← The Ezra Klein Show
The Ezra Klein Show
GLP-1s and the ‘Wild West’ of Wellness
01:13:57
Here’s a shocking number: One out of eight American adults is taking a GLP-1, like Ozempic or Zepbound, according to a KFF poll. GLP-1s are the biggest pharmaceutical story since antidepressants. But there’s still so much we don’t know. “We’re only at the beginning of what’s been called this Ozempic era,” the journalist Julia Belluz told me. “I think we’re really just at the beginning of discovering the benefits and the harms of these drugs.” These discoveries begin in the research but are also expanding into how we think about our punishing beauty standards and the blurry lines between illness and wellness. Belluz is a contributing Opinion writer and the author, with Kevin Hall, of “Food Intelligence.” She’s one of the best health and science reporters I know and has been reporting on GLP-1s for years. In this conversation, Belluz takes me through what we know — and don’t know — about GLP-1s, their unexpected uses, how they are clashing with a culture obsessed with thinness an...
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- [01:00]
Ezra Klein
Here's a number that actually shocked me when I learned it. It's from a new Kaiser Family foundation poll. One out of eight Americans, you know, taking a GLP one one out of eight. Maybe I shouldn't have been so shocked because the number is higher in my social circles. I have tried these for reasons I'll explain, but they're a strange medication, right? They don't make you lose weight, they make you not want to eat food. But then they do all these other things. They seem to protect people's heart health independent of losing weight. They're protective of kidneys, of livers. There is ongoing research about dementia and Alzheimer's. They have all these strange effects on addiction and desire. But should everyone be on these? Like, what does it mean for society to have access to drugs that regulate desire in this way? What do they mean for the sick? What do they mean for the well, I wanted to do an episode on this for a while, but haven't known quite how to approach it. And then Julie Ballouz, who's a contributing writer at New York Times Opinion and co author of the book Food Intelligence and also was a health and science reporter with me back at Vox, she started doing a lot of reporting on GLP1s and she's written a lot of great pieces on them, including doing some really interesting survey work. One of the survey questions that really stuck with me was of people on them, more than 60% would continue with them even if they didn't help them lose weight. So why is that? Well, I want to ask Julia. She's someone who I really, really trust to look at the science of these questions in the most rigorous way possible and also to look at the experiences patients are having on them in the most compassionate and curious way possible. As always, my email Ezra clientshowytimes.com. Julia Blues, welcome to the show.
- [03:07]
Julia Belluz
Thank you so much. It's a pleasure to be here.
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Ezra Klein
So I was shocked by this number. According to the Kaiser Family Foundation's poll, one in eight Americans are currently taking
- [03:16]
Julia Belluz
a GLP1 why, yes, it was surprising to me too. So one of the ways we can understand this is there's this very long history of people seeking out basically, the magical elixir for weight loss. Right. So I think that's one piece of it. And now we finally have something that rivals the only other effective medical intervention we've had to help people lose weight, which is bariatric surgery. On the other hand, there's a lot of people who are living with diabetes, and I think that's another reason that diabetes that we see so many people who are on these drugs. In addition, I think these drugs have really met a particular moment, which is this algorithmic social media age. They're everywhere. In the US we already had this relatively unrestricted approach to marketing pharmaceuticals. We see them advertised everywhere. We've seen this telemedicine industry flourish since COVID but also around these drugs, and I think that's why we're seeing these shocking numbers.
- [04:13]
Ezra Klein
So I want to start on the part of this that people actually don't talk about that much, which is diabetes, which is what these drugs are originally approved for. As you say, a huge number of Americans have diabetes and have terrible health consequences, often from it, including limb amputation and blindness. What do these drugs do for diabetics?
- [04:33]
Julia Belluz
Yeah, so our bodies produce GLP1 naturally. So we have this hormone that's produced in our gut, in our brains, and to a lesser extent, in the pancreas. Basically, they're this synthetic version, a hormone we produce naturally. And the big breakthrough for diabetes was that they're stimulating the pancreas to release insulin only in the context of high blood sugar. So it's not like when you take insulin and you need to be careful about what you're eating, and you're at risk of really low blood sugar levels, and the dangers that come with that. These are only stimulating insulin secretion when your blood sugar is running high. So as researchers who are working on this are trying higher and higher doses to help people with diabetes get more and more benefit, they start to discover these weight loss results in the trial. So people start to spontaneously lose weight. And then later, we're finding all these slew of other benefits that no one would have predicted. No pharma company would have bet on this. We're only at the beginning of what's been called this Ozempic era. I think we're really just at the beginning of discovering the benefits and the harms of these drugs.
- [05:34]
Ezra Klein
Okay. So you have the recognition, which is just something people begin observing, that diabetics on these drugs begin to lose weight and they don't feel hungry. And as researchers begin testing, you know, the first generation of this Ozempic, what we now in that context, call wegovy, how big is the effect size? What do we actually know about what wegovy does for weight loss? There's another one which is slightly more advanced. It has more mechanisms of action to its appetite, which is also goes by zepbound. How much weight do people lose on these?
- [06:12]
Julia Belluz
So it depends on the drug, but we're talking like 15 to 30%. So it's the first time we have a drug that really rivals the more effective types of bariatric surgery. The key point is that it's turning down appetite, so it's not ramping up metabolism or energy burn. And the idea was that this is a gut hormone. That's the thing that a lot of people focused on. It's released after eating, and it helps people signal satiety. It helps them feel full and know that they've eaten. And we're just giving a really souped up version of this gut hormone. And it turns out that actually you need to stimulate the brain GLP1 system to get the weight loss effects. So you only interfere with appetite. Once you reach this brain GLP1 system.
- [06:55]
Ezra Klein
You've written or co written a whole book about the metabolism. And one of the arguments of that book, one of the arguments of books in this space that I think people don't appreciate, is that hunger is a function of the brain, and it's a function of the brain's reaction and predictions about the world around it. We always have this idea that people just feel hungry and then, you know, you should use your brain to decide if you want to eat, but your brain is deciding if you feel hungry and you're sort of fighting its own instincts. So I'd like you to spend a minute on this idea that hunger is a function of the stomach versus hunger is a function of the brain. And sort of how researchers moved from one to the other.
- [07:37]
Julia Belluz
Yeah, the way we describe it in the book, we use this analogy of breathing. So if I tell you, like, take control of your breath right now, like breathe more slowly or breathe more quickly, or hold your breath, you can take control for short periods of time, but eventually physiology takes over. And the same thing is true of what we eat. So we have this illusion of control over our individual meals and snacks, but there's this symphony of internal signals that's going on inside of us all the time. And the brain is sort of leading this symphony. And. And the decisions we make are much less a product of conscious control that I think many people appreciate. So when you're taking a GLP one, you're getting a much higher, longer lasting version of what your body produces. And it has to reach the brain through the gut brain barrier. So it has to reach through the gut brain barrier. And the theory is that it's reaching into the part of the brain that usually signals that there's a toxin in circulation. And so that shuts down your appetite and increases your nausea.
- [08:36]
Ezra Klein
Like what you would get during food poisoning or something.
- [08:39]
Julia Belluz
Exactly. Or what you would have on a. These are the most common side effects of these drugs. Right. So it reaches into.
- [08:46]
Ezra Klein
So the wonder drug we've invented is we've made your brain slightly think it's being poisoned all the time.
