GLP-1s Are a Lot Weirder Than Anyone Thought | The Ezra Klein Show

0:00 Here's a number that actually shocked me when I learned it.

0:03 This from a Kaiser Family Foundation poll.

0:06 One out of eight Americans is now taking a GLP1.

0:09 One out of eight.

0:11 Maybe I shouldn't have been so shocked because

0:13 the number is higher in my social circles.

0:17 I have tried these uh for reasons I'll explain,

0:21 but they're a strange medication, right?

0:24 They don't make you lose weight.

0:25 They make you not want to eat food.

0:28 that like that's what they do, right?

0:30 But then they do all these other things.

0:32 They seem to protect people's heart health independent of losing weight.

0:37 They're protective of kidneys, of livers.

0:40 There is ongoing research about dementia, Alzheimer's.

0:43 They have all these strange effects on addiction [music] and desire.

0:47 But should everyone be on these?

0:49 Like, what does it mean for society to have

0:51 access to drugs that regulate desire in this way?

0:55 What do they mean for the sick?

0:57 What do they mean for the well?

1:00 I've wanted to do an episode on this for for a while,

1:02 but haven't known quite how to approach it.

1:04 And then Julia Beloo, who's a contributing writer at New York

1:07 Times Opinion [music] and co-author of the book

1:09 Food Intelligence and also was a health

1:12 and science reporter with me back at Vox,

1:14 she started doing a lot of reporting on JLP1s [music]

1:16 and she's written a lot of great pieces on them.

1:18 She is one of the best health and science reporters I have ever known.

1:22 incredibly deep on the science,

1:24 but really compassionate [music] and detailed and relentless about talking

1:28 to actual people about their experiences inside the health system.

1:32 And I wanted to have her on to hear what she's been learning.

1:34 [music] As always, my email is for client showy times.com.

1:40 [music] Julie Blues, welcome to the show.

1:45 Thank you so much.

1:45 It's a pleasure to be here.

1:47 So, I was shocked by this number.

1:49 According to the Kaiser Family Foundation's poll,

1:52 one in eight Americans are currently taking a GLP1.

1:56 Why?

1:56 Yes, it was surprising to me, too.

1:58 So, I think um one of the ways we can understand this is there's

2:02 this very long history of people seeking out

2:05 basically the magical elixir for weight loss, right?

2:08 So, I think that's one piece of it.

2:10 And now we finally have something that rivals the only

2:13 other effective medical intervention we've had to help people lose weight,

2:17 which is beriatric surgery.

2:19 On the other hand, there's a lot of people who are living with diabetes.

2:22 And I think that's another reason that that we

2:24 see so many people who are on these drugs.

2:26 In addition, I think these drugs have really met a particular moment,

2:29 which is this algorithmic social media age.

2:32 They're everywhere.

2:33 Um, in the US, we already had

2:35 this relatively unrestricted approach to marketing pharmaceuticals.

2:39 Um, we see them advertised everywhere.

2:42 we've seen this tele medicine kind of industry flourish since co but also around

2:47 these drugs [snorts] and um I think that's

2:49 why we're seeing these kind of shocking numbers.

2:53 So I want to start on the part of this that people actually don't

2:56 talk about that much which is diabetes which is what these drugs are originally

2:59 approved for as you say a huge number of Americans have diabetes and and have

3:04 terrible health consequences often from it

3:07 including limb amputation and and and blindness.

3:10 What do these drugs do for diabetics?

3:13 So, our bodies produce GLP-1 naturally.

3:16 So, we have this hormone that's produced in our gut,

3:18 in our brains, and to a lesser extent in the pancreas.

3:21 So, basically, they're this synthetic version of a hormone we produce naturally.

3:25 And the big breakthrough for diabetes was that they're stimulating the pancreas

3:29 to release insulin only in the context of high blood sugar.

3:33 So, it's not like when when you take insulin

3:35 and you need to be careful about what you're

3:36 eating and you're at risk of really low blood

3:39 sugar levels and the dangers that come with that.

3:41 These are only stimulating insulin secretion

3:43 when your blood sugar is running high.

3:45 So, as the re as researchers who are working on this are trying

3:48 higher and higher doses to help people with diabetes get more and more benefit,

3:53 they start to discover these weight loss um results in the trial.

3:57 So people start to spontaneously lose weight and then later we're finding

4:01 all these slew of other benefits that no one would have predicted.

4:05 No pharma company would have bet on this.

4:07 We're only at the beginning of what what's been called this ompic era.

4:11 I think we're we're really just at the beginning

4:13 of discovering the benefits and the harms of these drugs.

4:16 Okay.

4:16 So you have the recognition which is just something people

4:20 begin observing that diabetics on these drugs begin to lose weight

4:26 and they don't feel hungry and as researchers begin testing

4:32 you know the first generation of this ompic what we now

4:35 in that context calli how big is the effect size what

4:40 do we actually know about what wgoi does for weight loss

4:43 there's another one which is slightly more advanced it has more

4:47 mechanisms of action to his epatide which is also goes by zbound.

4:52 How much weight do people lose on these?

4:54 So it depends on the drug but we're talking like 15%.

4:58 [snorts] It's the first time we have a drug

4:59 that really rivals the more effective types of beriatric surgery.

5:03 The key point there is that it's turning down appetite.

5:06 So it's not ramping up metabolism or energy burn.

5:09 GLP1 is a hormone.

5:11 And the idea was that this is a gut hormone.

5:14 um or that that's the the thing that a lot of people focused

5:17 on and we're just and it it's released

5:19 after eating and it helps people signal satiety.

5:22 It helps them feel full and know that they've eaten and we're

5:26 just giving a really souped up version of this um this gut hormone.

5:30 [snorts] And it turns out that actually you need to stimulate

5:34 the brain GLP-1 system to get the weight loss effects.

5:37 So you only interfere with appetite once you reach this brain GLP-1 system.

5:42 Well, you've written [snorts] or co-written a whole book about the metabolism.

5:46 And one of the arguments of that book,

5:47 one of the arguments of of books in this space that I

5:50 think people don't appreciate is that hunger is a function of the brain.

5:55 And it's a function of the brain's

5:57 reaction and predictions about the world around it.

6:00 And we we always have this idea that, you know, people just feel hungry.

6:06 And then, you know, you should use your brain to decide if you want to eat,

6:09 but your brain is deciding if you feel hungry.

6:11 and and and you're sort of fighting its own instincts.

6:14 So, I'd like you to spend a minute on this like

6:16 idea that hunger is a function of the stomach

6:19 versus hunger as a function of the brain and sort

6:22 of how researchers moved from one to the other.

6:25 Yeah.

6:25 The way we describe it in the book, we use this analogy of breathing.

6:29 So if I tell you like take control of your breath right now,

6:32 like breathe more slowly or breathe more quickly or hold your breath,

6:36 you can take control for short periods of time,

6:39 but eventually physiology takes over.

6:41 Um, and the same thing is true of what we eat.

6:44 So we have this illusion of control over our individual meals and snacks,

6:48 but there's this symphony of internal signals that's

6:50 going on inside of us all the time.

6:52 And the brain is sort of leading this symphony.

6:55 And um the decisions we make are much less

6:58 a product of conscious control that I think many people appreciate.

7:02 So when you're taking a GLP1,

7:04 you're getting a much higher longerlasting version of what

7:07 your body produces and it has to reach the brain.

7:11 And the the theory is that it's reaching into the part

7:13 of the brain that usually signals that there's a toxin in circulation.

7:18 And so that shuts down your appetite and increases your nausea.

7:21 Like what you would get during food poisoning or something.

7:24 Exactly.

7:24 or what you would have on a these are

7:26 the most common side effects of these drugs, right?

7:29 Um so so it reaches into that.

7:31 So the wonder drug we've invented is we've made

7:33 your brain slightly think it's being poisoned all the time.

7:35 Um I I think that's one way to put it.

7:37 Absolutely.

7:37 [laughter] And so this so modernity baby.

7:41 I know.

7:41 And in the context of our completely toxic food environment, right?

7:45 It's just turning down your appetite by reaching into this GLP-1 brain system.

7:49 So it acts as a neurotransmitter in the brain

7:52 and from there reaches other parts of the brain.

7:55 Um yeah this is something this is a very

7:57 active area of research but that's the sort

8:00 of bottom line and and this dialing down

8:02 of appetite is the key key feature of these drugs.

8:05 One of the things that I find interesting about the GLP1s is we

8:11 basically created this food environment that does

8:13 not exist in nature of hypers sugary,

8:17 hyper fatty, hyper salty, hyperc calorie dense foods.

8:21 Our brains are evolved over very very long

8:25 periods of time to treat those as getting

8:29 you know three cherries on the slot machine and to really really want them.

8:34 So, we've put people into this hyper stimulating environment,

8:38 but we didn't change everybody's brain to turn down the level of hunger

8:43 when you come into something that is very calorie dense or very sugar dense.

8:47 And so we've been asking people with these like

8:49 caveman all of us myself um with these caveman

8:52 brains now surrounded by the fruits of modern industrialized

8:57 food production where the Mars company is spending god

9:00 knows how much on R&D to make my kids want M&M's and it doesn't work for people

9:06 and then we blame them and tell them they've

9:08 not done a good job exercising their willpower and self-control.

