Let them eat cake: We have a fix for obesity, but only the wealthy can afford it

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Opinion

December 29, 2025 — 7.00pm

Modern medicine has, at last, developed the means to change the course of one of the great epidemics of our age, yet the fruits of that success remain within reach only for those who can afford them.

The arrival of GLP-1 receptor agonists such as semaglutide and tirzepatide has transformed weight loss from an unreliable hope into something close to a predictable biological event. These medications work by modifying appetite signals, slowing gastric emptying and improving glucose regulation, and their effects on body mass can exceed those achieved through surgery. In clinical trials, patients have lost on average 15 per cent of their starting weight, and in some cases as much as 20 per cent. Yet for many, these breakthroughs might as well belong to another universe – the monthly cost can exceed $1000 and few insurers or public health systems will cover it.

Weight-loss drugs have become the domain of the wealthy.

Bariatric surgery tells the same story through a more invasive lens. It has been shown to halve long-term mortality in patients with severe obesity and to send type 2 diabetes into remission in almost 60 per cent of cases, yet in most countries it remains largely confined to those who can afford significant out-of-pocket costs even if privately insured.

For those dependent on the public system, waiting lists can stretch for years, by which time patients may have developed heart disease, sleep apnoea, or joint damage that might otherwise have been prevented. The practical outcome is that the ability to reverse obesity has ceased to be a public health triumph and has become, instead, a privilege of means.

The social gradient is inescapable. The cheapest calories in the modern diet are those that inflict the greatest harm, and the industrial logic of food production ensures that energy-dense, nutrient-poor products dominate the diets of people with the least disposable income. A family can buy a full bag of fried food for less than a small basket of fruit, and in many suburbs the nearest fresh produce requires a bus ride rather than a walk. When that reality collides with long commutes, shift work, and unpredictable childcare, it becomes difficult to view obesity as a failure of self-control. It looks instead like an entirely foreseeable consequence of social and economic design.

Even the pursuit of wellness has become a market rather than a mindset. Entire economies now orbit around the idea of personal optimisation. Exclusive gyms with long waiting lists, Pilates studios, ice baths, boutique yoga spaces, dietitians, exercise physiologists, personal trainers, and “wellness coaches” sell health in subscription form. They promise motivation, discipline and accountability, but they demand two commodities that are often scarce in the lives of those lower on the socioeconomic ladder: time and disposable income.

This divergence in opportunity has consequences that go well beyond appearance or comfort. We are quietly constructing a society in which life expectancy and quality of life will diverge along economic lines. A child born today in a low-income postcode may live 10 years less than one born in a wealthy suburb only a few kilometres away. Those with financial resources will not merely live longer but will also live better, enjoying extended decades of mobility, independence and cognitive function.

Those without such means will age early, burdened by the cumulative damage of metabolic and cardiovascular disease, often spending their final years in ill health.

It is tempting to attribute these outcomes to lifestyle choices, but such explanations conceal more than they reveal. The rhetoric of “personal responsibility” has become a convenient deflection that absolves society from confronting the structural inequalities that create disease in the first place. Telling people to “eat less and move more” is an insult when the urban landscape offers no safe footpaths, the working day ends long after dark, and the nearest affordable food outlet sells nothing fresh. Health, in that sense, has become both a mirror and a multiplier of inequality.

To reverse this trend, we must first acknowledge that obesity is not a moral weakness but a complex social disease. The solutions therefore must be structural rather than moralistic. Access to evidence-based therapies must be widened rather than confined to those with private insurance. Governments that subsidise the long-term costs of dialysis, amputations and cardiac surgery can surely justify subsidising the medicines and surgeries that prevent them.

Even health literacy, so often spoken of as a virtue, functions increasingly as a privilege. The educated can decipher medical research, distinguish science from advertising, and navigate complex healthcare systems. Those without that cultural capital are left to interpret a confusing mix of commercial messages, folk wisdom and online speculation. Investing in genuine public education about nutrition and exercise, delivered in schools and community centres rather than influencers’ feeds, would yield returns measured not only in dollars but in decades of healthier life.

It is also time to question the ethics of a system that can produce life-extending interventions and then restrict them to the affluent. We rightly recoil when water, shelter, or education are denied to those who cannot afford them; why should the capacity to remain healthy be any different? The problem is not that science has advanced too quickly but that policy and compassion have failed to keep pace.

Ultimately, the question of whether health has become a modern-day luxury is not rhetorical. In practice, it already is. Longevity has become the newest status symbol, and the ability to purchase health through medication, environment and expert guidance has replaced the conspicuous consumption of previous generations. The wealthy now collect decades of life in the same way they once collected art or property. The tragedy is that it need not be so. Affordable access to proven therapies, fair food pricing, equitable urban design, and investment in public health literacy are not extravagances. They are the minimum requirements of a civilised and forward-thinking society.

Associate Professor Vinay Rane is an obstetrician, gynaecologist and lawyer. He serves on the Australian Medical Association (Vic) Council.

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