O’Sullivan’s GP, he says, raised the prospect of gastric band surgery — a permanent and serious intervention. Or, he suggested, he could try a new class of weight-loss drugs: the glucagon-like peptide agonists, or GLP-1, drugs tirzepatide (sold as Mounjaro) or semaglutide (Wegovy/Ozempic). There was a catch. At the time, the drugs — which work by suppressing users’ appetites — were not available via the NHS.

He remembers being confused. “You’re telling me to go on it, but you won’t give it to me?” O’Sullivan, who is not working because of poor health, was desperate, and in May 2025, he paid for his first dose of Mounjaro.

Eight months later, he has lost 30 pounds. His diabetes is in remission; and his BMI has fallen from 47 to 33. Even his mental health — he has bipolar disorder — has improved. “It’s done wonders for me,” he says.

But he is struggling financially. “I’m behind on every bill because of it,” O’Sullivan says. In September, Eli Lilly increased the UK price of Mounjaro by 170%; it is now £330 per month for the highest dose. “I have to make choices every month with food, electric. I’ve got two dogs. What do you do?”

His story is not unusual. There are now 2.5 million British people — nearly one in 20 adults — taking weight-loss drugs. That figure has doubled in a year, even in the face of supply shortages and price hikes. Given those are figures from July 2025 and do not include the black market, the true number is likely already much higher. “Anyone who says they anticipated this is lying,” says Prof. Giles Yeo, an obesity expert and professor of molecular neuroendocrinology at Cambridge University. “Not even the drug companies.”

Arguably not since the pill has a medication changed society so widely, so fast. Grocery sales have fallen by an estimated £136 million per year. Alcohol sales are also down, with three-quarters of GLP users cutting back, according to research by Kantar. Restaurants from the Fat Duck to Greggs are introducing smaller-sized “Mounjaro menus”, while supermarkets from the Co-Op to Marks & Spencer have launched “nutrient dense” ranges for those on the jabs. The clothing industry is enjoying a surge in sales of smaller sizes, as users adjust their wardrobes. Tirzepatide manufacturer Eli Lilly, meanwhile, has doubled its profits and tripled its stock price, recently becoming the first healthcare company to be valued at $1 trillion.

But not everyone is seeing the benefits. Fewer than 200,000 patients currently receive tirzepatide through the NHS, due to a combination of strict prescription guidelines and challenges accessing funding. NHS England is phasing in GLP1-s for weight loss over several years; currently only patients with a Body Mass Index (BMI) of 40 and multiple comorbidities (such as diabetes, heart disease, and sleep apnea) are eligible. That’s a tiny fraction of Britain’s estimated 18 million obese people. Everyone else must pay privately: in many cases over £3,300 per year, which makes up nearly 10% of the UK’s average salary. For many, that price is too high.

O’Sullivan has been posting on YouTube about his Mounjaro journey. Through his followers, he has seen the drugs changing other people’s lives. “I have friends on it who have stopped drinking,” he says. “A few people gave up smoking.”

But since the price hike, he says, many have had to cut back, or give up entirely. “I speak to loads of subscribers and they’ve had to stop,” he says. “People who are working and they have families, and they just can’t [afford it]. It’s heartbreaking. It’s changed their life, and now they’re back to eating again.”

***

Nearly two-thirds of British adults are obese or overweight, according to the NHS. Those on low income are more likely to be overweight — women from the most deprived areas, for example, are twice as likely to be obese than those from the most affluent ones. Naveed Sattar, professor of cardiometabolic medicine at the University of Glasgow and Chair of the government’s Obesity Healthcare Goals program, tells me that 25 years ago, he considered obesity was a major factor in around one in 20 patients. “Now I’m seeing it in four in ten, five in ten,” he tells me. The complications multiply: “More people with diabetes or prediabetes, more people with high blood pressure, fatty liver disease, more people with arthritis, knee pain, sleep apnea.”

GLP-1s are not only helping tens of millions of people lose weight; they are also creating a cultural shift in our understanding of obesity. If hunger is not a question of willpower, but a function of hormones — dictated by genetics, and tweaked with a simple injection — then moral judgments about obesity now look outdated. Instead, we are now starting to reexamine the roles of our food system and environment, both of which make it harder for people on lower incomes to be healthy.

“You’re up against it from multiple levels,” Sattar says. Poorer people tend to have more limited access to outdoor spaces and exercise, additional psychosocial stress, and less time to cook. Shopping at Waitrose and farmers markets also costs considerably more than fast-food or ready meals. According to research by the Food Foundation, merely following the NHS’s healthy eating guidelines would cost the average person on low wages 50% of their disposable income. “I’ve got to eat chicken and fish and steak and fresh vegetables now,” O’Sullivan says, darkly. “It was cheaper on frozen pizza.”

To date, the conversation around GLP-1s has often framed them as a luxury lifestyle choice — “skinny shots” taken by celebrities and the vain middle class wanting to look better on social media. But for the dangerously obese, particularly those on low incomes, these are life-saving medications for a life-threatening disease. Only right now, they are being priced out of the cure.

***

Excluded by the NHS and priced out of private healthcare, many Britons are getting the jabs by less legal means. On TikTok and Instagram, I was able to find sellers touting black market GLP-1s with a simple search. “There are all these different labs in China producing these chemicals,” explains Luke Turnock, a criminologist at the University of Lincoln who studies illicit performance-enhancing drugs, including GLPs. “Bodybuilders, who were using growth hormone-stimulating peptides, got very used to buying peptide vials in powder form, reconstituting them, and selling them within gyms. So when this massive interest in GLP-1s blew up, a lot of these peptide sellers said: ‘Let’s pivot to selling GLP-1s.’”

The black market is now outstripping the health system’s ability to keep up. On social media, many users boast of using retatrutide, an as-yet-unreleased triple-action weight-loss drug being developed by Eli Lilly. Although the platforms have attempted to limit mentions of GLP-1s, it took me minutes to find users openly talking about taking “reta” or tirzepatide — as well as phone numbers or links to WhatsApp or Telegram groups offering to sell it. Turnock noticed an uptick of interest in retatrutide in 2024. “It absolutely took over, because it’s ‘Oh, we can get this cheaper than legitimate prescription ones, and it’s said to be more effective.’” (In clinical trials, retatrutide has shown greater weight loss effects than similar-length trials of tirzepatide, and twice that of patients on semaglutide.)

Fraud is rife. One study of black-market weight-loss drugs found that, if they did contain the active ingredient, they sometimes contained wildly incorrect doses. “Some of them were as low as 14% [of the listed dose] and some were 139% of what they should be. So there are obvious potential risks,” Turnock says. On social media, some influencers have reported their accounts being cloned or hacked by black-market sellers, looking to push products to their large audiences.

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Marc McKee, a weight-loss influencer who has built up more than 91,000 followers on Instagram through sharing his journey on GLP-1s, has lost over nine stone in less than a year on Mounjaro. After the September price hike, he watched as his followers were drawn to the black market. “Somebody messaged me that they had injected themselves. They were actually in hospital, and wanted me to put out a warning,” he says. “They’d injected themselves with expired insulin.” Some patients have been hospitalized; at least one has died. “You have no idea what you’re putting into your body,” says McKee.

Even when black market drugs do contain the promised active ingredient, there are still risks. “Because we haven’t had the clinical studies, we don’t actually know the correct dosing of retatrutide,” says Turnock. “Online you’ll hear people say, ‘this is what you should be dosing reta at.’ That is just essentially based on supposition and some experimentation.” As it is still in clinical trials, retatrutide’s side effects are not clearly known, but some users report serious complications.

One of the challenges with GLPs, Turnock says, is that many customers don’t understand the difference between licensed online pharmacies and unlicensed sellers — or are willing to look past them in their desperate search for cheaper drugs. “A lot of them might not even see themselves as ‘I’m engaging with a black market’,” he says. “They just see this as, ‘it’s being advertised, I’ll access it.’”

