Opinion | GLP-1s and the ‘Wild West’ of Wellness

This is an edited transcript of “The Ezra Klein Show.” You can listen to the episode wherever you get your podcasts.

Here’s a number from a KFF poll that actually shocked me when I learned it: One out of eight American adults is taking a GLP-1.

Maybe I shouldn’t have been so shocked, because the number is higher in my social circles. I have tried these, for reasons I’ll explain. But they’re a strange medication. They really treat people’s desire. They don’t make you lose weight — they make you not want to eat.

But then they do all these other things. They seem to protect people’s heart health, independent of losing weight. They’re protective of the kidneys, of the liver. There is ongoing research about GLP-1s and dementia and Alzheimer’s. They have all these strange effects on addiction and desire.

But should everyone be on these? And what does it mean for society to have access to drugs that regulate desire in this way? What do they mean for the sick? What do they mean for the well?

I have wanted to do an episode on this topic for a while but haven’t known quite how to approach it.

But then Julia Belluz started doing a lot of reporting on GLP-1s. She’s a Times Opinion contributor and the co-author with Kevin Hall of the book “Food Intelligence.” Belluz was also a health and science reporter with me back at Vox. And she’s someone whom I really trust to look at the science of these questions in the most rigorous way possible, and also to look at the experiences patients are having on them in the most compassionate and curious way possible.

Ezra Klein: Julia Belluz, welcome to the show.

Julia Belluz: Thank you so much. It’s a pleasure to be here.

I was shocked by this number: According to a KFF poll, one in eight American adults is currently taking a GLP-1. Why?

Yes. It was surprising to me, too.

One of the ways we can understand this is that there’s a very long history of people seeking out the magical elixir for weight loss. I think that’s one piece of it. And now we finally have something that rivals the only other effective medical intervention we’ve had to help people lose weight, which is bariatric surgery.

On the other hand, there are a lot of people who are living with diabetes. I think that’s another reason that we see so many people who are on these drugs.

In addition, I think these drugs have really met a particular moment, which is this algorithmic social media age. They’re everywhere in the U.S. We already had this relatively unrestricted approach to marketing pharmaceuticals. We see them advertised everywhere. We’ve seen this telemedicine industry flourish since Covid, but also around these drugs. And I think that’s why we’re seeing these shocking numbers.

I want to start on the part of this that people actually don’t talk about that much, which is diabetes — which is what these drugs were originally approved for.

As you say, a huge number of Americans have diabetes and have terrible health consequences often from it, including limb amputation and blindness.

What do these drugs do for diabetics?

Our bodies produce GLP-1 naturally. We have this hormone that’s produced in our gut, in our brains and, to a lesser extent, in the pancreas.

Basically, they’re this synthetic version of a hormone we produce naturally. The big breakthrough for diabetes was that they’re stimulating the pancreas to release insulin only in the context of high blood sugar.

So it’s not like when you take insulin, and you need to be careful about what you’re eating, and you’re at risk of really low blood sugar levels and the dangers that come with that. These are only stimulating insulin secretion when your blood sugar is running high.

As researchers who were working on this were trying higher and higher doses to help people with diabetes get more and more benefit, they start to discover these weight-loss results in the trial. People start to spontaneously lose weight.

Then later, we’re finding all these other benefits that no one would have predicted. No pharma company would have bet on this.

We’re only at the beginning of what’s being called this Ozempic era. We’re really just at the beginning of discovering the benefits and the harms of these drugs.

So people begin observing that diabetics on these drugs begin to lose weight, and they don’t feel hungry. As researchers begin testing the first generation of this — Ozempic, what we now in that context call Wegovy — how big is the effect? What do we actually know about what Wegovy does for weight loss?

There’s another one that is slightly more advanced. It has more mechanisms of action, tirzepatide, which goes by Zepbound.

How much weight do people lose on these?

It depends on the drug, but we’re talking like 15 to 22 percent. So it’s the first time we have a drug that really rivals the more effective types of bariatric surgery.

The key point is that it’s turning down appetite. It’s not ramping up metabolism or energy burn. The idea was that this is a gut hormone — that’s the thing that a lot of people focused on. It’s released after eating, and it helps people signal satiety. It helps them feel full and know that they’ve eaten. We’re now giving a really souped-up version of this gut hormone.

And it turns out that, actually, you need to stimulate the brain GLP-1 system to get the weight-loss effects. So you only interfere with appetite once you reach this brain GLP-1 system.

You’ve co-written a whole book about metabolism. And one of the arguments of that book was that hunger is a function of the brain, and it’s a function of the brain’s reaction and predictions about the world around it.

We’ve always had this idea that people just feel hungry, and then you should use your brain to decide if you want to eat. But your brain is deciding if you feel hungry, and you’re sort of fighting its own instincts.

So I’d like to spend a minute on this idea that hunger is a function of the stomach versus hunger is a function of the brain, and how research has moved from one to the other.

The way we describe it in the book, we use this analogy of breathing. I can tell you to take control for short periods of time, but eventually, physiology takes over.

The same thing is true of what we eat. We have this illusion of control over our individual meals and snacks, but there’s this symphony of internal signals that’s going on inside of us all the time. The brain is leading this symphony, and the decisions we make are much less a product of conscious control than I think many people appreciate.

So when you’re taking a GLP-1, you’re getting a much higher, longer-lasting version of what your body produces. And it has to reach the brain through the gut-brain barrier. And the theory is that it’s reaching into the part of the brain that usually signals that there’s a toxin in circulation. So that shuts down your appetite, it increases your nausea ——

Like what you would get during food poisoning or something?

Exactly. These are the most common side effects of these drugs.

So the wonder drug we’ve invented makes your brain slightly think it’s being poisoned all the time?

I think that’s one way to put it, absolutely.

Modernity, baby. [Laughs.]

I know, and in the context of our completely toxic food environment, right? It’s just turning down your appetite by reaching into this GLP-1 brain system. So it reaches through the gut-brain barrier, but it acts as a neurotransmitter in the brain, and from there it reaches other parts of the brain.

This is a very active area of research. But that’s the sort of bottom line, and this dialing down of appetite is the key feature of these drugs.

One of the things that I find interesting about the GLP-1s is that we basically created this food environment that does not exist in nature, of hypersugary, hyperfatty, hypersalty, hyper-calorie-dense foods.

Our brains have evolved over very long periods of time to treat those as getting three cherries on the slot machine and to really want them. So we’ve put people into this hyperstimulating environment, but we didn’t change everybody’s brain to turn down the level of hunger when you encounter something that is very calorie dense or very sugar dense.

All of us, myself, with these cave-man brains, are now surrounded by the fruits of modern industrialized food production, where the Mars company is spending God knows how much on research and development to make my kids want M&M’s. And then we blame them and tell them they’ve not done a good job exercising their willpower and self-control.

