Johann Hari: I went to the KFC on West Sahara, for people who know Vegas, they'll know that's the roughest KFC in the world, and that's really saying something, and believe me, I've been to all of them. I went there and I just ordered what I would have ordered a year before. I ordered a bucket of fried chicken, right? And I sat there and I had a, had a chicken drumstick, and I looked at this food and I suddenly thought, shit, I can't eat this. And Colonel Sanders was on the wall, like he is in all the KFCs, and I really felt like he was looking down at me going, mate, what happened to my best customer, right?
Dr Rupy: Welcome to the Doctor's Kitchen podcast. The show about food, lifestyle, medicine and how to improve your health today. I'm Dr Rupy, your host. I'm a medical doctor, I study nutrition and I'm a firm believer in the power of food and lifestyle as medicine. Join me and my expert guests where we discuss the multiple determinants of what allows you to lead your best life.
Johann Hari is back on the podcast today and he looks completely different to the last time I saw him. He has lost an incredible amount of weight. His face looks completely different and it's all because of a drug you've probably heard of, Ozempic. Also known as GLP-1 agonists, these drugs were initially used by doctors like myself in general practice for type two diabetics but have now found a use case to treat obesity. For over a year, Johann has been self-treating with the drugs and diving into the history of how these drugs were discovered and utilised, from the lab to pharmaceutical companies and the doctor's surgery to the popular pages of celebrity gossip columns. Johann tells the full story without shying away from the potentially dangerous reality of the side effects and the risks of these popular medications. Today, we talk about what Ozempic and similar drugs do to your brain and gut, how it impacts addiction to food and other substances, what the potential risks are, including cancer, pancreatitis and bowel obstruction, and why ultra-processed foods and obesity are the main concern. You can purchase Johann's newest book, Magic Pill, the extraordinary benefits and disturbing risks of the new weight loss drugs, available on the 2nd of May 2024 from all good bookstores and online. And if you remember, Johann is a New York Times bestselling author of other books including Chasing the Scream, Lost Connections and Stolen Focus, which is one of my favourites, all about the realities of our digital revolution with a particular reference to social media. Remember, you can watch the podcast on YouTube where he talks about how he sees my hair for the real, for the first time in real life and it is just as impressive as he thought on Zoom, which I thought was quite funny. And and obviously you can see our smiling faces and that is the easiest, no-cost way of supporting the podcast by checking us out on YouTube, hitting subscribe and liking whilst you're there. I do hope you enjoy this podcast. We are as sensitive as we can to the subject of obesity without shying away from the realities and I really think this is an important conversation that you will benefit from listening to. Please do share and enjoy my podcast with the wonderful Johann Hari.
Dr Rupy: Johann, great to have you back in the pod.
Johann Hari: Hooray. I exist in three dimensions.
Dr Rupy: You do, you do. I know, I know. The last time we we did this was by Zoom, which I actually.
Johann Hari: It was the height of the plague.
Dr Rupy: It was the height of the plague and I, yeah, I'm glad we get to do this in person and actually, you know, experience each other's company and stuff.
Johann Hari: And your hair is even more impressive in the flesh than it was on Zoom. It's, I'm very jealous. It's a sort of weird Lego effect. I like it.
Dr Rupy: It's great to know. Look, you've done this wonderful book, Magic Pill. This is one of the first copies that you've, you haven't even seen this copy.
Johann Hari: This is the first time I've seen the British edition because I've been in the US and out of the country for ages, so it's very exciting.
Dr Rupy: Amazing, amazing. And um, look, you you've literally been on this drug now for how long?
Johann Hari: More than a year, yeah.
Dr Rupy: More than a year. Okay. I want to start off by asking you about the side effects of the drug. I know we're starting on quite a negative tone here, but what are the side effects of the magic pill, Ozempic and all the other GLP-1 agonists that no one's talking about?
Johann Hari: This is something I thought about a lot because I don't remember with any topic ever feeling so immediately conflicted. From the moment I learned about these drugs, I immediately thought, so for people who don't know, there's a new form of weight loss drugs which work in a completely new way, which produce staggering levels of weight loss in the average person who uses them. So the average person who uses Ozempic or Wegovy will lose 15% of their body weight in a year. For Mounjaro, which is the next class of this drug, next version of this class of drug, you lose on average 21% of your body weight. And for the next ones to come down the stream that will probably be out next year, you lose on average 24% of your body weight, which is only a little bit below bariatric surgery. So we're talking about remarkable levels of weight loss. And I remember first time I heard about these drugs, thinking straight away, okay, I can see the appeal of this. I'm older now than my grandfather ever got to be. He died of a heart attack when he was 44. My dad had heart bypass surgery, my uncle died of a heart attack. We know sadly the evidence is very clear that obesity increases a huge array of health problems. Heart disease is an obvious one, but actually there's over 200 known diseases and complications that are either caused or boosted by obesity. So I thought, wow, if we've got a drug that reduces obesity or even reverses it as it does with many people, that's going to have massive health implications. But I also thought exactly what you want to ask, which is, well, is there really such a thing as a free lunch here? Or I guess a smaller free lunch, but I thought, you know, we've seen this story before. We've had pretty much every 20 years going right back to the First World War, a new miracle diet drug is announced. And it follows the same pattern. Great news, everyone, we've come to save you. Huge numbers of people start taking it. Then it's always in the past been discovered to have some horrendous side effect and it has to be yanked from the market, leaving a trail of devastated people in its wake. So I thought, can you really get all these benefits and so radically interrupt people's eating patterns without there being a cost? So to get to the bottom of the benefits and risks of these drugs, I went on this big journey all over the world from Reykjavik to Minneapolis to Tokyo. I interviewed over a hundred of the leading experts and other people affected by this, you know, the biggest defenders of the drugs, the biggest critics of the drugs. And I learned, you know, the subtitle of the book is the extraordinary benefits and disturbing risks of the new weight loss drugs. And it turns out both halves of that equation are true. It's why this is a really complicated story. People who are responding either with just a yay, the drugs are going to save us all, or a kind of boo, this is going to cause a catastrophe. I think are missing the much more interesting question in the middle. So what I actually learned is there's, in terms of the risks, there's kind of 12 quite big risks associated with these drugs. It's a bit different to the side effects. I can talk about the side effects, the kind of more common side effects if you like.