McKee has started a petition, urging the government to further reduce the price of medications like Mounjaro, in order to make access more equitable. It has reached over 7,000 signatures. He advises his followers to stay away from them, and advocates that people considering peptides do so legally, and only for health reasons. “There’s people that are trying to get it that maybe shouldn’t.”

“What does that tell us?” says Yeo, of the black-market explosion. “It tells us about our obsession with ‘weight equals beauty’. At the other end of the spectrum: that people really need the drug, and are desperate.”

***

Talking to patients, it’s clear that GLPs are transformative for many people who have struggled with their weight, and with it their health and even their sense of self, for most of their lives. “My knees were starting to hurt, my blood pressure was increasing. I’d tried to lose weight, but the biggest thing for me was emotional eating,” says Ese, 36, from Bedford. She had tried numerous times to lose weight, including signing up to the NHS weight-loss program, but didn’t find it effective. Then she started Mounjaro. “I literally forgot to eat,” Ese says. “It was like the food noise had vanished.”

McKee tells a similar story. “I’d gone through multiple different health problems: my liver, kidneys, high blood pressure, cholesterol, all that stuff was all really, really high,” he says. “For me it was never about looking better. It was more about being healthier.” McKee is now in the best shape of his life. “My blood pressure came down, my liver function came back, same with kidneys, cholesterol, everything.”

There is also growing evidence that GLPs have additional benefits beyond treating diabetes and weight loss, lowering the risk of heart disease, kidney disease, and possibly even cancer. (A trial testing semaglutide to treat Alzheimer’s disease, however, failed.) There is also anecdotal and pretrial evidence that GLP-1s may be effective in the treatment of serious addiction.

Given their benefits, and the risk of the black market, some experts believe that GLP-1s could — and should — be rolled out more widely. “Only the most severely ill people are getting it [on the NHS] at the moment,” says Yeo. “We could be benefiting many other people as well. From a health economics perspective, it’s a no-brainer, right? Roll it out as quickly as possible to people who need it.”

Sattar agrees. “We need to think how we can cut our costs to get more people on the drugs faster.”

Doing that, however, is complicated. When the UK’s National Institute for Health and Care Excellence (NICE) — which decides which medications should be available through the NHS — ruled on tirzepatide, its findings were mixed. Although it agreed that tirzepatide is safe and effective for weight loss, it found that the benefits of the treatment did not reach its cost-effectiveness thresholds, judged in cost per quality-adjusted life year (or QALY) gained, except in those with extreme obesity-related health difficulties — hence the NHS’s cautious rollout.

The NHS has a confidential commercial arrangement with Eli Lilly to buy Mounjaro at a discounted rate. Currently, the NICE ruling for tirzepatide includes factoring in numerous costs — such as diet and exercise counseling, and psychological support for a third of patients — that most people do not get when paying privately. (“Most of them we don’t need,” Sattar says.) And in December, as a result of the UK-US trade deal, the UK finally raised the threshold it is willing to pay for innovative drugs by 25%. Given the growing evidence for their benefits, therefore, there is a case that NICE look again at its guidance, which is currently under review.

But GLP-1s are expensive, and, thanks to pressure from the Trump administration, only getting more so (in effect, the Mounjaro price rise was Eli Lilly bringing UK prices into alignment with US prices). Calculating their benefits for the healthcare system (in preventing costly treatments for other diseases) and economy (in getting healthy people back to work) is difficult, because studies show that most users regain the weight lost — and the associated health risks — within three years of coming off the drug. They also require constant treatment, whereas gastric band surgery is one-off, and permanent.

Besides, Sattar told me, even if lowering diabetes-related complications, such as heart and liver disease, did bring substantial cost-savings, the up-front cost of buying that many drugs is currently simply too prohibitive. “It will save a lot of money, but it won’t save it that quickly,” Sattar says. “Cost effectiveness only matters when you’re talking about a few hundred or a few thousand [patients]. When you’re starting to talk about a drug that 10 million could take, and the cost is so high, you can’t afford it.” In other words: there are simply too many obese people in the UK for the NHS to treat them all.

***

Nevertheless, 2026 might be the year that the scales start to tip. Although the patents for the early GLP-1s are valid until at least 2031 in the UK and US, the patent for semaglutide (Wegovy/Ozempic) expires this year in China, Brazil, India, Turkey, and Canada — that is to say, in some of the biggest generic medication manufacturing countries in the world. If we think the black market is big now, it’s about to be supercharged — not with knock-offs, but with cheap generics.

There are also around 100 new weight-loss drugs in development, including retatrutide, which could be approved in some markets towards the end of this year. One of those new drugs, Orforglipron — also owned by Eli Lilly — is a once-a-day pill, rather than an injectable, and therefore likely to be cheaper to manufacture, as it does not require refrigeration. “The hope is in the next three or four years we might get four or five more drugs licensed, and then it’s competition and the prices come down,” Sattar says.

When that happens, the consequences for society will be profound. “Candy, beverages, alcohol, they are the most impacted,” Leigh O’Donnell of Kantar Research, which has done large surveys of GLP-1s’ impacts, told me. “71% of British respondents said that they were consuming less alcohol since they began the drug; 45% of folks said that they are consuming less tobacco.” Numerous industries — sugary foods, fast-food, restaurants of all kinds — will be disrupted. Other impacts, such as widespread anecdotal reports of users suffering from reduced libido, or giving up addictive behaviors, are yet to be clearly understood.

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“The interesting question to ask is: is this a way of actually beginning to reformulate our food environment?” says Yeo. One outcome could be that, if enough people go on GLPs, everyone benefits.

Sattar agrees. “My sense is that as more people come on these drugs, we will see slow, subtle evolutions of the food and drinks industry,” he says. “I hope it goes in the right direction: less fast food, smaller portions, better quality foods, less highly dense. But that’s being optimistic.”

Still, a world of ubiquitous weight-loss drugs still comes with risks. “My main issue I have is that there is no limit for when you begin to respond to the drugs,” says Yeo. “If you’re a 350-pound man looking to lose 100 pounds, excellent, this drug is designed for you. But it will also work for a 16-year-old girl who’s 70 pounds. And that is the problem. You don’t have to go that far onto the other end of the scale when it becomes dangerous.”

Most of the people I spoke to taking weight-loss drugs are planning to stop eventually. “I’d like to come off it,” O’Sullivan told me. “To be able to get back to normal, go back to work, not be broke all the time. That’d be great.” But he still has a way to go. Until then, unless NHS guidance changes, he will have to keep making sacrifices to pay for it.

“I know eventually when I do come off, my appetite may come back,” Ese tells me. “My plan was never to do Mounjaro for life. [But] I’m not at my goal weight, and I’ve had so many people go on Wegovy and they have regretted going on it, and then they’re coming back to Mounjaro.”

McKee has already taken one break from Mounjaro, and hopes to quit soon. He has been working on his fitness and diet, and building healthy habits, so that he can maintain his new weight for good. “I think when you put all that work in,” he says, “You never want to get back to being that person.”

1. Negative Partisanship

Many people’s political views revolve not around what they support, but what they oppose. They’re always fighting against something rather than for something, and the constant focus on what they hate makes them nasty and miserable.

2. Enshittification

Online services start out serving users. When they have enough users, they switch to serving advertisers/shareholders, at the expense of users. For instance, Google Search initially showed you what you searched for, but now largely shows what it wants you to see.

3. Dawkins’ Law of the Conservation of Difficulty

The easier an academic field, the more it will try to preserve its difficulty by using complex jargon. Physicists use simple terms if possible, while postmodern theorists try to complexify their discipline by writing like this:

“The move from a structuralist account in which capital is understood to structure social relations in relatively homologous ways to a view of hegemony in which power relations are subject to repetition, convergence, and rearticulation brought the question of temporality into the thinking of structure, and marked a shift from a form of Althusserian theory that takes structural totalities as theoretical objects to one in which the insights into the contingent possibility of structure inaugurate a renewed conception of hegemony as bound up with the contingent sites and strategies of the rearticulation of power.”

4. Reminiscence Bump

Americans of all ages tend to believe America peaked — morally, politically, economically, artistically — whenever they were a kid. Perhaps people who yearn for the time when their country was great are mostly just yearning for their childhood.

