The Obesity Podcast Ep. 4: The Evolution of the Swedish Obese Subjects (SOS) Study | J&J MedTech

Professor Lena Carlsson Ekander recounts the origins and evolution of the Swedish Obese Subjects (SOS) Study – the world’s longest prospective investigation into the effects of intentional weight loss on survival and metabolic health. She reflects on the vision of the study’s founder, Prof. Lars Sjöström, and how the team built a nationwide cohort across 25 hospitals and 480 primary-care centres. The discussion covers the scientific rationale, ethics of non-randomisation, landmark outcomes (increased life expectancy, cancer and diabetes reduction), and important safety insights such as fracture risk and alcohol-related mortality. The conversation closes with the public-health implications of early, proactive treatment of obesity and diabetes prevention.

Transcript

SPEAKER_00 0:17

Hi everyone, my name is Marco Buter, and I welcome you to the next episode of our Obesity Podcast. We are here in beautiful Barcelona, where we just finished the retreat of the European Council meeting of the IFSO European chapter. And as usually I'm not alone and I'm very happy to also welcome my co-host Paulina.

SPEAKER_02 0:38

Hello, everybody, and welcome. I'm Paulina Salvinen, and uh it was great to have uh the European chapter meeting here in beautiful Barcelona, and unfortunately, our distinguished guest, uh Lena Carlson, is not able to be here in person, but she's joining us from Sweden. And Lena is well known for uh her work uh within the SOS studies, and she's a professor of clinical uh metabolic research, correct, Lena? And then uh perhaps you could start by uh telling our listeners uh where you currently work and how you got uh involved with the SOS studies.

SPEAKER_01 1:20

Yes, sure. Um I currently work at the Solgansk Academy, which is the medical faculty of University of Gothenburg, and that's where the SOS study is coordinated from. And my professional background is that I went to medical school at the University of Gothenburg, and that's where I also did my PhD, looking at growth hormone secretion in rats. And after that, I moved to Genentech in San Francisco, and I continued to work on growth hormone, but in children instead of rats. And I got a permanent position there after a while, and I stayed there for three years. Then I went back to Gothenburg, and that was um almost exactly at the time when uh the obigene was cloned. And I was intrigued by the fact that the adipose tissue turned out to be an endocrine organ because I was very interested in endocrinology. So I decided to uh switch from growth research to obesity research, and I managed to get a large grant for young investigators from the Swedish Research Council and set up my own group. And that's when I started to collaborate with Professor Lars Röström, who was the founder of the SOS study. So we were actually doing molecular studies together for for a few years. He he managed to get samples from patients with obesity. He was very good at getting things done. So within a week, we could get samples from a hundred patients with uh uh obesity. The patients were very pleased that we really wanted to study something that had something to do with their disease because they knew that something was wrong in their bodies and it was not their character that was, you know, failing. And uh it was fun to work with Loash. He was uh he was a doer. So after we had sampled um a hundred patients and took their adipose tissue biopsies, I called him and said, we need some normal samples as well. And then he said, You're welcome to my office at four o'clock. And you can bring your brother as well, so we can get two samples. And at that time I was really scared of needles, but Lars was a very strong person, so I didn't dare to say that you know, I was scared to death and it hurt, and it turned out that my sample failed, we got no RNA at all. But that's that's how we started to work together. And um, then when Lars retired in 2005, um, there was no natural person to take over. So the head of our department decided that I should do that. And at the time I was hesitating because I wanted to do molecular studies, but now in retrospect, I realized that you know it was it was I was very lucky. I mean the SOS study is a gold mine. So I've been running this study for the last 20 years, and it's it's been a great time.

SPEAKER_00 4:11

That's a great insight, Lena. I I always personally thought that at least one of the S's of the SOS study was coming from Sjöström early in the uh in the beginning until I realized it's the Swedish Obese subject study. Um that was about in 2000 when you came back from San Francisco to Gothenburg, is that right?

SPEAKER_01 4:33

No, it was actually in in, I think it was in 1994.

SPEAKER_00 4:37

All right.

SPEAKER_01 4:37

You know, the the obigene was cloned in, I think it was December, it was published in December 1994, so it's around that time.