Dr Rupy: No, we can talk about the the 12.
Johann Hari: Yeah, I mean in terms of just because a lot of people might not know about the kind of more everyday side effects. There's a, one of the scientists who worked on these drugs, Carel le Roux, a brilliant South African psychiatrist, said to me, look, there's two kinds of drugs. There's drugs that have side effects and there's drugs that don't work, right?
Dr Rupy: That's a very good way of putting it.
Johann Hari: Good point. But, um, so in terms of the everyday side effects, which exist alongside benefits, the most common is nausea. A lot of people just get horrible nausea. It generally goes away. I got it pretty badly and then it just goes away after a few months. But, you know, a significant number of people, the nausea is so bad it never goes away and they have to stop taking the drug. There's other kind of common ones, constipation. For me, I had one that's a bit, a bit rarer but not uncommon, which is that it made my heartbeat faster, which is not bad for your health, but it's hard to have your heart race and not feel anxious. So for a while you have to be like, why do I feel so anxious? You're like, oh no, it's just the side effect. And that went away for me as well. But in terms of the risks, so there's a lot there and they range pretty widely. So I'll start with just one and it's one of my top four or five, but I'll just pluck one because there's a whole big broad array of them. So when you talk about the safety of these drugs with the leading scientists working on them or indeed the critics of them, a lot of them say, they make a very good point. They say, look, actually, although these drugs have only been used for obesity for a short amount of time, so we don't have a huge amount of information for that, we actually do have quite a lot of good data on these drugs. So what we know is that diabetics have been taking these drugs for 18 years now. These drugs, in addition to having this effect on massively reducing your appetite and therefore causing you to lose weight, they also stimulate the creation of insulin, which is what diabetics are lacking. So for a quite a long time now, diabetics in very large numbers all over the world have been taking these drugs. And what the defenders of the drugs say is, if it caused some catastrophic outcome, if it made you grow horns or something, we would know by now, it would have shown up in the diabetics. And that's a good and important point and we should give it weight and it should give people some sense of security.
Dr Rupy: Yeah, because I remember, sorry just to heighten that point, I remember coming across these classes of medications when I was even training as a general practitioner over 10 years ago. And we know that the side effect profile of those, there was definitely side effects, but they were tolerable. And I think that point probably needs to be underlined because a lot of people think incorrectly that this is a brand new drug and it's only just coming to the market and it's flooding the market immediately and everyone's getting their hands on it. Whereas actually we do have that safety profile for the last 18 years. Now, I'm not pro or anti these drugs. I think context matters, but that I think is something that people should should know more about.
Johann Hari: I think you're absolutely right. And for me, that that was a very important part of thinking about this. Against that, some other scientists say, okay, if we're going to base our feelings of safety around diabetics who've been using these drugs, let's actually dig into what's happening with the diabetics. So for example, I interviewed a brilliant scientist who's at the University Hospital in Montpellier in France called Jean-Luc Faillie. And he was commissioned by the French Medicines Agency to look into their safety for the French, for the French market. And he and his colleagues went through a lot of the research on this and they, their attention was caught by one thing in particular, which is when you give these drugs to rats, they are significantly more likely to get thyroid cancer by a really quite significant amount. And there's also a kind of plausible mechanism there because these drugs work on a hormone called GLP-1 that I'm sure we'll talk about more. And you actually have receptors for GLP-1 not just in your gut but in your thyroid. So it sort of makes sense that something that's playing with GLP-1 might have an effect in the thyroid. So what he did is he looked at a large number of diabetics who'd been taking these drugs for between, I think it was 20, 2006 to 2016. And he compared them to a very similar group of diabetics who had not taken these drugs to see are there differences in outcome. And what he and his colleagues calculated, this is disputed, but what they calculated is that these drugs increase your thyroid cancer risk by between 50 to 75%, which when I first heard it, you're like, I did the facial expression you just did, right? You're like, what? And Professor Faillie said to me, well, it's who was very alarmed by this, said, we need to understand what that doesn't mean. That doesn't mean if you take the drug, you have a 50 to 75% chance of getting thyroid cancer. If that was the case, no one would take it, obviously, it would be pulled from the market. What it means is, if you take the drug and they're right, which is disputed, whatever your thyroid cancer risk was at the start, it will increase by between 50 to 75%. Nonetheless, a big increase, right? It's, it remains overall quite a small risk, about 1.2% of people get thyroid cancer in their lifetime and 84% of them survive it. But nonetheless, when you're talking about millions and millions of people taking these drugs all over the world, 46% of Americans want to take these drugs. Best prediction is about 30% of British people will be on them in a few years. That's a a really significant concern and it's one of the kind of flashing red lights around these drugs. But at every stage for myself and for people I love who are thinking of taking these drugs, I had to keep making this comparison. So I've gone in and out of being obese pretty much all my adult life. And I tried dieting and exercise like pretty much every overweight person in Britain and like the vast majority but not all, I had gone back to being obese. And for me realistically, in the environment in which we currently live, the choice was between continuing to be obese or taking these drugs. So if you just look at the risk profile of the drugs, it seems like madness to take them. Why would you incur, and that's just one of the 12 risks, right? Why would you incur all those risks? But when you see it as, well, you're, you've got two risky scenarios. So I had to look very carefully at the risks associated with obesity. And I was quite taken aback by the, you won't be surprised by this as a doctor at all. I was quite taken aback by just how bad for your health on average obesity is. And one of them, even if you think about that thyroid cancer risk, again, against that, several scientists said to me, even if that's true, you've got to compare that to the cancer risk of simply continuing to be obese. As Cancer Research UK explains, if you carry excess weight, that excess weight doesn't just sit there, it's not inactive. It sends signals through your body. And one of the signals it often sends is for cells to divide more rapidly, which can cause cancer. It's why obesity is one of the biggest causes of cancer in Britain today. So you sort of, at every stage of this, you have to be weighing with a with a clear eye and a lot of compassion, these competing risks.
