Magic Pill by Johann Hari

Magic Pill by Johann Hari is about the new class of weight-loss drugs based on the GLP-1 receptor. I picked the book up mainly because Johann Hari is one of my favorite authors, but the book’s topic turned out to be even more fascinating than I thought.

What I Liked

I liked how he structured the book. Weight loss and food is an incredibly fraught topic. Drug use is a fraught topic. There are so many knotty ethical and medical issues that all interplay in complex ways. The narrative structure (and use of personal stories) allowed the book to work its way thoughtfully through all the different “extraordinary benefits and disturbing risks” of the new weight loss drugs.

I loved the author’s level of empathy and his considerations of human emotions and struggles that happen in the context of science and technology. I hope decision-makers have the same considerations when it comes to the rollout of these drugs, so we can avoid many of the mistakes made when we had our last rollout of drugs to “conquer” a scientific problem wrapped up in deep human emotion & struggle (i.e. opioids & physical pain).

I really appreciated the footnotes and references. It made it quick and easy to check up on ideas & debates that I was unfamiliar with. I also loved how he made the book global in context. Americans especially tend to treat our problems like they are somehow unique – rather than looking at how the same issue does or does not happen in other countries (especially now that there are soooo many wealthy, stable nations to learn from).

What I Did Not Like

Not a whole lot. It’s such a good nonfiction book about a pressing crisis. My only reservation is on how quickly the book will age. It’s about a specific moment in time that I think will change faster than anyone expects it to.

Takeaways

The biggest takeaway from the book is that food scientists have generally* figured out the main culprit for the unrelenting rise of obesity across the world – lack of satiety.

Our bodies do not know how to count calories. So it uses lots of “proxy” indicators to ballpark if we are getting enough energy. The primary indicator is satiety – that feeling of fullness.

However, as our food has changed to become more and more processed, we feel less and less satiated unless we eat an extraordinary amount of food…which leads to obesity.

Modern foods are different from foods in the past and work to prevent satiety in several ways –

• modern foods require no chewing…another proxy our body uses to judge calories
• modern foods have a perfect mix of sugars, fats, and carbs (only one food in nature that have carbs and fat mixed perfectly together – breast milk…which is made to maximize weight gain)
• modern foods create sharper peaks of energy so we start to feel hungry sooner
• modern foods have low protein and fiber to calorie ratio…so we consume more calories than we feel like we do
• modern drinks have calories and diet sodas mess with your brain like it was getting calories…but didn’t…which creates a “panic” to consume more. That’s why even though diet drinks don’t add calories, they spur you to eat more calories than you would later in the day
• modern foods separate nutrition from flavors so our bodies can’t tell caloric and nutrition intake…so our brain wants to make sure we’re good on calories by consuming even more
• modern foods mess up your gut bacteria – fewer food types mean fewer bacteria types, instead your gut bacteria just live on corn, meat, soy proteins

GPL-1 drugs work by creating satiety (or that feeling of fullness)…all day long so that you simply don’t want to eat more. But…GLP-1s also have direct and indirect side effects. Because food is not a typical environmental factor that we can just change.

We also eat for nourishment, pleasure, social bonding, but also for psychological protection and emotion comfort. So food gets wrapped up in all these impossible to untangle ways…and creates all these crazy indirect side effects when we could just solve the root of the problem by making modern foods…more like actual food.

Quotes

Here are a few long passages that I wanted to note.

On how cultural expectations are embedded in our ideas about health…

Lara was speaking with the rush that people have when they are letting out something that’s been on their chest – “How much is this really about improving your health think, for you, it is. Not really. Not primarily, I want you to and really think about it.”

She pushed her plate aside and said: “I’ve known you Twenty-five years, and you’ve never bought you look. You look good. I’ve always thought you looked good. But you don’t think you do. So you’re taking this drug-and all there huge risks to conform to a particular look, an approved look the most socially approved look. That’s why you’re doing it. You want to be thin. Those people at that Hollywood party you were to, where you learned about this drug for the first time, and you texted me all excited-they weren’t doing this to boost their health. They were already healthy. They had private chefs to cook them the healthiest possible food. They see a personal trainer every day. They were doing it to be unnaturally thin. You aren’t taking these risks to have a healthy heart. You’re taking them to have cheekbones. That’s what you’re encouraging this eating dis orders epidemic in all these young girls for. That’s what you’re risking thyroid cancer for. For vanity.”

