Ozempic: Miracle Weight Loss Drug Or A Secret Killer? - Johann Hari

Yan Harry welcome to the show hey Chris great to be with you again how are you you've lost a lot of weight I have I've lost what I believe the technical term is a load of weight I've lost three stone I'm good I'm cheerful life is good I can't complain talk to me about where this weight loss has come from well I remember the exact moment it All Began it was the winter of 2022 and I got invited to a party and it was that moment I had been to a party in whatever it was a year and a half two years cuz the world wish shut down and I thought [ __ ] it I'm going to go to this party and I was in the Uber on the way there and I felt a little bit self-conscious cuz I'd gained a load of weight and I was quite fat at the start and I'd gained a load of weight and the party was being thrown by an Oscar winning actor I'm not saying that just to name drop it's relevant to what happened next and on the way there I was both feeling this kind of like bit schlubby and embarrassed but I also thought oh wait everyone I know gained weight during lockdown this is going to be fascinating it's going to be super interesting to see these Hollywood people with a bit of Podge on them and I arrived and it was the weirdest sensation it's not just that they hadn't gained weight everyone was gunt right everyone had lost visibly lost weight they looked like their own Snapchat filters do you know what I mean they were like sharper and clearer and I stumbling around in a bit of a days and I bumped into an old friend of mine on the dance floor and I I said to her [ __ ] looks like everyone really did take up Pates during lockdown huh and she laughed at me me and I didn't know why she was laughing I must have done a kind of strange face and she said well Johan you know it wasn't Pilates right and she pulled up on her phone an image of an OIC pen so I did not know at that point that we now have a new kind of weight loss drug that works in a totally new way that causes people to lose 15% of their body weight for the next version of this class of drug moonaro you lose 21% of your body weight and for the next one Triple G that will probably come online next year people lose 24% of their body weight and when I started to learn about this I don't remember any subject in my whole life actually where I immediately felt so divided about it so I could obviously see the importance of it straight away right I knew even then that obesity is really bad for your health you know it makes over 200 diseases and complications more likely and this wasn't an abstract question for me I'm older than my grandfather ever got to be because he died of a heart attack when he was 44 my dad had very bad heart problems my uncle died of heart attack men on both sides of my family so I thought okay if there's a drug that reverses or massively reduces obesity that's a big deal I also thought come on now can you really have such a thing as a free lunch I guess with those EMP it be a smaller free lunch I thought I've seen this story before right every 20 years or so going right back to the first world war a new miracle diet drug is announced and people Stampede to get it they take it in huge numbers and we always Discover It causes something some horrendous dark side effect and it has to be yanked from the market leaving a trail of you know devastated people in its wake and I was worried about lots of things so really to get to the bottom of this for a year I took the drug and I went on a big Journey all over the world from Iceland to Minneapolis to Tokyo to interview huge array of people on this the biggest Defenders of the drugs including the people who made the breakthroughs that made it possible the biggest critics of the drugs everyone in between and it's a weird thing that I'm sure will come out in our conversation Chris I learned a huge amount about the extraordinary benefits and the 12 disturbing risks of these drugs um I learned that about the incredible effects it's going to have on the culture including people who don't even want to take these drugs but I'm got admit I'm still pretty conflicted it's actually a pretty complicated picture where people are going to have to weigh for themselves the the benefits and the risks and you still on it now I decided to carry on taking it after going after looking very closely at the benefits and risks for me the benefit that was just overriding is if you take these drugs and you had a BMI of 27 or higher when you start it reduces your risk of a heart attack or stroke by 20% so although I am very worried about some of the risks including for myself and I'm very worried for a lot of people I know taking them for various reasons for me that benefit just outweighed the risk and for me a cost benefit analysis absolutely all the way through this we've got to be doing cost benefit analysis between two things really the risk of continuing to be obese which for me realistically is what would have been the case right I had tried dieting and exercise loads of times I'd lost weight and it' always come back versus the risks of these drugs that won't be the choice for everyone clearly if you can lose weight without these drugs you should it's obviously better and some there's a minority of people who can um and all credit to them but for the people who can't that's basically the choice we face now we can make big changes as a culture so our kids don't face these choices and I went to places like Japan that have made those changes where you know there are almost no obese people and they don't have they're not in this [ __ ] shitty trap but for the rest of us that's the choice we got at the moment you mentioned the fact that every 20 years or so there is a new Miracle anti-obesity weight loss drug that gets released just how different is the glp1 agonists to what we've seen before well it works in a totally different way but I think it's worth just give an example of one of those previous drugs a lot of them but let's think about one in the mid90s called fenfen that was talked about in exactly the way OIC is talked about now right literally the front page of Time Magazine was the new Miracle weight loss drug so by 1995 18 million prescriptions were written in the United States alone for this drug and it was a combination of two things it was an appetite suppressant called Flex fomine which had been around for a long time but made you very drowsy so it was never that popular with an amphetamin called phentramine which had the advantage that it made you woke you up and also caused a bit more weight loss and this drug was hugely popular and massively widely used and then it was discovered it caused a series of horrific problems it caused a horrific lung disease problem and cause heart defects had to be yanked from the market it led to the biggest compensation payout in the history of the pharmaceutical industry at that point 12 billion dollars so obviously you come at this and all the previous diet drugs have that trajectory right so you come at this with a lot of anxiety rational anxiety right so these drugs work in a completely different way to all previous weight loss drugs and and there's a one of the things that's weird about it is there's actually a big debate about what these drugs even do which is a bit disconcerting but here's what we know for sure if you ate something now Chris don't matter what it is after a while your pancreas would produce a hormone called glp1 and glp1 we now know is just part of your body's natural systems going hey Chris you've had enough stop eating now right but that natural glp1 only stays in your system for a few minutes and then it's washed away and then obviously you can just carry on picking out if you want to what these drugs do is they inject you with an artificial copy of glp1 that instead of sticking around just for a few minutes sticks around for a whole week so it has this weird effect I'll never forget second day after I injected myself with a mpic I woke up I was lying in bed and I thought oh I feel something really weird what is it that I'm feeling and I couldn't place it I felt nauseous but I knew it'd feel that every almost everyone feels nauseous wasn't that bad so something else and it took me a while to realize [ __ ] I've woken up and I'm not hungry right every day before that going back to being a kid I used to be woken up with like a raging hunger right and I went to there's a cafe just out the road from where I live and I ordered the thing I used to get for breakfast every day a massive Brown roll with a shitload of chicken and a shitload of mayo in it and I had like three or four mouthfuls and I just felt full I couldn't eat anymore it was almost like how you'd feel after like Christmas or Thanksgiving dinner you know imagine you'd eaten the whole dinner you were stuffed and I turned up and said hey Chris mate I've got you a KFC bucket right You' just be like no way I felt like that after about three or four mouthfuls um and then for lunch again I went to this Turkish restaurant next to my office I used to go to every day I ordered a big Mediterranean lamb which is what I used to always order again like three or four mouthfuls I felt full so what we know is the drug makes you feel full very quickly very fast it was initially thought because that's a hormone that's made in your gut the effect is probably primarily in your gut that it slows down gastric emptying for example we now know there is definitely an effect on your gut but we now know that there are gp1 receptors not just in your gut but in your brain and from interviewing The Cutting Edge neuroscientists and