Absolutely. I think you were also someone who struggled with weight earlier in your life, right?

Yes. I was very, very heavy until I was almost an adult. I lost like 50-ish, 60-ish pounds when I was 16.

Then, ever since, I fight my food desires. If we had a bowl of Oreos on this table, 30 to 50 percent of my mental energy the whole time we were talking would be to not eat the Oreos.

Yes, absolutely. I remember we had lunch in Washington when I was doing lots of obesity reporting, and you said: Why am I a person who, if the chocolate cake is there, 50 percent of my brain is focused on the chocolate cake?

And I didn’t have a good answer for you then.

Do you have one now?

I do, yes. There are many different types of obesity, but what most people have is called common obesity. It arises from these tiny, more than 1,000 genetic variants that almost all act in the brain.

So you probably have a neurobiology that’s different from someone who doesn’t have to fight the chocolate cake.

I actually did genetic testing for the book, and I’m also someone who struggles with my weight, and it turns out I have a higher genetic risk than like 90 percent of the population.

But this risk in a particular environment won’t be expressed. But as you said, when you put people like us in environments where there are lots of M&M’s and lots of chocolate cake, it becomes much harder. And I think most people don’t have this privilege of being able to finely curate their environment to control their weight in maybe the way we might have had to.

I have a family member to whom I’m not related by blood. One thing that always amazes me is that she will order dessert — she loves dessert, and she loves chocolate cake — and she’ll eat half the cake and then take the rest home.

I always look at that and I think: Whatever is happening in you is not happening in me. Or possibly vice versa: Whatever is happening in me is not happening in you.

And then elsewhere in my life, I can have a cigarette or a puff on a vape, and I have no interest in another. It does not excite any desire in me.

I can have a whiskey and leave half of it or a glass of wine, and I don’t particularly want to keep going. I’ve had people in my life who struggle with alcoholism, and I don’t have willpower that they don’t. Something is happening in their bodies or in their minds that is not happening in mine.

Yes. Absolutely.

And I’ve always thought the way we blame people for this is so cruel, because it is so often people who don’t have the propulsive desire blaming people who do for not exercising willpower.

But those people aren’t exercising willpower. I’m not exercising willpower to not have more cigarettes. I just don’t want them.

I know, absolutely. I have this conversation all the time with my husband. For some people, the cards are just stacked against them.

One person who really helped my thinking on this was Robert Sapolsky. He talks about how we have these potentials or vulnerabilities that are created by our genetics, and then in different environments, they’re either expressed or activated or not expressed.

It’s extremely hard to do the right thing, to buy the foods that you know you should be eating or to exercise every day when you’re working the night shift and you’re raising kids and you’re maybe a single mom or dad or whatever it is.

How are you going to do all the things that you know you need to be doing to protect your health and to fight against this neurobiology that you might have?

You have this interplay of neurobiology; this thing we call willpower, which is a very poorly specified concept; and then environment.

To me, this question of environment is really important. I’ll use myself as the example. When I lost a lot of weight, when I was younger, a lot younger, I was a high school student with nothing to do. I was able to really hold that when I was a young adult.

I have not been able to diet successfully since I had kids because I can’t control the food environment.

Interesting.

There are a lot of other things I can control: I have money. I can go to the gym. I have a certain amount of autonomy over my schedule.

So as you say, when you add in things like the night shift, when you add in not having the money to get healthy foods or go to the gym, when you add in having more kids or less time — willpower works very differently when you’re able to have the autonomy or the money to create a certain environment around you that is conducive to living this certain way. It’s different if you’re a Hollywood celebrity with a personal chef versus if you’re a single mother of four who works two jobs.

There’s this idea that willpower is some unchanging muscle inside the mind as opposed to some reserve discipline that gets depleted. Like, if I don’t sleep enough, I eat more.

Right. Absolutely. And you’re designed to eat more when you don’t sleep enough.

You’re absolutely right that this symphony of internal signals that I was referring to earlier is interplaying with our environment.

One thing I’ve really appreciated about your work on the GLP-1s as a reporter and as somebody who’s very deep in the science is that you’ve done a tremendous amount of interviewing people on them.

You’ve interviewed many people who were exercising a tremendous amount of constant willpower, going on and off restrictive diets, losing 30 pounds, gaining it back.

What is it like for them? For the people who’ve seen huge amounts of weight loss? How do they describe the experience of being on a GLP-1 versus what it’s like off one?

The big common thread in people for whom the drugs are effective for weight loss is that this willpower that they were always searching for, that they felt they didn’t have enough of, suddenly, they have it.

Suddenly, it’s not that hard to say no to the extra piece of cake, or the cake altogether. They’re eating smaller portions. Their cravings change.

There’s a lot of discussion about food noise. That’s when the cake is there, and 30 to 50 percent of your brain is on the cake, or you have cravings that distract you. A lot of people say that this just disappears.

You said a second ago: “for whom the drugs are effective.” For whom are they effective? For whom aren’t they effective, and why?

This is another area we don’t fully understand, but it seems like there are some people who are quite sensitive to the drugs and others who are insensitive to the drugs. There might be a genetic component to this, too. That’s sort of a frontier area of science.

I think the quest that a lot of the companies are on is to understand: How do we differentiate the people who might need higher doses initially — or much lower doses because they’re having so much sensitivity to the drugs and side effects?

Some people are having such a strong response, they’re losing weight too fast. So there absolutely is variation in how people are responding.

Tell me about the side effects of these GLP-1 drugs. In studies, people often don’t stay on them that long. People do cycle off them, sometimes for cost, but sometimes for other reasons.

What is unpleasant about them? What can go wrong?

The most common, that we know of right now, are the gastrointestinal side effects — the nausea, the vomiting, the diarrhea. Those are the most common.

But it seems like there are other emerging potential problems. There are lawsuits around severe stomach problems, damage to the ocular nerve — so eye damage. I don’t think we have clear answers on how common that is. But the basis of those lawsuits is that people weren’t properly warned that this could happen.

One thing that a lot of people don’t seem to be warned about is the fact that you have to stay on them to keep reaping the weight-loss benefits. I think there’s an idea that a lot of people have: I’ll lose the weight, I’ll learn how to eat properly, and then I’ll go off the drugs.

I’m always surprised that even people who got the drugs from their doctors don’t seem to have been ——

What happens when people go off the drugs?

You tend to regain the weight.

You just feel hungrier again? The appetite resets?

Exactly. This appetite that was suppressed through acting on the GLP-1 brain system, that effect is gone, and you’re back to the food noise. You’re back to the hunger that you had before.

I’ve heard this, and it’s definitely true in the data.

People in my life have chronic conditions, and the drugs they’re on, they just have to stay on them. You stop taking statins and the effect goes away. If you’re diabetic, you have to keep taking your insulin.

I feel like people are used to drugs to treat acute conditions but not used to drugs to treat chronic conditions.