9:12 I think you were also someone who struggled with weight earlier in your life.

9:15 Uh, I was very very heavy until I was almost an adult.

9:19 Um, like I lost like 60-ish pounds, 50-ish pounds when I was uh, 16.

9:24 And then ever since like I fight my food desires.

9:29 Like if we had a bowl of Oreos on this table,

9:33 30% of my mental energy the whole time we were talking did not eat the Oreos.

9:39 Right.

9:39 Yeah.

9:39 Ex.

9:40 Absolutely.

9:40 I remember we had lunch in Washington when I was doing lots

9:43 of obesity reporting and you said why am I a person who if

9:45 the chocolate cake is there like 50% of my brain is focused

9:49 on the chocolate cake and I didn't have a good answer for you then.

9:53 Um do you have one now?

9:54 I do.

9:54 Yeah.

9:54 I think it's that you know so when when we think

9:56 about something like common obesity so there's many different types of obesity.

10:00 Um, but what most people have is called

10:02 common obesity and it arises from these tiny

10:05 [snorts] like over a thousand genetic variants

10:08 that all act almost all act in the brain.

10:11 And so you have a neurobiology probably that's different

10:14 from someone who doesn't have to fight the chocolate cake.

10:17 Um, and I actually did genetic testing for the book

10:20 and I'm also someone who struggled with my weight

10:22 and I I turns out I have a higher genetic risk than like 90% of the population.

10:28 But this risk in a particular environment won't be expressed.

10:31 But as you said, when you put people like us

10:33 in environments where there's lots of M&M's and lots of chocolate cake,

10:37 it becomes much harder.

10:38 Um, and I think most people don't have this um privilege, let's say,

10:42 of being able to finally curate their environment to control

10:47 their weight in maybe the way we might have had.

10:50 I have a family member who uh I'm not related

10:52 to by blood and one thing that always amazes me is she will

10:57 order dessert and she loves dessert and she loves chocolate cake

11:02 and she'll like eat half the cake and then take the rest home.

11:08 And I always look at that and I

11:09 think whatever is happening in you is not happening

11:13 or me or or possibly vice versa whatever

11:15 is happening in me is not happening in you.

11:17 And then I feel in other ways elsewhere in my life.

11:20 Uh I can have a cigarette or a puff on a vape.

11:26 I have no interest in another.

11:28 It does not exite any desire in me.

11:32 I can have a whiskey and leave half of it

11:35 or a glass of wine and I don't particularly want to keep going.

11:37 And I've had people in my life who

11:39 struggle with alcoholism and I don't have willpower.

11:43 They don't.

11:44 Yes.

11:44 something is happening in their bodies or in their minds

11:47 absolutely that is not happening in mine.

11:50 And I've always thought the way we blame people for this is so

11:53 cruel because it is so often people who don't have the propulsive desire,

12:02 blaming people who do for not exercising willpower.

12:04 But those people aren't exercising willpower.

12:06 I'm not exercising willpower to not have more cigarettes.

12:10 I don't want them.

12:12 No, absolutely.

12:12 I have this conversation all the time with my husband.

12:15 For some people, the cards are just stacked against them.

12:18 Um, one person that really helped my thinking on this was Robert Seapolski.

12:22 He talks about how we have these um potentials or vulnerabilities

12:25 that are created by our genetics and then in different environments,

12:29 they're either expressed or activated or not not expressed, right?

12:33 Like it's extremely hard to, you know,

12:35 do the right thing to buy the foods that you

12:37 know you should be eating or to exercise every

12:39 day when you're working the night shift and you're raising

12:42 kids and you're um maybe the single mom or dad

12:45 or whatever it is like um how how are you

12:48 going to do all like all the things that you

12:51 know you need to be doing to protect your health

12:53 and to fight against um this neurobiology that you might have.

12:57 So you have this you have this interplay of biology

13:00 neurobiology as you're as you're saying it this thing

13:02 we call willpower which is a very a very

13:04 poorly specified concept and then environment to me this question

13:10 of environment is really important I'll I'll use myself

13:12 as the example you know when I lost a lot

13:14 of weight I mean when I was younger a lot

13:17 younger a high school student with nothing to do

13:23 and I was able to really really hold that when I was a young adult.

13:29 Um, and I have not been able to diet successfully

13:32 since I had kids because I can't control the food environment.

13:35 And there's a lot of other things I can control.

13:37 I have money.

13:37 I can, you know, go to the gym.

13:39 I have a certain amount of autonomy over my schedule.

13:41 So, as you say, when you add in things like the night shift,

13:44 when you add in not having the money

13:46 to to to get healthy foods or or go to the gym,

13:49 when you add in having more kids or less time,

13:52 that we will power works very very differently when

13:57 you're able to have the autonomy or the money

14:02 to create a certain kind of environment around you

14:05 that is conducive to living in a certain way, right?

14:08 you're a Hollywood celebrity with a personal

14:10 chef versus you're a single mother of four,

14:14 you know, who works two jobs.

14:16 And this idea that like willpower is some

14:18 unchanging like muscle inside the mind as opposed

14:23 to some reserved discipline that gets depleted like

14:26 if I don't sleep enough, I eat more.

14:28 Right.

14:28 Absolutely.

14:29 And you're designed to eat more when you don't sleep enough.

14:31 And you're absolutely right that this symphony

14:34 of internal signals that I was referring to earlier,

14:36 it's interplaying with our environments.

14:38 So, one thing I've really appreciated about your work

14:40 on the GLP1s as a reporter and as somebody who's very deep

14:44 in the science is you've done a tremendous amount of interviewing

14:46 people on them and you've interviewed many of the kinds

14:50 of people and again to me this has always been

14:52 the cruelty of this conversation who were exercising a tremendous

14:56 amount of constant willpower going on and off like very

14:58 restrictive diets you know losing 30 lbs gaining it back.

15:03 What is it like for them?

15:05 Um, for the people who've seen huge amounts of of of weight loss,

15:09 how do they describe the experience of being

15:13 on a GLP1 versus what it's like off of one?

15:17 I think the big common thread for people in whom

15:20 the drugs are effective for weight loss is this idea

15:23 that suddenly this willpower that they were always searching for that they

15:26 feel they didn't have enough of, suddenly they have it.

15:29 Um, suddenly it's not that hard to say no

15:32 to the extra piece of cake or the cake altogether.

15:35 um they're eating smaller portions, their cravings change.

15:38 Like they have this complete there's a lot of discussion about food noise.

15:42 When the cake is there,

15:43 30 to 50% of your brain is on the cake or you have cravings that distract you.

15:47 A lot of people say that this just disappears.

15:50 You said a second ago, for whom the drugs are effective.

15:55 For whom are they effective and for whom aren't they effective and why?

16:00 So this is another area we don't fully understand but it

16:03 seems like there are some people who are quite sensitive

16:05 to the drugs and others who are insensitive to the drugs

16:08 and there might be a genetic component to this too.

16:11 um that that's sort of a frontier um area of science.

16:15 And so I think the the quest that a lot of the companies

16:19 are on is to understand like how how do we differentiate the people

16:22 who might need higher doses initially or much lower doses because they're having

16:27 um so much sensitivity to the drugs and side effects um and whatnot.

16:31 They're having such a strong response or losing weight too fast.

16:34 Um so there there absolutely is this variation in how people are responding.

16:39 Tell me about the side effects of these GLP1 drugs.

16:43 In studies, people often don't stay on them that long.

16:46 People do cycle off of them sometimes for cost,

16:48 but sometimes for for other reasons.

16:50 Like what what is unpleasant on them?

16:52 What what can go wrong?

16:54 So, the most common are that we know

16:55 of right now are the gastrointestinal side effects.

16:58 So, the nausea, the vomiting, the diarrhea.

17:01 Um those those are the most common,

17:03 but it seems like there's other emerging potential problems.

17:06 So there are lawsuits around um severe stomach problems um damage to the ocular

17:12 nerve um so so eye damage um and those I don't think we

17:17 have clear answers on how common that is um and but but the basis

17:22 of of those lawsuits is that people

17:24 weren't properly warned that this could happen.

17:27 One thing that a lot of people don't seem to be warned about is

17:30 the fact that you have to stay on them to keep reaping the weight loss benefits.

17:34 Um, so I think there's an idea that a lot of people have.

17:37 I'll lose the weight, I'll learn how to eat properly,

17:39 and then I'll go off the drugs.

17:41 I'm I'm always surprised that even people who

17:43 got the drugs from their doctors don't seem to

17:45 What happens when people go off the drugs?

17:47 You tend to regain the weight and you just feel hungrier again.

17:50 The the sort of resets exactly this this appetite that was suppressed through

17:54 the brain um through through acting on on the brain GLP1 brain system,

17:59 that effect is gone and you're back to the food noise.

18:02 you're back to um yeah the hunger that you had before.

18:06 Isn't that pretty?

18:06 I I've heard this and it's definitely true in the the data.

