Are we on the verge of a weight-loss revolution?

Are we on the verge of a weight loss revolution?

HELEN: It was like a light bulb had been switched on. And I'd be halfway through a plate of food and it would just be like a little voice would go off and say, ‘Oh, we're done now.’ …

And it was life changing. It was astonishing.

IQ MUSIC

JO VOICEOVER: Welcome to LSEiQ, the podcast where we ask social scientists and other experts to answer one intelligent question. I’m Joanna Bale from the iQ team where we work with academics to bring you their latest research and ideas - and talk to people affected by the issues we explore. In this episode I ask: ‘Are we on the verge of a weight-loss revolution?’

You just met Helen. She spent nearly two years on a weight loss drug Ozempic. It’s one of a new generation of anti-obesity drugs. These drugs have become known through their transformative, and sometimes controversial, effects on the appearance of celebrities such as Oprah Winfrey, Elon Musk and Sharon Osbourne. And they’re widely available online from private providers. Now the NHS is beginning to roll them out to try to tackle one of the biggest challenges it’s facing. After smoking, obesity is the second biggest cause of cancer. It also increases the risk of coronary heart disease, type 2 diabetes and stroke. With nearly two thirds of adults either overweight or obese, the government estimates that the annual costs of obesity in the UK are £6.5 billion to the NHS and £27 billion to wider society.

I want to find out if these drugs really are the answer to the obesity crisis.

I’ll speak to:

An LSE neuroscientist who scans brains to see how we make decisions about food - and believes the new drugs might even be able to treat addictions.

An LSE economist who insists that drugs are NOT the answer - but focusing more on our wellbeing and getting our leaders out of cars and onto bikes is essential.

And an NHS clinical psychologist, working on the frontline of the obesity crisis. She says the new drugs - and the necessary support - will be hard to access in an already overstretched health service.

But first, let’s speak again to Helen, who told us about her life-changing experience on Ozempic.

JO: For people that don't know, how do you administer Ozempic? Because it's an injection, isn't it?

HELEN: Yes. So you get these pens, they've got a little vial inside them with the liquid and you attach a needle and inject yourself in your stomach or I think for some people in the thigh. It's quite a little needle and it doesn't hurt, it's not painful. It takes a little while to get the hang of it, but it is fairly simple to self-administer. And it's just a weekly injection. They show you how to do it before sending you off with it.

It does make you feel very nauseous and unpredictably so, but it's particularly bad at the start while your body's building up tolerance to it. And even a year and a half in, I was still struggling with unpredictable bouts of nausea. So that's a definite downside. But it was worth it because my weight was dropping and my blood sugar was getting much better. And I thought, I'm making the surgery as safe as possible for myself.And they did say, you can expect to lose 5% to 12% of your body weight on this. And I lost 20%. So I did exceed expectations.

JO VOICEOVER: Helen took Ozempic as she had to lose weight to get ready for bariatric surgery. That’s where the stomach is made smaller to limit the amount of food you can eat. This was a drastic but permanent medical solution to reverse her obesity-related type 2 diabetes, which she was diagnosed with at the age of 27. Left unchecked it can cause serious health problems such as blindness and nerve damage, leading to limb amputation.

HELEN:

It doesn't take away personal responsibility, it's still very possible to make bad food choices while on Ozempic. It's not like now after surgery where it's basically impossible to choose to eat junk. You can definitely still choose to eat junk on Ozempic. And you might do if you're having a bad day, a stressful day, something throws you off track.

But what it stops is the constant, I've heard people describe it as ‘food noise’, where you're constantly thinking about food and obsessing about food and what am I going to eat next and what junk do I want? And I'm craving this and I'm craving that. It gives you the ability to just stop and think about what you're doing rather than feeling in the grip of a compulsion outside of your control.

JO VOICEOVER: Helen lost nine stone through Ozempic and surgery and says she’s relieved that her diabetes symptoms have now disappeared.

Nikki Sullivanis a neuroscientist and Assistant Professor of Marketing in LSE’s Department of Management. She’s researching patients who have undergone gastric bypasses to try to understand why dieting can be easier for some and harder for others.

NIKKI: People who are good at dieting, they actually have a very different pattern of brain activity when making food choices than people who are overweight and unable to diet successfully. And so there are two parts of the brain that interact and talk to each other, one that represents the value of options to you, so how much you really want to eat a food, for example. And there's another region that helps you factor long-term information into that valuation. So thinking about, "Oh, maybe that cupcake is tasty, but I am supposed to watch my cholesterol." And so that part of the brain is helping us to factor that long-term information into our valuations.