I let this sink in for a moment. Then, startled, I argued back. I told her that I really was worried about what would happen to my health if I continued at my previous weight. She leaned forward and asked: “If this drug gave you all the same benefits to your health, but it also gave you boils on your face, would you take it?” I stopped. I tried to genuinely think about the answer to her question. Would I take it if it boosted my health but harmed my looks? She was forcing me to disentangle the motives that had I along. I told her honestly: “No, been conveniently tied together all I wouldn’t” She said: “Doesn’t that tell you something about your motives? If it was really about health, you’d be to take a hit willing to your looks. I think you’ve used the health argument to rationalize taking a wild risk with your health, and with the young women of this society, so you can look better. If you want to do that, do it. But please-be honest about your motives. Level with yourself.”

I didn’t know what to say. Lara is one of the people who knows me best, and I wondered if she was right, and in fact articulating something I had been hiding from myself. Or was she misreading me? “If you were worried primarily about health, you would be talking to me about exercise and writing a book about that,” she said. “Exercise doesn’t lead to much weight loss, but my God, it leads to increased health, across the board. But you’ve barely mentioned exercise. Because it won’t make you more convention- ally hot. So you talk about drugs, not exercise.”

I brought up again the evidence that obesity really does harm your health. She had clearly been thinking about this, and had read up on it to back up what she said next. “Every time we’ve talked about this, you do this performance of carefully weighing the risks. You’re doing it now, and I can see you’ve persuaded yourself what you’re doing is real. But you’ve been rigging the calculations all along. Of course being seriously obese is really bad for you. Hannah was clearly really unhealthy”-she had been friends with her too-“but to talk about you as being in the same category as her is ridiculous. You were a bit overweight. You’ve always been able to buy clothes in normal shops. You had a BMI of 30. If you look at the evidence about what happens at that weight, it’s not good. It makes you more likely to get some health problems. But the big risks kick in at a much higher BMI-35 or over. That’s where people start to get seriously sick. You keep act as long like there’s two states: there’s people with a 24 of 25 or below and they’re fine and healthy, and then you hit 26 and above, and everyone is all in some terrible danger zone together. It’s not like that. It’s a slope, and you were at the lowest end of the slope. So when you tell me you are weighing the risks of taking these drugs against obesity, I call BS, because you keep taking the dangers faced by severely obese people and acting like they apply to much slimmer people like you, who face totally different odds.”

I told her again about my grandfather’s heart attack when he was my age. “But you don’t have heart problems,” she replied, “Look, I’m not saying that it’s not sensible for you to take steps to protect your health. Exercise. Eat better. I’ll talk to you all day about the psychological problems that led you to overeat. I have a lot of compassion for that. But the idea that, because you were a bit overweight, and because your grandfather died of a heart at- tack in the 1960s when the ability to detect heart conditions early was totally different, means that now, in 2023, you should be injecting yourself with a risky drug-it’s crazy.”

She continued: “You tell me you’re worried about all these young girls who are going to use this drug to starve themselves. But everyone taking these drugs who isn’t seriously obese or diabetic is helping to change the culture and make it different-to make it value thinness even more. Girls like your niece get the message loud and clear from that. What they hear is: it’s better to be thin than to eat. What was it Kate Moss said? Nothing tastes as good as skinny feels. Maybe it would be worth taking that risk if you really were going to massively boost your health. But you were healthy! No doctor told you you were sick. You didn’t have any heart problems, or pre-diabetes. You didn’t need a boost to your health.”I didn’t know what to make of any of this. My concerns about my health were real, and Lara was going too far in dismissing them. But she was also forcing me to confront something that was also real. I think, up to that moment, I had overstated how much I was driven by health, and how little by a concern about appearance. I was suddenly acutely aware of how ashamed I had been to be overweight, and how much it felt like a visible sign of failure. Had this skewed my judgment? Was I doing something harmful to myself, and to other people?

Her tone changed. I could see that her anger had passed. Now she just looked melancholic. “You know, I thought, at last, in the past few years, we were starting to let people like their bodies, whatever they looked like. It made me feel happy to see it. I hoped you would start to like yours. And now I’m seeing you waging war on your own body. It makes me sad.”

I realized I needed to spend more time researching the move- ment that has been trying to make us more accepting of our own bodies, whatever they look like. I wanted to know if the answer to Lara’s challenge to think more deeply about these questions might lie with them.

On how Japan is the only country that has urbanized and industrialized…without an obesity crisis.

In the corridors, kids waved at her affectionately and shouted her name, eager to know what they were having for lunch that day. Bylaw, Harumi said, every Japanese school has to employ a professional like her. It took her three years to qualify, on top of her teaching degree, and she explained that, in this position, you have several important roles to play. You design the school meals, in line with strict rules stipulating that they must be fresh and healthy. You oversee the cooking of the school meals. You then use these meals to educate the children about nutrition. Then you educate their parents on the same topic. And finally, you provide support and counseling to any kids who are under- eating or overeating. She said: “I’ve always loved eating. I enjoy eating, and I like watching people who are eating, and looking happy when they eat!”

