Hello! As with my previous books, I am posting here the endnotes for the book.

The US and British editions of the book have different page numbers, so in the descriptions below, the first page number you see is the US version and the second is the UK version.

 

Introduction: The Holy Grail

Page x/Page 2 – On the afternoon of Christmas Eve in 2009: I wrote about this experience in one of my previous books: Johann Hari, Lost Connections: Uncovering the Real Causes of Depression – And the Unexpected Solutions (Bloomsbury, 2018), p. 91.

Page xi/Page 2 – in ancient Greece, people believed: Hilde Bruch, Eating Disorders: Obesity, Anorexia Nervosa, and the Person Within (Routledge & Kegan Paul, 1973), p. 17.

Page xi/Page 3 – Emily Field, a sober-minded analyst at Barclays Bank: H. Kuchler, ‘Weight-loss drugs: will health systems and insurers pay for “skinny jabs”?’, Financial Times,11 August 2023, https://www.ft.com/content/81ca6f61-b945-4975-95ff-23ad0a4d8faa, as accessed 13 August 2023.

Page xii/Page 3 – In one survey, 47 per cent of Americans said: E. Silverman and E. Chen, ‘STAT-Harris Poll: Nearly half of U.S. adults would spend $100 a month for Ozempic, other weight loss drugs’, STAT+, 26 June 2023, https://www.statnews.com/pharmalot/2023/06/26/obesity-drugs-weight-loss-ozempic-wegovy-cost/.

Page xii/Page 3 – Some financial analysts believe that the market for them: https://www.cnbc.com/2023/04/28/obesity-drugs-to-be-worth-200-billion-in-next-10-years-barclays-says.html, as accessed 18 June 2023; https://companiesmarketcap.com/mcdonald/marketcap/, as accessed 28 September 2023.

Page xii/Page 4 – As a result, Novo Nordisk: https://edition.cnn.com/2023/09/05/investing/novo-nordisk-wegovy-europe-stock/index.html, as accessed 10 October 2023.

Page xii/Page 4 – The lowest credible calculation for the US is that it ends 112,000 lives a year: K. M. Flegal, B. I. Graubard, D. F. Williamson and M. H. Gail, ‘Excess Deaths Associated With Underweight, Overweight, and Obesity’, JAMA (2005), 293(15), pp. 1,861–7, doi:10.1001/jama.293.15.1861.

Page xii/Page 4 – At the upper end, Jerold Mande: This number comes from the 2016 version of the Global Burden of Disease study, as cited by the Center for Science in the Public Interest, ‘Why Good Nutrition is Important’, undated, https://www.cspinet.org/eating-healthy/why-good-nutrition-important, as accessed 18 October 2022. See also https://harvardpublichealth.org/nutrition/processed-foods-make-us-sick-its-time-for-government-action/, as accessed 10 October 2023.

Page xiii/Page 4 – even the most optimistic studies find that only approximately 20 per cent of us succeed: This is a rough estimate made by Brown University Medical School researchers based on past studies on dieting and weight loss. See R. R. Wing and S. Phelan, ‘Long-term weight loss maintenance’, American Journal of Clinical Nutrition (2005), 82, suppl. 1, pp. 222S–225S, https://pubmed.ncbi.nlm.nih.gov/16002825/. This is discussed further in Chapter 6.

Page xiii/Page 4 – Doctors warn us that obesity contributes to 200 known diseases and complications: https://dom-pubs.onlinelibrary.wiley.com/doi/10.1111/dom.15154#:~:text=Obesity%20is%20a%20worldwide%20health,%2C4%2C%2012%20and%20depression, as accessed 28 October 2023.

Page xiii/Page 5 – which according to some studies doubles your risk of dying: https://pubmed.ncbi.nlm.nih.gov/16926275/. I first learned about this in the Oxford Handbook of the Social Science of Obesity (OUP, 2011), p. 24.

Page xiii/Page 5 – obesity levels for adults have hit 26 per cent in Britain and 42.5 per cent in the United States: https://researchbriefings.files.parliament.uk/documents/SN03336/SN03336.pdf;https://www.cdc.gov/nchs/data/hestat/obesity-adult-17-18/overweight-obesity-adults-H.pdf; both as accessed 28 September 2023.

Page xv/Page 7 – I need to tell you about Hannah: I have changed Hannah’s name and a few minor identifying details here, to respect her and her family’s privacy. Because I am describing her from memory, I showed everything I wrote about her to another of her closest friends, Bronwen Carr. She confirmed that this matched her recollections. I also discussed this section with lots of other people who knew Hannah, who agreed that this is, to the best of our knowledge, an accurate picture of her.

Page xv/Page 7 – I sat down to watch a play called Atlantica: My description of Atlantica here is entirely from memory. I tried really hard to locate a text of the play but it seemed to have vanished. Since I’m recalling it from a distance of nearly twenty-five years, I’m sure I’m getting some details wrong, and the dialogue will not be exactly as it appeared in the script. I tracked down everyone I knew who had seen it and asked if this description matched their recollections. They said that broadly it did, though recollections differed a bit from person to person, as you’d expect after all this time. Some of them said that I am wrong to remember that only Hannah and I thought it was absurd, and in fact, a lot of the audience felt the same way. But by contrast, one of the cast members said that it was a more serious play than I remembered, and that lots of people took it seriously.

It’s possible we are all remembering it accurately. There were three performances of the play at the festival, and it looks like people at each reacted differently. One critic writing at the time noted that audiences reacted in contrasting ways, writing: ‘So that, for instance, Atlantica, a new save-the- whale play from Cambridge which blended B-movie and SF elements with an undertow of seriousness reminiscent of the TV series Edge Of Darkness, could play to three audiences giving radically different responses from silent seriousness to howls of campy laughter, and accept that each response was both legitimate and respectful on its own terms.’ See https://www.cix.co.uk/~shutters/reviews/01091.htm as accessed 20th February 2024.

Page xvii/Page 9 – Socrates whale, slugging hemlock: When I reflected on this memory, I had a recollection that in the festival’s newsletter, Noises Off, somebody published some sketches of suicidal whales based on famous people. I am not sure if Hannah told the person who drew these sketches this joke, and it was based on what she said; or if Hannah heard this joke from the person who drew them, and she then told it to me. If anyone knows the name of the person who drew them, please let me know, and I’ll credit him or her in future editions of the book!

Page xviii/Page 10 – I knew I shouldn’t have taken that paper bag off my head: I saw Joan Rivers live lots of times and heard versions on this line several times. For mild variations on it, see https://www.cracked.com/article_36112_15-joan-rivers-jokes-for-the-hall-of-fame.html, as accessed 11 November 2023, and Leslie Bennetts, Last Girl Before Freeway: The Life, Loves, Losses, and Liberation of Joan Rivers (Little Brown and Company, 2016).

Page xix/Page 11 – there is a restaurant named the Heart Attack Grill: As their website confirms, ‘All those who weigh over 350 pounds are invited to unlimited free food provided they weigh themselves on an electronic cattle scale affront a cheering restaurant crowd.’ https://www.heartattackgrill.com/press.html, as accessed 9 October 2023.

Page xxi/Page 14 – Then one night, she began to choke while eating: When I later ordered Hannah’s death certificate, it said she had suffered cardiorespiratory arrest triggered by choking, and listed Type II diabetes and thymoma (a disease where cancer cells form in the thymus, which is in your chest) as additional factors.

Page xxiii/Page 15 – Joseph Stalin reputedly said that one death is a tragedy: It’s possible this quote is apocryphal. To see the original source, go to https://quoteinvestigator.com/2010/05/21/death-statistic/, as accessed 28 September 2023.

Page xxiii/Page 16 – the most blubbery mammal: Blue whales have around 35 per cent body fat generally but can get up as high as 50 per cent in good times. Grizzly bears, polar bears and elephant seals can also all tip over 40 per cent in good times. See https://a-z-animals.com/blog/fattest-animals/, as accessed 9 November 2023. Note that if I were a forty-four-year-old woman, I’d actually have been within the ‘Ideal’ range with 32 per cent body fat, according to research published in the American Journal of Clinical Nutrition. As a forty-four-year-old man, however, I was firmly in the ‘Obese’ category. See D. Gallagher et al., ‘Health percentage body fat ranges: an approach for developing guidelines based on body mass index’, American Journal of Clinical Nutrition (2000), 72, pp. 694–701.

Page xxiii/Page 16 – My grandfather died of a heart attack when he was the age I am now, forty- four: My mother and grandmother found his death almost impossible to talk about. Throughout my childhood and all the way into my twenties, I had mistakenly believed he had died in an industrial accident. It was only when I spoke with one of my uncles while researching this book that I learned the full facts of his death.

Page xxvi/Page 19 – There are 38,000 branches of McDonald’s in the world: Michael Moss, Hooked: How We Became Addicted to Processed Food (W. H. Allen, 2022), p. xvi; https://corporate.mcdonalds.com/corpmcd/franchising-overview.html, as accessed 28 September 2023.

Page xxvi/Page 19 – One of my favourite writers, Graham Greene, said: https://www.theguardian.com/books/2004/sep/18/classics.grahamgreene, as accessed 12 August 2023.

Page xxvii/Page 20 – I want make you aware, right at the start, of a few caveats: Here’s another caveat. Because of social media, there is a constant threat that any group of people, anywhere in the world, can subject you to a reputational punishment-beating for disagreeing with them. As a result, a lot of people are frightened to think out loud or explore difficult subjects in writing. You’ll notice that the tone of a lot of books is becoming cringingly apologetic or bitterly sarcastic, as an attempt to ward off this danger. I am determined not to do this. You can’t have an adult conversation if you enter it in a defensive crouch. I am going into this with an open mind and an open heart, and I am assuming good-faith readers who want to come on the journey in the same spirit. It’s difficult to stay open-minded on such a sensitive subject, I know: our relationships with our bodies are so fraught with anxiety and shame that at times, writing this book felt like stomping into a field full of landmines in a pair of oversized boots. But I believe that if you tune out the hysteria online, it is still possible in our culture to follow the facts, in a spirit of rationality and love. Indeed, people are hungry for it.

Page xxviii/Page 21 – The World Health Organisation – the leading medical body in the world:https://www.who.int/health-topics/obesity#tab=tab_1,as accessed 19 June 2023.

 

Chapter One: Finding the Treasure Chest

 

Page 5/Page 27 – Svetlana Mojsov worked with a group to put GLP-1 into a rat’s pancreas: S. Mojsov, G. C. Weir and J. F. Habener, ‘Insulinotropin: glucagon-like peptide I (7-37) co-encoded in the glucagon gene is a potent stimulator of insulin release in the perfused rat pancreas’, Journal of Clinical Investigation (1987), 79(2), pp. 616–19, doi:10.1172/JCI112855. See also this fascinating piece for a fuller story of Svetlana Mojsov’s involvement in GLP-1 work: https://www.science.org/content/article/her-work-paved-way-blockbuster-obesity-drugs-now-she-s-fighting-recognition, as accessed 6 November, 2023.

Page 5/Page 28 – a team in Copenhagen put GLP-1 into a pig’s pancreas: C. Orskov, J. J. Holst and O. V. Nielsen, ‘Effect of truncated glucagon-like peptide-1 [proglucagon-(78-107) amide] on endocrine secretion from pig pancreas, antrum, and nonantral stomach’, Endocrinology (1988), 123, pp. 2,009–13; see also on severe obesity hypoventilation, https://err.ersjournals.com/content/28/151/180097/, as accessed 29 October 2023.

Page 7/Page 29 – He injected GLP-1 into rats, and found that: https://www.nature.com/articles/379069a0.

Page 8/Page 30 – a biochemist in the Bronx named John Eng noticed something weird: J. Eng, ‘Exendin peptides’, Mount Sinai Journal of Medicine (1992), 59, pp. 147–9.

See also https://www.diabetesincontrol.com/dr-john-engs-research-found-that-the-saliva-of-the-gila-monster-contains-a-hormone-that-treats-diabetes-better-than-any-other-medicine/, as accessed 28 October 2023.

Page 8/Page 31 – Thanks to this little desert-dwelling monster: As Daniel put it by email, they ‘extracted the RNA from the salivary gland, pancreas and intestine. Drucker showed that the lizard had two different genes, one encoding GLP-1 and the second, encoding the lizard exendin-4.’

Page 8/Page 31 – what happens if the effects of GLP-1 can be made to last: Another totally unexpected breakthrough made scientists realise why they should be doing this urgently.

One of John’s colleagues at the Hammersmith Hospital was an ambitious young medical doctor and PhD student from Durban, South Africa named Carel Le Roux, who arrived there in the year 2000. When he had grown up under Apartheid, there had been almost no obese people, and he was fascinated by it as a medical problem. He became particularly intrigued by a form of medical intervention that was, at that time, rare in Britain, and almost unknown in South Africa: bariatric surgery. This is where severely obese people whose health is in peril are given extensive internal surgery, some of their internal organs are rearranged and reconnected, and afterwards, they find it very hard to continue to eat in large quantities. As a result, most people who undergo the surgery lose enormous amounts of weight.

Looking at the research on this procedure, Carel wondered about one thing in particular. It is not totally clear why bariatric surgery works so effectively. Their stomachs are smaller after the operation – but your stomach has an extraordinary capacity to expand again. Somehow, though, most people who go through the surgery remain far below their previous weight levels. He began to have a hunch that it could be related to this new research on gut hormones. He knew that if you inject GLP-1 agonists into people, their appetites change, and they want to eat less. So Carel asked: could it be possiblethat after this surgery, your gut hormones also change? Might that be one of the reasons why it works so well?

He began to try to snuffle out the answer. He got bariatric surgery patients to come into the hospital not long after their operations, and gave each of them a small pot of ice cream to stimulate their GLP-1 production. Then he took samples of their blood, at timed intervals – one as soon as they had the ice cream, then another an hour later, then another two hours later. For a whole week, he worked flat-out for fourteen-hour days to process these samples, and at 7 p.m. on a Friday night, he finally got the results from the tests he had taken as the patients were eating the ice cream. He felt crushed. There was no difference between the gut hormones of those post-bariatric surgery patients and the rest of us. Nothing. He thought, ‘Well, that was a waste of a week of my life’. He went home, had a barbecue and drowned his sorrows in red wine.

On Monday morning, he went back to work, and with low spirits, he processed the remaining blood samples that had been taken at regular intervals after they’d eaten the ice cream, expecting to find more results that revealed nothing had changed. What he discovered shocked him.

In the samples taken two hours after eating the ice cream, the bariatric surgery patients’ GLP-1 levels had massively soared – to three times higher than in people who haven’t had the surgery.

It seemed that something was happening after surgery that meant these patients were flooded with GLP-1 at precisely the point at which they would previously have felt hungry again. It was this surge in GLP-1 that was dramatically reducing their appetites. Now, for Carel, it all fell into place: GLP-1 is one of the gut hormones that sends a signal to stop eating, and after surgery, ‘the gut is talking much louder to the brain, in a voice the brain can understand. The signal is now three times higher.’

Unlike in the previous experiments, where people were injected with GLP-1 agonists and only felt more full for a few minutes, it turned out that for these bariatric surgery patients, the effect had lasted. Indeed, higher levels of this hormone seemed to be one of the keys to their dramatic weight loss.

He had a hunch about why. When you have this surgery, your small intestine is moved to a different place, and it has GLP-1 receptors on top of it. So it seems that for these patients, when they eat, those receptors get hit by food later, and for longer. As a result, they are less hungry. It’s a key reason, he believes, why the surgery succeeds even though your stomach can expand afterwards.

‘It was a eureka moment,’ Carel told me. In science, with any change you want to produce – losing weight, for example – you are always searching for the mechanism that explains how that change can take place. ‘We were able to provide a mechanism. That was the crucial thing. Once we understand the mechanism, we come closer to the truth. We suddenly had insight into a mechanism we didn’t have before.’ The mechanism was GLP-1 itself.

To test their theory further, the team did more research. They gave patients who’d had bariatric surgery a drug that blocked GLP-1 from kicking in when they ate. Suddenly, they started stuffing their faces again, almost as if they’d never had the operation at all. ‘It was as if you switched off my bypass,’ the patients said. It really did seem that GLP-1 is a major brake on human appetite, and if you can boost its levels over the longer term, you produce dramatic weight loss.

In the wake of Carel’s discovery, a lot more scientists swung back to investigating GLP-1. They began to suspect that if you could give people a GLP-1 agonist – a copy of the real gut hormone – and you could make it last, then you could give them, in effect, a chemical form of bariatric surgery, with all the benefits, and without the quite serious risks. So Carel began to ask: ‘How can we create a bypass without using an operation?’

See C. M. Borg et al., ‘Progressive rise in gut hormone levels after Roux- en-Y gastric bypass suggests gut adaptation and explains altered satiety’, British Journal of Surgery (2006), 93(2), pp. 210–15, doi:10.1002/bjs.5227. the official results of their major trial giving semaglutide to obese people: J. P. H. Wilding et al., ‘Once-Weekly Semaglutide in Adults with Overweight or Obesity’, New England Journal of Medicine (2021), 384(11), pp. 989–1,002, doi:10.1056/NEJMoa2032183. compared to just 2.4 per cent who had been given a placebo: In the trial, some were given the real drug, and some were given the placebo. In that first trial, everyone – in both groups – was also given a lifestyle intervention. Both groups lost weight, but the people on the drug lost more. The placebo- subtracted weight loss of people given the drug was 12.5 per cent. See ibid. after they quit, most people regain two-thirds of the weight they have lost within a year: https://dom-pubs.onlinelibrary.wiley.com/doi/10.1111/dom.14725.

Page 11/Page 34 – It took almost four decades and thousands of dedicated scientists: https:// twitter.com/DanielJDrucker/status/1412160891840307203, as accessed 8 November 2023.

Page 11/Page 34 – lost, on average, 21 per cent of their body weight in the clinical trials: A. M. Jastreboff et al., ‘Tirzepatide Once Weekly for the Treatment of Obesity’, New England Journal of Medicine (2022), 387(3), pp. 205–16, doi:10.1056/ NEJMoa2206038, https://www.nejm.org/doi/full/10.1056/NEJMoa2107519. The 20.9 per cent figure is only for the highest dose; weight loss was lower at lower doses.

Page 12/Page 35 – Early studies suggest it produces 24.2 per cent weight loss: A. M. Jastreboff et al., ‘Triple-Hormone-Receptor Agonist Retatrutide for Obesity – A Phase 2 Trial’, New England Journal of Medicine (2023), 389(6), pp. 514–26, doi:10.1056/ NEJMoa2301972. See also https://www.newscientist.com/article/mg25934470-900-beyond-wegovy-could-the-next-wave-of-weight-loss-drugs-end-obesity/, as accessed 13 August 2023; https://www.reuters.com/business/healthcare-pharmaceuticals/lilly-experimental-triple-g-obesity-drug-leads-242-weight-loss-trial-nejm-2023-06-26/, as accessed 8 October 2023.

Page 12/Page 35 – there are now more than seventy anti-obesity drugs in development: https://www.statnews.com/2023/09/12/new-weight-loss-drug-tracker-novo-nordisk-eli-lilly/, as accessed 24 October 2023.

Page 13/Page 35 – two major studies were published that revealed semaglutide pills: The two main studies: https://www.nejm.org/doi/full/10.1056/NEJMoa2301972; https:// www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)01053-X/fulltext.

Page 13/Page 35 – Strategists at Barclays Bank urged investors: https://www.bloomberg.com/news/ articles/2023-10-03/barclays-recommends-shorting-fast-food-credit-because-of-ozempic, as accessed 12 October 2023.

Page 13/Page 35 – a decline in the value of the stocks of the doughnut company Krispy Kreme: https://www.forbes.com/sites/dereksaul/2023/10/30/will-ozempic-kill-donut-sales-krispy-kreme-stock-downgraded-as-weight-loss-drugs-boom/, as accessed 10 November 2023.

Page 13/Page 36 – Mark Schneider, the chief executive of Nestlé: https://www.bloomberg.com/news/ articles/2023-10-06/ozempic-threat-is-causing-a-selloff-in-candy-and-beer-stocks?leadSource=uverify%20wall; https://www.youtube.com/watch?v=C_4cTq7Yhnw; https://www.forbes.com/sites/tylerroush/2023/10/06/will-ozempic-users-really-buy-fewer-groceries-major-food-stocks-drop-after-walmart-execs-claim/?sh=193b34085c5d; https://www.bloomberg.com/news/articles/2023-10-02/with-ozempic-weight-loss-looming-kellanova-s-ceo-says-snack-maker-is-ready?embedded-checkout=true; https://futurism.com/neoscope/kellanova-ceo-ozempic; https://www.telegraph.co.uk/business/2023/10/20/weight-loss-drugs-spark-panic-junk-food-companies/, all as accessed 20 October 2023.

Page 13/Page 36 – there will likely be $3.5bn knocked out of the market for booze:https://www.washingtonpost.com/business/2023/09/01/ozempic-cuts-alcohol-cravings-liquor-beer-and-wine-companies-aren-t-ready/6a7621b0-48b5-11ee-b76b-0b6e5e92090d_story.html, as accessed 12 October 2023.

Page 13/Page 36 – Companies selling devices for hip and knee replacements: https://www.reuters.com/breakingviews/anti-obesity-drugs-can-shrink-more-than-patients-2023-09-20/, as accessed 12 October 2023.

Page 14/Page 36 – An analyst for Jefferies Financial said that airlines: https://www.bloomberg.com/ news/articles/2023-09-29/weight-loss-drugs-ozempic-wegovy-could-reduce- airlines-costs, as accessed 12 October 2023.

Page 14/Page 36 – jewellers have seen a shift in their business: https://nypost.com/2023/06/15/ ozempic-finger-is-diet-drugs-latest-side-effect-forcing-women-to-spend-more-money/, as accessed 12 October 2023.

Page 16/Page 38 – For many people, when they take these drugs, their resting heart rate increases: J. Seufert et al., ‘Increase in pulse rate with semaglutide did not result in increased adverse cardiac events in subjects with type 2 diabetes in the SUSTAIN 6 cardiovascular outcomes trial’, European Heart Journal (August 2018), 39, suppl. 1, ehy565.P2857, https://doi.org/10.1093/eurheartj/ehy565.P2857.

Page 16/Page 39 – For between 5 and 10 per cent of people who take these drugs: W. T. Garvey et al., ‘Two-year effects of semaglutide in adults with overweight or obesity: the STEP 5 trial’, Nature Medicine (2022), 28, pp. 2,083–91, https://doi.org/10.1038/s41 591-022-02026-4. It’s not absolutely certain that it’s the side effects that are the sole cause of patients not continuing with the drug. STEP 5, for example, had a 92.8 per cent completion rate, but that’s averaged across the placebo and semaglutide groups. And in some of the adolescent studies it’s almost the exact same drop-out rate for placebo as for the real drug, so more is at work here than side effects.

Page 17/Page 40 – Similarly, you burp because: There are some other theories about why people burp on these drugs. You can read a good summary of them here: https://www.theatlantic.com/health/archive/2023/05/ozempic-burping-smell-eggs-side-effect/673925/, as accessed 10 October 2023.

Page 18/Page 40 – At the moment, the drug companies are tweaking the drugs to reduce nausea: https://www.economist.com/business/2023/09/28/pharmas-big-push-for-a-new-generation-of-obesity-drugs, as accessed 10 October 2023. Curiously, a significant percentage of the people who use the first versions of these weight loss drugs face a different problem. They take them and learn to tolerate the side effects – but they don’t lose weight. For some unknown reason, the effects don’t kick in. In one trial of semaglutide, for example, 77 per cent of the people taking part lost 5 per cent or more of their body weight, and more than half lost 15 per cent – but there were quite a large number who didn’t lose any weight at all: 23 per cent. A small number even gained weight on the drug. Nobody knows why these disparities are happening. This doesn’t seem to be a problem with the next generation of the drugs though: in a trial of the ‘Triple G’ drug that boosts three different gut hormones, literally everyone on the trial taking the higher dose lost 5 per cent of their body weight or more. See Jastreboff et al., ‘Triple-Hormone-Receptor Agonist Retatrutide for Obesity’.

Chapter Two: Cheesecake Park

Page 19/Page 42 – the year that something unprecedented started to happen to human beings: C. M. Hales et al., ‘Prevalence of Obesity Among Adults and Youth: United States, 2015–2016’, NCHS Data Brief (2017), 28, pp. 1–8, https://pubmed.ncbi.nlm.nih.gov/29155689/ as cited in Michael Moss, Hooked: How We Became Addicted to Processed Food (W. H. Allen, 2022), p. 28.

Page 19/Page 42 – an ancient statue: R. J. Johnson, M. A. Lanaspa and J. W. Fox, ‘Upper Paleolithic Figurines Showing Women with Obesity may Represent Survival Symbols of Climatic Change’, Obesity (2021), 29(1), pp. 11–15, https://onlinelibrary.wiley.com/doi/10.1002/oby.23028.