SPEAKER_00 4:44

But but it was a time when the SOS study was already running for some time, right? Yes. So maybe you can take us back to that time when, you know, what was the rationale of Lars back at the years to start the study? What was the initial question he wanted to answer?

SPEAKER_01 5:02

Lars wanted to find out if um uh large weight loss could improve survival in patients with obesity. That was his idea. And I think a lot of people thought he was crazy. He designed a study where he knew that he would have to wait for at least 10 years to get the result. So he was a very strong person. Um, he was determined to do this, and he managed to get some funding, and he also managed to travel around the whole country because this is a national, nationwide study. So it involves 25 surgical departments and 480 primary healthcare centers. And I think he he visited most of these and convinced them to collaborate on this study. And um, then of course he had to wait for many years. It took a long time to recruit the patients because at that time um bariatric surgery was not that common. So it took some 13 years from the first to the last person to be recruited into the study. So he has a lot of patients, I must say. And then the study has a very rich data set because the patients have been examined uh repeatedly for 20 years. I think they have been examined on 12 different occasions, and of five of those, we have also taken samples, blood samples, and urine samples. So we have a huge biobank. We have 20 minus 80 freezers with samples. And uh at the time when the patients were examined, uh they were also asked a lot of questions about their lifestyle and psychosocial factors and their lives in general. So we have an extremely rich data set, and now we are also complemented that by um crosslinking to Swedish health registers, which are of very high quality. So we can basically answer most questions about the lives of these patients. So I think the study is really unique. There are a few studies in the world where you have followed patients with a chronic disease with and without treatment for more than three decades.

SPEAKER_02 7:22

That's that's definitely a landmark study, and and looking at uh long-term outcomes and assessing that, that is always the trickiest part. And when we have a chronic disease uh such as obesity, that is the only way to do it. But uh I think the story that you told is uh it's a good example of perseverance and and grit that you actually just have to do it because otherwise you will you have to start somewhere. But uh, can you highlight still how is it possible? Because you know, my hat off for you, that you're able to do uh the long-term follow-up, but how is it possible that you actually do get uh that after three decades you have you still have the data and you get the patients to come in?

SPEAKER_01 8:09

What's your secret? The last examination was at 20 years, so now we follow them with with registers because the patients are getting fairly old. Um so but I think that the follow-up was um it was a collaboration between uh the study coordinator and the different sites, and that if if the patients didn't turn up, they they were reminded to turn up, and and most of them did. So the follow-up was quite good.

SPEAKER_02 8:42

Yeah, and actually I think that's one of the issues in uh in the Nordic countries, at least in my uh experience, that we are uh a bit privileged because the patients actually they do want to participate in uh research and they do show up for the uh for the follow-up visits, which is very different from uh from other parts of the world. So, but it is truly a landmark study. So like you said at retrospect, uh, this was probably a very good uh choice in your career, and we're very happy that you made that choice. Yeah.

SPEAKER_01 9:18

Definitely, it's been so much fun.

SPEAKER_00 9:21

If I could go back, Lina, to the point when the study was initiated. You you said he wanted to investigate um how weight loss influences the mortality of people you know living with obesity. So at that time, baratic surgery was not very, you know, I would say established or popular. So I assume that that was just a mean to initiate, you know, reliably weight loss, right? So was there, was, was he talking about unintentional and intentional weight loss? Was there a difference? Because unintentional weight loss is definitely associated with a higher level of mortality, usually, as we know, because it can be linked to other diseases. But if you could take us back to the initial phase of when the study was initiated, and also maybe explain what was the rational to decide not to make it in a randomized fashion back at the days.

