There are some reports that buprenorphone causes weight loss (along with the other opiates). Of course, that wouldn't be a legal way to prescribe it and I can't imagine it's worth the dependence but I suspect it works (both from personal experience and some remarks online). Still, hard to tell since almost everyone using it is either shifting from opiates w/o a ceiling or abusing it so the effect could fade but I suspect there is some long term effect.
I just mention this for completeness as using it for weight loss seems kinda crazy.
This is interesting. I wonder how much eating is initiated by pain. I've noticed that pain sometimes causes me to want to eat...and sometimes to eat. (And by pain I'm not exactly talking about hunger. It's something else. Sometimes I experience it right after a meal that I know should be sufficient.)
So...is ibuprofen associated with weight loss? Aspirin? (I don't count acetaminophen, because that has almost no effect on me.)
Regarding costs to the medical system it occurs to me that an effective weight loss medication might increase costs even more via the indirect effect of enabling people to live longer.
Maybe it won't be of the same order of magnitude but I remember going through the numbers during the tobacco lawsuits and the claim that smoking increased the burden on state medical systems was complete bunk once you adjusted for the cost savings as a result of early death. Of course, those states likely lost tax revenue as a result but that too may have been offset by pension/etc savings.
Don't get me wrong, I don't have any sympathy for the tobacco companies in this case but morally speaking the states deserved almost none of that money but they got it rather than the smokers.
To put my 2¢ in, I'm a big believer—from personal experience, seeing others' results, Internet testimonials (least reliable, obviously), and reasoning, in the #Whole30, which is a Paleo-inspired elimination diet. I've never been able to sustain weight loss for months and months before. I think it goes to the heart of our obesity epidemic (and have some evolutionary theories as to why it works).
The more I look into it the more weight loss diet efficacy looks a lot like antidepressant efficacy-- you can find lots of anecdotes of people saying "x diet or y antidepressant saved my life", but when you assign people to x diet or y antidepressant in RCTs you get results only marginally better than placebo.
Reporting bias. If you feel motivated and accomplished enough to actually stick with any good diet/exercise routine for a long period it will probably produce results, which you'll be happy to brag about. If you half ass it and give up after a week then you probably won't remember the name let alone be in a situation where your opinion about it solicited.
However, an RCT naturally captures both the minority of people who use as intended and the minority who lack the willpower/self control to stick with it consistently enough to do anything.
This doesn't mean the RCTs are flawed, they just look at a very different question from the program designers; will this impact the average person who does day 1 vs. will this impact somebody who does day 1 all the way to the end 100% consistently.
Jacob is right. However, despite that, I would predict—to the point of betting reasonable money on it—that the Whole30 would get good results in a well-designed RCT.
Of course, I’d also be interested in seeing sub-portions of a good RCT on this; i.e. how people did who actually stuck with various regimes, and also how many people stopped after X time.
I think there's a couple things going on with the variance of diet efficacy.
One, people's appetites vary a lot, and different people will find it necessary to cut calories in different places. I can't overeat cake, so I don't need a diet to tell me not to eat cake. On the other hand, I instantly get full when eating potatoes, so it's a great diet food for me; that trick might not work for others.
Two, there's a potential "placebo effect" where simply believing in a diet leads to its success. Someone who genuinely believes in a diet will be more motivated to stick to it, and that'll make it more effective. With this perspective, the idea of "fad" diets makes a lot of sense: people believe that what's popular must work, so they will try their best to make it work, and then it works (for a while, anyway).
Among common foods potatoes were found to have the highest satiety per calorie, so they are generally very good for most people trying to cut calories.
>but when you assign people to x diet or y antidepressant in RCTs you get results only marginally better than placebo.
Half of the antidepressant issue is that placebo is very effective against depression. So if you do a placebo trial of mildly-depressed people who're 96% or whatever cured by placebo, there's just plain not much room for a drug to do better.
The other half is that SSRIs aren't a huge amount better than placebo. This is an *SSRI* problem, not an *antidepressant* problem; Scott wrote a whole post on this (https://slatestarcodex.com/2015/04/30/prescriptions-paradoxes-and-perversities/) and outright calls MAOIs "excellent" (at least in terms of antidepressant action; there are reasons they're not a first-line treatment, such as "fatal drug/drug and drug/food interactions"); tricyclics/tetracyclics are also generally acknowledged as Doing Something.
I lost a lot of weight (now BMI 22), and have kept it off, doing my own weird diet and exercise routine. I feel like most diets can work if you basically follow them obsessively and stick to them long term. But any diet can fail if you have people around you who aren't following it and are pressuring you via social eating, or worse, don't respect the idea that you want to lose weight. Nearly every person in my life now routinely comments to me that I am "too skinny" (and except for one they are all significantly overweight).
Following any diet and exercising is hard enough but when you add in social pressures I can see why its just too much for many people. Since the US obesity problem is so bad I'm in favor of meds, surgery or whatever it takes to help solve it.
Well I am sure it would drive most people insane but here goes: unsweetened oatmeal with frozen fruit every day for breakfast. Unsweetened soy milk or 1% milk with that. White bread with olive oil or peanut butter. Steamed frozen vegetables with olive oil, salt pepper. Frozen ravioli (3 or 4) pieces a couple days a week. 3 canned soups per week. One frozen pizza per week. 1 chocolate bar per week. 1 6 pack of beer per week (no other alcohol except on special occasions). Oranges, bananas, apples. Yogurt sometimes. Canned salmon/mackerel/chicken sometimes. No red meat, pork, or butter. Dozen eggs every few weeks. Plain microwave popcorn rarely. Copious amounts of unsweetened green tea. Almost zero restaurant food. If I had a late lunch I skip dinner and just eat fruit every couple hours those nights. Some random fresh vegetables now and then, I just got some asparagus which I am excited about.
I try to avoid all seed oils as well, for instance the bread I buy doesn't have them, but its hard to avoid in the pizza and soup.
Biggest problem is that its low protein and I'm trying to fix that with beans or something but haven't yet found something I like. Overall the diet is probably too restrictive. I hang out with my parents every few weeks and eat too much with them, including a bunch of tasty garbage snack food they buy, but if it wasn't for that I'd probably be underweight. A side bonus is before I started I had bad GERD and had to take two potent prescription anti-acids every day, now I take that only as needed, a few times a week max, and its just OTC stuff.
For exercise I just walk mostly now, 10-12 miles a week 3-3.5 MPH. In the beginning I walked a lot more.
Fascinating. Thanks for sharing. That’s what I often eat for breakfast and I also love green tea. I’m not gaining weight, I’m basically maintaining, but I’ve always been too chunky so dropping weight seems to be my struggle. I work out daily, in different ways, but I think restaurants are my downfall. Just going to a restaurant once a week basically keeps you fat...
Restaurant food is definitely a calorie bomb but with all the inflation they seem to be reducing portion sizes, at least in my area.
In the early days of my diet, my weight loss seemed annoyingly slow, so after working out at the gym I would go for a long walk too, though at a slow pace, since I was tired. It ended up being 4+ hours where I wasn't eating anything and was exercising. Of course that is a big time commitment, so hard for a lot of people, but it did help. Now fortunately I don't need to put all that time into it to maintain my weight.
I find it helps to plan on taking home half my meal (or splitting a meal with someone if I am not going to be in a position to take home leftovers). I don't always succeed, but starting the meal with that intention makes it easier to check in with myself halfway through, realize I'm not that hungry any more, and save the rest to look forward to later.
A quick google search shows whole30 isn't a diet but a nutritional plan, so it's possible to gain weight on it - but honestly if people ate that way they'd feel way better generally and be able to lose weight more easily regardless of it happens automatically or not
The point is that diets aren't equivalent even if htey prescribe equal calories. A diet that has foods that give you energy and don't make you hungry all the time is one people will stick to better.
Caloric deficits don't cause you to lose weight, because fat isn't the summed delta of calories-in and calories out, just like your retirement account isn't the summed delta of "income" and "spending."
I'm not sure how Adam is getting his $120 for a two month supply figure. Peptide Sciences is offering 3mg/$120, and Biotech Peptides is offering 3mg/$114. That's more like $120 for a *one week* supply.
I started thinking about allowing tags on comments, where the blog owner specifies a few tags for a post and then their commenters can use only those tags. But a) I don't like suggesting additional features for Substack comments until they get their performance issues under control, and b) I suppose that wouldn't really help for this particular case, which sounds like the blog owner noticing post facto (post post?) that a number of comments on a particular post tend to fall into a few distinct buckets.
I feel super lucky after reading these comments after how much people have been paying. I have just a standard issue HDHP through work (Anthem/Blue Cross Blue Shield in NY). Typically the full $2,000 deductible each year is paid by Gilead's savings program when I get my first Descovy for PreP prescription filled in January, so I just end up with regular co-pays after that. The co-pay for Wegovy has been $60, and that's reduced to $25 with a savings card (and I pay the $25 with a FSA card, so the after-tax cost to me is only like ~$150/year).
I think one reason a lot of eligible people might not take this drug is that insurance requires preapproval, and most doctors either genuinely think you won't be approved or will tell you that you won't because they don't want to deal with the hassle. My doctor has a strong interest in obesity issues and was very enthusiastic about the drug when I asked about it, but initially he told me it wouldn't be covered by insurance. I came armed with the preapproval criteria published on my insurer's web site, which as I showed him were quite lax (>30 BMI to start, >25 BMI required for renewal, and must be on a diet/exercise program as well). Ultimately, he prescribed Ozempic to avoid the preapproval hassle, but he agreed to try for preapproval with Wegovy once there was a nationwide shortage of Ozempic and my pharmacy couldn't fill a renewal for a while. We had no difficulty getting approval once we actually tried. It seems the insurer requires preapproval to scare doctors from even trying -- and most of the time, that works!
In terms of efficacy, I've lost more than 20 pounds (>10% of my starting weight) over the past 8 months and definitely and still in a groove of losing, but I do think you need to diet and exercise and complement the effects of the drug. If you can be somewhat disciplined about dieting, the drug will help a lot by making you not hungry even though you're on a calorie-restricted diet where you'd otherwise be rummaging through the fridge. But you won't see nearly as much progress if you don't actively track what you're eating at least part of the time and try to hit a reasonable calorie goal. Early on, I wasn't doing any dieting and the drug kept my weight stable (after I period when I had been gaining) but I didn't really lose anything until I decided to get more serious about tracking calories, working out 5-6 days a week, etc. It's made that effort much more impactful, I think.
Wait, bariatric surgery is that safe? I was just told yesterday by a surgeon that I ought to have my gallbladder removed after a quick referral process and an ultrasound from telling my PCP I had some mild pain in my gallbladder area. And he was like, all the complications are highly manageable, and are less than 1% each. This is a really significant update on my understanding.
Man, I really wish this stuff had been around ten years ago, two of my family members might still be alive and happier than I ever knew them to be if they'd been able to lose weight.
I strongly considered bariatric surgery back in 2019-ish (I went to like 10 weeks of classes at Kaiser), but I ended up not doing to because there are a lot of really hard and fast rules that govern what you can and cannot eat afterwards for the rest of your life. As someone who is quite fat but also perfectly healthy, and who truly does adore food, this was a deal-breaker for me.
I never considered the surgery. The risks of going under general anesthesia and failure are just to high. I have seen too many surgeries go badly on close family members to be happy about that idea.
A cholecystectomy is a very standard procedure, and basic abdominal surgery, but I am surprised that your surgeon told you all the complications are highly manageable. (That would seem to increase his legal liability unnecessarily.) The gall bladder is close to some large blood vessels and accidentally damaging them is life threatening. Also damaging the bile ducts can lead to significant problems. Any surgery involves the possibility of infection or problems under anestesia. (My purpose isn't to frighten you, I wouldn't be particularly nervous about a cholecystectomy, but it's not a trivial operation.)
Matt Yglesias recently reported that he got a newish kind of bariatric surgery that goes in down the throat. It sounded like regular sleeve gastrectomy, except without any incisions. He said recovery was (relatively) easy.
He also said he was gaining weight on it, so between the possibility that it doesn't work and the guarantee that you can never eat regular-people food ever again, it just doesn't seem worth it.
A couple of decades ago I looked into bariatric surgery. I *do* need to lose weight, but the number of suicides after the surgery was quite discouraging. There were also reports of a lot of other psychological problems and personality changes, so I decided to skip it. It would be really nice to lose weight, but not at the cost of killing myself or turning into somebody else.
I think maybe you should review the more recent literature. The population getting the surgery now might be very different. The moralistic garbage essays ("you'll just become addicted to something else! You'll just kill yourself!" etc.) have died down now. The surgery is much easier than it was a couple of decades ago, too. Just a suggestion to review the more recent literature.
"I prescribe a lot of people stimulants for ADHD, and my experience is that they rarely get any useful amount of weight gain."
Could this be in part that if the stimulants you prescribe are actually treating ADHD, they are causing your patients to sit still more and thus expend fewer calories?
The singular of “data” *absolutely is* “anecdote”, and the inverted version of that quote originally said “is” rather than “is not”. n = 1000 really is just a bunch of n = 1s!
Here’s my n = 1 on this topic: Metformin caused embarrassingly terrible stomach issues (for years, before a doctor who didn’t just go “of course the fat guy has a bunch of problems!” finally put two and two together). Ozempic injected abdominally caused random occasional throwing up. Mounjaro injected in the thigh is going well, assuming my current extreme fatigue is me getting over the COVID I had last week and not the meds; I’m currently worried to see several mentions of tiredness here.
Regarding the "savings cards should be illegal", something similar from my history:
I have Crohn's disease and was initially treated with Remicade, which is expensive: like four-to-five digit price tag expensive. This turns out to be a bad thing for getting people to actually use your drug, so the manufacturers solution is a "rebate program". As I understand it it works like:
1. You get billed for the drug
2. Insurance negotiates the price down, pays whatever, charges you the copay/deductible
3. You pay insurance with a rebate card (essentially a debit/credit card) the manufacturer gives you as part of the program. Essentially the manufacturer is "paying themselves".
I, of course, appreciate a mechanism by which I don't pay thousands of dollars for a medicine I basically need to keep a chronic illness under control... but based on my (limited) understanding, it's hard not to see this sort of thing as essentially a scam against insurance: it seems like the patient and manufacturer conspire so that the insurance is the only one who ends up paying anything for the medicine, and the manufacturer can charge basically whatever they like for it.
On the other hand, the insurer makes up that cost by raising premiums, and the higher spending actually *increases* their profit ceiling. Insurers are required to spend 80% of premiums on medical claims, leaving 20% for overhead and profit; more spending + unchanged overhead = more potential profit. So it's important not to see the insurer as a victim here.
The actual 'victims' of this 'scam' are people who have insurance but are not taking advantage of rebate programs, usually either because they don't need covered drugs or because they're not eligible (usually because their income is too high). So this is *mostly* health insurance working as intended (redistributing costs from poor and/or sick people to healthy and/or rich people). It's not the ideal way to do this, but it's an important workaround for the problem of cost-sharing formulas not being as income-sensitive as they should be.
It does have the added effect of raising the ceiling on prescription drug prices by eliminating consumer price sensitivity, which is mostly bad. But the solution of banning rebate programs has significant human costs which would be borne mostly by lower-middle-income patients. The ideal solution would be to first index copay/coinsurance rates to income in a more fine-grained way than the current 3-tier system, and then ban rebates.
>So this is *mostly* health insurance working as intended (redistributing costs from poor and/or sick people to healthy and/or rich people). It's not the ideal way to do this, but it's an important workaround for the problem of cost-sharing formulas not being as income-sensitive as they should be.
Insurance should be about collectivising risk, not redistribution. And its conflation with redistributive social programs is one of the main problems with the US system.
In principle, yes, but that just means the insurance model is a bad fit for healthcare. If you're going to force fit healthcare into the insurance model (and you're unwilling to just let poor people suffer), you're going to have to carve out some pathways for redistribution, and this is one of them.
Insurance plans in the US are fairly heavily stratified by income, though, so most of the cost redistribution within a given insurance plan is sick -> healthy (i.e. risk collectivisation) rather than poor -> rich.
I would rather they just be done under separate steams so it is clear. And the “sick>healthy” would be a lot less falling if the risk was pooled before people are one or the other.
> Sorry, I’m still not understanding this. Usualy weight loss dose of Wegovy is 2.4 mg per week = ~10 mg per month. The best I can find on CanShipMeds is 1 mg pens for $300. Doesn’t that suggest you’d need ten of those = $3000 per month? Or am I misunderstanding and that’s supposed to be the price for a month’s worth of 1 mg pens?