Page 19/Page 42 – Some people cannot produce a hormone called leptin: Ellen Ruppel Shell, The Hungry Gene: The Inside Story of the Obesity Industry (Grove Press, 2003), p. 113.

Page 19/Page 42 – Others have a condition called Prader-Willi syndrome: NHS, ‘Overview: Prader- Willi Syndrome’, https://www.nhs.uk/conditions/prader-willi-syndrome/, as accessed 26 June 2023.

Page 20/Page 43 – this began to change in the late 1970s: See ‘The Surgeon General’s Vision for a Healthy and Fit Nation’ (2010), https://www.ncbi.nlm.nih.gov/books/NBK44656/, as accessed 6 November 2023, for a good summary of studies on this.

Page 20/Page 43 – Obesity had likely been rising very slowly since the turn of the twentieth century: J. Komlos and M. Brabec, ‘The evolution of BMI values of US adults: 1882–1986’, Center for Economic Policy Research (blog), 31 August 2010, https://cepr.org/voxeu/columns/evolution-bmi-values-us-adults-1882-1986, as accessed 28 September 2023. This study found that BMI began to increase at this time, which is why I say it was ‘likely’ that obesity rose at this time. BMI and obesity are not synonymous, but they are often closely matched – see the explanation from Walter Willett in Chapter 11.

Page 20/Page 43 – Between the year I was born and the year I turned twenty-one: R. Casas, L. Brown and J. Gomez-Ambrosi, ‘The Origins of the Obesity Epidemic in the USA – Lessons for Today’, Nutrients (2022), 14(20), pp. 4, 253, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9611578/.

Page 20/Page 43 – The rate of severe obesity took a particularly disturbing turn: https://www.cdc. gov/obesity/data/adult.html, as accessed 23 November 2023.

Page 20/Page 43 – The average American adult weighs twenty-three pounds more than in 1960: Michael Moss, Salt Sugar Fat: How the Food Giants Hooked Us (W. H. Allen, 2014), p. 238; see also S. Gill, ‘Is there an average weight for men?’, Medical News Today (11 October 2014), https://www.medicalnewstoday.com/articles/320917#average-weight-of-men-in-the-us, as accessed 28 October 2023.

Page 20/Page 43 – more than 70 per cent of all Americans are either overweight or obese: National Institutes of Health, ‘Overweight and Obesity Statistics’, September 2021, https://www.niddk.nih.gov/health-information/health-statistics/overweight-obesity, as accessed 26 June 2023.

Page 20/Page 43 – England has followed a similar trend: C. Baker, ‘Obesity statistics’, House of Commons Library, Research Briefing, 12 January 2023, https://researchbr iefings.files.parliament.uk/documents/SN03336/SN03336.pdf. See also Tim Spector, The Diet Myth: The Real Science Behind What We Eat (Weidenfeld & Nicolson, 2016), p. 12.

Page 20/Page 43 – the World Health Organisation says that obesity has nearly tripled globally: World Health Organisation, ‘Obesity and overweight’, 9 June 2021, https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight, as accessed 28 September 2023.

Page 23/Page 46 – A researcher who compared food cultures across the world in the 1930s: Weston Price, Nutrition and Physical Degeneration: A Comparison of Primitive and Modern Diets and Their Effects (original edn, Paul B. Hoeber, Inc., Harper & Brothers, 1939; reprinted Benediction Classics, 2010).

Page 23/Page 46 – the second highest obesity levels in the developed world: J. Sturcke and agencies, ‘Scots rank second in world for obesity’, Guardian, 26 September 2007, https://www.theguardian.com/society/2007/sep/26/health.medicineandhealth, as accessed 28 September 2023.

Page 23/Page 46 – Instead, they started to buy food that was pre-packaged and pre-processed: There’s a big debate about how to define processed and ultra-processed food. Scientists in Brazil created something called the NOVA classification system, which defines ultra-processed foods as those ‘typically created by series of industrial techniques and processes’. For a discussion of the NOVA definitions and examples of other food classification systems, see C. A. Monteiro et al., ‘Ultra-processed foods, diet quality, and health using the NOVA classification system’, Food and Agricultural Organization of the United Nations, Rome (2019), https://www.fao.org/3/ca5644en/ca5644en.pdf, as accessed 11 October 2023. The UK’s National Health Service defines processed food simply as ‘any food that has been altered in some way during preparation’, such as by freezing, canning, cooking or drying. See NHS, ‘Eating processed food’, 12 June 2023, https://www.nhs.uk/live-well/eat-well/how-to-eat-a-balanced-diet/what-are-processed-foods/, as accessed 11 October 2023.

Page 25/Page 48 – The Chicken McNugget was invented when I was two years old:

https://www.everything80spodcast.com/chicken-mcnuggets/, https://www.history.com/news/who-invented-chicken-nuggets-mcdonalds, as accessed 26 June 2023.

Page 28/Page 51 – the missile-launching pad at the end of a James Bond film: Joanna Blythman, Swallow This: Serving Up the Food Industry’s Darkest Secrets (HarperCollins, 2015), p. 44.

Page 28/Page 51 – The people in charge of these factories don’t use the word ‘cooking’ at all: Ibid., p. 49. But in fact, in a typical strawberry-flavoured milkshake: Ibid., p. 144. For a grim list of those ingredients, see Eric Schlosser, Fast Food Nation: What the All- American Meal is Doing to the World (Penguin, 2002), pp. 125–6.

Page 29/Page 52 – So our food is filled with unheard-of amounts of all three: Tim Spector, Spoon Fed: Why Almost Everything We’ve Been Told About Food is Wrong (Vintage, 2022), p. 85; Spector, The Diet Myth, p. 95; Giles Yeo, Why Calories Don’t Count: How We Got the Science of Weight Loss Wrong (Orion Spring, 2021), p. 214. For evidence that this caused obesity, see David F. Marks, Obesity: Comfort vs Discontent (Yin and Yang Books, 2016), p. 57. See also (as cited in Obesity, p. 57): G. A. Bray and B. M. Popkin, ‘Dietary fat intake does affect obesity!’, American Journal of Clinical Nutrition (1998), 68(6), pp. 1,157–73, https://pubmed.ncbi.nlm.nih.gov/9846842/; J. E. Blundell and J. I. MacDiarmid, ‘Fat as a risk factor for overconsumption: satiation, satiety, and patterns of eating’, Journal of the American Dietetic Association (1997), 97(7), suppl., S63–S69, https://pubmed.ncbi.nlm.nih.gov/9216571/; J. A. Greenberg et al., ‘Chocolate-candy consumption and 3-year weight gain among postmenopausal U.S. women’, Obesity (Silver Spring) (2015), 23(3), pp. 677–83, https://pubmed.ncbi.nlm.nih.gov/25644711/; M. B. Schulze et al., ‘Sugar- sweetened beverages, weight gain, and incidence of type 2 diabetes in young and middle-aged women’, JAMA (2004), 292(8), pp. 927–34, https://pubmed.ncbi.nlm.nih.gov/15328324/; V. S. Malik et al., ‘Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis’, American Journal of Clinical Nutrition (2013), 98(4), pp. 1,084– 102, https://pubmed.ncbi.nlm.nih.gov/23966427/; L. Hooper et al., ‘Effect of reducing total fat intake on body weight: systematic review and meta-analysis of randomised controlled trials and cohort studies’, BMJ (2012), 345, e7666, https://www.bmj.com/content/345/bmj.e7666.

Page 29/Page 52 – the extreme temperatures and stress involved in industrial food manufacture: Blythman, Swallow This, p. 136. a dash of red makes pasta sauce look as if it contains more tomato than it really does: Ibid., p. 156.

Page 29/Page 53 – These industrial processes often leave the food tasting metallic or bitter: Ibid., p. 137.flavourings, glazing agents, improvers, anti-caking agents, solvents, preservatives: Ibid., p. 3.

Page 29/Page 53 – Our job is to make something taste like something: David A. Kessler, The End of Overeating (Penguin, 2010), p. 116.

Page 29/Page 53 – One of the most commonly used artificial flavourings in our food is vanillin: Blythman, Swallow This, p. 147.

Page 29/Page 53 – Food with a buttery taste gets there not with butter: Ibid., p. 36. relatively rare to see anything that looks much like food as we know it: Ibid., p. 45. fly spray, air freshener, shower sealant, deodorant, computer casing: Ibid., pp. 76–7. ‘meat glue’, a substance as gross as it sounds: Ibid., pp. 174–5.

Page 30/Page 54 – creating something a food executive called ‘pink slime’: Moss, Salt Sugar Fat, pp. 226–9; Yeo, Why Calories Don’t Count, p. 212.

Page 30/Page 54 – A similar product named ‘meat slurry’: Yeo, Why Calories Don’t Count, p. 213.

Page 30/Page 54 – The products that emerge from this manufacturing process have sometimes been named ‘Frankenfood’: J. Formosa, ‘Frankenfoods: How Fast, Fake and Processed Foods Are Killing Us’, Health Dynamics (blog), undated, https://healthdynamics360.com/frankenfoods-fast-fake-processed-foods-killing-us as accessed 10 October 2023.

Page 30/Page 54 – or ‘food-like substances’ as the writer Michael Pollan calls them: https://michaelpollan.com/books/in-defense-of-food/, as accessed 23 October 2023.

Page 30/Page 54 – The resulting pizza, curry and cheesecake retain only a blurry, faint memory: Blythman, Swallow This, p. 32.

Page 31/Page 54 – studied how to create what they call ‘bliss-points’: Kessler, The End of Overeating,
p. 14; Moss, Salt Sugar Fat, p. xxv.

Page 31/Page 54 – I had been eating an unnatural chemical stew: Michael Pollan, In Defense of Food
(Penguin, 2009), p. 143.

Page 32/Page 55 – With his colleagues, he designed an experiment to test this: P. M. Johnson and
P. J. Kenny, ‘Dopamine D2 receptors in addiction-like reward dysfunction and compulsive eating in obese rats’, Nature Neuroscience (2010), 13(5), pp. 635– 41, https://pubmed.ncbi.nlm.nih.gov/20348917/.

Page 32/Page 55 – It’s healthy. It’s balanced: There is a sense in which it is like the diet my dad grew up eating, and a sense in which it isn’t. It is like his diet because it is nutritionally balanced and not particularly high in sugars, fats or artificial sweeteners. It is 23 per cent protein. In another sense, it is not like the diet my dad grew up eating: it is created in a factory and consists of more than twenty ingredients.

Page 32/Page 56 – Then he introduced the rats to the hyper-American diet: In addition, there was a control group who continued to only get the standard rat chow. In order to measure their dopamine levels, all the rats I describe here had electrodes inserted into their brains. In the experiment, some other rats were injected with viruses that changed their DNA, to see if that affected the way they respond to dopamine. Those rats are not the ones I am describing here. Both groups also, at the same time, had access to as much of the healthy rat chow as they wanted: There was a third group, who acted as the control group.

Page 32/Page 56 – You might call these cages Cheesecake Park: I have nicknamed this experiment ‘Cheesecake Park’ in a cheeky tribute to a famous experiment named ‘Rat Park’, which I wrote about in my previous book Chasing the Scream: The Search for the Truth About Addiction (Bloomsbury, 2019).

To explain Cheesecake Park a little more, I’d like to recap a bit about the Rat Park experiment, drawing on what I said in my TED Talk, ‘Everything You Think You Know About Addiction Is Wrong’. If you had asked me, when I started researching this topic thirteen years ago, ‘what causes heroin addiction?’, I would have looked at you as if you were a bit stupid, and said – obviously, heroin causes heroin addiction. The clue is in the name. We think that if I kidnapped the next twenty people to walk past your home, and I injected them all with heroin every day for a month – like a villain in a horror movie – they would all become addicted to heroin, for a simple reason: there are chemical hooks in heroin that their bodies would start to desperately physically crave, and at the end of that month, they’d have a tremendous physical hunger for the drug, and that’s what addiction is. Indeed, that’s why another word for being addicted is being ‘hooked’.

It turns out that chemical hooks are real – but they are only one part of a much bigger picture. Here’s how I explained one aspect of this in Chasing the Scream:

A famous advertisement that ran on US TV in the 1980s, paid for by the Partnership for a Drug-Free America, explained it best. It shows a rat in close-up licking at a water bottle, as the narrator says: ‘Only one drug is so addictive, nine out of ten laboratory rats will use it. And use it. And use it. Until dead. It’s called cocaine. And it can do the same thing to you.’ The rat runs about manically, then – as promised by the scary music – drops dead. Similar rat experiments had been run, to prove the addictiveness of heroin and other drugs.

But when [the Canadian scientist] Bruce [Alexander] looked at these experiments, he noticed something. These rats had been put in an empty cage. They were all alone, with no toys, and no activities, and no friends. There was nothing for them to do but to take the drug.

What, he wondered, if the experiment was run differently? With a few of his colleagues, he built two sets of homes for laboratory rats. In the first home, they lived as they had in the original experiments, in solitary confinement, isolated except for their fix. But then he built a second home: a paradise for rats. Within its plywood walls, it contained everything a rat could want – there were wheels and coloured balls and the best food, and other rats to hang out with and have sex with.

He called it Rat Park. In these experiments, both sets of rats had access to a pair of drinking bottles. The first bottle contained only water. The other bottle contained morphine – an opiate that rats process in a similar way to humans and that behaves just like heroin when it enters their brains. At the end of each day, Bruce or a member of his team would weigh the bottles to see how much the rats had chosen to take opiates, and how much they had chosen to stay sober.

What they discovered was startling. It turned out that the rats in isolated cages used up to 25 milligrams of morphine a day, as in the earlier experiments. But the rats in the happy cages used hardly any morphine at all – less than 5 milligrams. ‘These guys [in Rat Park] have a complete total twenty- four-hour supply’ of morphine, Bruce said, ‘and they don’t use it. They don’t kill themselves. They choose to spend their lives doing other things.’ This led me to conclude that the opposite of addiction is connection.

As I wrote about Cheesecake Park, I began to wonder about the relationship between these two experiments.

Rat Park is an experiment that demonstrates that the environment plays a crucial role in addiction – a stronger one, in fact, than the inherently ‘hooking’ effects of the drugs.

But for a while, I wondered if this was contradicted by Cheesecake Park. It is an experiment in which the rats are not alone – they have plenty of friends to scamper around with and have sex with – yet they still gorge on the cheesecake.

How can these experiments be reconciled? I thought about this and discussed it with experts.

As I explain later in this book, both addiction and obesity can be explained by something called the ‘bio-psycho-social model’. This means there are three kinds of causes of these problems: biological (things like your genes, or brain changes), psychological (for example, trauma, or how you think of yourself) and social (for example, loneliness, or poverty). They all play out to some degree in any individual with these problems, though the exact ratios will vary from person to person, and from condition to condition.

Human circumstances are always complex and it’s hard to disentangle the different facts that drive us to behave the way we do, but one of the good things about rat experiments is that you can manipulate the lives of rats to simplify the factors affecting their behaviour down to a few variables. In Rat Park, you can make them isolated, and see how it affects them. In Cheesecake Park, you can expose them to food comprised of sugar and fat, and see how that affects them.

When you see it through the prism of the bio-psycho-social model, the relationship between the two experiments becomes clearer. Rat Park varies the social component of the problem, to see how much effect it has. Cheesecake Park varies the biological component of the problem, to see how much effect that has. They are both real, and out here in the complex messy human world, they both play out in our lives. Rat Park shows us that isolation supercharges loneliness. Cheesecake Park shows us that cheesecake and other processed foods override our sense of satiety and make us massively overeat.

I would love for a group of scientists to take this further, and test what happens when the social and biological components combine. You could take a group of rats and split them into two. The first group could be given access to cheesecake, but also have friends and a stimulating environment. The second group could have cheesecake, but no friends or stimulation. We know from Cheesecake Park that they would both eat a lot of cheesecake and gain a lot of weight – but Rat Park makes me suspect the second group would go even further and overeat to an even greater degree. It would be fascinating to see the interaction of the environmental and biological components in this context.

Page 33/Page 57 – He was struck by how quickly they flipped for the new food: Paul also says in the paper: ‘Consistent with previous reports, there was a tendency for consumption of the cafeteria diet to decrease over time in the extended access rats. This may reflect the development of tolerance to the palatability of the food items provided as part of the cafeteria diet over time. Nevertheless, the preference for the cafeteria diet versus standard chow remained consistently high throughout the experiment.’

Page 34/Page 57 – They basically starved, rather than eat this other food: In the write-up of the experiment, he explains, ‘extended access rats obtained only a small fraction (~5%) of their total caloric intake from chow (FIG. 2B), and consumed the cafeteria diet almost exclusively.’

Page 35/Page 59 – They were ‘ignoring the warning they had been trained to fear’, as Paul put it: P. J. Kenny, ‘Is Obesity an Addiction?’, Scientific American, 1 September 2013, https://www.scientificamerican.com/article/is-obesity-an-addiction/, as accessed 19 October 2023.

Page 35/Page 59 – But if you feed them Fruit Loops: A. Sclafani and D. Springer, ‘Dietary obesity in adult rats: Similarities to hypothalamic and human obesity syndromes’, Physiology & Behavior (1976), 17(3), pp. 461–71, https://www.sciencedirect.com/science/article/abs/pii/0031938476901098. I first learned of Sclafani’s experiments in Kessler, The End of Overeating, p. 15. See also M. Tordoff, ‘Obesity by choice: the powerful influence of nutrient availability on nutrient intake’, American Journal of Physiology-Regulatory, Integrative and Comparatory Physiology (2002), 282(5), R1536–R1539, https://pubmed.ncbi.nlm.nih.gov/11959698/, as cited in Kelly Brownell and Katherine Battle Horgen, Food Fight: The Inside Story of America’s Obesity Crisis – and What We Can Do About It (McGraw Hill, 2003), p. 25.

Page 35/Page 59 – Barry Levin, a professor at the New Jersey Medical School, bred a strain of rats: B. E. Levin and A. A. Dunn-Meynell, ‘Defense of body weight depends on dietary composition and palatability in rats with diet-induced obesity’, American Journal of Physiology-Regulatory, Integrative and Comparatory Physiology (2002), 282(1), R46–R54, doi:10.1152/ajpregu.2002.282.1.R46.

Chapter Three: The Death and Rebirth of Satiety

Page 37/Page 61 – Dunkin’ Donuts now sells enough doughnuts every day to circle the earth twice: Kelly Brownell and Katherine Battle Horgen, Food Fight: The Inside Story of America’s Obesity Crisis – and What We Can Do About It (McGraw Hill, 2003), p. 60.

Page 37/Page 61 – Ronald McDonald is the second most recognised figure in the world, beaten only by Santa Claus: Ibid., p. 13.

Page 37/Page 61 – More people recognise the Golden M as the symbol for McDonald’s:

https://www.marketingweek.com/mcdonalds-bigger-than-jesus-christ/, as accessed 27 June 2023. This study was conducted by McDonald’s themselves in 1995.

Page 38/Page 62 – The first glimmer of an answer was discovered in 1995: S. H. Holt, J. C. Miller, P. Petocz and E. Farmakalidis, ‘A satiety index of common foods’, European Journal of Clinical Nutrution (1995), 49(9), pp. 675–90. I first learned of this study in Herman Pontzer, Burn: The Misunderstood Science of Metabolism (Penguin, 2021), p. 226.

Page 39/Page 63 – He uncovered these insights in part by studying thousands of pairs of identical twins: See Tim Spector’s book Identically Different (Weidenfeld & Nicolson, 2013) for more information on this.

Page 39/Page 63 – generally very soft… It is adult baby food: For more information on this, see David A. Kessler, The End of Overeating (Penguin, 2010), pp. 69, 95.

Page 40/Page 64 – Chewing, Tim said, is a necessary brake on overeating: M. Borvornparadorn et al., ‘Increased chewing reduces energy intake, but not postprandial glucose and insulin, in healthy weight and overweight young adults’, Nutrition & Dietetics (2019), 76(1), pp. 89–94, doi:10.1111/1747-0080.12433; D. P. Bolhuis and C. G. Forde, ‘Application of food texture to moderate oral processing behaviors and energy intake’, Trends in Food Science & Technology (2020), 106, pp. 445–6, ISSN 0924–2244, https://doi.org/10.1016/j.tifs.2020.10.021. These findings have been used as a weight loss technique, with some success: https://www.researchgate.net/publication/330043007_A_Combined_Mindfulness’Prolonged_Chewing, as accessed 10 November 2023.

Page 40/Page 64 – most of our food is now less like an apple and more like that Fruit Squeeze: Chris van Tulleken, Ultra-Processed People (Cornerstone, 2023), p. 171.

Page 40/Page 64 – that uniquely powerful combination of sugar, fat and carbs: Kessler, The End of Overeating, p. 13.

Page 40/Page 64 – and it’s breast-milk: Giles Yeo, Why Calories Don’t Count: How We Got the Science of Weight Loss Wrong (Orion Spring, 2021), p. 222.

Page 41/Page 65 – That is because Pringles give you a sudden shot of energy and blood sugar: Michael Moss, Hooked: How We Became Addicted to Processed Food (W. H. Allen, 2022), pp. 50–1; Michael Moss, Salt Sugar Fat: How the Food Giants Hooked Us (W. H. Allen, 2014), p. 329.

Page 41/Page 65 – a roller coaster of energy spikes and energy crashes: Johann Hari, Stolen Focus: Why You Can’t Pay Attention – And How to Think Deeply Again (Bloomsbury, 2022), Chapter 12.

Page 41/Page 65 – Protein is a complex molecule that we all need to build muscles and healthy bones: Victoria State Government (Australia), ‘Protein’, Better Health (blog), 13 January 2022, https://www.betterhealth.vic.gov.au/health/healthyliving/ protein, as accessed 2 October 2023.

Page 42/Page 66 – To figure out if this was true, David designed a small but clever experiment: S. J. Simpson, R. Batley and D. Raubenheimer, ‘Geometric analysis of macronutrient intake in humans: the power of protein?’, Appetite (2003), 41(2), pp. 123–40, ISSN 0195-6663, https://doi.org/10.1016/S0195-6663(03)00049-7. See also C. Wilson, ‘What really makes junk food bad for us? Here’s what the science says’, New Scientist, 9 June 2021, https://www.newscientist.com/article/mg25033 380-700-what-really-makes-junk-food-bad-for-us-heres-what-the-science-says/, as accessed 1 July 2023; D. Raubenheimer and S. Simpson,‘You have five appetites, not one, and they are the key to your health’, New Scientist, 20 May 2020, https://www.newscientist.com/article/mg24632 831-400-you-have-five-appetites-not-one-and-they-are-the-key-to-your- health/, as accessed 14 August 2023.

Page 42/Page 66 – the people eating the processed food had to consume 35 per cent more calories: Simpson, Batley and Raubenheimer, ‘Geometric analysis of macronutrient intake in humans’. See also Raubenheimer and Simpson, ‘You have five appetites, not one’.

Page 42/Page 66 – David explained to me that (like chewing) this acts as ‘a brake’ on eating: He said this via email, which is why there’s no audio here.

Page 42/Page 66 – chemicals that may be actively triggering us to be more hungry: S. E. Swithers, ‘Artificial sweeteners produce the counterintuitive effect of inducing metabolic derangements’, Trends in Endocrinology and Metabolism (2013), 24(9), pp. 431–41, doi:10.1016/j.tem.2013.05.005; L. B. Sorenson et al., ‘Sucrose compared with artificial sweeteners: a clinical intervention study of effects on energy intake, appetite, and energy expenditure after 10 wk of supplementation in overweight subjects’, American Journal of Clinical Nutrition (2014), 100(1), pp. 36–45, https://pubmed.ncbi.nlm.nih.gov/24787495/.

Page 42/Page 67 – In my lifetime, the consumption of fizzy drinks has roughly tripled: Moss, Salt Sugar Fat, p. 116.

Page 43/Page 67 – for every extra soft drink a child consumes a day: D. S. Ludwig, K. E. Peterson and S. L. Gortmaker, ‘Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis’, Lancet (2001), 357(9255), pp. 505–8, doi:10.1016/S0140-6736(00)04041-1. I first
learned about this study in Brownell and Horgen, Food Fight, p. 169.

Page 43/Page 67 – the rats given artificial sweeteners gained more weight: S. E. Swithers and T. L. Davidson, ‘A role for sweet taste: calorie predictive relations in energy regulation by rats’, Behavioral Neuroscience (2008), 122(1), pp. 161–73, doi:10.1037/0735-7044.122.1.161. I first learned about this in Joanna Blythman, Swallow This: Serving Up the Food Industry’s Darkest Secrets (HarperCollins, 2015), p. 111.

Page 43/Page 67 – She said the sweeteners seem to cause ‘metabolic derangement’ in rats: Swithers, ‘Artificial sweeteners produce the counterintuitive effect of inducing metabolic derangements’.