- [08:49]
Julia Belluz
I think that's one way to put it. Absolutely. And so this modernity. Baby. I know. And in the context of our completely toxic food environment. Right. It's just turning down your appetite by reaching into this GLP1 brain system. So it's reaches through the gut brain barrier, but it acts as a neurotransmitter in the brain and from there reaches other parts of the brain. This is a very active area of research, but that's the sort of bottom line. And this dialing down of appetite is the key feature of these drugs.
- [09:20]
Ezra Klein
One of the things that I find interesting about the GLP1s is we basically created this food environment that does not exist in nature of hyper sugary, hyper fatty, hyper salty, hyper calorie dense foods. Our brains are evolved over very, very long periods of time to treat those as getting three cherries on the salt machine and to really, really want them. So we've put people into this hyper stimulating environment, but we didn't change everybody's brain to turn down the level of hunger. When you come into something that is very calorie dense or very sugar dense. And so we've been asking people with these, like caveman, all of us, myself, caveman brains. Now surrounded by the fruits of modern industrialized food production, where the Mars company is spending God knows how much on R and D to make my kids want M&MS. And it doesn't work for people. And then we blame them and tell them they've not done a good job exercising their willpower and self control.
- [10:25]
Julia Belluz
I think you were also someone who struggled with weight earlier in your life.
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Ezra Klein
I was very, very heavy until I was almost an adult. Like I lost like 60 ish. Pounds, 50 ish pounds when I was 16. And then ever since, like I fight my food desires. Like if we had a bowl of Oreos on this table, 30, 50% of my mental energy the whole time we were talking, but did not eat the Oreos.
- [10:51]
Julia Belluz
Right? Yeah, absolutely. I remember we had lunch in Washington when I was. Lots of obesity reporting. And you said, why am I a person who, if the chocolate cake is there, like 50% of my brain is focused on the chocolate cake. And I didn't have a good answer for you then.
- [11:06]
Ezra Klein
Do you have one now?
- [11:07]
Julia Belluz
I do, yeah. I think it's that, you know, so when, when we think about something like common obesity. So there's many different types of obesity, but what most people have is called common obesity. And it arises from these tiny, like over a thousand genetic variants that all act, almost all act in the brain. And so you have a neurobiology probably that's from someone who doesn't have to fight the chocolate cake. And I actually did genetic testing for the book. And I'm also someone who struggles with my weight. Turns out I have a higher genetic risk than like 90% of the population. But this risk in a particular environment won't be expressed. But as you said, when you put people like us in environments where there's lots of M and Ms. And lots of chocolate cake, it becomes much harder. And I think most people don't have this privilege, let's say, of being able to finally curate their environment, to control their weight and maybe the way we might have had.
- [12:00]
Ezra Klein
I have a family member who I'm not related to by blood. And one thing that always amazes me is she will order dessert, and she loves dessert and she loves chocolate cake, and she'll eat half the cake and then take the rest home. And I always look at that and I think, whatever is happening in you is not happening in me. Or possibly vice versa. Whatever's happening in me is not happening in you. And then I feel in other ways elsewhere in my life. I can have a cigarette or a puff on a vape. I have no interest in another. It does not excite any desire in me. I can have a whiskey and leave half of it or a glass of wine, and I don't particularly want to keep going. And I've had people in my life who struggle with alcoholism and I don't have willpower. They don't.
- [12:51]
Julia Belluz
Yes.
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Ezra Klein
Something is happening in their bodies or in their minds.
- [12:55]
Julia Belluz
Absolutely.
- [12:55]
Ezra Klein
That is not happening in mine. And. And I've always thought the way we blame people for this is so cruel because it is so often people who don't have the propulsive desire blaming people who do for not exercising willpower. But those people aren't exercising willpower. I'm not exercising willpower to not have more cigarettes. I don't want them.
- [13:19]
Julia Belluz
No, absolutely. I have this conversation all the time with my husband. For some people, the cards are just stacked against them. One person that really helped my thinking on this was Robert the Sapolsky, who you've probably talked about. Yeah. He talks about how we have these potentials or vulnerabilities that are created by our genetics. And then in different environments, they're either expressed or activated or not not expressed. Right. Like, it's extremely hard to, you know, do the right thing, to buy the foods that you know you should be eating or to exercise every day. When you're working the night shift and you're raising kids and you're the single mom or dad or whatever it is. Like, how are you going to do all the things that, you know you need to be doing to protect your health and to fight against this neurobiology that you might have?
- [14:04]
Ezra Klein
So you have this interplay of biology, neurobiology, as you're saying it, this thing we call willpower, which is a very poorly specified concept. And then environment, to me, this question of environment is really important. I'll use myself as the example. You know, when I lost a lot of weight, I mean, when I was younger, a lot younger, but high school student with nothing to do. And I was able to really, really hold that when I was a young adult. And I have not been able to diet successfully since I had kids because I can't control the food environment. And there's a lot of other things I can control. I have money, I can go to the gym. I have a certain amount of autonomy over my schedule. So as you say, when you add in things like the night shift, when you add in not having the money to get healthy foods or go to the gym, when you add in more kids or less time, willpower works very, very differently. When you are able to have the autonomy or the money to create a certain kind of environment around you that is conducive to living the certain way. Right. You're a Hollywood celebrity with a personal chef versus you're a single mother of four who works two jobs. And this idea that willpower is some unchanging muscle inside the mind as opposed to some reserve discipline that gets depleted. Like, if I don't sleep enough, I eat more, Right?
- [15:30]
Julia Belluz
Absolutely. And you're designed to eat more when you don't sleep enough. And you're absolutely right that this symphony of internal signals that I was referring to earlier, it's interplaying with our environment.
- [15:40]
Ezra Klein
So one thing I've really appreciated about your work on the GLP1s, as a reporter and as somebody who's very deep in the science, is you've done a tremendous amount of interviewing people on them, and you've interviewed many of the kinds of people, and again, to me, this has always been the cruelty of this conversation, who were exercising a tremendous amount of constant willpower, going on and off like very restrictive diets, losing 30 pounds, gaining it back. What is it like for them, for the people who've seen huge amounts of weight loss? How do they describe the experience of being on a GLP1 versus what it's like off of one?
- [16:18]
Julia Belluz
I think the big common thread for people in whom the drugs are effective for weight loss is this idea that suddenly this willpower that they were always searching for, that they feel they didn't have enough of, suddenly they have it. Suddenly it's not that hard to say no to the extra piece of cake or the cake altogether. They're eating smaller portions, their cravings change. Like, there's a lot of discussion about food noise. So that's this when the cake is there, 30 to 50% of your brain is on the cake, or you have cravings that distract you. A lot of people say that this just disappears.
- [16:51]
Ezra Klein
You said a second ago, for whom the drugs are effective, for whom are they effective and for whom aren't they effective and why?
- [17:00]
Julia Belluz
So this is another area we don't fully understand, but it seems like there are some people who are quite sensitive to the drugs and others who are insensitive to the drugs. And there might be a genetic component to this, too. That's sort of a frontier area of science. And so I think the quest that a lot of the companies are on is to understand, like, how do we differentiate the people who might need higher doses initially or much lower doses because they're having so much sensitivity to the drugs and side effects and whatnot, they're having such a strong response or losing weight too fast. So there absolutely is this variation in how people are responding.
- [17:37]
Ezra Klein
Tell me about the side effects of these GLP1 drugs. In studies, people often don't stay on them that long. People do cycle off of them, sometimes for cost, but sometimes for other reasons, like what is unpleasant on them, what can go wrong.
