0:00

One focus, one subject. Welcome

0:02

to The Real Story, the podcast that brings

0:04

together global experts to explain

0:07

one issue shaping the news. BBC

0:10

World Service podcasts are supported

0:12

by advertising.

0:16

This is The Real Story from the BBC.

0:19

I'm Sean Lay with your weekly exploration

0:21

of a story that's making news and

0:23

changing lives. And this week, over

0:26

one billion people worldwide are

0:28

obese. If current trends continue,

0:31

half the world could be obese or overweight

0:34

by 2035, something

0:36

that's alarming doctors.

0:37

Obesity really is a worldwide problem.

0:40

We are looking at about 150 million people in the

0:44

US alone by 2030

0:46

being in the obese category. It's

0:48

not a disease of vanity. This

0:51

is truly a neurohormonal disease

0:54

that needs long-term medication just like

0:56

anything else.

0:57

Once considered a problem of the affluent

0:59

West, obesity has been spreading

1:01

in recent years in low and middle-income

1:04

countries. More than half of Chinese

1:06

adults are now overweight or obese.

1:09

In India, the country's undernourished

1:11

population is being replaced by

1:13

an overweight one. The World Health

1:15

Organization says changing lifestyle

1:18

is creating an obesity epidemic.

1:20

We're living in an environment where

1:22

there's just an abundance of food,

1:25

which is extremely high in

1:28

calories and low in nutritional value.

1:31

And it's very difficult

1:33

to be active. And it's

1:36

almost the exception now. In fact,

1:38

in our region, you're in the minority to be

1:40

a normal weight.

1:41

Overweight people are constantly

1:43

told they must eat better and exercise

1:46

more. Clinicians say where that doesn't

1:48

work, new injectable weight loss

1:51

drugs like Wigovi could be a

1:53

game changer.

1:54

But most individuals with lifestyle modification

1:57

alone are going to lose around 5

1:59

kilograms kilograms to 10 kilograms.

2:01

Here with these weight loss medications

2:04

added, we are seeing much

2:06

larger weight losses through, say, 20

2:09

kilograms and beyond in some of

2:11

our patients that just aren't typical of

2:14

lifestyle modification by itself.

2:16

But these new drugs also carry

2:18

risks. They also come with a hefty

2:20

price tag, and in trials, users

2:23

often put weight back on after stopping

2:25

treatment.

2:26

So is it better to stick with diet

2:28

and exercise

2:28

which works for some than rely

2:30

on medicine to get us out of this crisis?

2:34

In Mexico, 75% of adults

2:36

are overweight or obese, and it has one

2:38

of the highest childhood obesity rates in

2:40

the world. One school there has

2:42

given each student a desk with a bicycle

2:45

attached so they're moving while they're

2:47

learning.

2:48

When we're

2:50

physically active, it really helps us keep

2:52

focused on our daily activities. It's actually

2:54

incredible. What

2:57

should

2:57

we be doing to tackle the global

2:59

obesity epidemic?

3:08

Well in this edition, we're exploring how obesity

3:11

has become a global health crisis and trying

3:13

to answer some of the questions posed by it.

3:15

Why, for some people more than others, pound

3:18

shed assume back on again, and why

3:20

obesity is appearing in countries that

3:22

have only recently escaped malnutrition? Just

3:24

some of the questions for this week's Real Story

3:27

panel. Joining us from Calcutta in India,

3:29

Dr. Binayak Sinha is an endocrinologist

3:32

with a special interest in obesity

3:34

and diabetes. Welcome Dr. Sinha. When

3:37

did you first notice obesity was becoming

3:39

a problem in your country?

3:41

I think it's always been there.

3:44

I think it wasn't all that prominent before,

3:46

and I think the awareness was a little low about obesity.

3:48

But you know, we had chubby kids in school

3:51

who were of the butt of all jokes, and that

3:53

kind of problem was always there. And

3:55

I do remember these

3:58

kids who were a little chubby. tended

4:00

to not take part in sport and be

4:02

a little bit ripped about their

4:04

problem quite a bit.

4:06

Rachel Nugent is Associate Professor

4:08

at the Department of Global Health at the University

4:10

of Washington on the west coast of the United

4:12

States. But today she's joining us from Argentina.

4:15

Rachel, welcome to the program. When did you first

4:17

notice obesity was an issue? Was it also something

4:20

that you were aware of when you were growing

4:22

up?

4:22

You know, so I'm not really. The

4:24

issue that I was aware of as

4:26

a young girl and young teen

4:29

was that especially girls

4:31

of normal healthy weight were very

4:33

worried about being overweight or obese

4:36

and so dieted excessively. That

4:38

was the problem in those days.

4:41

And it's still a problem and it's a serious one,

4:43

but I think of course the fastest growing

4:46

problem is that many,

4:48

many more

4:49

young people are obese

4:51

and overweight.

4:51

And I am concerned that maybe they

4:54

don't see it as something

4:55

to be addressed in

4:58

a serious way.

4:59

And Dr. Fatima Cody Stanford

5:01

studies obesity at Massachusetts

5:03

General Hospital and Harvard Medical School in

5:06

the United States from where she joins us. Dr.

5:08

Stanford, welcome. When did you first

5:10

notice obesity becoming an issue?

5:13

From the beginning of life, I

5:15

had individuals that were in my

5:17

family and my fear of childhood

5:20

friends and my church community

5:23

that had obesity. And it was

5:25

very clear that there were differences in them

5:27

versus those that looked like

5:29

me. And I didn't understand at the

5:32

time of that, I guess at my infancy

5:34

and youth, why they struggled in ways

5:37

that were different from myself. But as I've

5:39

come to study this disease process

5:41

and publish in this disease process, I've

5:43

come to understand the myriad of reasons why

5:46

one person may struggle while another

5:48

person doesn't struggle. Obese is a label,

5:50

a highly stigmatizing label

5:53

that really sets people up with a negative

5:56

judgment. Obesity is a disease.

5:58

Obese is a label.

5:59

often used to judge people negatively

6:03

with this disease. It's a wider

6:05

issue. We don't care about patients

6:07

with obesity. And we treat patients

6:10

with obesity in a way that we don't

6:12

treat patients

6:13

with other chronic disease. These are patients

6:15

with obesity, just like patients with cancer

6:17

or patients with diabetes.

