It was the first day of class. I was an eighteen-year-old Broadway geek entering Syracuse University’s (SU) acting program. I spent the morning seated on the floor of “movement” class with 29 other adolescents in front of our teacher, David, a loud and upbeat SU graduate, Broadway star and self-described “hotdog”—an actor who trained with the purpose-driven conformity of a sausage. David insisted that we would know our worth when we became hotdogs, too.

“I want to know who you are, where you’re from and why you’re HERE.” His gaze swept to the opposite side of the room where a doll-like actress with the weightless confidence of a foam roller was already mid-sentence.

I’m from New Jersey. I’m here because when I was nine… Suddenly, her image doubled. I felt panicked. Sweat soaked my vintage red Lacoste sweater. My heart grew wings, my skin sprouted feet and as it crawled, my colon began evacuating. I was too high to be in movement class. I should not have started my day by combining two cups of green tea with five Xenadrine-EFX, a diet pill concentrated with synephrine and caffeine which I remember as chunky, purple, and star-shaped, but I didn’t yet know that.

*

That year, 2006, marked two years since the U.S. Food and Drug Administration’s (FDA) shocking ban on ephedra—controversial amphetamine-esque compound and infamous darling of the 1990s weight loss industry. Ephedra contains ephedrine, a stimulant that imitates our fight-or-flight response, thereby triggering adrenaline. It’s also called ma huang, and is one of traditional Chinese medicine’s 5,000-year-old treatments for respiratory conditions. It holds a solid reputation for doing that job, though at much lower doses than what was later used in natural health products (NHPs).

NHPs gained popularity in the 1970s. Toxic pressure to be thin has been a predominant part of North American culture since at least the 1920s, but in Canada, it intensified in 1953 with the first Canadian weight-height survey, intended to trace the shape of Canadian body mass. From there, public health focused on discouraging personal habits that could lead to non-communicable diseases—inactivity, smoking, alcohol consumption. Body-size panic emerged in the 1970s in the U.S., too. By the 1990s, fatphobia became a moral panic. The World Health Organization labeled fatness an “epidemic,” media warned larger individuals to beware of certain oncoming death and the words “fat-free” convinced even my mother that trends like the Cabbage Soup Diet were totally healthy. Food became the enemy, and nutritional supplements rose as an obvious solution to the supposed problems of our bodies.

The issue with supplements, however, was that they weren’t stringently regulated. In the U.S., NHPs like ephedra were legally protected by the 1994 U.S. Dietary Supplement Health and Education Act (DSHEA) which stated that, unlike pharmaceuticals, NHPs were freed from testing. Companies were not required to state the risks around their products nor prove their benefits. The same products were approved in Canada, where NHP regulation didn’t exist under any act. In both countries, the burden of proof was on consumers. As long as no one got verifiably hurt, companies could sell their fat-burning potions.

By 2002, ephedra manufacturers were selling $1.3 billion in ephedra- containing products per year. Manufacturers would reportedly produce one-month’s supply for as little as $4 and sell the bottle at health stores for $40. The Ephedra Education Council, a PR group comprised of industry representatives, maintained that 15 million consumers took the herb annually. Meanwhile, over 2,200 complaints regarding cardiac-related side effects, including stroke and death, filed into the FDA. Ephedra accounted for 64 percent of all adverse reactions to herbs reported to U.S. poison control centres. Still, the FDA required more proof before they could take action.

Proof came in February 2003. Steve Bechler, a 23-year-old pitcher for the Baltimore Orioles, collapsed during spring training and died of complications relating to heatstroke less than 24 hours later. Bechler had been taking three ephedra-based diet pills per day. Toxicology reports confirmed high levels of it in his system. His death was one of several ephedra- related deaths in professional sports that had taken place since 2001.

In December 2003, the Bush administration announced a ban on ephedra. Manufacturers received letters demanding that they halt production of ephedra-related products, though they had already been in the news for 10 months and sales had sunk. But people’s desire to lose weight with the help of a pill hadn’t. There was already a new unregulated option out there, which the diet pill industry quickly latched onto: synephrine.