- [17:51]
Julia Belluz
So the most common that we know of right now are the gastrointestinal side effects. So the nausea, the vomiting, the diarrhea, those are the most common. But it seems like there's other emerging potential problems. So there are lawsuits around severe stomach problems, damage to the ocular nerve, so eye damage and those. I don't think we have clear answers on how common that is. But the basis of those lawsuits is that people weren't properly warned that this could happen. One thing that a lot of people don't seem to be warned about is the fact that you have to stay on them to keep reaping the weight loss benefits. There's an idea that a lot of people have. I'll lose the weight, I'll learn how to eat properly, and then I'll go off the drugs. I'm always surprised that even people who got the drugs from their doctors don't seem to.
- [18:38]
Ezra Klein
What happens when people go off the drugs?
- [18:39]
Julia Belluz
You tend to regain the weight.
- [18:41]
Ezra Klein
You just feel hungrier again. The appetite resets.
- [18:44]
Julia Belluz
Exactly. This appetite that was suppressed through acting on the brain GLP1 brain system. That effect is gone and you're back to the food noise. You're back to the hunger that you had before.
- [18:56]
Ezra Klein
I've heard this and it's definitely true in the data, but I guess people in my life have chronic conditions and the drugs are on, they just have to stay on them. You know, you stop taking statins and the effect goes away. If you're diabetic, you have to keep taking your insulin. That I get. I feel like that's like a. Like people who are used to drugs to treat acute conditions, not being used to drugs to treat chronic conditions.
- [19:17]
Julia Belluz
But I think that this is the thing like that goes back to the beginning of the conversation, that a lot of people still have this idea that they should just be able to will their way out of it. Right. I think these drugs helped reveal how much we are products of our physiology and that with this, you know, you take this drug and suddenly again you have the willpower you didn't have for your whole life. But there's still this expectation. It's like any other diet. And that feels like a place where people haven't been warned. But as we've been saying, there are now so many people on the drugs and I think these more rare side effects we're going to start to learn more about.
- [19:53]
Ezra Klein
I want to talk about a possible social side effect, which is our culture's expectations for what people's bodies should look like have been punishing for a long time, particularly Punishing for women and girls. I think we've interestingly been entering an era where they're increasingly punishing on boys and men. And there's this whole thing of, like, male look smacksing. And the guys in the Marvel movies are completely jacked now. And on all kinds of things you probably shouldn't be taking. And, you know, if you're obese or overweight and you're taking a GLP1 to lose weight or to, you know, protect your cardiovascular system, you know, great. But I think a lot of the cultural effect of them has come from celebrities and influencers who all of a sudden show up and are much thinner, at times skeletal now in ways that when you have the body's natural hunger signals coming back at you is harder to do. You know, there was, like, this big body positivity movement, and that was always gonna be a very uphill climb in this country. But how do you think about GLP1s as possibly a pharmaceutical accelerator of, you know, fairly dangerous body expectations? Because now it's like, well, if you wanna look thinner, why not just go on a GLP1?
- [21:19]
Julia Belluz
That's absolutely a strand in this conversation and in this moment that we're living in. The place that it freaks me out the most is I talk to pediatricians who are prescribing the drugs in children. There's no screening yet for these drugs and eating disorders in young people. And they anecdotally have seen people use these as aids for essentially eating disorders and kind of exacerbating eating disordered behavior. One of the underlying assumptions of the health at Every Size or fat activism or body positivity movements was that you can't control your body size, therefore you must accept it. We had surgery before. It wasn't as accessible or scalable, but now we do have this medication where people do have the option, right?
- [22:02]
Ezra Klein
Or at least the ones who are
- [22:03]
Julia Belluz
sensitive to it and the ones who can afford it and access it and all of that. We've seen influential people in the body positivity fat activism movement come forward and really grapple with starting on these drugs and losing weight on. And one thing that those movements did that was really important was highlight how much shame and stigma people who are living with obesity face every day, especially women. So, like, there was this great Economist article a few years ago where they parsed the data on the pay penalty, and they did such a great job of highlighting the discrimination and stigma that people with obesity face. But I think there was really a dangerous glossing over of the health Effects of, of carrying extra weight, that even if there is this variation in individuals at the population level, it's very clear that the higher you go up the BMI ladder, the more health risks you're carrying. I've spoken to people who are part of these movements. They had issues with movement, they had problems with their blood sugar, they were concerned about fertility, and they were so grateful to be able to now have a medication that could help with those issues. That debate became very polarized. It was either you're fat accepting or fat phobic. And I think we're kind of moving to something maybe in between.
- [23:20]
Ezra Klein
I take your point on that, but put that side of the debate over here. That was always an effort that was running up against the mainstream of American culture, which believes very strongly in thinness as a synonym for virtue. And one thing that the people I know are worried about and frankly that I'm worried about, I mean, I feel like I would not have had this concern for like young boys, which is what I have a while ago. And now I look at the rise of male look smackers and it looks a lot like toxic diet culture that girls were exposed to before, you know, and obviously clavicular, who is the avatar of that, has talked a lot about being on, you know, GLP1s or some form of these drugs. I wonder what it's going to do when it is just that much easier for people at the top of society to exert heretofore unknown levels of control over their bodies. And when they're doing it with these like wild stacks of GLP1s and peptides and, you know, pills to prevent hair loss and everything else, you know, constant botox like that filters down.
- [24:32]
Julia Belluz
Oh, absolutely.
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Ezra Klein
And it makes the, the ideal both like ever more unreachable and ever more punishing to try to reach.
- [24:41]
Julia Belluz
No, I think about this a lot with kids. There's this, basically this market that hasn't been tapped to the extent that the adults have, which is children with obesity and diet caused diseases. And I think it's something like 1% of children who are eligible are taking these drugs now. But I think that number is expected to rise stratospherically pretty quickly, especially with the expanded access and going to pill form. And there's so much, there's like a lot we don't know in adults. There's so much we don't know about what it means to suppress appetite during these critical phases of growth and development. At the same time, diet caused diseases like obesity and diabetes. They hit Young people particularly hard. And there's some question with diabetes, for example, about interactions with growth hormone and insulin signaling because the disease comes on so ferociously and it's so hard to treat in young people. So now we have this treatment or thing that can actually help young people in a way we couldn't accept with bariatric surgery before. But what is it gonna mean for them when we're. Yes, blunting appetite not only with the pressures on body image at that age, but also on, yeah, your muscles, bones, puberty, all these things. Right. We're about to put all these young people on these drugs. Right. Like, I think about my kids and the pressures that they're gonna face. I think about. I don't know if you've done this thought experiment, but imagine being like chubby 16 year old Ezra now. Would you have gone on one of these drugs at 16? You know, I also, I think my weight fluctuated a lot, but I think around 17 or 18, I would have had obesity. And would I have pushed, like my parents to say, you know, I really wanted GLP1 and where would I be now? Would I have had a happier childhood? And like our teens and early 20s, if I had one of these drugs, would I have learned to eat in the way that I've learned to eat by changing my food environment? I don't know. Like I've. But the pressures I think young people are going to face now, growing up in the culture that we have, it's scary, it's punishing. I'm terrified for my kids when I hope that there's some sort of correction, but I don't know if the correction is coming or how. You know,
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Ezra Klein
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- [28:47]
Ezra Klein
So the conversation we've been having here sort of tracks what I would call like the first cycle of Ozempic coverage. Excitement. And then a new thing begins happening. And it's sort of when I began paying closer attention, there was a study that came out that particularly caught my eye as a former healthcare reporter, which was that we were seeing huge drops in mortality from any form of cardiac event. But the drops didn't seem to be connected or didn't need to be connected to losing weight.
