It started with a single Christmastime TikTok: Jonathan Kaplan, a San Francisco plastic surgeon known online as “Real Dr. Bae,” posted a 58-second video about actress Mindy Kaling’s suspected use of weight-loss medications.
“I’d like to believe that Mindy Kaling lost all that weight with just diet and exercise, … but it’s possible that she and other people that aren’t talking about it are using new weight loss drugs, Ozempic or Wegovy,” Kaplan said in the video.
Kaplan’s video was viewed by over 3 million people; a follow-up about Kim Kardashian raked in another million viewers. In his clinic at Pacific Heights Plastic Surgery, Kaplan estimates that he went from seeing about 20 patients for weight loss treatment last year to now serving more than 380 San Franciscans looking to shed pounds through pharmaceuticals.
New weight-loss injectables have exploded onto the health care scene this year, particularly after several public figures rapidly slimmed down. These medications—which include the brand names Ozempic, Wegovy, Rybelsus and Mounjaro—originated as Type 2 diabetes treatments to help regulate glucose levels.
“When they came up with Ozempic in 2017 for Type 2 diabetes, they also noticed that it helped people lose weight. And the benefit of Ozempic was that it was a once-per-week injection, rather than a daily injection,” Kaplan said. “They rebranded Ozempic as Wegovy, and that was the first weekly injection that was FDA-approved specifically for weight loss.”
The drugs are now seemingly everywhere: Twitter/X boss Elon Musk recently credited Wegovy for his significant weight loss. The Danish company that makes Ozempic and Wegovy, Novo Nordisk, reported that its North American sales shot up 45% from January through June 2023, and the company’s market value has exceeded the size of the Danish economy.
As a result of unprecedented demand, the U.S. Food and Drug Administration (FDA) put these drugs on its nationwide shortage list in March 2022. The drugs, which are expensive and only covered by insurance under certain circumstances, can be hard to find in San Francisco and nationwide.
“We have a couple patients who have to wait an extra week, just because it’s in short supply,” said David Valencia, pharmacist at Reliable Rexall Pharmacy in the Sunset.
“I get calls every day for [Ozempic], and I say I don’t have it,” added Valencia, whose pharmacy was robbed of its entire Ozempic stock in February.
The shortage has pushed some residents to seek out cheaper, compounded versions of the weight-loss miracle drugs, while lower-income San Franciscans without insurance have scrambled to find alternative medications to handle their diabetes symptoms.
Meanwhile, plastic surgeons across the city—including Kaplan’s office—now offer off-brand injectables as part of their weight-loss care plans, and local wellness spas tout the drugs as the miracle cure for obesity.
For some, the Ozempic craze is a worrying trend reflective of America’s obsessive diet culture; for others, it’s a potential revolution that could reverse the country’s epidemic of obesity and related complications.
“This is going to be a part of society, just the way that Botox used to be sort of taboo to talk about—now everybody gets Botox,” Kaplan said. “This is going to be like that.”
‘I Feel Amazing on It’
Over 40% of Americans qualify as obese, meaning they have a body mass index greater than 30. Though trendy diets such as keto and weight-loss laxatives have come in and out of style, nothing has worked nearly as well as Ozempic. In San Francisco, the obesity rate has historically remained far below the national average, though there are still plenty of city residents who struggle with their weight.
Janet Rossi, a 55-year-old estate manager in San Francisco, started taking weight-loss injections in July. Rossi doesn’t have diabetes and is not considered obese, but wanted to shed a few pounds before going under the knife for a tummy tuck. Rossi was prescribed compounded versions of Ozempic—essentially more affordable, slightly altered Ozempic—by Kaplan, her plastic surgeon of 14 years.
“This shit is magic, and I hope it changes things for a lot of people,” Rossi said. “I feel amazing on it. Clothes fit better, I feel better, I have more energy and I’m not so consumed with outside stuff.”
Physicians prescribing semaglutide and triazepine—the scientific names for Ozempic and Mounjaro—report that patients lose dozens of pounds within months. Rossi, who started in early July, is down 28 pounds in just over two months. And Rossi says her side effects are minimal, ranging from intermittent nausea to excess burping and a newfound preference for “hella bland” food.
“It’s easier to use, more patient-friendly and better weight-loss results. Maybe all of those things combined has made it more popular,” said Dr. Sarah Kim, an endocrinologist at the University of California San Francisco who specializes in obesity and diabetes. Ozempic and Wegovy are weekly injectables, compared with older diabetes medications like Saxenda that require daily jabs.
Diabetes care providers, however, warn that the Ozempic shortage has potentially disastrous implications for lower-income Type 2 diabetic patients in San Francisco, who struggle to get the drug due to its high prices and low availability. Especially since the drugs are meant to be taken long-term, the demand for Ozempic and other name-brand semaglutides has only compounded over time.
“A lot of providers were just giving it for weight loss, and all of a sudden there’s a shortage—that puts the most vulnerable populations at risk,” said Jaime Martinez, a diabetes care coordinator at St. Anthony Health Foundation. The clinic is a “safety net service” that provides health care to low-income people in the Tenderloin.
Martinez’s diabetes patients used to be able to access a monthly supply of injectables for as little as a $5 copay. But last year, the Healthy San Francisco program—a city-run health coverage program for uninsured residents—stopped covering Ozempic at St. Anthony’s. Martinez attributes it to the shortage.
Immediately, 54 patients lost access to the drugs, according to Martinez. Those who weren’t able to get their hands on a replacement medication, such as Victoza, were given insulin as a last line of defense. Those treatments, he said, generally are not as effective as Ozempic in regulating blood glucose levels.
