How will cheaper versions of Ozempic tip the scales? | Canada Voices

Every two years, Statistics Canada publishes new data about obesity from a long-running project called the Canadian Health Measures Survey.

Contrary to its name, the survey is more than a questionnaire. It’s a head-to-toe checkup of more than 5,000 volunteers whose physical health is meant to stand in for the fitness of all Canadians.

Inside roving tractor trailers transformed by StatsCan into temporary examination centres, health professionals test the volunteers for a litany of health indicators.

They ask their subjects to step on a scale. They wrap a tape measure around each volunteer’s waist, providing StatsCan with a measurement of adiposity, or excess belly fat, which doctors around the world now consider a better proxy for health than body mass index alone.

By either measure, Canada has a weighty problem – and it’s growing.

Sixty-eight per cent of adults were classified as overweight or obese in 2022-2024, an 8-percentage-point increase from 2016-2019. What’s more, half of Canadian adults have abdominal obesity, a dangerous accumulation of fat around their midsections, up from 39.5 per cent in the pre-pandemic period.

“Obesity had been trending up for a very long time at a relatively stable rate,” said Arthur Sweetman, a health economist at McMaster University who analyzed a separate set of StatsCan data for a paper on obesity trends published in July. “And then during COVID, there was a big jump.”

The pandemic, and the rules imposed to control it, seem to have acted like an accelerant on a public-health crisis that had been smoldering for decades.

Canadians were gaining weight, most experts agreed, because the world around them had become an obesogenic trap filled with irresistible, calorie-rich convenience foods. Some could resist its pull, if they had favourable genetics and the means to buy healthy meals and gym memberships, but for many others, the snare felt inescapable.

So that is the shape of things – the shape of Canadians – as this country embarks on a history-making experiment in the fight against fat.

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This year, Canada could become the first country in the West, and possibly the first in the world, to get generic copies of semaglutide, the culturally ubiquitous Type 2 diabetes drug best known as Ozempic. Semaglutide is also sold as Wegovy, a higher-dose version approved specifically for weight loss, as well as for cardiovascular and metabolic liver disease in Canada.

For reasons Ozempic-maker Novo Nordisk has declined to explain, the Danish company allowed the Canadian patent on semaglutide to lapse in 2020. A related shield against generic copycats expired on Jan. 4, just as many Canadians were looking in the mirror and promising themselves that 2026 would be the year they’d finally make their weight-loss resolutions stick.

It’s not clear exactly when generic Ozempic will hit Canadian pharmacy shelves. Health Canada is still reviewing applications from drugmakers.

But whenever it debuts, generic Ozempic will be cheap. A pen containing four weekly injections of 0.5 milligrams of the medication could drop from a base price of $223 to as low as $78 – less than the cost of one fancy restaurant meal users will no longer have the appetite to finish.

Generic Ozempic could prove to be a godsend for Canadians who are obese and in ill health, especially those who’ve discovered for themselves what decades of research shows: Once weight is gained, it’s rarely lost and kept off with diet and exercise alone.

Most major medical societies, including the Canadian Medical Association, have recognized obesity as a chronic disease for years, but only one province, Alberta, has followed suit with a formal declaration of its own.

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Affordable semaglutide could lighten the load of weight-related chronic diseases on Canada’s public health system. Failing to treat obesity cost Canada $27.6-billion in 2023, including $5.9-billion in direct medical costs, according to a report from the advocacy group Obesity Canada and Eli Lilly, which, admittedly, has a vested interest in inflating the financial toll of obesity. Eli Lilly makes Zepbound, a Wegovy competitor.

There are, however, downsides to a world awash in cheap and plentiful copies of Ozempic.