really looking deeply into their work it's increasingly clear that these drugs are not actually primarily working on your gut they're primarily working on your brain they're changing what you want um and there's a huge debate about what that specific change is what it means the additional benefits and risks that might flow from the fact that this is a brain changing drug but those are things we know for sure there's a huge amount we we don't know and a huge amount of detail obviously in everything I just said what is it like mentally physically energetically psychologically to take these drugs how does it feel different people have different effects so there's a few effects that most people get so almost everyone gets nauseous at first you start off on a low dose um it's partly because what these drugs do is they produce a feeling of satiety the feeling of being full and the human body isn't very good at distinguishing between satiety and nausea so why often if you you know when you're really full you actually feel a little bit sick even just without these drugs so you feel nauseous you start on a low dose gets you used to it for about 5% people in the clinical trials the nausea was just so horrific they stopped taking the drug and I interviewed some people who had really terrible experiences with the nausea for me I think I was pretty normal it was unpleasant but if on a random day like three years ago I had felt that nauseous I wouldn't have like stopped going about my day do you know what I mean it wasn't so bad that it would have made me go to bed or anything it was just not nice um you feel nauseous a lot of people get constipated um various other side effects for me actually I didn't those side effects didn't bother me that much although I got them a bit actually weirdly I got a side effects more minority side effect but is in the warnings is not uncommon it makes your heart race a bit faster Fair bit faster for a minority of people which is hard to not it's hard to not feel a little bit anxious if your heart is racing you're bit like [ __ ] what's wrong what's going on they go oh no it's just a side effect right although as Professor Carell laru one of the scientists who developed these drugs said to me there's two kinds of drugs in the world there's drugs that don't work and there's drugs that have side effects right so the initial the initial side those are the kind of normal feelings but the main sensation is a bizarre feeling of satiety a feeling full a feeling really full really fast and that doesn't go away right it's why you eat dramatically less and it's why you know you lose on average a shitload of weight to use the clinical language how common is this how many people are taking it and famous people and all the rest of it it's absolutely massive 47% of Americans in a recent poll said they want to take these drugs it's really worth pausing and thinking about a lot of my book is exploring how the [ __ ] did we get to this point where almost half the population feel they need to drug themselves to eat less right that's an extraordinary moment in human history we actually know why it happened so there's far more people want to take the these drugs then can possibly take them partly because every person who takes them then becomes a walking advertisement for the drug I think for example about a guy I interviewed called Jeff Parker he's a 67y old former lighting engineer in San Francisco super nice guy and he was very severely overweight he a pretty bad way he had gout he had kidney problems liver problems he was finding it quite painful to walk every morning yet to swallow fistfuls of pills from the doctor he started to take mojarro which is one of these drugs and very rapidly lost a huge amount of weight his doctor took him off almost all his pills now every day he walks his dog over the Golden Gate Bridge he told me I feel like I'm going to enjoy my retirement now now everyone who knows Jeff when they see him goes [ __ ] what happened to Jeff what's going on there and he goes oh I'm taking monjaro right so partly what's happening the reason why they keep being these chronic shortages of the drugs is that the drug companies are racing to meet a Finish Line that keeps getting further and further away because everyone who uses it inspires five people to want to use it and then they demand it and it's going up and up and up so this is massive if you want to know how huge it's going to be um and we're talking obviously a lot here about the benefits quite rightly I'm also quite worried about the risk but if you want to you want to know how influential this is going to be I actually the best people to look at are the financial analysts who've been looking at this so Barkley's Bank commissioned a very sober-minded financial analyst called Emily field to go away and investigate these drugs figure out what's going on to guide their future investment decisions right they're making huge investment decisions the whole time she came back and said if you want a comparison for the effect these drugs will have you got to look at the invention of the smartphone right so look at this is me talking now not her look at so many of the effects this has already having on the economy Crispy Cream Donuts their stocks have gone down Nestle the CEO Mark Schneider making a lot of worrying noises about ice cream Jeff Financial just did a big report for the US Airlines saying they're going to have to spend a lot less money on jet fuel pretty soon because it takes a lot less jet fuel to fly a much thinner population there's a company that makes hinges for neon hip replacements their stocks have tanked because the main driver of neon hip replacements is obesity and there's going to be a lot fewer obese people right even think about Jewelers in La Jewelers have had a huge run because people's fingers are shrinking so much on people have had to have their wedding rings refitted right wow wild situation so if we had been talking in whatever it was I think it was April 2007 when Steve Jobs first unveiled the iPhone you and me would not have been able to game out you know Tick Tock and Uber Eats and hinge and all these other things that have transformed our lives right as the result of that moment but I think we can begin to see some of the ways I mean we're going to have a situation especially since 10 years from now these drugs will almost certainly be a daily pill that costs about a dollar a day I my anticipation is if we don't discover some horrific side effect and we might well if we don't I would anticipate half the population of the United States will be taking these drugs and it will have incalculably huge consequences for the way we all live why has Society become so much heavier then it's crazy to think about this I was actually stunned when I looked at the evidence on it right you're younger than me aren't you Chris how old are you 36 right so you're a little bit younger than me I'm 45 I'm going to pretend that's a little bit younger um so look at a photo from just before we were born right I'd urge people to Google if you're in the US Google uh photos of Americans on the beach 1975 right or for Britain or Australia whatever country you're in when you first look at it it it seems really strange to us when you look at these photos because everyone is what we would call skinny right everyone and you're like well where was everyone else on the beach that day what's going on was it a skinny person convention on the beach what's happening and then you look at the figures that is what people look like in 1975 right so between I was born in 1979 between the year I was born and the year I turned 21 obesity doubled in the United States and then in the next 20 years obesity severe obesity more than doubled again right Britain the country we're from very similar year I was born 6% of British people were obese uh by the time I was you know 45 now it's 27% of British people and it's put to understand you've got 300,000 years where human beings being exist and obesity is exceptionally rare and then literally in my lifetime this unprecedented explosion the World Health Organization says obesity is more than trebled in the world right in my lifetime obviously I'm not blaming myself I'm not like some Antichrist figure that caused it so what's happening here right I looked at the science and it's actually on this pretty straightforward obesity explodes in every single country that makes one change and one change only it's where people move from Mostly eating fresh Whole Foods that they prepare on the day they consume to mostly eating processed and ultra-processed foods that are constructed out of chemicals in factories in a process that isn't even called cooking it's called manufacturing food and it turns out this new kind of food which our grandparents wouldn't even have recognized and no humans before have ever eaten affects our bodies in a profoundly different way and it actually comes back to the word that we've been associating with these drugs really importantly satiety these drugs undermine your sorry this food undermines your satiety it undermines your ability to feel full and to know when to stop eating and there's an experiment there's loads of evidence for this I go through the seven reasons why this food undermines our sociiety but there's an experiment that to me just totally distilled it there's a professor uh brilliant Professor called Paul Kenny you should have in your podcast This brilliant person who's the head of neuroscience at Mount siai in New York and he grew up in Dublin in Ireland and in the 90s he moved to San Diego to continue his scientific research