The people who are really good at dieting, they actually have a really strong connection between these two regions, but people who aren't don't. And that predicts actually how successful people are going to become at dieting.

What's really good news about that is that you can actually strengthen those connections by practicing self-control. So you can over time, like going to the gym and exercising, you can increase those connections by just repeatedly exerting self-control in any domain. It doesn't have to be food choice because it really translates across different domains, which is I think also really good news.

Now, the other thing that makes people who are obese different from healthy people, and this is not as good news, is that we have all of these hormones in our bodies. For example, we have insulin, ghrelin, leptin, we have all of these hormones that are basically telling our bodies to maintain what we call homeostasis, so to maintain whatever body weight you're at. So if you're obese and you do lose a little bit of weight, these hormones are actually telling you to be hungry and consume more to get back to where you were before. And so this is something we had to be aware of so that we can try to counteract that in some way.

JO VOICEOVER: Nikki uses a process called functional magnetic resonance imaging, or FRMI, to scan the brains of obese patients before and after gastric bypass surgery to see how they react to being offered different food options. As well as restricting food intake, the surgery can manipulate gut hormones in a way that decreases hunger, promotes a feeling of fullness, and slows or minimizes the digestion of food.

NIKKI: What we're actually tracking is the blood flow in the brain, because when an area of the brain is much more active, we know that the blood goes to that area to provide that area more nutrition so it can fire more quickly. And so that's basically what we track so we can see in real time how different parts of the brain are firing and interacting with each other.

And so what we find before the surgery, the obese and lean patients, everyone has a bias towards yes, I want to eat the food, but actually what happens after surgery is that the obese patients, we see a dramatic difference. And so after the surgery, the obese patients, even before they see the options, their decision process is leaning towards no, I don't want to eat the foods even before seeing them.

JO: And that's because they don't have an appetite, presumably?

NIKKI: And so this is research that's active and currently in progress, and so that is exactly something we're going to check. We have the brain activity so we can see how their brain is processing the stimuli, what we call food cues, to see if that's true. We also have data about their hormone levels, insulin, ghrelin, leptin, and also how the gut microbiome has changed to see how those factors are influencing their feelings of hunger and therefore their just initial instinct about what to say about foods. And so we think that this is one of the things that's really facilitating that weight loss…

We haven't completely finished analysing all of that data yet, so I can't say for certain, but the initial results seem to be that yes, the decision process and the activity of patients after the gastric bypass surgery is different than either the obese patients who did not undergo the surgery or lean patients who didn't need the surgery. It is a little bit of a mystery why people after surgery are able to eat less when they hadn't been able to in the past. And so this is the question that we're trying to answer.

JO VOICEOVER: Nikki explained that a hormone called leptin that signals fullness doesn't appear to work the same way in people with obesity. They tend to have what scientists call "leptin resistance", meaning that it doesn't trigger fullness when their stomach is full, so they carry on eating. But after bariatric surgery, something makes them stop eating when their stomach is full. Nikki is trying to find out if it is changes in leptin levels, or something else.

I asked Nikki whether she thinks the new weight loss drugs are just a Hollywood fad or a revolution in weight loss.

NIKKI: These drugs are so fascinating because what they're meant to do is provide the body with a type of peptide that people normally feel when they've eaten a lot of food so that people will just feel more like they've eaten, they feel more satisfied, or we call it sated after a meal. They'll feel that without even having eaten anything at all. And so it's just a way to decrease the amount of food people actually want to eat.

This has been highly effective as has been shown in clinical trials, but also in the media. Everyone is wanting to take this drug.

Research has indicated that…as soon as you go off the drug, your appetite returns, and you will go back to eating the way you did before. So just like with dieting, if you go back to your previous lifestyle once you stop dieting or stop taking these drugs, you're going to be back in the same position you were before. So it's really a short-term fix for a problem that's really a lifelong problem.

And so I think when we're talking about these drugs, it's really important to frame them as a tool to help you change your lifestyle. Because research indicates that both this drug and diets will not work unless you just fundamentally change the way you live your life, making exercise a habit, totally changing the way you approach food and the kinds of foods that you eat. Otherwise, you're just going to go back to where you were.

But another thing that I find very fascinating about these drugs is that they actually don't just change your dietary choices, they seem to change any behaviour that we would consider bordering on an addiction. For example, if you have a problematic gambling behaviour, if you have a problematic relationship with alcohol, oftentimes these drugs are going to help you to say no to those things in the same way. This is a real mystery for us biologically because they really should just be changing your feelings of satiety, feeling full. But this is another avenue, and this is very exciting because this will help us to understand those addictive behaviours in the future and what is the actual mechanism.

