One of Dr. Mo Sarhan’s patients was experiencing intense cravings for opioids and alcohol when the Florida-based doctor offered him a striking solution: the Eli Lilly weight-loss drug Mounjaro.

“Within days, all of his cravings were gone and he was much more effective in his engagement and treatment. He’s done great since,” Sarhan says.

Sarhan and his colleague Steven Klein at the Caron Treatment Centers in Florida and Pennsylvania have prescribed a range of so-called glucagon-like peptide-1 receptor agonists (GLP-1s) to treat addictions, using them alongside traditional therapies, to around 75 patients.

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Kelly is aware that she should have been more careful when she signed up for a weight-loss medication online. She knows she should have looked into the company selling it, but, as she puts it, "desperate times call for desperate measures." She had gastric-bypass surgery in 2011, and that worked for a while, but then she started to gain the weight back after the "food noise" returned. "It's not like alcohol where you can abstain," she says. "You have to eat."

In May, she signed up for a subscription with Zealthy, a telehealth company she found through Google. It seemed simple enough: She was charged a subscription fee and a fee for the medication she ordered, semaglutide, which is basically generic Ozempic. She quickly noticed her food cravings and appetite had decreased. About six weeks later, she noticed she was losing weight. But then the billing got weird. Screenshots of the company's billing portal show that in September she was charged three times for one medication on top of the subscription fee and a separate "manual entry" charge of nearly $400. In October, her medication never arrived; the company blamed shipping delays on hurricanes in Florida. She tried to resolve the problem through the company's chat service and emails, trying to get the medication or a refund, but eventually, she gave up after failing to make progress on either front. She canceled the card she had on the account to prevent further charges. After filing a complaint with the Better Business Bureau, Kelly, which is a pseudonym, has gotten some of her money back, but she's still out hundreds of dollars. Zealthy didn't respond to a request for comment.

The topic of embarrassment came up throughout our conversation. Kelly has been overweight her whole life, and many people aren't particularly nice about it — they don't understand why she can't manage with just diet and exercise. "My pants don't fit if I so much as look at a cookie," she says. The experience with Zealthy only added to this sense of ostracism. Kelly's ashamed that she gained the weight back, that she let her guard down, and that she was taken for a ride.

But Kelly isn't alone: The explosion of new weight-loss medications has opened the door for all sorts of questionable business practitioners and outright scams. Drugs promising to help people lose weight are everywhere, and the fact that society prizes being thin — and punishes those who aren't — makes vulnerable people susceptible to tricks.

The diabetes and weight-loss drugs semaglutide and tirzepatide — which are generally referred to as GLP-1s and which you probably know by the names Ozempic or Wegovy, made by Novo Nordisk, and Mounjaro or Zepbound, made by Eli Lilly — have been game changers in obesity treatment and management. For people struggling with their weight, these drugs can seem like a miracle. But because the brand-name medications are so expensive and difficult to get, many people, like Kelly, are turning to other sources, buying copycats from online telehealth companies and sellers that have very little, if any, oversight.

Compounded versions of the drugs have been effective for many people, even if the Food and Drug Administration doesn't approve them and has warned against taking them. But not everyone has been so lucky. In Kelly's case, she's out a chunk of money. (She's not the only one with issues with Zealthy: The federal government has sued the company, alleging unfair and deceptive conduct including billing customers for things they didn't knowingly agree to and misleading people about their subscriptions.) For others, the consequences are not only financial but medical. Poison-control centers reported an enormous jump in semaglutide-related calls last year. One recent study looking at websites advertising semaglutide without a prescription found that 42% of the sites belonging to online pharmacies were part of illegal operations.

"We're a little bit in the Wild West," said John Hertig, an associate professor at Butler University's College of Pharmacy and Health Sciences. "It's just exploded so fast. There's so much money to be made here."

The marketplace is awash in companies trying to ride the Ozempic wave by selling compounded semaglutide, knockoff drugs, and similar-sounding supplements. Last year NBC News found that there were more ads on Instagram and Facebook mentioning semaglutide than there were ads for Viagra on the platforms. Semaglutide content is all over TikTok, much of it dubious. Phishing scams that use the medications as the hook have increased, as have other schemes designed to get people's data or payment information with the promise of access to the drugs. Reddit and the Better Business Bureau's website are filled with complaints about telehealth companies offering GLP-1 products — people describe unwittingly signing up for pricey subscriptions, never receiving medication, or finding it impossible to quit. It can be hard to discern a safe, legitimate offer from a dupe. Complicating things is that the FDA hasn't clearly established what's OK here, leaving consumers to figure things out for themselves. Even big-name telehealth companies are sending medications to patients without a lot of supervision.