6:19

The global population is 8 billion

6:22

people. And over 1 billion of us worldwide

6:24

are obese. The World Obesity Federation,

6:27

that's not a government body, but one made up of medical

6:29

doctors, scientists, and researchers in the field, says

6:32

more than 50% of the global population

6:34

are on track to be overweight or obese

6:37

by 2035 if the current

6:39

trends prevail. Rachel Nugent, how

6:41

do we define the term obesity?

6:43

There are many different measures that can be

6:46

done. But the most common term we use

6:48

and an easy measure

6:49

is called BMI, body

6:51

mass index. And it's a simple

6:53

fraction of

6:55

the kilograms squared

6:58

over the meters squared of an individual.

7:01

So then there are cutoff points

7:03

that define a healthy weight, an

7:06

overweight and obese and

7:08

severely and beyond very high

7:10

levels of obesity. That's what we commonly

7:13

use. There are other measures that are done

7:16

clinically. But for the

7:17

general population, most people aren't getting themselves

7:19

measured

7:19

for this regularly. And Benayak,

7:23

in Calcutta, what are the

7:25

wider factors that contribute to

7:27

this? There are multiple issues out here. But

7:29

I think primarily the main problems are definitely

7:32

diet and exercise. This is

7:35

energy misbalanced with too

7:37

much of food going in and too little coming out.

7:39

Now, this might vary from person to person.

7:42

And some people genetically

7:44

or biologically are more prone

7:47

to put on weight than others are. And

7:49

that in itself might be a big

7:52

issue. But essentially, it's

7:54

finally an energy misbalance. And it's diet

7:56

and exercise, which are the primary issues which

7:59

may be a problem.

7:59

a person put on weight excessively.

8:02

Dr. Fatima Stanford, is Body

8:04

Mass Index or BMI enough

8:07

to determine the health of an individual?

8:09

The American Medical Association

8:12

in their June 2023 meeting has determined that

8:14

BMI

8:14

alone

8:16

does not determine one's health status and

8:19

has decided that other metrics like

8:21

waist circumference which gives us more

8:23

information about metabolic health should

8:25

be used in conjunction with height

8:27

and weight and also the Lancet Commission

8:30

which

8:30

is a worldwide group of individuals

8:33

including myself has

8:35

determined that if we use other

8:37

metrics which include height and weight we

8:39

can get more information about

8:41

the health status of an individual which

8:43

go beyond just looking at height and weight. So

8:46

let's look at what happens if I just look at height

8:48

and weight and I just look at someone walking

8:50

down the street I assume that I know something about

8:53

their diet or their health or what they're eating

8:55

or how much they're exercising without doing a

8:57

deep dive to determine what their cholesterol

8:59

values are, what their liver looks like,

9:02

what their fasting blood sugar is.

9:04

I have no idea what that is. I assume that

9:06

someone that's lean is healthy and someone

9:08

that carries more excess adipose is unhealthy

9:11

without me knowing anything about them and

9:14

that is where some of that bias comes

9:16

in. Benayak

9:17

in Calcutta, what

9:20

are the health impacts because people look

9:22

at things like how big your stomach is

9:24

and your height and all the rest of it they make

9:27

various calculations but it's not so much

9:29

that it's what it may cause that we're most

9:31

concerned about. What are the impacts on someone's

9:33

health from this question of is their

9:36

weight too high? So this is

9:38

where I think the entire process

9:40

becomes a very difficult thing. I think

9:43

it's not just somebody putting on weight

9:45

becoming overweight or becoming obese.

9:47

The problem lies

9:49

in the baggage it carries. This fat

9:51

is getting deposited in the tummy and this is

9:54

getting deposited in the pancreas, the liver,

9:56

the heart. So it increases

9:58

every disease that you can think of. of heart

10:00

disease, diabetes, cancers.

10:03

And in addition to that, once you put on

10:05

weight, there is this stigmatization that

10:07

takes place. And that leads to a lot of problems

10:09

with mental health. There's problems with mechanical

10:12

issues like arthritis, with people having

10:14

it, finding it difficult to move around, which

10:16

in turn is kind of like, you know, it's

10:18

a jeopardy in the sense that people start

10:21

exercising even less and therefore

10:23

put on even more weight. So it's

10:25

a vicious cycle. And you know, the best thing

10:27

is to avoid putting on weight so

10:29

that, you know, you never get into this vicious

10:32

cycle when you're trying to continuously fight

10:34

your weight at the same time you're trying to

10:36

keep all these diseases at bay.

10:38

This is not only a disease of the wealthiest

10:40

economies in the industrialized North. In fact,

10:43

the numbers have been rising rapidly in

10:45

the global South. Official figures from

10:47

Beijing dating to 2020 put

10:50

more than 50% of Chinese men and

10:52

women in the category obese. The

10:54

World Obesity Federation says that in 12 years

10:57

from now, 47% of Mexicans, 46% of Iranians and South

10:59

Africans, and 42%

11:03

of Malaysians will be obese.

11:06

I've been speaking to Julianne Williams from the European

11:08

Central Asia regional office at the World

11:11

Health Organization. How has obesity

11:13

become more of an issue in middle and lower

11:15

income countries? What we

11:17

see is indeed this initially

11:20

lower levels of overweight and obesity, and

11:22

then the increase is

11:25

going very quickly over time. And

11:27

much of that has to do with just rapidly

11:30

changing environments. We

11:32

see that a lot of the big companies

11:34

who produce what we think of as energy-dense

11:37

foods,

11:38

which really contribute to the obesity

11:40

and overweight epidemic, are moving

11:42

into lower middle income countries as

11:45

it becomes more difficult for them to operate in

11:47

some of these higher income countries. So

11:50

there's kind of an unintended consequence

11:52

for many of our policies in high income

11:54

countries, which means the environments

11:57

are changing in lower income

11:58

countries and contributing.

11:59

to this problem.

12:01

Is it fair to say that

12:03

obesity is becoming a truly global

12:06

problem?

12:06

Yes, it's really alarming

12:08

for us. We see even in our

12:11

region, in the WHO European region,

12:13

this issue of what they call the double

12:15

burden of malnutrition, where

12:17

you have both the issues of

12:20

spending and wasting alongside

12:23

overweight and obesity, or sometimes

12:25

they even call it the triple burden of malnutrition.