5. Region-Beta Paradox

Often we fail to improve our lives simply because things don’t get bad enough. If your new job is hell, you’ll leave it, but if it’s just unsatisfying, you’ll likely grind it out. Thus, small problems often threaten our quality of life more than big ones.

6. Dark-Ego-Vehicle Principle

Social justice activism is widely regarded as driven by noble intentions, but it attracts large numbers of psychopaths, narcissists, and other “dark tetrad” personalities who use it to feed their sense of self-importance and to dominate others. As Aldous Huxley wrote: “To be able to destroy with good conscience, to be able to behave badly and call your bad behaviour righteous indignation — this is the height of psychological luxury, the most delicious of moral treats.”

7. Protégé Effect

The best way to learn something is to try to teach it to others. The sense of responsibility to your student motivates you to understand a topic, and the act of explaining something helps you to connect the dots and commit them to memory.

8. Baumol’s Cost Disease

As an industry’s productivity increases, wages in that industry naturally rise. This forces wages — and prices — in services without increased productivity to also rise to stay competitive. Thus, as a country gets richer, goods become cheaper, but labour-intensive services like healthcare and college tuition cost more.

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9. Stockdale Paradox

The optimal state of mind is neither optimism (which leaves you unprepared for adversity) nor pessimism (which destroys motivation), but optimistic pessimism: by preparing for the worst outcomes, you increase confidence in dealing with any outcome, and thus, you increase hope.

10. Ozemponomics

GLP-1 drugs like Ozempic are threatening “limbic capitalism” by reducing cravings. For instance, the average household with at least one family member on a GLP-1 spends around 10% less on snacks. If this can reduce addictions and obesity, it will likely also reduce healthcare costs and unemployment.

11. Explanatory Inversion

Questions rest on unexamined assumptions, so always try flipping them. For instance, don’t just ask why there is poverty, ask why there is prosperity. This helps you realise poverty is the norm and the lack of it is the thing that needs to be explained.

12. Event Bias

One reason negativity dominates the news is that bad news tends to happen suddenly while good news tends to happen gradually so is rarely newsworthy on any particular day. But even though it may not get as much attention, good news is always happening.

13. Pie Fallacy

Many believe wealth is zero-sum; that if someone gets richer, someone else must get poorer. But wealth creation is one of society’s few positive-sum games; if you fix up a battered old car, you increase its value, making yourself richer without making anyone else poorer.

14. Golden Law of Stupidity

A stupid person is a person who causes losses to others while themselves deriving no gain and even possibly incurring losses.

15. Goal Dilution Effect

We assume that the more arguments we give, the better our case. In reality, our weakest arguments dilute the strongest. Generally, you’ll only be as convincing as your worst point, so instead of making as many arguments as you can, make only the best.

16. Bias Blindspot

We see bias easily in others, but not in ourselves. Whenever I post about a bias or fallacy, people tell me how it explains their opponents’ beliefs, but never their own. The assumption that bias is just something that affects those we disagree with is our greatest source of bias.

17. Sheepskin Effect

Employers value qualifications more than education. This is because the purpose of the education system is not actually to educate people, but to sort the “wheat” (worker bees) from the “chaff” (slackers, dreamers). What students learn is not as important as demonstrating that they can follow instructions and complete what they started, which a qualification signifies.

18. Deviancy Amplification

An outrageous act or event gets the public’s attention, prompting reporters to look for new examples. Cases that previously would not have been considered newsworthy are reported just because they fit the trend, creating the impression of an epidemic of such events. A recent example is mystery drone sightings.

19. Rumsfeld Matrix

There are things you know you know, things you don’t know you know, things you know you don’t know, and things you don’t know you don’t know. The last group is the biggest pitfall. Always try to account for what you don’t know you don’t know.

20. Left-Brain Interpreter

Experiments on split-brain patients show that when the experimenters instruct the patient’s right-side of the brain to perform an action (e.g. open the window), the patient will do it, and then the left-side of their brain, which was unaware of the instruction, will convince the patient they chose to do it unbidden (e.g. “because I felt hot”).Our reasons are stories we tell ourselves.

21. Blue Dot Effect

The more we solve our problems, the more we widen the definition of “problem” so that our number of problems remains constant. So don’t expect a life without problems. Progress doesn’t mean reducing your quantity of struggles, but increasing their quality. The goal of life is to trade bad problems for better ones.

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22. Overview Effect

Although astronauts are chosen for their unflappability, when they see the Earth from space — a tiny marble in an infinite void — they’re often overcome with a sense of profound connection with all humanity, and everyone’s earthly squabbles suddenly seem trivial. In the words of Apollo 14 astronaut Edgar Mitchell: “on that fragile little sphere… all I had ever known, all I had ever loved and hated, longed for, all that I once thought had ever been and ever would be.” When something is bothering you, zoom out to see if it really matters.

23. Barrow’s First Law (aka Barrow’s Uncertainty Principle)

“Any universe simple enough to be understood is too simple to produce a mind able to understand it.” So don’t worry if you don’t know why you’re here, or where you’ll eventually go. Just focus on living. The purpose of life is to find purpose in life.

24. Ichi-go ichi-e

Every moment is unique and unrepeatable, so appreciate every experience as if it’s your last (which, in a way, it is). Even if your current situation sucks, be gracious that, of all the humans that will ever exist, only you will have the privilege of experiencing this moment in this specific way.

25. Sphexishness

Army ants follow each other’s pheromone trails to know where to go. Sometimes, they accidentally form a loop, or “ant mill”, circularly following each other until they die of exhaustion. Sphexishness is when you blindly follow a rule without checking if the rule works in the present situation. Don’t use the concepts in this list sphexishly. They’re not intended as rigid rules, only as food for thought.

This is an edited version of a list that first appeared on The Prism.

The five-year experiment is part of a £279 million deal struck with Lilly, the world’s biggest drug company, and aims to determine whether giving weight-loss injections to the obese will boost the economy. It will have two prongs. On one side, the NHS will identify potential participants for its trial on the basis of obesity, plus some combination of “hypertension, sleep apnea, cardiovascular disorders and unhealthy levels of … cholesterol”. It will then dose them with Mounjaro, Lilly’s competitor to Novo Nordisk’s Wegovy (better known as Ozempic). Meanwhile academics at the University of Manchester will be collecting data about the effects of the drug on “health-related quality of life and changes in participants’ employment status and sick days from work”.

Accustomed as we are to seeing the nation’s relatively poor health as a terrible financial burden, effectively Streeting is urging us to flip the script and see it as a possible goldmine. For ministers and managers desperate for cash injections to help get their most troublesome patient back on its feet, the implicit model must look deliciously appealing. At a price, it seems he is allowing one company exclusive access to a patient population: both to their bodies directly, via the use of a particular product, and apparently to some of their data afterwards. If public health does indeed improve as a result, the crippling financial burden on frontline resources, taxpayers, and employers will ease. Yet even if it doesn’t, sick people might continue to be a source of revenue in future, as companies like Lilly pay for access rights in the search for lucrative remedies and good publicity.

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Later on, once voters have got used to thinking of national ill health as an economic resource to offset the drain on public finances, similar initiatives might be rolled out for other expensive UK-wide disorders. Mental health conditions like depression and anxiety appear prime candidates for future government interventions like this one. In Streeting’s imagination, perhaps, biotech companies will start flocking to our shores, lured by the juicy prospect of exclusive access to a centralised pool of patients. Lazarus-like, the NHS will eventually stagger out of the tomb, throwing off its bandages. The economy will boom, replete with newly svelte and mentally balanced workers. Government ministers will dance nimbly in celebration to the sounds of Taylor Swift .

But aside from such grand visions, there are several more mundane questions that might be posed about rolling out Mounjaro as a state-backed strategy. Some of these hinge straightforwardly on what is already suspected about side effects. Vomiting is commonly reported, as are other relatively minor but still unpleasant gastric issues. A bigger issue is that even where nausea is absent, such drugs seem to remove a major source of subjective pleasure in life — namely, delight in eating — for which the satisfaction of once again becoming an efficient source of productivity units may come as scant consolation.