Dr Rupy: Yeah, yeah. And I I guess to to to hover on that point, the relative risk of thyroid cancer will increase to 75% or even let's say it was 100%. That's definitely something to to weigh up against the trade-off that you've eloquently described. And then also, we have to think about the absolute risk. So I imagine the absolute risk of thyroid cancer was quite low and even if it was to go up by 50 or 75%, it doesn't increase the overall likelihood of you suffering from thyroid cancer by that much. Now there's loads of other side effects of these drugs, but it's just something to bear in mind. It's a similar parallel with the contraceptive pill, for example, or even HRT, that's probably more of a a better a better example because the interpretation of the women's health initiative study was grossly misinterpreted. And I think there were undue risks associated with cancer because of using HRT, but for a former use of HRT, so we used a marine version of HRT before. Now we use newer drugs. And even using the old data, it didn't increase the cancer amount by an absolute level, just the relative amount, which is still very, very low. So it's important to to make sure that we have these caveats whenever discussing any drugs, let alone the new ones on the market.
Johann Hari: I think that's really important. And when we go down the the list of the 12 risks, and I'm sure we're going to come back to lots of them, I think we also need to weigh that against the benefits of these drugs. It was striking to me, and we'll talk, I'll talk a bit in a second about the what we know about the scientific evidence for the benefits of them, but the the experience of taking them was so weird. I remember, I'll never forget the second day I was taking them, I woke up and I was lying in bed and I thought, oh, I feel something really strange. What is it? And I couldn't figure out what it was and it was took me about five minutes to realise I had woken up and I wasn't hungry. Every previous day of my life, I remember waking up, I would often be woken up really hungry. And I wasn't hungry. I thought, this is really weird. And I went to, there's a a cafe at the road from where I live and I went there and I ordered what I would order every morning at that time, which was a a big kind of bap with loads of chicken and mayo in it, right? It was disgustingly large. You've literally never eaten a bap in your life, but I'll let you imagine it. And Tatiana, the woman who works there, brought it over to me and I put it down in front of me and I had like three or four mouthfuls and I just couldn't eat anymore. I wasn't hungry. I thought, this is really weird. So I left. I remember she literally called after me saying like, are you okay? And that lunchtime I went to next to my office, there's this Turkish restaurant I used to go to a lot. And I went in, again, I ordered the thing I would always order, which was a Mediterranean lamb. Again, I had like three or four mouthfuls. I just didn't want any more. It was, it was extremely disconcerting. And I I later learned from interviewing the scientists who played key roles in developing these drugs, some of what's happening there. One of the really weird things about these drugs is we don't entirely know how they work, but we know a bit about how they work. So one of the things we know is that if you ate something now, after a short while, you would get a surge, your your pancreas would produce a hormone called GLP-1. And we know that's part of the natural signals in your body just saying, mate, you've had enough, stop eating, right? And that natural GLP-1, that signal to say, give it a rest, only lasts in your body for a couple of minutes and then it's washed away. What these drugs do, these so-called GLP-1 agonists, is they inject you with an artificial copy of GLP-1. But instead of being washed away in a few minutes, this artificial copy stays in your system for a whole week. So that's one of the reasons why when I start eating that chicken roll, I'm I'm pretty, I start from pretty close to full. So it only takes a little bit for me to get to the point of feeling full, right? It's like shutters come down on your appetite. It's why I've lost three stone since the last time we spoke. Um, but one of the curious things about this is, so it was initially thought because it's produced in your gut that it's having an effect primarily on your gut and that that's why you have this. Increasingly from interviewing the cutting edge scientists on this, they increasingly believe that actually the effect is mostly on your brain. Actually, we know you have GLP-1 receptors in your brain. With rodents, if you give a rodent these drugs and you cut their brain open, which obviously we can't do to humans, what you see is the drug goes everywhere in their brain. So this is predominantly having an effect on your brain. We don't know exactly what that effect is. There's a big debate about it that I go through in the book, but that felt to me like a much more how would I put it? Intimate and frankly risky transformation. It's one thing to go, oh my gut's being altered. It's another thing to go, oh my brain, the centre of who I am is being altered. So it's it's a very, um, odd feeling. And odd in both positive and negative ways, right? Like the book is called Magic Pill because I feel like there's three ways in which these drugs could be magic, right? The first way is the most obvious. It could be that it just solves the problem, right? In a way that is so rapid and so extraordinary that it feels like magic. And there are days when it feels like that, right? My whole life, I've been pigging out and craving KFC and McDonald's. And what, once a week I inject myself in the leg and it's gone away. It feels like magic. The second way is much more disturbing. It could be a it could be magic in the sense of a magic trick, right? The conjurer who shows you a card trick while he's picking your pocket, right? It could be that it seems to be giving you this benefit, but it's actually screwing you over. And there's some reason to be concerned that may be the case. The third way in which it could be magic, I actually think is the most likely, which is you think about all the classic stories of magic like Aladdin, Fantasia, you find the lamp, you make your wish with the genie, and you get what you wanted, but never quite in the way you thought you were going to get it, right? Um, one of the Barclays Bank commissioned a very sober-minded financial analyst called Emily Field to investigate these drugs. And she came back and said, you want to know the impact this is going to have? You've got to compare it to the invention of the smartphone, right? This is just going to have an enormous effect on our society and culture in ways that I think we're going to really struggle to game out for, although I think we've got some hints now.