SPEAKER_01 10:21

Yeah. We can start with the randomization. I think Lars wanted to do a randomized study, but he wasn't allowed to do that. Um, since it's a nationwide study, he had to get approval from seven different ethical committees. And I think most of them didn't say yes to a randomized study. And the reason for that was that bariatric surgery had some risks. I think the the mortality at that time was about 5%. It turned out to be much lower in the SOS study, I think it's 0.25 or something. But because of that risk, it wasn't allowed to do a randomized study. So instead, he decided to do a matched study. So the study is carefully matched with a control group matched on, I think it's 18 variables that were assumed to affect uh survival. And I think that the control group in the SOS study is one of the unique features because we know that these patients they all volunteered to participate in the study. So the surgical and control cases are very similar in that way, and they have been going through the same examinations, exactly the same protocols, and answering the same questions, and we also know that the control group would be eligible for surgery. And I think that's an important point because when you use register-based controls, that is not the case. We actually looked into if I can if I can elaborate on that a bit. We thought about the control group when we published our results on um uh life expectancy. We saw that life expectancy and the SOS study was prolonged by three years, and then there was a meta-analysis, including 16 retrospective studies and the SOS study, and their survival was twice as high. And we didn't understand that, and we started to think what was the difference between our cohort and those cohorts. And I think a big difference is our control group, because we know that it is uh healthy enough to undergo surgery. So we decided to take a closer look at our control group and say what would have happened if we had used register-based controls. So we looked at the patients that at the time when the study started had a diagnosis of obesity in the registers, and we compared that to those that had just volunteered to participate. And it turns out that the patients that had an obesity diagnosis were much less healthy, they had shorter survival time, and I think that's extremely important that you know that when you do register-based studies.

SPEAKER_02 13:06

I think that's an interesting point, and I with this I have to go back to the idea when you look at your uh long-term analysis data and you look at uh perhaps the of course it's usually intention to treat uh within the groups, but if you would do a per protocol analysis when you look at the control group, a lot of the patients actually underwent surgery, correct?

SPEAKER_01 13:33

Yes, we usually do uh per protocol now. Intention to treat, we did that in the in our first paper on mortality, but now we we we realize that there are things happening over time. So we usually exclude the patients that have undergone surgery in the control group. And also we have a few cases in the um surgical group that have restored normal anatomy. So we we always control for those things. And that's the good thing with our study because we have all this information. We know exactly what's happening with these patients over time.

SPEAKER_02 14:04

Can I just go back a bit? You said you exclude the patients. So, do you actually have an analysis that shows the control group uh in a way that you would actually do uh see their weight loss, including the patients that did undergo surgery, because that probably uh is different when you compare within that control group these two groups of patients.

SPEAKER_01 14:28

We could, you know, we can decide if we want to plot graphs with and without the ones that have undergone surgery. Of course we can do that. Yeah, over time. At least I haven't switched stable over time.

SPEAKER_02 14:39

Yeah, and I at least haven't seen that uh analysis. It would be kind of interesting because looking at at the data, for example, from the Adams study that shows that you know the the bit of an uh stable state is actually related to the patients that underwent surgery.

SPEAKER_01 14:57

So uh looking at but the stable state in our case is without the patients that have undergone surgery, we we exclude those, and then you have a weight-stable group. Okay, thanks for that insight.

SPEAKER_00 15:11

Um based on your comment that you made earlier. I just want to mention for the listeners that you know are not experts in the field, the mortality rate of baratic surgery has significantly declined since the time when when you know the SOS study started. Yeah. I think back at those days, baratic surgery was still performed in a classical open conventional way, which is you know related to a much higher risk to these minimal invasive techniques that we use these days. That was just a disclaimer. I think that's important to make.

SPEAKER_02 15:44

Yeah, that's very important to make as sometimes patients still regard metabolic bariatric surgery as you know a risky procedure, which actually is uh very in contrast to that, is really actually very safe and uh experienced hands and uh in benchmark patients. So this really is a different, but like you said, the SOS study mortality rate is actually uh very much lower than anticipated when you when the study was initially uh uh started.

SPEAKER_01 16:16

Yeah, no, I that's that's true. And um in the beginning in the SOS study, it was mainly open surgery. So there are lots of open surgeries, and even so the mortality rate was was low. Yeah.

SPEAKER_00 16:31

Um Lina, before we come to all these incredible results that this study has produced, um can you just give us an overview? I mean, a study that that's being started more than 30 years ago now, even even more so, how many how many papers have been produced out of that activity? How many PhD students and postdocs you you brought out there in the market? Have you an idea of something? Yeah, it's amazing.