Page 43/Page 68 – But as Tim watched his glucose levels, he was startled: Tim Spector, Spoon Fed: Why Almost Everything We’ve Been Told About Food is Wrong (Vintage, 2022), p. 67.

Page 44/Page 68 – published in 2022, a team of Israeli scientists split 120 people: J. Suez et al., ‘Personalized microbiome-driven effects of non-nutritive sweeteners on human glucose tolerance’, Cell (2022), 185(18), pp. 3,307–28.e19, https://pubmed.ncbi.nlm.nih.gov/35987213/.

Page 44/Page 68 – they gave them either one of four artificial sweeteners or real sugar: There was also a control group who were given neither.

Page 44/Page 68 – The artificial sweeteners had a striking effect: There are other studies that show striking effects. A big French study published in 2022, following 103,000 people for an average of ten years, showed that use of artificial sweeteners seemed to raise the risks of heart attacks and strokes. There was a 9 per cent increase in risk of cardiovascular disease and an 18 per cent higher risk of cerebrovascular disease. C. Debras et al., ‘Artificial sweeteners and risk of cardiovascular diseases: results from the prospective NutriNet-Santé cohort’, BMJ (2022), 378, e071204, https://www.bmj.com/content/378/bmj-2022-071204. See also this study of over 3,000 Canadian pregnant women: the roughly 5 per cent of them who drank a diet soda every day were more than twice as likely to have a baby who counted as overweight at the age of one. A big effect was still there even when they controlled for BMI, smoking, maternal education, overall energy intake and various other factors: it was still nearly twice as likely. M. B. Azad et al., ‘Association Between Artificially Sweetened Beverage Consumption During Pregnancy and Infant Body Mass Index’, JAMA Pediatrics (2016), 170(7), pp. 662–70, https://jamanetwork.com/journals/jamapediatrics/fullarticle/2521471. In another study, after controlling for all other factors, people consuming the most artificial sweeteners were 9 per cent more likely to develop diabetes – which is less than for sugary drinks, but still high. L. de Koning, V. S. Malik, E. B. Rimm, W. C. Willett and F. B. Hu, ‘Sugar-sweetened and artificially sweetened beverage consumption and risk of type 2 diabetes in men’, American Journal of Clinical Nutrition (2011), 93(6), pp. 1,321–7, doi:10.3945/ajcn.110.007922.

Page 44/Page 68 – It is in part, Tim suspects, because these chemicals have an effect on your brain: Spector, Spoon Fed, pp. 70–2. See also Bruce Blumberg, The Obesogen Effect (Grand Central, 2018), pp. 137–9.

Page 44/Page 68 – When it doesn’t come – when your brain realises it’s been tricked: Spector, Spoon Fed, p. 68. See also Tim Spector, Food for Life: The New Science of Eating Well (Jonathan Cape, 2022), pp. 358–9.

Page 44/Page 68 – you suddenly want cake: He discusses this further in his book, The Diet Myth: The Real Science Behind What We Eat (Weidenfeld & Nicolson, 2016), p. 206. One group of scientists randomly got young people to either drink sugary Sprite, or sugar-free Sprite Zero, or fizzy water. They then followed them to see what happened – and they discovered that the students who drank Sprite Zero sought out extra calories later. There’s a good summary of the scientific debate about artificial sweeteners in the Financial Times: S. Neville and M. Speed, ‘Artificial sweeteners: the health controversy that will not go away’, Financial Times, 1 October 2023, https://www.ft.com/content/7d40bdcc-34b5-44c3-bf46-612ab47979e3, as accessed 2 October 2023.

Page 44/Page 68 – presence of artificial sweeteners in our diets might be one of the big drivers of the obesity crisis: T. Davidson and S. Swithers, ‘A Pavlovian approach to the problem of obesity’, International Journal of Obesity (2004), 28, pp. 933–5, https://doi.org/10.1038/sj.ijo.0802660; S. E. Swithers, ‘Artificial sweeteners are not the answer to childhood obesity’, Appetite (2015), 93, pp. 85–90, doi:10.1016/j.appet.2015.03.027. Professor Swithers’ arguments are controversial, and there have been some studies which seem to suggest her findings may not fully extrapolate to humans: https://www.foodnavigator.com/Article/2015/04/13/Report-and-industry-clash-over-artificial-sweeteners-role-in-childhood-obesity#, as accessed 10 November 2023.

Page 45/Page 70 – the average person has ‘lost about 40 per cent’ of the diverse life in our microbiomes: C. Clutter, ‘Disappearance of the Human Microbiota: How We May Be Losing Our Oldest Allies’, American Society for Microbiology, 8 November 2019, https://asm.org/Articles/2019/November/Disappearance-of-the-Gut-Microbiota-How-We-May-Be, as accessed 1 July 2023.

Page 46/Page 70 – Eighty per cent of processed food is made up of just four ingredients: Spector, The Diet Myth, p. 94.

Page 46/Page 70 – the health of your gut starts to dramatically change: Ibid., p. 99.

Page 46/Page 70 – we are ‘poisoning’ our microbes with ‘junk food, sweeteners and sugar’: Ibid., p. 283.

Page 46/Page 70 – likely to be responsible for much of our obesity epidemic: Ibid., p. 19. There is a potential eighth factor at work here too.

The eighth factor is that these foods promote what John Blundell, a Professor of Psychobiology at Leeds University, calls ‘passive over-consumption’.

When I was a child, a small soda from McDonald’s and Burger King was 8 ounces, and a large drink was 16 ounces. Now, a small drink is 12 ounces, and a large drink is 32 ounces – double the size, and double the calories. You used to get a cup of Coke. Now you get a bucket of it. Michael Lowe, a Professor
of Clinical Psychology at Drexel University, explained to me how this undermines satiety over time: ‘In the 1970s, a bagel was this size, and cookies were about this size.’ He made circles with his hands that looked pitifully small. ‘Over the decades, the cookie and the bagel and many things got progressively bigger and bigger. Humans have a tendency to eat what’s put in front of them, and they assume – “oh, a cookie? I can eat a cookie. As a matter of fact, I can eat two cookies, because in the seventies, that’s what I ate.” Well, two cookies back then was maybe 300 calories. Now it’s 700 calories or more.’

He leaned forward. ‘We didn’t change. The food changed.’

At the same time, not only did the portions get bigger, but they were redesigned so they become more dense in calories. Compare a potato you dug out of the ground to a potato chip. In the process of being transformed in a factory, the potato has been stripped of the vast majority of its water, making it drier, crunchier and far more dense with calories per mouthful than the original. This process – of cramming more calories into the same mouthful of food – is happening with a lot of what we eat, often without changing its external appearance at all.

So ‘the dish is now 800 calories, rather than 550. But you’re ordering the same thing.’ It seems fine: I had it then, why not have it now? But then ‘people start to notice: I’m looking a little pudgy in the face. My pants [i.e. trousers] are feeling a little tight around the waist. I haven’t been doing anything different. What is happening is passive over-consumption – the calories are slipped in under the radar.’

As we eat these larger, more calorie-dense portions that look the same to us, our stomachs expand, and over time, we need more food to be satiated.

Page 46/Page 70 – processed foods make you eat, on average, 500 calories more every day: K. Hall et al., ‘Ultra-Processed Diets Cause Excess Calorie Intake and Weight Gain: An Inpatient Randomized Controlled Trial of Ad Libitum Food Intake’, Cell Metabolism (2019), 30(1), pp. 66–77, https://www.cell.com/cell-metabolism/fulltext/S1550-4131(19)30248-7.

Page 47/Page 71 – making many of the animals they own as big and bulky as possible: This varies a little by species. With pigs, we mostly eat their muscles (that’s the pink bit of your bacon), so they have in fact been selectively bred to be less fat and more muscular. But the factory-rearing system means that most animals – including chickens, turkeys and cows – are much fatter.

Page 47/Page 71 – Thirty years ago, it took twelve weeks for a factory-farmed chicken to reach its slaughter weight: https://www.theguardian.com/environment/2016/apr/24/real-cost-of-roast-chicken-animal-welfare-farms, as accessed 6 November 2023.

Page 47/Page 71 – Broiler chickens are three times higher in fat today than they were when I was born: https://www.ciwf.org.uk/media/5234769/Nutritional-benefits-of-higher-welfare-animal-products-June-2012.pdf, as accessed 6 November 2023. These are the figures for intensively reared broiler chickens, which constitute the vast majority of chickens we consume, especially in the United States.

Page 47/Page 71 – the standard factory-farmed turkey now has such an obese chest that it can barely stand up: D. Imhoff, ‘Honoring the Food Animals on Your Plate’, Huffington Post (2011), https://www.huffpost.com/entry/honoring-food-animals-cafos_b_826016, as accessed 6 November 2023.

Page 47/Page 71 – a newly invented kind of ultra-processed feed: https://www.consumerreports.org/cro/magazine/2015/08/why-grass-fed-beef-costs-more/index.htm, as accessed 10 November 2023.

Page 47/Page 72 – Jell-O powder is popular, especially with a strawberry-banana flavouring: Mark Schatzker, The Dorito Effect: The Surprising New Truth About Food and Flavor (Simon & Schuster, 2016), p. 79.

Page 47/Page 72 – lambs will rapidly add 30 per cent to their body weight: Ibid., p. 80; ‘Molasweet palatant boosts lamb growth’, All About Feed (blog), 27 May 2008, https://www.allaboutfeed.net/home/molasweet-palatant-boosts-lamb-growth/ (this study was funded by the food industry).

Page 47/Page 72 – If you deliberately want to make an animal fat: Andrew Jenkinson, Why We Eat (Too Much) (Penguin Life, 2021), pp. 32–3.

Page 48/Page 72 – we are now living in a ‘perfect obesity storm’: https://www.pressreader.com/uk/the-mail-on-sunday/20160508/282999694047074, as accessed 18 October 2023.

Page 50/Page 75 – Robert Lustig, a professor of paediatrics: https://www.theguardian.com/society/2023/apr/30/can-drugs-fix-uk-adolescent-obesity-crisis, as accessed 29 October 2023.

Page 50/Page 75 – Henry Dimbleby, who led the British government’s inquiry into how to solve the obesity crisis: E. Stearn, ‘UK should beat obesity the “Japanese way”: Ex-Government food tsar Henry Dimbleby calls plan to dish out weight loss drugs to millions of Brits “reckless” ’, Daily Mail, 20 April 2023, https://www.dailymail.co.uk/health/article-11994187/UK-stop-reckless-reliance-weight-loss-drugs-claims-Governments-former-food-tsar.html; D. Sheldrick, ‘Former food tsar says tackling obesity as crucial as small boats and inflation’, Express, 18 May 2023, https://www.express.co.uk/life-style/health/1771993/Former-Food-Tsar-Henry-Dimbleby-UK-obesity, as accessed 1 July 2023.

Page 52/Page 76 – causing one in every seven women to get breast cancer: ‘Breast cancer statistics’, Cancer Research UK, https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/breast-cancer#:~:text=Breast%20cancer%20risk,in%20the%20UK%20are%20preventable, as accessed 1 October 2023.

Page 52/Page 76 – That wasn’t true ten years ago, twenty years ago, let alone two hundred years ago: ‘Since the early 1990s, breast cancer incidence rates have increased by around a sixth (18%) in the UK’, according to Breast Cancer UK. ‘Breast cancer statistics’, Cancer Research UK.

Page 56/Page 80 – Isn’t it driven, when it comes to type 2 diabetes, by the same factors that drive obesity?: Lots of research has identified bad diets and low physical activity as contributing risks to diabetes. See, for example: GBD 2021 Diabetes Collaborators, ‘Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the Global Burden of Disease Study 2021’, Lancet (2022), 402(10397), pp. 203–34, https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)01301-6/fulltext#seccestitle190; A. V. A. Korat, W. C. Willett and F. B. Hu, ‘Diet, lifestyle, and genetic risk factors for type 2 diabetes: a review from the Nurses’ Health Study, Nurses’ Health Study 2, and Health Professionals’ Follow-up Study’, Current Nutrition Reports (2014), 3(4), pp. 345–54, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4295827/.

Page 56/Page 81 – Research has linked diabetes to ultra-processed food consumption. See, for example: F. M. Delpino et al., ‘Ultra-processed food and risk of type 2 diabetes: a systematic review and meta-analysis of longitudinal studies’, International Journal of Epidemiology (2022), 51(4), pp. 1,120–41, https://pubmed.ncbi.nlm.nih.gov/34904160/; S.P. Mambrini et al., ‘Ultra-Processed Food Consumption and Incidence of Obesity and Cardiometabolic Risk Factors in Adults: A Systematic Review of Prospective Studies’, Nutrients (2023), 31(15), p. 2,583, https://pubmed.ncbi.nlm.nih.gov/37299546/.

A recent study found that your risk of getting diabetes increases as you eat more ultra-processed food, but that certain sub-types of ultra-processed food were associated with lower risk of diabetes: Z. Chen et al., ‘Ultra-Processed Food Consumption and Risk of Type 2 Diabetes: Three Large Prospective U.S. Cohort Studies’, Diabetes Care (2023), 46(7), pp. 1,335–44, https://diabetesjournals.org/care/article/46/7/1335/148548/Ultra-Processed-Food-Consumpt ion-and-Risk-of-Type.

Page 56/Page 81 – Whenever a celebrity posts pictures of themselves on social media showing weight loss now: G. Kolkata, ‘New Obesity Drugs Come With a Side Effect of Shaming’, New York Times, 14 June 2023, https://www.nytimes.com/2023/06/14/health/obesity-drugs-wegovy-ozempic.html, as accessed 10 October 2023; C. Graham, ‘Has Mad Men’s Christina Hendricks been taking Hollywood’s favourite slimming drug, Ozempic?’, Daily Mail, 8 July 2023, https://www.dailymail.co.uk/ news/article-12278477/Has-Mad-Mens-Christina-Hendricks-taking-Hollywoods-favourite-slimming-drug-Ozempic.html, as accessed 10 October 2023; N. Schimelpfening, ‘ “Real Housewives” Star Says She Was Shamed for Using Ozempic’, Healthline, 15 August 2023, https://www.healthline.com/health-news/real-housewives-star-says-she-was-shamed-for-using-ozempic, as accessed 10 October 2023.

Page 56/Page 81 – people are lazy and they don’t want to put in the work: C. Taylor, ‘Rebel Wilson’s trainer Jono Castano says using Ozempic for weight loss is “lazy” and “dangerous” – and reveals what dieters should be doing instead’, Daily Mail, 7 May 2023, https://www.dailymail.co.uk/tvshowbiz/article-12057971/Rebel-Wilsons-trainer-Jono-Castano-says-Ozempic-lazy-dangerous.html, as accessed 10 October 2023.

Page 56/Page 81 – The seven deadly sins were first spelled out by Pope Gregory I: M. Petruzzello, ‘Seven deadly sins’, Encyclopedia Britannica, https://www.britannica.com/ topic/seven-deadly-sins, as accessed 19 October 2023.

Page 57/Page 82 – I thought about this more deeply when I read an essay by the Irish journalist Terry Prone: T. Prone, ‘Moral outrage won’t halt demand for new weight-loss drug of choice’, Irish Examiner, 15 May 2023, https://www.irishexaminer.com/opinion/columnists/arid-41138794.html, as accessed 10 October 2023.

Chapter Four: Living in an Inflamed State

Page 61/Page 86 – As a result of type 2 diabetes, every year more than 120,000 people: Centers for Disease Control and Prevention, ‘National Diabetes Statistics Report – Coexisting Conditions and Complications’, 30 September 2022, https://www.cdc.gov/diabetes/data/statistics-report/coexisting-conditions-complications.html, as accessed 12 October 2023. See also Henry Dimbleby with Jemima Lewis, Ravenous: How to Get Ourselves and Our Planet into Shape (Profile, 2023), p. 258.

Page 62/Page 87 – You lose fifteen years of your life: Max Pemberton told me via email, ‘Adolescents/young adults with Type 2 diabetes lose approximately fifteen years from average RLE [remaining life expectancy] and may experience severe, chronic complications of Type 2 diabetes by their forties.’ See E. T. Rhodes et al., ‘Estimated morbidity and mortality in adolescents and young adults diagnosed with Type 2 diabetes mellitus’, Diabetic Medicine (2012), 29(4), pp. 453–63, https://onlinelibrary.wiley.com/doi/10.1111/j.1464-5491.2011.03542.x.

Page 62/Page 87 – An obese man is six times more likely to develop diabetes than a non-obese man: D. P. Guh et al., ‘The incidence of co-morbidities related to obesity and overweight: a systematic review and meta-analysis’, BMC Public Health (2009), 9(88), https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-9-88. I first learned about this study in Nadja Hermann, Conquering Fat Logic (Scribe, 2019), p. 101.

Page 62/Page 87 – A scientific overview looking at 2.3 million individuals with type 2 diabetes: A. Jayedi et al., ‘Anthropometric and adiposity indicators and risk of type 2 diabetes: systematic review and dose-response meta-analysis of cohort studies’, BMJ (2022), 376, https://www.bmj.com/content/376/bmj-2021-067516.

Page 62/Page 87 – If your BMI is over 35 when you are eighteen years old, you have an over 70 per cent chance of becoming diabetic: K. M. V. Narayan et al., ‘Effect of BMI on Lifetime Risk for Diabetes in the U.S.’, Diabetes Care, 1 June 2007, 30(6), pp. 1,562–6, https://doi.org/10.2337/dc06-2544.

Page 62/Page 87 – In a simple experiment, a team of scientists took six healthy men: G. Boden et al., ‘Excessive caloric intake acutely causes oxidative stress, GLUT4 carbonylation, and insulin resistance in healthy men’, Science Translational Medicine (2015), 7(304), p. 304re7, doi:10.1126/scitranslmed.aac4765. I first learned about this study in Rachel Herz, Why You Eat What You Eat (W. W. Norton & Co., 2019), pp. 12–13.

Page 62/Page 87 – more than a third of the US population is currently in a pre-diabetic state: A. Menke, S. Casagrande, L. Geiss and C. C. Cowie, ‘Prevalence of and Trends in Diabetes Among Adults in the United States, 1988–2012’, JAMA (2015), 314(10), pp. 1,021–9, doi: 10.1001/jama.2015.10029. I first learned about this study in Hermann, Conquering Fat Logic, p. 100. See also the CDC website, which estimates 96 million American adults have prediabetes, ‘more than 1 in 3’: https://www.cdc.gov/chronicdisease/resources/publications/factsheets/diabetes-prediabetes.htm, as accessed 24 August 2023.

Page 63/Page 88 – if you’re an overweight man, you are 176 per cent more likely: D. P. Guh et al., ‘The incidence of co-morbidities related to obesity and weight: a systematic review and meta-analysis’, BMC Public Health (2009), 9(88),doi:10.11.1186/1471-2458-9-88. I first learned about this study in Hermann, Conquering Fat Logic, p. 109.

Page 64/Page 89 – the number of Americans whose death from heart disease was attributed by doctors to obesity: https://www.washingtonpost.com/wellness/2023/09/18/obesity-heart-disease-cardiac-death/, as accessed 10 October 2023.

Page 64/Page 89 – greater probability of an ischemic stroke compared with normal-weight subjects: P. Strazzullo et al., ‘Excess Body Weight and Incidence of Stroke: Meta-Analysis of Prospective Studies With 2 Million Participants’, Stroke (2010), 41(5), e418-e426, https://doi.org/10.1161/STROKEAHA.109.576967. A different recent meta-analysis, using different statistical techniques, found associations between obesity and type 2 diabetes and obesity and coronary artery disease, but not with stroke: H. Riaz et al., ‘Association Between Obesity and Cardiovascular Outcomes: A Systematic Review and Meta-analysis of Mendelian Randomization Studies’, JAMA Network Open (2018), 1(7), e183788, doi:10.1001/ jamanetworkopen.2018.3788.

Page 64/Page 90 – between 4 and 8 per cent of cancers are attributable to obesity: S. Pati et al., ‘Obesity and Cancer: A Current Overview of Epidemiology, Pathogenesis, Outcomes, and Management’, Cancers (Basel) (2023), 15(2), p. 485, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9857053/; https://www.cancerresearchuk.org/about-cancer/causes-of-cancer/obesity-weight-and%20cancer, as accessed 28 October 2023.

Page 64/Page 90 – linking obesity to not just one but nine different types of cancer: K. Kelland, ‘Fat to blame for half a million cancers a year’, Reuters, 25 November 2014, https://www.scientificamerican.com/article/fat-to-blame-for-half-a-million-cancers-a-year/, as accessed 2 July 2023; M. Kyrgiou et al., ‘Adiposity and cancer at major anatomical sites: umbrella review of the literature’, BMJ (2017), 356, j477, https://www.bmj.com/content/356/bmj.j477.

Page 64/Page 90 – The leading British cancer charity, Cancer Research UK, explains: ‘How does obesity cause cancer?’, Cancer Research UK, 14 February 2023, https://www.cancerresearchuk.org/about-cancer/causes-of-cancer/bodyweight-and-cancer/how-does-obesity-cause-cancer, as accessed 14 October 2023.

Page 65/Page 90 – Because it knows something is wrong, your body floods the area with inflammation: Giles Yeo, Gene Eating: The Story of Human Appetite (Orion, 2018), p. 77.

Page 65/Page 91 – The processes that are meant to heal you start to hurt you: Rupa Marya and Raj Patel, Inflamed: Deep Medicine and the Anatomy of Injustice (Penguin, 2022), pp. 5, 30–1; N. M. Iyengar et al., ‘Obesity and Cancer Mechanisms: Tumor Microenvironment and Inflammation’, Journal of Clinical Oncology (2016), 34(35), pp. 4,270–6, https://ascopubs.org/doi/10.1200/JCO.2016.67.4283.

Page 65/Page 91 – They make it more likely you’ll develop asthma: W. L. Xu et al., ‘Midlife overweight and obesity increase late-life dementia risk: a population-based twin study’, Neurology (2011), 76(18), pp. 1,568–74, https://pubmed.ncbi.nlm.nih.gov/21536637/.

Page 65/Page 91 – you are less likely to break a bone or to develop osteoperosis: Hermann, Conquering Fat Logic, p. 129, quoting C. De Laet et al., ‘Body mass index as a predictor of fracture risk: a meta-analysis’, Osteoporosis International (2005), 16(11), pp. 1,330–8, https://pubmed.ncbi.nlm.nih.gov/15928804/.

Page 66/Page 91 – A large study by the US National Cancer Institute followed half a million Americans: Hermann, Conquering Fat Logic, p. 88; Oxford Handbook of the Social Science of Obesity (OUP, 2011), p. 24; K. F. Adams et al., ‘Overweight, obesity, and mortality in a large prospective cohort of persons 50 to 71 years old’, New England Journal of Medicine (2006), 355(8), pp. 763–78, https://pubmed.ncbi.nlm.nih.gov/16926275/.

Page 66/Page 91 – on average, after surgery, they lose 27.5 per cent of their body weight: M. L. Maciejewski, D. E. Arterburn and L. Van Scoyoc, ‘Bariatric Surgery and Long-term Durability of Weight Loss’, JAMA Surgery (2016), 151(11), pp. 1,046–55, https://jamanetwork.com/journals/jamasurgery/fullarticle/2546331.

Page 66/Page 92 – a little more than the most cutting-edge weight-loss drugs are producing: See, for example, ‘Tirzepatide demonstrated significant and superior weight loss compared to placebo in two pivotal studies’, Eli Lilly & Company, 27 July 2023, https://investor.lilly.com/news-releases/news-release-details/tirzepatide-demonstrated-significant-and-superior-weight-loss, as accessed 18 October 2023.

Page 67/Page 92 – The findings are startling: T. D. Adams et al., ‘Long-Term Mortality after Gastric Bypass Surgery’, New England Journal of Medicine (2007), 357, pp. 753–61, https://www.nejm.org/doi/full/10.1056/nejmoa066603, as cited in Oxford Handbook, p. 797; R. Khamsi, ‘Stomach stapling really can save lives’, New Scientist, 22 August 2007, https://www.newscientist.com/article/dn12526-stomach-stapling-really-can-save-lives/, as accessed 3 August 2023. See also Jenny Radcliffe, Cut Down to Size: Achieving Success with Weight Loss Surgery (Routledge, 2013), pp. 150–2; Hermann, Conquering Fat Logic, p. 116.

Page 67/Page 92 – around one in a thousand people who have it die in the operation or of complications later: A. G. N. Robertson, T. Wiggins and F. P. Robertson, ‘Perioperative mortality in bariatric surgery: meta-analysis’, British Journal of Surgery (2021), 108(8), pp. 892–7, https://doi.org/10.1093/bjs/znab245. H. Beiglbock et al., ‘Sex-Specific Differences in Mortality of Patients with a History of Bariatric Surgery: a Nation-Wide Population-Based Study’, Obesity Surgery (2021), 32, pp. 8–17, https://link.springer.com/article/10.1007/s11695-021-05763-6#Sec8.

