Johann Hari: Is it a Magic Pill?

Written By Alexandra Brockman

Johann Hari is an author of many bestselling books—Stolen Focus, Lost Connections, and Chasing the Scream. Johann is a fellow cultural psychic and his latest book—the subject of today’s conversation—bears this out. He takes on drugs like Ozempic and Mounjaro in Magic Pill: The Extraordinary Benefits and Disturbing Risks of the New Weight-Loss Drugs. He also writes about his own relationship to these drugs, as Johann is taking them. His book is a subtle and sensitive navigation of what is a tightly bound convergence of health and culture—and every page of his book anticipates and precedes the conversation. (As a disclaimer, I’m in it.) We talk about all  of it in today’s conversation, along with what would have happened if a woman had written this book first. Okay, this is a longer conversation, so let’s turn to it now.

TRANSCRIPT:

(Edited slightly for clarity.)

ELISE: Maybe someday I'll be in your company, but I think of you as one of our great cultural psychics. You tend to see what's coming, and maybe it's so obvious to you, but you tend to see what's coming, and you're so swift that you are one of the first writers, I feel like, out of the gate to attend to whatever wave is on us. You must sense that. Yeah?

JOHANN: Thank you for saying that. I think for me, any book I ever write, it's because there's a mystery that I want to solve for myself. I'm in a way I'm a bit selfish like that. so I'm not an expert. I'm a journalist who talks to experts and huge numbers of people. For me, The moment I heard about these weight loss drugs, I felt so deeply conflicted. I don't remember any subject on which I've ever felt as conflicted this quickly. I remember exactly how it happened. It was the winter of 2022, and I had, like everyone else, been shut away for, you know, nearly two years. And I hadn't been to a party in a really long time and it was that moment when it seemed like the pandemic was finally ending. And so for the first time in all that time, I went to a party. It was a party thrown by a Hollywood star and Oscar winning actor whose name you would know. And on the way there, I remember thinking, I'm feeling a little bit self conscious because I gained a lot of weight during COVID. Some people say that the vaccine is the reason they survived the pandemic. For me, it was delivery food services. And I remember on the way there thinking, sort of, a little bit awkwardly about my own weight, but also thinking, oh, this is going to be interesting, because everyone else is going to have gained weight as well, right? And I didn't expect Hollywood stars to have podged out quite as much as the rest of us, but I thought it was going to be interesting to see them with a few extra pounds on them.

And I remember arriving at the party and walking around and seeing these people, and most of them were people that I had seen before and I knew, and thinking, This is really weird. They all look better than they did before the pandemic. They all look sharper and more angular. Everyone looked like their own Snapchat filter. And it wasn't just like the kind of super famous people who you thought, okay, maybe they just hit it with their trainers or something. You know, the agents and the agent's partners and the agent's kids and everyone looked leaner. And I bumped into a friend of mine on the dance floor and I said to her, Shit, it looks like everyone really did take up Pilates during the pandemic. And she laughed. And I kind of looked at her and she said, you know this isn't because of Pilates, right? I had no idea what she was talking about. And I remember it so clearly on her phone, she showed me a picture of an ozempic pen. And in the next few days, I read a lot about these new weight loss drugs. And I just remember thinking, on the one hand, being really excited, all my life I've yo yoed between being slightly underweight and being obese.

I knew diets hadn't worked for me, not sustainably in the medium to long term. I knew there were loads of people like me. I knew that obesity, although I wish this wasn't the case, on average harms your health in quite serious ways. In fact, had harmed the health of many people in my family. I'm older now than my grandfather ever got to be. He died of a heart attack. My dad had had serious heart problems. My uncle died of a heart attack. So I could see, wow, if there really is a drug that really does mean you sustainably lose weight in a safe way, that would be an incredible thing. But I also thought immediately, at the same time, whoa, every previous diet drug has turned out to be a disaster that trashed people's health. We're just making progress with body positivity and people, you know, not being at war with their bodies. What's this going to do to that? Can there really be such a thing as a free lunch? You know, so I felt this tremendous mixture of feelings and the really weird thing about working on this, but magic pill as opposed to my other books is, so I spent a year really deeply researching this. I went all over the world from Reykjavik in Iceland to Minneapolis to Tokyo. I interviewed over 100 of the leading experts from the people who played a key role in designing these drugs to their biggest critics. And I learned a huge amount. I know much more than I did before, but to be totally honest with you, I'm not much less conflicted now than I was at the start.

ELISE: I know. It's so complicated. And one of the things I think that you did so astutely, there's been so much written about it, but yours is one of the first, it might be the first book about this, I don't know, but is that you really tease apart the biological questions and then the cultural implications, which as we know, so often these things are paired, particularly I can say as a woman, morality around food and being good or bad or having a good, obedient body that's compliant and under control, that's a measure of your ability to self restrict, is such a dominant part of our culture, and as we are learning more and more with drugs like Ozempic and whatnot, willpower and food is not a simple story for any of us, and women intuitively understand this, to be fair. I think weight loss tends to be easier for men, but I don't want to generalize. But for women, you invariably learn by the time you're 30, oh, this whole equation that I've been fed throughout my life, that calories in equals calories out, and if I just exercise, that my body will yield to my mind is not true.

Like you, I share all the consternation about what's happening, the way that we're setting ourselves back. I have a lot of anxiety about watching people who are already thin. use these drugs to become incredibly thin. But I'm glad that we're talking about it. You know, I wrote about Ozempic very briefly in my chapter on gluttony and thought that I was really blowing the whistle on something and I felt quite anxious about that. And then in the time that I sent my book to the printer and it came out, it's like the Oscars happened and suddenly everyone knew, but actually these drugs have been used, they were just called peptides in Hollywood, and they've been around for a lot longer than I think the public even realizes. So I'm glad we're talking about it and I'm glad now, I find it reassuring to just be like, Oh, it's probably a Ozempic and like, okay, rather than chastising myself for being at the party like you

JOHANN: totally, I think you put that really well. And I remember, obviously I quote you in the book 'cause we had conversations about this when I was working on it, and you really helped me to think about a lot of elements of this, Elise and what you write about it is brilliant. I mean, I guess I learned so many things on this, the journey for writing the book, both the physical journey across the world and kind of emotional and intellectual journey, partly of, I took the drugs and I'm still taking them, so I've been taking them for more than a year now. One of my favourite writers, Graham Greene, the British novelist, said when we are unsure, we are alive. And I feel very unsure, not about the facts, and there's a huge amount of facts I learned that I don't think are well understood by people, both about the benefits of these drugs... you know, the subtitle of the book is The Extraordinary Benefits and Disturbing Risks of the New Weight Loss Drugs. And I think that both halves of that equation are really important for us to understand, that there are Extraordinary potential benefits to this that we're already seeing in many aspects but there are also 12 really big risks that I go through in the book that I'm very worried about and then We need to understand it in the whole wider context of how did we even get here that we were making this choice between the potential risks of ongoing obesity or overweight and the potential risks of a whole new set of drugs where there are some real red flashing lights as well as some positive aspects.

But you talk in your book, brilliantly about an area where I think we don't need to weigh the risk, which is people who are already thin taking them to be super thin. And for that, in a sense, to me, that's outside the dilemmas I'm interested in talking about. I'm interested in the dilemmas about Someone like me who was overweight or obese and then the risk of the drug. There is no situation where someone who is thin should be taking these to be even thinner. For their own health, primarily, right, we know that any form of weight loss and particularly a rapid form of weight loss causes loss of muscle mass. So muscle mass is the amount of soft tissue, in your body, that's essential for you to move, carry out basic functions like walking up the stairs, bending down, whatever it might be. And these drugs, or any form of weight loss, cause loss of muscle mass. You lose muscle mass as you age anyway, after the age of 30, by about 6 percent a year, obviously On these drugs, you can use them very rapidly. Now, if you were slim, you already probably had lower muscle mass than the rest of the population. If you're shedding that, that won't cause any immediate problems for you in the next few years. But as you age, if you have low muscle mass, you're much more likely to become disabled, to injure yourself when you fall, to really struggle to carry out basic functions like climbing stairs. So for yourself as an individual, if you're already thin, doing something that will diminish your muscle mass is a really bad idea. And I think more broadly for the cultural effect it has, it's a really bad idea. I think there are many good moments I had in the year of researching this book and many good things that happened to me as a result of taking this drug, not least my neighbor's extremely hot gardener hit on me a few months in.

