CNN  — 

“One pill makes you larger,” wrote rocker Grace Slick in lyrics made famous by 1960s band Jefferson Airplane, “and one pill makes you small.” The song “White Rabbit” riffed, in psychedelic terms, on Lewis Carroll’s 19th-century imagery in “Alice’s Adventures in Wonderland” and “Through the Looking-Glass.” But lurking within these lines is also a most resonant 21st-century fantasy: a drug that can shrink your body.

For some, this isn’t a fantasy–or at least, it’s not just a fantasy. Semaglutide is hardly a household name, but depending on who you ask, this injectable medicine represents a revolution, a scourge and a long-term unknown. Say the word “Ozempic” and it’s more instant recognition: This brand name of semaglutide, also sold under the name Wegovy, in addition to treating type 2 diabetes, is now synonymous with weight loss.

Semaglutide is approved by the US Food and Drug Administration for weight loss only under the brand name Wegovy, but the off-label use of other brands, Ozempic among them, has become increasingly common. (The most common side effects of the drug include headaches and gastrointestinal issues.)

For many Americans who have struggled for years with their weight and associated health problems, semaglutide has been an effective means of treating obesity – as long as they remain on the drug. Studies show that most patients who stop taking the drug gain the weight back. Meanwhile, the cultural ubiquity of Ozempic and Wegovy as diet aids has spawned celebrity testimonials and thinkpieces galore.

Perhaps unsurprisingly, in recent weeks and months, medical and scientific authorities have also indicated that next-generation drugs are now in development that may be easier and more convenient to use and have even greater capacity to induce weight loss. As CNN recently reported, according to research from financial firm TD Cowen, nearly two dozen experimental drugs are now being designed to be taken as pills for obesity and related conditions.

Not just one drug that makes you small, then, but many?

For many patients and physicians, this expected surge of drugs is good news – in part because the Ozempic craze has made it more difficult for people with diabetes who need the drug to access it. But for many doctors, semaglutide is becoming increasingly important for treating obesity, so having more drugs that induce weight loss is a net positive.

That’s not so for many other observers, including journalist Virginia Sole-Smith, author of the recent book “Fat Talk: Parenting in the Age of Diet Culture,” who has reported for years on health, nutrition, fitness and beauty culture for the New York Times and other outlets (her first book, “The Eating Instinct,” was about how to deal with mixed cultural messages about food and our bodies). For Sole-Smith and others, proponents of Ozempic and drugs like it are missing the big picture: the diet culture that brands certain bodies acceptable, beautiful, healthy or worth seeing and relegates other bodies to the corners marked “diseased,” “ugly,” “lazy” or “just doesn’t care enough about being healthy.”

When considered in this context, Ozempic isn’t a wonder drug. Its popularity is a manifestation of a dangerous and pervasive message. In her book, Sole-Smith interviewed 65 parents and 45 kids from the US and Canada, along with 80 researchers, doctors, therapists, activists and thinkers.

The harm in the popularization of Ozempic lies not only in its impact on otherwise healthy bodies but also in the mentality that accompanies weight loss culture, she says. If we misguidedly assume that bodies are capable of becoming thin — and remaining thin — we give ourselves permission to castigate fat bodies for simply existing in their natural state, notes Sole-Smith. As she put it to us: “If we can make fat people thin, does that make it OK to hate fat people?”

Photo illustration: Jason Lancaster/CNN/Adobe Stock

This cultural permission to demonize fatness has devastating consequences, medically and otherwise. Revised obesity guidelines from the American Academy of Pediatrics that endorsed weight-loss surgery and medication in some cases prompted controversy earlier this year.  New research shows that weight-loss surgery is becoming more common for children and young people. At the same time, the myth of willpower – that if we only put our minds to it, we could all be thin – is baked into society and dominates so many obesity discussions in the United States, but it stands counter to a body of scientific and anecdotal evidence that our bodies prefer to exist at a biologically predetermined weight, said Sole-Smith.

This “set point theory” helps us to understand why weight is often impossible to keep off. When we change our lifestyles to maximize weight loss, our bodies respond by attempting to remain at their set point weights.  And as soon as we let up on diet, exercise or weight loss drugs, we usually see our bodies return to their original form. This is true, too, for weight loss drugs, making it hard to stop taking them without gaining the weight right back.

“This is not a bug; this is a feature,” says Sole-Smith.  “This is what enabled us to survive famines, to survive lean times when food was scarce. When you start to diet, your body does not understand. Your body says, ‘There’s food scarcity. I have to protect this body.’ And so your metabolism slows down, your hunger hormones increase and a number of other systems in your body kind of kick into gear to protect you.”