Sorry! I was referring to the Rybelsus. You can get 30 14mg tabs for $300. My understanding was that 14mg orally approximately equivalent to 2.4mg injected, but I could be wrong about that.
Thanks. I'm concerned because I can't find any good comparisons of oral vs. injected blood levels, and also pharma companies are usually too smart to leave obvious loopholes like this. I'll see if I can find more information.
"A carton that contains one pen with 2 mg/1.5 mL of Ozempic. This pen delivers 4 weekly doses of 0.25 mg plus 2 weekly doses of 0.5 mg per injection OR 4 weekly doses of 0.5 mg per injection. The carton also contains 6 NovoFine Plus needles. This pen is intended for treatment initiation at the 0.25 mg dose and maintenance treatment at the 0.5 mg dose. The pen delivers 4 doses of the 0.25 mg and 2 doses of the 0.5 mg strength. It can also deliver 4 doses of the 0.5 mg strength."
That's the pen for $300 on CanShipMeds. It's the starter dosage: 0.25 mg for 4 weeks. or going up to 0.5mg for 4 weeks. So one pen would last a month at the maintenance dosage of 0.5mg per week.
"Start at 0.25 mg once per week for the first 4 weeks. You start with a lower dose to help your body adjust to the medicine, but the 0.25 mg once per week dose is not effective in lowering your blood sugar over the long-term.
At Week 5, your doctor will increase the dose to 0.5 mg once a week. If, after at least 4 weeks on the 0.5 mg dose, you need further blood sugar control, your doctor may increase your dose to 1 mg once a week. There is a separate pen for this dose and you will need a new prescription.
If additional blood sugar control is needed, your doctor may increase the dose to 2 mg once weekly after at least 4 weeks on the 1 mg dose. There is also a separate pen for this dose."
That's this pen: Ozempic® 4mg/3ml from Canada
That is the 1mg once a week dose for 4 weeks. Both of them cost $300 (US). So yeah, the $300 is for a month's supply.
Just a small note, but for the Canadian Ozempic, the "1 mg pens" are four doses of 1mg ("Ozempic® 4mg/3ml from Canada".)
It's interesting that the 4mg and 2mg pens cost the exact same amount. The 2mg pens are the "introductory" version that last six weeks instead of four--you take 0.25mg/week for four weeks, then 0.5mg/week for two weeks.
So thankful that you’re covering this in depth. Fascinating.
Has anyone figured out what the best insurance would be for covering Wegovy? I’m looking to buy new insurance anyway (self-employed/business owner) and would love to find one that would cover this treatment.
Sounds like at least one person is recommending Anthem/blue cross, but I wonder which plan?
What makes Clen not an attractive option? Near as I can tell it's actually less dangerous than some other drugs I actually already take, and it fights perhaps the worst disease in america.
T3+T4 is as effective as Clen and far less unpleasant. Possibly more risky though. Clen, even at extremely low doses makes me (and most people I know who've tried it) super jittery.
I know of a company with a drug in clinical trials that causes weight loss faster and potentially larger than semaglutide and using a completely different mechanism that on theoretical grounds should be strongly synergistic with GLP-1 agonists. That company already applied for a patent on obesity treatment using a combination of GLP-1 and their therapeutic class. As they say, this changes everything! :)
I think that, as strange as it may seem from an observation of the American public at large, obesity has moved into the "solved medical research problem" category and all that remains is deployment.
Anecdotally, roughly one third of the female NPs at my ER are on semaglutide or equivalent drugs, and that's just the ones that told me about it. None of them are diabetic and they were not obese either, more like chunky. They report quite dramatic weight loss and, yes, many women working in the ED do appear quite a lot thinner than last year.
I expect that these and upcoming weight loss drugs will be much more widely used than you expect: Only the conscientious and the health freaks pay attention to e.g. their blood pressure, since hypertension is the silent killer that doesn't hurt until it's too late, so rates of compliance with treatment are modest. In contrast, obesity massively hurts people's love lives, and this creates a whole new level of urgency to obtain and conscientiously use the drugs that solve this problem.
I expect that in the next ten years Americans will collectively lose hundreds of thousands of tons of fat. There will be a tectonic shift in the dating market, which will be inundated by millions of lithe females and toned chads, fresh out of the weight loss clinic.
A new, gloriously thin future awaits!
A practical note on cheaper access to the drugs: There is one little trick obvious to anybody with a syringe that could reduce your cost of e.g. Mounjaro ($994 per month without insurance at Amazon Pharmacy) by a factor of six. I will not explain the trick because it could be construed as providing medical advice but, you know, it's obvious if you think about it for a moment.
I think the shortage is affecting Canadian supplies and prices. While I was waiting for insurance approval, which mercifully came through, I got my Ozempic from Mark's Marine. The other popular Canadian pharmacy for U.S. residents is Candian Insulin. In early 2022, you could get a 4mg pen for $300. Yes, it's true, that doesn't get you to the full Wegovy dosage. It just gets you 1mg per week, which works well for me and for many others. But now when I check those sources, they don't appear to have the 4mg pens available right now.
This is a pain, but Novo Nordisk knows which side its balance sheet is buttered on, and I have confidence that they'll manage to ramp up production. That should make the larger pens available in the next year or so.
This weight loss discussion has been very distressing to me because I went from just shy of 250 lbs in February to 160 lbs today through diet and exercise, and apparently I'm a freak who will inevitably put the weight back on. I think it worked because:
1. I live alone and cook only for myself so I basically have total control of my own diet most of the time. And I got really into breaking down the calorie count on every meal, weighing all the ingredients, calculating how many calories they are, then dividing that by the weight of the finished product for a calorie/gram total.
2. I used a calorie counter app and kitchen scale and got obsessed with tracking every calorie against my daily allowed total. It became sort of like a game where I had to pack all the food I wanted into the allowance + exercise total. At first this meant being hungry a lot, but gradually my diet shifted to lower calorie foods as I got "rewarded" for them by feeling fuller after eating them. I generally always have a bowl of salad in the fridge, because it fills out meals at basically no calories.
3. I discovered the secret of exercise is the treadmill incline. I am just incapable of keeping up running speeds for long periods of time, but it turns out I can easily push through very high inclines at anything below 4 mph. So I go slow(er) but really crank up the incline on an interval setting, and without my body constantly jerking up and down I can read books on my phone. If I'm reading while exercising, it's not boring at all, but the higher incline still lets me burn a lot of calories.
I'm pretty hopeful that even if I slack off and start putting the weight back on it will take a few years, and maybe I can achieve some kind of yoyo effect where I diet for six months, let the weight creep back up by a few dozen pounds, rinse and repeat. Though wow, I do miss ice cream a lot.
Your system worked well for you. Maybe you can use some modified version for maintaining it, like
-same diet but with slightly increased calories. Increase calorie count slowly til you find the point where you maintain.
-Pick a weight that's 5 lbs more than weight you want to keep, and every time you hit it go back to the original diet for a couple of weeks
-Have one day/week when you can eat what you like, but some mild restrictions (like no more than one serving of ice cream)
Also, frozen bananas actually are sort of like ice cream. They are sweet, and the thick starchiness of the banana, when frozen, is a reasonable stand-in for the creamy thickness of ice cream. Let the banana ripen first then put it in the freezer with skin still on.
It is not at all clear to me how an incline treadmill causes you to burn more calories. Clearly, you could place a bicycle wheel on it with any amount of weight and there would be no effort required to keep it stationary. So, biking on an incline "treadmill" requires no additional energy vs. biking on a flat "treadmill".
Possibly, when walking, your speed is non-constant enough that during the slow part of the gait, your vertical position in space is lowered and you have to recover this during the quicker part of your gait? It seems that if you were running your speed would be close enough to constant that the incline would mostly just change which muscles you use (by changing the angle of your foot).
Huh? Walking uphill and biking uphill definitely demand more energy than doing same on level ground. Life experience demonstrates this -- you get tired and out of breath going uphill at pace that would not affect you that way on level ground. And the physics of the situation explain why: Altitude gain = fighting the force of gravity with the force of your body.
I would guess it's because of the different levels of exertion required by two groups of muscles: the big "power" muscles, like your quadriceps, and the small "positioning" muscles, like the little guys that position your knee and hip correctly for the impact when you are walking or running.
There are certain forms of exercise that make more use of the little guys: exercise that is fast, not super effortful, with a lot of body motion. Walking is actually one of those: there's a lot of motion, relative to the actual effort required by the big muscles. So is stuff like some forms of dance, or ice skating. On the other hand, there are forms of exercise that use the big muscles more than the little guys: exercise that is slower, very effortful, and where body motion is less, or constrained by some external force so positioning is less critical. Riding a bike, using a weight machine, swimming. Running and gymnastics and some kinds of dance probably use both pretty heavily.
What I would guess is that if you're doing something where the positioning/effort ratio is higher, your perceived level of effort has a larger component from the little muscles, which tire faster, while if the positioning/effort ratio is lower, your perceived level of effort has a larger component from the bigger muscles, which can do more before tiring. That would mean for the same level of perceived effort, you are actually able to burn more calories with the lower positioning/effort ratio exercise. Hence, walking uphill versus downhill, riding a bike uphill versus level, hockey versus figure skating, using a weight machine versus free weights.
Placing a bicycle wheel on an incline requires force to keep it from rolling down. When muscles apply force--regardless of whether work (force x distance) is done--they burn calories. If you actually try an incline treadmill, you will quickly confirm your muscles need to use more force to sustain the same speed as a flat treadmill.
I have the fat gene, but maintain a relatively low (perhaps even "thin") weight. Here are some of the tricks I need to play in order to make this happen:
When I go out to eat with a group, I tell everyone at the table I already ate. Then order something small. If I must order something large while out to eat, I try to identify someone else who seems health conscious and ask if they'll split the big thing (burger, for example) with me. If I must order large, cannot split with anyone, I ask for a to-go box immediately upon receiving food, and put half of my food in the to-go container for later.
Constantly make it a game with the others around me to eat less or more healthy. Gamify everything you can here. It makes it less like: "Stop eating like shit and be more like me" and more like "Hey let's do this fun healthy skinny thing together!"
When eating alone, I do pretty much like you. Make it a game. Can I eat less? Can I just skip eating now even though I'm hungry? Can I just put off eating for 30 minutes? Now that I must eat because I'm hungry, and I want an entire bowl of X, can I instead just eat three bites of X then stop (the answer is "yes" surprisingly often)?
Constantly drink water. Say I want to eat chocolate cake. I want a big slice. Instead get a small slice. Promise myself if I really want more, I can get more. Put the rest of the cake away so now I only have my small slice. Take a tiny bite of my small slice of cake. Savour it. Drink a giant bunch of water. Lick the fork clean. Drink more water. Feel any leftover crumbs of cake in my mouth/teeth. Taste those. Drink more water. Is mouth completely cleansed of all bite #1 of chocolate cake? Yes? Cool. Now take my second bite of the slice of cake. Repeat. Once done, if not hungry/craving awfully, don't have more, promise yourself you can have more in a couple hours if you're still craving.
Out to eat with friends, and they insist on getting three desserts for the table? Do the water routine from above with your share, and take the rest to go in your to-go box.
When someone gives me a bunch of delicious (but awful) food like candy or cake as a gift: eat a little. Do the water routine from above. Feel free to ham up the water routine or offer to have them do the water routine with you. Thank them profusely. Be gracious and grateful. When they no longer can see (have gone home?) throw the rest of it out in a fashion I cannot possibly retrieve it, like put it in the toilet, or with disgusting garbage.
As you can tell, there's a lot to unpack here, and a lot of routines to work through, but I do manage to keep off most of the weight while still being social with people and going out to eat with them. The hardest thing is when the bill comes, and people want to split the $500 bill 5 ways, and you ate a dinner salad and drank a glass of water. Most socially-clued groups will have at least one person who will loudly note you had $12 of food while they all had >$120 each, and split it more fairly. If they don't, pay your $100 share, and don't go out to eat with that group again. Or do, and consider the other >$80 as the cost of being thin while living in this modern world.
"I see some bariatric surgery patients and I agree they generally do very well. The only disadvantages are: first, that surgery is scary. Second, that it’s irreversible and does leave you having a lot less appetite and ability to handle food for the rest of your life."
Half-serious question here: what is the risk of having this surgery, then like three years later I'm getting tipsy some night, beer munchies ensue as they have a tendency to do, I eat like three pieces of pizza and my insides explode?
I roll to disbelieve, the results are too good to be true. A single dose leading to a 3-5 kilo reduction in 20 days? That's crash diet levels of short-term results. No reversal, and potentially even a continued downward trend for a month+ after the end of treatment? I choose cynicism, and will be thrilled if even a third of the claim holds up.
This is great info, and even better with the crowd-sourced tweaks and additions!
Speaking of obesity, this article was in my Medscape bulletin this morning. Subjects are US children, & they're comparing brain MRI's of obese kids (17% of sample!) with those of non-obese.
Obesity Linked to Brain Abnormalities in Kids
CHICAGO -- Children with overweight or obesity appeared to have abnormalities in the brain that could affect executive functioning . . . Greater weight and body mass index (BMI) in typically developing 9- to 10-year-olds were associated with poor brain health . . . At higher weight and body mass index, we found extensive alterations in brain health, including in the gray matter cortex and in white matter fiber tracts, as well as the functional coupling of brain units . . . Essentially our work provides an explanation for previous research that has shown that obesity measurements are associated with poor cognitive performance and academic achievement
Personal anecdote: I've been on Mounjaro for a bit over a month using the $25 discount card because my insurance won't cover it. I started at 6'4" 295 and have since lost 15 lbs with no dieting effort beyond simply trying to eat a generally reasonable diet. Side effects are mild at worst - no nausea per se though it's much easier to feel overly full at a meal, which feels unpleasant. I've also stopped feeling cravings for sugar after meals, which seems like a good sign that it's helping with insulin resistance.
After the discount card runs out, I expect I'll switch to semaglutide, so I can report back after the switch.
Two of my friends are on semaglutide - one has lost about 12 pounds in the span of a bit over two months, the other is just starting. Both had a hard time finding a pharmacy that could get it for them.
Regarding the why-can't-you-fat-lazy-slobs-just-go-to-the-gym wars: I'm not sure people exactly enjoyed debating this -- seemed more like they couldn't help getting pulled in. The thread had much more of a Twitter feel to it than exchanges here usually do. This particular topic leads quickly to that kind of indignation machine that powers Twitter use. Lots of overweight people are in considerable distress about their weight and failure to change it, and lots of normal-weight people have a least a mild case of craving to fat-shame the overweight. Plus the empathy quotient of this group is on the low side, in my opinion -- consequence of group skewing male and techy, I think.
Hmm . . . how would that work? Let's say somebody writes that they've been 60 lbs overweight for years, and that despite being able to stick with lots of other hard things (they got a phd . . . they wrote a book . ..) they have never been able to stick with a diet, despite trying with several different that were recommended in reliable places, and that they do try to walk a lot, averaging maybe 1 mile a day, but that several other forms of exercise they have tried start out exceedingly unpleasant for them and stay that way. Is there some rationalist principle that would nudge the reader in the direction of "you're not trying hard enough"?
OK, I'm somebody who never had a weight problem until very recently, & the one I have now is pretty minor -- maybe 25 lbs. gained during the pandemic, probably as result of sliding into a habit of drinking a couple beers every day. I've stopped with the beer, and doubt that I will have a lot of trouble losing the weight. And I'm an exerciser, too. So I am sort of like you -- I'm in the "good" categories. I'm not a chronically overweight and I exercise. But I do NOT find it incomprehensible that someone could be unable to stick to a diet, or unable to get themselves to exercise regularly.
Here's why: When I hear these accounts of being unable to stick with dieting and exercise, despite the many excellent reasons for doing it, I reflect on things I have been unable to change, despite many excellent reasons for doing so. For instance I was a heavy smoker for many years. Of course I knew perfectly well how bad it was for me. I began trying to stop within a few years of starting. Some of my efforts failed after a couple of days or a couple of weeks, but others succeeded to the point that I did not smoke at all for a couple of years -- but then I relapsed. I finally quit cigarettes for good about 15 years ago, and am confident I will not relapse. It was *extremely* difficult. So when I hear someone talk about being unable to stick with diets or exercise, I remember what it was like to be unable to quit cigarettes for good. I know what it's like to be unable to break out of an unhealthy habit, even when trying very very hard.