Described as the “King Kong” of weight loss jabs, Mounjara’s key ingredient is terzepatide which, like semaglutide, works partly by causing appetite suppression. According to a former user of the latter “I didn’t even think of (food). … Looking at a bag of Doritos was kind of like looking at a pair of socks”. Another admitted: “Almost immediately I couldn’t eat at all. I couldn’t drink. I couldn’t do anything. Tea and toast in the morning is my go-to and I could not touch it from the very first day.”

To people of ascetic sensibilities, this might seem a negligible price to pay for health; but then again, ascetics are unlikely to need Mounjaro or Wegovy in the first place. In contrast, we constitutionally sybaritic types tend to place enormous importance in life on the sensory joy and comforting reassurance which food can bring, an enthusiasm which evidently crosses cultures, culinary tastes, and pay packets. Unless you are literally starving, food is practically the one daily pleasure in life you can reliably count on, be the fare grand or humble; and if it wasn’t for the prospect of breakfast, lunch, and dinner, some of us wouldn’t bother getting out of bed at all.  Indeed, along with what has become known as an “Ozempic face” and an “Ozempic butt” — both unfortunately drooping — there is now talk of an “Ozempic personality” to match, involving anhedonia, depression, and a loss of libido.

The counterargument says that obese people are often fed up with obsessing about food in one way or another; and that regaining mobility means they will be free to get out and about, and so discover less one-dimensional sources of personal meaning instead. Maybe so. But testimonies suggest that old fondnesses are not so much permanently extinguished by the drug as temporarily quashed.

The woman who used to think Doritos looked like socks reported that, after quitting the drug, “everything came back full force”; “all the crazy cravings that I’ve struggled with for the sweets, the junk food.” Another said: “Suddenly it was like my body woke up and discovered, ‘Hey, I like bread’”.  In some cases, it is thought that people will need to become lifelong Mounjaro users in order to avoid relapsing into enjoying food again — a tragic indictment of late modernity if ever there was one.

Indeed, to me the most interesting issues arise when we consider what kind of society we inadvertently might be creating in future, by introducing such ruthlessly effective weight-loss drugs at scale now. Politicians, it seems, aren’t properly exploring the landscape of nearby possible worlds. If, for instance, without pharmaceuticals such as Wegovy and Mounjaro, just over a quarter of us are likely to become obese at some point — the current figure — then this also suggests that, with access to the drugs, a quarter of us are going to become indifferent to food and perhaps even vaguely nauseated by it, in some cases for life.

What then is going to happen to the nation’s restaurants and pubs? What will happen to regular family meals round the dinner table, nearly a thing of the past anyway as many of us favour mindless mastication in front of the telly? What about luxury food products, presently coveted as obvious temptations and sold to the public as such — and to the companies and industries that produce them? It seems to me you can’t chemically neuter a huge part of the population’s taste buds and not see swingeing social effects elsewhere.

Another interesting question concerns notions of personal responsibility. At the moment, there is still too much emphasis on personal choice for obesity in many people’s minds, with structural features such as addictive hidden sugars and contributory environmental factors being improperly discounted. Equally, it would be an overstatement to say there was nothing an individual could do to change his or her shape.

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But with drugs available, obesity will become statistically much rarer. Fatness will become even less socially acceptable than it is now in the eyes of other people, and notions of personal responsibility yet more salient. Obese people who have ready access to the drugs and yet who fail to take advantage will become conceptualised by fellow taxpayers as wilfully stubborn drains on the public purse. They may even be thought undeserving of benefits, or of other NHS help. We have officially moved out of the “kindler, gentler politics” phase into the “tough choices” era, after all.

At the same time, in cases where the NHS positively withholds free treatment from someone in future — maybe, say, after an allotted period of treatment is up — it seems likely that such an individual will then see herself as having extra reason to blame the system for her physical state. Effectively, the NHS’s adoption of Mounjaro at scale will embolden some to equate the state’s failure to prevent obesity in their own case as equivalent to causing it. Already we have Daily Mail testimonies from hard-up private buyers of semaglutide, complaining it is “disgusting” that the jobless might get the medicine for free, when they themselves have to pay. Grievance culture can take many creative forms; feeling hard done by because the government won’t pay for injections that make Doritos look radically unlike Doritos is quite possibly the next one.

In the meantime, slender fashionistas on fashion show front rows are secretly buying Ozempic to make them yet more ethereal; adolescent girls are seamlessly incorporating the drug into their already vast repertoire of ways to mortify the flesh; plastic surgeons are busy informing those with “Ozempic face” about which fillers and surgeries are best to purchase, in order to disguise the sag. The future of weight loss is already hurtling towards us. Rather than focusing on appetising-looking new financial opportunities, we should probably have a proper think about the hidden additives.

Despite the risk of public shame and the menace of non-reimbursable insurance cost ($1,349 a month for Wegovy and $1,060 a month for Zepbound), steep demand has sent the stock market valuations of Novo Nordisk and Eli Lilly through the stratosphere of the S&P 500. Not since the debut of Viagra has there been such hype in pharma, raising questions as to whether Eli Lilly and Novo Nordisk can produce enough of the magical elixir, as demand outstrips supply.

As competitors flood the field — most recently, Amgen’s MariTide, yet another semaglutide already in Phase 2 trials — Goldman Sachs analysts estimate that by 2030, the market for such drugs will be worth in excess of $100 billion. The lion’s share will be sold in America, where for hundreds of years the seemingly simple alternative — to eat or not to eat — has been a national obsession. Washington Irving, America’s first author whose fame crossed the Atlantic, invested a great deal of his literary capital describing the young republic’s utter lack of proportion when it came to food. His History of New York, published in 1809, asserted that the earliest political leadership of Manhattan was a Dutch “colony of huge feeders”, in which the burgomasters were “generally chosen by weight”. Their chieftains were “the best fed men in the community; feasting lustily on the fat things of the land, and gorging so heartily on oysters and turtles, that in process of time they acquire the activity of the one, the form, the waddle, and the green fat of the other”.

Today, Americans are no less obsessed with weight. Such disses of the Dutch were the Federalist equivalent of present-day body-image disputes over Ozempic, typified by the hysterical row last month over Barbra Streisand’s intervention as to whether or not Melissa McCarthy was shooting up with the serum.

Despite the morass of scientific explainers, confessional essays and philosophical think pieces, all this food freak-out should be filed under “old news”. Americans have been gaining weight for as long as they have been trying to lose it. Indeed, a few hundred miles north of the turtle-gorging Dutch of Manhattan, the Puritans of Massachusetts were gauging their status as chosen people through their gastrointestinal tract, as Samuel Sewall’s noted in a diary entry from 1690: “Mr Torrey is for a fast or at least a fast first. Mr Willard for a Thanksgiving first. Mr Torrey fears lest a Thanksgiving should tend to harden people in their carnal confidence.”

Thus did binge-eating, spiked with self-induced starvation, find its earliest footholds in the land of milk and honey. The great Puritan divine Cotton Mather outlined the toxic paradox when he asked: “Has not my soul as much amiss in it as my stomach?” Mather’s unflinching investigations of depraved digestions came to all-too recognisable conclusions.

In the case of apoplexy, vomits do a deal of good.
In the case of vertigo, vomit.
In the case of hiccups, vomit.
In the case of nightmares, vomit.
In the case of a coma, more vomits …

Bulimarexia, like religious freedom, was native to these shores.

After the colonial period came America’s great expansion, in which the republic’s rampant eating mania — and subsequent dyspepsia — expressed itself in extraordinary feats of consumption. In 1789, the renowned Methodist John Wesley noted cases of “Canine Appetite”, and American frontier literature teems with stories of thunder-swallowing backwoodsmen who devoured buffalo, alligators and rattlesnakes. Davy Crocket’s penchant for eating bears was only matched by his passion for killing the natives. Today, the same sort of digestive blood lust can be observed across social media, which features endless streams depicting the carnivorous habits of modern day meat-eaters and paleo dieters, even though it’s growing ever more clear that the Neanderthals mostly ate roots and leaves.