Dr Rupy: Yeah, yeah. And in terms of that impact on society, you know, if we were to magic away, to use your terminology, obesity to less than 50% of what it is today in the US and the UK, what knock-on effects are those going to have on fast food chains, plane sizes, the market at large as it is constructed today, financially? Um, also people are going to be living longer as well. It's quite a morbid thing to think about, but what's that going to happen, what's what's going to happen to our pensions? So when when you interviewed market analysts particularly for the book, did they have somber things to say about these drugs and the from a from a financial commercial point of view?
Johann Hari: I mean, it's fascinating to see how the financial people are gaming it out. There was just a report for the US airlines saying they're going to have to spend much less on fuel in the pretty soon because it takes so much less fuel to fly a thinner population. There's all sorts of weird effects that are happening. Nestle, the CEO of Nestle, Mark Schneider, has just said, you know, I'm really worried about our ice cream market. Krispy Kreme stock is down. There are companies that make hinges for knee and hip replacements. Their stock is right down because if there's less obesity, there's going to be far fewer people who need knee and hip replacements. Even think about random things. There's been a huge rush on jewelers in Los Angeles because so many people in LA are taking the drugs and people's fingers are literally shrinking. So loads of people have to have their wedding bands refitted because it doesn't fit on their finger anymore, right? So there's all, if you imagine if we had been sitting here in whenever it was, I think it was April 2007 when Steve Jobs unveiled the iPhone. You might be sitting there going, I'm not interested in this thing, right? And loads of people that are watching are thinking, I'm not interested in weight loss drugs. But you know, we would not have been able to game out TikTok and Uber Eats and Donald Trump and all sorts of effects of the smartphone that were going to transform our lives. So I think there's just a huge amount, there's some stuff both positive and negative. And it's worth stressing just a little bit more about the positive because I have lots of worries, but I think it's really important to to be fair to these drugs and balanced and explain the complex truth about them. So these drugs have been around for diabetes for a while, but we actually haven't had them for very long for obesity. But we're getting increasing evidence about the drugs, but actually I think we've got pretty good evidence from a different area of science. So up to now, it's been very hard for obese people to lose huge amounts of weight and keep it off. Some people have done it, we can talk about how they did it without medical help, but it's rare, right? So the best kind of area of science for us to draw on, I think in terms of the benefits here, is actually to look at bariatric surgery, which is the other medical intervention that massively reduces weight and mostly helps you keep it off. So we're talking about things like stomach stapling, there's many different kinds of bariatric surgery. And look, bariatric surgery is a grim, grim operation. It's unbelievably grueling. One in a thousand people die in the operation. It's it's rough, right? But the reason why people take that extraordinary risk and go through this this horrible invasive surgery is because of the staggering health benefits. So if you have bariatric surgery in the seven years that follow, you are 56% less likely to die of heart-related problems. You're 60% less likely to die of cancer. You're 92% less likely to die of diabetes-related causes. In fact, it's so good for your health that you're 40% less likely to die of any cause at all. So we know, this is part of a much wider body of evidence that sadly, obesity is incredibly bad for your health on average. I was actually, it's weird to say this because I guess at any point since I was seven years old, I would have known at some level that obesity is bad for your health. I was quite taken aback by the research on it. Even something simple as diabetes, right? You know this very well. I can see diabetes for dummies on your point. I feel like a fool saying this to you because you know it much better than I do, but I'm ashamed to say, I think I thought before I did the research for this book, okay, I know that obesity makes it more likely you'll get diabetes. In fact, if you're obese when you're 18, you have a 70% chance of developing diabetes in your lifetime. But I thought, all right, if you live in Britain and you're diabetic, you get insulin, you're pretty much like everyone else, right? I was amazed interviewing doctors who treated diabetes, people like Dr. Max Pemberton, who explained to me, no, no, no, diabetes knocks 15 years off your life. It's the biggest preventable cause of blindness in this country. More people in the US have to have a limb or extremity amputated because of diabetes than because they got shot. And it's not like there's a shortage of Americans getting shot, right? It's extraordinary. And it's not just that it massively shortens your life, it massively, you know, reduces the quality of your life dramatically in many cases to the point where Dr. Pemberton said to me something that sounds viscerally shocking when you first hear it, but when you look at the evidence, you can see where he's coming from. He said, as a doctor, if you gave me a choice between becoming diabetic or becoming HIV positive, I would choose to become HIV positive every day of the week because if you're HIV positive and you get treatment, you live as long as everyone else. That's absolutely not the case with diabetes. And and that's just one of many, many factors that are made more likely by by obesity, which is a very painful, for me was a very painful thing to hear. But the evidence is very clear.