This is the thing that goes back to the beginning of the conversation. A lot of people still have this idea that they should just be able to will their way out of it.

I think these drugs helped reveal how much we are products of our physiology, and that with this, you take this drug and suddenly, again, you have the willpower you didn’t have for your whole life. But there’s still this expectation. It’s like any other diet. And that feels like a place where people haven’t been warned.

But as we’ve been saying, there are now so many people on the drugs, I think we’re going to start to learn more about these more rare side effects.

I want to talk about a possible social side effect, which is that our culture’s expectations for what people’s bodies should look like have been punishing for a long time — particularly punishing for women and girls.

We’ve, interestingly, been entering an era where they’re increasingly punishing on boys and men, and there’s the whole male “looksmaxxing” thing. The guys in the Marvel movies are completely jacked now — and on all kinds of things you probably shouldn’t be taking.

If you’re obese or overweight and you’re taking a GLP-1 to lose weight or to protect your cardiovascular system — great.

But I think a lot of the cultural effect of them has come from celebrities and influencers who, all of a sudden, show up and are much thinner — at times skeletal now — in ways that when you have the body’s natural hunger signals coming back at you, it’s harder to do.

There was this big body positivity movement, and that was always going to be a very uphill climb in this country.

But how do you think about GLP-1s as possibly a pharmaceutical accelerator of fairly dangerous body expectations? Because now it’s like: Well, if you want to look thinner, why not just go on a GLP-1?

That’s absolutely a strand in this conversation and in this moment that we’re living in.

The place that it freaks me out the most is when I talk to pediatricians who are prescribing the drugs in children. There’s no screening yet for these drugs and eating disorders in young people, and they’ve anecdotally seen people use these as essentially aids for eating disorders and to exacerbate eating disordered behavior.

One of the underlying assumptions of the health at every size or the fat activism or body positivity movements was that you can’t control your body size — therefore, you must accept it.

We had surgery before — it wasn’t as accessible or scalable. But now we do have this medication where people do have the option.

Or at least the ones who are sensitive to it.

And the ones who can afford it and access it and all of that.

We’ve seen influential people in the body positivity and fat activism movements come forward and really grapple with starting on these drugs and losing weight on them.

One thing that those movements did that was really important was highlight how much shame and stigma people who are living with obesity face every day, especially women.

There was this great Economist article a few years ago where they parsed the data on the pay penalty. And they did such a great job of highlighting the discrimination and stigma that people with obesity face.

But I think there was really a dangerous glossing over of the health effects of carrying extra weight. That even if there is this variation in individuals at the population level, it’s very clear that the higher you go up the B.M.I. ladder, the more health risks you’re carrying.

I’ve spoken to people who are part of these movements, they had issues with movement, they had problems with their blood sugar, they were concerned about fertility — and they were so grateful to be able to now have a medication that could help with those issues.

That debate became very polarized. It was either you’re fat-accepting or fatphobic, and I think we’re kind of moving to something maybe in between.

I take your point on that. But put that side of the debate over here. That was always an effort that was running up against the mainstream of American culture, which believes very strongly in thinness as a synonym for virtue.

One thing that the people I know are worried about — and frankly, that I’m worried about, and I feel like I would not have had this concern for young boys, which is what I have, a while ago. But now I look at the rise of male looksmaxxers, and it looks a lot like toxic diet culture that girls were exposed to before. Obviously, Clavicular, who is the avatar of this, has talked a lot about being on GLP-1s, or some form of these drugs.

I wonder what is going to happen when it is just that much easier for people at the top of society to exert heretofore unknown levels of control over their bodies.

And when they’re doing it with these wild stacks of GLP-1s and peptides and pills to prevent hair loss — and with constant Botox — that filters down.

Oh, absolutely. Yes.

It makes the ideal both ever more unreachable and ever more punishing to try to reach.

I think about this a lot with kids. There’s basically this market that hasn’t been tapped to the extent that the adults have, which is children with obesity and diet-caused diseases. I think it’s something like 1 percent of children who are eligible are taking these drugs now. But that number is expected to rise stratospherically pretty quickly, especially with the expanded access and going to pill form.

If there’s a lot we don’t know in adults, there’s so much we don’t know about what it means to suppress appetite during these critical phases of growth and development.

At the same time, diet-caused diseases like obesity and diabetes hit young people particularly hard. There’s some question with diabetes, for example, about interactions with growth hormone and insulin signaling, because the disease comes on so ferociously, and it’s so hard to treat in young people.

So now we have this treatment or thing that can actually help young people in a way we couldn’t, except with bariatric surgery, before.

But what is it going to mean for them when we’re blunting appetite — not only with the pressures on body image at that age, but also on your muscles, bones, puberty, all these things?

We’re about to put all these young people on these drugs. I think about my kids and the pressures that they’re going to face.

I don’t know if you’ve done this thought experiment, but imagine being a chubby, 16-year-old Ezra now. Would you have gone on one of these drugs at 16?

I’ve thought: Would I have? My weight fluctuated a lot, but I think around 17 or 18, I would have had obesity. Would I have pushed my parents, to say: I really want a GLP-1? And where would I be now?

Would I have had a happier childhood and teens and early 20s if I had one of these drugs? Would I have learned to eat in the way that I’ve learned to eat by changing my food environment?

I don’t know. But the pressures young people are going to face now, growing up in the culture that we have, it’s scary, it’s punishing. I’m terrified for my kids, and I hope that there’s some sort of correction. But I don’t know if the correction is coming or how.

The conversation we’ve been having here tracks what I would call the first cycle of Ozempic coverage excitement.

And then a new thing begins happening, and it’s when I began paying closer attention.

There was a study that came out that particularly caught my eye as a former health care reporter. We were seeing huge drops in mortality from any form of cardiac event. But the drops didn’t seem to be connected, or didn’t need to be connected, to losing weight.

That’s right.

Can you explain what we saw then and how that begins to shift the story here?

Sure. We have this drug that comes on the market for diabetes. In the diabetes trials, as we start ramping up the doses, people start to lose weight. For any diabetes drug that comes onto the market now, there’s a requirement that companies must look into what these drugs do to cardiovascular events and to look for harms.

So the companies were looking for harms, asking: Does this increase the risk of a cardiovascular event like heart attack or stroke?

Notably, past weight-loss drugs, like fen-phen, which were not diabetes drugs, did increase the risk of cardiovascular events, right? We’ve had wonder weight-loss drugs before, and they gave people heart issues.

Exactly. So they’re looking for harms, and instead they find this 20 percent risk reduction.

Put that in context for me. How big is that?

It’s big. Statins are a drug that is targeting these conditions, and the relative risk reduction for heart attacks is something like 29 percent. What’s really significant about it is that it seems that more and more of the benefits that researchers are discovering from these drugs seem to be weight independent.