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Ozempic has opened the door to what every psychiatrist will recognise as the danger zone of behaviour: the return of the repressed. And what have we repressed? The fact that in the beginning, the boundaries of consumption had been smashed. The fact that, here, it was finally possible to eat anything. In 1609, Henry Hudson sat down with some upstate Wappingers for a solemn feast of fatted dog. A bit farther south, the Lenapes were kind enough to share their raccoon and lynx, which they gobbled raw. Food publicity filled the 19th-century press with outrageous accounts of primordial American foodstuffs: out in the sticks there were caribou and antelope, epic beets the size of cedar stumps and corn that grew so fast its percussion killed a hog. Markets in New York City, Cleveland and throughout Iowa offered black-bear steaks and panther chops as late as 1832, and bison, elk, reindeer and moose remained available far into the 19th century.

The story of westward expansion was a romance of superhuman ingestions and prodigious wastes. Davy Crockett’s threat to “eat any man opposed to Jackson” did not land him in jail for threatened manslaughter, but in Congress. And Crockett was not alone. Liver-Eating Johnson hunted down and consumed Crow Indians. Mark Twain’s Mississippi raftsman ate “a bushel of rattlesnakes and a dead body”. The recipe for cowboy sonofabitch stew included everything from beef brains to beef liver, tongue, heart and bones. America in its 19th-century imperialist prime was an insatiable power that viewed the entire continent, if not the world, as its manifest dinner.

Then the frontier closed. The physical limits of continental expansion had been reached, so the stomach, given no other recourse, became a transcendent object of adoration. “The stomach-sac”, the American poet Walt Whitman proclaimed, “food, drink, pulse, digestion…”

“O I say these are not the parts and poems of the Body only, but of the Soul,
O I say now these are the Soul!”

The end of the American stomach’s will to political power meant a number of other curtailments, too, most clearly articulated by the 19th-century American diet guru, Catherine Beecher, when she noted that “it is the opinion of most medical men, that intemperance in eating is one of the most fruitful of all causes of disease and death”. Followed by her profound observation that “it is possible to put much more into the stomach than can be digested. To guide and regulate in this matter, the sensation called hunger is provided.”

Indeed. A “sensation called hunger”.

Thus did American eating mania crash into a new derangement: the diet. At the height of America’s literary renaissance, when Emerson, Thoreau, Dickinson and Whitman were furiously scribbling curricular content for the next century’s American Literature courses, neither Walden nor Moby Dick could boast sales anywhere near Sylvester Graham’s edition of Discourses on a Sober and Temperate Life. “Few things are more deceptive to children or adults, than soft lazy dishes,” Graham declared. “This is a universal rule.”

In 1838, the famous vegetarian (and author of more than 100 books) Dr William Andrus Alcott railed against ginger, fennel, cardamom, nutmeg and coriander, declaring that molasses and sauces were indecent “drugs”. He worshipped “pure, plain, unperverted pudding”. And he inspired a terror of mince pie, which might actually consist of a dozen or so ingredients, and thus would “stupify our immortal souls”.

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Meanwhile, the founder of Seventh-Day Adventism, America’s “Prophetess of Health”, Ellen Harmon White, sought God through her plant-based diet. In her wake, America’s diet culture has continued the tradition of eating as a way to pursue both spiritual and capitalist perfection, from Joran Rubin’s recent The Maker’s Diet (that implores disciples to eat what Jesus ate) to the latest from Park Avenue’s “top diet doctor”, Jana Klauer: How the Rich Get Thin. Not to mention the long history of American cookbooks wooing audience by trumpeting themselves as quasi-spiritual tomes: The Sauce Bible, The Smoothies Bible, The Bread Bible, and The Pie and Pastry Bible. Linking sanctity and thinness had long been a fixture of the American psyche, most recently demonstrated by participants in a recent survey of 260 Latter Day Saint BYU students, who judged that “smaller-bodied females” were, as a rule, “more moral than larger-bodied females”.

The American desire to discipline the dysfunctional stomach would soon be subverted into another instantly recognisable tradition: the fad diet. The evangelist John Wesley advised those who suffered from scurvy to “live on turnips for a month”. Dr Alcott’s associate, Samuel Larned, decided to subsist for one year on nothing but crackers. The next year, he ate nothing but apples. America introduced the milk diet, the turtle diet, grapefruit, bone broth, the infamous cabbage soup diet of the Fifties and the Nineties classic 12-step eating recovery programme, “The Love-Powered Diet”.

But the American stomach would not be so easily deterred from its voracious rounds, typified by what would prove to be a pivotal year in the history of eating. In 1997, when George and Richard Shea founded the International Federation of Competitive Eating (since re-branded as Major League Eating), which over the past quarter century has sponsored hundreds of eating contests — featuring gorgers of everything from jalapeños to buffalo wings, oysters to doughnut, pancakes to sushi, bologna to straight mayonnaise — not to mention the greatest triumph of American consumption, the Nathan’s Famous Fourth of July International Hot Dog Eating Contest. The professional gurgitator would be the final incarnation of the digestive imperialists, the grotesque and stunted descendants of industrialists, frontiersmen, and founders.

The dream of consuming everything might have been disciplined to a 12-minute eating contest, but it would not die. As the dimensions of American ambition contracted from mountains and valleys to the virtual horizons of the smartphone, it was, perhaps, inevitable that the fate of American eating would at long last devolve into yet another triumph of technology, the unsexy and unsavory glucagon-type agonist — and thus where we find ourselves today, stuck between the glories of Ozempic and the horrors of Ozempic face.

Novo and Lilly and Amgen come at the end of a long line of American diet history, whose gurus might have been surprised to learn the side effects of not eating, as monthly doses of Nordisk peptides have been known to cause nausea, diarrhea, vomiting, flatulence, constipation, fatigue, not to mention an increased risk of vision changes, kidney problems, gall bladder disease, hypoglycemia and pancreatitis. Such are minor inconveniences in light of the true American dream: the nirvana of bodily perfection. A shot of pure poison is a small price to pay for a glimmering mirage of health and wealth on Facebook, even if the sagging, haggard, fat-starved face has now been joined by Ozempic butt and boobs.

Will there be no more July 4th hot dog eating contest? No more avocado shortages on Super Bowl Sunday? No more gastroporn on Reelz? Can we finally foresee the tragic death of the foodie? Will there be no more food fads, food taboos, food fetishes and paranoias regarding what would or would not pass the holy threshold of our lips? There is much to mourn.

And, perhaps, something to celebrate. Ozempic may toll the death knell for America’s age-old mania of stuffing everything into our imperial systems, a delusion that dates back to our famished origins, when out of the howling wilderness appeared the grim shadows of natives bearing the makings of the first Thanksgiving. The American identity, no longer confined by the twin poles of feast and famine, might seize the moment to define itself anew.

I was training for a bodybuilding competition, and it had been weeks since I had eaten fruit, because fruit contained sugar, and sugar was off-limits. The only time I was allowed it was immediately after workouts, in the form of half a Gatorade mixed with a scoop of protein powder, gulped down to prevent my starving body from consuming its own lean mass.

There are few pictures of me from this time in my life, except the ones I took weekly to track my progress. I posed in a sports bra and underwear with my muscles tensed, and sent the results to my trainer. Your midsection is showing more separation every week!, he wrote, as my abdomen morphed from a smooth, flat expanse to a rippling six-pack. (The sports bra was a mere formality by then; breasts consist mainly of fat, and mine had shrunk down to nothing.) Ten years later, the thing I remember most is not how great I looked but how much work it was. If I wasn’t eating or exercising, I was thinking about these things: planning, prepping, setting timers so that I’d remember to swallow whatever was on the menu within however many minutes of a workout. By the time I abandoned my training regimen — around the time I found myself weeping over fruit on the internet — my body had become a vehicle whose maintenance was my full-time job.