*

I first laid eyes on Xenadrine-EFX when I was 17 years old, but I had been dieting since middle school. When I was 11, I tried my best to starve myself throughout the day. After school, I’d sit and binge-eat the contents of our kitchen cupboards.

I was a naturally lonely and panicked kid. I didn’t know it at the time, but I was going blind, and vision loss was affecting my sense of safety. Large blindspots fragmented my visual fields which were then filtered by constant blinking lights, as if I lived behind a broken TV screen. My eye doctor’s advice was to “relax.” In the meantime, I had an impossible time connecting with other kids or even with my own family.

My family was fragmented in its own right. My mom dealt with a mental illness which at times restricted her availability. My dad was often out of town, working. After school, food became a reliable friend. I spent hours unsupervised, watching TV, munching my dad’s neglected snacks. I hid Twizzlers and Twix wrappers in my room until I could sneak them to a public garbage can. In the evenings, I planned new remedies to undo the effects of my snacking—laxatives, restriction diets, intense cardio. I quickly discovered that I loved running. It was the one health initiative that felt like a safe escape from anxiety. As I ran, I could picture myself gracefully racing among other athletes, but I was too embarrassed of my body to ask if I could compete or train.

No one put me on a diet. I somehow just learned that I was “too big” through some kind of cultural osmosis. Maybe it was because I was curvy and didn’t fit into clothing at the mall. I felt awkward and I equated awkward to ugly, ugly to large, large to loser. One of the most insidious errors in the late twentieth-century zeitgeist is the unscientific assumption that large bodies are a clear and identifiable problem. If that pressure hadn’t existed, I would never have swallowed a diet pill. But it did exist, and when I was admitted into SU, I planned a total makeover. I was working as a tutor earning between $80-100 per week. I took my savings to the mall. Nothing fit me.

As I was leaving, I passed Nutrition House. The windows were plastered in glossy images of regular people, displaying their BEFORE—tired, desperate, bloated, ancient—and their AFTER—glowing, wide-eyed and somehow much younger. It was clear to me that I was the BEFORE. The AFTER was calling me.

Cytodyne Technologies, the makers of what was soon to become my drug of choice, Xenadrine-EFX, were the masters of the diet pill ads. “Our incredibly advanced thermogenic formula literally “revs up” your body’s metabolism for rapid reductions in body fat and an incredible boost to your energy levels…John Murphy lost 37 lbs in just weeks!”

BEFORE—Dark, low-contrast image of a sad John Murphy with a belly.

AFTER—John Murphy as Superman. Stories are soothing because they permit escape. Words like thermogenic or any of the listed active ingredients in the product, such as synephrine and caffeine, were safe enough for John Murphy. That meant they were safe enough for me.

The cashier silently took my cash.

Outside the store, I took two tasteless capsules (in retrospect, disappointingly not star-shaped after all), as directed on the bottle. After an hour-long trip home, my face tingled.

 

*

When I arrived at Syracuse in September, I was taking five to six pills every hour, which contained the equivalent of about 3.5 cups of coffee, chased with plenty of green tea. I barely lost any weight, but I gained confidence, like I’d jumped into a sparkling future where everybody loved me. But, if time could be manipulated that easily, we wouldn’t need drugs.

I felt unreal on that first day as my classmates introduced themselves, and not in a good way. Hi, I’m from Wisconsin and I applied because my dad thought…I tuned out. The movement studio was melting. When I tuned back in, the next voice I heard came from right in front of me: I’m from New York and I’m here because I NEED to be here.

The New Yorker triggered my deepest fear. I didn’t belong there. If anything, I belonged in a hospital. My heart spanked my ribcage. I realized from the silence that it was my turn to speak. “My name is Rachel. I’m from Toronto and I just.” I swallowed hot gas, afraid this might be my dying statement. “I just want everyone to be my friend.” My head nodded forward, I gasped for air. Sudden laughter boomed around me.

When class finally ended, my dream had come true. Everyone wanted to be my friend. But I didn’t know what was happening, couldn’t separate reality from fiction. I ran away and straight through the building until I found my faculty advisor, Craig.

“Hello.” Craig looked at me like I was on fire. He was the teacher who’d auditioned me for the program but he didn’t recognize me. “What’s going on with you?”