Page 68/Page 93 – the results of the first major study into how using Wegovy: H. Kuchler, ‘Weight-loss drugs: will health systems and insurers pay for “skinny jabs”?’, Financial Times, 11 August 2023, https://www.ft.com/content/81ca6f61-b945-4975-95ff-23ad0a4d8faa, as accessed 13 August 2023.

Page 68/Page 94 – we could prevent one in five of the heart attacks or strokes: N. D. Wong et al., ‘US Population Eligibility and Estimated Impact of Semaglutide Treatment on Obesity Prevalence and Cardiovascular Disease Events’, Cardiovascular Drugs and Therapy (2023), https://doi.org/10.1007/s10557-023-07488-3.

Page 68/Page 94 – It’s that obesity produces an extraordinary amount of harm: There may be some other effects of the drugs that improve health independent of reversing obesity, of course. For example, some scientists have questioned whether it could have an effect on the heart, or on blood vessels, independent of the obesity reduction effects. N. Davis, ‘Scientists hope weight-loss drugs could treat addiction and dementia’, Guardian, 21 August 2023, https://www.theguardian.com/society/2023/aug/21/scientists-hope-weight-loss-drugs-treat-addiction-dementia-ozempic-wegovy, as accessed 29 September 2023.

Page 69/Page 94 – could this turn around the lives of people like them?: Behind the statistics about the improvements in health caused by dramatically reversing obesity, there were a lot of human stories. I wanted to know: what does it feel like to come back from severe obesity? I had already spoken to Jeff Parker, who took Mounjaro for six months. Now I wanted to see what – in an optimistic scenario, where the drugs keep working without significant drawbacks – the effects might be on an obese person’s daily quality of life.

Brandon Youngblood is a professor of psychology at Sacramento City College in California. He explained to me that growing up in Stockton, California, ‘I was always a big kid. My family is an obese family. So I struggled with my weight my whole life.’ By the time he went to high school, he was rising through the 200-pound range, and by the time he got to college, ‘I ballooned into the 300s.’ Every year or so, he would lose some weight by dieting, but then he would regain it, plus some. ‘I never had a stable weight in my life,’ he said, and by the time he was in his thirties, he hit 506 pounds. He felt like a prisoner in his own body. ‘It was just like being trapped. Miserable. Hot all the time. Sweaty all the time … Your joints, your chest, your feet, your body would just be experiencing pain and tension soreness … I was just completely overwhelmed and uncomfortable constantly.’ The pain was so bad that ‘I wouldn’t want to do anything … I would sleep a lot. It would be very difficult for me to get up in the morning because you were just physically tired, but also because of severe sleep apnea, just not getting oxygen to your brain. And then you’d be fatigued easily.’ When you don’t get restful sleep, ‘nothing else functions to the degree that you’d like it to. Your cognitive abilities become reduced and you just get cranky and ornery.’ All the time, he felt ‘you’re just at the mercy of your body, and you’re not able to function’.

In an uncountable number of ways, he said, ‘you can’t live your life when you’re nearly 500 pound’. For example, he ‘wanted to be able to be a better partner intimately with my then-girlfriend. It was very difficult, as you might imagine, to be a good lover when you’re not able to feel good in your body, but also just perform. Being that heavy makes it very difficult to be sexually competent.’ He felt he was ‘in a body that was not functioning for me’, and it made him sullen, cranky and miserable.

He was thirty-one years old when he had bariatric surgery, and he lost more than 250 pounds in the first year. ‘I remember one of the first things my girlfriend at the time, now my wife, Mallory, and I did, right after the
surgery, was go down to Santa Monica, and we just walked the pier. It was not something I ever would have done. I couldn’t park the car, walk to the pier, walk the pier and then go back. Those were just things I couldn’t do. Now I don’t have to worry about that. I just walk like normal people would walk.’ As he looked out over the Pacific Ocean, he knew he had been on the path to diabetes and a much higher likelihood of hypertension, cancer, dementia, stroke. Now all that was receding like the tide.

‘I think I’m a happier, more joyous person now,’ he said. ‘I feel great. It was just a huge change in perspective. Just not as tired and sore all the time. Your mind is more clear. You almost feel like a new person.’ Now, ‘I’m not at the mercy of physical limitations.’ His career was transformed: with all the new energy he had, he became a successful professor. His marriage was transformed: sexually and emotionally, he was able to be present with his wife in a way that was impossible when he was so exhausted and unwell all the time.

He said that if he hadn’t been able to change in this way, ‘I would probably have just remained very miserable. I probably wouldn’t have been able to progress in my career. I would probably still be living with my folks …
I wouldn’t be able to live a life at all. It was just like becoming such a burden that I wasn’t able to kind of move forward … I think that my relationship with my wife would have ended.’ He said he is strongly opposed to stigma – he can remember the sting of cruel comments – and argued that we should do everything we can to dismantle it. ‘I strongly support body positivity,’ he added. Then he said carefully: ‘The wrong people take the stance that I’m about to take, and I don’t want to be associated with them by any means. But being 500 pounds is not healthy. We shouldn’t be 500 pounds.’

It nearly destroyed him, he believes, and we need to tell the truth about that. There are also certainly some serious negative effects to the surgery. He has something called ‘dumping syndrome’, where food passes quickly and painfully through you, and you sometimes need a toilet urgently.

Indeed, those significant downsides to the surgery are a reason why, for other people, he’s so excited about the new weight loss drugs, which seem – if the early signs are right – to provide all the benefits he’s experienced, without the extreme step of having major surgery. ‘I think if I could have had the same results and be at the same place with medication as opposed to intervention, I would strongly consider that. If I could guarantee the same trajectory, of course – I would love to not be a prisoner to the bathroom. Right? That would be something that would be wonderful. I would choose that in a heartbeat.’

Brandon looked back over all the years he was physically stifled and sickened by his obesity, how his health recovered when it was treated – and how his life then changed in incalculable ways when it was cured. This was far beyond vanity. His health was transformed. He looked a little ruminative and emotional. ‘It’s hard for me to imagine. My whole life I wanted a pill that would help me with this problem.’ He wondered: if now we have it, and it can reverse the huge health risks of obesity, why would we turn it down?

Chapter Five: An Old Story Repeating Itself?

Page 71/Page 97 – The drug companies of the day seized on this: Some sources for this chapter included Laura Fraser, Losing It: False Hopes and Fat Profits in the Diet Industry (Penguin, 1998), p. 89; Louise Foxcroft, Calories and Corsets: A History of Dieting over 2,000 Years (Profile, 2012), pp. 184–5; Shelley Bovey, The Forbidden Body: Why Being Fat Is Not a Sin (Rivers Oram Press, 1994), p. 212; Z. Huxford, ‘Ozempic and the dark history of weight-loss drugs’, Dazed Digital, 4 April 2023, https://www.dazeddigital.com/beauty/article/58533/1/brief-history-diet-pills-weight-loss-drugs-ozempic-obetrol-fenphen-benzedrine, as accessed 5 July 2023; J. Scutts, ‘The Depression Era’s Magic Bullet For Weight Loss’, The New Republic, 27 May 2016, https://newrepublic.com/article/133751/depression-eras-magic-bullet-weight-loss, as accessed 5 July 2023.

Page 71/Page 97 – the body succumbs to an extraordinarily high fever. It burns itself up: Hillel Schwartz, Never Satisfied: A Cultural History of Diets and Fantasies and Fat (Macmillan, 1986), pp. 191–3.

Page 72/Page 98 – 8 per cent of all prescriptions in the US were for amphetamines: Some additional sources for this section about amphetamines: Hilde Bruch, Eating Disorders: Obesity, Anorexia Nervosa, and the Person Within (Routledge & Kegan Paul, 1973), pp. 316–17; Schwartz, Never Satisfied, pp. 196–8; Anthony Warner, The Truth About Fat (Oneworld, 2019), p. 280; Foxcroft, Calories and Corsets, pp. 184, 186; Linda Bacon, Health at Every Size: The Surprising Truth About Your Weight (BenBella, 2010), p. 130; Ellen Ruppel Shell, The Hungry Gene: The Inside Story of the Obesity Industry (Grove Press, 2003), p. 139; Huxford, ‘Ozempic and the dark history of weight-loss drugs’.

Page 72/Page 98 – much more likely to experience paranoia, anxiety, psychosis and damage to your heart: Alicia Mundy, Dispensing With the Truth (St Martin’s Press, 2001), p. 38.

Page 72/Page 98 – In the early 1970s, one of the first big crusades: Charlotte Cooper, Fat Activism: A Radical Social Movement (HammerOn Press, 2016), pp. 123–4.

Page 73/Page 99 – One was known as the ‘Sleeping Beauty Diet’: S. Taylor, ‘The Women Sleeping Their Lives Away to Lose Weight’, Vice, 9 June 2017, https://www.vice.com/en/article/d3zy9k/the-women-sleeping-their-lives-away-to-lose-weight-id, as accessed 5 July 2023.

Page 73/Page 99 – Perhaps the most horrific ‘treatment’ was jaw-wiring: Shell, The Hungry Gene, p. 15; Henry Dimbleby with Jemima Lewis, Ravenous: How to Get Ourselves and Our Planet into Shape (Profile, 2023), pp. 67–8; Bovey, The Forbidden Body, p. 273.

Page 74/Page 100 – the announcement of something called fen-phen: Huxford, ‘Ozempic and the dark history of weight-loss drugs’; see also Warner, The Truth About Fat, p. 281; Fraser, Losing It, p. 193.

Page 74/Page 100 – Time magazine ran a cover story entitled ‘The New Miracle Drug?’: https://content.time.com/time/subscriber/article/0,33009,985187,00.html, as accessed 28 September 2023.

Page 74/Page 100 – By 1995, there were 18 million fen-phen prescriptions in the United States alone: Mundy, Dispensing With the Truth, p. 319.

Page 74/Page 100 – People were told by the drug companies: Ibid., p. 315.

Page 74/Page 100 – Richard Atkinson, who directed the Obtech Obesity Research Center: David A. Kessler, The End of Overeating (Penguin, 2010), pp. 142–3.

Page 75/Page 101 – Mary Linnen was a typical person taking the drug: Mundy, Dispensing With the Truth, pp. 1–8.

Page 75/Page 101 – Eventually, she was diagnosed with primary pulmonary hypertension: ‘What is primary pulmonary hypertension?’, Johns Hopkins Medicine website, undated, https://www.hopkinsmedicine.org/health/conditions-and-diseases/primary-pulmonary-hypertension, as accessed 4 October 2023.

Page 75/Page 102 – They were spotted by ordinary doctors in the town of Fargo, North Dakota: Mundy, Dispensing With the Truth, p. 97.

Page 76/Page 102 – a consultant employed by one of the companies had ‘pinpointed valve disease’ as a risk: Ibid., pp. 170, 179.

Page 76/Page 102 – bring doctors’ attention to the risk of primary pulmonary hypertension: Ibid., p. 319.

Page 76/Page 102 – signing checks for fat people who are a little afraid of some silly lung problem: Ibid., p. 9.

Page 76/Page 102 – real concerns… about the pulmonary hypertension issue: Ibid., p. 25.

Page 76/Page 102 – Moved by his eloquence, the others changed their minds, and voted to approve: G. Kolata, ‘How Fen-Phen, a Diet Miracle, Rose and Fell’, New York Times, 23 September 1997, https://www.nytimes.com/1997/09/23/science/how-fen-phen-a-diet-miracle-rose-and-fell.html.

Page 76/Page 103 – The companies and doctors responsible for these drugs: M. Herper, ‘Disaster Of The Day: American Home Products’, Forbes, 26 January 2001, https://www. forbes.com/2001/01/26/0126disaster.html?sh=77e984105aa5, as accessed
7 July 2023, https://www.ahajournals.org/doi/10.1161/01.CIR.100.25.e133, as accessed 28 October 2023.

Page 79/Page 105 – Indeed, they have a degenerative condition: M. Mahmoud et al., ‘The Relationship between Diabetes Mellitus Type II and Intervertebral Disc Degeneration in Diabetic Rodent Models: A Systematic and Comprehensive Review’, Cells (2020), 9, 10, https://www.mdpi.com/2073-4409/9/10/2208; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7600368/..

Page 79/Page 106 – This has become known as ‘Ozempic face’ and ‘Ozempic butt’: https://www.medicalnewstoday.com/articles/ozempic-face; https://www.forbes.com/sites/ariannajohnson/2023/02/01/ozempic-face-explained-why-it-happens-and-how-to-fix-it/?sh=70c234fa22c3; https://www.nytimes.com/2023/01/24/style/ozempic-weight-loss-drugs-aging.html; https:// www.womenshealthmag.com/weight-loss/a44495236/ozempic-butt-weight-loss-side-effect/, all as accessed 28 October 2023.

Page 80/Page 106 – announced ‘a thyroid cancer safety signal’ for all GLP-1 agonists: N. Skydsgaard, ‘Novo Nordisk says EMA raised safety signal on drugs including semaglutide’, Reuters, 22 June 2023, https://www.reuters.com/business/healthcare-phar maceuticals/novo-nordisk-shares-slip-ema-drug-safety-signal-2023-06-22/.

Page 80/Page 106 – when GLP-1 agonists are given to rats and mice: M. A. Nauck and N. Friedrich, ‘Do GLP-1-based therapies increase cancer risk?’, Diabetes Care (2013), 36, suppl. 2, S245–52, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3920 789/#B6; L. B. Knudsen et al., ‘Glucagon-Like Peptide-1 Receptor Agonists Activate Rodent Thyroid C-Cells Causing Calcitonin Release and C-Cell Proliferation’, Endocrinology (2010), 151(4), pp. 1,473–86, https://doi.org/10.1210/en.2009-1272; https://pubmed.ncbi.nlm.nih.gov/20203154/.

Page 80/Page 107 – Their findings were startling: J. Bezin et al., ‘GLP-1 Receptor Agonists and the Risk of Thyroid Cancer’, Diabetes Care (2023), 46(2), pp. 384–90, https://diabetesjournals.org/care/article/46/5/e120/148795/Comment-on-Bezin-et-al-GLP-1-Receptor-Agonists-and

Page 81/Page 107 – it was repeatedly argued that it was a low risk: See for example C. A. Thomspon and T. Sturmer, ‘Putting GLP-1 RAs and Thyroid Cancer in Context: Additional Evidence and Remaining Doubts’, Diabetes Care (2023), 46(2), pp. 249–51, https://doi.org/10.2337/dci22-0052; https://diabetesjournals.org/care/article/46/2/249/148141/Putting-GLP-1-RAs-and-Thyroid-Cancer-in-Context.

Page 81/Page 107 – around 1.2 per cent of people will get thyroid cancer in their lifetimes: ‘Cancer Stat Facts: Thyroid Cancer’, National Cancer Institute Surveillance, Epidemiology, and End Results Program website, undated, https://seer.cancer.gov/statfacts/html/thyro.html; ‘Thyroid cancer statistics’, Cancer Research UK, undated, https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/thyroid-cancer#:~:text=Thyroid%20cancer%20is%20the%202 0th,cases%20(2016%2D2018), as accessed 12 October 2023.

Page 81/Page 107 – people with a family history of thyroid cancer: https://medlineplus.gov/druginfo/meds/a618008.html. ‘Semaglutide injection may increase the risk that you will develop tumours of the thyroid gland, including medullary thyroid carcinoma (MTC, a type of thyroid cancer). Laboratory animals that were given semaglutide developed tumours, but it is not known if this medication increases the risk of tumours in humans. Tell your doctor if you or anyone in your family has or has ever had MTC or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2, a condition that causes tumours in more than one gland in the body). If so, your doctor will probably tell you not to use semaglutide injection.’ Ozempic’s own safety warnings, which are approved by the FDA, advise against it. See https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/209637lbl.pdf.

Page 82/Page 108 – a very slight chance of a condition named pancreatitis: S. Singh et al., ‘Glucagonlike Peptide 1-Based Therapies and Risk of Hospitalization for Acute Pancreatitis in Type 2 Diabetes Mellitus: A Population-Based Matched Case-Control Study’, JAMA Internal Medicine (2013), 173(7), pp. 534–9, https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1656537.

Page 83/Page 109 – analysed health data for people taking semaglutide (Ozempic and Wegovy): M. Sodhi et al., ‘Risk of Gastrointestinal Adverse Events Associated With Glucagon-Like Peptide-1 Receptor Agonists for Weight Loss’, JAMA, published online 5 October 2023, https://jamanetwork.com/journals/jama/fullarticle/2810542. See also Thomson Reuters, ‘New study ties weight-loss drugs Wegovy, Ozempic to serious gastrointestinal conditions’, CBC, 5 October 2023, https://www.cbc.ca/news/health/ozempic-wegovy-glp-1-1.6988122

Page 83/Page 109 – four out of five cases of pancreatitis go away when they are treated: https://www.nhsinform.scot/illnesses-and-conditions/stomach-liver-and-gastrointestinal-tract/acute-pancreatitis, as accessed 12 October 2023. See also https://edition.cnn.com/2023/10/05/health/weight-loss-drugs-serious-digestive-problems-study/index.html, as accessed 11 November 2023.

Page 83/Page 110 – that these new weight-loss drugs increase the odds of stomach paralysis by 3.67 times: Sodhi et al., ‘Risk of Gastrointestinal Adverse Events Associated With Glucagon-Like Peptide-1 Receptor Agonists for Weight Loss’.

Page 84/Page 110 – Brea Hand (who isn’t involved in the court case) told CBS News: S. Moniuszko, ‘Ozempic, Mounjaro manufacturers sued over claims of “stomach paralysis” side effects’, 3 August 2023, https://www.cbsnews.com/news/ozempic-mounjaro-lawsuit-gastroparesis-stomach-paralysis-side-effect/, as accessed 10 October 2023.

Page 84/Page 110 – The companies involved are disputing these legal cases vigorously: Ibid. See also: https://www.ft.com/content/0f0d222c-3b73-41d7-9f3b-e17879930691; https://www.nbcnews.com/health/health-news/makers-ozempic-mounjaro-sued-stomach-paralysis-claims-rcna97819; https://www.forbes.com/sites/ariannajohnson/2023/08/14/what-to-know-about-gastroparesis-lawsuit-claims-ozempic-and-mounjaro-causes-the-severe-stomach-disorder/?sh=7f74f 92064a0; https://edition.cnn.com/2023/08/03/business/ozempic-mounjoro-lawsuit/index.html, all as accessed 23 November 2023.

Page 84/Page 110 – This is the total amount of soft muscle tissue you have in your body: A. Kandola, ‘How and why to calculate muscle mass percentage’, Medical News Today, 9 April 2020, https://www.medicalnewstoday.com/articles/muscle-mass-percentage#definition, as accessed 12 October 2023.

Page 85/Page 111 – After the age of thirty, it begins to decline by around 8 per cent a year: E. Volpi et al., ‘Muscle tissue changes with aging’, Current Opinion in Clinical Nutrition and Metabolic Care (2004), 7(4), pp. 405–10,https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2804956/.After the age of thirty, it begins to decline by around 8 per cent a year: E. Volpi et al., ‘Muscle tissue changes with aging’, Current Opinion in Clinical Nutrition and Metabolic Care (2004), 7(4), pp. 405–10,https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2804956/.

Page 85/Page 111 – the biggest cause of accidental death among people aged over sixty-five: R. Fielding, ‘Muscle Loss in Older Adults and What to Do About It’, Tufts Now, 9 February 2021, https://now.tufts.edu/2021/02/09/muscle-loss-older-adults-and-what-do-about-it, as accessed 12 October 2023.

Page 85/Page 112 – giving people semaglutide in combination with a drug that preserves muscle mass: M. Lenharo, ‘Anti-obesity drugs’ side effects: what we know so far’, Nature, 13 October 2023, https://www.nature.com/articles/d41586-023-03183-3, as accessed 13 October 2023.

Page 86/Page 112 – The seventh risk is malnutrition: D. Blum, ‘An Extreme Risk of Taking Ozempic: Malnutrition’, New York Times, 21 April 2023, https://www.nytimes.com/2023/04/21/well/eat/ozempic-side-effects-malnutrition.html, as accessed 12 October 2023.

Page 86/Page 112 – When you have malnutrition, you are tired and lethargic all the time: ‘Malnutrition’, NHS website, 23 May 2023, https://www.nhs.uk/conditions/malnutrition/symptoms/, as accessed 12 October 2023.

Page 86/Page 112 – After bariatric surgery, malnutrition is quite common: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6873028/.

Page 87/Page 114 – Having elevated blood sugar, even for a few weeks, reduces your life expectancy: I checked to see if this is correct, and it seems to be true for a diabetic that managing your blood sugar levels well will increase life expectancy, along with other treatment goals, by several years. See H. Kianmehr et al., ‘Potential Gains in Life Expectancy Associated With Achieving Treatment Goals in US Adults With Type 2 Diabetes’, JAMA Network Open (2022), 5(4), e227705, doi:10.1001/jamanetworkopen.2022.7705.

Page 89/Page 115 – This kind of Breaking Bad Ozempic could, he said, be literally anything: E. Goldman, ‘Is Your Med Spa “Ozempic” What You Think It Is?’, Prevention, 22 June 2023, https://www.prevention.com/weight-loss/a44300552/ozempic-wegovy-med-spa-prescriptions-safe/, as accessed 7 October 2023.

Page 89/Page 115 – several people bought what they believed to be Ozempic: https://headtopics.com/us/suspected-fake-ozempic-puts-several-in-hospital-in-austria-47546077, as accessed 25 October 2023.

Page 89/Page 116 – there are also unknown unknowns. There are things we don’t know we don’t know: https://www.youtube.com/watch?v=REWeBzGuzCc, as accessed 28 October 2023.

Novo Nordisk – who make Ozempic and Wegovy – sent a detailed response, which you can read in full in the extended endnotes: I put the following questions to Novo Nordisk:

Dear Novo Nordisk media team,

I am a British journalist who has written a book which is being published by Bloomsbury Publishing in the UK and Crown Publishing in the US about the new weight loss drugs and their implications. There is information about me at www.johannhari.com. It is a balanced book investigating both the significant health advantages of these drugs (which I myself am taking, and benefitting from) and the potential risks. I am looking at this matter from a personal, human and scientific perspective.

I am writing to you to give you the right of reply and an opportunity to comment on the potential risks/drawbacks of these drugs that I will be raising in the book in respect of GLP-1 agonists.

Please could you respond with any comments on the below statements by Tuesday November 21st:

1. If a user stops taking Ozempic, Wegovy or other GLP-1 agonists, the user on average regains two-thirds of the weight they lost when on GLP-1 agonists within twelve months as shown for example in this study:

Wilding, JPH, Batterham, RL, Davies, M, et al. Weight regain and cardiometabolic effects after withdrawal of semaglutide: The STEP 1 trial extension. Diabetes Obes Metab. 2022; 24(8): 1553-1564. doi:10.1111/ dom.14725

2. The longer term risks to health from Ozempic, Wegovy or other GLP-1 agonists are not known and so there could be serious negative health effects for some users. For example, anti-psychotics were first developed in the 1950s, but the fact they cause dementia only became clear 50 years later: Jonas, K., Abi-Dargham, A., & Kotov, R. (2021). Two hypotheses on the high incidence of dementia in psychotic disorders. JAMA Psychiatry. Published online September 15, 2021. doi:10.1001/jamapsychiatry.2021.2584 (Link).

I am not suggesting GLP-1 agonists cause dementia – only that they may have presently unknown long-term effects.

3. One longer term effect of Ozempic, Wegovy or other GLP-1 agonists could be damage to children in the womb, where the mother has taken GLP-1 agonists during pregnancy, such that their brain development could be negatively impaired and could lead to increased risk of impaired reward responses, impulsivity, attentional issues, autism or predisposition to substance abuse:

Warning labels on these drugs advise women not to take them whilst pregnant – “may harm your unborn baby”, “may cause foetal harm”. Animal studies have indicated there may be risks to neonatal development, and no good human studies exist:

See: https://www.ozempic.com; https://www.wegovy.com/taking-wegovy/how-to-use-the-wegovy-pen.html; https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/215866s000lbl.pdf

For more detailed information see: https://www.drugwatch.com/news/2023/09/07/fda-warning-pregnancy-wegovy-ozempic/amp/

“Studies in pregnant rats have shown embryofoetal mortality, structural abnormalities, and alterations to growth when administered during organogenesis at maternal exposures below the maximum recommended human dose (MRHD). Early pregnancy losses and structural abnormalities were observed in rabbits at doses below the MRHD. In cynomolgus monkeys, early pregnancy losses and structural abnormalities were observed at exposures of 10-fold or higher that of the MRHD. In rabbits and monkeys, these finding coincided with marked maternal body weight loss. Salcaprozate sodium (SNAC), an absorption enhancer in the oral tablet has been shown to cross the placenta and reach fetal tissue in rats. Administration of SNAC to pregnant rats has shown an increase in number of stillbirths and a decrease in pup viability. There are no adequate and well-controlled studies in pregnant women.” From https://www.drugs.com/pregnancy/semaglutide.html

These concerns about neonatal development in humans were raised with me by reputable scientists in the field.