All of which is to say, when I read about Ozempic patients who are losing weight not just without trying, but without having to think about trying — the ones who, to quote one user, “just don’t think about food anymore” — I want to squawk with indignation. What do you mean, you don’t think about it?! That’s not fair; it’s cheating. But even among people who don’t share my peculiar history (okay, obsession) with manipulating the size and shape of their bodies, that instinctive reaction is commonplace. Whatever one’s reasons for losing weight, the common wisdom is that it’s not supposed to be easy, physically or mentally.

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Indeed, any experience to the contrary tends to inspire suspicion, even among those who believe wholeheartedly that being able to effectively cure obesity, and its litany of associated health conditions, would be an extremely good thing. The impulse to view Ozempic and other medicines of its ilk with mistrust, even derision — the equivalent of buying indulgences instead of performing atonement — has been compared with the taboo against Suboxone among former addicts, who “were skeptical of a fix so expedient, so simple, so biological”.

It’s not a bad analogy; Suboxone and Ozempic both work in their own way to suppress a person’s appetite, curbing an undesirable behaviour by eliminating the basic urge to engage in it. Another comparison might be the contemptuous moralising aimed at people who quit smoking by substituting tasty-flavoured vapes for combustible tobacco. It’s not that vaping doesn’t work; it’s that it’s too easy, too enjoyable. If smoking is a sin, quitting should be a crucible — or at the very least, it should not taste like cake. And in a world where an overweight body is seen as a sign of moral failure, thinness is seen as the just reward for those who atone through deprivation.

This ascetic immiseration is a chief characteristic of what social critics refer to as diet culture, which is adjacent to but separate from losing weight. Consider how many people are either perpetually on a diet — or at least, say they are — or just off one with little to show for it: it’s almost as if the point is not successful weight loss, but the show of compliance. You are depriving yourself of food not because it will make you thin — often, it does not do this — but because you are performing, for yourself and for the world, the role of a person who wants to be thin and is willing to hurt for it. Ordering the salad instead of the steak is a form of virtue signalling: “I am trying to be good.”

This entanglement of the moral with the biological has a long history, in which even doctors have been unable to entirely separate the two. The Victorian era, a time of ground-breaking advancement in the medical sciences, was also a time of great permeability between the social zeitgeist and the scientific community, in which cultural notions of beauty and femininity often reappeared in a doctor’s office disguised as medical advice. Among these dictums was the notion that appetite, particularly for women, was a signpost of both poor health and poor character. Then, as now, a slender figure was valued — and then, as now, achieving one was supposed to be accomplished through exquisite self-control. The ideal woman in the eyes of society and science alike not only ate very little, but made a show of it, demonstrating sovereignty over her appetites one dainty nibble at a time.

Those who took pleasure in eating, meanwhile, were viewed as courting disaster, an idea widely reflected in the medical wisdom of the era. John Harvey Kellogg, who in the late 1800s was considered America’s foremost pioneer in the field of gastroenterology, was convinced that robust appetites were inextricably linked with sexual depravity. “Candies, spices, cinnamon, cloves, peppermint, and all strong essences, powerfully excite the genital organs,” he warned in the 1880s. His guidelines for good gastrointestinal health, which included not just a bland vegetarian diet but a regular regimen of yoghurt enemas, were designed with the goal of curbing the desire for food and sex alike.

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This sense — that a healthy body is a thin body under control — recurs throughout history. At the turn of the 20th century, Kellogg pumps his patients full of bran flakes at one end and yoghurt at the other; at the dawn of the 21st, a fitness influencer dutifully crams exactly four ounces of chicken breast down her throat before heading to the gym. At the same time, to lose weight in other, easier ways — via liposuction or diet pills or, today, Ozempic — has long been viewed as not just unearned, not just cheating, but perhaps even a sort of devil’s bargain for which a harsh price will soon be paid. The history of scandals in the world of medically-assisted weight loss — the withdrawal of fen-phen from the market in the Nineties after research revealed that it could cause heart valve damage in up to a third of patients, or the rare but ghastly side effects of treatments like Coolsculpting — only serves to validate the moral superiority of the nay-sayers. We told you it couldn’t be that easy.

Of course, maybe this time it is that easy. Sure, there’s the occasional (albeit rare) horror story of Ozempic patients suffering stomach paralysis as a result of the drug — or the less ghastly, more quotidian concern that its appetite-suppressing effects cause the loss of not just fat but precious lean mass. But even if these apprehensions prove unfounded, the capacity of Ozempic to make weight loss not just effective but thoughtless is why it will almost certainly continue to occupy an important place in the medical consciousness, but a fraught place in our moral one.

Imagine: instead of sweating through gruelling workouts at the gym, the only effort you have to make is a weekly jab with a slender needle. Instead of battling your appetite at every meal, it retreats to a quiet corner on its own, until you’ve forgotten it ever existed. This doesn’t just flout the conventional wisdom, the studied science, of what it takes to lose weight; it flies in the face of every narrative in which weight loss is synonymous with redemption, in which every pound lost is a demon conquered.

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Time and research may reveal that Ozempic really is the future of weight loss, but I suspect that the stories we tell about it — and the perverse pride of having a body moulded by diet and exercise, yes, but also by focus and discipline and pain and tears — will be far harder to shed. It is almost certainly not a coincidence that my own brief foray into amateur bodybuilding was preceded by about 15 years of a more traditional eating disorder: the common thread in these experiences was not just a longing to be thin, but the satisfaction of putting in work here and seeing results there, of wrestling my body and its appetites alike into submission. Would I have felt so satisfied, so in control, if I had been able to simply neuter myself of those appetites with a weekly shot? Is self-deprivation still a triumph if there’s no desire to triumph over?

Here, it becomes important to note that in at least one way, Ozempic does suffer the same pitfalls as any other weight loss method that relies on eating less: people who stop using it tend to regain the weight. But unlike a diet, the idea of being on Ozempic permanently doesn’t inspire existential dread, evoking the dire image of spending the rest of your life tormented by raging and insatiable hunger. Indeed, one of the things that makes the drug so intriguing is that it curbs all manner of appetites. For food, yes, but also for alcohol, nicotine, gambling, sex — in short, for the pleasures that straddle the line between needing and craving. Ozempic patients will not burst into tears over a picture of a fruit salad. Instead, a lifetime on the drug will be characterised not by desire, but the absence of it. And this is perhaps its own sort of tragedy.

Discussion of obesity has similar vibes, but with this conversation specifically, there’s a sort of outdoor voice/indoor voice divide: one thing is said in public, another in private.

We have a big obesity problem, across the developed world and particularly in my home country of the United States. In the OECD countries, often used as shorthand for the advanced nations of the earth, half or more of all adults are overweight or obese. Here in America, one in every five children is obese. Overall, progress comes with a bitter (and expensive) problem: as countries become richer and more stable, obesity rates grow. Obesity is a classic “boiling frog” problem, both for individuals and for societies — a few pounds here and a few pounds there, and you’re suddenly facing real health consequences; a few percent here and a few percent there, and you’ve got projections showing that your already-overburdened healthcare system will eventually collapse. It contributes to heart disease, diabetes, cancer; it is estimated to cost the NHS £6 billion a year. Clearly, something has to be done.

And yet there’s an obvious set of complications. One stems from the simple fact that, though there have been some recent developments, consistent and scalable treatments for obesity are notoriously hard to come by. What works for some doesn’t work for most, and the constant endorsements of diet and exercise have proven totally unhelpful to many millions of people who have tried very hard to lose weight and found that they just can’t. And this connects to another complication: how do we create a public health system that helps people to lose weight and encourages healthy eating without unnecessarily insulting the people who struggle to do so?

It’s here that the polarisation comes in. While it’s increasingly unlikely for people to openly shame people for their weight problems, it’s still far more common than open racism or homophobia. Obesity is not in the same category as race or sexual identity, but as with those identity markers, being fat represents an unchosen vulnerability. The fat acceptance movement has been gathering steam for some time, arguing that not only does society unjustly mock and deride fat people, but does so based on bad science and bigoted ideology. While this general attitude is both understandable and humane, it’s taken to an unfortunate extreme. The “Healthy at Any Size” philosophy insists not only that fat people deserve equal rights and respect, but also that there is no inherent health disadvantage to being obese and that the public health community should be “weight neutral.”  Unfortunately, these claims aren’t true.