“A lot of our patients that were already on [Ozempic] had to get taken off. It had a real negative impact on their sugar control,” Martinez said. “We had to do a whole focused outreach on these patients and try to give them a soft landing, or other medications.”
The Department of Public Health, however, says that these diabetes medications are still available to patients using city-sponsored clinics and pharmacy services at Zuckerberg San Francisco General Hospital.
Brand Name or Generic? Neither.
Ozempic costs around $1,000 per month without insurance, and taking Ozempic for weight loss is considered an off-label use. This means many non-diabetic patients have difficulty getting insurance companies to pay for the pricey name-brand treatment, even if they can find a doctor to prescribe it.
Wegovy, Novo Nordisk’s other semaglutide injectable, is often shirked by insurers despite the fact that it is explicitly approved by the FDA as a weight-loss medication. Legal experts say that the Affordable Care Act does not mandate coverage for obesity medications, and insurers are not incentivized to cover the drug because of its high costs. For patients, Wegovy runs upward of $1,000 without insurance.
Novo Nordisk holds a patent on Ozempic that lasts until 2031, meaning that no generic—or cheaper—identical versions of the drug can be legally made before then.
That hasn’t stopped some physicians and patients from trying to find workarounds.
Antonio Ciaccia, a drug pricing analyst and co-founder of 46brooklyn Research, says that after the FDA put Ozempic and Wegovy on its shortage list, the agency effectively opened the door for compounding pharmacies to create slightly altered versions of the weight-loss drug. Some providers market these “compounded drugs” as being as effective as the brand-name versions, but different enough so as not to infringe on Novo Nordisk’s patent.
Compounding pharmacies offer specialized services to mix, alter and combine two or more drugs to create a medication tailored to an individual’s needs, such as if a patient requires a pill to be in liquid form or needs an allergen removed from a drug.
“In general, you’re not able to compound medicines just on a whim,” Ciaccia said. “There has to be a compelling need, meaning the patient has to be getting something not readily available by a mass-produced market, or they’re making something that is currently designated as a drug that is in shortage.”
Though the roughly 7,500 compounding pharmacies in the U.S. are state-regulated, the FDA does not approve or regulate compounded drugs and recently cautioned Americans to avoid compounded semaglutides, citing potential “adverse reactions” to the drugs.
Still, more and more doctors, including Kaplan’s practice in Pacific Heights, are turning to compounding pharmacies in order to offer a more affordable weight-loss drug option for patients—especially since some physicians have likened the hunt for brand-name Ozempic in local pharmacies as a health care Hunger Games.
“Everybody is in the same boat with the shortage, though it seems like the chain stores get preferential treatment because of the volume [of patients] that they serve,” said Valencia, Rexall Pharmacy’s manager. “I’m not going to say that I won’t stock Ozempic, but you have to screen patients. If you’ve got patients with no history of diabetes and an [Ozempic] prescription, I’ll say, ‘Hey, we prefer working with diabetics.’”
Abe Malkin, a Los Angeles-based physician who runs telehealth companies Concierge and Drip Hydration, also provides compounded and brand-name semaglutide injections. He works with several compounding pharmacies to keep up with the demand from his (mostly virtual) patients, who span nearly all 50 states.
“These medications are self-injectable, so there’s not really a need to have an in-person component to either prescribe or administer them,” Malkin said. “We’ve built a model of telemedicine capability across the country, so we can assess patients via virtual consults and make prescriptions for them and then ship them the medication they need to inject themselves.”
A Stopgap for a Shifting Medical Industry?
The FDA and Novo Nordisk have gone on the offensive against pharmacies and wellness spas that claim to offer brand-name Ozempic but really only provide compounded or lower-grade versions of the drugs. But drug-pricing analysts say those efforts have unfairly stigmatized compound drugs.
“Compounding is so misunderstood in that it is ultimately serving niche needs, relative to what the broader industry is,” Ciaccia said. “Sometimes that can be an actual clinical reason, other times it can be a shortage and other times it can be an affordability reason.”
Telehealth providers contend that a few bad actors—such as unlicensed health care providers who provide direct-to-consumer prescriptions—have soured people’s views of their work. For example, wellness apps such as Noom that previously only pushed behavioral changes for weight loss have shifted course: Noom now offers Ozempic and Wegovy subscriptions.
Malkin, who is licensed to practice in nearly every U.S. state, says it’s important to look for a health care provider who considers your holistic health history.
“There are companies out there, for example, that will send you a prescription without ever having done bloodwork to verify that you’re actually a good candidate to get their medication,” Malkin said. “To me, that’s kind of irresponsible. There’s exclusion criteria that can be uncovered during a lab review.”
Malkin sees the rise of these injectables as a natural result of the Covid pandemic: People think about their health more now, and they’re more willing to take proactive measures for their health.
“Medicine as a whole has been a disease-treatment model for the last 50 years: Patients kind of wait til they get sick to then get treated for that specific disease,” Malkin said. “Now, it’s a really critical time where the country is starting to take ownership of their health care in a more proactive way.”
But not everyone has that luxury. Martinez, who has helped diabetic patients in the Tenderloin for over 20 years, is frustrated by Ozempic’s off-label popularity and how it’s diminished his patients’ ability to stay healthy.
Ozempic “should be regulated a lot more and just be more specific to diabetics until they produce enough for everybody,” Martinez said. “It basically set our patients back a year with diabetes control. They had to start over to get their sugars back down again.”