Of course, since I did eventually quit smoking, I could also take the other path in my mind: "I quit nicotine, which is very addictive, some say more addictive than heroin. I quit, and lots of people fail. Hah! And these people can't even keep their weight down and do some exercise? If I can quit smoking, they can do that! It's ridiculous for them to say they can't ..." Actually, it seems to me that you are doing something like that. After 15 years of being drunk all day, you decided to stop and started to learn programming. You're using the fact that you decided to stop as evidence that anyone can decide to do the healthy thing. But think about it. What about the first 14 years of drinking? I can't believe you did not realize during those years that the drinking was bad for your health and your life. I can't believe you never tried to cut back on the alcohol or stop. So it seems to me you have a lot of info about what it is like to be unable to change a pattern for the sake of your health and your quality of life. Try accessing that the next time you hear from somebody with a similar problem.
During the first 14 years of drinking, before quitting, perhaps it would be "rational" to disbelieve him if he claimed quitting was too difficult for an intelligent fellow like him to have already figured out.
But, after a successful quit, *then* maybe it's "rational" to believe him if he testifies that he found quitting so overwhelming that it, well, overwhelmed him for some years or even decades. After all, once someone is already succeeding, others have less reason to suspect that he's testifying just to make excuses for himself.
Skepticism toward others' claims that a difficulty is as difficult as described while it's happening isn't so much rational as it is Prosperity-Gospel. I love much about America, but not the Prosperity Gospel, a gospel embedded in our secular thought, too, not just religious.
The time to have one's testimony about difficulties believed by "hard-nosed skeptics" is once they're already conquered. Then one's difficulties are part of an overcoming story, an empowerment story, one that fits the Prosperity-Gospel narrative. Admitting to difficulties not already overcome is just "negative affirmation", though.
And yet, there is something valid about pushing back against somebody's declaration that they can't stick with a diet. It's not bullshit, but it's also not the same sort of "can't" as the one in "I can't fly." I think the can't in "can't diet" is located more in the area of motivation.
Sometimes I go for the half the day feeling unable to go grocery shopping -- ugh, so tedious, takes so long, can't bear it -- even though I really need to. Then suddenly I find it easy to face, even though I still know it will be tedious and take up a good amount of time. *I* don't even know what changed then, but it was definitely something in my motivation, not my actual ability to do the task. But the thing is, if you can't access the motivation -- that does seem more like "I can't fly." How do you make yourself able to face an unpleasant task? So mostly I think of people who can't quit smoking, can't stick to a diet, whatever, as stuck in an amotivational state, rather than truly unable. But it's a "real" stuckness, not a bullshit one.
Does rationality require disbelieving others' exculpatory self-reports?
No, but I can think of some reasons why those who think of themselves as rationalists would.
"The first principle is that you must not fool yourself and you are the easiest person to fool."
The presumption that others are fooling themselves, especially in face-saving ways, seems to run strong. When a stranger whom you can't even see gives an account of himself containing a mix of embarrassing and face-saving claims, the embarrassing stuff is more likely to be believed as an admission against interest, while the face-saving stuff is not. Someone claiming, "I failed at this goal, but my failure comes with these face-saving qualifications" likely won't have the "I failed" part questioned. The face-saving qualifications more easily invite skepticism, though.
Many rationalists seem to take pride in skepticism. There's a common form of social skepticism that's quick to suspect others of shirking.
Generalizing/bastardizing the concept of revealed preference suggests that someone who complains of failing to achieve a desired goal has already revealed a preference for failing to achieve the goal by failing to achieve it.
More generally, it suggests that people have already revealed their preference for who they want to be and what they want to do by who they already are and what they've already done. While there's some truth to this, it also serves as an excuse to dismiss any aspiration that hasn't already been achieved as bad faith, and, quite uneconomically, leaves no moral space for risk (which includes the prospect of failure despite good-faith effort, else how is it risk?).
So, for example, parents who worked hard to get their kid into Fancy College, but not so hard that they went in for the bribery and corruption of the Varsity Blues scandal, revealed that they must not have wanted a kid in Fancy College so badly, after all. For, if they really wanted it, why wouldn't they have resorted to Varsity-Blues methods to get it? Hopefully, the flaw in that appeal to revealed preference is obvious (arguably, those who resorted to unscrupulous means to achieve something did want it worse than those who didn't, but those who didn't could nonetheless have wanted it quite badly and put considerable effort into achieving it), but other flawed appeals to revealed preference may be harder to spot, especially if they otherwise "smell" rationalist (sufficiently skeptical, etc).
Here's a thought experiment, useful in thinking about willpower, why can't somebody just do it: Suppose I proposed the following as a way to lose weight: Look over the available approaches, choose the calorie-reduction and exercise plans that look best to you. Now go to the bank and take out 80% of your savings in the form of $100 bills. OK, from now on every time you deviate in any way from the plan you chose, light one of those Ben Franklins and let it burn to ashes. If you take a day off from following the regimen, count that as 10 deviations, and burn $1000. You are now very well protected from cheating and quitting, and on the road to success!
Yes, I know and am a fan. And yet, if you showed that site to 100 people who were stuck, how many of them do you think would run towards it with open arms? As someone who works with people who are stuck, I can tell you very few would. And it's not out of "desire to fail" or something either. Some of the refusers say, "I'd never put money on the line, because I don't expect it to work." Other refusers say, "What's the point? If I didn't meet my goal for the day I'd just lie so that Beeminder didn't take my money."
Inability to have hope that something will work is a really important part of stuckness. There are probably things you think wouldn't work for *you*, too, in reaching some goal you'd like to. You are probably wrong about a few of them. And yet hope isn't really a fixed quantity either. Sometimes people take a motivated leap into hope.
Here's a story about that. I had a friend who was getting a doctorate in experimental psychology. She got stuck midway thru her dissertation -- couldn't focus, couldn't make progress, and eventually she couldn't even get herself to sit down at the desk and work on the sucker. So she bought some little bottles of Boch Flower Remedies. They're a New Age total bullshit thing -- flower-smell mixtures, each supposed to strengthen some one quality. She was as sure as I am that they are nonsense. Nevertheless she got the ones for Courage and Persistence. She'd sniff them before she sat down at her desk to work on the dissertation, which she managed to complete at a reasonable pace with the help of Boch. Here's how she explained it afterwards: "I really needed them to work. So after I sniffed them, I knew I had to make progress on my dissertation that day -- otherwise, I would not have believed they could help me. And I needed to believe that, so that they would help me the next day."
My reaction to the prediction that Americas obesity rate has a fair chance of halving by 2050 was incredulity. So I googled obesity in the US and found that the prevalence of obesity has gone from 30% to 42% in the last 20 years, during which time the rate of extreme obesity has doubled.
Given that I'm also not really into predictions about something that may or may not happen by 2050, my incredulity wants to ask "When is obesity in America going to stop increasing?"
If one of the people who think that obesity is going to halve over the next 28 years wants to make a prediction about the ending of this increasing trend, I may well be interested in a monetary wager.
Here's a dumb question: what is a “single-food” diet?
The extremes are easy to define. Only potatoes? Sure, that’s a mono diet. A 6-course dinner—not a mono diet.
What if you blend together a 6-course dinner and drink it at once? Have there been studies that measure how many fewer calories are consumed in that situation?
Is it driven by mono-flavor? Mono texture? Do people who lose their sense of smell also lose weight?
Before the innovation of laparoscopic surgery, a gall bladder extraction entailed a one-week hospitalization with a significant risk of short and long-term complications. Now, it is routinely performed as a same-day procedure.
Bariatric surgery has evolved enormously over the past 30 years and many centers now also offer bariatric surgery on an outpatient basis. The patient is admitted to the hospital in the morning and discharged in the evening.
Bariatric surgery today is even safer than gall bladder surgery.
This high-quality meta-analysis studied 174,772 bariatric surgery patients who were pared with carefully matched controls. They concluded that diabetic patients who have bariatric surgery live 9.3 years longer and non-diabetic patients live 5.1 years longer than the controls.
Surprisingly, the major health benefit from bariatric surgery is not the reduction in diabetic complications or cardiovascular disease. It is the reduction in cancer!
The mechanism by which bariatric surgery works is not from the creation of a small stomach or malabsorption. Bariatric surgery causes major hormonal changes that result in reduced appetite. One of those hormones is GLP1, the same hormone that semaglutide also mimics.
One of the fascinating things that I have observed is that patients who take semaglutide or have bariatric surgery almost invariably consume much healthier diets than they did before! Oatmeal and fruits and vegetables suddenly seem to taste much better, and Eggs Benedict seems to lose its appeal!
I know this is a tangent, but I was struck by "although I’m sometimes a little cavalier about pills I would be more nervous about things I inject into my body". I have the same feeling, but I'm curious whether that's just your gut reaction or whether it's a more informed opinion than my own gut reaction.
The Diabetes Prevention Program was a 4-year RCT designed to determine if a highly structured Medically Supervised Weight Loss Program could cause long-term weight loss and thereby prevent patients from developing diabetes.
DOI: 10.1056/NEJMoa012512
It has been cited almost 12,000 times, making it one of the most frequently cited medical papers ever to be published.
However, if you examine that paper carefully, you will see that it actually proved the exact opposite of what it was purported to prove. It actually proved that MSWLP's cause short-term weight loss that is invariably followed by long-term weight regain.
The American Diabetes Association, the American Diabetes Association and the US Preventive Services Task Force have all published guidelines in which they recommend that obese patients be referred to MSWLP's and they use the DPP as the principal study supporting those guidelines.
MSWLP’s are highly profitable privately run businesses and many of the people writing those guidelines have major financial ties to those programs.
I have posted a20 minute highly evidenced based video on YouTube in which I review the DPP in some detail.
Yes, walking uphill and biking uphill obviously require additional energy. However, biking uphill on a treadmill would involve positioning the upper wheel at a higher position (than the lower) but have no effect on the wheel through which you deliver energy. It would obviously not require additional energy. The bike never loses nor gains altitude as the wheel can spin at an absolutely constant speed.
That a variable speed (throughout one's gait, while walking) WOULD cause you to gain and lose some altitude (during each step) was the point of the remainder of my original post... The closer you can come to a constant speed, the less difference there is between incline and not for a treadmill.
What you've forgotten is that the treadmill is now providing only cos(a) of the force required to maintain the bike's vertical position, where a is the angle of inclination. That is, if the bike weighs m, then when the bike is level the treadmill provides mg of upward force, while if the treadmill is at a 30° angle then it only provides mg*cos(30) = 0.88mg of upward force. The remainder, which prevents the bike from falling downward, has to be supplied by the rider pedaling. So for a given wheel speed, the effort required is larger.
This is a good point (as is Luke's below). I was assuming that the bike was actually affixed to the treadmill's frame. Then, as Eremolalos' thought experiment points out, the incline does have no effect. However, your observation does bring to mind several other experiments.
In the case of the unaffixed bike, the bicycle would accelerate down the treadmill at a rate directly proportional to your weight (if you weren't pedaling. Thus energy needed to prevent this is rider-weight proportional (like climbing a hill). Similarly if a treadmill on an incline accelerated based on your weight then the energy input would be proportional to the weight of the user. I do not think this is the case. For one, it would force running above a certain incline as the treadmill continued to accelerate.
Increasing the load applied by the treadmill could prevent this need to run on an incline. However, if we are increasing the load on the treadmill, then it is not the incline that is increasing work, but the "load" setting. Except, increasing the load setting above a certain point will just cause your feet to slip on the (level) treadmill surface. Perhaps increasing the incline allows the load to be increased by forcing your increased work to be in a downward direction rather than lateral (and thus overcoming the finite friction issue)?
You mean the energy input to the treadmill, e.g. the current it draws? I'm not generally familiar with the internal workings of treadmills, but yes I would a priori expect it to draw more current as the incline goes up (and the treadmill is set to a fixed speed).
In addition to supplying the force necessary to overcome friction and keep the belt moving at a steady speed, the motor needs to supply a little extra kick of force every time the runner pushes off, to avoid the belt accelerating instead of the runner. It does this by having a strong enough magnetic field that when the motor shaft is accelerated or decelerated, the magnetic field resists and pushes it back into phase (to the location where it's supposed to be at that time in its revolution). But the pushing back costs at least a little bit of energy, because it isn't purely elastic, and as the excursion gets larger (because a larger force is required) the energy cost grows.
So when the incline goes up, the extra kick of force needed on each step will increase, because it needs to supply some of the force needed for the runner not to fall vertically, and that means the electrical power needed will increase.
I don't know if some treadmills have an increased friction setting. They are common on stationary bikes, but on a treadmill it might not be very useful, because it doesn't really correspond to any movement that mimics natural running, except maybe running through ankle-deep water or something. On the bike increased friction mimics riding at higher speeds in higher gears, which is realistic.
For energy input, I meant by the person exercising not the treadmill itself.
My original statement was that I was unconvinced about the increased energy usage (exertion) from inclining a treadmill. At this point I can see several mechanisms which allow for additional exertion. I do not think there is any guarantee that the exertion tracks with the incline at the same rate as if you were actually walking uphill. (more on that later)
I think that your motor supplying extra energy thing is backwards. The person walking supplies more energy to turn the treadmill in the same direction that the motor is turning. This means less load on the motor. The motor may act like a brake (dissipating energy in the resistance of the windings and generating heat) but the energy supplied is from the person exercising. The motor is acting like a generator at least part of the time, turning motion into electricity and then dissipating that electricity as heat.
I am still asking myself if there is (at least on real treadmills) a necessary relationship between incline and exertion that tracks with the actual energy used if you were walking up a hill with the same incline. If Potential Energy=mass*gravity*height is reflected in the energy delivered to the treadmill. Thus my previous discussion of an unrestrained treadmill accelerating until you were running and thus dissipating the same energy anyway.
I think, that if you take the analogy to its extreme and assume you are standing on a ladder that we find that this relationship is true. If the ladder is forced downwards by your foot, even if ladder motion is assisted by a motor, you are applying a force of at least your own weight (or else you are descending). And you are applying this force through a distance equal to the distance traveled. This suggests to me that (other than resting your weight on the handles of the treadmill), that my original thinking was incorrect and that the incline of a treadmill more-or-less mimics an incline in real life.
I'm rather surprised no one mentioned food subsidies and cheap food being part of the problem. The USA cheap food policies and the massive amounts of money making that happen just might be related. Obviously this is an unpopular perspective and once you give people cheap food, it is hard to get into political office saying you want to triple food costs. If you give people cheap food, offshore or mechanise most the physical jobs, and go into a service economy, then it is no surprise you end up with WALL-E level morbidly obese people.
There has also been a very successful class war going on in the US for decades to erode wages and increase profits, so poverty would be a huge issue where the minimum wage is already creating hunger problems. So this is certainly not ideal to implement on its own. But I wonder why no one is talking about something simple like evaluating the cost of food in household budget vs obesity rates between countries and regions.
So while not necessarily a good idea overall, but in terms of a narrow fixation on obesity...make food more expensive/reflect the real costs of production would make a lot of sense. I can't recall exact figured, but typical household budgets used to be something like 30% for food and it is now around 10% the US where farmers sell corn for less than it costs them to produce it due to subsidies which cause an entire market to operate at an internal loss. And farmers plant right up to the fence since there are no limits on several of these subsidies. It is odd how food policy and tens of billions of dollar spent to that affect is just 'out of scope' in obesity discussion. Is it power blindness or ignorance from decades of citizenry being powerless because corporations annexed the government?
Also with the corptocracy we have and the media amplified backlash against a simple tax in NY State on sugary drinks...it would be hard to pass legislation to alter current corruption money flows - but I think if we taxed processed foods based on their sugar content, then that'd make a big difference. If a soda cost $20 a can instead of less than $1, then people would drink less of it. We have no problem taxing cigarettes or other vices, sugar just needs to be reclassified as a vice and taxed into near oblivion. There is simply no valid reason an extremely obese society needs to sell small cans of bubbly acidic sugar water with 50g of sugar in them when tens or hundreds of billions of dollars in productivity, heath costs, etc. are being incurred.
The minimum food quality standards should be increased and simple things like caloric maximums in mass produced food or preposterous serving sizes need to be changed. Why wouldn't a big mac be half its current size? I recall research by those fast food places where they decided to go crazy on the calories in each order because most people are not willing to order 2 burgers and pay for 2 meals, but they will get fat and eat more if you make 1 burger twice as big.
This is just not part of the conversation taht just like social media companies profit from anger and division algos...fast food places for decades have weaponised and intentionally drive obesity up as their core profit model! It is simply a valid and legal business model to kill your customers! Why should a nation of laws and people tolerate these homicidal business models to sell cigarettes, high calories fast food, and horrible chemical industries of all kinds which have endangered the entire human race by lowering sperm counts, causing cancer, and making us sick in numerous ways?