The worst moment for me was actually a moment that I think speaks to the kind of cultural problem that is triggered by people are already slim, take it to be even thinner, but to be honest, also by people like me. So I have a niece called Erin. She's the only girl in my family, apart from my sister, but she's the only one in that generation. So I've got lots of nephews and godsons, but only one niece. No one could bring out my protectiveness more than her. In my head, she's always six years old. She's actually 19 now, but whenever she has a boyfriend, I want to kind of yell at them, get away from her, you pedophile. But I'm like, Oh no, she's actually an adult woman now. She's always been a healthy, normal way. And about six months after I started taking her Ozempic, we were FaceTiming, she was at a pub, she was like saying, Oh yeah, honey, you look really good. And I was sort of preening and then she said, Oh yeah, I can see your jaw. And I was like, Oh, I was so happy. And then she paused and looked down at herself and said, " Will you buy me some Ozempic?" And I thought she was kidding and I kind of laughed. And then I had this awful moment where I realized she was, she meant it, right? And I was like, what the fuck am I doing, right? All these messages that I've spent so long trying to convey to her about you don't want to aim to be skinny. This is not how you should be judged. You want to be able to take up space in the world. I thought, Oh, fuck. I've undermined everything.

She ended up not taking them and she's fine. I don't think that negative effect. outweighs all the positive effects. It's part of the mix. I think anyone who talks about these drugs without including these things in the mix, you know, we know that when a beauty norm shifts, it leads to young women starving themselves. I feel ridiculous saying this to you because you know this so much better than me, but even think about something as simple as between 1966 and 1968, there was a massive increase in young women hating their bodies and thinking they were too fat. What happened between 1966 and 1968, Twiggy, the famously very thin model, now she just happened to be very naturally thin, it's not her fault, but there was a 17 year old model who was named as like the face of beauty and promoted, who was exceptionally thin, and that shift in the beauty norm led to loads of Young girls hating their bodies and waging war on them, right?

So we know when beauty norms shift that leads to these problems and we know, I think about for my niece, all these female celebrities who she looked up to and admired who had a broader range of body shapes than the kind of one we've been taught to revere, are suddenly bone thin. Right? And unless there's been an outbreak of dysentery in Malibu, I think we know what's happened, right? Even though bizarrely they're claiming they're not taking it. And I appreciate that it's easier for a man like me to talk about it than for a woman to talk about it, but nonetheless, that's a kind of cultural aspect I'm very worried about alongside some really important benefits to these drugs that I'm sure we'll talk about as well.

ELISE: We can move to the biological, but I have this potentially perverse hope, that as these drugs become theoretically more widely available, I know that's not happening right now and more affordable. I also know that's not happening. So that I think the highest prescription of Ozempic and similar drugs is on the Upper East Side of Manhattan. I don't know if you've heard that as well, but it's definitely a drug being taken by the affluent. But that if it were to become more available than women like your niece or me, when I have this moment of self hate or doubt, can say, Oh, I could do that. in the same way that I could dye my hair blonde, right? But I choose not to. I only say this because knowing that I've been offered Ozempic, I know I could easily get it. I known about it since 2021, 2022, that somehow knowing that I could do that has made it much easier to not. So that's one weird, and maybe that's a, a perverse thing to think, but that maybe it becomes just like another mechanism. And I could get butt implants, but I choose not to, you know, or I could get a boob job. It's just part of this menu of ways that we can change our bodies. That said, as you explore quite deftly in the book, we don't quite know what the long term effects are, although they've been taken by diabetics for 20 years, is that accurate?

JOHANN: Yeah, 18 years.

ELISE: Yeah, let's get into the sort of, the biology, because you shine as sort of a citizen reporter. You're so fun to read I love it. But there were so many salient points that you made that I think are really important. Namely, this idea of satiety and what our food system has done to our brains. And yes, the problem of solving worldwide food system issue, although I guess there are pockets where obesity has not seen the same rise as it has here, but what does it mean to solve something like this through a pharmaceutical approach? So can you talk a little bit about this and I think you called it Cheesecake Park. Is that its official name?

JOHANN: That's the name I gave it, but I think it helps to think about it. So when you take these drugs, what they're doing is they're replicating a natural effect. So anyone listening, if you're listening to this while eating now, Sooner or later during eating, your gut is going to produce a hormone called GLP 1. And GLP 1 is part of your body's natural system that just says, okay, you've had enough, stop eating now. And you get a rush of GLP 1 in your gut, and most people when they get that stop eating. But that GLP 1 only sticks around in your system for less than 10 minutes, and then it gets washed away. If you kind of power through it, you can carry on eating and eating and eating. So what Ozempic and Weygovy do, they're actually the same drug with different names, what they do is they inject into you an artificial copy of GLP one that instead of getting washed away in 10 minutes sticks around in your system for a whole week. And that has a really strange effect. So I remember Very early after starting to take drugs, literally the day after, I went to this cafe where I go to have breakfast every day, used to, and I ordered the thing I always ordered, which was like a kind of brown chicken roll with loads of mayo in it, right?

And normally I'd eat the whole thing pretty quickly and still be a little bit hungry to be honest. And I ate like three or four mouthfuls and I was just full. I couldn't eat anymore. And then I remember for lunch that day, I went to this Turkish restaurant near my office, which I also used to go to every day and ordered my standard order, which was a Mediterranean lamb. And again, I ate like a fifth of it and I was just full. Right? So what it does is it means you feel full very fast. It was initially thought that this effect was primarily because of an effect on your gut. Actually we have GLP 1 receptors we now know in your gut and in your brain and we now know that this drug is mainly having an effect on your brain, not on your gut. I'm sure we'll come back to that. But it has this effect of an incredible sense of fullness very quickly. Right? I remember a few days after I started taking it, waking up one morning and having this really, lying there and having this really weird feeling. I said, what do I feel? I feel something really strange. What is it? And it took me a while to locate what it was, which is that I'd woken up and I wasn't hungry. I don't think I'd ever remembered a day when I woke up and I wasn't hungry. Actually, often I would be woken up by being so hungry. And it was, you know, Like the kind of shutters had come down on so much of my appetite I was literally 80 percent less hungry than I normally was which is why I've had this very high level of weight loss.

I've lost three stones. So what's that 42 pounds? Since this began I feel much better physically. So yeah, though I could feel the obvious benefits and I'm sure we'll go more into more of the benefits there but It really helped me to learn as well, to understand why have I been so fucking hungry all my life, right? Much more than my dad or my grandfather. So there's been an absolute explosion in obesity that coincides almost exactly with my lifetime. I was born in 1979. I'm not blaming myself. I'm not like Damien in the Omen, like my arrival triggers the apocalypse.

ELISE: I born in 1979 too, So it's my fault as well.

JOHANN: it's your fault. So the year we were born, right? In Britain, the country I'm from, 6 percent of British people were obese. It's now 27%. In a little bit longer than the time since we were born, but only a little bit, the average American has gained 23 pounds in weight. Right? So from the average American then to the average American now, this is literally unprecedented in the history of the human race, right? You have, you know, 300, 000 years where there's no obesity epidemic. And then there's us, right? Global obesity has tripled in our lifetimes. Childhood obesity has absolutely skyrocketed. And that's not because there was a sudden lack of willpower on the part of you, me, the people around us, right? That's not what happened. We know the primary reason, there's actually many reasons, but we know the overwhelming and dominant reason is because the food system completely transformed 78 percent of the calories that the average American child eats every day are now from what are called ultra processed foods, which are foods that are assembled in factories from chemical components and bear literally no relationship to the food that your grandparents, great grandparents, our ancestors ate, right?

And it turns out that food we eat is affecting us in ways that are very specific and that are intimately connected to what these drugs seem to put right. So I began to understand this much better when I looked at this experiment that, as you say, I've called Cheesecake Parks. It's carried out by an amazing man named Professor Paul Kelly, who's the head of neuroscience at Mount Sinai in New York and a very distinguished and brilliant scientist. So Professor Kenny grew up in Dublin, in Ireland, And he moved in his 20s to San Diego in California to do his PhD and really quickly after he arrived in the United States, he gained a lot of weight. He put on 30 pounds in like the first year. And he was like, Oh, what's going on here? And he noticed that American food seemed to be really different to the food he'd grown up eating. It was much more sugary and fatty, but there also seemed to be something else about it. He wondered if it was almost changing his brain. So he designed an experiment that then tested this theory. He raised a load of rats living in a cage. And for a long time they had just loads and loads of pellets that are made out of the kind of whole foods that rats evolved to eat over thousands of years. The kind of food that they know, right? And even though they had far more of these pellets than they could ever eat, they did something really interesting. They would eat them when they were hungry. And then they would stop when they weren't hungry. So when they had the kind of whole foods they evolved to eat, they never became overweight or obese.