12:27

So within a household, within

12:29

an individual, within a country at large,

12:32

you'll have all of these problems, under

12:35

nutrition, obesity and overweight, and

12:37

then sometimes even malnutrition or micronutrient

12:40

deficiency alongside overweight

12:42

and obesity, which makes it really difficult

12:45

for the health system to respond. We

12:48

went from an environment where there was

12:50

a scarcity of food to this

12:52

new environment where there's an abundance

12:54

of food. So from a time

12:56

when there was not enough to too much,

12:59

and our biology unfortunately

13:02

cannot adapt to this new environment

13:04

as much as we wish it could. For

13:07

example, an infant or even in

13:09

utero, if there is not

13:11

enough energy, and if you

13:13

have under nutrition, that

13:16

paradoxically that child is susceptible

13:18

to being overweight and obese later in life.

13:21

And I think for us, it's a relatively

13:23

new problem, this problem of overweight

13:25

and obesity compared to many

13:27

of the other diseases that we have. And

13:29

so one of the challenges that we have

13:32

is sort of understanding how we respond

13:35

to it. There's many different levers

13:37

that countries can pull, and

13:39

some countries have been really good at

13:42

pulling a few of those levers,

13:44

or several of those levers. But

13:46

what we haven't seen is we haven't seen a single

13:48

country kind of pull all the levers that are

13:50

needed.

13:51

Which countries are you most worried about,

13:53

and which countries are particularly good,

13:56

or at least appear to be being

13:58

effective at the moment?

13:59

So in our region where we're

14:02

seeing in the Central Asian countries,

14:04

for example, in Tajikistan, we

14:07

have almost no overweight and obesity

14:09

among boys who are primary school

14:11

aged, but 5% of them are underweight.

14:15

And so it's going to be really interesting to see what

14:17

happens to that population of children

14:20

as they grow into adults

14:22

who have, where they're living in environments

14:25

where there's just this explosion in the

14:27

availability of foods that are designed

14:29

to be extremely tasty and

14:32

dense in energy and low in micronutrients.

14:34

In our region as a whole, in the Southern

14:36

European countries, so

14:39

around the Mediterranean, that's where we see the highest

14:41

levels of

14:42

childhood overweight and obesity. So

14:44

everybody needs to keep their eye on the ball. There's

14:47

nobody really who can sit back and say, well, look,

14:49

we're doing the right things at the moment.

14:51

Every country in the world, the levels are

14:53

rising. The global WHO

14:55

goal for the monitoring framework

14:58

that we use is just to halt the rise, just

15:00

have those levels plateau. If

15:03

it can just stay the same year to year,

15:05

that is kind of what we're aiming for. And in no

15:07

country is that currently happening.

15:09

That was Julianne Williams

15:12

at the European Central Asia Regional Office

15:14

of the World Health Organization. Rachel Newt

15:17

in Argentina, let's talk about China. It's

15:19

a country I think you've researched. It went from

15:22

rural to heavily industrialized in

15:24

not much more than a generation from people

15:26

who've experienced famine to a nation of expanding

15:29

waste lines. What's been going on there and

15:31

what's happening now?

15:32

Well, China is a very interesting

15:34

story because we have only recently

15:36

thought of China as a country with

15:38

the kind of health problems that we've been

15:40

experiencing in richer countries

15:43

for a long time. But it's happening so fast

15:45

in China and China is so large, of course,

15:47

that it becomes a major issue. It is

15:49

getting a lot of attention from the government

15:52

there, particularly Chinese children

15:54

and adolescents are experiencing this

15:56

increase in overweight and obesity.

16:00

They've invested a lot in school-based

16:02

programs. So they're paying a lot

16:04

of attention to the children and adolescents, and

16:06

they've invested in school-based programs

16:08

that can help children become more aware,

16:11

that can limit sort of

16:13

the marketing to

16:15

children, that can encourage

16:17

and implement more physical

16:19

activity. They have

16:22

the whole plan now. I can't speak

16:24

in detail about it. It'll be published. It'll

16:26

be publicized and published next year

16:29

based on an investment case that we've done

16:31

that shows them how to choose priorities,

16:33

how to get the best return on investment

16:36

for the investments that they're making. And

16:38

Benayak Sinha in India, nine of

16:40

the ten countries of gracious expected increases

16:43

in obesity globally, according to

16:45

the World Obesity Federation, are low

16:47

or lower middle income states in Africa

16:50

and Asia. India too has seen this fast

16:52

rise. When did it start? Why

16:55

are we clear about why the acceleration has

16:57

apparently been so quick? I

16:59

think there are a few things actually. It's not just one

17:02

thing that you can put your finger on. The

17:04

low-hanging fruit is of course

17:06

that Indian economy

17:08

went up quite well over

17:10

the last 20 years or so. So people

17:12

in a sense got richer. What

17:15

did people do? They started making

17:17

their lives easier for themselves by

17:19

tending to eat more calorie-dense

17:22

food which was less nutritious and

17:24

also starting to take less exercise.

17:28

Normally people walking down the street to get a bus

17:30

would now probably take an Uber. So

17:32

this is one thing that's obviously made

17:35

a big difference. Secondly, I think in

17:37

India, the traditional feeling has been that

17:39

somebody is healthy if they are a

17:42

little on the heavier side. If

17:45

that kind of outlook on life,

17:47

I often have patients coming to my clinic and saying,

17:50

I've always been healthy, now I've

17:53

become healthier. That

17:55

has also been a misconception amongst Indians

17:57

in particular who have felt that being

17:59

a little bit overweight or being

18:02

a little bit more than overweight is

18:05

probably a sign of prosperity.

18:07

Right, well let's go back to the wealthier

18:10

nations. Over 40% of Americans

18:12

are living with obesity and the rate of obesity

18:15

is growing across the state. New

18:17

population data from last year showed 22

18:20

states had an adult obesity prevalence

18:22

at or above 35% compared to 19 states in 2021. Those

18:27

figures from the Centers for Disease

18:29

Control

18:29

and Prevention. Dr

18:32

Fatima Stanford in the United

18:34

States, a apparently deteriorating picture,

18:37

given how much effort, how

18:39

much money people pay

18:41

towards improving their fitness,

18:44

healthy eating and a kind

18:46

of fitness culture of recent decades, is

18:49

it disappointing to you that the figures seem to

18:51

be so much on an upward

18:54

trajectory in so many places?