4. Ozempic, Wegovy or other GLP-1 agonists increase the risk of contracting thyroid cancer. For instance, French scientists found that GLP-1 agonists increase an individual’s risk of thyroid cancer by 58 percent from what it would have been had they not taken the drug: https://diabetesjournals.org/care/article-abstract/46/2/384/147888/GLP-1-Receptor-Agonists-and-the-Risk-of-Thyroid?redirectedFrom=fulltext.

Julien Bezin, Amandine Gouverneur, Marine Pénichon, Clément Mathieu, Renaud Garrel, Dominique Hillaire-Buys, Antoine Pariente, Jean-Luc Faillie; GLP-1 Receptor Agonists and the Risk of Thyroid Cancer. Diabetes Care 1 February 2023; 46 (2): 384–390. https://doi.org/10.2337/dc22-1148; https://diabetesjournals.org/care/article-abstract/46/2/384/147888/GLP-1- Receptor-Agonists-and-the-Risk-of-Thyroid?redirectedFrom=fulltext

This was a study using statistical methods to estimate any increased risk of thyroid cancer found in diabetics taking GLP-1 receptor agonists between 2006 and 2018. They were matched with “control” diabetics who were
not taking the drugs. The analysis attempted to control for various factors including whether or not patients were taking any other antidiabetes drugs and relative levels of socioeconomic deprivation. After controlling for these they still found substantial increased risks.

The 58% increased risk is the estimate for all thyroid cancers; they found a 78% increased risk of medullary thyroid cancer in particular.

5. Ozempic, Wegovy or other GLP-1 agonists increase the risk of pancreatitis and stomach paralysis and bowel obstruction, which in some cases will result in a user’s organ failure and death. For instance, Canadian scientists found that GLP-1 agonists significantly increase the risks of pancreatitis and stomach paralysis: https://jamanetwork.com/journals/jama/fullarticle/2810542. Sodhi M, Rezaeianzadeh R, Kezouh A, Etminan M. Risk of Gastrointestinal Adverse Events Associated With Glucagon-Like Peptide-1 Receptor Agonists for Weight Loss. JAMA. Published online October 05, 2023. doi:10.1001/jama.2023.19574 https://jamanetwork.com/journals/jama/fullarticle/2810542

6. Those taking Ozempic, Wegovy or other GLP-1 agonists were nine times more likely than those taking a different anti-obesity drug to get pancreatitis, and more than three and a half times more likely to get gastroparesis (stomach paralysis). That’s a 909% increased risk of pancreatitis and a 367% increased risk of gastroparesis.

That, like other forms of weight loss, the loss caused by Ozempic, Wegovy or other GLP-1 agonists can cause a loss of muscle mass and sarcopenia, which can have negative health effects, especially for older people as it can lead to falls and death: This issue is widely discussed in relation to GLP-1 agonists, and pharmaceutical companies are currently investigating ways to mitigate this risk, see: M. Lenharo, “Anti-obesity drugs’ side effects: what we know so far”, Nature 622, 682 (2023), https://www.nature.com/articles/d41586-023-03183-3

There is evidence that a higher BMI may be protective as we age and/or that losing too much weight later in life isn’t necessarily a good thing, in part for this reason. See for example:

Associations of Change in Body Size With All-Cause and Cause-Specific Mortality Among Healthy Older Adults, 2023; “This study suggests that weight loss was associated with an increase in mortality, particularly among men, highlighting the need to monitor and investigate weight loss in older adults.”

Body mass index and all-cause mortality in older adults: A scoping review of observational studies, 2020; “Overweight BMI classification or a higher BMI value may be protective with regard to all-cause mortality, relative to normal BMI, in older adults. These findings demonstrate the potential need for age-specific BMI cut-points in older adults.”

The Influence of Age the BMI and All-Cause Mortality Association: A Meta-Analysis, 2017; “The recommended healthy weight range is appropriate for younger and middle aged adults but a higher BMI range should be recommended for older adults based on mortality.”

7. That a small minority of people taking these drugs may experience malnutrition as a result:

This issue is widely discussed in relation to Ozempic, Wegovy or other GLP-1 agonists, see for example: https://www.nytimes.com/2023/04/21/well/eat/ozempic-side-effects-malnutrition.html which includes quotes from Dr. Andrew Kraftson, a clinical associate professor in the division of metabolism, endocrinology and diabetes at Michigan Medicine, who prescribes diets to patients whom he puts on these drugs, hoping to ensure they eat a minimum level of calories.

8. That since these drugs seem to have positive effects on the brain, leading people to want to over-eat less, that there is the possibility that they also have negative effects on the brain, so that use of GLP-1 agonists may in the future be confirmed to cause harm to brain function:

Evidence that the drugs work on the brain’s reward system is extremely strong and well-accepted, see for example: Turton MD, O’Shea D, Gunn I, et al. ‘A role for glucagon-like peptide-1 in the central regulation of feeding’. Nature. 1996;379(6560):69-72. doi:10.1038/379069a0, Jerlhag E. ‘The therapeutic potential of glucagon-like peptide-1 for persons with addictions based on findings from preclinical and clinical studies’. Front Pharmacol. 2023 Mar 30;14:1063033. doi: 10.3389/fphar.2023.1063033.PMID: 37063267; PMCID: PMC10097922. Tufvesson-Alm M, Shevchouk OT, Jerlhag E. ‘Insight into the role of the gut-brain axis in alcohol-related responses: Emphasis on GLP-1, amylin, and ghrelin’. Front Psychiatry. 2023 Jan 9;13:1092828. doi: 10.3389/ fpsyt.2022.1092828. PMID: 36699502; PMCID: PMC9868418. Aranäs C, Edvardsson CE, Shevchouk OT, Zhang Q, Witley S, Blid Sköldheden S, Zentveld L, Vallöf D, Tufvesson-Alm M, Jerlhag E. ‘Semaglutide reduces alcohol intake and relapse-like drinking in male and female rats’. EBioMedicine. 2023 Jul;93:104642. doi: 10.1016/j.ebiom.2023.104642. Epub 2023 Jun 7. PMID: 37295046; PMCID: PMC10363436. Douton, JE, Horvath, N, Mills-Huffnagle, S, Nyland, JE, Hajnal, A, Grigson, PS. ‘Glucagon-like peptide-1 receptor agonist, liraglutide, reduces heroin self-administration and drug-induced reinstatement of heroin-seeking behaviour in rats’. Addiction Biology. 2022; 27(2):e13117. doi:10.1111/ adb.13117.

These concerns were raised to me when I interviewed many reputable scientists in the field.

9. Such harm to brain function as mentioned above may result in anhedonia or increased depression. Such harm to brain function as mentioned above may be related to the safety signal raised around suicide in relation to these drugs:

Brain effects are being actively explored for positive impact, but where there is impact there is always the risk of negative impacts also.

This 2023 online interview with an American researcher who is currently investigating semaglutide in relation to alcoholism makes it clear that anhedonia is widely discussed as a possible risk: https://news.okstate.edu/articles/health-sciences/2023/osu-chs-researcher-studying-weight-loss-drugs-alcohol-use-disorder-treatment.html

The European Medicines Agency released this press statement in July 2023 about the suicide safety signal which was raised by Icelandic doctors in relation to GLP-1 agonists: https://www.ema.europa.eu/en/news/ema-statement-ongoing-review-glp-1-receptor-agonists

These concerns were raised to me when I interviewed many reputable scientists in the field.

10. Even if Ozempic, Wegovy or other GLP-1 agonists are taken indefinitely, there are grounds to suspect that increasing tolerance or physiological and neural change may render the drug ineffective at weight control over time:

As the drugs are so newly-approved for treating obesity, it is hard to point to long-term studies indicating tolerance effects. However the rate of weight loss in the clinical trials seems to level off after several months on semaglutide, and there is an indication that weight may even be beginning to be regained at the end of the longest trial, STEP One: body weight change reached its nadir at week 60, with a slight uptick visible in the final 8 weeks on treatment. See Table 1 in: https://www.nejm.org/doi/full/10.1056/NEJMoa2032183

Interviews within my book make it clear that tolerance is well-known as a likely issue with long-term use of drugs.

See also: https://www.msdmanuals.com/en-gb/home/drugs/factors-affecting-response-to-drugs/tolerance-and-resistance-to-drugs

11. Use of Ozempic, Wegovy or other GLP-1 agonists might result in such loss of pleasure from eating for some people, that harmful habits may take hold as some users may seek stimulation and pleasure in other ways, which may be personally and socially harmful.

This side effect is widely reported, and many of my own interviewees referred to it. See also, for example, patients interviewed in this article: https://www.nytimes.com/2023/04/21/well/eat/ozempic-side-effects-malnutrition.html

12. Despite the fact there is guidance given for Ozempic, Wegovy or other GLP-1 agonists that they should not be given to people with a BMI lower than 27, some people with eating disorders who are highly motivated to deprive themselves of food may get hold of these drugs (mainly through online prescriptions) and harm themselves as a result. This risk is being widely discussed:

UK eating disorders charity, Beat, issued this press release 8 March 2023, when Wegovy was approved by the NHS, saying that semaglutide is “very dangerous for those with eating disorders”: https://www.beateatingdisorders.org.uk/news/semaglutide-weight-loss-medication-very-dangerous-for-those-with-eating-disorders/

In the same month UK pharmacist Superdrug was cautioned for advertising the drug online – see reporting in the Guardian: https://www.theguardian.com/society/2023/mar/12/explainer-new-skinny-jab-has-been-approved-by-the-nhs-but-does-it-work-and-can-you-buy-it

And the Chair of the eating disorder faculty at the Royal College of Psychiatrists was quoted as saying these drugs pose “a real danger for abuse of the medication by those for whom there is no clinical need to use it”: https://www.independent.co.uk/news/health/nhs-weight-loss-jab-eating-disorders- b2296680.html

These issues were raised with me by some of the leading experts on eating disorders in the United States.

Please do let me know if you would like to make any other comments about Ozempic, Wegovy or other GLP-1 agonists. In the book in addition to discussing these potential risks I also discuss many benefits of the drugs.

I received the following reply from their spokesperson.

Our Response, attributable to a Novo Nordisk spokesperson:

Patient safety is paramount to Novo Nordisk, and we work closely with national health authorities to continuously monitor the safety profile of our medicines.

GLP-1 RAs have been used to treat type 2 diabetes for more than
15 years, and for the treatment of obesity for 8 years, including Novo Nordisk medicines that have been on the market for more than 10 years. Semaglutide has been examined in large global clinical development programs, and real- world evidence studies. Cumulatively it has over 12 million patient years of exposure.[i]

Treatment decisions should be made together with a healthcare provider who can evaluate the appropriateness of using a GLP-1 RA medicine based on assessment of a patient’s individual medical profile and in accordance with the medicine Summary of Product Characteristics.

Additional Information on background

Please note that for any questions not directly referenced below, we would refer you to the above statement.

Please note that we have reason to feel that your book may be listed on Bloomsbury with working title “The Magic Pill”. If this is the case please note that Ozempic/Wegovy are available as subcutaneous injections and not as oral formulations or pills. If the use of pill in the title is intended to refer to Wegovy or Ozempic we would flag that “magic pill” is an inaccurate characterisation of these medicines and the title should be updated.

Indications

Please note the indications for our semaglutide products. UK indications

Ozempic® ▼ (semaglutide injection) is indicated for the treatment of adults with insufficiently controlled type 2 diabetes mellitus as an adjunct to diet and exercise. Ozempic® is not licensed for the treatment of weight management.[ii]

Rybelsus ▼ (semaglutide tablets) is indicated for the treatment of adults with insufficiently controlled type 2 diabetes mellitus to improve glycaemic control as an adjunct to diet and exercise. Rybelsus® is not licensed for the treatment of weight management.[iii]

Wegovy® ▼ (semaglutide injection) is indicated as an adjunct to a reduced- calorie diet and increased physical activity for weight management, including weight loss and weight maintenance, in adults with an initial Body Mass Index (BMI) of ≥30 kg/m2 (obesity), or ≥27 kg/m2 to <30 kg/m2 (overweight) in the presence of at least one weight-related comorbidity.[iv]

U.S. Indications

Ozempic® (semaglutide) is FDA-approved for the treatment of type 2 diabetes, to improve blood sugar, along with diet and exercise, and reduce the risk of major cardiovascular events such as heart attack, stroke, or death in adults with type 2 diabetes and known heart disease. Ozempic® is not approved for chronic weight management. Please see Ozempic® full prescribing information here.

Rybelsus® (semaglutide) tablets is FDA-approved for the treatment of type 2 diabetes, to improve blood sugar, along with diet and exercise in adults with type 2 diabetes. It was clinically researched and studied in patients with type
2 diabetes. Rybelsus® is not approved for chronic weight management. Please see Rybelsus® full prescribing information here.

Wegovy® (semaglutide) is FDA-approved for chronic weight management in adults with obesity (BMI > 30), or overweight (excess weight) (BMI > 27) who also have weight-related medical problems, used with a reduced- calorie meal plan and increased physical activity. Wegovy® is also indicated for use in patients aged 12 years and older with an initial BMI at or above the 95th percentile for age and sex. Please see Wegovy® full prescribing information here.

NOTE: Although Wegovy®, Ozempic® and Rybelsus® all contain semaglutide, they are different products with different indications, dosages, prescribing information, titration schedules, and delivery forms. The products are not interchangeable and should not be used outside of their approved indications. Novo Nordisk is committed to the responsible use of our medicines and is taking multiple steps to ensure responsible use of our semaglutide medicines which are detailed on semaglutide.com.

Re: Question 1 on weight regain.

Results from the STEP trials demonstrate that weight regain is likely once treatment with Wegovy® is stopped. Clinical experts consulted by Novo Nordisk view obesity as a chronic disease that should be managed similar to other long-term health conditions such as diabetes and hypertension.[v]

NOTE: Please note that the Wilding reference you have shared is with regards to Wegovy® specifically and not other GLP-1 receptor agonists.

Re: Question 3 on any effect of GLP-1 Ras on unborn children during pregnancy.

The Summary of Product Characteristics (SmPC) for our semaglutide medicines state that these medicines should not be used during pregnancy. [ii], [iii], [iv] We recommend patients take semaglutide only for its approved indications and under the supervision of a healthcare professional.

Pregnancy or intention to become pregnant were exclusion criteria in our trials with semaglutide in both obesity and type 2 diabetes. There are therefore limited clinical trial data with semaglutide use in pregnant women. However, in the U.S., information related to pregnancy appears in Section & 8.3 of the U.S. Prescribing Information for both Ozempic® and Wegovy®.

There is an ongoing study to evaluate the safety of exposure to Wegovy® during pregnancy on Clinical Trials.gov here: https://classic.clinicaltrials.govct2/show/NCT05503927

Re: Question 4 on any risk of contracting thyroid cancer from GLP-1 medicines.

Recently the European Medicines Agency has conducted an independent investigation into any association between GLP-1 RA medicines (note: as a class, not only our medicines) and risk of thyroid cancer. On 27th October 2023, the EMA found no causal association between the GLP-1 RAs, namely – exenatide, liraglutide, dulaglutide, semaglutide, and lixisenatide – and cancer of the thyroid.[vi]

Re: Question 5 on acute pancreatitis and gastroparesis. Gastrointestinal (GI) events are common side effects of the GLP-1 class. For semaglutide, most GI side effects were mild to moderate in severity and of short duration. [ii], [iii], [iv] GLP-1RAs are known to effect a delay in gastric emptying, as detailed in the Summary of Product Characteristics (SmPC). [ii], [iii], [iv] Acute Pancreatitis, is also listed as an adverse reaction in the SMPC. [ii], [iii], [iv]

The long-term data from SELECT published recently with Semaglutide exposure over 39 months is reassuring that there is no increase in the risk of pancreatitis with Semaglutide 2.4 in comparison with placebo.

Re: Question 6 on any effect of semaglutide on body composition (including fat mass and lean mass).

In clinical trials for Wegovy®, Ozempic® or Rybelsus®, we did not specifically study the medicine’s impact on muscle mass. In a sub-study of 140 patients with a BMI of 40 or less conducted as part of the STEP 1 trial, dual-energy x-ray absorptiometry (DEXA) analyses suggested that treatment with Wegovy® was accompanied by reductions in both fat mass and lean body mass, with a greater reduction in fat mass than lean body mass. We recommend that any patients experiencing side effects while taking Wegovy®, Ozempic® or Rybelsus® contact their healthcare provider.

Re: Question 9 on any risk of suicidal ideation.

Novo Nordisk will continue to monitor reports of adverse drug reactions, including suicide and suicidal ideation, through routine pharmacovigilance and in cooperation with local health authorities.

In the U.S., FDA requires medications for chronic weight management that work on the central nervous system, including Wegovy® and Saxenda®, to carry a warning about suicidal behavior and ideation. This event had been reported in clinical trials with other weight management products. Novo Nordisk is continuously performing surveillance of the data from ongoing clinical trials and real-world use of its products and collaborates closely
with the authorities to ensure patient safety and adequate information to healthcare professionals. Novo Nordisk remains confident in the benefit risk profile of the products and remains committed to ensuring patient safety.

The long term data from SELECT published recently with Semaglutide exposure over 39 months is reassuring that there is no increase in the risk of psychiatric disorders with Semaglutide 2.4 in comparison with placebo.

Re: Question 12 on potential use of GLP-1 RAs by people living with eating disorders.

Novo Nordisk does not promote, suggest, or encourage off-label use, or misuse, or any of our medications. We do our best to ensure patients and doctors are educated about the appropriate use of our products and encourage healthcare providers to only prescribe the right product for the right patient.

Novo Nordisk is committed to the responsible use of our medicines and is taking multiple steps to ensure responsible use of our semaglutide medicines which for people living in the US are detailed on semaglutide.com.

References
i. Novo Nordisk A/S. Semaglutide PSUR/PBRER dated 18 July 2023, Version
1.0 (01 Jun 2022–31 May 2023). Data on file.

ii. Ozempic® SMPC. Available at: https://www.ema.europa.eu/en/documents/ product-information/ozempic-epar-product-information_en.pdf [Last Accessed November 2023].

iii. Rybelsus® SMPC. Available at: https://www.ema.europa.eu/en/documents/ product-information/rybelsus-epar-product-information_en.pdf [Last Accessed November 2023].

iv. Wegovy® SMPC. Available at: https://www.ema.europa.eu/en/documents/ product-information/wegovy-epar-product-information_en.pdf [Last Accessed November 2023].

v. Novo Nordisk. Data on file.

vi. Meeting highlights from the Pharmacovigilance Risk Assessment Committee (PRAC) 23-26 October 2023. Available at: https://www.ema.europa.eu/en/news/meeting-highlights-pharmacovigilance-risk-assessment-committee-prac-23-26-october-2023 Last accessed November 2023

 

Chapter Six: Why Don’t You Diet and Exercise Instead?

Page 94/Page 120 – a friend of mine came back from a weight-loss clinic in Austria: I wrote about this at the time: J. Hari, ‘The Mayr health spa’, Independent, 31 October 2005, https://www.independent.co.uk/travel/news-and-advice/the-mayr-health-spa-323597.html, as accessed 15 October 2023.

Page 97/Page 124 – At any given time, around 17 per cent of us are on a diet: S. Phoenix, ‘Weight-Loss Statistics 2023’, Great Green Wall, 8 February 2023, https://www.greatgreenwall.org/supplements/weight-loss-statistics/#:~:text=Separate%20data%20from%20the%20 CDC,data%2C%20also%20from%20the%20CDC. See also Esther Rothblum and Sondra Solovay, eds, The Fat Studies Reader (NYU Press, 2009), p. 39.

Page 99/Page 125 – followed dieters rigorously for two years, or, in a few cases, five years: T. Mann et al., ‘Medicare’s search for effective obesity treatments: Diets are not the answer’, American Psychologist (2007), 62, pp. 220–33. See also A. J. Tomiyama, B. Ahlstrom and T. Mann, ‘Long-term effects of dieting: Is weight loss related to health?’, Social and Personality Psychology Compass (2013), 7(12), pp. 861–77.

Page 101/Page 127 – Michael was convinced that ‘we do have a set point’: William Bennett and Joel Gurin, The Dieter’s Dilemma (Basic Books, 1982). This was one of the earliest books putting forward this idea. See the following for more recent discussion: V. M. Ganipisetti and P. Bollimunta, ‘Obesity and Set-Point Theory’ (updated 25 April 2023), StatPearls; W. T. Garvey, ‘Is Obesity or Adiposity-Based Chronic Disease Curable: The Set Point Theory, the Environment, and Second-Generation Medications’, Endocrine Practice (2022), 28(2), pp. 214–22, doi:10.1016/j.eprac.2021.11.082.

Page 101/Page 129 – When Robert De Niro gained weight for the movie: Raging Bull: David A. Kessler, The End of Overeating (Penguin, 2010), pp. 10–11.

Page 103/Page 129 – Imagine if I had a twin who was 85 kilos: E. Fothergill et al., ‘Persistent metabolic adaptation 6 years after “The Biggest Loser” competition’, Obesity (Silver Spring) (2016), 24(8), pp. 1,612–19, https://pubmed.ncbi.nlm.nih.gov/27136388/.

Page 103/Page 130 – In fact, many people live in ‘food deserts’: The term ‘food desert’ was defined in the 2008 Farm Bill as an ‘area in the United States with limited access to affordable and nutritious food, particularly such an area composed of predominantly lower-income neighborhoods and communities’. However there is increasing controversy around this term. Some argue we should instead talk about ‘food insecurity’ and some activists prefer the term ‘food apartheid’. https://www.brookings.edu/articles/beyond-food-deserts-america-needs-a-new-approach-to-mapping-food-insecurity/; https://www.theguardian.com/society/2018/may/15/food-apartheid-food-deserts-racism-inequality-america-karen-washington-interview, both accessed 9 November 2023.

Page 103/Page 130 – Michael Lowe calls this kind of environment ‘obesogenic’: This term seems to have been invented by US medical researcher Boyd Swinburn. See https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61364-0/fulltext.

Page 106/Page 132 – all the best scientific studies of structured weight-loss programmes in the US: J. W. Anderson et al., ‘Long-term weight-loss maintenance: a meta-analysis of US studies’, American Journal of Clinical Nutrition (2001), 74(5), pp. 579–84, https://pubmed.ncbi.nlm.nih.gov/11684524/.

Page 105/Page 132 – Another team at Brown Medical School in Rhode Island surveyed the limited evidence: See R. R. Wing and S. Phelan, ‘Long-term weight loss maintenance’, American Journal of Clinical Nutrition (2005), 82, suppl. 1, pp. 222S–225S, https://pubmed.ncbi.nlm.nih.gov/16002825/.

Page 108/Page 134 – In 1998, 42 per cent of fifteen-year old kids had become drunk in the past thirty days: https://behavioralscientist.org/dan-heath-iceland-drinking-to-solve-problems-before-they-happen-you-need-to-unite-the-right-people-upstream/, as accessed 7 November 2023.

Page 108/Page 135 – He set up a government-backed initiative called Youth in Iceland: This concept was originally created by Harvey Milkman. See Harvey B. Milkman and Stanley G. Sunderwirth, Craving For Ecstasy and Natural Highs: A Positive Approach to Mood Alteration (SAGE Publications, 2009).

Page 109/Page 136 – At the start, 42 per cent of kids were getting drunk regularly: https://behavioralscientist.org/dan-heath-iceland-drinking-to-solve-problems-before-they-happen-you-need-to-unite-the-right-people-upstream/, as accessed 23 November 2023.

Page 109/Page 136 – Icelandic kids are among the fattest on the continent: This is especially true of Icelandic boys. See p. 12 of this PDF: https://www.who.int/europe/publications/i/item/9789289057738; ‘WHO European Regional Obesity Report 2022’, World Health Organization, 2 May 2022, https://www.who.int/europe/publications/i/item/9789289057738. See also University of Iceland, ‘Obesity among Icelandic children grows fast’, undated, https://english.hi.is/obesity_among_icelandic_children_grows_fast; ‘Icelandic children are the second fattest in Europe’, Iceland Monitor, 24 May 2017; https://icelandmonitor.mbl.is/news/politics_and_society/2017/05/24/.

Page 110/Page 136 – eighty-one women to walk on a treadmill for half an hour, three times a week: B. J. Sawyer et al., ‘Predictors of fat mass changes in response to aerobic exercise training in women’, Journal of Strength and Conditioning Research (2015), 29(2), pp. 297–304, https://pubmed.ncbi.nlm.nih.gov/25353081/; Nadja Hermann, Conquering Fat Logic (Scribe, 2019), p. 246.

