The preventive effect of GLP-1 drugs — a prediction

The bathtub metaphor is by now world-famous in obesity circles. The epidemic is like an overflowing bathtub; the water is running over the edge while the tap is turned on full blast. So we need to turn the tap off and pull the plug, so the tub can drain again. In that metaphor, "turning the tap off" stands for prevention, and "pulling the plug" stands for treatment. After all, we can turn the tap off, but we'd still be left with a bathtub full of people who are overweight. In this column I predict that the tap and the plug are about to start influencing each other.

The available treatments, such as gastric bypass surgery and GLP-1 drugs ("the jabs"), are therefore seen as a way to get people who are already overweight to a healthier weight. At the same time, more needs to happen on the prevention side, both at the level of behaviour and at the level of environment. On the behaviour side, think of teaching healthy habits such as taking the stairs instead of the lift, walking or exercising for an hour every day, and eating and drinking healthily. On the environment side, think of improving the supply of healthy food, making unhealthy food and drink more expensive, and above all curbing the constant presence of unhealthy food and drink and its promotion. In short: creating a healthy food environment.

“Those jabs are also going to have a preventive effect.”

My claim for today is this: those jabs are also going to have a preventive effect. I sense a new trend, and I base that on two observations. The first concerns a striking news story out of the US of A: the jabs are changing users' purchasing behaviour. In other words, people using a GLP-1 antagonist start putting different things in their trolley as they walk through the supermarket. That means supermarkets, and therefore also food manufacturers and even hospitality businesses, will have to adjust their offerings to stay successful. Fascinating that a medicine could bring about such a knock-on effect. It would mean that GLP-1 antagonists could end up having a positive impact on the food supply, and therefore on our food environment… even for people who don't (yet) need a jab.

The second observation comes from my own surroundings. I've overheard several conversations involving GLP-1 users receiving compliments from people around them about their new, slimmer appearance. The non-user would then let something slip along the lines of: "Maybe I should also start exercising more, eating healthier, etc."

It reminded me of my childhood. Back then, being overweight was rare. If anyone was overweight, they would quickly become known as "the fat one." Not nice, of course, but recognisable. In my football team we had one boy who was overweight. Partly because he couldn't run fast, he had become very good at shooting and passing. And I mean really good. He had an impressive long-range shot, and with his brilliant sense for the game he regularly set up his teammates clean through on goal. I couldn't play football as well as him, but I could run very fast and for a long time. Whenever that heavier teammate lost the ball, I happily ran myself into the ground to win it back and pass it to him quickly, because I knew he would then do something brilliant with it.

I was in the same team as him for many years, and every year he got heavier and slower, to the point where he could no longer compensate for his limited running ability with brilliant football. The season ended, we went into the summer break, and everyone went their own way. After a lovely summer holiday, we got to go back out onto the pitch at the end of August — great, some proper football. Then that teammate walked onto the field; completely transformed, having lost all the weight. He could still pass and shoot just as well, and speed was suddenly no longer his weak point. During training I cursed his transformation (he was unstoppable), but during matches I was rather pleased about it. What had happened? During the summer break he and his parents had decided it was time to intervene. He'd changed his diet, and he'd exercised the whole summer. I still remember what he told me: "Just played football with my mates, and on the days they didn't feel like it, I went running laps on the field behind our house. With a bin bag wrapped round my body. Really works up a sweat!" To this day I don't know whether that last bit was such a good idea, but his excess weight was gone within a single summer. And as I write this, I realise the obesity epidemic persists precisely because many people, for all sorts of reasons, are not in a position to intervene. They don't have the headspace, the knowledge, or even so much as a field behind their house in the neighbourhood where they live.

To be clear: I am against fat-shaming. That cannot be justified. And I understand the importance of body positivity, but it is starting to get in the way of an open dialogue. Being overweight, after all, is not about beautiful or ugly, but about healthy or unhealthy, and that needs to be something we can discuss. In my childhood, it really stood out when someone was overweight, and the unspoken social pressure on the child and the parents would eventually become so great that people often intervened of their own accord. Like it or not, we are herd animals, and the social norm (in other words, what we see around us) largely determines our behaviour. What is currently happening in our society is a group process of slowly but surely becoming overweight together. And thereby unhealthy. More than half of the Dutch population is now overweight. That means the social nudge to do something about our own weight and our own lives has disappeared. The social norm has effectively shifted to "being overweight." This shift, combined with body positivity and cancel culture, means it stands out less when someone is slowly but surely becoming overweight, and makes it all the more unmentionable.

Unless…

Unless people with obesity, or even significant excess weight, start taking the jab. As soon as obesity, and possibly also being overweight, becomes rare again in that way, it will naturally start to stand out again when someone is nevertheless overweight. Of course, the precondition here is that this applies to everyone, and not only to those who can afford it.

“Otherwise we'll end up like America: poor and obese versus rich and slim.”

Via the route of food supply and social norms, a treatment could therefore also end up having a preventive effect on the rest of the population that is not (yet) overweight. Whether it will actually work out that way? Time will tell, but I think it's worth considering making "The Jab" available to all Dutch people who need it, not only to those who can afford it. Otherwise we'll end up following America after all: poor and obese versus rich and slim.