"Movement offers us pleasure, identity, belonging, and hope."
Identity? What identity? "I can move my legs, that means I am A Leg-Moving Person"?
Sorry, but this is where the exercise evangelists get ridiculous. If I were to be confined to a wheelchair tomorrow, I *might* construct a new identity around being disabled or a wheelchair user (I don't think I would, but I might). However, I am positive I would never construct an identity around being a runner, and if someone feels that the most important thing in their life is that they are a runner - well, you do you, but heck.
Honestly, your McGonigal person sounds like all the dopeheads on here urging "LSD, man, psychedelics, will give you a cosmic experience and fix all your mental problems with a reset!" Maybe the exercise high people and the psychedelic high people should get together and get mutually baked before running a marathon, then they could both disappear up their own crown chakras about the cosmic best and highest human spirit coming out, maaaaaan.
What makes you think we don't exercise? I've exercised for a minimum of an hour a day, seven days a week, since elementary school. Usually I get more exercise than that. I'm past middle age now. It never made a dent in my weight. This is the kind of mean-spirited assumption that fat people have to fight all the time.
Exercise doesn't shift weight, unless (as has been mentioned) you are preparing for an expedition to the Antarctic or triathlons or the Tour de France.
What exercise will do is tone up muscles (I did find that the flabby underarms tightened up) and help with endurance (being able to walk distances without getting winded). But you can be fairly fit (able to do everyday tasks as normal) and still fat, even very fat.
I think the "diet and exercise" mantra comes from treating people who only have a few pounds excess to shift; the exercise will tone muscles and burn off some extra calories, and that in combination with restricting calories to below normal metabolism maintenance will shift enough weight/fat so that you do 'go down a dress size' or whatever.
But for seriously overweight people, it won't work like that. And exercise *alone* definitely won't work, because it makes you hungry so you eat to compensate.
No, this isn’t related to phentermine. It’s not any kind of stimulant. It works by making you think you are full and not hungry any more. Source: my better half takes one of the versions for diabetics.
Sorry, I thought I read somewhere that Wegovy is actually phentermine, but on further reading it seems you are correct. It is just a different weight loss medication. And has less long term results and perhaps more side effects.
There are shady weight loss clinics that prescribe and dispense "all natural weight loss supplements" that are actually phentermine. (Getting customers hooked on stimulants is a great way to ensure repeat business!) I wouldn’t be surprised if some of them latched on to the semaglutide hype and started pretending to offer that.
I dunno, I don't find that toooo shady — I'd be pleased to get something that actually works, if anything!
And stimulants mostly aren't physically addictive, so "getting hooked" on them because you took some for weight loss and really liked them sounds like complaining that Krispy Kreme got you hooked on food because you really like eating donuts, it seems to me...
Edit: Well, marketing it as "all-natural" *would* be shady — forgot about that part, sorry!
("All-natural" is a stupid term to base purchasing decisions on, though, for many different reasons... so I can't get too worked up about it, heh.)
Phentermine is fantastic for weight loss. There have been 3 studies to determine whether it's addictive, and all 3 concluded it is not. I took it myself for 2 years before the new, stricter, more-fascist rules saying you have to have a BMI of 30 to get it went into place.
Standard dose is 15-30mg / day. I was using 38mg tabs, and found it effective at 19mg/week, as taking 19mg on a single day enabled me to fast for that entire day.
I believe the medical community is so down on phentermine now for religious, not scientific reasons. Doctors really don't like it when a person can just take a pill instead of exercising. It feels like sin to them.
Phentermine is actually a controlled prescription medication under the same rules and regulations as ADD medications and pain medication. Phentermine is only available by prescription. There are supplements that weight loss specialists use but there is no reason to try to "hook patients" on a medication. Patients actually seek out Phentermine and try to rely on it versus actually changing their diets. Phentermine is highly controlled and should be in a prescription bottle from a pharmacy or a dispensing medical office.
All of the studies on the addictivity of phentermine that I have seen, concluded it is not addictive. I challenge you to find any experimental evidence that it's habit-forming. I took it myself for 2 years, and had no problem on being forced by new regulations to discontinue it suddenly, other than getting fatter as a result.
You said, “I have a pretty minimal insurance and it looks like if I got semaglutide my copay would be about $500/month until I reach my deductible.” I think you mean out of pocket limit, not deductible, though maybe your plan is odd. Usually, you get zero benefit until you hit the deductible.
I tried semaglutide and it did nothing to slow rate of weight gain, just produced stomach upset, going up to 2.4mg injectable. I know one other person trying semaglutide and they reported something similar. I wonder if they played some clever games with their choice of patients. My expectation of how the news goes here is a whole lot of people who try semaglutide, maybe after fighting really hard to get on it, and find that it does nothing. That said, I know at least one friend of a friend, if not a friend per se, who claims that semaglutide was their miracle drug. So maybe still worth that hard fight, even if I'm guessing that the real proportion who get nothing out of it will prove to be over 50% in real populations.
Further fun fact: Semaglutide comes heavily recommended with diet and exercise and many stern injunctions about that! The actual insert sheet includes a graph for how much weight people lose with and without "lifestyle interventions" added. The two graphs are roughly the same.
I hate to be that guy, but I do find all these debates about extremely expensive weight loss cures (Matt Yglesias has a recent article about getting [I forget which] surgery) kind of annoying, where there are literally money-saving ways to lose weight - and more importantly than that, improve your metabolic health (where obesity is a potential symptom).
"semaglutide comes heavily recommended with diet and exercise and many stern injunctions about that!"
I wonder what effect that heavily recommending things that cause weight loss alongside your weight loss drug does.... I also wonder "what" diet and exercise is being recommended, when there is so much (conventional wisdom) diet and exercise advice that will definitely not make you lose weight, or worse, make losing weight so unenjoyable that you don't want to do it.
Yes, and that's why just waving the magic totem labeled "do diet and exercise" doesn't work. Exercise done right doesn't make you lose weight, but you should still do it. Diet can, but most diet advice doesn't work, or works, but is too difficult to stick to - giving an out to the Puritans who lecture people for being insufficiently pious. And remember "work" isn't defined as "lose weight" it is "be healthier and less likely to have the bad health outcomes that are currently correlated with being overweight"
Yeah, my first year Behavioural Psych teacher had a great point when he said imagine a problem in the world (I picked AIDS). Then imagine a behavioural change that would 'cure' it. This idea was revitalised with Scot's post along the lines of technology is possible biology (behaviour change) is not (immutable).
>The same can be said about pregnancy and STDs ("Just don't have sex")
Terrible analogy. Not having sex works 100% (alright let's say 99.999% to account for urban legend-tier accidents) for STDs and pregnancy. It's not a problem of effectiveness, it's a problem of "people don't use it". If a medicine cures a disease, it's not a failure when people who decided to not take the medicine suffer from the disease.
"People don't use it" is very close to "the cure is more unpleasant than the disease", which is a failure of the cure.
Amputating one's hands is 100% effective against carpal tunnel syndrome, both as a cure and for prevention, but I wouldn't say it's not a failure of that treatment that people choose not to do it.
"eat less stuff" is a gold star way to lose weight except that people suck ass at it. I have succeeded in the past, but put back on 20 pounds from my ideal body and am failing currently; it's pretty damn hard. I don't know if that's what you mean by money-saving way to lose weight, but if it is then I think it's an incomplete solution--eat less stuff needs a very firm "how," and that seems to vary person-to-person
Why eating less is so difficult and why losing weight at all by any method is so difficult are questions at the very edges of current neuro- and metabolic research. Most of what we tell the obese is unhelpful.
The real reason it's so difficult is that eating too much has simply become too convenient, whereas not doing so apparently doesn't come natural for many people.
I can see it in my wife: when she had the mental strength to account for everything she ate, counting calories and adjusting her diet to get enough protein, she easily lost weight at exactly the expected rate. As soon as she stopped doing that she started to eat too much calories with too little nutritional value again, as those meals are way more convenient to make, more tastier for her and immediately rewarding for the brain (but don't actually make the hunger go away for long). Despite her noticing how a protein rich diet made her feel full for far longer, allowing her to eat only two meals a day easily, she can't maintain such a diet without dedicating substantial mental strength to it; and she can't properly limit her calories with a more convenient diet either.
The difference between her and me is that she absolutely can't tolerate hunger, like at all. Not eating breakfast when starting early into the day to achieve something is simply not an option for her. Neither is skipping meals when eating her usual diet.
I on the other hand would rather sleep in another 15 minutes than to get up early to find the time to eat something. I can easily skip two meals out of three without any issues for days. I feel hunger sometimes, but I can just ignore it for an hour or two, and then it goes away. For me its absolutely no issue to maintain a BMI of 22-23 without ever stepping on a scale, counting calories or diet adjustment. I just stop eating when it's too much. I also don't stuff in left-overs for the sake of finishing them, which makes my wife mad regularly. She just can't get off the idea that this means wasting food.
A drug that would make the feeling of hunger go away would certainly help. But the real message is: convenient diets are unhealthy. We should have more healthy food options which are convenient to consume. If eating healthy requires extra effort, a lot of people will fail to do so ...
And all of that is without even considering people who simply have to eat whatever is the cheapest option available ...
Sorry, but I'm a little miffed here. "Convenient diets are too easy" is certainly a contributing factor, but the rest of your comment reads like someone lecturing a person suffering from chronic pain.
"Well, *I* don't get sensations like my bones are splintering and turning into knives cutting my flesh, so an occasional aspirin handles things for me just fine! Why do *you* need strong pain-killers? Modern pharmaceuticals have made things way too convenient!"
You say you don't get hungry and can easily skip meals without noticing, or ignore any hunger you do feel. Yes, that means it's easier for you not to eat and to stay at a 'normal' weight.
Try imagining you *do* feel hungry. Not even that - do you get thirsty? Do you drink plenty of fluids during the day? Can you easily ignore being thirsty? The next time you are thirsty, try "no you can't have something to drink right now, you had a glass of water this morning, you have to wait a minimum of four hours before you can have your next glass - and only one!" and see how you hold out.
This is probably not how you intended it to sound, but your comment comes off as "my wife is so over-sensitive and has no grit, she can't handle a little bit of pain/hunger, she just needs to toughen up - me, I could have my hand chopped off and not even notice, *that's* normal!" - see what I mean about the comparison to chronic pain?
You took my post in exactly the opposite way it was meant. I'm not saying that anyone would be at fault in the way you construed it. Quite the opposite. I was saying that the individual experience of hunger was very different; as is btw. the individual experience of pain.
This makes it extremely difficult for my wife to maintain her weight while consuming exactly the same kind of diet which I eat. Where she needs willpower not to eat something, I just need lazyness to prepare food. While she had to adjust her diet to lose weight to a high protein one, I can live as a skinny fat on a low protein diet just fine without any effort (and then still suffer from much of the issues such a bad diet entails). None of this is my achievement or her failure. It's just a simple fact.
I'm sorry if it came off differently. But I feel as if you were reading my comment almost in bad faith here. How would it even be my wife's fault that she experiences hunger far more severely than I do? And how would it be an achievement of mine that my body reacts far more charitably to not getting any food for an extended period of time? Neither of us chose our bodies or our body experiences. And nowhere did I blame her for her way of experiencing it.
I then proceeded to say that the reason this difference leads to that much obesity is that high calorie diets with low nutritional value are much easier to purchase and consume nowadays than diets which are well balanced. My wife, when trying to lose weight, had to go to great lengths to get all the nutrients she needed, while going cal negative for an extended period of time. IMO this is something we as a society could and should address.
Here again I'm under the impression that you are reading my comment in bad faith, as your example with pain killers works exactly the opposite to what I said. So your comparison doesn't even make sense and IMO only serves to discredit my thought.
And to answer your similar bad faith attempt at thirst: yes, I also experience thirst way less severely than my wife. Again: this isn't her fault or my achievement, it's just a plain fact.
Btw.: I am a chronic pain patient, having shattered my left hip a few years ago. I don't have a single day in my life without pain. And I don't use any medication for it (though I had doctors call me out for it, claiming stupidly that no one should ever need to experience any pain at all). Yet I never told anyone that therefor they shouldn't need any either. That would be simply plain stupid. I did need quite a lot of those the day I shattered my hip ...
I sort of get the convenience complaint, but sort of don’t. I think it is mostly just about the raw hedons. A cucumber is pretty good and super convenient, and you can just eat it like an apple.
But people will make a sandwich or cook something in the microwave instead because that food simply tastes better.
I just don’t think convenience is as much of an issue compared to accessibility and the overlap between caloric density and tastiness. Sugar tastes great.
Maybe I phrased it wrong, but I was trying to convey the convenience of foods actually filling you such that you no longer have any cravings.
My wife eats lots of cucumber btw. ;-), but I wouldn't call them a meal. I could eat ten of them and still be hungry. They might help with alleviating thirst though ;-)
I'd consider accessibility the main part of the convenience btw. A major issue, while trying to lose some weight, for my wife was finding something suitable to eat when not eating at home and not having brought our own food along.
Your wife's (and yours!) experience is totally normal. Most people cannot (and shouldn't) abide hunger, and that is a huge part of why normal "eat 20% less calories" diets don't work, even for people (like her) who have the capacity to measure it. Eating 20% less at 3 meals is also far more difficult (and will result in those leftovers) than eating less in discrete chunks by eliminating meals. Obesity (or lack of it) does not come from
But yeah, if you feel HUNGRY, a "diet" isn't gonna work, period. No one can manage long term hunger in a world that has so many easy things to eat.
Not to be internet nutritionist, but the the thing that everyone I've spoken to has worked (for varying quantities of "worked") for is adding replacing carbs with fat/protein (eat as much as you want for dinner, earlier is better) and then just extending the time period until you eat next (breakfast, or lunch, or later lunch, etc...) til whenever you feel hungry. If you feel "kinda" hungry, drink a zero-cal electrolyte drink first and then check if you still wanna eat a meal. Measuring whether you ate 1741 calories or 1787 calories is impossible.
And also, I just want to reiterate: obesity is a symptom of underlying nutritional condition, not a disease. Some people who have it are fat, some are not. It has bad effects even if you aren't fat. Semiglutides (being diabetes treatments) may somewhat treat the underlying thing (I don't know for sure) but if you adopt a diet that you enjoy, and your A1c and other metabolic indicators get better, you are HEALTHIER, and much lower risk for a long laundry list of bad outcomes even if you don't lose any weight, or never had much fat in the first place. Depending on *what/when* you eat, you (with your low BMI) might have less healthy A1c/etc... than your wife, with the potential bad outcomes. This entire thread is far too focused on treating the symptom of obesity and pretending that if we removed that, we'd fix the problem. (it is possible that semiglutides DO partially treat the underlying problem) There are too many skinny 60 year olds who die of things and we go "so sad, what bad luck, they were so healthy!" but if they were fat we'd go "oh man, if only he'd kept in shape" but they died of the same thing for the same reasons.
Well, those diets actually do work. Physics can't be cheated. That's a big part of the problem. Because it puts so much guilt onto people to whom it doesn't come naturally. The problem is that hardly anyone can put up with them for long enough to get into another mindset, where those changes suddenly come naturally.
Btw.: my wife never felt hungry during her time of losing weight, simply because she did ensure to always consume enough protein. The problem is that most foods which are easily available don't come with enough protein to do that. Just eating less doesn't cut it most of the time, as your diet then quickly become protein deficient. You have to adjust your food items a lot to do it. And then convenience goes out the window. That's what made my wife fail eventually as well after nearly making it into perfect BMI territory.
As for "Some people who have it are fat, some are not.": that's exactly what the term skinny fat refers to.
Just for the record: I never pressured my wife into doing any of this and love her just the way she is. I'm merely trying to recount her experience when she tried a few yours ago.
This seems an extremely weakminded and degenerate statement to make. Hunger is a natural and healthy state we evolved to cope with. Certainly you SHOULD abide hunger if you are an unhealthy weight
What about, like, peanuts, though? Peanuts are convenient, nutritious, and filling, but eating lots and lots of peanuts isn't very palatable. I don't think we can blame this on convenience, except insofar as convenience is one of several competing, difficult things we're trying to simultaneously optimize for.
Well, good point. What about peanuts? Answer: they are one nutrient, not a meal, and thus lack lots of crucial trace elements. To add insult to injury, opposed to what you said, they aren't convenient at all. Not only don't they solve the issue at hand, but additionally where I live they aren't really readily available. I can easily get french fries, burgers and various other fast food meals on the go. I've never seen peanuts on offer (for obvious reasons). I could go into a super market and buy some; but then again I still wouldn't have a meal, and rather just one ingredient for a meal.
That's the exact opposite of convenient. Rather hard to come by and still lacking all but one ingredients for a meal I still would have to prepare. As opposed to just ordering the Pizza, wait 5 minutes, eat ...
Nuts are kind of weird. I don't know if other people experience this, but when I get a sudden pang of hunger my body completely rejects my suggestions that we eat some nuts. I'll be super hungry, staring into my cupboard, and that bag of peanuts will be completely unpalatable to me. This is in spite of the fact that I love nuts as a snack.
It think it's something where my body doesn't want to deal with a hard and dense fatty food on an empty stomach. Combined with the fact that nuts are quite slow to affect my blood sugar.
In general I think something with starch and fiber is the best remedy when I get that kind of sudden hunger.
I've had a lot more luck with "eat normal portion sizes with fewer calories, and track what you eat." It took me from BMI obese to BMI normal and has kept me there.
Portion control went so disastrously wrong that I'm skeptical of it as dietary advice. It doesn't seem supported by a lot of evidence, either (e.g. https://www.nature.com/articles/ijo201482#Sec11).
Can you elaborate on the distinction you're drawing here? You said you succeeded with a strategy that sounds to me a lot like "portion control", but then say portion control went disastrously wrong?
If the food you eat is smaller in mass, it will make you psychologically feel starved and physiologically feel unfull. Your brain will interpret this as 'you are going through a famine' and flip switches that make you value finding food more, because that was the appropriate response to a famine in the environment our ancestors lived in for millions of years.
If the food is bulky but has few calories, like potatoes, this makes the body and mind feel like you have plenty to eat, even when you are burning fat to sustain yourself.
> To go with the biscuit, sailors in the RN were issued other food on a standard weekly rotation. On Sunday and Thursday, this was a pound of salt pork and a half-pint of dried peas. Monday was a pint of oatmeal, two ounces of butter, and four of cheese. This was also served on Wednesday and Friday, along with a half-pint of peas. Finally, Tuesday and Saturday usually meant 2 pounds of salt beef. Conventionally, this was washed down with a daily gallon of beer. The total came to approximately 5,000 calories a day, an incredible amount to modern eyes but quite appropriate for sailors at the time.
For comparison, 3000kcal/day is about my current maintenance (180cm 72kg male). And I am _definitely_ way less active (and less muscular) than a sailor or soldier in history (1-2 hours of mostly anaerobic exercise every day).
I think you're right, and the "diet" suggestions tend to be "just eat 10/20% less calories during the day" which isn't gonna work: people don't suck ass at it because they have low discipline, but because it's enormously difficult to measure calories in this scenario, and your behavior/brain/metabolism compensate it. It's not a single-input mechanism black box. Your 20 off, 20 on experience is the absolutely normal failure mode for calorie restriction diets.
Not to be the Weirdo Diet person , but what I mean is: intermittent fasting, cutting out breakfast (and/or lunch) and replacing enough of your daily quick-burn carbs with long-burn fat so you don't feel very hungry while you're doing it. This works because unlike calorie restriction, it doesn't cut against daily Regular American Life behavior (you "fast" every night from after dinner until break-fast, this is just a few more hours) and all the countervailing mechanisms your body has evolved over a billion years to counter generalized calorie restriction.
I don't eat breakfast. I've never felt hungry in the mornings, and when I do eat then, it (ironically) makes me *hungrier*, e.g. at around 11 o'clock I feel like I need a quick snack, whereas without eating breakfast I don't feel that and can even go without lunch.
So all the well-intentioned advice about "skip meals" or "don't skip meals" or "eat more protein" or "eat saturated - I mean unsaturated - I mean polyunsaturated, not monounsaturated - I mean saturated fats" or "just cut out the junk and move more, what's so hard about that?" becomes frustrating.
Human biology is not like a tidy physics experiment. It *should* be "calories in, calories out". It *is* "calories in, calories out* but that is *not* the whole of it, and that is what gets forgotten.
Some people will react beautifully to "I fast X hours a day from this time at night to that time the next morning between meals" but some people will not. Some people will control hunger cravings by eating breakfast, other people will have their appetite stimulated. Some people will tolerate more fat in the diet than others. Potato diet works for one person, packs the pounds on for another.
I think you are right within the realm of the recommendations you are describing, because they're so vague/contradictory. I'm not advocating any of the advice you're mentioning, which you are rightly skeptical about them applying to everyone. Calories in, calories out doesn't "work", as a METHOD of dieting, not as a thermodynamic fact.
But is there any debate at all that replacing carbs with fat/protein in a meal will not result in greater satiety/less hunger later on, and therefore enable one to go longer before their next meal? I think everyone agrees on that, and that it applies to everyone - sure, perhaps in different ways/amounts!
Does it seem acceptable that if you go longer between meals, that your body will spend more time burning energy than storing it? Sort of by definition?
Does it seem acceptable that this would then (regardless of totally weekly calorie consumption) result in storing less energy (fat)?
And again, the goal should not be "weight loss" it should be "reducing the unhealthy outcomes", the likelihood of which can be more accurately measured by metabolic lab values like A1c than at the scale.
If you're someone who's had a good BMI forever and doesn't get their labs done, then you're never gonna notice anything because you aren't measuring anything.
"But is there any debate at all that replacing carbs with fat/protein in a meal will not result in greater satiety/less hunger later on, and therefore enable one to go longer before their next meal?I think everyone agrees on that, and that it applies to everyone - sure, perhaps in different ways/amounts!"
No, not everyone agrees, and it does not apply to everyone. It absolutely does not work for me; restricting carbs triggers middle-of-the-night half-asleep binge eating.
(I'm not normally a binge eater at all; I've only ever had this problem when I've restricted either carbs or eating in the evening.)
"counting calories of every thing one eats, to the gram" is not extremely hard. i know so because I'm doing it, and i do not ever do anything remotely hard.
To do so accurately is hard, because even if you're measuring the weight, you're relying on estimates of calorie density that are potentially many years out of date, wrong in the first place, or that the producer of the food is wrong is assessing.
And ok, that it is easy for you is fine - for millions of other people, it would be A) hard B) sufficiently time-consuming they wouldn't want to do it or C) would result in no measurable effect on their health/weight, so they would stop doing it. Maybe "hard" was the wrong term to use.
The approach you are describing sounds reasonable, but, as with most weight loss approaches, there are a lot of things that will make it hard for people to stick with over the long run:
(1)It is hard to change ones habits, including one's eating habits -- not impossible, of course, but HARD. The effort and attention devoted to that have to come out of the same pot of energy people are using to do all the other hard things in their lives -- do a good job parenting their difficult kid, produce good work in their field, keep their marriage in good shape, budget, ruminate about all the bad stuff in the news. On days when the energy pot's almost empty, most reasonable people are going to choose to reduce their effort to eat in a different way, rather than their effort in other areas which are more clearly crucial
(2) It is a heavy burden to stay continuously aware of something. Take blinking -- if I ask you now to notice your blinks, it's easy as pie, right? But how about if I ask you to stay aware of them continuously for the rest of the day? Very very few could succeed at that, especially while doing all the stuff they need to get done today, and responding to whatever comes at them this evening. Continuously monitoring eating to keep it in compliance with a certain pattern is the same -- easy in the short term, very hard in the longer term.
(3) We are surrounded by highly palatable foods, and our brains are not wired for an environment with that feature. We evolved in settings where it was hard to get enough calories. If you found a honeycomb or were presented with a bunch of roasted animal fat it was desirable to eat as much of that stuff as possible. The parts of our brain that push us to eat the sweet, fatty, salty stuff that is all around us is quite powerful, and the part that understands that it's undesirable to gorge on those things on 2022 cannot reason with the parts that want to gorge. It is possible to simply override them, but it is difficult, and it's probably not possible to override them most of the time if you have other heavy demands on you as well.
1) the goal is not weight loss. That is a side effect. The goal is a healthy diet, and reduction of serious bad outcomes in the future.
2) Yes it is hard to change habits. That's why the method is designed to affect the underlying drives that cause the habits to be hard to change. It IS hard to not eat when you are hungry. It is EASIER to not eat when you have made decisions in the past that mean you are less hungry now. Eating more fat and protein in your past makes you less hungry now.
3) There are immensely palatable foods that are not bad for you, and will provide more satiety so you are not driven to consume more so soon. Animal fat is not (particularly) bad for you. Salt is not bad for you. Replace carbs with them in your meal, eat them, and enjoy not feeling hungry so soon. The goal isn't to override your desire to eat awesome tasty food, it's to hack the system so you eat awesome tasty food that reduces your desire to need to eat ANY food for longer.
This is not a moral system. There are not desires to be overcome. There is not decadence to resist. This is not ascetism. There is no willpower. This is a physical system of chemical reactions that we can affect in different ways. We impute no moral significance to a molecule binding to one molecule instead of another, nor should we.
I do think content is certainly as important as portions, if one wants to control obesity. The national health system is pretty good about listing contents on food products. We respond to heat, salt, and sugar, and food manufacturers exploit that. I think if one adheres to a healthy, lean diet, obesity is easier to control. Another important aspect is the consumption of alcohol. Alcohol can provide energy and calories, but can maintain too much weight in an unhealthy body.
I used to be borderline obese when I drank beer or wine, but I lost 75 lbs. when I came down with pancreatitis. Today, after the most recent flare-up, I'm down to 114 lbs. -- but still 6 feet tall. For a time I thought marijuana might help ease the pain, but now my body objects when I try and ingest it, so I've given that up, too. There are certainly no easy answers, but I think the content of one's diet and the consumption of alcohol are important factors. My stomach emptied with this most recent flare-up, which is unusual, so I'm taking the opportunity to curate what I ingest carefully. I'm drinking kefir and Gatorade.
In this case, the problem with “that guy” is not that he’s stating an uncomfortable truth; the problem is that he’s missing the point.
If you think that we should downplay pharma/surgical interventions because dieting and exercise “work,” it is incumbent upon you to show how we will overcome the fact that people don’t seem to have the willpower required to use these tools longterm. What’s your plan?
Willpower is a choice. In this study alone https://www.cuimc.columbia.edu/news/new-weight-loss-drug-approved-fda-it-right-you, 5% of participants on placebo lost 15% or more of their body weight. The average placebo loss was 2.4%. Granted both of these are hugely less than the treatment group, but they're also hugely less expensive. This is the case in every weight-loss placebo study I'm aware of, just the simple act of taking a pill (sub vitamin or other "healthy" pill they believe could affect weight for placebo in non-lab use) or putting an ab roller in the living room, or anything else that moves diet and exercise slightly closer to the forefront of mind than it was previously can have a significant effect. According to the paper, the lower end fda approved weight loss drugs cause a 4% weight loss, so assuming equal treatment time periods, placebo is 60% as effective on average as some drugs, at 0% of the cost. People are all different, they just need to figure out what best triggers that effect for them, whether it's my examples above (variations of which work for me) or something else.
"just the simple act of taking a pill (sub vitamin or other "healthy" pill they believe could affect weight for placebo in non-lab use) or putting an ab roller in the living room, or anything else that moves diet and exercise slightly closer to the forefront of mind than it was previously can have a significant effect"
Whether you're talking to me or not, the solution is to reduce the thing that is calling on their willpower. It does not take much willpower to not eat if you are not hungry. You achieve being not hungry by increasing the satiety of the food you ate most recently. Food that does that is that which has more fat and protein, and less carbs.
> Granted both of these are hugely less than the treatment group, but they're also hugely less expensive.
Breaking: doing nothing has no effect; is free
> According to the paper, the lower end fda approved weight loss drugs cause a 4% weight loss
Yeah, if you move the goalposts to “the worst drug on the market” the relative effect of the placebo goes up. This doesn’t bear on the article, which is about the best drug on the market.
Breaking: 16% of the improvement of the best drug on the market from taking a sugar pill is not "doing nothing" and is in fact statistically significant. That's why it's included in this paper, and every paper on weight loss drugs.
> This doesn’t bear on the article, which is about the best drug on the market.
No, if you missed it the article is about the best drug on the market and how unattainable it is to most people (and statistically those who would most benefit from it) due to cost. So if we can get 16% of the benefits for almost zero cost that actually a huge deal on its own, and this could likely be improved significantly with other tweaks, as I've now mentioned twice. Less snark, more reading comp next time👍
What does that even mean? You state that conclusion as if it implies something significant but, I'd argue, it's really just a way to summarize the relation between incentives and behavior. Some things we call choices because they result in different outcomes when you change the incentives (prison for murder decreases murder rater but prison for being short doesn't increase height much). I mean, if you really get down into the details the difference between 'choices' and 'non-choices' isn't that the laws of physics plus initial conditions are any less binding in one than the other or that the biology that happens in the brain obeys some other kind of principle than that in the rest of the body.
But, given that background, saying something is a choice is just a shorthand for describing how responsive it is to incentives. Certainly, choosing not to eat as much is more responsive to incentives than height is but it's a lot less responsive to incentives than many other things.
And once we are made aware of how responsive it is talk of whether it is a choice or not becomes irrelevant. It's like saying something is heavy once you know it weighs 100lbs. It's not adding any information about the thing or helping you figure out what to do with it. Same with weight loss it seems. Absent interventions we aren't willing to make (for good reason) many people don't lose weight but they do on the drug and that's all that's really relevant to deciding policy.
You're exactly right, except that I'm biting the willpower point bullet. Maybe I'm bad at metaphors, sorry.
The plan is this:
1. Forget calorie restriction of the "just eat 20% less calories" form. It requires too much calculation and willpower, and your body will compensate. Forget any diet that stops you from participating in normal social rituals with friends, coworkers or family.
2. Replace carbs in your dinner with fat/protein. Eat as early as possible, eat as much as you want. Don't eat bedtime snacks.
3. Over time, extend the time from ending dinner (your "fast" length) til the next time you eat (breakfast? 12:30 lunch? 2:30 lunch?) as much as possible. Eat the next day when you're hungry, but if you're only feeling kinda hungry try drinking a zero-cal electrolyte drink and see if you still want to eat. Measuring exactly 50/100/150 less calories a day is impossible. Measuring that you ate 10 minutes later is easy. Don't put any sugar or carbs in your morning drinks.
4. Eventually cut out breakfast or lunch, or eat later lunch. Just like dinner, replace carbs with fat/protein as much as possible. Whatever feels okay.
5. Get your yearly blood work done so you can see the improvement in your metabolic indicators. Most importantly: if your numbers get better - whoever you get the labs from will tell you the health ranges - FORGET YOUR WEIGHT, sell your scale.
These are’t terrible recommendations. I do some of the things you list, and it helps me maintain my bodyweight.
But do you seriously think that an epidemic of 70M obese Americans would be fixed if only people would read your five bullet points about intermittent fasting? As per Scott’s math, you are claiming that your tweet-length comment on ACX is worth 500bil. The market disagrees.
"But do you seriously think that an epidemic of 70M obese Americans would be fixed if only people would read your five bullet points about intermittent fasting? As per Scott’s math, you are claiming that your tweet-length comment on ACX is worth 500bil. "
Yes.
But humbly, my comment is worthless. It's the advertising and execution that matters. Any idiot like me can say "gee, maybe we should build cars in assembly lines with replaceable parts" but it takes Henry Ford to execute. Even tougher, the actual problem here isn't knowing what to do, it's teleporting what to do into the minds and 70M people and then they all have to execute. Which is why I'm babbling my insane, otherwise-worthless ideas in a place run by a person who seems to do a decent job of teleporting ideas into other people's heads.
To elaborate, yes, I really do think it's worth half a trillion, obviously conditional on people actually doing it (though the lack of difficult in doing so is the key feature) and the cost of the advertisement/propaganda to publicize it, and coach people through it. There are companies (look up Virtahealth) that provide physician-led diabetes reversal for a few hundred a year using similar techniques and coaching on it. My only disagreement is you're understating the worth at 500B, because that's only the (estimated) consumer value of "weight loss", because if all 70M people did those 5 things, it would also reduce the downstream occurrence of diabetes, heart disease and cancer as well. (claiming that reducing weight/improving metabolic health reduces those things is a boring conventional medical claim).
Also, re: "the market disagrees", as I pointed out, there are lots of (small) companies providing these services successfully and getting paid for them. Markets can agree in differing amounts, and markets also need information/advertising to match sellers and buyers. If "make cars with assembly lines" was an idea that didn't actually get Ford any money, but rather only gave distributed consumer surplus, he probably wouldn't have executed it.
And while I am a committed free marketeer, markets for services that provide little financial benefits to those who provide them often don't work! I'm not making any money from this. Doctors won't make any money from this - in fact, they will lose money because their gov-mandated quality metrics don't support this type of treatment for obesity or diabetes. Novo Nordisk doesn't make any money recommending this. No supplement or food manufacturer can make money from this. It's not really a product or service to be sold, though some (like Virtahealth) are.
Looked up Virtahealth. Digging in a little it appears to be "we will teach you to eat a keto diet, which will have so few carbs in it that your blood sugar will remain low enough without drugs to call it reversal, except we don't count metformin as a drug because some people like to stay on it".
As someone who took metformin for 3 months and *absolutely could not* tolerate the severe GI side effects, which I never built any tolerance to: lol. lmao, even.
I don't care how much fat you have, if you get a good diet your body will figure that out on its own. But also, yes, going from obese to just chubby IS correlated (but not causative!) with better health outcomes.
I want you to be healthier, which isn't measured on the scale, but in your blood work and in long term lack of massive health disasters like diabetes, heart disease and cancer. If you're still "chubby" but you don't get those things, well, great!
You basically call "healthy" being fat but not sick. Better than being morbidly obese and sick, I guess, but that's not saying much.
That's not good enough, people want to be "fit". You are right by accident with "health isn't measured on the scale" because yes, body fat percentage is what actually matters but it's very hard to measure without (other than doing an autopsy). Unless you are extremely muscular or have great bone density, the scale is a good measure of fitness.
If you want to be fit you can't eat ass much you want for a meal. The usual guides of 2000 kcal a day for the average adult male is probably too much already an puts you on a slight calorie surplus.
This comment is not worth $500bil because, like all comments in this vein, it fails to take into account the complexity of human nutrition. There is no list of 5 points that will work for those 70M obese people. For some, the drug will be the only way. For some it will be a completely different diet. For some, your comment will work, but I expect it to be a decisive minority.
Comments like this are more common than you think, and for me they are just too naive.
2. Literally more than half of my meals are just pasta/rice/bread. Seriously, it's a carb fest down here*.
3. My breakfast is literally chocolate chip cookies. It's one step removed to just shove down my throat spoonfuls of sugar. And it's not even that big of a step.
4. I never skipped a meal. The idea alone of skipping breakfast or lunch is abhorrent to my Italian brain.
And yet, I'm chronically underweight. The only point of yours that I feel to thoroughly endorse without a second thought is the first one.
My set of oversimplified comments will be: never eat sodas, almost never drink alcohol (less than one beer / glass of wine per month), keep a super regular schedule (breakfast lunch, snack, dinner) and never eat out of it (forget chips at parties etc), cook your own meals and eat fast food only occasionally in special circumstances (e.g. you're late for your plane).
Will it work for a "random you" reading? Hell no.
* The hate carbs are getting lately is really puzzling to me. Sure, fat isn't as bad as once thought. But this notion that its ills are solely the product of an evil carb industry that captured the government is ridiculous. I'm sure there is no fat industry that has ever tried to manipulate the public, and, if they do, they only have the public's health interest in mind.
Do not adopt diets to lose weight. Adopt a diet to be healthier.
This is the hidden problem* with the semiglutide process: if you take it, lose 20 lbs, fit into your old clothes and declare success, but you're still eating a constant stream of crap 3 times a day, you are still gonna have a higher chance of bad outcomes.
* it's possible that semiglutide is actually affecting your metabolism, in which case it might directly affect your metabolic health, in which case, good for it - it overcomes my "hidden problem" above.
"it fails to take into account the complexity of human nutrition. There is no list of 5 points that will work for those 70M obese people. For some, the drug will be the only way. For some it will be a completely different diet. "
Why do you think human nutrition is only complex on the downside (i.e. losing weight) - in reality, human nutrition is so non-complex that hundreds of millions of people - through diet/lifestyle changes alone - became overweight when before they were not. Nutrition is so non-complex that millions of people were able to gain weight literally without even thinking about it, like breathing.
"And yet, I'm chronically underweight. "
This gets back to my main point: don't focus on weight. Don't think I'm focusing on weight. It's a symptom that does not always present when someone has an underlying issue caused by terrible diet. The key is to increase healthiness (the highly costly downstream effects that we associate with obesity), NOT to lose weight - except that it is often an indicator. I'm not going to judge you, but what you describe yourself consuming does seem to be an unhealthy diet. The key is that unhealthy diets do not always result in obesity for, as you point out, a wide array of reasons, especially age. Would I be wrong in guessing that you're probably under 30?
There is no point whatsoever for you to lose weight, in fact, if you are truly the clinical definition of "chronically underweight" *that itself* is an indicator of even worse health outcomes than being mildly overweight! I am telling you that, in this thread about obsessing over spending 15k a year on weight loss, you could probably stand to gain some pounds. You are not the average American, and to the goal of this post (from Alexander's perspective) you are already cured. But not to my goal, because my goal is "be healthy, avoid really bad health outcomes" and there are people (yourself included) that can (again, going only on your self-report) have unhealthy diets, experience the higher likelihood of bad health outcomes, while not displaying obesity.
I recommend getting some blood work and checking your metabolic indicators. It is possible that you have an unhealthy metabolism without displaying obesity. There are all kinds of people who die of a heart attack at 55 and people go "but he was so skinny!". I
"The idea alone of skipping lunch is abhorrent to my Italian brain."
It's not your Italian brain. It's that for breakfast you consumed a great deal of sugar/carbs, which (short version) burn in your body very fast, (or are stored as fat, which obviously your body is not doing) and your body concludes it needs more quickly, so it tells you are hungry for lunch. The chocolate chip cookies are not unusual. Most cold cereal that anyone actually likes has a similar sugar profile. You are absolutely correct about one thing: people have radically different "energy intake -> how much fat they get" curves, and you have (whatever your age) the "18 year old boy" curve. But the underlying metabolism can be healthy or unhealthy, and one that takes in cookies for breakfast probably isn't.
"The hate carbs are getting lately is really puzzling to me."
From me, it's not hate. It's the simple fact (conventional scientific wisdom) that carbs (especially sugar) are (again, short version) burned faster (some types more than others) in your body that fat or protein, remaining available to be consumed for activity for a shorter period of time, and therefore when they're gone (or converted to storage) your body tells your brain it needs more. It is conventional wisdom that fat and protein create more satiety, which is longer time before hunger. Therefore if you wish to spend more time burning energy (in your case, you want this for good metabolism reasons, rather than weight loss) than consuming energy, and to reduce hunger, carbs are just objectively inferior to fat/protein. It's not some theory that carbs infect your body like poison. Well, except for sugary high fructose corn syrup sodas, those are definitely poison.
About the complexity, I'm unconvinced that people having tried a million things and still being unhealthy is a proof that nutrition is simple. The two doesn't seem to follow.
Anyway, just because you asked, if you were to see a picture of me, you'd think I'm under 30 -- I've got such a baby face, no wrinkles, no grey hair. But I'm 38. And actually I checked, my BMI is 19 (roughly, I don't own a scale) so I was actually wrong about the underweight thing. I'd love to gain a few pounds, but I'd rather them being muscles rather than just fat, this clashes with my couch potato nature unfortunately.
The bit about being Italian is a poor attempt at conveying the memetic nature of eating. Really, the horror of skipping meals has nothing to do with how fast carbs burn (and, again, in the tangent of the carbs, Deiseach writes better than I can the fact that a model that lumps in the same class coca cola and polenta isn't... great?). It's just that meals are a sacred tradition. So my "one neat trick, nutritionists hate him" is: let's just get better memes about food. Italian memes seem to be working well.
This religious aspect colors my opinion, and then I asked myself: if I were to follow your advice, I'd only have one meal at day (dinner) and it should be mostly fat/protein to cover my entire daily calorie intake. Is that even physically possible?
Other than that, in many things we agree, I don't think the pill treatment is the best, since it's unclear whether a taker will then have to be on it for the rest of their life (15k/year, yikes). But if someone there's no other choice, why deny it?
"The hate carbs are getting lately is really puzzling to me."
Oh, diet recommendations have swung around all over the place. Fats of all kinds are bad for you, replace those fatty foods with (carbs) and (protein). Take the skin off chicken, trim the fat off red meat.
Then it was "not all fats", it was saturated fats, so consume unsaturated fats. Then it was well monounsaturated fats are bad for you, only consume polyunsaturated fats. Omega fats such as found in fish good for you! Well, no, hang on, too much omega-6 is bad for you, you need to up the omega-3 (jury still out on omega-9 for the moment, I suppose).
Dairy bad for you! Dairy good for you! Confused yet?
Then it was red meat is bad for you in excess, so that was (protein) the bad guy. Then smoked meats, because carcinogens.
(Carbs) were still okayish, but then SUGAR - THE PRIME EVILLEST EVIL THAT EVER EVILED. So cut out all the sugary junk (good enough advice). Then that expanded out into other carbs. Simple carbs like potatoes and rice and bread and pasta - bad. Need complex carbs. GI index, so forth and so on.
I think the swinging pendulum of "X is bad, Y is good - now X is good and Y is bad" is down to the complexity of nutrition and metabolism. People are getting fatter and unhealthier, how is this? The simple story of "consuming more calories, and being more sedentary, than past generations" seems not to be the whole picture. So there must be a 'bad' food or class of foods.
Fat makes you fat, right? So fats bad! Cut out fats!
Okay, people still getting fatter - why? how come?
Carbs bad?
Protein bad?
There will be people who eat lots of carbs or fat or protein or whatever, and don't get fat/are chubby but healthy. There will be people who cut out carbs or fat or protein and are fat/unhealthy. There is no simple "one easy fix, just change your portion/plate size and eat six tons of lettuce" cure.
I joke, but it's only half a joke, that the next recommended diet will be "you can only safely consume moss and water".
You know, I gained most of my body weight and reached my fattest point doing exactly that: keto, skipping meals, tons of water and zero calorie drinks. So I'm extremely skeptical of this being useful advice.
My numbers just got worse and worse until I bit the bullet and had them cut out half my stomach and part of my intestines.
"Get your yearly blood work done so you can see the improvement in your metabolic indicators. Most importantly: if your numbers get better - whoever you get the labs from will tell you the health ranges - FORGET YOUR WEIGHT, sell your scale."
Yes, Brian, but you are forgetting one thing - people in the street can't see your bloodwork numbers, they can see your double chin.
*That's* the metric by which people, including doctors, judge are you 'healthy' or not. I take your point that people confuse "healthy" and "thin", but given all the messaging about "fat is unhealthy", can you expect any different?
About ten to fifteen years back, I had *great* bloodwork numbers. I was still visibly porky. I still had kids yelling at me in the street about being an elephant. I still had at least one doctor visibly and openly furious with anger that he could not punish me for being fat because my blood work didn't back him up.
If you're pudgy, that is the metric society, and you yourself, judge you on. Have you dropped two dress sizes? No? Then it doesn't matter if you can run a mile or have perfect cholesterol levels, you are part of the obesity epidemic that is blighting our healthcare system.
(There's particular irony at work here; I have a sibling who has a thyroid condition and they have to be ultra-careful about their cholesterol levels and fat intake. They are also 'normal weight'. So anyone looking at the two of us together and being asked "who has the high cholesterol?" is going to pick me, the fat hippo. They'll be wrong, but they still won't change their mind - oh that number doesn't matter, we all know being fat is bad for you).
Improving or maintaining your health is worth doing if feasible.
The simplest thing I can think of to solve the prejudice against fat people is a famine, and it isn't worth it. It might not even work.
An expensive preventative for heart disease might work, but that's another version of turning being fat into a status symbol (perhaps an expensive watch is also required). This is better than a famine (do I need to say that?) but way short of excellent.
Yes, I don't know what to do about that, except advertise the fact that bloodwork is a better indicator than weight. The only thing I do know is that, in the case of "good bloodwork, overweight" the answer is NOT "$15k a year semiglutide" or "high mortality-rate surgery."
Speaking as a Person Of Amplitude, I think obesity isn't one disease (since we are now calling it that) but a range of factors that have been lumped under the one umbrella of "you're a fat pig".
(1) People who are naturally chunky versus those who are naturally skinny. I think we all know or have seen people who are like twigs, who don't put on weight, who have thin little limbs like sticks. That's not because they're dieting themselves down to that weight, it's natural for them. On the opposite end, I submit that there are people who are naturally going to be chunkier than the median, because that's how their metabolism is set up. They will go a few pounds over what is considered optimum weight, and if they go too far over, their doctor harrumphs at them about "diet and exercise" and they do that and lose the weight. It'll be tougher for them to keep off the weight and they will have to make lifestyle changes like "I can't eat birthday cake ever again", but in the main it will work for them. At the worst, they'll be 'pleasantly plump' or a bit chubby, but not grossly overweight.
An example of someone naturally skinny who is not doing cooking episodes about salads:
This is the good old "willpower" argument: if Joe can lose ten pounds simply by not stuffing his face with rubbish, why can't you?
That brings me on to:
(2) Slowing-down of metabolism. Middle-aged spread. "When I was younger, I could eat what I liked but now I eat the same and put on weight". People get more sedentary, they eat more convenience food, lifestyle changes.
Again, "diet and exercise" will help here. It'll be tougher, but if you were one of the 'naturally' slim types, it helps. Again, you'll probably have to make some lifestyle changes, but you will be able to get off the weight.
(3) Weight gain due to medication. I think we all know about steroids (my late father was put on a course of them and ballooned up, even though he wasn't eating more) and there are other medications with the same side-effects. It's difficult for people who gain weight like this, because they treated like the rest of us greedy lazy porkers, and get the "oh that's only an excuse" response unless they pull out the prescription to prove what they are saying is true, and who wants to have to reveal that *ackshully*, I'm on anti-psychotics which is why I'm stuffing my face with carbs?
Hard case here, since once you don't need to take the meds anymore, you will go back to your natural weight - unless of course you need to constantly be on psych meds, which means increased appetite/weight gain, which gets you the "just have some WILLPOWER" argument from everyone.
(4) And last, the rest of us fat, lazy, greedy slobs with no willpower who just stuff our faces with junk food and never get up off our idle behinds and just go for a walk or something.
The gluttons. The "why don't you just have some WILLPOWER?" people. The "diet and exercise, you moron, never heard of that?" folks.
And you know, there is something to that. Yes, we eat too much. Yes, we don't exercise enough. But, like the anecdote related in Dante, when the bishop asked his servant "What do the people say of me?" "Your Grace, that you are always drinking" "Ah yes, but I am always thirsty" - we're always hungry.
Scott mentioned a few years back examples of patients who suffered from unrelenting thirst, who had to be monitored with their fluid intake or else they would literally drink themselves to death, and even when they got enough to drink would still feel thirsty.
Nobody is going to condemn someone who is guzzling pints of water "Just have some WILLPOWER!", because they realise that's not normal and is indicative of a problem.
Now, for the likes of us that are always hungry and never feel full, even when "but I just ate a full meal a couple of hours ago, I shouldn't be feeling hungry", it's hard. Because yeah, you can visibly see we are gross landwhales. And yes, we are leeching the health services normal people should be using with our horrible diseases of obesity that are all our own fault. And yes, calorie-laden tasty modern processed foods, and yes sedentary lifestyles, and yes over-eating and being greedy, and yes diet and exercise work to a degree, and yes "why don't you just have some WILLPOWER?" and get used to feeling pangs all the time. And yes, "I'm big-boned/it's my glands/it's PCOS/it's a response to trauma" do get used as excuses. Yes to all of that, yes I admit we do contribute to our own problems. Having said that:
Do you really think it's a simple problem of NOT ENOUGH MORAL FIBRE once people are desperate enough to have the likes of this done in order to lose weight?
"Roux-en-Y (roo-en-wy) gastric bypass. This procedure is the most common method of gastric bypass. This surgery is typically not reversible. It works by decreasing the amount of food you can eat at one sitting and reducing absorption of nutrients.
The surgeon cuts across the top of the stomach, sealing it off from the rest of the stomach. The resulting pouch is about the size of a walnut and can hold only about an ounce of food. Typically, the stomach can hold about 3 pints of food.
Then, the surgeon cuts the small intestine and sews part of it directly onto the pouch. Food then goes into this small pouch of stomach and then directly into the small intestine sewn to it. Food bypasses most of the stomach and the first section of the small intestine, and instead enters directly into the middle part of the small intestine.
Sleeve gastrectomy. With sleeve gastrectomy, about 80% of the stomach is removed, leaving a long, tube-like pouch. This smaller stomach can't hold as much food. It also produces less of the appetite-regulating hormone ghrelin, which may lessen the desire to eat.
Advantages to this procedure include significant weight loss and no rerouting of the intestines. Sleeve gastrectomy also requires a shorter hospital stay than do most other procedures.
Biliopancreatic diversion with duodenal switch. This is a two-part surgery in which the first step involves performing a procedure similar to a sleeve gastrectomy. The second surgery involves connecting the end portion of the intestine to the duodenum near the stomach (duodenal switch and biliopancreatic diversion), bypassing the majority of the intestine.
This surgery both limits how much you can eat and reduces the absorption of nutrients. While it is extremely effective, it has greater risk, including malnutrition and vitamin deficiencies."
Reading those comments, they resonate with me. Constantly eating, never feeling 'full', eating until so stuffed I might throw up, And I've tried diets and they've worked - for a time. Then I plateau at a certain weight, and something happens (the last, most successful diet, I got swine flu then the weather was so unseasonably bad I couldn't go out for exercise) and I fall off the wagon and put all the weight back on.
So yeah, maybe all I need is some WILLPOWER, can you tell me where I can obtain a shot of that, because I don't manufacture enough myself? And that's where the "moral failing" angle of the condemnation of the overweight comes in - if we just gritted our teeth and scrunched up our eyes and *willed* hard enough, we could do it!
I don't know if this new drug *is* a miracle cure for weight loss, I think like all new treatments it is being hyped out of enthusiasm. Once it settles down, I think it's more likely to be at the 60% end of the successful treatments scale. And this is something you have to take forever, or else you will put the weight back on. And there probably will be some people for whom it doesn't work - I've had at least two medications prescribed where I was told that a side-effect was weight loss so that would help me, and no, it didn't happen at all.
So yeah, "CICO" - but that's simple. Why people consume a heck of a lot more CI than expend CO is the hard part to solve.
This doesn't respond to most of your very valid points, and it's definitely not meant as a "just exercise more" response, nor to suggest it will solve all your weight problems, but I think it is likely to be more effective and metabolically helpful than most forms of workouts: have you looked into Zone 2 exercise? Peter Attia has a number of podcasts and videos on it, and it's the central plank in his treatment of patients with metabolic disorders.
Briefly, zone 2 exercise is low intensity exertion which stays just within the energy regime at which the mitochondria in muscle cells can burn fat to supply the fuel they need. By training within that zone, not only are you specifically burning fat, but you are also training your mitochondria to be more effective at utilizing fat and less dependent on glucose, thus improving your overall metabolic health.
A simple way to try it is to get a cheap used rowing machine or exercise bike, set it up in front of the TV or computer, and ride them for 45 minutes to an hour at the intensity level that lets you still just barely breathe through your nose or maintain a conversation. Aim for at least 3 hours a week; more is better.
I'm surprised that you, usually a defender of religion and traditionalism, would have such a view on willpower. This isn't a criticism--when people are too predictable in their views, I tend to wonder if they ever think for themselves.
Isn't gluttony one of the seven deadly sins? Sin is part of the human condition, and the seven deadly sins are remarkable for their mundaneness: probably every person who ever lived has been guilty of all of them on a regular basis. But that doesn't mean societies (and not just Christian ones!) don't or shouldn't blame people for being lazy, angry, greedy, arrogant, or gluttonous. The purpose of the blaming and shaming is to discourage the sin by imposing a social cost. Just willpower alone may not be enough for someone to not have bursts of rage or to not eat to excess, but the combined effect of willpower and social disincentives might be enough to make people relatively healthy and well behaved. And so, in moderation, fat shaming is good in the same way that small amounts of sloth-shaming and wrath-shaming are good.
"I'm surprised that you, usually a defender of religion and traditionalism, would have such a view on willpower."
Oh ho, friend! What do you think I am, a Pelagian heretic?
We can do nothing of our own will to be freed from sin, we need the help of grace. Gluttony is a sin, but willpower alone won't free you from that sin.
I haven't enough willpower natively, I need the injection of it from outside to help me . Shaming people and blaming people is not that help.
God alone knows. If I were a totally different person with a totally different personality, maybe I would love exercise, or be able to muster willpower to only eat three slices of carrot and six heads of steamed unbuttered unoiled unsauced* broccoli for every meal.
*I mean white sauces like bread sauce, parsley sauce, cheese sauce, onion sauce, etc . The ones made with flour and butter and hence Bad For You.
"We can do nothing of our own will to be freed from sin, we need the help of grace. Gluttony is a sin, but willpower alone won't free you from that sin."
My theology is rusty, so forgive me if I'm wrong, but aren't we supposed to at least try? No Christian I've met has ever said "don't worry about it and sin as much as you want, because God will forgive you". At the very least they stress repentance, which doesn't sound very different from accepting blame--and when done publicly, it's not very different from shame.
"Eat less, cook instead of ordering takeout, walk instead of bus, bike instead of car, etc."
Excuse me while I rock in my chair, laughing.
In my 30s-40s I was one of the fittest fat people you'd ever meet. I can't drive, and there isn't a bus service in my town, so I walked everywhere I needed to go. Sometimes I'd cycle. That was my entire life, pretty much (if I needed to go somewhere further than my local town, I'd get the intercity bus or a lift from a family member with a car).
I had tree-trunk calves from about the age of twelve from all that cycling and walking and carrying things while I walked. Did it make me lose weight? No, I was still podgy of body and pudgy of face. But I was *fit*.
So yeah, "just exercise more and it'll drop off" was always a source of amusement to me. I once, due to a screw-up in getting paid, while living away from home spent an entire week living on soup once a day and (of course) walking everywhere. I was at the point of fainting into bed at night, but the one bright spot was that surely I'd lose *some* weight.
Guess what? No. Maybe a pound or two, but nothing significant. My body was grimly hanging on to the fat reserves come hell or high water. The biggest disappointment of my life, but the reality of what the hell my metabolism is and I don't know why. I keep being told my thyroid levels are fine, but I don't know.
[speculation] In men it's mostly testosterone levels. It signals the body to both repair+increase the muscle mass AND not to burn muscle for energy when on a calorie deficit. Some people will never be lean as their bodies prefer shedding muscle before burning fat.
There's also probably some other factor regulating this behavior. IIRC there's a yet unexplained effect of anabolic steroids that makes fat burning more predominant even beyond what would be accounted by the muscle gain. It could be that steroids activate what naturally lean people have going.
Did you grow up food-insecure? Because this sounds pretty in line with the 'thrifty phenotype/epigenotype' hypothesis: your body is hanging on to those fat reserves because experience has told it that reliable access to food is not something it can take for granted. Maybe the hunter gatherer lifestyle that it's adapted for needed all that fat when it was living on raw tubers and bugs for months on end, and it doesn't think a week on soup is an emergency worth burning more than two pounds of fat for.
I wouldn't say that, but there is obesity on one side of the family, so you tell me if it's genetics or what at work.
Also Irish, so... descendant of the people who *didn't* die in the Famine? 😁
Some of it is environmental/genetics, but some of it must be bad habits and no willpower, since I have a sibling who has the opposite problem (they get stressed and stop eating and over-exercise and are always skinny; I get stressed and comfort-eat).
Tangential to your main point (that one can't really lose weight by pure exercise), which so far as I know is quite accurate, I thought it might be worth mentioning that a pound or two is a pretty significant weight loss for a week.
1 lb = 3500 kcal, so if you actually lost 2 lb = 7000 kcal that implies a deficit of 1000 kcal/day, which would be very noticeable indeed. The basal metabolism demands for a 5'4" female age 35 at 135 lb is ~1400 kcal, and walking tends to burn ~200-350 kcal/hour, so to run a 1000 kcal deficit daily one would have to cut the usual ration by two thirds, walk 3-5 hours a day, or some combination of both -- pretty harsh.
I think Gary Taubes in one of his many diatribes against calories in/calories out points to some empirical evidence that if people exercise they almost always boost their intake more than enough to compensate for the calories burned, because exercise makes you hungrier of course.
No, the first weight you lose is water weight. It's easy to 'lose' weight like that, but it's not shifting fat. I was disabused of that the first time I had stuck to a diet (as advised by my doctor to go on a diet), lost a stone, and went back to report all pleased with myself.
Doctor told me that was just water weight, I hadn't really lost fat, and I would have to continue on a lot longer to really start losing weight.
So living on a bowl of soup and lots of water per day for a week got rid of some of that water weight, but didn't kick off the fat-burning. And of course once I got my money sorted out and could buy food, I went back to eating normally so naturally no weight loss. If I stuck to "one bowl of soup a day" for a month, then maybe real fat-burning weight loss would have happened.
The amount of water (and of (literal) shit) in your body can fluctuate by more than a pound or two -- you're better off treating the last digit of your weight as a random number generator. See _The Hacker's Diet_.
I don't even have a car or a bike, and since covid I also started avoiding buses. I walk to my work for 40 minutes.
I admit I could work harder about the eating less part.
The meta-point about the traditional advice is that either you need to do it 100% right and mere 90% gets you nowhere (possible, but then it would be nice to admit that following the advice is harder than it seems), or just one part of it is the real advice and the rest is bullshit (also possible, but then please stop telling the bullshit parts).
1. Forget calorie restriction of the "just eat 20% less calories" form. It requires too much calculation and willpower, and your body will compensate. Forget any diet that stops you from participating in normal social rituals with friends, coworkers or family.
2. Replace carbs in your dinner with fat/protein. Eat as early as possible, eat as much as you want. Don't eat bedtime snacks.
3. Over time, extend the time from ending dinner (your "fast" length) til the next time you eat (breakfast? 12:30 lunch? 2:30 lunch?) as much as possible. Eat the next day when you're hungry, but if you're only feeling kinda hungry try drinking a zero-cal electrolyte drink and see if you still want to eat. Measuring exactly 50/100/150 less calories a day is impossible. Measuring that you ate 10 minutes later is easy. Don't put any sugar or carbs in your morning drinks.
4. Eventually cut out breakfast or lunch, or eat later lunch. Just like dinner, replace carbs with fat/protein as much as possible. Whatever feels okay.
5. Get your yearly blood work done so you can see the improvement in your metabolic indicators. Most importantly: if your numbers get better - whoever you get the labs from will tell you the health ranges - FORGET YOUR WEIGHT, sell your scale.
Hey you have described your weight loss system multiple times here. I think readers get it. You sound like you think the reason we're not all converts is that we do not understand your system, and need to hear it explained again. In fact, people are telling you multiple reasons why things along these lines have not worked for them, and/or multiple reasons why they believe such things generally do not work for many people over the long run. Are you giving any thought to all this testimony and all these ideas?
"Are you giving any thought to all this testimony and all these ideas?"
Absolutely, previous people's testimony and experience (of which all of the versions given in this thread are a subset - not as a critical judgment of them, just that diet advice almost always fails in relatively predictable ways) is the reason this is my plan, instead of being traditional stuff like weight watchers calorie restriction.
"Hey you have described your weight loss system multiple times here. "
Well, not to be rude, but if you're describing it as a weight loss system, then I haven't explained it well, because it's not a weight loss system, it's a "increase healthiness system" and I posted it here because I think focus on specifically weight loss via semiglutides or surgery is part of the problem.
"In fact, people are telling you multiple reasons why things along these lines have not worked for them, and/or multiple reasons why they believe such things generally do not work for many people over the long run."
To be very specific, no one I've seen so far (maybe I missed it) is saying they have tried something like this and failed, (whereas I personally have succeeded, and know dozens of other real live people whose testimony is that it works) and the "such things" they present are often critically different in major ways that are also exactly the reason I present this strategy as an antidote to them. You're essentially saying "well, all these other people have tried such things like, leeches and balancing bodily humors, why do we expect your plan to take antibiotics to work?" Maybe I'm arrogantly assuming my method is superior, but it was created (not by me!) precisely to incorporate what you're saying - the testimony of millions of people saying that previously recommended "diet" advice didn't work. The key is in the "what" is being recommended, and whether it goes against the grain of how we understand humans and their metabolisms to function.
Additionally, when people are saying "diet advice X didn't work for me" in this thread, in every case they have cited weight. This is the part I want to repeat more than my strategy: don't measure success on the scale. You can't timetravel to see if you get diabetes 25 years from now, you have to get bloodwork done, or you have to read all the papers describing the other markers you can see to detect a healthier metabolism, or get a continuous glucose monitor, or you have to take my word for it. (This cost of this measuring indeed a major failure point of my plan, which you should critique)
OK, Brian, I have tried it and failed, and by failed I mean not simply that I did not lose weight, but that I did not stick with the plan. I had been reading about carbs, and how processed carbs and sugar do not really satisfy and you make you crave more of them. So I planned to follow a regimen of eating nothing sweet except fruit, not much refined flour & the like, and lots of protein, fruits and veggies. I did not avoid animal fat. I am a vegetarian, but ate lots of sharp cheddar, an animal fat favorite of mine. I did not count calories. I was not solely focused on losing the 20 pounds I wish I were not carrying, but of course that was on my mind. It is simply impossible not to care about that. And I did deviate from the approach you describe in that I did not make insanely delicious meals that gave me deep satisfaction. I absolutely hate cooking, and am simply not willing to take much time away from activities I value in order to do awesome cooking.
I have stuck with the no-sugar part for several years now, and find that cookies etc. are no longer calling my name when I'm in a bakery. However, I have not stayed with lots of fruits and veggies, I have slid back into eating simple carbs, things like slices of white bread, because I like them and they're easy to grab . And I never did do the part of preparing wonderfully palatable meals. The things that have kept me from sticking to my plan are things like this:
-Most vegetables are not pleasant to eat unless you chop them up and put a nice dressing on them, or cook them. I hate doing food prep. If I'm busy, tired, or preoccupied with something else important to me cooking is the first thing to go.
-I default to eating lots of cheddar cheese and little else -- because I'm out of fruit, and the veggies I have need prep to be bearable. I got busy and did not shop.
-I get busy doing something important to me, miss a meal, then am so hungry I grab whatever's handy that I can stand -- cans of cashews, lumps of cheese, fried stuff from Uber eats.
Obviously I *could* have done other things at those times. I could have made a salad or cooked the veggies or made an awesome delicious meal. I could have shopped more often so there was more healthy stuff in the house. I could have not let myself get so hungry. But it is an illusion that knowing that makes it likely that in the future one will act differently. The same factors that led to suboptimal eating in the recent past are all going to be there in the near future. Habits are hard to break, and the breaking of them draws on the same limited pool of energy and self-monitoring capacity as all the other things we need to accomplish. Eating is a simple pleasure and doing it provides a break from life's demands. Turning it into something that must be done a certain way both reduces the amount of simple pleasure in the day and also adds a new demand. That's a hard sell. There may exist some heaven of healthy eating, zero minutes per day of craving things that are unhealthy, and amazingly delicious meals that satisfy the living daylights out of a person, but then again there may not, for all of us. And even if it does exist, getting there is no easier than accomplishing lots of other goals we have for our careers and relationships, and far more dispensable.
isn't the way that semaglutide works is by making you feel full and satiated after eating? of course you need to be changing your diet -- if you continued eating the same way, you wouldn't be able to lose any weight. the hard thing about losing weight is that your body will do anything it can to make you eat the calories you're trying to avoid (and will hold on to the fat it already has, although that can usually be overcome with enough time). the brilliance of this drug is that it basically helps you stick to a diet.