and he quickly clocked Americans don't eat like British people right sorry [ __ ] don't re offend the Irish but say that and it it quickly CL it quickly clocked that Americans don't eat like Irish people did at the time right they ate much more processed and ultr processed food they ate much more sugary salty food and like many a good immigrant he quickly assimilated I see you haven't done this Chris and within a year he gained 30 and he started to feel like this food he was eating wasn't just changing his gut it was changing his mind right it was making him want different things so he did an experiment to test this which I have nicknamed cheesecake Park it's very simple he raised a load of rats in a cage and they had nothing to eat but the kind of healthy Whole Foods that rats evolved to eat over thousands of years right they got it in pellet form but it's the food they used to right and when they've got that food the rats eat when they're hungry and they stop they never make themselves fat when when they've got the kind of food they evolve for they have some kind of natural nutritional wisdom that kicks in and says all right mate enough right then Professor Kenny introduced these rats to the American diet he fried up a load of bacon he bought a load of Snickers bars and crucially he got a load of cheesecake and he put it into the cage and they still had the healthy food that they wanted it the rats went apeshit for the American diet they would hurl themselves into the cheesecake and literally eat their way out emerging just totally [ __ ] smothered with cheesecake right and and all this nutritional wisdom they'd had when they had the kind of food they evolv for disappeared the way Professor Kenny put it to me was within a couple of days they were different animals right they ate and ate and ate and ate and very rapidly they were all obese then Professor Kenny tweeted the experiment again in a way that as a former junk food addict seems pretty cruel to me he took away the American diet and he left them with nothing but the health food and he was pretty sure he knew what would happen they would eat more of the healthy food than they had before and this would prove that the kind of American diet expands the number of calories you eat every day that is not what happened something much [ __ ] weirder happened once they've been exposed to the American diet and it was taken away they refused to eat the healthy food at all it was like they no longer recognized it as food it was only when they were literally starving that they went back to properly eating it right now this fits with much wider body of evidence in human beings as Gerald M Professor Gerald M who's at Harvard uh who designed the food label that's on all food that's sold in the US as he put it to me there's something about the food we're eating that is undermining our ability to know when to stop right and for a long time I was investigating that question right oh why have we gained so much weight and I was also investigating how do these drugs work right and I thought there were different topics that would meet up at the end because obviously we got fat and that's why we want the drugs but actually it's much more dens interconnected than that the this processed food undermines our satiety and what these drugs do is they give you back your satiety right in fact one of the scientists says what they give you is satiety hormones but when you see it that way suddenly you realize as Professor Michael low put it to me these drugs are an artificial solution for an artificial problem right processed food digs the hole of hunger that I've had inside me my whole [ __ ] life and these drugs fill that hole in but come with their own set of risks yeah so these drugs are rebalancing the scales of a novel food environment that we've only recently created that's a brilliant way of putting it exactly right but it's adding more tension to the system right it's not like it precisely Reb well it it does rebalance the scales but it rebalances the scales by adding weight on both sides you're now still probably eating the same hyperpalatable stuff just less of it and you're having to take the drug to improve your Society level satiety so that you don't have the problem yeah that's a good way of putting I mean some people do more radically change their diet I actually was eating smaller portions of the same old [ __ ] for a long time and I have now changed a bit I would want to overstate it does it want you does it make you want to eat different sorts of foods does it make hyper palatable Foods less palatable yes but interestingly there's a range of experiences in this so I was unusual so I just want to preface this by saying my diet was unbelievably [ __ ] before this right one of the lowest points of my life was I could tell exactly when it happened Christmas Eve 2009 at 1: p.m. I went into my local branch of KFC in East the East End of London where I used to live and I went in I said my standard order which is so disgusting I'm not going to say it in front of someone who looks as glowingly healthy as you Chris and the guy behind the counter said oh Johan I'm really glad you're here I was like all right and he went off behind where they fry all the chicken and everything and he came back with all the other people who were working that day and a [ __ ] massive Christmas card in which they'd written to our best customer everyone had written like personal mess just for me and one of the reasons my heart sank is I thought this isn't even the Fried Chicken shop I come to the most right how this be [ __ ] happening to me it's a bad day right it was the second worst moment in the my life of being fat the worst was when I was fat shamed by the Dal Lama but that's a different story turns out he's a total [ __ ] [ __ ] but who knew the but the so this this for me you know that was my diet right going right back to when I was a kid I was raised by my mom and my grandmother who were working class Scottish women whose way of giving love was to give you shitty food right and God bless them though amazing people um and a lot of people the worst effect of the drug for them is it kills their pleasure in food so think for example about Jay Raina he's a brilliant British food critic I'm sure you've read him he writes for the guardian and the Observer he um he started to take OIC and he describes going into like the best Mitchell in stard restaurants in Paris and to him it was like a lump of wood right A lot of people report this problem what what is is that a downregulation of the way that your taste buds work have you got any idea what the mechanism is no one knows you ask the experts and they go uh we don't know I mean there's different speculative theories but we basically don't know um and and and this is a big worry Yen zuls Holst who was one of the scientists who designed these drugs for Novo Nordisk said in an interview with wi magazine you know this is going to make these drugs unsustainable people just can't live without the pleasure of food after a couple of years people are like this is too boring I'm going to give it up weirdly for me and I want to stress I know I'm an outlier it had the opposite effect but for a slightly weird reason so I grew up eating [ __ ] right and I ate huge amounts of [ __ ] and I grew up in um we've talked about this before but I grew up in a family where has a lot of addiction and mental illness and kind of uh craziness and I realize now looking back I never really ate for like much very little of my motivation in eating not nothing but little of my motivation in eating was actually the pleasure of the flavor and the texture I was eating to kind of stuff myself to calm myself down to manage my emotions I wasn't not totally consciously not totally unconsciously either but you know um and with these drugs what happened to me I remember going out for dinner with a friend of mine and she said to me after I started taking them and saying to me you know it's always been a bit weird eating with you because you eat so [ __ ] much so fast but you don't really seem to enjoy it very much now you're eating so much more slowly you do actually look like you're enjoying your food so for me I've actually gone from very low pleasure in food to a little bit of pleasure in food right I think that's that's something that people don't often think about that many people don't eat food to enjoy the process they do it to just have that sense of being full in that stomach it's almost like you know topping off your esophagus with a little bit more food in the end and that's kind of the Sensation that they're chasing totally and it was fascinating to go through so in the book I explained this actually five reasons why we eat only one of them is the one that is the most obvious which is feeding your body right like staying alive the need for sustenance actually and I realize how little of my eating was about that I mean I used to eat 3,200 calories a day now I eat about 1,800 I would have sworn I ate that food to sustain my body but here I am you know better than I was right still living yeah exactly certainly not dead right um so what else is going on and one of the really interesting things is one of the fascinating things about these drugs that I was not prepared for is because they interrupt your eating pattern so radically you can't carry on eating the way you did before what they can do for some people not everyone is they bring to the surface the underlying psychological drivers of why you were eating right now that can be a good thing it can come to the surface and you can deal with it but at first it's quite