18:56

No, I don't really think it's disappointing.

18:58

I think it points to our hyper focus on

19:00

just the food and beverage behavior

19:02

and our lack of focus on the other factors

19:05

that do contribute to obesity. So

19:07

for example, we haven't at all

19:09

really discussed those biological or

19:11

medical reasons that contribute to

19:14

the rise in obesity. For example, weight

19:16

promoting medications, about 20%

19:18

of obesity in the United

19:20

States is secondary to medications

19:22

we prescribe for other issues.

19:24

We never talk about that. Age related

19:26

changes which are really prominent in women's lives,

19:28

there are three major times in women's life where we see

19:30

major

19:31

weight shifts at the onset of menarche

19:33

when we first get our menstrual period.

19:35

When

19:35

we have children, whether or

19:37

pregnancy, whether or not that leads to a viable offspring

19:40

and menopause, where we see major hormonal

19:42

shifts where we often accumulate central

19:44

adiposity or central fat. Genetic

19:46

and epigenetic factors, sleep deficits

19:49

that shift in circadian rhythm that

19:51

happens often during our lifespans.

19:54

Genetic and epigenetic factors are changing

19:56

the gut microbiota that has shifted over

19:59

time. These things that

19:59

we don't talk about. We hyper focus on

20:02

one area and we've completely neglected

20:04

these other areas. In terms of your research,

20:07

I saw one article recently quoting

20:09

you which also suggested

20:12

a statistic that suggested as much as 65%

20:16

of an individual's risk of developing obesity

20:18

could be passed down in their genes.

20:21

Is that an accurate picture as far as it's possible

20:23

to tell?

20:23

Well it can be somewhere between 50 to 80%

20:27

of that high heritability.

20:28

So once you have a parent

20:30

that has obesity, unfortunately

20:32

there's a high heritability of that disease

20:35

passing down. So I care

20:37

for patients that range in age

20:39

from 2 to 90 years of age.

20:41

And so when I have children coming into me

20:44

at 2 or 4 or 5 years old, I'm

20:46

not indeed surprised when I'm taking

20:49

care of that child, the parent, the

20:51

grandparent and sometimes even the great grandparent

20:53

due to the high heritability of that disease. But

20:55

we neglect that really important

20:58

factor, particularly if we

21:00

look at this high heritability of this disease

21:03

process. Rachel Nugent

21:05

in Argentina, what's the picture in

21:07

Europe on this?

21:08

On Europe, we see in

21:11

the eastern part of

21:13

Europe that there

21:14

is high obesity

21:16

in most of the countries there. In

21:19

Western Europe it varies a lot. For instance, in Denmark

21:21

we've made projections up to the year 2060.

21:24

Denmark

21:24

is one of the countries that will not

21:26

be expected to have extremely high

21:28

prevalence of obesity. Whereas, for

21:30

instance, in the UK we've projected an 85%

21:33

prevalence of obesity if everything

21:35

stays the same.

21:36

I have to emphasize that because we

21:39

hope that things don't stay the same. And

21:41

again, it's an interesting policy question, is it? Because

21:43

we have free at the point of health

21:45

care in the UK

21:47

and indeed many parts of Western Europe, even

21:50

where health insurance is involved, is very

21:52

generous compared perhaps to parts of the United

21:55

States. And I wonder therefore if this is something

21:57

of a policy failure that these numbers

21:59

are...

21:59

of still rising?

22:01

Well, certainly it is, because there are policies

22:04

to be implemented that have not been implemented

22:06

in many places. So it's most

22:09

definitely a policy failure. And I think it's important

22:11

to point to that, rather than the

22:13

sort of longstanding prevailing belief that it was

22:15

an individual human failure. We've

22:17

moved away from that, I think,

22:19

quite felicitously.

22:21

It is not a failure of the individual.

22:24

But it's not only policy that can

22:26

change it. I just want to point out, too, it's a very

22:29

significant

22:29

economic cost, both

22:31

at the individual level and at the

22:34

national level. And that's getting people's

22:36

attention, the policymakers' attention.

22:38

A reminder, you're listening to the real story

22:40

from the BBC World Service with me, Sean

22:43

Lay. This week, we're asking,

22:45

how do we solve the global obesity

22:47

crisis? More than half the world's population

22:50

will be glassed as obese or overweight by 2035

22:54

if action is not taken. Some are

22:56

suggesting an injection, which appears

22:58

to help people to shed weight more rapidly

23:00

than diet and exercise alone have managed

23:03

could be a game changer. To

23:05

discuss the implications, still with me are our panel.

23:08

Dr. Fatima Cody-Stanford studies

23:10

obesity at Massachusetts General Hospital

23:13

and Harvard Medical School. She joins

23:15

us from the east coast of the United States.

23:17

Dr. Binayak Sinha is an endocrinologist

23:20

with a specialist interest in obesity and diabetes.

23:23

He's in Calcutta in India. And

23:25

in Argentina is Rachel Newton, who is

23:27

associate professor at the Department

23:29

of Global Health at the University

23:32

of Washington State on the west coast

23:34

of the United States. We've recently

23:37

seen the emergence of weight loss drugs like wagovi

23:39

and azenpic. Using them means a once

23:42

weekly injection that slows down the emptying

23:44

of the stomach and suppresses the hunger

23:46

hormone in our brains. Both these medications

23:49

are made of the same drug called samaglutide.

23:53

The drug was approved by regulators in the United

23:55

States in 2021. It was also approved

23:57

for use in the UK Health

24:00

Service earlier this year after

24:02

research suggested users could shed more

24:04

than 10% of their body

24:06

work. Dr. Fatima Stanford

24:09

tell us about these drugs. They're basically

24:11

brand-aids aren't they? As Zempic and Wagovi.

24:13

How do they work?

24:15

Yeah so these medications are what

24:17

we call GLP-1 agonists and these medications

24:20

work on the brain. They actually stimulate

24:21

the pathway of the brain

24:23

that we call an anorexigenic pathway

24:26

that tells you to eat less and store less

24:28

adipose and down regulates

24:30

the pathway of the brain

24:31

that tells you to eat more. So put in it's

24:33

put in layman's terms is it that it's tricking

24:36

the brain? It's

24:36

important to know that our bodies on

24:39

our own produce GLP-1 so a lot

24:41

of people don't know that our bodies on its own produce

24:43

GLP-1 some of our bodies do that better

24:45

than others okay so I would say

24:47

that for those of us that don't do it or

24:50

our bodies don't do it as well

24:51

it's an enabling those

24:53

persons

24:53

to do it well like those that

24:55

do it their bodies do it well on their own.