IMO exercise doesn't actually help you lose weight anyway except insofar as it helps you build muscle, which makes your metabolism higher, but it's a good thing that people should do regardless.
re: diet, I think semiglutide might being affecting your metablism too - hence its use as diabetes drug, but I'm not educated enough to know for sure.
re: exercise, yes, it may not make you lose weight (in fact I think you should gain weight, if you're doing strength training) but it makes you healthier.
And to dovetail both: we want to be healthier metabolically, that is the goal. Weight is just a symptom that we only care about as potential signal.
This jives with my experience on the drug earlier this year. I was on living primarily on pre-made keto meals and after starting on semaglutide I felt like it was too much food for a setting, switched to a lower cal option. When shortages of the drug caused me to miss a few weeks, the lighter meals were quickly noticed as not-satiating.
While this is technically true, there are a *lot* of things that would be unnecessary if everyone in the world always made good decisions and showed perfect discipline at all times and experienced no akrasia at all. That world would look extremely alien to the one we actually live in.
Given that we live in a world of imperfect willpower and decision making, finding ways to mitigate the consequences of those failures is both important and valuable.
I will say, though, this is one of the areas where I feel like government intervention may be warranted, or at least could have good outcomes. I don't think people would suffer if there was a tax on fat and sugar above a certain point on all foods such that all their food choices were healthier.
Wait, I've got an idea. Let's put everyone on the diet-that-can't-fail. Then, we can piggyback all the other things people have trouble sticking to onto it, like ornaments onto a Christmas tree: Every time you have a proteiny meal, write down a work goal for the next few hours -- productivity solved! Every time you lose a pound, pay any unpaid bills -- budgeting solved! Every time you lose 5 pounds, spend an afternoon working on that great idea you had that you've been procrastinating on fleshing out -- getting rich and famous solved!
Nope. It is the semaglutide. See my comment below for details. I lost 20% of my weight (55 lbs) in 14 months. I did not change what I ate (good fresh home prepared food) or how much I exercise (mostly an hour a day of walking). I just ate less of the same stuff.
Meh, I recommend weight loss to my diabetic patients until I’m blue in the face and for years nothing changes, but when I put them on GLP-1 agonists they generally do. Same for SGLT2 inhibitors. Some times it’s so dramatic that I get worried they have some kind of occult cancer until I hold the offending medication and the weight loss plateaus.
I'm 6 foot and was 235, took it and I'm now at 180. Uncle took a different glp-1 same thing happened. These are miracle drugs for most people. I also got upset stomach, and bad heartburn but that went away with the weight loss.
It’s quite disturbing how pills have become the answer to everything these days. The opioid crisis in rural America is a good example of what happens when pills are handed out like crazy. Nowadays any hyperactive kid is given what is essentially meth, anyone who is depressed is given SSRIs, etc. Big Pharma is swimming in money from America’s pill culture.
Edit: Okay, I’ll explain. You state that you hope semaglutide can be part of a transhumanist culture where all problems can be solved via taking pills. In this world, all of society’s ills can be solved via medication. We could also get rid of any disease, of anxiety, of depression, etc. Now, this does sound like a utopia… expect that it ensures that pharmaceutical companies will maintain an iron grip on society, like in Huxley’s Brave New World where Soma “solved” everyone’s problems. But we’ve seen from Big Pharma the failures of this method, most recently Purdue Pharmaceuticals being responsible for thousands of opioid overdoses a year. And you mention that semaglutide increases the chance of certain cancers. Who knows if there are more long-term side effects that may occur while taking it, just like with Oxycontin? That was supposed to be a miracle drug too, and look what happened.
Also, in a perfect transhumanist fully-automated-luxury-space-communism world, would obesity really exist? Everyone would have perfect GMO food engineered to be as delicious and nutritious as possible. No one would even be fat to begin with unless they want to be. In that case semaglutide would not be necessary at all.
Also, the promotion of semaglutide would divert attention from the current problems of food deserts. Instead of making sure communities have access to cheap and healthy food, it lets food companies put out as much junk as possible and hope the pill fixes everything. In addition, semaglutide would increase America's problem of instant gratification without facing the consequences, which many members of Red Tribe see as a problem (bootstrap theory/no holdouts ethos).
And then there's the whole other can of worms about transhumanism and designer babies and what it means to be human. But let's not even get into that.
Trivial warning (1% of ban) - please try to justify your opinions instead of just asserting them hyperbolically. If there's a controversial question (like whether the current amount of these medications is good or bad), explain your position such that someone on the other side could understand where you're coming from.
I really don't like these trivial warnings. Just the word "ban", even preceded by "trivial" and "1% of", has a chilling effect on free speech. Nothing that isn't worth more than a 1/3 ban should have a warning, in my opinion. If it's really a "trivial warning", why do you need it at all? Why not just state your point directly?
I disagree. Free speech is an important value, but it need not be the paramount value in all situations. A moderation policy that has a "chilling effect" on posting unsupported hyperbolic assertions should be seen as a good thing. If people want to make bold unconventional claims with strong moral implications, it is perfectly reasonable to expect them to explain their positions. The use of words like "warning" and "ban" sends a clear signal that low-quality comments that do not contribute substantially to the discussion should be avoided at all costs.
Thanks for pushing back on this. I'll think about it more, but two reasons I'm doing it this way now:
- I like to have these in my List Of Warnings I've Given so I can interpret people's future offenses in the context of past offenses. I suppose I could do this quietly, but it seems less transparent.
- I like to have separation between my role as moderator and my role as a commenter just like everyone else who sometimes disagrees with you guys and gets angry. Otherwise I worry that everyone I disagreed with would interpret my disagreement as "the moderator doesn't like you and is gearing up to ban you", whereas in most cases I appreciate your feedback but still disagree with it.
- I really do feel like King Canute turning back a tide of bad commenters, and I'm more worried about not doing this enough than about accidentally banning an innocent person. If chilling effects cause one warning to chill five people, that's a victory in my book (even though it sounds kind of offensive to say it that way)
- I do feel like this conversation went well and that speaks well of Sheluyang, but a lot of people respond with "@#$% you, I'm leaving", and for those people, that is a good outcome.
Thanks for taking my concerns seriously! I really appreciate that you took the time to read my comment and give a detailed response.
My opinion is that "doing this quietly" is the better option, even though it is slightly less transparent. Everyone already knows that their offenses will be judged in the context of their previous words. That's as true in real life as it is on the Internet. A "trivial warning" presumably won't shift the balance that much in favor of a ban anyways, and that's the way it should be.
I don't know how to turn back a tide of bad commenters, but I doubt banning and scaring people is the answer. We already have plenty of heavily moderated (I would say "censored") online platforms. The more open you can keep your platform, the more valuable and distinctive of a public service it is.
Chilling out these kinds of comments is the intended and justified result. No one has a right to comment on Scott's blog, it's a privilege that Scott and Substack allow us.
> Expect that it ensures that pharmaceutical companies will maintain an iron grip on society, like in Huxley’s Brave New World where Soma “solved” everyone’s problems. But we’ve seen from Big Pharma the failures of this method, most recently Purdue Pharmaceuticals being responsible for thousands of opioid overdoses a year.
How is this different from the fact that we abandoned subsistence farming, but now agricultural companies have an iron grip on society because we can't get food without them? How is it different from using electricity for warmth but now utility companies have an iron grip on society?
The problem with opioids is that they're addictive and potentially deadly. Semaglutide doesn't have either of these problems. I agree you can think about this on a very broad level where drugs are inherently scary and even if we don't think they have side effects they probably do. But I think that level is the wrong level, and if used consistently would have you avoid stoves because eg fire is bad.
> Also, in a perfect transhumanist fully automated luxury space communism world, would obesity really exist? Everyone would have perfect GMO food and no one would even get fat to begin with. So the idea of using semaglutide to cure obesity is self-defeating.
In a perfect transhumanist world, obesity wouldn't exist because we would have some powerful technology that could eliminate it. I think medication is the most likely such technology. Maybe in the far far future we will have even easier and better technologies, but I don't think we should skip the first just because there might be other ones decades down the line.
I remember a piece you did some years back. It's one of my favorite works of political commentary. The one about how rightist/leftist is basically a survive mindset versus a thrive mindset, that conservatives focus on survival in a primitive world, and liberals focus on building an egalitarian utopia.
The idea of transhumanism and a drug-induced utopia is essentially the thrive mindset fulfilled. It assures no problems will ever happen in the world and there will be no zombie apocalypse.
Yes, we live in a world where our needs are all tendered for us. We have all the food and energy our ancestors could only dream of. But one day, the improbable could happen. Agricultural companies and utility companies may not last. Maybe it's zombies, maybe it's Covid-666, maybe it's the Seattle Mariners winning the World Series. And in that world, transhumanist theories will vanish in the blink of an eye.
Don't get me wrong, I appreciate modern medicine. I know many adults with type 1 diabetes that would all have died as kids without insulin. But if the insulin supply chain is disturbed, that's all gone.
So maybe we can't see eye to eye because you are thrive-brained and I am survive-brained. But I'd rather solve obesity via getting rid of food deserts and returning to a diet like those of our ancestors. That way the risk is minimized for if the economy collapses, or pharma companies can't get the ingredients needed anymore, etc. I am all about minimizing risk. I would love to live in a transhumanist utopia, but I'd rather focus on the practical now.
>So maybe we can't see eye to eye because you are thrive-brained and I am survive-brained. But I'd rather solve obesity via getting rid of food deserts and returning to a diet like those of our ancestors.
I guess a good thing about this example is that if society collapses so much we can't produce semaglutide, we'll probably go back to agrarian living without processed foods and the obesity crisis will solve itself.
>I'd also rather do that, but we've spent ~30 years trying really hard and it's gone terribly and obesity rates have actually kept going up the whole time.
Have you (I'm assuming that "we" refer to the American society), tho? Have the US -and that's a totally genuine question, not a rethorical one- implemented many policies to promote weight loss, healthy diet & exercise? Some countries have increased taxes on unhealthy food, some have mandatory labels, some, I heard, even toyed with litteraly taxing the fat. Some even forbid free soda refills. I think US health insurance providers offer discount for practicing sport, but beyond that? I haven't heard of much. Then there's plenty of weird, attention-grabbing stories ("school consider pizza as a vegetable" was a very popular one back in the days), aspects of the food culture leaking into pop culture (I learned of "lunchables" from watching "fresh of the boat").
I'm not claiming that the policies cited works, or are even well thought of or well implemented (nutriscore is pretty shitty to judge food with small serving size, for instance, and is apparently lackluster on plenty of metrics), but they're attempts. Compared to the rest of the developped world, the American society at large don't seem to be trying "very hard" to crack down on obesity. Which can be explained by multiple factors, and considered as a negative side effect to an overall positive culture of personal responsability (and, it just occured to me, any policy to crack down on obesity is probably going to make the obese unhappy. Which, once you reach a large enough share of the population, may become a political suicide). But you probably shouldn't think "oh well everything that was possible to do has been done, let's pop some pills".
And, sure, I was thinking of "society-is-fixed-biology-is-mutable", society is hard to change and all that. But is it harder to change than 15k/y/40% of the population?
> But is it harder to change than 15k/y/40% of the population?
Yes.
Also, outside of the US, it's nowhere near 15K/y. And medical patents ensure monopoly - but only for a very limited time. Few years after it becomes really widespread, it'll be sold as generic drug.
The question "How are pharma companies different from agricultural and electricity ones?" seems to be key here. I think the general consensus in US and many other countries is that pharma companies are quite different. This can be seen from the fact that agriculture and electricity are not subject to such a draconian regulation, with every new version of the product required to pass multiple year + $billion approval. Also, I do not think that any shareholders of a farm or a power station were ever at risk of proceedings such as ones against the Sacklers. Of course, existence of this consensus does not prove that it is correct, but, I think, it shifts the burden somewhat to demonstrating that pharma companies are, indeed not different from agri or utility ones.
I could speculate on why the consensus could be such as it is and what is so different about pharma. There are probably several reasons for that. The simple one is that it is harder for a consumer to form an good opinion on product benefits, even if the consumer is a professional doctor. This explains the first consensus observation (on FDA), but does not really explain the Sacklers. Another reason as that pharma companies rely on state enforcement of temporary monopoly power in a way few other industries do.
The third reason is a bit more involved. Many usual economic and public policy arguments involving utility functions assume that these functions are unmutable. This assumption is probably ok in many cases, but is obviously broken with many medicines. Addiction, in a general sense, is when consumption of a good radically increases future subjective utility of further consumption of the same good. It was, obviously, an important factor in the opioid/Purdue/Sacklers saga. It may be also at play with the obesity drugs, although in a subtler way. Of course, there is no reason to believe that these drugs lead to an addiction similar in medical sense to an opioid addiction. However, people using these drugs to successfully control their weight, will find themselves at the mercy of 2-3 large companies in a way they are not at a mercy of their baker or their electricity supplier. Stopping eating any kind of white bread or moving to an area supplied by a completely different set of electricity companies is a much more palatable lifestyle choice than having one's weight increase back 20% because one goes off a particular drug. So once one becomes a client of such a company, it is very hard and expensive, in utility loss sense, to go back, quite unlike any agricultural or electricity companies.
Definitely. As long as the pharma company's patent is still active, which for semaglutide will be for over a decade, all consumers will be beholden to the company, and depend on it for weight loss. They are getting people hooked on pills to fix obesity, something that barely existed 100 years ago.
I note that Agriculture and Pharma in fact share the same regulator, it's the *Food* and Drug Administration, after all. Agriculture just comes up with entirely new products far far more rarely, but new GMO crops go through similarly massive hurdles to new drugs.
Actually, the same level of regulation for food, would be something like "any change in a bagel recipe that substantially changes its chemical composition and nutritional properties, such as adding raisins and increasing baking temperature by 20F is illegal until you spend 2 years and $1e9 on approvals". Luckily, food regulation is not like that.
For a slightly different take on this, I find it disconcerting that we're using pills to solve a very new problem that our ancestors definitely didn't solve with semaglutide. We're not making progress, we're abandoning the very interesting and likely very important question of "why are people fat now and what can we do to avert the cause of people being fat now" and just slapping a medical band-aid on top of it.
Are we ever going to figure it out? What happens if the underlying issue gets worse and worse, and we medicate and medicate instead of solving the issue, and the medicine runs out?
I agree this is concerning. I think the main reason people are gaining weight is the rise of hyperprocessed foods; I stopped all of these for a while and lost ~20% body weight, but it was tough and unpleasant because there were lots of processed foods available that would have been very easy to take in a moment of poor willpower (though I know other people say they've tried the same experiment and it didn't work for them). I feel like this solves the mystery and I don't really have a good solution to the existence of processed food (beyond extreme authoritarianism) so I will grudgingly accept the transhumanist solution.
When I moved out of my Orthodox Jewish home to Atlanta, I started eating a lot more processed food and promptly lost 50 pounds. Later on, I tried many diets with no processed food, paleo and others; of course none of those worked at all. I am reasonably sure that this, too, does not solve the mystery.
Based on our previous conversations, my understanding is you've eliminated almost every possible bad thing from your diet without significant change. Either you have some kind of extremely weird condition that would have made you the one obese person in your village in 1850, or it's a ratchet effect where some factor causes weight gain when present, but doesn't (always) remove weight gain when absent. Compare to how eg everybody will be unhappy when tragedies are happening, but some genetically unlucky people will stay unhappy even after the tragedy ends (PTSD, depression, etc).
I believe Eliezer has an extremely weird metabolism. As I recall, missing a meal or two makes him lose the ability to think. (From memory and possibly old news.)
This is not how most people react to missing a meal or two-- they may be miserable and/or hungry, but the effect isn't that extreme.
In the middle ages, a person like Eliezer would simply seem to be not particularly bright.
Maybe, but that sounds a lot like how many people react to *hunger*. At least for me, it causes a hyperfocus on food until I resolve the cause. The effect is similar to being horny, but what the body craves isn't an orgasm but a sandwich.
When you moved out of your orthodox jewish home you may? have let up on the shul kiddushes, simchas which involve large meals, shabbat dinner which is often a pretty elaborate multi-course meal etc. which might have helped you out there.
Serious question: if you rate your awareness of your food patterns high, what probability would you assign to having one or more significant psychological blind spots interfering? Would you assign roughly the same probability to other people who rate themselves highly food pattern aware?
If you don't rate your awareness of food patterns high, do you have some speculations about what's standing in the way?
Asking as the sometimes heavy, sometimes thin child of an endocrinologist and a biochemist dietician person, having observed really enormous variability in awareness levels, even among people who thought they were careful.
Did you eat a lot of fruit? https://www.amazon.com/Nature-Wants-Fat-Prevent-Reverse-ebook/dp/B097XMY9VG/ says a big problem is fructose, which signals the body it's autumn: time to prepare for winter and get fat. That's not all there is to it, I'm sure (the book mentions salt, too, for one), but cutting out all sugar and artificial sweeteners (some of which get converted to fructose in the body) and reducing the amount of fruit I eat has definitely made me less hungry.
I looked it up, and it's really only one of them, but some of the others have other problems:
"Despite having minimal calories, some artificial sugars still activate the survival switch. For example, sorbitol, which is often used in sugar-free syrups, is part of the polyol pathway and is actually converted to fructose in the body.
Absorption of sorbitol is variable, but it can be significant. Tagatose is another artificial sugar that can substitute for fructose and directly activates the survival switch because it, like fructose, is metabolized by fructokinase. While saccharin does not activate the survival switch, it has been reported to cause insulin resistance in animals, likely through an effect on gut bacteria. Excess intake of saccharin in mice has also led to bladder tumors. My recommendation is to avoid these three sweeteners."
(The "survival switch" is the process that shifts your body towards fat-saving mode.)
I avoid *all* sweeteners myself, because I've read that other types are bad for your intestinal flora, and I don't like the taste of most of them anyway.
Fair enough. I think I have very very far from baseline food preferences/requirements in a few ways so I am not a very good judge of what diets most people would consider reasonable.
Is processed foods messing with the lipostat still the best supported theory? And if so, has anybody discovered whether/how it's possible to undo the damage?
Can you unpack the words "processed" and "hyperprocessed"? They seem to be used more as virtue labels than anything objective about the ingredients and process. At least, I've never seen anyone say what they mean by the words. All cooking is "processing", but hopefully something more specific is intended.
And "junk food", for that matter. I suspect that with my eating habits and preferences, and affluence, I never see any "junk food" from one year to another, so I am unsure what is being talked about.
It's a gradient, and not really that complex. Compare carrots and steamed carrots. Cabbage and steamed cabbage. The processing makes digestion a lot easier, makes the calories a lot more available.
The thing that make it a bit complex are things like unflavored yogurt, which *are* hyperprocessed, but are still good food choices. Some foods are "hyperprocessed" to improve their durability. But this doesn't always mean that the calories are more available.
It's really slightly the wrong dimension, but there's a very strong correlation with "hyperprocessed" and "no fiber, lots of starch and sugar".
Processing (including cooking) tends to make foods easier to digest. This means that your GI system doesn't burn as many calories, that more of the calories in the food are actually absorbed (rather than pooped out) and that you get hungry again sooner. Some processed foods are also designed to act as a superstimulus, making you want to eat more of them even when you're not hungry.
Have you never found yourself eating more potato chips than intended because they're more-ish? I very rarely eat the kind of food that triggers this effect in me - I have chronic health issues and am exceptionally conscious of what I eat as a result - but I'm aware it exists.
Basically all food is "Processed" to some extent, unless it's literally raw fruit and veg I guess, but "processed" and "hyperprocessed" are basically shorthand for "comes in a packet and is high in salt, fat and/or sugar". It would say that its more about the incentives behind the design of most processed food than the fact of processing itself.
That's more or less how I understand it. Basically, foodstuffs in a style/composition similar to mid-to-late 20th century mass-produced convenience foods, which is used as a heuristic for foods with a particular cluster of characteristics that makes a diet that relies on such foods as staples to be particularly apt for overeating.
The representative features of "processed" foods is that they're designed for cheap and easy mass production and distribution in a 1950-ish environment, and for palatability across a wide range of local food cultures. White flour, corn syrup, and vegetable shortening were and are cheap and conducive to making stuff that doesn't need to be refrigerated and has very long shelf lives. Starchy and fatty foods tend to keep longer at room temperature as well: starchy stuff with appropriate preservatives doesn't really spoil the way most fruity or protein-based foods tend to, shortening doesn't go rancid like many cooking fats, and presence of fats helps the foods not feel dry even if they're very low moisture (low moisture being one of the keys to minimizing spoilage), and both lots of fat and minimal moisture both help prevent the starches retrograding (i.e. going stale). And to appeal to a wide range of palates, much of it is pretty bland and inoffensive, relying on various combos of fat, sweetness, and saltiness for palatability. Heavily sweetening or salting also helps shelf life, since lots of salt or sugar with little moisture helps make it inhospitable to bacteria and molds.
Nutritionally, such foods tend to high glycemic indices (from white flour and sugar), lots of omega-6 fats (from the shortening and a little from the flour), and to generally be calorie dense relative to satiation.
Guyenet's formulation of it is actually "hyperpalatable", and based on some very limited exchanges I've had with him, I don't think he can nail down precisely what it means. I think he's working honestly with the empirical data we have available, but it's a bit undertheorized.
> I don't really have a good solution to the existence of processed food
Many people buy their food online. I could imagine a software solution that would support automatic filtering or blocklists.
Imagine that you are a vegetarian, so you go to the application settings and check "do not show me products that contain meat", and from that moment (until you change the settings again in the future), the application will pretend that products containing meat simply do not exist. Not just showing you the message "4 out of 15 products were hidden because of your filter settings", but simply there would only be the 11 products displayed, with no indication that anything else exists. Categories that only contain hidden items would themselves also become hidden, so instead of seeing an empty category for "bacon", there would be no such category in the menu. Unless someone makes a soy bacon, in which case the category would appear again.
In other words, shopping at a normal supermarket with this setting turned on should feel indistinguishable from shopping at a vegetarian supermarket. (Which removes the need to actually build a separate vegetarian supermarket.) Out of sight, out of mind. Willpower is no longer necessary when the temptations are removed.
You would be able to create your own blocklist (for example, you may decide to boycott Nestlé), or subscribe to other people's blocklists. Maybe even write your own algorithm in some scripting language, using the available metadata, such as "hide everything that contains more carbs than proteins". This of course assumes that the web application would contain the metadata.
I would love to have such application available, because every time I regret buying and eating something, I could simply add it to my personal blocklist and never see it again.
There is probably an economical incentive against creating an application like this; maybe the problematic products are the most profitable ones, and if you allow your customers to remove them too effectively, you hurt your profits. Maybe this application would have to be created by a third party. (In which case, it could perhaps integrate products from multiple supermarkets, that would be even better.)
This actually seems like a really valuable idea! I worry that the metadata wouldn't be available to a third party though (I give it 50/50 odds that some of the metadata you would really want isn't available internally either)
Yeah when I switched to a fruit and veggies and yogurt and other simple foods diet, I just ate a lot more of those foods. Didn’t really help at all.
It’s all CICO, and when I actually stick to say a 1700/day budget, the weight flies off because I am fairly active. When I don’t stick to that budget I quickly balloon up because I suspect my bodies generic desire for food is something like 3500/day or some other unhealthy level. Probably learned at teenage years when I was an athlete.
Don’t you think the change in job type has had an influence, along with the rise of cars and the like? Walking, and even riding horses, burns a lot of calories, as does stuff like hauling, tilling, or even standing in a manufactury. Most of those jobs have been so heavily accompanied by technology that little exercise is involved anymore.
My point is just that doctors prescribe diet and exercise, and I don’t think it’s just diet that’s causing modern problems.
I also think we’re a lot less shaming of obese people, and that probably makes a difference
Even quite large differences in lifestyle have a fairly small impact on the number of calories burned, which is why most people focus on the diet side of the equation - both when explaining the problem and when trying to fix it.
I am sceptical of this. The caloric difference between heavy manual labour and total couch potato is IIRC a factor of 2 or more, though sedentary white collar labour that involves heavy thinking does still burn a fair few calories from the intellectual labour.
I agree with this. Why do we need drugs for weight loss? This isn't solving the real problem. (For clarity: I mostly hold the same position for every disease where the environment-body EMH interaction is unclear.)
Kind of depends what you think the real problem is.
If you think the real problem is eating too much unhealthy food, and the drug helps you not eat so much unhealthy food, then you could say that yes it is solving the real problem.
Using pills to fix obesity may be beneficial in the short term but may make things worse off in the long term. Obesity is relatively new. Just 100 years ago, people were at risk of starving to death. In some countries that's still the case. Obesity is a modern problem humans have created ourselves. All we need to do is look back and realize how junk food and the move to a less manual labor intensive workforce have led to these problems, and realize we don't need pills to solve it.
No. The type of food matters too. CICO doesn't take into account how the body processes different foods. 100 calories of soda loaded with HFCS is not the same as 100 calories of walnuts.
It depends on the person's weight. 3k calories is roughly maintenance level for an obese male (~120 kg). For a lower weight, that would be strong evidence against CICO of course.
As I understand, the recent trends and findings have pretty much killed the theory of wrong macronutrients > obesity, haven't they? E.g. americans and europeans reducing both their sugar and fat intakes quite a lot during the last 20 years (and increasing their excercise levels) while obesity rates going steadily up anyway as if they didn't care. If fructose was the culprit then this wouldn't make sense, right?
"Processed foods" makes more sense as a culprit (consumption seems to have gone up in these 20 years). But the problem with those are, we don't know what part of the processing is bad. Heating several times? Some often used flavor or preservative? Just one or several of them? We don't even have good evidence if processed foods as such directly cause obesity or not. We do have consistent correlative data that they co-occur with several health problems. So one should avoid them anyway, but it would help very much if we just knew which part of the processing makes food unhealthy. Because e.g. conserving foodstuff for longer preservation is a good way to fight world hunger. We would want to save the baby, just throw out some dirty bath water.
The issue is that the category of 'macronutrient' is too broad. While there have been periods of both less sugar and less fat in the average diet, with a corresponding increase in obesity, one thing that has changed long term is the type of fat people eat.
Vegetables oils (really seed oils) did not exist before 1900, neither did obesity, heart disease or T2 diabetes in any appreciable numbers. Only once we started adding seed oils to our diet did the diseases of civilisation start to arrive. Dietary fat before the invention of seed oils was mostly stable saturated or monounsaturated fats. Seed oils contain predominantly unstable (easily oxidised) polyunsaturated fats (PUFAs). Small amounts of these are essential, but not the 20%+ of calories that modern Americans eat.
'Processed foods' doesn't mean all that much as a category. Bread, cheese and strawberry jam are all processed, but none of them are obviously obesegenic. However, one thing that most modern processed foods have is significant amount of seed oils. I think that is the most likely culprit here.
This is the best primer I've found, although there is an obvious conflict of interest in that its authors are a company that makes low PUFA cooking oil.
CICO is a thermodynamic necessity, there's no arguing with it on the technical level. But the "CO" part is quite mutable by what you eat affecting energy (upstream of activity) and hormones (upstream of metabolic rate)
In order to hunt a deer I'd need three separate licenses (gun, car, hunting), a car, and it would take hours of driving to and from their habitat. My local supermarket is a 6 minute walk away.
While subsistence hunting would be awful, I don't think my choice to go to the supermarket in today's regulatory and social environment reveals an underlying preference for modernity over subsistence hunting.
There aren't enough huntable animals left in our environment for more than a tiny fraction of people to hunt. If 2% of the global population decided to fulfill their dietary needs by hunting, then in short order, none of them actually would, because there wouldn't be enough left to survive on.
If we judge how desirable a thing is by how many people do it, we'd have to conclude that being a drug addict is more desirable than being a pro athlete.
The problem in what you're saying is located in the phrase "All we need to do." It's extremely difficult to remove the conditions that make obesity more prevalent now than they used to be, for a variety of reasons. If the alternative solution is to fully reorder western society so that people work more with their hands, heavily regulate stuff that huge majorities of the voting population enjoy every day, discover all chemicals or pollutants that affect obesity and eradicate them from the environment, etc., then there's no alternative solution at all.
It is much easier to invent a cure for obesity than it is to create an entirely new and popular political movement devoted to making people poorer (by increasing labor jobs and reducing economic productivity) and giving them fewer choices.
It's pretty close to an understood problem. SSC is right, hyper palatable food cause all or most of it.
If you want to read more about the underlying neurology and cause of obesity Stephan J. Guyenet is a neurologist who is bright and very well informed on the topic.
Guyenet is the author of The Hungry Brain, a very good book on eating and weight. Alas, the "how to lose weight" recommendations are underwhelming, e.g., keep hyperpalatable foods out of sight or hard to get to.
There are likely to be several underlying issues. We don't know what all of them are yet, but we have very good reason to believe that parental obesity is involved somehow, and probably not just through genetic predisposition. (Supported hypotheses include but are not limited to epigenetic effects, prenatal/perinatal hormone and nutrient exposures, family eating habits, and social contagion through normalization.)
There are almost certainly some underlying environmental stimuli that caused people to start getting fat in the first place, but even if we found them tomorrow, it's not at all certain that fixing them would solve the problem in the near term. We'd probably still need a combined treatment/prevention approach. I don't see a good reason to deny people treatment now just because we haven't figured out prevention yet.
Pill culture is great, if pills are safe and effective and cost $1, or very crappy when they cost $100.
Furtunately the natural cost of pills is like $10c when intellectual property runs out and they are sold in the highly competitive open market. That's the beautiful future of pill culture.
I agree with you for the short term, but I think it's worrying when we brush fundamental societal issues like obesity (and depression very similarly) with medication.
An analogy from my POV is that we're in a boat with a hole in the bottom and we keep bailing the water out with medication. Sure we can keep bailing out the water, even if the hole gets bigger, until it gets truly unmanageable. At that point we'll be facing a massive issue and effectively be back at square one.
I know this sounds like a slippery slope, but these simply weren't issues 100 years ago and they have been steadily becoming bigger and bigger issues, I don't see why they wouldn't continue to grow.
"Instead of making sure communities have access to cheap and healthy food"
I'm going to pull this out because of the underlying assumption. "Just make sure there are enough vegetable selections in the local shops and everyone will naturally eat raw broccoli instead of chocolate!"
People won't. You can over-eat on healthy foods, too. Too many bananas not good for you. Same with vegetables - one reason I'm sceptical of the potato diet is that potatoes are one of the carbs I'm constantly being told by my doctor and the diabetic clinic nurse to cut out of my diet since they put on the pounds. I eat a lot of potatoes and could eat an all-potato diet easily, but I don't expect any dramatic weight loss at all.
When I was carb-counting back on one diet, there are vegetables that are carb-dense (and hence calorific) - see this below (and by the way, the advice on this is so contradictory - one source told me carrots were fine, another that carrots were high carb):
Yes, even peas are high-carb. So while you might think they're a green vegetable and therefore good, you need to be careful how many you eat.
"For some perspective, the Dietary Guidelines for Americans 2015-2020 recommends that 45 to 65 percent of your daily calories come from carbs. Depending on your weight and body, this could be anywhere from 150 to 300 grams."
I set a target of 33g of carbs a day, which I had to do some juggling to work out. I did lose weight, but it wasn't a smooth, easy downward curve of constant weight loss. And of course, I gained it all back when I stopped that diet.
Things like lettuce are very low, so you can eat lettuce all day. But who eats lettuce all day? Not even rabbits!
My experience, albeit more with other gastric issues than with any weight concerns, is that grains interact with (my) guts very differently than potatoes, and that while I do really need to absolutely minimise my intake of grains in general and wheat especially, I'm fine with potatoes as long as I don't eat an unreasonable amount in a single sitting (and eating 500g of almost any single thing as a snack is going to cause issues)
As someone who has spent some time in the developing world I find the concept of American “food deserts” hilarious. There are millions upon millions of people where they don’t have access to x or y or z regularly, sometimes for months. Meanwhile someone living in an American “food desert” has a grocery store that is a literal cornucopia a 12 minute bus ride away instead of a 4 minute bus ride, and it is a “food desert”, because there is a gas station and a McDonald’s closer to their house.
Maybe "food desert" isn't the right word to use to describe the problem, but that doesn't mean it's not a problem. The problem is that there are millions of low-income Americans that don't have A) Access to healthy food without cheap transportation, and B) cheap transportation. They end up paying a lot more than most Americans to have access to nutritional food. And this is one proposed cause of the obesity epidemic.
The problem isn't solved with gas stations and McDonald's restaurants. For a lot of these low-income communities, the closest "grocery store" is a Dollar General. They're fully stocked with highly processed foods, but no produce to be seen anywhere.
Maybe "food dessert" is a better name. Your body is craving vitamins and minerals, but you're surrounded by cake without a leafy green in sight. "Food desert" is closer to, well, an actual desert.
There are very few "food deserts" if you mean places where you can't buy food at all. There are lots of places where it is easier to get junk food than healthier food. But that's largely because the people there will buy the junk food and won't buy the healthy food. Retailers stock what people buy. To solve that problem would require treating junk food like prohibited drugs, but probably that wouldn't work any better than marijuana prohibition has.
This is a pretty big deal if you're literally homeless but for most people this is a matter of convenience of storage and preparation rather than difficulty of obtaining the food. "Food desert" seems like a misleading way of describing this, if the problem is that healthy food is less convenient to prepare and eat.
I was thinking about the cost to the store. Just putting things on shelves is cheaper than needing to keep them cold and having shorting expiration periods.
Refrigerated stuff expires, but frozen stuff keeps basically indefinitely, and frozen vegetables are actually *more* nutritious than 'fresh' (unless you're actually getting them fresh from the garden; supermarket 'fresh' was picked days ago); are freezers that expensive for stores to run?
"The opioid crisis in rural America is a good example of what happens when pills are handed out like crazy."
Surveys of addicts have found that most first started taking opioids via the black market, not prescription by a doctor. They have every incentive to claim they were prescribed pills by doctors in order to deflect blame.
"Also, the promotion of semaglutide would divert attention from the current problems of food deserts. Instead of making sure communities have access to cheap and healthy food, it lets food companies put out as much junk as possible and hope the pill fixes everything"
So the problem is that food companies will put out junk food, which people won't buy because of the pill, and that's a problem why?
I wanted to try semaglutide. My doctor was perfectly willing to prescribe it but my insurance wouldn't cover it and the out of pocket is steep. Ended up with phentermine which seems to be working well, we'll see how it goes. I'm curious why it's not prescribed, cheap and there's good evidence it works, although not as well as the new stuff.
I couldn’t get Wegovy at a reasonable price when it was approved, and then Novo Nordisk started having huge supply chain problems with their injectors. Fortunately, Eli Lilly’s coupon for Mounjaro was less restrictive at first, though they’ve had to crack down as they have trouble meeting demand for both off-label weight loss use and for the approved T2D use.
I am what the doctors call “morbidly obese,” and it’s been more effective than anything else I’ve ever tried. Down about 35 lbs in the first three months, and unlike with other diets I’ve tried, I’m not feeling miserable or hungry all the time. Assuming there aren’t scary side-effects in the future, these really are miracle drugs.
I do expect the price to come down relatively quickly due to competition, which is a good thing.
Congratulations on the weight loss. I'm interested in why you expect the price to come down. I looked into it just for a few minutes and found some people saying that one or two competitors don't usually bring prices down in health care. but I'm definitely not an expert.
Because I expect there to be more than one or two competitors soon enough, and the newer ones look to be even more effective. Since these aren’t being covered by insurance, that’s going to force competition on price more than for other drugs—for example, the extremely generous coupon for Mounjaro was likely done to compete with Wegovy until demand started outstripping supply.
But there are already quite a few GLP-1 agonists on top of semaglutide and tirzepatide.. Theres exenatide, liraglutide, dulaglutide, lixisenatide. and all of them are expensive and brand name only. I have to agree that only when these drugs go generic will they likely see a drop in price (and maybe not even immediately then)
Insurance companies have ways of denying coverage and making it ver hard for you and your doctors to get it to you. Been there personally (but not for this issue.). All the obese would never get it at the price you quote, though it would be interesting to know how many morbidly obese there are and what the accompanying burden would be if only they were to get it.
Even in the absence of competition, drug companies stand to make more money if they lower the price enough to encourage willing coverage by insurance companies and thus reach a larger group of patients. I'm not sure how likely this is, with such a large pool of potential patients to expand into, it's possible.
I agree with @Maximum_Liberty that the price will drop further when the drug becomes generic. Before then, there could be competition as @Edgehopper responded.
I would guess that multiple drug companies are now at least considering whether to work on developing a competitive drug and to the extent that they get lucky (yes, drug development still is a crap shoot), competitive pricing could come about.
Are these drugs that have to be taken forever, or just for the duration while someone is trying to lose weight? And is there any data on whether, once weight is lost, there are recurring cycles where patients regain and have to go back on the drugs to lose again? I'm assuming those factors would be important in a long term cost model.
I think forever; if you stop, unless something big has changed in your life then the same factors that made you gain weight the first time will probably make you gain it again.
Anecdote is not the singular of data, but my better half lost 25 pounds on it, then had to get off it for reasons unrelated to the drug. She has not regained the weight yet -- and consistently eats less now that she had for years. So in at least one case, the drug helped with a successful change in eating habits.
So, to be 10% lighter I need to take a drug forever? Or will I continue to lose 10%/time period of the study indefinitely? Or will I go down 10%, and also continue to gain weight at 90% of my previous speed, assuming no changes in diet/activity?
I think semaglutide works mostly by making you feel full even when you haven't eaten too much. So you can think of it as the same as dieting. If you're currently eating unhealthy (let's say 4000 calories a day) your weight will stabilize at some high number. If you eat healthier (let's say 2000 calories a day) your weight will stabilize at some lower number. This is because it takes calories to support the extra weight, and when calories in = calories out, your weight stabilizes. You can play around with https://www.calculator.net/calorie-calculator.html to get an idea of how this looks.
That is not my experience. I still eat a lot of junk but I'm maintaining an 11% weight loss. Yes, it's an anecdote, but it's my anecdote, and I believe in it. I've fought my weight my whole life and I can't eat a bite without mentally counting calories, carbs, etc. I don't think I'm fooling myself about food quantity (large) and quality (poor).
As an addendum the stabilization happens through three forces. One is you are smaller so you burn less calories moving, and have less tissue you need to keep alive. The second is your body slows down your metabolism. The third is it ramps up hunger.
Say at equilibrium you burn 2000 calories and crave 2000 calories. You use your will to eat 1500 calories and lose some weight. Your body slows down your metabolism by 100 calories, you burn 200 calories less from being smaller. But your body hungers for 2800 calories. Now instead of exerting 500 calories of will you need to exert 1100 calories of will. This is born out by studies on hunger and fullness, that basically the majority of diet adaptation that stabilizes weight loss is hunger.
This is why weight loss is so insidious and so difficult to maintain.
so there's been a lot of research on dieting and losing weight, etc., and one of the things that has been found is that your body has a "set" point weight wise that it will try REALLY hard to return you to. If you lose weight, your body will slow its metabolism until you return to that weight. If you gain weight, your body will rev up metabolism. That's why you might gain 10 lbs over Christmas and then lose it in January without purposefully trying to lose weight. (this is all in the short term, ofc, as people do tend to naturally gain weight as they age).
This seems to imply that semaglutide would need to be taken forever. However, there seems to be an important caveat: you *can* reset your set point, it just takes a long time at the new weight. When most people go on diets and lose weight, they end up regaining the new weight quite quickly after they "end" their diet, so they don't have a chance to reset their set point.
Speaking from personal experience, I had kind of an accidental natural experiment with this: I once lost 40 lbs over the course of a year and a half, where I began with a very strict low carb diet that very very slowly trailed off to a normal diet, mostly because I got progressively more tired of being on the low carb diet. So by the time I had gotten back to my normal diet, I had been losing weight for a long time. I ended up regaining 10 lbs of the weight, but no more, and am still ~30 lbs below my peak even today (5 years later). I noticed that my own "set point" seemed to reset: when I would overindulge during the holidays and the like, I would often lose the weight the next month without really trying. All of this to say that I do think patients will have to take semaglutide for a while, but not necessarily forever. The brilliant thing about the drug is that it essentially just works like extra strength willpower. If someone takes the drug for a while, loses weight, and their body eventually resets to a new set point, and they themselves eventually get used to their new level of calories/diet, I expect that they could then come off the drug. Personally, that's my plan for ~20 years from now: I don't qualify for the drug at the moment (BMI of around 25-26, so overweight very slightly) and I probably won't ever, but I expect it will become far more available and affordable in the future to the point where even just overweight people are taking it.
AFAIK there's no real evidence for a set point. It's one of those folk-sciencey things that people just accept without real evidence.
Our behaviors and food environment don't *tend* to change much through life, so somewhat naturally people will have an equilibrium with respect to those factors. But people *can* change their behavior, which would change their "set point" in the same way a drug can (which AFAIK just changes behavior by changing satiety response)
Yeah set point I don’t know the research on (which might be because it doesn’t actually exist) but what I do know there’s now a good body of research on how your body slows down metabolism, gives more hunger symbols, etc, when you lose weight. So it could be that set point is half true in that your body will seek to return itself to its old weight if it loses weight, but not if it gains weight. Which is super depressing but also fits with what we see in the real world.
Think of it like blood pressure medicine. When you take the drug your blood pressure drops, when you get off it it goes back to your bodies natural equilibrium point.
It's the same with weight. Your body has a set point and weight loss drugs move that set point down. Then when you get stop your body goes back to it's natural higher set point.
Looking at the study on wegovy.com that I think your graph is ultimately derived from, " Both groups were instructed to take the medicine along with a reduced-calorie meal plan and increased physical activity. " Is this normal for this sort of study, do patients actually do it, does this reduce veracity of results?
On that note 7% of Wegovy takers left the study due to side effects while 3.1% of the placebo did, which is makes me somewhat skeptical that there won't be some side effects coming up in mass adoption. https://www.wegovy.com/FAQs/frequently-asked-questions.html ("How much weight have people lost")
Re your first question, I haven't looked into this myself, but Eliezer's comment above suggests the diet and exercise aren't playing a very big part. Also, the studies I cited were placebo controlled, so I imagine the placebo group also diets and exercises.
Check out Wegovy.com- like so many other expensive drugs the company themselves offer a copay card for pts with commercial insurance, to bring copay down to $15, no negotiation needed.
Thanks - has anyone tried this and confirmed it works and that you can keep doing it for a long period of time (one pharma trick is "first month free" and then once you feel like you need it they start charging you full price again)
So there’s a max amount of saving of $200 per month for insured patients and $500 per month for cash paying patients, up to a max amount of lifetime savings that I can’t remember. It’s also not usable with any govt insurance (medicaid, Medicare, tricare(military),etc).
Ozempic coupon cards also should not be used for weight loss, since they need a diagnosis code and the Ozempic coupon card specifically needs Type 2 Diabetes since that’s what it’s approved for. Technically, it would go through if a pharmacist is not careful and doesn’t get the diagnosis code. They’ll get a paid claim and then months down the line the pharmacy will get railed in the ass with a clawback for the money. A patient could try to abuse this at a chain pharmacy where the pharmacists are just trying to do things as fast as possible and don’t have an interest in making sure the company gets paid properly since it doesn’t affect them (as a matter of fact they want it to work since telling patients it doesn’t makes them mad and thats annoying and a time sink “but my dr told me it would work!”). At an independent pharmacy the pharmacists likely know this or they would prob be out of business before long.
Mounjaro also requires a type 2 diabetes code to properly go through like ozempic. Mounjaro has a cap of $250/month saving for insured patients and $500 for uninsured patients with an annual max of $3000.
Patients aren't happy to hear this about ozempic, especially recently as patients have been hopping from pharmacy to pharmacy trying to get ozempic because it has been backordered.
I should have wrote this in my first comment but I am a pharmacist, in case that wasn't clear lol
It’s not much of a contribution. People have been shouting “Eat vegetables!” For thirty years now, but the percentage of obese Americans keeps going up.
You can shout about vegetables all you want, it won't do a thing when Uncle Sam subsidizes all of the precursors to the highly-processed packaged-ready-to-eat junk food.
I wonder how much the demand for Wegovy gets reduced by it being an injection rather than a convenient pill that you can swallow. Is there any chance it can be turned into a pill?
There is a pill, but you have to take it at least once a day (maybe more), and the effects aren’t as steady as the depot injectable.
My doc was laughing about this (as he wrote my scrip); he says he could give people a prescription for a brand new poorly tested pill with little benefit and tons of side effects, and most of his patients would be fine to take it. But make an excellent, well researched medication that has been working well for years and years into an injection and suddenly everyone is hesitant.
I’m not even the least bit scared of needles, and I was hesitating! Injection just seems so much more SERIOUS. But it’s actually not.
One legitimate reason to be more hesitant about the injectable version of a medication is the corresponding change in dosing schedule: if anything does go wrong, side effect or interaction wise, you can't exactly suck it back out, and you're stuck with the situation for much longer (a week to a month) than if you had been taking daily pills.
I was very concerned with the injections before I started Weygovy. My experience is that the injector is fast and almost painless. My pharmacist was important because he showed me how to do it correctly before I started.
In Brazil medications are in general very cheap, due to being completely on the open the market (you pay out of pocket, no insurance involved at all), there being a robust and we'll regulated generics market, and there being a lot of basic medications on public healthcare.
Yes and no. It's called price discrimination, and it can be occasionally pretty counterintuitive. Selling to some at a high price and to some at a lower price may actually bring in more money than selling to everybody at the average, if fewer people would buy it at the average price. In some cases, price discrimination is the only way to make something profitable and thus make it happen.
Also the American market doesn't have high prices _because_ this is where research happens. If anything, you'd expect lower prices in the home market - that's how it happens with the majority of products simply because you have less logistics. The high prices are primarily due to a generally dysfunctional health market, most likely due to trying to solve everything with regulation. Very much USSR style.
Of course selling in other countries at lower price is price discrimination - but that is not an explanation, it's a definition.
You're getting the causality wrong. I'm not saying that prices are high in America because research happens there. I'm saying research happens because of the high prices that you can get in America. That's what allows the higher average price and subsidises the research for the free riding nations.
But isn't the money going all in the same place? Why would it matter in which particular country it's more expensive, once you're already a global company?
It doesn't matter which country pays more, certainly, but it does matter that A country pays more. Are there other large economies that are paying a lot of money for drugs to create the incentive for carrying out research?
Isn't it that the research wouldn't be so horrendously expensive if it wasn't over-regulated? And it's never quite so expensive anywhere else in the world? And the reason why still mostly American companies keep doing it in mostly America is that a) American companies are the richest and b) American legislator's won't accept any research done outside America. Is this correct? And the high prices in America then come from two limiting factors: 1) someone has to pay to make the costs for the companies worthwhile, and 2) only or mostly Americans are able to pay such costs.
Seems like a lot of unnecessary money lost, but, on the other hand, it keeps the money in circulation. :) From companies to the government, government > people, people > insurance, insurance > companies.
Certainly part of the reason pharmaceutical research is expensive is regulation, but that's not all. It also requires significant physical and human capital and also a great deal of time and risk, which would still exist with or without the regulation, though certainly better regulation could reduce substantial elements of cost. However, regulation on pharmaceutical research is not vastly simpler anywhere in the developed world. My sense for why most of it is done in the US is that the US is the richest economy in the world, it also has some of the best human capital in its universities. The regulatory requirements are mainly about the safety and efficacy trials being held in the US, not about where the research is conducted. As for the last part of your post, I highly recommend reading about the broken windows fallacy. Resources spent on unproductive uses is not a net positive (edited to add : those uses of money are not a net positive just because 'money is in circulation'. Money would stay in circulation if you were to pay people to dig and fill ditches, but money is simply a symbol of value, it is not value in and of itself, especially when you're not talking about voluntary trades. The appropriate measure is opportunity cost - the money you pay someone to dig a ditch and fill it up could be used to pay them or others to do work that is more valuable)
Depends what you mean by regulate versus over-regulated. The FDA sets a high bar for new drugs to be approved. They have to be safe, first of all, which requires expensive Phase I & II trials, and they have to be better than the existing standard of care, which requires a very much more expensive Phase III trial. And very few drugs make it all the way through Phase III.
For each approved drug you can actually sell you may have to start off with 10,000 compounds that work in vitro, 10-20 that work in animal models, and 6 or so that pass basic safety screening in Phase I.
So the bulk of drug R&D cost that must be paid back by each successful drug is paying the R&D costs for the 9,999 candidates that didn't make it.
An enormous amount of effort has gone into trying to "fail faster" and get rid of candidates that won't work at an earlier and cheaper stage in the pipeline, but results have been a bit mixed.
Yes, but in Brazil there are several classes of prescriptions and semaglutine seems to require the lowest class. For that one pharmacists will usually sell you without a prescription.
Wegovy is not yet available in Australia but Ozempic has been widely used off label with anecdotally great results despite the dose difference. It costs only $130/month (no govt subsidy applies). Sadly due to supply issues it's now impossible to get.
We have liraglutide as our GLP-1 that is approved for weight loss. It costs almost $400 a month but a lot of people report success on lower doses (presumably trying to stretch the pens out a bit longer).
I haven't had a good look at any papers discussing dosing, but I do wonder how important it is to be hitting the higher doses that are recommended for the weight loss indication.
Semaglutide and tirzepatide are both taken as weekly injections for weightloss correct? Could that also discourage people from taking it since a lot of folks don't like getting poked weekly with needles?
I don't know. There's an oral form of semaglutide, but it's not approved for weight loss, and the dosing is such that it would be very expensive to try to use it to make a weight loss dose. I don't know if this is just that the pharma company hasn't bothered getting the oral approved yet, or if there are other reasons it's hard.
Orally it has a very poor absorption, only 1% or so is absorbed. Currently there is shortage of manufacturing capacity that it seems inappropriate to waste 99% of the drug.
It also needs to be taken on empty stomach with just a little bit of water. Many patients do not follow this and then it becomes another waste of a good drug.
I suspect that even with good adherence, the variability of absorption between persons is quite large which makes it harder to know if the problem is that the drug is not working or is not absorbed.
Compared to all this, using auto-injector pens once per week maybe is not that bad after all.
> Until now, doctors didn’t really use medication to treat obesity; the drugs either didn’t work or had too many side effects.
Is it the drugs not working or just FUD about prescribing drugs off label?
The side effects and abuse risk for stimulants can't be THAT different than prescribing to a normal weight college student vs obese. Maybe a bit more concern for cardiac issues but minor I think.
Less controlled and weaker stimulants could also be used like Modafinal or Nicotine. Even a small calorie intake reduction could mean a large difference in total body weight over a few years.
I think phentermine is as good as any other stimulant, it's just not good enough for most people. A lot of my Adderall patients don't really lose that much weight.
Doses needed for consistent weight loss/maintenance are much higher than for, say, ADHD. Plus every time the damned things wear off, ALL the hunger arrives at once. And you have to let them wear off, because otherwise sleep is terrible. (I was prescribed Dexedrine for weight loss several decades ago by a crazy doctor, and am now on a decently high dose of Vyvanse for ADHD).
As a minor anecdote corroborating this, I had a college roommate prescribed an unusually high dose of adderall (60mg/day), to which he was addicted. While it's true he regularly did not eat (or sleep) for 36 hours, upon waking up sober he would eat a single meal that compensated for all the missed calories--most commonly an entire large pizza and 10+ chicken wings. He did not lose any weight pre- and mid-addiction.
I'm on Ritalin for ADHD. Anecdotally, I seem to have developed a tolerance, and this applies to the appetite effects as much or more than the cognitive ones. I lost a bit of weight when I first started taking it, but I'm on a higher dose now and the effect seems mostly gone.
Someone made this argument in the subreddit about a year ago, I think, and the basic response was that stimulants just don't work well enough to make the risk/benefit tradeoff work. If amphetamine was really, really good at making people lose weight, that might outweigh the side effects, but it's just not that great at it.
I think the amount of semaglutide being prescribed for weight loss is being undercounted in this post. I prescribe semaglutide regularly for weight loss but I have never once prescribed wegovy. It’s just way too hard to get approved. Instead I prescribe ozempic for impaired fasting glycemic or pre-diabetes (basically anyone with fasting blood glucose >100 or hgba1c >5.5) which seems to go through way easier. I don’t think the difference of 2mg vs 2.4mg is all that meaningful in terms of overall weight loss. Would be interesting to see what the real number is including these other diagnoses.
as an interesting aside, Janssen's Invokana diabetics drug has also been proven to cause weight loss. https://www.fiercepharma.com/pharma/proof-concept-trial-j-j-s-invokana-combo-helps-non-diabetics-shed-significant-weight sadly the trials went nowhere after in 2017 invokana got slapped with a black box warning for heightened risk of big toe amputations. A risk that one may be willing to take to treat diabetes but not weight problems. There must be something in mechanism of action of diabetes drugs that causes this nice weight loss side effect.
That interested me, since I'm on Invokana. That one you linked is a combination of canagliflozin with phentermine. Looking at my medication, it's canagliflozin only. I didn't get any warnings about toe amputation etc. so I'm wondering if the phentermine was to blame there?
And no, it didn't make me drop any significant amount of weight, which is in line with the quoted results:
"After 26 weeks, patients using the combo had lost 7.5% of their body weight, compared with 4.1% in those taking phentermine alone, 1.9% of those only taking canagliflozin, and 0.6% of placebo patients."
Yeah the weight loss effects aren't drastic on Invokana alone, I was looking at a project to fund a (different that one in article) drug combo that would have hopefully yielded more noticeable results, but it never went ahead.
If it weren't so late, I'd try and do some back-of-the-envelope-math myself but how many fewer calories will Americans be eating if semaglutide is made widely available and works? Will the industries dependent on Americans eating calories put up any kind of fight to increased availability of a weight-loss drug?
Punching some numbers into the calorie calculator linked above, the difference in calorie needs is a few hundred calories on a diet that's >2000 calories. So call it a ballpark of 10% reduction in calorie consumption? I doubt that's significant enough for a company to willingly take the PR hit of being pro-obesity, especially since the loss is distributed across the entire food industry.
Edit: Also, not all calories are equally profitable - if a drug enables you to eat the proper amount of any food you choose, then people will probably choose the tasty and profitable processed foods instead of the cheap grains.
Perhaps fortunately, it doesn’t seem to do that, at least for me . On Ozempic anything too sugary is totally ‘blech’, and too much high fat food gives me terrible heartburn.
I wonder if semaglutide works best in those who overeat to begin with, rather than those who eat normally but have conditions that predisposes them to gaining weight, like Hashimoto's or PCOS, or genetically slow metabolism. If you gain weight on 2000 kcal/day, reducing your appetite might not do much.
Anecdotal reports from friends and subreddits suggest that the health benefits are actually a greater relief for diabetics and PCOS symptoms, with weight loss as a nice side effect.
Speaking as someone with Hashimoto and PCOS and a genetically "slow" metabolism (fat parents), a lot of it is still due to overeating. I'm more hungry than my peers and have less energy / less willpower to resist it when it hits, and when I do exert willpower to not eat I end up eating vast amount of food when hunger shuts my rational brain down later with no leftover willpower to pace it. Sometimes to the point of vomiting. Those nights I also often end up with insomnia because I can't bring myself to stop doing fun-thing and sleep (so it doesn't exactly only affect food).
Yes, I've been to (many!) doctors about this behaviour, the most they decided I had was a little anxiety.
I've had a gastric bypass now and that seems to help, by physically reaching the vomiting point far far sooner on bad days to the point that it basically cured my binge eating.
84% experience >5% weight loss and 66% experience >10% doesn't seem to me like it would make people's physical appearance change very much from how it is now, even if 100% of obese people can get the medicine. A 300-pound person who loses 10% of their weight is still 270 pounds. Am I not understanding some key part of this?
I guess I'm making assumptions. If it brought everybody down to their ideal weight, you could still get those numbers, since maybe most people only need a 5% loss and the percentage of people needing a 50% loss is very low?
Only about 33-35 million Americans have a BMI of 40 or more; a hundred million of them are obese in the 30-40 BMI range. For a guy at 5'8" (ideal weight around 165), that corresponds to a weight range of about 200-260 pounds, or a target weight loss between 20% and 60%. On the new meds, that guy can reasonably expect to lose more than 20-25 pounds at the median; if he's towards the bottom of the range, the pill mostly solves his problem outright, and even towards the top of this range it's still much more than a drop in the bucket. From personal experience, going from 250 to 225 makes a large difference in appearance and lifestyle.
Relatively few people actually need to cut their weight by more than half- in those cases, surgical intervention seems like a more likely solution at this level of technology. I would agree that in those cases, a pill that takes you from 350 to 315 is probably not doing as much good at the margins.
Hmm. I get an Ideal weight for 5'8" male to be between 139 - 169 lb. So while 165 falls within the range, it's on the high end.
But your points are very well taken!
If we were looking at this like a quality control problem. We'd propose different solutions for the outliers (more than 3 std from mean), special causes of variation.
And we'd investigate the common causes of variation (the societal shift toward heavier and heavier people) and develop solutions that directly attack common causes. Maybe a per calorie tax and exercise tax credit? I don't know. But let's make available to everyone an Rx seems like a special cause solution to a common cause problem. Especially when we don't really have a good theory for this only 80 year old trend in more consumption and less exercise.
If they keep taking it and losing weight year after year, it gets a 300 lb person under 200 in a few years and let me tell you as someone who used to weigh at least (my data back then is sketchy) 280 lbs, going down to 250 is a big improvement even if it's not an immense one.
It can also get some people to lose more than 10 percent. Last November I was over 225, and now I'm 195 and again, that's a very noticeable amount.
Using a BMI of 30+ as the definition of obese, a 6' 1" man weighing 230 pounds is obese. A 10% reduction in weight would move that person to merely overweight, but 230 vs 205 would likely be noticeable. Most people think 300 pounds when the hear "obese," but the definition kicks in much earlier than that and folks can be quite healthy by some metrics while being obese.
I'll note that 6' 1" and 190 is still (just barely) overweight [if overweight is a BMI of 25+]
But there are responders and non-responders. I lost 25% and my doctor has said that for a significant number of her patients she had to the lower the dose because they lost too much weight.
6 foot went from 235-> 180. I went from having having a large gut to a flat stomach. People definitely noticed. Though the noticed the last 15-20 more than the first 35.
Interesting! I’m guessing that picking 5 and 10 percent for the sake of comparing it with the less-effective medications gave me a wrong impression of how effective it is.
Over the past two years I've dropped from roughly 185 lbs (overweight) to 165 lbs (healthy BMI), which is about an 11% loss, just a little higher than what we're talking about here. The change in my physical appearance has been extremely noticeable.
I've learned some good information from the replies to this, so thanks! But I also want to stick up for my original sentiment, at least a little. Scott asked:
>> Will there be an inflection point, where so many people use semaglutide that obesity becomes unusual again, and then the remaining obese people start using it just to fit in? Will obesity become an optional fashion statement, like shaving your head or getting a tattoo?
If all obese people took this medicine, and they all experienced 15% weight loss, and they all had awesome health benefits, and lived longer, and looked better... that's not enough to make obesity unusual. That's not enough of a change to make obesity into an optional fashion statement. The 5 foot tall, 300-pound people are still 255 pounds.
So isn't the obvious answer to these questions "no"?
I imagine that the folks thinking about an inflection point expect these sorts of drugs to get better over time, not that 10% - 15% would make obesity a fashion statement.
Wait, how is NextMed is promising to get it for $138/month? That's less than half what you said it costs at a compounding pharmacy, and you already said that was inexplicably low.
Do we have any estimate for the other medical treatment costs that are prevented by giving this $15k/yr treatment? Presumably heart disease goes down. What % of our healthcare spending is paying for emergency treatment for heart attack treatments in uninsured individuals?
I could believe this is one of those cases where prophylaxis is way more efficient than treating the later-stage / downstream health incidents -- although I wouldn't predict that we actually reduce medical spending (that would be too good a marketing claim for the companies to miss), this effect might substantially dampen the cost increase.
Ok this gives me a chance to talk about my weird way of thinking about exercise and money.
Let's say that people genuinely would pay $15k per year for this drug if they had the money, but money is tight for them. This doesn't surprise me. People spend astonishing amounts of money on clothes, phones, cars, etc. to try to sexually attract people (in part) but this will almost always be less effective than moving from obese to healthy weight, regardless of how much you spend.
Ok, so, the way I think about this is that when I eat healthy and exercise, I am paying myself whatever I would otherwise pay to a drug company to achieve it.
So take the $15k. If doing 1 hour of hard exercise per day results in the same weight loss (which it totally would of course), then assuming a tax rate of 30%, that is the same as me earning $21.42k, paying $6.42k in tax (30%), and then paying the $15k to a pharma company.
So doing exercise earns me $21.42k/365 = $58.70 per hour before tax.
I bet a lot of the obese Americans would love side income of $58.70 per hour, work when you want, plus it'll significantly reduce your anxiety and depression, with no side effects other than positive ones...
Unfortunately, there doesn't seem to be any way for people to monetize this, since the people for whom this deal is attractive would never pay the full price out of pocket anyway. And the people who could pay the full price out of pocket are, for a variety of reasons, less likely to be obese.
>If doing 1 hour of hard exercise per day results in the same weight loss
Does it? That doesn't match my understanding of how it works for most obese people, though I'm not too informed on the matter. It's not just the exercise, but not increasing eating to compensate, which is a monotonous full day low effort task.
But anyway, there are a lot of things I wouldn't do for $58/hr. I can make $35/hr by supervising kids who are doing whatever activity we happen to find enjoyable at the time, and I still only do that an hour a week, despite negative cash flow. If I told my family I was going to do an hour of hard exercise before/after work every day instead of coming home to do stuff with them, they would not be happy, even if I were then fitter and more attractive and energetic at other times. They would tell me to just eat less when we were all eating spaghetti together. This is probably the position of many, many obese people -- in my experience it's a state a person ends up in through things like negotiated family meals, babies, and commutes.
I would be happy to do 1 hour of hard exercise every day, if you could magically give me 1 *extra* hour per day, freezing the rest of the world for that hour, especially my kids.
A day is like a puzzle where pieces have to fit together, and sometimes there is no place left for the "1 hour of hard exercise" piece. There are constraints on time, energy, money, attention, willpower. Eight hours of sleep, eight hours of work, lunch break, commute, shopping, cleaning, cooking, doing dishes, taking the kids to/from school, making sure they are ready for the school next day... oops, the day is gone, and I was also supposed to exercise, meditate, read, learn something new, socialize, perhaps try creating a second source of income... haha, maybe the next day, or more likely the weekend. Oops, something unexpected happened on top of this, the weekend is also gone. Okay, this is a bit of exaggeration, there *is* some extra space, but not reliably.
I usually return from my job at 17:30. Told my wife I could go to a gym along the way and return at 18:30 every day instead. She wasn't happy. So I usually exercise at home after 22:00 when the kids finally sleep, but I am already quite tired at that time.
For obese people “1 hour of hard exercise per day” would seem to have a likely side effect of soreness and injury risk and pain, would it not? Exercise gets much easier *after* you’ve lost the weight.
If you *don’t* modify diet away from natural inclination the person who exercises more will tend to eat more to compensate and not lose *any* weight…whereas if you *do* modify diet away from inclination the person doesn’t need to do the exercise to lose weight - eating less than one is inclined is the *entire problem*.
Given a choice between being hungry all the time or taking a drug, the drug seems like a better option.
