Junk food is addictive. Drugs like Ozempic treat addiction. But when will we tackle Big Food like we did Big Tobacco?

Since Ozempic hit the public consciousness as a weight-loss medication, one in eight Americans have tried it (or a version of it) to lose weight.

This is remarkable: less than five years ago, most people reading this would not have known these drugs existed. As availability of Ozempic and other GLP-1 based medications has increased, so has controversy. Are they worsening “fat stigma”? Are they safe in the long term? Why aren’t they more affordable? Aren’t they just a chemical solution to a man-made problem?

Review: Diet, Drugs and Dopamine: The Promise – and Peril – of the Latest Weight-Loss Drugs – David A. Kessler (Text Publishing)

When the former head of the United States Food and Drug Administration (FDA), Dr David A. Kessler, suggests answers to these questions, it is worth pausing to listen. As a GP who regularly treats patients with obesity, I found many of his arguments convincing. In Diet, Drugs and Dopamine, he writes:

We can now effectively treat obesity [with GLP-1 injectables], even if we are only masking the root cause. It may seem absurd to have one industry make us sick only to have another industry develop drugs to treat that sickness.

Provocatively, he directly likens the smoking industry of the past to today’s food industry: specifically, ultra-formulated foods, which are foods with “super-normal combinations of fat and sugar, fat and salt, and carbs and salt, that are always within reach”. These foods have been modified from their original form to such an extent they are barely recognisable, but highly palatable and easily transportable.

Speaking from experience

Kessler speaks not only with the authority of decades of scientific understanding, but with the empathy of personal understanding: he struggles with obesity himself and used GLP-1 drugs to cut his body fat in half: from 30% to 15%.

He told the Washington Post the side effects were unpleasant, including bloating, intense chills and “occasional sharp abdominal pains”. He also said these drugs could “halt the trajectory of chronic disease in the United States if used under medical supervision and by the right people”.

This book deep dives into why Kessler personally, along with millions around the world, struggles to lose weight and keep it off. He points out:

I have two advanced degrees […] I have been Dean of two medical schools. I’ve run the FDA. No-one would ever accuse me of not having discipline and determination.

If managing weight were simply about sufficient education and willpower, Kessler – for one – would not struggle with it. But he does. His book invites readers to lay down their assumptions and be open to new ways of thinking about obesity.

He is not presenting anything new. His unique contribution here is the drawing together of insights from various fields of research (addiction, endocrinology, obesity medicine), telling a compelling story about why obesity is so prevalent and difficult to treat. It is a story of many influences: including biology, psychology and even the economy.

Weight is a health issue

In some ways, this is a dense read. Kessler’s references (at the end) take up a full third of the book. But in other ways, it’s an easy read. He writes in a narrative style, weaving conversations with researchers into his personal story of struggle. In this way, he pre-empts reader arguments, showing us how his views differ from others.

For example, he gives voice to the opinions of the “Body Positivity” movement – which advocates for respect and acceptance of all body sizes – while still concluding losing weight is something we need to aim for. He recognises weight is not a cosmetic issue, but a health issue: many serious diseases, like heart failure, stroke, rheumatioid arthritis and diabetes, share obesity as a risk factor.

Our society’s failure to act on obesity will lead to increasing illness, Kessler argues. He backs this – and all his claims – with pages of data, which he presents in relatable forms. For example, 13 types of cancer have an increased risk with obesity. A man with a BMI greater than 40 gets nine years shaved off his life.

Kessler structures the book in four parts. The first, provocatively, is about the addictive power of food. This way of viewing food underpins the rest of the book. Part 2 explains the complex biology of weight gain and loss. (Spoiler: it’s not just about counting calories and exercising.) Part 3 outlines the role of GLP-1 medications in sustainable weight loss in a comprehensive, practical and nuanced way.

And the final part cautions readers not to rely purely on medication, pointing to environmental factors that have led to obesity in the first place, like sedentary lifestyles and diets dominated by unhealthy foods.

Ultra-formulated foods: the culprit

Humming throughout, rising to a crescendo in the last section, is the accusation of a prime mover behind the obesity epidemic: hyper-palatable foods that have been created this way on purpose by adding sugar, salt and fat. This results in both long shelf lives, and enjoyable sensations when eaten (for example: crunchy or soft). Creating these properties means significantly changing a food from its original state, or even creating it from scratch in a laboratory.

He wisely refuses to get dragged into discussing “ultra-processed foods” (UPFs), which have become a politically contentious topic. Debate around the exact definition of a “UPF” has allowed the food industry to distract and deflect from their potential harms. By using the term “ultra-formulated food”, Kessler neatly side-steps those with a vested interest in defending UPFs.

The problem, he contends, lies in the addictive qualities of ultra-formulated foods, which – coupled with diminished nutrient content – cause metabolic mayhem when we eat them. Our glucose levels spike and visceral fat builds up.

Ultra-formulated foods are abundant, too. There are reasonable arguments that processing food has been essential in staving off starvation. But instead of helping us avoid illness, ultra-formulated products are “weapons against our biology”.

The FDA, his prior workplace, sets guidelines around food safety, he points out. But, he asks, why there are no regulations protecting the community from food that is heavily processed to become hyper-palatable and energy dense, but low in nutrition?

What needs to happen?

Kessler’s final call is directed at both individuals and communities. He calls on us to untangle ourselves from dependence on ultra-formulated foods. And he wants communities to collectively demand a healthier future.

Kessler is methodical in his explanations, continually anticipating and rebutting potential arguments. Much of what he says is compelling – but the real question is what each of us chooses to do about it.

His take-homes in a nutshell: ultra-formulated foods are addictive. GLP-1 injectables treat that addiction. But the ultimate solution is to regulate ultra-formulated foods in the first place.

Natasha Yates is affiliated with the RACGP