They had a kind of nutritional wisdom that told them when to stop eating. But then Paul, Professor Kelly, tweaked the rats, right? He made a change. He introduced them to the American diet. He fried up some bacon, he bought some Snickers bars, he put in some cheesecake, and really quickly the rats reacted to this food completely differently. They would gorge themselves on it. The rats would hurl themselves into the cheesecake and then literally eat their way out and emerge just kind of slicked with this cheesecake all over them. And that nutritional wisdom they had when they had the kind of whole foods they'd evolved to eat just completely disappeared. Very rapidly, they were extremely obese. All sorts of health problems started to kick in. They just lost it. But then Paul did another tweak to the experiment. One that seems to me as a former, a long time junk food addict, somebody basically ate nothing but junk food until I was like in my thirties, seems to me a little bit cruel, he took away all the junk food. So the rats again had nothing but the kind of healthy pellets they'd evolved to eat. And he was pretty sure that he knew what would happen. He thought, having had this obsession with junk food, the rats would now eat more of the pellets than they ate before and that would prove that junk food expanded your appetite. But that's not what happened. What happened was much weirder. Once they'd been exposed to all this sugary, you know, American food, When they were deprived of it, it was like they didn't recognize the old healthy food as food at all. They refused to eat anything. They almost starved. It was only when they were really starving to death that they ended up eating the healthy old food again.

Now, I think what this shows us in a kind of microcosm is what's been happening to so many of us. Professor Gerald Mand, who's a professor of nutrition at Harvard, he designed the nutrition label that's on all the food that you buy in the U. S. He said to me, There's something about the food we're eating that is profoundly undermining our ability to know when to stop. And for a long time when I was researching Magic Pill in my book, I was looking at two topics and I thought They were sort of parallel lines that only met at the end. So one of the topics I was looking at was why we gain so much weight. And one of the other topics was how do these drugs work. But what I realized is far from being like these separate parallel lines, they were actually like densely locked together. So there was a word that kept coming up in both topics when I looked at them. It's a word we don't use that often in everyday English, but most people know what it means. Satiety, right? Satiety is, you know, feeling of being sated. It's the feeling that you've had enough and don't want any more. And you know, we will have all had that feeling at some point, whether it's from food or sex or something, you know, you could have had sex and it was really good and you're done. And then even if Keanu Reeves walks into the room, you're like, sated, I can't do this. I mean, just in case Keanu Reeves is listening, Keanu, I would find a way. But we've all had that feeling of being sated, right? In some area or other of our lives. The evidence is very clear that this new kind of processed and factory assembled ultra processed food has done to us is trash our sense of satiety.

I go through in the book the seven different ways it destroys our satiety and what these drugs do is they give us back our sense of satiety. Karel Leroux, who's the South African psychiatrist who played a key role in the development of these drugs, said to me, what these drugs do is they give you satiety hormones. They give you back the sense that you can be full, right? When you understand it in that context, you can see how fucked this situation is. You know, Professor Michael Lowe, who's at Drexel University in Philly and one of the leading experts on hunger in the said to me, these drugs are an artificial solution to an artificial problem. Right? We create this problem artificially through natural processed food. It screws us up. It's trashed our metabolisms. It's made us sick. And here are these drugs appearing to restore that lost satiety. But of course they bring with them their own risks. And of course, we never had to do that. Like you mentioned, there are countries that Never made that bargain that actually never moved to processed foods like Japan where I spent a lot of time for the book. So I think there's a lot there that we need to kind of, I'm about to say process But that makes it ironic because I'm arguing against processed food, but you see what I mean.

ELISE: Yeah, I loved the chapter on Japan and now I'm sort of trying to build my plate, although not with the level of decadent gorgeousness that you described, but trying to eat a little of this and then eat a little of that and then eat a little of this. There's something very compelling about that. Can you tell us a little bit about why Japan and I just want to mention I'm glad you mentioned the thrashing of not only of our satiety, but also of our metabolisms which a lifetime of dieting and restriction and Permitting can really do I think and it's probably why women in particular besides hormones have so much trouble Trying to use those restraints on ourselves to any success, or at least that's what I found. I can, at this point I do not restrict because it doesn't do anything. But anyways, Japan, let's talk about Japan.

JOHANN: Yeah, so I've spent this year researching scientific evidence about what obesity does to your body on average. The scientific evidence about what these drugs do and the 12 big risks associated with these drugs, And feeling like I was trapped in a choice between the two, right? And I can talk more about why, obviously, I had tried the option of dieting and why it had failed for me, catastrophically as it fails for the vast majority of people who try it. I was kind of angry and frustrated that I was in this choice, right? The food system fucked me over. I didn't design the food system, right? I grew up in a working class family. My grandmother and mother were exhausted and they fed me shit because that was what they ate and that was the easy thing to do and that's what everyone was doing, right? And that's what I wanted, right? And that's what billions of dollars of advertising trained me to want, in addition to the poisoning element of the food itself. So I was feeling so frustrated and thinking, well, this should never have happened. And okay, now I'm stuck in this choice and I've got to weigh these risks. But are we saying that everyone's going to be stuck in this choice forever? Are we going to have a situation where, you know, A few years from now, 40%, 50 percent of people are taking these drugs and it was heartening to learn that this never had to happen and we can make sure it doesn't happen for future generations because there is, sometimes people say, look, this is just a product. This is just, this dilemma is just the result of being rich in a country and having food, right? Having a surplus of food. You go, look, humans are designed to eat food. If you've got too much food, if you're a rich country. If you've got enough food, people will eat too much of it. That's just the way it is, we need these drugs to fix it, right?

But Japan proves that's not the case, because in the United States at the moment, 42. 5 percent of people are obese. In Japan, it's just over 4%, right? And it's actually declining. Japan got rich, without getting fat, right? It's in fact the only country in the world that did that. And I wanted to understand, well, how did they do that? For people who don't want to choose these drugs and when they look at the very difficult weighing of the risks and benefits that I go through a magic pill, come down on the side of going, You know what? The risks seem to outweigh the benefits. And that is a very reasonable response. Reasonable people have sided either way when they read the book. For people in that position, it will massively help to know, okay, what did Japan do, right? And at first I thought, well, I don't think there's anything we can learn from Japan. for a couple of reasons. It must be genetic, right? I thought it must be genes, right? They must have just won the genetic lottery.

But we know that's not the case. In the late 19th century, loads of Japanese people moved to Hawaii, which funny enough where I just was, it was just in Hawaii. And they've now been there for four or five generations. And Japanese Hawaiians are almost as fat as other Hawaiians, right? and their genes could not possibly mutated in that period of time. So actually, Japanese people living in the same environment as us will gain more or less the same amount of weight, possibly slightly less, but not by much. So I wanted to understand what do they do differently? And interestingly, the way they eat now is quite a recent invention. It only goes back to the 1920s when it was sort of consciously invented by their government at the time. So I remember my first day in Tokyo, I took my godson. He's had a lot of weight issues and we were staying in this hotel. Kind of standard touristy slightly hotel. And about half the people staying in the hotel were Japanese tourists from the rest of Japan and half were, you know, Westerners. So they had two breakfasts. When you go to have a breakfast in the morning, there's the Japanese breakfast and there was the Western breakfast. So the Western breakfast was like piles of pancakes, bacon, scrambled eggs, you know, syrup. And the Japanese breakfast was tiny little bits of white fish. A little bit of miso soup, right? And so we're kind of watching the Japanese people. Anyway, I was sitting down and my godson comes over to me and he says, Johan, I've just seen the weirdest thing. I was like, what is it? He said, there's a Japanese woman over there, which I tried to look discreetly. And he said, so she took a tiny bit of fish and a little bit of miso soup and then she came over to our bit of the breakfast area and she took one french fry and put it on her plate and left. And then she came back, put the french fry back and took a smaller french fry. I was like, what? And it's like, I didn't even know the word french fry could be used in the singular, right?