Ozempic’s side effects of nausea, vomiting, diarrhea and constipation are common and sometimes severe. Rapid weight loss with glucagon-like-peptide-1 receptor agonists (GLP-1s), the class to which Ozempic belongs, can lead to sarcopenia, a significant loss in muscle mass. A minority of users lose little to no weight on Ozempic. Most who do must inject GLP-1s in perpetuity to keep the pounds off – although, as obesity doctors note, that’s also true of medications for other chronic diseases.

Perhaps just as concerning, generics will make semaglutide affordable to nearly every person who’s ever pinched an inch of fat on her thighs and wished she lived in a lighter, more waif-like body.

“She” is the right pronoun because, if current sales of weight-loss drugs are any guide, it will be Canadian women crashing telehealth platforms and begging their doctors for prescriptions of semaglutide, despite rates of overweight and obesity being higher among Canadian men than women.

In other words, cheap copies of Ozempic aren’t entering a body-neutral culture. They’re entering a world of SkinnyTok and weight-loss influencers and a COVID-era rise in eating disorders that was the twin ill of the pandemic-associated spike in obesity rates.

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As the age of inexpensive weight-loss drugs begins, perhaps the trickiest question to answer is a twist on the old saw at the end of every drug commercial – is Ozempic right for you if you merely have 20 or 30 pounds to lose and are otherwise healthy?

Pharmaceutical companies, recognizing the gargantuan market for thinness, are already pushing the culture in that direction. They have pipelines stuffed with next-generation drugs that target multiple satiety-inducing hormones and produce more weight loss than Ozempic.

Cheap Canadian semaglutide is only the beginning.

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‘I wish my brain didn’t think like that’

Eva Zhu has had a tumultuous relationship with her body, and society’s expectations of it, for as long as she can remember. Her parents, who are from mainland China, where she was born, would have her step on a scale in front of them when she was a teenager.

Her naturally thick frame – muscular from practicing karate and playing sports – set her apart from the rail-thin Chinese girls her family considered normal.

Ms. Zhu, now 29 and working as a freelance journalist in Toronto, says she’s more confident in her body today than ever. She’s getting married this year. Her eclectic friend group is made up of women of different sizes who have more important things to talk about than their waistlines.

Yet a beat after pronouncing herself body-confident, Ms. Zhu had this to say: “It’s not like I’m perfect. I still stare in the mirror a lot. I still analyze my face at every angle. I still stand facing sideways in the mirror and look at the pouch on my stomach and think, ‘Oh, is that smaller than it was last month?’ I still look in the mirror and I’m like, ‘Oh, I don’t have very much of a neck, and I would love to get chin lipo one day. I wish my brain didn’t think like that. But having been, I think, conditioned in my life, especially when I was younger, to believe that I was overweight … that really sticks to you.”

Ms. Zhu started taking Ozempic last February on the advice of her doctor, who was worried about her high cholesterol, polycystic ovarian syndrome and a hemoglobin A1C reading, a long-term measure of blood sugar, that put her in the prediabetic range.

The nausea, which was ferocious in her early weeks on the medication, has mostly subsided. She lost about 10 pounds over eight months. The last she checked, she weighed 188 pounds. Her A1C is now in the normal range. Blood sugar control is important enough to her that she plans to keep taking Ozempic, the cost of which is mostly covered by her partner’s private insurance.

Ms. Zhu is glad to hear that uninsured patients who need GLP-1s for weight-related illnesses will be able to get inexpensive semaglutide in Canada this year, but she bristles at the idea of people using it for cosmetic purposes, despite her complicated view of her own size.

“People who are already a very healthy weight, who want to look like Kim Kardashian, are going to be using the drug just for that purpose,” she said. “But I do think the benefits outweigh the problems.”

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Despite Ozempic being a widely discussed cultural force, few rigorous studies have explored how GLP-1s affect body image and weight stigma, particularly for women, who’ve long paid a higher price than men in the job and dating markets for being overweight.

In 2024, nearly 530,000 Canadian women took drugs for weight loss, according to a report from IQVIA Canada, which aggregates prescription sales. Only about 150,000 men took them, a stark reminder of the way women are judged, and judge themselves, by the size of their bodies.