24:58

So it's kind of almost like training the body or retraining

25:00

them. Yeah retraining those those bodies

25:02

that may not do it as well on their own. And

25:05

this it's a Danish company Novo Nordisk

25:08

they've got two products really so Zempic was

25:11

originally for persons with diabetes. Right diabetes

25:13

type 2 diabetes and Wagovi

25:15

for specific reasons. Yes

25:18

right and just a full disclosure

25:21

you've worked in the past I think for Novo Nordisk

25:23

as an obesity content. Is

25:25

that correct? I've advised all of the companies.

25:28

I don't think any company I have an advice. And

25:31

you've got no research

25:33

connections as such with them that's fine. No no

25:35

I don't I'm not I've not been on any of the

25:37

trials. What about the side effects

25:39

or potential drawback? Yeah absolutely

25:42

so that the most common side effects for these drugs

25:45

actually the number one side effect is nausea

25:48

followed by constipation and that really

25:50

that's not really surprising that gets the

25:52

slowing of gastric

25:53

emptying meaning the slowing of movement

25:55

of food through the GI tract is the second

25:57

most common side effect.

25:59

Other people may experience

26:02

issues like diarrhea, which is

26:03

interesting because constipation is a side effect.

26:06

Some people may experience abdominal pain, some

26:08

people may experience fatigue. There's

26:10

been some findings to suggest that you

26:13

may lose not just fat, but you

26:15

can also lose muscle as well. Presumably

26:17

that's a potential drawback.

26:18

Yeah. For any really

26:21

strategy that we use to address weight, whether

26:23

it's medications or metabolic

26:26

and bariatric surgery, you do lose both

26:28

fat and you can lose muscle mass. But

26:31

you can help retain lean muscle by engaging

26:33

in activities that help retain that lean

26:36

muscle. So it's not going to

26:38

be a case of jab rather than jog.

26:40

You're still going to have to do both. We'd

26:43

love for you to continue

26:44

to engage in activities

26:46

that help retain lean muscle. I would say

26:48

we become more concerned when we get into

26:50

our older adult population. That there

26:53

are 60, 65 plus population, but I do

26:55

still utilize these medications in

26:57

that population as well. There's obviously a lot

26:59

more research being done ongoing as people use

27:01

these. And we'll talk about what the company

27:04

is saying because it said in a statement

27:06

that it's, you should say it is paramount,

27:08

works closely with authorities

27:11

in this country and others to monitor safety

27:13

profile of its medicines. It also recommends

27:15

patients only take them

27:17

under approved indications and under

27:19

supervision of a healthcare professional, which

27:21

I guess is something all of you taking

27:24

part in the panel would absolutely emphasize.

27:27

So that's Novo Nordisk's statement

27:30

on patient safety. One

27:32

just last quick point if I may, Fatima. Yes. What

27:35

about this question has also been raised in

27:37

some of the coverage of these drugs that if

27:39

people stop taking them, the weight

27:41

goes back on. Absolutely.

27:43

So these medications are acting

27:45

on the brain like we just talked about. As soon as

27:47

we take away agents that are acting on the

27:49

brain, just like if we take away a medicine

27:52

that we use to treat high blood pressure

27:54

or a medicine that we might be using to treat high

27:56

cholesterol, as soon as we take that away, we expect

27:58

those agents to be able to take away the medicine. agents to rebound

28:01

or those issues to

28:02

rebound and that's exactly what we'd

28:04

expect here. So you do start

28:06

to see weight regain when we pull these medications

28:09

back because we're no longer treating the issue

28:11

that we were treating. Thank you very much. I should

28:13

say the figures at the moment of cost of something

28:16

like in the United States at least $1,300 a month.

28:21

Dr. Benaiac Sinner in Calcutta

28:23

listening to all of that. Novo Nordisk

28:25

is now Europe's most valuable company.

28:28

Stock has risen I think fourfold since 2018.

28:30

Suddenly everybody wants

28:32

to get in on the act. From where you're

28:34

sitting in India could that in time do you think

28:36

reduce the cost and so make these

28:39

treatments much more affordable

28:41

globally?

28:42

It should happen but I don't

28:44

see it happening in the near future because it's all

28:46

on patent at the moment and patent clauses

28:48

such that I don't think the companies are

28:51

kind of mandated to do that. I think

28:54

this is where governmental pressure and societal

28:56

pressure needs to come in. Particularly I know for

28:58

a fact in the NHS you know there

29:00

is issues in which the

29:03

government actually tells the companies that

29:05

hey give it to us at this price

29:08

or else we don't take it. If such

29:10

a system were to arise here in India

29:12

that would be a very positive system as well. India

29:14

does not have the Ozempic

29:17

or the Vigovia at the moment. We have the oral

29:19

version of that which is rubelsus

29:21

which is semaglutide but in the oral

29:24

form and it also is

29:26

quite expensive but you know unless

29:28

there is some kind of government input or some

29:31

kind of a association based input

29:33

into this I don't see the price of these

29:35

products coming down in the near future. Rachel

29:38

Nugent you talked about the financial

29:40

cost. The World Obesity

29:42

Federation I think is saying that by 2035

29:44

the costs of this problem could

29:48

swell up 3% of global

29:50

gross domestic product which sounds

29:53

phenomenal. I mean are people looking at

29:55

this these new drug treatments therefore

29:57

as a potential magic bullet.

29:59

In many ways, they seem like a magic bullet,

30:02

I would say, certainly from the medical and

30:04

health side because they can address

30:06

so many problems that people

30:08

may experience, as was talked

30:10

about earlier, cardiovascular disease, diabetes,

30:12

hypertension, cancers, musculoskeletal.

30:15

So in a sense, there's a medical

30:17

magic bullet, although

30:18

definitely needing to

30:20

have a surrounding environment of

30:22

good

30:22

clinical advice. From the economic

30:25

perspective, yes, overweight

30:27

and obesity at the population level is a big issue

30:30

when you think about, right, we did this work with

30:32

World Obesity Federation and

30:34

published it in the BMJ Global Health

30:37

this past year, estimating already 2%

30:39

of global

30:40

gross domestic product is lost

30:43

to the impacts of overweight and obesity.