So we went that day to the Tokyo College of Sushi, which is run by a wonderful guy, Masaru Watanabe, who is one of the leading chefs in Japan, who began to teach us about Japanese food and principles of Japanese food. So the first thing he cooked for us was a mackerel. That's really interesting, he was grilling this mackerel, and this fat was sort of dripping out of it, and I was watching it as it dripped out. And he said, So, One of the big differences you need to understand is in the western diet you have what's called an adding cuisine. Before you eat something you add a load of stuff. You add salt, you add sugar, you add sauces, you have butter, herbs, whatever it might be. We have a minus cuisine. I'm going to give you this mackerel. I'm not going to add anything to it. All I'm doing is taking out the fat by grilling it in this way, right? So we have a minus cuisine. We make the food more intensely itself to intensify its flavor and make it delicious. Then he explained, so in every Japanese meal, you actually have more portions than we have.

They generally have five portions with every meal, but they're all smaller. So you have a bigger variety. That's better for your gut health as well. You have a bigger variety of dishes and you eat them in a different way to us. If you gave me a meal that had three components, let's say you gave me, I don't know, lasagna, carrots, and fries, in the West, what we would do is we would eat all the fries, all the carrots, then all the lasagna, we'd eat one, then the other, then the other. In Japanese tart, you don't do that. You eat in a triangle shape. You have one mouthful out of the first dish. Then you have one mouthful out of the next dish, one mouthful out of the next dish, one mouthful out of the next dish, and then back to the start, right? It slows down your eating, and it means you're happier with less. Also in Japanese cuisine, you're trained to eat until you're 80 percent full. So, what they say is, quite rightly, the signal telling you you've had enough to eat, is a bit delayed. So if you're getting that signal while you're still eating, then you've already eaten too much, right? So you should eat until you're 80 percent full.

So I learned loads of these principles. I went to the schools in Japan where all the children eat fresh food. Processed food is illegal in Japanese schools. Every school employs a nutritionist whose job is to feed the kids fresh food and use that fresh food to educate the kids about how to eat. I saw how this whole concept of, Culture is created around healthy eating and it's not that they restrict themselves, Japanese people love food. They take enormous pleasure in food. Their food is absolutely delicious I did not have one bad meal in the whole time I was in Japan, right? They love food, but they create a culture of loving healthy food and that was consciously designed, but they actually had very unhealthy diets until the 1920s. And then the Japanese government wanted to build an army to invade all these other countries. And the population was too sick to do it. The average Japanese person only ate protein once a week at that time. So they consciously created this new kind of diet through the food system. So it's fascinating to me to learn that. Also, they eat the kind of foods that create satiety, which I think is really interesting.

Unlike the the processed foods that undermine our satiety. There was so much I learned in Japan and I really saw the benefits of it. I think the most moving moment I had in the whole writing of the book was we went to Okinawa. It's the archipelago of islands in the far south of Japan. And I went to this place that almost sounds like magical. It's the oldest village in the world. It's a village called Ogimi, they've got 215 households, and 190 of the households have people in them who are over 90 years old. So one day, I turned up and I went to their little community center. And the first person I met was a 102 year old woman called Matsu Fukuchi, who had walked from her home up the hill on her own, no stick or anything, to this center to hang out with her friends. She told me she couldn't stay long, because she was looking after her son who was in his 80s, who fell off the roof fixing the aerial the other day. I was like, okay, this doesn't sound so good. But she was like, this woman was like glowing with like happiness, you know, she talked to me all about how it was the volleyball season, how much she loved watching volleyball with her great grandchildren. And then at one point they turned on this Okinawan music and she put on this amazing red cloak and started to dance. And I danced with this 102 year old woman, right? And I thought, God, this woman was born before they started broadcasting radio in Japan. And I recorded our interview on my iPhone.

And I thought, this is what you get. If you get these things right. You get, they have the longest life expectancy in the whole world in Japan by far. And you don't just get to live longer, you get to live longer and be healthy. You get more joy, you get more laughter, you get more dancing. And I thought about how many people I know, you know, my own grandmother, who I loved as much as I've ever loved anyone. An incredible woman who was hugely overweight. It destroyed her knees. She could barely walk. It played a role almost certainly in giving her dementia. I thought about one of my closest friends who died during COVID. We had bonded over our love for shitty food who was carrying a huge amount of excess fat. It probably killed her. Those jokes turned to dust in my mouth, right? And I thought When we carry excess weight, we blame ourselves. It's not that people in Japan are morally virtuous and we're morally depraved. It's that we were fucked over and they weren't, right? And I felt this such a strange mixture of emotions dancing with this amazing one hundred and two year old.

ELISE: Yeah. it's so true. And it's such an important point and 'cause I feel like we end up railing against each other and then our finger wagging about on either end of the spectrum of this debate and all, and somehow in defense of a food system that certainly doesn't have any of our backs and is not supporting our health. But it's like we forget, I certainly have, where I'm like, why am I somehow perversely defending this sort of patriarchal food system by saying, do not tell people what to eat and all of that's true. It's like, how do we go hard at this system or this structure while being really loving with each other? Amazing how we turn on each other in this debate.

JOHANN: I think you've put it in such a profound way and the honest answer is I struggle with this and I don't entirely know, and I don't think any of us fully know the answer, but what I'm sure of is there is a, I passionately want people to experience self acceptance. There is a difference between self acceptance and accepting the fact that the food industry is poisoning us all, right? And we need one and not the other, right? I don't know how we get there. And I've always been passionately in favor of body positivity and remain passionately in favor of body positivity. And I really wrestle in the book, along with, as I say, obviously talking about the science of the risks and the benefits and how it makes you feel and the psychological effects of taking these drugs and all sorts of things.

I obviously wrestle a lot with these questions about body positivity, one of my biggest worries about these drugs is what they are already doing to people with eating disorders. I interviewed some eating disorders experts that really frightens me. And I'm sure we should talk about that because it's something very practical we can do to reduce that danger that we're not doing. But in terms of the broader body positive question, there was someone who really helped me to think about this, a really amazing woman called Shelley Bovey. So when I was a kid, it was completely taken for granted on television that fat people were just the butt of the joke, right? And you could say the cruelest possible things. And the first person I ever heard challenge that was this woman called Shelley Bovey. So when I was about 10, I saw her on TV on the British equivalent of Oprah. Not that there ever could be any British equivalent to Oprah because Oprah is unique and perfect. And I love her, but the closest we had, the poor British pale in every sense imitation of Oprah. But Shelley went on the show. And she had this really fascinating story. So Shelley's from a working class town in Wales called Port Talbot. It was a kind of rough, poor, working class town. Kind of like the kind of place my mother was from. And she was the only overweight girl in her school. And one day when she was 12, her teacher said to her, Bovie, stay behind after class.

So she stayed behind after class and she's thinking, what have I done wrong? And the teacher said to her, you're much too fat. Go to see the matron, the school nurse. Go and see matron. She'll sort you out. So sort of a bit thrown. Shelley goes to the matron, the school nurse, and the school nurse says, yep, you're much too fat. Take off your clothes. I want to see you. So she sort of takes off her clothes and the matron sort of pinches her fat and says, this is terrible. This is disgusting. And sort of berates her. I'll tell you, eat less. And then just sends her on her way. And of course, Shelley, who's already being constantly insulted by all the other girls in the school, sort of internalizes this, that, God, there's something really wrong with me, there's something wrong with my body. Not long afterwards, she's eating in the school cafeteria and a different teacher sees her eating two desserts and says, you pig, you filthy pig, come here. And makes her eat like eight desserts in a row until she vomits while all the other kids like laugh at her. So she's constantly absorbing this abuse. She's really clever, and her teachers tell her she should apply to Cambridge, which was a huge deal for a working class girl at that time, it still would be now.

And she's like, look, I can't take going to university, they'll just be horrible to me, they'll call me fat. She ended up just staying and working in her parents pub. And all through her life, this kind of cruelty stalks her. When she thinks she might be pregnant, she goes to the doctor. The doctor says, well, you shouldn't be thinking about being pregnant when you're as fat as you are. When she gives birth. She has a very difficult birth. She's lying there covered in blood and one of the first things the midwife says to her is, you know, you really need to lose some weight. Not long afterwards when her baby couldn't breastfeed properly, she takes him to the doctor. The doctor said, what are you trying to do? Make the baby as fat as you are. So this just constant and, you know, women with a BMI higher than 45 are insulted on average every single day, every day. And it's significantly worse for women than for men.