So in other words, what everyone expected is that you make people lose weight, inflammation in the body goes down, your metabolism of fat and sugar improves, so maybe you see improvements in fatty liver disease or your diabetes or whatever it is.

Sleep apnea is a big one. Sleep apnea is weight-dependent, so you need to lose the weight to see the benefit. But that’s another indication that these drugs are approved for now.

So some of this was predictable. But what no one predicted was that you would start to see these weight-independent benefits — and that goes for the heart, it goes for the liver, I think also for the kidneys.

There’s a slew of benefits that seem to be weight independent.

There are possible benefits for dementia. My understanding of this is that, observationally, people on these seem to have much lower risk of dementia.

They did a randomized control trial to see if it improves people who have Alzheimer’s — and it didn’t. But we’re not sure about whether or not it can prevent Alzheimer’s. Some people seem to believe Alzheimer’s or dementia are metabolically activated.

And so now there’s this whole question of: Is it cognitively protective?

The Alzheimer’s trials were really anticipated, randomized control trials to see what would happen with these drugs in Alzheimer’s, and they had negative results. So it was a big disappointment to the community and to the companies.

But there is this question of: In a different population, or with a different dose or a different drug, will we see the benefits? And that’s an active question and area ——

Or if it’s earlier, right?

Yes, if you’re intervening earlier. It’s an active question and area of study. So I don’t think that case is closed.

Sleep apnea is a big one. Sleep apnea is weight-dependent, so you need to lose the weight to see the benefit, but that’s another indication that these drugs are approved for now.

These weight-independent results, they break our theory of the mechanism of health improvement here a little bit. So as doctors and scientists try to grapple with this, how does their sense of what the drug is doing and why it is helping the body change?

There’s a researcher in Toronto, Dan Drucker, who helped discover this whole class of drugs.

He described them to me like this: Basically, there are three buckets. One is the weight-loss bucket. That’s clear. It’s going to help you lose weight, and you’ll get the benefits from the weight loss.

The second bucket is reducing inflammation. Inflammation is when you’re exposed to a pathogen, an infection, an injury, and your body mounts this immune response. It can signal healing.

But when it goes into overdrive at low levels, you have this chronic inflammation, and that’s a hallmark of many of these diseases we’ve been talking about: obesity, diabetes, cardiovascular disease. These drugs seem to work on inflammation. They seem to lower inflammation.

This, to me, is the most exciting area, because we’ve had drugs in the past that kind of shut down inflammation, like steroids. But you put people at risk because you’re essentially shutting down the immune system. You’re putting people at higher risk for cancer or other infections.

But the way this is described to me is that GLP-1s seem to act as these fine tuners of inflammation, so they have a more subtle approach. It’s not something we’ve really had in medicine before.

We’re using these drugs, like GLP-1s — and there are other drugs that are coming on the market with the dual and triple agonists that use more than GLP-1. The question is: Are we going to discover these other hormones that we can subtly use to manipulate the immune system and inflammation?

We might just be at the beginning of this. I think the other exciting facet of it is we might really get amazing insights into the immune system through these drugs that we haven’t had before, because we haven’t been able to do these more subtle manipulations.

But the third way these drugs seem to help people is by directly targeting the organs that are involved in particular diseases. So sending signals to the liver to heal scarring involved in fatty liver disease, or to clear the fat from the liver, or whatever it is, to promote healing in the liver or the kidneys — that’s a third way these drugs seem to be helping people.

Well, why would they do any of that?

Your guess is as good as mine. There are models in mice of what’s going on. But how this is working inside of us, we don’t know.

My family has a lot of cardiovascular disease in it that has hit members young. As everybody around me began going on GLP-1s, I began reading these things about cardiac events. I was like: Well, am I an idiot for not being on one? Are we all going to be on one of these in a few years?

So I’ve tried them. I want to talk about that experience in a minute.

But I want to ask that underlying question of you, given these three buckets you just described and how many things they seem to be helping to treat. It increasingly seemed to me like, shouldn’t everybody be on low-dose Ozempic or tirzepatide? If you’re seeing possible reductions in dementia? Reductions in weight, reductions in cardiovascular events, reductions in liver and kidney disease, improved blood sugar, reductions in sleep apnea?

We’ll talk about the addiction and compulsivity findings later, but it began to seem like a thing we should be putting in the water.

No, I had the same question as you. The deeper I dive into the science, the more I’ve wondered the same thing. We did this poll of GLP-1 users with The Times for a piece on GLP-1 users and asked them: What has your experience been like?

And I went into that poll thinking we would get negative results. I had a feeling that a lot of the headlines in the media had been quite triumphalist about these wonder drugs, but we weren’t reporting what the lived experiences of people on these drugs was really like — with the side effects and cycling in and out of insurance.

What we got back was people generally feeling great and having benefits that they didn’t expect, and that they wanted to stay on the drug for benefits, for reasons other than for which the drugs were prescribed.

This was amazing to me, that 63 percent of people in your survey said even if the drug didn’t work for what it was originally prescribed for — weight loss — they’d want to stay on it.

It shocked me. I did not expect this.

One of the most amazing stories to me is the woman who had postconcussion syndrome for almost a decade, whose life was essentially — I don’t want to say shut down, but it was. She was suffering deeply with symptoms, and she started to find mice and cell research suggesting these drugs could benefit postconcussion syndrome.

So she talked to her doctor, she got the prescription, and she tried it. And within days, she started to experience benefits, and now she’s back to her normal life.

But the big key is we haven’t done a randomized control trial on this. We don’t have the high-quality evidence to say whether this is going to be everyone with postconcussion syndrome, 80 percent of people or 2 percent. We don’t know.

In addition, we don’t understand how these drugs interact if, for example, you were on, God forbid, some other type of a cancer therapy or something like that. We don’t know how this fine-tuning of the immune system I talked about works when you’re taking an immunotherapy.

There are so many unknowns, and researchers are always going to be cautious. I ask almost all the researchers I talk to this question, and they all say: We’re not at that stage where we should just all be on this.

I understand why the researchers have to say: Well, look, we don’t know. But “we don’t know” actually isn’t an answer to that question.

You have to make a decision, as a person with one life, and a life where you have a chance of getting heart disease, a chance of developing dementia, a chance of developing kidney disease, a chance of developing all these different things.

You have to look at these studies, or the coverage of these studies, more to the point, and say, or say with your doctor: Do I think I should be on this thing that seems to modulate inflammation, which appears to be a source of all kinds of major chronic and acute illnesses people develop or not?

One reason I think you’re seeing really, really aggressive experimentation, particularly around this class of drugs, is because something that has all these effects for the well or for chronic conditions — saying in 12 years that maybe we’ll know more creates this problem where you actually have to make a yes or no decision as a person. Because if you miss out on protecting your body from the chronic effects of ongoing inflammation for five years, you’ve missed out on five years of protection, and you have accumulated five years of damage.