SPEAKER_01 17:02

I I actually try to look and see how many papers, and I think it's around 160.

SPEAKER_00 17:08

Wow.

SPEAKER_01 17:08

Um, but I I I can I can't give you an idea how many postdocs and and students.

SPEAKER_00 17:14

I know that Lars had lots of students in the beginning, and I don't I I'm not sure how many, but um I'm I'm sure there's been many that there must be an army of PhD students and theses out there based on the SOS study.

SPEAKER_02 17:29

Yes, there is to perhaps all the surgeons, scientists, listeners, that how I think one of the tricky issues of long-term follow-up is actually to get funding for that. So, but it uh of course I'm I'm absolutely convinced that you have this uh issue solved, but it's like how are you still getting funded after 30 years?

SPEAKER_01 17:52

It's still a struggle. I do have some money for it for next year. Um, we have large applications this year to the Medical Research Council, and we're waiting for the results. So we don't know. It's always like that. Every third year or every fourth year, you you have to see what happens next. Okay, that's hopefully.

SPEAKER_02 18:11

That's consoling. Yep. So also you guys struggle, but maybe we move on to the outcomes of these trials because you uh there are still landmark papers coming out, and uh maybe do you uh, as you have uh very long experience with the study, so if you would choose uh what would be the long-term outcomes that you yourself find most interesting that you guys have published? Is it the uh related to cancer, related to other prevention of type 2 diabetes? What would you like to point out to the listeners?

SPEAKER_01 18:55

It's hard to choose, but I think um maybe um when we could show um that it increased life expectancy because for before we did that, nobody had really put a figure to that. We we expected, of course, when the mortality goes down, but we didn't know how much. So I think that was um one of the landmark studies from from the SOS showing that we had three years longer survival in the patients that underwent surgery. But we could still show that they were not normalized compared to the normal population. There is still a few years lag. So I think that's um definitely one of the main papers. Um I we've have also had quite a few papers on cancer, uh different types of cancer, and I think that's one thing that usually when you talk about patients with obesity, most people focus on cardiovascular outcomes. And that's very important, but uh half about half of them die from um cancer, so that's a very important um outcome.

SPEAKER_02 20:02

No, I I fully agree with you on that because I think this is an overlooked aspect of the uh issues uh with severe obesity, is that it predisposes you to uh various uh cancers. So I think that's I I really like your paper from uh from 2024 on the uh on cancer.

SPEAKER_00 20:23

Yeah. So um can you you know help our listeners and viewers uh with with those data? So obviously uh obesity is associated with a higher incidence of cancer. Uh is that true for all sorts of cancers? Are there differences in cancers? Is that related to uh you know sex of the patients being affected?

SPEAKER_01 20:49

Um yes, I I think it is affected by the the sex of the patients, but um it's clear that obesity increases the risk for several different cancers, and there are 13 cancers that are supposed to be obesity related, but I think that number is too low. I think there are additional cancers that are also obesity related. And for example, we have found some um effects on skin cancer, uh, which I don't think is an obesity-related cancer, and we've also published on hematological cancers. So I think that list is too short. It's probably more than 13 um cancers that are obesity related. When we have looked at um the effect of bariatric surgery on overall cancer, we can see that it's actually an effect that is mainly restricted to women, or it is restricted to women, and that's what other people have seen as well. So, for some reason, there is a clear sex difference, and many of the cancers that affect patients with obesity in women are female specific. So we have also looked at that and and we've seen that um it reduces female specific cancers, for example, endometrial cancer. So that I think weight loss and the metabolic improvements probably um reduces the risk of cancers on on a wide scale. It's really not directed to specific cancers, it seems like it's more like an overall effect.

SPEAKER_02 22:28

Yeah. Uh looking at, I think the data is very convincing of the papers from the SOS study from the from Ali Ammunions group showing really an impact on uh on cancer prevalence and also cancer mortality. But when you when you think about like real life practice, we we know this data. So how would you take it forward to actually benefit the patients? So, how would we implement this uh data into uh daily clinical practice?