18:10 But I guess like people in my life have chronic conditions

18:13 and the drugs are on like they just have to stay on them.

18:16 You know, you stop taking statins and the effect goes away.

18:19 Um if you're diabetic, you have to keep taking your insulin.

18:21 That like I feel like that's like a like people who are used

18:24 to drugs to treat acute conditions not

18:26 being used to drugs to treat chronic conditions.

18:29 But I think that this is the thing like that goes

18:31 back to the beginning of the conversation that a lot

18:33 of people still have this idea that they should just

18:36 be able to will their way out of it, right?

18:39 I think these drugs helped reveal how much we are

18:41 products of our physiology and um that with this, you know,

18:46 you take take this drug and suddenly again you have

18:48 the willpower you you didn't have for your whole life.

18:51 Um but there's still this expectation.

18:53 It's like any other diet.

18:55 And um that feels like a place where people haven't been warned.

18:58 But as you as we've been saying, there are now so many people on the drugs.

19:02 And I think these more rare side effects

19:04 we're going to start to learn more about.

19:06 I want to talk about a possible social side effect,

19:10 which is the our cultures expectations for what people's bodies

19:15 should look like have been punishing for a long time.

19:19 Um particularly punishing for women and girls.

19:22 I think we we've interestingly been

19:24 entering an era where they're increasingly punishing

19:26 on boys and men and there's this whole thing of like male looks

19:29 maxing and uh you know the guys in the Marvel movies are completely

19:34 jacked now and on all kinds of things you probably shouldn't be taking.

19:38 And you know, if you're obese or overweight and you're

19:42 taking a GLP1 to lose weight, you know, great.

19:44 Um, or to, you know, protect your cardiovascular system.

19:49 But I think a lot of the cultural effect of them has come

19:52 from celebrities and influencers who all of a sudden show up and are much

19:59 thinner at times skeletal now in ways that you know when you have

20:05 the body's natural hunger signals coming back at you is is harder to do.

20:09 [gasps] You know there was like this big body positivity movement

20:12 and that was always going to be a very uphill climb in this country.

20:16 But how do you think about GLP1s as possibly

20:21 a like a like a pharmaceutical accelerator of, you know,

20:26 fairly dangerous body expectations because now it's like, well,

20:31 if you want to look thinner, why not just go on to GLP1?

20:34 [snorts] I think that's that's absolutely a strange um in this conversation

20:38 and in this in this moment that we're living in.

20:41 Um the place that it freaks me out the most is

20:45 um I talked to pediatricians who are prescribing the drugs in children.

20:49 There's no screening yet for for these drugs and eating

20:52 disorders in young people and and they've they anecdotally

20:56 have seen people use these as aids for essentially

20:58 eating disorders and and kind of exacerbating eating disordered behavior.

21:03 One of the underlying assumptions of the health at every size or fat

21:06 activism or body positivity movements um was

21:10 that you can't control your body size.

21:12 Therefore, you must accept it.

21:13 We had surgery before.

21:15 It wasn't as accessible or scalable.

21:16 But now we do have this medication where people do have the option, right?

21:21 Or at least the ones who are sensitive to it

21:23 and the ones who can afford it and access it and all all of that, right?

21:27 We've seen influential people in these the body

21:30 positivity fat activism movement come forward

21:32 and really grapple with starting on these drugs

21:35 and um and losing weight on them.

21:37 And one thing that those movements did

21:39 that was really important was highlight how

21:41 much shame and stigma people who are

21:43 living with obesity face every day, especially women.

21:46 So, like there was this great economist article a few

21:49 years ago where they parsed the data on the pay

21:52 penalty and they they did such a great job

21:55 of highlighting the discrimination and stigma that people with obesity face.

21:59 But I think there was really a dangerous

22:01 glossing over of the health effects of carrying

22:04 extra weight that even if there is

22:06 this variation in individuals at the population level,

22:09 it's very clear that the higher you go up the BMI ladder,

22:12 the more um health risks you're you're carrying.

22:16 I I've spoken to people who were part of these movements.

22:18 They had issues with movement.

22:19 Um they had problems with their blood sugar.

22:21 They had um they were concerned about fertility and they were so grateful

22:25 to be able to now have a medication that could help with those issues.

22:29 That debate became very polarized.

22:31 It was either you're fat accepting or fat phobic.

22:35 And I think we're kind of moving to something maybe in between.

22:39 But but you but I take your point on that.

22:42 But put put that side of the debate over here, right?

22:45 That was always a like an like an effort

22:49 that was running up against the mainstream of American culture,

22:54 which believes very strongly in thinness as a synonym for virtue.

23:00 And you know, one thing that the people I know

23:02 are worried about and frankly that I'm worried about, I mean,

23:04 I feel like I would not have had this concern for like young boys,

23:09 which is what I have a while ago.

23:10 And now I look at the rise of male looks maxers and it looks a lot

23:13 like toxic diet culture you know that girls were exposed to before and you know

23:20 and obviously you know clavvicular who's the uh

23:23 avatar of that has talked a lot about

23:25 being on you know GLP1s or some some form of these drugs and I wonder what

23:30 it's going to do when it is just that much easier for people at the top

23:34 of society to exert like hair24 unknown

23:39 levels of control over their bodies and when

23:42 they're doing it with these like wild stacks

23:44 of GLP1s and peptides and you know uh

23:48 pills to prevent hair loss and everything else

23:50 you know constant Botox like that filters down.

23:55 Oh, absolutely.

23:56 And it makes the the the ideal both like ever

23:59 more unreachable and ever more punishing to try to reach.

24:04 No, I think about this a lot with kids, right?

24:06 there's this basically this market that hasn't been tapped to the extent

24:10 that the adults have which is children

24:12 with obesity and diet-caused diseases and I

24:16 think it's something like 1% of um children who are eligible are

24:19 taking these drugs now but I think that number is expected to rise

24:24 stratospherically um pretty quickly especially

24:27 with the expanded access and going to pill

24:29 form and there's so much there's if we if there's like a lot

24:34 we don't know in adults there's so much we don't know about what

24:37 it means to suppress appetite during

24:39 these critical phases of growth and development.

24:42 At at the same time, um diet caused diseases like obesity and diabetes,

24:48 they hit young people particularly hard.

24:51 Um and there's some question with diabetes

24:53 for example about interactions with growth hormone and insulin

24:56 signaling because the disease comes on so ferociously

24:59 and it's so hard to treat in young people.

25:02 So now we have this treatment or or thing that can actually

25:05 help young people in a way we couldn't accept with beriatric surgery before.

25:09 But what is it going to mean for them when we're yes blunting appetite um not

25:14 only with the pressures on body image at that age but also on yeah your muscles,

25:19 bones, um puberty, all these things, right?

25:22 We're we're about to put all these young people on these drugs.

25:25 Like I think about my kids and the pressures that they're going to face.

25:29 Um, I think about I don't know if you've done this thought experiment,

25:33 but imagine being like chubby 16-year-old Ezra now.

25:37 Would you have gone on one of these drugs at 16?

25:39 Like I I I've thought I would I have, you know,

25:42 I I also I think my weight fluctuated a lot,

25:45 but I think around 17 or 18 I would have had obesity.

25:48 And would I would I have pushed like my parents to say,

25:52 you know, I really wanted GLP-1.

25:54 And where would I be now?

25:55 Would I have had a happier childhood and like or teens and early 20s?

26:00 Um, if I had one of these drugs, would I have learned to eat in the way

26:05 that I've learned to eat by changing my food environment?

26:08 I I don't know.

26:09 Like I I've But the pressures I think young people are going

26:12 to face now growing up in the culture that we have, it's it's scary.

26:16 It's punishing.

26:17 I'm terrified for my kids when I hope that there's some sort of correction,

26:22 but I don't know if the correction is coming or how, you know.

26:27 So, the conversation we've been having here sort of tracks what

26:30 I would call like the first cycle of ompic coverage excitement.

26:38 And then a new thing begins happening.

26:40 And it's sort of when I began paying closer attention.

26:42 There was a study that came out that particularly

26:45 caught my eye as a former healthcare reporter,

26:48 which was that we were seeing huge drops

26:52 in mortality from any form of cardiac event,

26:58 but the drops didn't seem to be connected

27:01 or didn't need to be connected to losing weight.

27:03 That's right.

27:04 Yeah.

27:04 So, can you explain what we saw then

27:07 and then how that begins to shift the story here?

27:09 Sure.

27:10 Yes.

27:10 So we have this drug that comes on the market for diabetes in the diabetes

27:14 trials as as we start ramping up the doses people start to lose weight

27:18 and then for any diabetes drug now

27:20 that comes onto the market there's a requirement

27:22 that companies must look into what these drugs

27:25 do to cardiovascular events to look for harms.

27:28 So so they were so the companies were looking for harms.

27:30 Does this increase the risk of a cardiovascular event?

27:35 Past past weight loss drugs like fenfen, you know,

27:38 which were not diabetes drugs like

27:39 did increase the risk of cardiovascular events.

27:41 Right.

27:42 We've had wonder weight loss drugs before and they gave people heart issues.

27:47 Exactly.