I don’t know, it sure seems like maybe. But I know different doctors feel differently about this, and I feel like we’re in this place where it’s actually really tender and tricky.

Absolutely. But I think the question I was answering earlier was: Should it be in the drinking water?

Sure, yes. I didn’t mean to actually make it mandatory.

No, no, no, no, no. But this question: Should you, Ezra, as an individual with your particular family history and your underlying disease risk profile or whatever you’ve struggled with already, should you be on the drug?

That’s a conversation people, and you, should certainly have with your doctor. Get the prescription, and have someone monitor you.

What scares me about this GLP-1 era is how many people are circumventing the medical system. They’re getting these very low-barrier prescriptions through telemedicine. They’re going to illicit research chemicals through influencers on TikTok.

There’s so much enthusiasm, and I’ve seen this happen with other drugs — it seems to do everything, and then we dial it back. We’re not quite there yet that we can just say: Put it in the drinking water.

So I went on the lowest dose of tirzepatide, like two and a half milligrams, and I did not have the experience that people in your survey had.

On the one hand, it’s the most interesting drug — or one of them — that I’ve ever tried, legal or nonlegal. I seem to be sensitive to it, and all of a sudden I just didn’t want to eat, which is never an experience I’ve had before.

It was like living in somebody else’s brain.

I used a slot machine analogy earlier. The way I’ve described it to people, it’s like being a gambler who loves slots and going up to a slot machine and pulling the thing and getting the three cherries, and then nothing lights up.

That’s scary.

It made me feel like there was this level of experience that I hadn’t even recognized I had, which was around desire.

I would taste something, and it would be good. Or I’d smell something, and I hadn’t noticed that the thing would then trigger another feeling, which was desire, because the feelings were so connected for me.

But all of a sudden, I would have that same experience, and then the desire wouldn’t trigger. I would walk by the candy bowl and not stop, or I would leave half the burrito on my plate.

It was, in a way, revelatory. The problem is, it made me quite depressed and anhedonic.

Interesting. OK.

Whether that was because I wasn’t eating enough or whatever was going on. But the thing where people report more energy and more focus and feeling cheerier — for me, it really dulled experience.

It almost sounds like an antidepressant experience.

Well, and that’s why I think it’s interesting to bring in my own experience, because there is this whole thing where it’s working on some kind of reward mechanism, too. Maybe dopamine?

But people are reporting not just a desire to eat less, but a desire to do all kinds of things less: drink alcohol, take drugs, online shop.

And then this anhedonia thing is also being reported by people. So what have you seen about the whole reward system dynamic of it in your reporting?

This has been a very exciting area, and one that we’ve paid a lot of attention to, particularly in the media, because the anecdotes are so startling — and I think they’re real.

I’ve talked to people who have reported reversals of alcoholism, the desire to smoke, sex addiction — any kind of addictive behavior you can imagine seemed to be dialed down with these drugs.

The trials to date have been mixed, and the researchers who study reward are quite cynical that these results are going to endure.

The way it has been described to me is: For a long time, we’ve known that if you make rodents hungry, they’re more likely to have addictive behaviors. They’re more likely to get hooked on cocaine or push the lever.

So hunger has this overlapping pathway with these other motivated behaviors, and it can increase the risk of addictive behavior, it seems.

One explanation is that once you’ve been on these drugs for a while and your appetite starts to normalize, you’ve lost the weight and your hunger starts to normalize again, whether the results for addiction are going to actually endure after that.

A lot of people think about these as clear treatments for these addictive behaviors, and that’s where I think we don’t have the high-quality research we want to have to defend that.

Well, my assumption of why some people were getting anhedonia — some people were seeing lower desire for drinking — it was actually not necessarily that it would end up proving to be a clear treatment, but that it is messing with a system we don’t really understand.

I mean, what’s interesting about this whole conversation is we’re basically saying we don’t understand any of the systems very well.

We don’t understand the appetite system — it’s working a different way than we hypothesized. The cardiac system is not doing what we thought it would be doing. We don’t know why the inflammation system is responding. The reward system is changing.

The human body is a very, very, very complex set of systems, and this seems to be a complex change to them that, at the population level, is positive, probably — but not in a way where we can precisely define the mechanisms by which it is positive or tell you for whom it will be positive and for whom it’ll be negative and who will actually lose weight and who won’t and how much.

It’s a very weird space, actually. [Laughs.]

Absolutely. I really feel that we’re just at the beginning of this.

After we ran this piece where we did the poll and talked about all these other surprising benefits people have experienced, I got lots of emails about weird experiences.

For example, people who were on S.S.R.I.s, they were on antidepressants, and started on a GLP-1, they completely spiraled. That’s not something that I’ve seen show up in the randomized controlled trials or in the research, but it’s an experience that people have.

I think we’re going to have lots more of this at the scale that people are taking these drugs.

We’re seeing these new drugs coming down the pipeline. We’re seeing that there are now oral forms of these drugs available. The drugs are going generic.

We’re going to see more and more people on these drugs and learn much more about them. There’s so much we don’t know.

What about all the drugs that are coming now?

I know people who are getting retatrutide from some compounding pharmacy in China or something. And retatrutide — maybe you can explain it, but it’s another Eli Lilly drug.

Eli Lilly also makes Zepbound, the tirzepatide variant. This is in trials now, and it’s expected that it will be approved in some amount of time. It will probably be a big deal — it works even better than the other two.

But I don’t really understand why all these people I know are getting a compounded thing from pharmacies they can’t oversee, when there are perfectly good GLP-1s on the market now that you could get and have full confidence in the way they’re being manufactured.

Like, what’s going on with retatrutide? Why is it both around my community and all over my social media feeds?

Oh, interesting. This says something about — are you in bodybuilding algorithms or longevity algorithms?

No, this is just straight-up X for me.

Interesting. OK. So it’s a research compound that’s still under study. It’s targeting three hormone receptors. Semaglutide — Ozempic or Wegovy — is targeting one. And this is where, at the beginning of the conversation, we talked about how we had a lot of research on these diabetes drugs over many years, and we could be fairly confident in their safety profile.

These drugs that have come on since, like Mounjaro, tirzepatide and retatrutide, they’re targeting more than just the GLP-1s. They’re targeting other hormone receptors. We don’t have long-term data on these drugs, and I think that’s a really important thing that a lot of people overlook.

This one is still under study, but in the research we have so far, it looks like it’s causing faster and more dramatic weight loss, and it’s taken off in longevity and bodybuilding social media.

The argument I keep seeing about it is it increases energy use — that it seems to have some independent effect on the calories you’re burning.

Yes, I’m not sure what the mechanism is, but that could make sense — that it’s not just reducing appetite, it’s also increasing metabolism. And maybe that’s why people lose even more weight more quickly.

