Three years ago, a fashion editor friend returned from Milan Fashion Week bursting with a story to tell.

Most fashion editors stayed at the same hotel, she explained, and each bedroom had its own mini fridge. After checking out, en route to the airport, a stylist in her party cried out that he’d left “an important package” in his fridge and telephoned the hotel, pleading with them not to throw it away.

“Turns out he’d forgotten his Ozempic,” my editor friend whispered. We were baffled. Ozempic?

Back then, Ozempic was not part of the common lexicon. But quietly, in certain circles, this injectable drug, which is licensed for the treatment of type 2 diabetes, was being prescribed privately and off-label for weight loss.

Flash forward to today and the picture is vastly different. “So many fashion people are on it,” she tells me today. “And now they’re very vocal.”

Serena Williams, Elon Musk and Whoopi Goldberg have all spoken about using weight-loss injections. Some are now prescribed by the NHS, including Wegovy and Mounjaro, generating scores of headlines.

Really, this should have made it a great leveller. In theory, anyone struggling with obesity can – without the expense of a private doctor – get help to manage their weight.

Only that’s not the full picture.

Thousands of NHS patients are believed to be missing out. And with the NHS tightly restricting access, some working in the field warn a two-tier system around weight-loss drugs is developing – one that’s benefitting the most well-off.

Martin Fidock, who is UK managing director of Ovivia, which provides Wegovy and lifestyle support to NHS patients, claims that thanks to varying thresholds of eligibility in different regions, NHS prescriptions are a “postcode lottery”.

An estimated 1.5 million people in the UK use these drugs – but more than nine in 10 are believed to pay privately. Prices vary but it generally costs between £100 and £350 a month, depending on the dose and lifestyle support.

Then, last month, it was reported that pharmaceutical giant Eli Lilly was expected to increase the list price of Mounjaro by as much as 170%.

They have since done a deal for UK distributors, meaning rises are likely to be less, and the deal doesn’t affect the cost to the NHS – but it has still caused concern in some quarters.

“It’s scary,” says Brad, a tech company worker in his 40s. He has been taking Mounjaro for a year and worries he may not be able to afford to continue.

“I’ve lost 20kg and want to keep using it, but it’s a lot of money. It’s unfair.”

Nutritionists and GPs I spoke to have also expressed concerns about the broader system, and in particular whether existing health inequalities could worsen.

“We cannot allow good health to become a luxury for the wealthiest by limiting access to weight-loss drugs to those who can pay privately,” argues Katharine Jenner, executive director of Obesity Health Alliance.

So could it really be that weight-loss injections – for all of their benefits – are turning obesity into a wealth issue?

Weight-loss drugs have been available on the NHS for some time, but the landscape changed significantly with the introduction of some newer medications – among them, semaglutide, marketed under the brand name Wegovy, and tirzepatide, sold as Mounjaro.

Wegovy was first prescribed for obesity by the NHS in 2023, while Mounjaro followed earlier this year. They work in part as an appetite suppressant by mimicking a hormone, which makes people feel fuller.

Studies have suggested patients can lose as much as a fifth of their body weight.

They are licensed for people with a BMI of 27 or more for those with a health condition or above 30 for those without (adjusted for certain ethnic groups). But tougher NHS criteria are being applied, and in England and Wales the drugs are mostly restricted to those with a BMI of over 35.

Plus there are more restrictions too.

For Wegovy, local areas are making their own decisions on access.

Martin Fidock claims that in recent months a third of regional health boards have increased the BMI threshold, which he says has resulted in fewer people being able to get it. (The BBC has been unable to verify this data.)

A spokesperson for Novo Nordisk, the pharmaceutical giant that makes Wegovy, told the BBC it is “concerned about the growing disparity” in access to NHS specialist weight management services.

“This has led to a large proportion of people needing to pay out of pocket, an option which is out of reach in areas of depravation where obesity rates are significantly higher.”

NHS England has said the differences could be related to different levels of need and other providers being more active in certain regions, but confirmed it was up to local areas to decide how much to spend.

For Mounjaro, NHS England has started it for people with a BMI above 40 who also have certain health conditions. The NHS roll-out officially began in June, but a report published earlier this month suggests that not all general practices had started offering it.

Just 18 out of 42 NHS boards across England confirmed that they’d begun prescribing it in line with the roll-out plan, according to data obtained by freedom of information requests published in the BMJ.

The NHS has previously said it is supporting the phased rollout for eligible patients and that “these represent brand-new services in primary care that are being established and scaled up over time”.

But Mr Fidock believes we are seeing a “postcode lottery”.

“We have got an obesity epidemic and these drugs provide us with an opportunity to tackle it in a way we have never been able to do before. But your ability to benefit is dependent largely on whether you have the means to pay.”

Adding to the challenge is the fact that more people from deprived areas struggle with obesity in the first place: more than a third of people in the most deprived areas are obese – twice that of more affluent neighbourhoods.

Beyond the physical health risks – and there are many, including higher risks of cancer and heart disease, plus mental health problems – there may be social consequences too.

One US study found that obese men with a bachelor’s degree earn 5% less than their thinner colleagues, while those with a graduate degree earn 14% less. For obese women it is worse still, earning 12% and 19% less respectively, based on data concerning 23,000 US workers, published in The Economist in 2023.

