The FDA approved semaglutide ↗, liraglutide ↗, and tirzepatide ↗ for type 2 diabetes and for obesity carrying weight-related complications. A study in Obesity ↗ finds that a fast-growing share of the people getting these drugs fit neither approved box.
Start with the counts. Using Cosmos, a database that pools electronic health records across US health systems, researchers led by Babak Orandi at NYU identified 92,415,648 adults with no documented FDA-approved reason to be on one of these drugs, meaning no type 2 diabetes and no qualifying obesity in the chart. Of those, 1,133,953, about 1.2 percent, were prescribed a GLP-1 drug anyway between January 2021 and December 2025. The share climbed from 0.1 percent in 2021 to 1.5 percent in 2025. That is a 15-fold rise in four years, off a small base but steep.
Then look at who the recipients were. They skewed heavily female, 85.5 percent, and White, 60 percent, with a higher median body mass index than the adults who did not get a prescription, 25.9 against 24.5. A body mass index of 25.9 sits in the overweight band, below the obesity threshold of 30, which is the number the GLP-1 receptor ↗ drugs were approved to treat. And 35.1 percent of recipients, better than one in three, had a body mass index in the normal range, meaning they were not overweight at all by the standard measure. Hypertension and high cholesterol were more common among recipients, while coronary artery disease and heart failure were less common, a profile that reads younger and less sick than the approved population.
One clinical signal stands out. Recipients carried a recorded eating disorder six times as often as non-recipients, 1.8 percent against 0.3 percent. GLP-1 drugs work by blunting appetite, and an expert panel earlier this month urged clinicians to screen for eating disorders before prescribing them ↗. A cohort where the drug is reaching normal-weight people and people with eating-disorder histories at elevated rates is exactly the cohort that guidance was written for.
The access pattern points the same direction. Off-label recipients had lower social vulnerability and were more likely to hold private insurance. The people getting these drugs outside the approved indications, in other words, tended to be the more advantaged ones, which is what you would expect when demand runs ahead of coverage and the list price is high.
The authors are careful about what the data can and cannot say, and so should any reader. Electronic health records cannot see cash-pay compounded versions, prescriptions written outside the network, or the full reasoning a clinician had in mind. The phrase without an apparent FDA-approved indication is a records-based inference, not proof any single prescription was wrong. A real indication can simply be missing from the chart. What the numbers do show, at a scale of nearly 92 million adults, is a prescribing pattern moving faster than the evidence base for these populations, with a risk-benefit balance the authors call uncertain in people who are not obese and not diabetic.
It is the same shape seen at the other end of the age range. The same database method recently found off-guideline GLP-1 prescribing in children aged 8 to 11 rose 310-fold ↗. The drugs are spreading past their labels in both directions, and the trailing question is the same each time. What happens to the people taking a metabolic drug they were never studied to need.