The Business of Weight Loss

TH: Hello, I’m Tom Hosking. Welcome to Global Infusions, an investment podcast from the Liontrust Global Fundamental team that takes a long-term view of today's stories.  

 

Last episode we chatted about the business of Champagne from exploding bottles to illegal balloons. This episode we’re looking at weight-loss from gym subscriptions to new drugs. If your taste buds are tickled or you have any questions for our next episode, please do send them in via your client contact or through the contact us link on the Liontrust website. 

 

So sit back, grab a cup of tea, and remember that when we talk about individual companies, we are not making a recommendation to buy or sell shares and that some of these companies may not be held across Liontrust’s global fund range. 

 

TH: Right, I'm delighted to welcome back Hong Yi Chen to the podcast. Who better to chat about weight-loss than the individual with the most impressive metabolism in the office! Welcome back Hong.

 

HC: Thanks Tom. It’s that time of the year again, where you look yourself in the mirror, after an indulgent holiday season, and decide that it’s time to take action! I am of course talking about New Year’s resolutions and often that involves weight loss.

 

TH: Yes, we have to take our fair share of blame for encouraging the listeners to indulge with our episode on Champagne in December! Sorry.

 

HC: But we’re back in January to make amends.

 

TH: Indeed and it’s a topic we’ve wanted to talk about on the podcast for a long time. Weight-loss is this huge industry and one that is going through a major change due to the introduction of GLP-1s…

 

HC: That’s the likes of Wegovy and Ozempic that the listeners may have heard of.

 

TH: Yes exactly. But before we get onto that, let’s chat about the underlying problem: growing obesity.

 

HC: It’s much more prevalent than I had originally thought: it is estimated that, as of 2023, roughly 14% of the world's population over 5 years old are obese. And a further 24% of over-fives are overweight.

 

TH: So that’s nearly 38% of the world’s population with an unhealthy Body Mass Index or BMI.

 

HC: Yes, and if current trends continue that will reach half of everyone over 5 by 2035, so in just over a decade from now. In fact, there has been an inflection point. In the last 10 years, more people have died from obesity than malnutrition.

 

TH: That’s a really sad downside to humanity’s progress. No wonder the World Health Organisation recognises Obesity as an epidemic.

 

HC: Yeah it affects large number of people and has a lot of consequences. The global economic impact of obesity is estimated at $1.96bn, so about 2.4% of GDP.

 

TH: Yes, the largest impacts seem to be the cost of healthcare and the impact on labour as obesity lowers workers productivity. So that would also include things like absenteeism or premature retirement.

 

HC: Yes exactly. And if current trends continue that will increase to 2.9% of global GDP. To put that in context that would be equivalent to the impact of the covid pandemic every year.

 

TH: Wow, that really puts the scale of the problem into perspective. One positive from the pandemic, you could argue, is that it did raise awareness that obesity is a comorbidity and needs to be tackled as a disease in its own right.

 

HC: Obesity can affect many of the body’s organ systems. It can result in diabetes, liver diseases, osteoarthritis and cardiovascular problems.

 

TH: It also increases the risk of 13 types of cancer.

 

HC: OK, so this trend is all very worrying. What’s causing it?

 

TH: Well, our environment has changed basically from what we evolved with. People’s diets are different and we live a more sedentary lifestyle.

 

HC: There some more surprising changes as well. So for example some Dutch researchers found that the advent of central heating means that our bodies no longer need to burn extra calories to keep warm.

 

TH: Interesting. There’s also evidence that the prescription of depression medication is a factor. One study found that it accounted for as much 20% of the increase in US obesity.

 

HC: And it can’t help that obesity can lead to poor mental health outcomes as well. So you get in this downward spiral.

 

TH: Agreed. That being said, the two big factors are diet and physical activity. We evolved in an environment where it was an advantage to be able to hold onto fat to get through lean times. That’s no longer the case. We have gone from food scarcity to food abundance.

 

HC: And often it’s ultra-processed food.

 

TH: Yes it’s not just that these foods can be high in fat, sugar and carbs. It’s the ultra-processed nature of it which means that it is all delivered very quickly to the gut; they are absorbed very quickly, and crucially before a fullness signal can tell the brain to stop eating.

 

HC: And it’s that speed which makes them addictive?

 

TH: Yes that’s part of it as well as the flavouring. Our brains experience dopamine responses to certain food properties such as concentrated carbohydrates and fat, because historically these would have been signals that calories are present and you should stock up as it were because you might not be able to find calories elsewhere.