NHS GP Matthew Calcasola, who is also involved in a service Get a Drip, which offers weight-loss drugs privately, has his own concerns.

“We’re concerned health inequality will build,” he says. “GPs worry about this.”

Meanwhile, a booming private market has emerged. Sara de Souza, a business analyst from Nottingham, is among those delighted that it has.

Following the birth of her son Vito in 2023, she put on 30kg. “I got to 96kg,” she recalls. “Me and my husband both got into bad habits. We were so busy, we were eating junk food and having chocolates.

“I was always tired and struggled to pick up my baby. But I just couldn’t lose the weight.”

Sara tried dieting and went to see her GP who referred her to a lifestyle diet and activity programme. But still the pounds stuck.

At her heaviest her BMI was 37.5, but she wasn’t eligible for NHS access and paid £200 a month for the drug through an app called Juniper, which also gave her diet and lifestyle advice. Within a year she had lost the full 30kg.

“It completely changed my life. I felt like a new person, alive again. It’s not just how I look, it’s how I feel and being able to keep up with my son.”

Sara says the cost didn’t impact her. “Even if it had, I’d have carried on, because of the benefits.”

Not everyone feels the same. Some 18% of overweight Britons would be willing to pay for weight-loss drugs – but if they were available on the NHS, 59% said they would be keen on using them, according to new polling by communications agency Strand Partners.

And some of those willing to pay privately fear they could find themselves being priced out following the proposed price spike.

“If I’d had to pay £300 or even more, I would have really struggled to afford it,” says Pete Beech, 57, from Southampton.

He weighed 18 stone and paid £160 a month for a prescription of Mounjaro to help him lose weight to qualify for an ultrasound treatment as part of his treatment for prostate cancer.

“The way the NHS is rationing these drugs has consequences beyond just obesity.”

James O’Loan, head of online pharmacy Chemist 4 U, has already observed some people stretching themselves financially to get hold of weight-loss drugs – some have asked for payment plans, which they cannot offer.

“Some people can’t move on to the higher doses because of cost,” he explains.

Then there are concerns about a weight-loss drug black market, or unscrupulous dispensing.

“Some services are desperate to dispense the stuff and don’t care what happens,” claims Professor Richard Donnelly, editor of medical journal Diabetes, Obesity and Metabolism. “People are just asked to fill in a quick questionnaire. There’s no proper medical assessment or follow up.”

He also stresses that they should not be seen as a quick fix. “They’re not there to lose a bit of fat around the tummy.”

Whilst generally well tolerated, there are risks of certain side effects — including nausea, constipation and diarrhoea. A study into potential serious side effects of weight loss jabs has also been launched after hundreds of people reported problems with their pancreas.

The NHS advises people never take a medicine for weight management if it has not been prescribed for them.

Some argue that the answer is, simply, to widen NHS access. The issue, of course, comes in part down to cost.

Michael Shah, senior analyst at Bloomberg Intelligence, believes that this could start to resolve itself in time.

“There are more than 160 weight-loss drugs in clinical development,” he says. Once available, he predicts that the competition could push costs down across the board.

“NHS bargaining power should improve as additional players and treatments enter the space.”

Earlier this year the Tony Blair Institute suggested that the drugs should be offered to everyone with BMIs over 27, arguing that it costs even more to deal with the consequences of obesity.

Obesity is estimated to cost the economy £98bn a year, according to research commissioned by the think tank, once you take into account lost productivity as well as the NHS treatment costs and the impact on the individual.

The Institute suggests a means-tested system with those entitled to free prescriptions getting it free and others self-funding or encouraging employers to share the cost.

NHS England has said it is looking at an option to “accelerate roll out to even more people in the future”.

But it also pointed out that weight loss drugs should not be seen as a “magic bullet”.

All of this begs a broader question – that is, in medicalising debates around tackling obesity, do we risk overlooking the wider social issue?

“By thinking we have a treatment for obesity we lose focus and stop thinking about the more difficult issues around the food industry and regulation, which are the root cause of this,” warns Greg Fell, president of the Association of Directors of Public Health.

“I do have concerns about equity of access,” he adds. “But I think the NHS has carefully thought about this and probably is, more or less, in the right place.”

In post-war Britain, obesity was rare due to food shortages and physically demanding lifestyles – lower-income groups were more likely to suffer from malnutrition.

Only since the 1980s have obesity rates risen across all social classes, with a growing disparity between rich and poor.

It is driven by several interconnected factors. Katharine Jenner argues there needs to be more done to address one of them in particular: our “broken food system”.

“People in poorer areas are surrounded by junk food advertising, more unhealthy takeaways, and face bigger barriers to buying healthy food,” she says.

“Without investment in prevention, health will get worse, inequalities will widen, and the costs will fall on all of us.”

How to effectively achieve that is perhaps the biggest question of all. But whatever the answer – and regardless of whether the onus really should be on the state or as others argue, the individual – it runs far deeper than the cost of a weight-loss jab.

“We live in a society that prizes freedom of choice and expression, values material wealth and tolerates vast inequality,” argues Chris Rojek, sociology professor at City St George’s, University of London. “In such a system, casualties are inevitable.

“It would be naïve — or even pious — to claim we can simply solve this. The answer is complex and touches the very fabric of our society.”

Top picture credit: Onzeg/ Getty Images

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