SPEAKER_01 23:07

I think the first thing is to keep this in mind that cancer is an important outcome and not just focus on the cardiovascular effects and perhaps inform the patients that this is also a potential benefit that they could have if they undergo surgery and perhaps also other types of weight loss treatments.

SPEAKER_02 23:26

Yeah, and I also think that maybe we should uh partially focus on our colleagues within oncology, within uh gynecology, you know, uh patients that have had, for example, breast cancer that actually have severe obesity. We should probably target, you know, some of these groups or uh patients with uh colonic adenomas or something like that, which actually uh have a higher risk of uh so pre-malignant uh uh situations.

SPEAKER_01 23:59

Can I can I ask you? I mean, we we have seen that it it reduces the risk of these cancers, but we don't know anything about what happens if you've had the cancer. Does it reduce the risk of recurrence? Exactly. Reoccurrence. That's something we have no idea about exactly.

SPEAKER_00 24:15

Can I can I ask you to give us a little bit more details on on you know this relationship between sex and cancer incidence and obesity? Because if I'm not mistaken, the the the population included in the SOS study consists of 80% female patients and 20% male patients. May that also be a reason that there is, you know, that you see more changes in a female population compared to the male population? And secondly, out of personal interest, because that was one of my research aspects back in the days, was there a difference between pre- and post-menopausal women in in cancer incidents? Did you look at that?

SPEAKER_01 24:59

We looked at that, but we couldn't see that. And when we talk about men and women, of course, um, there could be a power issue in the SOS study in the male population, but even when we do renewed analysis and have more cases, it seems like there is no effect at all in men in the SOS.

SPEAKER_00 25:19

All right. That's interesting because there are also some studies. I remember that was a registered study also from Sweden suggesting that baretic surgery may even increase the risk, for example, of colorectal cancer. And they were speculating that that would be due to changes in bile acid metabolism in the in a common channel, but that has never been shown. So this is why I'm specifically asking. I uh, you know, I would I would love to see this data from the SOS study.

SPEAKER_01 25:48

After looking at that paper, we analyzed colon cancer uh in in the SOS study, and we cannot see any increased risk. And I think we have a better control group. Yes. Definitely that yes, I fully agree. So I think the risk is not elevated. Yeah.

SPEAKER_00 26:03

That's an important statement. Thank you very much for that.

SPEAKER_02 26:06

Going back to the uh type 2 diabetes, uh, I think did you actually show that there was a difference in the cancer-related uh prevalence? Uh that was there was an association with the type 2 diabetes remission. So it was lowering patients that uh actually had remission at 10 years?

SPEAKER_01 26:27

Um I have to go back actually and check that paper because I I I think we did look at remission and and cancer, but can we stop and I can go back and see if or it's fine. I think that's that's that's that's what you wrote. Can we cut that? Because I can't give you the I can't remember if we did that or not. I know we did, but that's actually what you wrote. So okay, good. So I mean, there's so many, so many papers.

SPEAKER_02 26:57

I can imagine. I can imagine it's very hard to remember. Uh, I did want to go back to the paper from this year that was looking at alcohol use disorder. Do you maybe you want to highlight that for the readers?

SPEAKER_01 27:13

Yes, I I think um the SOS study, we we don't only focus on on positive outcomes, we have also studied side effects. And there are a few side effects, and and one of them is the increased risk of alcohol um abuse. And we published our first paper on that in 2013. And now we have a new paper where we have also looked at mortality, and it turns out that um bariatric surgery and and and gastric bypass is associated with increased risk for um alcohol-related mortality. So, this is something that is very important to be aware of in these patients and really talk to them about the risks, I think.

SPEAKER_00 27:55

What do you mean by alcohol-related mortality? Is that you know liver cirrhosis, metabolic consequences? Is this car incidents, accidents? Or is that everything available?

SPEAKER_01 28:06

Unless it's it's stated that it was under uh alcohol abuse. But but otherwise, we have looked at the the um in the the uh the cause of death register, and if they had indicated that it's in uh uh alcohol-related death, that's what we have uh okay analyzed.

SPEAKER_02 28:26

Did you actually do something? Because I uh from the uh 2013 paper looking at this issue, did you actually uh go back to the patients and you know try to give them further support? Uh because I think this is something that you really have to discuss with the patients that they are aware of this risk?