JO: Yeah, because my understanding is that something like Ozempic just makes you feel slightly nauseous a lot of the time. So how that would stop you gambling I have no clue. So yeah, that's interesting. What do you think is going on?

NIKKI: Well, there are a lot of hypotheses, and one I think that makes sense to me is breaking the chain of what we call stimulus and reward. When you gamble or when you drink alcohol or smoke a cigarette or eat unhealthy foods, all of these things activate what we call the reward system in the brain. What I think might be happening is that these drugs are actually decreasing the reward that you feel from these behaviours, and that will then decrease your desire to do them. That's my hypothesis, but it'll be very exciting to actually see what is going on.

HALFWAYIQ MUSIC

JO VOICEOVER: You’re listening to LSEiQ. If you like this podcast you might like the LSE Events podcast which features talks by some of the most influential figures in the social sciences. Listen to a recent talk, for example, by sociologist Richard Sennett about his new book The Performer. This explores relations between performing in art - particularly music - in politics and in everyday life. For more inspiring content search LSE lectures and events wherever you get your podcasts. Now back to iQ where this month I’m asking, ‘Are we on the verge of a weight-loss revolution?’ We met Helen, who said the effects of Ozempic on her appetite were life changing. And LSE’s Dr Nikki Sullivan who believes the new drugs are an exciting tool which could also help treat addictions.

But are drugs really the answer?

Paul Frijters is Professor in Wellbeing Economics in LSE’s Department of Social Policy. He’s sceptical.

PAUL:If you have a high weight, then there's a lot of evidence to suggest that you feel worse about yourself simply because you are high weight…

But we were interested in our research in the opposite way around, whether if your self-worth was down for some particular reason. For instance, you just lost a friend or you got fired or for some other reason you felt badly about yourself, whether or not that made you increase your weight. So whether or not in those periods you'd do less exercise, you'd eat more, you would sort of go for comfort more, and also that you would be less oriented towards the future. You'd be more in survival mode you might say. And we found strong evidence for that in Australia so that there was a quite large effect of sort of a period of unusual self-worth due to external circumstances on your self-image, on the degree to which you cared about yourself in future years and you were just sort of trying to feel okay now, and hence as a result, your weight went up.

JO:OK. And what's the implication of that research from a policy perspective, do you think?

PAUL:The easy policy implication could be that we try to avoid people having low self-esteem, but of course that's a difficult one. We can do a bit of that because we know that self-esteem is tied to people's positions in groups. And so we can try to resurrect community life to a larger degree than we've had. And particularly what was bad for community life and for people's sense of self-worth around that time was lockdowns. Lockdowns was very much a sort of an assault on normal social living. People no longer mixed, they were more isolated. If they met, they met on Zoom, but it's not the same. It's not as warm.

It doesn't make us feel as good. It takes energy rather than gives energy. And so my number one policy implication would be, well stop doing these mass self-worth harming activities. Lockdowns is one of them, but I think in general, alarmism, safetyism as it's called, and so that's alarmism over the climate or alarmism over the next war. Those things are all bad for the self-worth and community feel of individuals.

And one should treat those things more as well. These are the challenges of life, and we may be worried about them, but let’s not go apocalyptic.

JO VOICEOVER: During the pandemic, some economists argued that lockdowns were damaging to wellbeing and to economies, and that blanket restrictions should be replaced with measures targeted specifically at groups most at risk. Paul says the data shows that obesity increased during lockdowns, particularly among children, meaning they are at greater risk of developing diseases like cancer, diabetes, arthritis and stroke.

I asked him what he thinks of the new drugs.

PAUL: So I've looked at the clinical trial studies that have been recently published in the New England Journal of Medicine on this, and there are several things to say about those studies. One is they found within the space of...64 weeks, so a bit over a year, a quite significant weight loss for those people who kept at it, something like 10% among the obese, but still a 10% weight loss within a year is quite a strong weight loss. And so I think we'll see a lot of that in the magazines. What the unknown is in the longer term is how severe the side effects are going to be.

So they found quite a number of people with gastrointestinal problems, so basically diarrhoea and stomach problems. And something like 60 out of a thousand dropped out, which is a quite large percentage. It was so bad basically, their intestinal problems, that they dropped out. There were also gallbladder issues, which might be significant and loss of sugar levels in the blood, which is what these things are supposed to do, but that also might cause fainting in some people. So there is an unknown long-run side effects story, but of course there's also a known long-run nasty side effect of being obese.