Although fat men don't get it so nicely either, but it's much worse for women. And Shelley learned to hate her own body. She had never looked at herself naked. She thought she was disgusting. She'd internalized all and then she learned about the body positivity movement, which kind of existed for a while in the US. In fact, one of its very first campaigns was warning about one of the diet drugs of its day amphetamines, 8 percent of all drug prescriptions in 1970 in the United States were for amphetamines for weight loss, which not a good idea, as anyone who's taken loads of amphetamines will know, like psychosis. And she started to think, you know, maybe there's a different way of thinking about this. And she wrote a wonderful book called The Forbidden Body. It was the first kind of body positivity book ever in Britain. She was just monstered. She was ridiculed. Daily Mail writes this article calling her a fat pig, defending fat pigs. And Shelley did this amazing debunking of shame. And she explained why stigma is so harmful. It's a form of cruelty. It makes people hate their bodies. And It's not even a good tool for promoting change. In fact, it makes people eat more. But the reason I wanted to talk to Shelley was not just because of that profound and moving though that story is, but because it's something that happened to her next. By the time she was 50, Shelley weighed nearly 300 pounds, and she was starting to have heart problems and she was finding it hard to walk. And one day she took her kids to a theme park. It's a bit like a British version of Disneyland, like Disneyland after an apocalypse, is how I would describe this theme park, and she couldn't walk around it, and she had to, they get, found her a wheelchair, but her husband and her kids couldn't even push her around, because she weighed so much, and she was really worried about her weight, and she was really conflicted, because at the time there was a body positivity newsletter called Fat News in Britain, and she wanted to write about this dilemma, she wanted to write about diabetes, and they were like, no we don't want to hear about this dilemma, we're here to promote the good news, to challenge stigma, and she's like, right, but this is also a challenge that we're facing, and she was really trapped in this dilemma about is there some choice between opposing stigma and where you can, reducing your weight, because on average that harms your health. Not in every case, but on average. Just like we know, you know, my mother is 78 years old, she smokes 70 cigarettes a day, she's alive and well, but most smokers are not like that. And unfortunately, the evidence is very clear.

And I looked at this with an open mind, and I looked at the people who argue this isn't the case. I'm afraid the evidence is really clear that obesity makes all sorts of health problems vastly more likely. They're not a dead cert, but they are vastly more likely. And a really broad range from cancer to diabetes, to dementia, to just knee problems, a whole range. And Shelley became convinced that These are both forms of harm and that we need to talk about both and she puts it's not either or it's both and right and she lost a lot of weight. She actually did it and she knows that she's unusual and a statistical outlier, but she did do it through dieting and she has kept the weight of successfully for more than 20 years now. And it did reverse her health problems. It really helped me to talk to Shelly because I thought it was such an important way that she put it, it's not either or it's both and, right? That whatever choices people make about their weight and whatever happens to them that's not their choice, which is determining most of the outcomes. People deserve to be loved and protected and valued and to feel good about themselves and we should stand up to every nasty prick in the world who wants to say something mean or cruel to them. Also, we want to protect those people from the harms caused by obesity if we possibly can. And we've talked about some of the harms and risks around these drugs. And I'm sure we'll talk about that more in this conversation but it's also important to talk about the benefits.

And there's a huge benefit to these drugs, which is on the main, they lead to enormous amounts of weight loss, first of all. So the average person taking ozempic or Weygovy loses 15 percent of their body weight within a year. On Morjano, which is the next drug that was developed, which works not just on GLP 1, but another gut hormone called GIP, reduces your body weight by 21 percent within a year if you started with a BMI higher than 27. And the next drug to come down the line that works on three gut hormones, which is called triple G, which will probably be available next year. That reduces your body weight on average by 24 percent within a year, which is not far off bariatric surgery. I'm sure we're going to come to the risks about that, and there's a lot and a lot of reasons I'm worried, but I want to be really honest with people about the benefits. So we now know that if you take these drugs and your BMI was higher than 27 to start with, your chance of having a heart attack or stroke is reduced by 20 percent over the next five years, which is a staggering level of decrease in the risk, right? And particularly, obviously, I was very acutely aware of that, because so many men in my family have died of heart attacks. These drugs might literally be saving my life. But also, essentially think about it in relation to bariatric surgery. So, because losing huge amounts of weight and keeping it off in the long term is so rare, the best comparison we have is with bariatric surgery.

Now, bariatric surgery is very controversial for very good reasons. It's a horrifically invasive form of surgery. One in a thousand people die during the operation, which is very extreme. There's also other very terrible negative effects that we might want to talk about. But we do know It massively reduces obesity and in many cases actually reverses obesity, and we know what the effects of that are on health. So if you have bariatric surgery, which is of course why people do it, no one would do it, if you risk, take this enormous risk and this absolutely agonizing surgery if it didn't lead to significant benefits. So if you have bariatric surgery, in the next five years, you are 56 percent less likely to die of a heart attack, 60 percent less likely to die of cancer, 92 percent less likely to die of diabetes related causes. In fact, the improvement to your health is so enormous, you are 40 percent less likely to die of any cause over the next seven years, after that surgery. And these drugs are giving us, particularly the triple G, the one that is almost the same level of weight loss, these drugs are giving us the benefits of bariatric surgery without the nightmarish surgery and all the terrible complications that come from it. So the really significant benefit is that obesity on average harms health, in a very broad range of complex ways and if you reverse or hugely reduce obesity, on average you hugely improve people's long term health. That's not to be sniffed at, you've got to weigh that against the risks, but that's really, really substantial.

ELISE: Yeah.

JOHANN: I saw this with lots of people I spoke to. I interviewed a guy called Jeff Parker, who lives in San Francisco. He's 66 years old. He'd be 67 now. And he was a retired lighting designer and he was extremely overweight and he had kidney problems, liver problems. He got gout, he was in a lot of pain. He was struggling to walk and he started taking Monjano. And really rapidly, he lost a huge amount of weight. His liver problems went away, his kidney problems went away, his doctor actually took him off most of his meds. Now he walks his little dog over the Golden Gate Bridge every day. And I remember talking to him, expressing a lot of my doubts, saying, you know, like, but shouldn't we be dealing with the underlying issue with the food system? And he said, I totally agree with you. You want to start that campaign? Sign me up. I'll be right there. But I've got to tell you, by the time we achieve that, I'll be dead. And I've got one life to live, and I don't want to die, and I did find that quite hard to argue against. Of course, Jeff is well aware of the risks and the cost, I mean, not just the potential cost in health, but the physical, the actual cost in money. I don't believe that Jeff has made the wrong choice, right, for him. It doesn't mean that choice would be right for everyone. And there's lots of people for whom that choice would be wrong because of some of the risks which play out differently for different people. But I think for him, he has made the right choice.

ELISE: Yeah. There's research that suggests, again, and we can talk about sort of eating disorders and whatnot, if we get to it, there's some, there's a lot. But to be sort of normal weight, quote unquote, I recognize all of these terms are very loaded or overweight can be just slightly overweight in that first category can be quite health protective, to be underweight is very bad for you. And to be extremely overweight is also very bad for you. You mentioned when you were talking about Japan and some of the downsides to just that how much they love food and there's this through line of pleasure and love of food that runs throughout the book, which is one of the things that sort of saddens me about what I see. And I know you write about this and experience this, which is that my friends who are on these drugs don't really desire or love. food anymore, or at least with the same passionate intensity that maybe they would have enjoyed, like a cheese plate with me and in months or years past. And so I want to talk a little bit about that.

And then also what you write, I think really beautifully about, which is, I think all of us can relate to this, that food is one of our primary substances for celebration, and also for numbing, and for contending with our feelings. But when you take away the ability to do that, you're still left with the feelings, which I think can be hard. And the research that you cite about bariatric surgery was fascinating. I didn't know how much there would be a counter, I can't remember what you call it, but like an addiction can emerge in other parts of life because you've taken away a primary lover. So can you talk a little bit about your relationship to food and pleasure and comfort?