30:46

And it will grow to more than 3%

30:48

globally unless something

30:50

is done. So we do need something

30:52

big, bigger than what we've been doing so far.

30:55

Thank you very much. Well, one of the biggest hurdles

30:57

people who are overweight or

30:59

who are diagnosed as having obesity face

31:02

is the attitude of those who are not.

31:05

In May this year, New York City approved legislation

31:08

outlawing discrimination based

31:10

on weight.

31:10

Let's hear from some women here in the UK now

31:13

who are part of what's become known as the body

31:15

positivity movement.

31:17

The word fat is just like being petite or

31:20

tall. It's literally just describing my body

31:22

shape. Society is very, very

31:24

fat phobic and it's the worst thing in the world

31:27

is to be fat. But when you reclaim the word

31:29

fat, it takes the power away. So

31:31

yeah, you can call me fat. That's

31:34

what I am. I'm also incredibly

31:36

buff.

31:40

The body positivity

31:40

movement has made an

31:43

absolutely incredible difference in

31:45

my life. It really has changed everything for

31:47

me knowing that it is possible to

31:49

feel positive about myself

31:51

or even to feel neutral about myself.

31:54

But just it's not a given that I have to always feel negative

31:57

because I'm fat. It was definitely a turning

31:59

point for me.

31:59

I uploaded my first ever fashion blog

32:02

post with my whole body and

32:04

I received

32:04

positive feedback because that was such

32:07

a difference for me. There's

32:09

no pressure to be perfect for me anymore because

32:11

I've allowed myself

32:13

to be so unperfect that people just take me

32:15

where I am and if they don't, they're

32:17

cancelled. Rather than putting

32:19

it on me to subvert stereotypes

32:22

about fat people and what that means, I

32:24

think it's more useful for people who

32:26

aren't fat to ask themselves why it's

32:29

so important to them that even

32:31

if those stereotypes were true, it would give them the right

32:33

to treat fat people badly. I'm

32:36

not this,

32:36

you know, disgusting, you know,

32:38

horrible person that I've always thought I was.

32:40

I'm actually a person of value

32:43

and somebody that, you know, deserves

32:45

to be respected and deserves

32:46

to be loved. We don't have to always be living in

32:48

this suspended state of waiting to do

32:51

all the stuff you want to do that

32:53

you can't do until you're thin. I love

32:56

going to spinning, I have a personal

32:58

trainer and I've only really been able

33:00

to embrace those things that I

33:03

really enjoy since

33:05

I have stopped thinking about exercise

33:07

in terms of its like potential for

33:09

weight loss. Just try and live as unapologetically

33:12

and as loudly as possible. It's okay

33:14

to be vulnerable, it's okay to be fat,

33:17

it's okay to be whatever it is that you think

33:19

it's not and that's why I tell my

33:21

story because I hope it inspires people to just

33:24

be who they are. There

33:27

you go, you heard some voices there

33:30

that the BBC recorded a little earlier.

33:32

They're Grace Victory, who's a blogger and body positivity

33:35

activist, Stephanie Yeboah, who's a body

33:37

positivity campaigner and Bethany Rutter,

33:40

a writer who blogs about plus-size fashion.

33:43

Rachel Nugent listening in Argentina,

33:45

the body positivity movement is trying to make society

33:48

more accepting but it has been accused

33:50

of promoting obesity and unhealthy

33:52

lifestyles. Is that a fair criticism, do you

33:54

think?

33:55

No, I don't think it's fair. What we just heard

33:57

was wonderful and I think it's fantastic.

34:00

that people are shifting minds about

34:03

what it means to be healthy. Because really we're

34:05

not talking about fat or thin, we're talking

34:07

about healthy body weight, healthy

34:10

people. And that's what we want. That's

34:12

what policies should encourage

34:14

and that's what the images in

34:16

the media and so on should

34:19

also perpetuate.

34:21

Because there have been some striking findings.

34:23

Earlier this year one piece of research

34:25

suggested that a third of people with a normal

34:28

body mass index rating actually

34:30

had unhealthy metabolic metrics. About

34:32

a quarter of those classified as having

34:35

obesity were metabolically healthy.

34:37

I mean this is a real problem isn't

34:39

it for us as patients to

34:41

understand what we're being told when

34:43

we're diagnosed.

34:45

Well that makes the

34:47

point exactly what we were talking about that

34:49

it really isn't as simple as thin

34:51

or fat right and what Fatima was

34:54

saying earlier about having

34:56

to do a deep dive. But I would say

34:58

doing a deep dive into somebody's health

35:01

with all of the different measures we can take the

35:04

blood glucose and cholesterol etc. That's

35:06

not going to happen for everybody particularly

35:09

in lower-income countries. So we

35:11

do need to have some guidance and we

35:13

do need to know how people can

35:16

be encouraged to live in a healthy way, to eat

35:18

in a healthy way, to move in a healthy way and to

35:21

know when to seek medical care when

35:24

their weight or anything else is suggesting

35:27

a risk.

35:28

Benayak you're in

35:30

a country that is a low-income country although

35:32

it's moving rapidly up the income scale

35:35

still low income on average in

35:38

India. How then do you change

35:40

I mean I know there are two things are different aren't there. Number

35:42

one in some of the Asian countries

35:45

the BMI is measured differently so the

35:48

kind of readings that trigger the medical

35:50

interventions are different for

35:52

that reason. But also this

35:54

question of how do you change the attitudes

35:57

of some practitioners so patient

36:00

don't feel they're being shamed into taking

36:02

action when it's action that's in their own healthy

36:05

interest rather than judgment on their

36:07

appearance?

36:09

That is probably the point that I

36:11

was just about to make. It's not a question

36:13

of fat shaming or body shaming or anything

36:15

like that. I think Indians per

36:17

se are known as the thin fat Indians

36:20

because the BMI might not be too high

36:23

but the amount of fat that they contain inside their

36:25

body is far more than the Caucasian

36:28

or Western counterparts.

36:31

So what it means is for a lesser BMI,

36:34

Indians have far higher risk for heart

36:36

disease or diabetes and this has been proven

36:38

in various studies which have been conducted worldwide.