painful so I remember very vividly a moment I had an epiphany about this it was 7 months into taking the drugs and I was in last Vegas as you know I'm writing a book about a series of murders that have been happening in Vegas that I've been researching for a long time and I was researching the murder of someone that I knew and loved so you know it's pretty unpleasant thing to do so I had a rough day and totally on autopilot I went to a KFC I've been to a thousand times for people in Vegas it's the KFC on West Sahara which I maintain is the grimmest KFC in the whole world and believe me I've been to very many of them but anyway and I went in and I ordered um what I would have ordered a year before just a bucket of fried chicken right and I sat there and I had a chicken drumstick and I suddenly I looked at this chicken and thought [ __ ] I can't eat this I'm just going to have to feel bad right and Colonel Sanders was on the wall there like he's in all KFC's and it's like he was looking down at me going hey buddy what happened to my best customer right so it definitely surfaces these strange and unexpected emotions now that can be very dramatic we know so one of the best ways of thinking about the what these drugs do for us both the benefits and the risks is actually to look at a parallel area of science I think these drugs have only been used for obesity for a couple of years we've got a fair bit of evidence but you know we'll know a lot more as the years pass but actually it's a very good comparison point I think not perfect but good which actually bariatric surgery so up to now it's been hard certainly not impossible but it's been hard to lose a huge amount of weight very quickly and keep it off sustainably over the long term right the best comparison point is bariatric surgery things like stomach stapling stomach gastric sleeves that kind of thing so we can look at well what happens to people when they have bariatric surgery now some of it is negative think about what we just said about Comfort eating and the other psychological factors we know that if you have bariatric surgery your suicide risk almost quadruples in the years that follow quite shocking right now I think that's that maybe some of it is that the surgery is actually pretty rough and you you have horrible uh physical effects afterwards for some people that'll be a factor for some of them but I think most of it is look by definition if you needed Buri out surgery you were severely overweight so you were very heavily eating a very large number of those people will have been using food to numb or their emotions or Comfort themselves or regulate their emotions and if that's taken away from you you you can't do that after bariatric surgery for a lot of people that will that will at least for a while manifest as just profound psychological distress but you also see if you look at bariatric surgery the Staggering benefits right so it's a really rough operation one in a thousand people die during the operation right it's no joke but if you survive it why does anyone do it it's because the benefits of reversing or reducing obesity for your health are staggering if you have bariatric surgery in the seven years that follow you are 56% less likely to die of a heart attack you are 60% less likely to die of cancer you are 92% less likely to die diabetes related causes and you are it's so good for your Health that you're actually 40% less likely to die of anything at all right that's how good it is for you so you begin to see again that very difficult cost benefit analysis right you get huge benefits to your health from reversing obesity but there psychological cost and there also of course with these drugs physical risks and um dangers that you don't get with bariatric surgery what about the people who say this is all [ __ ] can't you just diet and exercise yeah I mean I kept thinking that to myself the whole way through I remember few months into taking them I'm sitting I was having dinner with my friend Dave he was eating a massive chicken schnitzel and I been talking to him about benefits and risks right I'm go ah there's benefits of the drugs benefits of risk and Dave said what the [ __ ] are you talking about Johan there's a third option I've seen you do it go on a [ __ ] diet right like exercise I've seen that when you do that you lose weight and you know i' had done that many times and it had worked right so I spent a lot of time looking at the science of dieting and what we actually know about it it's a few things we know for sure if you understand the laws of physics you know this is true if you burn more calories than you consume you will lose weight right no one disput or no sensible person disputes that right so you hear that and yet you look at the evidence most people on diets over time do not lose weight and you're like what's going on here so I went interviewed the leading expert on diets in the world from my point of view brilliant Professor called Tracy man who's in Minneapolis who's done I think some of the most important and Cutting Edge research on the effects of diets particular on the long-term effects of diets and when she started to study this in the year 2000 the science was very clear and gave very solid advice diets work so she looked at this and there were many thousands of studies demonstrating this but she noticed something a bit weird about these these studies they followed people for three months so you massively cut back your calories you exercise more you lose a shitload of weight and at the end of those three months it just assumes well now you live happily ever after at this lower weight and then were you know a few thousand studies that also looked at people for six months and it found they found broadly the same thing but Professor M was like well I know quite a lot of people have been on diets and a while down the line they're fatter than they were at the start what's going on here so she looked at well what are what do we know about people who diet for like longer than that for like two years for example at the time there were 24 studies on that and when she looked at their results it was completely different if you diet for 2 years you at the end of it two pounds lighter than you were at the start which is not nothing it is statistically significant but it's shockingly low right so it's like well what's going on there what what's happening 10 grams per week or something across the space of two years exactly it's it's it's it's not a lot right she's like what's going on here and to understand this uh broad diet F when you look at the wider evidence there is a small subsection of people who diet and lose significant amount of weight and keep it off I've got someone very close to me and my family like that everyone knows someone like that but the evidence is pretty clear as well in the longer term they are statistical outliers right they exist they're very real it's certainly worth trying to be one of those people but they're about 10 to 15% of people right who try dieting and pretty much every fat person has tried dieting it's very rare you get when who hasn't so what's going on with the others right what what's happening and to dig into this iview loads of experts on it and this contested much debated but I think the evidence is pretty clear around one set of things so if you go back to the 70s before the Obesity crisis happened people were pretty sure they knew the science of this they thought that when you were born you had what was called a biological set point that determined your weight basically your genes say what you're going to be and you know you can go a little bit above it or a little bit below it but not by much right if you think about your body temperature you get a good analogy right your body really wants you to be whatever it is 40 degrees Centigrade right it fixes your temperature at that if you go above it say you go to the Sahara Desert it will make you sweat like a [ __ ] to bring your body temperature down it will make you crave shade if you go below it like you go to the Arctic it will make you shiver like a [ __ ] to get your weight back up your body works extremely hard to keep you at that biological set point for your temperature and they thought there was something similar for weight you can try and go outside it but your body will fight to bring you back to that set point but then the Obesity crisis happened and the whole thing went out the window because if you had a fixed set point from birth how could it be that you know obesity more than doubled in 20 years right it makes no sense but then what scientists began some scientists like Professor Michael L began to argue is something a bit different you do have a biological set point but as you gain weight your biological set point Rises so let's imagine that you gained like three stone now Chris right please don't it would be a tragedy for gays of the world over but if if you did um your brain in this Theory would then fight to keep you at that higher weight and there's a lot of evidence for that we know that if you gain weight and try to lose it your metabolism slows down so you burn calories more slowly you crave more sugary fatty salty foods uh you're more lethargic so it's harder to exercise these things are not impossible you can overcome them but it's a whole strain of obstacles and the evidence for that is really clear particularly metabolic slowdown but I remember scientists kept explaining that to me and after a while I said to a load of them this doesn't ring true to me because why would Evolution endow us with such a a maladaptation right that's obvious why would