JOHANN: So it's funny you asked us about pleasure because I want to stress my experience was very atypical, right? I'm unusual. My answer is very unusual and most people did not have this experience. So most people who take these drugs experience a profound reduction in the pleasure they get from food. For example, there's a British food critic, a brilliant writer who just describes, you know, going to the best restaurants in Paris when he's on Ozempic and just taking no pleasure in the food, which for him was nightmarish, right? One of the scientists who designed these drugs, Jens Jols Holst, said in an interview with Wired Magazine, you know, after a couple of years on these drugs, people just find life so boring, they just can't continue with them. That wasn't my experience, but I think it's for a quite depressing reason. I realized that the pleasure I got from food was very specific. So I grew up in a very violent and chaotic environment where there was a lot of addiction and madness. I developed a way of eating that comforted me, which is that what I would do is I would stuff myself. And the pleasure I got from the food I ate was not primarily that tasting the flavors of it. I'm sure, obviously, I got some pleasure from that, but it was pretty limited. It was that feeling of being stuffed.

Everyone would have had the feeling of being stuffed, maybe at Thanksgiving dinner or something, you can get a pleasure from feeling stuffed. It's a pleasure of like pressure outwards on your stomach and upwards on your esophagus. It's a feeling of being full, right? And That was how I ate. Not all the time, but most of the time. And I remember going for dinner with a friend of mine, one of my closest friends, maybe three or four months after I started taking the Ozempic. And they're saying to me, I've got to tell you, it's much more soothing having dinner with you now. And I said, why? She said, because normally you eat so much so quickly, but you never seem to be taking any pleasure in it.

ELISE: Mm.

JOHANN: Now you're eating much more slowly. It looks like you are actually tasting your food. And I realized, because like you can't stuff when you're on Ozempic, you would just vomit. You just couldn't do it. More than that, I don't feel the inclination to do it. Because of that, I did start eating more slowly and tasting my food a little bit more. Now, I don't want to overstate it, right? I'm not a foodie, I'm never going to be that guy, that's not who I am. But for me, it's increased my pleasure. But as I say, I think that's probably only going to be true of people who have this kind of rather manic relationship with food. But also I think that's connected to probably for me personally, the hardest element of this. I mean, there were lots of things I was worried about and lots of risks that I go through in the book, but the one that most concerned me in relation to myself was a few months into taking the drugs. I noticed that it was this weird thing. I was losing weight. I was getting what I wanted, but I actually felt quite muted. I don't want to overstate it. I wasn't depressed or anything, but I was muted. I felt a bit out of sorts. I thought maybe it's just a coincidence, but then I learned that most people who take these drugs feel better for it. But there are concerns that a significant minority are experiencing depression or even suicidal thoughts.

There's actually a warning from the FDA on the drugs in the US that they may cause suicidal ideation. Again, in a very small minority of people, but that's a big, big risk, right? Because it's such a catastrophic outcome. And this has been much debated by scientists and they don't agree on that risk. I started to think about this in relation to myself. You know, there's a typo I made the whole time I was writing the book. So KFC was my like obsession and I kept mistyping fried chicken as friend chicken. I don't think you need to be Freud to figure out what's going on there, right? It was interesting because for me, you're deprived of comfort eating when you take these drugs, you just kind of can't. And I remember one day, I had a bad day, not like horrific or anything, but a bad day and I was in Vegas and I went to this KFC in Vegas that I always go to, it's one of the skeeziest KFCs in the history of the world, and I almost literally on autopilot, I ordered my kind of standard thing, a kind of bucket, and I had it in front of me, and a year before I would have just inhaled it, and I had like four or five mouthfuls and I couldn't eat any more, and I was sitting there and really consciously thinking, huh, you're just gonna have to feel your feelings then.

I remember Colonel Sanders was staring down at me from the wall and it was like, he was like thinking, What happened to my best customer? What's going on? Right. So there's a debate about why some people feel worse. It's also question marks, whether there's some biological contributions, which we can talk about, but I think a significant part for some people, clearly not everyone is when you take these drugs and you interrupt your eating patterns, You begin to see the job that eating was doing for you psychologically all along and that was so onerous to me That I went to one of my closest friends and you know I'm thinking of stopping taking these drugs and she said look, yeah, and you can stop taking, that's fine. You can go back to how you were before but no the drugs didn't create this problem, The drugs have just brought it to the surface. And I think now it's at the surface, you should actually deal with these feelings, not bury them under a bucket of KFC again, right? Did help me to do that, to some degree, I don't want to overstate that, but it did help me to some degree, but I can see people who hadn't done industrial strength therapy like I have, might struggle more with processing that negative feeling and the recurrence of these bad feelings and not having your normal way of dowsing it.

ELISE: Yeah.

JOHANN: Does that make sense?

ELISE: Yeah, no, it totally makes sense. And I think that everyone can relate. I mean, you write about sort of how food is a sedative in this culture, probably across the world. But the you like these stats about on the night when Donald Trump was elected in 2016, that there was a 46 percent surge in people ordering pizza, 79 percent surge in people ordering cupcakes, and 115 percent increase in people ordering tacos. Democrats comfort even more. Fried chicken was up 243 percent in Los Angeles. Mac and up 302 percent in Chicago. So everyone relates. We eat our feelings. We know this. It's interesting that you mentioned KFC, Colonel Saunders sort of lamenting the loss of his best customer because we're also seeing this in a weird way is affecting the food system.

I think Krispy Kreme's stock is down, right? You mentioned and that they attribute it to Ozempic. You have to wonder if in an upside, weird upside of capitalism that there's a response to this. somehow in terms of the foods. Is your palate expanding? Are you liking things that are more whole or quote unquote, more healthy or you're just eating less? So at first, for the first six months, I was eating, to put it crudely, smaller portions of the same old shit, right? Something jolted me out of that. So if you look at the studies of these drugs, the longer term studies, for example, there's a 63 month study. It was looking at weight loss on Ozempic. And what it shows is, these are the averages obviously, not everyone, but a massive fall in weight. And then it plateaus, right? It stays steady and that's what you'd want because obviously if it, if you carried on losing weight infinitely, it would kill you, right? It plateaus. But the thing that caught my attention is at the very end of that 63 month period, it slightly ticks back up again. And I wondered, what do we know about tolerance in relation to these drugs?

So we know with previous diet drugs, people tend to develop tolerance. So for example, think about amphetamines, right? If you take amphetamines, it'll suppress your appetite. It'll also make you manic and all the fun stuff we know about amphetamines. But your body adapts, gets used to the, Amphetamines, so it down regulates other aspects. So you have to take higher and higher doses to get the same effect, right? This is why there was such a disaster as a diet drug, because if you're taking really high doses of amphetamines, you become psychotic, right? Or you can become psychotic. So I wanted to know, do people develop tolerance to these weight loss drugs, these new weight loss drugs, which work in a completely different way, obviously, to the previous generation. And the truth is, we don't know. So some scientists said to me, I think that will probably happen. It would be weird if it didn't. I mean, there are some drugs that people never develop tolerance to, antihistamines you can take every day. You don't need escalating doses. Some scientists said no, and they pointed some good evidence, which is, if you look at diabetics, as you mentioned, diabetics have been taking these drugs for 18 years. So, GLP 1, in addition to making you feel full, also stimulates the creation of insulin, which is obviously essential for diabetics who struggle to produce it. So, diabetics have been taking these drugs for 18 years now, and they're not developing tolerance, because they don't need higher and higher doses, right, to keep their blood sugar under control. So maybe we will, maybe we won't, we don't know. But I realize it's at least possible that this is just opening a window of change. And okay, I've got a, take this as an opportunity to actually make the changes I want to make. So I'm embarrassed to say I was in the middle of my 40s, I learned how to cook for the first time as an adult man. I learned how to dance, which turns out is great fun. Who knew? I made all sorts of changes that were about reconnecting with my body, repairing my sense of being in my body and I'm preparing myself for being healthier if I decide to stop taking these drugs or if some of the alarm signs around these drugs end up to be accurate and we all have to stop taking them or if they just wear off.

Elise

Yeah. And I think that that's, that's potent. And I think that one thing that everyone across the board can agree on is that exercise is incredibly health protective and that we all have to do it. It's like an absolute non negotiable for heart health, regardless of the size of your body. And so I think too anything that allows people to move or makes that enjoyable or pleasurable or a little bit easier is Great. You mentioned it, but besides this specter of maybe increased suicidal ideation, which is certainly no small thing, what do you think is lurking as a potential significant downside or a reason that these would be pulled? Or is there nothing that's quite emerged yet?