36:41

So for me, as far as a patient

36:43

is concerned, if the patient seeks

36:45

help, it's not a question of treating their

36:48

vanity. I don't think that's the thing

36:50

that the doctor is supposed to be doing

36:52

or any kind of healthcare practitioner should be

36:54

aiming to address. I think they should be

36:56

trying to address the metabolic defects,

36:59

the diseases that can happen because

37:01

of this excess fat inside

37:04

the body in spite of having a normal BMI.

37:07

If you look at Indians, Indians have this problem

37:09

with central obesity which in

37:11

turn translates into a lot

37:14

of horrible diseases taking place.

37:17

So the

37:17

focus needs to be to try and

37:20

keep these diseases at bay and

37:22

to do that, you need to lose weight and

37:24

for that, you take the help of

37:27

the diet, you take care of

37:29

your exercise and of course, there are multiple

37:31

medications now that are available

37:33

which can help you to lose weight. So this

37:35

is the way the focus should be made

37:38

as far as treating patients who are overweight

37:40

or suffering from obesity. Is that something

37:43

you're mindful then of as you're

37:45

treating patients? I mean, I always

37:48

say, has it changed your attitude over time

37:50

in terms of how you speak about

37:52

these conditions? I personally

37:55

always have had this thing that

37:57

I have never had a problem about.

37:59

telling the patient that you need

38:02

to lose weight, not because of your looks, not

38:04

because of what society thinks of you, it's

38:07

because you yourself need to be healthy.

38:09

And that is something I think patients

38:11

accept very nicely and they realize

38:14

that the doctor means well and is

38:16

trying to help out by trying to give them a

38:18

longer and happier life. That is the way

38:20

to focus on it. And how do you persuade other doctors

38:23

to take that approach? Because lots of patients

38:25

say that's not what they're experiencing around

38:28

the world.

38:28

So it's education, education

38:30

and education. You know, there's no

38:33

end of this. I think various

38:35

aspects can be educated not only through

38:37

medical kind of programs and conferences

38:40

and things like that. And I think nowadays

38:42

most conferences are having a lot

38:44

of sessions on obesity. There's a

38:46

lot of research happening out of India as far as obesity

38:49

is concerned. There's a new obesity guideline

38:51

being published very soon, which is

38:54

probably next week. And you know, the

38:57

main focus has

38:58

definitely changed. And though some

39:00

people are still not managing

39:02

to address the patients in the correct way, I

39:05

think a large number of people are changing

39:07

and changing their practice and the way they deal with

39:09

patients who come in to see them for their weight

39:11

problems. Dr Fatimi Stanford

39:14

in Massachusetts. What about

39:16

the experience in the United States where you could argue

39:18

that this kind of put crudely

39:20

fat shaming, which people use, influences

39:24

advertising, influences all kinds

39:26

of factors, does it actually start to bleed

39:28

into what you might call what should

39:30

be medical decisions, medical judgments?

39:33

Absolutely. I think that this

39:35

idea of bias starts

39:38

super early in life. And if we look at the research

39:40

and data, if we look at how early

39:43

weight bias starts, the data

39:45

states that it starts around three years

39:47

of age. So when we start

39:49

teaching doctors, if I start

39:52

teaching medical students, I'm

39:54

really kind of starting way

39:56

behind the eight ball because

39:59

I am dealing with people. that have already determined

40:02

what they think about patients, they

40:04

determined what they thought about individuals

40:06

that carried excess weight when they were three years

40:09

old. And I'm getting them in their 20s and

40:11

30s and having to really

40:14

re-educate them about what

40:16

they feel about people that carry excess

40:18

weight. Some of these entrenched beliefs,

40:21

what we call that implicit bias,

40:23

I can't change. The explicit

40:26

bias I can really try to attack

40:28

and address to them then, but

40:31

that's really, I'm starting with an uphill battle.

40:34

And of course, it's really permeates

40:37

throughout our society and it's

40:39

unfortunate it's in our media and it's

40:42

unfortunately really also permeates

40:44

our healthcare system. You obviously have an insurance-based

40:46

system which presumably means all of these

40:48

things can affect things like

40:51

eligibility criteria and all the rest of

40:53

it in terms of the judgments people make. What

40:55

about then this kind of growing campaign?

40:58

And I mentioned the New York example, but it's spreading

41:00

across the United States to look

41:02

at making size a protected

41:05

trait on par with race and

41:07

gender. I wonder what you think

41:09

of that based on your experience of dealing with

41:12

patients of different ethnicities and of course,

41:14

men and women.

41:15

Yeah, well, actually some of my research has actually

41:17

been directly in this area, looking at

41:19

what we've been doing here in the state of Massachusetts.

41:22

We've been trying to get a bill through our state

41:24

house to make sure we're not discriminating

41:27

against someone based upon their size.

41:29

This had a lot of momentum leading

41:31

into the COVID-19 pandemic. And

41:34

as you guys may know, we had a big COVID-19

41:36

that happened that really

41:38

delayed us getting this bill across the

41:41

finish line here in Massachusetts. And so

41:43

that bill is seeking to pick up momentum

41:45

here again in Massachusetts. But

41:48

right now throughout most of the United

41:50

States, you can willingly discriminate

41:52

against someone because of their size. And

41:55

I don't believe that you should be able

41:57

to discriminate against someone because...

42:00

of their size

42:00

with hiring or whatever or whatever

42:03

reason, just like you shouldn't be able to discriminate

42:05

against

42:06

me because I'm a black woman. I

42:08

don't believe

42:08

that that should be allowed. Thank

42:10

you all. Now listen to this.

42:12

That

42:17

is the

42:17

sound of Mexican school children

42:20

hard at work at their desks. Actually

42:22

they're multitasking on what are

42:24

called bike desks, which are basically designed

42:26

to keep students active while being taught.

42:28

And here's what one of the pupils told us about

42:31

the initiative.

42:32

When we're

42:34

physically active, it really helps us keep

42:36

focused on our daily activities. It's actually

42:38

incredible.

42:40

Some enthusiasm there's great

42:42

idea. It's not a reason to add a

42:45

bike with a desk on it. So you

42:47

cycle around the school play yard.

42:49

They're at their desks, but think of it like

42:51

an exercise bike whilst you're

42:54

working. About 75% of Mexico's grownups are

42:58

overweight or obese and the country has one of the highest

43:00

childhood obesity rates in

43:03

the world. Dr. Bernayak Sinha,

43:05

is this the sort of unorthodox initiative

43:07

that governments perhaps need to start thinking about?