We arrived at the kitchen and stared in through a large glass panel. Harumi told me that today’s meal consisted of five small portions: some white fish, a bowl of noodles with vegetables, milk, some sticky white rice, and a tiny dollop of sweet paste. All the kids eat the same meal, and packed lunches are forbidden. No processed or frozen food ever goes into any of the meals here. Even if they use something as simple as curry paste, they don’t buy it pre-made. “We start from scratch.” I asked her why, and she said: “It’s all about nutrition… Sometimes with frozen food, they use a lot of artificial additives.”

Once the meal was ready, Harumi carried a tray over to the office of the school’s head, Minoru Tanaka. It is a legal requirement that the principal of each school has to have the same lunch as the kids, and he has to eat it first, to make sure it’s safe, nutritious, and delicious. He rolled up his sleeves and started to eat. After a moment, he nodded to her that it was good. Once he had given this green light, a group of eight children from each class arrived at the kitchen, dressed in little chef outfits. They collected a trolley and pushed it back to their classroom. The kids dressed as cooks stood at the front of the class while the others stepped forward to be served. (This is as adorable as it sounds.) Before they began to eat, a child then stood at the front of the class and read out what today’s meal was, which part of Japan it came from, and how the different elements are good for your health. She then said, “Meshiagare!,” the Japanese equivalent of “bon appétit,” and everyone applauded.

While the kids were eating, Harumi held up four colored ropes. Each one represented a different kind of food you need to be healthy-on this day, they represented carbohydrates, calcium, carbohydrates containing additional calcium, and green vegeta- bles. She held up the yellow rope, representing carbs, and asked what they do for your health. A child yelled: “Give you energy!” She held up the red rope, representing calcium, and a child shouted out that it makes your bones stronger. As she went though the food groups, she tied each rope together, to show that in combination they make a healthy meal. She told me: “By eating this school lunch every day, which is well balanced, they learn what a balanced meal is.” The principal, Mr. Tanaka, agreed, say- ing: “Through the school lunches, we explain the food itself.”

Often, Harumi tells the kids: “Your body is made up of what you’re eating right now. Your body’s cells are replenished every three months. So what you’re eating makes your body now, and your future body… You have to eat with your brain.”

My translator and I walked from class to class, asking the kids what they most liked to eat. The first child I spoke to, a ten-year- old girl, said: “I like green vegetables, like broccoli.” The next kid said he liked fish. The third said he loved seaweed rice. I asked why, and he said: “I don’t usually like the seaweed, but if it’s cooked with rice, I can eat it.” and he was proud that he’d expanded his palate. One eleven-year-old boy told me he loves rice because “the rice has protein. If you eat balanced food every meal then you have a very strong body,” and he flexed his tiny biceps, and giggled.

I asked my translator: Is this a joke? Are they trolling me? A bunch of ten-year-olds, telling me how much they love broccoli, fish, seaweed, and rice? But most of the Japanese people I dis. cussed this with were puzzled to see that I was puzzled. We teach kids to enjoy healthy food, they explained. Don’t you?

As I walked around, I had a nagging sense that there was something unusual about this place, but it was only after a few hours that I realized what it was. There were no overweight children. None. I asked Harumi if there were any, and she told me there was one kid she was worried about. That’s one overweight child, out of nearly a thousand students.

And yet it was clear that this is not a culture that teaches kids to deprive themselves of food. The meal the kids ate was hearty, and filling. “I think it’s important to enjoy eating, and enjoy meals,” Harumi said. “I never say, ‘No, you can’t have that. If you like cake, you can have that. If you like fried chicken, you can of course have that. But if you have it every day, it might not be very good.” They have a mission to encourage children to expand their tastes, and learn to like new foods that they might not enjoy at first. Some kids, she explained, find the taste of vegetables horri- ble when they initially try them. So she turns it into a game, ask ing them to help prepare the vegetables, and then challenging them to try just a little bit of what they have made for themselves. “I am always impressed by how they grow up,” she said.

As the kids finished up their lunch, I pulled out my phone and showed them photographs of typical American and British school meals, to see what they made of them. I deliberately didn’t choose the most disgusting meals-just images of the normal mixtirosefied food, chips, and baked beans that I grew up eating from my school canteen. When they saw the pictures, they gasped. “Oh my God!” one little boy cried out in English. Another yelled: “It looks disgusting!” One asked incredulously: “Did you eat like this every day?”