Johan

Oh no, there's a lot that's emerged. So there's a few that I would just give as headlines. The one that worries me most is the risk around thyroid cancer. So what a lot of people who are supporters of these drugs say, and it's a reasonable and good argument, is that actually people have been taking these drugs for a really long time, 18 years with diabetics, that's a long period of actually testing out the drug in a very large population. Many hundreds of thousands of people across the world have been using this drug for diabetes. So say, look, if this caused some catastrophic effect, it would have become clear by now, right? Which is powerful and persuasive. Obviously, even within that, it might affect people who use it for obesity differently to people who use it for diabetes. But actually, some other people then go, well, okay, let's actually dig into what is happening with the people who've been taking it for diabetes. So we know that when rats are given these drugs, their rate of thyroid cancer really hugely increases. So a group of French scientists were worried about could this be happening with humans? So a brilliant scientist called Professor Jean Luc Fayy who's a professor at the University Hospital in Montpellier in Paris was put in charge of investigating this by the French Medicines Agency, just figure out the risks of these drugs. And he did a quite simple and quite significant piece of analysis. So France has incredibly good medical databases. They don't really have the equivalent of HIPAA, so everyone's data is there. And what they looked at was they looked at people who had been using these medications for diabetes between, I think it was 2006 and 2012. It was quite a large population. And then they compared them to diabetics who were very similar in every other respect, but had not taken these medications. And what they calculated was these drugs seem to increase your thyroid cancer risk by between 50 and 75 percent. Now, it's important to understand what that doesn't mean, because when you first hear that you're like, what the fuck?

So that doesn't mean you've got a 50 to 75 percent chance of getting thyroid cancer. If that was it, they'd immediately withdraw the drug everywhere. What it means is whatever your thyroid cancer risk was at the start, if this piece of research is right, and there's a debate going on, and some people disagree, then whatever that risk was at the start, it is increased by 50 to 75 percent. And so, some people say, okay, you've got a very small risk of getting thyroid cancer, 1. 2 percent of people get it, 80 percent of them survive. So this is a medium sized increase in a very small risk. So overall, the risk remains relatively small, right? That's true, but I remember saying to Professor Fahy, But this isn't a small increase, right? This is 50 to 75 percent. That's a lot. And he said, yeah, this is a big increase, right? And it is worrying. And all throughout this debate, there's so much complexity. But the other side, the proponents of the drug, and I don't just mean people who are paid to be proponents, but sort of analysts who've been persuaded by the case of the drug, would say is, some of them would grant that there's an increase in thyroid cancer. Some of them would say it's disputed, but they would say you have to compare that to what we know about obesity and cancer. So obesity hugely increases your risk of cancer. Cancer UK, the main Cancer Research UK, the main British charity on cancer explains, when you carry excess weight, it doesn't just sit there, right? It's active. It sends signals through your body. And one of the signals it sends often is for your cells to divide more rapidly, which can cause cancer. This is why there's such a big, Increase in cancer risk among people who've developed obesity and why there's such a reversal of that when people have bariatric surgery.

So again, you've got all this complexity, but I'm very worried about the thyroid cancer risk. I'm worried about pregnant women. We know that when non human animals, are taking these drugs and giving these drugs and get pregnant, they could often develop horrible birth deformities. I'm worried about pancreatitis. It's a rare condition, but it's excruciatingly painful. I interviewed a woman, called Michelle Stesniak in North Carolina, she got pancreatitis after taking Ozempic and said it was the worst pain she'd ever experienced. A lot of doctors compare it to being stabbed. We know research from the University of British Columbia found that although it remains a relatively small risk, you are nine times more likely to develop pancreatitis when you're taking these drugs. It's no joke. If it's untreated, you can die of pancreatitis. We talked about eating disorders. I'm really worried about that, also one of the things I worry about is, to borrow a phrase from Donald Rumsfeld, the unknown unknowns. So I'll give you an example: in the 60s, doctors started giving a lot of people antipsychotics, and they were judged by doctors to be safe. I mean there's a big debate about antipsychotics, but set that aside, doctors at the time judged it to be safe. And it was only 50 years later that they discovered that if you take antipsychotics you're much more likely to develop dementia later in life, right? Now they couldn't have known that at the start, you had to have people taking it for 50 years to find that out, right? Because how else could you know? Now I'm not suggesting that these drugs will give people dementia, there's no reason to believe that, but what I'm saying is there could just be unknown things, right? These drugs are working on the brain, they're having a big effect. Maybe there's something we can't see right now that will emerge further down the line. So there's lots of reasons to be worried and lots of reasons to be cautious. And it was interesting for me, before the book came out, the first people who read it, apart from my editors and my friends, were the marketing teams at my publishers in Britain and the US. And it was so interesting to me, some of the people in the marketing team, and I know the marketing teams and love them, came up to me and said, you know, I really liked your book, Johan, it made me absolutely convinced to go out and get Ozempic. Some other people said to me, I really liked your book, Johan, it made me convinced it would be absolutely fucking insane to go and take Ozempic, right? And it was a bit like, you remember the dress that it was Orange is blue, or whatever it was, I saw it as kind of gold. It was a bit like that, and I thought, Oh, that's a sign that I think I've done my job right. That I've laid out the best evidence we have. Different people have different appetites for risk, and different people will weigh these risks differently, and different people will bring different risk profiles to it.

If you've got thyroid cancer in your family, I would really strongly urge you not to take these drugs. If you've got history of eating disorders, I would really recommend that you don't take these drugs. If you've been suicidal, I'd say really be careful if you're going to take these drugs. If you've got low muscle mass, if you're older than 60, because these drugs cause a decline in muscle mass in most people, if you're older than 65, I would say be pretty cautious about this. So there's all sorts of risks. But on the other hand, if you are very severely overweight, If nothing else has worked for you, I would say the case for taking these drugs is quite strong actually. Or if you've got like terrible heart disease in the men in your family, like me, I'd say the risk/ benefit balance for you is probably that you should take it. But different people will look at the facts and disagree, and I think that's how it should be, right? What I hope Magic Pill does is equip people, in addition to thinking more about the cultural effects of these drugs, how they're going to affect everyone, help people to make sort of sane decisions for themselves, and think through as well some of the things this is activating in us. It was so strange to me, for the first four or five months I took these drugs, I felt really guilty. I had this recurrent feeling that I was cheating. It's like, this is weird. What's that about? Like, I've got a friend who takes statins to lower her cholesterol. It would never occur to me to think she was cheating, right? I've taken medication before in my life. I never thought I was cheating. And I realized I think there's a few things that are in our heads that are so deep in the culture. One of them is the idea that being overweight is a sin. It goes right back to if you look at Pope Gregory I in the 6th century when he first formulates the seven deadly sins, gluttony is there, it's always depicted with some fat person who looks monstrous, overeating. And how do we think about sin? If being overweight is a sin, we think sin requires punishment before you get to redemption. The only forms of weight loss that we admire are where you suffer horribly, right? You think about The Biggest Loser, that horrid, disgusting game show. If you go through agony, if you starve yourself, if you do extreme forms of exercise that devastate your body, then we'll go, he suffered. We forgive you. Well done. We'll let you be thin now, right? So I think it's partly that. A sort of sin based model. I think it's also the idea of cheating. We're in a culture where we're all pitted against each other, like you said before. And a lot of us make huge sacrifices to be thin. We literally starve ourselves. And then you see someone who gets to be thin just through injecting themselves once a week, or taking a pill, and they look to you like Lance Armstrong.

It's like, what do you mean you fucker? I'm sitting here starving myself to be thin, and you get to just have a shot once a week and do it. And I realised how deep those ideas that I was a sinner, I was cheating. You kind of go, there is someone to be angry with here, but it's not each other, it's the food system that did this to us that we can fix. In a way, To have that rational conversation about the benefits and the costs of the drug, we have to unpick these mad ideas that we've got in our head about weight and shame and loss and yeah, all these different ideas that I was surprised bubbled out in my consciousness must been there all along.