Page 110/Page 136 – only 2 per cent of people who lost 2.2 stone or more: E. Dolgin, ‘The appetite genes: Why some of us are born to eat too much’, New Scientist, 31 May 2017, https://www.newscientist.com/article/mg23431281-600-the-appetite-gene
s-why-some-of-us-are-born-to-eat-too-much/.

Page 110/Page 137 – If you eat a large Big Mac meal, you’d have to run for roughly two hours: B. Kenyon, ‘Here’s how long it takes to burn off your favourite McDonald’s meals’, Joe Ireland, undated, https://www.joe.ie/fitness-health/imlovingfit-539764, as accessed 15 July 2023.

Page 110/Page 137 – develop over forty chronic diseases, ranging broadly from diabetes to colon cancer: N. Twilley, ‘A pill to make exercise obsolete’, The New Yorker, 30 October 2017, https://www.newyorker.com/magazine/2017/11/06/a-pill-to-make-exercise-obsolete.

Page 111/Page 137 – If you exercise for 270 hours a year, you’ll add, on average, three years to your life: Tim Spector, The Diet Myth: The Real Science Behind What We Eat (Weidenfeld & Nicolson, 2016), p. 37.

Chapter Seven: The Brain Breakthrough

Page 115/Page 142 – It turned out that they have actually receptors for GLP-1 in their brains: https://www.sciencedirect.com/science/article/abs/pii/0006899389906288.

Page 117/Page 144 – Diana discovered that the rats who’d had GLP-1: M. D. Turton et al., ‘A role for glucagon-like peptide-1 in the central regulation of feeding’, Nature (1996), 379(6560), pp. 69–72, doi:10.1038/379069a0, https://pubmed.ncbi.nlm.nih.gov/8538742/.

Page 119/Page 146 – So she embarked on a series of experiments to find out: E. Jerlhag, ‘The therapeutic potential of glucagon-like peptide-1 for persons with addictions based on findings from preclinical and clinical studies’, Frontiers in Pharmacology (30 March 2023), 14, 1063033, doi: 10.3389/ fphar.2023.1063033. PMID: 37063267; PMCID: PMC10097922; M. Tufvesson-Alm, O. T. Shevchouk and E. Jerlhag, ‘Insight into the role of the gut-brain axis in alcohol-related responses: Emphasis on GLP-1, amylin, and ghrelin’, Frontiers in Psychiatry (9 January 2023), 13, 1092828, doi: 10.3389/fpsyt.2022.1092828; C. Aranäs et al., ‘Semaglutide reduces alcohol intake and relapse-like drinking in male and female rats’, EBioMedicine (July 2023), 93, 104642, doi: 10.1016/j.ebiom.2023.104642.

Page 120/Page 147 – when you stop, you’ll experience withdrawal effects: ‘Alcohol withdrawal’, Drinkaware, 6 January 2022, https://www.drinkaware.co.uk/facts/health-effects-of-alcohol/general-health-effects/alcohol-withdrawal-symptoms, as accessed 12 October 2023.

Page 121/Page 149 – giving GLP-1 agonists to rats cut their use of heroin or fentanyl: J. E. Douton et al., ‘Glucagon-like peptide-1 receptor agonist, liraglutide, reduces heroin self-administration and drug-induced reinstatement of heroin- seeking behaviour in rats’, Penn State Neuroscience Institute (2022),doi: 10.1111/adb.13117. As Patricia explained via email: ‘The GLP-1R agonists reduced cue-induced opioid seeking again very reliably, by about 50%, and when seeking was elicited by a drug prime (or reminder) opioid seeking was reduced by more than 80%. Douton et al., 2021, doi: 10.1097/FBP.0000000000000609; PMID, 33229892 shows the effect of exendin-4 on cue- and drug-induced heroin seeking; Evans et al., 2022; Evans et al., 2022, doi: 10.1016/j.brainresbull.2022.08.022 shows effect of chronic treatment with the longer acting GLP-1R agonist, liraglutide, on cue- and drug-induced heroin seeking; Douton et al., 2022, doi: 10.1097/FBP.0000000000000685. Epub 2022 Jun 7. PMID, 35695511 shows the effect of acutely administered liraglutide on cue-, drug-, and stress-induced heroin seeking; Urbanik et al. 2022 doi: 10.1016/j.brainresbull.2022.08.023 shows the effect of acute administration of liraglutide on cue- and drug-induced fentanyl seeking.’

Page 122/Page 149 – A team at Florida State University: G. Sørensen et al., ‘The glucagon-like peptide 1 (GLP-1) receptor agonist exendin-4 reduces cocaine self-administration in mice’, Physiology Behavior (2015), 149, pp. 262–8, doi:10.1016/j.physbeh.2015.06.013.

Page 122/Page 149 – does concurrently reduce – for example – drinking and smoking: Patricia Grigson also told me by email: ‘The drug also blocks all three “roads to relapse”. It reduces opioid seeking elicited by drug-related cues, the drug itself, and stress (Douton et al., 2022 doi: 10.1097/FBP.0000000000000685; Urbanik et al., 2022 doi: 10.1016/j.brainresbull.2022.08.023.; Evans et al., 2022 doi: 10.1016/j.brainresbull.2022.08.022).’

I also recommend checking out these studies, all as cited by S. Zhang, ‘Did Scientists Accidentally Invent an Anti-addiction Drug?’, The Atlantic, 19 May 2023, https://www.theatlantic.com/health/archive/2023/05/ozempic-addictive-behavior-drinking-smoking/674098/: S. E. Kanoski et al., ‘Peripheral and central GLP-1 receptor populations mediate the anorectic effects of peripherally administered GLP-1 receptor agonists, liraglutide and exendin-4’, Endocrinology (2011), 152(8), pp. 3,103–112, https://pubmed.ncbi.nlm.nih.gov/21693680/; N. Jayaram- Lindstrom et al., ‘Dopamine and Alcohol Dependence: From Bench to Clinic’, InTech (2016), https://www.intechopen.com/chapters/50688; D. Vallof et al., ‘Glucagon-like peptide-1 receptors within the nucleus of the solitary tract regulate alcohol-mediated behaviors in rodents’, Neuropharmacology (2019), 149, pp. 124–32, https://www.sciencedirect.com/science/article/pii/S0028390819300541; Y. Zhang et al., ‘Activation of GLP-1 receptors attenuates oxycodone taking and seeking without compromising the antinociceptive effects of oxycodone in rats’, Neuropsychopharmacology (2020), 45(3), v451–61, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6969180/; N. S. Hernandez et al., ‘Glucagon-like peptide-1 receptor activation in the ventral tegmental area attenuates cocaine seeking in rats’, Neuropsychopharmacology (2018), 43, pp. 2000–8, https://doi.org/10.1038/s41386-018-0010-3; M. Thomsen et al., ‘Effects of glucagon-like peptide 1 analogs on alcohol intake in alcohol-preferring vervet monkeys’, Psychopharmacology (Berl) (2019), 236(2), pp. 603–11, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6428196/; G. A. Angarita et al., ‘Testing the effects of the GLP-1 receptor agonist exenatide on cocaine self-administration and subjective responses in humans with cocaine use disorder’, Drug Alcohol Dependence (2021), 221, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8026565/; M. K. Klausen et al., ‘Exenatide once weekly for alcohol use disorder investigated in a randomized, placebo- controlled clinical trial’, JCI Insight (2022), 7, 19, e159863, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9675448/; K. J. Steffen et al., ‘Alcohol and Other Addictive Disorders Following Bariatric Surgery: Prevalence, Risk Factors and Possible Etiologies’, European Eating Disorders Review (2015), 23(6), pp. 442–50, https://pubmed.ncbi.nlm.nih.gov/26449524/.

Page 124/Page 152 – So far, it looks like GLP-1 agonists do reduce smoking: Yammine et al., 2021; Yammine et al., 2023. DOI: 10.1097/ADM.0000000000001147 https://academic.oup.com/ntr/article-abstract/23/10/1682/6217746 See also https://sciencenews.dk/en/weight-loss-drug-shows-potential-in-smoking-cessation.

Page 124/Page 152 – They do reduce alcohol use – but only in overweight people who had an alcohol problem: https://doi.org/10.1172/jci.

Page 125/Page 153 – For example, if you have Parkinson’s disease: D. Weintraub et al., ‘Association of dopamine agonist use with impulse control disorders in Parkinson disease’, Archives of Neurology (2006), 63(7), pp. 969–73, doi:10.1001/archneur.63.7.969; Laura E. De Wit, et al., ‘Impulse control disorders associated with dopaminergic drugs: A disproportionality analysis using vigibase’, European Neuropsychopharmacology (2022), 58, pp. 30–8, ISSN 0924-977X, https://doi.org/10.1016/j.euroneuro.2022.01.113. See also ‘The medications that change who we are’, BBC, undated, https://www.bbc.com/future/article/20200108-the-medications-that-change-who-we-are, as accessed 13 July 2023.

Page 128/Page 155 – In July 2023, the European Medicines Agency: https://www.ema.europa.eu/en/news/ema-statement-ongoing-review-glp-1-receptor-agonists, as accessed 28 October 2023.

Page 128/Page 155 – Shortly afterwards, the British medical regulator also opened an investigation: M. Fick, ‘Exclusive: UK probes Novo’s Ozempic, weight-loss drug Saxenda over suicidal, self-harming thoughts’, Reuters, 26 July 2023, https://www. reuters.com/business/healthcare-pharmaceuticals/uk-probing-novos-ozempic-weight-loss-drug-saxenda-over-suicidal-self-harming-2023-07-26/, as accessed 3 August 2023.

Page 128/Page 155 – By September 2023, though, this had grown to more than 150 reports across Europe: S. Lumpkin, ‘As Ozempic use grows, so do reports of possible mental health side effects’, NPR, 21 September 2023, https://www.npr.org/sections/ health-shots/2023/09/21/1200201186/as-ozempic-use-grows-so-do-reports-of-possible-mental-health-side-effects, as accessed 10 October 2023.

Page 134/Page 162 – women who were exposed to chemicals in the environment: See for example M. Vänskä et al., ‘Toxic Environment of war: Maternal prenatal heavy metal load predicts infant emotional development’, Infant Behavior and Development (2019), 55, pp. 1–9, ISSN 0163-6383, https://doi.org/10.1016/j.infeh.2019.01.002; A. Etemadi-Aleagha and M. Akhgari, ‘Psychotropic drug abuse in pregnancy and its impact on child neurodevelopment: A review’, World Journal of Clinical Pediatrics (2022), 11(1), pp. 1–13, doi:10.5409/wjcp. v11.i1.1.

Page 135/Page 163 – we need to think about these drugs very differently: The geneticist Tim Spector said it shouldn’t surprise us that so much of how these drugs work seems to come down to the brain. Ten years before, in 2013, he – along with other scientists – had carried out crucial work mapping many of the genes that relate to obesity. ‘We found about a thousand genes for obesity,’ and ‘it turned out when you saw what those genes did, most of it was affecting the brain.’ The genes that contributed to obesity ‘all seemed to be relating to the brain pathways, rather than purely energy pathways, or fat deposition pathways … It was all pointing to the brain, rather than the metabolism.’

Chapter Eight: What Was Over-Eating Doing For You?

Page 138/Page 166 – Jens Juul Holst, one of the scientists who helped develop Ozempic, agrees: M. Reynolds, ‘What the Scientists Who Pioneered Weight-Loss Drugs Want You to Know’, Wired, 12 June 2023, https://www.wired.co.uk/article/obesity-drugs-researcher-interview-ozempic-wegovy, as accessed 10 October 2023.

Page 139/Page 167 – The third reason is that we eat to calm and soothe ourselves: Of course, some people respond to stress by eating less, but they are a minority. See ‘More Stress Means Less Eating’, Scientific American, 27 September 2007, https://www.scientificamerican.com/podcast/episode/439f9f3d-e7f2-99df-36218f52e9bf75b2/.

Page 139/Page 167 – When a group of scientists were investigating comfort eating: David F. Marks, Obesity: Comfort vs Discontent (Yin and Yang Books, 2016), p. 52.

Page 139/Page 167 – Nearly 31 per cent of women and 19 per cent of men say they respond to stress by eating: Jenny Radcliffe, Cut Down to Size: Achieving Success with Weight Loss Surgery (Routledge, 2013), p. 21, citing Z. Stambor, ‘Stressed out nation’, Monitor on Psychology (2006), 37, 4, https://www.apa.org/monitor/apr06/nation.

Page 139/Page 167 – This coping mechanism has become very widespread: See for example L. E. Canetti et al., ‘Food and Emotion’, Behavioural Processes (2002), 60, pp. 157– 64, https://www.researchgate.netpublicationhttps://www.researchgate.netpublication11040898_Food_and_emotion.

Page 139/Page 167 – The following sources are cited in Marks, Obesity, p. 52: S. Byrne et al., ‘Weight maintenance and relapse in obesity: a qualitative study’, International Journal of Obesity and Related Metabolic Disorders (2003), 27(8), pp. 955–62, https://pubmed.ncbi.nlm.nih.gov/12861237/; G. M. Timmerman and G. J. Acton, ‘The relationship between basic need satisfaction and emotional eating’, Issues in Mental Health Nursing (2001), 22(7), pp. 691–701, https://pubmed.ncbi.nlm.nih.gov/11881182/; T. F. Heatherton and R. F. Baumeister, ‘Binge eating as escape from self-awareness’, Psychological Bulletin (1991), 110(1), pp. 86–108, https://pubmed.ncbi.nlm.nih.gov/1891520/.

In Marks, Obesity p. 65, ‘Chao (2015) examined the relationships between chronic stress, food cravings, and BMI with a community-based sample of 619 adults. Chronic stress had a significant effect on food cravings, and food cravings had a significant direct effect on BMI. The total effect ofchronic stress on BMI was significant.’ A. Chao et al., ‘Food cravings mediate the relationship between chronic stress and body mass index’, Journal of Health Psychology (2015), 20(6), pp. 721–9, https://pubmed.ncbi.nlm.nih.gov/26032789/.

Page 139/Page 167 – scientists analysed 475 games from the 2004–5 National Football League season: Rachel Herz, Why You Eat What You Eat (W. W. Norton & Co., 2019), pp. 247–8, citing Y. Cornil et al., ‘From Fan to Fat? Vicarious Losing Increases Unhealthy Eating, but Self-Affirmation Is an Effective Remedy’, Psychological Science (2013), 24(10), pp. 1, 936–46, https://doi.org/10.1177/0956797613481232.

Page 140/Page 168 – On the night Donald Trump was elected President in 2016: V. Chamlee, ‘On election night, Americans self-medicated with delivery food and booze’, Eater, 14 November 2016, https://www.eater.com/2016/11/14/13621652/election-night-food-postmates-grubhub; M. LaMagna, ‘Here are the comfort foods America binged on as the election unfolded’, MarketWatch, 16 November 2016, https://www.marketwatch.com/story/this-is-what-americans-ate-on-election-day-and-after-2016-11-11, as cited in Herz, Why You Eat What You Eat, pp. 234–5.

Page 140/Page 168 – After 9/11, sales of unhealthy snack foods soared too: Ellen Ruppel Shell, The Hungry Gene: The Inside Story of the Obesity Industry (Grove Press, 2003), p. 225.

Page 140/Page 168 – if you lose your job, your chances of adding 10 per cent or more of your body weight shoot up: J. K. Morris et al., ‘Non-employment and changes in smoking, drinking, and body weight’, BMJ (1992), 304(6826), pp. 536–41, https://pubmed.ncbi.nlm.nih.gov/1559056/; I first learned about this in Esther Rothblum and Sondra Solovay, eds, The Fat Studies Reader (NYU Press, 2009), p. 26.

Page 140/Page 168 – In Western culture, poorer people are often more overweight: C. Stival et al., ‘Prevalence and Correlates of Overweight and Obesity in 12 European Countries in 2017–2018’, Obesity Facts (2022), 15, 5, https://doi.org/10.1159/000525792; Eurostat, ‘Overweight and obesity – BMI statistics’, Statistics Explained, 2019, https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Overweight_and_obesity_-BMI_statistics#Education_l evel_and_overweight; A. Marques et al., ‘Prevalence of adult overweight and obesity in 20 European countries, 2014’, European Journal of Public Health (2018), 28(2), pp. 295–300, https://doi.org/10.1093/eurpub/ckx143.

Page 141/Page 169 – It also helps to explain why Black people in the US are more likely to be obese: H. Lofton, J. D. Ard, R. R. Hunt and M. G. Knight, ‘Obesity among African American people in the United States: A review’, Obesity (Silver Spring) (2023), 31, pp. 306–15. The paper says: ‘Among individuals aged ≥20 years in 2017–2018, prevalence rates for obesity were highest in African American people (49.6%) compared with other racial groups (e.g., non-Hispanic White, 42.2%), and rates were higher in African American women (56.9%) than in African American men (41.1%).’ It also explains: ‘Structural racism remains a major contributor to health disparities between African American people and the general population, and it limits access to healthy foods, safe spaces to exercise, adequate health insurance, and medication, all of which impact obesity prevalence and outcomes.’ See also Oxford Handbook of the Social Science of Obesity (OUP, 2011), p. 264, citing Y. C. Cozier et al., ‘Perceived racism in relation to weight change in the Black Women’s Health Study’, Annals of Epidemiology (2009), 19(6), pp. 379–87, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2755225/.

Page 141/Page 169 – it was even given a term: Kummerspeck, or ‘fat of sorrow’: Hilde Bruch, Eating Disorders: Obesity, Anorexia Nervosa, and the Person Within (Routledge & Kegan Paul, 1973), p. 126.

Page 141/Page 169 – Among American soldiers who fought in the Vietnam War: Michael Moss, Hooked: How We Became Addicted to Processed Food (W. H. Allen, 2022), p. 70, citing W. V. R. Vieweg et al., ‘Body mass index relates to males with posttraumatic stress disorder’, Journal of the National Medical Association (2006), 98(4), pp. 580–6, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2569214/.

Page 143/Page 171 – In 1934, a German-Jewish psychoanalyst named Hilde Bruch: Sander L. Gilman, Obesity: The Biography (OUP, 2010), p. 96.

Page 143/Page 171 – Under Hitler, obesity was explained entirely in ‘racial’ terms: Ibid., pp. 86–7.

Page 143/Page 171 – there was something going on in the psyches of people who overeat: For this section about Hilde, I have drawn on a range of sources, particularly Hilde’s excellent book Eating Disorders. See also Gilman, Obesity: The Biography, pp. 94–105; Shell, The Hungry Gene, pp. 44–5; Rothblum and Solovay, The Fat Studies Reader, pp. 114–17; Virginia Sole-Smith, Fat Talk: Coming of Age in Diet Culture (Ithaka, 2023), pp. 9, 152; Amy Erdman Farrell, Fat Shame: Stigma and the Fat Body in American Culture (NYU Press, 2011), pp. 77–80; Oxford Handbook, p. 89.

Page 143/Page 171 – So she got a job working in the obesity clinic at Columbia Presbyterian Medical Center: Bruch, Eating Disorders, p. 135.

Page 144/Page 172 – This early “programming” of his regulatory centers became his permanent pattern: Ibid., pp. 60–1.

Page 145/Page 173 – they use food to shut the baby up, or they withhold food as a punishment: Ibid., p. 58.

Page 146/Page 174 – psychological problems were responsible for 90 per cent of obesity: Roberta Pollack Seid, Never Too Thin: Why Women Are at War with Their Bodies (Prentice Hall, 1991), p. 123; Laura Fraser, Losing It: False Hopes and Fat Profits in the Diet Industry (Penguin, 1998), p. 153.

Page 146/Page 174 – In the 1970s, a scientist named Leann Birch at Penn State University: https://www.nytimes.com/2019/06/02/obituaries/leann-birch-dead.html, as accessed 20 October 2023. I know she was deeply inspired by Hilde from my interview with her colleague Ian Paul.

Page 146/Page 175 – her team at Penn State Children’s Hospital took a group of 279 first-time mothers: I. M. Paul et al., ‘Effect of a Responsive Parenting Educational Intervention on Childhood Weight Outcomes at 3 Years of Age: The INSIGHT Randomized Clinical Trial’, JAMA (2018), 320(5), pp. 461–8, doi:10.1001/jama.2018.9432.

Page 147/Page 176 – explore how it helped me to think about these new drugs: Johann Hari, Lost Connections: Uncovering the Real Causes of Depression – And the Unexpected Solutions (Bloomsbury, 2018), Chapter 9.

Page 149/Page 178 – What we had perceived as the problem – namely, major obesity: These results have now been found in many studies. Similarly, a study in Sweden that followed kids from birth to the age of fifteen found that you were significantly more likely to have gained weight if you had experienced a lot of stress and distress. T. Mellbin and J. C. Vuille, ‘Rapidly developing overweight in school children as an indicator of psychosocial stress’, Acta Paediatrica Scandinavica (1989), 78(4), pp. 568–75, https://pubmed.ncbi.nlm.nih.gov/2782072/, as cited in Gilman, Obesity: The Biography, p. 60; Anthony Warner, The Truth About Fat (Oneworld, 2019), p. 237: ‘A 2001 study found that 83 percent of binge-eating sufferers had a history of childhood abuse, 30 percent had experienced sexual violence, and 69 percent had suffered from emotional neglect.’

See also C. M. Grilo and R. M. Masheb, ‘Childhood psychological, physical, and sexual maltreatment in outpatients with binge eating disorder: frequency and associations with gender, obesity, and eating-related psychopathology’, Obesity Research (2001), 9(5), pp. 320–5, https://pubmed.ncbi.nlm.nih.gov/11346674/, as cited in Warner, The Truth About Fat, p. 237; Radcliffe, Cut Down to Size, p. 23, explains: ‘The more negative events a child is exposed to the more at risk they are of being obese as an adult’; D. F. Williamson et al., ‘Body weight and obesity in adults and self-reported abuse in childhood’, International Journal of Obesity and Related Metabolic Disorders (2002), 26(8), pp. 1,075–82, https://pubmed.ncbi.nlm.nih.gov/12119573/, as cited in Radcliffe, Cut Down to Size, p. 23; J. W. Rich-Edwards et al., ‘Abuse in childhood and adolescence as a predictor of type 2 diabetes in adult women’, American Journal of Preventive Medicine (2010), 39(6), pp. 529–36, https://pubmed.ncbi.nlm.nih.gov/21084073/, as cited in Radcliffe, Cut Down to Size, p. 23.

On bariatric surgery, see James E. Mitchell and Martina de Zwaan, eds, Bariatric Surgery: A Guide for Mental Health Professionals (Routledge, 2016), p. 23: ‘King, Clark and Pera (1996) found that patients in their weight loss program with a history of sexual abuse lose significantly less weight and were less compliant with treatment than patients without a history of sexual abuse… One study found that those who were sexually abused were less dissatisfied with their current overweight status.’

See also T. K. King et al., ‘History of sexual abuse and obesity treatment outcome’, Addictive Behaviors (1996), 21(3), pp. 283–90, https://pubmed.ncbi.nlm.nih.gov/8883480/, as cited in Mitchell and de Zwaan, Bariatric Surgery, p. 23. Even when people take the drastic step of bariatric surgery, ‘Ray, Nickels, Sayeed and Sax (2003) found that patients with a history of sexual abuse lost significantly less of their excess weight at 1-year follow-up than those without such a history.’ Another study found that survivors of sexual abuse lost as much after surgery but were more likely to become depressed. See E. C. Ray et al., ‘Predicting success after gastric bypass: the role of psychosocial and behavioral factors’, Surgery (2003), 134(4), pp. 555–64, https://pubmed.ncbi.nlm.nih.gov/14605615/, as cited in Mitchell and de Zwaan, Bariatric Surgery, p. 26; J. Vandewalle et al., ‘Comprehending emotional eating in obese youngsters: the role of parental rejection and emotion regulation’, International Journal of Obesity (2014), 38, pp. 525–30, https://doi.org/10.1038/ijo.2013.233, as cited in Gilman, Obesity: The Biography, p. 63.

Page 149/Page 178 – The writer Roxane Gay writes about this in her moving memoir: I quote here from Roxane Gay, Hunger: A Memoir of (My) Body (Harper, 2017), pp. 11 and 142–3.

Page 151/Page 179 – That’s why most people are glad they did it: Mitchell and de Zwaan, Bariatric Surgery, p. 102; F. Larsen, ‘Psychosocial function before and after gastric banding surgery for morbid obesity. A prospective psychiatric study’, Acta Psychiatrica Scandinavica (1990), suppl. 359, pp. 1–57, https://pubmed.ncbi.nlm.nih.gov/2220412/. See also R. Woods et al., ‘Evolution of depressive symptoms from before to 24 months after bariatric surgery: A systematic review and meta-analysis’, Obesity Reviews (2023), 24, 5, e13557, https://pubmed.ncbi.nlm.nih.gov/36823768/, R. Fu et al., ‘Bariatric surgery alleviates depression in obese patients: A systematic review and meta-analysis’, Obesity Research and Clinical Practice (2022), 16(1), pp. 10–16, https://pubmed.ncbi.nlm.nih.gov/34802982/.