27:47 So, so, so they're looking for harms

27:50 and instead they find this 20% risk reduction.

27:55 And put that in context for me.

27:56 How big is that?

27:57 It's big.

27:58 Um, statins are a drug that are targeting

28:00 these conditions and the risk reduction is something like 29%.

28:04 What's really significant about it is it seems that more and more

28:08 of the benefits that researchers are discovering

28:10 from these drugs seem to be weight independent.

28:13 So in other words, what everyone expected is you make people lose weight,

28:16 inflammation in the body goes down,

28:19 um your metabolism of fat and sugar um improves.

28:22 So maybe um you see improvements in fatty

28:25 liver disease or your diabetes or whatever it is.

28:28 But what no one predicted was that you would start to see

28:30 these weight independent benefits and that that goes for the heart,

28:35 it goes for the liver, I think the kidney,

28:38 there's a slew of benefits that seem to be weight independent.

28:41 There's possible benefits on dementia.

28:43 Um I mean my understanding of this is that observationally

28:46 people on these seem to have much lower risk of dementia.

28:49 They did a study seeing if it uh a randomized control

28:52 trial seeing if it improves people who have Alzheimer's and it didn't.

28:57 But we're not sure about whether or not it can prevent Alzheimer's

29:00 and some people seem to believe

29:01 Alzheimer's or dementia are metabolically activated.

29:06 And so now there's this whole question of does it is it cognitively protective.

29:10 So the Alzheimer's trials,

29:12 so these were really much anticipated um randomized control trials to see what

29:16 would happen with um these drugs in Alzheimer's and they had negative results.

29:21 And so it was a big disappointment um to the community and to the companies,

29:25 but there is this question of in a different

29:28 population or with a different dose or a different drug,

29:30 will we see the benefits?

29:31 And that's an active um question, right?

29:34 Yeah.

29:34 If you're intervening earlier, it's an active um question and area of study.

29:38 So I don't think that case is closed.

29:41 And sleep apnea is a big one.

29:43 Sleep apnea is weight dependent.

29:45 So you need to lose the weight to see the benefit.

29:47 That's another indication that these drugs are approved for now.

29:51 So these weight independent results,

29:54 they break our theory of the mechanism of health improvement here a little bit.

29:59 So as doctors and scientists try to grapple with this, how does our sense

30:03 of what the drug is doing and why it is helping the body change?

30:07 So there's a researcher in Toronto, Dan Ducker,

30:10 who helped discover this whole class of drugs and he

30:14 described to me like let let basically there's these three buckets.

30:17 So one is the weight loss bucket that's clear it's going to help

30:20 you lose weight and you'll get the benefits from the weight loss.

30:23 Um the second bucket is reducing inflammation.

30:27 So inflammation is when you're exposed to a pathogen um an infection and injury,

30:32 your body mounts this immune response and it can signal healing.

30:35 But when it goes into kind of overdrive at low levels,

30:39 you have this chronic inflammation and that's a hallmark

30:41 of many of these diseases we've been talking about.

30:43 Obesity, diabetes, cardiovascular disease.

30:46 And these drugs seem to lower work on inflammation.

30:50 They seem to lower inflammation.

30:51 And this to me is the most exciting area because

30:54 we've had drugs in the past that kind of shut down

30:58 inflammation like steroids um let's say but but you put

31:02 people at risk because you're essentially shutting down the immune system.

31:06 You're putting people at higher risk for cancer or other infections.

31:10 But the way this is described to me is

31:12 that GLP1 seem to act as these finetuners of inflammation.

31:16 So they have this more subtle approach and um

31:19 it's not something we've really had in medicine before.

31:22 So we're using these drugs.

31:23 So GLP-1 and there's other drugs that are coming on the market

31:26 with like the dual and triple agonist um that use more than GLP-1.

31:31 And the question is like are we going to discover these other

31:33 hormones that we can subtly manipulate the immune system and inflammation with?

31:39 And so we might just be at the beginning of this.

31:42 And I think the other exciting facet of it

31:44 is we might really get amazing insights into the immune

31:47 system through these drugs that we haven't had before because

31:50 we haven't been able to do these more subtle manipulations.

31:54 But the third bucket that the the third way these drugs seem to help

31:57 people is by directly targeting the organs

32:00 that are involved in particular diseases.

32:03 So, um sending signals to the liver to heal

32:07 scarring involved in fatty liver disease or to clear

32:10 the fat from the liver um or whatever it

32:13 is to promote healing in the liver or the kidneys.

32:16 That that's a third way these drugs seem to be helping people.

32:19 Why would it do any of that?

32:22 Your guess is as good as but um there's models in mice of what's going on.

32:27 Um [snorts] but how this is working inside of us, we don't know.

32:31 My family has a lot of cardiovascular disease in it

32:35 that um has hit members of my family young.

32:38 And as everybody sort of around me began going on GLP1s,

32:41 I began reading these things about cardiac events.

32:44 Um I was like, well, am I an idiot for not being on one?

32:49 Are we all going to be on one of these in a few years?

32:53 And so I've tried them.

32:54 I want to talk about that experience in a minute,

32:56 but I want to ask that underlying question of you given these three buckets

32:59 you just described and how many things they seem to be helping to treat.

33:04 It increasingly seemed to me like shouldn't everybody be

33:06 on lowd dose ompic or toeptide if you're seeing

33:10 reduction possible reductions in dementia that we don't really

33:13 know but reductions in weight reductions in cardiovascular events reductions

33:18 in liver and kidney disease reductions in sleep apnea

33:22 improved blood sugar we'll talk about the addiction um

33:25 and compulsivity findings later but it began to seem

33:29 like a thing we should be putting in the water

33:32 you know I had the same question is you and the the deeper

33:35 I've gotten into the the deeper I dive into the science,

33:38 the more I've wondered the same.

33:40 We did this poll with the Times um for a piece on of GLP-1

33:43 [clears throat] users and asked them like what's your experience been like?

33:47 And I went into that poll thinking we would get these kind of negative results.

33:50 I I had a feeling that a lot of the headlines

33:53 in the media had been quite triumphalist about these wonder drugs,

33:56 but we weren't reporting what the lived experiences of people on these drugs

34:01 was really like with the side effects and cycling in and out of insurance.

34:04 And what we got back was people kind of generally

34:07 feeling great and having benefits that they didn't expect

34:10 and that they wanted to stay on the drug for benefits

34:13 for for reasons other than which the drugs were prescribed.

34:16 This was amazing to me that 63% of people in your survey

34:18 said even if the drug didn't work for weight loss,

34:20 they would want to stay on it.

34:22 No, this was it shocked me.

34:23 I did not expect this.

34:25 Um, one of the most amazing stories to me is the woman who had um

34:29 postconussion syndrome for almost a decade whose

34:32 life was essentially I don't want to say

34:34 shut down but it was she was suffering suffering deeply um with symptoms and she

34:39 started to find mice and cell research

34:42 suggesting these drugs could benefit postconussion syndrome.

34:46 So, she talked to her doctor, she got the prescription, and she tries it.

34:49 And within days, she starts to experience benefit,

34:52 and now she's back to her normal life.

34:54 Um, but the big key is we haven't done a randomized control trial on this.

34:59 We don't have the high quality evidence to say,

35:02 is this going to be everyone with postconussion syndrome,

35:04 80% of people or like 2%, we don't know.

35:08 In addition, we don't understand the how these drugs interact.

35:11 For example, if you were on, god forbid,

35:13 but some other type of like a cancer therapeutic

35:16 or something like this, we don't know how how

35:18 does this fine-tuning of the immune system I talked

35:21 about work when you're taking an imunotherapy, for example.

35:25 There are so many unknowns and and researchers are always going to be cautious.

35:30 But I ask almost all the researchers I talk to this question and they

35:33 all say we're not at that stage where we should just all be on this.

35:38 I understand why the researchers have to say well look we don't

35:42 know but we don't know actually isn't an answer to that question

35:47 right you have to make a decision like as a person

35:51 with one life and a life where you have a chance of getting

35:55 heart disease a chance of developing dementia a chance of developing

35:59 kidney disease a chance of developing all these different things and you

36:03 have to look at these studies or the coverage of these studies

36:07 is more to the point and say or say with your doctor,

36:12 do I think I should be on this thing

36:15 that seems to modulate inflammation which appears

36:18 to be a source cause of all kinds

36:21 of major chronic and acute illnesses people develop or not.

36:26 And you know, one reason I think you're seeing like really really

36:29 aggressive experimentation particularly around this class

36:33 of drugs is because something that has

36:36 all these effects for the well or for the you know for chronic

36:40 conditions saying well I don't know in 12 years maybe we'll know more.

36:44 You actually kind of have to make a yes or no decision as a person because if

36:48 you miss out on protecting your body

36:51 from the chronic effects of ongoing inflammation for five years,

36:54 you've missed out on 5 years of protection

36:56 and you have accumulated 5 years of damage.

36:58 I don't know.

36:59 It sure seems like maybe,

37:00 but I know different doctors feel differently about this.

37:02 And I feel like we're in this place.

37:04 It's actually like really tender and tricky.

37:09 Absolutely.