Medical institutions, for their part, have played a significant role in promoting a culture in which dieting is the norm and weight loss drugs are sought after. Though medical science has long pathologized fatness, it formalized a narrow definition of “healthy weight” through the adoption of the body mass index (BMI) in the 1970s.  BMI uses only height and weight to determine where an individual falls on a spectrum from underweight to obese and has been heavily criticized for the crudeness of its measurement, failing to distinguish between fat, bone and muscle mass.

“If you get on the scale and the doctor calculates your BMI, that number then dictates the whole rest of your appointment. That number will guide the doctor’s recommendations, but we know that number tells us very little about our health,” says Sole-Smith.  Research has also shown that BMI is an especially flawed and problematic metric for people of color. And yet, it remains ubiquitous in most doctors’ offices.

As Sole-Smith writes in “Fat Talk,” unlearning our society’s unswerving fealty to the importance of thinness “means deciding that thin bodies and fat bodies have equal value. To do this, you have to know that humans have always come in a variety of sizes; that body diversity is both beautiful and necessary. You have to believe that being fat isn’t a bad thing. And that means you have to challenge a lot of what you thought you knew about health, beauty and morality.”

With all that at stake, it’s no wonder that so many of us would find a weekly injection an infinitely easier proposition. So, if you’re a health-conscious adult or a parent trying to raise a healthy child, what does living in the age of Ozempic mean? CNN Opinion spoke with Sole-Smith about Ozempic, diet culture and how to begin to answer these questions in a new way.

This interview has been edited and condensed for clarity. 

CNN Opinion: Can you explain what diet culture and anti-fat bias are and how they manifest in everyday life and in popular culture?

Virginia Sole-Smith: Diet culture is all the messages that we get about how our bodies are supposed to be – how we’re supposed to eat, move, take care of our bodies. And it has lots of different sources: media, social media, doctors, government, public health messaging and so on. It’s also created within families.

And then underpinning diet culture is anti-fat bias: the belief that bigger bodies are less valuable, less healthy, less beautiful, less everything than thinner bodies. It shows up in terms of the cultural messaging that we get around food. But it also manifests in very real ways. People in larger bodies tend to earn less money than thinner folks. We’ve got research on teachers’ attitudes towards fat students in school showing that they think they’re less intelligent, less social. It’s all these negative stereotypes about fat people that then translate to the way we treat fat people in every realm of society.

CNN: How do you see Ozempic affecting or changing diet culture and how we as a society perceive or talk about our bodies?

Sole-Smith: In some ways, this isn’t new. I think we’ve been here before with other weight loss drugs, but Ozempic is definitely turning up the volume.

We all know diets don’t work. That message is out there already. Even diet companies always say they’re not a diet, because diets don’t work. We know they have a really high failure rate.

If we think of fatness as something we can change, it becomes culturally more OK to no longer want to be fat or to feel negatively toward fat people.  And this is what I think is really scary. Number one, it’s extremely unlikely that Ozempic is going to be the silver bullet for everybody. Not everybody is going to lose dramatic amounts of weight on it. Number two, it’s very expensive. So this “fixing fatness” is only going to be available to people who can afford it. (A 30-day course of semaglutide for weight loss costs over $800 in the US.)

You’re going to see a whole class stratification around this. And there’s something really, really dark about the idea that we can just change people’s bodies and not deal with the bias that we have toward those bodies.

CNN: You’ve been studying and writing about food and body image for a number of years. How does this current moment in culture and society, in your estimation, compare with previous ones? Where are we right now on this issue?

Sole-Smith: We’re in a kind of a messy middle space. When I was a teenager in the 1990s, diet culture was very loud. This was the era of Jessica Simpson, Britney Spears – a very clear ideal:  thin, low-rise jeans, all of that. It felt like there was no alternative path available for young women in that generation.

Now, we have seen fat activism and body positivity getting more attention. And this is one of the good things about places like Instagram and TikTok: They have given rise to more body-positive folks and have allowed their voices to be amplified.

But with that progress definitely comes a backlash. And I think Ozempic is a big part of that backlash. We’re talking about billion-dollar industries here. No one is going to say: “You’re right. We’ve been so mean to people. Let’s change our tune.” No, they’re constantly repackaging and finding new ways to sell us the same things.

CNN: How do you see the popularization of weight-loss drugs impacting the body image of adults and of particularly young people, who are taking in these messages at such a young age?

Sole-Smith: I mean, this is the really scary thing, right? Ozempic is going to be prescribed by doctors. I think parents feel more comfortable telling kids, “Don’t listen to that YouTuber. Don’t listen to that beauty influencer.” Those are so obviously sources of toxic body messaging that we can identify. But when it comes from health care providers, it’s so much more complicated, because these are people we should be able to trust. These are people who should have our best interest front and center. And yet the medical profession is not a profession that has done a very good job of grappling with their endemic anti-fat bias.