SPEAKER_01 28:47

No, we didn't contact the patients. No, we didn't. Okay, yeah.

SPEAKER_00 28:52

So let me quickly summarize, you know, an interim uh summary quickly. So baratic surgery reduces mortality, increases life expectancies, you know, reduces cardiovascular risk, reduces the risk of several cancers, but on the other side, it increases the risk for alcohol abuse and alcohol abuse-related mortality. They also, if I remember correctly, you had data on suicidal rates, which is always an issue that you hear, or other addictions. Can you can you, you know, uh enlighten us a little bit more about the other side effects that the SOS study um showed for barotic surgery?

SPEAKER_01 29:36

Yes. I mean, in addition to the risk of alcohol abuse, we also see an increased risk of um non-alcohol uh drug misuse.

SPEAKER_00 29:46

Ah, okay.

SPEAKER_01 29:47

Yeah. But other risks that we see is that you have an increased uh risk of fractures, and you also have an increased risk of anemia after bariatric surgery, and um also an increased fall risk. Fall accidents are increased, especially in patients uh that have undergone gastric bypass.

SPEAKER_00 30:10

And and I I assume you don't have any data on vitamin and mineral supplementation in that group, whether anemia might be related to simply not taking the supplements, for example, yeah, and and bone mineral density might be related to calcium supplementation and vitamin D supplementation. Do you have data on that one as well?

SPEAKER_01 30:30

Or we have self-reported data on uh I I don't know how reliable that is. Yes, but I think it's definitely a problem with compliance taking you know vitamins and and other things after minerals. I'm sure that a lot of people don't do that. I mean, they they should have been doing that for 30 years now. And I I know that you know, for many drugs, there's a difficulty with compliance after a year or so. So I'm sure that that is an issue.

SPEAKER_00 31:02

Yeah, that's an entire different issue, right? But yeah, I I think it's important to highlight that biouristic surgery, without a doubt, is beneficial for people living with obesity, but there are a few side effects that that people need to know about, and and and thank you for highlighting a few of those because there are not many studies you know that show that with the same level of credibility as the SOS study.

SPEAKER_02 31:27

Definitely. Maybe for the last few minutes uh we need to touch up on uh on type 2 diabetes because that is a major issue. So, like summarizing all the SOS results uh and outcomes on type 2 diabetes, what would you uh pick out? Lena, you have 160 papers, so we have to we have to ask you to pick out the ones that you think are most important.

SPEAKER_01 31:57

I think it's very important to know that if you don't have diabetes, but you have obesity, you have a high risk of obesity, and if you manage to lose weight, um that risk is very much reduced. And that's you will probably not have um the complications because the microvascular complications can be very severe unless you do something very early on. We see that even patients with pre-diabetes, they have a risk of um uh microvascular complications. So I think the the prevention that you can do in patients that are not yet affected by diabetes, I think that's extremely important. And also for the patients with diabetes, it's very important to treat early. If you catch them when they get the diabetes or within the first year or so, you have much greater um chances of getting remission and having them free from diabetes for a long time, and also prevent um the microbascular complications. So I think it's extremely important to treat early to prevent things.

SPEAKER_00 33:11

I think that's that's such an important message, right?

SPEAKER_02 33:15

I mean that's an important message to all the physicians, everybody that you know sees patients with severe obesity in cases of prediabetes or just you know, when they get the diabetes, you actually do have to take them forward to active uh treatment.

SPEAKER_00 33:32

But even also in addition to prevent diabetes, I mean, the the preventive character of surgery is very difficult to transport to people who are critical about surgery. But that's basically, you know, that's one aspect of it. So if we at some point will be able to show which patient population has the highest risk of developing type 2 diabetes, I think you know, these patients need to be offered, at least they need to be offered an access to barietic surgery.

SPEAKER_02 34:02

Exactly, like Lena said. That that's probably one of the because the reduced risk is that that is the that's a very uh main uh outcome of I think one of uh the biggest ones for SOS to show that that actually you're able to uh reduce that risk markedly.