37:09 But I think the question I was answering earlier was this.

37:12 Should it be in the drinking water?

37:14 Yes.

37:14 I didn't mean to actually make it mandatory.

37:16 No, no, no.

37:17 But yeah, no, but this question of should you, Ezra,

37:19 as an individual with your particular family history and your underlying

37:24 disease risk profile or whatever you've struggled with um already.

37:28 Should you be on the drug?

37:29 That's a conversation people and you should certainly have with your doctor

37:34 and um get the prescription and have someone monitor you.

37:37 What scares me about this GLP1 era is

37:40 how many people are circumventing the medical system.

37:43 They're getting these very low barrier um prescriptions through tele medicine.

37:47 Um they're going to like elicit research

37:49 chemicals through people like influencers on Tik Tok.

37:54 Um there's so much enthusiasm and I've seen this happen with other drugs.

37:57 It's like it seems to do everything and then we dial it back.

38:01 We're not quite there yet that we can just say put it in the drinking water.

38:05 So I went on the lowest dose of toeptide and like two and a half

38:10 um milligrams and I did not have the experience that people in your survey had.

38:15 Uh so on the one hand it's like the most interesting drug

38:17 or one of them that I've ever tried uh you know legal or non-legal

38:21 because I seem to be sensitive to it and all of a sudden

38:25 I just didn't want to eat which is never an experience I've had before.

38:29 It was like living in somebody else's brain.

38:31 The way I've described it to people, I used a slot machine analogy earlier.

38:35 It's like being a gambler who loves slots and going up to a slot

38:39 machine and pulling the thing and getting

38:41 the three cherries and then nothing lights up.

38:45 It made me feel like that there was this level

38:48 of experience that I hadn't even recognized I had, which was around desire.

38:53 Like I would taste something and it would be

38:55 good or I'd smell something and I hadn't noticed

38:58 that the thing it would then trigger another feeling which

39:00 was desire because like the feelings were so connected for me.

39:04 But all of a sudden I would have that same I would have

39:06 that same experience and then the desire wouldn't trigger and I would walk

39:11 by the candy bowl and not stop or I would leave half the burrito

39:15 on my plate and it was in a it was in a way revelatory.

39:21 Um, the problem is it made me quite depressed.

39:28 Interesting.

39:27 And andhonic.

39:28 And whether that was because I wasn't eating

39:30 enough or or what what was going on.

39:32 But the thing where people report more energy

39:34 and and and more focus and feeling cheerier for me, it really doled experience.

39:40 Almost sounds like an anti-depressant experience.

39:43 Well, and that's why I think it's like

39:45 interesting to bring in my own experience because there

39:46 is this whole thing where it's working on some

39:48 kind of reward mechanism too on maybe dopamine,

39:52 but people are reporting not just a desire to eat less,

39:55 but a desire to do all kinds of things less.

39:57 Drink alcohol, take drugs, online shop,

40:00 and then this anhidonia thing is also being reported by people.

40:05 And so, what have you seen about the whole

40:08 reward system dynamic of it in your reporting?

40:11 Yeah.

40:11 So, this has been a very exciting area and one

40:14 that we've paid a lot of attention to, I think,

40:16 in particular in the media because the anecdotes

40:18 are so startling and I think they're real.

40:20 I've talked to people who have reported like reversals of um alcoholism,

40:26 um the desire to smoke,

40:28 um sex addiction, like any kind of addictive behavior you

40:32 can imagine seem to be dialed down with these drugs.

40:36 The trials to date have been mixed and the researchers who

40:39 study reward are quite cynical that these results are going to endure.

40:44 And the way it's been described to me is so

40:46 for a long time we know that if you make rodents hungry,

40:50 they're more likely to have addictive behaviors like they're more

40:53 likely to get hooked on cocaine or push the lever.

40:57 So hunger has this overlapping pathway with these other motivated

41:01 behaviors and it [snorts] can increase the risk of addictive behavior.

41:06 Um it seems and so it's it so one explanation is that once

41:10 you've been on these drugs for a while and your appetite starts to normalize,

41:14 you've lost the weight and your hunger starts to normalize again

41:17 whether the results for addiction are going to actually endure after that.

41:22 I think a lot of people think about

41:24 these as like clear treatments for these addictive behaviors

41:28 and that's where I think we don't have

41:30 the the high quality research we want to have.

41:33 Well, that my assumption of why some people were getting uh anhidonia,

41:38 some people were seeing, you know,

41:40 lower desire for drinking that that was actually not necessarily

41:43 that it would end up proving to be a clear treatment,

41:46 but that it is messing with a system we don't really understand.

41:49 And I mean I I sort of think what's interesting about this whole

41:52 conversation is we're basically saying we don't

41:54 understand any of the systems very well.

41:56 We don't understand the appetite system.

41:58 It's working a different way than we hypothesized.

42:00 The cardiac system is not doing what we thought it would be doing.

42:04 We don't know why the inflammation system is responding.

42:07 The reward system is changing.

42:08 I mean the human body is a very very very

42:12 complex set of systems and this seems to be a complex

42:19 change to them that like at the population level is

42:24 positive probably but not in a way where we can

42:28 precisely define the mechanisms by which it is positive or tell

42:33 you for whom it will be positive for whom it

42:35 will be negative and who will actually lose weight and who

42:37 won't and how It it's a very weird space actually.

42:43 Absolutely.

42:44 And and that's where Yeah.

42:45 I feel I really feel this like there were

42:47 just at the beginning of this um after we ran

42:50 this piece where we did the poll and and talked

42:52 about all these other surprising benefits people have experienced.

42:55 I got lots of emails about weird like people who were on SSRI.

43:00 So they were on anti-depressants and they

43:02 start on a GLP1 and they completely spiral.

43:06 Um, and that's not something that I've seen show up

43:08 in the randomized control trials or or in in um the research,

43:13 but it's an experience that people have.

43:14 So, I think we're going to have lots more

43:16 of this at the scale that people are taking um these drugs.

43:20 Um, we're [snorts] seeing these these new drugs are coming down the pipeline.

43:23 Um, we're seeing that there's now oral forms of these drugs available.

43:27 The drugs are going generic.

43:29 We're going to see more and more people

43:30 on these drugs and learn much more about them.

43:33 There's so much we don't know.

43:34 What about all the drugs that are coming now?

43:37 So I know people who are getting

43:39 reatitride from some compounding pharmacy in China

43:44 or something and reitatride maybe you can explain

43:46 it but it's another Eli Liy drug eli

43:49 also makes the makes zeppound the tepatide um variant and this is in trials now

43:55 and it's expected that it will be approved in the next some amount of time

43:59 and it'll probably be a big deal but it works even better than the other

44:02 two but I don't really understand why all

44:04 these people I know are getting a compounded

44:06 thing fromies they can't like oversee when there

44:10 are perfectly good GLP ones on the market now that you could get and have

44:14 full confidence in the way they're being manufactured.

44:15 Like what's going on with Reddit Tutread?

44:17 Why is it like both like around my community and all over my social media feeds?

44:22 Oh, interesting.

44:23 Um, this says something about are you in bodybuilding algorithms or

44:27 No, this is just straight up X for me.

44:30 Oh, interesting.

44:30 Okay, that's interesting.

44:32 Um so so it's still it's a research compound that's still under study.

44:36 It's targeting three hormone receptors.

44:38 So simaglletide um ompicovi is targeting one.

44:43 Um and this is where at the beginning of the conversation

44:45 we talked about how we had this a lot

44:47 of research on these diabetes drugs over many years

44:50 and we could be fairly confident in their safety profile.

44:54 these drugs um that have come on since um like Mangaro,

44:58 like so trespide and like reatride,

45:02 they're they're targeting more than just the GLP1.

45:04 So they're they're targeting other hormone receptors

45:07 and we don't have long-term data on these drugs

45:10 and I think that's a really important um

45:12 thing that a lot of people overlook, right?

45:14 Um, so, so this one is still under study, but in the research we have so far,

45:18 it looks like it's causing faster and more dramatic weight loss

45:22 and it's taken off in I think longevity and bodybuilding, social media.

45:28 The the argument I keep seeing about it is it it increases energy use that it

45:33 seems to have some independent effect on how

45:35 much how on the calories you're burning.

45:37 Yeah, I'm not sure what the mechanism um

45:40 but that could make sense that it's not just reducing appetite,

45:43 it's also increasing metabolism and maybe that's

45:46 why people lose even more weight more quickly.

45:49 Um but but the point is we have this emerging evidence

45:52 that it might be even more effective than what's already available.

45:56 And I think it just speaks to the frenzy around these drugs that people don't

45:59 want to wait for the FDA to get

46:02 the randomized control trials to approve the drug.

46:05 they're going directly to illicit sources um and trying

46:08 to buy the drug which is still a research compound.

46:12 People I knew who used to order drugs on the internet,

46:14 they they were ordering fun drugs.

46:16 Now it's like [laughter] these weird Yes.

46:19 eat less and focus more.

46:21 One thing I think is interesting about the GLP1s,

46:23 I mean for everything we've talked about here is for instance, you know,

46:26 the categories of who might want to lose a little bit of weight

46:30 or even more so who might want to protect themselves from inflammation.