43:10

Yes. And I'm really enthused by the initiative

43:12

that's been taken up in Singapore. I

43:15

think what they have said is they have started

43:17

encouraging healthy eating, not only in

43:19

schools, but even if you go for a takeout,

43:22

you're offered a healthier

43:24

meal for a lesser price. You're offered a healthier

43:27

drink for a lesser price. The government

43:29

has taken initiatives of building multiple

43:31

parks at various places which are accessible

43:34

at all hours, not only to people of working

43:36

age, but to elderly and little children. And

43:39

these kinds of things, I

43:40

think, can go a long way in improving

43:43

the general health and general wellbeing and

43:45

the general body weight of the entire population.

43:47

Rachel Newton, you do a lot of statistical

43:50

work. What evidence is there

43:52

about different solutions that

43:54

have been tried by policymakers? I mean, we've

43:57

had all kind of things, haven't we, like the sugar

43:59

tax in Mexico. Mexico, like attempts

44:01

to force restaurants and

44:03

fast food outlets to put calorific

44:06

details on their menus.

44:07

Yes, thanks. I'll mention a few

44:10

of these. The taxes are effective.

44:12

In fact, national sugar taxes,

44:15

or sugar sweetened beverage taxes actually, are

44:17

in effect in 117 countries,

44:19

covering more than half of the world's population. The

44:21

US is not included in that. In fact,

44:24

the US still subsidizes the main

44:26

ingredient, high fructose corn syrup. Sugar

44:29

taxes are very, very useful. Mexico

44:31

was a forerunner in implementing

44:34

a sugar sweetened beverage tax and then

44:36

evaluating it. In addition,

44:39

the work that we've just done with Mexico, I'm glad you

44:41

called them out because they've been such a leader. We published

44:43

earlier this year in

44:44

obesity reviews.

44:45

It implements a

44:48

model to test several other things. For

44:50

instance, a subsidy on healthy foods, especially

44:52

fruits and vegetables and legumes

44:54

and nuts, to restrict restrictions

44:57

on marketing on healthy foods to children,

44:59

to do social marketing of healthy activities

45:02

in schools, breastfeeding promotion,

45:06

and then guidelines in schools that

45:08

already have had policy changes. Our

45:10

work has already been passed

45:13

by the Senate in Mexico just last week

45:15

to

45:15

prohibit junk food in schools. There

45:18

are a lot of things. I just want to say though

45:20

that many of these things

45:22

have small impact. On

45:25

a population level, that's big and it's important

45:27

and it should be done. On an individual

45:29

level, it's still relatively small impact.

45:32

We need bigger structural

45:34

change. I'll leave it at that.

45:37

Can I pick up on that broader point

45:40

though about ... It's easy to

45:42

blame the food industry, isn't

45:46

it? In a sense, a lot of this is

45:49

down to our demand and what we

45:51

expect. I just wonder, Rachel, whether

45:53

you think in some ways we've normalized

45:56

this to say, oh, well, it's okay to eat

45:58

the food of the world. this kind

46:01

to kind of go for fast fixes that culturally

46:03

we've made that all really easy.

46:06

Well in fact we've normalized

46:08

it to the extent that it's very difficult to

46:11

find alternatives. I

46:13

think about when I was a kid and we had Campbell's

46:16

tomato soup in my household and it didn't

46:18

have sugar in it. Now it does. We

46:20

have many, many products that have been

46:22

changed over time to add more

46:24

sugar, more salt, more fat. And

46:27

that's what's become normal is that young people

46:29

today, their taste buds, not

46:32

to mention adults, but their taste buds have been

46:34

affected throughout their entire lives to

46:37

want those kinds of ingredients. So we

46:39

have to deal with it in

46:42

a very holistic way with industry

46:45

as well as with the policies.

46:47

Let me ask you each intern then finally,

46:50

Dr. Fatima Stanford, what

46:52

would be your solution

46:55

to the obesity problem?

46:57

I think we need to take a multi-sector,

46:59

multi-disciplinary approach. I

47:01

think we overemphasize

47:03

just the food and beverage behavior and environment and

47:06

when we continue to just focus on that

47:08

one sector without recognizing the

47:10

full nature of

47:13

biological, medical reasons, maternal and

47:15

developmental, economic, psychological,

47:17

social will continue to fail and

47:19

I want us to be more comprehensive

47:22

in our approach to obesity.

47:23

And Rachel Nugent at the University

47:26

of Washington, what would be your solution?

47:29

I'll pick up on Fatima's last comment

47:31

about comprehensive. I fully agree. We need

47:33

all the countries that implement policy need to do

47:36

it as a comprehensive package of policies.

47:39

And then on a global basis, countries

47:41

need to band together, if you will,

47:44

and say to the industry members, here's

47:46

what we expect of you and we are not going

47:49

to allow anything else. If we do that

47:51

together comprehensively, they will have

47:53

the force to cause change from

47:55

the industry. Benayak Sinha, do

47:57

you have a different

47:58

solution to that?

48:00

I think we should come up with a proper slogan

48:02

worldwide to try and control

48:04

this epidemic that seems to

48:06

be engulfing us and there needs to be something

48:09

like you know, keep your weight healthy Propagated

48:12

at every doctor's surgery and every

48:15

medical consultation and every health

48:17

care initiative that goes up So maybe

48:19

we need to learn a lesson from the the

48:21

people who advertise and promote food

48:24

globally and and slogans of for

48:26

products globally We need we need to kind of get

48:28

into that game Absolutely. Thank

48:31

you very much to our guests on the

48:33

real story this week Dr. Benaiak Sinha

48:35

is an endocrinologist with a special

48:37

interest in obesity and diabetes

48:40

in Calcutta in India Rachel Newtons

48:42

is associate professor at the Department of Global

48:44

Health at the University of Washington State

48:47

in the United States and also in the US in

48:49

dr. Fatima Cody Stanford who studies

48:52

obesity at Massachusetts General

48:54

Hospital and Harvard Medical School

48:56

Thank you to them for this week from Ishaal

48:59

and my editors

48:59

Max Hawberry and Ellen Otsun. That's

49:02

the real story Thank you so much for your company.

49:04

Do please join us again

49:05

next time