Are extreme ownership and profit protection activities by our neo-aristocracy which is a death cult to be raised above all other possible consideration in the universe simply the correct and right way to live? The highest moral imperative is an Ayn Randian fixation on making already extremely wealthy people slightly richer or more powerful? Because it is hard to see it any other way when the government pays for a negative corn market used to make sugar to sell soda for under a dollar and everyone is obese and dying. Very profitable and you're very sick and dead!
> I'm rather surprised no one mentioned food subsidies and cheap food being part of the problem.
I think it's unlikely to be a major part of the problem. If it were, you'd expect rich people (for whom food is effectively even _cheaper_) to be fatter than poor people.
Or to put it another way, there's a "food price relative to income" vs "calories eaten per day" curve. At the "starving poor" end the curve bends quickly, but once you're making $10K+ per year it's pretty flat. Changing food prices or incomes might change the kind of food you eat, but not the amount of food you eat.
When fatness was a marker of high status, rich people *were* fatter.
But now thinness is a marker of high status, so rich people are thin - because those who would be inclined to fatness under other conditions can buy their way to thinness via various routes (personal trainers, personal chefs, medication, etc).
Also, poverty, especially poverty in the US (google 'food deserts'), places all kinds of restrictions on the kinds of foods you have access to - the available food is often cheap and plentiful but poorly balanced in terms of macronutrients and downright appalling in terms of micronutrients. Cheap food is often bad food.
>When fatness was a marker of high status, rich people *were* fatter.
Yes, but that's completely irrelevant. If virtually unlimited access to calories necessarily resulted in obesity, the rich would be at least as fat as the poor. They aren't, which means access to surplus calories per se cannot possibly be the cause of the difference.
>But now thinness is a marker of high status, so rich people are thin - because those who would be inclined to fatness under other conditions can buy their way to thinness via various routes (personal trainers, personal chefs, medication, etc).
Do you have any data /whatsoever/ susbtantiating your claim that personal trainers, perosnal chefs and medications explains the obesity gap between rich and poor?
The gap exists for people *nowhere near wealthy enough* to afford personal chefs, and most high income earners are not on weight loss medication. High income earners are leaner because they consume far fewer surplus calories.
Exercise is not an effective way of losing weight. The overwhelming reason people are overweight is because they consume too many calories, not because they don't have personal trainers. If you're exercising enough to make a serious dent in your caloric stores (which is very hard), your apetite is going to increase accordingly, and if obese people had good enough self control not to eat more when they're hungrier, they wouldn't be obese in the first place.
High income earners consume fewer calories, partly by eating less, partly by eating lower calorie foods, partly by eating a lower-sugar diet that doesn't inflate their apetite. Not from having "personal chefs" or by eating the same calories as fat people and then burning off thousands of calories at the gym (which would require *hours* of exercise per day).
>Also, poverty, especially poverty in the US (google 'food deserts'), places all kinds of restrictions on the kinds of foods you have access to - the available food is often cheap and plentiful but poorly balanced in terms of macronutrients and downright appalling in terms of micronutrients.
Yes yes, we've all heard about food deserts. The obvious reason why they exist is because *poor people don't but that kind of food* so shops stop stocking it.
Eggs, tuna, frozen brocolli, brown rice. All these things are dirt cheap and super nutritious. I practically lived on this kind of stuff through college. People don't eat this stuff because they prefer to eat tastier stuff.
Poor people eats LOTS of sugary foods. There's no reason for this other than their preferences. I'm not talking about non-dessert foods that have added sugar, I mean foods directly consumed for their sweetness like soda. Guzzling litres of soda a day is not something anyone does because they're too poor to do anything else to sustain themselves. This is a self-destructive, unnecessary behavior of their own choosing. It would cost them less to drink water. It would cost them no more to buy coke no sugar instead of coke.
And a lack of micronutrients does not explain the obesity ecidemic.
Michelle Obama tried to call attention to this problem, I believe she got significant push back from the lobbyists working for the major food manufactures. It would be nice if someone in DC with a large platform would pick up where she left off. More work needs to be done, and it’s most certainly a bipartisan issue. (This comment is not endorsing any party or individual. To me it’s simply good public policy.)
I'm not Scott, but from my perspective the tedium of at least the first two topics seems obvious; they consist entirely of arguments like this:
- Diet and exercise are extremely hard! If they were easy, everyone would do them!
- No they're not, you're just lazy!
- What about the 35% of Americans who are obese? Can every single one of them be wrong about their own internal experience of finding it difficult to lose weight? Are they all just lazy?
I'll make one last comment on my tangent but after this thread I promise to drop the subject forever.
Some other people in this thread have brought up the analogy between exercising and quitting addictive substances (cigarettes, alcohol, etc). I'll bring up another analogy: exercise and veganism. I will confess that I am not vegan or vegetarian even though I know on some level that eating meat is really really wrong, and whenever I've been proselytized to by vegans it's always made me upset in a way that I never felt upset at for bullying or homophobia directed at me. For the latter two, it's easier for me not to get angry because it's not something that bothers me about myself and I can feel a sense of moral or intellectual superiority to the aggressors. I wonder if the anger I feel from the former is similar to any anger that people felt reading my posts; if so, I apologize for that.
Part of my suggestion of opening state-run gyms or subsidizing gym memberships comes from what I would imagine it would take for me to go vegan. Right now I think it is a matter of convenience for me; it's hard to get enough protein for my needs on a vegan diet, and it would require more structured eating and shopping habits. Certainly if every restaurant had the same level of vegan options as meat options and meat substitutes were in more grocery stores and were cheaper or a similar price to meat I would have a much easier time going vegan. Just like in the example of exercise, there are some people that would be unable to go vegan no matter how convenient it is, and some people that aren't vegan for reasons other than convenience, but I still think that making veganism more convenient would result in more people going vegan.
Let us bear in mind, though, that doing stuff that isn't made easy for you, hacking your own path through the jungle of temptation, distraction, and assorted social headwinds is a major part of adulting. Only being able to do things when the road is made smooth for you is what it's like ot be a kid, where all the rest of adult society kind of looks out for you, helps you on the road.
When you reach adulthood, we kind of expect you to pull up your socks and get stuff done without needing someone to clear the path for you, indeed even if the path is overgrown or there are some people who stand in your way, on account of all the rest of us are pretty busy ourselves. There's actually no "society" out there that can take care of all of us, there's only ourselves, and if you have to take care of me and help me solve my problems as well as take care of yourself and solve your own problems, that's rather a burden.
I guess I'm not sure I buy into this analogy. Exercise really doesn't require much inconvenience in comparison to veganism, if you're only requiring the basics. There are huge health benefits just from 30 minutes of daily walking and some simple bodyweight exercises for strength.
That said, I do believe everyone should lift weights, and in this case I think the veganism analogy is apt. I sometimes see parks with exercise machines--basically free gyms--and would like to see more of that. I'd also like to see physical education improved: it seems like almost no one except fitness enthusiasts have any idea what to do with weights.
Re: stimulants and weight loss, this describes my own experience... kinda. I was not obese, but I was overweight, with noticeable amounts of visceral fat. Then I was put on 16mg of Concerta (ER Ritalin) daily. I found that, by concentrating my hunger (i.e. cutting down on snacking) I was better able to plan ahead and therefore eat healthier overall. I was also able to use the energy and willpower from the meds to start working out more regularly. As such, my scale weight didn't drop much at all, but my body composition noticeably shifted to much lower body fat and much higher muscle mass. For obese people, I imagine this might not work out as well for obvious reasons, but I can definitely see where the idea comes from.
I find the emphasis on weight so... limiting. Only a few place emphasis on metabolic indicators you might measure with bloodwork, and about zero people place emphasis on the body's ability to work: strength, flexibility, and endurance.
I don't care if I have a high BMI or a low BMI, I care if I can pick up more weight than I could last week. I have never been able to stay on a diet to save my life (literally), but I have been able to stay on a diet design to increase muscle mass - eating for the purpose 'lose weight' was always a failure, eating for the purpose 'bulk up and recover from exercise' has been one of the easiest things (it does help that diet is heavy on protein - H.E.A.V.Y. 1g protein per 1 lb body weight per day). My focus has been on body composition (muscle vs fat) not amount of fat.
I just believe based on my experience the answer to 'why not just diet and exercise' is few people have exercise goals but have a weight/BMI goal that translates into calorie restriction which translates into failure for a variety of reasons. Exercise might become a part of that, but it is secondary to the weight goal - I exercise because I want to weigh less or get rid of that double chin. Instead, I suspect if people started with a physical performance goal (I want to bench press my body weight, I want to deadlift 2x my body weight, I want to run a marathon) that would lead to diet and other physical forms of recovery and self care with far greater success and compliance.
I'd love to take 100 high BMI people and task then with lowering their BMI, and 100 high BMI people and task then with a physical performance goal (like deadlift or a marathon) and see which group over time has great success in achieving their goal. In my head group A is 'You wear an XL or XXL shirt; your goal is to go down a shirt size' and group B is 'You wear a XL or XXL shirt, your goal is to go up a shirt size and deadlift your body weight' and I'd bet money more of group B achieves their goal and group B is healthier across a broad range of metabolic measures and outcomes.
Weight can be measured directly, and reducing weight tends to reduce other metabolic factors associated with disease and is easier to reduce than those things directly.
Exercise is not and CANNOT be the foundation of weight loss. You simply do not burn enough calories with even intense exercise for it to make the differencee, and obese people cannot generally perform intense exercise. Walking for 45 minutes per day (vastly more exercise than the average obese person does) is equivalent to burning the calories in 1 can of coke. Small diet modifications absolutely dwarf the impact that exercise can have. And that ignores the fact that exercise usually increases appetite! If obese people could resist hunger, they wouldn't be obese, so exercise is going to be especially ineffective.
It sounds like the ideal diet drug would be one that targets your set point weight directly. If you could change that like a dial, you could rely more on your own body's weigh management mechanisms to burn off the extra weight. Also, since set point appears to be something that generally stays static, if a drug could move it, perhaps you would only need to take it for a short period and the impact would last. Perhaps this approach could "cure" obesity.
I hope someone is studying the biological mechanisms that underlie the set point weight, and how to intervene in them.
Interesting wrt to the tiredness comment, since I remember a lot of SMTM potato study participants reported similar effects (not any overall lethargy, but sleeping many more hours).
Saturday's Wall Street Journal: "Why You Can’t Find Wegovy, the Weight-Loss Drug: Novo Nordisk underestimated demand for drug that went viral on TikTok and YouTube: by Peter Loftus and Denise Roland
Focuses, as one might expect from the Wall Street Journal, on the impact shortages are having on Novo Nordisk's business .
On a practical level, in the first Quarter of 2022, there were a few occasions on which I had to go around to several pharmacies to refill my prescription. By summer, that issue had gone away and I have had no problems getting refills on request. I do not know what is happening outside of my hometown or in foreign countries.
Price:
I think Scott wrote that the price per milligram of Ozempic and Wegovy, which are both injectable forms of semaglutide, is the same. My doctor and I are discussing switching me from Wegovy 2.4 mg to Ozempic 2 mg as a maintenance dose. The prices in my area of the two formulations (both manufactured by Novov Nordisk) are given in the following tables derived from GoodRx*.
Ozempic 2 mg × 4:
CVS Pharmacy retail: $1,053; with GoodRx coupon: $922.50.
Walgreens retail: $1,070; with GoodRx coupon: $928.35.
Meijer Pharmacy retail: $1,083; with Good Rx coupon: $886.18.
Wegovy 2.4 mg × 4:
CVS Pharmacy: retail $1,590; with GoodRx coupon: $1,391.34.
Walgreens retail: $1,619; with GoodRx coupon: $1,399.94.
Meijer Pharmacy: retail $1,637: with GoodRx coupon: $1,327.44.
Note that the most important non price difference between the two formulations other than amount of the drug per dose, is that Ozempic comes in a single four dose pen and Wegovy comes as four separate pens.
Also note that WSJ article says: "Novo lists Wegovy at $1,349 a month", but that is not the list price used by any of the pharmacies surveyed by GoodRx.
For those of you who are unfamiliar with the US or the Great Lakes area retail merchants, CVS and Walgreens are both nationwide pharmacy chains. Meijer is a regional competitor to Wal*Mart and Target.
The two formulations do have different prices per milligram. Note that the cheapest Wegovy per mg is more expensive than the most expensive Ozempic per mg.
Per mg (highest -- lowest)
Ozempic $135.38 -- $110.77
Wegovy $177.93 -- $144.29
Further research reveals that both formulations are priced without reference to dosage. The 0.5 mg pens are priced the same as the 2 or 2.4 mg pens.
*If you buy drugs in the US and have to pay cash or have large deductibles or co-pays, GoodRx.com is valuable. They provide price information for most prescription medicines used in the US. they also have free coupons that get discounts on cash payments. It is accessible via web browsers and by phone apps.
CoverMyMeds' software automates the prior authorization process used by some health insurance companies in the United States, helping to save time and eliminate paperwork. Traditionally, prior authorization required phone calls and faxes between multiple parties; CoverMyMeds circumvents this by automating the process. Involved parties are able to view the status of the authorization as it progresses.
America's hispanic population is expected to increase significantly by 2050. Hispanic americans are very fat and are probably less able/inclined to get bariatric surgery or expensive weight loss pills, so this should cause one to update downwards at least a bit on the probability of obesity halving.
Glp1 agonists reduce the liver’s production of glucose, so although these drugs might have an acute insulin effect, the net effect over time is less basal insulin needed from the “savings” from less liver glucose. Leptin works partially by interacting with and releasing GLP1 so more GLP1 is likely a positive thing with regards to leptin functioning. If one is deficient in leptin, which anyone will be if weight reduced, there’s less leptin to release glp1, so supplementing glp1 is a pretty effective way of bypassing the lack of leptin.
Regarding #3 (Other Weight Loss Drugs), there are small molecule GLP1R agonists in development (there are many, many patents), and I imagine they'll replace semaglutide/Wegovy if they make it through the clinic. Novo has been struggling for a decade to make adequate amounts of semaglutide, but the small molecules can be made by the ton. So, wait 5 years and see where we are.
If you search, you can order Ozempic at a very low price in Canadian online pharmacies, and many give a discount on the first order, for example, 5% off on the Insulin.store website.
There are some reports that buprenorphone causes weight loss (along with the other opiates). Of course, that wouldn't be a legal way to prescribe it and I can't imagine it's worth the dependence but I suspect it works (both from personal experience and some remarks online). Still, hard to tell since almost everyone using it is either shifting from opiates w/o a ceiling or abusing it so the effect could fade but I suspect there is some long term effect.
I just mention this for completeness as using it for weight loss seems kinda crazy.
This is interesting. I wonder how much eating is initiated by pain. I've noticed that pain sometimes causes me to want to eat...and sometimes to eat. (And by pain I'm not exactly talking about hunger. It's something else. Sometimes I experience it right after a meal that I know should be sufficient.)
So...is ibuprofen associated with weight loss? Aspirin? (I don't count acetaminophen, because that has almost no effect on me.)
Did you mean to write this or its opposite (i.e. “weight *loss*”)?
>I prescribe a lot of people stimulants for ADHD, and my experience is that they rarely get any useful amount of weight gain.
You're right, sorry, fixed.
Regarding costs to the medical system it occurs to me that an effective weight loss medication might increase costs even more via the indirect effect of enabling people to live longer.
Maybe it won't be of the same order of magnitude but I remember going through the numbers during the tobacco lawsuits and the claim that smoking increased the burden on state medical systems was complete bunk once you adjusted for the cost savings as a result of early death. Of course, those states likely lost tax revenue as a result but that too may have been offset by pension/etc savings.
Don't get me wrong, I don't have any sympathy for the tobacco companies in this case but morally speaking the states deserved almost none of that money but they got it rather than the smokers.
To put my 2¢ in, I'm a big believer—from personal experience, seeing others' results, Internet testimonials (least reliable, obviously), and reasoning, in the #Whole30, which is a Paleo-inspired elimination diet. I've never been able to sustain weight loss for months and months before. I think it goes to the heart of our obesity epidemic (and have some evolutionary theories as to why it works).
The more I look into it the more weight loss diet efficacy looks a lot like antidepressant efficacy-- you can find lots of anecdotes of people saying "x diet or y antidepressant saved my life", but when you assign people to x diet or y antidepressant in RCTs you get results only marginally better than placebo.
Why's that? Hell if I know.
Reporting bias. If you feel motivated and accomplished enough to actually stick with any good diet/exercise routine for a long period it will probably produce results, which you'll be happy to brag about. If you half ass it and give up after a week then you probably won't remember the name let alone be in a situation where your opinion about it solicited.