I asked a twelve-year-old girl, who seemed to be stunned into silence, what she was thinking. She tilted her head and said: “It’s very greasy. It might be very strenuous for your body.” Another boy asked: “Is there no salad with that?” I said that I never ate a salad at school, not a single time. He looked taken aback, and told me: “It’s better if you eat it. It’s good for your health. It’s good to be healthy. If you don’t eat salad, you’ll gain weight, or have stomach problems.”

Another child, looking pained, said: “I think you’re missing a lot in life if you don’t eat salad.” Then she touched my arm and, clearly trying to find a way to incentivize me to expand my palate, said: “It goes well with meat.”

The next day, in a different school in another part of Tokyo, I showed a group of mothers the same photos. They looked equally stunned. One of them, a woman named Maiko Arai, asked me- is there a movement, to change this terrible situation? I looked back at her, and didn’t know what to say.

On the author’s conclusion…

I was breathing. Was I asphyxiating? Adam took his turn next, eating a lump of its [the Fugu fish, a fish that is toxic unless prepared correctly] white flesh. And on we went, carefully chewing. As we slowly and delicately ate this killer, it occurred to me:

Even this, the most dangerous food in Japan, is safer than the food we eat every day in the West. Junk food, processed food, and the obesity they produce kill 112,000 Americans a year at least. Fugu kills a handful of the Japanese. I said to Adam: “I should feel more anxious eating at McDonald’s or when I chow down on a ready-made lasagna than I do here, eating fugu and waiting for signs of death.”

When we walked into Tokyo Haneda Airport to board our flight home, Adam looked thoughtful. “Eating Japanese food for two weeks has made me realize…” He hesitated for a moment. “It’s made me realize how shit the food I’ve eaten all my life really is.” He said that, at home, he frequently has terrible constipation and stomach pains, but within a few days here, these symptoms had gone. “I don’t want to be one of those wankers who says to people ‘Oh, you’re eating that? Well, when I was in Japan… But, God, we need to learn from this.” Suddenly, the sheer artificiality of the obesity crisis seemed clear to me, more than at any other point on this journey. It is created by the way we live. It should be possible, therefore, to un-create it.

But how can we do that? At first glance, the gap between us and the Japanese seemed unbridgeable. But then I thought about something from my own childhood. I told Adam that if I could take him back to the Britain or the United States of, say, 1987, he would be astonished by one thing, more than anything else. People smoked cigarettes everywhere. They smoked in restaurants. They smoked on planes. They smoked on game shows. When you went to see the doctor, he would smoke while he examined you. (I’m not kidding: I remember this happening.) There’s a photograph of me and my mother, when I am a baby. She’s breastfeeding me, smoking, and resting the ashtray on my stomach. (When I found this photo a few years ago and showed it to her, she said: “You were a fucking difficult baby. I needed that cigarette.”)

If you had said to people in 1987 that within a generation, smoking would have almost vanished, we would not have believed you. In 1982, 71 percent of men and 54 percent of women had been smokers. Today, only 12 percent of people are smokers, and it’s falling further. The British government is about to slowly criminalize the sale of cigarettes. Almost none of Adam’s friends smoke them. This is an enormous cultural transformation, in a very short period of time.

My friend Lara challenged me about my motives. I am aware that in addition to boosting my health, these drugs bring me more into line with the conventional idea of what it means to be good-looking. I am still not sure if this is skewing my reasoning and tilting it in favor of the drugs. It might be

But after thinking about this a lot, I have tentatively concluded that, for me, the benefits outweigh the risks, and for that reason, I’m going to carry on taking these drugs for the foresee- able future. The advice I started to offer other people was: if your BMI is lower than 27, you definitely shouldn’t take these drugs. If your BMI is higher than 35, you don’t have a family history of thyroid cancer, and you’re not trying to get pregnant, you should probably take these drugs. If your BMI is between 27 and 35, it’s more of a finely balanced debate. But I am also conscious that lots of reasonable people will look at the same facts I have looked at and reach different conclusions on this.

My third conviction is that, whatever you decide for yourself, we should be urgently putting measures in place to prevent some of the problems these drugs will cause for more vulnerable people. I remain really worried about people with eating disorders using these drugs to try to achieve their goal of starving them- selves. We can’t prevent it entirely, but we can do a lot to limit it. We need to stop these drugs from being prescribed online. To get them, you should have to go, in person, to a doctor who is trained in detecting eating disorders.

So with these three convictions, I thought I had the moral finale for this book. Fight for an environment where we don’t face the choices like this in the first place.