Evolution make us want us to be really really fat when that kills you right um and Professor low and lots of other people explained to me You' got to think about the circumstances where human beings evolved right in the circumstances where human beings evolved the situation we now live in where there are just a massive number of abundant excess calories all around you all the time for your whole life never happened right or would have been extraordinarily rare it certainly would have lasted over your whole life right so Evolution didn't prepare us for this scenario because it never happened for the first 300,000 years we existed what evolution prepared us for is a very different situation that existed frequently which was the risk of famine right so you weren't at risk of being surrounded by calories excess calories the whole time you were at risk of calories is running out at any moment and you being [ __ ] and you think about a famine in a famine the fattest guy at the start will be the last man standing right Timothy shalamay will die in week one and me and my fatest will cry over his corpse and still be alive a month later right so you can see when you see it from that perspective the circumstances of our Evolution why as Dr jaro one of the leading obesity specialists in Britain put it to me your brain hates it when you lose weight and will fight to drag you back to your highest weight it's preparing you for a famine but in our case it's preparing us for a famine that will never come right now some people argue in the huge debate about so I think that's why diets fail for most people right it's interesting to think about well what's going on with that Minority who do manage to break it we can talk about that but for me that also Lees an interesting debate about the drugs because there's a huge debate about given the drugs work on your brain we now know that right you give the drugs to rodents and then you cut open their brain what you see is these drugs go everywhere in the brain right every part of the brain and there's a huge de about what they're doing in your brain it's slly disconcerting to interview the leading neuroscientists and they kind of go well we're not really sure Dr clemon bluea at Cambridge University said to me you know the brain is the most complex object in the whole universe it shouldn't surprise you that we don't entirely understand how it works but one Theory and I stress it is a theory and there are other theories disputing it is that what these drugs do is it basically lowers your biological set point it's the equivalent to put it very crudely of taking your iPhone back to the factory settings right it makes your brain stop fighting to bring you back to that higher weight yeah it's very interesting I think you know it's a it's an easy criticism and we've had an unlimited number of people on the show talking about the benefits of diet and exercise and digging into the real nuances of exactly how you need to be timing your protein and what's the reps and sets and recovery and periodizing and meso cycles and stuff but the research suggests that most people who start diets and try to lose weight through diet and exercise don't and you know you can say and many people probably will these people just need to be less psychologically weak they need more willpower they're not working hard enough it's like but that's a a fine rationale narrative to push forward but like ultimately the evidence doesn't show I I don't know how much you can castigate or shame people into trying to lose weight I don't know if that's going to work yes is diet and exercise a very reliable route out of this yes would it be best if everybody could do it through that yes but but does it seem to be a like reliable route to it not working over a 2-year plus time span also yeah and uh I I kind of get the sense that given that we're in such a novel food environment hyper palatable processed foods it has become an unfair fight for many people who perhaps 40 years ago would have been able to lose weight through diet and exercise but the environment that they find themselves in now their particular horific psychology is outgunned that's a really smart analogy I mean actually what we know is that 40 years ago they wouldn't have become fat in the first place and if they did they would have found it easier to get it off but I think in terms of the willpower argument I really like how you just framed that Chris in terms of willpower so there are people who deny that willpower exists or can be used for weight and they're just obviously wrong right willpower is a real phenomenon it exists everyone listening will have exercised willpower at some point in their life in relation to food right of course sometimes you turn down dessert or whatever even if you're the fattest person in the world sometimes you say no to something right um but the way I began to think about willpower because precisely because it is real and it is important is the way I think you have to look at willpower is it is the environment in which willpower operates I think you just framed it really well so the kind of fancy way of putting it the technical term if you look at what causes obesity and actually lots of other problems like depression anxiety a whole lot of other things is what's called the bioy psychosocial model it sounds technical but it's actually very simple there's three kinds of CA of this problem like obesity there's biological causes right your genes can make you more sensitive to these problems more importantly there are biological changes that happen as you gain weight that make it harder to go back like we've been talking about so those are biological causes there are psychological causes that drive eating we've talked about Comfort eating for example that's just one of them if you're a man who loses his job you way more likely to gain weight and that's partly like just feeling like [ __ ] because you've lost your job and haven't got another one right and your sense of purpose but there's lots of others and then there's social causes like the fact that we live in this completely as you say a completely unprecedented food environment right so you think about the biopsychosocial model explains why we became obese where does willpower fit into that willpower is one sliver of the psychological component to it right it's very real people with strong willpower I really admire them they deserve a lot of credit it's a it's a good quality to have as a human being not just relation to food but generally in life right but the way I think of it is it's like an umbrella in a really powerful storm right some people are going to hold that umbrella and they're going to be able to get through the storm and get to their destination and be dry but because the storm is so bad because of all these other factors for most people the umbrella is just going to break right and you can slag them off and say you're full it's your fault but I don't know that gets us very far I think you're right that we we've got to live in reality we have tried just chiding people for 40 years right there will not be a single fat person listening to this who's not had a million time someone say to them use some willpower you fat right that that message is every day right um if that if the solution was to just urge fat people to have more willpower and pull themselves together there wouldn't be a fat person left in fact you look at fat women in particular women with a BMI higher than 35 42% of them get insulted every single day so the issue here is not the lack of insults or even the lack of well- me advice about willpower right and and i' actually separate separate that because there is genuine well meant there is shaming and stigma and all of that a lot of it is very well meant and a lot of it is useful right there's some truth in it but it's one truth among a much more complex picture the only thing I object to about that advice is if you act like it's everything that's going on it's not everything right it's one small part of a bigger picture talk to me about how glp1 agonists have effects on other behaviors addiction drugs behavioral stuff screen time those stuff this is massively contested of all the areas that I write about in the book this is the one where there's the least agreement and that's saying something because there's a lot of debate about almost everything attached to these drugs there's one thing we know for sure these drugs have an extraordinary effect in animal studies on reducing the consumption of alcohol cocaine heroin and fenil so I interviewed the scientist who've done The Cutting Edge research on this give you an example brilliant scientist at the University of gothenberg in Sweden called Professor Elizabeth yog has done cutting edge research on this for 10 years now so what you do is you get a load of rats it turns out rats [ __ ] love alcohol right they drink it they'll wobble about their cage they look very happy and so she gets these rats and gets them to use alcohol for quite a long period of time until eventually their you know their cage looks like a really rough Dive Bar in North Las Vegas and then she comes along and injects them in the nape of their neck with a gp1 Agonist and what happens is that alcohol consumption massively reduces by 50% in most of the studies right quite remarkable Decline and interestingly the rats who drank the most that kind of these are very rough terms but the closest you'll get to an alcoholic in a rat are the ones who cut back the most right but at first with these studies people thought okay maybe it's obviously we know these drugs reduce your desire for calories