 

HC: So food companies can create products that tap into these cravings.

 

TH: Yes. And we end up eating more of this food which is outside the normal range of what we evolved with.

 

HC: And it’s worse than that. There’s growing evidence that it’s not just that these foods are high in sugar and salt etc, i.e. it’s the very nature of them being ultra-processed.

 

TH: That’s right. Humans have to expend less energy to digest processed food.

 

HC: And things like emulsifiers, sweeteners and preservatives destroy your microbiome in the gut.

 

TH: Yes exactly, as the listeners will remember from our Microbiome episode in September.

 

HC: Ok, so that’s diet, the other major part of our so called-obesogenic environment is reduced physical activity.

 

TH: So people like us sitting at desks all day.

 

HC: Yes. Work used to mean manual labour for the vast majority of the population. Nowadays that’s not the case especially in developed countries.

 

TH: There was a good study on this that examined how many calories the average American worker has expended over time. They found that between 1960 and 2006, there was a reduction of 100 calories a day on average. And that accounted for much of the weight gain seen in the population.

 

HC: Interesting. One way of putting it, going back to what you were saying about evolution, is that exercise has changed from a necessity for survival to a voluntary leisure based activity.

 

TH: Exactly. We don’t have to go into the wild to catch our dinner. And the convenience of supermarkets and take-aways needs to be balanced by choosing to go to the gym instead.

 

HC: Talking of gyms, they have an interesting history. They’ve been around for literally thousands of years. The word gymnasium is of course Ancient Greek, it comes from the word gymnos, which means naked. That’s because you had to be naked and only men were allowed.

 

TH: Oh so like the ancient Olympics?

 

HC: Precisely, gymnasiums were used as training grounds for competitors of public games such as the Olympics, where they also competed naked. The Greeks had a healthy appreciation of the male form.

 

TH: Yes! And maybe because that didn’t translate across cultures that gyms fell out of favour right before coming back into fashion in the 19^th century. That was driven largely by the YMCA and strongman or bodybuilding culture.

 

HC: Yes that’s right, Gold’s opened their first gym in Venice, California in 1965. That marked the beginning of big box gyms that we know today. At this point, Gyms were still overwhelmingly for men – mostly bodybuilders and sportsmen.

 

TH: How did women get involved then?

 

HC: Well, for that, we need to thank Jane Fonda and her ‘80s exercise videos. That got women interested in lifting light weights and exercise classes. Today, women outnumber men in gym memberships.

 

TH: Do they now? Well gyms overall are big business today. I read that the US alone as over 30k gyms and over 20% of the population or 64m people have a gym membership.

 

HC: It’s also a very fast growing industry. From 2000 to 2019, just before COVID hit, gym membership doubled in the US, which is just under a 4% annualised growth rate. That’s much faster than population growth of less than 1% a year

 

TH: Yes, I think it’s one of these hierarchy of needs phenomena. Once your basic needs are met, you are able to spend your incremental time and money on things like your health and wellbeing, and your appearance.

 

HC: No doubt social media probably played a big part. We are just so much more visible nowadays and that has perhaps given us more motivation to improve our appearance, or even curate our personal brand.

 

TH: You mentioned COVID earlier, that must have been devastating for the industry

 

HC: It was, lockdowns meant that many gyms went bust. In 2019, there were over 40k gyms in the US. That number has come down almost a quarter. However, those that shut were likely subscale anyway, because gym memberships have largely recovered.

 

TH: So it’s just that the larger brands have gained share?

 

HC: Yes. Planet Fitness, the largest US chain, has, for example, grown their members by a third from 14m in 2019 to almost 19m today.

 

TH: Interesting.

 

HC: How often do you go to the gym, Tom?

 

TH: Not that often I’m afraid. In my defence, I do a fair bit of sport- I play hockey and go running or swimming in the park.

 

HC: So why don’t you cancel the gym membership then?

 

TH: Good question… Partly, guilt. Partly because it’s useful when I’m injured and I have to do physio exercises to get fit again. But even then it’s not like I’m going everyday or anywhere near that. I guess I’m probably their dream customer!

 

HC: Well, funny you should say that, budget chains like Planet Fitness count on just that. With memberships starting at around $10 per month, it’s the just the right price you can kind of forget about, without hurting your wallet too much.

 

TH: Yes, that’s very helpful when something like 50% of new gym members cancel within the first 6 months.

 

HC: It’s a very seasonal business too. About 2/3 of new members sign up in Q1, presumably because of new year's resolutions, and they give up by June.