And so you're trading in one set of side effects, which are still somewhat unknown, for known major health problems in being obese. And so the jury is a little bit out as to what the long-run health consequences will be. But so far, the data does suggest that there is a weight loss gain from that, and that then feeds over into mobility and other kind of advantages. So I don't think the fad is over yet. If it proves to be a fad, like many diets, which often look good in the first year, particularly among people who do them, but then turns out people can't keep at them, and two years later people end up being even higher weight than before so we'll see. But I doubt the craze is over.

JO: Yeah. I guess as soon as you come off the drug, you put the weight back on unless you make some permanent changes so it would involve people being on those drugs for life.

PAUL:Well, one never knows. It is a medicalization, of course, of what is really a behavioural thing. And so if you want permanent changes, then behaviour has to change. But in that sense, drugs are the wrong answer because we are such social animals that to change our behaviour in isolation is almost impossible for us as humans. We really only change our behaviour if our whole group changes behaviour and that requires a group response. So that requires us sitting together with our groups and with parliamentarians and with our representatives and our leaders, and also at LSE and also in businesses. And then there's got to be real conversations, which is, well, do we want to remain like this? And if not, what are we prepared to do different….

Are we going to insist that, for instance, that our politicians don't go to their work in a big… car but like in the Netherlands they arrive by bike. In fact, there's not even an option of arriving by car. And we do this for foreign dignitaries too. They want to visit us; they can come walk or cycle the last couple of kilometres to show a good example. Are we prepared to go there or are we not prepared to go there? Are we not that serious about this? …

JO: But can you really see the British Prime Minister foregoing the big car, and the helicopter even?

PAUL: I come from the Netherlands and so we are used to having not just the prime minister, but also the king and the queen going places on foot and on bike and in various other ways be seen to be involved in sports. And so I think that that is what a good example would be like. And I think Rishi Sunak probably is quite a healthy dude and so I don't think he'd mind. I mean, there may be security arrangements might have to be made, but I don't think that this would be a bad idea if the whole of the cabinet does this right and that they're seen to be exercising with all their senior staff regularly, and in fact that they have meetings whilst moving. Why do we have to sit down for meetings all the time? That is not actually necessary in many cases.

But it requires a serious commitment. And of course, also a kind of national conversation that we have to say, look, enough is enough. We're all becoming obese. This is not good for any of us. It's costing us billions for the National Health Service, which takes up services that could be had for people with far less preventable illnesses. This is a bad example to our children. Is this really how we want to exist in the coming centuries? No, this is unsustainable.

I think that if we start seeing our habits around food as something that we as a group can change, that we can also start seeing our current behaviour in a less positive light. Because I mean, if I give my friends and family cakes, I feel good. I'm filling them up with sugar and they're grateful. And as we say, you don't make friends with salad. And so if I alone change my behaviour, I'll be the outlier, I'll be the one without friends. But we can of course, make a national deal out of this….

So if someone else at some conference has a whole spread of cakes and hamburgers, then well, maybe we should be a little bit angry. What are you trying to do to me? Are you trying to make my health worse?...

I don't think I want to do away with alcohol in office life because otherwise it's just unbearable, but I do think we can do away with all the cakes and the fatty stuff.

JO: (laughing) I agree!

PAUL: Right. There are limits.

JO: Yes.

PAUL: We've got to pick our winners here.

JO: Absolutely! (laughter)

JO VOICEOVER: Paul believes the new drugs will prove popular but what is really needed are behavioural changes in the way we eat and exercise. He says that politicians and other high-profile people should lead by example. One British politician regularly filmed and photographed while out running was Boris Johnson. He recently revealed that he had also tried the new drugs - but said he couldn’t tolerate the nausea.

Former health secretary Steve Barclay hailed the drugs as a potential gamechanger for the NHS. So, will those of us who want to lose weight soon be able to ask our GP for a prescription? Or will it continue to be available only to those who can afford the £300 a month charged by private online providers?

Dr Sarah Appleton is a highly specialist clinical psychologist working in weight management at Guy’s and St Thomas's NHS Foundation Trust in London. She works in what’s known as Tier 3 interventions. That means treating people living with complex and enduring obesity. But there are long waiting lists. She told me some shocking statistics about lack of resources.

SARAH: We are working in an NHS at the moment that is really strained and I really feel it as a clinician and I really feel for the people that we are working with.…

About 4.1 million people are eligible for tier three support within the UK, yet we have something like 35,000 places. So there's already a huge difficulty in access and we really see that across the country with areas just not having tier three provision. That also represents a real challenge for things like the medication that's obviously coming out if these are being prescribed in a specialist weight management service, that I think is really, really important. But fundamentally we may not have the infrastructure to be able to do that. So that is a huge challenge that we see.