"Every medication carries a risk, and they don't affect everyone equally," said Jessica Bartfield, a clinical associate professor at Wake Forest University's Bariatric and Weight Management Center. "So when you see these images and testimonials and stories about people who are on it for maybe inappropriate purposes or who are losing tremendous weight or who aren't being monitored the right way, then it normalizes it, and people think that that's OK."

The body-positive movement has spread the message over the past decade or two that you can and should love your body at any size and that health and beauty are not synonymous with thinness. That movement isn't necessarily a failure, but the rush to get semaglutide shows that American culture's preference toward skinny never went away, said Natalia Mehlman Petrzela, a history professor at The New School who wrote the book "Fit Nation: The Gains and Pains of America's Exercise Obsession."

"It's very clear that there are still a lot of people who — medical issues aside — really want to be thin," she said.

As much as the FDA and doctors might tell people that off-brand semaglutide and other products are risky, people aren't necessarily deterred from seeking them out. They see others getting results, and they want the same.

"You don't see this with cancer treatment. You don't see this with blood-pressure medications. You don't see this with antibiotics," Bartfield said. "This is a very unique field, and I can appreciate the appeal."

The rush of gray-market semaglutide and scams riffing on the desire for the drugs are a confluence of market need and market want — some people who really do need to lose weight for medical reasons are turning to alternative methods because they can't get or afford the "official" stuff, while others are using the medications more out of vanity. After all, the pursuit of dubious miracle products in the name of being thin and attractive has existed forever.

"I mean, Jane Fonda tells stories of mailing away for tapeworms," Mehlman Petrzela said. "In the '90s — and this is an approved thing — Olestra was a fat substitute, and the warning was anal leakage. And people were like, 'OK, whatever, if it makes you skinny.'"

The promise of being thin is an incredibly effective marketing tactic and one that's hard to resist, especially with this new class of drugs. My Instagram feed is filled with nearly indistinguishable ads for weight-loss medications that show a little vial of some clear substance, list facts and figures about weight loss, and mention how expensive the real stuff is. Sometimes it takes me a second to realize I'm looking at an ad, because it's just a person talking to the camera. Mehlman Petrzela told me she often sees ads for supplements promising to be "nature's Ozempic" on her feed. An acquaintance recently mentioned that after seeing all the ads, she signed up with a telehealth company to see if she qualified to get compounded semaglutide. After a consultation, she was denied. (She's quite thin and pretty clearly didn't need them.) But then, months later, she noticed the company had been quietly withdrawing $30 from her bank account each month. She'd missed it because the purchases were categorized as "groceries."

Eric Feinberg has researched Ozempic scams on TikTok in his role as vice president of content moderation at the Coalition for a Safer Web. He told me the social-media platform's algorithm is good at sending people down a "rabbit hole" of content once it figures out they might be interested in losing weight. "I'm not searching TikTok videos on Ozempic; it's coming right through my feed," he said. "That's the danger."

As part of his research, Feinberg engages with people purporting to be selling Ozempic or some version of it on TikTok. He sent screenshots of one of his recent exchanges with an account called Ozempicweightloos0 where the seller sent over a list of prices ranging from $90 for 0.25 milligrams of Ozempic to $110 for 1 mg. (For comparison, Novo Nordisk's website lists the price of 1 mg of Ozempic as $968.52.) The account stopped responding after he asked where the medication shipped from. It's a type of conversation he's had often — and alerted lawmakers and TikTok to.

Michael Jabbara, a senior vice president and global head of fraud services at Visa, said it saw a huge spike in chatter on the dark web about weight-loss scams in May and June. He posited that it was tied to the World Health Organization's warning around that time about fake semaglutide: The WHO noticed enough nefarious activity to issue an alert, triggering more conversations among bad actors about how well the scams are working. He said they realize that "this is a successful fraud scheme that is yielding a good return on investment for us, so we're going to continue to pursue it."

May and June are also the start of beach season, when people are looking to get their summer bodies — and maybe realizing it's too late unless they take some extreme measures. "Fraudsters are very attuned to cultural moments and what is attractive to consumers," Jabbara said. "They're very keen marketers."

One can't paint all the operators in the compounded-semaglutide and GLP-1 markets with a broad brush, because there's a lot of variation. There's a difference between major telehealth companies like Ro or Hims doling out prescribed medication and illegal pharmacies and scammers on WhatsApp or Telegram sending medications willy-nilly, if at all. But the reality is that everyone is operating in a bit of a gray area.