Dr Rupy: Yeah, yeah. And you know what, your, um, your thoughts about type two diabetes, I think are shared amongst most people. And the reason why I say that is because whenever I've had to give the bad news to a patient that they are within the range of type two diabetes according to the blood results and everything else that we've done, um, I'm always taken aback by how blase certain people take it. And I think particularly within the South Asian community where it's so rampant and the predisposition is so high, it's almost like collecting one of those badges that you just get when you're in your 50s and 60s and every one of your friends has got it as well. And I don't think they fully understand the ramifications that you've described there about how it impacts your likelihood of going blind, your likelihood of amputation, your likelihood of having a poor response after an infection, your the the number of life, the number of years it takes off your life as well, the risk of dialysis, kidney disease, etc, etc. The list goes on. And so when we have these medications that can potentially massively reduce type two diabetes, we have to take into consideration all these different elements as well.
Johann Hari: Exactly. And and another thing I don't think people realise, and I don't say that with any judgment because I don't think I understood it fully, is how incredibly recent a change this is, right? I think we're probably similar age. How old are you?
Dr Rupy: I'm 39.
Johann Hari: Right, you're slightly younger than me. I'm I'm 45. I'm slightly jealous of your youth and freshness, but the, you know, the year I was born, 1979, 6% of British people were obese. It's now 27%. Between the year I was born and the year I turned 21, obesity more than doubled in the US and then in the next 20 years, severe obesity doubled again, right? So this is unprecedented in human history. I would really recommend everyone watching or listening, pause for a second and Google photos of beaches in Britain in the early 1970s. Just look at it. When you look at them, it's really weird. You look at it and you go, what, everyone is what we would call skinny. Where was everyone else that day on the beach, right? And then you look at the population figures, that is what everyone looked like in Britain, almost everyone. Obesity was extremely rare. So there's been an extraordinary transformation in a really short period of time. It has blown up. In the in the world in total, obesity has more than tripled in my lifetime. And we know why it happened. It's not because people lacked willpower. It's not because people were greedy. It's because of one specific change. Whenever this change happens in a country, the obesity blows up. It's when people move from eating mostly fresh whole foods that were prepared on the day to mostly eating processed and ultra-processed foods which are assembled, made out of chemicals in factories in a process that isn't even called cooking, it's called manufacturing food, right? And it turns out that new kind of food, or what my friend Michael Pollan calls food-like substances, affects your body in a completely different way. And interestingly, this is intimately connected to the drugs. For a long time, I was researching when I was writing Magic Pill, two topics that I thought were distinct or only joined up at the end. I was looking at why we gain so much weight and then I was looking at how these drugs work. But actually the same word kept coming up in both. And I'll explain what it is in a second, but there's an experiment that I think really helps us to understand what this new kind of food does to us, factory assembled food. There's a scientist I interviewed, an amazing guy called Professor Paul Kenny, who's the head of neuroscience at Mount Sinai University in New York. And Professor Kenny grew up in Dublin in Ireland. And in the 90s, he moved to California to carry on his scientific research. And he quickly clocked that Americans do not eat like Irish people did at the time, right? They eat a lot more processed and ultra-processed food. They ate a lot more sugary and salty food. He was quite taken aback at first. And like many a good immigrant, he assimilated and within a year he gained like well more than a stone, right? And after a while, he started to feel like this food not only made him gain weight, but actually changed his brain, changed what he wanted. So he designed an experiment to try to figure out what was going on, which I have nicknamed Cheesecake Park. That's not the official title. Um, very simple experiment. He got a load of rats and raised them in a cage. And from birth, all they have to eat is the kind of natural whole foods that rats have evolved to eat over thousands of years. They've got it in pellet form, but it's pretty much the kind of food that my dad grew up eating in a village in the Swiss mountains, right? Healthy, natural food. And they had far more of it than they could eat, but interestingly, when they had the kind of natural food they evolved for, they would eat when they were hungry and then they would stop. They had some kind of natural nutritional wisdom. They confronted with this food, they made them go, don't need any more now. Then Professor Kenny introduced them to the American diet. He got them some Snickers bars, he fried up some bacon, he got some cheesecake and he put it in the cage. And the rats went crazy for it. They still had the healthy food, but they shunned that immediately. When he put down the cheesecake, they would hurl themselves into it and literally eat their way out, like completely slicked with the with the cheesecake. And that nutritional wisdom that they'd had telling them when to stop, disappeared. They ate and ate and ate and ate and would not stop. And in fact, as Professor Kenny put it to me, within a few days, they were different animals. Within a few weeks, they were obese, all sorts of health indicators were going wrong. But then Professor Kenny did something that to me as a recovering junk food addict, feels is a bit cruel. Um, he took away all that American food and left them with nothing but the healthy food they'd had before. And he thought he knew what would happen. He was pretty sure they would eat more of the healthy food than they had before. And this would prove that junk food expands the number of calories you eat. That's not what happened. Something much weirder happened. When the American diet was taken away, they refused to eat anything at all. They they literally starved until they were so hungry that they had no choice but to eat the food. But for a long time, it was like they no longer recognized the healthy food as food at all, right? Now, this fits with a much wider body of evidence about what's happening to human beings. This guy called Professor Gerald Mand, who's at Harvard, he designed the food label that's on all food that's sold in the US by law. He said to me, there is something about the food we're eating that is profoundly undermining our ability to know when to stop, right? I go through in the book the seven bits of science that actually are contributing to that effect. But crucially, this is where I think we get to the link with the drugs. So what this processed and ultra-processed food does is it has robbed us of our feeling of satiety. You know, satiety is not a word we use that often in everyday English, but we all know what it means. It's when you're sated, it's when you've had enough and you don't want any more, right? We've all had that experience with, I don't know, Christmas day or stuffed yourself, you're sated. We've all had that feeling sexually sometimes, you know, you just you've had your fill and you can't have any more, right? Um, this food profoundly undermines your ability to get that feeling. And what these drugs do is they give you back your feeling of satiety. In fact, one of the scientists who worked on them said, what they stimulate are, what they simulate are our satiety hormones, right? But when you see it in that context, you begin to realize, well, one of the scientists put it to me really well, a brilliant man named Professor Michael Lowe at Drexel University, said they're an artificial solution to an artificial problem, right? These drugs profoundly undermined our ability to feel full. They drove us to hugely overeat. And these drugs give us back that feeling of being full, but at a cost, right?