Deborah McPhail, a health sociologist and associate professor in the College of Community and Global Health at the University of Manitoba, is among those who wish there was more time to stop and consider the unintended cultural consequences of weight-loss drugs.

The body positivity movement was just starting to put a dent in bias against people who are overweight and obese, she said. “Now we’re at this place where everyone’s like, ‘Well, great, now just take a drug. But what if you can’t take a drug? Or what if you don’t want to take a drug?” she said. “People are worried it’s going to double or triple people’s experience of stigma.”

One recent study of 225 students at a northeastern U.S. university found, perhaps unsurprisingly, that the respondents most eager to try GLP-1s reported “greater body shame, body surveillance, weight concerns, anti-fat bias, disordered eating behaviors, and higher BMIs, as well as lower body appreciation and body neutrality.”

Another American study predicted that, if those shame-riddled respondents went ahead and tried a GLP-1, they would be shamed for taking a shortcut to thinness.

That study asked nearly 360 people to pass judgment on a fictional white woman in her 30s named Sarah. In one scenario, Sarah lost 15 per cent of her body weight through diet and exercise alone. In another, she dropped pounds with the help of a GLP-1 drug. Survey-takers viewed the Sarah on a GLP-1 as a lazy cheat, regardless of what weight she started out with.

Those findings mirror the larger body of research on perceptions of weight-loss surgery, said Katey Park, a postdoctoral fellow at the bariatric surgery clinic at Toronto’s University Health Network who is in the early stages of developing a study of GLP-1s and body image.

“Metabolic and bariatric surgery doesn’t eliminate weight stigma. Even though weight bias may decrease alongside weight loss, many patients face judgment for their treatment route. Some may believe that they took the ‘easy way out,’ quote unquote.”

Societal bias against people with obesity persists, doctors in the field say – nowhere more plainly than in how provincial public insurance plans treat semaglutide and other drugs in the GLP-1 class. They cover semaglutide for diabetes, but not for weight loss.

“Imagine if you had limited therapy for a different chronic disease?” said Stephen Glazer, medical director of both the medical and surgical bariatric programs at Humber River Hospital in Toronto. “Obesity is a chronic, relapsing, unrelenting, recurring disease that absolutely deserves the same status as diabetes and hypertension and coronary disease.”

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Is it really right for everyone?

In the early days of Dr. Glazer’s two-decade career, there weren’t many treatment options for people living with obesity.

He and his colleagues didn’t have much to offer patients beyond diet-and-exercise advice, a welcoming clinic space with generously-sized chairs and toilets, and bariatric surgery.

Gastric bypasses and other procedures that shrink patients’ stomachs and appetites have long track records of producing durable weight loss, but they carry the risks of a major operation.

The medical weight-loss landscape began to shift with the arrival of the first generation of GLP-1 medicines, which mimic a hormone that acts on receptors in the brain to make users feel full quicker and for longer.

Early GLP-1s such as liraglutide, sold as Saxenda for weight management, were immediate-release formulas that had to be injected daily and prompted modest weight loss. Semaglutide, first approved as Ozempic for diabetes in Canada in 2018, was revolutionary because it was long-acting, could be injected weekly and, for some patients, produced substantial weight loss.

What the pioneers of GLP-1 science didn’t know at the outset was that the class would prove to be a Swiss Army knife for metabolic diseases, capable of reducing the risks of cardiovascular disease, kidney disease, sleep apnea, peripheral artery disease, osteoarthritis and liver disease.

Slimming down reduces the risk of chronic illness, but GLP-1s also appear to provide some benefits independent of weight loss. For instance, a new analysis of data from the Novo Nordisk-funded SELECT study – a randomized control trial with nearly 18,000 participants that led to semaglutide being approved to lower the risk of heart attacks – found that markers of cardiovascular health improved for participants who didn’t lose much weight or weren’t very heavy to begin with.