Page 152/Page 181 – Roughly one in ten of the people who have bariatric surgery develop an addiction: J. E. Mitchell et al., ‘Addictive disorders after Roux-en-Y gastric bypass’, Integrated Health (2015), 11, 14, https://doi.org/10.1016/j.soard.2014.10.026. Many of them had had addictions in the past, which were now reactivated.

Page 152/Page 181 – They are often referred to as ‘addiction transfers’: Radcliffe, Cut Down to Size, p. 180.

Page 152/Page 181 – Actually, it wasn’t the disease of obesity that made my life terrible: See Fraser, Losing It, p. 277.

Page 153/Page 182 – the increased attention from potential sexual partners triggers memories: A. Buser et al., ‘Outcome following gastric bypass surgery: impact of past sexual abuse’, Obesity Surgery (2004), 14(2), pp. 170–4, https://pubmed.ncbi.nlm.nih.gov/15018744/.

Page 154/Page 182 – the surgery and the alcoholism led her to confront the underlying issues: When I showed Robin what I had written, she asked me to add: ‘when I was five years sober from alcohol, I realized that I was back up to 256 lbs and in another terrible spiral. I entered a recovery program for food and have lost more than half of my body weight from the time I had surgery in 2001.’

Page 155/Page 184 – a significant minority – 17 per cent – experience depression and anxiety: Mitchell and de Zwaan, Bariatric Surgery, p. 103: ‘Powers et al (1992) reported that 17 percent of patients experienced significant psychiatric symptoms postsurgically that required hospitalisation. Mitchell et al (2001) found that 29 percent of their sample experienced an episode of major depression post surgically.’ P. S. Powers et al., ‘Psychiatric Issues in Bariatric Surgery’, Obesity Surgery (1992), 2(4), pp. 315–25, https://pubmed.ncbi.nlm.nih.gov/10765 191/; J. E. Mitchell et al., ‘Long-term follow-up of patients’ status after gastric bypass’, Obesity Surgery (2001), 11(4), pp. 464–8, https://pubmed.ncbi.nlm.nih.gov/11501356/.

Page 155/Page 184 – After bariatric surgery, we [see an] increase [in] suicide fourfold: It varies by procedure, and is almost fourfold for gastric bypass, while for others, it is lower. The overall adjusted hazard ratio for suicide after all bariatric surgery is 3.16. See https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5932484/. See also C. Peterhansel et al., ‘Risk of completed suicide after bariatric surgery: a systematic review’, Obesity Reviews (2013), 14(5), pp. 369–82, https://pubmed.ncbi.nlm.nih.gov/23297762/; D. Castaneda et al., ‘Risk of Suicide and Self- harm Is Increased After Bariatric Surgery – A Systematic Review and Meta- analysis’, Obesity Surgery (2019), 29(1), pp. 322–33, https://pubmed.ncbi.nlm.nih.gov/30343409/.

Chapter Nine: I Don’t Think You’re in Your Body

Page 159/Page 188 – In one study of the effects of Ozempic on weight: See Figure 1 in J. P. H. Wilding et al., ‘Once-Weekly Semaglutide in Adults with Overweight or Obesity’, New England Journal of Medicine (2021), 384(11), pp. 989–1,002, doi:10.1056/ NEJMoa2032183.

Page 161/Page 190 – This suggests to him that the drug will continue to work consistently over the long- term: Kushner also said: ‘There’s a new normal that’s beginning in the body.’ It wouldn’t be normal ‘to never feel hungry. You have to sustain your body. So what we think is happening is the body is reorganising – renormalising the waves of hunger, fullness and so on, but it’s modified,’ and being experienced at a lower level. When his patients start to feel hungry again, they feel the drug has worn off. ‘I have to reinterpret what hunger is for them. That it’s completely normal. Congratulations! Everyone gets hungry but you don’t need as much food to feel full. Don’t overeat … Your weight is stable.’

Page 164/Page 193 – In it, she explains: Bee Wilson, First Bite: How We Learn to Eat (Fourth Estate, 2016), p. 3.

Page 164/Page 193 – The reason many find it hard to eat healthily is that we have never learned any differently: Ibid., pp. 4, 6.

Page 164/Page 193 – If our food habits are learned, they can also be relearned: Ibid., p. 7.

Page 164/Page 193 – Give yourself one month of your life where you try only eating freshly cooked wholefoods: This was said to me by Rangan when I didn’t have a recorder running. He confirmed by email that it’s accurate.

Page 166/Page 193 – From the age of five, she was sexually abused by her father: V writes about this beautifully in her book The Apology (reprinted Bloomsbury, 2023).

Page 167/Page 196 – In her fifties, V was so cut off: She describes her cancer experience in her book In the Body of the World (Picador, 2014).

Page 168/Page 197 – Research in the 1950s found that very few people were unhappy with their bodies: T. F. Cash and L. Smolak (2011), ‘Understanding body images: Historical and contemporary perspectives’, in Thomas F. Cash and Linda Smolak, eds, Body Image: A Handbook of Science, Practice, and Prevention (Guilford Press, 2012), pp. 3–11.

Page 168/Page 197 – upwards of 90 per cent of women feel some aspect of negative body image: V. Swami et al., ‘Associations between women’s body image and happiness: Results of the YouBeauty.com Body Image Survey (YBIS)’, Journal of Happiness Studies (2015), 16, pp. 705–16. See also https://www.psychologytoday.com/us/articles/199702/body-image-in-america-survey-results, as accessed 6 November 2023.

Page 169/Page 198 – It tells you you are incomplete: V. Swami, ‘Cross-cultural perspectives on body size’, in Maxine Leeds Craig, ed., The Routledge Companion to Beauty Politics (Routledge, 2021), pp. 103–11.

Page 169/Page 198 – Then, on social media, we reinforce these ideas: S. Stieger et al., ‘Engagement with social media content results in negative body image: An experience sampling study using wearables and a physical analogue scale’, Body Image (2022), 43, pp. 232–43.

Page 169/Page 199 – One group of scientists gathered a hundred people: B. M. Dolan, S. A. Birtchnell and J. H. Lacey, ‘Body image distortion in non-eating disordered women and men’, Journal of Psychosomatic Research (1987), 31(4), pp. 513–20, doi:10.1016/0022-3999(87)90009-2.

Page 170/Page 199 – The technical term for what this question stirs in us is ‘functionality appreciation’: J. M. Alleva, T. L. Tylka and A. M. Kroon Van Diest, ‘The Functionality Appreciation Scale (FAS): Development and psychometric evaluation in U.S. community women and men’, Body Image (2017), 23, pp. 28–44, doi:10.1016/j.bodyim.2017.07.008.

Page 170/Page 199 – when people get out into the natural world, their body image improves significantly: V. Swami, D. Barron and A. Furnham, ‘Exposure to natural environments, and photographs of natural environments, promotes more positive body image’, Body Image (2018), 24, pp. 82–94.

Page 170/Page 200 – In nature, most people feel less egotistical: V. Swami, U. S. Tran, S. Stieger and M. Voracek, ‘Developing a model linking self-reported nature exposure and positive body image: A study protocol for the Body Image in Nature Survey (BINS)’, Body Image (2022), 40, pp. 50–7. See also Johann Hari, Lost Connections: Uncovering the Real Causes of Depression – And the Unexpected Solutions (Bloomsbury, 2018), Chapter 11.

Page 170/Page 200 – This is anything that makes you feel more situated in your own body: V. Swami and A. S. Harris, ‘Dancing toward positive body image? Examining body- related constructs with ballet and contemporary dancers at different levels’, American Journal of Dance Therapy (2012), 34, pp. 39–52.

Page 170/Page 200 – or CrossFit: V. Swami, ‘Is CrossFit associated with more positive body image? A prospective investigation in novice CrossFitters’, International Journal of Sport Psychology (2019), 50, pp. 370–81.

Chapter Ten: Self-Acceptance vs. Self-Starvation?

Page 173/Page 203 – a survey of high school girls found that 50 per cent of them believed they were too fat: Roberta Pollack Seid, Never Too Thin: Why Women Are at War with Their Bodies (Prentice Hall, 1991), p. 150.

Page 173/Page 203 – In 1966, a seventeen-year old model named Lesley Hornby: Laura Fraser, Losing It: False Hopes and Fat Profits in the Diet Industry (Penguin, 1998), p. 43; Shelley Bovey, What Have You Got to Lose?: The Great Weight Debate and How to Diet Successfully (The Women’s Press, 2001), p. 9.

Page 173/Page 203 – She weighed six and a half stone: https://www.theguardian.com/lifeandstyle/2009/sep/19/twiggy-at-60-interview, as accessed 3 August 2023.

Page 175/Page 205 – In the sitcom Absolutely Fabulous, a fashion magazine editor: https://www.imdb. com/title/tt0504672/characters/nm0525921, as accessed 11 October 2023.

Page 176/Page 206 – She believes that today ‘dieting is out, while “elimination” is in’: https://www.stylist.co.uk/long-reads/wellness-ozempic-self-denial/786606, as accessed 3 August 2023.

Page 177/Page 207 – seems like a type of death: https://www.stylist.co.uk/long-reads/wellness-ozempic-self-denial/786606, as accessed 3 August 2023.

Page 177/Page 207 – held congressional hearings on diet pills: https://www.nytimes.com/1990/03/28/garden/congress-looking-into-the-diet-business.html; https://www.nytimes.com/1990/10/03/garden/eating-well-children-are-focus-of-diet-pill-issue.html; https://centerforinquiry.org/wp-content/uploads/sites/33/quackwatch/casewatch/hearings/101-50.pdf; https://centerforinquiry.org/wp-content/uploads/sites/33/quackwatch/casewatch/hearings/101-80.pdf; https://www.latimes.com/archives/la-xpm-1990-09-25-mn-1094-story.html, all as accessed 3 August 2023.

Page 177/Page 207 – the most popular kind was a drug that was chemically very similar: Fraser, Losing It, pp. 100–3.

Chapter Eleven: The Forbidden Body

Page 188/Page 219 – Her parents were extremely busy running the family pub: Shelley also discussed this in an interview with William Leith, which I have been informed by – see William Leith, The Hungry Years: Confessions of a Food Addict (Bloomsbury, 2006), p. 282.

Page 190/Page 221 – What are you trying to do? Make the child as fat as yourself?: Shelley Bovey, The Forbidden Body: Why Being Fat Is Not a Sin (Rivers Oram Press, 1994), p. 46.

Page 190/Page 221 – For people with a BMI higher than 35, it’s much worse: Oxford Handbook of the Social Science of Obesity (OUP, 2011), p. 92; R. M. Puhl et al., ‘Perceptions of weight discrimination: prevalence and comparison to race and gender
discrimination in America’, International Journal of Obesity (London) (2008), 32(6), pp. 992–1,000, https://pubmed.ncbi.nlm.nih.gov/18317471/.

Page 190/Page 221 – Landlords are 50 per cent less likely to rent their property to a fat person: Esther Rothblum and Sondra Solovay, eds, The Fat Studies Reader (NYU Press, 2009), pp. xix–xx; L. Karris, ‘Prejudice against obese renters’, Journal of Social Psychology (1977), 101(1), pp. 159–60, https://doi.org/10.1080/00224545.1977.9924002.

Page 190/Page 222 – Incredibly, fat people are more likely to be convicted of a crime: D. E. White II et al., ‘The influence of plaintiff ’s body weight on judgments of responsibility: the role of weight bias’, Obesity Research and Clinical Practice (2014), 8, 6, e599-607, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4250925/; N. A. Schvey et al., ‘The influence of a defendant’s body weight on perceptions of guilt’, International Journal of Obesity (London) (2013), 37(9), pp. 1,275–81, https://pubmed.ncbi.nlm.nih.gov/23295503/. I first learned about this in Anthony Warner, The Truth About Fat (Oneworld, 2019), p. 106.

Page 190/Page 222 – When Esquire magazine polled a thousand women: Laura Fraser, Losing It: False Hopes and Fat Profits in the Diet Industry (Penguin, 1998), p. 47.

Page 190/Page 222 – Every time she sees you, she is made aware of what she could become: Bovey, The Forbidden Body, p. 21.

Page 190/Page 222 – women who believed they were overweight, and women who didn’t: B. Major, J. M. Hunger, D. P. Bunyan and C. T. Miller, ‘The ironic effects of weight stigma’, Journal of Experimental Social Psychology (2014), 51, pp. 74–80, https://doi.org/10.1016/j.jesp.2013.11.009. I learned about this study in K. Gunnars, ‘The Harmful Effects of Fat Shaming’, Healthline, 19 January 2022, https://www.healthline.com/nutrition/fat-shaming-makes-things-worse#overeating.

Page 192/Page 223 – overweight people who were shown a harsh and judgemental video: N. A. Schvey et al., ‘The impact of weight stigma on caloric consumption’, Obesity (Silver Spring) (2011), 19(10), pp. 1,957–62, https://pubmed.ncbi.nlm.nih.gov/21760636/ as accessed 10 October 2023.

Page 192/Page 223 – stigmatising overweight people is in fact counterproductive: This meta-analysis shows the wider evidence for this: X. Zhu et al., ‘A meta-analysis of weight stigma and health behaviors’, Stigma and Health (2022), 7(1), pp. 1–13, https://doi.org/10.1037/sah0000352; see also A. Tomiyama et al., ‘How and why weight stigma drives the obesity “epidemic” and harms health’, BMC Medicine (2018), 16, p. 123, https://doi.org/10.1186/s12916-018-1116-5.

Page 192/Page 223 – Stigma also makes overweight people far less likely to exercise: L. R. Vartanian et al., ‘Effects of Weight Stigma on Exercise Motivation and Behavior: A Preliminary Investigation among College-aged Females’, Journal of Health Psychology (2008), 13(1), pp. 131–8, https://doi.org/10.1177/1359105307084318.

Page 192/Page 223 – The Fat Pride activist and bestselling author Aubrey Gordon: Aubrey Gordon, What We Don’t Talk About When We Talk About Fat (Beacon Press, 2020), pp. 42–3.

Page 192/Page 223 – postponed going to the doctor until they lose weight: A. Shelley, ‘Women’s Heart Health Hindered by Social Stigma About Weight’, Medscape, 3 April 2016, https://www.medscape.com/viewarticle/861382?form=fpf.

Page 192/Page 223 – Loving yourself is not antithetical to health, it is intrinsic to health: Warner, The Truth About Fat, p. 290, citing Lindy West, Shrill: Notes From A Loud Woman (Quercus, 2017).

Page 193/Page 224 – Why do we believe that making people loathe their bodies will make them take care of them?: Many people believe this stigma is a relatively recent invention. Dina Amlund has been carrying out academic research in Denmark on this topic, and she told me that she had been insulted and mocked for her weight since she was a child. In 2010, she began to research the history of how fat people had been seen in the past, because she had been told that not so long ago, ‘there were fat people and they were loved’, so ‘I wanted to go back, to find some sort of comfort – to see all the fat adoration I had heard about.’ She began to look at the most famous images and stories that people believe celebrated fat women in the past. What she saw took her aback. ‘I was like – oh no, we got it all wrong.’

The first thing that puzzled her is that throughout so much of recorded human history, people have worn shapewear – uncomfortable clothes, such as corsets, that sculpt their bodies into slimmer shapes. She asked: ‘If they liked fat people, how come we’ve never had a period of time without shapewear trying to shape the body and make it thinner?’ The oldest shapeware in the West was ‘worn by the Minoan people and it dates back to 1000 BCE and some say even longer, 1500–1600 BCE’. The women who wore them would look like ‘a very hourglassy hourglass – a very slender ideal. A thin ideal … To me, it looks very painful’ to wear.

Then she studied the famous paintings and statues from the Renaissance that are presented as evidence that people venerated fatness. ‘I always ask people to Google them to look at them to see … If they came alive, they would be able to walk into regular clothing shops and buy clothes there, and not plus-size clothes. So I don’t consider them fat.’ In fact, many of them are ‘definitely slender’. Look, she says, at Botticelli, who many people cite as proof that fat people were seen as beautiful in the past. ‘The newborn Venus is always the example. She’s just not fat. There’s nothing there.’

So she dug into the stories behind the few representations of genuinely obese people in the past that we have, and discovered a horror story. The artist Juan Carreño de Miranda painted a woman named Eugenia Martinez Valejo, whose images I have seen in the Prado Museum in Madrid. This work is often presented as evidence that in the Baroque Era, fat women were admired. Dina explained to me: ‘She was born to peasants in the second half of the seventeenth century and she was brought to court to work as a jester when she was six years old.’ She was very fat from a very young age, at a time when that was very rare. She was brought to court in effect as a ‘freak’, to be displayed as an amusement, alongside people with physical disabilities. ‘It was because she was fat that she was brought to court … She was there to be fat. That was her job’, and like the jesters, she was there to be humiliated. They would throw food at her. The two paintings Juan Carreño de Miranda did of her are titled Monster Nude and Monster Dressed. This was not a story of celebrating fatness – it was a story of sadistically abusing a fat child and young woman.

After learning all this, Dina told me, ‘At first, I was really sad. I came here [to this history] looking for friends’, and all she found was ‘enemies’. But ‘I do think there’s something very positive about it, and it is that we will never be able to untangle fatphobia if we don’t understand what a serious grip it has on us. Some people say “oh, it came with social media”, or “it came with Twiggy”’, while the American academic ‘Sabrina Strings argued it started in the 1700s with racism. And I would say – no, it could be used to enhance already existing racism because the world was so fatphobic already.’ This changed her own perspective. ‘Ever since I was a child, I’ve experienced horrible comments in public, and I used to [just] think this person is rude.’ Now, she also thinks that person is ‘a symptom of an oppressive structure that is not his own fault. It’s his responsibility what he says, but it’s not his fault that he thinks like that.’ This insight, she says, ‘made my life very different’, and spurred her to fight against this prejudice.

Page 193/Page 224 – There is no way to hide being fat except by staying indoors: Bovey, The Forbidden Body, p. 1.

Page 193/Page 224 – A fat man is a joke, and a fat woman is two jokes: Louise Foxcroft, Calories and Corsets: A History of Dieting over 2,000 Years (Profile, 2012), unnumbered opening page.

Page 193/Page 224 – She also read testimonies from women: Bovey, The Forbidden Body, pp. 44–5. they published a manifesto: Erec Smith, Fat Tactics: The Rhetoric and Structure of the Fat Acceptance Movement (Lexington Books, 2018), pp. 24–5.

Page 195/Page 227 – one of the first people to warn that obesity had begun to rise: R. J. Kuczmarski, K. M. Flegal, S. M. Campbell and C. L. Johnson, ‘Increasing Prevalence of Overweight Among US Adults: The National Health and Nutrition Examination Surveys, 1960 to 1991’, JAMA (1994), 272(3), pp. 205–11, doi:10.1001/jama.1994.03520030047027.

Page 196/Page 227 – she and her colleagues had analysed a dataset of over 36,000 people: K. M. Flegal et al., ‘Excess Deaths Associated With Underweight, Overweight, and Obesity’, JAMA (2005), 293(15), pp. 1,861–7, https://jamanetwork.com/journals/jama/fullarticle/200731. For Katherine Flegal’s perspective on the controversy that followed, see K. M. Flegal, ‘The obesity wars and the education of a researcher: A personal account’, Progress in Cardiovascular Diseases (2021), 67, pp. 75–9, https://www.sciencedirect.com/science/article/pii/S0033062021000670.

Page 196/Page 227 – has been dubbed the ‘obesity paradox’: K. M. Flegal, ‘Excess Deaths Associated With Underweight, Overweight, and Obesity’. The term ‘obesity paradox’ refers to findings that in some instances there are lower mortality rates for overweight people than for those with BMIs usually described as healthy, in certain situations or groups. Flegal and her colleagues were not the first to report on this phenomenon. It seems to have been identified as far back as 1985. Dr Kamyar Kalantar-Zadeh prefers the term ‘reverse epidemiology’ and was arguably amongst the first to highlight the issue. See also: R. Andres et al., ‘Impact of Age on Weight Goals’, Annals of Internal Medicine (1985), 103, pp. 1,030–3; H. Lennon, M. Sperrin, E. Badrick and A. G. Renehan, ‘The Obesity Paradox in Cancer: a Review’, Current Oncology Reports (2016), 18(9), p. 56, doi:10.1007/s11912-016-0539-4; M. R. Carnethon et al., ‘Association of weight status with mortality in adults with incident diabetes [published correction appears in JAMA (28 November 2012), 308(20), p. 2085]’, JAMA (2012), 308(6), pp. 581–90, doi:10.1001/jama.2012.9282; K. Kalantar-Zadeh, G. Block, M. H. Humphreys and J. D. Kopple, ‘Reverse epidemiology of cardiovascular risk factors in maintenance dialysis patients’ Kidney International (2003), 63(3), pp. 793–808, doi:10.1046/j.1523-1755.2003.00803.x; Dr Kalantar-Zadeh once commented on the fact that obesity seems to make it more likely you will get certain diseases, but then increase your chances of surviving them for longer, by saying obesity is like ‘that guy who led you to prison, becomes your friend in prison’; S. Gupta, ‘Obesity: The fat advantage’, Nature (2016), 537, S100–S102, https://doi.org/10.1038/537S100a.

Page 196/Page 227 – a dastardly ploy by the fat-hating medical profession to rid the world of the dreaded obese: Shelley Bovey, What Have You Got to Lose?: The Great Weight Debate and How to Diet Successfully (The Women’s Press, 2001), p. 117.

Page 196/Page 227 – By this time, she weighed nineteen and a half stone: This was how Shelley recalled her weight when we spoke; she also described it similarly in this interview: Libby Brooks, ‘Size matters’, Guardian, 15 March 2002, https://www.theguardian.com/lifeandstyle/2002/mar/16/features.weekend, as accessed 15 October 2023.

Page 196/Page 228 – I could not help feeling a burden, literally: Bovey, What Have You Got to Lose, pp. 42–3.

Page 196/Page 228 – had a newsletter named Fat News: Ibid., p. 32.

Page 197/Page 229 – Walter Willett is professor of epidemiology and nutrition: ‘What longtime nutrition expert Walter Willett still wants to know’, Harvard School of Public Health, undated, https://www.hsph.harvard.edu/news/hsph-in-the-news/nutrition-walter-willett-health-sustainability/, as accessed 28 September 2023.

Page 198/Page 229 – the more obese a person becomes, the greater the risk to their health: The scientists I interviewed kept reiterating these broad points, with the same amount of sadness – and genuine compassion for the people who don’t want to believe it. Robert Kushner said people who say obesity doesn’t harm health are ‘ignoring all the science’. Graham MacGregor reiterated this point, and stated plainly: ‘It’s not their fault’ they are obese. ‘Let’s keep that clear. It’s
the food industry’s fault. But if you’re obese, you’re much more likely to die, you’re much more likely to get type two diabetes, you’re much more likely to have all sorts of complications.’

Page 198/Page 229 – a small body of scientific research based on a concept called ‘Health at Every Size’: See D. Clifford et al., ‘Impact of Non-Diet Approaches on Attitudes, Behaviors and Health Outcomes: A Systematic Review’, Journal of Nutrition Education and Behavior (2015), 47(2), pp. 143–55; L. Bacon and L. Aphramor, ‘Weight Science: Evaluating the Evidence for a Paradigm Shift’, Nutrition Journal (2011), 10(9), https://doi.org/10.1186/1475-2891-10-9; L. Bacon, J. S. Stern, M. D. Van Loan and N. L. Keim, ‘Size acceptance and intuitive eating improve health for obese, female chronic dieters’, Journal of the American Dietetic Association (2005), 105(6), pp. 929–36, doi:10.1016/j. jada.2005.03.011; L. Rapoport, M. Clark and J. Wardle, ‘Evaluation of a modified cognitive-behavioural programme for weight management’, International Journal of Obesity and Related Metabolic Disorders (2000), 24(12), pp. 1,726–37, doi:10.1038/sj.ijo.0801465.

If these approaches really can increase people’s exercise levels, they could have a big impact on health – see for example this study (not a ‘Health at Every Size’ one), which found that an obese person in the ‘active’ group had half the risk of cardiovascular disease of someone entirely sedentary: X. Zhang et al., ‘Physical activity and risk of cardiovascular disease by weight status among US adults’, PLoS One (2020), 15(5), e0232893, doi:10.1371/ journal.pone.0232893.