Dr Rupy: Yeah, yeah. And I I guess one of the most poignant bits of the book actually, I think, was where essentially you draw a connection between this book and previous books as well, where you're actually uncovering the reason why so many people are overweight. And yes, we can look at UPF, ultra-processed foods, we can definitely look at the food landscape that clearly is having an impact. But what are we suppressing by doing as you described, stuffing food into us to numb a pain? And there's some really interesting research that you surfaced in your book looking at the commonality or how common it is to have abuse as a child and the connection between obesity later on in life. And so if somebody who is overweight and takes this drug and is unable to use food as a crutch in that way, what does it reveal? What does it surface? And if we're not going upstream to figure out why someone is obese in the first place other than they're like motivation or they're having too many ultra-processed foods, then we risk unveiling something that hasn't actually got a solution.
Johann Hari: Yeah, I think you put that really well. One of the an interview I thought about a lot was I interviewed a scientist who made an incredible breakthrough in researching this topic in the 1980s. A super nice man called Dr. Vincent Felitti, who I went to interview in San Diego. And um, it's slightly strange how it happened. So in the early 1980s, Dr. Felitti was approached, he was just a doctor, and he was approached by Kaiser Permanente, who are a big not-for-profit medical provider in California. And they said to him, look, we've got a problem and we don't know what to do. At that time, obesity was rising. In fact, it was very low compared to now, but it was hugely rising. And they said, look, we give people diet advice, we give people personal trainers, nothing is working. What should we do? And they said, can we give you a budget to just do blue skies research and figure out what will work? So he took the money and suddenly thought, oh jeez, I've got to figure out what to do now. So he started working with 200 severely obese people, people who weighed more than 300 pounds, very overweight people. And he had an idea that sounds and in fact is quite stupid. He asked himself, well, what would happen if really obese people literally stopped eating? So we gave them, you know, vitamin C shots so they didn't get scurvy or something. Would they burn through the fat supplies in their body and get down to a healthy weight? So with a ton of medical supervision, they tried it. And incredibly, at first it worked. There's a woman who I'm going to call Susan, who went from being more than 400 pounds to 138 pounds, staggering, right? Her family are contacting him saying you've saved her life. You know, she's thrilled. And then one day something happened that no one expected. She cracked, she went to KFC or I actually don't think it was KFC, it's me projecting whether it was. And she starts obsessively eating again and she quite quickly gets back not where she was, but to a dangerous weight. And Dr. Felitti called her in. He said, Susan, what happened? She looked down, she was clearly really ashamed. She said, I don't know. I don't know. He said, well, tell me about the day that you cracked. Did anything in particular happen that day? It turned out something happened that day that had never happened to Susan. She was in a bar and a man hit on her, not in a nasty way, in a nice way. And she felt totally freaked out and she fled to a fast food joint. That was when Dr. Felitti asked her something he'd never thought to ask his patients before. He said, Susan, when did you start to gain your weight? In her case, it was when she was 11. He said, well, did anything happen when you were 11 that didn't happen when you were, I don't know, 9, 14, anything happened that year? And she looked down and she said in a very soft voice, well, that's when my grandfather started to rape me. Dr. Felitti interviewed everyone in the program. He discovered that 60% of them had made their extreme weight gain in the aftermath of being sexually abused or assaulted. And at first he's just like, what, how this makes no sense. What's going on? Susan explained it to him really well. She said, overweight is overlooked and that's what I need to be. That in fact, obesity was performing a positive protective function for many of the women and a few of the men in the program, right? If you've been through the devastating experience of being sexually abused or assaulted, if you gain a lot of weight, of course you're not invulnerable, but you're less likely to be sexually assaulted. And you see that in relation to these drugs. Why would some people when they take these drugs become acutely depressed? Well, suddenly you feel really vulnerable. You feel very frightened. It's bringing back this feeling of vulnerability and in fact, the reality of vulnerability that you have a lot of reason to want to protect yourself from. So it's easy to look at obesity and go, as we do overwhelmingly as a culture, oh, this is just, if we're being sympathetic, we go, it's based on just an error or, you know, if we're being cruel, which we are most of the time, you know, 45% of women who've got a BMI higher than 35 get insulted every single day. We kind of just attribute it to, I don't know, weakness of character or whatever, fill in your stigmatizing insults there. But actually we need to understand this is a much more complicated phenomenon. It's got biological causes in our environment and indeed in our own brains and our genes. It's got psychological causes like what Dr. Felitti discovered. It's got social causes, the way we've been screwed up with our relationship with food. We've got to understand all of these different causes and we've got to treat all of those causes with love and compassion and actually deal with the underlying crises and choose the best solutions we can in the meantime.