 

TH: That rings true and is why gyms get less busy during the year. But exercise is only one part of losing weight, the other is dieting.

 

HC: Another big industry. Globally we spent nearly $250bn on dieting last year.

 

Th: It shows how desperate people are to lose weight. Is that money well spent?

 

HC: That’s a great question, and the science is still evolving on this. I think there are lots of “myths” around weight-loss, what works and what doesn't.

 

TH: The best scientific evidence suggests that trying to lose weight through diet and exercise alone works for only about 10-20% of the population.

 

HC: Right, and I think it mainly comes down to our assumptions of “all else equal”, when in the real world there are feedback loops.

 

TH: What do you mean by that?

 

HC: Take exercise, for example. It should help you lose weight, all else equal. It’s very simple maths. If your calorie consumption stays the same but your calorie expenditure increases and you end up with a calorie deficit, you will lose weight. But all else isn’t equal, because exercise makes you hungry and you end up eating more.

 

TH: Yes, our evolutionary past means our bodies hate losing weight, because losing weight usually meant premature death. Our bodies fight really hard against that.

 

HC: That’s right. Let's play a game. Why don’t you give me some popular things people do to lose weight and we’ll see if they are effective or not?

 

TH: Okay, I’ll start with running.

 

HC: So we just mentioned exercise makes you hungry. One other thing our bodies do is our metabolism slows down when we have a calorie deficit, which means the body kind of slows down to preserve calories. But some exercises are better than others. Building muscle is better than aerobic exercises like running because muscle mass increases your metabolism, so you burn more calories even in your sleep.

 

TH: That makes sense because one of the reasons we gain weight as we get older is because our metabolism slows down. And one of the reasons for that is we lose muscle mass as we age.

 

HC: Okay, what’s next?

 

TH: How about calorie counting?

 

HC: So, generally speaking, not all calories are created equal. The number of calories printed on the packet is not what you can absorb. So if you ate 100 calories of sugar, you absorb pretty much all of it, but if you ate 100 calories of protein, you can typically only absorb about 70 calories.

 

TH: Why is that?

 

HC: Well, protein is chemically the most complex vs. fats, carbs, sugars etc. It takes the longest to digest and metabolise, which makes you feel fuller for longer. It also requires the most energy to metabolise, to turn amino acids into glucose and triglycerides – the base fuel of our body.

 

TH: So calorie counting is all meaningless?

 

HC: It is in a way. You buy a raw stick of celery in the supermarket and it says 6 calories on the packet, but once you cook it and break down the fibre into carbs it becomes 30 calories. Magic!

 

TH: Ok to sum-up, I can see a theme developing here. Although dieting and exercise can work, it’s often the case that willpower alone is not enough to lose weight, because our regulatory systems fight back by increasing hunger and lowering our metabolism. So dieting becomes harder and harder to sustain.

 

HC: That explains why yo-yo dieting is so common.

 

TH: We have to somehow trick it into feeling full.

 

HC: Yes, it’s all about these signalling pathways from the body to the brain that help control your appetite. In fact, there are people who have an “obesity gene” where this signal is faulty and their brain thinks they are starving all the time. These signals are typically hormones that help regulate your appetite.

 

TH: Even though that’s an extreme example, genetics does seem to be the other piece of the puzzle. Scientists think that roughly 50% of an individual’s predisposition of becoming obese is inherited. So it’s misleading to say it’s all about personal choices.

 

HC: One of the genetic pathways that sometimes break down are Leptins, which are hormones. It's secreted in proportion to fat mass. It also goes up when you’ve just eaten. So high levels of leptins make you less hungry. They’ve even done experiments where they inject starving rats with leptins and they lose their appetite.

 

TH: Poor rats.

 

HC: The obvious question then is why don’t we take advantage of these hormones and trick our bodies into losing weight?

 

TH: Well, that’s exactly what scientists have done. This new generation of drugs are called GLP-1 agonists, where GLP stands for Glucagon like peptide. The brand names you may have heard of are Wegovy and Ozempic from the Danish company Novo Nordisk and Mounjaro and Zepbound from US giant Eli Lily.

 

HC: So how do they work exactly?

 

TH: Well, there are several methods of action. Firstly, they mimic the hormones the body produce naturally after a meal, which stimulate the release of other things like insulin. Together these regulate the amount of glucose in the blood. The result is that the hypothalamus switches off that hunger signal we were talking about. If that wasn’t enough it also slows down the rate at which food moves through the stomach so you feel fuller.