46:35 They speak to this reality that the difference between

46:40 well and sick is not this like clear binary thing.

46:44 We now have these categories like pre-diabetic and prehypertensive

46:48 and premenopausal and we didn't used to have them.

46:51 I mean we keep expanding the space in which you should worry and I

46:56 think that there is an interesting dimension as people start looking for like

47:02 chemical answers to wellness because the truth is for a lot of people get

47:08 enough sleep and go to the gym regularly and eat whole foods is hard.

47:11 If you could just like give yourself a shot or take a pill, people want it.

47:18 How do you think about the broader shift, which is not new,

47:22 but it's happening with more force right now

47:25 towards medicine as not a way of treating illness,

47:30 but as a way of optimizing wellness?

47:35 Do you see it as something new?

47:36 Is that something old?

47:38 I think it's more pervasive maybe, but I think we have to be careful.

47:41 So like in if you think about the American

47:44 public like most people aren't eating the minimum

47:46 daily requirements of fruits and vegetables let alone

47:49 like personalizing or optimizing their diet beyond that.

47:53 Most people aren't getting enough sleep.

47:54 Most people aren't getting enough physical activity.

47:57 And I think that's the majority.

47:58 Right.

47:59 Right.

47:59 That's I'm agreeing with that.

48:00 Yeah.

48:00 But but then there is I think there is this minority that we pay a lot

48:04 of attention to in the media um

48:07 that that is interested in the longevity and the optimization.

48:10 I don't think there's anything that new about wanting to use

48:14 medicine to be more well as opposed to heal from illness.

48:21 And we've been doing that forever

48:23 and we've had health and wellness influencers forever.

48:27 But I think if you look around the mediacape

48:30 at this exact moment and you think about how big like Rogan

48:35 and Huberman and Aia and then you have like Brian

48:39 Johnson is one of the breakout media figures of the era.

48:44 This sort of former entrepreneur who's trying to never die and is like

48:47 the you know has like ended up

48:49 in this incredibly incredibly intense regimen of optimization.

48:54 Like I'm very skeptical this is ultimately going to be

48:56 good for him but you know it's his life I guess.

48:59 Clevicular this like look maxer streamer who like hits

49:02 his head with a hammer and is on these like

49:04 crazy stacks and you know oded the other day

49:08 uh on a live stream but you know has become

49:11 like is getting billions of views on his clips

49:14 and I think there's something about the way like how

49:17 dominant this has become in the media sphere and it

49:21 doesn't have checks it used to have on it.

49:23 I mean, you were talking I remember the coverage you would do at Vox of of Dr.

49:26 Oz, but one of the things happening on Dr.

49:28 Oz was like there was a network behind that.

49:30 I mean, there were gatekeepers.

49:31 There were people who didn't want to see

49:33 their stock price go down if something went wrong.

49:35 And now it's a complete wild west boosted by algorithmic interest.

49:40 And I think it's going to push us into a real period of like

49:45 a longevity and optimization focused system because

49:50 like there's going to be money for it.

49:51 there's going to be attention for it and so yeah I mean a lot of people

49:55 in this country are very very sick and what

49:56 they need is treatment for chronic illness but I think

49:59 there's going to be a real push

50:00 in the system towards treating these people who what they

50:02 are is not very sick what they are is they are well and they want to be weller

50:07 right we we so we always had the worried well and like

50:11 we've always people have always done really wild things to optimize their health

50:16 as you're saying but the megaphone is so much bigger and more

50:19 fragmented and it's so much more effective at creating this confirmation bias.

50:24 Like I think about my mom who was

50:26 diagnosed with osteoporosis and she was trying to decide

50:29 whether to go on one of these um medicines

50:32 it's available for the condition and she ended up

50:34 in a complete YouTube rabbit hole of doctors

50:38 who were really skeptical of osteoporosis drugs and she

50:41 became quite frightened and and it took her like

50:43 a couple of years to go on the medication.

50:46 Um and this is happening at a scale that we've never seen before, right?

50:51 But this desire to optimize like like

50:53 in our book we found this wild example of after

50:57 the first world war there was an ingredient

51:00 in explosives manufacturing that sped up the metabolism and caused

51:04 people to lose weight and doctors at Stanford

51:06 pivoted and turned it into a drug that was

51:08 taken by like hundreds of thousands of people

51:11 and became one of the first targets of the FDA.

51:14 Um and it had terrible side effects

51:16 and c like killed people and caused eye problems

51:19 and um so so I think we've we've always done these wild things in search of yeah

51:24 looking for the magic cure um the quick

51:27 fix or bettering our health but the the in-your-facess

51:31 of the messages and the the way they're

51:33 targeted um with the algorithms this we've never seen.

51:36 So, I think you're touching on something really important,

51:39 which is how this media landscape has changed,

51:42 not only around the blockbuster FDA approved drugs like the GLP1s,

51:46 but around this broader ecosystem of um yeah, wellness hacks and optimizers.

51:52 I mean, this goes to something that you wrote about

51:54 in your in in a piece you did for the times,

51:57 which is that these are the first blockbuster

51:58 drugs to collide with our wellness obsessed algorithmic age.

52:02 And yeah, I mean I must have clicked and at some point on Reddit

52:07 who tried content on X and now every time I turn on the system,

52:12 the platform, I get these videos from people like telling me how great Reddit

52:17 tried and there's a huge boom in people just getting random peptides from China.

52:22 I shouldn't say random,

52:24 but ordering peptides from places where they can't really tell what's in them.

52:28 Um, the New Yorker tested some of these and found uh a lot of them

52:31 have lead or impurities or things you don't

52:35 want or they're not at the right dose.

52:38 Like there there's something wrong.

52:39 We got these blockbuster drugs and you might expect

52:41 everybody to be really excited and be on them,

52:43 but it seems to have exploded into this biohacking moment

52:50 in which it's like if something like Mgoi could exist,

52:55 well then who knows what is out there and you should order

52:58 it from China and inject it into yourself and find out, right?

53:02 Like what do you make of it?

53:03 I think it it was it's sort of the perfect drug

53:06 for this social media algorith al algorithmic age that we're in.

53:11 Um because it's visual, right?

53:13 It's not like like you have the before and after photos.

53:16 You have I spend way more time than I'd like

53:18 to admit on different social like Tik Tok and um

53:22 Reddit accounts where you see the videos and the before

53:26 and after photos and how people's bodies are transforming.

53:29 Um, and we we're kind of living in this very appearance obsessed culture.

53:33 And now for the first time again,

53:35 we have this drug that does something that humans

53:39 have quested after for like a century or more.

53:42 Um, and and so it's meeting that moment.

53:45 Um, I think like I was doing a thought experiment

53:49 when I was working on that piece you mentioned about,

53:51 you know, what would it have been like?

53:53 Okay.

53:53 So when Prozac came on the market um what what that was another

53:57 blockbuster drug that was another drug where we had a cultural moment around

54:01 it but we didn't have tele medicine so you still had to go

54:04 to your doctor to get a prescription the internet wasn't in widespread use so

54:08 you couldn't order a research compound from China there was no social media

54:12 to compare you know do do your um person like compare your personal experiences

54:18 and share them with the world so yeah we have all those things

54:21 now when we have this this elixir that we've wanted for so long, right?

54:26 The weight loss elixir.

54:27 So many people have wanted this.

54:29 We have it at the same time as we

54:31 have all these other things that have just helped create,

54:34 I think, the moment that we're in.

54:36 I guess this does reflect what I've told my algorithm to to tell me,

54:39 although not intentionally.

54:42 I see so many people just posting about like random

54:46 studies that are not full randomized control trials are often

54:50 not even in human beings and being like see look

54:53 at this amazing mechanism and look at these early results

54:56 and at least according to them they're getting them compounded

54:58 and and and ordering them and I'm fascinated by this because

55:05 there is some weird overlap between the community of people

55:10 who are incredibly skeptical of vaccines of the FDA.

55:15 And at one point that was understood as a preference

55:18 for naturalism that there was a primitivist impulse here.

55:23 And yet some of these same people who were so skeptical about was what

55:27 was a very wellstudied class of drugs

55:31 are now ordering completely unknown forms of peptides.

55:36 some which are about weight loss,

55:37 but some of which are just to increase energy use

55:40 or to cure your tennis elbow or to, you know,

55:43 try to improve like, you know, cell regeneration.

55:46 And they're stacking them in different formulations.

55:50 Like it's like a mistrust of the authorities,

55:53 but a belief in unproven technologies in a way

55:57 that like that I find culturally very interesting.

56:00 And I'm curious as somebody who's been around the space for a long time,

56:03 what you've made of it.

56:05 Well, I think it kind it kind of goes together.

56:07 So maybe even it was brewing before the pandemic,

56:09 but we've had this uptick in an appreciation,

56:13 an interest in um health and health optimization.

56:16 Um and then we have these technologies

56:19 now to spread information about um health optimization,

56:24 podcasts in particular, that are often sponsored by supplement makers.