Dr Rupy: Yeah, yeah. And I think, you know, a lot of people would like to believe that it is a magic pill and that we can medicate our way out of this situation. But unless you uncover the real foundations of how we've got into this in the first place, it's never going to be a one-size-fits-all solution. And I that's the, you know, an area that I think needs a lot more attention than it's currently being given. Um, and you mentioned um, the stigmatization of um, people who are overweight. And I think you pragmatically discussed the pros and cons of health at every size, um, being um, body positive, um, in a way that was respectful but also um, privy to the science, respectful of the science of of how unhealthy it is to be overweight. Did you find yourself wrestling with that quite a bit during that process? Because, you know, on the one hand, you want to be respectful for people for whom a lot of the reasons as to why they're obese in the first place is because of psychological trauma.
Johann Hari: Or that we all got fucked over by the food industry, right? Like, I mean, that, you know.
Dr Rupy: That's another element.
Johann Hari: Yeah, I I mean, it was a subject I thought about very deeply and there was a person in particular, a really wise person who really helped me to think about this. So when we were kids, you only ever saw fat people on television as the butt of a joke, right? I can remember it, you know, the the kind of everyday common cruelty about it. And the first person I ever saw on television challenging that was a really fascinating woman called Shelley Bovey. Um, so Shelley had grown up in Port Talbot in Wales when it was, you know, the biggest steelworks in in Europe, big working class town. She was the only, as she would put it, she was the only fat girl in her school. And one day after school when she was 11 or 12, the teacher said to her, Bovey, stay behind after class. She was like, what have I done? So she waited and the teacher said to her, you're much too fat. It's disgusting. Go and see matron, she's going to sort you out. So she went to the school nurse and the nurse said, why are you here? And she said, well, the teacher says I'm too fat. And she says, take off your clothes, I'm going to inspect you. So she takes off her clothes and the matron said, disgusting, far too fat. Stop being such a greedy pig, just berates her, right? So of course Shelley leaves completely shaken up and traumatized, but also this was happening to her the whole time. Every day other kids are kind of tormenting her, being vile to her, saying, thank God I'm not as fat as you. And really her whole life is this cycle of abuse, right? She was really smart. She was told to apply to Cambridge, which was a big deal for a working class girl then, it would be now. Um, and she was like, they'll just abuse me for being fat. I can't take it. She just stayed in in Port Talbot. Um, when she got pregnant, first thing her doctor said to her was, you shouldn't be pregnant when you're as fat as you are. When she had her baby, she had quite a difficult birth. She's lying there covered in blood and the midwife looked at her and said, you know, you really need to lose some weight. When her baby couldn't feed, he wasn't attaching properly, she went to the doctor and he said, what are you trying to do, make the baby as fat as you are? So you can see she's soaking up this humiliation and completely internalizing it. She'd never even looked at her own body naked because she was so ashamed. And one day she learned that in the US, there was this movement, we would now call it body positivity, that was trying to challenge this and saying, enough of this shit, right? Stop treating us like this. Uh, and she wrote the first book ever to argue back against this in Britain, a brilliant book called The Forbidden Body. And I saw her on TV. I remember, you remember Kilroy, the cheesy terrible person in many ways, but I remember the Kilroy program very clearly. And, um, I saw her on it. I remember as a kid. And I think, what is this? And she was of course completely ridiculed and presented as a mad person. But the book became quite successful and she became the kind of most prominent figure in what we'd now think of as body positivity. And Shelley makes brilliant arguments against stigma. You know, stigma is a catastrophic, firstly, it's just a form of cruelty and bullying and we should oppose it on those grounds alone. But also, it actually makes the problem worse. As Lindy West is a very wise body positivity advocate puts it, why do we think it will make someone take better care of their bodies if we make them hate their bodies? You don't take good care of a thing you hate. And we know that shaming people actually makes them comfort eat more. So Shelley made these brilliant arguments against stigma and is very proud to this day of everything she argued. Shelley also began to face a problem in her late 40s, early 50s. Her doctor warned her that she had, she was very overweight. She was 19 and a half stone. Warned her that she was getting heart problems. And she took her kids one day to Center Parcs and she just couldn't walk anywhere. She couldn't get up hills. She so someone found her a wheelchair, but her husband couldn't push her in the wheelchair. She was only 50 and she was losing the ability to walk. And she felt that she was in this real dilemma. Because she, she was like, well, I've made this argument against stigma. Am I betraying that if I now try to lose weight? And she tried to discuss this with people in the body positivity movement. At that time, there was um, a publication called Fat News. But her and some other women wanted to write about, a lot of them had become diabetic and they wanted to write about the challenges of diabetes. And the people running it said, no, that's not what we want. We want to tell positive stories about being obese. And they were like, but don't we need to tell the whole story? Of course, positive elements are part of it. And Shelley, and she's the first person to point out she's unusual, but she was then able to lose a huge amount of weight just through diet and exercise. She actually lost more than seven stone and kept it off and still kept it off. Um, but Shelley became this really interesting and complicated thinker on this because she said, well, the conclusion she came to is it's not either or. Either you're against stigma or you're in favour of reducing the harms caused to people's bodies by obesity. We've got two things here that harm obese people. We've got stigma, hateful, cruel, makes the problem worse. And we've got the physical problems caused by obesity, which also harm obese people. And we should and must reduce all this stigma, indeed we should end it. But even if we got rid of all the stigma in the world, obesity would still make you much more likely to become diabetic, to have heart disease, to get dementia, to get cancer. And actually, if you really love someone in that situation, you oppose both. Now, there's dumb, cruel ways to to try to reduce obesity and there's loving and compassionate ways to try to reduce obesity, particularly now we have these new tools of these drugs, risky though they are. So to me, you know, Shelley asks, you know, what kind of body positivity would it be that required me to literally end my body's existence? That's not body positivity, right? If she had remained as overweight as she was, she would not be alive at the age of 76 now if the if if she was typical of people of that size. Um, so I think Shelley puts it very well. She says we have to live in reality. The reality is both that stigma is cruel and harmful and that obesity on average, of course there are exceptions. My mother smokes 70 cigarettes a day, is alive and well at the age of 78. There are exceptions, but but they are exceptions. We don't treat statistical outliers as the best evidence, right? We we have to do both with a great deal of love and compassion, while always stressing that it's not the fault of obese people that they are obese. I didn't, I didn't design the fact that more three-year-old children in this country know what the McDonald's M means than know their own last name. From the moment we're born, our appetites are screwed, our satiety is undermined, we're pumped with this knowledge. Watch any children's TV now, it's staggering. It's all fast food ads, right? And toy ads, usually toys that you get from the fast food restaurant, right? We didn't choose that. We didn't design that. It's not our fault. But we it's not love to pretend. So some people respond to, you know, talking about weighing the risks of these drugs against the risks of ongoing obesity by saying, there are no ongoing risks to obesity, that that there are, it's a small minority within the body positivity movement. And I've got a lot of sympathy for why they have got into this position. But they argue that it is, it's self a form of stigma to point out the scientific evidence about how obesity on average harms your health. And there, with a lot of love and compassion, I disagree with them. I understand where it comes from. They are soaking up insults all the time. I completely understand why they want to believe that. But the evidence, not least from these drugs and from bariatric surgery is very clear. If you reverse obesity, you massively reverse these problems, right? Well, how could that be if it wasn't that obesity is the cause of the problem, right?