- [29:23]
Julia Belluz
That's right, yeah.
- [29:24]
Ezra Klein
So can you explain what we saw then and then how that begins to shift the story here?
- [29:29]
Julia Belluz
Sure, yeah. So we have this drug that comes on the market for diabetes in the diabetes trials, as we start ramping up the doses, people start to lose weight. And then for any diabetes drug now that comes onto the market, there's a requirement that companies must look into what these drugs do to cardiovascular events to look for harms. Does this increase the risk of a cardiovascular event?
- [29:53]
Ezra Klein
Past weight loss drugs like fen phen, which were not diabetes drugs, did increase the risk of cardiovascular events. Right. We've had wonder weight loss drugs before and they gave people heart issues.
- [30:04]
Julia Belluz
Exactly. So they're looking for harms and instead they find this 20% risk reduction.
- [30:10]
Ezra Klein
And put that in context for me, how big is that?
- [30:12]
Julia Belluz
It's big. Statins are a drug that are targeting these conditions and the risk reduction is something like 29%. What's really significant about it is it seems that more and more of the benefits that researchers are discovering from these drugs seem to be weight independent. So in other words, what everyone expected is you make people lose weight, inflammation in the body goes down, your metabolism of fat and sugar improves. So maybe you see improvements in, in fatty liver disease or your diabetes or whatever it is. But what no one predicted was that you would start to see these weight independent benefits. And that goes for the heart, it goes for the liver, I think the kidney. There's a slew of benefits that seem to be weight independent.
- [30:57]
Ezra Klein
There's possible benefits on dementia. I mean, my understanding of this is that observationally, people on these seem to have much lower risk of dementia. They did a study seeing if it a randomized controlled trial, seeing if it, it improves people who have Alzheimer's and it didn't. But we're not sure about whether or not it can prevent Alzheimer's. And some people seem to believe Alzheimer's or dementia are metabolically activated. And so now there's this whole question of is it cognitively protective?
- [31:26]
Julia Belluz
So the Alzheimer's trials, so these were really much anticipated, randomized controlled trials to see what would happen with these drugs in Alzheimer's and they had negative results. And so it was a big disappointment to the community and to the companies. But there is this question of in a different population or with a different dose or a different drug, will we see the benefits? And that's an active question or if it's earlier, right? Yeah, if you're intervening earlier, it's an active question and area of study. So I don't think that case is closed. And sleep apnea is a big one. Sleep apnea is weight dependent, so you need to lose the weight to see the benefit. But that's another indication that these drugs are approved for now.
- [32:06]
Ezra Klein
So these weight independent results, they break our theory of the mechanism of health improvement here a little bit. So as doctors and scientists try to grapple with this, how does our sense of what the drug is doing and why it is helping the body change?
- [32:23]
Julia Belluz
So there's a researcher in Toronto, Dan Drucker, who helped discover this whole class of drugs. And he described to me like, let's. Basically there's these three buckets. So one is the weight loss bucket, that's clear. It's going to help you lose weight and you'll get the benefits from the weight loss. The second bucket is reducing inflammation. So inflammation is when you're exposed to a pathogen, an infection, an injury, your body mounts this immune response and it can signal healing. But when it goes into kind of overdrive at low levels, you have this chronic inflammation. And that's a hallmark of many of these diseases we've been talking about obesity, diabetes, cardiovascular disease. And these drugs seem to lower work on inflammation, they seem to lower inflammation. And this to me is the most exciting area because we've had drugs in the past that kind of shut down inflammation, like steroids, let's say. But you put people at risk because you're essentially shutting down the immune system. You're putting people at higher risk for cancer or other infections. But the way this is described to me is that GLP1 seem to act as these fine tuners of inflammation. So they have this more subtle approach and it's not something we've really had in medicine before. So we're using these drugs. So GLP1 and there's other drugs that are coming on the market with like the dual and triple agonists that use more than GLP1. And the question is, like, are we going to discover these other hormones that we can subtly manipulate the immune system and inflammation with? And so we might just be at the beginning of this. And I think the other exciting facet of it is we might really get amazing insights into the immune system through these drugs that we haven't had before because we haven't been able to do these more subtle manipulations. But the third way these drugs seem to help people is by directly targeting the organs that are involved in particular diseases. So sending signals to the liver to heal scarring involved in fatty liver disease, or to clear the fat from the liver or whatever it is to promote healing in the liver or the kidneys. So that's a third way these drugs seem to be helping people.
- [34:33]
Ezra Klein
Why would it do any of that?
- [34:35]
Julia Belluz
Your guess is as good as mine. There's models in mice of what's going on. But how this is working inside of us, we don't know.
- [34:44]
Ezra Klein
My family has a lot of cardiovascular disease in it that has hit members of my family young. And as everybody sort of around me began going on GLP1, so I began reading these things about cardiac events. I was like, am I an idiot for not being on one? Are we all going to be on one of these in a few years? And so I've tried them. I want to talk about that experience in a minute, but I want to ask that underlying question of you given these three buckets you just described and how many things they seem to be helping to treat. It increasingly seemed to me like, shouldn't everybody be on low dose Ozempic or Tirzepatide if you're seeing possible reductions in dementia that we don't really know, but reductions in reductions in cardiovascular events, reductions in liver and kidney disease, reductions in sleep apnea, improved blood sugar. We'll talk about the addiction and compulsivity findings later. But it began to seem like a thing we should be putting in the water.
- [35:44]
Julia Belluz
No? I had the same question as you. And the deeper I dive into the science, the more I wondered the same thing. We did this poll with the Times for a piece of of GLP1 users and asked them, like, what's your experience been like? And I went into that poll thinking we would get these kind of negative results. I had a feeling that a lot of the headlines in the media had been quite triumphalist about these wonder drugs, but we weren't reporting what the lived experiences of people on these drugs was really like with the side effects and cycling in and out of insurance. And what we got back was people kind of generally feeling great and having benefits that they didn't expect and that they wanted to stay on the drug for reasons other than which the drugs were prescribed.
- [36:26]
Ezra Klein
It was amazing to me that 63% of people in your survey said even if the drug didn't work for weight loss, they'd want to stay on it.
- [36:31]
Julia Belluz
No, this was. It shocked me. I did not expect this. One of the most amazing stories to me is the woman who had post concussion syndrome for almost a decade, whose life was essentially, I don't want to say shut down, but it was. She was suffering deeply with symptoms, and she started to find mice and cell research suggesting these drugs could benefit post concussion syndrome. So she talked to her doctor, she got the prescription, and she tries it, and within days she starts to experience benefit, and now she's back to her normal life. But the big key is we haven't done a randomized controlled trial on this. We don't have the high quality evidence to say, is this going to be everyone with Post concussion syndrome, 80% of people are like 2%. We don't know. In addition, we don't understand how these drugs interact. For example, if you were on, God forbid, but some other type of, like a cancer therapeutic or something like this, we don't know how does this fine tuning of the immune system. I talked about work when you're taking an immunotherapy, for example. There are so many unknowns, and researchers are always going to be cautious. But I ask almost all the researchers, I talk to this question, and they all say, we're not at that stage where we should just all be on this.