However, an RCT naturally captures both the minority of people who use as intended and the minority who lack the willpower/self control to stick with it consistently enough to do anything.
This doesn't mean the RCTs are flawed, they just look at a very different question from the program designers; will this impact the average person who does day 1 vs. will this impact somebody who does day 1 all the way to the end 100% consistently.
Well, and it’s not just that some are more motivated, it’s that the diet works better for some and those are the ones who stick to it.
Any elimination diet, no matter how crazy, predictably works for some.
Jacob is right. However, despite that, I would predict—to the point of betting reasonable money on it—that the Whole30 would get good results in a well-designed RCT.
Of course, I’d also be interested in seeing sub-portions of a good RCT on this; i.e. how people did who actually stuck with various regimes, and also how many people stopped after X time.
I think there's a couple things going on with the variance of diet efficacy.
One, people's appetites vary a lot, and different people will find it necessary to cut calories in different places. I can't overeat cake, so I don't need a diet to tell me not to eat cake. On the other hand, I instantly get full when eating potatoes, so it's a great diet food for me; that trick might not work for others.
Two, there's a potential "placebo effect" where simply believing in a diet leads to its success. Someone who genuinely believes in a diet will be more motivated to stick to it, and that'll make it more effective. With this perspective, the idea of "fad" diets makes a lot of sense: people believe that what's popular must work, so they will try their best to make it work, and then it works (for a while, anyway).
Among common foods potatoes were found to have the highest satiety per calorie, so they are generally very good for most people trying to cut calories.
>but when you assign people to x diet or y antidepressant in RCTs you get results only marginally better than placebo.
Half of the antidepressant issue is that placebo is very effective against depression. So if you do a placebo trial of mildly-depressed people who're 96% or whatever cured by placebo, there's just plain not much room for a drug to do better.
The other half is that SSRIs aren't a huge amount better than placebo. This is an *SSRI* problem, not an *antidepressant* problem; Scott wrote a whole post on this (https://slatestarcodex.com/2015/04/30/prescriptions-paradoxes-and-perversities/) and outright calls MAOIs "excellent" (at least in terms of antidepressant action; there are reasons they're not a first-line treatment, such as "fatal drug/drug and drug/food interactions"); tricyclics/tetracyclics are also generally acknowledged as Doing Something.
I lost a lot of weight (now BMI 22), and have kept it off, doing my own weird diet and exercise routine. I feel like most diets can work if you basically follow them obsessively and stick to them long term. But any diet can fail if you have people around you who aren't following it and are pressuring you via social eating, or worse, don't respect the idea that you want to lose weight. Nearly every person in my life now routinely comments to me that I am "too skinny" (and except for one they are all significantly overweight).
Following any diet and exercising is hard enough but when you add in social pressures I can see why its just too much for many people. Since the US obesity problem is so bad I'm in favor of meds, surgery or whatever it takes to help solve it.
What is your weird diet?
Well I am sure it would drive most people insane but here goes: unsweetened oatmeal with frozen fruit every day for breakfast. Unsweetened soy milk or 1% milk with that. White bread with olive oil or peanut butter. Steamed frozen vegetables with olive oil, salt pepper. Frozen ravioli (3 or 4) pieces a couple days a week. 3 canned soups per week. One frozen pizza per week. 1 chocolate bar per week. 1 6 pack of beer per week (no other alcohol except on special occasions). Oranges, bananas, apples. Yogurt sometimes. Canned salmon/mackerel/chicken sometimes. No red meat, pork, or butter. Dozen eggs every few weeks. Plain microwave popcorn rarely. Copious amounts of unsweetened green tea. Almost zero restaurant food. If I had a late lunch I skip dinner and just eat fruit every couple hours those nights. Some random fresh vegetables now and then, I just got some asparagus which I am excited about.
I try to avoid all seed oils as well, for instance the bread I buy doesn't have them, but its hard to avoid in the pizza and soup.
Biggest problem is that its low protein and I'm trying to fix that with beans or something but haven't yet found something I like. Overall the diet is probably too restrictive. I hang out with my parents every few weeks and eat too much with them, including a bunch of tasty garbage snack food they buy, but if it wasn't for that I'd probably be underweight. A side bonus is before I started I had bad GERD and had to take two potent prescription anti-acids every day, now I take that only as needed, a few times a week max, and its just OTC stuff.
For exercise I just walk mostly now, 10-12 miles a week 3-3.5 MPH. In the beginning I walked a lot more.
Fascinating. Thanks for sharing. That’s what I often eat for breakfast and I also love green tea. I’m not gaining weight, I’m basically maintaining, but I’ve always been too chunky so dropping weight seems to be my struggle. I work out daily, in different ways, but I think restaurants are my downfall. Just going to a restaurant once a week basically keeps you fat...
Restaurant food is definitely a calorie bomb but with all the inflation they seem to be reducing portion sizes, at least in my area.
In the early days of my diet, my weight loss seemed annoyingly slow, so after working out at the gym I would go for a long walk too, though at a slow pace, since I was tired. It ended up being 4+ hours where I wasn't eating anything and was exercising. Of course that is a big time commitment, so hard for a lot of people, but it did help. Now fortunately I don't need to put all that time into it to maintain my weight.
I find it helps to plan on taking home half my meal (or splitting a meal with someone if I am not going to be in a position to take home leftovers). I don't always succeed, but starting the meal with that intention makes it easier to check in with myself halfway through, realize I'm not that hungry any more, and save the rest to look forward to later.
Any diet will work given caloric deficit
A quick google search shows whole30 isn't a diet but a nutritional plan, so it's possible to gain weight on it - but honestly if people ate that way they'd feel way better generally and be able to lose weight more easily regardless of it happens automatically or not
"if people ate that way they'd feel way better generally and be able to lose weight more easily regardless of it happens automatically or not"
And if my grandmother had balls she would be my grandfather.
The point is that diets aren't equivalent even if htey prescribe equal calories. A diet that has foods that give you energy and don't make you hungry all the time is one people will stick to better.
Caloric deficits don't cause you to lose weight, because fat isn't the summed delta of calories-in and calories out, just like your retirement account isn't the summed delta of "income" and "spending."
I'm not sure how Adam is getting his $120 for a two month supply figure. Peptide Sciences is offering 3mg/$120, and Biotech Peptides is offering 3mg/$114. That's more like $120 for a *one week* supply.
Sorting comments by topic is awesome, but also a lot of work. I wonder if there's a good way to delegate it or crowd source it.
I started thinking about allowing tags on comments, where the blog owner specifies a few tags for a post and then their commenters can use only those tags. But a) I don't like suggesting additional features for Substack comments until they get their performance issues under control, and b) I suppose that wouldn't really help for this particular case, which sounds like the blog owner noticing post facto (post post?) that a number of comments on a particular post tend to fall into a few distinct buckets.
I feel super lucky after reading these comments after how much people have been paying. I have just a standard issue HDHP through work (Anthem/Blue Cross Blue Shield in NY). Typically the full $2,000 deductible each year is paid by Gilead's savings program when I get my first Descovy for PreP prescription filled in January, so I just end up with regular co-pays after that. The co-pay for Wegovy has been $60, and that's reduced to $25 with a savings card (and I pay the $25 with a FSA card, so the after-tax cost to me is only like ~$150/year).
I think one reason a lot of eligible people might not take this drug is that insurance requires preapproval, and most doctors either genuinely think you won't be approved or will tell you that you won't because they don't want to deal with the hassle. My doctor has a strong interest in obesity issues and was very enthusiastic about the drug when I asked about it, but initially he told me it wouldn't be covered by insurance. I came armed with the preapproval criteria published on my insurer's web site, which as I showed him were quite lax (>30 BMI to start, >25 BMI required for renewal, and must be on a diet/exercise program as well). Ultimately, he prescribed Ozempic to avoid the preapproval hassle, but he agreed to try for preapproval with Wegovy once there was a nationwide shortage of Ozempic and my pharmacy couldn't fill a renewal for a while. We had no difficulty getting approval once we actually tried. It seems the insurer requires preapproval to scare doctors from even trying -- and most of the time, that works!
In terms of efficacy, I've lost more than 20 pounds (>10% of my starting weight) over the past 8 months and definitely and still in a groove of losing, but I do think you need to diet and exercise and complement the effects of the drug. If you can be somewhat disciplined about dieting, the drug will help a lot by making you not hungry even though you're on a calorie-restricted diet where you'd otherwise be rummaging through the fridge. But you won't see nearly as much progress if you don't actively track what you're eating at least part of the time and try to hit a reasonable calorie goal. Early on, I wasn't doing any dieting and the drug kept my weight stable (after I period when I had been gaining) but I didn't really lose anything until I decided to get more serious about tracking calories, working out 5-6 days a week, etc. It's made that effort much more impactful, I think.
Thanks, Scott, for the table of contents. Makes it easier to navigate long posts
Wait, bariatric surgery is that safe? I was just told yesterday by a surgeon that I ought to have my gallbladder removed after a quick referral process and an ultrasound from telling my PCP I had some mild pain in my gallbladder area. And he was like, all the complications are highly manageable, and are less than 1% each. This is a really significant update on my understanding.
Man, I really wish this stuff had been around ten years ago, two of my family members might still be alive and happier than I ever knew them to be if they'd been able to lose weight.
I strongly considered bariatric surgery back in 2019-ish (I went to like 10 weeks of classes at Kaiser), but I ended up not doing to because there are a lot of really hard and fast rules that govern what you can and cannot eat afterwards for the rest of your life. As someone who is quite fat but also perfectly healthy, and who truly does adore food, this was a deal-breaker for me.
I never considered the surgery. The risks of going under general anesthesia and failure are just to high. I have seen too many surgeries go badly on close family members to be happy about that idea.
A cholecystectomy is a very standard procedure, and basic abdominal surgery, but I am surprised that your surgeon told you all the complications are highly manageable. (That would seem to increase his legal liability unnecessarily.) The gall bladder is close to some large blood vessels and accidentally damaging them is life threatening. Also damaging the bile ducts can lead to significant problems. Any surgery involves the possibility of infection or problems under anestesia. (My purpose isn't to frighten you, I wouldn't be particularly nervous about a cholecystectomy, but it's not a trivial operation.)
Matt Yglesias recently reported that he got a newish kind of bariatric surgery that goes in down the throat. It sounded like regular sleeve gastrectomy, except without any incisions. He said recovery was (relatively) easy.
He also said he was gaining weight on it, so between the possibility that it doesn't work and the guarantee that you can never eat regular-people food ever again, it just doesn't seem worth it.
A couple of decades ago I looked into bariatric surgery. I *do* need to lose weight, but the number of suicides after the surgery was quite discouraging. There were also reports of a lot of other psychological problems and personality changes, so I decided to skip it. It would be really nice to lose weight, but not at the cost of killing myself or turning into somebody else.
I think maybe you should review the more recent literature. The population getting the surgery now might be very different. The moralistic garbage essays ("you'll just become addicted to something else! You'll just kill yourself!" etc.) have died down now. The surgery is much easier than it was a couple of decades ago, too. Just a suggestion to review the more recent literature.
These days I'm a couple of decades older, so surgery is a lot more dangerous.
"I prescribe a lot of people stimulants for ADHD, and my experience is that they rarely get any useful amount of weight gain."
Could this be in part that if the stimulants you prescribe are actually treating ADHD, they are causing your patients to sit still more and thus expend fewer calories?
The singular of “data” *absolutely is* “anecdote”, and the inverted version of that quote originally said “is” rather than “is not”. n = 1000 really is just a bunch of n = 1s!
Here’s my n = 1 on this topic: Metformin caused embarrassingly terrible stomach issues (for years, before a doctor who didn’t just go “of course the fat guy has a bunch of problems!” finally put two and two together). Ozempic injected abdominally caused random occasional throwing up. Mounjaro injected in the thigh is going well, assuming my current extreme fatigue is me getting over the COVID I had last week and not the meds; I’m currently worried to see several mentions of tiredness here.
(Very mildly worried; I am 95% certain my issue is the COVID, and most of the remaining 5% also has nothing to do with the Mounjaro)
The plural of 'anecdote' is 'data with a massive selection bias'.
Regarding the "savings cards should be illegal", something similar from my history:
I have Crohn's disease and was initially treated with Remicade, which is expensive: like four-to-five digit price tag expensive. This turns out to be a bad thing for getting people to actually use your drug, so the manufacturers solution is a "rebate program". As I understand it it works like:
1. You get billed for the drug
2. Insurance negotiates the price down, pays whatever, charges you the copay/deductible
3. You pay insurance with a rebate card (essentially a debit/credit card) the manufacturer gives you as part of the program. Essentially the manufacturer is "paying themselves".
I, of course, appreciate a mechanism by which I don't pay thousands of dollars for a medicine I basically need to keep a chronic illness under control... but based on my (limited) understanding, it's hard not to see this sort of thing as essentially a scam against insurance: it seems like the patient and manufacturer conspire so that the insurance is the only one who ends up paying anything for the medicine, and the manufacturer can charge basically whatever they like for it.
On the one hand, yes, that's exactly what it is.
On the other hand, the insurer makes up that cost by raising premiums, and the higher spending actually *increases* their profit ceiling. Insurers are required to spend 80% of premiums on medical claims, leaving 20% for overhead and profit; more spending + unchanged overhead = more potential profit. So it's important not to see the insurer as a victim here.
The actual 'victims' of this 'scam' are people who have insurance but are not taking advantage of rebate programs, usually either because they don't need covered drugs or because they're not eligible (usually because their income is too high). So this is *mostly* health insurance working as intended (redistributing costs from poor and/or sick people to healthy and/or rich people). It's not the ideal way to do this, but it's an important workaround for the problem of cost-sharing formulas not being as income-sensitive as they should be.
It does have the added effect of raising the ceiling on prescription drug prices by eliminating consumer price sensitivity, which is mostly bad. But the solution of banning rebate programs has significant human costs which would be borne mostly by lower-middle-income patients. The ideal solution would be to first index copay/coinsurance rates to income in a more fine-grained way than the current 3-tier system, and then ban rebates.
>So this is *mostly* health insurance working as intended (redistributing costs from poor and/or sick people to healthy and/or rich people). It's not the ideal way to do this, but it's an important workaround for the problem of cost-sharing formulas not being as income-sensitive as they should be.
Insurance should be about collectivising risk, not redistribution. And its conflation with redistributive social programs is one of the main problems with the US system.
>Insurance should be about collectivising risk
In principle, yes, but that just means the insurance model is a bad fit for healthcare. If you're going to force fit healthcare into the insurance model (and you're unwilling to just let poor people suffer), you're going to have to carve out some pathways for redistribution, and this is one of them.
Insurance plans in the US are fairly heavily stratified by income, though, so most of the cost redistribution within a given insurance plan is sick -> healthy (i.e. risk collectivisation) rather than poor -> rich.
I would rather they just be done under separate steams so it is clear. And the “sick>healthy” would be a lot less falling if the risk was pooled before people are one or the other.
> Sorry, I’m still not understanding this. Usualy weight loss dose of Wegovy is 2.4 mg per week = ~10 mg per month. The best I can find on CanShipMeds is 1 mg pens for $300. Doesn’t that suggest you’d need ten of those = $3000 per month? Or am I misunderstanding and that’s supposed to be the price for a month’s worth of 1 mg pens?
Sorry! I was referring to the Rybelsus. You can get 30 14mg tabs for $300. My understanding was that 14mg orally approximately equivalent to 2.4mg injected, but I could be wrong about that.
Thanks. I'm concerned because I can't find any good comparisons of oral vs. injected blood levels, and also pharma companies are usually too smart to leave obvious loopholes like this. I'll see if I can find more information.
"Or am I misunderstanding and that’s supposed to be the price for a month’s worth of 1 mg pens?"
Looking up the dosing guide:
https://www.drugs.com/medical-answers/many-doses-ozempic-pen-3543050/
"A carton that contains one pen with 2 mg/1.5 mL of Ozempic. This pen delivers 4 weekly doses of 0.25 mg plus 2 weekly doses of 0.5 mg per injection OR 4 weekly doses of 0.5 mg per injection. The carton also contains 6 NovoFine Plus needles. This pen is intended for treatment initiation at the 0.25 mg dose and maintenance treatment at the 0.5 mg dose. The pen delivers 4 doses of the 0.25 mg and 2 doses of the 0.5 mg strength. It can also deliver 4 doses of the 0.5 mg strength."
That's the pen for $300 on CanShipMeds. It's the starter dosage: 0.25 mg for 4 weeks. or going up to 0.5mg for 4 weeks. So one pen would last a month at the maintenance dosage of 0.5mg per week.