Of course an even *better* better option might be to eat foods that *already contain* whatever drugs you need. In libertopia you’d be able to order tasty personalized MealSquares or frozen waffles or after-dinner mints that come pre-fortified to already contain your daily allowance of semaglutide!
But separate from that, I don't think most people would do embarrassing, painful, and difficult manual labor for an hour a day even if you promised to pay them 60 dollars an hour for it after 3 years.
“ If doing 1 hour of hard exercise per day results in the same weight loss (which it totally would of course),”
No it won’t. Exercise is very good for you but doesn’t have much of a weight loss impact as exercise makes you hungry. If you’d like a link to the relevant studies they can be provided.
Sure, and if everybody spent one hour a day working on improving their skills, many of them could move to more interesting, higher-paying jobs. If introverted, lonesome people devoted an hour per day to forcing themselves to leave home and chat with strangers they would become less shy, and quite likely meet some people who would become friends. If sloppy people devoted an hour per day to organizing and cleaning their home, car, yard and office, they would become spiffy people. (And if my grandmother had balls she would be my grandfather.)
Lots of people have raised some fair criticisms of this but I wanted to say that this actually might just motivate me to get to the gym more, so thank you
Depends where you’re at for dosage. A 1.5 ml pen gets you the first 4 weekly doses of 0.25 ml, plus the first of 4 at 0.5, for under $200 Canadian. Next pen that same size gets you the other three 0.5 doses. Then a 2 ml pen gives 2 weeks of 1 ml doses for about $200. If you get up to the 2 ml dose, that’ll be a pen a week.
I'm taking the 1mg/week dose for diabetes (in Australia) and the pen holds 4mg = 4 doses. That's $42.50 for 4 weeks (subsidised for diabetes prescriptions https://www.pbs.gov.au/medicine/item/12075m-12080t). Off-label prescriptions for weight-loss are not subsidised and I think are about $130/month. Big shortages here in the last few months as the off-label prescriptions have increased.
After being well controlled for many years, my glocose levels had slipped up over the year or two before I started on Ozempic. Now nearly back to where the doc wants, plus I've lost 8kg in 8 months without much trouble (only some slight gastro issues, nothing that would make me want to stop using it).
Here https://insulin.store/ozempic/ you can buy ozempic for $292 plus a 5% discount. It is also possible to register a new account for a new mail and again get a 5% discount, at the moment it works =)
Not sure how much of them are true, but that's what I heard as recommendations:
- Buying long in advance is often cheaper. Though cheap tickets are sometimes also available on very short term when the airplanes are not full.
- Prices are cheaper outside of office hours, like in the evening or on weekends. Don't order from the IP addresses of large companies. (I.e., don't order from work.)
- Order from cheap devices. Never order from Macs/Iphones. Apple users get more expensive offers since they accept higher prices.
- If you want to go from X to Y, then buy tickets from X to Z via Y, and simply drop out at Y. Those are often much(!) cheaper than tickets from X to Y. May not work if you have to check in luggage though, that would end up at Z.
I churn credit cards and I have more points than I can ever hope to spend. The idea of paying cash to fly is offensive to me at this point.
In the process of that hobby I learned some tricks but the low hanging fruit is just opening 2-4 cards per year, using your natural expenses to meet minimum spending requirements - that should easily cover the vacation flights most people would realistically want to take, I think.
Do you have any basic beginner tips for churning? I'm sort of interested in it but (I guess like most people) I'm very nervous about ruining my credit accidentally
Practical update. I recently found that some varieties of Blue Cross Blue Shield insurance (through the federal employee program, at least) will now cover Wegovy (Ozempic) for weight loss, starting in January 2023. https://www.fepblue.org/open-season/whats-new-2023
Wegovy is on their formulary as a Tier 2 drug, meaning a copay of roughly $60/month.
I’m in Canada, and started Ozempic for wait loss 7 weeks ago, at my GP’s suggestion. Still only at 0.5 ml/week. (Diabetic dose is 1 ml, weight loss dose is 2 ml.) My doc says it would cost me about $300 a month once on the full dose, and likely wouldn’t be covered by insurance (yet). But my weight loss is steady, about a kilo a week since starting, and side effects are very manageable now. Because I’m still on a dose the insurance is used to, it’s covered. If the weight loss continues like this for a while, I will likely stay on just 1 ml, so as not to lose coverage.
My weight had crept up through middle age. About 7 years ago I had lost the recommended 10% of body weight, to improve cholesterol and sleep apnea. Did that quite easily by cutting out all sugar and refined grains (even fruit except the very occasional tangerine or grapefruit after supper). Maintenance of my lower weight wasn’t that hard, possibly because I’m quite active. Then COVID, work-from-home for a year and a half, everyone in the house cooking and baking up a storm, much less physical activity. All the weight came back, plus a couple of kilos, and I wasn’t managing to lose it again. Cholesterol back up, blood sugar creeping up, apnea worse, one knee starting to give me trouble, hormones getting out of whack because of excess estrogen storage (I’m post-menopausal)….
If these drugs continue to work as well as they seem to, the system will figure out it’s cheaper to pay for them and keep people’s weight down than to withhold them and pay to treat the consequences of the excess weight.
I wonder if how I feel on Ozempic is how naturally thin people feel all the time ; I get somewhat hungry, although it’s ignorable. I enjoy good food, but don’t crave sugar or junk food even when hungry. I eat a small amount and am satisfied, have no desire to continue. If I eat past that point (eating fast can take me there), I feel quite nauseous for a couple of hours.
So WHY is it that medications are so damned expensive in the US? I’ve never really understood.
I would want functional wings in addition to arms, and will accept significant hits to my living space needs and personal grooming difficulty levels. I think wings wd improve my sex life, based on the weirdness level of wings being a good filter for those insufficiently weird for me to want sex with. But I would rather have a prehensile tail.
I would love to have wings. I have had frequent dreams of flying my whole life. The way I do it in my dreams is to flap my arms really really fast, sort of like a bumble bee does it's wings. It is hard work, but worth it, and after launch I don't need to flap as hard. However, once launched it's crucial to believe I am really able to do fly and that this isn't just another one of those flying dreams, because if that enters my mind I start to fall. . . Anyhow, if I had wings I'd look and smell just the same, and sex would be the same vexing but delightful possibility as ever, but I would be SO HAPPY.
Functional wings on a human sized body with Earth's current atmosphere and biologically normal muscles are simply not possible. Fancy metamaterial muscles is probably the way a sci-fi future would solve it, and I'd take functional wings (in addition to arms) if they had no drawbacks, but I don't want them nearly enough to accept the trade-off of eg. hollow bones
True! But by the time this is possible, we will probably have space stations and maybe colonies on moons or asteroids. I do think wings wd be a good way to move around in pressurized microgravity
I'd want functional wings, if they could be made to work. I might even accept being two feet tall (same intelligence) if it was necessary to be able to fly.
I suspect that for a human to groom wings would take a tool or a partner.
Great post! I’ve done some research on this issue, so here are a few thoughts. I put relevant links at the bottom of the post to support my specific claims.
First, the low volume for semaglutide that you are observing is at least partially due to supply shortages. The drug has been in serious shortage for a while. Novo Nordisk also sells Saxenda (liraglutide) for weight loss. Over the last 2 quarters, Saxenda sales are up 59%, while Wegovy sales are down 18%. Saxenda is priced similarly, and Wegovy is a better product. So I suspect a lot of the Saxenda spending would be going towards Wegovy in the absence of the semaglutide supply shortage.
Second, spending on Wegovy might not fully capture use of semaglutide for weight loss, because some people might be taking Ozempic primarily for weight loss benefits. Ozempic sales are huge, and it is a top-20 spending drug in Medicare. After the clinical trial was published showing sustained weight loss benefits from semaglutide, Ozempic sales growth accelerated (though sales were already growing fast). Even though Ozempic is approved for the diabetes indication, it makes sense that people would take it for weight loss, because (1) there is a big overlap between the obese and diabetic population and (2) Ozempic is more likely to be covered by insurance.
Third, your estimates of the costs are somewhat exaggerated, because the drug manufacturer pays significant discounts to insurers. These discounts do not reduce cost-sharing, but they do reduce premiums. When thinking about the social cost of the drug, it's more accurate to think about the price net of discounts, as opposed to the list price. The Morgan Stanley report that you cited reports roughly a 30% typical discount from the list price.
Fourth, this is nitpicky, but when you say "almost 10% of all US drug spending," you are dividing a 2030 spending projection by what U.S. prescription drug spending was in ~2020. The Medicare actuaries project U.S. prescription drug spending in 2030 to be closer to 600 million, not 300 million. That's still a massive projection for spending in the obesity class. If you believe the Morgan Stanley projection, spending on the obesity class as a share of national health spending will be comparable to peak spending on the Hepatitis C drugs. The financial impact of the Hepatitis C drugs was a huge story. But this would be even bigger, because the Hepatitis C drugs were a cure, such that the spending surge was short-lived. Conversely, the obesity drugs are chronic medications, and we should probably expect volume to continue to increase post-2030.
Fifth, a remarkable thing about semaglutide that may have been under-emphasized in your post is the extent to which the weight loss benefits are being sustained. People who successfully lose weight tend to have a very difficult time keeping the weight off. To my knowledge, before semaglutide, the only intervention that had been demonstrated to sustain a >10% weight loss benefit for more than 1-year was bariatric surgery. So far, clinical trails are showing sustained weight loss benefits from semaglutide for at least 2-years.
Sixth, this post focuses on GLP-1 agonists, which makes sense, because those drugs are starting to have an impact today. But the Morgan Stanley report also notes that amylin analogue cagrilintide may be approved for weight loss as soon as 2025. This drug has a completely different mechanism than semaglutide, but likely offers similar weight loss benefits. The crazy thing is that the weight loss benefits stack. So Novo Nordisk hopes to sell Cagrisema, which combines amylin analogue cagrilintide with semaglutide, and hopes to offer a ~30% average weight loss. This is roughly double what semaglutide offers, and is getting closer to bariatric surgery efficacy.
Seventh, if Medicare decides to cover Wegovy, it would be relatively affordable for Medicare beneficiaries. Starting in 2025, out-of-pocket costs for prescription drugs will be capped at $2,000 for Medicare beneficiaries. And most Medicare enrollees with a 30+ BMI are probably already spending a lot on drugs. So at the end of the day, the marginal cost might be $100 per month or even less. And if you are near-poverty, you get cost-sharing subsidies, so the cost is only about $10 per month. Of course, this all depends on Congress changing the law such that Medicare can cover obesity drugs. Currently, there is a statutory exclusion that can only be changed through Congressional action.
That’s all I have for now. Here are some citations for various claims I made in this comment.
Another data point: was prescribed liraglutide in Switzerland. The cost is about $150 / month on the highest dose.
I lost roughly 8% of weight, then went off it due to gastrointestinal problems. It's very far from a miracle drug, feels pretty nasty. Have since gained back the weight (confounded with other medical issues, complete lack of exercise). I might try again with a lower dose.
I was on liraglutide before I switched to semaglutide. I noticed the ratio of gastrointestinal issues to weight loss was lower with semaglutide. With liraglutide I felt much more full and nauseous and had worse heart burn. Then when I switched to semaglutide my appetite dropped significantly and I experienced much less fullness/nausea/heart burn. I suspect liraglutide has a relatively stronger effect on gastric emptying than appetite when compared to semaglutide.
Serious though somewhat rude question - for people who don't go to the gym, why not and what would get you to go? It seems like for an individual doing an hour of cardio 3-4 days a week is a much lower hanging fruit than getting a prescription, dealing with insurance, remembering to take the medicine, and dealing with the side effects. I wonder if we're missing a similarly low-hanging fruit on a large scale by not subsidizing gym memberships or having state-run public gyms (this seems logistically way easier than solving the food desert problem). I've been fortunate enough to live within a short walking distance of a gym my whole life and although I'd probably still work out even if I had to drive/walk longer I probably wouldn't go as frequently as I do and might not have started in the first place.
"Are you enjoying that yet, Kelly? Keep at it, your brain will learn to adapt, and it will become an acquired pleasure drowning while being bitten, pecked, and scratched by snakes, dogs and poultry!"
This sounds like all the people pushing how drugs really are great and will change your life for the better if you only try psychedelics/mushrooms/weed/nootropics on here. I am coming to the opinion that exercise *is* a drug, and you lot are junkies who need your fix or else.
As a formerly 315lb person I am inclined to agree. I started lifting heavy free weights this year and it put me in a caloric deficit that I literally can’t eat enough most days to meet so I’ve started losing fat fast while building significant muscle. My only diet change was to make sure I eat 0.75g of protein per pound I weight every day.
It cured some chronic back and knee pain I had as well. Down about 20lbs of fat and added about 10 lbs of muscle so far… and it’s only 1 hour, 3x per week.
I don't find any of this surprising as I was already well-aware sedentary life and hating physical activity is more or less the norm for industrialized nations, but yes, it is radically contrary to my own personal experience. Everyone in my family at least lettered in two high school varsity sports. My dad was offered a NCAA scholarship for baseball, but didn't qualify academically. I won multiple California state championships in track and cross-country, and then got really into sort of outdoor adventure type stuff in my 20s, open-water swimming, thru-hiking the Pacific Crest Trail, alpine mountaineering, rock climbing, basically anything you might picture Bear Grylls doing for fun (and, like him, I also served in the Army, though not spec ops).
The only time I have ever been inactive was the 2nd half of my 30s because of severe spinal degeneration. I eventually needed five surgeries, couldn't put socks on without an assistance device at one point, and was more or less bedridden more than half the time during the worst of it. Even then, I never got particularly fat. In my 40s now, I can't do any sort of long-duration activity without totally knotting up and barely being able to stand, so the types of endurance stuff I used to do is out the door, and wilderness treks are probably not safe. But I've got into weightlifting instead because I absolutely need to be doing something physical. I make no particularly effort to be lean or lose weight. I haven't eaten at an intentional calorie deficit in over a decade and am currently trying to gain weight, but I'm still 6'2" 190 lbs at somewhere in the area of 10-12% bodyfat. Nowhere near "shredded," but every muscle is visible. There's fat on me, but not enough to result in any visible rolls. Nothing that jiggles.
It is absolutely not miserable to train and become better at something, and for that matter, given I couldn't pick up my cats six years ago, it is not miserable to go from that to being able to lift multiple of my own bodyweight. Exercise is not a chore to me. It's as natural a habit and a part of life as eating out with friends and watching television seems to be for an average American. And, of course, given this kind of life history and my family, that has been the case for many, if not most, people I have ever known and spent a lot of time with, anywhere except on the Internet.
So yeah, I see the studies and the anecdotes and see the obesity rate skyrocketing in the general population and it's obvious something is up, but it gets even more frustrating that it doesn't have to be this way. I realize this is at least partly genetic. I don't have a ton of athletic talent, but certainly some. But a lot of this is just habit, and it's habits that were instilled at a young age. They've been part of my personal and cultural identity for my entire life and really before that since it's a part of my family as well. When I played as a kid, whether alone or with friends, at least half of that play was either a sport or we just drew lines on the street and raced each other. The other half was more legos and sometimes video games, but that never got to be dominant. I still know a lot of those people, and I'm not going to say none of them ever got fat, because one of them did, but it's literally only one, and her entire family is fat.
All of these people saying movement and exercise hurt and make them miserable. You know what hurts me? Being sedentary. When recovering from all the spine problems, the biggest problem I had is my hips started to feel like they were made of concrete. I couldn't even straighten my legs if I sat upright. My hip flexors were constantly aching and throbbing. All of that totally went away within a week of starting to squat. And I don't squat particularly well. I imagine I never will. My hip mobility is still terrible. But a lot of joint pain goes away when those joints are supported by larger, stronger muscles that get used regularly.
Ten years ago, I may have fit your "inspiring" category. Now I don't anymore. I tried the "no excuses" thing, which works... until it doesn't.
At what point does an excuse become legitimate? It's not never. At what point are we allowed to say, "I have limitations that I have so little direct control over that it's unreasonable to expect me to overcome them. I should devote my resources to something else"? There is a long-toed armless man, Liu Wei, famous for playing piano with just his toes, but we don't normally expect the armless to become concert pianists. Liu Wei, impressive as he is, also isn't competitive as a concert pianist against concert pianists with actual hands.
"In professional poker—my former field—knowing when to quit is a survival skill that separates elite players from the rest of the pack. Yet, despite the obvious virtues of folding a bad hand, in most areas of life human beings tend to extol perseverance, so much so that a quick Google search turns up many other stories of distance runners around the world suffering horrifying injuries mid-race but refusing to give up. We look at these types of stories and think, I wish I had that kind of grit.
"But is grit a virtue when we stay too long in bad relationships, bad jobs, and bad careers?"
Or if we let ourselves persist in discomfort that results in long-term damage to our bodies in hopes that "no excuses" can only make us stronger?
Cognitive psychologist and professional poker player Annie Duke remarks, "Contrary to popular belief, winners quit a lot. In fact, that’s how they win."
"It is absolutely not miserable to train and become better at something,"
That is not true. It can be very miserable to train, become quite good at something, then have your prowess snatched away at a moment it matters most because your body failed you in a way mostly outside your control.
That kind of heartbreak can be tough to deal with, and happens to some people a lot. Perhaps not very many people, but the fact that it happens *at all* contradicts assertions that training is absolutely not miserable.
It happens to me as a singer, and is one reason I never tried to sing professionally. Residual tobacco smoke from a previous auditionee or on the auditioners' clothes, or even on transportation to the audition, can physically tank my auditions with asthma. (Sometimes cat dander does it, too.) If I do wow someone at an audition, I might be voiceless from lung trouble by time of performance. I have an unpredictably crappy body. Possibly better medical technology and more attentive medical care would help, but it's fairly obvious by now that my sheer determination alone just isn't enough.
So much can go wrong, no matter how well-rehearsed I am, that sometimes I regret having loved to sing. But I also love music, and can't seem to quit it – but not because it isn't making me miserable: quite often, it is.
I am overjoyed for you that your recovery from spinal degeneration went better than is typically expected. It sounds like you had atypically good results even for a "good patient". When and even whether back surgery actually helps is still poorly-understood, so I'm glad it worked for you. Having previously been a very healthy, active person no doubt helped you, but it sounds like one reason you could be that previously-healthy-active person is because it you didn't start life dealing with hard-to-control health problems.
"Most people seem effectively crippled to me, and I don’t understand how they can stand it."
As one who was born that way, and who wouldn't have survived childhood in an earlier time, it can be hard to stand, but there you are.
"Maybe I’m just lucky for having the right genes. I’m convinced that the way genes make the biggest difference is in what you feel motivated to do. Some people have natural talent, but talent is only expressed through practice. Anyone would get better at piano if they did it for 10 hours a day, but maybe only people with brains wired a certain way can actually find joy in that."
I doubt genes influence motivation more directly than they do bodily features, like whether one's airway is reactive, tissue fragility, match of body type to choice of activity, and pain threshold and tolerance.
Also, speaking as a musician who only learned to practice deeply in college, environment really, *really* matters to whether one is "wired" to put in long practice hours. Many people simply don't have environments where they *can* practice uninterrupted. Those who do usually do so, not merely because of individual force of will, but because those around them support or at least tolerate them putting in long practice hours.
Practice time is *not* supposed to be performance time. It should not be time you're pathologically worried about offending others with your mistakes. It should be a time to work through the mistakes, as long as it takes, as many mistakes as it makes. If the other musicians in your family keep interrupting your practice time with, "You mean you still don't have that right?" "Can't you practice something else now, we're getting sick of this," "I think your intonation is terrible and is giving me a headache," you become "wired" to find practice stressful, hopeless unless you get it right the first (or at least first few) times, and full of distractions taking you out of the music – not because of your genes, but environment.
Re: genes and motivation - there's actually a long-running experimental evolution experiment on "high runner mice", mice which have been selected to run on their wheels as often and long as possible. While there are musculoskeletal differences, these lagged behind performance, and a lot of it seems to be in the brain, especially motivation.
If you'd like to read up on it, the experiment is run by Ted Garland at UC Riverside.
The report suggests even fairly small changes to environment, like a temporary course of antibiotics, can significantly tank these mices' performance, perhaps by making running more metabolically difficult for them.
As I understand it, "high runner mice" are a strain artificially selected for the trait of preferring wheel-running as a source of amusement in their caged life. That this trait can be bred for isn't surprising, but how much does it say about the genetics of motivation more generally, especially if simply changing something like gut microbiota significantly reduces the bred-for trait?
Marcus had written, "Anyone would get better at piano if they did it for 10 hours a day, but maybe only people with brains wired a certain way can actually find joy in that." I replied with,
"I doubt genes influence motivation more directly than they do bodily features, like whether one's airway is reactive, tissue fragility, match of body type to choice of activity, and pain threshold and tolerance." Posing a false dichotomy of brain-vs-musculoskeleton could miss airway reactivity and pain threshold/tolerance, as well as gut microbiota, and other physical factors influencing motivation. True, pain threshold/tolerance *is* quite brain-based, but is also a more specific difference than "maybe some people's brains are wired for motivation and others' aren't".
I see little evidence that motivation is something you either have or don't, irrespective of environmental influence, including whether you're lucky enough to be in an environment that gives you healthy exposure to whichever activities do motivate you more. "High runner mice" are "lucky" to live as lab mice, for example, in a standardized environment with working mouse treadmills.
Though, has anyone tested what happens to "high runner mice" deprived of the environment they were bred to find rewarding? How is their motivation affected, say, by treadmills that stop working unpredictably?
A treadmill rigged to shock mice who fall behind is used for forced-running tests. What if the shocks are random, not a predictable consequence of falling behind? What if mice are shocked for getting ahead on their treadmill? Are "high runner mice" still "inherently" motivated to run under such circumstances?...
Despite all our rage, we are still not just rats in a cage.
I almost thought this was a parody of something a thin person would say to a fat person.
Marcus, what works for you isn't going to work for everybody.
Perhaps thinking about the reality of other people's lives might take you to a place other than "shock and horror." Not just about physical fitness, but about . . . well, anything.
I've gone to the gym off and on over the course of 20+ years.
Sometimes it really is difficult to prioritize. It takes a larger chunk out of one's day and energy budget than most people estimate. Prep, commute, exercise, shower, and reduced energy/focus for at least an hour.
I tried going to gym maybe 3 times, each time lasting about half a year, and I hated it every time and dreaded the day when I went there. It IS boring, and the atmosphere is unpleasant, and the aftermath is painful. I wonder, though, if "the future of fitness" is in VR. If I was cycling or rowing a boat in a game (or at least in an interesting environment), I think would enjoy it more. I'm not sure how can it be applied to lifting weights, though. (Why not REALLY cycle or row a boat? Because it's too cold 6+ months out of 12 here, and I only ever had time in those months).
Actually, rowing is one type of exercise I enjoy. Wish I could do it more often than once a year or so, but it requires too much free time.
I think this is...perhaps not appropriate advice for the intended audience.
Per my understanding, most workouts are not going to burn more than 300-400 calories, which is good but trivially overcome by bad diet, like a single candy bar. I have met a few people who do, legitimately, burn enough calories to not worry about their diet but they're trained runners and bikers. For example, guys who run 5-10 miles a day at pace for an hour can reasonably burn 700-1000 calories and get away with eating pretty badly (1). But again, they've trained to run a 10k every day and can do it comfortably; the average obese individual can't burn calories like that and, honestly, would be lucky to walk for an hour straight.
I seriously doubt your average 230 lb+ individual can burn enough calories at the gym 3-4x a week to meaningfully impact their weight. And, honestly, I don't think there's much low-hanging fruit here. Lifestyle change will generate results but it needs to be pretty dramatic; think completely altering your diet or training to run marathons. If just showing up at the gym helped you lose weight, everyone at Planet Fitness would be thin.
Is there an effect where exercising also increases the amount of snacking? I was operating on a mental model of 'given diet vs given diet + exercise' but if it's 'given diet vs given diet + exercise + additional snack' that's not as cut-and-dry.
I think the lifestyle change doesn't need to be dramatic but it does need to be consistent; most PF members don't go at all and a significant number of those that do go once a month or less. Some cursory googling suggests that it takes roughly a 3500 calorie deficit to lose a pound of fat; if you keep the same diet and do a 400 calorie workout three times a week for a year that's ~18 pounds lost.
The emphasis towards dramatic lifestyle changes probably does more harm than good. It's much easier to sustain a habit than it is to start one and the more dramatic your change is at the beginning the harder it is to start and the more likely you are to give it up in the first month.
I dunno about the snacking. One the one hand, you will definitely need to eat more on a high cardio (like 6k runner) or serious weightlifter. On the other hand, I don't have any snacks in the house, so I don't have experience.
On the need for dramatic changes...I mean, this is an area of personal experience, not academic study, but my understanding is the overwhelming clinical evidence is that virtually no one is able to sustain significant weight loss over a 5 year period. For example, the first pubmed article I found (1) says that you should expect to regain >80% of the weight lost during a diet program within 5 years and, in talking about how to help patients, it mentions that most people expectations are too high and that losing 5-10% of their bodyweight is the most that can reasonably be expected from diet and exercise. Trying to be anything but an extreme outlier fails.
I mean, I get CICO, these things should theoretically work but, to the best of my understanding, we have a deep and robust literature showing that this doesn't work.
My take on “exercise doesn’t make you lose weight” findings is that the experiments are done on people who don’t usually exercise. So they fail because those people don’t continue exercising because they are selecting the people who don’t like exercise not because exercise doesn’t work. People who have figured out ways to get exercise regularly and continuously don’t feature in those studies but they definitely exist and are usually not obese.
My experience is that getting reasonably hard exercise for one hour per day five times a week will definitely lower your weight. I am no superman but I managed to do this while working long hours and bringing up a family by exercising in the morning before work started by getting up an hour earlier. It took a lot of willpower to initially start this but eventually it became a habit. Exercise first thing in the morning removed all my end of day or midday excuses, like I am busy or I am too tired or my friend want to go for a lunch etc. But that trick may not work for you. Note I don’t do any special eating and I drink alcohol.
The other thing about exercise is that it is very slow to make progress, maybe a year or two before you really start seeing results as the amount of exercise you can do at first without getting exhausted is small. As you get fitter you can do more exercise in the same amount of time..
Finally you don’t need a gym, a 5k run can be done anywhere and even in high heat and humidity like Houston in the summer.
I agree with everything you have said here, except that it doesn't hold up in the real world.
If you could figure out a treatment that - when applied to real people in the real world- got people to go exercise, you would likely earn yourself a Nobel. No one has, yet.
Most people who can exercise don’t go to the doctor to get them to tell them to exercise to lose weight, they have already figured it out on their own. So you are right that as a treatment it is not much use, but it doesn’t mean that you, a randomly selected individual, would not be able to lose weight by exercise. Put it this way, some people can’t study (perhaps because of ADD), and if you try to find ways to get them to study you would probably fail, but it doesn’t mean that studying for exams doesn’t work.
I think that *if* the "diet and exercise don't work" research turns out to be wrong, it's likely to be for reasons similar to what you are describing - that these studies disproportionately enroll the really hard cases who are unusually bad at diet and exercise. However, I'm going to need a lot more than your personal anecdote before I conclude that the existing body of research is wrong.
I'm reasonably overweight (6'2 220-ish) and have been forever. Recently started going to the gym and lifting weights fairly seriously. After six months I am pretty much exactly the same weight I was before. I might look a little better, and I enjoy going to the gym, but I think two things you might be missing are that—
1. Exercise just doesn't work that well for weight reduction if your diet sucks. I am motivated to look good to not waste all the time I spend at the gym, but also I just ate a big bowl of barbecue chips while reading this post. It's way easier to eat food that's bad for me than food that's good for me, plus I love the way all the food that's bad for me tastes and have my entire life. I followed a Mounjaro subreddit out of curiosity after Matt Yglesias's bariatric surgery piece came out, and the thing people talk about a lot on there is how the drug makes them just... not eat in all the disordered ways they used to eat. Like they no longer want to wolf down a bunch of cereal late at night, they don't feel like they need three sodas at lunch, a lot of them are even finding they don't want alcohol as much, which is a fascinating window onto whatever these drugs are doing.
I'm not overweight enough to really want to try Mounjaro (at least not yet), but I absolutely relate to their stories—I just have a really hard time fighting the urge to snack in stupid and not even very satisfying ways, and I think a lot of people are like that. I have every reason to want to eat better, but I've tried for years and it hasn't happened yet. If, five years from now, the diet drugs appear to have no unusual side effects, I would absolutely pay $100 a month to not eat a big bag of M&Ms in the car twice a week and derive zero enjoyment from them. That'd be saving me $30 a month on M&Ms! (I'd keep paying $10 a month for the gym, too.)
2. An hour of cardio 3-4 days a week is for a lot of people way higher on the fruit tree than a drug you have to inject once a week or however this works. What dollar figure would you put on 3-4 hours of free time a week? We just had our second kid, so my number is temporarily much higher than it was last month. Cardio can be rewarding on its own merits, but so can losing 15% of your body weight with a pill and spending 4 hours a week building ships in a bottle.
That's reasonable. I'm biased here as a young guy, since I don't have kids or significant non-work commitments so it's easier for me to fit that in to my schedule. I also really enjoy exercising so it's easier for me to prioritize - to answer your question about the dollar figure, I would say it's low or even negative since it's eating from my 'netflix/reddit/hobbies' time rather than 'family/work/self-improvement' time.
Have you just been doing weightlifting or cardio as well? I wouldn't expect someone to lose significant weight from just weightlifting, although you could probably have some recomposition effects (lower bodyfat% and more lean mass) while staying at a similar weight.
I guess my argument comes from the conventional wisdom is that it's easier psychologically to do something (exercise) than it is to not do something (eat less). If we shift eating less from 'not doing something' to 'doing something' (taking an injection or pill) then the tradeoff becomes something like money + time cost of taking the drug vs exercising, which is probably more towards the drug for most people.
"I'm reasonably overweight (6'2 220-ish) and have been forever. Recently started going to the gym and lifting weights fairly seriously. After six months I am pretty much exactly the same weight I was before.
...
An hour of cardio 3-4 days a week is for a lot of people way higher on the fruit tree than a drug you have to inject once a week or however this works..."
I have another (late) anecdote to contribute to this thread. Even an hour of cardio 3-4 days a week may have limits on how effective it can be [for weight loss].
I am a bit under 6' 2" and am currently around 220 lbs. I 'm down from 232 in March, which was up from 220 in late fall of 2020, which was down from 225 in early 2020. I lost weight by doing a lot of walking during the early part of Covid, then put it back on, then was able to go back to the gym and have started losing. I *did* exercise all through Covid, but clearly there was a year in there where I still gained 12+ pounds.
And ... 232 -> 220 in 8 months is 12 pounds over 8 months. For a while I was losing 2 pounds/month, so things have plateaued ... and maybe will start dropping again. Plateaus seem to be common. But at 1.5 pounds per month I'll still need an additional year to lose 10% more and get down to 200 pounds.
And ... my gym routine is pretty intense for a non-athlete. I burn around 850 calories in an hour (as reported by the machines, but also confirmed by on-line calculators that take as input my weight, heart rat during the exercise and duration).
850 calories burned in an hour is, objectively, a LOT for non-athletes. I alternate elliptical and stairmill and my stairmill days usually see me 'climb' 190-ish stairs in the hour. My rate limiter is that I don't want to exceed 85% of my max heart rate for very long and I don't want to be in the gym for 2 hours at a time. When all was going well this was resulting in 2 pounds of loss per month. I do not expect very many people will be willing to do this on an ongoing basis. And operating at 80% - 85% of max heart rate for an hour is a pretty big ask for most people, too.
I've recently added weights for upper body and we'll see how that goes, but, yeah exercise is a good thing but makes for VERY slow weight loss.
[Also, to (again) point out that obese isn't what a lot of people mean. At 6' 1" and 230 pounds I was obese using the BMI calculators. I was also able to climb 180+ flights of stairs in an hour. I looked overweight but maybe not the stereotypical image when people think 'obese.']
Exercise is just a tough way to lose (and maintain the loss) weight.
Firstly: exercise doesn't work to reduce weight, it's almost all a matter of diet.
Secondly: gyms are beside the point. Almost anyone can do cardio or weight training for free in their own home or outside, with barely any equipment. You can run outside, or do jumping jacks in your house, or do push-ups and sit-ups, and so on.
People don't because it's unpleasant. It's suffering, and it's suffering that you have to force yourself to do, which makes it doubly hard to actually do it when you could do anything else with your time.
Ways to get people to exercise that makes it not feel like suffering exist (eg vr videogames), but they're still pretty niche and no one has figured out how to sell it to the masses.
I'm surprised to hear this sentiment and the similar comments elsewhere in the thread. I really enjoy exercise for its own sake, and most people in my friend group also do (but I've met a lot of my friends at the gym so of course there's a bias there). Just as an informal poll:
Exercise that's delightful in an already-fit body is not necessarily so in an unfit body, whether the body is injured, ill, or just awkwardly-sized.
Both my husband and I usually enjoy push-mowing the lawn. I've always been sickly. He was healthy as a horse until recently. Both of us are having trouble getting timely medical care in a backed-up system. Unsurprisingly, push-mowing has (hopefully temporarily) lost its zing for us. As have other, more conventionally-interesting, active pursuits. This relatively sudden change from "we positively enjoy even push-mowing" to "what'll break next if we're too active?" is a fairly dramatic lesson in what might demotivate people.
>I really enjoy exercise for its own sake, and most people in my friend group also do
>Exercise that's delightful in an already-fit body is not necessarily so in an unfit body, whether the body is injured, ill, or just awkwardly-sized.
This. Moreover:
1. Jogging / running / any intensive cardio is absolutely horrible if you have never done such thing before / since childhood. Everything aches, breathing is all weird and possibly unpleasant. It took me some months to experience anything resembling "runner's high".
2. Fundamentally, running or weightlifting is pretty boring activity. It is not of course totally uneventful: I can look at scenery while running, I need to concentrate on posture and stuff while doings reps, but fundamentally, it is repetitive. Actual competitive sports are much more active and interesting: there are much more varied skills to build, many different situations, moving your ass is much more motivating. However, if you are out-of-shape, you will soon notice that competitive sports are competitive. If you compete with more athletic people, you are going lose, and many people won't find it fun.
Jogging never worked for me. Alternating sprinting with slow walks did until I blew an ACL. "Runner's high" just isn't for everyone.
It can take surprisingly little strength training to be (rather than look) healthier: https://www.painscience.com/articles/strength-training.php – though, of course, our typical notions of fitness aren't just about being healthier. They're also about looking better.
Even sports competitions I could win bored me. Hiking, cross-country skiing, dancing, heavy yardwork are more amusing to me, if I'm not too injured/ill for them. Heck, so is high-intensity interval training on an elliptical – provided I don't have to worry about bonking my head on the ceiling (which, in our new place, I do) – if only because it takes relatively little time.
Getting some sort of amusement out of exercise seems extremely important to making it a habit. It's all the more important the more uncomfortable your body is.
I can see both perspectives because I also enjoy exercise (running and cycling), but also regard it as unpleasant, at least some of the time. I guess the parts we enjoy (fitness, sense of progress and accomplishment, socialisation with friends) outweigh the inevitable aches and pains, and there's probably some amount of satisfaction derived from overcoming (mild) suffering.
Nah, Drethelin is right; it's suffering. It may be suffering that does you go, but when you're hobbling around the day after all that 'healthy' exercise because your muscles are tight and your joints ache, that does not encourage you to keep doing this.
I honestly think this is the big, unacknowledged difference: some people enjoy exercise for whatever reason, and some people don't, because it hurts and you can feel the pain while the benefits are largely invisible.
Being well and truly *in* shape just isn't going to be an option for some people, even if the look visibly trim and toned.
"Your body adapts."
Your body adapted. Not everyone's body can.
I spent nearly all my time from high school to childbearing at normal BMI, never washboard-abbed but quite flat-tummied, toned, with positively burly legs for a gal. I still wasn't really in shape, and could never be. I did the best I could, which was sometimes pretty damn good, but my body still failed in stereotypically "unfit" ways.
"I used to get completely winded and feel like I was dying when I ran"
No matter how fit I am, getting completely winded during exercise could happen at any time for me, from asthma. More than once, I've been tooling along on my bike, suddenly found pedaling "mysteriously" difficult, assumed it was "just asthma again", and only after stopping for another reason, realized I had shredded a tire or had back brakes rubbing the tire rim. Imagine being in a body so unreliable that you don't even think of equipment failure while your equipment is failing in ways that would be obvious to nearly anyone else! No amount of fitness gets me to not have that body.
Strength training can compensate for congenitally-weak connective tissue, too, but nothing makes that congenital weakness disappear, and with it, the risk of hard-to-rehab injury and immune derangement that interferes with fitness goals.
If nearly everything else is going right in life, juggling all the little extras needed to stay fit in a congenitally-unfit body can be doable. Not much has to go wrong, though, for the impediments to exercise to snowball.
I love the feeling of sore muscles, and the pain of pushing a set to failure. Besides the sense of progress, it grounds me in my body.
Pain not associated with actual disease or injury can safely be sublimated into pleasure (see also: spicy food, BDSM), this is a useful and healthy cognitive trick
For training rats to run mazes, perhaps. If you enjoy being a rat on a treadwheel, don't let me stop you. But I am not going to put on whiskers and a tail for anyone's urging.
Well, raj, think of a kind of pain you do not like. How about stitches in your side when you're running? Headaches? Being extremely tired and drowsy but obligated to stay awake? Lemon juice in a cut? Labor pains? Break-up pain? OK, that pain you do not like and can't sublimate? That's what exercise-related pain feels like to some people. Some people can't sublimate it.
If exercise hurts instead of being fun, you're probably doing the wrong type/intensity of exercise. If your diet and sleep are reasonable, the comfort zone will gradually expand so long as you are regularly working at the limits of the comfort zone. Even if it's just walking at 3mph for 10 minutes daily, that is hugely better than being sedentary, and doing that regularly almost anybody could work their way up to 30 minutes at 3.3mph or something without pain.
> Pain not associated with actual disease or injury can safely be sublimated into pleasure
You are typical-minding.
> see also: spicy food
I also hate that. I've only gotten an endorphin rush from spicy food once or twice. If I could reliably do that, I would put up with the pain. But I can't, so I won't. Also - capsicum tastes very soapy for me, though I don't have that problem with other sources of heat like mustard or horseradish.
"Pain not associated with actual disease or injury can safely be sublimated into pleasure"-- it isn't necessarily safe. People get exercise and BDSM injuries.
So far as I know, people only get spicy food injuries in eating contests.
> People don't because it's unpleasant. It's suffering, and it's suffering that you have to force yourself to do, which makes it doubly hard to actually do it when you could do anything else with your time.
I find it interesting how differently people feel about that. I really look forward to excercise, to the point where I probably train more than the optimal amount just because I like doing it and sometimes have to hold myself back
I'm usually anhedonic, video games and TV bring me almost no pleasure anymore but pushing my body is consistently rewarding.
I think it's one of those things that's possible to learn to like - it is not *inherently* unpleasant, our bodies are designed to work hard and in fact it is good for your health so it shouldn't be sending painful signals. But perhaps for those far outside the envelope of 'normative health' that's not true, and/or they associate an anxiety with the activity (as opposed to others who associate it to euphoria?)
After starting a diet the summer before I turned 14, I've spent most of my life at a normal BMI, whether I exercised at a gym, outdoors, or at home. I'd temporarily creep into overweight if seriously injured. Then I had kids. And COVID happened. And the medical system is still backed up, and I can't get timely asthma or rheumatological (for EDS) care. We also know something we didn't before, which is that asthmatics' individual environmental hygiene isn't as important as we thought, while the bugs asthmatics catch from other people are more important triggers than we thought:
Hire someone to supervise my kids so I can go to a gym to breathe in others' germs, after I caught a lung infection so bad during my last pregnancy I nearly ended up with a COPD diagnosis on top of asthma? Especially when I can't get timely medical care? No thanks.
I should get back to my old, fitter self, not least because pudge is inflammatory and hard on the joints, making both asthma and EDS harder to control. But go to a gym to do it? Not feasible for the near future.
Before I got in semaglutide I spent 40-50 hours on pubmed looking for any exercise/diet regimen that was shown to be effective over 5+ years. There aren't any. Only a slim few manage to keep weight off for long periods of time and every one I've known has become obsessed like anorexia level ocd obsessed with keeping it off. They build their entire lives around it.
Anecdote:
I've had time in my life when I went to the gym (5-6 hrs a week) other when I didn't. When I go I'm in better shape and more muscular but I'm not any lighter.
Data:
Also if you look at pubmed exercise causes minimal weight loss unless you're doing herculean marathon training levels of exercise.
I usually force myself to go to the gym once a week, but the main reason I don't go more often is that it leaves me exhausted for the rest of the day, and with muscle pain for 3-4 days, and I can't afford to be that non-functional more frequently than that.
I keep wondering if that stops being the case when you reach a certain level of fitness, and how far from that level I am.
(You're probably thinking "you're overdoing it", but I mostly either lift wimpy little free weights in the <20kg range, or do classes intended for "those new to fitness")
I'm loathe to give workout advice, but 20kg is a lot. Wimpy is 1kg. I don't know about the classes, but even if it's for newbies, it may be calibrated towards healthy 20 year olds.
My point is that the bottom of fitness for sedentary, unhealthy people is way lower than most people, including fitness trainers, expect.
Yeah, I think you're right about the expectations of fitness trainers. I tried saying to both the class instructor and the gym manager that I find the classes too demanding and that maybe they should be at a more approachable level if they're marketed to beginners, to not scare people off and to help them ease gradually into a sustainable fitness habit, but they both just doubled down and said it's good if it's challenging.
I recommend the youtube vids by rennaissance periodization for guides about getting started. The way to do it seems to be based on targetting a certain number of reps to get to failure, and seeing what weight will do that for you.
e.g. If I tried my absolute hardest gun to my head, i could do 10 reps at X weight, so i will do 8 reps at X weight, with 2 'reps in reserve'. (failure means you can no longer do it with good technique, you don't want to do a super sloppy rep and get bad habits). And then you keep adjusting your weights to keep your maximum reps more or less consistent. The number of reps you should target depends on your goals (strength is something like 3-6, muscle size is like 6-12 or something and endurance is more).
And then you can do multiple sets of however many reps it is and do more sets in a day as you get more advanced, but getting close to failure within a set is important and kind of non-negotiable to get any results at all. To start with you can even do just one set of however many reps get you close to failure, and then gradually add more sets. (but do like, one set of a bunch of exercises to target your whole body).
here's a link to the first in the playlist of how to design a workout for beginners.
"Yeah, I think you're right about the expectations of fitness trainers. I tried saying to both the class instructor and the gym manager that I find the classes too demanding and that maybe they should be at a more approachable level if they're marketed to beginners, to not scare people off and to help them ease gradually into a sustainable fitness habit, but they both just doubled down and said it's good if it's challenging."
A suggestions: See if there is a Planet Fitness near you and if so whether their class schedule works for you.
As a general rule, "real" gym goers hate Planet Fitness. It isn't a real gym and targets newbies and doesn't have many freeweights and ... You can Google for why Planet Fitness sucks and find a number of articles on the subject.
But you also make it sound like YOU might be a very good fit for Planet Fitness and your current gym folks are exhibiting exactly those behaviors that Planet Fitness advertises against. I don't use the class option at Planet Fitness, but there is a good chance that the trainers there are more aware of beginners.
I, myself, exercise at a Planet Fitness because (a) the price is very difficult to beat (around $10/month), and (b) Planet Fitness has what I need. It might be a fit for you, too.
Try eating more protein, on the order of 0.75g per pound of body weight. I do heavy weight lifting with free weights and rarely have muscle soreness since I started doing that, but regularly had it before I upped my protein.
Also, you may actually need to increase the calories you are eating if you are feeling that tired after lifting weights. My wife jumped from 1800 calories per day to 2200 with similar weights as you and that finely started giving her the energy she needed to sustain the program she is doing and she is losing fat and building muscle.
Also every 4-6 weeks I need to take a week off to recover. I cut way back on weight and reps.
> I keep wondering if that stops being the case when you reach a certain level of fitness, and how far from that level I am.
DOMS (muscle soreness) isn't even technically necessary to make strength gains in the gym, in fact advanced bodybuilders often say it simply hinders recovery.
However, I know whenever I start lifting after taking a break I'll get a little soreness for a while. I encourage you to try to reduce intensity, but also endure soreness and stick with it, it should decrease in frequency and severity as you gain experience, as long as you don't let your regimen lapse for too long.
But also, there should quickly come a point where even the sore version of you is more functional than the not-sore, but untrained version of you.
I'm a bit late to this thread, but I wanted to share a tip: there's no need to be sore from working out. Some people seem to have this idea that a workout isn't good if you're not sore, but that's simply false. If you work out regularly, your body will adapt, and soreness will disappear. Ease in to new exercise routines to avoid soreness, and train regularly (preferably 3x a week) to stay in shape.
I think it's a common mistake that people will jump into a workout routine that's too far above their level, and get into a feedback loop of "too sore to train again"-"get out of shape from not training"-"get sore from training because out of shape". In particular, a 45-minute workout class is going to be too much for someone who's usually sedentary--they should probably start with a 15 minute session.
Haha, no worries, asking a question is much *less* rude than assuming an answer, which is what most people do.
For me it's currently mostly a question of *time*. I have two small kids; the younger one at kindergarten age, sick almost all the time (nothing serious, but cannot go to kindergarten while sick), at the very annoying age of 4. Both me and my wife have full-time jobs, and we also have to share the childcare. Both of us can work from home half of the week, so we alternate staying at home and being interrupted all the time by the child. After work, it is time to buy food, cook food, convince the kids to eat something (much more work than cooking for adults, who will eat almost anything without throwing a tantrum), do the dishes, check the homework of the older child... soon it is time to wash up, and read the bedtime story.
So, *when* exactly am I supposed to go to the gym? Early morning? I would need to wake up at 5PM to go to the gym, spend an hour there, and return back early enough to make breakfast for the older one and bring her to school. (This actually sounds interesting, I should probably try it once, assuming the gym opens early enough, at least it would be quite empty. But that means going to sleep immediately when the kids do. Nevermind... checked online, the gyms in my proximity do not open before 6:30, that is too late for my purpose.)
After the work? I usually bring my child to school before 8:00, so I get to my job at 8:30, after eight hours and lunch break it is 17:00, getting home past 17:30. Going to gym after work would mean getting home every day at 18:30 or 19:00. I would actually try that, but my wife disagrees. (Unfortunately, when you have a family, you need to take their votes into account.) Going to the gym after 21:00 is also not an option, they are already closed then. That only leaves weekends, when random things happen, so I cannot say anything consistent about them. But usually weekend is the time to do things I did not have enough time to do during the workweek.
I actually prefer exercising at home, because at gym 1 hour of exercise can mean 2 hours of wasted time (going to the gym and back), but at home, I can spend the breaks between the sets watching a movie, reading a book, or doing dishes. The problem is, if the kids are not in the bed, they keep me busy, and when they are in the bed, I am already quite tired. Still, I exercise about 30-50% of evenings, depending on circumstances. When I exercise more regularly, I keep getting stronger, but I do not lose weight anyway.
The only thing that helps me lose weight is "starving". I already skip breakfast every day (which sounds to me like the intermittent fasting that most people recommend), it has no effect. To lose weight, I need to be very careful about what I eat, and to only eat frustratingly small amounts of it, consistently for several days in a row. Unfortunately, doing that has huge *mental* costs -- as a consequence, the whole day I am irritated and can't stop thinking "fuck, I am hungry". If I had no work and no kids, I could probably distract myself somehow, like taking a walk or playing computer games. But in that mood, any stressful thing would make me explode. I would either yell at my kids, or just scream "fuck this" and stuff my face full of chocolate. :(
I hope this gets better when the younger child grows up a bit. The older one is already okay. (Okay = not driving parents crazy all the time, not extremely picky about food.) But right now, a pill that would allow me to eat small amount of healthy foods without feeling hungry and irritated all the time would be really helpful.
"To lose weight, I need to be very careful about what I eat, and to only eat frustratingly small amounts of it, consistently for several days in a row. Unfortunately, doing that has huge *mental* costs -- as a consequence, the whole day I am irritated and can't stop thinking 'fuck, I am hungry'. If I had no work and no kids, I could probably distract myself somehow, like taking a walk or playing computer games. But in that mood, any stressful thing would make me explode. I would either yell at my kids, or just scream 'fuck this' and stuff my face full of chocolate. :( I hope this gets better when the younger child grows up a bit."
This reminds me that it took parenting to get me to stress-eat.
I used to be OK with pretty heavily restricting amount, type, and timing (no calories after 9pm) of food, even if that meant mild insomnia from going to bed rather hungry. Now? I need the sleep. I need to not be crazy, and kids, for all their joys, can drive us crazy!
Also, atopy (allergies, asthma, itching) can be pretty crazy-making, too. Doctors can prescribe treatments other than antihistamines, but the effective OTC meds are antihistamines, which can interfere with weight loss. (For whatever reason, childbearing seems to have made my atopy worse.) Using a drowsy-making antihistamine to knock me out every night would likely nonetheless cause less weight gain than bedtime comfort-eating. And either is likely superior to what... a benzo habit?... In any case, I dislike *feeling* sedated, even from alcohol: food is a milder sedative.
In terms of responsible parenting – especially a responsible mom (during pregnancy) – food is one of the least-bad addictions to have. The downside is you're not modeling the best eating habits for your kids, which sucks, especially when you did have good eating habits before. But modeling less-than-ideal eating habits is still less likely to get your kids hauled off to foster care than drinking and drugging, so there's that :-)
Just as a general thing, this is one of the reasons no dieting method should be considered effective unless it works for at least five years. Life happens, and that includes caretaking, illness, injury, and financial problems.
I am very sceptical of this specific policy proposal, simply because I don't think money is the barrier, but time and effort. Observe the many people who pay gym memberships, and therefore have free access to a gym, and still do not go.
I am not a fan of the gym personally, I find it much easier to motivate myself to go for a run than to go to the gym. I suspect this varies from person to person, but it seems the trick is to find a form of exercise that you enjoy? Which is hard to recommend even on a personal level, because exercise is always somewhat unpleasant, its even worse as a recommendation on a policy level.
PE classes at school were miserable and embarrassing and I swore once I left school I would never, ever, voluntarily attempt to play a sport or run or anything ever again.
No gyms around where I lived. Not easy to access. Plus, when you're very very fat, it's difficult and off-putting to try and go someplace and use equipment and do exercises you don't know anything about and are worrying about sweating, red face, people looking at you, etc.
Never got any of the endorphins from exercising. Never got pleasure or enjoyment out of it. Never got "but don't you feel good when your body is moving the way it is meant to move?". Got the cramps and pains and sweatiness and tired afterwards, often the day afterwards. Did loosen up a bit, did get a bit more fit, never got "oh this feels good".
More enjoyable things to do. When I was exercising, I had to force myself "okay, it is now 6 pm and you said you would do an hour of exercise a day every day", even mild exercise. Dreaded the time when I *had* to exercise would come, couldn't wait for it to be over.
Let me turn the question back: for people who go to the gym, why and what would get you not to go? If it's "but of course I want to go, why wouldn't I?" as your first response, that is the first response for me "but of course I don't want to go, why would I?" and any arguments pro- or con- are not going to convince those who like and enjoy exercise to give it up, and those who don't like or enjoy it to take it up.
No, not even the health ones. Suppose I argued that running, games, sports, whatever were wrecking your joints and would turn you into a hobbling cripple in later years and it damaged your heart and lungs despite what you think - would that still put you off? Same with "but exercise makes you healthier" - yeah, maybe, but it still feels awful.
"PE classes at school were miserable and embarrassing"
They were for me, too. They were humiliating despite my setting school records for long jump and situps, since I failed at other tasks so spectacularly. I didn't have to be particularly fat, just asthmatic, weird, and not-skinny to be mocked as "too fat" for fitness.
Fortunately, midway through high school, we could take modern dance for PE instead. Rinky-dink stuff, but even a modicum of artistic expression made exertion around other people more bearable for me.
Exertion that lets me make or see something pretty, or build something useful, is more appealing to me. Hiking and dance? Prettiness – pretty scenery, pretty movements. Dance also let me socialize without having to make much small talk. Heavy yardwork and other building? Utility. Exertion seems worthwhile when I can "Cock[] a squint eye aloft, and sa[y], 'I bloody did that.'"
Some of the "thats" I bloody did were pretty stupid in retrospect – wouldn't recommend, wouldn't do again, but they were, of course, the most thrilling at the time.
I don't go to the gym, but I'm also likely underweight (I haven't been on a scale in a long time) and don't take any medicine. I rarely have any interaction with health insurance since I don't consume much medicine, but I did recently get some vaccines where I had to hand in my insurance cards and after a long wait was told one was expired.
One point of data. I'm in Canada. My partner has been using Ozempic (that's what it says on the box) for weight loss for a few weeks. It was prescribed by their general practitioner. I have no idea what it costs because it's covered by our additional medical insurance.
Re canada, if you are american and have a prescription you should be able to get semaglutides for a couple hundred dollars a month through CanShipMeds. (At least, you could as of a couple months ago).
Also, thanks for the shout-out! If I had known so many people were going to read that post I’d have probably edited it a bit more haha.
I'm late commenting but I don't see anyone mentioning metformin yet.
** THIS IS NOT MEDICAL ADVICE **
Metformin is off-patent and although its only on-label use is for diabetes, some people think it extends life expectancy. (The main evidence for this is that diabetics who take metformin live longer on average than people who aren't diabetic.)
Since I started taking it my blood sugar has dropped from the high end of the normal range to the low end, which I imagine is a good place for it to be. And I've lost a noticeable thought not dramatic amount of weight: maybe 5% or thereabouts, which moved me from "overweight" to the high end of normal.
Surely people who are thinking about taking semaglutide should try metformin first?
Even though this is *not medical advice* I think it might be helpful to point out a few things:
- I got my baseline blood sugar and blood pressure checked before I started on metformin, then again afterwards. The drug can reduce both and you don't want either to go too low, although lower is better within reason.
- The one initial side effect I experienced was orthostatic hypotension (dizziness when standing up suddenly), which went away after a few days. Starting at a low dose and increasing it gradually can make that less likely.
- I live outside the US and I have no idea if metformin is sold over the counter there. In most countries it's OTC and costs almost nothing.
Metformin has absolutely crippling gastrointestinal side effects (we're talking "you better remain near a bathroom for most of your day" level, in my case) that never go away, for some significant number of people who take it. It was bad enough that I discontinued it 3 months in despite needing the A1C reduction, and I rarely discontinue drugs due to side effects.
Also, I've lost far more weight on adderall. I lost basically none on metformin.
I'm on metformin (that's what my doctor started me off on first). Had the gastrointestinal effects V-I mentions but they cleared up within a week. I'm tolerating it well but it didn't shift any weight for me.
Like everything else about how biology is complicated, I think it will work for some people that way but not for everyone. Some people, like V-I, will have the bad side-effects persisting so they have come off it, some people will tolerate it easily like I did. Some people will lose weight on it, some won't.
The idea that it's some miracle anti-aging/anti-death drug for non-diabetics makes me laugh; I think it may help diabetics live longer than if they weren't on it, but that doesn't mean it will work if you don't have diabetes. If you have a rash and put cream on it, the cream will clear it up. But putting cream on your skin with no rash will do nothing.
I was on metformin for years. Still am, since I see no reason to stop.
The gastrointestinal issues (think explosions) were awful in the first two years. I couldn't go for a walk for an hour anywhere without a public toilet near. After that they remained bad but manageable.
When I started taking metformin I combined it with a keto diet and I lost a lot of weight then (about 30 pounds? I went from clothing size 48EU to 42-44-ish EU). I stagnated about half a year later but the weight staid off for ~4 years. Then I had to change my routine, added intermittent fasting to the mix (not because I wanted to, it just ended up that way with my job) and put all of it back twice or thrice over. Despite still being on keto and metformine. I couldn't lose any more weight after fixing that irregular meal schedule and was stuck.
Would I recommend metformin for weight loss for anyone? Hell no. It's far far more painful, awkward and difficult to manage than even a gastric bypass. Get a gastric bypass instead if you're that desperate.
Two *years*?! Yeah, "explosions" sounds like about how I reacted. I wouldn't do that for two years running even if you told me it'd make me weigh 185, which I haven't weighed since high school - just not worth it. Major respect to you for sticking that out, though.
Okay, clearly different people react differently to this drug (and to many other drugs).
My 2c worth is just my own personal experience: I started taking it, scaled up the dose gradually, had minimal and temporary side effects, and got modest but very persistent weight loss.
So if anyone else reacts to metformin the way I did, it seems as if it would be a good idea to try it before moving to a drug that costs $15,000 per year.
Particularly in interesting if this works by the same mechanism as the weight loss effects, which seems plausible. What other willpower weaknesses will be treatable by medication?
Would you take a drug that made you not want to cheat on your spouse? Would you want your spouse to?
As far as drugs affecting willpower, I quite smoking about a decade ago with Chantrix, which let me remember that I hated smoking even when going through physical withdrawal. My husband is now taking Naltrexone for the Sinclair Method for drinking, to reduce the dopamine spike associated with the reward. I took Saxenda related to Ozempic, for obesity for about a year out of pocket, through Canadian and UK pharmacies, where Saxenda was a lot cheaper. I personally think a much better move is to pay what the rest of the world pays.
Now I use a telemedicine site that has discovered my glucose is slightly higher than normal and has my insurance covering the medication minus the co-pay. A lot of the weight comes on quickly when going off the medication, but not all, and timing a diet can mitigate the effects. These drugs REALLY work by controlling satiety and insulin responses and leptin/ghrelin, not dopamine like the others. When you go onto the drug company sites, they do encourage you to lobby politicians to cover obesity.
Huh. From the reddit thread: "It works well for anything that may have had an addictive potential. Food at its core is a drug, and Semaglutide helps you feel full but also decrease all cravings." That... sounds like the stuff may soon be handed out at addiction rehab clinics as well as Buddhist meditation retreats.
"Would you take a drug that made you not want to cheat on your spouse? Would you want your spouse to?" Interesting question! Since these desires (to the extent they exist) have not had any tangible effects in my marriage, I don't see the need. And I am fundamentally non-Buddhist in my approach to life - my desires/ cravings/ whatever you call them are part of what make me me, and what makes life worth living. As long as they don't cause problems, artificially removing them would feel like chopping off a part of myself.
What about long term weight management with semaglutide? I’m under the impression that it can’t be taken long term and it’s unclear whether people regain the weight afterwards. Anyone researched this more extensively?
My pops is doing the Calibrate program that combines nutrition coaching with semaglutide doses. Apparently they MDs at Calibrate are aiming to get people off semaglutide after about a year.
Sounds like maybe that's unnecessary or even risky
Based on how Europeans react to discussions of obesity drugs, I expect that European healthcare systems will not cover it at large scale until it goes generic.
Maybe for BMI > 40 or something, they'll pay $200/mo; but obesity drugs are seen as vaguely immoral and if they cost a lot money over the short term (maybe it'll save a lot in the long-term, but if you're a health minister facing elections in 2 years, what do you prioritize, tackling obesity or the waiting lists that pregnant women face?), I don't see them being used at scale for a while.
Is it just me or is a 30% chance obesity is cut in half by 2050 really low if you expect it to be reasonably cheaper by 2040 (66% chance its less than $100/month). Do you expect there to be other factors keeping people from getting it? Doctors still insisting on diet/exercise first on a large scale? As yet unseen side effects? Something else I'm missing?
Edit: or maybe its just what Neo says in his comment and a good number of obese people are more are more than 15% above obese for their height.
- it's really hard to get half of a target group to take a drug. Do half of all hypertensive people take antihypertensives? Do half of depressed people take antidepressants? I'm not sure but I would guess no. This is by far the main reason for my skepticism.
- Maybe the factors causing obesity will get worse by 2050.
- As you say, maybe these drugs won't be strong enough to get obese people all the way to normal weight.
- Maybe somebody finds side effects and people stop using them.
> - As you say, maybe these drugs won't be strong enough to get obese people all the way to normal weight.
They have amylin agonist + glp-1 agonist drugs coming down the pipeline that look even more promising. (from Stephen Guyenet)
These advances are already coming. In May, Novo Nordisk published a trial combining semaglutide with another drug called cagrilintide for weight loss in people with obesity. Cagrilintide is based on the protein amylin, a hormone that’s released by the pancreas when we eat and that reduces food intake via the brain. Adding cagrilintide nearly doubled the weight loss caused by semaglutide alone, with an apparently similar safety profile. This was only a 20-week safety trial, but it seems likely that longer trials will reveal weight losses of more than 20%, which would place it in the range of bariatric surgery.
Do we know what percentage of the patients lost weight? One of the things with semaglutide is that there was still something like ~40% that didn't lose weight in the trial, so it would be great if cagrilintide upped the number of people responding.
To make an anecdotal point about accessibility and costs: my wife has been on ozempic for weight loss since 2021. She was never obese, but using the Alpha Medical telehealth service, she was able to get a prescription easily. The "visits" with her physician occurred on a monthly basis to evaluate her tolerance and progress with the drug, visits cost $30 out of pocket.
She's been on Medicaid (Medi-Cal in California), and ozempic is completely free for her. Her Medicaid eligibility recently came under review due to our marriage, so we'll see what happens there.
I'm not sure if her situation is unusual or an edge case of sorts, but ozempic has been quite literally miraculous for her. Low cost, unimaginably effective, and accessible.
After a well reasoned article, the last line "US obesity half or less of current rate in 2050: 30%" seems to come out of nowhere. If Wegovy users on average lose only 15% of their weight, then even if 100% of obese people were using Wegovy by 2050, the obesity rate still wouldn't go down by half unless most obese people were <15% above the weight threshold that defines obesity, right?
#1 is a good point, but I'd still doubt that it would result in a 50% reduction in obesity, since probably well under 100% of obese people would use it. #2-#4 may be true but are so speculative that I don't think they're a worthy basis for a formal prediction. In a few years we should know more about #3 and #4.
Anyway, this drug is a noteworthy development. Thanks for the thoughtful introduction.
I think probably all one-food diets make people lose weight by decreasing variety, making eating more boring, and eliminating some of the worst foods. I haven't seen any evidence that potato diet is any better than that.
I was under the same impression, but the slimemoldtimemold experiment (they ran a trial across a couple of hundred readers) brought up some interesting results. Mainly that potatoes in particular seemed to do something interesting to lower people's metabolic setpoint, multiple participants claiming that hunger felt 'weird'. And unlike many other mono-foods, potatoes actually were the main staple diet of many people for a long time, primarily in Europe.
They're running a follow-up experiment with potassium salt to see if the high potassium in potatoes is the cause, which should be quite interesting to see the results of too.
Wait, I thought I read the experiment - did they have a control with people limiting themselves to some other single food? If not, I would expect all of this including the weird hunger to happen on any monofood diet.
No, they didn't run a control, it's a fair point. There was plenty of anecdotal data from people who said they had already tried other mono-diets and not had the same success, but only anecdotal. As well as people who did a 'half diet' with one meal of all potatoes daily and one normal meal. They still experienced some of the effects and about half the weight loss on average.
I was personally intrigued enough that I'm trying the diet myself (although only on week one), but I acknowledge there is only anecdotal evidence that there is something uniquely different about potatoes vs other foods.
I’m notoriously bad at history when not fact checking with the husband pre-post (he’s finishing up the turkey), so take this with a few grains of salt: I thought potato staple diets were in times of famine & led to malnutrition deaths where diet wasn’t supplemented. If that’s accurate, is it known the length of time one can diet safely before worrying about malnutrition /increased disease rate? (As that would defeat the main purpose of tackling obesity (mental & physical health)). I’m confident one could eat all potatoes for two days without any illness, and one could eat all potatoes for two years with very obvious illness and complications, but I’m not sure where the threshold is in between.