- [37:46]
Ezra Klein
I understand why the researchers have to say, well, look, we don't know. But we don't know actually isn't an answer to that question. You have to make a decision like as a person with one life and a life where you have a chance of getting heart disease, a chance of developing dementia, a chance of developing kidney disease, a chance of developing all these different things. And you have to look at these studies or the coverage of these studies more to the point, and say, or say with your doctor, do I think I should be on this thing that seems to modulate inflammation which appears to be a source of cause of all kinds of major chronic and acute illnesses people develop or not. And one reason I think you're seeing, like, really, really aggressive experimentation, particularly around this class of drugs, is because something that has all these effects for the well or for chronic conditions, saying, well, I don't know, in 12 years maybe we'll know more. You actually kind of have to make a yes or no decision as a person, because if you miss out on protecting your body from the chronic effects of ongoing inflammation for five years, you've missed out on five years of protection and you have accumulated five years of damage. But I know different doctors feel differently about this, and I feel like we're in this place. It's actually like really tender and tricky.
- [39:14]
Julia Belluz
Absolutely. But I think the question I was answering earlier was this. Should it be in the drinking water?
- [39:18]
Ezra Klein
Should everybody. I didn't mean to actually make it mandatory.
- [39:21]
Julia Belluz
No, no, no. But, yeah, no, but this question of should you, Ezra, as an individual with your particular family history and your underlying disease risk profile or whatever you've struggled with already, should you be on the drug? That's a conversation people and you should certainly have with your doctor and get the prescription and have someone monitor you. What scares me about this GLP1 era is how many people are circumventing the medical system. They're getting these very low barrier prescriptions through telemedicine. They're going to elicit research chemicals through people like influencers on TikTok. There's so much enthusiasm and I've seen this happen with other drugs. It's like it seems to do everything and then we dial it back. We're not quite there yet that we can just say, put it in the drinking water.
- [40:10]
Ezra Klein
So I went on the lowest dose of tirzepatide, like 2 1/2 milligrams. And I did not have the experience that people in your survey had. So on the one hand, it's like the most interesting drug or one of them that I've ever tried, legal or non legal, because I seem to be sensitive to it. And all of a sudden I just didn't want to eat, which is never an experience I've had before. It was like living in somebody else's brain, the way I've described it to people. I used a slot machine analogy earlier. It's like being a gambler who loves slots and going up to a slot machine and pulling the thing and getting the three cherries and then nothing lights up. It made me feel like that there was this level of Experience that I hadn't even recognized I had, which was around desire. Like, I would taste something and it would be good, or I'd smell something and I hadn't noticed that the thing. It would then trigger another feeling, which was desire. Because, like, the feelings were so connected for me. But all of a sudden I would have that same experience, and then the desire wouldn't trigger, and I would walk by the candy bowl and not stop, or I would leave half the burrito on my plate. It was, in a way, revelatory. The problem is it made me quite depressed, Interesting and anhedonic. And whether that was because I wasn't eating enough or what was going on. But the thing where people report more energy and more focus and feeling cheerier, for me, it really dulled experience.
- [41:39]
Julia Belluz
Almost sounds like an antidepressant experience.
- [41:41]
Ezra Klein
Well, and that's why I think it's interesting to bring in my own experience, because there is this whole thing where it's working on some kind of reward mechanism, too, maybe dopamine. But people are reporting not just a desire to eat less, but a desire to do all kinds of things less. Drink alcohol, take drugs, online, shop. And then this anhedonia thing is also being reported by people. And so what have you seen about the whole reward system dynamic of it?
- [42:08]
Julia Belluz
Yeah.
- [42:08]
Ezra Klein
So this was in your reporting.
- [42:10]
Julia Belluz
Yeah. So this has been a very exciting area and one that we've paid a lot of attention to, I think, in particular in the media, because the anecdotes are so startling, and I think they're real. I've talked about to people who have reported, like, reversals of alcoholism, the desire to smoke. Sex addiction, like any kind of addictive behavior you can imagine, seem to be dialed down with these drugs. The trials to date have been mixed, and the researchers who study reward are quite cynical that these results are going to endure. And the way it's been described to me is so for a long time, we know that if you make rodents hungry, they're more likely to have addictive behaviors. Like, they're more likely to get hooked on cocaine or push the lever. So hunger has this overlapping pathway with these other motivated behaviors, and it can increase the risk of addictive behavior, it seems. And so one explanation is that once you've been on these drugs for a while and your appetite starts to normalize, you've lost the weight and your hunger starts to normalize again. Whether the results for addiction are gonna actually endure after that. I think a lot of people think about these as clear treatments for these addictive behaviors. And that's where I think we don't have the high quality research we wanna have to defend that.
- [43:31]
Ezra Klein
My assumption of why some people were getting anhedonia, some people were seeing, you know, lower desire for drinking, that was actually not necessarily that it would end up proving to be a clear treatment, but that it is messing with a system we don't really understand. I mean, I sort of think what's interesting about this whole conversation is we're basically saying we don't understand any of the systems very well. We don't understand the appetite system. It's working in different way than we hypothesized. The cardiac system is not doing what we thought it would be doing. We don't know why the inflammation system is responding. The reward system is changing. I mean, the human body is a very, very, very complex set of systems and this seems to be a complex change to them. That at the population level is positive, probably, but not in a way where we can precisely define the mechanisms by which it is positive or tell you for whom it will be positive, for whom it will be negative, and who will actually lose weight and who will won't and how much. It's a very weird space, actually.
- [44:37]
Julia Belluz
Absolutely. And that's where I really feel this, like that we're just at the beginning of this. After we ran this piece where we did the poll and talked about all these other surprising benefits people have experienced, I got lots of emails about weird people who were on SSRIs. So they were on antidepressants and they start on a GLP1 and they completely spiral. And that's not something that I've seen show up in the randomized control trials or the research. But it's an experience that people have. So I think we're gonna have lots more of this. At the scale that people are taking these drugs. We're seeing these new drugs are coming down the pipeline. We're seeing that there's now oral forms of these drugs available. The drugs are going generic. We're gonna see more and more people on these drugs and learn much more about them. There's so much we don't know what
- [45:27]
Ezra Klein
about all the drugs that are coming now. So I know people who are getting reditride from some compounding pharmacy in China or something. And reditoutride, maybe you can explain it, but it's another Eli Lilly drug. Eli Lilly also makes Zepound, the tirzepatide variant. And this is in trials now, and it's expected that it will be approved in the Next some amount of time and it'll probably be a big deal, but it works even better than the other two. But I don't really understand why all these people I know are getting a compounded thing from pharmacies they can't oversee when there are perfectly good GLP1s on the market now that you could get and have full confidence in the way they're being manufactured. Like what's going on with reddit2tread? Why is it both, like, around my community and all over my social media feeds?
- [46:13]
Julia Belluz
Oh, interesting. This says something about are you in bodybuilding algorithms or.
- [46:17]
Ezra Klein
No, this is just longevity algorithms. This is a straight up X for me.
- [46:20]
Julia Belluz
Oh, interesting. Okay, that's interesting. So it's a research compound that's still under study. It's targeting three hormone receptors. So semaglutide, Ozempic, or wegovy is targeting one. And this is where at the beginning of the conversation we talked about how we had this, a lot of research on these diabetes drugs over many years, and we could be fairly confident in their safety profile. These drugs that have come on since, like Manjaro, like Tirzepatide and like Radatrutride, they're targeting more than just the GLP one, so they're targeting other hormone receptors. And we don't have long term data on these drugs. And I think that's a really important thing that a lot of people overlook. Right. So this one is still under study, but in the research we have so far, it looks like it's causing faster and more dramatic weight loss and it's taken off in, I think, longevity and bodybuilding social media.