SPEAKER_01 34:22

Yeah, I think you know we have some recent papers where we looked at if you can manage to get patients um if you can prevent diabetes for two years, you know, you have the group that don't develop diabetes compared to those that develop diabetes, there is a difference in mortality. And the same for remission. If you go into remission, short-term remission for two years, that's associated with increased life expectancy. So these are really important um uh uh indications that you need to treat early and do it, you know, efficiently. You need to inform the patients about these risks and that you can do something about it with surgery.

SPEAKER_02 35:02

Definitely. Uh, I think at this point we need to thank Lena for uh her valuable insight. It was really fun to uh hear the stories behind the uh these landmark uh studies and and kind of the history, and and thank you for picking out like all of the most important outcomes that uh the studies have shown because it is uh it's very high respect. It has really uh the study has uh has had a market impact on the uh field. So we're very grateful for your hard work and and for the whole uh SOS study group.

SPEAKER_00 35:40

Yeah, thank you very much for all what you've done for the field, and thank you very much for taking time on a Saturday morning to chat with us. Thank you very much. Thank you, Lil.

SPEAKER_01 35:47

Thank you for having me. It was nice. Thank you. Thank you.

SPEAKER_00 35:50

Thank you. Bye bye.

SPEAKER_01 35:51

Bye, bye.

SPEAKER_00 35:52

Well, that was an interesting conversation with Lena, wasn't it? I it was so interesting to talk to someone who manages data that were started to be collected 40 years ago, 35 years ago, and it still, you know, keeps on giving data that are so important for us.

SPEAKER_02 36:12

But that's actually I think uh currently because when we discuss that, you know, this trial may be too hard to do, that just means that I I love the pride that you know Lars Jostrum was a doer because you know, you just sometimes you just have to get things done. It's like you have to start somewhere, and it's gonna be difficult, but without, you know, that uh amount of work that they put in, uh we would not have the landmark data showing uh all of these issues, like prevention of type 2 diabetes, their decreased mortality rate, uh, the effect on cancer incidence, uh, all of these issues. And they actually did put a lot of effort uh because I knew that they were not allowed to have a randomized trial, and they did it uh the next best scenario, like having a very good control group.

SPEAKER_00 37:05

Yeah, I found that so interesting to hear because that's one of the criticisms. You know, they're always confronted with, well, they should have done it in a randomized way. They were simply not being allowed to do it. Yeah, and they had to consult seven ethical communities.

SPEAKER_02 37:19

Yeah, no, but that's yeah, that's uh that's the Nordic system.

SPEAKER_00 37:23

So lucky you again.

SPEAKER_02 37:25

Yeah. But it's I also found it interesting because this sometimes, I don't know whether you look when you look back on your own career, it's like you don't, not all of the choices you make, they may seem like, you know, this is, you know, I planned that this is like, you know, sometimes things just happen. And I think when you keep your mind open for opportunities and and look at things differently. So that was not her origin original idea, but at retrospect, like she said, that was maybe the best career decision that she went uh on and moved to a field of obesity research.

SPEAKER_00 37:59

Yeah, and simply trust your instincts, right? Yeah, and and keep digging, right? You know, jumping around, but stay in the field, right?

SPEAKER_02 38:07

Exactly. And and looking at the papers and and the outcomes is like how much they actually have contributed, so you can look it back, you're like, you know, you did something of uh value. So I think but that's I think that's kind of funny because I think it was a bit of unfair of us because we we made her choose. We made her choose from like 160 papers. So it's like, could you please summarize? But I think uh I think she picked out like the ones that I I would have probably said that I think are the most landmark uh results that you're not able to get from uh any other, because this is like a three decades of uh follow-up and and long-term follow-up in my uh experience is like insanely hard to do for any trial. So that takes up so much effort. So we're uh we're indebted to the uh SOS study group for contributing to the field, I think.

SPEAKER_00 39:01

Yeah, we owe them a big time. Yeah, yeah. We wouldn't be where we are now without them.

SPEAKER_02 39:06

Yeah, definitely.

SPEAKER_00 39:07

Thank you very much.

SPEAKER_02 39:08

Thank you.