“My name is Rachel Ganz and I’m an acting student and I shouldn’t have come here and I don’t want to stay here and I’m so sorry.”

Craig watched me sob.

“Look,” He waited for me to look at him. “I think you should stay. I can tell you have a lot—” he moved his hand to his chest and gestured outwards— “in you.”

I nodded my head many times, thanked him, and ran through campus to the back of my dorm to throw my freezer bag full of Xenadrine-EFX into the dumpster.

The next morning, throbbing pain radiated throughout my entire body.

At the time, I didn’t know very much about the effects of synephrine. However, as a stimulant, when combined with caffeine, it became the upper I felt I was missing. It seems possible that I’d developed a dependence on the pills, especially considering that when I stopped I had no appetite, no energy and no will to live.

After I stopped taking the supplement, I lost twenty pounds in less than a month. My mom came to visit and was disturbed by my new appearance; she said I looked sick. But I loved the way I looked. I began smoking to mitigate symptoms of withdrawal.

When my appetite returned over two months later, I went to the meal hall and ate a muffin. Then I ate another, then a third. I could not stop eating and my mood sank even deeper. I dropped most of my classes and waited, mostly in bed, for some kind of ending. I surfed pro-ana web forums, studied starvation tips and experimented with bulimia. My attitude needed an overhaul.But I was only 18 and severely depressed. Luckily, my roommate was also an acting student. She woke me up and walked me to class every morning. Without her, I don’t think I would have moved.

*

Sometimes, and from certain vantage points, it seems like we’re in a new era when it comes to our conceptions of bodies. Body positive celebrities are embracing themselves as they are naturally, and a quick scroll through TikTok and Instagram will reveal strong body positive, or at least neutral, communities. But other times, it seems like all that’s changed is the framing. While I faced the pressure to be thin at the mall, today we feel it in our beds, in our cars, on the toilet.

Robert Chinery Jr., Tracey Chinery and one of their companies, RTC Research & Development, LLC, the marketers of Xenadrine-EFX, were charged in 2005 with false advertising. They were fined $8 million in consumer redress.

Today, low dosages of synephrine and ephedra are still approved by Health Canada for use as natural health products. They’re sold in supplement stores, branded as decongestants by companies such as 4EverFit (Ephedra) and Synephrine 30. However, the combination of synephrine and caffeine is banned under Canadian law.

That doesn’t mean one can’t still access federally approved drugs that can make people smaller. A new kind of diet drug has emerged as a trend. Most famously, Ozempic, generically known as semaglutide and intended as a medicine to treat diabetes, has been popularized by the media as a “treatment” for living in a large body. As a result, it’s becoming harder for many to avoid the pressure to be thin.

Semaglutide was approved by the FDA in 2017. In some respects, its success is revolutionary. It works by mimicking GLP-1, a hormone that we produce in our gut. “After you eat food, the hormone goes from your gut to your pancreas to release insulin and to allow the insulin to store that food for later on,” explains Dr. Sean Wharton, who specializes in diabetes and weight loss and runs a clinic in Burlington, Ontario. “It also tells the brain that you’ve eaten food and to stop eating.” People living with type 2 diabetes often do not have enough GLP-1. Drugs that mimic GLP-1 are an immediate game-changer for them, but also for many people who want to lose weight.

Previously, bariatric surgery was the only available treatment for people who wanted or needed to lose a lot of weight quickly. Over a longer period of time, psychological interventions such as cognitive behavioural therapy (CBT) have been shown to be useful, too. But, CBT is a privileged approach that’s often only available to people with time, money and stable lives. Medications such as semaglutide, in theory, can offer immediate intervention for people who want to lose weight who are also surviving complex, destabilizing pressures such as poverty, violence or racism.

Barriers to semaglutides include their cost, which is about $200 to $300 per month in Canada, or the fact that they are currently mostly injectables, which can be difficult to produce, store and ship. Also, at the time of publication, Ozempic has not been approved by Health Canada as a weight loss drug, though the agency acknowledges it may be prescribed “off-label,” meaning for a purpose other than that for which it’s approved. For those with type 2 diabetes, costs may be covered by provincial drug plans or private insurance plans, but it’s not a guarantee. Side effects are an issue, too: Ozempic’s include diarrhea, constipation, nausea, vomiting, and abdominal pain. The drug can also cause gallbladder and kidney problems, pancreatitis and low blood sugar. Thyroid tumours are another potential side effect.