- [47:14]
Ezra Klein
Well, because the argument I keep seeing about it is that it increases energy use, that it seems to have some independent effect on how much calories are burning.
- [47:23]
Julia Belluz
Yeah, I'm not sure what the mechanism, but that could make sense that it's not just reducing appetite, it's also increasing metabolism. And maybe that's why people lose even more weight more quickly. But the point is we have this emerging evidence that it might be even more effective than what's already available. And I think it just speaks to the frenzy around these drugs that people don't want to wait for the FDA to get the randomized controlled trials to approve the drug. They're going directly to illicit sources and trying to buy the drug, which is still a research compound.
- [47:56]
Ezra Klein
People I knew who used to order drugs on the Internet, they were ordering fun drugs. Now it's like these weird eat less and focus more. One thing I think is interesting about the GLP1s, I mean, for everything we've talked about here is for instance, the categories of who might want to lose a little bit of weight or even more so who might want to protect themselves from inflammation. They speak to this reality that, that the difference between well and sick is not this clear binary thing. We now have these categories like pre diabetic and pre hypertensive and pre menopausal. And we didn't used to have them. I mean, we keep expanding the space in which you should worry. We have pre overweight, pre obese kind of things. And I think that there is an interesting dimension as people start looking for chemical answers to wellness. Because the truth is, for a lot of people, get enough sleep and go to the gym regularly and eat whole foods is hard. If you could give yourself a shot or take a pill, people want it. And so how do you think about the broader shift, which is not new, but it's happening with more force right now towards medicine as not a way of treating illness, but as a way of optimizing wellness? Do you see it as something new? Is that something old?
- [49:26]
Julia Belluz
I think it's more pervasive maybe, but I think we have to be careful. So if you think about the American public, like most people aren't eating the minimum daily requirements of fruits and vegetables, let alone personalizing or optimizing their diet. Beyond that, most people aren't getting enough sleep, most people aren't getting enough physical activity. And I think that that's the majority. Right?
- [49:47]
Ezra Klein
I'm agreeing with that.
- [49:48]
Julia Belluz
Yeah. But then there is, I think, this minority that we pay a lot of attention to in the media that is interested in the longevity and the optimization.
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- [51:39]
Ezra Klein
I don't think there's anything that new about wanting to use medicine to be more well as opposed to heal from illness. And we've been doing that forever and we've had health and wellness influencers forever. But I think if you look around the media scape at this exact moment and you think about how big Rogan and Huberman and Attia and then you have like Brian Johnson as one of the breakout media figures of the era. This sort of former entrepreneur who's trying to never die and is like the, you know, has like ended up in this incredibly, incredibly intense regimen of, of optimization. I'm very skeptical this is ultimately going to be good for him, but it's his life I guess. Clavicular, this lookmaxer streamer who hits his head with a hammer and is on these crazy stacks and OD'd the other day on a live stream is getting billions of views on his clips. And I think there's something about the way how dominant this has become in the media sphere and it doesn't have checks it used to have on it. I mean you were talking, I remember the coverage you would do at Vox of Dr. Oz. But one of the things happening on Dr. Oz was there was a network behind that. I mean there were gatekeepers, there were people who didn't want to see their stock price go down if something went wrong. And now it's a complete wild west boosted by algorithmic interest. And I think it's going to push us into a real period of a longevity and optimization focused system because there's going to be money for it, there's going to be attention for it. And so yeah, I mean a lot of people in this country are very, very sick and what they need is treatment for chronic illness. But I think there's gonna be a real push in the system towards treating these people who what they are is not very sick. What they are is well and they want to be weller.
- [53:33]
Julia Belluz
So we always had the worried well and like people have always done really wild things to optimize their health. But the megaphone is so much bigger and more fragmented and it's so much more effective at creating the, this confirmation bias. Like I think about my mom who was diagnosed with osteoporosis and she was trying to decide whether to go on one of these medicines, it's available for the condition. And she ended up in a complete YouTube rabbit hole of doctors who were really skeptical of osteoporosis drugs. And she became quite frightened and it took her like a couple of years to go on the medication. And this is happening at a scale that we've never seen before. Right, but this desire to optimize. Like, like in our book, we found this wild example of after the first World War, there was an ingredient in explosives manufacturing that sped up the metabolism and caused people to lose weight. And doctors at Stanford pivoted and turned it into a drug that was taken by like hundreds of thousands of people and became one of the first targets of the fda. And it had terrible side effects and killed people and caused eye problems. And so I think we've always done these wild things in search of looking for the magic cure, the quick fix or bettering our health. But the in your face ness of the messages and the way they're targeted with the algorithms, this we've never seen. So I think you're touching on something really important, which is how this media landscape has changed not only around the blockbuster FDA approved drugs like the GLP1s, but around this broader ecosystem of, yeah, wellness hacks and optimizers.
- [55:12]
Ezra Klein
I mean, this goes to something that you wrote about in a piece you did for the Times, which is that these are the first blockbuster drugs to collide with our wellness obsessed algorithmic age. And yeah, I mean, I must have clicked at some point on Reddit who tried content on X. And now every time I turn on the system, the platform, I get these videos from people like, tell me how great reditoutride is. And there's a huge boom in people just ordering peptides from places where they can't really tell what's in them. The New Yorker tested some of these and found a lot of them have lead or impurities or things you don't want or they're not at the right dose. There's something wrong. We got these blockbuster drugs and you might expect everybody to be really excited and be on them, but it seems to have exploded into this biohacking moment in which it's like, if something like WeGovy could exist, well then who knows what is out there? And you should order it from China and inject it into yourself and find out, right? Like what do you make of it?
- [56:18]
Julia Belluz
I think it's sort of the perfect drug for this social media algorithmic age that we're in. Because it's visual, right? It's not like you have the before and after photos. You have. I've spent spend way more time than I'd like to admit on TikTok and Reddit accounts where you see the videos and the before and after photos and how people's bodies are transforming and we were kind of living in this very appearance obsessed culture. And now for the first time again, we have this drug that does something that humans have quested after for like a century or more. And so it's meeting that moment. I was doing a thought experiment when I was working on that piece. So when Prozac came on the market, that was another blockbuster drug. That was another drug where we had a cultural moment around it. But we didn't have telemedicine, so you still had to go to your doctor to get a prescription. The Internet wasn't in widespread use, so you couldn't order a research compound from China. There was no social media to compare your personal experiences and share them with the world. So yeah, I think that we have all those things now when we have this elixir that, that we've wanted for so long, right, the weight loss elixir. So many people have wanted this. We have it at the same time as we have all these other things that have just helped create, I think the moment that we're in.
- [57:36]
Ezra Klein
I guess this does reflect what I've told my algorithm to tell me, although not intentionally. I see so many people just posting about random studies that are not full randomized, controlled trials are often not even in human beings. And being like, see, look at this amazing mechanism and look at these early results. And at least according to them, they're getting them compounded and ordering them. I am fascinated by this because there is some weird overlap between the community of people who are incredibly skeptical of vaccines, of the fda and at one point that was understood as a preference for naturalism, that there was a primitivist impulse here. And yet some of these same people who were so skeptical of ouch, who was what was a very well studied class of drugs, are now ordering completely unknown forms of peptides, some which are about weight loss, but some of which are just to increase energy use or to cure your tennis elbow or to try to improve like, you know, cell regeneration. And they're stacking them in different formulations. Like, it's like a mistrust of the authorities, but a belief in unproven technologies in a way that, like, that I find find culturally very interesting. And I'm curious, as somebody who's been around the space for a long time, what you've made of it.