"Start at 0.25 mg once per week for the first 4 weeks. You start with a lower dose to help your body adjust to the medicine, but the 0.25 mg once per week dose is not effective in lowering your blood sugar over the long-term.
At Week 5, your doctor will increase the dose to 0.5 mg once a week. If, after at least 4 weeks on the 0.5 mg dose, you need further blood sugar control, your doctor may increase your dose to 1 mg once a week. There is a separate pen for this dose and you will need a new prescription.
If additional blood sugar control is needed, your doctor may increase the dose to 2 mg once weekly after at least 4 weeks on the 1 mg dose. There is also a separate pen for this dose."
That's this pen: Ozempic® 4mg/3ml from Canada
That is the 1mg once a week dose for 4 weeks. Both of them cost $300 (US). So yeah, the $300 is for a month's supply.
>I prescribe a lot of people stimulants for ADHD, and my experience is that they rarely get any useful amount of weight gain.
I’m very surprised by this; I’m down 10% just from the minimum dose of provigil (side effect) after 3 months.
Just a small note, but for the Canadian Ozempic, the "1 mg pens" are four doses of 1mg ("Ozempic® 4mg/3ml from Canada".)
It's interesting that the 4mg and 2mg pens cost the exact same amount. The 2mg pens are the "introductory" version that last six weeks instead of four--you take 0.25mg/week for four weeks, then 0.5mg/week for two weeks.
So thankful that you’re covering this in depth. Fascinating.
Has anyone figured out what the best insurance would be for covering Wegovy? I’m looking to buy new insurance anyway (self-employed/business owner) and would love to find one that would cover this treatment.
Sounds like at least one person is recommending Anthem/blue cross, but I wonder which plan?
The only other drug I know of that is used for weight loss successfully is Clen. https://www.webmd.com/pain-management/what-you-need-to-know-about-clenbuterol-for-bodybuilding it appears to be extremely effective, It's a 30% improvement over diet/exercise alone. Clen is also illegal to buy so you need to find some sketchy russian pharma company to get it to you.
What makes Clen not an attractive option? Near as I can tell it's actually less dangerous than some other drugs I actually already take, and it fights perhaps the worst disease in america.
T3+T4 is as effective as Clen and far less unpleasant. Possibly more risky though. Clen, even at extremely low doses makes me (and most people I know who've tried it) super jittery.
I know of a company with a drug in clinical trials that causes weight loss faster and potentially larger than semaglutide and using a completely different mechanism that on theoretical grounds should be strongly synergistic with GLP-1 agonists. That company already applied for a patent on obesity treatment using a combination of GLP-1 and their therapeutic class. As they say, this changes everything! :)
I think that, as strange as it may seem from an observation of the American public at large, obesity has moved into the "solved medical research problem" category and all that remains is deployment.
Anecdotally, roughly one third of the female NPs at my ER are on semaglutide or equivalent drugs, and that's just the ones that told me about it. None of them are diabetic and they were not obese either, more like chunky. They report quite dramatic weight loss and, yes, many women working in the ED do appear quite a lot thinner than last year.
I expect that these and upcoming weight loss drugs will be much more widely used than you expect: Only the conscientious and the health freaks pay attention to e.g. their blood pressure, since hypertension is the silent killer that doesn't hurt until it's too late, so rates of compliance with treatment are modest. In contrast, obesity massively hurts people's love lives, and this creates a whole new level of urgency to obtain and conscientiously use the drugs that solve this problem.
I expect that in the next ten years Americans will collectively lose hundreds of thousands of tons of fat. There will be a tectonic shift in the dating market, which will be inundated by millions of lithe females and toned chads, fresh out of the weight loss clinic.
A new, gloriously thin future awaits!
A practical note on cheaper access to the drugs: There is one little trick obvious to anybody with a syringe that could reduce your cost of e.g. Mounjaro ($994 per month without insurance at Amazon Pharmacy) by a factor of six. I will not explain the trick because it could be construed as providing medical advice but, you know, it's obvious if you think about it for a moment.
I think the shortage is affecting Canadian supplies and prices. While I was waiting for insurance approval, which mercifully came through, I got my Ozempic from Mark's Marine. The other popular Canadian pharmacy for U.S. residents is Candian Insulin. In early 2022, you could get a 4mg pen for $300. Yes, it's true, that doesn't get you to the full Wegovy dosage. It just gets you 1mg per week, which works well for me and for many others. But now when I check those sources, they don't appear to have the 4mg pens available right now.
This is a pain, but Novo Nordisk knows which side its balance sheet is buttered on, and I have confidence that they'll manage to ramp up production. That should make the larger pens available in the next year or so.
This weight loss discussion has been very distressing to me because I went from just shy of 250 lbs in February to 160 lbs today through diet and exercise, and apparently I'm a freak who will inevitably put the weight back on. I think it worked because:
1. I live alone and cook only for myself so I basically have total control of my own diet most of the time. And I got really into breaking down the calorie count on every meal, weighing all the ingredients, calculating how many calories they are, then dividing that by the weight of the finished product for a calorie/gram total.
2. I used a calorie counter app and kitchen scale and got obsessed with tracking every calorie against my daily allowed total. It became sort of like a game where I had to pack all the food I wanted into the allowance + exercise total. At first this meant being hungry a lot, but gradually my diet shifted to lower calorie foods as I got "rewarded" for them by feeling fuller after eating them. I generally always have a bowl of salad in the fridge, because it fills out meals at basically no calories.
3. I discovered the secret of exercise is the treadmill incline. I am just incapable of keeping up running speeds for long periods of time, but it turns out I can easily push through very high inclines at anything below 4 mph. So I go slow(er) but really crank up the incline on an interval setting, and without my body constantly jerking up and down I can read books on my phone. If I'm reading while exercising, it's not boring at all, but the higher incline still lets me burn a lot of calories.
I'm pretty hopeful that even if I slack off and start putting the weight back on it will take a few years, and maybe I can achieve some kind of yoyo effect where I diet for six months, let the weight creep back up by a few dozen pounds, rinse and repeat. Though wow, I do miss ice cream a lot.
Your system worked well for you. Maybe you can use some modified version for maintaining it, like
-same diet but with slightly increased calories. Increase calorie count slowly til you find the point where you maintain.
-Pick a weight that's 5 lbs more than weight you want to keep, and every time you hit it go back to the original diet for a couple of weeks
-Have one day/week when you can eat what you like, but some mild restrictions (like no more than one serving of ice cream)
Also, frozen bananas actually are sort of like ice cream. They are sweet, and the thick starchiness of the banana, when frozen, is a reasonable stand-in for the creamy thickness of ice cream. Let the banana ripen first then put it in the freezer with skin still on.
It is not at all clear to me how an incline treadmill causes you to burn more calories. Clearly, you could place a bicycle wheel on it with any amount of weight and there would be no effort required to keep it stationary. So, biking on an incline "treadmill" requires no additional energy vs. biking on a flat "treadmill".
Possibly, when walking, your speed is non-constant enough that during the slow part of the gait, your vertical position in space is lowered and you have to recover this during the quicker part of your gait? It seems that if you were running your speed would be close enough to constant that the incline would mostly just change which muscles you use (by changing the angle of your foot).
Huh? Walking uphill and biking uphill definitely demand more energy than doing same on level ground. Life experience demonstrates this -- you get tired and out of breath going uphill at pace that would not affect you that way on level ground. And the physics of the situation explain why: Altitude gain = fighting the force of gravity with the force of your body.
Try it and let us know what you find out.
I would guess it's because of the different levels of exertion required by two groups of muscles: the big "power" muscles, like your quadriceps, and the small "positioning" muscles, like the little guys that position your knee and hip correctly for the impact when you are walking or running.
There are certain forms of exercise that make more use of the little guys: exercise that is fast, not super effortful, with a lot of body motion. Walking is actually one of those: there's a lot of motion, relative to the actual effort required by the big muscles. So is stuff like some forms of dance, or ice skating. On the other hand, there are forms of exercise that use the big muscles more than the little guys: exercise that is slower, very effortful, and where body motion is less, or constrained by some external force so positioning is less critical. Riding a bike, using a weight machine, swimming. Running and gymnastics and some kinds of dance probably use both pretty heavily.
What I would guess is that if you're doing something where the positioning/effort ratio is higher, your perceived level of effort has a larger component from the little muscles, which tire faster, while if the positioning/effort ratio is lower, your perceived level of effort has a larger component from the bigger muscles, which can do more before tiring. That would mean for the same level of perceived effort, you are actually able to burn more calories with the lower positioning/effort ratio exercise. Hence, walking uphill versus downhill, riding a bike uphill versus level, hockey versus figure skating, using a weight machine versus free weights.
Placing a bicycle wheel on an incline requires force to keep it from rolling down. When muscles apply force--regardless of whether work (force x distance) is done--they burn calories. If you actually try an incline treadmill, you will quickly confirm your muscles need to use more force to sustain the same speed as a flat treadmill.
For what it's worth, I believe it's common but not universal to regain lost weight, and sometimes to regain weight plus more.
I have the fat gene, but maintain a relatively low (perhaps even "thin") weight. Here are some of the tricks I need to play in order to make this happen:
When I go out to eat with a group, I tell everyone at the table I already ate. Then order something small. If I must order something large while out to eat, I try to identify someone else who seems health conscious and ask if they'll split the big thing (burger, for example) with me. If I must order large, cannot split with anyone, I ask for a to-go box immediately upon receiving food, and put half of my food in the to-go container for later.
Constantly make it a game with the others around me to eat less or more healthy. Gamify everything you can here. It makes it less like: "Stop eating like shit and be more like me" and more like "Hey let's do this fun healthy skinny thing together!"
When eating alone, I do pretty much like you. Make it a game. Can I eat less? Can I just skip eating now even though I'm hungry? Can I just put off eating for 30 minutes? Now that I must eat because I'm hungry, and I want an entire bowl of X, can I instead just eat three bites of X then stop (the answer is "yes" surprisingly often)?
Constantly drink water. Say I want to eat chocolate cake. I want a big slice. Instead get a small slice. Promise myself if I really want more, I can get more. Put the rest of the cake away so now I only have my small slice. Take a tiny bite of my small slice of cake. Savour it. Drink a giant bunch of water. Lick the fork clean. Drink more water. Feel any leftover crumbs of cake in my mouth/teeth. Taste those. Drink more water. Is mouth completely cleansed of all bite #1 of chocolate cake? Yes? Cool. Now take my second bite of the slice of cake. Repeat. Once done, if not hungry/craving awfully, don't have more, promise yourself you can have more in a couple hours if you're still craving.
Out to eat with friends, and they insist on getting three desserts for the table? Do the water routine from above with your share, and take the rest to go in your to-go box.
When someone gives me a bunch of delicious (but awful) food like candy or cake as a gift: eat a little. Do the water routine from above. Feel free to ham up the water routine or offer to have them do the water routine with you. Thank them profusely. Be gracious and grateful. When they no longer can see (have gone home?) throw the rest of it out in a fashion I cannot possibly retrieve it, like put it in the toilet, or with disgusting garbage.
As you can tell, there's a lot to unpack here, and a lot of routines to work through, but I do manage to keep off most of the weight while still being social with people and going out to eat with them. The hardest thing is when the bill comes, and people want to split the $500 bill 5 ways, and you ate a dinner salad and drank a glass of water. Most socially-clued groups will have at least one person who will loudly note you had $12 of food while they all had >$120 each, and split it more fairly. If they don't, pay your $100 share, and don't go out to eat with that group again. Or do, and consider the other >$80 as the cost of being thin while living in this modern world.
This may be presumptuous of me to say, but your approach to food has a lot of overlap with anorexia.
Good. Because we have an obesity epidemic, not an anorexia epidemic. Anything that tilts the scales toward anorexia is a huge win.
"I see some bariatric surgery patients and I agree they generally do very well. The only disadvantages are: first, that surgery is scary. Second, that it’s irreversible and does leave you having a lot less appetite and ability to handle food for the rest of your life."
Half-serious question here: what is the risk of having this surgery, then like three years later I'm getting tipsy some night, beer munchies ensue as they have a tendency to do, I eat like three pieces of pizza and my insides explode?
It happens, and it's bad.
https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=134&contentid=154
That link doesn't work.
Alcoholism at least used to be a non-obvious risk from bariatric surgery. Anyone have current information?
> GLP-1-proximal treatments
> https://twitter.com/DanielJDrucker/status/1591171488002232320?s=20&t=HWuGywdinWSLxCtYDJva2A
I roll to disbelieve, the results are too good to be true. A single dose leading to a 3-5 kilo reduction in 20 days? That's crash diet levels of short-term results. No reversal, and potentially even a continued downward trend for a month+ after the end of treatment? I choose cynicism, and will be thrilled if even a third of the claim holds up.
This is great info, and even better with the crowd-sourced tweaks and additions!
Speaking of obesity, this article was in my Medscape bulletin this morning. Subjects are US children, & they're comparing brain MRI's of obese kids (17% of sample!) with those of non-obese.
Obesity Linked to Brain Abnormalities in Kids
CHICAGO -- Children with overweight or obesity appeared to have abnormalities in the brain that could affect executive functioning . . . Greater weight and body mass index (BMI) in typically developing 9- to 10-year-olds were associated with poor brain health . . . At higher weight and body mass index, we found extensive alterations in brain health, including in the gray matter cortex and in white matter fiber tracts, as well as the functional coupling of brain units . . . Essentially our work provides an explanation for previous research that has shown that obesity measurements are associated with poor cognitive performance and academic achievement
https://www.medpagetoday.com/meetingcoverage/rsna/101964?xid=nl_mpt_morningbreak2022-11-30&eun=g1760882d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=MorningBreak_113022&utm_term=NL_Gen_Int_Daily_News_Update_active
Yikes! Of course study says nothing about direction of causality but . . .
Personal anecdote: I've been on Mounjaro for a bit over a month using the $25 discount card because my insurance won't cover it. I started at 6'4" 295 and have since lost 15 lbs with no dieting effort beyond simply trying to eat a generally reasonable diet. Side effects are mild at worst - no nausea per se though it's much easier to feel overly full at a meal, which feels unpleasant. I've also stopped feeling cravings for sugar after meals, which seems like a good sign that it's helping with insulin resistance.
After the discount card runs out, I expect I'll switch to semaglutide, so I can report back after the switch.
Two of my friends are on semaglutide - one has lost about 12 pounds in the span of a bit over two months, the other is just starting. Both had a hard time finding a pharmacy that could get it for them.
Regarding the why-can't-you-fat-lazy-slobs-just-go-to-the-gym wars: I'm not sure people exactly enjoyed debating this -- seemed more like they couldn't help getting pulled in. The thread had much more of a Twitter feel to it than exchanges here usually do. This particular topic leads quickly to that kind of indignation machine that powers Twitter use. Lots of overweight people are in considerable distress about their weight and failure to change it, and lots of normal-weight people have a least a mild case of craving to fat-shame the overweight. Plus the empathy quotient of this group is on the low side, in my opinion -- consequence of group skewing male and techy, I think.
Possibly also due to rationalism specifically on top of the general male/techy impact.
Hmm . . . how would that work? Let's say somebody writes that they've been 60 lbs overweight for years, and that despite being able to stick with lots of other hard things (they got a phd . . . they wrote a book . ..) they have never been able to stick with a diet, despite trying with several different that were recommended in reliable places, and that they do try to walk a lot, averaging maybe 1 mile a day, but that several other forms of exercise they have tried start out exceedingly unpleasant for them and stay that way. Is there some rationalist principle that would nudge the reader in the direction of "you're not trying hard enough"?
OK, I'm somebody who never had a weight problem until very recently, & the one I have now is pretty minor -- maybe 25 lbs. gained during the pandemic, probably as result of sliding into a habit of drinking a couple beers every day. I've stopped with the beer, and doubt that I will have a lot of trouble losing the weight. And I'm an exerciser, too. So I am sort of like you -- I'm in the "good" categories. I'm not a chronically overweight and I exercise. But I do NOT find it incomprehensible that someone could be unable to stick to a diet, or unable to get themselves to exercise regularly.
Here's why: When I hear these accounts of being unable to stick with dieting and exercise, despite the many excellent reasons for doing it, I reflect on things I have been unable to change, despite many excellent reasons for doing so. For instance I was a heavy smoker for many years. Of course I knew perfectly well how bad it was for me. I began trying to stop within a few years of starting. Some of my efforts failed after a couple of days or a couple of weeks, but others succeeded to the point that I did not smoke at all for a couple of years -- but then I relapsed. I finally quit cigarettes for good about 15 years ago, and am confident I will not relapse. It was *extremely* difficult. So when I hear someone talk about being unable to stick with diets or exercise, I remember what it was like to be unable to quit cigarettes for good. I know what it's like to be unable to break out of an unhealthy habit, even when trying very very hard.