56:28 They're mistrustful of authority and a lot of people I think were left quite

56:31 cynical after the pandemic of um public

56:34 health and the medical establishment and now we

56:37 have this vehicle actually that was helped

56:39 also in the pandemic with tele medicine um

56:42 where people can take their health in their own hands in a way that they

56:46 haven't been able to before and then this this idea that you can just

56:50 do it yourself but it it feels like that's almost the currency today of social

56:54 media like you know you say there's this new study and this I found

56:58 this new use for something and now I'm going to promote it on my feeds.

57:03 Um, well, I think it reflects this way in which you have to trust something.

57:09 The world is simply too complex for anybody to have

57:13 firstirhand knowledge of very much of it at all.

57:16 So you can trust established authorities like the FDA and the CDC,

57:22 but if you lose trust in them, you have to still find some way of deciding

57:27 what to believe and what not to believe.

57:31 And a lot of people choose individual voices, you know,

57:36 Andrew Huberman or Joe Rogan or Peter Aia,

57:39 uh, or people further into the the Maha world.

57:42 And I'm not even saying they're necessarily corrupt,

57:45 but if you're in media, for instance,

57:47 and you run a podcast on health and wellness week after week,

57:51 you have to find new things to say.

57:54 Just getting on the mic every week and saying,

57:56 "Here's another week when you should eat whole foods

57:58 and try to reduce your stress and sleep well,

58:00 it doesn't last." Even putting aside the fact that some of them

58:04 are getting a cut of either supplement companies or advertising for it,

58:09 they have this huge bias towards the next new thing

58:13 and it was always there, right?

58:14 I spent a lot of time earlier in my reporting

58:16 career with you at Vox like looking at Dr.

58:19 Oz and I remember once interviewing him years ago and he said, you know,

58:23 that I I think I said like why do you have the magic and miracles on your show?

58:27 Like you're you're a cardiothoracic surgeon.

58:29 You know, this isn't um research base.

58:32 It was a question like that and he said you know if

58:34 I didn't have the magic in miracles I wouldn't have a show.

58:37 Um I think there's also something that like the you know that the very

58:42 sound advice the very sound scientific foundation

58:45 we have for how to optimize your health.

58:47 [snorts] It's so boring.

58:49 Right.

58:49 It's what you said.

58:50 It's like sleep more have social relationships.

58:52 Eat more vegetables.

58:53 The stuff your mom has been saying to you since you were in your high chair.

58:57 And yeah, but to to have the podcast or to have the social media feed,

59:00 you need to have this new advice.

59:03 I totally agree with you.

59:04 I I will say before I make this next point

59:06 that I think injecting yourself or taking poorly studied peptides,

59:11 it's a stupid idea and people shouldn't do it.

59:12 So, I really want to say this very clearly,

59:15 but in preparing this episode and reading what

59:18 some of the peptide booster types are saying,

59:22 their argument is, look, people have a right to do this.

59:25 It is their body.

59:26 They are doing it and it would be better

59:29 if we let them buy them from domestic compounders

59:34 whose processes we could regulate and oversee rather than

59:39 these fly by night Chinese companies that we can't trust.

59:46 But how do you think about balancing this this argument

59:48 like look people are doing this it's their right.

59:51 um we should allow them to get things that are

59:53 safely made against this like the government doesn't want you doing

59:57 this and we're going to try to make it hard to get

59:59 them and increase the you know the risk so more people you know don't try.

1:00:03 So that argument is how we got the supplement market.

1:00:06 We have you know do you know that the history

1:00:08 of how supplements became kind of this thing that FDA

1:00:13 um it's that there there was a big

1:00:14 campaign push in particular helped by supplement makers.

1:00:18 It was like a massive letterw writing campaign on the part of the public

1:00:22 um TV ads with famous actors and the thing was like don't touch my supplements.

1:00:26 I have the right to use these supplements.

1:00:29 representatives who were from states with um large supplement manufacturers

1:00:33 really pushed to to have this kind of lacks regulatory environment.

1:00:38 Um but it was this this argument that Americans have

1:00:41 the right to use the supplements they want to use.

1:00:43 That's why we have this regulatory regime around supplements that we have today.

1:00:48 Which way does a supplement argument actually point?

1:00:52 You know, you walk into Whole Foods or you walk

1:00:53 into CVS and there's a lot of supplements and I don't

1:00:56 think we see it as like a national tragedy

1:00:58 and a lot of those supplements have names I don't even know.

1:01:01 So, is that a bad thing or a good thing?

1:01:04 Right.

1:01:05 Am I upset people can create these supplement stacks?

1:01:07 I mean, not really.

1:01:08 If you want to take aine or whatever, go for it.

1:01:11 I think I think when people are being misled and using

1:01:15 like scarce resources on things that aren't going to help them,

1:01:20 I think actually it is a problem.

1:01:22 Um I I personally think like you know the government

1:01:26 has a role in protecting public health and protecting consumers.

1:01:31 Um, but it's a very sensitive topic and a lot of people,

1:01:34 especially in the American context, it's this idea that, you know,

1:01:38 you have the right to do what you want with your body

1:01:41 and to access the the um products that you want to access.

1:01:46 And like I I guess I have a more conservative view

1:01:49 on that, but a lot of people definitely disagree with me.

1:01:53 I mean, my gut is that this is going to become a disaster.

1:01:56 My my personal view is actually fairly conservative.

1:01:59 I'm trying to be the devil's advocate here,

1:02:01 but it seems like people are taking a lot

1:02:04 of things right now to increase cell growth,

1:02:07 which maybe is good in the short term,

1:02:10 but has really frightening cancerous properties in some of these cases.

1:02:14 In the long term, I mean, I think we might end up realizing that a couple

1:02:18 of the things that people are starting to get excited about,

1:02:21 you know, are really not good for folks, which has happened before.

1:02:23 I mean, we were talking about Fenfen and things like that earlier.

1:02:26 We have had periods where people got really

1:02:28 into something and it wasn't good for you.

1:02:31 We used to put cocaine in Coca-Cola.

1:02:33 Absolutely.

1:02:34 Yeah.

1:02:34 If you know anything about the history of medicine,

1:02:36 it's littered with examples like this.

1:02:38 And that's also why I always come at this um much more conservatively.

1:02:43 Um but I I think yeah,

1:02:44 we're we're we're definitely in this big experiment now where yeah,

1:02:49 these these different things are colliding, right?

1:02:51 this interest in wellness and longevity and health optimization,

1:02:55 the availability of these drugs that seem to do everything and then these um

1:02:59 these over-the-counter variants that people are accessing

1:03:02 and buying online or in the pharmacy.

1:03:05 It's a it's a potential disaster waiting to happen.

1:03:08 One thing that I think is just a deep appeal

1:03:11 of these drugs of of broader peptides and other things

1:03:15 that are you know becoming culturally uh influential is you

1:03:21 know what on some level we all want is control.

1:03:24 Control over our bodies, control over our health,

1:03:27 control over never getting the diseases that scare all of us.

1:03:33 And on the one hand, if you are able to be given a real possibility for control,

1:03:40 if it's true that the GLP1s at low

1:03:42 doses protect you against heart disease, amazing.

1:03:45 Uh, statins have been amazing.

1:03:48 If it's true, I have a friend,

1:03:49 somebody who I I I care about tremendously, whose parent died young of dementia,

1:03:55 and I've been following all this Alzheimer's research on them, you know,

1:03:58 very closely because if they're prophylactic against dementia,

1:04:00 like I want my friend to take them.

1:04:03 So, I'm not saying that wanting to protect yourself is a bad impulse.

1:04:08 It isn't.

1:04:09 On the other hand, a desire for endless control over your own

1:04:13 body and future can be mentally poisonous too because you can't control it.

1:04:19 Right?

1:04:19 The the great insight of Buddhism is that you know desire

1:04:22 and craving are the root of suffering and you know the more we

1:04:27 trick ourselves into believing we can control what will happen to us

1:04:30 then when things do happen to us we feel like we failed.

1:04:33 Absolutely.

1:04:34 We live I think we live

1:04:35 in this in particular around controlling food and the body.

1:04:39 We live in food environments that are so

1:04:42 gamed against making the right choices for most people.

1:04:45 Right?

1:04:46 So even if you are on the GLP1 and I've talked to many of these people,

1:04:49 they're not losing the amount of weight they want to lose um because they

1:04:53 have other barriers to eating the way or exercising the way they'd like to.

1:04:57 We've created these systems and um food environments

1:05:02 that make it literally impossible for most regular

1:05:05 people to do the things that they know they need to be doing for their health.

1:05:09 [snorts] And that's something that I would love

1:05:11 more attention paid to um by whoever's in power,

1:05:15 like pulling more levers to help prevent these diseases

1:05:18 from the first place so that we don't have

1:05:20 to do things like um inject young people

1:05:23 with drugs that we don't understand the long-term effects of.

1:05:27 And I'm not anti-GLP1 at all.

1:05:29 Like I think they've been absolute like game changers

1:05:34 for so many people I've talked about for friends and family.

1:05:38 But we're doing this big experiment on the population

1:05:41 because of diseases that really are preventable.