maybe it's because alcohol has a caloric component that you know that's why the drugs that's why the rats drink less so this was tried with drugs that are don't have any calories in them so Professor Patricia grigson who's the head of neuroscience at Penn State University who I interviewed did this with rats with heroin and Fentanyl again massive decline in them using those drugs self- administering those drugs ditto uh Dr Greg Stanwood at Florida State university did cocaine with mice um uh got the co got a load of mice to use loads of cocaine I imagine they went on long boring monologues uh gave gave them glp1 agonists 50% reduction and one of the things that's really striking about this um as Professor Heath Schmidt put it to me is what's crazy is it works with all drugs that's very unusual you know we have treatments for you know methadone that reduces heroin use or whatever but to have something that seems to reduce all drug use across the board that is unprecedented the human research on this is interesting so we have a lot of anecdotal evidence so for example I int interviewed a woman called Tracy a mental health nurse in Canada who had been a very heavy um she had a problem she basically broke up from her ex-boyfriend and went on a kind of spending binge so she would obsessively like buy clothes she wouldn't wear buy books she'd never read she was just spending she got that real you know Rush from clicking by by by she started taking oen piic for her weight and just noticed all this compulsive shopping went away so lots of doctors are having lots of patients report similar things the actual studies in humans we have so far are very small and they're a bit of a mixed bag surprisingly and a bit disappointingly actually um so we know they do reduce cigarette smoking but only if you combine them with a nicotine patch no one knows why we know they do reduce alcohol consumption uh but only people who had a drinking problem in the first place there's a shitload of studies going on now looking at these drugs uh in addiction so we'll know a lot more soon but the most the most optimistic way of interpreting this and we should say it with a lot of skepticism this is quite speculative but if you wanted to be really optimistic some people looking at this evidence say actually this isn't a weight loss drug this is a drug that boosts self-control across the board now we need a lot of evidence to back that up as a big claim but I wouldn't rule it out it's not imposs I think it's likely but it's not impossible I have a friend who is a huge huge evangelist for all of the glp 1s he's on this is it tepati I think yeah TTI yeah which is the second generation and uh he told me a couple of weeks ago uh it turns out turns out that willpower is just a drug and the dosage is around about 0.5 milligrams per day so he he's a he's seen fantastic IC returns I guess from taking it but talking about the Light Side what about the dark side what are the main risks of taking these things well there are 12 big risks I go through in the book but I'll give you an example one so when you talk to experts about the safety of these drugs the first thing most of them say is a very good point that should give people some level of reassurance they say look actually we've got loads of evidence about what these drugs do to people because diabetics have been taking them for 18 years so for people who don't know in addition to having these effects on your appetite these drugs also stimulate the creation of insulin which is obviously what diabetics both type 1 and type two need so 18 years ago we started prescribing them all over the world you know hundreds of thousands of diabetics have been taking them so what a lot of the experts say look if these drugs had some terrible short or medium-term effect we would know by now if they gave you horns the diabetics would have horns by now right but what some other exp and that that's a very good point that's there's a lot of legitimacy in that point but what some other experts said okay if we're going to base our conviction on the safety of the drugs largely on the diabetics let's dig a little bit more into what's actually going on with the diabetics so I'll give you an example there's a brilliant scientist called Professor Jean Luke F who's at the University Hospital in melier in France who I interviewed who was commissioned by the French medicines agency to investigate the safety of these drugs for the French market so he looked at the What's called the preclinical evidence the experiment on animals first and was quite taken back by something which is if you give these drugs to rats you really significantly increase their risk of thyroid cancer and we know that you have glp1 receptors not just in your gut and in your brain but in your thyroid so there's a plausible mechanism of causation there that oh if you're [ __ ] with gp1 you might [ __ ] with your thyroid right to put it in a slightly unscientific terms so he went to the French medical databases they have really good medical databas you because you basically can't opt out of them in France they don't have the equivalent of HIPPA and he compared diabetics who've been taking these drugs between I think it was 2006 and 2016 if I remember right with a comparable group of diabetics who were similar in every other way but had not taken these drugs and what he found at first is pretty eye-catching he calculated with his colleagues if you take these drugs you are increasing your thyroid cancer risk by between 50 to 75% now he said to me don't misunderstand that 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 we'd be having bomb fires of OIC all over the world what it means is whatever your thyroid cancer rate was at the start if he's right and this is highly disputed um it will increase by 50 to 75% now thyroid cancer is fairly rare 1.2% of people get it in their life 84% of them survive it nonetheless it's a pretty big increase in a relatively small risk but against that you have to weigh and this always comes back with all these risks to what is the cancer risk just from being obese and continuing to be obese I have to say of all the things I learned for the book I'm a bit embarrassed to say this the thing that most shocked me was the thing I thought I had known since I was a little boy I'm pretty sure at any point in my life if you'd said to me if you're obese is it bad for your house health I would have said yes right from when I was like five or something but I was stunned by the evidence for how bad obesity is for your health or just being overweight never mind obese right so think about it in relation to cancer as cancer research UK the biggest cancer charity in Britain explains if you carry excess weight it doesn't just sit there in your body it's not inert it's active it sends signals throughout your body and one of the signals it can send is for cells to divide more rapidly which can cause cancer this is why obesity is in fact one of the biggest causes of cancer in the United States and Britain right by but it's quite shocking the figures when you look at them um and that's just one of an enormous array of effects of obesity so whenever you're looking at the risks of these drugs and that thyroid cancer is a very alarm risk is alarming and it's why if anyone listening if you have thyroid cancer in your family I don't think you should take these drugs if you if you have any reason or certainly if you've had thyroid cancer before you definitely shouldn't anyone who has any reason to believe they're at risk of that I would I'd say it should weigh very heavily on you that risk um but again you got to weigh it against these the the what for a lot of people realistically will be the risk of obesity as Dr sha alevy who's an obesity specialist at tilan University School of Medicine in New Orleans said to me you know we don't know the long-term risks of these drugs but we do know the long-term risks of obesity and they are shocking I'm I think I'm right in saying that rats on mice have a special type of receptor on their thyroids as well so that some of the studies that are done on them aren't necessarily portable across onto humans in the same way that was something that I learned while I was away a couple of weeks ago what about muscle mass what does it do to muscle mass this is a really big issue um so any form of weight loss on average causes a loss of muscle mass weirdly that hasn't happened with me but I think that's cuz my muscle mass was so [ __ ] puny at the start there we'll get you in the gym we'll get you in you're L me there Chris you're the one of few people good um so what we know is most people shed muscle I know you know it's much better than I do any form of weight loss generally causes a loss of muscle mass which is the total amount of soft tissue in your body obviously you need it for things like climbing the stairs getting up out of the chair you know movement um and we know that this is risky it's not that risky if you're in your 30s or 40s but as you age you shed quite a lot of muscle mass each year if you're going into the aging process with depleted muscle mass low levels it massively increases the odds that as you age you'll develop a condition called sarcopenia which means Poverty of the flesh which is basically where you just can't [ __ ] do anything you can't climb the stairs you can't get out of a chair on your own you're much more likely to fall over if you do fall over you're much more likely to die and this is particularly worried because I would I would argue there's sort of two categories of people here I mean this is a very broad brush statement but