Elise

it's so deep. It's so deep. And thank you for writing the book. You sort of anticipated all of my questions and whatabouts, as take us through the experience. And it's really important for, I think, people to be honest about their experiences as part of the relieving of that cultural shame. And I think that we can imply or we can infer that all these people are on it, but I think the more people who can be honest about it and say, yeah, This is ozempic, this is not the treadmill, would be very relieving, particularly for women. And then if we can uncouple that from shame in the same way that as a woman who has worked in this industry, it's like, do whatever you want to your face. Like it is not for me to judge. And I very much believe in body autonomy and I understand the pressures that people feel to look a certain way. I think the only problem for me is when people who are responsible for establishing these beauty standards and pushing them into the culture, mainstreaming them, when there's a level of deception about it, to me, it's like, do it, do it, go nuts, but please tell us, please be transparent about what's required or what you're doing so that we say, okay, I'll do that too, or, eh, no thanks. The same response your marketing team.

JOHANN: I wonder what you thought about this. One of my editors said to me such an interesting thing. We were talking about, why are there no other books about Ozempic yet? Why don't there seem to be any on the horizon? And she said Because if you were a woman and you'd written this book, you would be absolutely crucified. And she said only a man could have written the first book because a woman would just be, I mean, I think it's really helped that Oprah has talked out as bravely as she has. And weirdly, Oprah is my friend, which is a sentence that will never cease to seem surreal to me, but like we are friends, every now and then she texts me and I'm immediately like, shut up everyone. Oprah needs us. Or emails, right. I've been to her house. I'll tell you the story one day, but, yeah I think women, well, it's absolutely stupid of me to say this to you because you know this a million times better than me and I'm in danger of mansplaining here, but do you think that's true that as a man I'm going to get it so much easier than if I was a female?

ELISE: Yeah, I think any move by a woman is traitorous to some camp or other, and it's so loaded. It's the most loaded conversation. There's so much pain, there's so much shame, there's fear and it's so, so complicated by so many other factors, like. class, like how much trauma you've experienced or how much food insecurity you've experienced or how you were raised. It is sort of the ultimate expression of of what we value in our culture. And you can see it, it's sort of in its physical expression. And so fraught and hard. As someone who's sort of sat in the middle of this conversation, it's a real no win. It's a real no win, and it's ultimately a no fly zone, and anything you say will be used against you or other women in a way that I don't think, what we really want. But that's sort of the state of the conversation.

JOHANN: I'm really moved by how you put that and so frustrating and I'm very conscious of the kind of male privilege that I have going into this debate. Okay, so I'm a gay man, so we're at a slightly right angle to the patriarchy, but we still get all the patriarchal benefits when it comes to this sort of thing, right? You know, I think it's really important for thinking about these drugs and for some, it's going to be a minority of people listening, but not such a small minority. One of the most moving interviews I've ever done is with a man named Dr. Vincent Felitti. He was a doctor in San Diego in the early 1980s when he was approached by Kaiser Permanente, one of the big not for profit medical providers in California. And they said, look, we've got a problem. Obesity is rising. In fact, it was very low at the time, but compared to now, but it was rising. This is causing escalating health costs. Nothing we do works. We're giving people diet plans, we're giving them advice, we give them personal trainers, it's not working. We need to figure out what we can do, can we give you blue sky, a load of money to just do blue skies research.

And he's like, fine, I'll do it. And he's got all this money, he's like, shit, what am I going to do? So he starts to work with 200 severely obese women. They were overwhelmingly women, there were a few men. These are people who had tried everything, nothing seemed to have worked. They were, you know, unwell. And he's trying to think, well, what can I do with these women? And one day he had an idea that seems, and in fact is, quite stupid. He asked himself, well, what would happen if these women literally just stopped eating? And we gave them like vitamin shots and, you know, so they didn't get scurvy or whatever. Would they burn through the fat supplies in their body and get down to a healthy weight? And so they tried it with obviously a load of medical supervision and incredibly at first it seemed to work, right? Their weight massively fell and people start celebrating. There's a woman, I'll call her Julie, that's not her real name, who went from being more than 400 pounds to 138 pounds, staggering weight loss, her family are telling Dr. Felitti that he saved her life. And then one day something happened that nobody expected, Julie cracked, she went to KFC, I don't think it was KFC, that's me projecting, she went somewhere, some fast food place, and She started eating obsessively again and quite soon she was not back where she'd been but back at a dangerous weight.

And Dr. Felitti called her in, he said, Julie, what happened? And she looked down, she was really ashamed. She said, I don't know, I don't know what happened. And he said, Well, tell me about that day, the day that you crack. Was there anything that happened that day that hadn't happened any other day? It turned out something had happened that day that had never happened to Julie before. She was in a bar and a man hit on her, not in a horrible predatory way, quite a nice way. And she felt completely freaked out. And that's when she went to go and start eating again. That's when Dr. Felitti asked her a question he never asked any of his patients before. He said to her, Julie, when did you 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 10 or 40? Anything in particular happen that year? Shook down again. She said, well, that's when my grandfather started to rape me.

ELISE: Mm hmm.

JOHANN: He interviewed everyone in the program. He discovered that 60 percent of the women had made their extreme weight gain in the aftermath of being sexually abused or assaulted. And at first he's like, well, this seems bizarre. What's going on? And Julie explained it very well to him. She said, overweight is overlooked. And that's what I want to be. Right? He discovered that obesity had a profound protective function for these women. Right? Many of these women. That in the main, obviously not in every case, but in the main, obese women attract less sexual attention and are safer from predatory sexual behavior. And for one thing I worry about in relation to these drugs, obviously when we talked about, you know, some people become much more depressed when taking them or seem to, there's lots of psychological things going on, I go through many of them in the book, but one of them is going to be, and I spoke to women in this position, what happens when you lose that protection?

ELISE: Mm hmm.

JOHANN: For a lot of people, that will be a source of joy because they'll rediscover sexuality and be able to overcome that trauma. But for a lot of people that will be terrifying and profoundly disturbing. And I also think it's one of the reasons we need to communicate sensitively about whether people should take this drug. Because you want to say to people, you don't know what positive function carrying excess weight may be carrying out for these people, right? When you're making the calculation, I'm worried about diabetes on this side, but I'm worried about thyroid cancer on this side, but it might just be your trauma is so great that it will be profoundly destabilizing and horrific for you to again be the subject of sexual attention from men. Roxane Gay, the brilliant writer, has written about how she was gang raped when she was very young. It's just unspeakable what happened to her. She very consciously gained a huge amount of weight afterwards. Every time she lost weight, she had bariatric surgery. I don't know if she's taking these drugs or not, so I don't want to set in relation to this, but she felt really unsafe and afraid. So we've got to be really attentive to people's emotional, psychological and biological complexities. And what we don't want is to move from a kind of, God, you should go on a fucking diet to God, you should go on fucking Ozempic, right? We need a much more complex and compassionate, a more intelligent conversation about it, right? Because I think it's one of things that's so fascinating when you look at this subject, and I found doing all the research on so many different areas, and lots of areas we haven't covered obviously, is how much this affects every aspect of life, and interconnected it all is, and how complex it is to unpick these phenomena. And sometimes there'll be a huge benefit from unpicking them, but how complicated and how interesting it is, right? Like to some degree, the doubt was uncomfortable. But to some degree, the doubt was really interesting, right? I found it fascinating.

ELISE: Yeah. No, it's where everything collides, and it's a Gordian knot for sure, and and I think the more that we can really become literate about this and talk about it in a way that is allowing for everyone's choice, and hopefully these drugs provide more choices while not becoming cattle prods. Yeah, I think that my fantasy is that someday through science, they'll be able to just go in and reset our satiety or reset our, I know that sort of this idea of a set weight is more or less a fantasy, but that we can in some ways return that to ourselves. So we're not dependent on drugs and we could potentially stand a chance against our food system. Who knows? Who knows what will happen? Thank you for giving me so much time. I mean, we could keep going for hours.

Johann really does tackle complex, nuanced, thorny issues, deep social issues that we have to pay attention to, with so much deftness and so much heart and compassion for himself and really for all of us. And I’m excited about this book, if only because I hope people read it and feel like they can and want to engage deeply with these issues, as anyone listening knows, there’s nothing more front and center, for women in particular, that our relationship with our bodies, our appetites, our appearance. Thank you, as always for listening. I will see you next time.

Alexandra Brockman
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