Page 201/Page 232 – much more powerful changes than have ever been documented by changes in stress: Poverty and stress unambiguously do have negative health effects. See for examplehttps://www.thelancet.com/journals/lanepe/article/PIIS2666-7762(22)00095-3/fulltext. For a discussion of the link between poverty and mortality, see S. Stringhini et al., ‘Socioeconomic status and the 25 × 25 risk factors as determinants of premature mortality: a multicohort study and meta-analysis of 1.7 million men and women’, Lancet (2017), 389(10075), pp. 1,229–37, https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32380-7/fulltext. For a discussion of the link between stress and mortality, see F. Tian et al., ‘Association of stress-related disorders with subsequent risk of all-cause and cause-specific mortality: A population-based and sibling-controlled cohort study’, Lancet Regional Health Europe (2022), 18, https://www.thelancet.com/action/showPdf?pii=S2666-7762%2822%2900095-3.

Page 204/Page 235 – In response to this critique, Katherine Flegal then did another large-scale study: K. M. Flegal, B. K. Kit, H. Orpana and B. I. Graubard, ‘Association of All-Cause Mortality With Overweight and Obesity Using Standard Body Mass Index Categories: A Systematic Review and Meta-analysis’, JAMA (2013), 309(1), pp. 71–82, doi:10.1001/jama.2012.113905.

Page 204/Page 235 – her published data did not properly exclude those groups: He organised a symposium at Harvard where he and several other speakers sought to rebut Flegal’s data. See V. Hughes, ‘The big fat truth’, Nature (2013), 497, pp. 428–30, https://doi.org/10.1038/497428a. This piece in Harvard’s ‘Nutrition Source’ blog from 2005 lays out some of Walter’s and his colleagues’ arguments against Flegal’s findings: https://www.hsph.harvard.edu/nutritionsource/2005/05/02/obesity-controversy/.

In 2013 on public radio Walter referred to Flegal’s 2013 follow-up study as ‘a pile of rubbish’; see ‘Shades of grey’, Nature (2013), 497, p. 410, https://doi. org/10.1038/497410a.

Page 204/Page 235 – A complex and quite bitter argument over this is still ongoing: For an excellent summary of that debate, see https://www.theatlantic.com/health/archive/2017/08/is-fat-bad/536652/.

Page 204/Page 236 – She believes ‘we have to deal in reality’: Bovey, What Have You Got to Lose, p. 34. Being fat is never a sin. It’s never anybody’s fault: Ibid., p. 44.

Page 205/Page 236 – That there are health problems at high weights is irrefutable: Ibid., p. 43.

Page 205/Page 237 – A study by scientists at University College London: J. Bell et al., ‘The Natural Course of Healthy Obesity Over 20 Years’, Journal of the American College of Cardiology (2015), 65(1), pp. 101–2, https://doi.org/10.1016/j.jacc.2014.09.077. See also Nadja Hermann, Conquering Fat Logic (Scribe, 2019), p. 83. ‘Healthy’ and ‘unhealthy’ had to be very carefully defined in this study. ‘Metabolically healthy’ they defined as having less than two of the following symptoms: ‘high-density lipoprotein cholesterol level <1.03 mmol/l (men) and <1.29 mmol/l (women); blood pressure ≥130/85 mm Hg or use of antihypertensive medication; fasting plasma glucose level ≥5.6 mmol/l or use of antidiabetic medication triacylglycerol level ≥1.7 mmol/l; homeostatic model assessment of insulin resistance >2.87’.

Page 205/Page 237 – obesity made you eight times more likely to become unwell: In Conquering Fat Logic p. 83, Nadja Hermann writes: ‘Obesity is a bit like smoking: the tumours don’t start growing right after the first cigarette. For someone who is naturally prone to lung problems, it might take five years. Another person’s lungs might be able to take fifty years of constant damage.’ Bell, ‘The Natural Course of Healthy Obesity Over 20 Years’. Similarly, Krista Varady, who is a Professor of Nutrition, told me: ‘I think the thing people don’t understand is that when they are young and obese, their cholesterol levels are fine, their blood pressure is fine. But carrying that weight for a long period of time dramatically increases their risk of high blood pressure and high cholesterol levels and heart attacks’ later in life. ‘A lot of people in that movement are pretty young. They’re like “I’m healthy, I don’t understand – it’s not that big a deal.” But they’re not looking at longitudinal data that shows carrying obesity for a long time will put you at much higher risk of all these diseases that will lead to an early death … You just need to look at the longitudinal data.’

Page 205/Page 237 – You can’t lose weight – you’d be betraying the cause: Bovey, What Have You Got to Lose, p. 44.

Page 205/Page 237 – she had been very critical of these groups in her book: Bovey, The Forbidden Body, pp. 33–5.

Page 206/Page 238 – to expect a fat person to become thin is as unreasonable: Ibid., p. 15.

Page 206/Page 238 – She had gone from almost losing her ability to walk, to being able to run: Bovey, What Have You Got to Lose, p. 136.

Page 207/Page 238 – no contradiction between these twinned goals: Dr Shauna Levy made similar points to me. She said: ‘it’s so complicated, because it’s such a good thing when it comes to body positivity … But we just know from the data that there’s harmful effects from this disease … They’re separate points. Why can’t we keep them separate? … I suspect that this movement is born out of people just being mistreated for so long – in this thin-centric, fat-phobic culture that we still live in – admitting there’s disease, and admitting there’s a problem would minimise their perspective … I think they’re coming from such a hurt place. You have to be very strong in your opinions to stand up for your cause, and if you relax on that, it always feels like defeat.’ To people who don’t believe that obesity harms health, she said, ‘I don’t know how to answer that other than – do you also not believe data? From my vantage point, most of the people who are fighting’ for fat pride ‘are young people. I don’t see a lot of sixty-five-year-olds as healthy at every size advocates … Sixty years of walking around with this sheer weight on your body is going to lead to problems… The more weight you put on, the more likely you are to develop another problem.’

many of her former friends lashed out at Shelley: As Shelley and I talked about this, I thought about a moment in the history of a community I belong to. In the early 1980s, the HIV virus began to spread, and gay men were one of the groups worst affected. This was because gay men on average have more sexual partners, and because the virus is more easily spread through anal sex. When scientists started to explain to gay men that they were at particular risk, some gay men heard it as yet more cruel stigma. They had spent their whole lives being told that they were sexually disgusting and immoral (often by doctors), and that they would be punished for it. Now, here was a group of scientists who seemed to them to be saying the same.

Some gay men rejected this message with fury. They insisted on keeping the bathhouses open. It’s very easy to understand why. They were good people, reacting in understandable ways. And – sadly – many of them as a result got sick. Some other gay men – like one of my heroes, the activist Larry Kramer – reacted differently. They said: we need to live in reality, and if we are at greater risk than other people, then we need to know that, and we need to take action together. Instead of denying the science, these gay men, who made up the majority, deliberately spread awareness of the best evidence among their community, and embraced measures like condom distribution and, eventually, antiretroviral drugs that reduced the risks.

Some of the Fat Pride movement – not all – seem to me to be a little like the gay men who said the scientists warning about AIDS were just homophobes in white coats. Some people in the Fat Pride movement argue that the only way to destigmatise obesity is to say that there is no difference between the health of non-obese and obese people. But nobody today would claim that the way to destigmatise HIV is to claim that HIV-positive people are exactly like HIV-negative people when it comes to health challenges. Indeed, one of the ways we reduced stigma in the end was by acknowledging the difference, and giving more help, support and care to HIV-positive people.

Tackling stigma does not require a fantasy of exact sameness. Pretending we are the same when we are not in fact ends up reinforcing the stigma, by denying people the help they need. Where there are differences, we need
to tell the truth about them in a spirit of love and compassion, and build practical solutions.

Page 209/Page 241 – a passionate commitment to bringing about an end of prejudice: Bovey, What Have You Got to Lose, p. ix.

Page 209/Page 241 – reconciling size acceptance and weight loss: Ibid., p. 30.

Page 209/Page 241 – things are never either/or. They are both/and: Ibid., p. xii.

Chapter Twelve: The Land That Doesn’t Need Ozempic

Page 210/Page 242 – In July 2023, I stumbled across a curious news story: ‘Slow initial uptake of Novo Nordisk’s Wegovy likely in Japan, says analyst’, The Pharma Letter, 28 July 2023, https://www.thepharmaletter.com/article/slow-initial-uptake-of-novo-nordisk-s-wegovy-likely-in-japan-says-analyst, as accessed 20 September 2023.

Page 210/Page 242 – Just 3.6 per cent of its people are obese: N. Yoshiike and M. Miyoshi, ‘Epidemiological aspects of overweight and obesity in Japan – international comparisons’, Nihon Rinsho (2013), 71(2), pp. 207–16, https://pubmed.ncbi.nlm.nih.gov/23631195/, as accessed 20 September 2023.

Page 211/Page 243 – something happened over a hundred years ago: Hawaii Health Matters, ‘Adults Who Are Obese’, https://www.hawaiihealthmatters.org/indicators/index/view?indicatorId=54, as accessed 15 October 2023. For additional discussion on the comparative health of Japanese Americans and mainland Japanese, see M. Yoneda and K. Kobuke, ‘A 50-year history of the health impacts of Westernization on the lifestyle of Japanese Americans: A focus on the Hawaii–Los Angeles–Hiroshima Study’, Journal of Diabetes Investigation (2020), 11(6), pp. 1,382–7, https://onlinelibrary.wiley.com/doi/full/10.1111/jdi.13278.

Page 214-215/Page 246 – we went to the Tokyo College of Sushi and Washoku to interview Masaru Watanabe: I also interviewed him on Zoom – I have used quotes from both interchangeably here.

Page 216/Page 248 – We appreciate fish: There’s a prosaic reason for this – see Alan Macfarlane, Japan Through the Looking Glass (Profile, 2008), p. 51. ‘Japan is a very rocky island, with thin soils and steep slopes. Most of its landmass cannot be used effectively for agriculture because it is too high, cold or steep … The soil tends to be poor, deposited black volcanic ash with little nutrient value. Even grass suitable for animals does not grow in much of Japan.’ They had to get their protein from the water.

Page 216/Page 248 – The blackness often comes from seaweed: There is a lot of evidence for this. In Tim Spector, The Diet Myth: The Real Science Behind What We Eat (Weidenfeld & Nicolson, 2016), pp. 137–8, Spector explains it is ‘an important source of iodine in preventing thyroid disease, and contains potentially beneficial antioxidants … Japanese who lived on or near the cost for centuries enjoyed eating seaweed in many different forms, for instance as additives to soups or salads or to wrap their raw fresh fish in … The average Japanese … consume[s] an amazing 5kg per person per year. This is neatly three times their digestion of dairy.’ In Michael Booth, Sushi and Beyond: What the Japanese Know About Cooking (Vintage, 2010), pp. 120–1, Booth explains that fifty types of seaweed are eaten in Japan: ‘There is every reason to believe konobu is one of the most significant foodstuffs in terms of the Japanese’s famed good health and longevity. It has more minerals than anything else they eat, including potassium, iron, iodine, magnesium and calcium, as well as vitamins B and C, and is thought to aid the removal of toxins from the body. Seaweed also contains lignins believed to prevent cancer. Plus, of course, it is fat- and calorie-free.’

Page 218/Page 250 – In Japan, you are taught from a very early age: Booth, Sushi and Beyond, p. 275. The Japanese diet is full of foods that create satiety: David A. Kessler, The End of Overeating (Penguin, 2010), p. 94.

Page 221/Page 253 – Life expectancy was forty-seven: Christopher Harding, Japan Story: In Search of a Nation, 1850 to the Present (Penguin, 2018), p. 366.

Page 221/Page 253 – culture is neither timeless nor unchanging: Bee Wilson, First Bite: How We Learn to Eat (Fourth Estate, 2016), pp. 308–15.

Page 221/Page 253 – Japan shows the extent to which food habits evolve: Ibid., pp. 313, 315.

Page 224/Page 256 – he was proud that he’d expanded his palate: This made me think of ibid., p. 71, where Bee Wilson writes: ‘The psychologist E.P. Koster has shown that one of the beneficial effects when children are exposed though “sensory education to a wider range of flavours is that they start to love complexity and be bored by simplicity”.’

Page 224/Page 256 – showed them photographs of typical American and British school meals: As Eric Schlosser explains in Fast Food Nation: What the All-American Meal is Doing to the World (Penguin, 2002), p. 66, ‘The American School Food Service Association estimates that about 30 per cent of the public high schools in the United States offer branded fast food.’ Food from Pizza Hut, McDonald’s and Subway is served in elementary schools.

Page 226/Page 258 – metabolic syndrome, a combination of obesity, diabetes and high blood pressure: Anthony Warner, The Truth About Fat (Oneworld, 2019), p. 85.

Page 229/Page 263 – $19 million in fines for the poor health of its workforce: https://eu.jacksonville.com/story/news/reason/2016/09/16/fact-check-it-illegal-japanese-residents-be-overweight/985445007/, as accessed 28 October 2023.

Page 231/Page 264 – Japan become the world’s most long-lived country: insights from a food and nutrition perspective’, European Journal of Clinical Nutrition (2021), 75, pp. 921–8, https://doi.org/10.1038/s41430-020-0677-5.

Page 231/Page 264 – The average American and British person is in poor health: ‘Healthy life expectancy (HALE) at birth (years)’, Global Health Observatory, World Health Organization, 12 April 2020, https://www.who.int/data/gho/data/indicators/indicator-details/GHO/gho-ghe-hale-healthy-life-expectancy-at-birth, as accessed 26 October 2023.

Page 231/Page 264 – In Japan, it’s five to six years: See Table 1 in S. Tsugane, ‘Why has Japan become the world’s most long-lived country’. See also S. Tokudome, A. Igata and S. Hashimoto, ‘Life expectancy and healthy life expectancy of Japan: the fastest graying society in the world’, BMC Research Notes (2016), 9, pp. 1–6. in Japan, it’s just one in thirty-eight: ‘Breast Cancer Rates Rising Among Japanese Women’, Roswell Park Comprehensive Cancer Center, 25 July 2017, https://www.roswellpark.org/cancertalk/201707/breast-cancer-rates-rising-among-japanese-women, as accessed 1 October 2023.

Page 232/Page 265 – It has 215 households, and 173 people there are ninety or older: I was given these numbers by Fumiaru Osaki, who works in the nearby tourist office, and consulted the official Japanese census figures for me. I got the idea to go to Ogimi after reading about it in Booth, Sushi and Beyond, pp. 267–81.

Page 232/Page 265 – The people who live here have had hard lives: Harding, Japan Story, p. 351.

Page 234/Page 267 – Yet by some calculations, nobody in the world lives longer than they do: Rupa Marya and Raj Patel, Inflamed: Deep Medicine and the Anatomy of Injustice (Penguin, 2022), p. 141.

Page 234/Page 267 – It’s an extraordinarily poisonous pufferfish: Booth, Sushi and Beyond, p. 253.

Page 234/Page 267 – Every year, two or three people die after eating fugu: R. Buerk, ‘Fugu: The fish more poisonous than cyanide’, BBC, 18 May 2012, https://www.bbc.co.uk/news/magazine-18065372; J. McCurry, ‘Last supper? Japan’s diners divided over killer puffer fish’, Guardian, 5 August 2016, https://www.theguardian.com/world/2016/aug/05/last-supper-japan-killer-puffer-fish-fugu.

In 1982, 71 per cent of men and 54 per cent of women were smokers: K. B. Filion et al., ‘Trends in Smoking Among Adults from 1980 to 2009: The Minnesota Heart Survey’, American Journal of Public Health (2012), 102(4), pp. 705–13, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3489364/.

Page 236/Page 269 – Today, only 12 per cent of people are smokers, and it’s falling further: ‘Current Cigarette Smoking Among Adults in the United States’, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, 4 May 2023, https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.html.

Page 236/Page 269 – In most places where this has been tried, it has reduced purchases of these drinks: One review of studies estimated that purchases and consumption of sugary drinks drop by 10 per cent with each 10 per cent increase in taxes. See A. M. Teng et al., ‘Impact of sugar-sweetened beverage taxes on purchases and dietary intake: Systematic review and meta-analysis’, Obesity Reviews (2019), 20(9), pp. 1,187–204, https://onlinelibrary.wiley.com/doi/10.1111/obr.12868; see also https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5525113/.

Page 237/Page 270 – In just four years, they cut childhood obesity: Warner, The Truth About Fat, p. 323; S. Boseley, ‘Amsterdam’s solution to the obesity crisis: no fruit juice and enough sleep’, Guardian, 14 April 2017, https://www.theguardian.com/society/2017/apr/14/amsterdam-solution-obesity-crisis-no-fruit-juice-enough-sleep, as accessed 12 October 2023. See also UNICEF, City of Amsterdam and EAT, ‘The Amsterdam Healthy Weight Approach: Investing in healthy urban childhoods: A case study on healthy diets for children’, 2020, https://www.unicef.org/media/89401/file/Amsterdam-Healthy-Weight-Approach-Investing-healthy-urban-childhoods.pdf, as accessed 12 October 2023. I also consulted the report by NJi, VU University Amsterdam and Cuprifère Consult, ‘Amsterdam Approach to Healthy Weight: promising? A search for the active elements’, https://npo.nl/npo3/brandpuntplus/hoe-een-wethouder-afrekende-met-obesitas-in-zijn-stad, as accessed 12 October 2023. Thank you to Rosanne Kropman for translating.

Page 237/Page 270 – A study showed that after six months, her patients felt significantly healthier: S. Kempainen et al., ‘A Collaborative Pilot to Support Patients With Diabetes Through Tailored Food Box Home Delivery’, Health Promotion Practice (2023), 24(5), pp. 963–8, doi:10.1177/15248399221100792.

Page 237/Page 270 – It saves between 6,000 and 9,000 lives a year from strokes in the UK alone: J. Song et al., ‘Salt intake, blood pressure and cardiovascular disease mortality in England, 2003–2018’, Journal of Hypertension (November 2023), doi: 10.1097/ HJH.0000000000003521. See also https://journals.lww.com/jhypertension/fulltext/2023/11000/salt_intake,_blood_pressure_and_cardiovascular.6.aspx, https://www.qmul.ac.uk/wiph/news/latest-news/items/increased-salt-intake-in-england-from-2014-18.html, as accessed 25 November 2023.

Page 238/Page 271 – It increased life expectancy in the country by ten years: V. Salomaa et al., ‘Decline of coronary heart disease mortality in Finland during 1983 to 1992: roles of incidence, recurrence, and case-fatality. The FINMONICA MI Register Study’, Circulation (1996), 94(12), pp. 3,130–7, doi:10.1161/01.cir.94.12.3130; P. Puska and P. Jaini, ‘The North Karelia Project: Prevention of Cardiovascular Disease in Finland Through Population-Based Lifestyle Interventions’, American Journal of Lifestyle Medicine (2020), 14(5), pp. 495–9, https://pubmed.ncbi.nlm.nih.gov/32922234/. As reported in the latter paper, the death rate from cardiovascular disease in North Karelia reduced from 690 per 100,000 in the 1960s to 100 per 100,000 in 2011; that’s less than half the current USA rate of 209 per 100,000. See https://www.cdc.gov/nchs/fastats/heart-disease.htm, as accessed 24 November 2023.

Page 243/Page 276 – And then you feel guilty: At school, kids would walk by Anna and jeer: ‘You’re so fat, your clothes don’t even fit.’ One day, she told her mother that a boy had approached her in the school canteen and said: ‘You’re not going to eat that are you – you’ll just get fatter!’ Anna was stoical and told her mum: ‘I only let one tear drop.’ A few years later, Debrah read a text on her daughter’s phone to a friend, saying that she didn’t want to live any more. She moved her to a different school, one that cracked down much harder on bullying.

Page 244/Page 278 – the number of obese kids in Britain shot up by 70 per cent: Ellen Ruppel Shell, The Hungry Gene: The Inside Story of the Obesity Industry (Grove Press, 2003), p. 3.

Page 245/Page 278 – the rate of increase in childhood obesity doubled during the pandemic years: O. Dyer, ‘Obesity in US children increased at an unprecedented rate during the pandemic’, BMJ (2021), 374, n2332, https://www.bmj.com/content/374/ bmj.n2332, as accessed 21 September 2023.

Page 245/Page 278 – consumed by kids in the US come from ultra-processed foods: L. Wang et al., ‘Trends in Consumption of Ultraprocessed Foods Among US Youths Aged 2–19 Years, 1999–2018’, JAMA (2021), 326(6), pp. 519–30, doi:10.1001/jama.2021.10238. I first learned about this figure in Tim Spector, Food for Life: The New Science of Eating Well (Jonathan Cape, 2022), p. 36.

Page 245/Page 278 – The likelihood is therefore you end up with obesity for life: Obese kids are roughly five times more likely to become obese adults than non-obese kids. See https://pubmed.ncbi.nlm.nih.gov/26696565/, as accessed 10 October 2023.

Page 245/Page 278 – A summary of the evidence was published in Pediatrics: S. Hampl et al., ‘Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity’, Pediatrics (2023), 151, 2, e2022060640, https://doi.org/10.1542/peds.2022-060640.

Page 245/Page 278 – The largest clinical trial on young people: D. Weghuber et al., ‘Once-Weekly Semaglutide in Adolescents with Obesity’, New England Journal of Medicine (2022), 387(24), pp. 2,245–57, doi:10.1056/NEJMoa2208601. Sixty-two of the kids in the trial were just given a placebo, and they aren’t included in the 131 figure given. See also https://www.theguardian.com/society/2023/may/17/half-of-children-given-skinny-jab-no-longer-clinically-obese-us-study, as accessed 24 November 2023.

Page 246/Page 279 – these results are ‘historically unprecedented with treatments other than bariatric surgery’: M. Guenot, ‘Almost half of children on the weight-loss drug semaglutide are no longer clinically obese, landmark study finds’, Insider, 18 May 2023, https://www.insider.com/ozempic-semaglutide-study-almost-half-children-on-jab-clinically-obese-2023-5, as accessed 10 October 2023.

Page 246/Page 279 – Dan Cooper, a professor of paediatrics at the University of California, Irvine: https://www.cambridge.org/core/journals/journal-of-clinical-and- translational-science/article/unintended-consequences-of-glucagonlike-peptide1-receptor-agonists-medications-in-children-and-adolescents-a-call-to-action/F0286F2FBBD7F6E4E75A6A383F3C82BB

Page 247/Page 280 – Novo Nordisk is carrying out a clinical trial on giving them to children: C. Wilson, ‘Beyond Wegovy: Could the next wave of weight-loss drugs end obesity?’, New Scientist, 11 July 2023, https://www.newscientist.com/article/mg25934470-900-beyond-wegovy-could-the-next-wave-of-weight-loss-drugs-end-obesity/.

Page 248/Page 281 – a company that makes a lot of the biscuits you’ve probably eaten: Michael Moss,Hooked: How We Became Addicted to Processed Food (W. H. Allen, 2022), pp. 134–5.

Page 249/Page 282 – Some people taking chemical antidepressants experience a long-lasting boost: See Johann Hari, Lost Connections: Uncovering the Real Causes of Depression – And the Unexpected Solutions (Bloomsbury, 2018), Chapter 2; D. Warden et al., ‘The STAR*D Project Results: A Comprehensive Review of Findings’, Current Psychiatry Reports (2007), 9(6), pp. 449–59; A. J. Rush et al., ‘Acute and Longer-Term Outcomes in Depressed Outpatients Requiring One or Several Treatment Steps: A STAR*D Report’, American Journal of Psychiatry (2006), 163, pp. 1,905–17; B. Gaynes et al., ‘What Did STAR*D Teach Us? Results from a Large-Scale, Practical, Clinical Trial for Patients With Depression’, Psychiatric Services (November 2009), 60(11), http://dx.doi.org/10.1176/ps.2009.60.11.1439; M. Sinyor et al., ‘The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Trial: A Review’, Canadian Journal of Psychiatry (March 2010), 55, pp. 126–35, doi: 10.1177/070674371005500303; T. Insel et al., ‘The STAR*D Trial: Revealing the Need for Better Treatments’, Psychiatric Services (2009), 60, pp. 1,466–7.

Page 250/Page 283 – giving these drugs to everyone who qualifies for them could add 50 per cent: https://www.nytimes.com/2023/10/22/health/ozempic-wegovy-price-cost.html, as accessed 25 October 2023.

Page 250/Page 283 – This is not because of the inherent cost of these drugs: J. Levi et al., ‘Estimated minimum prices and lowest available national prices for antiobesity medications: Improving affordability and access to treatment’, Obesity (Silver Spring) (2023), 31, pp. 1,270–9, https://doi.org/10.1002/oby.23725, as accessed 10 October 2023.

Page 251/Page 284 – by 2032, the copyright on many of these drugs will have expired: R. Shin, ‘Ozempic isn’t alone. A whole class of “revolutionary” weight-loss drugs is on the market – but only for the wealthy’, Fortune, 9 July 2023, https://fortune.com/well/2023/07/09/ozempic-isnt-alone-a-whole-class-of-revolutionary-weight-loss-drugs-is-on-the-market-but-only-for-the-wealthy/, as accessed 10 October 2023.