 

HC: Clever. Does it do anything to counteract the metabolic effects we were talking about.

 

TH: Yes it even does that- GLP-1s also seem to make the body more likely to break down fat.

 

HC: Ok I’m beginning to see why there has been so much hype. Not many drugs go viral on TikTok and have popstars like Robbie Williams saying “Babe, I’m on Ozempic”!

 

TH: Yes indeed, the clamour for these drugs is such that there have been supply shortages.

 

HC: So how much weight do you lose if you take them?

 

TH: Between 15-20% of your body weight in medical trials.

 

HC: That really is quite impressive in the context of this being the first real medicine for a disease. It’s not too far off the 30% weight loss you get with bariatric surgery, which obviously is a much more radical and expensive procedure.

 

TH: Yes, history is littered with failed obesity drugs. There were diet pills first used in the 1930s called DNP, and they caused some people to lose their sight. And there have been many other failed attempts such as Effedra which was banned for causing strokes.

 

HC: With that history, it’s no wonder that Novo Nordisk had to think carefully before developing this drug.

 

TH: Well quite! I suppose they had two main advantages. They have been specialising in diabetes research for 100 years and through that, discovered this GLP-1 mechanism. And 15/20 years ago they decided to take it into obesity research,

 

HC: Which eventually led to the first obesity drug Wegovy being approved by the FDA in 2021.

 

TH: Indeed. And secondly they have an unusual governance structure where a charitable foundation controls over 70% of the voting rights. This enables them to take long term investment decisions without risking the wrath of short-termist shareholders.

 

HC: Although we wouldn’t count ourselves in that bracket would we?

 

TH: No quite the opposite, we’ve held Novo Nordisk in our funds since 2014, so we’re definitely in the long-term shareholder camp!

 

HC: That’s fair. And the opportunity for them is still quite considerable, even with inevitable competition.

 

TH: Yes to put it in context, only 2% of obese people are currently treated with any anti-obesity medication so it’s an immature market.

 

HC: Is there anything that will limit uptake? For example what are the side effects?

 

TH: Well there are some concerns, for example, over a rare form of pancreatitis. But the evidence suggest these drugs are really quite safe. About 3% of people of stop taking the drug because of side effects, usually vomiting and diarrhoea. Which may sound like a lot but for in the world of pharmaceuticals is quite small, all drugs do have side effects after all.

 

HC: That’s true.

 

TH: Cost may be an issue. Wegovy costs around $1,300 a month in the US. It costs a fraction of that elsewhere in the world, but the US price is very high.

 

HC: But the list prices aren’t normally paid in the US because insurers negotiate hefty discounts. What will be key is getting insurance coverage so people aren’t paying this price out of pocket.

 

TH: Yes this is particularly important given that it seems as though you have to stay on these drugs forever.

 

HC: This is the downside isn’t it. You likely gain the weight back if you come off them. That means high lifetime cost to payers. So to be cost effective for healthcare systems, these drugs need to lower overall economic effects of obesity. 

 

TH: That’s what will need to be proven. To this aim, Novo Nordisk concluded a large study on cardiovascular outcomes last year which showed some benefits of GLP-1s. They work there because they also dampen inflammatory processes in the body.

 

HC: We also don’t know the long-term consequences of taking these drugs for a long time.

 

TH: That is unknown but medicines are often prescribed for life in the case of chronic diseases, take statins as an example.

 

HC: That’s true. It’s going to be really interesting to see the changes that come from GLP-1s. Companies like Weightwatchers in the US, for example, have come under pressure and are trying to reinvent themselves as prescribers of these medicines.

 

TH: The most interesting insights come from thinking about the potential second order effects of GLP-1s.

 

HC: Yes, the best evidence of this came from Walmart executives last year. They said that shoppers who were picking up GLP-1 prescriptions in their pharmacies were also seeing changes in their shopping behaviours. They were buying less junk food like frozen pizzas.

 

TH: It could really have quite a significant effect on food companies and fast food restaurants.

 

HC: Particularly so if the pareto principle applied. You know, the 80/20 rule. 80% of your output can be achieved with 20% of your effort etc. So in the US 12% of Americans eat 50% of beef. 10% of Americans drink >70% of the alcohol. If the majority of junk foods are consumed by the morbidly obese who are about to go on GLP-1s then that could be a big hit to packaged food companies

 

TH: I’m less sure about the materiality of others though- For example, airlines are hoping they will be able to consume less jet fuel because passengers will weigh less.