JO VOICEOVER: The NHS has strict criteria for those seeking the new drugs. NICE, the National Institute for Health and Care Excellence, which provides recommendations to the NHS, has approved Wegovy, also known as semaglutide, for the treatment of obesity - but only to those with a Body Mass Index, or BMI, of over 35, or a BMI of 30 to 34.9 with a weight related disease such as diabetes. They have to be prescribed within specialist weight management services, which, as Sarah explained, have limited availability. And they can’t be prescribed for more than two years at a time.

SARAH: (SECOND RECORDING –first answer) I think medication can be and is a really helpful tool for people living with obesity. In terms of the outcomes that I’ve seen in clinical practice so far, and I want to acknowledge that these numbers are limited at the moment, I’ve seen people have really good weight outcomes from the medication. That said, I’ve also seen a number of challenges including people losing weight and still not "feeling better" within their body which can be hugely distressing, or people having to stop the medication and their weight increasing. Importantly, the people I have spoken with seem to really want to make long-term changes to their health and to use this window of opportunity when they are on the medication to do the psychological work and embed new habits. It’s important to acknowledge that the medication isn’t going to address some of the underlying reasons why someone might be experiencing difficulty with weight – for example trauma or binge eating – so accessing the medication in addition to psychological support is hopefully going to offer the best support.

JO: I know they're new medications, so nobody really knows what the long-term effects are, but I just wondered whether people will start taking them almost permanently as a way of just controlling their appetite or whatever- if that's something that could happen in the future?

SARAH: I think it’s something that could happen in the future and to be honest I think this makes sense in terms of obesity being a chronic disease. Ultimately, the longer-term prescribing of these drugs is still being worked out so we don’t really have the answers to this yet – and I think it’s important that anyone who is taking these drugs is aware of that. I know that there are other medications that may be even more effective on the horizon, such as Tirzepatide, but again we don’t know when this will be or what the long-term solution will look like. I recognise that this is a lot of uncertainty for both patients and healthcare providers but I do think it’s hugely exciting that the landscape around medication and hopefully the support that we can offer to those living with obesity is changing.

Fundamentally, while improving our treatment for obesity is hugely important, I think we also need to take a look at why we’re having to put people on medication in the first place. Why do we have this rising obesity crisis and what can we do to focus on prevention at a whole system level – looking at our obesity strategy – rather than just on treatment.

JO VOICEOVER: Global demand for the new drugs is so high that Novo Nordisk, the Danish manufacturer of Ozempic and Wegovy, last year became the most valuable company in Europe – superseding the French luxury goods maker LVMH, which owns brands like Louis Vuitton and Dior. The success of the drug has caused the value of the company’s shares to more than quadruple since 2018, gaining 41 per cent last year alone. Other companies are joining in on the boom by developing similar drugs.

So does this signal the start of a weight-loss revolution?

Everyone we’ve met believes the drugs are an exciting new tool to help tackle the obesity crisis. But they are not a miracle solution. They say policy makers urgently need to address the reasons why people become obese in the first place and fundamental change is needed.

The last word goes to Helen who suffered nausea for nearly two years on Ozempic then underwent painful bariatric surgery to help her lose nine stone.

HELEN: We're in a society where women are heavily sexualized. I'm sure lots of women will recognize the sense of during teens and early twenties being subject to a lot of harassment. And when you put on weight that goes away or at least cuts down significantly.

So, I feel more vulnerable physically than I did. I feel like I've lost my armour. And that takes some getting used to. You'll probably notice, Jo, these glasses are quite severe, and that's a very deliberate choice. I knew I was going to feel quite vulnerable after surgery when I lost lots of weight rapidly. And I thought I want to look as stern as possible to help me deal with that.

The main thing is in terms of diabetic symptoms, the whole reason I did this to try and reverse the diabetes, is that lots of the fiddly little diabetic symptoms….

are clearing up, which is wonderful. I don't currently know if I'm still diabetic or not, but presumably they test me at some point. And I think hopefully they'll say, "Yep, your type two is in reverse, you're not diabetic anymore." That will be the moment when I think this was definitely worth it.

IQ MUSIC

JO OUTRO: This episode was produced and written by me, Joanna Bale, with script development by Sophie Mallett and editing by Oliver Johnson. If you’d like to find out more about the research in this episode, head to the show notes. And if you enjoy iQ, please leave us a review.

Next month?