritionist defended that "the acceptance of shapes, curves, and body composition is undoubtedly a necessity nowadays. However, this acceptance must have a limit. As much as we accept it as it is, we know that a high Body Mass Index (BMI) or fat mass levels in the visceral area are a risk factor for several metabolic diseases. Therefore, just as we should not promote unrealistic and pseudo-perfect bodies, we should also not fall into the error of normalizing a weight and waist circumference that is dangerous for our health."

That's why, as Jácome de Castro asserts, "one cannot trivialize and transform 'this' into a joke (...) The state can't subsidize those who want to lose a few kilos." Ozempic is not for the Kardashians or for the reader who wants to lose five kilos in the coming summer. Rather, it is intended for sick people, whether diabetic or obese. "In Portugal, medicines for diabetes have a high reimbursement system, and at the moment, medicines for obesity are not reimbursed. The scientific societies are in negotiations with the health authorities in the sense that there may be reimbursement, in selected cases, of medicines for obesity and overweight," clarifies the doctor. He continues, "With Wegovi, studies show that about half of the people lose 20% or more of their body weight, a result that is close to the results of surgery." He also reports the importance of small losses: "It has been proven that losses starting at 5% of body weight have significant health benefits by improving obesity-associated diseases." This is a very safe drug in which side effects are of no concern. These have to do with the action of Ozempic in delaying the emptying of the stomach, which can cause bloating, nausea, vomiting and also changes in intestinal transit, usually constipation. "The percentage of complaints, however, is usually low and transient," says the endocrinologist, adding that all these pharmacological measures "should be taken simultaneously with a program of lifestyle changes, promoting healthy eating and physical activity habits." In a testimonial published in The New York Times, a woman who went through fertility treatments to get pregnant that made her gain weight, recounts that resorting to Mounjaro "was like pushing a button" (...) I would look at the food and it wasn't even attractive, and I'm a person who loves food! I almost had to remember to eat." Thrilled with her new body, there was, however, a downside to the sudden weight loss: her face looked exhausted and aged. To the same newspaper, Oren Tepper, a New York plastic surgeon, said it is common for weight loss to deflate key areas of the face, leading to an older appearance. "When it comes to facial aging, fat is usually more friend than foe," he said. "Weight loss may delay biological age, but it tends to advance the facial clock." The same once expounded Catherine Deneuve: "After a certain age, the choice is between the butt or the face." Although these days, in certain circuits where money abounds, the saying may no longer apply, since the methodologies for getting the desired appearance are more than plenty. Can we add to the expression "there are no ugly people, there are poor people", the motto that thinness is no longer just for those who just are, but for those who take Ozempic? Only time will tell.

Originally translated from The Revolution Issue, published April 2023.Full stories and credits on the print issue.