Of course, since I did eventually quit smoking, I could also take the other path in my mind: "I quit nicotine, which is very addictive, some say more addictive than heroin. I quit, and lots of people fail. Hah! And these people can't even keep their weight down and do some exercise? If I can quit smoking, they can do that! It's ridiculous for them to say they can't ..." Actually, it seems to me that you are doing something like that. After 15 years of being drunk all day, you decided to stop and started to learn programming. You're using the fact that you decided to stop as evidence that anyone can decide to do the healthy thing. But think about it. What about the first 14 years of drinking? I can't believe you did not realize during those years that the drinking was bad for your health and your life. I can't believe you never tried to cut back on the alcohol or stop. So it seems to me you have a lot of info about what it is like to be unable to change a pattern for the sake of your health and your quality of life. Try accessing that the next time you hear from somebody with a similar problem.
"What about the first 14 years of drinking?"
During the first 14 years of drinking, before quitting, perhaps it would be "rational" to disbelieve him if he claimed quitting was too difficult for an intelligent fellow like him to have already figured out.
But, after a successful quit, *then* maybe it's "rational" to believe him if he testifies that he found quitting so overwhelming that it, well, overwhelmed him for some years or even decades. After all, once someone is already succeeding, others have less reason to suspect that he's testifying just to make excuses for himself.
Skepticism toward others' claims that a difficulty is as difficult as described while it's happening isn't so much rational as it is Prosperity-Gospel. I love much about America, but not the Prosperity Gospel, a gospel embedded in our secular thought, too, not just religious.
The time to have one's testimony about difficulties believed by "hard-nosed skeptics" is once they're already conquered. Then one's difficulties are part of an overcoming story, an empowerment story, one that fits the Prosperity-Gospel narrative. Admitting to difficulties not already overcome is just "negative affirmation", though.
And yet, there is something valid about pushing back against somebody's declaration that they can't stick with a diet. It's not bullshit, but it's also not the same sort of "can't" as the one in "I can't fly." I think the can't in "can't diet" is located more in the area of motivation.
Sometimes I go for the half the day feeling unable to go grocery shopping -- ugh, so tedious, takes so long, can't bear it -- even though I really need to. Then suddenly I find it easy to face, even though I still know it will be tedious and take up a good amount of time. *I* don't even know what changed then, but it was definitely something in my motivation, not my actual ability to do the task. But the thing is, if you can't access the motivation -- that does seem more like "I can't fly." How do you make yourself able to face an unpleasant task? So mostly I think of people who can't quit smoking, can't stick to a diet, whatever, as stuck in an amotivational state, rather than truly unable. But it's a "real" stuckness, not a bullshit one.
Does rationality require disbelieving others' exculpatory self-reports?
No, but I can think of some reasons why those who think of themselves as rationalists would.
"The first principle is that you must not fool yourself and you are the easiest person to fool."
The presumption that others are fooling themselves, especially in face-saving ways, seems to run strong. When a stranger whom you can't even see gives an account of himself containing a mix of embarrassing and face-saving claims, the embarrassing stuff is more likely to be believed as an admission against interest, while the face-saving stuff is not. Someone claiming, "I failed at this goal, but my failure comes with these face-saving qualifications" likely won't have the "I failed" part questioned. The face-saving qualifications more easily invite skepticism, though.
Many rationalists seem to take pride in skepticism. There's a common form of social skepticism that's quick to suspect others of shirking.
Generalizing/bastardizing the concept of revealed preference suggests that someone who complains of failing to achieve a desired goal has already revealed a preference for failing to achieve the goal by failing to achieve it.
More generally, it suggests that people have already revealed their preference for who they want to be and what they want to do by who they already are and what they've already done. While there's some truth to this, it also serves as an excuse to dismiss any aspiration that hasn't already been achieved as bad faith, and, quite uneconomically, leaves no moral space for risk (which includes the prospect of failure despite good-faith effort, else how is it risk?).
So, for example, parents who worked hard to get their kid into Fancy College, but not so hard that they went in for the bribery and corruption of the Varsity Blues scandal, revealed that they must not have wanted a kid in Fancy College so badly, after all. For, if they really wanted it, why wouldn't they have resorted to Varsity-Blues methods to get it? Hopefully, the flaw in that appeal to revealed preference is obvious (arguably, those who resorted to unscrupulous means to achieve something did want it worse than those who didn't, but those who didn't could nonetheless have wanted it quite badly and put considerable effort into achieving it), but other flawed appeals to revealed preference may be harder to spot, especially if they otherwise "smell" rationalist (sufficiently skeptical, etc).
Here's a thought experiment, useful in thinking about willpower, why can't somebody just do it: Suppose I proposed the following as a way to lose weight: Look over the available approaches, choose the calorie-reduction and exercise plans that look best to you. Now go to the bank and take out 80% of your savings in the form of $100 bills. OK, from now on every time you deviate in any way from the plan you chose, light one of those Ben Franklins and let it burn to ashes. If you take a day off from following the regimen, count that as 10 deviations, and burn $1000. You are now very well protected from cheating and quitting, and on the road to success!
Will this work?
There's an app for that!
https://www.beeminder.com/
Yes, I know and am a fan. And yet, if you showed that site to 100 people who were stuck, how many of them do you think would run towards it with open arms? As someone who works with people who are stuck, I can tell you very few would. And it's not out of "desire to fail" or something either. Some of the refusers say, "I'd never put money on the line, because I don't expect it to work." Other refusers say, "What's the point? If I didn't meet my goal for the day I'd just lie so that Beeminder didn't take my money."
Inability to have hope that something will work is a really important part of stuckness. There are probably things you think wouldn't work for *you*, too, in reaching some goal you'd like to. You are probably wrong about a few of them. And yet hope isn't really a fixed quantity either. Sometimes people take a motivated leap into hope.
Here's a story about that. I had a friend who was getting a doctorate in experimental psychology. She got stuck midway thru her dissertation -- couldn't focus, couldn't make progress, and eventually she couldn't even get herself to sit down at the desk and work on the sucker. So she bought some little bottles of Boch Flower Remedies. They're a New Age total bullshit thing -- flower-smell mixtures, each supposed to strengthen some one quality. She was as sure as I am that they are nonsense. Nevertheless she got the ones for Courage and Persistence. She'd sniff them before she sat down at her desk to work on the dissertation, which she managed to complete at a reasonable pace with the help of Boch. Here's how she explained it afterwards: "I really needed them to work. So after I sniffed them, I knew I had to make progress on my dissertation that day -- otherwise, I would not have believed they could help me. And I needed to believe that, so that they would help me the next day."
Motivation is complicated.
My reaction to the prediction that Americas obesity rate has a fair chance of halving by 2050 was incredulity. So I googled obesity in the US and found that the prevalence of obesity has gone from 30% to 42% in the last 20 years, during which time the rate of extreme obesity has doubled.
Given that I'm also not really into predictions about something that may or may not happen by 2050, my incredulity wants to ask "When is obesity in America going to stop increasing?"
If one of the people who think that obesity is going to halve over the next 28 years wants to make a prediction about the ending of this increasing trend, I may well be interested in a monetary wager.
Here's a dumb question: what is a “single-food” diet?
The extremes are easy to define. Only potatoes? Sure, that’s a mono diet. A 6-course dinner—not a mono diet.
What if you blend together a 6-course dinner and drink it at once? Have there been studies that measure how many fewer calories are consumed in that situation?
Is it driven by mono-flavor? Mono texture? Do people who lose their sense of smell also lose weight?
Surgery is scary.
Before the innovation of laparoscopic surgery, a gall bladder extraction entailed a one-week hospitalization with a significant risk of short and long-term complications. Now, it is routinely performed as a same-day procedure.
Bariatric surgery has evolved enormously over the past 30 years and many centers now also offer bariatric surgery on an outpatient basis. The patient is admitted to the hospital in the morning and discharged in the evening.
Bariatric surgery today is even safer than gall bladder surgery.
https://doi.org/10.1007/s11695-017-2664-z
This high-quality meta-analysis studied 174,772 bariatric surgery patients who were pared with carefully matched controls. They concluded that diabetic patients who have bariatric surgery live 9.3 years longer and non-diabetic patients live 5.1 years longer than the controls.
https://doi.org/10.1016/s0140-6736(21)00591-2
Surprisingly, the major health benefit from bariatric surgery is not the reduction in diabetic complications or cardiovascular disease. It is the reduction in cancer!
https://doi.org/10.1097/sla.0000000000002525
The mechanism by which bariatric surgery works is not from the creation of a small stomach or malabsorption. Bariatric surgery causes major hormonal changes that result in reduced appetite. One of those hormones is GLP1, the same hormone that semaglutide also mimics.
One of the fascinating things that I have observed is that patients who take semaglutide or have bariatric surgery almost invariably consume much healthier diets than they did before! Oatmeal and fruits and vegetables suddenly seem to taste much better, and Eggs Benedict seems to lose its appeal!
I know this is a tangent, but I was struck by "although I’m sometimes a little cavalier about pills I would be more nervous about things I inject into my body". I have the same feeling, but I'm curious whether that's just your gut reaction or whether it's a more informed opinion than my own gut reaction.
The Diabetes Prevention Program was a 4-year RCT designed to determine if a highly structured Medically Supervised Weight Loss Program could cause long-term weight loss and thereby prevent patients from developing diabetes.
DOI: 10.1056/NEJMoa012512
It has been cited almost 12,000 times, making it one of the most frequently cited medical papers ever to be published.
However, if you examine that paper carefully, you will see that it actually proved the exact opposite of what it was purported to prove. It actually proved that MSWLP's cause short-term weight loss that is invariably followed by long-term weight regain.
The American Diabetes Association, the American Diabetes Association and the US Preventive Services Task Force have all published guidelines in which they recommend that obese patients be referred to MSWLP's and they use the DPP as the principal study supporting those guidelines.
MSWLP’s are highly profitable privately run businesses and many of the people writing those guidelines have major financial ties to those programs.
I have posted a20 minute highly evidenced based video on YouTube in which I review the DPP in some detail.
https://www.youtube.com/watch?v=wapjMQIpPAY&t=998s
And this is a somewhat more technical 10-minute video in which I dispute their claim that the DPP caused a 58% reduction in diabetes.
https://www.youtube.com/watch?v=wjN-1rPShC4&t=7s
Yes, walking uphill and biking uphill obviously require additional energy. However, biking uphill on a treadmill would involve positioning the upper wheel at a higher position (than the lower) but have no effect on the wheel through which you deliver energy. It would obviously not require additional energy. The bike never loses nor gains altitude as the wheel can spin at an absolutely constant speed.
That a variable speed (throughout one's gait, while walking) WOULD cause you to gain and lose some altitude (during each step) was the point of the remainder of my original post... The closer you can come to a constant speed, the less difference there is between incline and not for a treadmill.
What you've forgotten is that the treadmill is now providing only cos(a) of the force required to maintain the bike's vertical position, where a is the angle of inclination. That is, if the bike weighs m, then when the bike is level the treadmill provides mg of upward force, while if the treadmill is at a 30° angle then it only provides mg*cos(30) = 0.88mg of upward force. The remainder, which prevents the bike from falling downward, has to be supplied by the rider pedaling. So for a given wheel speed, the effort required is larger.
Right: As a thought experiment, think of the limiting case with the treadmill is dead vertical.
This is a good point (as is Luke's below). I was assuming that the bike was actually affixed to the treadmill's frame. Then, as Eremolalos' thought experiment points out, the incline does have no effect. However, your observation does bring to mind several other experiments.
In the case of the unaffixed bike, the bicycle would accelerate down the treadmill at a rate directly proportional to your weight (if you weren't pedaling. Thus energy needed to prevent this is rider-weight proportional (like climbing a hill). Similarly if a treadmill on an incline accelerated based on your weight then the energy input would be proportional to the weight of the user. I do not think this is the case. For one, it would force running above a certain incline as the treadmill continued to accelerate.
Increasing the load applied by the treadmill could prevent this need to run on an incline. However, if we are increasing the load on the treadmill, then it is not the incline that is increasing work, but the "load" setting. Except, increasing the load setting above a certain point will just cause your feet to slip on the (level) treadmill surface. Perhaps increasing the incline allows the load to be increased by forcing your increased work to be in a downward direction rather than lateral (and thus overcoming the finite friction issue)?
You mean the energy input to the treadmill, e.g. the current it draws? I'm not generally familiar with the internal workings of treadmills, but yes I would a priori expect it to draw more current as the incline goes up (and the treadmill is set to a fixed speed).
In addition to supplying the force necessary to overcome friction and keep the belt moving at a steady speed, the motor needs to supply a little extra kick of force every time the runner pushes off, to avoid the belt accelerating instead of the runner. It does this by having a strong enough magnetic field that when the motor shaft is accelerated or decelerated, the magnetic field resists and pushes it back into phase (to the location where it's supposed to be at that time in its revolution). But the pushing back costs at least a little bit of energy, because it isn't purely elastic, and as the excursion gets larger (because a larger force is required) the energy cost grows.
So when the incline goes up, the extra kick of force needed on each step will increase, because it needs to supply some of the force needed for the runner not to fall vertically, and that means the electrical power needed will increase.
I don't know if some treadmills have an increased friction setting. They are common on stationary bikes, but on a treadmill it might not be very useful, because it doesn't really correspond to any movement that mimics natural running, except maybe running through ankle-deep water or something. On the bike increased friction mimics riding at higher speeds in higher gears, which is realistic.
Sorry for the delay on replying to this.
For energy input, I meant by the person exercising not the treadmill itself.
My original statement was that I was unconvinced about the increased energy usage (exertion) from inclining a treadmill. At this point I can see several mechanisms which allow for additional exertion. I do not think there is any guarantee that the exertion tracks with the incline at the same rate as if you were actually walking uphill. (more on that later)
I think that your motor supplying extra energy thing is backwards. The person walking supplies more energy to turn the treadmill in the same direction that the motor is turning. This means less load on the motor. The motor may act like a brake (dissipating energy in the resistance of the windings and generating heat) but the energy supplied is from the person exercising. The motor is acting like a generator at least part of the time, turning motion into electricity and then dissipating that electricity as heat.
I am still asking myself if there is (at least on real treadmills) a necessary relationship between incline and exertion that tracks with the actual energy used if you were walking up a hill with the same incline. If Potential Energy=mass*gravity*height is reflected in the energy delivered to the treadmill. Thus my previous discussion of an unrestrained treadmill accelerating until you were running and thus dissipating the same energy anyway.
I think, that if you take the analogy to its extreme and assume you are standing on a ladder that we find that this relationship is true. If the ladder is forced downwards by your foot, even if ladder motion is assisted by a motor, you are applying a force of at least your own weight (or else you are descending). And you are applying this force through a distance equal to the distance traveled. This suggests to me that (other than resting your weight on the handles of the treadmill), that my original thinking was incorrect and that the incline of a treadmill more-or-less mimics an incline in real life.
I'm rather surprised no one mentioned food subsidies and cheap food being part of the problem. The USA cheap food policies and the massive amounts of money making that happen just might be related. Obviously this is an unpopular perspective and once you give people cheap food, it is hard to get into political office saying you want to triple food costs. If you give people cheap food, offshore or mechanise most the physical jobs, and go into a service economy, then it is no surprise you end up with WALL-E level morbidly obese people.
There has also been a very successful class war going on in the US for decades to erode wages and increase profits, so poverty would be a huge issue where the minimum wage is already creating hunger problems. So this is certainly not ideal to implement on its own. But I wonder why no one is talking about something simple like evaluating the cost of food in household budget vs obesity rates between countries and regions.
So while not necessarily a good idea overall, but in terms of a narrow fixation on obesity...make food more expensive/reflect the real costs of production would make a lot of sense. I can't recall exact figured, but typical household budgets used to be something like 30% for food and it is now around 10% the US where farmers sell corn for less than it costs them to produce it due to subsidies which cause an entire market to operate at an internal loss. And farmers plant right up to the fence since there are no limits on several of these subsidies. It is odd how food policy and tens of billions of dollar spent to that affect is just 'out of scope' in obesity discussion. Is it power blindness or ignorance from decades of citizenry being powerless because corporations annexed the government?