Covered in the slimemoldtimemold article but for the most part potatoes have a pretty good, balanced nutritional coverage, even enough protein. The main things missing (besides sodium, which isn't hard to supplement as you're probably salting the potatoes anyway) are vitamin A, vitamin B12 and vitamin D IIRC.
Quoting:
>We’re not so sure. In particular, why do people think that other mono diets work? We haven’t seen any. We encourage anyone to find anecdotes, studies, or better yet, run their own Onion Diet study or whatever.
> The potato diet isn’t even really a mono diet. We explicitly allow for oil and seasonings, and lots of people lost weight with tons of cheat days. The mono-ness (monotony?) of the potato diet clearly is not the active ingredient.
> Potatoes are also unusual in that they are (almost) nutritionally complete. You couldn’t do the white bread diet and get far. But you could maaaaaaaybe do the whole wheat bread and oil diet, or the wheat bread and cheese diet. Also known as: the basic daily diet in Europe for centuries.
The eyes of the potato are meant to remind us of Bodhidharma, who according to legend sat and stared at a cave wall for so long that his eyelids fell off.
(Although AFAIK, Bodhidharma's branch of Buddhism mostly ignores jhana, so this is more of a meditation joke.)
I can't find the full original study but you can mostly predict the satiety of a food based on caloric density/fiber/protein. But potatoes are a weird outlier.
I once read that baked potatoes are one of the most satiating foods (more feeling of fullness after eating only a few kcal worth relative to other foods). Maybe that's part of it?
I am also surprised by how often Slime Mold Time Mold is brought up here with respect. I read some of their blog posts and they have really lazy analyses and 'just so' anecdotes. Scott, might be fun to go through at some point (?) )
Interesting way to put it 'with respect'. The way I tend to view them is as a fun, loosely scientific blog. The experiment design leaves a lot to be desired but they're also covering (potatoes in particular) in more depth and in a more evidence based fashion than anything else out there, relatively speaking. It's not great, but it's certainly better than all the blog posts by nutritionists saying it's a bad diet without any evidence, or the glowing Reddit posts doing the opposite based on personal anecdotes only.
That's part of why I asked in the OP if Scott had considered doing a post on the potato diet - it's an interesting topic but one that hasn't been covered yet to a higher level of rigor
For myself, I will never forgive SMTM for their lithium posts (A Chemical Hunger), which still have not been retracted or corrected despite containing grevious errors. They handwaved away a 10% increase in average caloric intake (which is enough to fully explain the American obesity crisis) in favor of a speculative compound which does not show the alleged effect at 100x the dosages alleged. And they word their arguments so convincingly. Better to avoid the infohazard.
I left a comment on their survey of /r/nootropics users who'd taken "low dose lithium", I think it's their 2nd post down still. A good example of how not controlling for time-as-a-variable can fuck you up. They're a promising bunch of kids, but got some learning to do before they're good scientists
The 4-week potato diet per the study caused me to lose 15 pounds which then stayed off "permanently" (as of 7 months later). Previously I'd never managed to lose any weight for any appreciable duration on any diet I'd ever tried.
My mindset has changed from "my weight is outside my locus of control" to "my weight is within my locus of control" and I will be forever grateful to Slime Mold Time Mold's role in that.
So I don't claim to be objective as far as Slime Mold Time Mold is concerned. But sometimes the weird thing works and all too often societal and social pressures conspire to stifle investigation of the weird thing. So to the extent that Slime Mold Time Mold is a force for investigating the weird thing I think they're on the side of the angels!
The side effects are real. In addition to my own experience, the Facebook and Reddit groups are full of people complaining about constipation and nausea. After a year, my side effects have let up. But initially I was carrying barf bags everywhere and chugging Miralax daily. Sorry if that's TMI, but if you're considering it, go in with your eyes open. Oh, and a couple of months of brutal fatigue, which mercifully resolved after 2 or 3 months.
Yikes, that's rough. I've been lucky, only occasional mild constipation and very rare mild nausea, nothing else. Good luck and hope yours don't get worse again!
Pharmacist from The Netherlands. Price Ozempic is about 105 euro a month overhere. In about 2-5 years generic forms will be available, price will be than even lower. Furthermore: even more potent medicines and combinatioins are expected the comming years (average weight reduction about 20%?).
Me and my public sector GP colleagues in Finland do prescribe semaglutide (Ozempic) off-label for weight loss. It is not covered by the national insurance unless you have both BMI>30 and uncontrolled diabetes despite at least one ongoing antidiabetic medication. However, the cost of 115€/month(1) can be afforded by many. Lately the biggest issue has been the inadequate supply due to surging demand(2).
Why dystopia? If fat people have proportionate strength and better joints (improved joints for everyone would be part of my ideal future) what's the problem? If people aren't inclined to heart problems, how does this not make the world better?
Feasibility is a different problem, especially for extremely fat people, but improvements in default health for ordinary fat people doesn't sound impossible.
If that's the case, there ought to be cultures with no distaste for fat people. Are there? I know that some cultures have a more positive attitude toward slightly chubby people, but none that see morbidly obese as attractive.
"I don't blame fat people for being fat. I pity them. I understand that it can be very hard not to be for some people. I have ADD, so I know what it's like for what you know you should do and what you actually do to end up being very different no matter how much you'd like it to be otherwise. Lucky for me, I haven't had that problem when it comes to fitness."
Out of curiosity, do you take one of the ADD meds that tends to cause decreased appetite and/or increased NEAT (Non-Exercise Activity Thermogenesis)?
I expect it'll be easier to alter most peoples' metabolism and energy balance so they don't get obese in the first place than to keep coronary arteries healthy despite it. And I hope we do learn to grow spare hearts in a jar and what have you but I can't see that not being a 2nd line solution. (assuming obesity is a roughly unidimensional thing. I know that subcutaneous fat and visceral fat have somewhat different effects)
I don't think we have an understanding of why coronary arteries get obstructed so I'm not going to have a strong opinion about which problem is easier to solve.
In Finland, a relative of mine got Rybelsus prescribed to her for treating obesity (paying something in the order of 50e/month from her own pocket). For the record, she reports loss of appetite, but weight loss wasn't realized.
I know nothing about weight loss, but if this really is a drug that makes you "feel full" then the pharma industry's gain should be the food industry's loss. I am not going to try to quantify anything but if tens of millions of Americans start eating less due to medication then that should have a noticeable effect on food consumption.
From the other perspective one could argue that it is a bit silly to spend big money to eat less when eating less is actually the economical alternative. In my experience stingy people, people who count their pennies, are almost never obese. For them it is simply more fun to save a dollar than to eat an extra dollar worth of food that they do not really need. It is probably no coincidence that the world's richest country, and the one that has been rich for longest, is also famous for its obesity. Penny-pinching might have had a better reputation if its role in keeping people slim was better known.
I don't know about stingy people, but there is a link between poverty and obesity, and it is the opposite of what you suggest. For example, see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6497220/. The researchers found that the odds of obesity were greater for the lowest-income participants compared to the highest. Less surprisingly, the odds of obesity were also (independent of income) greater for those with the highest proximity to fast food outlets compared to those with the lowest. It's much more complicated than just eating less.
The study you link to concerns relative poverty. Someone in the UK (or anywhere else in the Western world) will be quite rich despite being relatively poor. Definitely rich enough to buy all the calories they crave, even if they do not need them from a nutritional standpoint.
Stingyness in this context is something else. It is an unwillingness to spend money on something not technically necessary, a hostility to waste so to speak. This attitude leads to less spending on things that are superfluous, like all those calories you do not need after your sustenance has been covered.
"Someone in the UK (or anywhere else in the Western world) will be quite rich despite being relatively poor. Definitely rich enough to buy all the calories they crave, even if they do not need them from a nutritional standpoint."
Since the UK is currently experiencing a meteoric rise in people needing to use food banks, I would question this assertion. Anyway, the point is that people who need to watch every penny will buy the cheapest food they can which makes them feel satisfied. That cheapest food is not healthy food. In addition, financial poverty is usually accompanied by poverty of time and opportunity. I have the option of buying food in bulk (good quality chicken, onions, tomatoes, spices etc) and making a huge pot of curry, then freezing what's left after eating a meal for later times when I don't have time to cook, in the large, reliable freezer which I have all to myself in my kitchen. The cost of those frozen portions is probably <£1, but the initial outlay in terms of cost, time, kitchen capacity and freezer space is well beyond someone working three jobs, living in a bedsit and sharing a kitchen. In their case, buying a £1 ready meal makes a lot of sense.
1. Scott writes: "I come at semaglutide from a transhumanist perspective. I want to hack genetics and biology until everyone is as tall as they want, as strong as they want, as smart as they want, and whatever gender they want. If you want wings, you should be able to have wings. And yes, part of this vision is everyone having the weight they want."
I'm not sure how this jives with either EA or a rationalist program. Maximizing the individual without aim cannot maximize the whole.
2. According to NYT, 11/22/22 "What Is Ozempic and Why Is It Getting So Much Attention?" $892 a month without insurance.
3. Wouldn't a large RCT really be the first step? There are side effects to this as is noted.
4. Obesity is obviously a significant problem. But I am ambivalent about the "disease ification". Eating less and exercise more seemed to work for a million years. Are there any other creatures with an obesity problems? Consider 11/21/22 NYTimes "Scientists Don’t Agree on What Causes Obesity, but They Know What Doesn’t", By Julia Belluz.
> I'm not sure how this jives with either EA or a rationalist program. Maximizing the individual without aim cannot maximize the whole.
Could you elaborate on the perceived problem? Increasing preference satisfaction of an individual can be in conflict with global preference satisfaction in some cases, namely when the individual in question wants to cause dissatifaction to other people. But when we are talking about personal stuff which doesn't involve other people, like "being taller" or "having wings" then what's the issue?
The whole is not equal to the sum of the parts. It's equal to the sum of the part PLUS the interactions of the parts.
Just as example, could being taller mean you eat more and thus create more competition for food? I'm sure we could think of lots of unintended consequences.
Wings - I'd not know maybe it would give you a figurative bird brain? Or if the wings are in place of arm, hands, fingers and opposable thumbs perhaps there would be a downside to the ability for a winged human to assist the rest of humanity?
I find the amount of time and money spent on tattoos and cosmetic surgery to have almost no overall salubrious effect to the whole. And the idea that a tattoo might make one happier, does not seem to be born out by research on the happiness of the tattooed (when tattooing is not part of a cultural norm and ritual.)
The transhuman project sounds like what Lysenko tried to do for agriculture. Lysenko was masquerading as science.
I'm just not seeing how libertarianism could ever lead to more effective altruism. Selfishness and self absorbedness cannot really be jujitsued into altruism or solidarity.
Everyone doing their own thing willy nilly does not sound like EA.
Like if someone claims to want to live in a world where everyone has enough food and then you accuse them of wanting to create a global pandemic, a la Vonnegut's Slapstick: Lonesome no More scenario. Or even kill most of the human population and replace them with agri-drones for food production, and thus this claim would be incompatible with humanist values.
I mean sure there are possible scenarios where this idea would lead to bad consequences. Obviously we wouldn't want them. There are also possible scenarious where it wouldn't. That's obviously what we want. When people make claims as "I want to live in a world with X" they don't usually mean "I want X no matter the consequences". They mean, "All things being equal a world with X is better than the world without X"
>And the idea that a tattoo might make one happier, does not seem to be born out by research on the happiness
I think the fact that people voluntary pay money for getting tattoos is a common sense evidence in favor of hypothesis that a world with tattoos as an option is better than a world without them. We may make a claim that the resources could be redistributed in a more effective way, but then tattoos allocated resources would be one of the last things we would try to redistribute and at that moment probably all our global problems would be fixed and we could just as well let tattoos be.
> The transhuman project sounds like what Lysenko tried to do for agriculture.
You may look at some of the USSR efforts as flawed naive transhumanism. But I'm quite sure the problem were not rooted in too much individualism and trying to satisfy the preferences of every person in the population while sacrifying the good of the whole.
> I'm just not seeing how libertarianism could ever lead to more effective altruism.
I somewhat agree here, but also don't see how it's relevant. You do not have to be libertarian to be transhumanist or want to be taller.
State attempts to optimize the whole without regard to actual science is not the point.
Lysenko was a neo Lamarkian who thought exposing seeds to cold will make them grow in the cold. This is in principle the transhuman project and body and brain hacking. It can only work, if at all, on an individual today - it will do nothing for the next generation.
I don't really care if someone wants to spend money on boob job or tattoos or on pets or on a bionic arm, but that can't really fit into effect altruism and long termism.
And it's about as rational as the pianist schumann trying to stretch his fingers in a contraption. There is just a bunch of alchemy and voodoo mixed in with body hacking.
Does anything go? Should we restrict someone from cutting off a health arm in order to have a prosthetic?
You have to be confusing descriptive and prescriptive reasoning in order to make your methaphor work.
Lysenko was factually wrong. He ignored scientific consensus for ideological reasons, discarding evidence he didn't like. You disagreement with transhumanism, however, is on ethical grounds. As long as transhumanist do not endorse Lamarkism and disavow genetics there are no actual similarities.
What's more, transhumanism includes all kind of different approaches, including genetical modifications. There is no conflict here between affecting next generation and not affecting next generation. We can use the best tool to achieve our goal, not just one specific.
> but that can't really fit into effect altruism and long termism.
You still fail to explain why. The only problem is if we lack the resources and have to sacrifice something more important in order to keep doing tattoos. But we are very much not sure whether this is the case.
> There is just a bunch of alchemy and voodoo mixed in with body hacking.
Oh for sure. Obviously one have to separate the baby from the bath water.
> Does anything go? Should we restrict someone from cutting off a health arm in order to have a prosthetic?
As with everything else. If we get more preference satisfaction from the consequences of allowing people to cut their hands for prosthetics than we shouldn't restrict it.
The issue is an arms race in "having X". I get taller, then you get taller than me, then I get taller still. This is why our cars don't fit in our parking spots anymore. The average human's satisfaction seems to involve a lot of Veublen goods.
I think that there are both an absolute part and a competetive part in our preferences. It's indeed impossible to let everyone be above average in height but quite possible to let everyone be 2 meters tall. If we can satisfy the absolute component in everyone preferences this would be much better than it's now.
We should be ready to prevent arm races just in case, though I don't expect them to actually happen in the scale that would lead to many issues. If needed maximum allowed height can be restricted.
"Increasing preference satisfaction of an individual can be in conflict with global preference satisfaction in some cases, namely when the individual in question wants to cause dissatifaction to other people. But when we are talking about personal stuff which doesn't involve other people"
First you seem to imply "intention" matters. Of course it does but I didn't intend to hurt anybody is hardly a defense.
Second, there is a lot less really truly personal stuff. We're connected to each other as social creatures.
I'm thinking of Vonnegut's Slapstick: Lonesome no More.
The pandemic which leads to the dystopia is in part caused by the transhuman hack of miniaturizing people so they aren't starving ( they need less food) but it goes too far and the small people are so small that they are effectively virii causing illness in unshrunk people.
Not sure how this example is relevant even if we ignore that it's imaginary.
It's not that people wanted to be miniaturised, thus unpredictably leading to loss in utility for other people. It seems to be the opposite situation where someone tried to optimise for humanity as a whole (solve global hunger) and ended up with unintentianal consequences.
No, I don't. If a person preferes to have slaves it doesn't really matter whether this person intends the slaves to suffer or not. Slavery just creates more and stronger unsatisfied preferences than it would satisfy for this person regardless of intentions.
> We're connected to each other as social creatures.
True. But there is an obvious and well understood distinction between affecting other people by photons reflecting off me to their eyes, and forcing other people to do things. That's a good enough line for the ideas of "personal stuff" and "involement" to have meaning. Can you bring up an actual example of a problem, that would require us to use more accurate categories, to adress?
The same drug in Brazil costs $ 500 / month and you don’t need a prescription (just go to the pharmacy and ask for it). So you could fly to Brazil ($2000) , buy the drug for you ($6000), someone else ($6000), go back to the US, sell the extra one for $15k. You got the medication for one year and made a profit of $1000 :)
So who is ready for the headlines calling for these drugs to be banned because normal weight people are taking them to achieve the “starvation look” desired by models, resulting in anorexia style deaths?
Can the percentage loss of body weight really be constant across weights? Doesn't that sound crazy? And if it isn't, you'd have to already be on death's door for these drugs to push you over the edge (though I guess some people are already underweight...).
Unlike amphétamines, it doesn’t suppress appetite. It makes satiety arrive faster, and stay longer. But when you are hungry, you are fairly hungry, and when you eat you can enjoy the food.
I’m intrigued now, though, by the idea it’s suppressing craving. That would certainly be consistent with my experience, in that my 50 year addiction to Coca-Cola (with periods of abstinence from it and others of relatively controlled use, but always craving) has turned to … disinterest.
The economics of pharma is just so weird. I've been on injectable semaglutide for quite some time now (for diabetes), and my copay is $25/month. Apparently I haven't bankrupted my family's insurer yet.
As for the drug itself:
I've experienced none of the "oh, you'd immediately notice those" side effects, but I I hear that quite a few people do.
My A1C runs MUCH lower than it used to under any circumstances other than the one circumstance I couldn't sustain long-term -- lots of exercise that inevitably ended with terrible knee problems which brought the exercise to a long halt.
As for weight, mine used to bounce back and forth between 220 pounds and 250 pounds. Now it bounces back and forth between 210 and 220. I have dietary and exercise plans to get down to 200 soon, after which I'm hoping more aggressive exercise won't be as hard on my knees, which may lead to no longer needing semaglutide for diabetes OR weight control. I guess we'll see.
I can't help but think that even in a country whose eating culture is as fundamentally messed up as the US, you could probably get a healthy, tasty, weight-loss-conducive diet for a lot less than 15000$ a year...
Also, what is it with diabetes that its medications turn out to be so beneficial? Metformin also has a reputation for helping with weight loss, plus reducing cardiovascular problems and maybe having general anti-aging properties.
Because it doesn't mess with the blood sugar levels as much and is conducive to a better microbiome in the intestines and... I don't know, but obesity is less of a problem in countries like France and Japan, even though people there could overeat just like in the US.
Because the most unhealthy foods tend to be the ones that humans crave and are most likely to overeat: chips, candy, chocolate, cake, cookies, liquid calories like juice and soda, etc. Pretty much by definition, a healthy diet doesn't have a lot of stuff that humans love to overeat. Broccoli is delicious when lightly steamed and drizzled with a bit of olive oil and garlic, but still, nobody says to themselves, "Mmmm, I think I'm going to have a third bowl of steamed broccoli!"
I think I really set myself on the path to Type 2 diabetes through, ironically, trying to eat healthier and being a moron about it.
All the stuff about 'cut out soda', well I did that. But I replaced it with fruit juice, because "well fruit juice must be healthy, right, and it counts towards those portions of fruit and veg you are supposed to eat", so I started drinking the good stuff (not from concentrate which had added sugar). Being virtuous, right? No more soda, cutting down on drinking tea with sugar, upping my intake of fruit easily.
Too late, I discovered "well uh, fruit juice *is* full of sugar". I honestly do think *that* was what tipped me over into Type 2 diabetes; before that, I was fat but had normal (or at least not diabetic) blood results (one doctor was *furious* when the results came back "nah, blood sugars normal reading" because he *wanted* to lecture me for my weight and wanted to be able to go "I told you so" if the test came back "diabetic levels").
Genuine attempt at an answer to the second part of your question: Diabetes is a disease of metabolism, and metabolism is fundamental to biology, therefore expect drugs that treat diabetes to have a variety of other interesting effects.
~€150 per month for Ozempic in Ireland. My doctor told me she was expecting shortages. She considers it a miracle drug for obesity, and also for older people with alzheimers/dementia because it keeps their blood sugar down which apparently has benefits for them.
I've been prescribed Semaglutide for Type 2 diabetes for about six months now. It does seem to lead to earlier satiety, but I've not had any weight loss. Oh, and being in Scotland, the prescription is free.
I'm not seeing any commentary for how well GPL-1 drugs work for those that have a disconnect between hunger cues and eating, like anorexics turned binge eaters and all the people who could be classified as disordered eaters. I can easily see how drugs like this would work well for someone who always feels actual hunger pangs, so I think my question is, how well does it work for someone who doesn't/has never associated eating with anything other than as a reward or a drug in and of itself? Who couldn't tell you what "feeling hungry" even means? The idea that a drug would make a person feel full or not hungry and therefore not eat ... I can't even envision what that means thanks to said disordered eating.
I do have experience with taking phentermine. It helped calm my mind and by escaping that noise helped improve my overall attitude, but I was still quite capable of gaining weight while taking it.
In such circumstances, does anyone have experience or thoughts with how well GPL-1 drugs would work for weight loss/maintenance?
Personally, I've gone from about 185 to about 140 with moderate restriction of carbs, but I know people vary so much that nothing works for everyone, and most weight loss methods aren't a stable solution at all.
Part of my situation is that I actually like high-fat/high protein, though I don't like going without carbs completely.
I believe the culture is all too cavalier about the quality of life-- and the lives-- of fat people. Considering the extent to which the income and romantic possibilities for fat people are limited, not to mention the general lack of respect I wonder how much of the health effects (not all of them, but a fair amount) can be explained that way.
Since the patent on semaglutide doesn’t expire until 2032, the prediction of a price lower than $100 by 2030 seems off to me. I’d bet against that, but I’m too lazy to set up an account for only play money.
I wonder about the adoption of the medication, though. I took victoza (=saxenda, but approved for diabetes) and the absence of the desire to eat lead to some unforeseen lifestyle side effects. Given that 5 almonds made me full for the day, I was not interested in having dinner with the family or going out with friends. There is the reality that some restaurants would probably not be happy if you only ordered the smallest appetizer. In addition, alcohol was also very difficult, because the drug slows down gastric emptying and your stomach ends up absorbing alcohol for hours. I got really, really drunk for an entire night from a single glass of wine once. Before taking this drug I had not fully appreciated how much of one's (social) life revolves around food; lunch break with colleagues, dinner with family or friends, drinks on the weekend, a sweet treat, snacks and a movie etc. But once I was not interested in food anymore, combined with the tiredness that comes with eating little, a lot of those activities also lost their appeal. (On the upside, I slept like a log.)
Given that obese people's lives likely revolve a lot around food, its selection and its enjoyment, halting that activity so drastically may not be all that desirable for this population from a quality of life perspective.
Interesting perspective, though maybe if your relationship with food is rather unhealthy not having an appetite and then feeling guilty for it is an improvement.
I am a pharmacist from The Netherlands. Price for Ozempic here is about 105 euro a month. In 2-5 years I will expect generic forms that willbe much cheaper. Furthermore I expect newer and better medicines and combinations (about 20% weigh reduction?). These products are a gamechanger for diabetic treatment and weight treatment. However the weight reduction is somtimes so quick and intense that I have a feeling that this is somtimes to intense and not healthy.
It seems to me that America basically has a tiny communist microstate consisting of health care, plus insurance and academia.
Prices have basically nothing to do with supply and demand of goods produced in competitive markets, and are instead set, more or less, through central planning. Bureaucrats decide where to allocate research dollars, how much medical procedures cost, what insurance must cover, etc.
It's not _totally_ communist, because you do have different business competing, but it feels like it's maybe ... 70% of the way there.
The thing that perplexes me here is that basically everyone seems to do it the same way. That 'health care systems different from ours' post makes it clear that there really isn't anyone treating health care for humans the way we do it for, say, animals, or cosmetic surgery where price signals reflect supply and demand, insurance doesn't cover anything, and as a result things are cheaper.
Why is that? How come there isn't a single state doing something 'free market' with health care?
The best answer i have says something like, 'if the capacity exists to save a dying person, and it doesn't get used, people will rebel against whatever political status quo prevents that capacity from being used, even in autoritarian situations'. If the capacity does exist, and it _can_ be used in theory, but in practice you can't because it's too slow an ineffective, people are less likely to rebel.
So it seems like, 'constraints must be illegible in order to survive popular wrath'. You can have much, much tighter constraints than 'you can't afford this so you can't use it', and people will generally accept them so long as they involve 'safety regulation' and 'labor shortages', etc. A cartel that restricts the number of doctors is totally politically feasible, in a way that 'this machine could save your child but you cannot afford its use' is not, even if the cartel restricting doctors is way, way way more destructive.
“It seems to me that America basically has a tiny communist microstate consisting of health care ...”. I think you’ve got the wrong model. Communism asserts government ownership of the means of production (of health care). That’s only really true of government hospitals, which are not overwhelming. Although there’s no set economic form for racism, I think that is closer: a typical fascist approach to labor relations is to put everyone parties at the table -- capital, labor, and government -- and have government play the leading role to assure that the result supports the greatness of our great and glorious, really great awesome nation. Getting people to the table means that only the biggest players get a seat, so you also see a lot of concentration of economic activity. That seems an awful lot like our healthcare system -- medical providers, insurers, drug maker, and so on get forced to the table to negotiate with each other, under the government’s watchful eye and guidance. And the government’s goal is as cloudy as the fascists’ goal in labor relations. But maybe I’m reaching.
You answered your own question. With pets, it's considered acceptable to say, " We can't afford to spend $10k on Fluffy's cancer treatment; we'll have to put him to sleep." with human patients this is not acceptable.
Because we are unwilling to say, "there is a machine that can keep grandpa alive for another day but it costs $100k per day to use, so we won't use it because (that would not be a good use of his remaining funds) or, even less acceptable (because grandpa doesn't have that much)", we instead are in a situation where literally every other aspect of grandpa's care costs ~10x what it otherwise would.
I would guess that adding obesity related conditions would help with getting insurance to cover it, and this may play a role with how startups are getting insurance coverage: eg, hypertension, sleep apnea, etc.
Here's my Ozempic story: So I wanted to get pregnant and had been trying 'the old-fashioned way' for a year. My fertility doctor says I have to lose weight for fertility treatment. In a panic I rush over to my endocrinologist who says 'let's put you on this Ozempic stuff so you can get Clomid.' Okay great. Two weeks in and I'm down 10 lbs. I have to take a pregnancy test before each injection. Okay, about to do infection #3...take my test...and I'm pregnant!! For the next 9 months, I keep hearing jokes about how Ozempic must be a fertility drug....your AMH was WAY too low to get pregnant, etc. Okay, October 2021, I have a beautiful, healthy baby girl. Endocrinologist says I can start my injections as soon as baby's calories are at least 50% from solid food or formula, 50% breastmilk. Okay, okay. I just need to wait and be patient. Well, joke's on me, and my baby girl won't eat and won't drink anything other than breastmilk. She's 12 months old, and in OT to teach her how to chew. And it will be almost 2 years that I will have had 6 months of Ozempic sitting in my fridge. Is it expired? Do I try to sell it?! I don't know...
I have a theory about obesity. The mention of the “family” factors — small group - is on the right track. Some people have a condition where they themselves are not overweight but they obsess about the weight of those in their immediate circle. We arrived at the home of this relative last night. This person complains significantly about others’ weight behind their backs. For some reason they had a large tin of cookies & immediately made sure we took it with us to where we were staying (this was not a planned gift). They’re almost a type of poisoner. I resisted the cookies but dang. Someone who hangs around undermining the willpower of others is a common character in the US I think, maybe everywhere, I just happen to be related to this one. Seventy percent odds this person mentions Wegovy before today’s large meal. 99% mentions within 48 hrs. Finding and somehow intervening with the people playing these roles would lead to improved weight control among those in their circles.
Your estimate of the proportion of annual healthcare expenses going toward semaglutide in a world without barriers to usage assumes that the obesity rate (or population of obese Americans) stays fixed. If this drug works, there'd be a significant one-time expense and then, presumably, minimal expenses to follow (unless the drug were required for weight maintenance in the formerly obese). Not to mention the knock-on effects of lower expenses for obesity-related disease. As an extreme example, imagine a one-time 50k pill that prevented you from ever getting sick again - I couldn't care less about the proportion of annual spending going toward that drug the first year it was released.
Good article about the drug, the annoying thing is the use of BMI.
It's a bad measure.
1. It's not dimensionless even though people use it like it is. Metric BMI vs. Imperial BMI are not the same number.
2. The (admittedly small) minority of people who have more muscle are unjustly persecuted by their doctors for being "obese".
I admit self-interest here. My (Imperial) BMI is 35, I'm able to deadlift at least 3 times what my doctor does, but I'm the obese one who needs to go on a diet. I did shut him up about it by pointing out that even the US Navy has stopped using it as a measure for their incoming recruits (IIRC they use height/weight/waist/neck plus a chart now - I guess they had too many people able to lift a car but they can't run so they can't be on a ship until they lose weight).
Yeah it's something the GP can run on a calculator after the nurse has run the measurements before he brings out his prescription pad. Rather than actually looking at me and saying "Does this guy actually need to lose weight?".
Sorry I'm not enamored of the bedside manner of my GP.
35 is enormous, dude. BMI is definitely a flawed measure that can neglect the affect of muscle in extremely large elite strength athletes, but even so. I'm 6'2" 189 right now. I can probably deadlift 3 times what my doctor does, but I imagine I'll never be great at deadlifting because I've got ten screws in my spine, but still, well over double bodyweight at least.
But to get to 30, I'd need to be 234 lbs. That's closing in fast on peak Arnold. That's possible, but it's not possible without steroids, and even most serious bodybuilders are going to admit the size they achieve is not healthy, in spite of being lean. They still end up with elevated resting heart rate, elevated blood pressure, elevated LDL, sleep apnea. Effectively everything you'd associate with being very fat, except diabetes (but still might get that, too, thanks to HGH abuse).
It's great to be strong, but that doesn't make it healthy. By all means, if you've got a shot at being an NFL lineman, a pro sumo wrestler, strongman champion, absolutely go for it anyway. But understand you're sacrificing health to do it. And yeah, military can go overboard with the endurance over strength focus, but there isn't no reason for it. You need to be able to fit into standard sized seats and cockpits. The bulk of jobs involve moving your own body more than they involve moving external heavy objects against resistance. If you become incapacitated, the other people in your unit need to be able to carry you.
5'8", 230 lbs., 58 years old, deadlift of 415 for 3. Normal heart rate, blood pressure and LDL according to tests. No drugs - including no prescriptions at all, which is unusual (all my friends of similar age are on something or other).
I lift 3 times a week for about an hour, almost all triples or 5s. No cardio.
My doctor thinks a deadlift of 135 is a lot - I think that's what he does (admittedly he's likely in his 70s, so there's that).
I'm looking at your stats and thinking that you don't lift, you run. If you get more muscle, the weight will go up a lot faster than your measurement.
I have no experience with being in the armed forces. I suspect that jobs lifting heavy things are more common now that the army is almost all mounted, e.g. loading artillery or tank shells rather than marching off to the trenches.
There's a reason the Army's old fitness test was all endurance and the new one has deadlift and sprint-drag-carry.
I think you're underestimating BMI for natty strength athletes. You can be really fit and 30 BMI natty--I've been there, and I don't have a particularly big frame or anything to suggest I'm an outlier. (Though I'm down to 29 now as I've improved my composition after my last cut.) When I looked at it a while ago, I think 28-30 BMI was typical for elite drug-tested weightlifters (US weightlifters who actually get legit drug tests), many of whom cut weight for competition, so they'd be walking around bigger than that.
Arnold was huge at 240 not because 240 is huge, but because he was well under 10% bf at the time.
IIRC Calibrate's pitch to insurers is that by pairing Semaglutide with their behaviour change program (app + coaches) they can eventually wean people off the medication while maintaining the weight loss effects, saving insurers lots of $$ in the long term. So far they've been quite successful convincing insurers (and VCs) of this but I think the evidence shows people need to stay on Semaglutide forever to maintain their weight so I don't think this will hold up.
I would be surprised if Semaglutide was cheaply available as a generic by the mid-2030s unless there are significant reforms made to the patent system or pharma industry rules. Humira and Lantus are good examples of drugs which would be significantly cheaper by now except for repeated patent extension and industry deals maintaining monopolies (although hopefully coming down soon).
I have a condition that the NHS doesn't really have a good way of treating (eczema), except for an American drug, called "dupixent" or "dupilumab", that they're extremely reluctant to prescribe because of the cost (about 40k annually).
Should I expect a much more affordable generic, or the cost to go way down, when the patent runs out?
Maybe someone here has some insight, I really would like to know. Apparently it's a type of drug called "biologicals", which are expensive to produce, so maybe even at production cost it would still be prohibitively costly, but surely not 40k costly.
My son uses that drug (dupixent). He contacted the company directly and somehow got it at a huge discount because our insurance company wouldn’t cover it. We are in NYC.
Similar story here -- I live in the Northeast, my spouse takes it off-label for very serious asthma. There's a ridiculous discount the manufacturer offers via a coupon, I have no idea how the economics of this works, it might as well be Scott's "burn them for warmth" theory.
I will tell you that stuff really works, at least for her type of asthma which is apparently related to eczema. She's been on it for a couple years. She went from regular asthma exacerbations, hospitalizations (for massive IV steroid treatments) about once a year after otherwise minor respiratory infections, and long courses of high-dose oral steroids to ... none of that. At all. For about three years.
In terms of medical costs, the insurance company should be paying for the drug! They'd clearly come out ahead, at least in her case. If it were eczema, I'm not sure the cost/benefit would work out (at least under US health care math), but if it works anywhere near as well for its on-label use as off, I'd try hard to get ahold of it, too.
It works really well for my son, both asthma and eczema. As far as the discount goes, I don’t know, but sometimes I wonder if the company is building a track record for the drug that will force insurance companies to cover it.
One thing about the idea of a post-obesity future: if the average responder can reasonably expect to lose 10% of body weight on Semaglutide, that would still leave most of them obese.
AFAIK the standard categorization for 'obese' starts at 30 bmi. Rough napkin math with a BMI calculator makes me think that anyone who starts at about 30-33.5 bmi and then loses 10% of body weight will end up below 30 bmi, but anyone who starts out above ~33.5 and loses 10% will still be obese.
5 minutes of google didn't find me a precise answer to 'what percent of the US population is above '33.5bmi', but it did find some distribution graphs that makes me roughly guess it would still be like 25%-35%.
But maybe the 10% figure comes from a 3-month clinical trial, and if you take it for 5 years you just keep losing until you are at a 'healthy' weight? Or maybe you gain tolerance over 5 years and end up back at your original weight? Seems like a lot is left to be learned about those dynamics.
Yeah, this is the angle I had as well. I know this is a miraculous drug because so few things work at all, but how much do obesity-related risks fall if a 5’8” person goes from 300 to 255 and has to stay on it for life? (My understanding is people regain weight if they stop: it’s not like the drug recalibrates your “set point” permanently or anything.)
Health risks for obesity drop SUBSTANTIALLY with a loss of 10% of body weight. It’s shocking how much difference even that relatively small loss can make.
My father is Canadian, and I was talking about weight loss with him a couple of weeks ago, and he says he has semaglutide. But he doesn't take it because he feels it would be cheating to lose weight that way.
I came to make the "using a pill to fix all our problems sounds terrible" post. I see others have made the same point above. To take a step back, this feels like more of a me-midlife-crisis problem than a problem with Scott's analyses or arguments.
There are two things recently that have made me think "the modern world is terrible." The first is Britain's new and ongoing reliance on food banks. A rich country in which a significant number of people can't get enough to eat: that's gotta be a sign that something is messed up.
The second is this: rich and resourceful societies around the world that can't get a grip on the deliberate infliction of chronic disease on its citizens by themselves/corporations/society, and instead turn to a pill to solve the problem.
These problems aren't turning me into a conservative, as is often supposed to happen, but they are for the first time ever making me think, at the age of 41, that the world is going to hell in a handbasket. I apply a very low level of credence to this belief, because it's overwhelmingly likely that I'm just thinking it because I'm middle aged. But I definitely do think it now.
In both these cases, it feels like building the right kind of institutions could prevent these things from happening; but something is preventing us from building those institutions. I can't work out what's going wrong. I mean, bloody Tories or whatever, but I don't know if it's really a party political problem.
I'm not sure if you're asking to see if I have a conflict of interest, or asking to see if I put my money where my mouth is. If the former, I don't. If the latter, I assume I'm late enough that all of this is already priced in.
> I model semaglutide use as interest * awareness * prescription accessibility * affordability.
You are multiplying quantities that are uncertain and the product of multiple distributions is better modeled as a log-normal distribution (and I guess some of your inputs are also already log-normally distributed). And for a product of such quantities the mode is left of the mean by more than one std dev. Did you take that effect into account when estimating the individual numbers?
I friend of mine is on Contrave, and has lost *lots* of weight. I tried two of her pills, and somehow forgot to eat most of both days!
She got them through a "fly-by-night telemedicine company" and pays $600/month. The pills themselves cost ~$100/month, and $40 if you get the components separately.
Are there more reasonably priced telemedicine places? I fully expect tons of hidden fees on top of their advertised rates...
I suspect my regular doctors would get me on diet & exercise, which I'm already failing at. But maybe I should give them a try before I go Gray Market?
For what it's worth, Scott, though people may feel it isn't worth the risk due to not exactly being legal, it is fairly trivial to get semaglutide from a grey market lab that just buys bulk chemicals from Chinese raw suppliers to package and resell in western countries. At the one supplier I know for sure is selling tested, real stuff I've seen other people use and get results from, it's currently $120 for a two-month supply. But many, if not most, sellers of research peptides will stock this. You can even get reasonably-priced HGH if you want a little extra lipolysis kick, and in spite of the scare stories from moralizing legislators trying to make examples of pro athletes for cheating, it is extremely safe if you're not doing bodybuilder-level doses. Yet another thing anyone over the age of 40 can get a prescription for by going to any anti-aging clinic, but they're going to charge through the roof and your insurance will definitely not cover it.
Feel free to cry for pharma companies losing some fraction of their precious patent-protected dollars, but $15,000 is utterly absurd. There is no need at all to pay that much.
"PCP" means "personal care physician" in the context that Scott is using it. I only bring it up because the expansion of the acronym wasn't obvious to me and googling it isn't helpful.
"Only 75% of Americans have PCPs at all." Just curious if am I the only one who got confused by this?
Ugh. I’ve been wanting to take Wegovy ever since I heard of it after Elon Musk’s tweet, then went down a rabbit hole on it. Sounds waaaaay safer than Phentermine, which they give out like cheap candy and is terrible for you, plus doesn’t work for many because of the side effects.
I hope they can reduce the Wegovy price. I can’t justify the payments.
"(there’s also a third-level effect where it costs the health system money again, because it prevents people from dying of obesity-related complications, and dead people stop needing expensive health care. I think health economists are supposed to ignore this level.)"
I am regularly pretty frustrated by arguments that ignore this level, because if we're going to have a discussion specifically on economic grounds, it seems like a glaring omission. There are many versions of "Spend money to prevent this person from dying, because people use a lot of resources when they die, so costs will actually go down." You can still make the argument on moral grounds, but don't use an economic argument that assumes that near-future people will be immortal.
I came to make this comment. This really annoys me so much. People should weigh less because they will live longer and feel better but dying at 60 of a diabetic related infection, heart attack, or stroke, is a lot cheaper than five years in the nursing home at 85 years old. that doesn’t mean we should want people to die early, but it does make the economic argument illiterate. She also: smoking.
Don’t forget that better overall health also means compression of morbidity; you are sick or disabled for a shorter time before that (later) death.
For example, the average smoker lives about 8 years less than the average non-smoker. But also the average smoker is significantly ill or disabled for about 5 years before death, while for the average non-smoker, that period of illness before dying is about 2 years.
"Until age 56 y, annual health expenditure was highest for obese people. At older ages, smokers incurred higher costs. Because of differences in life expectancy, however, lifetime health expenditure was highest among healthy-living people and lowest for smokers. Obese individuals held an intermediate position. Alternative values of epidemiologic parameters and cost definitions did not alter these conclusions."
Basically, lifetime healthcare expenditures seem to be dominated by how long you live.
Obesity should be renamed to crappyprocessedfoodoholism, to highlight the fact that you can avoid it by eliminating all the crappy processed food from the environments where you eat. Obesity was almost nonexistent before we got an industrialized supply of highly refined carbohydrates and oils combined into superstimuli. If you eliminate all the liquid/powdered calories and deriviatives thereof from your food supply, it's really hard to get fat. OTOH 97% of the calories in the supermarket consist of that kind of crap, so it's hard. People don't want to be thin as much as they want to eat processed crap, and there's a lot of bad information out there that derives from rationalizations thereof.
I have been taking Wegovy for 14 months. When I began I weighed 275 lbs and my BMI was 39.9. I have hypertension, albeit well controlled by medicines. Diet and exercise phaaahhh. I could eat faster than I could exercise. And no, I eat very little fast food and little candy and soda.
I worked with my doctor to be prescribed Wegovy. It was only approved by the FDA in June 2021. My doctor was reluctant because he was unfamiliar with the class of compounds. He does not like to prescribe off label so he was not willing to to start me on Ozempic. But, the FDA solved that problem.
I knew to ask for the drug because my daughter was pre-diabetic and had been put on Metformin and Ozempic. She lost 100 lbs. in 2019 and 2020.
I started on Wegovy in September 2021. I now weigh 220 and my BMI is 31.5. That represents a 20% reduction in my original weight. 220 was my original goal. To get a BMI under 30 I would have to be under 209. I doubt that I will get there. I am back in 40 in. trousers which I had not been able to wear in 30 years. 220 was my original goal.
I have had no major side effects other than constipation. Even that is a little hard to tease out. I am on 7 Rx drugs and at least 5 of them are constipating. I have been pounding Metamucil and Colace for years.
I have been able to fill my prescriptions using a GoodRx coupon at $1328 for a box with 4 injectors. A year requires 13 boxes. The total cost for 15 boxes has been about $20,000.
I understand that it still way too expensive for the American health care system to afford. But given the bonanza size of the market. There will be lots of competition starting with the Lilly's tirzepatide. There are several other pharma's with GLP-1 agonists in development. I am sure that the cost will come down.
My doctor tells me that I can expect to stay on semaglutide for the long term. He is proposing that I switch to Ozempic 2 mg for maintenance as I can buy that for less than $1,000 for a four dose pen.
My only sadness is that semaglutide wasn't invented 40 years ago when i would have saved me from a lot of damage. But, I am grateful that it exists now and that it has helped my daughter so much.
"The STEP 5 trial assessed the efficacy and safety of once-weekly subcutaneous semaglutide 2.4 mg versus placebo (both plus behavioral intervention) for long-term treatment of adults with obesity, or overweight with at least one weight-related comorbidity, without diabetes. The co-primary endpoints were the percentage change in body weight and achievement of weight loss of >=5% at week 104. Efficacy was assessed among all randomized participants regardless of treatment discontinuation or rescue intervention. From 5 October 2018 to 1 February 2019, 304 participants were randomly assigned to semaglutide 2.4 mg (n=152) or placebo (n=152), 92.8% of whom completed the trial (attended the end-of-trial safety visit). Most participants were female (236 (77.6%)) and white (283 (93.1%)), with a mean (s.d.) age of 47.3 (11.0)years, body mass index of 38.5 (6.9) kg/m–2 and weight of 106.0 (22.0) kg. The mean change in body weight from baseline to week 104 was 15.2% in the semaglutide group (n=152) versus 2.6% with placebo (n=152), for an estimated treatment difference of 12.6 %-points (95% confidence interval, 15.3 to 9.8; P<0.0001). More participants in the semaglutide group than in the placebo group achieved weight loss >=5% from baseline at week 104 (77.1% versus 34.4%; P<0.0001). Gastrointestinal adverse events, mostly mild-to-moderate, were reported more often with semaglutide than with placebo (82.2% versus 53.9%). In summary, in adults with overweight (with at least one weight-related comorbidity) or obesity, semaglutide treatment led to substantial, sustained weight loss over 104 weeks versus placebo. NCT03693430"
Health care economic observation. I have read that some health economists believe that declining rates of cigarette smoking have cost the health care system a lot of money because cigarettes killed a lot of people before they got old enough for really expensive sorts of care.
I ma not sure that obesity is like that because it is not a quick or certain killer.
Maybe. I was something I read a while back, and my brother the pulomary doctor thinks it was true. I am too lazy to research the issue. If you have a citation you win.
Is the mechanism of action just suppressing hunger? Wondering how this would interact with a bodybuilding-style cut in terms of preserving lean mass, if at all.
I am on Mounjaro, and have been for four months. Lost 20 pounds so far, and I'm not yet on full dosage. Occasional mild nausea but real issue for me is....tiredness. Not fatigue or exhaustion. I'm a former insomniac who can now hit the sack at 9:00 and sleep happily to 6 am, which is insanely weird.
I have been trying to lose weight for 6 years, and for most of that time been in a 20 pound range that is 100 pounds over what someone of my height should weigh. I've eaten 1500 calories a day and not lost a pound, have to drop to 1100 to lose weight verrry slowly (that's with intermittent fasting and low carbs, around 50 grams). Last year before Mounjaro I started intermittent fasting and lost 20 pounds very quickly and then stopped cold. I do not have eating issues. I don't binge. I cut out the "four white foods" six years ago because I learned that I do better on meat and cheese and vegetables than I do on pasta or bread or potatoes and vegetables. I put on weight despite walking two and in some cases four miles a day, which I can do easily.
I am ridiculously healthy and do not have an obesity diagnosis. Stone cold normal readings in A1c, glucose, cholestrol. My doctor sent me to an endocrinologist after I lost 20 pounds and then stopped cold despite the same behavior (which I still do today) because she agreed I might be insulin resistant. Endocrinologist shrugged, said it's multifactorial, but agreed that anyone with my numbers, appearance, and obvious good health was clearly doing everything right and put me on Mounjaro with no further questions. Diagnosis: insulin resistance. My insurance pays around $500 but I'm on the $25 coupon.
I didn't change a single thing about my eating habits and lost ten pounds in 2 months on the low dosage. Higher dosages have finally reduced my appetite somewhat, but my endocrinologist and I have decided to stop the increases at 12.5 (15 is the top) and then maybe even reduce, since my appetite is decreasing but the weight loss rate is constant.
Because I lost weight doing the same behavior and no drop, I'm quite convinced that something far different than appetite suppressing is also going on (fwiw, I was on phentarmine back in the day and liked it fine). Mounjaro is supposed to increase insulin production and reduce the liver's sugar production, although what that means I dunno.
I have no idea what's up with obesity but the idea that it's all about cutting intake and exercise is just stupid. I should have been losing weight for all of the past six years and haven't. Plenty of people eat healthily and are still obese. We're probably the descendants of famine survivors.
My weight is not considered a health issue. This despite the fact that my weight, for my height, is shocking. Fifty pounds below my highest weight would still leave me medically obese. 50 pounds lost moves me at most one or two clothing sizes. I can lose 30 pounds without anyone noticing.
My height and weight suggests a person needing two airplane seats, XXXXL clothing, wheezing, and inability to climb three stairs. In fact I’m in normal clothing sizes, hike and walk frequently, can run a mile if you make me, and only wheeze because of my allergies. I’m not bragging. My weight bothers me. A lot. But I’m grateful that my appearance suggests I need to lose 30-40 pounds, not 100.
My weight history was quite consistent until 2016. I have a big appetite that didn’t make me fat until I was 30. From that point on, I’d have to cut back my intake every five years or so because the same amount of calories wasn’t burning off reliably. I’d ignore my weight gain until something forced me to acknowledge it, then diet to successfully lose weight I’d keep off for five years or more. My methods are a recitation of conventional food wisdom because I always went to doctors to lose weight.
1992: start exercising, cut way back on fat. That rule, I kept as a guideline until 2016. Kept off for five years.
1997: Fenphen, just in time for the fen to be banned. But phentermine by itself kept working until 2008 or so–that is, slow weight gain but no ballooning. Then my doctor told me I couldn’t have phentermine because of my blood pressure, took me off that and put me on hydrochlorothiazide, which I’ve been on ever since (lisinopril and nifedipine added in 2016). Ending phentermine kicked off a ballooning that I ignored because I was worried that cutting calories wouldn’t work.
2010: I bit the bullet, just cut calories, and lost over 50 pounds in eight months. At that time, I vowed to monitor my weight and not ignore weight problems and over that time did pretty well. I didn’t keep all the weight off, but keeping a scale kept me from ignoring it and I’d cut back and minimize weight gains, even lose a few pounds.
In 2015, I started renting with my brother, which operated on my eating like an invasive species. His leftovers were my undoing: fettucine alfredo, fried chicken, fried fucking porkchops, fresh baguettes, and he keeps peanut butter on hand. That was when I learned that 30+ years of being solely in control of food purchases had created strictures I didn’t even know existed–like don’t buy it and you won’t eat it. It only took me a year to regroup but that year was a 30 pound weight gain and I was back to my all-time high. Wah.
2016 is when the history pattern changed. I cut calories and didn’t lose weight past a given limit. However, two things occurred that year. First, I got much better at watching my weight. I could gain ten pounds from the low limit and then lose them instead of ignoring the problem. Of equal importance, I decided to cut both calories and carbs, which focused me on carbs for the first time since the 70s and the Atkins plan.
*****
The endocrinologist is constantly asking me how my behavior changes, am I eating less, and so on, and is skeptical that I’m dropping weight with no other changes.[note--this was written six weeks ago, before recent dosage increases] My internist is much more friendly to my theory that this drug is changing my body chemistry in some way. Various reddit threads have testimonials to how the drug has stopped the taker’s binge-eating and hunger pangs. None of that applies to me. I wasn’t a binger, had no food issues, and my appetite hasn’t changed much.
My own theory is that changing my carb intake in 2016 took me off the Type 2 diabetes path, but that the insulin resistance path is unaffected by diet changes? Keep in mind I have only a vague idea what insulin does. Science is still the one subject I don’t teach. In any event, if this continues to work, my doctor agrees with me I’ll probably have to take it permanently.
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I'm hoping the cost will come down, but I'm pretty sure my insurance will cover a lot of it, and I'm willing to pay quite a bit to keep weight off. It's all tax-deductible, anyway.
I have to ask the stupid, obvious question, but is your weight due to muscle under a layer of fat? Because if you say you need to lose 100lbs but look like you only need to drop 30lbs and you can fit into normal range of clothing, then that doesn't sound like purely fat alone to me.
It does sound like there is *something* going on with your metabolism, but if a qualified endocrinologist doesn't know, I certainly have no idea.
It's not a stupid or obvious question. Yes, I have a lot of muscle mass. I believe you do as well, if I read your posts correctly. I'm only class 2 obesity (under 40 BMI), which given my weight is pretty impressive. But there's plenty of fat to spare on top of the muscle, so it's not the muscle that's failing to disappear.
Losing 10-15% (at best) of one's body weight honestly wouldn't cut it for a large portion of the obese population (15% of 300 lbs puts you at 255, which is still obese). Hearing "you can solve your huge life-altering problem for $15K/year" would be worth it for a lot of people. But hearing "you can solve half of your problem for $15K and then you'll still need a massive amount of effort to finish it off" sounds way less attractive. These drugs may be better than previous solutions but they'd still need to be improved another doubling or more.
>you can solve half of your problem for $15K and then you'll still need a massive amount of effort to finish it off
This is more less describing bariatric surgery. Though the pills trades less risk for less reward. I wonder how Wegovy compares against lap bands, which are one of the least effective but less obviously invasive versions of bariatric surgery.
Even given that the pharma company that developed it has a monopoly this pricing seems strange. If it's really on the verge of being prescribed so widely and the company can produce it for a relatively low marginal cost the price charged per dose seems wildly above the profit maximizing price.
More generally, why the hell would they price a drug that's likely to have a large market so high while they don't seem to be extracting the maximum profits from other drugs that have fewer applications but are less likely to be denied by insurance?
Should rationalists be more able to lose weight than others? Various people have said something along the lines of, it's obvious that overweight people could lose weight if they stuck with eating less and exercising vigorously. I think that's probably true for most overweight people. Some have health problems that would interfere with their doing vigorous workouts, and a few may have some metabolic quirk that keeps exercise and caloric deficits from taking off the pounds, but I believe that far more than 50% of us could in fact lose weight if we stuck with caloric restriction and increased exercise.
The problem, of course, is that most people fail at sticking to that regimen, including most people posting here today. It seems like most of us must be making simple, obvious errors in our thinking about weight loss regimens when we are on them. Stuff like, today doesn't count -- I deserve a treat -- I'll go back to the regimen tomorrow -- this isn't even going to work, why stick with it?
OK, so it's not motte & baily, but it's simple, obvious errors in reasoning about the situation. Shouldn't rationalists be better than other people at not falling into these thinking errors that lead to abandonment of weight loss regimens?
It sounds like you're asking "should rationalists have more willpower?" I think the first level answer is "no, why would they, low willpower isn't a cognitive error, try kicking a heroin addition, and see how far your being very smart gets you". The second level answer is that reading George Ainslie ( https://www.picoeconomics.org/HTarticles/Bkdn_Precis/Precis2.html ) helped me understand what willpower was in a way that actually did seem to give me slightly more willpower, but I don't want to attribute this to "rationality" specifically because if I knew everything I know now *except* the Ainslie stuff I don't think it would help.
I will read the Ainslie tonight or tomorrow, so I am responding without the benefit of whatever's there. But actually I was not saying that surely rationalists should have more willpower. I was saying that abandoning long term goals because of short term cravings and pain involves various cognitions that clearly do not stand up to close examination, and asking whether we shouldn't expect rationalists to be better than the average person at examining and rejecting these cognitions. So I am not talking here about the sort of thought structures and thinking errors identified in the rationalist canon, but about the kinds of clearly inaccurate ideas that are addressed in cognitive therapy.
Here are some examples of distorted cognitions in someone struggling to break a habit or abstain from use of an addicting substance. They come from my struggles to quit smoking, something I eventually succeeded at 20 years ago. ( I actually have not struggled much with my weight over the years, but I'm sure people struggling to stick with an eating plan have similar thoughts.)
Without cigarettes I will not be able to . . .
-concentrate well enough on my dissertation topic to make any progress
-enjoy talking with friends
-finish eating a meal and feel satisfied
If I do not have a cigarette right now I will . . .
-suffer unbearably intense cravings which continue undiminished for hours, days, and weeks until I eventually give in and have a cigarette.
It's ok to have a cigarette right now because . . .
-I have overcome the addiction enough that one cigarette will not lead to a relapse.
-this is a special occasion and the only way to properly celebrate it is with a cigarette.
-I had one yesterday, after abstaining for 4 weeks, so the whole quit-smoking project is a failure, and I may as well give up and have a cigarette whenever I crave one.
OK, so a few of these are pretty indefensible, and the rest are questionable -- before accepting them as valid you'd want some evidence to support them (are you sure your craving would continue indefinitely? what actually happens when you try not lighting up when you crave a cigarette?). And these statements, if simple accepted as true, lead directly to abstinence violation. They justify it, in a bullshit kind of way, right? So my question is, should we expect rationalists trying to lose weight to do better than others at mistrusting such ideas when they come to mind? It does seem like people who are less likely to just accept these rather silly thoughts as valid predictions would be less likely to be swayed by them, and less likely to relapse.
Thanks, I see more now why you would expect this to work.
I agree it would make sense if good rationalists could also fight distorted cognitions better. My only evidence either way on this is that the LW survey shows readers here have a much higher rate of depression (but lower rate of addictions) than the general population. Since a lot of people say negative cognitions are involved in depression, if you assume people at LW are better rationalists than the average, there doesn't seem to be enough effect to overwhelm whatever else is causing more depression. My guess is that the fewer addictions thing is something else (maybe class?)
Is there a conflation of "distorted cognitions" and "negative cognitions" here? Isn't it possible that an accurate, intelligent, rational assessment of the world produces depression, and that lack of depression is a result of cognitive distortions that most people don't even think of trying to eliminate? And that there's a somewhat benign social rule to lie to each other about this?
As with some other stuff, I don't want this to be the case, and I hope this is not the case, but I don't know of a good argument against it. If you happen to have one ready off the cuff, I'm all ears, but otherwise, please don't feel pressure to come up with one. I mostly just wanted to note the logical possibility.
The strong evidence of the benefits of religion suggests that rationalism would be expected to increase depression.
You could potentially argue from there that reducing addictions increases depression. After all religion is the opiate of the masses.
There's no reason to believe that the universe functions in such a way that understanding it implicitly improves outcomes.
Suppose a world in which humans as raised in matrix like creches by aliens. At the age of puberty they procreate and then are harvested for consumption. Cause they taste delicious when in the stew of puberty chemics. Suppose there was no situation in which humans could rise up and free themselves.
Would you be happier knowing you were being consumed for food and losing ~80 years of your potantial life span? Or would you be happier thinking the angels took away successful procreators into a magical land in the sky?
So I ruminated about this, and actually I do not expect rationalists would be any better than anyone else at challenging the kind of thoughts that people learn to challenge in cognitive therapy. The kinds of bad thinking rationalists have learned to recognize and challenge are much more clever and complex. You have to really apply your mind to see what’s wrong with them. In contrast, the pro-relapse thoughts I was giving as examples are really pretty dumb and easy to spot, especially if they are not the products of your own mind. It doesn’t take no rationalist to shoot them down. For instance say your 15 year old had earnestly shaken hands with you on an agreement not to attend parties where no parents were present, and then you found out he’d been to one. What if he defends his actions by saying “If I hadn’t gone to that party the craving I would have suffered would have been unbearable, and would not have diminished at all over the course of the evening no matter what I did instead.” You’re going to laugh and say “oh, come on,” right? Or how about “it’s a special day, the first day of summer vacation, and going to an unsupervised party was the only appropriate way to celebrate it”? Just silly, right?
Another thing about these “distorted cognitions,” as they’re called in the trade, is that they’re not exactly cognitions — if by cognitions we mean thoughts experienced as factual statements, in the same category as “I’m wearing an overcoat.” They’re more attempts to bridge the gap between one’s craving to smoke and one’s picture of oneself as a reasonable being. If you just go buy a pack and light up all the while thinking of yourself as being in the process of sensibly quitting smoking — you’re kind of fractured & incoherent. We’re not built to endure experiencing ourselves that way. So maybe the lame case in favor of smoking — “if I don’t I won’t be able to focus on my dissertation” — should be thought of almost as the confabulations people with Korsakoff’s or other mental disabilities come up with to reconcile disparities in what they remember.
If there’s any sort of training that would give people an edge in catching thoughts of this kind, it would probably be training simply in catching thoughts. I did a little research on that in grad school, having a roomful of freshman record what they were thinking when I rang a bell, once every 5 minutes or so. Most could do that, though some, like the woman in the Buddhist tale, said they hadn’t been having any thoughts. On some trials I asked people to try to reconstruct the train of thought they had had since the previous bell, and a few seemed to be to be pretty good at doing that. They produced little ramshackle lists of topics, connected by “and then that made me think about . . .” Sounded like the same kind of thing I unearth when I manage to capture a chain of my recent thoughts.
I think believing your own rationalization is a non-trivial part of being stuck, in (mild) addiction and many other forms of modestly dysfunctional behavior. I'm very dubious of the proposition that it's a matter of willpower. When I do see people overcome dysfunctional patterns of behavior, it's not by summoning unusual reserves of willpower. Rather, they stop bullshitting themselves and start making plans that allow them to succeed without the necessity of extra willpower.
They may for example just start playing mind games with themselves -- I can do Y if I first do X, or I'll just do 2 minutes of X and quit if I hate it...OK, 2 minutes down, that wasn't so bad, I'll do just 2 minutes more and then quit if I hate it... Or they'll deliberately put themselves in situations where the temptation is simply impossiible to act on. In any of the times when I've personally had to do stuff I don't want to do, but know I should, that's how it goes. I don't summon herculean reserves of willpower, I just set myself up, so to speak. I may not be happy in the moment that I fall into my own Woozle trap -- damn it, what asshole dug this pit right here?! -- but usually I'm happy enough later with the outcome that I can set the trap up again.
From that point of view, I'd say a rationalist is a priori more and not less likely to have difficulty breaking mildly addictive behavior, because he believes more strongly in the power of reason and is probably better than most at coming up with plausible theories in which to believe.
"they stop bullshitting themselves and start making plans that allow them to succeed"
Sounds like a thing you need willpower for. Bullshitting is part of what failure of willpower looks like.
There's also another part where you recognize the bullshit, make rational plans, then fail to follow them (due to failure of willpower in the moment and/or circumstances beyond your control) and feel like shit about it. Feeling like shit makes it hard to be rational. This is a cycle that lends itself to disordered eating.
"better than most at coming up with plausible theories in which to believe."
This cuts both ways. If someone identifies as a rationalist they probably have pretty high opinions of their own reasoning abilities, and they may even be correct in most cases. This can make it harder to spot one's own bullshit.
I don't think you need willpower especially to recognize bullshit when you see it, even your own. Unless we are going to define "willpower" as merely "what you must have exerted if anything got done," but then I think the concept loses sufficient specificity to be useful.
You do need...something, to be willing to recognize bullshit for bullshit. Personally, I would say an empiricist mind-set does the trick. You have to have greater faith in observations than in theories, and be very willing to doubt theories when seemingly contradictory data comes along.
Honestly, what you've written seems to me an illustration of my point: you sound like you are rationalizating why being a rationalist might actually not be more likely to believe his own bullshit, and it's not a bad rationalization -- much better than someone without the same level of theory-building ability would be able to devise. Which is my point.
Rationalists can be better at choice architecture / environment control so they don't need willpower to eat fewer calories:
* stocking your kitchen with more high-fiber and high-protein solids
* throwing out all the liquid calories and sugar/flour/oil derivatives, no exceptions
* precommit to avoiding any restaurant order with >500 or unknown calories, no exceptions.
It's easy for an occasional "exception" to turn into a habit, so for some people it might make sense to be a teetotaler with respect to some entire categories of food e.g. soda, juice, pastries, ice cream, pizza, and heroin.
Some prescription guidance from Norway. Basically: don't prescribe Wegovy for weight loss yet as we haven't bought the magic injector pens at the right dosage.
I get the need for caution, but does anyone ever make a running tally of the human suffering and mortality caused by bureaucratic foot dragging?
In Denmark this costs ~€200/month and in Sweden it's similar, but this includes virtual doctor's appointments and coaching etc. I believe the actual drug is heavily subsidised by the respective government health systems, but also heavily negotiated with Novo Nordisk, since it's the health system that purchases it centrally for the entire country.
I have a prescription as a diabetic and I cannot get this since it is always on back order at any pharmacy. I’d love it for weight loss but need it for A1C. How do I solve that?
If semaglutide reduces ad lib caloric intake by 35% (https://doi.org/10.1111/dom.14280), and 10–40% of the U.S. population wants or would benefit from it, then it seems possible that the "ubiquitous cheap semaglutide" scenario could reduce total food demand in the U.S. by 3–10%. (as a first-order effect—there would probably be second-order effects relating to changes in diet composition, food waste patterns, etc.).
Would this be enough to have appreciable effects on global food prices, agricultural emissions, and farmed animal suffering? Presumably the population that might use semaglutide eats more and has more money than the global average, making their consumption patterns particularly impactful. Perhaps EAs focused on farmed animal suffering should be trying to nudge the trajectory towards ubiquitous cheap semaglutide; it's not every day one finds an opportunity to reduce demand for meat by 5% without asking consumers to make any sacrifices!
I use Saxenda for a year now, list price is 500 Canadian dollar per month but with Manulife insurance im payong 100/ per month.
I lost 25 kg in the first 6 months, then I felt "acclimated" to the drug and started eating a lot again. Seeing that the drug is no longer working I stopped. You feel nausea using this drug at first, when the nausea subside the drug is not working anymore for me.