there's people who are like that guy Jeff Parker I mentioned in San Francisco there's people who are overweight or obese who are taking these drugs to come down to a healthy weight I think that's very defensible although plenty of people in that position look at the other 11 risks and think well it's not worth it for me but that's very defensible then you've got people who are already a healthy weight or in fact are underweight who are taking it to be super skinny right we can all think fill in name of famous actress here right think about people at that party I went to none of them were obese right at the start far from it they are particularly incurring this muscle mass risk that won't show up now but it could really pose problems for their health as they age and it could create a kind of ticking Time Bomb problem a population where you know half the people are taking these drugs that could have a real problem when people are aging if they're taking too high a dose or they're taking it to be super skinny what do you think the introduction of these drugs means in a world where people are more concerned with their appeal than ever before it's complicated question the worst moment for me when I was working on the book was a moment with my niece so she's she's I can't I can't bear to say that she's 19 years old now but she's the baby in my family she's the only girl in her generation so in my head she's fixed as a six-year-old right whenever she has a boyfriend I always want to go get away from her you [ __ ] pedo but they're always like oh well she's an adult woman now um and one day I was so four or five months into taking the drugs maybe I was FaceTiming with her she was in a pub in Liverpool and you know she was kind of teasing me going no I never knew you had a neck before you I never knew you had a jaw right but saying I look good and I was kind of preining and then she looked down and she said will you buy me some oen piic and I laughed because she's like a perfectly healthy weight and suddenly I realized she meant it and I thought [ __ ] what am I doing here right am I counteracting all these messages I've given her since she was a little girl and we know that if you change the kind of the body the beauty Norms particularly women are vulnerable to this or men are vulnerable in a different way because men generally want to become bigger rather than exactly which certainly of course as you know very well has all sorts of problems that youve discussed on your podcast but that's a different thing right so set that aside for a minute I'm not worried that these drugs will affect that um although there plenty things to worry about in relation to that with with with girls so think for example really weird fact between 1966 and 1968 the percentage of girls who thought they were fat exploded percentage of girls who were unhappy with their bodies right it's a very short amount of time you're like well what happened between 1966 and 1968 what happened is there was a famous model named Twiggy who was just naturally extremely thin um who was sort of presented as like the face of beauty the face of the 60s and suddenly people look to her and were like well [ __ ] I don't look like Twiggy I don't like my body right so we know when a body Norm changes um a Beauty Norm changes it can change well it changes how people feel about their bodies right um so I'm I'm really worried for young girls in particular about what I think about just even like my niece all the actresses she likes or pop stars who were a little bit kind of broader range of body types they're all [ __ ] bone thin now and by the way they all claim that they're doing Pates or you know I don't know maybe there's been an outbreak of dentry in Malibu or something but you know the the what's that doing I mean the biggest worry I have if you said SEC this is not a worry I have for myself but if you said what is my single biggest worry out of the 12 for these drugs my biggest worry is what it'll do with eating disorders right so even before the pandemic we had the highest level of Eating Disorders in the history of the United States and Britain and then during the pandemic actually Rose that's obviously overwhelming the young girls is some young boys but it's mostly young girls um we're in it's complex range of reasons but I would say social media loneliness whole roaded range of things people should read my friend Jonathan Height's excellent book The anxious generation for more insight on that but um what my what these drugs do anyone who's known anyone with an eating disorder knows they're in a conflict there's the psychological part of them that wants to starve themselves and there's the physical part of them in their body that wants to stay alive and eat and what these drugs do is give you an unprecedented tool to amputate your appetite right this is why Eating Disorders experts are extremely worried about uh people like Dr Kimberly Dennis one of the leading Eating Disorders experts in the US who I interviewed are extremely worried about you know this could produce an opioid like death toll of very large numbers of young girls who would not have been able to kill themselves without these drugs who are now there's something we can do to massively reduce that risk which is at the moment anyone listening you can just go online and get these drugs on Zoom you see a doctor on Zoom well that's how well is a doctor able to assess your BMI on Zoom not very right so Dr Dennis argues I think very persuasively you should only be able to get these drugs from in-person appointments with doctors who are trained in spotting Eating Disorders obviously if you have a BMI lower than 27 they should not give it to you H and if they suspect you have an eating disorder they shouldn't right because people are basically enhancing their ability to access malnutrition that's a brilliant way of putting it that's exactly right and malnutrition is a huge huge risk here um that that's exactly correct what happens if you stop taking it there's a bit of a debate about this and we don't have a lot of good evidence it looks like you regain all the weight pretty quickly uh there does seem to be a subsection of people who use it to interrupt their habits develop new habits then come off the drug and remain at a lower weight but people have only been using this for obesity for a couple of years we basically don't know uh what the drug companies are saying and bear in mind they obviously have a strong vested interest in wanting you to take it forever because they get more money the more you buy um they say it's like blood pressure medications it's like statins they work as long as you take them you stop taking them they stop working that does seem to be the case for most people I wonder how many people are going to be confronted with a bit of an existential crisis when they lose a ton of weight by taking these drugs and it's revealed to them that being overweight wasn't the root of all of their psychological problems because you're now skinny but still miserable I that's a really important question Carell laru who I mentioned before I think a brilliant um expert and a bar has also a lot of work on bariatric surgery he said he thinks that's one of the reasons why the suicide rate goes up so much after bariatric surgery that a lot of people imagine what's wrong with my life is that I'm fat and if I was thin I'd be okay and then they lose all this weight and their husband's still a prick and their job's still [ __ ] and the life isn't what they wanted it to be and it's they're supposed to confront oh actually while this may well obviously have benefits for their physical health it's not resolved all these problems magically right I I do think there's um there's a lot of Truth in in that what about women who are either going to become pregnant trying to become pregnant are pregnant is there dangers for them yes so what we know again in animal models is rats who get pregnant when take when taking these drugs or giving these drugs in the case of rats I'm much more likely to have children with birth deformities um you're advised to not take these drugs if you're trying to get pregnant but of course some people will just accidentally get pregnant or whatever I'm I'm worri I'm quite worried about that and it could be that there's some immediate short-term effect but that seems unlikely because it would have probably shown up in the diabetics by now what people like Dr Greg Stanwood at Florida State University are concerned about and he stressed this is speculative because by definition we don't know he said he's has some concern that there may be a parallel look at what happens to pregnant women who are exposed to environmental contaminants like lead for example when their babies are born their babies appear to be like everyone else but when their kids get to go through ad become adolescent they seem to have poor regulation control poorer um attention that it turns out that that exposure to lead in the womb has had an effect on them that only emerges later he said and he stressed it was speculative but he said he is concerned we should keep an eye on the possibility that will be the case well I mean the natal the natal environment is every time that I learn something about it it blows my mind Robert sski did this great study where I think some of his colleagues looked at women who enter poverty during pregnancy poverty is a very reliable source of stress and uh it's crazy like and the other thing to consider is if a woman is pregnant with a female she is also pregnant with every egg that that female fetus is ever going to be able to produce so you