But the point is, we have this emerging evidence that it might be even more effective than what’s already available. I think it just speaks to the frenzy around these drugs, that people don’t want to wait for the F.D.A. to get the randomized controlled trials to approve the drug. They’re going directly to illicit sources and trying to buy the drug, which is still a research compound.

People I knew who used to order drugs on the internet were ordering fun drugs. Now it’s like these weird eat-less-and-focus-more drugs. [Laughs.]

Something interesting about the GLP-1s are the categories of who might want to lose a little bit of weight — or even more so, who might want to protect themselves from inflammation — speak to this reality that the difference between well and sick is not this clear, binary thing. We now have these categories like prediabetic and prehypertensive and perimenopausal, pre-overweight, pre-obese, these kinds of things. We didn’t use to have them. We keep expanding the space in which you should worry.

I think that there is an interesting dimension as people start looking for chemical answers to wellness. Because the truth is, for a lot of people, getting enough sleep and going to the gym regularly and eating whole foods is hard. If you could just give yourself a shot or take a pill, people want it.

So how do you think about the broader shift, which is not new, but it’s happening with more force right now, toward medicine as not a way of treating illness but as a way of optimizing wellness?

Do you see that as something new? Is that something old?

I think it’s more pervasive, maybe. But I think we have to be careful.

If you think about the American public, most people aren’t eating the minimum daily requirements of fruits and vegetables, let alone personalizing or optimizing their diet beyond that.

Most people aren’t getting enough sleep. Most people aren’t getting enough physical activity, and I think that’s the majority, right?

Right, I’m agreeing with that.

Yes, but then there is this minority who we pay a lot of attention to in the media, who is interested in longevity and optimization.

I don’t think there’s anything new about wanting to use medicine to be more well as opposed to heal from illness. We’ve been doing that forever, and we’ve had health and wellness influencers forever.

But I think, if you look around the mediascape at this exact moment and you think about how big Rogan and Huberman and Attia are, and then you have Bryan Johnson as one of the breakout media figures of the era — this former entrepreneur who’s trying to never die and has ended up on this incredibly intense regimen of optimization. I’m very skeptical this is ultimately going to be good for him, but it’s his life, I guess.

And Clavicular, this looksmaxxer streamer who hits his head with a hammer and is on these crazy stacks and OD’d the other day on a livestream — is getting billions of views on his clips.

I think there’s something about how dominant this has become in the mediasphere, and it doesn’t have the checks on it that it used to have.

I remember the coverage you would do at Vox of Dr. Oz, but one of the things happening with Dr. Oz was that there was a network behind that. There were gatekeepers. There were people who didn’t want to see their stock price go down if something went wrong.

Now it’s a complete Wild West boosted by algorithmic interest. And I think it’s going to push us into a real period of a longevity- and optimization-focused system because there’s going to be money for it, there’s going to be attention for it.

A lot of people in this country are very sick, and what they need is treatment for chronic illness. But I think there’s going to be a real push in the system toward treating these people who are not very sick. What they are is well, and they want to be weller.

We’ve always had the worried well. People have always done really wild things to optimize their health. But the megaphone is so much bigger and more fragmented, and it’s so much more effective at creating this confirmation bias.

I think about my mom, who was diagnosed with osteoporosis. She was trying to decide whether to go on one of these medicines that are available for the condition. She ended up in a complete YouTube rabbit hole of doctors who were really skeptical of osteoporosis drugs, and she became quite frightened, and it took her a couple of years to go on the medication.

This is happening at a scale that we’ve never seen before. But this desire to optimize isn’t new. In our book, we found this wild example. After World War I, there was an ingredient in explosives manufacturing that sped up the metabolism and caused people to lose weight.

Doctors at Stanford pivoted and turned it into a drug that was taken by hundreds of thousands of people and became one of the first targets of the F.D.A. It had terrible side effects. It killed people and caused eye problems.

So I think we’ve always done these wild things in the search for the magic cure or the quick fix or bettering our health.

But the in-your-face-ness of the messages and the way they’re targeted with the algorithms — this we’ve never seen.

I think you’re touching on something really important, which is how this media landscape has changed, not only around the blockbuster FDA-approved drugs like the GLP-1s, but around this broader ecosystem of wellness hacks and optimizers.

This goes to something that you wrote about in a piece you did for The Times, which is that these are the first blockbuster drugs to collide with our wellness-obsessed algorithmic age.

I mean, I must have clicked on retatrutide content on X at some point, and now every time I turn on the platform, I get these videos from people telling me how great retatrutide is. And there’s a huge boom in people just getting random peptides from China. I shouldn’t say random, but ordering peptides from places where they can’t really tell what’s in them.

The New Yorker tested some of these and found a lot of them have lead or impurities or things you don’t want. Or they’re not at the right dose.

There’s something wrong. We got these blockbuster drugs, and you might expect everybody to be really excited and be on them. But it seems to have exploded into this biohacking moment where it’s like if something like Wegovy could exist, then who knows what is out there — and you should order it from China and inject it into yourself to find out.

What do you make of it?

It’s sort of the perfect drug for this social media algorithmic age that we’re in because it’s visual. You have the before-and-after photos.

I spend way more time than I’d like to admit on different socials, like TikTok and Reddit accounts, where you see the videos and the before and after photos and how people’s bodies are transforming.

We’re living in this very appearance-obsessed culture. Now, for the first time, we have this drug that does something that humans have quested after for a century or more. So it’s meeting that moment.

I was doing a thought experiment when I was working on that piece. When Prozac came on the market, that was another blockbuster drug. That was another drug where we had a cultural moment around it, but we didn’t have telemedicine, so you still had to go to your doctor to get a prescription.

The internet wasn’t in widespread use, so you couldn’t order a research compound from China. There was no social media to compare your personal experiences and share them with the world.

So we have all those things now when we have this elixir that we’ve wanted for so long, the weight-loss elixir. So many people have wanted this.

We have it at the same time as we have all these other things that have just helped create the moment that we’re in.

I guess this does reflect what I’ve told my algorithm to tell me, although not intentionally: I see so many people just posting about random studies that are not full randomized controlled trials, are often not even on human beings and being like: See, look at this amazing mechanism, and look at these early results.

And, at least according to them, they’re getting them compounded and ordering them.

I’m fascinated by this because there is some weird overlap between the community of people who are incredibly skeptical of vaccines, of the F.D.A. At one point that was understood as a preference for naturalism — there was a primitivist impulse here.

And yet some of these same people who were so skeptical about what was a very well-studied class of drugs are now ordering completely unknown forms of peptides, some of which are about weight loss, but some of which are just to increase energy use or to cure your tennis elbow or to try to improve cell regeneration. And they’re stacking them in different formulations.

It’s like a mistrust of the authorities, but a belief in unproven technologies in a way that I find culturally very interesting. I’m curious, as somebody who’s been around the space for a long time, what you’ve made of it.

