Obesity levels for adults have hit 26% in Britain and 42.5% in the United States, journalist Johann Hari writes in his new book, Magic Pill. In Australia, recent data shows we’re somewhere in the middle at 31%.
Hari, who grew up eating “almost nothing but junk and processed food”, describes himself as ranging from “slightly underweight to quite seriously obese” from his late teens onwards. He describes a family history of heart problems and diabetes. Shortly before he began writing this book, he recorded his BMI at “just over 30”.
Worried about his health, he says, he accessed Ozempic though a doctor, “after some brief questions and some cursory measuring”. On the first page of chapter one, two days after beginning to inject the drug, he wakes up with mild nausea and “no appetite at all”. Ozempic, he writes, “made food, beyond small quantities, feel unfeasible”.
If you are looking for a book that succinctly summarises the pros and cons of injectable weight-loss drugs like Ozempic and Mounjaro, this is not it. Instead, Hari has woven the science into a narrative that traces his thoughts, feelings and discoveries around these drugs since he first heard about them, and then started to use Ozempic.
In my opinion, as a GP and a reader, this is even better.
“This is a mass experiment, carried out on millions of people, and I am one of the guinea pigs,” he writes.
Science is definitely front and centre: he has interviewed “over a hundred experts”. However, he knows from lived experience and observations gathered through his journalism that the science of obesity is only part of the picture.
Hari is not afraid to raise difficult questions. How much are people taking the drugs for their health versus for their appearance? Should it should be used in kids? (In one sense, they have the most to gain from losing weight early, before damage is done.) What effect do these drugs have on those with eating disorders?
He is vulnerable, too: not in a way that leads the reader to feel like he wrote this book as his personal therapy session, but in a way that starts a deeper conversation.
No doubt readers will come to this topic with their own ideas and biases. Some of these will be held strongly.
In particularly, some of us in healthcare, who have developed whiplash from watching weight-loss drugs and diets come and go, will have a great deal of scepticism. Hari sees these biases and scepticism and raises them with his own.
He does not hold back as he names, considers, explores and then reconsiders the use of this medication in his own life. Some impressive and knowledgeable scientists are interviewed throughout.
Here I should note that Hari, who has faced issues with his journalistic ethics in the past, has been rightly criticised for a mistakenly attributed quote. He wrote that a restaurant critic (who has never taken Ozempic) said the drug “robbed him of his pleasure in food so severely that even in great restaurants in Paris, he couldn’t find any joy”.
But it would be unfortunate to dismiss the book because of one wrong quotation, especially since the underlying point in that quote, echoed by many of my patients, remains valid. I believe the references to scientific studies, as well as his own personal thoughts, hold up to scrutiny.
Hari notes early on that weight-loss drugs are an artificial solution to an artificial problem. He argues that the obesity-promoting environment we are experiencing is something we created over the past 50 or so years – and therefore something we can reverse.
Currently, unhealthy food is cheap, easy to come by and heavily promoted (even to children). It takes effort, money, education and willpower to regularly eat healthy food. It’s not impossible, but “the odds are rigged against you”, as Hari writes.
However, for the average reader, a complete change in the environmental factors that support obesity is not going to happen fast enough to salvage our personal health. So, we still have to make a decision on whether this drug is right for us – for those who live in obese bodies.
I appreciated the way Hari addressed the stigma of obesity head-on. His personal experience no doubt gave him insight. He asks why our culture thinks obese people are fully responsible for their weight, and therefore need to suffer in any efforts they make to lose it.
Any weight loss that does not involve some kind of suffering (extreme calorie restriction, exercise) is often seen as “cheating”. Shame is frequently used to “motivate” people to lose weight. Ironically, if they try to lose it in the most effective way science can offer to date – these drugs – they are still shamed. Our collective psyche around this is confusing.
The evidence for the science behind GLP-1, the molecule these medications are based on, is explained by outlining how it was first discovered, and how it has been researched since.