- [59:02]
Julia Belluz
Well, I think it kind of goes together. So we. We have, I think, since the pandemic we've had, and maybe even it was brewing before the pandemic, but we've had this uptick in an appreciation, an interest in health and health optimization. And then we have these technologies now to spread information about health optimization. Podcasts in particular, that are often sponsored by supplement makers. They're mistrustful of authority. And a lot of people, I think, were left quite cynical after the pandemic of public health and the medical establishment. And now we have this vehicle, actually, that was helped also in the pandemic with telemedicine, where people can take their health in their own hands in a way that they haven't been able to before. And then this idea that you can just do it yourself, it feels like that's almost the currency today of social media. Like, you know, you say, there's this new study and this new. I found this new use for something, and now I'm going to promote it on my feeds.
- [60:02]
Ezra Klein
Well, I think it reflects this way in which you have to trust something. The world is simply too complex for anybody to have firsthand knowledge of very much of it at all. So. So you can trust established authorities like the FDA and the cdc, but if you lose trust in them, you have to still find some way of deciding what to believe and what not to believe. And a lot of people choose individual voices, you know, Andrew Huberman or Joe Rogan or Peter Attia or people further into the Maha world. And I'm not even saying they're necessarily corrupt. But if you're in media, for instance, and you run a podcast on health and wellness, week after week, you have to find new things to say. Just getting on the mic every week and saying, here's another week when you should eat whole foods and try to reduce your stress and sleep well, it doesn't last. Even putting aside the fact that some of them are getting a cut of either supplement companies or advertising for it, they have this huge bias towards the next new thing.
- [61:10]
Julia Belluz
And it was always there. Right. I spent a lot of time earlier in my reporting career with you at Vox, like, looking at Dr. Oz, and I remember once interviewing him years ago and he said, you know that I think I said, like, why do you have the magic and miracles on your show? Like, you're a cardiothoracic surgeon. You know, this isn't research based. It was a question like that. And he said, you know, if I didn't have the magic in miracles, I wouldn't have a show. I think there's also the very sound advice, the very sound scientific foundation we have for how to optimize your health. It's so boring, right? It's what you said. It's like sleep more, have social relationships, eat more vegetables. The stuff your mom has been saying to you since you were in your high chair.
- [61:50]
Ezra Klein
And yeah, I will say before I make this next point that I think injecting yourself or taking poorly studied peptides is a stupid idea and people shouldn't do it. So I really want to say this very clearly, but in preparing this episode and reading what some of the peptide booster types are saying, their argument is, look, people have a right to do this. It is their body, they are doing it. And it would be better if we let them buy them from domestic compounders whose processes we could regulate and oversee rather than these fly by night Chinese companies that we can't trust. But how do you think about balancing this argument? Like, look, people are doing this. It's their right. We should allow them to get things that are safely made against this. Like, the government doesn't want you doing this and we're gonna try to make it hard to get them and increase the risk so more people don't try.
- [62:49]
Julia Belluz
So that argument is how we got the supplement market. We have. Do you know that the history of how supplements became kind of this.
- [62:56]
Ezra Klein
No.
- [62:56]
Julia Belluz
Tell me about the fda. There was a big campaign push in particular helped by supplement makers. It was like a massive letter writing campaign on the part of the public. TV ads with famous actors. And the thing was like, don't touch my supplements. I have the right to use these. Supplement and representatives who are from states with large supplement manufacturers really pushed to have this kind of lax regulatory environment. But it was this argument that Americans have the right to use the supplements they want to use. That's why we have this regulatory regime around supplements that we have today. I personally think the government has a role in protecting public health and protecting consumers.
- [63:39]
Ezra Klein
Which way does a supplement argument actually point? You walk into Whole Foods or you walk into CVS and there's a lot of supplements. And I don't think we see it as like a national tragedy. And a lot of those Supplements have names. I don't even know. And it doesn't seem like they do that much when I look into it. But maybe, and some people seem to think so. So is that a bad thing or a good thing? Right. Am I upset people can create these supplement stacks? I mean, I mean, not really. If you want to take L Theanine or whatever, go for it.
- [64:07]
Julia Belluz
I think when people are being misled and using scarce resources on things that aren't going to help them, I think actually it is a problem, but it's a very sensitive topic. And a lot of people, especially in the American context, it's this idea that, you know, you have the right to do what you want with your body and to access the products that you want to access. And I guess I have a more conservative view on that. But a lot of people definitely disagree with me.
- [64:37]
Ezra Klein
I mean, my gut is that this is going to become a disaster. My personal view is actually fairly conservative. I'm trying to be the devil's advocate here, but it seems like people are taking a lot of things right now to increase cell growth, which maybe is good in the short term, but has really frightening cancerous properties in some of these cases. In the long term, I mean, I think we might end up realizing that a couple of the things that people are starting to get excited about are really not good for folks, which has happened before. I mean, we were talking about fen, phen and things like that earlier. We have had periods where people got really into something and it wasn't good for you. We used to put cocaine in Coca Cola.
- [65:17]
Julia Belluz
Absolutely, yeah. If you know anything about the history of medicine, it's littered with examples like this. And that's also why I always come at this much more conservatively. But I think we're definitely in this big experiment now where these different things are colliding, right? This interest in wellness and longevity and health optimization, the availability of these drugs that seem to do everything and then these over the counter variants that people are accessing and buying online or in the pharmacy. It's a potential disaster waiting to happen.
- [65:49]
Ezra Klein
One thing that I think is just a deep appeal of these drugs of broader peptides and other things that are becoming culturally influential is on some level, we all want is control. Control over our bodies, control over our health, control over never getting the diseases that scare all of us. And on the one hand, if you are able to be given a real possibility for control, if it's true that the GLP1s at low doses protect you against heart disease, amazing statins have been amazing. I have a friend, somebody who I care about tremendously, whose parent died young of dementia. And I've been following all this Alzheimer's research on them, you know, very closely because if they're prophylactic against dementia, like I want my friend to take them. So I'm not saying that wanting to protect yourself is a bad impulse. It isn't. On the other hand, a desire for endless control over your own body and future can be mentally poisonous too, because you can't control it. The great insight of Buddhism is that desire and craving are the root of suffering. And the more we trick ourselves into believing we can control what will happen to us, then when things do happen to us, we feel like we failed.
- [67:10]
Julia Belluz
Absolutely. We live in food environments that are so gamed against making the right choices for most people. Right. So even if you are on the GLP1 and I've talked to many of these people, they're not losing the amount of weight they want to lose because they have other barriers to eating the way or exercising the way they'd like to. We've created these systems and food environments that make it literally impossible for most regular people to do the things that they know they need to be doing for their health. And that's something that I would love more attention paid to by whoever's in power, like pulling more levers to help prevent these diseases from the first place so that we don't have to do things like inject young people with drugs that we don't understand the long term effects of. And I'm not anti GLP1 at all. Like I think they've been absolute game changers for so many people I've talked about for friends and family. But we're doing this big experiment on the population because of diseases that really are preventable if we do the things that we've long known we need to do, like restricting junk food marketing to kids, figuring out ways to make healthy food more accessible. Actually it enrages me as a person who struggled with my weight before, like this realization that this was preventable. I didn't have to suffer like that. And like the kids who are now going through this now, they don't have to suffer like this.