Except for the really sketchy stuff, compounded semaglutide and tirzepatide are generally coming from compounding pharmacies that make customized medications. Most of the time these pharmacies make medications for people with unique needs: You have an allergy to a certain dye usually used in the name-brand drug, so they make the drug without it for you. But when there's a shortage of the drugs — as there has been for GLP-1 drugs — the rules for compounding get a little looser, and the FDA allows copying.

There are some confusing wrinkles. For one thing, shortages don't last forever, and when they end, the copying is supposed to stop. The FDA took tirzepatide off its shortage list in the fall, which should have meant no more compounding. But after a compounding trade group sued the FDA over the decision, it said it would reevaluate.

Novo Nordisk and Eli Lilly both have patents on their drugs, and they're not eager to give up their secret sauce — meaning it's not clear how close the compounded concoctions are to the real stuff. And though the FDA has warned people that all the compounded drugs are risky, it's at the same time somewhat greenlighting them, people are being inundated with ads for them, and people are trying them out. The cat's already out of the bag.

"We're in somewhat of a no-man's-land in terms of no clear regulation, reduced government oversight, and a straight lab-to-lap delivery model," said Anthony Mahajan, a founding partner at the Health Law Alliance, a healthcare-focused law firm.

He added that telehealth and direct-to-consumer GLP-1 sales circumvent many of the checkpoints in traditional prescribing. Because these prescriptions aren't covered by insurers and are instead paid for directly by the consumer, there's no inspection by the government or insurers reviewing whether a drug is medically necessary and deciding whether to authorize payment. Compounds are also generally exempt from a federal law meant to stop harmful drugs from getting into the US's supply chain, meaning checkpoints for product sourcing and supply-chain integrity are missing. "Oversight agencies are cut out," he said.

It's tough to blame consumers or the companies distributing compounded semaglutide for getting into this business, given how expensive and difficult it is to get the name-brand drugs. Insurers generally won't cover Ozempic or Mounjaro unless a patient has diabetes, meaning that to get the medications, people who want to use them for weight loss have to cough up thousands of dollars a year. That's assuming their doctors will prescribe them, which, some won't.

"If you don't price it appropriately, if you don't have enough supply, then people are always going to find another way to get it," Hertig said. "And sometimes that other way to get it is safe, but in many examples it's not."

To ward off telehealth companies, Eli Lilly cut the price of Zepbound for certain patients who order directly from the company, though the drug is still pricey.

To some extent, this is a tale as old as time: People want to be thin and will go to great lengths to achieve that, and businesses are happy to oblige. But GLP-1 medications do seem to have put this dynamic into overdrive. These drugs really are everywhere — in commercials, on social media, in the news, in conversations. And everyone's getting into the semaglutide game: diet companies, gyms, even grocery stores.

Maybe this will all turn out fine. The regular versions of the drugs will become more available, and the generic ones will, by and large, work fine. Sure, there will be scams; that's true of everything. But that's not the only possible outcome. Many people may wind up not only losing money but also harming their bodies by injecting medications that aren't safe. And these medications are so new that it's hard not to worry that in five or 10 years we'll wonder why we allowed online companies to send compounded injected drugs around the country to people who were prescribed a medication after completing a five-minute survey.

Hertig said he expects tighter and clearer regulations on GLP-1s in the years ahead, which is good, though it doesn't help people trying to sort things out now. In the meantime, the miracle drug has people looking for miracles everywhere, including in places they shouldn't.

When people fall for traps or scams, they're often hesitant to admit it or advertise it. That's especially true for weight-loss products — the message American culture sends is that you're supposed to be thin and fit but you're not supposed to talk about how you do it. Society often treats being overweight as a moral failure and using a medication to take off pounds as cheating.

Kelly hasn't given up on semaglutide altogether. She's switched providers — she's now getting her medication from Hers — and continues to shed weight. The experience is "night and day." Her mom is nervous about her taking medication and worries about the unknowns, but that hasn't deterred Kelly. She hasn't told many people about the Zealthy experience, and she doesn't advertise that she's taking a weight-loss drug, though she'll be honest if people ask. Her doctor has been reluctant to prescribe her a GLP-1 medication, meaning she's still paying out of pocket. She thinks the reluctance was part of what landed her in a bad spot in the first place.

"That makes patients like myself especially vulnerable for fraud in the telemedicine world. We want and need to lose weight, have tried everything, and this is working for so many people," she said. "So we turn a blind eye to the risks."

Emily Stewart is a senior correspondent at Business Insider, writing about business and the economy.

The Biden administration on Tuesday issued sweeping health care proposals that would see Medicare plans greatly expand access to blockbuster GLP-1 weight-loss drugs, bar insurers from skipping out on paying certain claims that were granted prior authorization, and reinforce guardrails on the use of AI.