I can tell you when I interview people about their eating disorder histories or relationships with their bodies, one of the most common origin stories is a comment their pediatrician made about their body and about their weight. So doctors are doing real harm. And I think it’s much tougher to unhear a comment coming from a source like that than it is to sort of step back from a celebrity.

CNN: You write in the book that bodies by definition are ever-changing. How does internalizing that message change the conversation?

Sole-Smith: I think about that a lot. I was a thin kid, and I live in what I describe as a “small fat” body as an adult. I remember when I realized I wasn’t going to be thin for my whole life. I felt like I had failed myself in some profound way. Like I had abandoned who I really was, when in fact this is just what my adult body is. I’m still the same person. I still have the same identity and talents and flaws. But because we’ve been sold this myth of this idea that our bodies should be a fixed point in time, that’s what leads us to attach our self-worth and our identity to our body size.

I worry about this a lot with kids. I worry for kids in bigger bodies who are being told from such a young age, “your body’s a problem. You have to fix it.” That fix is probably not something that’s attainable or sustainable or safe for them and is going to raise their risk for eating disorders and other issues. And if you’re telling thin kids, “Your body is your value; you have a runner’s body; you have a dancer’s body,” well, guess what? They’re going go through puberty. They’re going to age and grow up. Maybe they’re going to have a baby. Their bodies aren’t always going to be 12. And that’s a good thing.

If we could embrace the idea of bodies changing as a given – as something to celebrate – it would really make it easier to step back from all this pressure.

CNN: Does prescribing weight loss drugs even to people who aren’t overweight reinforce the presumption that being thin is healthier than being fat? You point out in your book that fatness isn’t inherently unhealthy or a disease. What are the risks of conflating thinness with health?

Sole-Smith: We’ve been pathologizing fat bodies for decades now, and we’re seeing the harm of that for sure.

So many studies start out with an accepted premise that being fat is unhealthy and then go from there with whatever question they’re researching when the reality is that we only have correlation showing relationships between weight and health. We don’t have causation in any studies. And when we look at those correlations, very often they’re mitigated by other social determinants of health, such as experiences of weight stigma.  We know weight stigma can be a driver of poor health outcomes because your doctor might not give you the same level of treatment they give a thin person. They might be less likely to refer you for tests. They might take you less seriously. They might not listen to your pain.

All of that has pretty concrete outcomes on people’s health. And it also means that people are more likely to avoid going to the doctor. So then when they finally do go, they’re sicker when they get there, and then that reinforces the whole stereotype.

Photo illustration: Jason Lancaster/CNN/Adobe Stock

I think making obesity a disease, which the American Medical Association did in 2013, had some good intentions behind it. I think they thought it was a way of combating the willpower myth and helping people understand that body size is not a choice or something that people have as much control over as we think. But it feels like all it really did was give people another reason to stigmatize fat bodies.

Imagine if you go to the doctor’s office and they don’t have a blood pressure cuff that fits your arm, they don’t have an exam table that’s big enough for you. They don’t have a gown that fits you. They don’t have chairs in the waiting room you can sit in. All of that is telling you that your health is not valuable to the system. If considering obesity a disease was really about promoting the health of fat people, you would have systemic changes to health care so that fat people’s bodies were safe and welcome in those settings. And that’s just absolutely not the case.

CNN: There has been a cultural push to embrace all types of bodies such as clothing and beauty brands hiring models with a wide range of body types and celebrities posting unretouched photos. How do we reconcile that effort with the rise of Ozempic? Did body positivity fail?

Sole-Smith: I think the body positivity effort has been pretty strong and successful in a lot of ways. And I think the diet industry and the weight loss drug industry are all paying attention and realizing that they need to come back with bigger weapons. So I think that’s what we’re seeing.

I think the other piece of it where body positivity has failed or at least has not yet succeeded is the rhetoric. “You just need to let yourself be, embrace your cellulite, it’s fine. Just be you.”

But we’re talking about systemic bias. So I can love my body in my house all I want, but when I go to the doctor or out on the street, I’m still going to experience weight discrimination. So working on the personal issues is important, and people’s personal struggles are valid, and they deserve support for them. But if we’re not also thinking about this as a systemic social issue to address, we’re not making enough progress. We’re not actually undoing systems that are perpetuating the bias, and that’s what’s allowing things like Ozempic to continue to flourish.

CNN: We wanted to ask you about terminology and specifically the binaries that organize how we talk about bodies – thin versus fat, or in medical terms, healthy versus overweight – and how the concept of BMI contributes to what labeling. Can you talk about overreliance on BMI for a minute?

Sole-Smith: BMI is trash. That’s the bottom line. It’s useful in large-scale population tracking, but unless you’re an epidemiologist, it’s not a useful tool for you. And bringing it into clinical health care settings, I think, is one of the biggest failings of the last 40 or 50 years.