1:05:44 If we do the things that we've long known we

1:05:47 need to do like restricting junk food marketing to kids,

1:05:50 um figuring out ways to make healthy food more accessible.

1:05:53 It actually it enrages me as a person who struggled

1:05:56 with my weight before like this realization that this was preventable.

1:06:00 I didn't have to suffer like that.

1:06:02 And kids like the kids who are now going through this now,

1:06:05 they don't have to suffer like this.

1:06:06 I feel like I've heard this argument

1:06:08 as long as I've been touching this issue which

1:06:10 like as you know the beginning of my career

1:06:12 as a healthcare reporter and I, you know,

1:06:14 we debate food deserts and what would happen

1:06:17 if we put you know good grocery stores

1:06:19 in food deserts and we did this in a bunch of places and it didn't really work.

1:06:23 I I've become very cynical about this.

1:06:25 I mean, yes, it would be much better if

1:06:28 everybody had was like wrapped around with, you know,

1:06:31 more walkable places to live and and better and healthy foods.

1:06:34 And I don't think you should be able to advertise junk food at all to children.

1:06:39 I think it should be illegal to have Paw Patrol on kids cereals.

1:06:43 I think this whole thing where we

1:06:44 allow endless advertising children is completely insane.

1:06:47 And it makes every parent's life

1:06:49 in the grocery store a nightmare, myself included.

1:06:53 And for the society at large,

1:06:56 I think the problem is people want things that aren't good for them.

1:07:00 But we've never done enough.

1:07:02 But people don't want you to do enough.

1:07:04 But which people?

1:07:05 I feel like the people who vote like this happened in in New York.

1:07:08 Bloomberg wanted to tax sodas.

1:07:10 They almost ran them out of town on a rail.

1:07:12 Okay.

1:07:12 Okay.

1:07:12 No, but I think things are the politics of this are changing.

1:07:15 I think like more and more people are raising kids with diseases like

1:07:18 diabetes and fatty liver and they're aware that this is caused by the food

1:07:22 environment and I feel like that that the politics there is shifting but we've

1:07:27 never done the inversion of our food environment that we need to do.

1:07:31 It's going to take many many levers to really

1:07:34 see an impact and that really hasn't been done.

1:07:37 I've just become I I think you would need a level

1:07:39 of paternalism for that that I guess what I would

1:07:44 say about it is that there is not a single jurisdiction

1:07:47 in this entire country where the politics of that have worked.

1:07:51 Like we cannot point at one thing, one place, one state,

1:07:54 one city where we've been able to do that much.

1:07:56 If it were there to do, I would be the first one to say we should do it.

1:08:00 But I don't think it's there to do.

1:08:01 like the public health community like we tried to get people to take

1:08:05 vaccines in the like aftermath or the the the math during a deadly pandemic

1:08:11 and it led to like the largest public health backlash

1:08:16 um in my lifetime such an RFK Junior is now

1:08:19 the secretary of health and human services people's sensitivity to paternalism

1:08:23 is very very very high it's a very potent political force

1:08:27 but I think one thing that I'm talking about and that that we write

1:08:30 about in the book it's not about

1:08:32 taking people's fried chicken or their M&M's away.

1:08:34 It's about making a food environment where the healthy

1:08:38 options are as accessible as the unhealthy stuff.

1:08:41 And and so so I'm living now

1:08:42 in France and obviously the politics are completely different.

1:08:46 There's no shortage of chocoliers of places where I can buy croissant bos

1:08:51 like all these things that I know I shouldn't be eating every day.

1:08:54 But as accessible are the healthy options.

1:08:57 So they they've done things like fresh um food markets in every district.

1:09:01 Um they minimize the size of grocery stores um through land use planning since

1:09:06 the late 1800s like using school lunches

1:09:08 as a lever to feed children healthfully.

1:09:11 And over time they've become more

1:09:12 and more avancgard about what that actually means.

1:09:16 They pull all these different levers.

1:09:18 But what we're what we're talking about I

1:09:20 think is creating this regulatory environment around chronic disease.

1:09:23 like how do you protect the public from developing these diseases like obesity,

1:09:27 diabetes, cardiovascular disease?

1:09:30 And it seems like impossible now because it

1:09:32 does involve these radical changes to the food environment.

1:09:35 But America did this over 100 years ago, right?

1:09:38 When we started to protect people against acute food poisoning,

1:09:41 it was just it was wild west.

1:09:43 They were putting calf brains in milk at this time and putting

1:09:46 like brick dust to dye food in a certain way and lead.

1:09:50 That's where the FDA came from.

1:09:52 And that's where the meat inspection program of the USDA came

1:09:55 from after um like the the publication of Upton Sinclair's book.

1:10:00 And but I hear you.

1:10:01 It's going to be very difficult.

1:10:02 I do think the politics are changing.

1:10:04 So we're in a moment where like places like

1:10:07 California and West Virginia are both looking at, you know,

1:10:10 doing things like reducing ultrarocessed foods

1:10:12 in school lunches and um banning certain additives.

1:10:16 Um, so, so really politically distinct places and people like Robert F.

1:10:22 Kennedy Jr.

1:10:22 and Trump and the former FDA commissioner David Kesler.

1:10:26 Um, what they're saying about diet caused diseases,

1:10:29 you can't tell who's saying it anymore.

1:10:32 That's true.

1:10:32 But I've been extremely disappointed by the abil by Kennedy.

1:10:40 I've been extremely disappointed to see that even the parts

1:10:42 of Maha that I thought made sense like have made it nowhere.

1:10:46 right?

1:10:46 You will watch Kennedy now at like like eating his call

1:10:50 fried French fries and you know go into um like

1:10:54 these fast food restaurants that you know if they really wanted

1:10:58 to make America the um American food environment better like they could.

1:11:03 Meanwhile, the president of the United States is like forcing RFK Jr.

1:11:09 to eat McDonald's and photo ops, right?

1:11:11 Like their actual willingness when it came down

1:11:13 to it to take on industry was extremely low.

1:11:16 No, absolutely.

1:11:17 Like Yeah.

1:11:17 Like if you listen to what they're saying, it's fine.

1:11:21 Have they done anything that will in a sustained

1:11:24 way change the food environment for people?

1:11:26 I would love to have seen Maha ban, you know, advertising to kids.

1:11:31 They didn't.

1:11:32 No.

1:11:32 The way I think about it is we, you know,

1:11:34 you had the the new nutrition guidelines come out which had this great message,

1:11:38 eat real food, right?

1:11:40 But no one is doing anything to make it easier for the people who

1:11:44 actually really struggle to afford and access real food to to to eat that food.

1:11:49 Right.

1:11:49 It's like there's something like 3 million

1:11:51 fewer people on SNAP and that's something

1:11:53 that the administr the administration has made

1:11:56 it more and more difficult for people

1:11:57 huge cuts are are continuing to go into effect there.

1:12:00 And um and there there were programs to make um local

1:12:04 and fresh produce available for school lunches and those have been cut.

1:12:08 And then there's a lot of like um tweaking at the edges

1:12:11 of you know swap out high fructose corn syrup with cane sugar or focusing

1:12:17 on certain food additives and there's such marginal problems in in the greater

1:12:21 system if you really want to help more Americans eat real food.

1:12:24 You're going to have to do a lot more than that and you're going

1:12:26 to have to focus on the segments

1:12:28 of society that were on food stamps for example.

1:12:31 Um so so I completely agree.

1:12:34 I think a lot of the rhetoric has been in the right place.

1:12:36 Like this is the first time I've seen at that political

1:12:40 level people talking about the food environment and saying,

1:12:43 you know, these diseases are preventable and they are caused

1:12:46 by these environmental factors um taking

1:12:49 the taking the pressure off individuals.

1:12:52 But then a lot of the solutions that have been proposed have also been

1:12:55 focused on individuals like give Americans more

1:12:58 wearable devices and and continuous glucose monitors.

1:13:01 It's not the intensity of the intervention that I think we we actually need.

1:13:06 Then always was our final question.

1:13:07 What are three books you'd recommend to the audience?

1:13:09 Three books that really shaped my thinking as I was writing um my book.

1:13:13 Um one was Behave by Robert Seapolski.

1:13:17 Um he wrote another book determined about

1:13:19 um basically it's an argument against free will.

1:13:22 Um but he comes at this I think

1:13:24 from a really interesting um and important angle.

1:13:27 Another one is Deb Blum's Poison Squad.

1:13:30 And this is like an excellent look through a biography of one

1:13:33 of the of a former chemist at the USDA who did research

1:13:38 that helped lead to the establishment of the FDA and a lot

1:13:41 of the food regulations and other types

1:13:43 of consumer protection laws that we have.

1:13:46 Um, I love that book.

1:13:48 The third book that I really

1:13:50 enjoyed was ultrarocessed people by Chris Vanelikin.

1:13:53 And this is really a palemic um and much more than

1:13:57 um where where I ended up coming down in my book,

1:14:00 but I I thought that was a really

1:14:02 illuminating um and fascinating book on ultrarocessed foods.

1:14:06 Julie Blues, thank you very much.

1:14:07 Thank you so much.

1:14:09 [music] [music] [music]