Is there no hope of synthesising these perspectives? Can we not communally agree not to be cruel to fat people, regardless of the origins of their condition, and recognise that people have profoundly different odds of being fat or thin, while also insisting on the importance of a healthy diet and regular exercise? Is it really so hard to say: “Obese people deserve love, respect, and understanding, even as we recognise that being overweight is unhealthy and that the obesity epidemic is a public health crisis”?

Two new books address some of these questions: the recently-published Ravenous, by Henry Dimbleby, and the forthcoming Ultra-Processed People, by Chris van Tulleken. Both of the authors have impressive credentials. Both take wide-ranging journeys through the obesity crisis. Both offer up explanations, largely complementary, for why we’ve become fat. And like so many analyses of contemporary problems, their diagnoses are more compelling than their prognoses. Only one of the books comes up with a vaguely realistic solution.

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Neither of the overviews of the obesity problem offered here is novel, exactly, but they both make a point that needs to be hammered home: expanding waistlines are not the result of declining public virtue, but of structural factors. For reasons of commerce, the modern diet has become unhealthy, filled with foods that offer us a caricature of real nutrition. This shifts some of the moral responsibility for our BMIs off our shoulders and onto the systems in which we live.

“Over the past 150 years food has become … not food,” writes van Tulleken. His definition of ultra-processed foods stresses artificiality in packaging and ingredients: “If it’s wrapped in plastic and has at least one ingredient that you wouldn’t usually find in a standard home kitchen, it’s UPF.” Dimbleby, meanwhile, writes of UPFs: “Colourings, emulsifiers, flavourings and other additives are added to make the products better-looking, tastier, more stable and longer-lasting. This makes them extremely ‘moreish’ – or ‘hyper-palatable’.”

Hyper-palatable, here, does not simply mean tasty. This food is dangerous not merely because it prompts us to desire it, but because eating it does not satiate that desire. These foods are engineered to keep you eating, to a degree that was unheard of prior to modern production techniques. Consider the relationship between fibre and sugars. In nature, they tend to be found together. Your body might crave the sugar in apples, but you can’t sit down and eat an entire bag of them, because apples are highly fibrous, and fibre makes you feel full. In contrast, you most certainly can sit down and eat an entire king-size bag of M&Ms, which have a dramatically lower calories to fibre ratio (1023 calories and 5.8 grams of fibre in a cup) to raw apple (65 calories and 3 grams in a cup).

Modern food is specifically designed so that you never want to stop eating, which makes the food manufacturers rich and you fat. Another element of this broader reality is that ultra-processed foods are often lacking in micronutrients such as vitamins and minerals. This, in turn, makes people continue to crave food even after consuming many calories, as they’re simply not getting what their body needs. In communities where UPFs are the norm, it’s very common for obesity and nutritional deficiencies to be found together.

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In fairness, the development of these techniques was not undertaken for entirely nefarious reasons. Dimbleby points out that the last food crisis created the conditions that led to the current food crisis. Early in the 20th century, concerns about how to feed a human population that was absolutely exploding — there’s Malthus again — created intense pressure to derive more calories from a given portion of land. There was also a compelling need for better food preservation, leading to the addition of a lot of new substances in our food and the removal of others. It turns out that making food last longer often involves removing fibre. (Think of the way celery goes soft over time and you have a sense of how short fibre’s shelf-life is.) In an earlier era, when there was a deficit of calories, this probably didn’t seem like a bad bargain for food scientists.

But the legitimate need to feed more people fits all too well with the capitalist dictates of the food industry. There’s little inherent financial reason for any given food producer to prioritise nutritional value, and those foods that do are usually more expensive or, at least, practically inaccessible to those who do not frequent farmers’ markets or upscale grocery stores. The “normal” food distribution system continues to prioritise selling as many calories for as little money as possible. As Dimbleby writes, “the food system we created prioritises quantity over quality. We have changed our diet to match this system, and this diet is now making both us and our planet ill.”

Both of the books are potential fodder for the obesity culture war, though they pretty firmly reject simplistic characterisations of obesity as a matter of character or willpower. “Every discussion of weight gain, whether in the press or in our own heads, is suppurating with blame, which is always directed at the people who live with it,” writes van Tulleken. He sees this as straightforwardly unfair in the face of the structural forces that have altered our food supply. Similarly, Dimbleby writes: “Berating or despising individuals for being overweight is unkind, counter-productive (it exacerbates the depression and self-reproach that so often characterise disordered eating) and, above all, misplaced.” Both authors reference research that demonstrates that, while exercise has a number of health benefits, weight loss isn’t among them; Dimbleby has a chapter titled “You can’t outrun a bad diet”, which underlines the fact that exercise increases food cravings, which prompt eating that undoes calorie loss. This has grown to become a bit of conventional wisdom over time, but the age-old advice to eat less and exercise more is hard to shake.

But what can you do? Van Tulleken suggests… just about nothing. He’s insistent that genetics, the presence of unhealthy food options, and marketing essentially hold fat people hostage. Ultra-processed foods, he argues, “hijack our brains”. Even his brief final chapter on trying to live without UPFs is positively fatalistic, mostly counselling people not to hold out hope. As is the fashion, he laboriously argues that poverty effectively prevents the impoverished from making any decisions at all.

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It’s a conclusion that is not, I think, supported by the evidence he presents. The existence of genetic predispositions and just-so stories about neurological predispositions don’t amount to a compelling dismissal of the role of the conscious mind. It is also a good example of yet more binary, polarised maximalism: it seems not to have occurred to van Tulleken that he could argue persuasively that poverty influences food choices and that our system incentivises eating unhealthy food without arguing that we are all essentially automatons in the hands of food companies that can literally dictate our behaviours to us. I suspect, frankly, that this lack of nuance had more to do with selling books than anything else.

And yet this extreme pessimism is undermined where van Tulleken argues that we must make demands of government. Mandatory food labelling, he suggests, is effective: “The labelling has had huge impact, with decreases in food purchases and, perhaps most significantly, research showing that the regulation made children ask their parents not to buy the products.” If labels can prompt better eating behaviour, how can van Tulleken go to painful lengths to insist on the futility of trying to make good choices. Over and over again, he emphasises that the individual is simply no match for the power of the food industry and their dastardly techniques. But elsewhere, his certainty slips, and he seems to suggest that, perhaps, maybe, just a little, an individual can moderate their consumption of the food he describes as poisonous, and in so doing improve their health. It’s a glaring contradiction.

Dimbleby is a little more sanguine, and allows for a bit more hope. But, like van Tulleken, he emphasises systems over individuals. Dimbleby’s chapter on solutions — titled “The Power of Love”, I’m sorry to say — insists that solving our problems will involve creating a new “food culture”. Using both government intervention and community effort, we can change both the economics of food production and our habits regarding food preparation, in a way that promotes healthier eating. “Change has to come from both directions,” writes Dimbleby: “top-down, in the form of government legislation, taxes and regulations, but also bottom-up, with talented and dedicated people determined to improve the food in their own families, schools or communities.” This simultaneously sounds like a very natural and necessary evolution for our society, and like a heavy lift. But it’s a more humanistic and workable vision than that of van Tulleken, who largely seems content to describe why things are so bad without imagining how they might get better.

Recently, a great deal of ink has been spilled on the power of semaglutides, drugs developed to combat diabetes that have been shown to have meaningful impacts on obesity where so many others have failed. With brand names such as Ozempic and Wegovy, these new treatments are not stimulants, which have often been used for weight loss, and don’t appear to be addictive. But can they tame an epidemic? Van Tulleken doesn’t mention these drugs, but Dimbleby does briefly. He offers an evenhanded approach, insisting that they aren’t a silver bullet, but also admits that the very few other treatments actually work.