In many cases, BMI is the first thing they calculate when you go into the doctor’s office. That number then dictates the rest of your appointment. But we know that number is telling us very little about our health.

It also gets used in really dangerous ways; lots of different health care specialties use BMI cutoffs. So, for example, at fertility clinics if you’re over a certain BMI, they often won’t give you infertility treatment. To use BMI as a weapon in this way against fat patients causes so much harm. Getting BMI out of American health care would be an enormous victory.

CNN: The popularity of weight loss drugs is skyrocketing at a moment when 1 in 5 kids worldwide are showing signs of an eating disorder and there are a lot of post-pandemic concerns about kids’ mental health.

Sole-Smith: It’s been really disheartening to me to see that we are only now having the conversation about kids’ mental health. But the conversation we had first was about pandemic weight gain and all the hand-wringing about kids getting fatter because of the pandemic. Yeah, people’s bodies changed during the pandemic, people’s activity levels changed, we were experiencing trauma, and we know there’s a relationship between trauma and weight gain.

Even now that the mental health conversation is happening more, it seems like there’s still this focus of, like, “Well let’s get kids more active, and let’s get kids off screens.” And it’s not like “Let’s sit and help kids process the trauma of the last few years. Let’s help them grieve for what they lost, the experiences they lost. Let’s give them tools to talk about their feelings.”

CNN: Meghan McCain reported being offered Ozempic as a kind of postpartum fix. Can you talk about the intersections between diet culture and beauty culture, especially for women? There’s the narrative of getting your body back or the “mommy makeover,” even beautification filters on TikTok. Will we ever accept women’s bodies especially as ever-changing? What do we need to do to get there?

Sole-Smith: I think for women, and mothers in particular, it’s really tied to a societal change in terms of how we value caregiving and parenting. We still operate from this perspective that being a mother is a woman’s most important contribution to society – but also something you should do invisibly and that should not impact your ability to have a hard-charging career or result in a messy house.

I think if we were a culture that valued caregiving and motherhood in a different way, in a more actually supportive way, we would celebrate the body changes, right? There would be no need to still look five years, 10 years younger and like you never gave birth. You wouldn’t be paying a price for looking like you “let yourself go” for aging, for gaining weight. It wouldn’t work against you in job interviews. It wouldn’t work against you if you’re dating again. It wouldn’t be this albatross around your neck like feels to a lot of us now.

I don’t blame any individual women for pursuing the cultural standard of beauty, because it often feels like a necessary survival strategy in our culture. That just is the reality. You have to play this game that someone else rigged, and maybe you have to do what you have to do. But that being said, I think to whatever extent we can, maybe the first step is being more honest. To say: I’m doing this as a survival strategy. I’m not doing this because I’m going to be so happy and feel so much more fulfilled if I’m a size six.

CNN: Speaking of survival strategies, we were wondering if you have any advice for people who are going to continue to engage on social media platforms but don’t want to take in or inadvertently amplify content with an anti-fat bias.

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Sole-Smith: You can’t recast a Netflix show to have fat actors if they’ve put all skinny people in it. But you can go on your Instagram feed and unfollow any account that promotes diet culture, that perpetuates anti-fat bias, that makes you feel icky about yourself in any way. And you can actively seek out body diversity in anything you’re interested in. I follow fat rock climbers, fat figure skaters, fat dancers. You can find people doing whatever passion you have in non-traditional bodies. I think it can be a force for good in that sense. I’m not a proponent of taking social media away completely. I am a proponent of delaying how old kids are when they get on. Because we know that once you open up this can of worms, there’s no going back.

I talked to parents in the book who had pretty relaxed approaches to screen time. But they were talking to their kids about what they were doing, and their kids were saying, “Hey, look at this TikTok. This is so fatphobic.” And so then it became this great opportunity to, you know, to actually help kids question for themselves what they’re seeing.

CNN: Do you have thoughts about how to change the stigma around language? Is that a big piece of changing anti-fat bias?

Sole-Smith: I absolutely do, and I recognize this is a really difficult one for people. If the word “fat” has been weaponized against you – if you were teased for being fat as a kid – it feels really hard to say “fat” in a neutral way. I think often I have been able to reclaim it because I was a thin kid who became a fat adult. But I have found it to be absolutely revolutionary in my own relationship with my body and in my own parenting.

This is one aspect of me, this does not totally define me. It’s like saying I have brown hair or I wear glasses. It makes fat no longer the sort of evil thing to be avoided, because it’s just a fact about you. So it can be really liberating, but it is hard to do, and I think it’s important, that you can’t reclaim it for other people. If someone else is not comfortable identifying as fat, it is not your place to call them that.