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All that said, Ozempic won’t end obesity or its associated illnesses, said Sanjeev Sockalingam, scientific director of Obesity Canada. “There’s never been a magic bullet for obesity, despite every commercial telling us otherwise.”

One group often forgotten beneath the hype, Dr. Sockalingam said, are those for whom GLP-1 drugs simply don’t cause much weight loss.

In the pivotal Novo Nordisk-funded trial of injectable semaglutide for weight loss, 86.4 per cent of participants who took a weekly 2.4-mg injection lost at least 5 per cent of their body weight, which means about 14 per cent didn’t achieve even that modest goal. Other studies have put the share of so-called non-responders even higher.

Scientists still are trying to determine why GLP-1s don’t help everyone lose weight. One possible culprit is genetic variations that influence hunger and satiety.

Where does that leave people like Jill Hepburn, a 70-year-old Woodstock, Ont., woman who is 100 pounds overweight and who found that Ozempic and Wegovy didn’t help?

“I kept thinking, ‘am I doing something wrong? Why is it not working?’” Ms. Hepburn said.

Ms. Hepburn, who was vice president of underwriting and claims for an insurance organization before retiring, became violently ill when she started on the lowest dose of Ozempic in 2024. She stopped after a month. Then she decided to try again, staying on the lowest dose for three months.

As her body adjusted to the medication and the side effects subsided, her hunger returned. Switching to Wegovy and increasing her dose didn’t curb it.

For Ms. Hepburn, who has a warm laugh and self-deprecating manner, Ozempic was no more effective at controlling her appetite than a lifetime of white-knuckle dieting.

“I’ve tried everything,” she said. “I’ve tried Weight Watchers and all those clubs for weight loss. I’ve done Dr. Bernstein, where you get the needles in your butt. I paid $14,000 for a lap band. Yes, I did lose the weight, but I spent 10 years throwing up on a regular basis. And then one time I felt my stomach was wet, and I looked and there was a hole in my stomach, so I had to go back in the hospital.”

For a time, she stopped trying.

“I just said, ‘This isn’t working for me, because no matter how little I ate, the weight just kept coming back.”

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‘The easiest thing I’ve ever done’

For people who’ve battled their weight unsuccessfully for years, the inner turmoil can feel never-ending. Consumed with thoughts of food and how to eat less of it, they deprive themselves of simple pleasures − homemade stuffing at Thanksgiving, sweets on birthdays − often with nothing to show for it. Their hunger roars on. Their weight barely budges.

That was how Virginia MacKinnon felt when she tried to lose weight without the help of medication. Ms. MacKinnon, a 70-year-old retired social worker from Sault Ste. Marie, found taking the weekly injections, first of Ozempic, then of Wegovy, to be a revelation.

“This was the easiest thing I’ve ever done,” she said.

Once she got over her initial nausea, Ms. MacKinnon felt liberated from food cravings. She often felt so full so fast she couldn’t leave a restaurant without a doggy bag.

Saving on food helped Ms. MacKinnon offset her monthly bill for Wegovy, which comes to about $110 after private insurance covers 75 per cent of the cost.

In a little less than a year, Ms. MacKinnon shed 90 pounds from her 5-foot-7 frame, dropping to 160 pounds from 250 pounds. Her joints ache less. She has cut her dose of blood-pressure medicine in half. She feels healthy enough to care for her husband, who uses a wheelchair, for years to come.

“I’m very grateful that they found something that will work,” Ms. MacKinnon said. “And I’m looking forward to the generic one coming out, so that it could be a little cheaper and possibly covered completely, because I plan to stay on it for the rest of my life.”

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Abdul Hanan, 36, is taking a different approach. He stopped using Ozempic last August after losing 30 pounds in about five months. He is down to about 150 pounds and has managed to keep the weight off, although he’s aware of the studies that suggest the pounds are likely to return without medication.