I am a psychiatry resident and am interested in semaglutide as a method of counteracting the metabolic side-effects of second-generation antipsychotics (SGAs), and most prominently the so-called "-pine" drugs: olanzapine, quetiapine, and clozapine. These drugs are fairly effective antipsychotics, but many are hesitant to take them and/or stop taking them due to weight gain. I spoke to an endocrinologist from Columbia University Hospital who said that the psychiatry department there occasionally consults endocrinology to start patient's on semaglutide at the same time as starting an SGA if the patient is already obese. None of my attendings are willing to do this and I have never heard of any other psychiatrists doing it, but I think it is an interesting idea. Scott, have you considered doing this in your practice? Have you seen others doing it? If not, why? A drug that can counteract the metabolic side-effects of SGAs could potentially change psychiatry and would be one of the biggest boosts to compliance in the history of the field.
I am a general internist with a longstanding interest in the medical management of obesity and I think that you are asking an important question. Olanzepine is a highly effective antipsychotic drug and for years, Lilly denied the fact that it caused weight gain and they had to pay one of the highest penalties in pharmaceutical history because they had misrepresented the data!
One of the most common incorrect beliefs about obesity is that it is a psychiatric disorder. There is no convincing evidence to back that up! I often prescribe semaglutide to obese psychiatric patients and they almost invariably do much better, no matter what the psychiatric diagnosis is.
Semaglutide is much less expensive in Canada. I have posted a series of highly evidence based videos on YouTube on the management of obesity. I suspect you would enjoy the one on medically supervised weight loss programs.
I agree this could be valuable. I haven't done it yet because I haven't started a lot of patients on antipsychotics recently, but it's something I should keep in mind.
It was my understanding that Yagmuk just can't read english specifically, not that he is fully illiterate. Have I had the lore of this selfless hero wrong this whole time?
I am an internist with a longstanding interest in the medical management of obesity.
Bariatric surgery keeps getting better and better and safer and safer. A Sleeve Gastrectomy in the year 2022 is safer that a gall bladder extraction, a hysterectomy or even a TURP for benign prostate disease.
We now have strong evidence from several high quality prospective studies that obese patients who have bariatric surgery live longer and have much higher quality of lives than carefully matched patients who don’t. If I experienced biliary colic, I would not hesitate to have my gallbladder removed. If I was a woman and I had severe menorrhagia or painful periods, I would not hesitate to have a hysterectomy.
IFSO and the ASMBS, the two largest bariatric surgical associations in the world, recently updated their guideline recommendations for the first time in 30 years. They are now recommending that all patients with a BMI of 35 (except for the occasional weight lifter) should consider bariatric surgery as well as all diabetics with a BMI of 30 (about 90% of diabetics) and that surgery can even be considered in selected patients with no co-morbidities.
I completely support those recommendations. I recently posted a 17 minute highly evidence based discussion on bariatric surgery on YouTube which I think might interest you.
I am a huge fan of semaglutide and here in Canada, it is really not that expensive (about $3,000 /year).
However, for a one-shot payment of $14,000, one could get a Sleeve Gastrectomy by a world class bariatric surgeon. After that the need for meds for diabetes hypertension, arthritis, depression and heart disease all plumet!
From a societal perspective, the cost savings would be incalculable.
I have posted on YouTube a video of a presentation that I gave at an international bariatric surgery conference in which I argued that bariatric surgery pays for itself in less than one year!
One interesting tidbit about Mounjaro's discount program:
Through November, Mounjaro's manufacturer coupon was really generous. You'd bill the primary insurance first and, after getting a rejected claim)/request for a prior authorization, bypass the initial payer and receive a pay amount of $24.99. You didn't need an actual insurance authorization, just proof of insurance to be eligible.
However, it appears this deal is ending. The most recent claim I processed (Monday or Tuesday evening) came back with a patient pay amount over $500 after bypassing the initial payer. Upon calling the pharmacy help desk, the representative informed me that patients with new coupons (anything after mid-november) would have to pay the elevated price sans insurance approval, and that the preexisting $24.99 coupons would be grandfathered in.
Thus, it looks like new patients seeking Mounjaro will need a PA before seeing an affordable price. It's too bad from a pharmacy standpoint, given how much easier it was to bill the drug without getting insurance providers involved.
I predicted back in April that the plethora of obesity-drugs found with A.I. assistance in the next FIVE years would be sufficient to cause a wave of angst against the Pharmafia, such that cheap knock-offs or price-competition finally come into play. We'll see if who's right!
Glad to clarify :) 5 years before a wave of AI-tailored drugs have been found which are able to "re-normalize", not just -15% weight. I expect a huge push, with AlphaFold et al. And, with such a plethora, each will be redonkulously priced for its sub-population, which will create a larger *general* public backlash, as opposed to a single drug or maker. We might see price competition happen due to new industry *entrants and small-players* as discovery costs have dropped so much.
Semaglutide was as far as I know discovered entirely the old-fashioned way, with plenty of natural (human) intelligence and a crapton of high-quality med chem synthesis and characterization. Not a trace of AI in sight. Story is nicely told here:
After GLP-1 itself and its role was discovered in the 90s, it became an obvious target for therapy. The principle problem to be solved was extending its life in vivo: native GLP-1 has a half-life of mere minutes, and what was needed was a half-life of at least several days for a reasonable therapy.
The clever bit appears to have been designing semaglutide to have a long fatty-acid tail that causes it to bind to serum albumin, which itself has an unusually long half-life on account of after it gets taken into a cell it promptly binds to a certain receptor that causes it to be ejected before it can be degraded. The ultimate challenge was to find the right length of tail plus attaching spacer that would optimize the combination of lifetime (through binding to albumin) and affinity for the GLP-1 receptor.
I don't recall saying you did. But I don't see that it matters. My point is a strong rebuttal to your assumption beause for an obesity drug "found with AI assistance" to be approved -- or even submitted for approval -- in the next five years, it would already have to be in very late stage development, probably at least in animals studies, if not Phase I trials. And if the use of "AI assistance" were common enough in the past 5-10 years of research on obesity therapies that there were already drugs in late-stage development that had been developed that way, it would certainly have played a role in the development of semaglutide. Which it did not.
Also, being a smartass doesn't really help your argument, you just sound immature.
No, you did not provide a rebuttal; the case of industry over the last ten years is clearly *not* indicative of its progress in the next 5 years; they didn't have AlphaFold. Due to A.I. a researcher can now fold a protein that acts as a receptor site, and then *ask* A.I. to design a protein that will target that receptor. That was previously impossible, just a few years ago. Already "Whether in preclinical stages or in the commercialization of a drug, AI-enabled drug development is now used by an estimated 400 companies and has reached a $50 billion market" according to MIT Technology Review.
"Several biotech companies have recently announced drugs discovered or developed using AI that have progressed to clinical trials, including Exscientia, Evotec and Insilico Medicine." from Financial Times, talking about funding round for one of those companies, merged under Eli Lily, so you know it's serious.
You're behind the state of the art, making an argument that is out of date. I specifically said that we would *find* such treatments in 5 years, and that the delays which are normal for FDA would cause a public backlash, potentially accelerating access. I didn't say "access in 5 years."
[[Details - that Financial Times company, as they mentioned, is already going into human trials - this is clearly accelerated. Further, robotic labs are beginning to work! And, those articles I linked were both written in the last few weeks; acceleration is here.]]
In this context, the transhumanist argument is not very convincing. The technology to lose weight already exists. It's called "healthy food". It's widely available and not patented.
The magical weight-loss pill is meant for people who do not want to use healthy food as a weight loss method. Instead of eating healthy, they want to consume psychoactive drugs which contain also lots of calories. Those are called "junk food".
The primary problem is dealing with the addiction to junk food. That's a serious mental health problem.
Maybe the transhumanist solution would be the development of new psychoactive drugs that won't cause enormous health problems to the users. People could add them to healthy food in order to consume it instead of junk food.
There’s already a lot of literature on the topic, but it’s a lot more complicated than “healthy or junk”. Brief summary here (brief compared to the lit):
1.) All food is unhealthy past a certain threshold, so creating lower calorie foods that provide any type of nutrients or macros that are more addicting than junk food would still be pretty detrimental to health, and sometimes it turns out they’re also less healthy at smaller volumes (this has been tried multiple times on a national scale already- see trans fats). Another option: one would have to balance zero macro addictive foods with non addictive macros--which is already a popular diet form that is complicated & also has a lot of barriers. I know one person that has succeeded at this and two dozen that have failed.
2.) For a long time, snack food and fast food were significantly cheaper than any “better “ foods aside from a handful of staples (flour, rice, beans) so anyone struggling with money or trying to save on costs for any reason (like paying for education!) were highly incentivized to get poor quality food. This dynamic is a lot weaker now but still prevalent + folks that developed habits under previous conditions will have to actively break those habits, which is much more difficult than starting the habit because a.) still addicting b.) your entire social circle eats unhealthy snack foods c.) busy busy busy busy d.) YOU ARE ACTIVELY BEING TARGETED BY MARKETING CAMPAIGNS.
3.) Underlying health problems. 3.5) Underlying health problems that previously would’ve caused moderate weight gain on a healthy diet now cause severe weight gain on a diet-thats-not-that-unhealthy-but maybe allows chips and soda once every five days. (“My gym bros have a cheat day fridays and they’re still ripped? WTF?”) 3.55) Underlying health problems that previously would’ve caused severe weight gain and high mortality, but now only cause severe weight gain.
4.) Education! Lots of folks go out of their way to avoid food they think is unhealthy, and DO only eat food they think is healthy, but it doesn’t work! I’m sure it has nothing to do with the “””health””” industry being whole magnitudes larger than health education... or that whole scandal from the 70s where suppliers told the government to tell everyone “our food is the healthiest”, and the government did it. RIP Food Pyramid.
5.) Did I mention how busy and disconnected people are? Everyone is expected to work overtime (maybe even raise kids with two parents working overtime or a single parent household.) On top of that, many people have used the mobility of the modern era to leave their traditional family communities (for very good reasons) but failed to find new, better ones that could support them.
Aside from number three, there are better solutions to many of these problems than simply “take pills” yes, but they’re incredibly difficult to solve on the macro scale, and unless we see folks that have figured out how to fast-track all these problems, we desperately need an interim solution- perhaps something that’s as simple as a visit to the pharmacy. (On the individual scale, if anyone reading this post is considering pursuing weight loss or general lowered disease risk, I definitely recommend at least attempting the community-building option and freeing-up-time-for-self-care option. Even if you end up failing to lose weight, there are many other benefits to reap here, so it’s a much better investment of time than a fad diet.)
Do you suppose there’s a pill that would cure people suffering from the delusion that things that come easily to them would come easily to everyone else too if only they weren’t a bunch of lazy, whining assholes?
Just as a point of information, my Medicare Advantage plan covers Ozempic with a 20% copay which was $94 for the first prescription and $47 thereafter at CVS so I think the $1,000 price is not correct. I think uptake will be very fast among those of us over 65.
I don't think you'd need more than 10% or whatever of people to take the drug to have a large effect on obesity in general.
Very smart people in the comments have noticed that obesity is caused by eating too much food, and that the permanent cure to it is to eat less food. This has the great advantage of being true, but is incredibly unhelpful to the people who actually are obsese. That's really hard, and it's hard for a lot of psychological reasons and social reasons and structural reasons that have a lot less to do with personal willpower and a lot more to do with what everyone else is doing around you. You don't eat because you're hungry, you eat because it's there/you're tired/everyone else is doing it/you're used to it. Exercising and increasing activity suffers from the same problem: it's not that you don't want to exercise, it's that it's hard and nobody else is doing it so there's no immediate profit to doing so.
However, if the hype is real and semaglutide really works like that, it sounds like it removes a lot of the social/psychological pressures and lets your body's metabolism figure out how much you need to eat without all the extra noise. It's a lifestyle drug, not a weight-loss drug. If you had a drug that, say, can make people walk around the block every day after dinner, you'd get a similar result. (At least, in my limited understanding of the actual mechanics here).
Obese people tend to travel in the same circles as other obese people for obvious social and economic reasons. If you could take 10% of those people and cause them to magically change their lifestyles (say, by giving them a drug or something), you'd have spillover effects within their social circles. This isn't just that the family goes to a salad bar instead of the fried cheese palace for dinner (although that will probably help on the margins), it's dumb but important stuff like how they see themselves and what they think is possible and even guilt about losing weight because you'll be making yourself "better than" your friends/family. (I've heard this from several obese and formerly obese people, including my mother, this sentiment is *shockingly* common). If your friend or family member is losing weight and you can see them feeling better and they're less likely to indulge in behaviors like overeating when they're around you, you have a model for instigating those same lifestyle changes and the motivation to do so.
You don't need everyone to take the drug, you just need a small population to change their lifestyles enough that their social circles can follow suit. Does the snowball effect eliminate obesity in burgerstan? Probably not, but it could be a serious factor and reduce obesity rates much more than the 10% of semaglutide users would indicate.
For what it's worth, I use a similar savings card for a far more expensive medication, and it basically does what it says on the tin, no weird gotchas. In fact, mine's better, it brings the out-of-pocket cost down to $5 and has no limit on monthly rebates.
It's basically a dance where the medication company says "we'll sell you this drug for *a million bajillion dollars* and not a cent less! but your patient needs it, so you must pay!" and the insurance company says "well, we'll cover $4,000 dollars, the patient can pay the rest" and the medication company says "the *patient*? have you no *pride* in the health of our citizens? why, out of the goodness of our hearts, *we* will altruistically cover the rest! also thanks for the four grand".
1) I’m not certain where other folks are getting semaglutide, but I would imagine Chinese pharma companies. You may have heard of the pharmacy in SLC, UT that attempted to compound hcq for COVID and sell it to the state of Utah? He bought it from a Chinese pharma company and what he eventually got busted for was false shipping manifests, not the blatant violation of the FDCA. I imagine something similar happened here.
2) while I can’t speak to the legality of sourcing the active ingredient, preparing the compound is probably legally fine. Wegovy and Ozempic has been in a shortage state for nearly 2 years now. In cases of shortages, I CAN legally compound products, including those protected by a patent or otherwise theoretically available. Patient access comes first- if I can’t source a finished product due to the manufacturer not having adequate supply, I’m good. I have to maintain documentation of my inability to source the patented products or the otherwise available product, but this is accepted practice. See, for example, this week’s FDA GFI re: compounding amoxicillin suspension for kids.
1) wegovy is sold in monthly dose paks, not weekly doses.
2) no, we don’t compound semaglutide in my pharmacy, and no I don’t intend to. The legal risks of compounding sterile products (ie injectables like this one) are intense enough for me to not do sterile products, let alone involving possible patent claims.
3) the savings card thing is “if your insurance pays something, we’ll cover most of your copay.” In the case of wegovy, they’ll pay up to $200/28 days for commercially insured prescriptions and up to $500/28 days for prescriptions paid out of pocket. The basis of these programs is that there is solid evidence that when prescriptions are >$50/month, people pick them up way less frequently. Coupons like these ShOULD be illegal, imo, as they basically invalidate the whole concept of copays and therefore allow pharma companies to Jack their prices into the stratosphere because the end user has no concept of the actual price. Without these cards, they would lower their prices so that people’s copays would typically hit a price of ~$50/month or less, out of pure profit maximization. (There’s also the fact that pharma pays rebates to PBMs to lower their prices are NOT used by those PBMs/insurers to set patient copays lower, ever, which is manifestly unfair and results in situations where people pay more for their insulin than their insurer has landed on with their rebates- ie the insurer collects a rebate so large that the patient is effectively subsidizing their insurer, rather than the other way around- I call this “reverse insurance”).
Also also, among small business pharmacists, there is a substantial fear of dispensing ozempic or Mounjaro for anything other than very obvious diabetes, due to the fact that
1) I typically make <$10 per branded prescription like these.
2) insurers and their PBMs routinely audit pharmacies for documentation to substantiate the insurance claim. In the case that an insurer finds anything they don’t like (missing information, unclear directions from the physician, a diagnosis of weight loss, a LACK of diagnosis of diabetes, etc), the insurer recoups the full amount of the claim, not just the pharmacy’s profit. In this case, that would mean that if I dispensed ozempic and billed your insurance for it, and they later audited and recouped the full amount, I would lose ~$1000. That means I would have to dispense >100 prescriptions at that same <$10 profit in order to break even on this drug.
The reimbursement for branded drugs to small pharmacies has gotten SO bad that it’s literally impossible to source product at the price the PBM is willing to pay (outside of stupid programs like the 340b drug pricing program, or counterfeiting). This has predictable results: https://benjaminjolley.substack.com/p/pbms-3-counterfeit-drugs
Can you refuse to fill a valid prescription in the US? It looks to me like the insurance companies expect you to somehow give a second opinion on the prescribing physicians diagnosis and otherwise carry the risk the insurer is supposed to carry.
I know that there is some law around moral objection for things like Plan-B or whatever. But not generally for branded drugs. I suppose that they could just stop carrying branded drugs, though the PBMs would probably be delighted in that - they trying to push everybody to use their in-house mail-order pharmacies in the first place.
Really enjoyed this article, didn’t know much about these drugs post-Elon mentioning he uses them.
As someone who eats healthy, works out a lot and still struggles to lose weight, seems like a really great option for millions of people in the same camp trying to live their best lives.
I'm on it (have been for the past 1.5 mo) and have taken two prior "cycles" going a few years back. The effects described on the Reddit screenshots are pretty much what I've felt. On the side-effect side, on a previous attempt at starting the current cycle (maybe 3mo ago) I've had such an upset stomach that it felt just like it feels when I'm extremely anxious (say, before giving a talk or starting an Ironman)... in a very bad way, so bad that the feeling reminded be of my worst days of depression. Anyway, I started on a higher dose (.5mg) straight away; on this current attempt, I started at .1mg, and increased dosage *very* slowly, so that I'm only now reaching .5mg.
When I was working at an outpatient hospital pharmacy briefly in Bakersfield we had tons of medical residents writing Ozempic prescriptions for themselves so they could get it for cash cheap with a huge 340B discount (I want to say it was something ridiculous like $400ish per month). We had to constantly reprimand them not because they were outrageously abusing 340B but because almost all of them were doing it incorrectly by not having their attending document an office visit and then writing the prescription for them.
The pancreatitis thing worries me with semaglutide. There's already a huge spike in that going on that is poorly understood, and as someone who got hit with it last year, it appears to have permanently effed my digestion, even as mild an episode as it was (no walled necrosis or multisystem organ failure). Ironically, I did lose a ton of weight (who knew permanent exocrine damage was so good for the waist line?). Anyways, I'm probably overly sensitive to that risk, given personal trauma, but at the same time, given the already rising tide of pancreatic issues, it would seem that putting 10s of millions of people on this drug might be a tough situation. But maybe the risk is small enough its ok. I've not seen any hard number put to it anywhere so I don't really know how to judge it.
In Portugal the price of the drugs is available publicly on Infarmed's website (the Portuguese counterpart for the DA part of the FDA).
Wegovy is not yet being sold here, but the price for Ozempic is 120€/month. The government supports 90% of that, and the patient the other 10%. I believe that for Wegovy, the patients will have to pay the whole amount (or have some health insurance pay it, but I think that's unlikely).
Edit: I've seen a chinese pharma that seems legit enough selling it for 50$/month (considering the weekly dosage of 2.4mg, while Novo Nordisk is selling in Portugal for 120€/month the 1mg dosage)
Ozempic 1g /week one year. 5'10". From 285 lb to 265lb.
Stopped because of hepatic pains getting consistently relatable post injections.
Worked by aversion mechanism to fat , permanent bloated uncomfortable feel, and making sugary things very unappealing ( which are to me anyway).
After being miserable and ( more ) depressed , I stopped it.
Next week I finally enjoyed my favourite cheeses and sourdough.
Never ever eating fast food, greasy spoon , buffet. Gourmandly hedonistic ( lived all over the world ( Europe mostly) and that's actually a curse.
I gained 16 back ( within two month). Now I'm shedding 2 lb/ month just doing portion control ( inflation and scarcity ) helps . At this pace , in 3 yrs will be overweight ( BMI 29.5) . In 6 yrs within normal ( BMI 24). Then retirement and ensuing poverty will potentially be contributing factors to go at the 20-21 BMI . If I won't die until then, that's my plan.
There's gut bacteria that result in increased GLP-1 production in response to food intake.
I suspect some people just have a lot of these. Something happened in environmental factors to kill a lot of these in people. Semaglutide works by replacing the lost endogenous GLP-1.
Rybelsus is much cheaper here in Brazil. A box of 30 pills 3mg (with manufacturer coupon) cost like U$ 50. 7 mg would be around U$ 110 and 14mg about U$ 200.
In Denmark, the home country of Novo Nordisk, Wegovy litterally just arrived on the market the other day. The price is around DKK 1,500 (~$200) per month.
The Danish health authorities have denied the application for public subsidies for the drug, citing that the price is too high, lack of evidence of the long-term effects, and lack of evidence of effectiveness against cardiovascular disease.
"Movement offers us pleasure, identity, belonging, and hope."
Identity? What identity? "I can move my legs, that means I am A Leg-Moving Person"?
Sorry, but this is where the exercise evangelists get ridiculous. If I were to be confined to a wheelchair tomorrow, I *might* construct a new identity around being disabled or a wheelchair user (I don't think I would, but I might). However, I am positive I would never construct an identity around being a runner, and if someone feels that the most important thing in their life is that they are a runner - well, you do you, but heck.
Honestly, your McGonigal person sounds like all the dopeheads on here urging "LSD, man, psychedelics, will give you a cosmic experience and fix all your mental problems with a reset!" Maybe the exercise high people and the psychedelic high people should get together and get mutually baked before running a marathon, then they could both disappear up their own crown chakras about the cosmic best and highest human spirit coming out, maaaaaan.
What makes you think we don't exercise? I've exercised for a minimum of an hour a day, seven days a week, since elementary school. Usually I get more exercise than that. I'm past middle age now. It never made a dent in my weight. This is the kind of mean-spirited assumption that fat people have to fight all the time.
Exercise doesn't shift weight, unless (as has been mentioned) you are preparing for an expedition to the Antarctic or triathlons or the Tour de France.
What exercise will do is tone up muscles (I did find that the flabby underarms tightened up) and help with endurance (being able to walk distances without getting winded). But you can be fairly fit (able to do everyday tasks as normal) and still fat, even very fat.
I think the "diet and exercise" mantra comes from treating people who only have a few pounds excess to shift; the exercise will tone muscles and burn off some extra calories, and that in combination with restricting calories to below normal metabolism maintenance will shift enough weight/fat so that you do 'go down a dress size' or whatever.
But for seriously overweight people, it won't work like that. And exercise *alone* definitely won't work, because it makes you hungry so you eat to compensate.
Isn’t this phentermine? Wasn’t it part of the old phen-phen diet? One “phen” was found to cause heart problems.
No, this isn’t related to phentermine. It’s not any kind of stimulant. It works by making you think you are full and not hungry any more. Source: my better half takes one of the versions for diabetics.
Sorry, I thought I read somewhere that Wegovy is actually phentermine, but on further reading it seems you are correct. It is just a different weight loss medication. And has less long term results and perhaps more side effects.
There are shady weight loss clinics that prescribe and dispense "all natural weight loss supplements" that are actually phentermine. (Getting customers hooked on stimulants is a great way to ensure repeat business!) I wouldn’t be surprised if some of them latched on to the semaglutide hype and started pretending to offer that.
I dunno, I don't find that toooo shady — I'd be pleased to get something that actually works, if anything!
And stimulants mostly aren't physically addictive, so "getting hooked" on them because you took some for weight loss and really liked them sounds like complaining that Krispy Kreme got you hooked on food because you really like eating donuts, it seems to me...
Edit: Well, marketing it as "all-natural" *would* be shady — forgot about that part, sorry!
("All-natural" is a stupid term to base purchasing decisions on, though, for many different reasons... so I can't get too worked up about it, heh.)
Phentermine is fantastic for weight loss. There have been 3 studies to determine whether it's addictive, and all 3 concluded it is not. I took it myself for 2 years before the new, stricter, more-fascist rules saying you have to have a BMI of 30 to get it went into place.
Standard dose is 15-30mg / day. I was using 38mg tabs, and found it effective at 19mg/week, as taking 19mg on a single day enabled me to fast for that entire day.
I believe the medical community is so down on phentermine now for religious, not scientific reasons. Doctors really don't like it when a person can just take a pill instead of exercising. It feels like sin to them.
Phentermine is actually a controlled prescription medication under the same rules and regulations as ADD medications and pain medication. Phentermine is only available by prescription. There are supplements that weight loss specialists use but there is no reason to try to "hook patients" on a medication. Patients actually seek out Phentermine and try to rely on it versus actually changing their diets. Phentermine is highly controlled and should be in a prescription bottle from a pharmacy or a dispensing medical office.
All of the studies on the addictivity of phentermine that I have seen, concluded it is not addictive. I challenge you to find any experimental evidence that it's habit-forming. I took it myself for 2 years, and had no problem on being forced by new regulations to discontinue it suddenly, other than getting fatter as a result.
They're both drugs used to treat obesity, no other connection. Are you asking about something more complicated than that?
Can you extend the cost benefit analysis to include stimulants and other harmful weight loss drugs?
No, GLP-1 drugs work completely differently. Here’s a useful summary by Stephan Guyenet, whom SA has written about approvingly before: https://www.worksinprogress.co/issue/the-future-of-weight-loss/
Wegovy is unrelated, but Qysymia, the less-functional diet drug mentioned in passing from the chart, is phentermine + topiramate.
You said, “I have a pretty minimal insurance and it looks like if I got semaglutide my copay would be about $500/month until I reach my deductible.” I think you mean out of pocket limit, not deductible, though maybe your plan is odd. Usually, you get zero benefit until you hit the deductible.
Thanks, corrected.
I tried semaglutide and it did nothing to slow rate of weight gain, just produced stomach upset, going up to 2.4mg injectable. I know one other person trying semaglutide and they reported something similar. I wonder if they played some clever games with their choice of patients. My expectation of how the news goes here is a whole lot of people who try semaglutide, maybe after fighting really hard to get on it, and find that it does nothing. That said, I know at least one friend of a friend, if not a friend per se, who claims that semaglutide was their miracle drug. So maybe still worth that hard fight, even if I'm guessing that the real proportion who get nothing out of it will prove to be over 50% in real populations.
Further fun fact: Semaglutide comes heavily recommended with diet and exercise and many stern injunctions about that! The actual insert sheet includes a graph for how much weight people lose with and without "lifestyle interventions" added. The two graphs are roughly the same.
I thought the comments at https://www.reddit.com/r/slatestarcodex/comments/y40owh/semaglutide_has_changed_the_world/ were impressive, although of course that's a different kind of selection bias.
I hate to be that guy, but I do find all these debates about extremely expensive weight loss cures (Matt Yglesias has a recent article about getting [I forget which] surgery) kind of annoying, where there are literally money-saving ways to lose weight - and more importantly than that, improve your metabolic health (where obesity is a potential symptom).
"semaglutide comes heavily recommended with diet and exercise and many stern injunctions about that!"
I wonder what effect that heavily recommending things that cause weight loss alongside your weight loss drug does.... I also wonder "what" diet and exercise is being recommended, when there is so much (conventional wisdom) diet and exercise advice that will definitely not make you lose weight, or worse, make losing weight so unenjoyable that you don't want to do it.
Yes, and that's why just waving the magic totem labeled "do diet and exercise" doesn't work. Exercise done right doesn't make you lose weight, but you should still do it. Diet can, but most diet advice doesn't work, or works, but is too difficult to stick to - giving an out to the Puritans who lecture people for being insufficiently pious. And remember "work" isn't defined as "lose weight" it is "be healthier and less likely to have the bad health outcomes that are currently correlated with being overweight"
This works: https://moore2024.substack.com/p/no?sd=pf
Yeah, my first year Behavioural Psych teacher had a great point when he said imagine a problem in the world (I picked AIDS). Then imagine a behavioural change that would 'cure' it. This idea was revitalised with Scot's post along the lines of technology is possible biology (behaviour change) is not (immutable).
Behavior does change, but that doesn't mean anyone can reliably choose to make it change, for themselves, or large groups, or for everyone.
yes. Human behavior is immutable. That's why we still live in tribal societies of no more than a couple hundred people led by hereditary nobles.
>The same can be said about pregnancy and STDs ("Just don't have sex")
Terrible analogy. Not having sex works 100% (alright let's say 99.999% to account for urban legend-tier accidents) for STDs and pregnancy. It's not a problem of effectiveness, it's a problem of "people don't use it". If a medicine cures a disease, it's not a failure when people who decided to not take the medicine suffer from the disease.
"People don't use it" is very close to "the cure is more unpleasant than the disease", which is a failure of the cure.
Amputating one's hands is 100% effective against carpal tunnel syndrome, both as a cure and for prevention, but I wouldn't say it's not a failure of that treatment that people choose not to do it.
"eat less stuff" is a gold star way to lose weight except that people suck ass at it. I have succeeded in the past, but put back on 20 pounds from my ideal body and am failing currently; it's pretty damn hard. I don't know if that's what you mean by money-saving way to lose weight, but if it is then I think it's an incomplete solution--eat less stuff needs a very firm "how," and that seems to vary person-to-person
Why eating less is so difficult and why losing weight at all by any method is so difficult are questions at the very edges of current neuro- and metabolic research. Most of what we tell the obese is unhelpful.
The real reason it's so difficult is that eating too much has simply become too convenient, whereas not doing so apparently doesn't come natural for many people.
I can see it in my wife: when she had the mental strength to account for everything she ate, counting calories and adjusting her diet to get enough protein, she easily lost weight at exactly the expected rate. As soon as she stopped doing that she started to eat too much calories with too little nutritional value again, as those meals are way more convenient to make, more tastier for her and immediately rewarding for the brain (but don't actually make the hunger go away for long). Despite her noticing how a protein rich diet made her feel full for far longer, allowing her to eat only two meals a day easily, she can't maintain such a diet without dedicating substantial mental strength to it; and she can't properly limit her calories with a more convenient diet either.
The difference between her and me is that she absolutely can't tolerate hunger, like at all. Not eating breakfast when starting early into the day to achieve something is simply not an option for her. Neither is skipping meals when eating her usual diet.
I on the other hand would rather sleep in another 15 minutes than to get up early to find the time to eat something. I can easily skip two meals out of three without any issues for days. I feel hunger sometimes, but I can just ignore it for an hour or two, and then it goes away. For me its absolutely no issue to maintain a BMI of 22-23 without ever stepping on a scale, counting calories or diet adjustment. I just stop eating when it's too much. I also don't stuff in left-overs for the sake of finishing them, which makes my wife mad regularly. She just can't get off the idea that this means wasting food.
A drug that would make the feeling of hunger go away would certainly help. But the real message is: convenient diets are unhealthy. We should have more healthy food options which are convenient to consume. If eating healthy requires extra effort, a lot of people will fail to do so ...
And all of that is without even considering people who simply have to eat whatever is the cheapest option available ...
Sorry, but I'm a little miffed here. "Convenient diets are too easy" is certainly a contributing factor, but the rest of your comment reads like someone lecturing a person suffering from chronic pain.
"Well, *I* don't get sensations like my bones are splintering and turning into knives cutting my flesh, so an occasional aspirin handles things for me just fine! Why do *you* need strong pain-killers? Modern pharmaceuticals have made things way too convenient!"
You say you don't get hungry and can easily skip meals without noticing, or ignore any hunger you do feel. Yes, that means it's easier for you not to eat and to stay at a 'normal' weight.
Try imagining you *do* feel hungry. Not even that - do you get thirsty? Do you drink plenty of fluids during the day? Can you easily ignore being thirsty? The next time you are thirsty, try "no you can't have something to drink right now, you had a glass of water this morning, you have to wait a minimum of four hours before you can have your next glass - and only one!" and see how you hold out.
This is probably not how you intended it to sound, but your comment comes off as "my wife is so over-sensitive and has no grit, she can't handle a little bit of pain/hunger, she just needs to toughen up - me, I could have my hand chopped off and not even notice, *that's* normal!" - see what I mean about the comparison to chronic pain?
You took my post in exactly the opposite way it was meant. I'm not saying that anyone would be at fault in the way you construed it. Quite the opposite. I was saying that the individual experience of hunger was very different; as is btw. the individual experience of pain.
This makes it extremely difficult for my wife to maintain her weight while consuming exactly the same kind of diet which I eat. Where she needs willpower not to eat something, I just need lazyness to prepare food. While she had to adjust her diet to lose weight to a high protein one, I can live as a skinny fat on a low protein diet just fine without any effort (and then still suffer from much of the issues such a bad diet entails). None of this is my achievement or her failure. It's just a simple fact.
I'm sorry if it came off differently. But I feel as if you were reading my comment almost in bad faith here. How would it even be my wife's fault that she experiences hunger far more severely than I do? And how would it be an achievement of mine that my body reacts far more charitably to not getting any food for an extended period of time? Neither of us chose our bodies or our body experiences. And nowhere did I blame her for her way of experiencing it.
I then proceeded to say that the reason this difference leads to that much obesity is that high calorie diets with low nutritional value are much easier to purchase and consume nowadays than diets which are well balanced. My wife, when trying to lose weight, had to go to great lengths to get all the nutrients she needed, while going cal negative for an extended period of time. IMO this is something we as a society could and should address.
Here again I'm under the impression that you are reading my comment in bad faith, as your example with pain killers works exactly the opposite to what I said. So your comparison doesn't even make sense and IMO only serves to discredit my thought.
And to answer your similar bad faith attempt at thirst: yes, I also experience thirst way less severely than my wife. Again: this isn't her fault or my achievement, it's just a plain fact.
Btw.: I am a chronic pain patient, having shattered my left hip a few years ago. I don't have a single day in my life without pain. And I don't use any medication for it (though I had doctors call me out for it, claiming stupidly that no one should ever need to experience any pain at all). Yet I never told anyone that therefor they shouldn't need any either. That would be simply plain stupid. I did need quite a lot of those the day I shattered my hip ...
I sort of get the convenience complaint, but sort of don’t. I think it is mostly just about the raw hedons. A cucumber is pretty good and super convenient, and you can just eat it like an apple.
But people will make a sandwich or cook something in the microwave instead because that food simply tastes better.
I just don’t think convenience is as much of an issue compared to accessibility and the overlap between caloric density and tastiness. Sugar tastes great.
Maybe I phrased it wrong, but I was trying to convey the convenience of foods actually filling you such that you no longer have any cravings.
My wife eats lots of cucumber btw. ;-), but I wouldn't call them a meal. I could eat ten of them and still be hungry. They might help with alleviating thirst though ;-)
I'd consider accessibility the main part of the convenience btw. A major issue, while trying to lose some weight, for my wife was finding something suitable to eat when not eating at home and not having brought our own food along.
Your wife's (and yours!) experience is totally normal. Most people cannot (and shouldn't) abide hunger, and that is a huge part of why normal "eat 20% less calories" diets don't work, even for people (like her) who have the capacity to measure it. Eating 20% less at 3 meals is also far more difficult (and will result in those leftovers) than eating less in discrete chunks by eliminating meals. Obesity (or lack of it) does not come from
But yeah, if you feel HUNGRY, a "diet" isn't gonna work, period. No one can manage long term hunger in a world that has so many easy things to eat.
Not to be internet nutritionist, but the the thing that everyone I've spoken to has worked (for varying quantities of "worked") for is adding replacing carbs with fat/protein (eat as much as you want for dinner, earlier is better) and then just extending the time period until you eat next (breakfast, or lunch, or later lunch, etc...) til whenever you feel hungry. If you feel "kinda" hungry, drink a zero-cal electrolyte drink first and then check if you still wanna eat a meal. Measuring whether you ate 1741 calories or 1787 calories is impossible.
And also, I just want to reiterate: obesity is a symptom of underlying nutritional condition, not a disease. Some people who have it are fat, some are not. It has bad effects even if you aren't fat. Semiglutides (being diabetes treatments) may somewhat treat the underlying thing (I don't know for sure) but if you adopt a diet that you enjoy, and your A1c and other metabolic indicators get better, you are HEALTHIER, and much lower risk for a long laundry list of bad outcomes even if you don't lose any weight, or never had much fat in the first place. Depending on *what/when* you eat, you (with your low BMI) might have less healthy A1c/etc... than your wife, with the potential bad outcomes. This entire thread is far too focused on treating the symptom of obesity and pretending that if we removed that, we'd fix the problem. (it is possible that semiglutides DO partially treat the underlying problem) There are too many skinny 60 year olds who die of things and we go "so sad, what bad luck, they were so healthy!" but if they were fat we'd go "oh man, if only he'd kept in shape" but they died of the same thing for the same reasons.
Well, those diets actually do work. Physics can't be cheated. That's a big part of the problem. Because it puts so much guilt onto people to whom it doesn't come naturally. The problem is that hardly anyone can put up with them for long enough to get into another mindset, where those changes suddenly come naturally.
Btw.: my wife never felt hungry during her time of losing weight, simply because she did ensure to always consume enough protein. The problem is that most foods which are easily available don't come with enough protein to do that. Just eating less doesn't cut it most of the time, as your diet then quickly become protein deficient. You have to adjust your food items a lot to do it. And then convenience goes out the window. That's what made my wife fail eventually as well after nearly making it into perfect BMI territory.
As for "Some people who have it are fat, some are not.": that's exactly what the term skinny fat refers to.
Just for the record: I never pressured my wife into doing any of this and love her just the way she is. I'm merely trying to recount her experience when she tried a few yours ago.
> Most people cannot (and shouldn't) abide hunger
This seems an extremely weakminded and degenerate statement to make. Hunger is a natural and healthy state we evolved to cope with. Certainly you SHOULD abide hunger if you are an unhealthy weight
What about, like, peanuts, though? Peanuts are convenient, nutritious, and filling, but eating lots and lots of peanuts isn't very palatable. I don't think we can blame this on convenience, except insofar as convenience is one of several competing, difficult things we're trying to simultaneously optimize for.
Well, good point. What about peanuts? Answer: they are one nutrient, not a meal, and thus lack lots of crucial trace elements. To add insult to injury, opposed to what you said, they aren't convenient at all. Not only don't they solve the issue at hand, but additionally where I live they aren't really readily available. I can easily get french fries, burgers and various other fast food meals on the go. I've never seen peanuts on offer (for obvious reasons). I could go into a super market and buy some; but then again I still wouldn't have a meal, and rather just one ingredient for a meal.
That's the exact opposite of convenient. Rather hard to come by and still lacking all but one ingredients for a meal I still would have to prepare. As opposed to just ordering the Pizza, wait 5 minutes, eat ...
Nuts are kind of weird. I don't know if other people experience this, but when I get a sudden pang of hunger my body completely rejects my suggestions that we eat some nuts. I'll be super hungry, staring into my cupboard, and that bag of peanuts will be completely unpalatable to me. This is in spite of the fact that I love nuts as a snack.
It think it's something where my body doesn't want to deal with a hard and dense fatty food on an empty stomach. Combined with the fact that nuts are quite slow to affect my blood sugar.
In general I think something with starch and fiber is the best remedy when I get that kind of sudden hunger.
I've had a lot more luck with "eat normal portion sizes with fewer calories, and track what you eat." It took me from BMI obese to BMI normal and has kept me there.
Portion control went so disastrously wrong that I'm skeptical of it as dietary advice. It doesn't seem supported by a lot of evidence, either (e.g. https://www.nature.com/articles/ijo201482#Sec11).
Can you elaborate on the distinction you're drawing here? You said you succeeded with a strategy that sounds to me a lot like "portion control", but then say portion control went disastrously wrong?
If the food you eat is smaller in mass, it will make you psychologically feel starved and physiologically feel unfull. Your brain will interpret this as 'you are going through a famine' and flip switches that make you value finding food more, because that was the appropriate response to a famine in the environment our ancestors lived in for millions of years.
If the food is bulky but has few calories, like potatoes, this makes the body and mind feel like you have plenty to eat, even when you are burning fat to sustain yourself.
Evolutionary mismatch, IMHO. No way to get a 3000 calorie diet 200 years ago unless you were a king.
There's also a lot of calorically dense processed food out there.
> To go with the biscuit, sailors in the RN were issued other food on a standard weekly rotation. On Sunday and Thursday, this was a pound of salt pork and a half-pint of dried peas. Monday was a pint of oatmeal, two ounces of butter, and four of cheese. This was also served on Wednesday and Friday, along with a half-pint of peas. Finally, Tuesday and Saturday usually meant 2 pounds of salt beef. Conventionally, this was washed down with a daily gallon of beer. The total came to approximately 5,000 calories a day, an incredible amount to modern eyes but quite appropriate for sailors at the time.
https://www.navalgazing.net/Naval-Rations-Part-1
For comparison, 3000kcal/day is about my current maintenance (180cm 72kg male). And I am _definitely_ way less active (and less muscular) than a sailor or soldier in history (1-2 hours of mostly anaerobic exercise every day).
Absolutely untrue. Bread and lard weren't that expensive, and it's easy to get up there in calories on them.
I think you're right, and the "diet" suggestions tend to be "just eat 10/20% less calories during the day" which isn't gonna work: people don't suck ass at it because they have low discipline, but because it's enormously difficult to measure calories in this scenario, and your behavior/brain/metabolism compensate it. It's not a single-input mechanism black box. Your 20 off, 20 on experience is the absolutely normal failure mode for calorie restriction diets.
Not to be the Weirdo Diet person , but what I mean is: intermittent fasting, cutting out breakfast (and/or lunch) and replacing enough of your daily quick-burn carbs with long-burn fat so you don't feel very hungry while you're doing it. This works because unlike calorie restriction, it doesn't cut against daily Regular American Life behavior (you "fast" every night from after dinner until break-fast, this is just a few more hours) and all the countervailing mechanisms your body has evolved over a billion years to counter generalized calorie restriction.
I don't eat breakfast. I've never felt hungry in the mornings, and when I do eat then, it (ironically) makes me *hungrier*, e.g. at around 11 o'clock I feel like I need a quick snack, whereas without eating breakfast I don't feel that and can even go without lunch.
So all the well-intentioned advice about "skip meals" or "don't skip meals" or "eat more protein" or "eat saturated - I mean unsaturated - I mean polyunsaturated, not monounsaturated - I mean saturated fats" or "just cut out the junk and move more, what's so hard about that?" becomes frustrating.
Human biology is not like a tidy physics experiment. It *should* be "calories in, calories out". It *is* "calories in, calories out* but that is *not* the whole of it, and that is what gets forgotten.
Some people will react beautifully to "I fast X hours a day from this time at night to that time the next morning between meals" but some people will not. Some people will control hunger cravings by eating breakfast, other people will have their appetite stimulated. Some people will tolerate more fat in the diet than others. Potato diet works for one person, packs the pounds on for another.
I think you are right within the realm of the recommendations you are describing, because they're so vague/contradictory. I'm not advocating any of the advice you're mentioning, which you are rightly skeptical about them applying to everyone. Calories in, calories out doesn't "work", as a METHOD of dieting, not as a thermodynamic fact.
But is there any debate at all that replacing carbs with fat/protein in a meal will not result in greater satiety/less hunger later on, and therefore enable one to go longer before their next meal? I think everyone agrees on that, and that it applies to everyone - sure, perhaps in different ways/amounts!
Does it seem acceptable that if you go longer between meals, that your body will spend more time burning energy than storing it? Sort of by definition?
Does it seem acceptable that this would then (regardless of totally weekly calorie consumption) result in storing less energy (fat)?
And again, the goal should not be "weight loss" it should be "reducing the unhealthy outcomes", the likelihood of which can be more accurately measured by metabolic lab values like A1c than at the scale.
If you're someone who's had a good BMI forever and doesn't get their labs done, then you're never gonna notice anything because you aren't measuring anything.
"But is there any debate at all that replacing carbs with fat/protein in a meal will not result in greater satiety/less hunger later on, and therefore enable one to go longer before their next meal?I think everyone agrees on that, and that it applies to everyone - sure, perhaps in different ways/amounts!"
No, not everyone agrees, and it does not apply to everyone. It absolutely does not work for me; restricting carbs triggers middle-of-the-night half-asleep binge eating.
(I'm not normally a binge eater at all; I've only ever had this problem when I've restricted either carbs or eating in the evening.)
"counting calories of every thing one eats, to the gram" is not extremely hard. i know so because I'm doing it, and i do not ever do anything remotely hard.
To do so accurately is hard, because even if you're measuring the weight, you're relying on estimates of calorie density that are potentially many years out of date, wrong in the first place, or that the producer of the food is wrong is assessing.
And ok, that it is easy for you is fine - for millions of other people, it would be A) hard B) sufficiently time-consuming they wouldn't want to do it or C) would result in no measurable effect on their health/weight, so they would stop doing it. Maybe "hard" was the wrong term to use.
The approach you are describing sounds reasonable, but, as with most weight loss approaches, there are a lot of things that will make it hard for people to stick with over the long run:
(1)It is hard to change ones habits, including one's eating habits -- not impossible, of course, but HARD. The effort and attention devoted to that have to come out of the same pot of energy people are using to do all the other hard things in their lives -- do a good job parenting their difficult kid, produce good work in their field, keep their marriage in good shape, budget, ruminate about all the bad stuff in the news. On days when the energy pot's almost empty, most reasonable people are going to choose to reduce their effort to eat in a different way, rather than their effort in other areas which are more clearly crucial
(2) It is a heavy burden to stay continuously aware of something. Take blinking -- if I ask you now to notice your blinks, it's easy as pie, right? But how about if I ask you to stay aware of them continuously for the rest of the day? Very very few could succeed at that, especially while doing all the stuff they need to get done today, and responding to whatever comes at them this evening. Continuously monitoring eating to keep it in compliance with a certain pattern is the same -- easy in the short term, very hard in the longer term.
(3) We are surrounded by highly palatable foods, and our brains are not wired for an environment with that feature. We evolved in settings where it was hard to get enough calories. If you found a honeycomb or were presented with a bunch of roasted animal fat it was desirable to eat as much of that stuff as possible. The parts of our brain that push us to eat the sweet, fatty, salty stuff that is all around us is quite powerful, and the part that understands that it's undesirable to gorge on those things on 2022 cannot reason with the parts that want to gorge. It is possible to simply override them, but it is difficult, and it's probably not possible to override them most of the time if you have other heavy demands on you as well.
1) the goal is not weight loss. That is a side effect. The goal is a healthy diet, and reduction of serious bad outcomes in the future.
2) Yes it is hard to change habits. That's why the method is designed to affect the underlying drives that cause the habits to be hard to change. It IS hard to not eat when you are hungry. It is EASIER to not eat when you have made decisions in the past that mean you are less hungry now. Eating more fat and protein in your past makes you less hungry now.
3) There are immensely palatable foods that are not bad for you, and will provide more satiety so you are not driven to consume more so soon. Animal fat is not (particularly) bad for you. Salt is not bad for you. Replace carbs with them in your meal, eat them, and enjoy not feeling hungry so soon. The goal isn't to override your desire to eat awesome tasty food, it's to hack the system so you eat awesome tasty food that reduces your desire to need to eat ANY food for longer.
This is not a moral system. There are not desires to be overcome. There is not decadence to resist. This is not ascetism. There is no willpower. This is a physical system of chemical reactions that we can affect in different ways. We impute no moral significance to a molecule binding to one molecule instead of another, nor should we.
I do think content is certainly as important as portions, if one wants to control obesity. The national health system is pretty good about listing contents on food products. We respond to heat, salt, and sugar, and food manufacturers exploit that. I think if one adheres to a healthy, lean diet, obesity is easier to control. Another important aspect is the consumption of alcohol. Alcohol can provide energy and calories, but can maintain too much weight in an unhealthy body.
I used to be borderline obese when I drank beer or wine, but I lost 75 lbs. when I came down with pancreatitis. Today, after the most recent flare-up, I'm down to 114 lbs. -- but still 6 feet tall. For a time I thought marijuana might help ease the pain, but now my body objects when I try and ingest it, so I've given that up, too. There are certainly no easy answers, but I think the content of one's diet and the consumption of alcohol are important factors. My stomach emptied with this most recent flare-up, which is unusual, so I'm taking the opportunity to curate what I ingest carefully. I'm drinking kefir and Gatorade.
In this case, the problem with “that guy” is not that he’s stating an uncomfortable truth; the problem is that he’s missing the point.
If you think that we should downplay pharma/surgical interventions because dieting and exercise “work,” it is incumbent upon you to show how we will overcome the fact that people don’t seem to have the willpower required to use these tools longterm. What’s your plan?
Willpower is a choice. In this study alone https://www.cuimc.columbia.edu/news/new-weight-loss-drug-approved-fda-it-right-you, 5% of participants on placebo lost 15% or more of their body weight. The average placebo loss was 2.4%. Granted both of these are hugely less than the treatment group, but they're also hugely less expensive. This is the case in every weight-loss placebo study I'm aware of, just the simple act of taking a pill (sub vitamin or other "healthy" pill they believe could affect weight for placebo in non-lab use) or putting an ab roller in the living room, or anything else that moves diet and exercise slightly closer to the forefront of mind than it was previously can have a significant effect. According to the paper, the lower end fda approved weight loss drugs cause a 4% weight loss, so assuming equal treatment time periods, placebo is 60% as effective on average as some drugs, at 0% of the cost. People are all different, they just need to figure out what best triggers that effect for them, whether it's my examples above (variations of which work for me) or something else.
Again. What’s your plan to get people to actually succeed in exercising willpower?
"just the simple act of taking a pill (sub vitamin or other "healthy" pill they believe could affect weight for placebo in non-lab use) or putting an ab roller in the living room, or anything else that moves diet and exercise slightly closer to the forefront of mind than it was previously can have a significant effect"
Whether you're talking to me or not, the solution is to reduce the thing that is calling on their willpower. It does not take much willpower to not eat if you are not hungry. You achieve being not hungry by increasing the satiety of the food you ate most recently. Food that does that is that which has more fat and protein, and less carbs.
And yet, I was easily overeating and hungry as usual after the first year on a keto diet.
Well, Kenny, just try very hard to try very hard. And if that doesn't work, just try very hard to try very hard to try very hard.
> Granted both of these are hugely less than the treatment group, but they're also hugely less expensive.
Breaking: doing nothing has no effect; is free
> According to the paper, the lower end fda approved weight loss drugs cause a 4% weight loss
Yeah, if you move the goalposts to “the worst drug on the market” the relative effect of the placebo goes up. This doesn’t bear on the article, which is about the best drug on the market.
>Breaking: doing nothing has no effect; is free
Breaking: 16% of the improvement of the best drug on the market from taking a sugar pill is not "doing nothing" and is in fact statistically significant. That's why it's included in this paper, and every paper on weight loss drugs.
> This doesn’t bear on the article, which is about the best drug on the market.
No, if you missed it the article is about the best drug on the market and how unattainable it is to most people (and statistically those who would most benefit from it) due to cost. So if we can get 16% of the benefits for almost zero cost that actually a huge deal on its own, and this could likely be improved significantly with other tweaks, as I've now mentioned twice. Less snark, more reading comp next time👍
What does that even mean? You state that conclusion as if it implies something significant but, I'd argue, it's really just a way to summarize the relation between incentives and behavior. Some things we call choices because they result in different outcomes when you change the incentives (prison for murder decreases murder rater but prison for being short doesn't increase height much). I mean, if you really get down into the details the difference between 'choices' and 'non-choices' isn't that the laws of physics plus initial conditions are any less binding in one than the other or that the biology that happens in the brain obeys some other kind of principle than that in the rest of the body.
But, given that background, saying something is a choice is just a shorthand for describing how responsive it is to incentives. Certainly, choosing not to eat as much is more responsive to incentives than height is but it's a lot less responsive to incentives than many other things.
And once we are made aware of how responsive it is talk of whether it is a choice or not becomes irrelevant. It's like saying something is heavy once you know it weighs 100lbs. It's not adding any information about the thing or helping you figure out what to do with it. Same with weight loss it seems. Absent interventions we aren't willing to make (for good reason) many people don't lose weight but they do on the drug and that's all that's really relevant to deciding policy.
You're exactly right, except that I'm biting the willpower point bullet. Maybe I'm bad at metaphors, sorry.
The plan is this:
1. Forget calorie restriction of the "just eat 20% less calories" form. It requires too much calculation and willpower, and your body will compensate. Forget any diet that stops you from participating in normal social rituals with friends, coworkers or family.
2. Replace carbs in your dinner with fat/protein. Eat as early as possible, eat as much as you want. Don't eat bedtime snacks.
3. Over time, extend the time from ending dinner (your "fast" length) til the next time you eat (breakfast? 12:30 lunch? 2:30 lunch?) as much as possible. Eat the next day when you're hungry, but if you're only feeling kinda hungry try drinking a zero-cal electrolyte drink and see if you still want to eat. Measuring exactly 50/100/150 less calories a day is impossible. Measuring that you ate 10 minutes later is easy. Don't put any sugar or carbs in your morning drinks.
4. Eventually cut out breakfast or lunch, or eat later lunch. Just like dinner, replace carbs with fat/protein as much as possible. Whatever feels okay.
5. Get your yearly blood work done so you can see the improvement in your metabolic indicators. Most importantly: if your numbers get better - whoever you get the labs from will tell you the health ranges - FORGET YOUR WEIGHT, sell your scale.
These are’t terrible recommendations. I do some of the things you list, and it helps me maintain my bodyweight.
But do you seriously think that an epidemic of 70M obese Americans would be fixed if only people would read your five bullet points about intermittent fasting? As per Scott’s math, you are claiming that your tweet-length comment on ACX is worth 500bil. The market disagrees.
"But do you seriously think that an epidemic of 70M obese Americans would be fixed if only people would read your five bullet points about intermittent fasting? As per Scott’s math, you are claiming that your tweet-length comment on ACX is worth 500bil. "
Yes.
But humbly, my comment is worthless. It's the advertising and execution that matters. Any idiot like me can say "gee, maybe we should build cars in assembly lines with replaceable parts" but it takes Henry Ford to execute. Even tougher, the actual problem here isn't knowing what to do, it's teleporting what to do into the minds and 70M people and then they all have to execute. Which is why I'm babbling my insane, otherwise-worthless ideas in a place run by a person who seems to do a decent job of teleporting ideas into other people's heads.
To elaborate, yes, I really do think it's worth half a trillion, obviously conditional on people actually doing it (though the lack of difficult in doing so is the key feature) and the cost of the advertisement/propaganda to publicize it, and coach people through it. There are companies (look up Virtahealth) that provide physician-led diabetes reversal for a few hundred a year using similar techniques and coaching on it. My only disagreement is you're understating the worth at 500B, because that's only the (estimated) consumer value of "weight loss", because if all 70M people did those 5 things, it would also reduce the downstream occurrence of diabetes, heart disease and cancer as well. (claiming that reducing weight/improving metabolic health reduces those things is a boring conventional medical claim).
Also, re: "the market disagrees", as I pointed out, there are lots of (small) companies providing these services successfully and getting paid for them. Markets can agree in differing amounts, and markets also need information/advertising to match sellers and buyers. If "make cars with assembly lines" was an idea that didn't actually get Ford any money, but rather only gave distributed consumer surplus, he probably wouldn't have executed it.
And while I am a committed free marketeer, markets for services that provide little financial benefits to those who provide them often don't work! I'm not making any money from this. Doctors won't make any money from this - in fact, they will lose money because their gov-mandated quality metrics don't support this type of treatment for obesity or diabetes. Novo Nordisk doesn't make any money recommending this. No supplement or food manufacturer can make money from this. It's not really a product or service to be sold, though some (like Virtahealth) are.
Looked up Virtahealth. Digging in a little it appears to be "we will teach you to eat a keto diet, which will have so few carbs in it that your blood sugar will remain low enough without drugs to call it reversal, except we don't count metformin as a drug because some people like to stay on it".
As someone who took metformin for 3 months and *absolutely could not* tolerate the severe GI side effects, which I never built any tolerance to: lol. lmao, even.
This sounds okey if your goal is to go from obese to just chubby.
I don't care how much fat you have, if you get a good diet your body will figure that out on its own. But also, yes, going from obese to just chubby IS correlated (but not causative!) with better health outcomes.
I want you to be healthier, which isn't measured on the scale, but in your blood work and in long term lack of massive health disasters like diabetes, heart disease and cancer. If you're still "chubby" but you don't get those things, well, great!
You basically call "healthy" being fat but not sick. Better than being morbidly obese and sick, I guess, but that's not saying much.
That's not good enough, people want to be "fit". You are right by accident with "health isn't measured on the scale" because yes, body fat percentage is what actually matters but it's very hard to measure without (other than doing an autopsy). Unless you are extremely muscular or have great bone density, the scale is a good measure of fitness.
If you want to be fit you can't eat ass much you want for a meal. The usual guides of 2000 kcal a day for the average adult male is probably too much already an puts you on a slight calorie surplus.
This comment is not worth $500bil because, like all comments in this vein, it fails to take into account the complexity of human nutrition. There is no list of 5 points that will work for those 70M obese people. For some, the drug will be the only way. For some it will be a completely different diet. For some, your comment will work, but I expect it to be a decisive minority.
Comments like this are more common than you think, and for me they are just too naive.
2. Literally more than half of my meals are just pasta/rice/bread. Seriously, it's a carb fest down here*.
3. My breakfast is literally chocolate chip cookies. It's one step removed to just shove down my throat spoonfuls of sugar. And it's not even that big of a step.
4. I never skipped a meal. The idea alone of skipping breakfast or lunch is abhorrent to my Italian brain.
And yet, I'm chronically underweight. The only point of yours that I feel to thoroughly endorse without a second thought is the first one.
My set of oversimplified comments will be: never eat sodas, almost never drink alcohol (less than one beer / glass of wine per month), keep a super regular schedule (breakfast lunch, snack, dinner) and never eat out of it (forget chips at parties etc), cook your own meals and eat fast food only occasionally in special circumstances (e.g. you're late for your plane).
Will it work for a "random you" reading? Hell no.
* The hate carbs are getting lately is really puzzling to me. Sure, fat isn't as bad as once thought. But this notion that its ills are solely the product of an evil carb industry that captured the government is ridiculous. I'm sure there is no fat industry that has ever tried to manipulate the public, and, if they do, they only have the public's health interest in mind.
Thank you.
A lot of diets will work for a few people, assuming the only purpose is to lose weight.
Normal people believe that quality of life as reposted by fat people is irrelevant.
Do not adopt diets to lose weight. Adopt a diet to be healthier.
This is the hidden problem* with the semiglutide process: if you take it, lose 20 lbs, fit into your old clothes and declare success, but you're still eating a constant stream of crap 3 times a day, you are still gonna have a higher chance of bad outcomes.
* it's possible that semiglutide is actually affecting your metabolism, in which case it might directly affect your metabolic health, in which case, good for it - it overcomes my "hidden problem" above.
"it fails to take into account the complexity of human nutrition. There is no list of 5 points that will work for those 70M obese people. For some, the drug will be the only way. For some it will be a completely different diet. "
Why do you think human nutrition is only complex on the downside (i.e. losing weight) - in reality, human nutrition is so non-complex that hundreds of millions of people - through diet/lifestyle changes alone - became overweight when before they were not. Nutrition is so non-complex that millions of people were able to gain weight literally without even thinking about it, like breathing.
"And yet, I'm chronically underweight. "
This gets back to my main point: don't focus on weight. Don't think I'm focusing on weight. It's a symptom that does not always present when someone has an underlying issue caused by terrible diet. The key is to increase healthiness (the highly costly downstream effects that we associate with obesity), NOT to lose weight - except that it is often an indicator. I'm not going to judge you, but what you describe yourself consuming does seem to be an unhealthy diet. The key is that unhealthy diets do not always result in obesity for, as you point out, a wide array of reasons, especially age. Would I be wrong in guessing that you're probably under 30?
There is no point whatsoever for you to lose weight, in fact, if you are truly the clinical definition of "chronically underweight" *that itself* is an indicator of even worse health outcomes than being mildly overweight! I am telling you that, in this thread about obsessing over spending 15k a year on weight loss, you could probably stand to gain some pounds. You are not the average American, and to the goal of this post (from Alexander's perspective) you are already cured. But not to my goal, because my goal is "be healthy, avoid really bad health outcomes" and there are people (yourself included) that can (again, going only on your self-report) have unhealthy diets, experience the higher likelihood of bad health outcomes, while not displaying obesity.
I recommend getting some blood work and checking your metabolic indicators. It is possible that you have an unhealthy metabolism without displaying obesity. There are all kinds of people who die of a heart attack at 55 and people go "but he was so skinny!". I
"The idea alone of skipping lunch is abhorrent to my Italian brain."
It's not your Italian brain. It's that for breakfast you consumed a great deal of sugar/carbs, which (short version) burn in your body very fast, (or are stored as fat, which obviously your body is not doing) and your body concludes it needs more quickly, so it tells you are hungry for lunch. The chocolate chip cookies are not unusual. Most cold cereal that anyone actually likes has a similar sugar profile. You are absolutely correct about one thing: people have radically different "energy intake -> how much fat they get" curves, and you have (whatever your age) the "18 year old boy" curve. But the underlying metabolism can be healthy or unhealthy, and one that takes in cookies for breakfast probably isn't.
"The hate carbs are getting lately is really puzzling to me."
From me, it's not hate. It's the simple fact (conventional scientific wisdom) that carbs (especially sugar) are (again, short version) burned faster (some types more than others) in your body that fat or protein, remaining available to be consumed for activity for a shorter period of time, and therefore when they're gone (or converted to storage) your body tells your brain it needs more. It is conventional wisdom that fat and protein create more satiety, which is longer time before hunger. Therefore if you wish to spend more time burning energy (in your case, you want this for good metabolism reasons, rather than weight loss) than consuming energy, and to reduce hunger, carbs are just objectively inferior to fat/protein. It's not some theory that carbs infect your body like poison. Well, except for sugary high fructose corn syrup sodas, those are definitely poison.
"I recommend getting some blood work and checking your metabolic indicators."
And if his bloodwork comes back with "he's fine, he's healthy", then what, Brian? Your tidy clockwork explanation has failed.
About the complexity, I'm unconvinced that people having tried a million things and still being unhealthy is a proof that nutrition is simple. The two doesn't seem to follow.
Anyway, just because you asked, if you were to see a picture of me, you'd think I'm under 30 -- I've got such a baby face, no wrinkles, no grey hair. But I'm 38. And actually I checked, my BMI is 19 (roughly, I don't own a scale) so I was actually wrong about the underweight thing. I'd love to gain a few pounds, but I'd rather them being muscles rather than just fat, this clashes with my couch potato nature unfortunately.
The bit about being Italian is a poor attempt at conveying the memetic nature of eating. Really, the horror of skipping meals has nothing to do with how fast carbs burn (and, again, in the tangent of the carbs, Deiseach writes better than I can the fact that a model that lumps in the same class coca cola and polenta isn't... great?). It's just that meals are a sacred tradition. So my "one neat trick, nutritionists hate him" is: let's just get better memes about food. Italian memes seem to be working well.
This religious aspect colors my opinion, and then I asked myself: if I were to follow your advice, I'd only have one meal at day (dinner) and it should be mostly fat/protein to cover my entire daily calorie intake. Is that even physically possible?
Other than that, in many things we agree, I don't think the pill treatment is the best, since it's unclear whether a taker will then have to be on it for the rest of their life (15k/year, yikes). But if someone there's no other choice, why deny it?
"The hate carbs are getting lately is really puzzling to me."
Oh, diet recommendations have swung around all over the place. Fats of all kinds are bad for you, replace those fatty foods with (carbs) and (protein). Take the skin off chicken, trim the fat off red meat.
Then it was "not all fats", it was saturated fats, so consume unsaturated fats. Then it was well monounsaturated fats are bad for you, only consume polyunsaturated fats. Omega fats such as found in fish good for you! Well, no, hang on, too much omega-6 is bad for you, you need to up the omega-3 (jury still out on omega-9 for the moment, I suppose).