Dr Rupy: Yeah, yeah. And I guess, you know, you've been on this medication now for over 12 months. Uh, clearly it's worked for you. Clearly in your scenario, you've weighed up the side effect profile, the pros and cons of it. You've lost three stone. Um, how are you feeling about the drug long term? And what are you thinking about using your own scenario as as the example here as to how you might navigate maybe even coming off the drug or staying on the drug long term over the next 5, 10 years? Is that something that you've thought about much?
Johann Hari: Yeah, the thing that really decided it for me to continue taking it is when a study was published that showed if you take these drugs and you started with a BMI higher than 27, it reduces your risk of a heart attack or stroke by 20%. And given the heart disease in my family, I just thought, okay, for me, that outweighs the very real risks. But you've alluded to a really important thing, which is the the long term. So for me personally, there's lots of reasons to be worried, but a lot of them don't apply to me. I don't have thyroid cancer in my family. I'm obviously not going to get pregnant. Um, a lot of the things that I'm worried about don't apply. But for me personally, the thing I most worry about is the unknown long-term effects. So Dr. Greg Stanwood at Florida State University made a comparison. He stressed he doesn't think these drugs, there's no reason to think these drugs will have this effect, but it just helps us to think by analogy. You go back to the 1950s, doctors started giving people antipsychotics and it was judged at the time that they benefits outweigh the risks. 40, 50 years down the line, it was discovered if people take antipsychotics for a very long period of time, decades, you're much more likely to develop dementia, really, Alzheimer's and other forms of dementia. It's a really significant increase. Now, there's no way you could have known that at the start. It's happened, you couldn't have known. My worry, my biggest worry is these drugs work, it seems, by activating key brain areas, including places that are parts of the brain that are really important that relate to memory, taste, all sorts of really important things. This is purely speculative, but it's not a kind of ill-informed speculation. Could chronically activating these regions of the brain over many decades lead to some problems with those regions of the brain? Against that, you have to weigh what Dr. Shauna Levy, who's a brilliant obesity specialist at Tulane University School of Medicine in New Orleans said to me, we don't know the long-term effects of these drugs. We do know the long-term effects of obesity and they're really severe. So for me personally, what we know is most people who stop taking these drugs regain the weight pretty rapidly. It's like blood pressure medication or statins. It works as long as you take it and it doesn't work when you stop taking it. So with some pretty heavy concerns, my my plan is for the indefinite future to continue taking them. But I don't say that without a lot of unease about a lot of the the worries in connection to it. But equally, there'll be lots of people who have different risk profiles, you know, different family issues, all sorts of things going on. So I don't think there's sort of blanket advice that you can give just to everyone. I think it depends on your risk profile. You need to go down the risks of obesity that I describe in the book, the risks of these drugs that I describe in the book and really think through in a complicated way, how which of those risks you're willing to take, right? And I don't think there's an easy answer for anyone. I think anyone who's super confident about this, I'm very skeptical of. Given that when you speak to the very best experts, they're not confident. I I I would be wary of people who are kind of going, well, let me tell you. Following three things are all you need to know. Don't don't be wary of those people.
Dr Rupy: Yeah. Johann, honestly, the the rigor and the way in which you've dealt with what is a really complicated subject matter is it's just done so well with the book. You've done it with compassion, you've done it with obviously your own personal lived experience. I think you've really covered it like amazingly, like you do with all your books. So honestly, it's a pleasure to chat to you about it. And I really hope that people do read it. They take away so many different elements that I perhaps didn't appreciate as much before, you know, as a medical professional who has used these drugs, who's prescribed this kind of drugs before, I don't think I knew as much as I did learn from from the book. So it's incredible. It's a pleasure to chat to you about it.
Johann Hari: Oh, I'm really chuffed about you saying that. Thanks so much. You ask great questions and you have superb hair. So always good to talk to you. Cheers.
Dr Rupy: I'm going to have to put that as a quote on the cover of my next book.
Johann Hari: Objectively the best hair. That's the that's the quote you can have.
Dr Rupy: Perfect.