 

HC: Ha! Well maybe that could be true. I think some of the most significant effects will come in the healthcare sector. A healthier population could mean less cardiovascular diseases, less cancer, less arthritis…

 

TH: Or less demand for obesity related medical devices related to dialysis and sleep apnoea. For example, earlier in the year the share price of Resmed, a maker of sleep apnoea equipment fell on the back of the potential GLP-1 impact.

  

HC: Yeah, the list goes on and on.

 

TH: On that positive note of a potentially healthier world, let’s move onto the news. Hong what do you have for us this episode?

 

HC: Well Tom, have you seen the new trailer for Grand Theft Auto 6?

 

TH: Actually I have. It was released recently and generated quite a few news headlines. What do you think all the fuss is about?

 

HC: Well It’s one of the best-selling video game franchises of all time! The last iteration, GTA 5, sold 190m copies and grossed >8bn dollars. That’s almost 3x more than the most successful movie of all time, Avatar.

 

TH: So how long ago did they release the last one?

 

HC: That’s the other reason why fans are so excited, because that was a full 10 years ago. People joke that young analysts lack experience because they haven’t seen a full economic cycle. Well, GTA cycles are even rarer!   

 

TH: So GTA are open world games where you control a small time gangster trying to make a name for themselves in a big city. The last one was set in San Andreas, modelled on LA, and the upcoming game is set in Vice City, based on Miami.

 

HC: Yes, the reason why they are so popular is the compelling story line and open world aspect. It’s a sandbox of the real world, where you can buy and sell property and cars, or even trade the in game stock market.

 

TH: Prior to the last game, GTA 5, the developers mainly made money from full games sales. However, with GTA 5, they introduced a multiplayer element called GTA Online, where you can play with other gamers.

 

HC: Yes, that turned out to be bigger than anyone imagined. There were strong network effects as people enjoyed playing with their friends online. It’s been a gift that has kept on giving ever since. Players would spend real money to buy in game money so that they could buy in game items.

 

TH: It’s been a big boon to publisher Take Two Interactive. It used to be very much a feast and famine company that would only make money on GTA release years. However, with the growth of recurring digital revenue from GTA online, that has smoothed the cycle and made them consistently very profitable.

 

HC: Maybe that’s why the cycles are so long now. There’s no impetus to release the next one if you’re not loss making!

 

TH: Well quite! Do you think GTA 6 is going to be as transformative for Take Two?

 

HC: That’s a difficult one. GTA 5 brought with it GTA Online, which was the really transformative element. But that already exists now. If they are just replacing existing revenue streams, I suppose the impact won’t be as big as if you had created something completely new. No doubt GTA 6 will be positive for Take Two as GTA Online sales have been fading. A refresh should help accelerate growth.   

 

TH: Talking of cars, I saw that BYD has overtaken Tesla as the world’s largest electric vehicle maker. Most people in the west won’t have heard of BYD because it’s not really a household name.

 

HC: Yes, it’s a Chinese battery maker that has branched out into making EVs. The reason people won’t have heard of it is because their biggest market is the Chinese domestic market. In fact, China now accounts for 60% of global EV sales and the top 5 models in China are all made by BYD.

 

TH: They are also starting to export their EVs to the rest of the world. China now accounts for 35% of all global EV exports, amazingly.

 

HC: China has big cost advantages in manufacturing EVs because of labour, scale and supply chain advantages. It’s estimated that the cost of manufacturing an EV is €10k less in China compared to Europe.

 

TH: That’s a huge advantage. They have been able to leverage the size of their domestic market and gain scale. It's an advantage the US has enjoyed historically.

 

HC: Yes, and the west is worried. There’s talk of tariffs to protect their domestic auto industries. In fact, the US already has a 25% tariff on EV imports from China, thanks to Donald Trump. The EU is also considering introducing tariffs on top of their current 10% import duty. That could come as early as July this year.

 

TH: Europe is really treading a fine line here. China is a hugely profitable market for European car makers. There is a risk that if they impose tariffs on Chinese imports there could be a tit for tat response.

 

HC: The question is how helpful will tariffs be? China can just export to developing nations who would likely welcome cheap imports and displace Western brands there. It’s going to be a thorn in the side for western automakers for the foreseeable future.

 

TH: Agreed. And on that note, Thank you for listening to Global Infusions – a podcast that believes that the best discussions are had over tea and cake. We hope you've enjoyed your cuppa and our thoughts on Weight-loss. Please do subscribe through Apple or Spotify and with that we wish you goodbye!

 

HC: Goodbye!