Also with the corptocracy we have and the media amplified backlash against a simple tax in NY State on sugary drinks...it would be hard to pass legislation to alter current corruption money flows - but I think if we taxed processed foods based on their sugar content, then that'd make a big difference. If a soda cost $20 a can instead of less than $1, then people would drink less of it. We have no problem taxing cigarettes or other vices, sugar just needs to be reclassified as a vice and taxed into near oblivion. There is simply no valid reason an extremely obese society needs to sell small cans of bubbly acidic sugar water with 50g of sugar in them when tens or hundreds of billions of dollars in productivity, heath costs, etc. are being incurred.
The minimum food quality standards should be increased and simple things like caloric maximums in mass produced food or preposterous serving sizes need to be changed. Why wouldn't a big mac be half its current size? I recall research by those fast food places where they decided to go crazy on the calories in each order because most people are not willing to order 2 burgers and pay for 2 meals, but they will get fat and eat more if you make 1 burger twice as big.
This is just not part of the conversation taht just like social media companies profit from anger and division algos...fast food places for decades have weaponised and intentionally drive obesity up as their core profit model! It is simply a valid and legal business model to kill your customers! Why should a nation of laws and people tolerate these homicidal business models to sell cigarettes, high calories fast food, and horrible chemical industries of all kinds which have endangered the entire human race by lowering sperm counts, causing cancer, and making us sick in numerous ways?
Are extreme ownership and profit protection activities by our neo-aristocracy which is a death cult to be raised above all other possible consideration in the universe simply the correct and right way to live? The highest moral imperative is an Ayn Randian fixation on making already extremely wealthy people slightly richer or more powerful? Because it is hard to see it any other way when the government pays for a negative corn market used to make sugar to sell soda for under a dollar and everyone is obese and dying. Very profitable and you're very sick and dead!
> I'm rather surprised no one mentioned food subsidies and cheap food being part of the problem.
I think it's unlikely to be a major part of the problem. If it were, you'd expect rich people (for whom food is effectively even _cheaper_) to be fatter than poor people.
Or to put it another way, there's a "food price relative to income" vs "calories eaten per day" curve. At the "starving poor" end the curve bends quickly, but once you're making $10K+ per year it's pretty flat. Changing food prices or incomes might change the kind of food you eat, but not the amount of food you eat.
When fatness was a marker of high status, rich people *were* fatter.
But now thinness is a marker of high status, so rich people are thin - because those who would be inclined to fatness under other conditions can buy their way to thinness via various routes (personal trainers, personal chefs, medication, etc).
Also, poverty, especially poverty in the US (google 'food deserts'), places all kinds of restrictions on the kinds of foods you have access to - the available food is often cheap and plentiful but poorly balanced in terms of macronutrients and downright appalling in terms of micronutrients. Cheap food is often bad food.
>When fatness was a marker of high status, rich people *were* fatter.
Yes, but that's completely irrelevant. If virtually unlimited access to calories necessarily resulted in obesity, the rich would be at least as fat as the poor. They aren't, which means access to surplus calories per se cannot possibly be the cause of the difference.
>But now thinness is a marker of high status, so rich people are thin - because those who would be inclined to fatness under other conditions can buy their way to thinness via various routes (personal trainers, personal chefs, medication, etc).
Do you have any data /whatsoever/ susbtantiating your claim that personal trainers, perosnal chefs and medications explains the obesity gap between rich and poor?
The gap exists for people *nowhere near wealthy enough* to afford personal chefs, and most high income earners are not on weight loss medication. High income earners are leaner because they consume far fewer surplus calories.
Exercise is not an effective way of losing weight. The overwhelming reason people are overweight is because they consume too many calories, not because they don't have personal trainers. If you're exercising enough to make a serious dent in your caloric stores (which is very hard), your apetite is going to increase accordingly, and if obese people had good enough self control not to eat more when they're hungrier, they wouldn't be obese in the first place.
High income earners consume fewer calories, partly by eating less, partly by eating lower calorie foods, partly by eating a lower-sugar diet that doesn't inflate their apetite. Not from having "personal chefs" or by eating the same calories as fat people and then burning off thousands of calories at the gym (which would require *hours* of exercise per day).
>Also, poverty, especially poverty in the US (google 'food deserts'), places all kinds of restrictions on the kinds of foods you have access to - the available food is often cheap and plentiful but poorly balanced in terms of macronutrients and downright appalling in terms of micronutrients.
Yes yes, we've all heard about food deserts. The obvious reason why they exist is because *poor people don't but that kind of food* so shops stop stocking it.
Eggs, tuna, frozen brocolli, brown rice. All these things are dirt cheap and super nutritious. I practically lived on this kind of stuff through college. People don't eat this stuff because they prefer to eat tastier stuff.
Poor people eats LOTS of sugary foods. There's no reason for this other than their preferences. I'm not talking about non-dessert foods that have added sugar, I mean foods directly consumed for their sweetness like soda. Guzzling litres of soda a day is not something anyone does because they're too poor to do anything else to sustain themselves. This is a self-destructive, unnecessary behavior of their own choosing. It would cost them less to drink water. It would cost them no more to buy coke no sugar instead of coke.
And a lack of micronutrients does not explain the obesity ecidemic.
Michelle Obama tried to call attention to this problem, I believe she got significant push back from the lobbyists working for the major food manufactures. It would be nice if someone in DC with a large platform would pick up where she left off. More work needs to be done, and it’s most certainly a bipartisan issue. (This comment is not endorsing any party or individual. To me it’s simply good public policy.)
Thanks for the post!
Are you willing to describe why you find the first three topics under "Tangents That I Find Tedious" are tedious to you?
I'm not Scott, but from my perspective the tedium of at least the first two topics seems obvious; they consist entirely of arguments like this:
- Diet and exercise are extremely hard! If they were easy, everyone would do them!
- No they're not, you're just lazy!
- What about the 35% of Americans who are obese? Can every single one of them be wrong about their own internal experience of finding it difficult to lose weight? Are they all just lazy?
- Yes, obviously! I'm glad you understand now!
I'll make one last comment on my tangent but after this thread I promise to drop the subject forever.
Some other people in this thread have brought up the analogy between exercising and quitting addictive substances (cigarettes, alcohol, etc). I'll bring up another analogy: exercise and veganism. I will confess that I am not vegan or vegetarian even though I know on some level that eating meat is really really wrong, and whenever I've been proselytized to by vegans it's always made me upset in a way that I never felt upset at for bullying or homophobia directed at me. For the latter two, it's easier for me not to get angry because it's not something that bothers me about myself and I can feel a sense of moral or intellectual superiority to the aggressors. I wonder if the anger I feel from the former is similar to any anger that people felt reading my posts; if so, I apologize for that.
Part of my suggestion of opening state-run gyms or subsidizing gym memberships comes from what I would imagine it would take for me to go vegan. Right now I think it is a matter of convenience for me; it's hard to get enough protein for my needs on a vegan diet, and it would require more structured eating and shopping habits. Certainly if every restaurant had the same level of vegan options as meat options and meat substitutes were in more grocery stores and were cheaper or a similar price to meat I would have a much easier time going vegan. Just like in the example of exercise, there are some people that would be unable to go vegan no matter how convenient it is, and some people that aren't vegan for reasons other than convenience, but I still think that making veganism more convenient would result in more people going vegan.
Let us bear in mind, though, that doing stuff that isn't made easy for you, hacking your own path through the jungle of temptation, distraction, and assorted social headwinds is a major part of adulting. Only being able to do things when the road is made smooth for you is what it's like ot be a kid, where all the rest of adult society kind of looks out for you, helps you on the road.
When you reach adulthood, we kind of expect you to pull up your socks and get stuff done without needing someone to clear the path for you, indeed even if the path is overgrown or there are some people who stand in your way, on account of all the rest of us are pretty busy ourselves. There's actually no "society" out there that can take care of all of us, there's only ourselves, and if you have to take care of me and help me solve my problems as well as take care of yourself and solve your own problems, that's rather a burden.
I guess I'm not sure I buy into this analogy. Exercise really doesn't require much inconvenience in comparison to veganism, if you're only requiring the basics. There are huge health benefits just from 30 minutes of daily walking and some simple bodyweight exercises for strength.
That said, I do believe everyone should lift weights, and in this case I think the veganism analogy is apt. I sometimes see parks with exercise machines--basically free gyms--and would like to see more of that. I'd also like to see physical education improved: it seems like almost no one except fitness enthusiasts have any idea what to do with weights.
Some insurance includes gym memberships or exercise at the Y or somesuch. I don't know know what proportion of people use it.
If people literally cannot get themselves to go walking for 30 minutes every morning they aren't going to gyms, free or not.
Re: stimulants and weight loss, this describes my own experience... kinda. I was not obese, but I was overweight, with noticeable amounts of visceral fat. Then I was put on 16mg of Concerta (ER Ritalin) daily. I found that, by concentrating my hunger (i.e. cutting down on snacking) I was better able to plan ahead and therefore eat healthier overall. I was also able to use the energy and willpower from the meds to start working out more regularly. As such, my scale weight didn't drop much at all, but my body composition noticeably shifted to much lower body fat and much higher muscle mass. For obese people, I imagine this might not work out as well for obvious reasons, but I can definitely see where the idea comes from.
I find the emphasis on weight so... limiting. Only a few place emphasis on metabolic indicators you might measure with bloodwork, and about zero people place emphasis on the body's ability to work: strength, flexibility, and endurance.
I don't care if I have a high BMI or a low BMI, I care if I can pick up more weight than I could last week. I have never been able to stay on a diet to save my life (literally), but I have been able to stay on a diet design to increase muscle mass - eating for the purpose 'lose weight' was always a failure, eating for the purpose 'bulk up and recover from exercise' has been one of the easiest things (it does help that diet is heavy on protein - H.E.A.V.Y. 1g protein per 1 lb body weight per day). My focus has been on body composition (muscle vs fat) not amount of fat.
I just believe based on my experience the answer to 'why not just diet and exercise' is few people have exercise goals but have a weight/BMI goal that translates into calorie restriction which translates into failure for a variety of reasons. Exercise might become a part of that, but it is secondary to the weight goal - I exercise because I want to weigh less or get rid of that double chin. Instead, I suspect if people started with a physical performance goal (I want to bench press my body weight, I want to deadlift 2x my body weight, I want to run a marathon) that would lead to diet and other physical forms of recovery and self care with far greater success and compliance.
I'd love to take 100 high BMI people and task then with lowering their BMI, and 100 high BMI people and task then with a physical performance goal (like deadlift or a marathon) and see which group over time has great success in achieving their goal. In my head group A is 'You wear an XL or XXL shirt; your goal is to go down a shirt size' and group B is 'You wear a XL or XXL shirt, your goal is to go up a shirt size and deadlift your body weight' and I'd bet money more of group B achieves their goal and group B is healthier across a broad range of metabolic measures and outcomes.
Weight can be measured directly, and reducing weight tends to reduce other metabolic factors associated with disease and is easier to reduce than those things directly.
Exercise is not and CANNOT be the foundation of weight loss. You simply do not burn enough calories with even intense exercise for it to make the differencee, and obese people cannot generally perform intense exercise. Walking for 45 minutes per day (vastly more exercise than the average obese person does) is equivalent to burning the calories in 1 can of coke. Small diet modifications absolutely dwarf the impact that exercise can have. And that ignores the fact that exercise usually increases appetite! If obese people could resist hunger, they wouldn't be obese, so exercise is going to be especially ineffective.
It sounds like the ideal diet drug would be one that targets your set point weight directly. If you could change that like a dial, you could rely more on your own body's weigh management mechanisms to burn off the extra weight. Also, since set point appears to be something that generally stays static, if a drug could move it, perhaps you would only need to take it for a short period and the impact would last. Perhaps this approach could "cure" obesity.
I hope someone is studying the biological mechanisms that underlie the set point weight, and how to intervene in them.
Interesting wrt to the tiredness comment, since I remember a lot of SMTM potato study participants reported similar effects (not any overall lethargy, but sleeping many more hours).
Semaglutide Non Medical issues
Availability:
Saturday's Wall Street Journal: "Why You Can’t Find Wegovy, the Weight-Loss Drug: Novo Nordisk underestimated demand for drug that went viral on TikTok and YouTube: by Peter Loftus and Denise Roland
https://www.wsj.com/articles/why-you-cant-find-wegovy-the-weight-loss-drug-11670108199
Focuses, as one might expect from the Wall Street Journal, on the impact shortages are having on Novo Nordisk's business .
On a practical level, in the first Quarter of 2022, there were a few occasions on which I had to go around to several pharmacies to refill my prescription. By summer, that issue had gone away and I have had no problems getting refills on request. I do not know what is happening outside of my hometown or in foreign countries.
Price:
I think Scott wrote that the price per milligram of Ozempic and Wegovy, which are both injectable forms of semaglutide, is the same. My doctor and I are discussing switching me from Wegovy 2.4 mg to Ozempic 2 mg as a maintenance dose. The prices in my area of the two formulations (both manufactured by Novov Nordisk) are given in the following tables derived from GoodRx*.
Ozempic 2 mg × 4:
CVS Pharmacy retail: $1,053; with GoodRx coupon: $922.50.
Walgreens retail: $1,070; with GoodRx coupon: $928.35.
Meijer Pharmacy retail: $1,083; with Good Rx coupon: $886.18.
Wegovy 2.4 mg × 4:
CVS Pharmacy: retail $1,590; with GoodRx coupon: $1,391.34.
Walgreens retail: $1,619; with GoodRx coupon: $1,399.94.
Meijer Pharmacy: retail $1,637: with GoodRx coupon: $1,327.44.
Note that the most important non price difference between the two formulations other than amount of the drug per dose, is that Ozempic comes in a single four dose pen and Wegovy comes as four separate pens.
Also note that WSJ article says: "Novo lists Wegovy at $1,349 a month", but that is not the list price used by any of the pharmacies surveyed by GoodRx.
For those of you who are unfamiliar with the US or the Great Lakes area retail merchants, CVS and Walgreens are both nationwide pharmacy chains. Meijer is a regional competitor to Wal*Mart and Target.
The two formulations do have different prices per milligram. Note that the cheapest Wegovy per mg is more expensive than the most expensive Ozempic per mg.
Per mg (highest -- lowest)
Ozempic $135.38 -- $110.77
Wegovy $177.93 -- $144.29
Further research reveals that both formulations are priced without reference to dosage. The 0.5 mg pens are priced the same as the 2 or 2.4 mg pens.
*If you buy drugs in the US and have to pay cash or have large deductibles or co-pays, GoodRx.com is valuable. They provide price information for most prescription medicines used in the US. they also have free coupons that get discounts on cash payments. It is accessible via web browsers and by phone apps.
I note comments about prior approvals. There is a service to help navigate the prior approval labyrinth called Cover My Meds (CoverMyMeds.com)
https://en.wikipedia.org/wiki/CoverMyMeds:
CoverMyMeds' software automates the prior authorization process used by some health insurance companies in the United States, helping to save time and eliminate paperwork. Traditionally, prior authorization required phone calls and faxes between multiple parties; CoverMyMeds circumvents this by automating the process. Involved parties are able to view the status of the authorization as it progresses.
https://www.covermymeds.com/main/
America's hispanic population is expected to increase significantly by 2050. Hispanic americans are very fat and are probably less able/inclined to get bariatric surgery or expensive weight loss pills, so this should cause one to update downwards at least a bit on the probability of obesity halving.
Scott, I read the following tweet and was interested to know in your research on semaglutide have you found any evidence of the following:
"I expect prescriptions for GLP1s and SGLT2 inhibitors to go vertical, but they're not safe
In the long term, higher basal insulin will foment insulin + leptin resistance as receptors are increasingly desensitized"
https://twitter.com/GCRClassic/status/1602726776484073474
Glp1 agonists reduce the liver’s production of glucose, so although these drugs might have an acute insulin effect, the net effect over time is less basal insulin needed from the “savings” from less liver glucose. Leptin works partially by interacting with and releasing GLP1 so more GLP1 is likely a positive thing with regards to leptin functioning. If one is deficient in leptin, which anyone will be if weight reduced, there’s less leptin to release glp1, so supplementing glp1 is a pretty effective way of bypassing the lack of leptin.
Regarding #3 (Other Weight Loss Drugs), there are small molecule GLP1R agonists in development (there are many, many patents), and I imagine they'll replace semaglutide/Wegovy if they make it through the clinic. Novo has been struggling for a decade to make adequate amounts of semaglutide, but the small molecules can be made by the ton. So, wait 5 years and see where we are.
If you search, you can order Ozempic at a very low price in Canadian online pharmacies, and many give a discount on the first order, for example, 5% off on the Insulin.store website.