Dairy bad for you! Dairy good for you! Confused yet?
Then it was red meat is bad for you in excess, so that was (protein) the bad guy. Then smoked meats, because carcinogens.
(Carbs) were still okayish, but then SUGAR - THE PRIME EVILLEST EVIL THAT EVER EVILED. So cut out all the sugary junk (good enough advice). Then that expanded out into other carbs. Simple carbs like potatoes and rice and bread and pasta - bad. Need complex carbs. GI index, so forth and so on.
I think the swinging pendulum of "X is bad, Y is good - now X is good and Y is bad" is down to the complexity of nutrition and metabolism. People are getting fatter and unhealthier, how is this? The simple story of "consuming more calories, and being more sedentary, than past generations" seems not to be the whole picture. So there must be a 'bad' food or class of foods.
Fat makes you fat, right? So fats bad! Cut out fats!
Okay, people still getting fatter - why? how come?
Carbs bad?
Protein bad?
There will be people who eat lots of carbs or fat or protein or whatever, and don't get fat/are chubby but healthy. There will be people who cut out carbs or fat or protein and are fat/unhealthy. There is no simple "one easy fix, just change your portion/plate size and eat six tons of lettuce" cure.
I joke, but it's only half a joke, that the next recommended diet will be "you can only safely consume moss and water".
There's a similar dance around eggs.
I reserve a special rage for the people who said, "Actually, eggs aren't bad for you. You can have one or two per week."
You know, I gained most of my body weight and reached my fattest point doing exactly that: keto, skipping meals, tons of water and zero calorie drinks. So I'm extremely skeptical of this being useful advice.
My numbers just got worse and worse until I bit the bullet and had them cut out half my stomach and part of my intestines.
Which numbers are we talking about? Weight/BMI? Or ones like A1c?
Weight/BMI, but A1c also got worse. My diabetes had progressed to a point where I couldn't control it with diet and metformin.
Everyone is different. If I could send a letter back to my younger self, the advice I'd put there is to sleep at night and never, ever skip meals.
"Get your yearly blood work done so you can see the improvement in your metabolic indicators. Most importantly: if your numbers get better - whoever you get the labs from will tell you the health ranges - FORGET YOUR WEIGHT, sell your scale."
Yes, Brian, but you are forgetting one thing - people in the street can't see your bloodwork numbers, they can see your double chin.
*That's* the metric by which people, including doctors, judge are you 'healthy' or not. I take your point that people confuse "healthy" and "thin", but given all the messaging about "fat is unhealthy", can you expect any different?
About ten to fifteen years back, I had *great* bloodwork numbers. I was still visibly porky. I still had kids yelling at me in the street about being an elephant. I still had at least one doctor visibly and openly furious with anger that he could not punish me for being fat because my blood work didn't back him up.
If you're pudgy, that is the metric society, and you yourself, judge you on. Have you dropped two dress sizes? No? Then it doesn't matter if you can run a mile or have perfect cholesterol levels, you are part of the obesity epidemic that is blighting our healthcare system.
(There's particular irony at work here; I have a sibling who has a thyroid condition and they have to be ultra-careful about their cholesterol levels and fat intake. They are also 'normal weight'. So anyone looking at the two of us together and being asked "who has the high cholesterol?" is going to pick me, the fat hippo. They'll be wrong, but they still won't change their mind - oh that number doesn't matter, we all know being fat is bad for you).
Improving or maintaining your health is worth doing if feasible.
The simplest thing I can think of to solve the prejudice against fat people is a famine, and it isn't worth it. It might not even work.
An expensive preventative for heart disease might work, but that's another version of turning being fat into a status symbol (perhaps an expensive watch is also required). This is better than a famine (do I need to say that?) but way short of excellent.
Continuous blood glucose monitors that displays the numbers on a big LED across your shirt? :)
Yes, I don't know what to do about that, except advertise the fact that bloodwork is a better indicator than weight. The only thing I do know is that, in the case of "good bloodwork, overweight" the answer is NOT "$15k a year semiglutide" or "high mortality-rate surgery."
Speaking as a Person Of Amplitude, I think obesity isn't one disease (since we are now calling it that) but a range of factors that have been lumped under the one umbrella of "you're a fat pig".
(1) People who are naturally chunky versus those who are naturally skinny. I think we all know or have seen people who are like twigs, who don't put on weight, who have thin little limbs like sticks. That's not because they're dieting themselves down to that weight, it's natural for them. On the opposite end, I submit that there are people who are naturally going to be chunkier than the median, because that's how their metabolism is set up. They will go a few pounds over what is considered optimum weight, and if they go too far over, their doctor harrumphs at them about "diet and exercise" and they do that and lose the weight. It'll be tougher for them to keep off the weight and they will have to make lifestyle changes like "I can't eat birthday cake ever again", but in the main it will work for them. At the worst, they'll be 'pleasantly plump' or a bit chubby, but not grossly overweight.
An example of someone naturally skinny who is not doing cooking episodes about salads:
https://www.youtube.com/shorts/513TiHieN9c
This is the good old "willpower" argument: if Joe can lose ten pounds simply by not stuffing his face with rubbish, why can't you?
That brings me on to:
(2) Slowing-down of metabolism. Middle-aged spread. "When I was younger, I could eat what I liked but now I eat the same and put on weight". People get more sedentary, they eat more convenience food, lifestyle changes.
Again, "diet and exercise" will help here. It'll be tougher, but if you were one of the 'naturally' slim types, it helps. Again, you'll probably have to make some lifestyle changes, but you will be able to get off the weight.
(3) Weight gain due to medication. I think we all know about steroids (my late father was put on a course of them and ballooned up, even though he wasn't eating more) and there are other medications with the same side-effects. It's difficult for people who gain weight like this, because they treated like the rest of us greedy lazy porkers, and get the "oh that's only an excuse" response unless they pull out the prescription to prove what they are saying is true, and who wants to have to reveal that *ackshully*, I'm on anti-psychotics which is why I'm stuffing my face with carbs?
https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(21)00500-9/fulltext
Hard case here, since once you don't need to take the meds anymore, you will go back to your natural weight - unless of course you need to constantly be on psych meds, which means increased appetite/weight gain, which gets you the "just have some WILLPOWER" argument from everyone.
(4) And last, the rest of us fat, lazy, greedy slobs with no willpower who just stuff our faces with junk food and never get up off our idle behinds and just go for a walk or something.
The gluttons. The "why don't you just have some WILLPOWER?" people. The "diet and exercise, you moron, never heard of that?" folks.
And you know, there is something to that. Yes, we eat too much. Yes, we don't exercise enough. But, like the anecdote related in Dante, when the bishop asked his servant "What do the people say of me?" "Your Grace, that you are always drinking" "Ah yes, but I am always thirsty" - we're always hungry.
Scott mentioned a few years back examples of patients who suffered from unrelenting thirst, who had to be monitored with their fluid intake or else they would literally drink themselves to death, and even when they got enough to drink would still feel thirsty.
Nobody is going to condemn someone who is guzzling pints of water "Just have some WILLPOWER!", because they realise that's not normal and is indicative of a problem.
Now, for the likes of us that are always hungry and never feel full, even when "but I just ate a full meal a couple of hours ago, I shouldn't be feeling hungry", it's hard. Because yeah, you can visibly see we are gross landwhales. And yes, we are leeching the health services normal people should be using with our horrible diseases of obesity that are all our own fault. And yes, calorie-laden tasty modern processed foods, and yes sedentary lifestyles, and yes over-eating and being greedy, and yes diet and exercise work to a degree, and yes "why don't you just have some WILLPOWER?" and get used to feeling pangs all the time. And yes, "I'm big-boned/it's my glands/it's PCOS/it's a response to trauma" do get used as excuses. Yes to all of that, yes I admit we do contribute to our own problems. Having said that:
Do you really think it's a simple problem of NOT ENOUGH MORAL FIBRE once people are desperate enough to have the likes of this done in order to lose weight?
https://www.mayoclinic.org/tests-procedures/bariatric-surgery/about/pac-20394258
"Roux-en-Y (roo-en-wy) gastric bypass. This procedure is the most common method of gastric bypass. This surgery is typically not reversible. It works by decreasing the amount of food you can eat at one sitting and reducing absorption of nutrients.
The surgeon cuts across the top of the stomach, sealing it off from the rest of the stomach. The resulting pouch is about the size of a walnut and can hold only about an ounce of food. Typically, the stomach can hold about 3 pints of food.
Then, the surgeon cuts the small intestine and sews part of it directly onto the pouch. Food then goes into this small pouch of stomach and then directly into the small intestine sewn to it. Food bypasses most of the stomach and the first section of the small intestine, and instead enters directly into the middle part of the small intestine.
Sleeve gastrectomy. With sleeve gastrectomy, about 80% of the stomach is removed, leaving a long, tube-like pouch. This smaller stomach can't hold as much food. It also produces less of the appetite-regulating hormone ghrelin, which may lessen the desire to eat.
Advantages to this procedure include significant weight loss and no rerouting of the intestines. Sleeve gastrectomy also requires a shorter hospital stay than do most other procedures.
Biliopancreatic diversion with duodenal switch. This is a two-part surgery in which the first step involves performing a procedure similar to a sleeve gastrectomy. The second surgery involves connecting the end portion of the intestine to the duodenum near the stomach (duodenal switch and biliopancreatic diversion), bypassing the majority of the intestine.
This surgery both limits how much you can eat and reduces the absorption of nutrients. While it is extremely effective, it has greater risk, including malnutrition and vitamin deficiencies."
Reading those comments, they resonate with me. Constantly eating, never feeling 'full', eating until so stuffed I might throw up, And I've tried diets and they've worked - for a time. Then I plateau at a certain weight, and something happens (the last, most successful diet, I got swine flu then the weather was so unseasonably bad I couldn't go out for exercise) and I fall off the wagon and put all the weight back on.
So yeah, maybe all I need is some WILLPOWER, can you tell me where I can obtain a shot of that, because I don't manufacture enough myself? And that's where the "moral failing" angle of the condemnation of the overweight comes in - if we just gritted our teeth and scrunched up our eyes and *willed* hard enough, we could do it!
I don't know if this new drug *is* a miracle cure for weight loss, I think like all new treatments it is being hyped out of enthusiasm. Once it settles down, I think it's more likely to be at the 60% end of the successful treatments scale. And this is something you have to take forever, or else you will put the weight back on. And there probably will be some people for whom it doesn't work - I've had at least two medications prescribed where I was told that a side-effect was weight loss so that would help me, and no, it didn't happen at all.
So yeah, "CICO" - but that's simple. Why people consume a heck of a lot more CI than expend CO is the hard part to solve.
This doesn't respond to most of your very valid points, and it's definitely not meant as a "just exercise more" response, nor to suggest it will solve all your weight problems, but I think it is likely to be more effective and metabolically helpful than most forms of workouts: have you looked into Zone 2 exercise? Peter Attia has a number of podcasts and videos on it, and it's the central plank in his treatment of patients with metabolic disorders.
Briefly, zone 2 exercise is low intensity exertion which stays just within the energy regime at which the mitochondria in muscle cells can burn fat to supply the fuel they need. By training within that zone, not only are you specifically burning fat, but you are also training your mitochondria to be more effective at utilizing fat and less dependent on glucose, thus improving your overall metabolic health.
A simple way to try it is to get a cheap used rowing machine or exercise bike, set it up in front of the TV or computer, and ride them for 45 minutes to an hour at the intensity level that lets you still just barely breathe through your nose or maintain a conversation. Aim for at least 3 hours a week; more is better.
I'm surprised that you, usually a defender of religion and traditionalism, would have such a view on willpower. This isn't a criticism--when people are too predictable in their views, I tend to wonder if they ever think for themselves.
Isn't gluttony one of the seven deadly sins? Sin is part of the human condition, and the seven deadly sins are remarkable for their mundaneness: probably every person who ever lived has been guilty of all of them on a regular basis. But that doesn't mean societies (and not just Christian ones!) don't or shouldn't blame people for being lazy, angry, greedy, arrogant, or gluttonous. The purpose of the blaming and shaming is to discourage the sin by imposing a social cost. Just willpower alone may not be enough for someone to not have bursts of rage or to not eat to excess, but the combined effect of willpower and social disincentives might be enough to make people relatively healthy and well behaved. And so, in moderation, fat shaming is good in the same way that small amounts of sloth-shaming and wrath-shaming are good.
"I'm surprised that you, usually a defender of religion and traditionalism, would have such a view on willpower."
Oh ho, friend! What do you think I am, a Pelagian heretic?
We can do nothing of our own will to be freed from sin, we need the help of grace. Gluttony is a sin, but willpower alone won't free you from that sin.
I haven't enough willpower natively, I need the injection of it from outside to help me . Shaming people and blaming people is not that help.
What works?
Semaglutide, apparently
God alone knows. If I were a totally different person with a totally different personality, maybe I would love exercise, or be able to muster willpower to only eat three slices of carrot and six heads of steamed unbuttered unoiled unsauced* broccoli for every meal.
*I mean white sauces like bread sauce, parsley sauce, cheese sauce, onion sauce, etc . The ones made with flour and butter and hence Bad For You.
"We can do nothing of our own will to be freed from sin, we need the help of grace. Gluttony is a sin, but willpower alone won't free you from that sin."
My theology is rusty, so forgive me if I'm wrong, but aren't we supposed to at least try? No Christian I've met has ever said "don't worry about it and sin as much as you want, because God will forgive you". At the very least they stress repentance, which doesn't sound very different from accepting blame--and when done publicly, it's not very different from shame.
> there are literally money-saving ways to lose weight
Too bad you didn't mention them.
Eat less, cook instead of ordering takeout, walk instead of bus, bike instead of car, etc.
"Eat less, cook instead of ordering takeout, walk instead of bus, bike instead of car, etc."
Excuse me while I rock in my chair, laughing.
In my 30s-40s I was one of the fittest fat people you'd ever meet. I can't drive, and there isn't a bus service in my town, so I walked everywhere I needed to go. Sometimes I'd cycle. That was my entire life, pretty much (if I needed to go somewhere further than my local town, I'd get the intercity bus or a lift from a family member with a car).
I had tree-trunk calves from about the age of twelve from all that cycling and walking and carrying things while I walked. Did it make me lose weight? No, I was still podgy of body and pudgy of face. But I was *fit*.
So yeah, "just exercise more and it'll drop off" was always a source of amusement to me. I once, due to a screw-up in getting paid, while living away from home spent an entire week living on soup once a day and (of course) walking everywhere. I was at the point of fainting into bed at night, but the one bright spot was that surely I'd lose *some* weight.
Guess what? No. Maybe a pound or two, but nothing significant. My body was grimly hanging on to the fat reserves come hell or high water. The biggest disappointment of my life, but the reality of what the hell my metabolism is and I don't know why. I keep being told my thyroid levels are fine, but I don't know.
I have a theory people vary in their ability to take fat out of storage and use it for energy.
Yeah, I think the actual pill we need is: "convince the fat cells to release their energy into the bloodstream".
[speculation] In men it's mostly testosterone levels. It signals the body to both repair+increase the muscle mass AND not to burn muscle for energy when on a calorie deficit. Some people will never be lean as their bodies prefer shedding muscle before burning fat.
There's also probably some other factor regulating this behavior. IIRC there's a yet unexplained effect of anabolic steroids that makes fat burning more predominant even beyond what would be accounted by the muscle gain. It could be that steroids activate what naturally lean people have going.
Did you grow up food-insecure? Because this sounds pretty in line with the 'thrifty phenotype/epigenotype' hypothesis: your body is hanging on to those fat reserves because experience has told it that reliable access to food is not something it can take for granted. Maybe the hunter gatherer lifestyle that it's adapted for needed all that fat when it was living on raw tubers and bugs for months on end, and it doesn't think a week on soup is an emergency worth burning more than two pounds of fat for.
I wouldn't say that, but there is obesity on one side of the family, so you tell me if it's genetics or what at work.
Also Irish, so... descendant of the people who *didn't* die in the Famine? 😁
Some of it is environmental/genetics, but some of it must be bad habits and no willpower, since I have a sibling who has the opposite problem (they get stressed and stop eating and over-exercise and are always skinny; I get stressed and comfort-eat).
Tangential to your main point (that one can't really lose weight by pure exercise), which so far as I know is quite accurate, I thought it might be worth mentioning that a pound or two is a pretty significant weight loss for a week.
1 lb = 3500 kcal, so if you actually lost 2 lb = 7000 kcal that implies a deficit of 1000 kcal/day, which would be very noticeable indeed. The basal metabolism demands for a 5'4" female age 35 at 135 lb is ~1400 kcal, and walking tends to burn ~200-350 kcal/hour, so to run a 1000 kcal deficit daily one would have to cut the usual ration by two thirds, walk 3-5 hours a day, or some combination of both -- pretty harsh.
I think Gary Taubes in one of his many diatribes against calories in/calories out points to some empirical evidence that if people exercise they almost always boost their intake more than enough to compensate for the calories burned, because exercise makes you hungrier of course.
No, the first weight you lose is water weight. It's easy to 'lose' weight like that, but it's not shifting fat. I was disabused of that the first time I had stuck to a diet (as advised by my doctor to go on a diet), lost a stone, and went back to report all pleased with myself.
Doctor told me that was just water weight, I hadn't really lost fat, and I would have to continue on a lot longer to really start losing weight.
So living on a bowl of soup and lots of water per day for a week got rid of some of that water weight, but didn't kick off the fat-burning. And of course once I got my money sorted out and could buy food, I went back to eating normally so naturally no weight loss. If I stuck to "one bowl of soup a day" for a month, then maybe real fat-burning weight loss would have happened.
The amount of water (and of (literal) shit) in your body can fluctuate by more than a pound or two -- you're better off treating the last digit of your weight as a random number generator. See _The Hacker's Diet_.
I don't even have a car or a bike, and since covid I also started avoiding buses. I walk to my work for 40 minutes.
I admit I could work harder about the eating less part.
The meta-point about the traditional advice is that either you need to do it 100% right and mere 90% gets you nowhere (possible, but then it would be nice to admit that following the advice is harder than it seems), or just one part of it is the real advice and the rest is bullshit (also possible, but then please stop telling the bullshit parts).
Let me fix that failure here:
<< reposted from other comment >>
1. Forget calorie restriction of the "just eat 20% less calories" form. It requires too much calculation and willpower, and your body will compensate. Forget any diet that stops you from participating in normal social rituals with friends, coworkers or family.
2. Replace carbs in your dinner with fat/protein. Eat as early as possible, eat as much as you want. Don't eat bedtime snacks.
3. Over time, extend the time from ending dinner (your "fast" length) til the next time you eat (breakfast? 12:30 lunch? 2:30 lunch?) as much as possible. Eat the next day when you're hungry, but if you're only feeling kinda hungry try drinking a zero-cal electrolyte drink and see if you still want to eat. Measuring exactly 50/100/150 less calories a day is impossible. Measuring that you ate 10 minutes later is easy. Don't put any sugar or carbs in your morning drinks.
4. Eventually cut out breakfast or lunch, or eat later lunch. Just like dinner, replace carbs with fat/protein as much as possible. Whatever feels okay.
5. Get your yearly blood work done so you can see the improvement in your metabolic indicators. Most importantly: if your numbers get better - whoever you get the labs from will tell you the health ranges - FORGET YOUR WEIGHT, sell your scale.
Hey you have described your weight loss system multiple times here. I think readers get it. You sound like you think the reason we're not all converts is that we do not understand your system, and need to hear it explained again. In fact, people are telling you multiple reasons why things along these lines have not worked for them, and/or multiple reasons why they believe such things generally do not work for many people over the long run. Are you giving any thought to all this testimony and all these ideas?
"Are you giving any thought to all this testimony and all these ideas?"
Absolutely, previous people's testimony and experience (of which all of the versions given in this thread are a subset - not as a critical judgment of them, just that diet advice almost always fails in relatively predictable ways) is the reason this is my plan, instead of being traditional stuff like weight watchers calorie restriction.
"Hey you have described your weight loss system multiple times here. "
Well, not to be rude, but if you're describing it as a weight loss system, then I haven't explained it well, because it's not a weight loss system, it's a "increase healthiness system" and I posted it here because I think focus on specifically weight loss via semiglutides or surgery is part of the problem.
"In fact, people are telling you multiple reasons why things along these lines have not worked for them, and/or multiple reasons why they believe such things generally do not work for many people over the long run."
To be very specific, no one I've seen so far (maybe I missed it) is saying they have tried something like this and failed, (whereas I personally have succeeded, and know dozens of other real live people whose testimony is that it works) and the "such things" they present are often critically different in major ways that are also exactly the reason I present this strategy as an antidote to them. You're essentially saying "well, all these other people have tried such things like, leeches and balancing bodily humors, why do we expect your plan to take antibiotics to work?" Maybe I'm arrogantly assuming my method is superior, but it was created (not by me!) precisely to incorporate what you're saying - the testimony of millions of people saying that previously recommended "diet" advice didn't work. The key is in the "what" is being recommended, and whether it goes against the grain of how we understand humans and their metabolisms to function.
Additionally, when people are saying "diet advice X didn't work for me" in this thread, in every case they have cited weight. This is the part I want to repeat more than my strategy: don't measure success on the scale. You can't timetravel to see if you get diabetes 25 years from now, you have to get bloodwork done, or you have to read all the papers describing the other markers you can see to detect a healthier metabolism, or get a continuous glucose monitor, or you have to take my word for it. (This cost of this measuring indeed a major failure point of my plan, which you should critique)
OK, Brian, I have tried it and failed, and by failed I mean not simply that I did not lose weight, but that I did not stick with the plan. I had been reading about carbs, and how processed carbs and sugar do not really satisfy and you make you crave more of them. So I planned to follow a regimen of eating nothing sweet except fruit, not much refined flour & the like, and lots of protein, fruits and veggies. I did not avoid animal fat. I am a vegetarian, but ate lots of sharp cheddar, an animal fat favorite of mine. I did not count calories. I was not solely focused on losing the 20 pounds I wish I were not carrying, but of course that was on my mind. It is simply impossible not to care about that. And I did deviate from the approach you describe in that I did not make insanely delicious meals that gave me deep satisfaction. I absolutely hate cooking, and am simply not willing to take much time away from activities I value in order to do awesome cooking.
I have stuck with the no-sugar part for several years now, and find that cookies etc. are no longer calling my name when I'm in a bakery. However, I have not stayed with lots of fruits and veggies, I have slid back into eating simple carbs, things like slices of white bread, because I like them and they're easy to grab . And I never did do the part of preparing wonderfully palatable meals. The things that have kept me from sticking to my plan are things like this:
-Most vegetables are not pleasant to eat unless you chop them up and put a nice dressing on them, or cook them. I hate doing food prep. If I'm busy, tired, or preoccupied with something else important to me cooking is the first thing to go.
-I default to eating lots of cheddar cheese and little else -- because I'm out of fruit, and the veggies I have need prep to be bearable. I got busy and did not shop.
-I get busy doing something important to me, miss a meal, then am so hungry I grab whatever's handy that I can stand -- cans of cashews, lumps of cheese, fried stuff from Uber eats.
Obviously I *could* have done other things at those times. I could have made a salad or cooked the veggies or made an awesome delicious meal. I could have shopped more often so there was more healthy stuff in the house. I could have not let myself get so hungry. But it is an illusion that knowing that makes it likely that in the future one will act differently. The same factors that led to suboptimal eating in the recent past are all going to be there in the near future. Habits are hard to break, and the breaking of them draws on the same limited pool of energy and self-monitoring capacity as all the other things we need to accomplish. Eating is a simple pleasure and doing it provides a break from life's demands. Turning it into something that must be done a certain way both reduces the amount of simple pleasure in the day and also adds a new demand. That's a hard sell. There may exist some heaven of healthy eating, zero minutes per day of craving things that are unhealthy, and amazingly delicious meals that satisfy the living daylights out of a person, but then again there may not, for all of us. And even if it does exist, getting there is no easier than accomplishing lots of other goals we have for our careers and relationships, and far more dispensable.
isn't the way that semaglutide works is by making you feel full and satiated after eating? of course you need to be changing your diet -- if you continued eating the same way, you wouldn't be able to lose any weight. the hard thing about losing weight is that your body will do anything it can to make you eat the calories you're trying to avoid (and will hold on to the fat it already has, although that can usually be overcome with enough time). the brilliance of this drug is that it basically helps you stick to a diet.
IMO exercise doesn't actually help you lose weight anyway except insofar as it helps you build muscle, which makes your metabolism higher, but it's a good thing that people should do regardless.
You're spot on, on both diet and exercise.
re: diet, I think semiglutide might being affecting your metablism too - hence its use as diabetes drug, but I'm not educated enough to know for sure.
re: exercise, yes, it may not make you lose weight (in fact I think you should gain weight, if you're doing strength training) but it makes you healthier.
And to dovetail both: we want to be healthier metabolically, that is the goal. Weight is just a symptom that we only care about as potential signal.
This jives with my experience on the drug earlier this year. I was on living primarily on pre-made keto meals and after starting on semaglutide I felt like it was too much food for a setting, switched to a lower cal option. When shortages of the drug caused me to miss a few weeks, the lighter meals were quickly noticed as not-satiating.
While this is technically true, there are a *lot* of things that would be unnecessary if everyone in the world always made good decisions and showed perfect discipline at all times and experienced no akrasia at all. That world would look extremely alien to the one we actually live in.
Given that we live in a world of imperfect willpower and decision making, finding ways to mitigate the consequences of those failures is both important and valuable.
I will say, though, this is one of the areas where I feel like government intervention may be warranted, or at least could have good outcomes. I don't think people would suffer if there was a tax on fat and sugar above a certain point on all foods such that all their food choices were healthier.
My quality of life drops sharply if I don't eat a fair amount of fat, possibly more than some theory of health would permit.
Wait, I've got an idea. Let's put everyone on the diet-that-can't-fail. Then, we can piggyback all the other things people have trouble sticking to onto it, like ornaments onto a Christmas tree: Every time you have a proteiny meal, write down a work goal for the next few hours -- productivity solved! Every time you lose a pound, pay any unpaid bills -- budgeting solved! Every time you lose 5 pounds, spend an afternoon working on that great idea you had that you've been procrastinating on fleshing out -- getting rich and famous solved!
Nope. It is the semaglutide. See my comment below for details. I lost 20% of my weight (55 lbs) in 14 months. I did not change what I ate (good fresh home prepared food) or how much I exercise (mostly an hour a day of walking). I just ate less of the same stuff.
Meh, I recommend weight loss to my diabetic patients until I’m blue in the face and for years nothing changes, but when I put them on GLP-1 agonists they generally do. Same for SGLT2 inhibitors. Some times it’s so dramatic that I get worried they have some kind of occult cancer until I hold the offending medication and the weight loss plateaus.
Does the weight return once treatment is ceased? Or is this a situation where one would take the medication for the rest of their life?
From the description of its mechanism (feeling sated with less in the stomach), I would think so.
What method of weight loss are you recommending?
Additional anecdata - I'm only on the 1mg dose for diabetes, but I've lost 8kg over 8 months with only minor stomach upset.
I'm 6 foot and was 235, took it and I'm now at 180. Uncle took a different glp-1 same thing happened. These are miracle drugs for most people. I also got upset stomach, and bad heartburn but that went away with the weight loss.
It’s quite disturbing how pills have become the answer to everything these days. The opioid crisis in rural America is a good example of what happens when pills are handed out like crazy. Nowadays any hyperactive kid is given what is essentially meth, anyone who is depressed is given SSRIs, etc. Big Pharma is swimming in money from America’s pill culture.
Edit: Okay, I’ll explain. You state that you hope semaglutide can be part of a transhumanist culture where all problems can be solved via taking pills. In this world, all of society’s ills can be solved via medication. We could also get rid of any disease, of anxiety, of depression, etc. Now, this does sound like a utopia… expect that it ensures that pharmaceutical companies will maintain an iron grip on society, like in Huxley’s Brave New World where Soma “solved” everyone’s problems. But we’ve seen from Big Pharma the failures of this method, most recently Purdue Pharmaceuticals being responsible for thousands of opioid overdoses a year. And you mention that semaglutide increases the chance of certain cancers. Who knows if there are more long-term side effects that may occur while taking it, just like with Oxycontin? That was supposed to be a miracle drug too, and look what happened.
Also, in a perfect transhumanist fully-automated-luxury-space-communism world, would obesity really exist? Everyone would have perfect GMO food engineered to be as delicious and nutritious as possible. No one would even be fat to begin with unless they want to be. In that case semaglutide would not be necessary at all.
Also, the promotion of semaglutide would divert attention from the current problems of food deserts. Instead of making sure communities have access to cheap and healthy food, it lets food companies put out as much junk as possible and hope the pill fixes everything. In addition, semaglutide would increase America's problem of instant gratification without facing the consequences, which many members of Red Tribe see as a problem (bootstrap theory/no holdouts ethos).
And then there's the whole other can of worms about transhumanism and designer babies and what it means to be human. But let's not even get into that.
Trivial warning (1% of ban) - please try to justify your opinions instead of just asserting them hyperbolically. If there's a controversial question (like whether the current amount of these medications is good or bad), explain your position such that someone on the other side could understand where you're coming from.
I really don't like these trivial warnings. Just the word "ban", even preceded by "trivial" and "1% of", has a chilling effect on free speech. Nothing that isn't worth more than a 1/3 ban should have a warning, in my opinion. If it's really a "trivial warning", why do you need it at all? Why not just state your point directly?
I disagree. Free speech is an important value, but it need not be the paramount value in all situations. A moderation policy that has a "chilling effect" on posting unsupported hyperbolic assertions should be seen as a good thing. If people want to make bold unconventional claims with strong moral implications, it is perfectly reasonable to expect them to explain their positions. The use of words like "warning" and "ban" sends a clear signal that low-quality comments that do not contribute substantially to the discussion should be avoided at all costs.
Thanks for pushing back on this. I'll think about it more, but two reasons I'm doing it this way now:
- I like to have these in my List Of Warnings I've Given so I can interpret people's future offenses in the context of past offenses. I suppose I could do this quietly, but it seems less transparent.
- I like to have separation between my role as moderator and my role as a commenter just like everyone else who sometimes disagrees with you guys and gets angry. Otherwise I worry that everyone I disagreed with would interpret my disagreement as "the moderator doesn't like you and is gearing up to ban you", whereas in most cases I appreciate your feedback but still disagree with it.
- I really do feel like King Canute turning back a tide of bad commenters, and I'm more worried about not doing this enough than about accidentally banning an innocent person. If chilling effects cause one warning to chill five people, that's a victory in my book (even though it sounds kind of offensive to say it that way)
- I do feel like this conversation went well and that speaks well of Sheluyang, but a lot of people respond with "@#$% you, I'm leaving", and for those people, that is a good outcome.
Thanks for taking my concerns seriously! I really appreciate that you took the time to read my comment and give a detailed response.
My opinion is that "doing this quietly" is the better option, even though it is slightly less transparent. Everyone already knows that their offenses will be judged in the context of their previous words. That's as true in real life as it is on the Internet. A "trivial warning" presumably won't shift the balance that much in favor of a ban anyways, and that's the way it should be.
I don't know how to turn back a tide of bad commenters, but I doubt banning and scaring people is the answer. We already have plenty of heavily moderated (I would say "censored") online platforms. The more open you can keep your platform, the more valuable and distinctive of a public service it is.
Chilling out these kinds of comments is the intended and justified result. No one has a right to comment on Scott's blog, it's a privilege that Scott and Substack allow us.
And that's how another previously free and vibrant community descends into group think.
Thanks for the explanation:
> Expect that it ensures that pharmaceutical companies will maintain an iron grip on society, like in Huxley’s Brave New World where Soma “solved” everyone’s problems. But we’ve seen from Big Pharma the failures of this method, most recently Purdue Pharmaceuticals being responsible for thousands of opioid overdoses a year.
How is this different from the fact that we abandoned subsistence farming, but now agricultural companies have an iron grip on society because we can't get food without them? How is it different from using electricity for warmth but now utility companies have an iron grip on society?
The problem with opioids is that they're addictive and potentially deadly. Semaglutide doesn't have either of these problems. I agree you can think about this on a very broad level where drugs are inherently scary and even if we don't think they have side effects they probably do. But I think that level is the wrong level, and if used consistently would have you avoid stoves because eg fire is bad.
> Also, in a perfect transhumanist fully automated luxury space communism world, would obesity really exist? Everyone would have perfect GMO food and no one would even get fat to begin with. So the idea of using semaglutide to cure obesity is self-defeating.
In a perfect transhumanist world, obesity wouldn't exist because we would have some powerful technology that could eliminate it. I think medication is the most likely such technology. Maybe in the far far future we will have even easier and better technologies, but I don't think we should skip the first just because there might be other ones decades down the line.
I remember a piece you did some years back. It's one of my favorite works of political commentary. The one about how rightist/leftist is basically a survive mindset versus a thrive mindset, that conservatives focus on survival in a primitive world, and liberals focus on building an egalitarian utopia.
The idea of transhumanism and a drug-induced utopia is essentially the thrive mindset fulfilled. It assures no problems will ever happen in the world and there will be no zombie apocalypse.
Yes, we live in a world where our needs are all tendered for us. We have all the food and energy our ancestors could only dream of. But one day, the improbable could happen. Agricultural companies and utility companies may not last. Maybe it's zombies, maybe it's Covid-666, maybe it's the Seattle Mariners winning the World Series. And in that world, transhumanist theories will vanish in the blink of an eye.
Don't get me wrong, I appreciate modern medicine. I know many adults with type 1 diabetes that would all have died as kids without insulin. But if the insulin supply chain is disturbed, that's all gone.
So maybe we can't see eye to eye because you are thrive-brained and I am survive-brained. But I'd rather solve obesity via getting rid of food deserts and returning to a diet like those of our ancestors. That way the risk is minimized for if the economy collapses, or pharma companies can't get the ingredients needed anymore, etc. I am all about minimizing risk. I would love to live in a transhumanist utopia, but I'd rather focus on the practical now.
>So maybe we can't see eye to eye because you are thrive-brained and I am survive-brained. But I'd rather solve obesity via getting rid of food deserts and returning to a diet like those of our ancestors.
I'd also rather do that, but we've spent ~30 years trying really hard and it's gone terribly and obesity rates have actually kept going up the whole time. See also https://slatestarcodex.com/2014/09/10/society-is-fixed-biology-is-mutable/
I guess a good thing about this example is that if society collapses so much we can't produce semaglutide, we'll probably go back to agrarian living without processed foods and the obesity crisis will solve itself.
>I'd also rather do that, but we've spent ~30 years trying really hard and it's gone terribly and obesity rates have actually kept going up the whole time.
Have you (I'm assuming that "we" refer to the American society), tho? Have the US -and that's a totally genuine question, not a rethorical one- implemented many policies to promote weight loss, healthy diet & exercise? Some countries have increased taxes on unhealthy food, some have mandatory labels, some, I heard, even toyed with litteraly taxing the fat. Some even forbid free soda refills. I think US health insurance providers offer discount for practicing sport, but beyond that? I haven't heard of much. Then there's plenty of weird, attention-grabbing stories ("school consider pizza as a vegetable" was a very popular one back in the days), aspects of the food culture leaking into pop culture (I learned of "lunchables" from watching "fresh of the boat").
I'm not claiming that the policies cited works, or are even well thought of or well implemented (nutriscore is pretty shitty to judge food with small serving size, for instance, and is apparently lackluster on plenty of metrics), but they're attempts. Compared to the rest of the developped world, the American society at large don't seem to be trying "very hard" to crack down on obesity. Which can be explained by multiple factors, and considered as a negative side effect to an overall positive culture of personal responsability (and, it just occured to me, any policy to crack down on obesity is probably going to make the obese unhappy. Which, once you reach a large enough share of the population, may become a political suicide). But you probably shouldn't think "oh well everything that was possible to do has been done, let's pop some pills".
And, sure, I was thinking of "society-is-fixed-biology-is-mutable", society is hard to change and all that. But is it harder to change than 15k/y/40% of the population?
I believe Japan has laws penalizing being fat, including penalizing employers for having fat employees. I don't know how it's worked out.
Perhaps mixed use neighborhoods would encourage walking.
> But is it harder to change than 15k/y/40% of the population?
Yes.
Also, outside of the US, it's nowhere near 15K/y. And medical patents ensure monopoly - but only for a very limited time. Few years after it becomes really widespread, it'll be sold as generic drug.
The question "How are pharma companies different from agricultural and electricity ones?" seems to be key here. I think the general consensus in US and many other countries is that pharma companies are quite different. This can be seen from the fact that agriculture and electricity are not subject to such a draconian regulation, with every new version of the product required to pass multiple year + $billion approval. Also, I do not think that any shareholders of a farm or a power station were ever at risk of proceedings such as ones against the Sacklers. Of course, existence of this consensus does not prove that it is correct, but, I think, it shifts the burden somewhat to demonstrating that pharma companies are, indeed not different from agri or utility ones.
I could speculate on why the consensus could be such as it is and what is so different about pharma. There are probably several reasons for that. The simple one is that it is harder for a consumer to form an good opinion on product benefits, even if the consumer is a professional doctor. This explains the first consensus observation (on FDA), but does not really explain the Sacklers. Another reason as that pharma companies rely on state enforcement of temporary monopoly power in a way few other industries do.
The third reason is a bit more involved. Many usual economic and public policy arguments involving utility functions assume that these functions are unmutable. This assumption is probably ok in many cases, but is obviously broken with many medicines. Addiction, in a general sense, is when consumption of a good radically increases future subjective utility of further consumption of the same good. It was, obviously, an important factor in the opioid/Purdue/Sacklers saga. It may be also at play with the obesity drugs, although in a subtler way. Of course, there is no reason to believe that these drugs lead to an addiction similar in medical sense to an opioid addiction. However, people using these drugs to successfully control their weight, will find themselves at the mercy of 2-3 large companies in a way they are not at a mercy of their baker or their electricity supplier. Stopping eating any kind of white bread or moving to an area supplied by a completely different set of electricity companies is a much more palatable lifestyle choice than having one's weight increase back 20% because one goes off a particular drug. So once one becomes a client of such a company, it is very hard and expensive, in utility loss sense, to go back, quite unlike any agricultural or electricity companies.
Definitely. As long as the pharma company's patent is still active, which for semaglutide will be for over a decade, all consumers will be beholden to the company, and depend on it for weight loss. They are getting people hooked on pills to fix obesity, something that barely existed 100 years ago.
I note that Agriculture and Pharma in fact share the same regulator, it's the *Food* and Drug Administration, after all. Agriculture just comes up with entirely new products far far more rarely, but new GMO crops go through similarly massive hurdles to new drugs.
Actually, the same level of regulation for food, would be something like "any change in a bagel recipe that substantially changes its chemical composition and nutritional properties, such as adding raisins and increasing baking temperature by 20F is illegal until you spend 2 years and $1e9 on approvals". Luckily, food regulation is not like that.
For a slightly different take on this, I find it disconcerting that we're using pills to solve a very new problem that our ancestors definitely didn't solve with semaglutide. We're not making progress, we're abandoning the very interesting and likely very important question of "why are people fat now and what can we do to avert the cause of people being fat now" and just slapping a medical band-aid on top of it.
Are we ever going to figure it out? What happens if the underlying issue gets worse and worse, and we medicate and medicate instead of solving the issue, and the medicine runs out?
I agree this is concerning. I think the main reason people are gaining weight is the rise of hyperprocessed foods; I stopped all of these for a while and lost ~20% body weight, but it was tough and unpleasant because there were lots of processed foods available that would have been very easy to take in a moment of poor willpower (though I know other people say they've tried the same experiment and it didn't work for them). I feel like this solves the mystery and I don't really have a good solution to the existence of processed food (beyond extreme authoritarianism) so I will grudgingly accept the transhumanist solution.
When I moved out of my Orthodox Jewish home to Atlanta, I started eating a lot more processed food and promptly lost 50 pounds. Later on, I tried many diets with no processed food, paleo and others; of course none of those worked at all. I am reasonably sure that this, too, does not solve the mystery.
Based on our previous conversations, my understanding is you've eliminated almost every possible bad thing from your diet without significant change. Either you have some kind of extremely weird condition that would have made you the one obese person in your village in 1850, or it's a ratchet effect where some factor causes weight gain when present, but doesn't (always) remove weight gain when absent. Compare to how eg everybody will be unhappy when tragedies are happening, but some genetically unlucky people will stay unhappy even after the tragedy ends (PTSD, depression, etc).
I believe Eliezer has an extremely weird metabolism. As I recall, missing a meal or two makes him lose the ability to think. (From memory and possibly old news.)
This is not how most people react to missing a meal or two-- they may be miserable and/or hungry, but the effect isn't that extreme.
In the middle ages, a person like Eliezer would simply seem to be not particularly bright.
Maybe, but that sounds a lot like how many people react to *hunger*. At least for me, it causes a hyperfocus on food until I resolve the cause. The effect is similar to being horny, but what the body craves isn't an orgasm but a sandwich.
When you moved out of your orthodox jewish home you may? have let up on the shul kiddushes, simchas which involve large meals, shabbat dinner which is often a pretty elaborate multi-course meal etc. which might have helped you out there.
Serious question: if you rate your awareness of your food patterns high, what probability would you assign to having one or more significant psychological blind spots interfering? Would you assign roughly the same probability to other people who rate themselves highly food pattern aware?
If you don't rate your awareness of food patterns high, do you have some speculations about what's standing in the way?
Asking as the sometimes heavy, sometimes thin child of an endocrinologist and a biochemist dietician person, having observed really enormous variability in awareness levels, even among people who thought they were careful.
Did you eat a lot of fruit? https://www.amazon.com/Nature-Wants-Fat-Prevent-Reverse-ebook/dp/B097XMY9VG/ says a big problem is fructose, which signals the body it's autumn: time to prepare for winter and get fat. That's not all there is to it, I'm sure (the book mentions salt, too, for one), but cutting out all sugar and artificial sweeteners (some of which get converted to fructose in the body) and reducing the amount of fruit I eat has definitely made me less hungry.
> artificial sweeteners (some of which get converted to fructose in the body)
Which artificial sweeteners get converted to fructose?
I looked it up, and it's really only one of them, but some of the others have other problems:
"Despite having minimal calories, some artificial sugars still activate the survival switch. For example, sorbitol, which is often used in sugar-free syrups, is part of the polyol pathway and is actually converted to fructose in the body.
Absorption of sorbitol is variable, but it can be significant. Tagatose is another artificial sugar that can substitute for fructose and directly activates the survival switch because it, like fructose, is metabolized by fructokinase. While saccharin does not activate the survival switch, it has been reported to cause insulin resistance in animals, likely through an effect on gut bacteria. Excess intake of saccharin in mice has also led to bladder tumors. My recommendation is to avoid these three sweeteners."
(The "survival switch" is the process that shifts your body towards fat-saving mode.)
I avoid *all* sweeteners myself, because I've read that other types are bad for your intestinal flora, and I don't like the taste of most of them anyway.
Fair enough. I think I have very very far from baseline food preferences/requirements in a few ways so I am not a very good judge of what diets most people would consider reasonable.
Is processed foods messing with the lipostat still the best supported theory? And if so, has anybody discovered whether/how it's possible to undo the damage?
Can you unpack the words "processed" and "hyperprocessed"? They seem to be used more as virtue labels than anything objective about the ingredients and process. At least, I've never seen anyone say what they mean by the words. All cooking is "processing", but hopefully something more specific is intended.
And "junk food", for that matter. I suspect that with my eating habits and preferences, and affluence, I never see any "junk food" from one year to another, so I am unsure what is being talked about.
It's a gradient, and not really that complex. Compare carrots and steamed carrots. Cabbage and steamed cabbage. The processing makes digestion a lot easier, makes the calories a lot more available.
The thing that make it a bit complex are things like unflavored yogurt, which *are* hyperprocessed, but are still good food choices. Some foods are "hyperprocessed" to improve their durability. But this doesn't always mean that the calories are more available.
It's really slightly the wrong dimension, but there's a very strong correlation with "hyperprocessed" and "no fiber, lots of starch and sugar".
Processing (including cooking) tends to make foods easier to digest. This means that your GI system doesn't burn as many calories, that more of the calories in the food are actually absorbed (rather than pooped out) and that you get hungry again sooner. Some processed foods are also designed to act as a superstimulus, making you want to eat more of them even when you're not hungry.
How odd. I never want to eat when I'm not hungry. I mean...why?
Boredom. Where's Amy?
It varies. There are times when eating remains interesting even if I'm not hungry.
The worst was when I'd get irritated when I was full because I didn't want to eat more. Fortunately, I didn't have a bad case of that one.
Have you never found yourself eating more potato chips than intended because they're more-ish? I very rarely eat the kind of food that triggers this effect in me - I have chronic health issues and am exceptionally conscious of what I eat as a result - but I'm aware it exists.
Basically all food is "Processed" to some extent, unless it's literally raw fruit and veg I guess, but "processed" and "hyperprocessed" are basically shorthand for "comes in a packet and is high in salt, fat and/or sugar". It would say that its more about the incentives behind the design of most processed food than the fact of processing itself.
That's more or less how I understand it. Basically, foodstuffs in a style/composition similar to mid-to-late 20th century mass-produced convenience foods, which is used as a heuristic for foods with a particular cluster of characteristics that makes a diet that relies on such foods as staples to be particularly apt for overeating.
The representative features of "processed" foods is that they're designed for cheap and easy mass production and distribution in a 1950-ish environment, and for palatability across a wide range of local food cultures. White flour, corn syrup, and vegetable shortening were and are cheap and conducive to making stuff that doesn't need to be refrigerated and has very long shelf lives. Starchy and fatty foods tend to keep longer at room temperature as well: starchy stuff with appropriate preservatives doesn't really spoil the way most fruity or protein-based foods tend to, shortening doesn't go rancid like many cooking fats, and presence of fats helps the foods not feel dry even if they're very low moisture (low moisture being one of the keys to minimizing spoilage), and both lots of fat and minimal moisture both help prevent the starches retrograding (i.e. going stale). And to appeal to a wide range of palates, much of it is pretty bland and inoffensive, relying on various combos of fat, sweetness, and saltiness for palatability. Heavily sweetening or salting also helps shelf life, since lots of salt or sugar with little moisture helps make it inhospitable to bacteria and molds.
Nutritionally, such foods tend to high glycemic indices (from white flour and sugar), lots of omega-6 fats (from the shortening and a little from the flour), and to generally be calorie dense relative to satiation.
Guyenet's formulation of it is actually "hyperpalatable", and based on some very limited exchanges I've had with him, I don't think he can nail down precisely what it means. I think he's working honestly with the empirical data we have available, but it's a bit undertheorized.
> I don't really have a good solution to the existence of processed food
Many people buy their food online. I could imagine a software solution that would support automatic filtering or blocklists.
Imagine that you are a vegetarian, so you go to the application settings and check "do not show me products that contain meat", and from that moment (until you change the settings again in the future), the application will pretend that products containing meat simply do not exist. Not just showing you the message "4 out of 15 products were hidden because of your filter settings", but simply there would only be the 11 products displayed, with no indication that anything else exists. Categories that only contain hidden items would themselves also become hidden, so instead of seeing an empty category for "bacon", there would be no such category in the menu. Unless someone makes a soy bacon, in which case the category would appear again.
In other words, shopping at a normal supermarket with this setting turned on should feel indistinguishable from shopping at a vegetarian supermarket. (Which removes the need to actually build a separate vegetarian supermarket.) Out of sight, out of mind. Willpower is no longer necessary when the temptations are removed.
You would be able to create your own blocklist (for example, you may decide to boycott Nestlé), or subscribe to other people's blocklists. Maybe even write your own algorithm in some scripting language, using the available metadata, such as "hide everything that contains more carbs than proteins". This of course assumes that the web application would contain the metadata.
I would love to have such application available, because every time I regret buying and eating something, I could simply add it to my personal blocklist and never see it again.
There is probably an economical incentive against creating an application like this; maybe the problematic products are the most profitable ones, and if you allow your customers to remove them too effectively, you hurt your profits. Maybe this application would have to be created by a third party. (In which case, it could perhaps integrate products from multiple supermarkets, that would be even better.)
This actually seems like a really valuable idea! I worry that the metadata wouldn't be available to a third party though (I give it 50/50 odds that some of the metadata you would really want isn't available internally either)
Yeah when I switched to a fruit and veggies and yogurt and other simple foods diet, I just ate a lot more of those foods. Didn’t really help at all.
It’s all CICO, and when I actually stick to say a 1700/day budget, the weight flies off because I am fairly active. When I don’t stick to that budget I quickly balloon up because I suspect my bodies generic desire for food is something like 3500/day or some other unhealthy level. Probably learned at teenage years when I was an athlete.
Don’t you think the change in job type has had an influence, along with the rise of cars and the like? Walking, and even riding horses, burns a lot of calories, as does stuff like hauling, tilling, or even standing in a manufactury. Most of those jobs have been so heavily accompanied by technology that little exercise is involved anymore.
My point is just that doctors prescribe diet and exercise, and I don’t think it’s just diet that’s causing modern problems.
I also think we’re a lot less shaming of obese people, and that probably makes a difference
Even quite large differences in lifestyle have a fairly small impact on the number of calories burned, which is why most people focus on the diet side of the equation - both when explaining the problem and when trying to fix it.
I am sceptical of this. The caloric difference between heavy manual labour and total couch potato is IIRC a factor of 2 or more, though sedentary white collar labour that involves heavy thinking does still burn a fair few calories from the intellectual labour.
I agree with this. Why do we need drugs for weight loss? This isn't solving the real problem. (For clarity: I mostly hold the same position for every disease where the environment-body EMH interaction is unclear.)
Kind of depends what you think the real problem is.
If you think the real problem is eating too much unhealthy food, and the drug helps you not eat so much unhealthy food, then you could say that yes it is solving the real problem.
Using pills to fix obesity may be beneficial in the short term but may make things worse off in the long term. Obesity is relatively new. Just 100 years ago, people were at risk of starving to death. In some countries that's still the case. Obesity is a modern problem humans have created ourselves. All we need to do is look back and realize how junk food and the move to a less manual labor intensive workforce have led to these problems, and realize we don't need pills to solve it.
(You believe it's all just CICO?)
No. The type of food matters too. CICO doesn't take into account how the body processes different foods. 100 calories of soda loaded with HFCS is not the same as 100 calories of walnuts.
Hm, would you consider a case of someone who eats 3,000 calories of meat a day evidence in support of, or against, the CICO hypothesis?
A guy who eats 3000 meat calories a day versus what?
It depends on the person's weight. 3k calories is roughly maintenance level for an obese male (~120 kg). For a lower weight, that would be strong evidence against CICO of course.
As I understand, the recent trends and findings have pretty much killed the theory of wrong macronutrients > obesity, haven't they? E.g. americans and europeans reducing both their sugar and fat intakes quite a lot during the last 20 years (and increasing their excercise levels) while obesity rates going steadily up anyway as if they didn't care. If fructose was the culprit then this wouldn't make sense, right?
"Processed foods" makes more sense as a culprit (consumption seems to have gone up in these 20 years). But the problem with those are, we don't know what part of the processing is bad. Heating several times? Some often used flavor or preservative? Just one or several of them? We don't even have good evidence if processed foods as such directly cause obesity or not. We do have consistent correlative data that they co-occur with several health problems. So one should avoid them anyway, but it would help very much if we just knew which part of the processing makes food unhealthy. Because e.g. conserving foodstuff for longer preservation is a good way to fight world hunger. We would want to save the baby, just throw out some dirty bath water.
The issue is that the category of 'macronutrient' is too broad. While there have been periods of both less sugar and less fat in the average diet, with a corresponding increase in obesity, one thing that has changed long term is the type of fat people eat.
Vegetables oils (really seed oils) did not exist before 1900, neither did obesity, heart disease or T2 diabetes in any appreciable numbers. Only once we started adding seed oils to our diet did the diseases of civilisation start to arrive. Dietary fat before the invention of seed oils was mostly stable saturated or monounsaturated fats. Seed oils contain predominantly unstable (easily oxidised) polyunsaturated fats (PUFAs). Small amounts of these are essential, but not the 20%+ of calories that modern Americans eat.
'Processed foods' doesn't mean all that much as a category. Bread, cheese and strawberry jam are all processed, but none of them are obviously obesegenic. However, one thing that most modern processed foods have is significant amount of seed oils. I think that is the most likely culprit here.
This is the best primer I've found, although there is an obvious conflict of interest in that its authors are a company that makes low PUFA cooking oil.
https://www.zeroacre.com/blog/seed-oils-to-avoid
The problem is people move less on a day-to-day basis outside of exercise, and food is delicious, cheap and easily available.
CICO is a thermodynamic necessity, there's no arguing with it on the technical level. But the "CO" part is quite mutable by what you eat affecting energy (upstream of activity) and hormones (upstream of metabolic rate)
I understand that energy conversation is required here, but I see no reason why humans can't just poop out extra calories. Any ideas?
I'm pretty sure we do, sometimes.
Obesity is less bad than a subsistence farming lifestyle.
What about a hunting lifestyle back before the megafauna extinction? more representative
Obesity is also less bad than a subsistence hunting lifestyle.
As should be obvious by how many people are obese and how few people hunt.
emphasizing point about it being specifically megafauna
In order to hunt a deer I'd need three separate licenses (gun, car, hunting), a car, and it would take hours of driving to and from their habitat. My local supermarket is a 6 minute walk away.
While subsistence hunting would be awful, I don't think my choice to go to the supermarket in today's regulatory and social environment reveals an underlying preference for modernity over subsistence hunting.
There aren't enough huntable animals left in our environment for more than a tiny fraction of people to hunt. If 2% of the global population decided to fulfill their dietary needs by hunting, then in short order, none of them actually would, because there wouldn't be enough left to survive on.
If we judge how desirable a thing is by how many people do it, we'd have to conclude that being a drug addict is more desirable than being a pro athlete.
The problem in what you're saying is located in the phrase "All we need to do." It's extremely difficult to remove the conditions that make obesity more prevalent now than they used to be, for a variety of reasons. If the alternative solution is to fully reorder western society so that people work more with their hands, heavily regulate stuff that huge majorities of the voting population enjoy every day, discover all chemicals or pollutants that affect obesity and eradicate them from the environment, etc., then there's no alternative solution at all.
It is much easier to invent a cure for obesity than it is to create an entirely new and popular political movement devoted to making people poorer (by increasing labor jobs and reducing economic productivity) and giving them fewer choices.
So what do you propose? Ban junk food and do more manual labor?
It's pretty close to an understood problem. SSC is right, hyper palatable food cause all or most of it.
If you want to read more about the underlying neurology and cause of obesity Stephan J. Guyenet is a neurologist who is bright and very well informed on the topic.
https://twitter.com/sguyenet
Side node he's not a typical weight loss hack, his opinions are standard obesity researcher opinions.
Guyenet is the author of The Hungry Brain, a very good book on eating and weight. Alas, the "how to lose weight" recommendations are underwhelming, e.g., keep hyperpalatable foods out of sight or hard to get to.
There are likely to be several underlying issues. We don't know what all of them are yet, but we have very good reason to believe that parental obesity is involved somehow, and probably not just through genetic predisposition. (Supported hypotheses include but are not limited to epigenetic effects, prenatal/perinatal hormone and nutrient exposures, family eating habits, and social contagion through normalization.)
There are almost certainly some underlying environmental stimuli that caused people to start getting fat in the first place, but even if we found them tomorrow, it's not at all certain that fixing them would solve the problem in the near term. We'd probably still need a combined treatment/prevention approach. I don't see a good reason to deny people treatment now just because we haven't figured out prevention yet.
Pill culture is great, if pills are safe and effective and cost $1, or very crappy when they cost $100.
Furtunately the natural cost of pills is like $10c when intellectual property runs out and they are sold in the highly competitive open market. That's the beautiful future of pill culture.
I agree with you for the short term, but I think it's worrying when we brush fundamental societal issues like obesity (and depression very similarly) with medication.
An analogy from my POV is that we're in a boat with a hole in the bottom and we keep bailing the water out with medication. Sure we can keep bailing out the water, even if the hole gets bigger, until it gets truly unmanageable. At that point we'll be facing a massive issue and effectively be back at square one.
I know this sounds like a slippery slope, but these simply weren't issues 100 years ago and they have been steadily becoming bigger and bigger issues, I don't see why they wouldn't continue to grow.
"Instead of making sure communities have access to cheap and healthy food"
I'm going to pull this out because of the underlying assumption. "Just make sure there are enough vegetable selections in the local shops and everyone will naturally eat raw broccoli instead of chocolate!"
People won't. You can over-eat on healthy foods, too. Too many bananas not good for you. Same with vegetables - one reason I'm sceptical of the potato diet is that potatoes are one of the carbs I'm constantly being told by my doctor and the diabetic clinic nurse to cut out of my diet since they put on the pounds. I eat a lot of potatoes and could eat an all-potato diet easily, but I don't expect any dramatic weight loss at all.
When I was carb-counting back on one diet, there are vegetables that are carb-dense (and hence calorific) - see this below (and by the way, the advice on this is so contradictory - one source told me carrots were fine, another that carrots were high carb):
https://aaptiv.com/magazine/high-carb-vegetables
Yes, even peas are high-carb. So while you might think they're a green vegetable and therefore good, you need to be careful how many you eat.
"For some perspective, the Dietary Guidelines for Americans 2015-2020 recommends that 45 to 65 percent of your daily calories come from carbs. Depending on your weight and body, this could be anywhere from 150 to 300 grams."
I set a target of 33g of carbs a day, which I had to do some juggling to work out. I did lose weight, but it wasn't a smooth, easy downward curve of constant weight loss. And of course, I gained it all back when I stopped that diet.
Things like lettuce are very low, so you can eat lettuce all day. But who eats lettuce all day? Not even rabbits!
Anecdotally I thought similar and then I tried the potato only diet and lost 10 pounds in a month feeling totally fine
My experience, albeit more with other gastric issues than with any weight concerns, is that grains interact with (my) guts very differently than potatoes, and that while I do really need to absolutely minimise my intake of grains in general and wheat especially, I'm fine with potatoes as long as I don't eat an unreasonable amount in a single sitting (and eating 500g of almost any single thing as a snack is going to cause issues)
As someone who has spent some time in the developing world I find the concept of American “food deserts” hilarious. There are millions upon millions of people where they don’t have access to x or y or z regularly, sometimes for months. Meanwhile someone living in an American “food desert” has a grocery store that is a literal cornucopia a 12 minute bus ride away instead of a 4 minute bus ride, and it is a “food desert”, because there is a gas station and a McDonald’s closer to their house.
Maybe "food desert" isn't the right word to use to describe the problem, but that doesn't mean it's not a problem. The problem is that there are millions of low-income Americans that don't have A) Access to healthy food without cheap transportation, and B) cheap transportation. They end up paying a lot more than most Americans to have access to nutritional food. And this is one proposed cause of the obesity epidemic.
The problem isn't solved with gas stations and McDonald's restaurants. For a lot of these low-income communities, the closest "grocery store" is a Dollar General. They're fully stocked with highly processed foods, but no produce to be seen anywhere.
Maybe "food dessert" is a better name. Your body is craving vitamins and minerals, but you're surrounded by cake without a leafy green in sight. "Food desert" is closer to, well, an actual desert.
There's a difference between pills replacing an already-working, better solution of something, vs pills offering a solution where we had none before.
I think a lot of cases are the latter.
There are very few "food deserts" if you mean places where you can't buy food at all. There are lots of places where it is easier to get junk food than healthier food. But that's largely because the people there will buy the junk food and won't buy the healthy food. Retailers stock what people buy. To solve that problem would require treating junk food like prohibited drugs, but probably that wouldn't work any better than marijuana prohibition has.
Healthy food tend to need being refrigerated or frozen. It doesn't keep as well as a lot of junk food.
This is a pretty big deal if you're literally homeless but for most people this is a matter of convenience of storage and preparation rather than difficulty of obtaining the food. "Food desert" seems like a misleading way of describing this, if the problem is that healthy food is less convenient to prepare and eat.
I was thinking about the cost to the store. Just putting things on shelves is cheaper than needing to keep them cold and having shorting expiration periods.
Refrigerated stuff expires, but frozen stuff keeps basically indefinitely, and frozen vegetables are actually *more* nutritious than 'fresh' (unless you're actually getting them fresh from the garden; supermarket 'fresh' was picked days ago); are freezers that expensive for stores to run?
My point is that the freezer is more expensive for the store than just having shelf-stable food.
"The opioid crisis in rural America is a good example of what happens when pills are handed out like crazy."
Surveys of addicts have found that most first started taking opioids via the black market, not prescription by a doctor. They have every incentive to claim they were prescribed pills by doctors in order to deflect blame.
"Also, the promotion of semaglutide would divert attention from the current problems of food deserts. Instead of making sure communities have access to cheap and healthy food, it lets food companies put out as much junk as possible and hope the pill fixes everything"
So the problem is that food companies will put out junk food, which people won't buy because of the pill, and that's a problem why?
I wanted to try semaglutide. My doctor was perfectly willing to prescribe it but my insurance wouldn't cover it and the out of pocket is steep. Ended up with phentermine which seems to be working well, we'll see how it goes. I'm curious why it's not prescribed, cheap and there's good evidence it works, although not as well as the new stuff.
I couldn’t get Wegovy at a reasonable price when it was approved, and then Novo Nordisk started having huge supply chain problems with their injectors. Fortunately, Eli Lilly’s coupon for Mounjaro was less restrictive at first, though they’ve had to crack down as they have trouble meeting demand for both off-label weight loss use and for the approved T2D use.
I am what the doctors call “morbidly obese,” and it’s been more effective than anything else I’ve ever tried. Down about 35 lbs in the first three months, and unlike with other diets I’ve tried, I’m not feeling miserable or hungry all the time. Assuming there aren’t scary side-effects in the future, these really are miracle drugs.
I do expect the price to come down relatively quickly due to competition, which is a good thing.
Congratulations on the weight loss. I'm interested in why you expect the price to come down. I looked into it just for a few minutes and found some people saying that one or two competitors don't usually bring prices down in health care. but I'm definitely not an expert.
I hate to say it, but the time that the price will probably come down is about 18 months after it goes generic.
Because I expect there to be more than one or two competitors soon enough, and the newer ones look to be even more effective. Since these aren’t being covered by insurance, that’s going to force competition on price more than for other drugs—for example, the extremely generous coupon for Mounjaro was likely done to compete with Wegovy until demand started outstripping supply.
But there are already quite a few GLP-1 agonists on top of semaglutide and tirzepatide.. Theres exenatide, liraglutide, dulaglutide, lixisenatide. and all of them are expensive and brand name only. I have to agree that only when these drugs go generic will they likely see a drop in price (and maybe not even immediately then)
Insurance companies have ways of denying coverage and making it ver hard for you and your doctors to get it to you. Been there personally (but not for this issue.). All the obese would never get it at the price you quote, though it would be interesting to know how many morbidly obese there are and what the accompanying burden would be if only they were to get it.
Even in the absence of competition, drug companies stand to make more money if they lower the price enough to encourage willing coverage by insurance companies and thus reach a larger group of patients. I'm not sure how likely this is, with such a large pool of potential patients to expand into, it's possible.
I agree with @Maximum_Liberty that the price will drop further when the drug becomes generic. Before then, there could be competition as @Edgehopper responded.
I would guess that multiple drug companies are now at least considering whether to work on developing a competitive drug and to the extent that they get lucky (yes, drug development still is a crap shoot), competitive pricing could come about.
Congrats on the weight loss!