The proposals fit into the administration's existing aims to improve and protect access to care in Medicare and Medicaid programs. But, the future of the proposals is uncertain, as it will be up to the Trump administration to finalize the policies.

Anti-obesity drugs

The flashiest of the proposals is to reinterpret existing law in such a way as to allow Medicare and Medicaid coverage of anti-obesity drugs—particularly the extremely popular and pricy GLP-1 drugs Wegovy and Zepbound. Existing policy excludes coverage of drugs used for "weight loss" or "weight gain."

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• GLP-1 medications like Ozempic and Wegovy have skyrocketed in popularity for weight management.
• Taking them doesn't have to disrupt holiday celebrations, a doctor explained.
• Avoid mistakes like changing your dose, and don't worry about traveling with meds, she said.

Popular weight-loss drugs shouldn't keep you from enjoying the holidays, according to a doctor.

GLP-1 medications like semaglutide (sold as Ozempic and Wegovy) and tirzepatide (Mounjaro and Zepbound) have been a game-changer for weight management in recent years. Recent evidence also shows they may help prevent serious health threats like heart attacks and stroke.

They can influence appetite and the types of foods you might crave, but there's no reason they should dampen your holiday cheer, said Dr. Caroline Apovian, co-director of the Center for Weight Management and Wellness at Brigham and Women's Hospital.

"These drugs seem to alter what kinds of foods you're attracted to, but you still have pleasure with the food that you have an appetite for," she told Business Insider.

To stay on track and enjoy the season, avoid these misunderstandings about GLP-1 medications that arise around food-related holidays.

Don't stop taking medications or change your dose

It doesn't make sense to skip a dose of GLP-1 medication or take less over the holidays, Apovian said — you wouldn't do so with other prescribed medications.

The drugs work by acting on hormones that influence appetite and digestion, helping to lower what's known as your weight set point. That influences your hunger and metabolism.

As a result, it's a bad idea to try to tweak your dose or schedule without talking to your doctors.

"These drugs are not meant to be manipulated like that," Apovian said.

Don't feel like you're going to miss out on holiday fun

Taking a GLP-1 over the holidays won't prevent you from enjoying the festivities.

"It doesn't mean that you have no appetite. It doesn't mean that you're not going to want to eat turkey and the foods you'll have over the holidays. You're just going to probably want to eat less of them," she said.

Smaller portions are key — don't forget you can look forward to leftovers. It can also be helpful to slow down and savor your food so you can tell when you're starting to feel full.

And you may not feel hungry for another helping of dessert or may be more inclined to pass on that extra glass of wine.

If you miss a dose by accident, don't panic

While it's a bad idea to skip doses on purpose, it's not a crisis if you forget to pack it or forget to take it on time. The best course of action is to resume your normal weekly dosing routine as soon as you can.

"You just take it in the next time you have it. Nothing bad will happen," Apovian said.

If it's been more than five days since you were supposed to take it, move on to your next weekly dose. Don't double up.

Don't worry about refrigerating medications while you travel

GLP-1 medications like Wegovy and Mounjaro should be stored in the fridge, but will be just fine for a day of travel as long as they're not exposed to heat, according to Apovian.

"It's OK. All you have to do is not keep it at 100 degrees," she said.

Remember, this is not a quick fix

It's a mistake to think that weight loss medications can temporarily prevent weight gain over the holidays, or reverse it for New Year's resolutions.

Like any other medications for chronic conditions, GLP-1s are prescribed to people long-term.

"This a not a short-term anything, You're changing your metabolism," she said. "If you stop taking it, your metabolism will go back to where it was and defend that higher body weight."

People are sometimes hesitant to think of staying on GLP-1s forever, in part because of ongoing stigma around weight. However, they shouldn't be treated differently than drugs for other chronic conditions like high blood pressure.

"I think the stigma is affecting our understanding of the disease. That understanding will continue to expand. We'll get there," Apovian said.

Patients in China will be able to purchase the blockbuster weight-loss drug Wegovy for 1,400 yuan, or about $193, just a fraction of the US list price of $1,349, according to media reports.

The price in China is in line with pricing elsewhere outside of the US. As Sen. Bernie Sanders (I-Vt.) noted in a September Senate hearing, Wegovy, made by Novo Nordisk, is sold for $265 in Canada, $186 in Denmark, $137 in Germany, and just $92 in the United Kingdom. In the hearing, Sanders and other senators grilled Novo Nordisk CEO Lars Jørgensen on the "outrageously high prices" in the US of Wegovy and the company's other popular GLP-1 drug, Ozempic, used for diabetes.

"What we are dealing with today is not just an issue of economics, it is not just an issue of corporate greed. It is a profound moral issue," Sanders said in opening remarks about the prices of the highly effective drugs.

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