- [68:34]
Ezra Klein
I feel like I've heard this argument as long as I've been touching this issue which, like, as you know, the beginning of my career as a healthcare reporter, you know, we would debate food deserts and what would happen if we put, you know, good grocery stores in food deserts. And we did this in a bunch of places, and it didn't really work. I've become very cynical about this. I mean, yes, it would be much better if everybody had. Was like, wrapped around with, you know, more walkable places to live and better and healthy foods. And I don't think you should be able to advertise junk food at all to children. I think it should be illegal to have Paw Patrol on kids cereals. I think this whole thing where we allow endless advertising children is completely insane, and it makes every parent's life in the grocery store a nightmare. Myself included. And for the society at large. I think the problem is people want things that aren't good for them, but
- [69:26]
Julia Belluz
we've never done enough.
- [69:28]
Ezra Klein
But people don't want you to do enough.
- [69:30]
Julia Belluz
But which people? I feel like the people who vote
- [69:32]
Ezra Klein
like this happened in New York. Bloomberg wanted to tax sodas. I think they almost ran them out of town on a rail.
- [69:38]
Julia Belluz
Okay. No, but I think things are. The politics of this are changing. I think, like, more and more people are raising kids with diseases like diabetes and fatty liver, and they're aware that this is caused by the food environment. And I feel like that the politics there is shifting, but we've never done the inversion of our food environment that we need to do. It's gonna take many, many levers to really see an impact, and that really hasn't been done.
- [70:03]
Ezra Klein
I think you would need a level of paternalism for that. That. I guess what I would say about it is that there is not a single jurisdiction in this entire country where the politics of that have worked. We cannot point at one thing, one place, one state, one city where we've been able to do that much. If it were there to do, I would be the first one to say we should do it. But I don't think it's there to do. The public health community, we tried to get people to take vaccines in the aftermath or the. The math during a deadly pandemic. And it led to the largest public health backlash in my lifetime, such that RFK Jr. Is now the Secretary of Health and Human Services. People's sensitivity to paternalism is very, very, very high. It's a very potent political force.
- [70:52]
Julia Belluz
But I think one thing that I'm talking about and that we write about in the book, it's not about taking people's fried chicken or their M&Ms. Away. It's about making a food environment where the healthy options are as accessible as the unhealthy stuff. And so I'm living now in France, and obviously the politics are completely Different. There's no shortage of chocolatiers of places where I can buy croissant, brioche, like all these things that I know I shouldn't be eating every day. But as accessible are the healthy options. So they've done things like fresh food markets in every district. They minimize the size of grocery stores through land use planning since the late 1800s, like using school lunches as a lever to feed children healthfully. And over time, they've become more and more avant garde about what that actually means. They pull all these different levers. What we're talking about, I think, is creating this regulatory environment around chronic disease. Like, how do you protect the public from developing these diseases like obesity, diabetes, cardiovascular disease? And it seems like, seems like impossible now because it does involve these radical changes to the food environment. But America did this over a hundred years ago, right when we started to protect people against acute food poisoning. It was just, it was wild west. They were putting calf brains in milk at this time and putting like brick dust to dye food in a certain way. And lead. That's where the FDA came from. That's where the meat inspection program of the USDA came from after, like the publication of Upton Sinclair's book. But I hear you. It's gonna be very difficult. I do think the politics are changing. So we're in a moment where like, places like California and West Virginia are both looking at, you know, doing things like reducing ultra processed foods in school lunches and banning certain additives. So really politically distinct places. And people like Robert F. Kennedy Jr. And Trump and the former FDA commissioner David Kessler, what they're saying about diet caused diseases. You can't tell who's saying it anymore.
- [72:55]
Ezra Klein
That's true. But I've been extremely disappointed to see that even the parts of Maha that I thought made sense have made it nowhere. Right. You will watch Kennedy now at like, like eating his tallow fried French fries and you know, go into like these fast food restaurants that, you know, if they really wanted to make America the American food environment better, they could. Meanwhile, the President of the United states is forcing RFK Jr to eat McDonald's and photo ops.
- [73:26]
Julia Belluz
Right.
- [73:27]
Ezra Klein
Like, their actual willingness, when it came down to it, to take on industry was extremely low.
- [73:32]
Julia Belluz
No. Absolutely.
- [73:33]
Ezra Klein
Yeah. If you listen to what they're saying, it's fine. Have they done anything that will, in a sustained way, change the food environment for people? I would love to have seen Maha ban, you know, advertising to kids. They didn't.
- [73:48]
Julia Belluz
No. The way I think about it is, you know, you had the new nutrition guidelines come out which had this great message, eat real food. Right. But no one is doing anything to make it easier for the people who actually really struggle to afford and access real food to eat that food. Right. It's like there's something like 3 million fewer people on SNAP. The administration has made it more and more difficult for people to cut.
- [74:11]
Ezra Klein
Yeah, huge cuts are continuing to go into effect there.
- [74:14]
Julia Belluz
And there were programs to make local and fresh produce available to schools, canteens available for school lunches, and those have been cut. And then there's a lot of, like, tweaking at the edges of, you know, swap out high fructose corn syrup with cane sugar or focusing on certain food additives. And there's such marginal problems in the greater system. If you really want to help more Americans eat real food, you're going to have to do a lot more than that. And you're going to have to focus on the segments of society that were on food stamps, for example. So I completely agree. I think a lot of the rhetoric has been in the right place. Like this is the first time I've seen at that political level people talking about the food environment and saying these diseases are preventable and they are caused by these environmental factors taking the pressure off individuals. But then a lot of the solutions that have been proposed have also been focused on individuals like give Americans more wearable devices and continuous glucose monitors. It's not the intensity of the intervention that I think we actually need.
- [75:18]
Ezra Klein
Then always our final question. What are three books you'd recommend to the audience?
- [75:22]
Julia Belluz
Three books that really shaped my thinking as I was writing my book. One was Behave by Robert Sapolsky. He wrote another book, Determined About. Basically it's an argument against free will. But he comes at this, I think, from a really interesting and important angle. Another one is Deb Blum's Poison Squad. And this is like an excellent look through a biography of one of the. Of a former chemist at the USDA who did research that helped lead to the establishment of the FDA and a lot of the food regulations and other types of consumer protection laws that we have. I loved that book. And a third book that I really enjoyed was Ultra Processed People by Chris Van Tulleken. And this is really a polemic and much more than where I ended up coming down in my book. But I thought that was a really illuminating and fascinating book on ultra processed foods.
- [76:19]
Ezra Klein
Julie Blues, thank you very much.
- [76:21]
Julia Belluz
Thank you so much.
- [76:32]
Ezra Klein
This episode of the Israel Client show is produced by Annie Galvin. Fact checking by Michelle Harris with Mary Marge Locker. Our recording engineer is Johnny Simon. Our senior audio engineer is Jeff Gelb with additional mixing by Johnny Simon. Our executive producer is Claire Gordon. The show's production team also includes Jack McCordick, Roland Hu, Marie Cassion, Marina King, Kristin Lin, Emma Kelbeck and Jan Kobel. Original music by Aman Sahota and Pat McCusker. Audience strategy by Shannon Busta. The director of Opinion Shows is Annie Rose Strasser.
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Julia Belluz
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