Mr. Hanan, who doesn’t have diabetes or a family doctor, turned for his Ozempic to one of the for-profit virtual care companies that have sprung up in Canada since the COVID-19 pandemic. Several specialize in prescribing weight-loss drugs and shipping them in discreet packaging to clients’ front doors.

Mr. Hanan paid $320 for each pen containing four 0.5-mg doses of Ozempic, which he injected weekly.

He considers it cash well spent. Like Ms. MacKinnon, Mr. Hanan marveled at how Ozempic reduced and changed his appetite. McDonald’s meals, once a source of comfort, repelled him. “I was eating a lot of greens, a lot of salad, a lot of fruit, because that was more comfortable,” he explained.

Most important to him personally, Mr. Hanan’s physical fitness improved. He was spurred to try Ozempic by the humbling experience of turning back near the start of the Grouse Grind, a notoriously punishing uphill hike in Vancouver, where he lives. He completed the hike in one hour and 39 minutes this past summer.

Mr. Hanan has even become comfortable enough with his Ozempic experience to joke about it during his sets as an amateur comedian.

His decision to stop was not motivated primarily by the cost, but because he had reached his goal weight. Even now, Mr. Hanan said, “the change in appetite and the change in habits have stayed with me.”

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Body mass index in the Ozempic era

When Ms. MacKinnon started on semaglutide, her BMI was in the obese range, meaning she met the terms of the label for Wegovy. Mr. Hanan’s BMI was lower and he didn’t have any weight-related illnesses, though he feared developing one.

The fact that both were able to get prescriptions for GLP-1 medications in Canada highlights that access to the drugs is already something of a Wild West.

For decades, public health authorities around the world defined obesity through BMI, a crude scale in which the dividing lines between “normal,” overweight and obese are based, in part, on the insurance records of white men in mid-20^th Century America.

Canada and most other countries classify people as underweight if their BMI is less than 18.5. Normal is 18.5 to 24.9, overweight is 25 to 29.9 and obese is 30 or over. For simplicity’s sake, a 5-foot-7 person (the index doesn’t differentiate between men and women) would be considered normal at 150 pounds, overweight at 175 pounds and obese at 200 pounds or more.

Critics of BMI – and they are legion – say the index doesn’t illuminate whether patients carry dangerous visceral fat around their central organs, the kind most associated with diabetes, hypertension, heart disease, non-alcoholic fatty liver disease and other metabolic illnesses. If BMI is to be trusted, Dwayne “The Rock” Johnson is, famously, obese.

“As I explain it to my patients, quite simply and clearly, weight doesn’t tell us anything about fat,” said Katherine Morrison, co-director of the Centre for Metabolism, Obesity and Diabetes Research at McMaster University in Hamilton.

Dr. Morrison was part of a 58-member international commission convened by medical journal The Lancet that in January of 2025 proposed a new definition of obesity, along with specific criteria to diagnose it.

The commission, whose conclusions were endorsed by 76 groups, including scientific societies and patient advocacy organizations, divided obesity into two categories: clinical obesity, for people with excess adiposity and one or more of the illnesses associated with excess fat, and pre-clinical obesity for people with excess adiposity who were otherwise healthy.

Excess adiposity, the Lancet group said, should be confirmed through a direct measure of fat such as a body composition scan. If that equipment isn’t handy, a tape measure to note waist circumference, waist-to-hip ratio, or waist-to-height ratio will do. What won’t, the commission added, is relying on BMI for anything other than a population-level view of how rates of overweight and obesity have changed over time.

That’s how Statistics Canada views the body mass index.

“It gives us an idea of where the population is, and it does show a trend that it is upward, and that’s where it becomes worrisome, no matter how flawed the indicator is,” said Philippe Rousseau, a StatsCan analyst who works on the Canadian Health Measures Survey, the one that uses in-person exams. “We try to be clear that it’s not a measure of beauty.”