Are these drugs that have to be taken forever, or just for the duration while someone is trying to lose weight? And is there any data on whether, once weight is lost, there are recurring cycles where patients regain and have to go back on the drugs to lose again? I'm assuming those factors would be important in a long term cost model.
I think forever; if you stop, unless something big has changed in your life then the same factors that made you gain weight the first time will probably make you gain it again.
Anecdote is not the singular of data, but my better half lost 25 pounds on it, then had to get off it for reasons unrelated to the drug. She has not regained the weight yet -- and consistently eats less now that she had for years. So in at least one case, the drug helped with a successful change in eating habits.
So, to be 10% lighter I need to take a drug forever? Or will I continue to lose 10%/time period of the study indefinitely? Or will I go down 10%, and also continue to gain weight at 90% of my previous speed, assuming no changes in diet/activity?
I think semaglutide works mostly by making you feel full even when you haven't eaten too much. So you can think of it as the same as dieting. If you're currently eating unhealthy (let's say 4000 calories a day) your weight will stabilize at some high number. If you eat healthier (let's say 2000 calories a day) your weight will stabilize at some lower number. This is because it takes calories to support the extra weight, and when calories in = calories out, your weight stabilizes. You can play around with https://www.calculator.net/calorie-calculator.html to get an idea of how this looks.
That is not my experience. I still eat a lot of junk but I'm maintaining an 11% weight loss. Yes, it's an anecdote, but it's my anecdote, and I believe in it. I've fought my weight my whole life and I can't eat a bite without mentally counting calories, carbs, etc. I don't think I'm fooling myself about food quantity (large) and quality (poor).
As an addendum the stabilization happens through three forces. One is you are smaller so you burn less calories moving, and have less tissue you need to keep alive. The second is your body slows down your metabolism. The third is it ramps up hunger.
Say at equilibrium you burn 2000 calories and crave 2000 calories. You use your will to eat 1500 calories and lose some weight. Your body slows down your metabolism by 100 calories, you burn 200 calories less from being smaller. But your body hungers for 2800 calories. Now instead of exerting 500 calories of will you need to exert 1100 calories of will. This is born out by studies on hunger and fullness, that basically the majority of diet adaptation that stabilizes weight loss is hunger.
This is why weight loss is so insidious and so difficult to maintain.
so there's been a lot of research on dieting and losing weight, etc., and one of the things that has been found is that your body has a "set" point weight wise that it will try REALLY hard to return you to. If you lose weight, your body will slow its metabolism until you return to that weight. If you gain weight, your body will rev up metabolism. That's why you might gain 10 lbs over Christmas and then lose it in January without purposefully trying to lose weight. (this is all in the short term, ofc, as people do tend to naturally gain weight as they age).
This seems to imply that semaglutide would need to be taken forever. However, there seems to be an important caveat: you *can* reset your set point, it just takes a long time at the new weight. When most people go on diets and lose weight, they end up regaining the new weight quite quickly after they "end" their diet, so they don't have a chance to reset their set point.
Speaking from personal experience, I had kind of an accidental natural experiment with this: I once lost 40 lbs over the course of a year and a half, where I began with a very strict low carb diet that very very slowly trailed off to a normal diet, mostly because I got progressively more tired of being on the low carb diet. So by the time I had gotten back to my normal diet, I had been losing weight for a long time. I ended up regaining 10 lbs of the weight, but no more, and am still ~30 lbs below my peak even today (5 years later). I noticed that my own "set point" seemed to reset: when I would overindulge during the holidays and the like, I would often lose the weight the next month without really trying. All of this to say that I do think patients will have to take semaglutide for a while, but not necessarily forever. The brilliant thing about the drug is that it essentially just works like extra strength willpower. If someone takes the drug for a while, loses weight, and their body eventually resets to a new set point, and they themselves eventually get used to their new level of calories/diet, I expect that they could then come off the drug. Personally, that's my plan for ~20 years from now: I don't qualify for the drug at the moment (BMI of around 25-26, so overweight very slightly) and I probably won't ever, but I expect it will become far more available and affordable in the future to the point where even just overweight people are taking it.
AFAIK there's no real evidence for a set point. It's one of those folk-sciencey things that people just accept without real evidence.
Our behaviors and food environment don't *tend* to change much through life, so somewhat naturally people will have an equilibrium with respect to those factors. But people *can* change their behavior, which would change their "set point" in the same way a drug can (which AFAIK just changes behavior by changing satiety response)
Yeah set point I don’t know the research on (which might be because it doesn’t actually exist) but what I do know there’s now a good body of research on how your body slows down metabolism, gives more hunger symbols, etc, when you lose weight. So it could be that set point is half true in that your body will seek to return itself to its old weight if it loses weight, but not if it gains weight. Which is super depressing but also fits with what we see in the real world.
I saw on the 1 year follow-up to the STEP-1 trial that most of the participants gained all of their lost weight back.
Think of it like blood pressure medicine. When you take the drug your blood pressure drops, when you get off it it goes back to your bodies natural equilibrium point.
It's the same with weight. Your body has a set point and weight loss drugs move that set point down. Then when you get stop your body goes back to it's natural higher set point.
Looking at the study on wegovy.com that I think your graph is ultimately derived from, " Both groups were instructed to take the medicine along with a reduced-calorie meal plan and increased physical activity. " Is this normal for this sort of study, do patients actually do it, does this reduce veracity of results?
On that note 7% of Wegovy takers left the study due to side effects while 3.1% of the placebo did, which is makes me somewhat skeptical that there won't be some side effects coming up in mass adoption. https://www.wegovy.com/FAQs/frequently-asked-questions.html ("How much weight have people lost")
Re your first question, I haven't looked into this myself, but Eliezer's comment above suggests the diet and exercise aren't playing a very big part. Also, the studies I cited were placebo controlled, so I imagine the placebo group also diets and exercises.
Neat, I was waiting for this post.
Btw a quick google search says it's "tirzepatide", not "tirzapatide"
Thanks, fixed.
Check out Wegovy.com- like so many other expensive drugs the company themselves offer a copay card for pts with commercial insurance, to bring copay down to $15, no negotiation needed.
Thanks - has anyone tried this and confirmed it works and that you can keep doing it for a long period of time (one pharma trick is "first month free" and then once you feel like you need it they start charging you full price again)
So there’s a max amount of saving of $200 per month for insured patients and $500 per month for cash paying patients, up to a max amount of lifetime savings that I can’t remember. It’s also not usable with any govt insurance (medicaid, Medicare, tricare(military),etc).
Ozempic coupon cards also should not be used for weight loss, since they need a diagnosis code and the Ozempic coupon card specifically needs Type 2 Diabetes since that’s what it’s approved for. Technically, it would go through if a pharmacist is not careful and doesn’t get the diagnosis code. They’ll get a paid claim and then months down the line the pharmacy will get railed in the ass with a clawback for the money. A patient could try to abuse this at a chain pharmacy where the pharmacists are just trying to do things as fast as possible and don’t have an interest in making sure the company gets paid properly since it doesn’t affect them (as a matter of fact they want it to work since telling patients it doesn’t makes them mad and thats annoying and a time sink “but my dr told me it would work!”). At an independent pharmacy the pharmacists likely know this or they would prob be out of business before long.
Mounjaro also requires a type 2 diabetes code to properly go through like ozempic. Mounjaro has a cap of $250/month saving for insured patients and $500 for uninsured patients with an annual max of $3000.
Patients aren't happy to hear this about ozempic, especially recently as patients have been hopping from pharmacy to pharmacy trying to get ozempic because it has been backordered.
I should have wrote this in my first comment but I am a pharmacist, in case that wasn't clear lol
'Eat vegetables' gets removed?
Wow
Just, Wow.
It’s not much of a contribution. People have been shouting “Eat vegetables!” For thirty years now, but the percentage of obese Americans keeps going up.
You can shout about vegetables all you want, it won't do a thing when Uncle Sam subsidizes all of the precursors to the highly-processed packaged-ready-to-eat junk food.
More like 80 years, really. With, as you note, dismal success.
It's not just Americans. Other countries are seeing obesity increase as their wealth increases as well.
Good to see low effort glibness like this gone, keep it up Scott.
I wonder how much the demand for Wegovy gets reduced by it being an injection rather than a convenient pill that you can swallow. Is there any chance it can be turned into a pill?
There is a pill, but you have to take it at least once a day (maybe more), and the effects aren’t as steady as the depot injectable.
My doc was laughing about this (as he wrote my scrip); he says he could give people a prescription for a brand new poorly tested pill with little benefit and tons of side effects, and most of his patients would be fine to take it. But make an excellent, well researched medication that has been working well for years and years into an injection and suddenly everyone is hesitant.
I’m not even the least bit scared of needles, and I was hesitating! Injection just seems so much more SERIOUS. But it’s actually not.
One legitimate reason to be more hesitant about the injectable version of a medication is the corresponding change in dosing schedule: if anything does go wrong, side effect or interaction wise, you can't exactly suck it back out, and you're stuck with the situation for much longer (a week to a month) than if you had been taking daily pills.
I was very concerned with the injections before I started Weygovy. My experience is that the injector is fast and almost painless. My pharmacist was important because he showed me how to do it correctly before I started.
In Brazil medications are in general very cheap, due to being completely on the open the market (you pay out of pocket, no insurance involved at all), there being a robust and we'll regulated generics market, and there being a lot of basic medications on public healthcare.
I just checked and Rybelsus is $80 for 30 3mg capsules (https://www.drogariaspacheco.com.br/rybelsus-3mg-novo-nordisk-30-comprimidos/p). That equals <$200 per year if I'm computing doses right (Wegovy standard dose is 2.4mg/week). That's $200 in Brazil vs $15k in the US. That's just crazy!
The main reason most medicines anywhere are available and cheap is, as Scott points out, free riding off the American market.
Yes and no. It's called price discrimination, and it can be occasionally pretty counterintuitive. Selling to some at a high price and to some at a lower price may actually bring in more money than selling to everybody at the average, if fewer people would buy it at the average price. In some cases, price discrimination is the only way to make something profitable and thus make it happen.
Also the American market doesn't have high prices _because_ this is where research happens. If anything, you'd expect lower prices in the home market - that's how it happens with the majority of products simply because you have less logistics. The high prices are primarily due to a generally dysfunctional health market, most likely due to trying to solve everything with regulation. Very much USSR style.
Of course selling in other countries at lower price is price discrimination - but that is not an explanation, it's a definition.
You're getting the causality wrong. I'm not saying that prices are high in America because research happens there. I'm saying research happens because of the high prices that you can get in America. That's what allows the higher average price and subsidises the research for the free riding nations.
But isn't the money going all in the same place? Why would it matter in which particular country it's more expensive, once you're already a global company?
I wonder if it possibly could be some "artificial" reason, like maybe it is easier to get something approved in USA if it was researched in USA.
(This is just a wild guess; I have no data to support this.)
It doesn't matter which country pays more, certainly, but it does matter that A country pays more. Are there other large economies that are paying a lot of money for drugs to create the incentive for carrying out research?
Isn't it that the research wouldn't be so horrendously expensive if it wasn't over-regulated? And it's never quite so expensive anywhere else in the world? And the reason why still mostly American companies keep doing it in mostly America is that a) American companies are the richest and b) American legislator's won't accept any research done outside America. Is this correct? And the high prices in America then come from two limiting factors: 1) someone has to pay to make the costs for the companies worthwhile, and 2) only or mostly Americans are able to pay such costs.
Seems like a lot of unnecessary money lost, but, on the other hand, it keeps the money in circulation. :) From companies to the government, government > people, people > insurance, insurance > companies.
Certainly part of the reason pharmaceutical research is expensive is regulation, but that's not all. It also requires significant physical and human capital and also a great deal of time and risk, which would still exist with or without the regulation, though certainly better regulation could reduce substantial elements of cost. However, regulation on pharmaceutical research is not vastly simpler anywhere in the developed world. My sense for why most of it is done in the US is that the US is the richest economy in the world, it also has some of the best human capital in its universities. The regulatory requirements are mainly about the safety and efficacy trials being held in the US, not about where the research is conducted. As for the last part of your post, I highly recommend reading about the broken windows fallacy. Resources spent on unproductive uses is not a net positive (edited to add : those uses of money are not a net positive just because 'money is in circulation'. Money would stay in circulation if you were to pay people to dig and fill ditches, but money is simply a symbol of value, it is not value in and of itself, especially when you're not talking about voluntary trades. The appropriate measure is opportunity cost - the money you pay someone to dig a ditch and fill it up could be used to pay them or others to do work that is more valuable)
Depends what you mean by regulate versus over-regulated. The FDA sets a high bar for new drugs to be approved. They have to be safe, first of all, which requires expensive Phase I & II trials, and they have to be better than the existing standard of care, which requires a very much more expensive Phase III trial. And very few drugs make it all the way through Phase III.
Nice graph here:
https://theconversation.com/90-of-drugs-fail-clinical-trials-heres-one-way-researchers-can-select-better-drug-candidates-174152
For each approved drug you can actually sell you may have to start off with 10,000 compounds that work in vitro, 10-20 that work in animal models, and 6 or so that pass basic safety screening in Phase I.
So the bulk of drug R&D cost that must be paid back by each successful drug is paying the R&D costs for the 9,999 candidates that didn't make it.
An enormous amount of effort has gone into trying to "fail faster" and get rid of candidates that won't work at an earlier and cheaper stage in the pipeline, but results have been a bit mixed.
Is a prescription required?
Yes, but in Brazil there are several classes of prescriptions and semaglutine seems to require the lowest class. For that one pharmacists will usually sell you without a prescription.
Wegovy is not yet available in Australia but Ozempic has been widely used off label with anecdotally great results despite the dose difference. It costs only $130/month (no govt subsidy applies). Sadly due to supply issues it's now impossible to get.
We have liraglutide as our GLP-1 that is approved for weight loss. It costs almost $400 a month but a lot of people report success on lower doses (presumably trying to stretch the pens out a bit longer).
I haven't had a good look at any papers discussing dosing, but I do wonder how important it is to be hitting the higher doses that are recommended for the weight loss indication.
Semaglutide and tirzepatide are both taken as weekly injections for weightloss correct? Could that also discourage people from taking it since a lot of folks don't like getting poked weekly with needles?
I don't know. There's an oral form of semaglutide, but it's not approved for weight loss, and the dosing is such that it would be very expensive to try to use it to make a weight loss dose. I don't know if this is just that the pharma company hasn't bothered getting the oral approved yet, or if there are other reasons it's hard.
Orally it has a very poor absorption, only 1% or so is absorbed. Currently there is shortage of manufacturing capacity that it seems inappropriate to waste 99% of the drug.
It also needs to be taken on empty stomach with just a little bit of water. Many patients do not follow this and then it becomes another waste of a good drug.
I suspect that even with good adherence, the variability of absorption between persons is quite large which makes it harder to know if the problem is that the drug is not working or is not absorbed.
Compared to all this, using auto-injector pens once per week maybe is not that bad after all.
Sorry, oral bioavailability of semaglutide is only 1%. I vaguely remembered that it was a round number and didn't check.
> Until now, doctors didn’t really use medication to treat obesity; the drugs either didn’t work or had too many side effects.
Is it the drugs not working or just FUD about prescribing drugs off label?
The side effects and abuse risk for stimulants can't be THAT different than prescribing to a normal weight college student vs obese. Maybe a bit more concern for cardiac issues but minor I think.
Less controlled and weaker stimulants could also be used like Modafinal or Nicotine. Even a small calorie intake reduction could mean a large difference in total body weight over a few years.
I think phentermine is as good as any other stimulant, it's just not good enough for most people. A lot of my Adderall patients don't really lose that much weight.
Doses needed for consistent weight loss/maintenance are much higher than for, say, ADHD. Plus every time the damned things wear off, ALL the hunger arrives at once. And you have to let them wear off, because otherwise sleep is terrible. (I was prescribed Dexedrine for weight loss several decades ago by a crazy doctor, and am now on a decently high dose of Vyvanse for ADHD).
As a minor anecdote corroborating this, I had a college roommate prescribed an unusually high dose of adderall (60mg/day), to which he was addicted. While it's true he regularly did not eat (or sleep) for 36 hours, upon waking up sober he would eat a single meal that compensated for all the missed calories--most commonly an entire large pizza and 10+ chicken wings. He did not lose any weight pre- and mid-addiction.
I'm on Ritalin for ADHD. Anecdotally, I seem to have developed a tolerance, and this applies to the appetite effects as much or more than the cognitive ones. I lost a bit of weight when I first started taking it, but I'm on a higher dose now and the effect seems mostly gone.
Someone made this argument in the subreddit about a year ago, I think, and the basic response was that stimulants just don't work well enough to make the risk/benefit tradeoff work. If amphetamine was really, really good at making people lose weight, that might outweigh the side effects, but it's just not that great at it.
I think the amount of semaglutide being prescribed for weight loss is being undercounted in this post. I prescribe semaglutide regularly for weight loss but I have never once prescribed wegovy. It’s just way too hard to get approved. Instead I prescribe ozempic for impaired fasting glycemic or pre-diabetes (basically anyone with fasting blood glucose >100 or hgba1c >5.5) which seems to go through way easier. I don’t think the difference of 2mg vs 2.4mg is all that meaningful in terms of overall weight loss. Would be interesting to see what the real number is including these other diagnoses.
Interesting, thanks!
as an interesting aside, Janssen's Invokana diabetics drug has also been proven to cause weight loss. https://www.fiercepharma.com/pharma/proof-concept-trial-j-j-s-invokana-combo-helps-non-diabetics-shed-significant-weight sadly the trials went nowhere after in 2017 invokana got slapped with a black box warning for heightened risk of big toe amputations. A risk that one may be willing to take to treat diabetes but not weight problems. There must be something in mechanism of action of diabetes drugs that causes this nice weight loss side effect.
That interested me, since I'm on Invokana. That one you linked is a combination of canagliflozin with phentermine. Looking at my medication, it's canagliflozin only. I didn't get any warnings about toe amputation etc. so I'm wondering if the phentermine was to blame there?
And no, it didn't make me drop any significant amount of weight, which is in line with the quoted results:
"After 26 weeks, patients using the combo had lost 7.5% of their body weight, compared with 4.1% in those taking phentermine alone, 1.9% of those only taking canagliflozin, and 0.6% of placebo patients."
Plus, I'm on 100mg not 300mg.
didn't see your comment when you posted initially, but no the black box was for Invokana only https://www.drugwatch.com/sglt2-inhibitors/invokana/amputation/
Yeah the weight loss effects aren't drastic on Invokana alone, I was looking at a project to fund a (different that one in article) drug combo that would have hopefully yielded more noticeable results, but it never went ahead.
Invokana sounds like a future scion of the Kushner-Trump family.
Never previously heard of any of these drugs.
If it weren't so late, I'd try and do some back-of-the-envelope-math myself but how many fewer calories will Americans be eating if semaglutide is made widely available and works? Will the industries dependent on Americans eating calories put up any kind of fight to increased availability of a weight-loss drug?
Punching some numbers into the calorie calculator linked above, the difference in calorie needs is a few hundred calories on a diet that's >2000 calories. So call it a ballpark of 10% reduction in calorie consumption? I doubt that's significant enough for a company to willingly take the PR hit of being pro-obesity, especially since the loss is distributed across the entire food industry.
Edit: Also, not all calories are equally profitable - if a drug enables you to eat the proper amount of any food you choose, then people will probably choose the tasty and profitable processed foods instead of the cheap grains.
Perhaps fortunately, it doesn’t seem to do that, at least for me . On Ozempic anything too sugary is totally ‘blech’, and too much high fat food gives me terrible heartburn.
I am taking Weygovy. I love the Trader Joe Vanilla Meringues.
Couldn't companies take advantage of this and instead make their portions smaller but keep the prices the same?
I'm pretty sure the "costs" would be way too distributed for this to be a reasonable strategy for food companies.
I wonder if semaglutide works best in those who overeat to begin with, rather than those who eat normally but have conditions that predisposes them to gaining weight, like Hashimoto's or PCOS, or genetically slow metabolism. If you gain weight on 2000 kcal/day, reducing your appetite might not do much.
Anecdotal reports from friends and subreddits suggest that the health benefits are actually a greater relief for diabetics and PCOS symptoms, with weight loss as a nice side effect.
Huh, interesting.
I thought PCOS was pretty closely tied to insulin resistance so that tracks for me in a hand-wavy way.
But given that I wonder what utility it might have in antipsychotic-related metabolic derangement and weight gain.
Speaking as someone with Hashimoto and PCOS and a genetically "slow" metabolism (fat parents), a lot of it is still due to overeating. I'm more hungry than my peers and have less energy / less willpower to resist it when it hits, and when I do exert willpower to not eat I end up eating vast amount of food when hunger shuts my rational brain down later with no leftover willpower to pace it. Sometimes to the point of vomiting. Those nights I also often end up with insomnia because I can't bring myself to stop doing fun-thing and sleep (so it doesn't exactly only affect food).
Yes, I've been to (many!) doctors about this behaviour, the most they decided I had was a little anxiety.
I've had a gastric bypass now and that seems to help, by physically reaching the vomiting point far far sooner on bad days to the point that it basically cured my binge eating.
84% experience >5% weight loss and 66% experience >10% doesn't seem to me like it would make people's physical appearance change very much from how it is now, even if 100% of obese people can get the medicine. A 300-pound person who loses 10% of their weight is still 270 pounds. Am I not understanding some key part of this?
I guess I'm making assumptions. If it brought everybody down to their ideal weight, you could still get those numbers, since maybe most people only need a 5% loss and the percentage of people needing a 50% loss is very low?
Back of the napkin-
Only about 33-35 million Americans have a BMI of 40 or more; a hundred million of them are obese in the 30-40 BMI range. For a guy at 5'8" (ideal weight around 165), that corresponds to a weight range of about 200-260 pounds, or a target weight loss between 20% and 60%. On the new meds, that guy can reasonably expect to lose more than 20-25 pounds at the median; if he's towards the bottom of the range, the pill mostly solves his problem outright, and even towards the top of this range it's still much more than a drop in the bucket. From personal experience, going from 250 to 225 makes a large difference in appearance and lifestyle.
Relatively few people actually need to cut their weight by more than half- in those cases, surgical intervention seems like a more likely solution at this level of technology. I would agree that in those cases, a pill that takes you from 350 to 315 is probably not doing as much good at the margins.
Hmm. I get an Ideal weight for 5'8" male to be between 139 - 169 lb. So while 165 falls within the range, it's on the high end.
But your points are very well taken!
If we were looking at this like a quality control problem. We'd propose different solutions for the outliers (more than 3 std from mean), special causes of variation.
And we'd investigate the common causes of variation (the societal shift toward heavier and heavier people) and develop solutions that directly attack common causes. Maybe a per calorie tax and exercise tax credit? I don't know. But let's make available to everyone an Rx seems like a special cause solution to a common cause problem. Especially when we don't really have a good theory for this only 80 year old trend in more consumption and less exercise.
If they keep taking it and losing weight year after year, it gets a 300 lb person under 200 in a few years and let me tell you as someone who used to weigh at least (my data back then is sketchy) 280 lbs, going down to 250 is a big improvement even if it's not an immense one.
It can also get some people to lose more than 10 percent. Last November I was over 225, and now I'm 195 and again, that's a very noticeable amount.
Ah! Interesting, thanks.
The definition of obese may surprise you.
Using a BMI of 30+ as the definition of obese, a 6' 1" man weighing 230 pounds is obese. A 10% reduction in weight would move that person to merely overweight, but 230 vs 205 would likely be noticeable. Most people think 300 pounds when the hear "obese," but the definition kicks in much earlier than that and folks can be quite healthy by some metrics while being obese.
I'll note that 6' 1" and 190 is still (just barely) overweight [if overweight is a BMI of 25+]
The average was a 15% weight loss.
But there are responders and non-responders. I lost 25% and my doctor has said that for a significant number of her patients she had to the lower the dose because they lost too much weight.
6 foot went from 235-> 180. I went from having having a large gut to a flat stomach. People definitely noticed. Though the noticed the last 15-20 more than the first 35.
Interesting! I’m guessing that picking 5 and 10 percent for the sake of comparing it with the less-effective medications gave me a wrong impression of how effective it is.
Over the past two years I've dropped from roughly 185 lbs (overweight) to 165 lbs (healthy BMI), which is about an 11% loss, just a little higher than what we're talking about here. The change in my physical appearance has been extremely noticeable.
For people who are obese, even a modest weight reduction (even if not with appearance changes) can have significant impacts on health conditions.
People vastly underestimate the negative health consequences of being overweight.
I've learned some good information from the replies to this, so thanks! But I also want to stick up for my original sentiment, at least a little. Scott asked:
>> Will there be an inflection point, where so many people use semaglutide that obesity becomes unusual again, and then the remaining obese people start using it just to fit in? Will obesity become an optional fashion statement, like shaving your head or getting a tattoo?
If all obese people took this medicine, and they all experienced 15% weight loss, and they all had awesome health benefits, and lived longer, and looked better... that's not enough to make obesity unusual. That's not enough of a change to make obesity into an optional fashion statement. The 5 foot tall, 300-pound people are still 255 pounds.
So isn't the obvious answer to these questions "no"?
I imagine that the folks thinking about an inflection point expect these sorts of drugs to get better over time, not that 10% - 15% would make obesity a fashion statement.
Wait, how is NextMed is promising to get it for $138/month? That's less than half what you said it costs at a compounding pharmacy, and you already said that was inexplicably low.
I read that as being able to get it prescribed at that price. Meaning you have the right/authorization to buy at market price. Could be wrong tho
Do we have any estimate for the other medical treatment costs that are prevented by giving this $15k/yr treatment? Presumably heart disease goes down. What % of our healthcare spending is paying for emergency treatment for heart attack treatments in uninsured individuals?
I could believe this is one of those cases where prophylaxis is way more efficient than treating the later-stage / downstream health incidents -- although I wouldn't predict that we actually reduce medical spending (that would be too good a marketing claim for the companies to miss), this effect might substantially dampen the cost increase.
See the paragraph starting "from a purely economic perspective"
Ok this gives me a chance to talk about my weird way of thinking about exercise and money.
Let's say that people genuinely would pay $15k per year for this drug if they had the money, but money is tight for them. This doesn't surprise me. People spend astonishing amounts of money on clothes, phones, cars, etc. to try to sexually attract people (in part) but this will almost always be less effective than moving from obese to healthy weight, regardless of how much you spend.
Ok, so, the way I think about this is that when I eat healthy and exercise, I am paying myself whatever I would otherwise pay to a drug company to achieve it.
So take the $15k. If doing 1 hour of hard exercise per day results in the same weight loss (which it totally would of course), then assuming a tax rate of 30%, that is the same as me earning $21.42k, paying $6.42k in tax (30%), and then paying the $15k to a pharma company.
So doing exercise earns me $21.42k/365 = $58.70 per hour before tax.
I bet a lot of the obese Americans would love side income of $58.70 per hour, work when you want, plus it'll significantly reduce your anxiety and depression, with no side effects other than positive ones...
Unfortunately, there doesn't seem to be any way for people to monetize this, since the people for whom this deal is attractive would never pay the full price out of pocket anyway. And the people who could pay the full price out of pocket are, for a variety of reasons, less likely to be obese.
>If doing 1 hour of hard exercise per day results in the same weight loss
Does it? That doesn't match my understanding of how it works for most obese people, though I'm not too informed on the matter. It's not just the exercise, but not increasing eating to compensate, which is a monotonous full day low effort task.
But anyway, there are a lot of things I wouldn't do for $58/hr. I can make $35/hr by supervising kids who are doing whatever activity we happen to find enjoyable at the time, and I still only do that an hour a week, despite negative cash flow. If I told my family I was going to do an hour of hard exercise before/after work every day instead of coming home to do stuff with them, they would not be happy, even if I were then fitter and more attractive and energetic at other times. They would tell me to just eat less when we were all eating spaghetti together. This is probably the position of many, many obese people -- in my experience it's a state a person ends up in through things like negotiated family meals, babies, and commutes.
I would be happy to do 1 hour of hard exercise every day, if you could magically give me 1 *extra* hour per day, freezing the rest of the world for that hour, especially my kids.
A day is like a puzzle where pieces have to fit together, and sometimes there is no place left for the "1 hour of hard exercise" piece. There are constraints on time, energy, money, attention, willpower. Eight hours of sleep, eight hours of work, lunch break, commute, shopping, cleaning, cooking, doing dishes, taking the kids to/from school, making sure they are ready for the school next day... oops, the day is gone, and I was also supposed to exercise, meditate, read, learn something new, socialize, perhaps try creating a second source of income... haha, maybe the next day, or more likely the weekend. Oops, something unexpected happened on top of this, the weekend is also gone. Okay, this is a bit of exaggeration, there *is* some extra space, but not reliably.
I usually return from my job at 17:30. Told my wife I could go to a gym along the way and return at 18:30 every day instead. She wasn't happy. So I usually exercise at home after 22:00 when the kids finally sleep, but I am already quite tired at that time.
> with no side effects other than positive ones
For obese people “1 hour of hard exercise per day” would seem to have a likely side effect of soreness and injury risk and pain, would it not? Exercise gets much easier *after* you’ve lost the weight.
If you *don’t* modify diet away from natural inclination the person who exercises more will tend to eat more to compensate and not lose *any* weight…whereas if you *do* modify diet away from inclination the person doesn’t need to do the exercise to lose weight - eating less than one is inclined is the *entire problem*.
Given a choice between being hungry all the time or taking a drug, the drug seems like a better option.
Of course an even *better* better option might be to eat foods that *already contain* whatever drugs you need. In libertopia you’d be able to order tasty personalized MealSquares or frozen waffles or after-dinner mints that come pre-fortified to already contain your daily allowance of semaglutide!
Exercise doesn't actually make you lose weight.
But separate from that, I don't think most people would do embarrassing, painful, and difficult manual labor for an hour a day even if you promised to pay them 60 dollars an hour for it after 3 years.
“ If doing 1 hour of hard exercise per day results in the same weight loss (which it totally would of course),”
No it won’t. Exercise is very good for you but doesn’t have much of a weight loss impact as exercise makes you hungry. If you’d like a link to the relevant studies they can be provided.
Sure, and if everybody spent one hour a day working on improving their skills, many of them could move to more interesting, higher-paying jobs. If introverted, lonesome people devoted an hour per day to forcing themselves to leave home and chat with strangers they would become less shy, and quite likely meet some people who would become friends. If sloppy people devoted an hour per day to organizing and cleaning their home, car, yard and office, they would become spiffy people. (And if my grandmother had balls she would be my grandfather.)
Right. So by definition, people are poor only because they want to be or are lazy.
Lots of people have raised some fair criticisms of this but I wanted to say that this actually might just motivate me to get to the gym more, so thank you
Thanks! I agree some of the criticisms were valid but I also think this framing has been a great motivator for me.
Canadian pharmacies charge about $300 per month for Ozempic.
I'm looking at https://www.buycanadianinsulin.com/product/ozempic/ and it looks like $300 for one pen. I had figured a pen = 1 week, is that wrong?
Depends where you’re at for dosage. A 1.5 ml pen gets you the first 4 weekly doses of 0.25 ml, plus the first of 4 at 0.5, for under $200 Canadian. Next pen that same size gets you the other three 0.5 doses. Then a 2 ml pen gives 2 weeks of 1 ml doses for about $200. If you get up to the 2 ml dose, that’ll be a pen a week.
I'm taking the 1mg/week dose for diabetes (in Australia) and the pen holds 4mg = 4 doses. That's $42.50 for 4 weeks (subsidised for diabetes prescriptions https://www.pbs.gov.au/medicine/item/12075m-12080t). Off-label prescriptions for weight-loss are not subsidised and I think are about $130/month. Big shortages here in the last few months as the off-label prescriptions have increased.
After being well controlled for many years, my glocose levels had slipped up over the year or two before I started on Ozempic. Now nearly back to where the doc wants, plus I've lost 8kg in 8 months without much trouble (only some slight gastro issues, nothing that would make me want to stop using it).
What Kfix said. Though I'm on it for weight loss, I take 1mg per week, so a pen lasts 4 weeks.
Here https://insulin.store/ozempic/ you can buy ozempic for $292 plus a 5% discount. It is also possible to register a new account for a new mail and again get a 5% discount, at the moment it works =)
So . . . what are people's tricks for airline tickets?
Not sure how much of them are true, but that's what I heard as recommendations:
- Buying long in advance is often cheaper. Though cheap tickets are sometimes also available on very short term when the airplanes are not full.
- Prices are cheaper outside of office hours, like in the evening or on weekends. Don't order from the IP addresses of large companies. (I.e., don't order from work.)
- Order from cheap devices. Never order from Macs/Iphones. Apple users get more expensive offers since they accept higher prices.
- If you want to go from X to Y, then buy tickets from X to Z via Y, and simply drop out at Y. Those are often much(!) cheaper than tickets from X to Y. May not work if you have to check in luggage though, that would end up at Z.
Be very careful on that last one. If you do it on a round trip, the airline will likely drop your return flight.
Thank you! I'll definitely be trying these out next time I have to book a flight
I churn credit cards and I have more points than I can ever hope to spend. The idea of paying cash to fly is offensive to me at this point.
In the process of that hobby I learned some tricks but the low hanging fruit is just opening 2-4 cards per year, using your natural expenses to meet minimum spending requirements - that should easily cover the vacation flights most people would realistically want to take, I think.
Do you have any basic beginner tips for churning? I'm sort of interested in it but (I guess like most people) I'm very nervous about ruining my credit accidentally
Laughed and giggled- had fun reading this while learning much.
Practical update. I recently found that some varieties of Blue Cross Blue Shield insurance (through the federal employee program, at least) will now cover Wegovy (Ozempic) for weight loss, starting in January 2023. https://www.fepblue.org/open-season/whats-new-2023
Wegovy is on their formulary as a Tier 2 drug, meaning a copay of roughly $60/month.
https://www.caremark.com/portal/asset/z6500_drug_list807_OE.pdf
I don’t know how common this will be in the coming year, but it’s a start.
I couldn't easily find out in the link, is that on the BCBS lower or higher plan? (Basic or focus)? Thanks for the pointer!
Update -- found it on the formulary-- it's on both plans!
Yep!
I’m in Canada, and started Ozempic for wait loss 7 weeks ago, at my GP’s suggestion. Still only at 0.5 ml/week. (Diabetic dose is 1 ml, weight loss dose is 2 ml.) My doc says it would cost me about $300 a month once on the full dose, and likely wouldn’t be covered by insurance (yet). But my weight loss is steady, about a kilo a week since starting, and side effects are very manageable now. Because I’m still on a dose the insurance is used to, it’s covered. If the weight loss continues like this for a while, I will likely stay on just 1 ml, so as not to lose coverage.
My weight had crept up through middle age. About 7 years ago I had lost the recommended 10% of body weight, to improve cholesterol and sleep apnea. Did that quite easily by cutting out all sugar and refined grains (even fruit except the very occasional tangerine or grapefruit after supper). Maintenance of my lower weight wasn’t that hard, possibly because I’m quite active. Then COVID, work-from-home for a year and a half, everyone in the house cooking and baking up a storm, much less physical activity. All the weight came back, plus a couple of kilos, and I wasn’t managing to lose it again. Cholesterol back up, blood sugar creeping up, apnea worse, one knee starting to give me trouble, hormones getting out of whack because of excess estrogen storage (I’m post-menopausal)….
If these drugs continue to work as well as they seem to, the system will figure out it’s cheaper to pay for them and keep people’s weight down than to withhold them and pay to treat the consequences of the excess weight.
I wonder if how I feel on Ozempic is how naturally thin people feel all the time ; I get somewhat hungry, although it’s ignorable. I enjoy good food, but don’t crave sugar or junk food even when hungry. I eat a small amount and am satisfied, have no desire to continue. If I eat past that point (eating fast can take me there), I feel quite nauseous for a couple of hours.
So WHY is it that medications are so damned expensive in the US? I’ve never really understood.
Asking the big questions: what percentage of people would actually want wings?
I think it depends a lot on the details.
- functional vs non-functional
- instead of arms vs in addition to arms
- do they smell? how long does your daily shower now take? Do you just shampoo them?
- expected impact on your sex life?
I would want functional wings in addition to arms, and will accept significant hits to my living space needs and personal grooming difficulty levels. I think wings wd improve my sex life, based on the weirdness level of wings being a good filter for those insufficiently weird for me to want sex with. But I would rather have a prehensile tail.
I would love to have wings. I have had frequent dreams of flying my whole life. The way I do it in my dreams is to flap my arms really really fast, sort of like a bumble bee does it's wings. It is hard work, but worth it, and after launch I don't need to flap as hard. However, once launched it's crucial to believe I am really able to do fly and that this isn't just another one of those flying dreams, because if that enters my mind I start to fall. . . Anyhow, if I had wings I'd look and smell just the same, and sex would be the same vexing but delightful possibility as ever, but I would be SO HAPPY.
Functional wings on a human sized body with Earth's current atmosphere and biologically normal muscles are simply not possible. Fancy metamaterial muscles is probably the way a sci-fi future would solve it, and I'd take functional wings (in addition to arms) if they had no drawbacks, but I don't want them nearly enough to accept the trade-off of eg. hollow bones
True! But by the time this is possible, we will probably have space stations and maybe colonies on moons or asteroids. I do think wings wd be a good way to move around in pressurized microgravity
I'd want functional wings, if they could be made to work. I might even accept being two feet tall (same intelligence) if it was necessary to be able to fly.
I suspect that for a human to groom wings would take a tool or a partner.
Great post! I’ve done some research on this issue, so here are a few thoughts. I put relevant links at the bottom of the post to support my specific claims.
First, the low volume for semaglutide that you are observing is at least partially due to supply shortages. The drug has been in serious shortage for a while. Novo Nordisk also sells Saxenda (liraglutide) for weight loss. Over the last 2 quarters, Saxenda sales are up 59%, while Wegovy sales are down 18%. Saxenda is priced similarly, and Wegovy is a better product. So I suspect a lot of the Saxenda spending would be going towards Wegovy in the absence of the semaglutide supply shortage.
Second, spending on Wegovy might not fully capture use of semaglutide for weight loss, because some people might be taking Ozempic primarily for weight loss benefits. Ozempic sales are huge, and it is a top-20 spending drug in Medicare. After the clinical trial was published showing sustained weight loss benefits from semaglutide, Ozempic sales growth accelerated (though sales were already growing fast). Even though Ozempic is approved for the diabetes indication, it makes sense that people would take it for weight loss, because (1) there is a big overlap between the obese and diabetic population and (2) Ozempic is more likely to be covered by insurance.
Third, your estimates of the costs are somewhat exaggerated, because the drug manufacturer pays significant discounts to insurers. These discounts do not reduce cost-sharing, but they do reduce premiums. When thinking about the social cost of the drug, it's more accurate to think about the price net of discounts, as opposed to the list price. The Morgan Stanley report that you cited reports roughly a 30% typical discount from the list price.
Fourth, this is nitpicky, but when you say "almost 10% of all US drug spending," you are dividing a 2030 spending projection by what U.S. prescription drug spending was in ~2020. The Medicare actuaries project U.S. prescription drug spending in 2030 to be closer to 600 million, not 300 million. That's still a massive projection for spending in the obesity class. If you believe the Morgan Stanley projection, spending on the obesity class as a share of national health spending will be comparable to peak spending on the Hepatitis C drugs. The financial impact of the Hepatitis C drugs was a huge story. But this would be even bigger, because the Hepatitis C drugs were a cure, such that the spending surge was short-lived. Conversely, the obesity drugs are chronic medications, and we should probably expect volume to continue to increase post-2030.
Fifth, a remarkable thing about semaglutide that may have been under-emphasized in your post is the extent to which the weight loss benefits are being sustained. People who successfully lose weight tend to have a very difficult time keeping the weight off. To my knowledge, before semaglutide, the only intervention that had been demonstrated to sustain a >10% weight loss benefit for more than 1-year was bariatric surgery. So far, clinical trails are showing sustained weight loss benefits from semaglutide for at least 2-years.
Sixth, this post focuses on GLP-1 agonists, which makes sense, because those drugs are starting to have an impact today. But the Morgan Stanley report also notes that amylin analogue cagrilintide may be approved for weight loss as soon as 2025. This drug has a completely different mechanism than semaglutide, but likely offers similar weight loss benefits. The crazy thing is that the weight loss benefits stack. So Novo Nordisk hopes to sell Cagrisema, which combines amylin analogue cagrilintide with semaglutide, and hopes to offer a ~30% average weight loss. This is roughly double what semaglutide offers, and is getting closer to bariatric surgery efficacy.
Seventh, if Medicare decides to cover Wegovy, it would be relatively affordable for Medicare beneficiaries. Starting in 2025, out-of-pocket costs for prescription drugs will be capped at $2,000 for Medicare beneficiaries. And most Medicare enrollees with a 30+ BMI are probably already spending a lot on drugs. So at the end of the day, the marginal cost might be $100 per month or even less. And if you are near-poverty, you get cost-sharing subsidies, so the cost is only about $10 per month. Of course, this all depends on Congress changing the law such that Medicare can cover obesity drugs. Currently, there is a statutory exclusion that can only be changed through Congressional action.
That’s all I have for now. Here are some citations for various claims I made in this comment.
Semaglutide is currently in shortage.
https://www.ashp.org/drug-shortages/current-shortages/drug-shortage-detail.aspx?id=813&loginreturnUrl=SSOCheckOnly
Recent sales growth for Saxenda has been much faster than Wegovy.
https://www.novonordisk.com/content/dam/nncorp/global/en/investors/pdfs/financial-results/2022/Q3-2022-financial-workbook.xlsx
Ozempic was a top-20 drug in Medicare for 2020.
https://data.cms.gov/summary-statistics-on-use-and-payments/medicare-medicaid-spending-by-drug/medicare-part-d-spending-by-drug/data
For these obesity medications, manufacturers pay a 30% discount to insurers off the list price.
https://khn.org/wp-content/uploads/sites/2/2022/09/Morgan-Stanley_Unlocking-the-Obesity-Challenge.pdf
Prescription drug spending in the US in 2030 will be closer to 600 million than 300 million.
https://www.cms.gov/files/zip/nhe-historical-and-projections-data.zip
Context on the financial impact of Hepatitis C.
https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2015.1194
The benefits of semaglutide are being sustained for two years.
https://www.nature.com/articles/s41591-022-02026-4
The Medicare out-of-pocket cap will be $2,000 in 2025.
https://www.kff.org/medicare/issue-brief/how-will-the-prescription-drug-provisions-in-the-inflation-reduction-act-affect-medicare-beneficiaries/
Background on cost-sharing subsidies for low-income Medicare enrollees.
https://www.cms.gov/files/document/lis-memo.pdf#page=3
Another data point: was prescribed liraglutide in Switzerland. The cost is about $150 / month on the highest dose.
I lost roughly 8% of weight, then went off it due to gastrointestinal problems. It's very far from a miracle drug, feels pretty nasty. Have since gained back the weight (confounded with other medical issues, complete lack of exercise). I might try again with a lower dose.
I was on liraglutide before I switched to semaglutide. I noticed the ratio of gastrointestinal issues to weight loss was lower with semaglutide. With liraglutide I felt much more full and nauseous and had worse heart burn. Then when I switched to semaglutide my appetite dropped significantly and I experienced much less fullness/nausea/heart burn. I suspect liraglutide has a relatively stronger effect on gastric emptying than appetite when compared to semaglutide.
Thanks, I will bug my GP about that!
Serious though somewhat rude question - for people who don't go to the gym, why not and what would get you to go? It seems like for an individual doing an hour of cardio 3-4 days a week is a much lower hanging fruit than getting a prescription, dealing with insurance, remembering to take the medicine, and dealing with the side effects. I wonder if we're missing a similarly low-hanging fruit on a large scale by not subsidizing gym memberships or having state-run public gyms (this seems logistically way easier than solving the food desert problem). I've been fortunate enough to live within a short walking distance of a gym my whole life and although I'd probably still work out even if I had to drive/walk longer I probably wouldn't go as frequently as I do and might not have started in the first place.
This may sound harsh, but after reading that chunk of goo, I want to do to Mr/Ms Kelly McGonigal what the Romans did here:
https://en.wikipedia.org/wiki/Poena_cullei
"Are you enjoying that yet, Kelly? Keep at it, your brain will learn to adapt, and it will become an acquired pleasure drowning while being bitten, pecked, and scratched by snakes, dogs and poultry!"
This sounds like all the people pushing how drugs really are great and will change your life for the better if you only try psychedelics/mushrooms/weed/nootropics on here. I am coming to the opinion that exercise *is* a drug, and you lot are junkies who need your fix or else.
As a formerly 315lb person I am inclined to agree. I started lifting heavy free weights this year and it put me in a caloric deficit that I literally can’t eat enough most days to meet so I’ve started losing fat fast while building significant muscle. My only diet change was to make sure I eat 0.75g of protein per pound I weight every day.
It cured some chronic back and knee pain I had as well. Down about 20lbs of fat and added about 10 lbs of muscle so far… and it’s only 1 hour, 3x per week.
I don't find any of this surprising as I was already well-aware sedentary life and hating physical activity is more or less the norm for industrialized nations, but yes, it is radically contrary to my own personal experience. Everyone in my family at least lettered in two high school varsity sports. My dad was offered a NCAA scholarship for baseball, but didn't qualify academically. I won multiple California state championships in track and cross-country, and then got really into sort of outdoor adventure type stuff in my 20s, open-water swimming, thru-hiking the Pacific Crest Trail, alpine mountaineering, rock climbing, basically anything you might picture Bear Grylls doing for fun (and, like him, I also served in the Army, though not spec ops).
The only time I have ever been inactive was the 2nd half of my 30s because of severe spinal degeneration. I eventually needed five surgeries, couldn't put socks on without an assistance device at one point, and was more or less bedridden more than half the time during the worst of it. Even then, I never got particularly fat. In my 40s now, I can't do any sort of long-duration activity without totally knotting up and barely being able to stand, so the types of endurance stuff I used to do is out the door, and wilderness treks are probably not safe. But I've got into weightlifting instead because I absolutely need to be doing something physical. I make no particularly effort to be lean or lose weight. I haven't eaten at an intentional calorie deficit in over a decade and am currently trying to gain weight, but I'm still 6'2" 190 lbs at somewhere in the area of 10-12% bodyfat. Nowhere near "shredded," but every muscle is visible. There's fat on me, but not enough to result in any visible rolls. Nothing that jiggles.
It is absolutely not miserable to train and become better at something, and for that matter, given I couldn't pick up my cats six years ago, it is not miserable to go from that to being able to lift multiple of my own bodyweight. Exercise is not a chore to me. It's as natural a habit and a part of life as eating out with friends and watching television seems to be for an average American. And, of course, given this kind of life history and my family, that has been the case for many, if not most, people I have ever known and spent a lot of time with, anywhere except on the Internet.
So yeah, I see the studies and the anecdotes and see the obesity rate skyrocketing in the general population and it's obvious something is up, but it gets even more frustrating that it doesn't have to be this way. I realize this is at least partly genetic. I don't have a ton of athletic talent, but certainly some. But a lot of this is just habit, and it's habits that were instilled at a young age. They've been part of my personal and cultural identity for my entire life and really before that since it's a part of my family as well. When I played as a kid, whether alone or with friends, at least half of that play was either a sport or we just drew lines on the street and raced each other. The other half was more legos and sometimes video games, but that never got to be dominant. I still know a lot of those people, and I'm not going to say none of them ever got fat, because one of them did, but it's literally only one, and her entire family is fat.
All of these people saying movement and exercise hurt and make them miserable. You know what hurts me? Being sedentary. When recovering from all the spine problems, the biggest problem I had is my hips started to feel like they were made of concrete. I couldn't even straighten my legs if I sat upright. My hip flexors were constantly aching and throbbing. All of that totally went away within a week of starting to squat. And I don't squat particularly well. I imagine I never will. My hip mobility is still terrible. But a lot of joint pain goes away when those joints are supported by larger, stronger muscles that get used regularly.
Ten years ago, I may have fit your "inspiring" category. Now I don't anymore. I tried the "no excuses" thing, which works... until it doesn't.
At what point does an excuse become legitimate? It's not never. At what point are we allowed to say, "I have limitations that I have so little direct control over that it's unreasonable to expect me to overcome them. I should devote my resources to something else"? There is a long-toed armless man, Liu Wei, famous for playing piano with just his toes, but we don't normally expect the armless to become concert pianists. Liu Wei, impressive as he is, also isn't competitive as a concert pianist against concert pianists with actual hands.
"In professional poker—my former field—knowing when to quit is a survival skill that separates elite players from the rest of the pack. Yet, despite the obvious virtues of folding a bad hand, in most areas of life human beings tend to extol perseverance, so much so that a quick Google search turns up many other stories of distance runners around the world suffering horrifying injuries mid-race but refusing to give up. We look at these types of stories and think, I wish I had that kind of grit.
"But is grit a virtue when we stay too long in bad relationships, bad jobs, and bad careers?"
Or if we let ourselves persist in discomfort that results in long-term damage to our bodies in hopes that "no excuses" can only make us stronger?
Cognitive psychologist and professional poker player Annie Duke remarks, "Contrary to popular belief, winners quit a lot. In fact, that’s how they win."
https://www.theatlantic.com/ideas/archive/2022/09/why-quitting-is-underrated/671562/
"It is absolutely not miserable to train and become better at something,"
That is not true. It can be very miserable to train, become quite good at something, then have your prowess snatched away at a moment it matters most because your body failed you in a way mostly outside your control.
That kind of heartbreak can be tough to deal with, and happens to some people a lot. Perhaps not very many people, but the fact that it happens *at all* contradicts assertions that training is absolutely not miserable.
It happens to me as a singer, and is one reason I never tried to sing professionally. Residual tobacco smoke from a previous auditionee or on the auditioners' clothes, or even on transportation to the audition, can physically tank my auditions with asthma. (Sometimes cat dander does it, too.) If I do wow someone at an audition, I might be voiceless from lung trouble by time of performance. I have an unpredictably crappy body. Possibly better medical technology and more attentive medical care would help, but it's fairly obvious by now that my sheer determination alone just isn't enough.
So much can go wrong, no matter how well-rehearsed I am, that sometimes I regret having loved to sing. But I also love music, and can't seem to quit it – but not because it isn't making me miserable: quite often, it is.
I am overjoyed for you that your recovery from spinal degeneration went better than is typically expected. It sounds like you had atypically good results even for a "good patient". When and even whether back surgery actually helps is still poorly-understood, so I'm glad it worked for you. Having previously been a very healthy, active person no doubt helped you, but it sounds like one reason you could be that previously-healthy-active person is because it you didn't start life dealing with hard-to-control health problems.
"Most people seem effectively crippled to me, and I don’t understand how they can stand it."
As one who was born that way, and who wouldn't have survived childhood in an earlier time, it can be hard to stand, but there you are.
"Maybe I’m just lucky for having the right genes. I’m convinced that the way genes make the biggest difference is in what you feel motivated to do. Some people have natural talent, but talent is only expressed through practice. Anyone would get better at piano if they did it for 10 hours a day, but maybe only people with brains wired a certain way can actually find joy in that."
I doubt genes influence motivation more directly than they do bodily features, like whether one's airway is reactive, tissue fragility, match of body type to choice of activity, and pain threshold and tolerance.
Also, speaking as a musician who only learned to practice deeply in college, environment really, *really* matters to whether one is "wired" to put in long practice hours. Many people simply don't have environments where they *can* practice uninterrupted. Those who do usually do so, not merely because of individual force of will, but because those around them support or at least tolerate them putting in long practice hours.
Practice time is *not* supposed to be performance time. It should not be time you're pathologically worried about offending others with your mistakes. It should be a time to work through the mistakes, as long as it takes, as many mistakes as it makes. If the other musicians in your family keep interrupting your practice time with, "You mean you still don't have that right?" "Can't you practice something else now, we're getting sick of this," "I think your intonation is terrible and is giving me a headache," you become "wired" to find practice stressful, hopeless unless you get it right the first (or at least first few) times, and full of distractions taking you out of the music – not because of your genes, but environment.
Re: genes and motivation - there's actually a long-running experimental evolution experiment on "high runner mice", mice which have been selected to run on their wheels as often and long as possible. While there are musculoskeletal differences, these lagged behind performance, and a lot of it seems to be in the brain, especially motivation.
If you'd like to read up on it, the experiment is run by Ted Garland at UC Riverside.
The first thing I pull up searching for Ted Garland's "high runner mice" is a report on how changing gut microbiota affects those mices' performance:
https://iigb.ucr.edu/news/2022/06/23/theodore-garland-lab-demonstrate-how-antibiotics-affect-running-performance-mice
The report suggests even fairly small changes to environment, like a temporary course of antibiotics, can significantly tank these mices' performance, perhaps by making running more metabolically difficult for them.
As I understand it, "high runner mice" are a strain artificially selected for the trait of preferring wheel-running as a source of amusement in their caged life. That this trait can be bred for isn't surprising, but how much does it say about the genetics of motivation more generally, especially if simply changing something like gut microbiota significantly reduces the bred-for trait?
Marcus had written, "Anyone would get better at piano if they did it for 10 hours a day, but maybe only people with brains wired a certain way can actually find joy in that." I replied with,
"I doubt genes influence motivation more directly than they do bodily features, like whether one's airway is reactive, tissue fragility, match of body type to choice of activity, and pain threshold and tolerance." Posing a false dichotomy of brain-vs-musculoskeleton could miss airway reactivity and pain threshold/tolerance, as well as gut microbiota, and other physical factors influencing motivation. True, pain threshold/tolerance *is* quite brain-based, but is also a more specific difference than "maybe some people's brains are wired for motivation and others' aren't".
I see little evidence that motivation is something you either have or don't, irrespective of environmental influence, including whether you're lucky enough to be in an environment that gives you healthy exposure to whichever activities do motivate you more. "High runner mice" are "lucky" to live as lab mice, for example, in a standardized environment with working mouse treadmills.
Though, has anyone tested what happens to "high runner mice" deprived of the environment they were bred to find rewarding? How is their motivation affected, say, by treadmills that stop working unpredictably?
A treadmill rigged to shock mice who fall behind is used for forced-running tests. What if the shocks are random, not a predictable consequence of falling behind? What if mice are shocked for getting ahead on their treadmill? Are "high runner mice" still "inherently" motivated to run under such circumstances?...
Despite all our rage, we are still not just rats in a cage.
I almost thought this was a parody of something a thin person would say to a fat person.
Marcus, what works for you isn't going to work for everybody.
Perhaps thinking about the reality of other people's lives might take you to a place other than "shock and horror." Not just about physical fitness, but about . . . well, anything.
Thank you.
I've gone to the gym off and on over the course of 20+ years.
Sometimes it really is difficult to prioritize. It takes a larger chunk out of one's day and energy budget than most people estimate. Prep, commute, exercise, shower, and reduced energy/focus for at least an hour.
Very simple: I can't exercise due to health issues.
I despise exercise. It is so, so, so boring.
I tried going to gym maybe 3 times, each time lasting about half a year, and I hated it every time and dreaded the day when I went there. It IS boring, and the atmosphere is unpleasant, and the aftermath is painful. I wonder, though, if "the future of fitness" is in VR. If I was cycling or rowing a boat in a game (or at least in an interesting environment), I think would enjoy it more. I'm not sure how can it be applied to lifting weights, though. (Why not REALLY cycle or row a boat? Because it's too cold 6+ months out of 12 here, and I only ever had time in those months).
Actually, rowing is one type of exercise I enjoy. Wish I could do it more often than once a year or so, but it requires too much free time.
I think this is...perhaps not appropriate advice for the intended audience.
Per my understanding, most workouts are not going to burn more than 300-400 calories, which is good but trivially overcome by bad diet, like a single candy bar. I have met a few people who do, legitimately, burn enough calories to not worry about their diet but they're trained runners and bikers. For example, guys who run 5-10 miles a day at pace for an hour can reasonably burn 700-1000 calories and get away with eating pretty badly (1). But again, they've trained to run a 10k every day and can do it comfortably; the average obese individual can't burn calories like that and, honestly, would be lucky to walk for an hour straight.
I seriously doubt your average 230 lb+ individual can burn enough calories at the gym 3-4x a week to meaningfully impact their weight. And, honestly, I don't think there's much low-hanging fruit here. Lifestyle change will generate results but it needs to be pretty dramatic; think completely altering your diet or training to run marathons. If just showing up at the gym helped you lose weight, everyone at Planet Fitness would be thin.
(1) https://captaincalculator.com/health/calorie/calories-burned-running-calculator/
Is there an effect where exercising also increases the amount of snacking? I was operating on a mental model of 'given diet vs given diet + exercise' but if it's 'given diet vs given diet + exercise + additional snack' that's not as cut-and-dry.
I think the lifestyle change doesn't need to be dramatic but it does need to be consistent; most PF members don't go at all and a significant number of those that do go once a month or less. Some cursory googling suggests that it takes roughly a 3500 calorie deficit to lose a pound of fat; if you keep the same diet and do a 400 calorie workout three times a week for a year that's ~18 pounds lost.
The emphasis towards dramatic lifestyle changes probably does more harm than good. It's much easier to sustain a habit than it is to start one and the more dramatic your change is at the beginning the harder it is to start and the more likely you are to give it up in the first month.
I dunno about the snacking. One the one hand, you will definitely need to eat more on a high cardio (like 6k runner) or serious weightlifter. On the other hand, I don't have any snacks in the house, so I don't have experience.
On the need for dramatic changes...I mean, this is an area of personal experience, not academic study, but my understanding is the overwhelming clinical evidence is that virtually no one is able to sustain significant weight loss over a 5 year period. For example, the first pubmed article I found (1) says that you should expect to regain >80% of the weight lost during a diet program within 5 years and, in talking about how to help patients, it mentions that most people expectations are too high and that losing 5-10% of their bodyweight is the most that can reasonably be expected from diet and exercise. Trying to be anything but an extreme outlier fails.
I mean, I get CICO, these things should theoretically work but, to the best of my understanding, we have a deep and robust literature showing that this doesn't work.
(1) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5764193/
My take on “exercise doesn’t make you lose weight” findings is that the experiments are done on people who don’t usually exercise. So they fail because those people don’t continue exercising because they are selecting the people who don’t like exercise not because exercise doesn’t work. People who have figured out ways to get exercise regularly and continuously don’t feature in those studies but they definitely exist and are usually not obese.
My experience is that getting reasonably hard exercise for one hour per day five times a week will definitely lower your weight. I am no superman but I managed to do this while working long hours and bringing up a family by exercising in the morning before work started by getting up an hour earlier. It took a lot of willpower to initially start this but eventually it became a habit. Exercise first thing in the morning removed all my end of day or midday excuses, like I am busy or I am too tired or my friend want to go for a lunch etc. But that trick may not work for you. Note I don’t do any special eating and I drink alcohol.
The other thing about exercise is that it is very slow to make progress, maybe a year or two before you really start seeing results as the amount of exercise you can do at first without getting exhausted is small. As you get fitter you can do more exercise in the same amount of time..
Finally you don’t need a gym, a 5k run can be done anywhere and even in high heat and humidity like Houston in the summer.
I agree with everything you have said here, except that it doesn't hold up in the real world.
If you could figure out a treatment that - when applied to real people in the real world- got people to go exercise, you would likely earn yourself a Nobel. No one has, yet.
Most people who can exercise don’t go to the doctor to get them to tell them to exercise to lose weight, they have already figured it out on their own. So you are right that as a treatment it is not much use, but it doesn’t mean that you, a randomly selected individual, would not be able to lose weight by exercise. Put it this way, some people can’t study (perhaps because of ADD), and if you try to find ways to get them to study you would probably fail, but it doesn’t mean that studying for exams doesn’t work.
I think that *if* the "diet and exercise don't work" research turns out to be wrong, it's likely to be for reasons similar to what you are describing - that these studies disproportionately enroll the really hard cases who are unusually bad at diet and exercise. However, I'm going to need a lot more than your personal anecdote before I conclude that the existing body of research is wrong.
Exercise doesn't just burn calories. It changes your body's expectations + 'operating mode'.
I'm reasonably overweight (6'2 220-ish) and have been forever. Recently started going to the gym and lifting weights fairly seriously. After six months I am pretty much exactly the same weight I was before. I might look a little better, and I enjoy going to the gym, but I think two things you might be missing are that—
1. Exercise just doesn't work that well for weight reduction if your diet sucks. I am motivated to look good to not waste all the time I spend at the gym, but also I just ate a big bowl of barbecue chips while reading this post. It's way easier to eat food that's bad for me than food that's good for me, plus I love the way all the food that's bad for me tastes and have my entire life. I followed a Mounjaro subreddit out of curiosity after Matt Yglesias's bariatric surgery piece came out, and the thing people talk about a lot on there is how the drug makes them just... not eat in all the disordered ways they used to eat. Like they no longer want to wolf down a bunch of cereal late at night, they don't feel like they need three sodas at lunch, a lot of them are even finding they don't want alcohol as much, which is a fascinating window onto whatever these drugs are doing.
I'm not overweight enough to really want to try Mounjaro (at least not yet), but I absolutely relate to their stories—I just have a really hard time fighting the urge to snack in stupid and not even very satisfying ways, and I think a lot of people are like that. I have every reason to want to eat better, but I've tried for years and it hasn't happened yet. If, five years from now, the diet drugs appear to have no unusual side effects, I would absolutely pay $100 a month to not eat a big bag of M&Ms in the car twice a week and derive zero enjoyment from them. That'd be saving me $30 a month on M&Ms! (I'd keep paying $10 a month for the gym, too.)
2. An hour of cardio 3-4 days a week is for a lot of people way higher on the fruit tree than a drug you have to inject once a week or however this works. What dollar figure would you put on 3-4 hours of free time a week? We just had our second kid, so my number is temporarily much higher than it was last month. Cardio can be rewarding on its own merits, but so can losing 15% of your body weight with a pill and spending 4 hours a week building ships in a bottle.
That's reasonable. I'm biased here as a young guy, since I don't have kids or significant non-work commitments so it's easier for me to fit that in to my schedule. I also really enjoy exercising so it's easier for me to prioritize - to answer your question about the dollar figure, I would say it's low or even negative since it's eating from my 'netflix/reddit/hobbies' time rather than 'family/work/self-improvement' time.
Have you just been doing weightlifting or cardio as well? I wouldn't expect someone to lose significant weight from just weightlifting, although you could probably have some recomposition effects (lower bodyfat% and more lean mass) while staying at a similar weight.
I guess my argument comes from the conventional wisdom is that it's easier psychologically to do something (exercise) than it is to not do something (eat less). If we shift eating less from 'not doing something' to 'doing something' (taking an injection or pill) then the tradeoff becomes something like money + time cost of taking the drug vs exercising, which is probably more towards the drug for most people.
"I'm reasonably overweight (6'2 220-ish) and have been forever. Recently started going to the gym and lifting weights fairly seriously. After six months I am pretty much exactly the same weight I was before.
...
An hour of cardio 3-4 days a week is for a lot of people way higher on the fruit tree than a drug you have to inject once a week or however this works..."
I have another (late) anecdote to contribute to this thread. Even an hour of cardio 3-4 days a week may have limits on how effective it can be [for weight loss].
I am a bit under 6' 2" and am currently around 220 lbs. I 'm down from 232 in March, which was up from 220 in late fall of 2020, which was down from 225 in early 2020. I lost weight by doing a lot of walking during the early part of Covid, then put it back on, then was able to go back to the gym and have started losing. I *did* exercise all through Covid, but clearly there was a year in there where I still gained 12+ pounds.
And ... 232 -> 220 in 8 months is 12 pounds over 8 months. For a while I was losing 2 pounds/month, so things have plateaued ... and maybe will start dropping again. Plateaus seem to be common. But at 1.5 pounds per month I'll still need an additional year to lose 10% more and get down to 200 pounds.