I think it kind of goes together. Since the pandemic — and maybe it was even brewing before the pandemic — we’ve had this uptick in appreciation and interest in health and health optimization.

Then we have these technologies now to spread information about health optimization — podcasts, in particular — that are often sponsored by supplement makers. They’re mistrustful of authority — a lot of people were left quite cynical after the pandemic of public health and the medical establishment.

And now we have this vehicle of telemedicine that was actually helped in the pandemic, where people can take their health in their own hands in a way that they haven’t been able to before — this idea that you can just do it yourself.

It feels like that’s almost the currency today of social media. You say there’s this new study, and I found this new use for something, and now I’m going to promote it on my feeds.

Well, I think it reflects this way in which you have to trust something.

The world is simply too complex for anybody to have firsthand knowledge of very much of it at all. So you can trust established authorities like the F.D.A. and the C.D.C. But if you lose trust in them, you still have to find some way of deciding what to believe and what not to believe.

A lot of people choose individual voices like Andrew Huberman or Joe Rogan or Peter Attia, or people further into the MAHA world.

I’m not even saying they’re necessarily corrupt, but if you’re in media, for instance, and you run a podcast on health and wellness week after week, you have to find new things to say. Just getting on the mic every week and saying: Here’s another week when you should eat whole foods and try to reduce your stress and sleep well — doesn’t last.

Even putting aside the fact that some of them are getting a cut of either supplement companies or advertising for it, they have this huge bias toward the next new thing.

And it was always there, right? I spent a lot of time earlier in my reporting career with you at Vox looking at Dr. Oz. I remember once interviewing him years ago, and I think I said: Why do you have the magic and miracles on your show? You’re a cardiothoracic surgeon. You know this isn’t research based.

And he said: If I didn’t have the magic and miracles, I wouldn’t have a show.

The very sound advice, the very sound scientific foundation we have for how to optimize your health, is so boring. It’s what you said: Sleep more, have social relationships, eat more vegetables. It’s the stuff your mom has been saying to you since you were in your high chair.

I will say, before I make this next point, that I think injecting yourself or taking poorly studied peptides is a stupid idea — and people shouldn’t do it. I really want to say this very clearly.

But in preparing this episode and reading what some of the peptide booster types are saying, their argument is: Look, people have a right to do this. It is their body. They are doing it, and it would be better if we let them buy them from domestic compounders whose processes we could regulate and oversee rather than these fly-by-night Chinese companies that we can’t trust.

But how do you think about balancing this argument: People are doing this. It’s their right. We should allow them to get things that are safely made — against: The government doesn’t want you doing this, and we’re going to try to make it hard to get them and to increase the risk so more people don’t try?

So that argument is how we got the supplement market we have. Do you know the history of how supplements became this thing that the F.D.A. ——

No. Tell me.

There was a big campaign push, in particular helped by supplement makers. It was a massive letter-writing campaign on the part of the public, TV ads with famous actors, and the message was: Don’t touch my supplements. I have the right to use these supplements.

Representatives who were from states with large supplement manufacturers really pushed to have this lax regulatory environment. But it was this argument that Americans have the right to use the supplements they want to use. That’s why we have this regulatory regime around supplements that we have today.

Personally, I think the government has a role in protecting public health and protecting consumers.

Which way does the supplement argument actually point? You walk into a Whole Foods or a CVS, and there are a lot of supplements. I don’t think we see it as a national tragedy.

A lot of those supplements have names I don’t even know. It doesn’t seem like they do that much when I look into them, but maybe, and some people seem to think so.

So is that a bad thing or a good thing? Am I upset that people can create these supplement stacks? I mean, not really. If you want to take L-theanine or whatever, go for it.

When people are being misled and using scarce resources on things that aren’t going to help them, I think it is actually a problem.

But it’s a very sensitive topic. For a lot of people, especially in the American context, it’s this idea that you have the right to do what you want with your body and to access the products that you want to access. I guess I have a more conservative view on that. But a lot of people definitely disagree with me.

I mean, my gut is that this is going to become a disaster. My personal view is actually fairly conservative. I’m trying to be the devil’s advocate here.

It seems like people are taking a lot of things right now to increase cell growth, which may be good in the short term but has really frightening cancerous properties in some of these cases in the long term.

I think we might end up realizing that a couple of the things that people are starting to get excited about are really not good for folks, which has happened before.

We were talking about fen-phen and things like that earlier. We have had periods when people got really into something, and it wasn’t good for you. We used to put cocaine in Coca-Cola.

Absolutely, yes. If you know anything about the history of medicine, it’s littered with examples like this. And that’s also why I always come at this much more conservatively.

But we’re definitely in this big experiment now where these different things are colliding. This interest in wellness and longevity and health optimization, the availability of these drugs that seem to do everything, and then these over-the-counter variants that people are accessing and buying online or in the pharmacy — it’s a potential disaster waiting to happen.

One deep appeal of these drugs, of broader peptides and other things that are becoming culturally influential, is, on some level, we all want control: control over our bodies, control over our health, control over never getting the diseases that scare all of us.

On the one hand, if you are able to be given a real possibility for control, if it actually turns out it’s true that GLP-1s at low doses protect you against heart disease — amazing. Statins have been amazing.

I have a friend, somebody who I care about tremendously, whose parent died young of dementia, and I’ve been following all this Alzheimer’s research on GLP-1s very closely because if they’re prophylactic against dementia, I want my friend to take them.

On the other hand, a desire for endless control over your own body and future can be mentally poisonous, too, because you can’t control it. The great insight of Buddhism is that desire and craving are the root of suffering.

The more we trick ourselves into believing we can control what will happen to us, then when things do happen to us, we feel like we failed.

Absolutely. In particular around controlling food and the body, we live in food environments that are so gamed against making the right choices for most people.

So even if you are on a GLP-1, and I’ve talked to many of these people — they’re not losing the amount of weight they want to lose because they have other barriers to eating or exercising the way they’d like to.

We’ve created these systems and food environments that make it literally impossible for most regular people to do the things that they know they need to be doing for their health. That’s something that I would love more attention paid to by whoever is in power — pulling more levers to help prevent these diseases in the first place so that we don’t have to do things like inject young people with drugs that we don’t understand the long-term effects of.

And I’m not anti-GLP-1 at all. I think they’ve been absolute game changers for so many people I’ve talked about, for friends and family.

But we’re doing this big experiment on the population because of diseases that really are preventable if we do the things that we’ve long known we need to do, like restricting junk food marketing to kids, figuring out ways to make healthy food more accessible.

And that actually enrages me as a person who struggled with my weight before, this realization that this was preventable. I didn’t have to suffer like that. And the kids who are going through this now don’t have to suffer like this.

I feel like I’ve heard this argument as long as I’ve been touching this issue, which, as you know, in the beginning of my career, I was a health care reporter.