Scientist Daniel Drucker was trying to find out if the molecule GLP-1 (a small part of glucagon, which our guts produce) had any function by itself. When he mixed GLP-1 with insulin synthesising cells, he was excited to see those cells were stimulated to produce insulin. Of course, his first thought was for how it could help people with diabetes.
Another scientist, John Wilding, found giving it to rats greatly reduced the amount of food they ate: it seemed to make them full, fast.
For a several decades, scientists worked hard to bring GLP-1 from a petri dish to become a safe and usable medication in humans. Though it was first approved for use in people with diabetes, the effect on appetite and weight reduction was so marked in early studies that conversation quickly turned to how it could be used for weight loss too.
The physical effects it produces of satiety (feeling of fullness) and slowing of the gut (with resulting nausea, diarrhoea and/or constipation), are now well known.
Even more compelling reading to me, however, was the drug’s impact on the relationship between food and pleasure. As a GP, I’ve been trained to see a loss of pleasure in food as potentially pathological, signalling an underlying problem.
Enjoyment of food is a fundamental human experience that has kept humans alive. It only derails when something is wrong with us, physically or mentally. Potential causes of someone no longer wanting to eat include things like infection, cancer, depression, even an eating disorder.
So the fact these drugs often interfere with the pleasure of eating concerns me. Why is giving up the pleasure we get from eating seen as a reasonable exchange for losing weight? Is this really a healthy long-term solution?
One of the most helpful chapters, I found, is titled: “What job was over-eating doing for you?”. It explores the reasons we eat and what happens when overeating is taken from us. Hari asks: “What, I wondered, will be the effect when millions of people are deprived of the psychological protections they get from overeating?”
Scientific evidence is systematically entwined with personal narrative about what overeating, and even being overweight, does for people. This can be surprising. For example, overeating may offer a form of comfort, or may even be a deliberate way traumatised people try to make themselves sexually unattractive: “overweight is overlooked”.
These important insights can be applied not just to overeating, but other addictions too. Hari is familiar with this subject: his 2015 book, Chasing the Scream, explored the history, treatment and causes of addiction.
In one sense, this book is an impassioned plea to everyday people to pause and reconsider what we want as a society. Hari challenges us to consider the world we leave to our kids: “Why is this the choice we are faced with: leave your kids with a dangerous physical condition that could trash their health, or give them a potentially dangerous drug forever?”
While he raises many sometimes disheartening questions, he concludes on a hopeful note, by exploring the modern approach to eating and food in Japan – whose low obesity rate (4.5%) is the envy of the Western world.
Incredibly, much of what the Japanese have done to achieve this has been within two generations. It seems very achievable for the rest of the world. They have prioritised healthy food being both obtainable and understood, by everyone: from children to the elderly.
They eat slowly, mixing flavours and textures, and are careful to balance each meal nutritionally as well as aesthetically. Exercise is built into their workplaces and schools. The environment is literally set up for people to maintain a healthy weight.
“Suddenly, the sheer artificiality of the obesity crisis seemed clear to me,” writes Hari. “It is created by the way we live. It should be possible, therefore, to un-create it.” It seems we don’t just face a choice between obesity and weight-loss drugs: there is a third option.
This message will not be popular with mass-producers of food, or people who make a lot of money out of the obesity epidemic. Addressing our environment means addressing dysfunctions in our modern food system.
Most convenient and affordable foods are processed, packaged and bear little resemblance to the original plants or animals they (supposedly) came from. In Hari’s opinion, most governments (Japan excepted) hesitate to regulate these kinds of food in ways that will improve health.
Though he recognises this is a big call to make, he draws parallels with the tobacco industry. There, it eventually took a groundswell of community sentiment to force governments to act – but that action has resulted in massive improvement in related illnesses in just one generation. There is hope.
“Who stole our satiety?” is Hari’s persistent question throughout this book. The implicit ensuing question is: what am I/what are we going to do about it?
What our society decides about the role of these drugs, and how we decide to address obesity more broadly, will have ramifications for generations to come.
This Review of Magic Pill: The Extraordinary Benefits and Disturbing Risks of the New Weight-Loss Drugs by Johann Hari was published by The Conversation.