And this might just be all we’re left with. Government intervention seems unlikely; the voluntary pursuit of virtue rather than profit by private corporations unthinkable; and individual choice deeply constrained by external factors. The immensity of the problem, the sheer destructive potential of obesity, leaves me wondering if a pharmaceutical solution is the only one we can really count on. No, hundreds of millions of people injecting themselves every week for the rest of their lives doesn’t seem particularly sensible or sustainable to me. But it is perhaps the least bad solution to obesity, a problem from hell.

Neither my wife nor I use Adderall with any regularity. A 60-count “break-in-case-of-emergency” supply might last the Bateman family ‘til death do us part. But the same cannot be said for millions of others who are reliant on the drug: since last August, the world has experienced a shortage of Adderall. This is probably tied to manufacturing and supply chain issues combined with rapidly increasing demand — though nobody knows for sure. It has had a particularly acute effect on the US. A high-income country of 330 million people is bound to have an outsized impact on world affairs. But the numbers related to Adderall beggar belief. America consumes 80% of the drug’s global supply. Back in 2013, there were 18 million Adderall prescriptions in circulation in the United States — a number that exploded to 41.4 million in 2021.

These statistics can be partly explained by another equally astonishing set, relating to the condition for which Adderall is prescribed. According to the US Centers for Disease Control and Prevention, 6.3% of US children aged 5-9 have ADHD, compared to 1.5% of UK children aged between 6-8. Some attribute that to differences in diagnostic principles. The criteria used in the US are considerably more detailed, allowing for diagnosis only if at least five symptoms are present, whereas the globally-accepted standard gives more leeway to the clinician, only stating that symptoms should be “sufficient in number” and cause “significant psychological, social, educational or occupational impairment”.

When I asked one therapist why this leads to a much higher number of ADHD diagnoses in the US — rather than the opposite — she pointed to the laws governing education. Here, the Individuals with Disabilities Education Act mandates that schools provide special education services and accommodations to students with ADHD, while in the UK, there’s no specific legislation for ADHD, and schools have more flexibility to support students with diverse learning needs without a formal diagnosis. American doctors know that parents and students need this diagnosis for paperwork purposes, so they, to borrow a line from Jean-Luc Picard, “make it so”.

In other words, an ADHD diagnosis opens a lot of doors in the US. If you know what to say, it’s not hard to get Adderall. And there are plenty of reasons to want Adderall. It significantly improves cognitive function, increases wakefulness, and enhances mood — temporarily turning poor learners into decent ones, and good ones into rock stars. Longer-lasting than other ADHD drugs like Ritalin, Adderall offers that intense “clear” feeling I mentioned, resulting in higher levels of focus, attention, and motivation.

These stimulants can improve, among other things, performance on various standardised tests that (at least for now) still have an outsized impact on admission to the most prestigious academic programmes. Unsurprisingly, there’s plenty of evidence that rich parents and their kids are working with willing doctors to secure easy access to Adderall, and other so-called “smart drugs”. A 2016 study found that 10.7% of high school students who had used Adderall in the past year had obtained it from a doctor. Meanwhile, 13.2% had obtained it from a friend or family member, indicating that these drugs circulate widely in certain academic and social circles — a fact many of us may know all too well.

I’ve watched a number of friends and relatives game the system to receive legal prescriptions for ADHD, visiting physicians and uttering the magic words needed to meet diagnostic criteria. Their motivations varied: one cousin likes to be “amped up” on stimulants at all hours of the day, while a friend from college uses it to improve his performance as an esports athlete. And I’m willing to admit that the drug has benefited me in small and very infrequent doses. But there are obvious ethical concerns here. Adderall, like Ozempic (for weight loss) or testosterone (for muscle building), gives some people an unfair advantage over others.

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The US Drug Enforcement Administration acted last month to rein in what some now consider a “Wild West” environment. Adderall prescriptions in the US rose 16% during the pandemic, with telehealth appointments a main driver. The DEA’s proposed rule would require at least one in-person visit to the physician prescribing controlled substances such as Adderall. But it faces stiff resistance from clinicians and users, who argue that remote consultations increased access to life-changing medications. People whose lives and identities are tied up in ADHD have been lamenting that their condition, defined by an inability to focus without Adderall, becomes doubly hellish when they’re required to actually go somewhere to get prescriptions filled; the complaint of one legal aid attorney, representative of thousands of others, was that the “nationwide adderall shortage means I skipped my doses this weekend and fucking fought for my life to do the dishes”.

And yet, the rate at which Adderall is prescribed in the US must mean that the majority of diagnosed cases of ADHD are not life-destroying, merely life-affecting. Moreover, even long-tenured experts on ADHD, including Remembering Ritalin author Lawrence Diller, have serious qualms about the “realness” of the “disease”. In his book, Diller reflects on the various young patients — “Generation Rx”, he calls them — with whom he worked during the Eighties and Nineties, probing the extent to which ADHD is a legitimate diagnosis or an oversimplified, harmful label that could be applied to anyone in certain conditions. “For patients, if ADHD truly exists, risking their health by taking a drug to treat the condition or disease makes a lot more sense… [but] if it doesn’t exist, then perhaps they’re just using it as a crutch… and setting themselves up to abuse it,” he writes. Adderall, like other stimulants, presents numerous dangers: side effects that run the gamut from high blood pressure, increased heart rate, panic attacks, psychosis, agitation and irritability. And of course, there’s the horrific feeling of crashing when one doesn’t have regular access to the stimulant.

Diller’s concerns are echoed by my neurologist acquaintance. ADHD, like most diseases of the mind, are “all in one’s head”: the symptoms are not verifiable by any methods beyond the claims of the patient. Physicians have a duty to take these claims seriously, but it’s difficult to gauge the roots of a symptom from the outside. Is lack of concentration, far from being a “disease”, merely a sign that someone is a poor student — a sad but unavoidable fact of life that one must confront in the ordinary course of existence? And if so, would liberally prescribing this now-scarce drug be the ethical thing to do? Or would that be unfair on those who use Adderall to get through the day, rather than excel?

These are loaded questions, but important ones. In response to the Adderall crisis, the media has pumped out nuts-and-bolts policy proposals. A recent New York Times column, for instance, argued for maintaining full telehealth physician availability and boosting Adderall production by shifting regulation and oversight from the DEA — which is primarily interested in drug interdiction — to the FDA — which is more concerned with drug safety and access. There is certainly much to recommend such arguments. The libertarian, “government is the problem” side of me favours wide latitude with regard to drug access, but that doesn’t acknowledge the core cultural questions fuelling all of this feverish pill-popping.

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It’s hardly surprising that increasing numbers of people are struggling to concentrate. We are bombarded with stimuli, which naturally leads to difficulty focusing and increased impulsivity in day-to-day life — symptoms of ADHD — and the subsequent prescription of Adderall. If assigned, a diagnosis can become a core plank in an individual’s sense of self; as Freddie deBoer has written for UnHerd, our very online culture encourages people to turn diagnoses into identities. Viewed this way, Adderall’s is a toxic, “ouroborotic” cycle of consumption — the culture fosters the behaviours that result in an ADHD diagnosis, Big Pharma sells you the medication needed to address it, and the various social media platforms that monetise your freely-provided content offer you space to earn attention by #ShoutingYourStigma.

Are you your disease — as a young influencer might proclaim on TikTok — and therefore entitled to Adderall access as some sort of fundamental human right? By extension, is someone who has the attention span of a feral cat that’s locked onto its prey not entitled to this “smart drug”? Or should everyone have access to Adderall, since it’s a tool that might encourage further human flourishing, before we’re forced to insert neural implants and merge with AI? Or should no one, since our “human essence” is sacred and must remain unsullied by chemical interventions?

These are the questions we will need to answer. But for now, all we can be sure of is that fewer people will get Adderall, particularly cheaper generic-brand Adderall, than want it. Those that do will probably be the richest — who may use it to get richer — rather than those who most need it. We can only hope that these dynamics will encourage us to reflect on whether wanting and needing, like our illness and our selves, are inextricably linked, or merely connected because “thinking makes it so”.