We would debate food deserts and what would happen if we put good grocery stores in food deserts. And we did this in a bunch of places, and it didn’t really work.

I’ve become very cynical about this. Yes, it would be much better if everybody was wrapped around with more walkable places to live and better and healthy foods. And I don’t think you should be able to advertise junk food at all to children. I think it should be illegal to have “Paw Patrol” on kids’ cereals.

I think this whole thing where we allow endless advertising to children is completely insane, and it makes every parent’s life in the grocery store a nightmare, myself included. And for the society at large, I think the problem is people want things that aren’t good for them.

But we’ve never done enough.

But people don’t want you to do enough.

But which people? I feel like this is changing.

The people who vote. This happened in New York. Bloomberg wanted to tax sodas. They almost ran him out of town on a rail.

OK, but I think the politics of this is changing. More and more people are raising kids with diseases like diabetes and fatty liver, and they’re aware that this is caused by the food environment. I feel like the politics there is shifting.

But we’ve never done the inversion of our food environment that we need to do. It’s going to take many, many levers to really see an impact, and that really hasn’t been done.

I think you would need a level of paternalism for that. I guess what I would say about it is that there is not a single jurisdiction in this entire country where the politics of that have worked.

We cannot point at one thing, one place, one state, one city where we’ve been able to do that much. If it were there to do, I would be the first one to say we should do it. But I don’t think it’s there to do.

The public health community tried to get people to take vaccines in the aftermath, or in the math, during a deadly pandemic, and it led to like the largest public health backlash in my lifetime, such that R.F.K. Jr. is now the secretary of Health and Human Services.

People’s sensitivity to paternalism is very high. It’s a very potent political force.

One thing that I’m talking about and that we write about in the book is that it’s not about taking people’s fried chicken or their M&M’s away. It’s about making a food environment where the healthy options are as accessible as the unhealthy stuff.

I’m living in France now, and obviously, the politics are completely different. There’s no shortage of chocolatiers, of places where I can buy croissants, brioche, all these things that I know I shouldn’t be eating every day, but the healthy options are as accessible.

They’ve done things like fresh food markets in every district. They’ve minimized the size of grocery stores through land use planning since the late 1800s. They are using school lunches as a lever to feed children healthfully, and over time they’ve become more and more avant-garde about what that actually means. They pull all these different levers.

But what we’re talking about, I think, is creating this regulatory environment around chronic disease. How do you protect the public from developing these diseases like obesity, diabetes, cardiovascular disease? And it seems impossible now because it does involve these radical changes to the food environment.

But America did this over 100 years ago, when we started to protect people against acute food poisoning. It was the Wild West. They were putting calf brains in milk at this time and using brick dust to dye food in a certain way, and lead. That’s where the F.D.A. came from. That’s where the meat inspection program of the U.S.D.A. came from, after the publication of Upton Sinclair’s book.

But I hear you. It’s going to be very difficult. I do think the politics are changing. We’re in a moment where places like California and West Virginia are both looking at doing things like reducing ultraprocessed foods in school lunches and banning certain additives — really politically distinct places.

And people like Robert F. Kennedy Jr. and Trump and David A. Kessler, the former F.D.A. commissioner, what they’re saying about diet-caused diseases, you can’t tell who’s saying it anymore.

That’s true, but I’ve been extremely disappointed to see that even the parts of MAHA that I thought made sense have made it nowhere.

You will watch Kennedy now, eating his tallow-fried French fries. You go into these fast food restaurants that, if they really wanted to make the American food environment better, they could.

Meanwhile, the president of the United States is forcing R.F.K. Jr. to eat McDonald’s in photo ops, right? Like, their actual willingness when it came down to it to take on industry was extremely low.

No, absolutely.

If you listen to what they’re saying, it’s fine. Have they done anything that will, in a sustained way, change the food environment for people?

I would love to have seen MAHA ban advertising to kids. They didn’t.

We had the new nutrition guidelines come out, which had this great message: Eat real food. But no one is doing anything to make it easier for the people who actually really struggle to afford and access real food to eat that food.

There are three million fewer people on SNAP. The administration has made it more and more difficult for people to access ——

Yes, huge cuts are continuing to go into effect there.

There were programs to make local and fresh produce available to schools’ canteens, available for school lunches, and those have been cut.

And then there’s a lot of tweaking at the edges like swapping out high fructose corn syrup with cane sugar or focusing on certain food additives. They’re such marginal problems in the greater system.

If you really want to help more Americans eat real food, you’re going to have to do a lot more than that. And you’re going to have to focus on the segments of society that were on food stamps, for example.

So I completely agree. I think a lot of the rhetoric has been in the right place. This is the first time I’ve seen, at that political level, people talking about the food environment and saying that these diseases are preventable, and they are caused by these environmental factors — taking the pressure off individuals.

But then a lot of the solutions that have been proposed have also been focused on individuals — like giving Americans more wearable devices and continuous glucose monitors. It’s not the intensity of the intervention that I think we actually need.

Then, always our final question: What are three books you’d recommend to the audience?

Three books that really shaped my thinking as I was writing my book — one was “Behave: The Biology of Humans at Our Best and Worst” by Robert Sapolsky. He wrote another book, “Determined: A Science of Life Without Free Will.” It was basically an argument against free will. But he comes at this, I think, from a really interesting and important angle.

Another one is Deb Blum’s “The Poison Squad: One Chemist’s Single-Minded Crusade for Food Safety at the Turn of the Twentieth Century.” This is an excellent look through a biography of a former chemist at the U.S.D.A. who did research that helped lead to the establishment of the F.D.A. and a lot of the food regulations and other types of consumer protection laws that we have. I loved that book.

And a third book that I really enjoyed was “Ultra-Processed People: The Science Behind Food That Isn’t Food” by Chris van Tulleken. This is really a polemic and much more than where I ended up coming down in my book. But I thought that it was a really illuminating and fascinating book on ultraprocessed foods.

Julia Belluz, thank you very much.

Thank you so much.

You can listen to this conversation by following “The Ezra Klein Show” on the NYTimes app, Apple, Spotify, Amazon Music, YouTube, iHeartRadio or wherever you get your podcasts. View a list of book recommendations from our guests here.

This episode of “The Ezra Klein Show” was produced by Annie Galvin. Fact-checking by Michelle Harris, with Julie Beer. Our senior engineer is Jeff Geld, with additional mixing by Johnny Simon. Our recording engineer is Aman Sahota. Our executive producer is Claire Gordon. The show’s production team also includes Marie Cascione, Rollin Hu, Kristin Lin, Emma Kehlbeck, Jack McCordick, Marina King and Jan Kobal. Original music by Pat McCusker. Audience strategy by Shannon Busta. The director of New York Times Opinion Audio is Annie-Rose Strasser. Transcript editing by Sarah Murphy and Marlaine Glicksman.

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