Still, these side effects aren’t warning people off the drug. This matters for another reason: people who hop on board celebrities’ and influencers’ endorsements of Ozempic as a weight loss tool could adversely affect the health of people with diabetes by causing shortages of the drug through their demand. That’s been happening globally at various points for the past year. The drug’s manufacturer, Novo Nordisk, announced in August that shortages are expected in Canada into October. There was a shortage here for a week in March, which was corrected after doctors reigned in prescriptions to Americans (in the U.S. the drug was largely unavailable, and can cost over $900 per month). In January and February, nearly one in five Ozempic prescriptions filled in B.C. was for an American. Over 30, 000 prescriptions for the drug were issued to Americans between Jan. 1 and April 19. In April, the province announced that non-residents will no longer be able to get Ozempic through mail-order or online. Americans can still buy Ozempic in Canada, but they have to do it in person. It was found by provincial health authorities that one Nova Scotia doctor, currently based in the U.S., was allegedly responsible for writing more than 17, 000 prescriptions over a period of a few months, and two online pharmacies in B.C. had filled most of them. That person’s licence has now been temporarily suspended.

It’s clear from this craze, and the boom in other semaglutide-based drugs like Rybelsus, a pill, and Wegovy, an injection approved for weight loss in Canada but not yet available here, that Ozempic is only the beginning.

As the drugs become more popular, though, the eating disorder treatment community expresses concern. “The temptation for people who are in larger bodies to take medication [like Ozempic] is really strong,” says Dr. Karen Trollope-Kumar, family physician and co-founder of Body Brave, a charity offering online eating disorder treatment and support services. Trollope-Kumar worries about adding to the “internalized stigma” of larger-bodied people and says the onslaught of self-blame may provoke disordered eating.

The rise in GLP-1 receptor agonists has strengthened the discussion of obesity as a disease, a stance that has been critiqued by fat activists, racialized people, and medical professionals. Obesity is determined by one’s body mass index, or BMI, which measures body fat based on height and weight. A person with a score of 30 or over is deemed to be obese. But pathologizing larger bodies and problematizing them doesn’t help people and can lead to disregard for people’s true health concerns. Further, BMI was created almost 200 years ago by a non-doctor who measured white bodies and created standards from those measurements. Today, it has been debunked by many as a largely unscientific, racist tool.

Trollope-Kumar’s approach is to think about health from a broader perspective and to prioritize social connections as a means of staying healthy. “If we feel socially connected to other people,” she says, “that’s actually the most protective factor for our health, not weight.”

*

I used to think weight loss would lead me to social connection. My sense of isolation has intensified as I’ve aged, possibly hitting its peak in 2018 when I was diagnosed with retinitis pigmentosa, a genetic retinal disease which causes vision loss. Scared to lose all of my vision, I quit hobbies that felt dangerous or embarrassing, including fitness and running. Instead of participating, I sat alone and scrolled through fitness influencer content on Instagram, eating candy and gazing into the AFTER—transformed women with rippling muscles, long straight hair and impossible joy.

Later, when pandemic restrictions had come and then eased off again, my partner and I moved to Leslieville, a neighbourhood in Toronto’s east- end with large parks that’s close to waterfront trails. The long paved paths were populated with happy, healthy runners of all shapes, sizes and colours. They reminded me of the teenage treadmill escapes I used to take every morning and I wanted to join them.

But, I was afraid to be a blind runner. It wasn’t the AFTER I imagined. To conquer my fear, I began running with my dog. After a month, I ventured for longer runs, alone. I started signing up for races which introduced me to a long-sought-after community.

This past May, I ran my first marathon. By the 30th kilometre, I hit a wall and wasn’t sure if I was going to finish. But then, I noticed other people around me were also struggling. I followed a woman. She followed another guy. We became a small group, loosely connected by our will to keep going. We shared a rhythm and an experience, trotting in our bodies of all sizes, through the beautiful AFTER.