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Of course, BMI could wind up mattering a great deal to individual Canadians who want cheap semaglutide but don’t meet the terms of the drug’s label. Wegovy, the version of semaglutide approved explicitly for weight loss, is Health Canada-approved for people who are obese (a BMI of 30 or higher) or overweight (a BMI of 27 or higher) with at least one weight-related comorbidity, such as hypertension or obstructive sleep apnea.

However, physicians and nurse practitioners in Canada have wide latitude to prescribe medications off-label if they feel it’s best for their patients. People who don’t fit the parameters but are carrying a few extra pounds might prefer to nip the problem in the bud before they develop a weight-related chronic illness.

Many physician leaders are urging their colleagues not to prescribe weight-loss drugs to patients who don’t meet the terms of the label.

“This is not a cosmetic medication for me,” said Subodh Verma, a cardiac surgeon and scientist at St. Michael’s Hospital in Toronto who co-led SELECT, the international trial of semaglutide for cardiovascular disease.

“I’m completely for using it for people with overweight and obesity who have comorbidities and people with advanced obesity, but not for people who actually are not even overweight, who feel like they want to lose a few pounds,” he added. “That is truly colouring outside the lines.”

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‘I know how hard you work at this’

It’s too early to tell if GLP-1s will affect overall obesity rates in Canada. The most recent reliable data, as StatsCan has reported, show the rates going up, not down.

Novo Nordisk says about one million Canadians are taking Ozempic or Wegovy. But Wegovy, the weight-loss-specific version, didn’t become available in Canada until May of 2024, near the end of the data collection period for the most recent Canadian Health Measures Survey, and after the 2023 cut-off for StatsCan’s Canadian Community Health Survey, which asks respondents to self-report their height and weight to calculate BMI.

In the meantime, some Canadian doctors hope the widespread availability of a cheap GLP-1 will reframe obesity for the wider public as a chronic disease arising from a complex interplay of genetics, the social determinants of health and a food environment stuffed with processed junk – not a moral failing.

“Just as you don’t control your estrogen levels or your progesterone levels with your will power, you don’t control your satiety hormones or your hunger hormone, ghrelin,” said Sabrina Kwon, medical director of the Alberta Obesity Centre North in Edmonton.

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Dr. Glazer of Humber River, who is also the immediate past-president of the Canadian Association of Bariatric Physicians and Surgeons, added that, “As we’re learning more and more about the biological control of appetite, hunger and cravings, it provides not only a legitimacy to the discipline of obesity medicine, but also an element of compassion, understanding and forgiveness for those living with obesity.”

That grace should be extended to people like Ms. Hepburn, the Woodstock senior who didn’t lose weight on Ozempic. She knows others, including a male friend and her sister-in-law, who are taking Ozempic for diabetes and haven’t lost weight, either.

Ms. Hepburn is at last finding success with a high dose of tirzepetide, the drug sold as Mounjaro and Zepbound that targets GLP-1 and a second hormone receptor abbreviated as GIP.

She’s happy to have lost about 27 pounds since the end of October, although she’s bothered by the price of the still-patented drug. It was nearly $700 a month until a pharmacist told her about a drug-company savings card that dropped the price to $384 at one point. The magnitude of the discount keeps changing, she added, making her monthly bill unpredictable.

Ms. Hepburn’s family loves her no matter her size. She has a grown son and daughter and two grandchildren. “My kids say, ‘Oh Mom, don’t lose weight. You’re my mom. That’s how we know you,’” she said. “And my husband says, ‘I know how hard you work at this.’ He’s my biggest defender.”

But oftentimes people who’ve struggled with obesity for decades have the hardest time extending grace to themselves. “So many times I’ve said to myself, ‘That’s it. I’m not spending any more money trying to lose weight. It’s not working.’ And then I get discouraged, and try something new.”

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