were inside of your grandmother at one point which I'm sure is something you've thought about a lot exactly you who who told you my web Brower who told you my pornh search history but yeah you know the the Cascade sort of carries and and yeah it's um it's a concern it it really is so where did you come into land with this after taking it yourself after speaking to experts after looking at the state of our diet and ultr processed foods and Science and all the rest of it how have you come to weigh the scales of the glp 1es yeah the book is called Magic Pilker there's kind of three ways these drugs could be magic they could just solve the problem right in a way that is so Swift that it feels like magic and I got to tell you Chris there are days it feels like that my whole life I've eaten way too much and I've eaten [ __ ] and now I inject myself once a weak in the leg tiny little mosquito bite like feeling and I eat radically less and I eat differently that feels like magic right the second way in which it could be magic is it could be like a magic trick an illusion it could be like a you know magician who shows show you a great card trick while picking your pocket it could give you these benefits but [ __ ] you over in the longer term I don't rule that out the third way I actually think is most likely if you think about the classic stories about magic that we grow up with think about Aladdin right you find the lamp you rub it the genie appears and you get to make your wishes and your wishes come true but never quite in the way that you expected right think about Fantasia you unleash the magic and it runs away from you in all these un ictable and chaotic ways I think it's probably going to be like that it's probably going to have some good stuff and some bad stuff in terms of personal advice I have to say it's disconcerting to have been on this huge journey to have gone all over the world to have interviewed all the leading experts to learn so muching what we haven't covered and still not be able to give you all my other books I've kind of come to a conclusion like well dear reader I think we should do the following you should do the following three things and as a society we should do the five things and here's the stuff we can do and here's how we can solve this problem I don't really feel like that I end the book by talking about five possible scenarios for how this could turn out now um and they really range very widely from the super pessimistic this could be like fenfen the 90s disaster drug we could discover some catastrophic effect I don't think that's likely but I don't think you can rule it out um or it could be that the drugs work in the long term the benefits outweigh the risks we get them to everyone who needs them that's a big shift because at the moment only tiny numbers of rich people can get them um and crucially they [ __ ] wake us up to go how did we end up with this how did we end up having to choose between a risky drug and a risky medical condition is this what we [ __ ] want for our children or shall we look at Japan where they never had an obesity crisis and there is no market for these drugs because almost nobody is obese right and I went to Japan I learned how they did that that's what I hope will happen that that final scenario but I don't really know if you ask me for purely personal advice and I want to stress I am not a doctor I'm a journalist people should talk to their doctors but having looked at all this evidence and I give this evidence with a I give this advice with a low level of confidence so you might want to sue me in 20 years for giving it to you but if your BMI is lower than 27 I would say you definitely shouldn't take these drugs you're incurring all the risks like to your muscle mass for no benefit apart from an aesthetic one if your BMI is higher than 35 I if you were someone I loved I would urge you to take the drugs if assuming that you've tried dieting and it hasn't you know you haven't been able to keep the weight off because for me the evidence is so clear that the risk of being obese at that level is so great even things like I'm really embarrassed to say I didn't know this think about diabetes if you're obese when you're 18 you have a 70% chance of getting diabetes in your life but I always thought all right it's not good to have diabetes but if you live in a country where you get good health care you get given insulin you're basically like everyone else right that is not the case if I'm interviewing doctors like people like Dr Max pton one of the most high-profile doctors in Britain Jesus the facts are shocking diabetes knocks 15 years off your life it is the biggest cause of preventable blindness more people in the US have to have a limb or extremity amputated because they got diabetes than because they got shot and you will have noticed there ain't a shortage of people getting shot in the United States right um and that's just diabetes I mean Dr pton said to me as a doctor if you gave me a choice tomorrow between becoming diabetic or becoming HIV positive no contest I choose to become HIV positive if you get HIV and you get treatment you live as long as everyone else that is absolutely not the case with diabetes you die sooner and you're much more likely to have a horrific last few years of your life life where you are blind demented lose a limb agonized I mean it's really and that's just diabetes right so if your BMI is higher than 35 that would be my advice if your BMI is between 27 and 35 I think it's a much harder judgment call and I would recommend you go through the risk of obesity in the book the RIS of the drugs in the book really think about which one is more likely to play out for you and really what your risk appetite is is Right different people have different I have great respect for people who come to very one of the things I've really liked about the reaction to the book so far if some people read the book and go I really like this book you've made me be convinced that I must go out and get these drugs tomorrow other people have said to me I really like this book you made me convinced you'd be [ __ ] insane to take these drugs right it's a bit like what was the dress where some people saw it as what do they the blue and green or the black and gold or whatever exactly I saw it as black and gold right the um it's a bit like that I'm fascinated by how people read the book and come to completely different conclusions and are absolutely convinced that I shared their secret conclusion all along so I feel it makes me feel like I sort of did my job right but the I think we don't know one thing I'm completely confident of is the stakes here are unbelievably high this is by some measures the biggest cause of death preventable cause of death in our societies right Gerald man who I mentioned before at Harvard says obesity and food food caused illnesses kill 678 th000 people in the United States every year that's all the wars of the 20th century for American soldiers combined plus some right every year so whether we get this right will determine whether lots of people live or die I think these drugs are an interesting and important tool the way I think of it is for a lot of us we're in a trap and this is the rusty risky trapo we're being offered we've got to change up the way our society works so we're not in this [ __ ] trap and we can change it so that our kids really won't be in this trap we can do that I go through how we can do it I've been to places that have done it but for now we're facing a pretty shitty decision and we've got to think it through in detail Johan hary ladies and gentlemen Johan where should people go they want to keep up to date with everything that you're doing oh uh if they go to my website it's j n NH h r i.com if they want know more about where to get the audio book physical book or ebook you go to magic pill book.com I meant to say you can get it from all good book shops but the truth is you can get it from [ __ ] book shops as well we don't have like a quality test you know but um but yeah I'm very glad I don't if I said this to you last time I spoke to Chris if it already happened or not but I had this really unfortunate um moment at the end of a podcast um must have been a couple years ago probably before we spoke I was interviewed by someone I won't say who but it's quite high-profile podcast and at the end of it the guy said what's your Twitter and I said it and he said what's your Instagram and I said it he said what's your Facebook and I said it and then he said what's your Snapchat and I said I am a 45-year-old man the only 45-year old men on Snapchat are certainly pedophiles right why else would they be on there and he didn't laugh at all and I've got a bad habit if someone doesn't laugh at my jokes I lean into it more so I said you know that TV show To Catch a Predator where they sort of catfish pedophiles I said the next season of To Catch a Predator should be they just go up to adult men in the street and say what is your Snapchat handle and if they've got one [ __ ] throw them in the van right that's it immediately imprisonment he didn't laugh at that I later looked him up and he's quite active on Snapchat so my goal now in all podcast interviews is to get through it without accidentally accusing the host of being a pedophile right well so far so good hooray congratulations so much Chris really enjoyed always enjoy talking to you you ask really good questions thanks Chris thank you if you enjoyed that episode you will love a selection of the best clips from the podcast over the last couple of months and it's available right here go on give them a watch