And ... my gym routine is pretty intense for a non-athlete. I burn around 850 calories in an hour (as reported by the machines, but also confirmed by on-line calculators that take as input my weight, heart rat during the exercise and duration).
850 calories burned in an hour is, objectively, a LOT for non-athletes. I alternate elliptical and stairmill and my stairmill days usually see me 'climb' 190-ish stairs in the hour. My rate limiter is that I don't want to exceed 85% of my max heart rate for very long and I don't want to be in the gym for 2 hours at a time. When all was going well this was resulting in 2 pounds of loss per month. I do not expect very many people will be willing to do this on an ongoing basis. And operating at 80% - 85% of max heart rate for an hour is a pretty big ask for most people, too.
I've recently added weights for upper body and we'll see how that goes, but, yeah exercise is a good thing but makes for VERY slow weight loss.
[Also, to (again) point out that obese isn't what a lot of people mean. At 6' 1" and 230 pounds I was obese using the BMI calculators. I was also able to climb 180+ flights of stairs in an hour. I looked overweight but maybe not the stereotypical image when people think 'obese.']
Exercise is just a tough way to lose (and maintain the loss) weight.
Firstly: exercise doesn't work to reduce weight, it's almost all a matter of diet.
Secondly: gyms are beside the point. Almost anyone can do cardio or weight training for free in their own home or outside, with barely any equipment. You can run outside, or do jumping jacks in your house, or do push-ups and sit-ups, and so on.
People don't because it's unpleasant. It's suffering, and it's suffering that you have to force yourself to do, which makes it doubly hard to actually do it when you could do anything else with your time.
Ways to get people to exercise that makes it not feel like suffering exist (eg vr videogames), but they're still pretty niche and no one has figured out how to sell it to the masses.
> People don't because it's unpleasant
I'm surprised to hear this sentiment and the similar comments elsewhere in the thread. I really enjoy exercise for its own sake, and most people in my friend group also do (but I've met a lot of my friends at the gym so of course there's a bias there). Just as an informal poll:
https://strawpoll.com/polls/YVyP2AVE1gN
I was under the impression that logistical challenges were the main barrier for a lot more people, so this is a valuable perspective for me to hear.
Exercise that's delightful in an already-fit body is not necessarily so in an unfit body, whether the body is injured, ill, or just awkwardly-sized.
Both my husband and I usually enjoy push-mowing the lawn. I've always been sickly. He was healthy as a horse until recently. Both of us are having trouble getting timely medical care in a backed-up system. Unsurprisingly, push-mowing has (hopefully temporarily) lost its zing for us. As have other, more conventionally-interesting, active pursuits. This relatively sudden change from "we positively enjoy even push-mowing" to "what'll break next if we're too active?" is a fairly dramatic lesson in what might demotivate people.
>I really enjoy exercise for its own sake, and most people in my friend group also do
>Exercise that's delightful in an already-fit body is not necessarily so in an unfit body, whether the body is injured, ill, or just awkwardly-sized.
This. Moreover:
1. Jogging / running / any intensive cardio is absolutely horrible if you have never done such thing before / since childhood. Everything aches, breathing is all weird and possibly unpleasant. It took me some months to experience anything resembling "runner's high".
2. Fundamentally, running or weightlifting is pretty boring activity. It is not of course totally uneventful: I can look at scenery while running, I need to concentrate on posture and stuff while doings reps, but fundamentally, it is repetitive. Actual competitive sports are much more active and interesting: there are much more varied skills to build, many different situations, moving your ass is much more motivating. However, if you are out-of-shape, you will soon notice that competitive sports are competitive. If you compete with more athletic people, you are going lose, and many people won't find it fun.
Jogging never worked for me. Alternating sprinting with slow walks did until I blew an ACL. "Runner's high" just isn't for everyone.
It can take surprisingly little strength training to be (rather than look) healthier: https://www.painscience.com/articles/strength-training.php – though, of course, our typical notions of fitness aren't just about being healthier. They're also about looking better.
Even sports competitions I could win bored me. Hiking, cross-country skiing, dancing, heavy yardwork are more amusing to me, if I'm not too injured/ill for them. Heck, so is high-intensity interval training on an elliptical – provided I don't have to worry about bonking my head on the ceiling (which, in our new place, I do) – if only because it takes relatively little time.
Getting some sort of amusement out of exercise seems extremely important to making it a habit. It's all the more important the more uncomfortable your body is.
I can see both perspectives because I also enjoy exercise (running and cycling), but also regard it as unpleasant, at least some of the time. I guess the parts we enjoy (fitness, sense of progress and accomplishment, socialisation with friends) outweigh the inevitable aches and pains, and there's probably some amount of satisfaction derived from overcoming (mild) suffering.
Nah, Drethelin is right; it's suffering. It may be suffering that does you go, but when you're hobbling around the day after all that 'healthy' exercise because your muscles are tight and your joints ache, that does not encourage you to keep doing this.
I honestly think this is the big, unacknowledged difference: some people enjoy exercise for whatever reason, and some people don't, because it hurts and you can feel the pain while the benefits are largely invisible.
"That only happens when you're out of shape."
Being well and truly *in* shape just isn't going to be an option for some people, even if the look visibly trim and toned.
"Your body adapts."
Your body adapted. Not everyone's body can.
I spent nearly all my time from high school to childbearing at normal BMI, never washboard-abbed but quite flat-tummied, toned, with positively burly legs for a gal. I still wasn't really in shape, and could never be. I did the best I could, which was sometimes pretty damn good, but my body still failed in stereotypically "unfit" ways.
"I used to get completely winded and feel like I was dying when I ran"
No matter how fit I am, getting completely winded during exercise could happen at any time for me, from asthma. More than once, I've been tooling along on my bike, suddenly found pedaling "mysteriously" difficult, assumed it was "just asthma again", and only after stopping for another reason, realized I had shredded a tire or had back brakes rubbing the tire rim. Imagine being in a body so unreliable that you don't even think of equipment failure while your equipment is failing in ways that would be obvious to nearly anyone else! No amount of fitness gets me to not have that body.
Strength training can compensate for congenitally-weak connective tissue, too, but nothing makes that congenital weakness disappear, and with it, the risk of hard-to-rehab injury and immune derangement that interferes with fitness goals.
If nearly everything else is going right in life, juggling all the little extras needed to stay fit in a congenitally-unfit body can be doable. Not much has to go wrong, though, for the impediments to exercise to snowball.
I love the feeling of sore muscles, and the pain of pushing a set to failure. Besides the sense of progress, it grounds me in my body.
Pain not associated with actual disease or injury can safely be sublimated into pleasure (see also: spicy food, BDSM), this is a useful and healthy cognitive trick
"this is a useful and healthy cognitive trick"
For training rats to run mazes, perhaps. If you enjoy being a rat on a treadwheel, don't let me stop you. But I am not going to put on whiskers and a tail for anyone's urging.
Well, raj, think of a kind of pain you do not like. How about stitches in your side when you're running? Headaches? Being extremely tired and drowsy but obligated to stay awake? Lemon juice in a cut? Labor pains? Break-up pain? OK, that pain you do not like and can't sublimate? That's what exercise-related pain feels like to some people. Some people can't sublimate it.
If exercise hurts instead of being fun, you're probably doing the wrong type/intensity of exercise. If your diet and sleep are reasonable, the comfort zone will gradually expand so long as you are regularly working at the limits of the comfort zone. Even if it's just walking at 3mph for 10 minutes daily, that is hugely better than being sedentary, and doing that regularly almost anybody could work their way up to 30 minutes at 3.3mph or something without pain.
> Pain not associated with actual disease or injury can safely be sublimated into pleasure
You are typical-minding.
> see also: spicy food
I also hate that. I've only gotten an endorphin rush from spicy food once or twice. If I could reliably do that, I would put up with the pain. But I can't, so I won't. Also - capsicum tastes very soapy for me, though I don't have that problem with other sources of heat like mustard or horseradish.
"Pain not associated with actual disease or injury can safely be sublimated into pleasure"-- it isn't necessarily safe. People get exercise and BDSM injuries.
So far as I know, people only get spicy food injuries in eating contests.
> People don't because it's unpleasant. It's suffering, and it's suffering that you have to force yourself to do, which makes it doubly hard to actually do it when you could do anything else with your time.
I find it interesting how differently people feel about that. I really look forward to excercise, to the point where I probably train more than the optimal amount just because I like doing it and sometimes have to hold myself back
I'm usually anhedonic, video games and TV bring me almost no pleasure anymore but pushing my body is consistently rewarding.
I think it's one of those things that's possible to learn to like - it is not *inherently* unpleasant, our bodies are designed to work hard and in fact it is good for your health so it shouldn't be sending painful signals. But perhaps for those far outside the envelope of 'normative health' that's not true, and/or they associate an anxiety with the activity (as opposed to others who associate it to euphoria?)
After starting a diet the summer before I turned 14, I've spent most of my life at a normal BMI, whether I exercised at a gym, outdoors, or at home. I'd temporarily creep into overweight if seriously injured. Then I had kids. And COVID happened. And the medical system is still backed up, and I can't get timely asthma or rheumatological (for EDS) care. We also know something we didn't before, which is that asthmatics' individual environmental hygiene isn't as important as we thought, while the bugs asthmatics catch from other people are more important triggers than we thought:
https://www.theatlantic.com/health/archive/2021/07/the-pandemic-drove-asthma-attacks-down-why/619396/
Hire someone to supervise my kids so I can go to a gym to breathe in others' germs, after I caught a lung infection so bad during my last pregnancy I nearly ended up with a COPD diagnosis on top of asthma? Especially when I can't get timely medical care? No thanks.
I should get back to my old, fitter self, not least because pudge is inflammatory and hard on the joints, making both asthma and EDS harder to control. But go to a gym to do it? Not feasible for the near future.
Before I got in semaglutide I spent 40-50 hours on pubmed looking for any exercise/diet regimen that was shown to be effective over 5+ years. There aren't any. Only a slim few manage to keep weight off for long periods of time and every one I've known has become obsessed like anorexia level ocd obsessed with keeping it off. They build their entire lives around it.
Anecdote:
I've had time in my life when I went to the gym (5-6 hrs a week) other when I didn't. When I go I'm in better shape and more muscular but I'm not any lighter.
Data:
Also if you look at pubmed exercise causes minimal weight loss unless you're doing herculean marathon training levels of exercise.
Isn't there an issue with these studies, in that you would stop participating in weight loss trials if you successfully lost weight?
I usually force myself to go to the gym once a week, but the main reason I don't go more often is that it leaves me exhausted for the rest of the day, and with muscle pain for 3-4 days, and I can't afford to be that non-functional more frequently than that.
I keep wondering if that stops being the case when you reach a certain level of fitness, and how far from that level I am.
(You're probably thinking "you're overdoing it", but I mostly either lift wimpy little free weights in the <20kg range, or do classes intended for "those new to fitness")
I'm loathe to give workout advice, but 20kg is a lot. Wimpy is 1kg. I don't know about the classes, but even if it's for newbies, it may be calibrated towards healthy 20 year olds.
My point is that the bottom of fitness for sedentary, unhealthy people is way lower than most people, including fitness trainers, expect.
Yeah, I think you're right about the expectations of fitness trainers. I tried saying to both the class instructor and the gym manager that I find the classes too demanding and that maybe they should be at a more approachable level if they're marketed to beginners, to not scare people off and to help them ease gradually into a sustainable fitness habit, but they both just doubled down and said it's good if it's challenging.
I recommend the youtube vids by rennaissance periodization for guides about getting started. The way to do it seems to be based on targetting a certain number of reps to get to failure, and seeing what weight will do that for you.
e.g. If I tried my absolute hardest gun to my head, i could do 10 reps at X weight, so i will do 8 reps at X weight, with 2 'reps in reserve'. (failure means you can no longer do it with good technique, you don't want to do a super sloppy rep and get bad habits). And then you keep adjusting your weights to keep your maximum reps more or less consistent. The number of reps you should target depends on your goals (strength is something like 3-6, muscle size is like 6-12 or something and endurance is more).
And then you can do multiple sets of however many reps it is and do more sets in a day as you get more advanced, but getting close to failure within a set is important and kind of non-negotiable to get any results at all. To start with you can even do just one set of however many reps get you close to failure, and then gradually add more sets. (but do like, one set of a bunch of exercises to target your whole body).
here's a link to the first in the playlist of how to design a workout for beginners.
https://www.youtube.com/watch?v=QlZPCJJOUfQ
"Yeah, I think you're right about the expectations of fitness trainers. I tried saying to both the class instructor and the gym manager that I find the classes too demanding and that maybe they should be at a more approachable level if they're marketed to beginners, to not scare people off and to help them ease gradually into a sustainable fitness habit, but they both just doubled down and said it's good if it's challenging."
A suggestions: See if there is a Planet Fitness near you and if so whether their class schedule works for you.
As a general rule, "real" gym goers hate Planet Fitness. It isn't a real gym and targets newbies and doesn't have many freeweights and ... You can Google for why Planet Fitness sucks and find a number of articles on the subject.
But you also make it sound like YOU might be a very good fit for Planet Fitness and your current gym folks are exhibiting exactly those behaviors that Planet Fitness advertises against. I don't use the class option at Planet Fitness, but there is a good chance that the trainers there are more aware of beginners.
I, myself, exercise at a Planet Fitness because (a) the price is very difficult to beat (around $10/month), and (b) Planet Fitness has what I need. It might be a fit for you, too.
Try eating more protein, on the order of 0.75g per pound of body weight. I do heavy weight lifting with free weights and rarely have muscle soreness since I started doing that, but regularly had it before I upped my protein.
Also, you may actually need to increase the calories you are eating if you are feeling that tired after lifting weights. My wife jumped from 1800 calories per day to 2200 with similar weights as you and that finely started giving her the energy she needed to sustain the program she is doing and she is losing fat and building muscle.
Also every 4-6 weeks I need to take a week off to recover. I cut way back on weight and reps.
> I keep wondering if that stops being the case when you reach a certain level of fitness, and how far from that level I am.
DOMS (muscle soreness) isn't even technically necessary to make strength gains in the gym, in fact advanced bodybuilders often say it simply hinders recovery.
However, I know whenever I start lifting after taking a break I'll get a little soreness for a while. I encourage you to try to reduce intensity, but also endure soreness and stick with it, it should decrease in frequency and severity as you gain experience, as long as you don't let your regimen lapse for too long.
But also, there should quickly come a point where even the sore version of you is more functional than the not-sore, but untrained version of you.
I'm a bit late to this thread, but I wanted to share a tip: there's no need to be sore from working out. Some people seem to have this idea that a workout isn't good if you're not sore, but that's simply false. If you work out regularly, your body will adapt, and soreness will disappear. Ease in to new exercise routines to avoid soreness, and train regularly (preferably 3x a week) to stay in shape.
I think it's a common mistake that people will jump into a workout routine that's too far above their level, and get into a feedback loop of "too sore to train again"-"get out of shape from not training"-"get sore from training because out of shape". In particular, a 45-minute workout class is going to be too much for someone who's usually sedentary--they should probably start with a 15 minute session.
> Serious though somewhat rude question
Haha, no worries, asking a question is much *less* rude than assuming an answer, which is what most people do.
For me it's currently mostly a question of *time*. I have two small kids; the younger one at kindergarten age, sick almost all the time (nothing serious, but cannot go to kindergarten while sick), at the very annoying age of 4. Both me and my wife have full-time jobs, and we also have to share the childcare. Both of us can work from home half of the week, so we alternate staying at home and being interrupted all the time by the child. After work, it is time to buy food, cook food, convince the kids to eat something (much more work than cooking for adults, who will eat almost anything without throwing a tantrum), do the dishes, check the homework of the older child... soon it is time to wash up, and read the bedtime story.
So, *when* exactly am I supposed to go to the gym? Early morning? I would need to wake up at 5PM to go to the gym, spend an hour there, and return back early enough to make breakfast for the older one and bring her to school. (This actually sounds interesting, I should probably try it once, assuming the gym opens early enough, at least it would be quite empty. But that means going to sleep immediately when the kids do. Nevermind... checked online, the gyms in my proximity do not open before 6:30, that is too late for my purpose.)
After the work? I usually bring my child to school before 8:00, so I get to my job at 8:30, after eight hours and lunch break it is 17:00, getting home past 17:30. Going to gym after work would mean getting home every day at 18:30 or 19:00. I would actually try that, but my wife disagrees. (Unfortunately, when you have a family, you need to take their votes into account.) Going to the gym after 21:00 is also not an option, they are already closed then. That only leaves weekends, when random things happen, so I cannot say anything consistent about them. But usually weekend is the time to do things I did not have enough time to do during the workweek.
I actually prefer exercising at home, because at gym 1 hour of exercise can mean 2 hours of wasted time (going to the gym and back), but at home, I can spend the breaks between the sets watching a movie, reading a book, or doing dishes. The problem is, if the kids are not in the bed, they keep me busy, and when they are in the bed, I am already quite tired. Still, I exercise about 30-50% of evenings, depending on circumstances. When I exercise more regularly, I keep getting stronger, but I do not lose weight anyway.
The only thing that helps me lose weight is "starving". I already skip breakfast every day (which sounds to me like the intermittent fasting that most people recommend), it has no effect. To lose weight, I need to be very careful about what I eat, and to only eat frustratingly small amounts of it, consistently for several days in a row. Unfortunately, doing that has huge *mental* costs -- as a consequence, the whole day I am irritated and can't stop thinking "fuck, I am hungry". If I had no work and no kids, I could probably distract myself somehow, like taking a walk or playing computer games. But in that mood, any stressful thing would make me explode. I would either yell at my kids, or just scream "fuck this" and stuff my face full of chocolate. :(
I hope this gets better when the younger child grows up a bit. The older one is already okay. (Okay = not driving parents crazy all the time, not extremely picky about food.) But right now, a pill that would allow me to eat small amount of healthy foods without feeling hungry and irritated all the time would be really helpful.
"To lose weight, I need to be very careful about what I eat, and to only eat frustratingly small amounts of it, consistently for several days in a row. Unfortunately, doing that has huge *mental* costs -- as a consequence, the whole day I am irritated and can't stop thinking 'fuck, I am hungry'. If I had no work and no kids, I could probably distract myself somehow, like taking a walk or playing computer games. But in that mood, any stressful thing would make me explode. I would either yell at my kids, or just scream 'fuck this' and stuff my face full of chocolate. :( I hope this gets better when the younger child grows up a bit."
This reminds me that it took parenting to get me to stress-eat.
I used to be OK with pretty heavily restricting amount, type, and timing (no calories after 9pm) of food, even if that meant mild insomnia from going to bed rather hungry. Now? I need the sleep. I need to not be crazy, and kids, for all their joys, can drive us crazy!
Also, atopy (allergies, asthma, itching) can be pretty crazy-making, too. Doctors can prescribe treatments other than antihistamines, but the effective OTC meds are antihistamines, which can interfere with weight loss. (For whatever reason, childbearing seems to have made my atopy worse.) Using a drowsy-making antihistamine to knock me out every night would likely nonetheless cause less weight gain than bedtime comfort-eating. And either is likely superior to what... a benzo habit?... In any case, I dislike *feeling* sedated, even from alcohol: food is a milder sedative.
In terms of responsible parenting – especially a responsible mom (during pregnancy) – food is one of the least-bad addictions to have. The downside is you're not modeling the best eating habits for your kids, which sucks, especially when you did have good eating habits before. But modeling less-than-ideal eating habits is still less likely to get your kids hauled off to foster care than drinking and drugging, so there's that :-)
Just as a general thing, this is one of the reasons no dieting method should be considered effective unless it works for at least five years. Life happens, and that includes caretaking, illness, injury, and financial problems.
I am very sceptical of this specific policy proposal, simply because I don't think money is the barrier, but time and effort. Observe the many people who pay gym memberships, and therefore have free access to a gym, and still do not go.
I am not a fan of the gym personally, I find it much easier to motivate myself to go for a run than to go to the gym. I suspect this varies from person to person, but it seems the trick is to find a form of exercise that you enjoy? Which is hard to recommend even on a personal level, because exercise is always somewhat unpleasant, its even worse as a recommendation on a policy level.
PE classes at school were miserable and embarrassing and I swore once I left school I would never, ever, voluntarily attempt to play a sport or run or anything ever again.
No gyms around where I lived. Not easy to access. Plus, when you're very very fat, it's difficult and off-putting to try and go someplace and use equipment and do exercises you don't know anything about and are worrying about sweating, red face, people looking at you, etc.
Never got any of the endorphins from exercising. Never got pleasure or enjoyment out of it. Never got "but don't you feel good when your body is moving the way it is meant to move?". Got the cramps and pains and sweatiness and tired afterwards, often the day afterwards. Did loosen up a bit, did get a bit more fit, never got "oh this feels good".
More enjoyable things to do. When I was exercising, I had to force myself "okay, it is now 6 pm and you said you would do an hour of exercise a day every day", even mild exercise. Dreaded the time when I *had* to exercise would come, couldn't wait for it to be over.
Let me turn the question back: for people who go to the gym, why and what would get you not to go? If it's "but of course I want to go, why wouldn't I?" as your first response, that is the first response for me "but of course I don't want to go, why would I?" and any arguments pro- or con- are not going to convince those who like and enjoy exercise to give it up, and those who don't like or enjoy it to take it up.
No, not even the health ones. Suppose I argued that running, games, sports, whatever were wrecking your joints and would turn you into a hobbling cripple in later years and it damaged your heart and lungs despite what you think - would that still put you off? Same with "but exercise makes you healthier" - yeah, maybe, but it still feels awful.
As an enjoyable but difficult physical activity, I recommend trying this:
https://en.wikipedia.org/wiki/Dance_pad
https://en.wikipedia.org/wiki/StepMania
"PE classes at school were miserable and embarrassing"
They were for me, too. They were humiliating despite my setting school records for long jump and situps, since I failed at other tasks so spectacularly. I didn't have to be particularly fat, just asthmatic, weird, and not-skinny to be mocked as "too fat" for fitness.
Fortunately, midway through high school, we could take modern dance for PE instead. Rinky-dink stuff, but even a modicum of artistic expression made exertion around other people more bearable for me.
Exertion that lets me make or see something pretty, or build something useful, is more appealing to me. Hiking and dance? Prettiness – pretty scenery, pretty movements. Dance also let me socialize without having to make much small talk. Heavy yardwork and other building? Utility. Exertion seems worthwhile when I can "Cock[] a squint eye aloft, and sa[y], 'I bloody did that.'"
https://www.poemhunter.com/poem/the-cathedral-builders/
Some of the "thats" I bloody did were pretty stupid in retrospect – wouldn't recommend, wouldn't do again, but they were, of course, the most thrilling at the time.
I believe we were evolved to move, not to exercise.
An hour of cardio burns 600 calories, according to the first Google result.
You can eat that much in less than a minute.
Exercise is important for your health, but it's very hard to lose weight that way.
I don't go to the gym, but I'm also likely underweight (I haven't been on a scale in a long time) and don't take any medicine. I rarely have any interaction with health insurance since I don't consume much medicine, but I did recently get some vaccines where I had to hand in my insurance cards and after a long wait was told one was expired.
One point of data. I'm in Canada. My partner has been using Ozempic (that's what it says on the box) for weight loss for a few weeks. It was prescribed by their general practitioner. I have no idea what it costs because it's covered by our additional medical insurance.
Re canada, if you are american and have a prescription you should be able to get semaglutides for a couple hundred dollars a month through CanShipMeds. (At least, you could as of a couple months ago).
Also, thanks for the shout-out! If I had known so many people were going to read that post I’d have probably edited it a bit more haha.
Would the following conditions cause any updates on your predictions?
1. Humans are heavily influenced by celebrity endorsements.
2. Humans are motivated by perceived scarcity.
3. It's now an open secret that Hollywood, influencer, and tech celebrities are taking this.
4. There's shortages at certain doses already and supply is somewhat constrained.
I'm late commenting but I don't see anyone mentioning metformin yet.
** THIS IS NOT MEDICAL ADVICE **
Metformin is off-patent and although its only on-label use is for diabetes, some people think it extends life expectancy. (The main evidence for this is that diabetics who take metformin live longer on average than people who aren't diabetic.)
Since I started taking it my blood sugar has dropped from the high end of the normal range to the low end, which I imagine is a good place for it to be. And I've lost a noticeable thought not dramatic amount of weight: maybe 5% or thereabouts, which moved me from "overweight" to the high end of normal.
Surely people who are thinking about taking semaglutide should try metformin first?
Even though this is *not medical advice* I think it might be helpful to point out a few things:
- I got my baseline blood sugar and blood pressure checked before I started on metformin, then again afterwards. The drug can reduce both and you don't want either to go too low, although lower is better within reason.
- The one initial side effect I experienced was orthostatic hypotension (dizziness when standing up suddenly), which went away after a few days. Starting at a low dose and increasing it gradually can make that less likely.
- I live outside the US and I have no idea if metformin is sold over the counter there. In most countries it's OTC and costs almost nothing.
Metformin has absolutely crippling gastrointestinal side effects (we're talking "you better remain near a bathroom for most of your day" level, in my case) that never go away, for some significant number of people who take it. It was bad enough that I discontinued it 3 months in despite needing the A1C reduction, and I rarely discontinue drugs due to side effects.
Also, I've lost far more weight on adderall. I lost basically none on metformin.
I'm on metformin (that's what my doctor started me off on first). Had the gastrointestinal effects V-I mentions but they cleared up within a week. I'm tolerating it well but it didn't shift any weight for me.
Like everything else about how biology is complicated, I think it will work for some people that way but not for everyone. Some people, like V-I, will have the bad side-effects persisting so they have come off it, some people will tolerate it easily like I did. Some people will lose weight on it, some won't.
The idea that it's some miracle anti-aging/anti-death drug for non-diabetics makes me laugh; I think it may help diabetics live longer than if they weren't on it, but that doesn't mean it will work if you don't have diabetes. If you have a rash and put cream on it, the cream will clear it up. But putting cream on your skin with no rash will do nothing.
I was on metformin for years. Still am, since I see no reason to stop.
The gastrointestinal issues (think explosions) were awful in the first two years. I couldn't go for a walk for an hour anywhere without a public toilet near. After that they remained bad but manageable.
When I started taking metformin I combined it with a keto diet and I lost a lot of weight then (about 30 pounds? I went from clothing size 48EU to 42-44-ish EU). I stagnated about half a year later but the weight staid off for ~4 years. Then I had to change my routine, added intermittent fasting to the mix (not because I wanted to, it just ended up that way with my job) and put all of it back twice or thrice over. Despite still being on keto and metformine. I couldn't lose any more weight after fixing that irregular meal schedule and was stuck.
Would I recommend metformin for weight loss for anyone? Hell no. It's far far more painful, awkward and difficult to manage than even a gastric bypass. Get a gastric bypass instead if you're that desperate.
Two *years*?! Yeah, "explosions" sounds like about how I reacted. I wouldn't do that for two years running even if you told me it'd make me weigh 185, which I haven't weighed since high school - just not worth it. Major respect to you for sticking that out, though.
Okay, clearly different people react differently to this drug (and to many other drugs).
My 2c worth is just my own personal experience: I started taking it, scaled up the dose gradually, had minimal and temporary side effects, and got modest but very persistent weight loss.
So if anyone else reacts to metformin the way I did, it seems as if it would be a good idea to try it before moving to a drug that costs $15,000 per year.
Possible side effect: cures alcoholism.
https://twitter.com/bigjoshlevine/status/1550715749563613184
Particularly in interesting if this works by the same mechanism as the weight loss effects, which seems plausible. What other willpower weaknesses will be treatable by medication?
Would you take a drug that made you not want to cheat on your spouse? Would you want your spouse to?
As far as drugs affecting willpower, I quite smoking about a decade ago with Chantrix, which let me remember that I hated smoking even when going through physical withdrawal. My husband is now taking Naltrexone for the Sinclair Method for drinking, to reduce the dopamine spike associated with the reward. I took Saxenda related to Ozempic, for obesity for about a year out of pocket, through Canadian and UK pharmacies, where Saxenda was a lot cheaper. I personally think a much better move is to pay what the rest of the world pays.
Now I use a telemedicine site that has discovered my glucose is slightly higher than normal and has my insurance covering the medication minus the co-pay. A lot of the weight comes on quickly when going off the medication, but not all, and timing a diet can mitigate the effects. These drugs REALLY work by controlling satiety and insulin responses and leptin/ghrelin, not dopamine like the others. When you go onto the drug company sites, they do encourage you to lobby politicians to cover obesity.
Huh. From the reddit thread: "It works well for anything that may have had an addictive potential. Food at its core is a drug, and Semaglutide helps you feel full but also decrease all cravings." That... sounds like the stuff may soon be handed out at addiction rehab clinics as well as Buddhist meditation retreats.
"Would you take a drug that made you not want to cheat on your spouse? Would you want your spouse to?" Interesting question! Since these desires (to the extent they exist) have not had any tangible effects in my marriage, I don't see the need. And I am fundamentally non-Buddhist in my approach to life - my desires/ cravings/ whatever you call them are part of what make me me, and what makes life worth living. As long as they don't cause problems, artificially removing them would feel like chopping off a part of myself.
What about long term weight management with semaglutide? I’m under the impression that it can’t be taken long term and it’s unclear whether people regain the weight afterwards. Anyone researched this more extensively?
Where did you get this impression? My doctor told me it's intended to be taken indefinitely.
My pops is doing the Calibrate program that combines nutrition coaching with semaglutide doses. Apparently they MDs at Calibrate are aiming to get people off semaglutide after about a year.
Sounds like maybe that's unnecessary or even risky
Diabetics take it indefinitely and no significant risks have shown up.
Clinical trials have shown good results at a 104 week follow-up. Patients who discontinue regain weight usually.
https://scholar.google.com/scholar?hl=en&as_sdt=0%2C21&q=semaglutide+104+weeks&btnG=#d=gs_qabs&t=1669286473687&u=%23p%3D6X5Nn99uEnsJ
Based on how Europeans react to discussions of obesity drugs, I expect that European healthcare systems will not cover it at large scale until it goes generic.
Maybe for BMI > 40 or something, they'll pay $200/mo; but obesity drugs are seen as vaguely immoral and if they cost a lot money over the short term (maybe it'll save a lot in the long-term, but if you're a health minister facing elections in 2 years, what do you prioritize, tackling obesity or the waiting lists that pregnant women face?), I don't see them being used at scale for a while.
Is it just me or is a 30% chance obesity is cut in half by 2050 really low if you expect it to be reasonably cheaper by 2040 (66% chance its less than $100/month). Do you expect there to be other factors keeping people from getting it? Doctors still insisting on diet/exercise first on a large scale? As yet unseen side effects? Something else I'm missing?
Edit: or maybe its just what Neo says in his comment and a good number of obese people are more are more than 15% above obese for their height.
A combination of:
- it's really hard to get half of a target group to take a drug. Do half of all hypertensive people take antihypertensives? Do half of depressed people take antidepressants? I'm not sure but I would guess no. This is by far the main reason for my skepticism.
- Maybe the factors causing obesity will get worse by 2050.
- As you say, maybe these drugs won't be strong enough to get obese people all the way to normal weight.
- Maybe somebody finds side effects and people stop using them.
> - As you say, maybe these drugs won't be strong enough to get obese people all the way to normal weight.
They have amylin agonist + glp-1 agonist drugs coming down the pipeline that look even more promising. (from Stephen Guyenet)
These advances are already coming. In May, Novo Nordisk published a trial combining semaglutide with another drug called cagrilintide for weight loss in people with obesity. Cagrilintide is based on the protein amylin, a hormone that’s released by the pancreas when we eat and that reduces food intake via the brain. Adding cagrilintide nearly doubled the weight loss caused by semaglutide alone, with an apparently similar safety profile. This was only a 20-week safety trial, but it seems likely that longer trials will reveal weight losses of more than 20%, which would place it in the range of bariatric surgery.
Do we know what percentage of the patients lost weight? One of the things with semaglutide is that there was still something like ~40% that didn't lose weight in the trial, so it would be great if cagrilintide upped the number of people responding.
To make an anecdotal point about accessibility and costs: my wife has been on ozempic for weight loss since 2021. She was never obese, but using the Alpha Medical telehealth service, she was able to get a prescription easily. The "visits" with her physician occurred on a monthly basis to evaluate her tolerance and progress with the drug, visits cost $30 out of pocket.
She's been on Medicaid (Medi-Cal in California), and ozempic is completely free for her. Her Medicaid eligibility recently came under review due to our marriage, so we'll see what happens there.
I'm not sure if her situation is unusual or an edge case of sorts, but ozempic has been quite literally miraculous for her. Low cost, unimaginably effective, and accessible.
After a well reasoned article, the last line "US obesity half or less of current rate in 2050: 30%" seems to come out of nowhere. If Wegovy users on average lose only 15% of their weight, then even if 100% of obese people were using Wegovy by 2050, the obesity rate still wouldn't go down by half unless most obese people were <15% above the weight threshold that defines obesity, right?
That's a good point, but a few things:
1. BMI is a bell curve centered (slightly) to the left of the obesity cutoff, so most obese people will be close to the cutoff. See eg https://www.mdpi.com/ijerph/ijerph-17-02330/article_deploy/html/images/ijerph-17-02330-g001.png
2. Drugs might get better by 2050.
3. More obese people might lose more weight on semaglutide because there's more to lose (I haven't actually checked if this is true)
4. I think those numbers might be "over one year", and they could stay on it longer than a year.
#1 is a good point, but I'd still doubt that it would result in a 50% reduction in obesity, since probably well under 100% of obese people would use it. #2-#4 may be true but are so speculative that I don't think they're a worthy basis for a formal prediction. In a few years we should know more about #3 and #4.
Anyway, this drug is a noteworthy development. Thanks for the thoughtful introduction.
There are already drugs in pipeline that have shown greater weight loss effects.
tirzepatide and semaglutide+cagrilintide
On weight loss, have you considered/are you interested in looking into the potato diet? Recently covered on slimemoldtimemold (https://slimemoldtimemold.com/2022/07/12/lose-10-6-pounds-in-four-weeks-with-this-one-weird-trick-discovered-by-local-slime-hive-mind-doctors-grudgingly-respect-them-hope-to-become-friends/) and touched on by acesounderglass (https://acesounderglass.com/2022/10/13/my-resentful-story-of-becoming-a-medical-miracle/)
I think probably all one-food diets make people lose weight by decreasing variety, making eating more boring, and eliminating some of the worst foods. I haven't seen any evidence that potato diet is any better than that.
I was under the same impression, but the slimemoldtimemold experiment (they ran a trial across a couple of hundred readers) brought up some interesting results. Mainly that potatoes in particular seemed to do something interesting to lower people's metabolic setpoint, multiple participants claiming that hunger felt 'weird'. And unlike many other mono-foods, potatoes actually were the main staple diet of many people for a long time, primarily in Europe.
They're running a follow-up experiment with potassium salt to see if the high potassium in potatoes is the cause, which should be quite interesting to see the results of too.
Wait, I thought I read the experiment - did they have a control with people limiting themselves to some other single food? If not, I would expect all of this including the weird hunger to happen on any monofood diet.
No, they didn't run a control, it's a fair point. There was plenty of anecdotal data from people who said they had already tried other mono-diets and not had the same success, but only anecdotal. As well as people who did a 'half diet' with one meal of all potatoes daily and one normal meal. They still experienced some of the effects and about half the weight loss on average.
I was personally intrigued enough that I'm trying the diet myself (although only on week one), but I acknowledge there is only anecdotal evidence that there is something uniquely different about potatoes vs other foods.
I’m notoriously bad at history when not fact checking with the husband pre-post (he’s finishing up the turkey), so take this with a few grains of salt: I thought potato staple diets were in times of famine & led to malnutrition deaths where diet wasn’t supplemented. If that’s accurate, is it known the length of time one can diet safely before worrying about malnutrition /increased disease rate? (As that would defeat the main purpose of tackling obesity (mental & physical health)). I’m confident one could eat all potatoes for two days without any illness, and one could eat all potatoes for two years with very obvious illness and complications, but I’m not sure where the threshold is in between.
Covered in the slimemoldtimemold article but for the most part potatoes have a pretty good, balanced nutritional coverage, even enough protein. The main things missing (besides sodium, which isn't hard to supplement as you're probably salting the potatoes anyway) are vitamin A, vitamin B12 and vitamin D IIRC.
Quoting:
>We’re not so sure. In particular, why do people think that other mono diets work? We haven’t seen any. We encourage anyone to find anecdotes, studies, or better yet, run their own Onion Diet study or whatever.
> The potato diet isn’t even really a mono diet. We explicitly allow for oil and seasonings, and lots of people lost weight with tons of cheat days. The mono-ness (monotony?) of the potato diet clearly is not the active ingredient.
> Potatoes are also unusual in that they are (almost) nutritionally complete. You couldn’t do the white bread diet and get far. But you could maaaaaaaybe do the whole wheat bread and oil diet, or the wheat bread and cheese diet. Also known as: the basic daily diet in Europe for centuries.
Jeez, maybe potatoes make you experience jhana . . .
The synthesis of these two topics is hilarious, thank you!
The eyes of the potato are meant to remind us of Bodhidharma, who according to legend sat and stared at a cave wall for so long that his eyelids fell off.
(Although AFAIK, Bodhidharma's branch of Buddhism mostly ignores jhana, so this is more of a meditation joke.)
I can't find the full original study but you can mostly predict the satiety of a food based on caloric density/fiber/protein. But potatoes are a weird outlier.
https://twitter.com/caloriesproper/status/1148764776023109632?lang=en
I once read that baked potatoes are one of the most satiating foods (more feeling of fullness after eating only a few kcal worth relative to other foods). Maybe that's part of it?
I am also surprised by how often Slime Mold Time Mold is brought up here with respect. I read some of their blog posts and they have really lazy analyses and 'just so' anecdotes. Scott, might be fun to go through at some point (?) )
Interesting way to put it 'with respect'. The way I tend to view them is as a fun, loosely scientific blog. The experiment design leaves a lot to be desired but they're also covering (potatoes in particular) in more depth and in a more evidence based fashion than anything else out there, relatively speaking. It's not great, but it's certainly better than all the blog posts by nutritionists saying it's a bad diet without any evidence, or the glowing Reddit posts doing the opposite based on personal anecdotes only.
That's part of why I asked in the OP if Scott had considered doing a post on the potato diet - it's an interesting topic but one that hasn't been covered yet to a higher level of rigor
For myself, I will never forgive SMTM for their lithium posts (A Chemical Hunger), which still have not been retracted or corrected despite containing grevious errors. They handwaved away a 10% increase in average caloric intake (which is enough to fully explain the American obesity crisis) in favor of a speculative compound which does not show the alleged effect at 100x the dosages alleged. And they word their arguments so convincingly. Better to avoid the infohazard.
I'm really interested to hear more about this - do you have any more information/links I can read to understand the criticisms/grievous errors?
They wrote an extra interlude specifically addressing this criticism: https://slimemoldtimemold.com/2021/07/15/a-chemical-hunger-interlude-a-cico-killer-quest-ce-que-cest/
They didn't really handwave away the increase in caloric intake because the point of the articles is *why* are people eating more calories.
I left a comment on their survey of /r/nootropics users who'd taken "low dose lithium", I think it's their 2nd post down still. A good example of how not controlling for time-as-a-variable can fuck you up. They're a promising bunch of kids, but got some learning to do before they're good scientists
The 4-week potato diet per the study caused me to lose 15 pounds which then stayed off "permanently" (as of 7 months later). Previously I'd never managed to lose any weight for any appreciable duration on any diet I'd ever tried.
My mindset has changed from "my weight is outside my locus of control" to "my weight is within my locus of control" and I will be forever grateful to Slime Mold Time Mold's role in that.
So I don't claim to be objective as far as Slime Mold Time Mold is concerned. But sometimes the weird thing works and all too often societal and social pressures conspire to stifle investigation of the weird thing. So to the extent that Slime Mold Time Mold is a force for investigating the weird thing I think they're on the side of the angels!
The side effects are real. In addition to my own experience, the Facebook and Reddit groups are full of people complaining about constipation and nausea. After a year, my side effects have let up. But initially I was carrying barf bags everywhere and chugging Miralax daily. Sorry if that's TMI, but if you're considering it, go in with your eyes open. Oh, and a couple of months of brutal fatigue, which mercifully resolved after 2 or 3 months.
Yikes, that's rough. I've been lucky, only occasional mild constipation and very rare mild nausea, nothing else. Good luck and hope yours don't get worse again!
Thank you!
I had pretty serious constipation too. To the point that I didn't even finish one month as the constipation seriously aggravated my hemorrhoids.
That's a bummer. I've been able to deal with it through Miralax and occasionally bisacodyl.
Pharmacist from The Netherlands. Price Ozempic is about 105 euro a month overhere. In about 2-5 years generic forms will be available, price will be than even lower. Furthermore: even more potent medicines and combinatioins are expected the comming years (average weight reduction about 20%?).
Why does it cost $15,000 a year? That seems like a colossal amount of money for a drug.
Me and my public sector GP colleagues in Finland do prescribe semaglutide (Ozempic) off-label for weight loss. It is not covered by the national insurance unless you have both BMI>30 and uncontrolled diabetes despite at least one ongoing antidiabetic medication. However, the cost of 115€/month(1) can be afforded by many. Lately the biggest issue has been the inadequate supply due to surging demand(2).
1) https://www.yliopistonapteekki.fi/ozempic-1-mg-injektioneste-esitaytetty-kyna-4-annosta-1-kpl-78173
2) https://yle-fi.translate.goog/a/3-12638874?_x_tr_sl=auto&_x_tr_tl=en&_x_tr_hl=fi&_x_tr_pto=wapp
I look forward to a transhumanist future where obesity doesn't matter because the diseases associated with obesity aren't a problem.
Why dystopia? If fat people have proportionate strength and better joints (improved joints for everyone would be part of my ideal future) what's the problem? If people aren't inclined to heart problems, how does this not make the world better?
Feasibility is a different problem, especially for extremely fat people, but improvements in default health for ordinary fat people doesn't sound impossible.
I suggest that the fairly common distaste for fat people is trained in rather than innate.
I don't know what might be able to reverse the effects of social pressure which is so common that it feels innate.
If that's the case, there ought to be cultures with no distaste for fat people. Are there? I know that some cultures have a more positive attitude toward slightly chubby people, but none that see morbidly obese as attractive.
In Mauritania fat is valued so much in women that girls are often force-fed to achieve it.
I've heard that traditional Polynesian culture had it that the taller and fatter a person was, the more godlike they were.
"I don't blame fat people for being fat. I pity them. I understand that it can be very hard not to be for some people. I have ADD, so I know what it's like for what you know you should do and what you actually do to end up being very different no matter how much you'd like it to be otherwise. Lucky for me, I haven't had that problem when it comes to fitness."
Out of curiosity, do you take one of the ADD meds that tends to cause decreased appetite and/or increased NEAT (Non-Exercise Activity Thermogenesis)?
It woud still makes us unattractive.
Maybe. Beauty standards are rather difficult to forecast.
People would still want their body to take on certain (probably non-obese) forms for aesthetic purposes.
Until we fully transcend the body but that's just too far away to reason about.
I expect it'll be easier to alter most peoples' metabolism and energy balance so they don't get obese in the first place than to keep coronary arteries healthy despite it. And I hope we do learn to grow spare hearts in a jar and what have you but I can't see that not being a 2nd line solution. (assuming obesity is a roughly unidimensional thing. I know that subcutaneous fat and visceral fat have somewhat different effects)
I don't think we have an understanding of why coronary arteries get obstructed so I'm not going to have a strong opinion about which problem is easier to solve.
Semaglutide here in the UK is pretty easily available privately for £199 a month.
Also I can report that it works and the side effects are mild (n=1)
In Finland, a relative of mine got Rybelsus prescribed to her for treating obesity (paying something in the order of 50e/month from her own pocket). For the record, she reports loss of appetite, but weight loss wasn't realized.
I know nothing about weight loss, but if this really is a drug that makes you "feel full" then the pharma industry's gain should be the food industry's loss. I am not going to try to quantify anything but if tens of millions of Americans start eating less due to medication then that should have a noticeable effect on food consumption.
From the other perspective one could argue that it is a bit silly to spend big money to eat less when eating less is actually the economical alternative. In my experience stingy people, people who count their pennies, are almost never obese. For them it is simply more fun to save a dollar than to eat an extra dollar worth of food that they do not really need. It is probably no coincidence that the world's richest country, and the one that has been rich for longest, is also famous for its obesity. Penny-pinching might have had a better reputation if its role in keeping people slim was better known.
I don't know about stingy people, but there is a link between poverty and obesity, and it is the opposite of what you suggest. For example, see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6497220/. The researchers found that the odds of obesity were greater for the lowest-income participants compared to the highest. Less surprisingly, the odds of obesity were also (independent of income) greater for those with the highest proximity to fast food outlets compared to those with the lowest. It's much more complicated than just eating less.
The study you link to concerns relative poverty. Someone in the UK (or anywhere else in the Western world) will be quite rich despite being relatively poor. Definitely rich enough to buy all the calories they crave, even if they do not need them from a nutritional standpoint.
Stingyness in this context is something else. It is an unwillingness to spend money on something not technically necessary, a hostility to waste so to speak. This attitude leads to less spending on things that are superfluous, like all those calories you do not need after your sustenance has been covered.
"Someone in the UK (or anywhere else in the Western world) will be quite rich despite being relatively poor. Definitely rich enough to buy all the calories they crave, even if they do not need them from a nutritional standpoint."
Since the UK is currently experiencing a meteoric rise in people needing to use food banks, I would question this assertion. Anyway, the point is that people who need to watch every penny will buy the cheapest food they can which makes them feel satisfied. That cheapest food is not healthy food. In addition, financial poverty is usually accompanied by poverty of time and opportunity. I have the option of buying food in bulk (good quality chicken, onions, tomatoes, spices etc) and making a huge pot of curry, then freezing what's left after eating a meal for later times when I don't have time to cook, in the large, reliable freezer which I have all to myself in my kitchen. The cost of those frozen portions is probably <£1, but the initial outlay in terms of cost, time, kitchen capacity and freezer space is well beyond someone working three jobs, living in a bedsit and sharing a kitchen. In their case, buying a £1 ready meal makes a lot of sense.
This is the most I’ve enjoyed an article of yours since the taxometrics series in 2020-ish
1. Scott writes: "I come at semaglutide from a transhumanist perspective. I want to hack genetics and biology until everyone is as tall as they want, as strong as they want, as smart as they want, and whatever gender they want. If you want wings, you should be able to have wings. And yes, part of this vision is everyone having the weight they want."
I'm not sure how this jives with either EA or a rationalist program. Maximizing the individual without aim cannot maximize the whole.
2. According to NYT, 11/22/22 "What Is Ozempic and Why Is It Getting So Much Attention?" $892 a month without insurance.
3. Wouldn't a large RCT really be the first step? There are side effects to this as is noted.
4. Obesity is obviously a significant problem. But I am ambivalent about the "disease ification". Eating less and exercise more seemed to work for a million years. Are there any other creatures with an obesity problems? Consider 11/21/22 NYTimes "Scientists Don’t Agree on What Causes Obesity, but They Know What Doesn’t", By Julia Belluz.
> I'm not sure how this jives with either EA or a rationalist program. Maximizing the individual without aim cannot maximize the whole.
Could you elaborate on the perceived problem? Increasing preference satisfaction of an individual can be in conflict with global preference satisfaction in some cases, namely when the individual in question wants to cause dissatifaction to other people. But when we are talking about personal stuff which doesn't involve other people, like "being taller" or "having wings" then what's the issue?
The whole is not equal to the sum of the parts. It's equal to the sum of the part PLUS the interactions of the parts.
Just as example, could being taller mean you eat more and thus create more competition for food? I'm sure we could think of lots of unintended consequences.
Wings - I'd not know maybe it would give you a figurative bird brain? Or if the wings are in place of arm, hands, fingers and opposable thumbs perhaps there would be a downside to the ability for a winged human to assist the rest of humanity?
I find the amount of time and money spent on tattoos and cosmetic surgery to have almost no overall salubrious effect to the whole. And the idea that a tattoo might make one happier, does not seem to be born out by research on the happiness of the tattooed (when tattooing is not part of a cultural norm and ritual.)
The transhuman project sounds like what Lysenko tried to do for agriculture. Lysenko was masquerading as science.
I'm just not seeing how libertarianism could ever lead to more effective altruism. Selfishness and self absorbedness cannot really be jujitsued into altruism or solidarity.
Everyone doing their own thing willy nilly does not sound like EA.
This sounds really weird to me.
Like if someone claims to want to live in a world where everyone has enough food and then you accuse them of wanting to create a global pandemic, a la Vonnegut's Slapstick: Lonesome no More scenario. Or even kill most of the human population and replace them with agri-drones for food production, and thus this claim would be incompatible with humanist values.
I mean sure there are possible scenarios where this idea would lead to bad consequences. Obviously we wouldn't want them. There are also possible scenarious where it wouldn't. That's obviously what we want. When people make claims as "I want to live in a world with X" they don't usually mean "I want X no matter the consequences". They mean, "All things being equal a world with X is better than the world without X"
>And the idea that a tattoo might make one happier, does not seem to be born out by research on the happiness
I think the fact that people voluntary pay money for getting tattoos is a common sense evidence in favor of hypothesis that a world with tattoos as an option is better than a world without them. We may make a claim that the resources could be redistributed in a more effective way, but then tattoos allocated resources would be one of the last things we would try to redistribute and at that moment probably all our global problems would be fixed and we could just as well let tattoos be.
> The transhuman project sounds like what Lysenko tried to do for agriculture.
You may look at some of the USSR efforts as flawed naive transhumanism. But I'm quite sure the problem were not rooted in too much individualism and trying to satisfy the preferences of every person in the population while sacrifying the good of the whole.
> I'm just not seeing how libertarianism could ever lead to more effective altruism.
I somewhat agree here, but also don't see how it's relevant. You do not have to be libertarian to be transhumanist or want to be taller.
State attempts to optimize the whole without regard to actual science is not the point.
Lysenko was a neo Lamarkian who thought exposing seeds to cold will make them grow in the cold. This is in principle the transhuman project and body and brain hacking. It can only work, if at all, on an individual today - it will do nothing for the next generation.
I don't really care if someone wants to spend money on boob job or tattoos or on pets or on a bionic arm, but that can't really fit into effect altruism and long termism.
And it's about as rational as the pianist schumann trying to stretch his fingers in a contraption. There is just a bunch of alchemy and voodoo mixed in with body hacking.
Does anything go? Should we restrict someone from cutting off a health arm in order to have a prosthetic?
You have to be confusing descriptive and prescriptive reasoning in order to make your methaphor work.
Lysenko was factually wrong. He ignored scientific consensus for ideological reasons, discarding evidence he didn't like. You disagreement with transhumanism, however, is on ethical grounds. As long as transhumanist do not endorse Lamarkism and disavow genetics there are no actual similarities.
What's more, transhumanism includes all kind of different approaches, including genetical modifications. There is no conflict here between affecting next generation and not affecting next generation. We can use the best tool to achieve our goal, not just one specific.
> but that can't really fit into effect altruism and long termism.
You still fail to explain why. The only problem is if we lack the resources and have to sacrifice something more important in order to keep doing tattoos. But we are very much not sure whether this is the case.
> There is just a bunch of alchemy and voodoo mixed in with body hacking.
Oh for sure. Obviously one have to separate the baby from the bath water.
> Does anything go? Should we restrict someone from cutting off a health arm in order to have a prosthetic?
As with everything else. If we get more preference satisfaction from the consequences of allowing people to cut their hands for prosthetics than we shouldn't restrict it.
> I find the amount of time and money spent on tattoos and cosmetic surgery to have almost no overall salubrious effect to the whole.
I think this could be said of the vast majority of what we spend our time and energy on
The issue is an arms race in "having X". I get taller, then you get taller than me, then I get taller still. This is why our cars don't fit in our parking spots anymore. The average human's satisfaction seems to involve a lot of Veublen goods.
Nicely put.
I think that there are both an absolute part and a competetive part in our preferences. It's indeed impossible to let everyone be above average in height but quite possible to let everyone be 2 meters tall. If we can satisfy the absolute component in everyone preferences this would be much better than it's now.
We should be ready to prevent arm races just in case, though I don't expect them to actually happen in the scale that would lead to many issues. If needed maximum allowed height can be restricted.
"Increasing preference satisfaction of an individual can be in conflict with global preference satisfaction in some cases, namely when the individual in question wants to cause dissatifaction to other people. But when we are talking about personal stuff which doesn't involve other people"
First you seem to imply "intention" matters. Of course it does but I didn't intend to hurt anybody is hardly a defense.
Second, there is a lot less really truly personal stuff. We're connected to each other as social creatures.
I'm thinking of Vonnegut's Slapstick: Lonesome no More.
The pandemic which leads to the dystopia is in part caused by the transhuman hack of miniaturizing people so they aren't starving ( they need less food) but it goes too far and the small people are so small that they are effectively virii causing illness in unshrunk people.
Not sure how this example is relevant even if we ignore that it's imaginary.
It's not that people wanted to be miniaturised, thus unpredictably leading to loss in utility for other people. It seems to be the opposite situation where someone tried to optimise for humanity as a whole (solve global hunger) and ended up with unintentianal consequences.
> First you seem to imply "intention" matters.
No, I don't. If a person preferes to have slaves it doesn't really matter whether this person intends the slaves to suffer or not. Slavery just creates more and stronger unsatisfied preferences than it would satisfy for this person regardless of intentions.
> We're connected to each other as social creatures.
True. But there is an obvious and well understood distinction between affecting other people by photons reflecting off me to their eyes, and forcing other people to do things. That's a good enough line for the ideas of "personal stuff" and "involement" to have meaning. Can you bring up an actual example of a problem, that would require us to use more accurate categories, to adress?
The same drug in Brazil costs $ 500 / month and you don’t need a prescription (just go to the pharmacy and ask for it). So you could fly to Brazil ($2000) , buy the drug for you ($6000), someone else ($6000), go back to the US, sell the extra one for $15k. You got the medication for one year and made a profit of $1000 :)
Illegal to buy FDA approved drugs abroad, definitely illegal to sell them
Can get it for a few hundred AUD per month in Australia as Ozempic. Well, you could, shortages now mean you can't.
I'm in the UK and Ozempic is fully covered by the NHS (0 copay) for type 2 Diabetes patients.
So who is ready for the headlines calling for these drugs to be banned because normal weight people are taking them to achieve the “starvation look” desired by models, resulting in anorexia style deaths?
Can the percentage loss of body weight really be constant across weights? Doesn't that sound crazy? And if it isn't, you'd have to already be on death's door for these drugs to push you over the edge (though I guess some people are already underweight...).
My understanding is the drug works by suppressing appetite, so why would it not work for low weight people?
Unlike amphétamines, it doesn’t suppress appetite. It makes satiety arrive faster, and stay longer. But when you are hungry, you are fairly hungry, and when you eat you can enjoy the food.
I’m intrigued now, though, by the idea it’s suppressing craving. That would certainly be consistent with my experience, in that my 50 year addiction to Coca-Cola (with periods of abstinence from it and others of relatively controlled use, but always craving) has turned to … disinterest.
I'm ready to see the drugs banned because side effects turn out to be more serious than expected, as with phen-fen.
The economics of pharma is just so weird. I've been on injectable semaglutide for quite some time now (for diabetes), and my copay is $25/month. Apparently I haven't bankrupted my family's insurer yet.
As for the drug itself:
I've experienced none of the "oh, you'd immediately notice those" side effects, but I I hear that quite a few people do.
My A1C runs MUCH lower than it used to under any circumstances other than the one circumstance I couldn't sustain long-term -- lots of exercise that inevitably ended with terrible knee problems which brought the exercise to a long halt.
As for weight, mine used to bounce back and forth between 220 pounds and 250 pounds. Now it bounces back and forth between 210 and 220. I have dietary and exercise plans to get down to 200 soon, after which I'm hoping more aggressive exercise won't be as hard on my knees, which may lead to no longer needing semaglutide for diabetes OR weight control. I guess we'll see.
I can't help but think that even in a country whose eating culture is as fundamentally messed up as the US, you could probably get a healthy, tasty, weight-loss-conducive diet for a lot less than 15000$ a year...
Also, what is it with diabetes that its medications turn out to be so beneficial? Metformin also has a reputation for helping with weight loss, plus reducing cardiovascular problems and maybe having general anti-aging properties.
Why wouldn’t you overeat on this healthy tasty diet?
Because it doesn't mess with the blood sugar levels as much and is conducive to a better microbiome in the intestines and... I don't know, but obesity is less of a problem in countries like France and Japan, even though people there could overeat just like in the US.
Because the most unhealthy foods tend to be the ones that humans crave and are most likely to overeat: chips, candy, chocolate, cake, cookies, liquid calories like juice and soda, etc. Pretty much by definition, a healthy diet doesn't have a lot of stuff that humans love to overeat. Broccoli is delicious when lightly steamed and drizzled with a bit of olive oil and garlic, but still, nobody says to themselves, "Mmmm, I think I'm going to have a third bowl of steamed broccoli!"
I think I really set myself on the path to Type 2 diabetes through, ironically, trying to eat healthier and being a moron about it.
All the stuff about 'cut out soda', well I did that. But I replaced it with fruit juice, because "well fruit juice must be healthy, right, and it counts towards those portions of fruit and veg you are supposed to eat", so I started drinking the good stuff (not from concentrate which had added sugar). Being virtuous, right? No more soda, cutting down on drinking tea with sugar, upping my intake of fruit easily.
Too late, I discovered "well uh, fruit juice *is* full of sugar". I honestly do think *that* was what tipped me over into Type 2 diabetes; before that, I was fat but had normal (or at least not diabetic) blood results (one doctor was *furious* when the results came back "nah, blood sugars normal reading" because he *wanted* to lecture me for my weight and wanted to be able to go "I told you so" if the test came back "diabetic levels").
Genuine attempt at an answer to the second part of your question: Diabetes is a disease of metabolism, and metabolism is fundamental to biology, therefore expect drugs that treat diabetes to have a variety of other interesting effects.
~€150 per month for Ozempic in Ireland. My doctor told me she was expecting shortages. She considers it a miracle drug for obesity, and also for older people with alzheimers/dementia because it keeps their blood sugar down which apparently has benefits for them.
I've been prescribed Semaglutide for Type 2 diabetes for about six months now. It does seem to lead to earlier satiety, but I've not had any weight loss. Oh, and being in Scotland, the prescription is free.
I'm not seeing any commentary for how well GPL-1 drugs work for those that have a disconnect between hunger cues and eating, like anorexics turned binge eaters and all the people who could be classified as disordered eaters. I can easily see how drugs like this would work well for someone who always feels actual hunger pangs, so I think my question is, how well does it work for someone who doesn't/has never associated eating with anything other than as a reward or a drug in and of itself? Who couldn't tell you what "feeling hungry" even means? The idea that a drug would make a person feel full or not hungry and therefore not eat ... I can't even envision what that means thanks to said disordered eating.
I do have experience with taking phentermine. It helped calm my mind and by escaping that noise helped improve my overall attitude, but I was still quite capable of gaining weight while taking it.
In such circumstances, does anyone have experience or thoughts with how well GPL-1 drugs would work for weight loss/maintenance?
Personally, I've gone from about 185 to about 140 with moderate restriction of carbs, but I know people vary so much that nothing works for everyone, and most weight loss methods aren't a stable solution at all.
Part of my situation is that I actually like high-fat/high protein, though I don't like going without carbs completely.
I believe the culture is all too cavalier about the quality of life-- and the lives-- of fat people. Considering the extent to which the income and romantic possibilities for fat people are limited, not to mention the general lack of respect I wonder how much of the health effects (not all of them, but a fair amount) can be explained that way.
I just created Manifold markets for the 5 predictions to hold Scott accountable.
https://manifold.markets/Max_Goerlitz/will-10-million-americans-be-on-sem
https://manifold.markets/Max_Goerlitz/will-medicare-cover-semaglutide-or
https://manifold.markets/Max_Goerlitz/will-semaglutide-or-an-alternative
https://manifold.markets/Max_Goerlitz/will-semaglutide-or-an-alternative-d020ed1f4c1d
https://manifold.markets/Max_Goerlitz/will-us-obesity-be-half-or-less-of
Since the patent on semaglutide doesn’t expire until 2032, the prediction of a price lower than $100 by 2030 seems off to me. I’d bet against that, but I’m too lazy to set up an account for only play money.
Ozempic is available in Germany, 3 Pens (0.5mg each) cost around ~240€ so 80€ per 0.5mg.
I wonder about the adoption of the medication, though. I took victoza (=saxenda, but approved for diabetes) and the absence of the desire to eat lead to some unforeseen lifestyle side effects. Given that 5 almonds made me full for the day, I was not interested in having dinner with the family or going out with friends. There is the reality that some restaurants would probably not be happy if you only ordered the smallest appetizer. In addition, alcohol was also very difficult, because the drug slows down gastric emptying and your stomach ends up absorbing alcohol for hours. I got really, really drunk for an entire night from a single glass of wine once. Before taking this drug I had not fully appreciated how much of one's (social) life revolves around food; lunch break with colleagues, dinner with family or friends, drinks on the weekend, a sweet treat, snacks and a movie etc. But once I was not interested in food anymore, combined with the tiredness that comes with eating little, a lot of those activities also lost their appeal. (On the upside, I slept like a log.)
Given that obese people's lives likely revolve a lot around food, its selection and its enjoyment, halting that activity so drastically may not be all that desirable for this population from a quality of life perspective.
Interesting perspective, though maybe if your relationship with food is rather unhealthy not having an appetite and then feeling guilty for it is an improvement.
Might it make sense to take a lower dose?
I am a pharmacist from The Netherlands. Price for Ozempic here is about 105 euro a month. In 2-5 years I will expect generic forms that willbe much cheaper. Furthermore I expect newer and better medicines and combinations (about 20% weigh reduction?). These products are a gamechanger for diabetic treatment and weight treatment. However the weight reduction is somtimes so quick and intense that I have a feeling that this is somtimes to intense and not healthy.
It seems to me that America basically has a tiny communist microstate consisting of health care, plus insurance and academia.
Prices have basically nothing to do with supply and demand of goods produced in competitive markets, and are instead set, more or less, through central planning. Bureaucrats decide where to allocate research dollars, how much medical procedures cost, what insurance must cover, etc.
It's not _totally_ communist, because you do have different business competing, but it feels like it's maybe ... 70% of the way there.
The thing that perplexes me here is that basically everyone seems to do it the same way. That 'health care systems different from ours' post makes it clear that there really isn't anyone treating health care for humans the way we do it for, say, animals, or cosmetic surgery where price signals reflect supply and demand, insurance doesn't cover anything, and as a result things are cheaper.
Why is that? How come there isn't a single state doing something 'free market' with health care?
The best answer i have says something like, 'if the capacity exists to save a dying person, and it doesn't get used, people will rebel against whatever political status quo prevents that capacity from being used, even in autoritarian situations'. If the capacity does exist, and it _can_ be used in theory, but in practice you can't because it's too slow an ineffective, people are less likely to rebel.
So it seems like, 'constraints must be illegible in order to survive popular wrath'. You can have much, much tighter constraints than 'you can't afford this so you can't use it', and people will generally accept them so long as they involve 'safety regulation' and 'labor shortages', etc. A cartel that restricts the number of doctors is totally politically feasible, in a way that 'this machine could save your child but you cannot afford its use' is not, even if the cartel restricting doctors is way, way way more destructive.
“It seems to me that America basically has a tiny communist microstate consisting of health care ...”. I think you’ve got the wrong model. Communism asserts government ownership of the means of production (of health care). That’s only really true of government hospitals, which are not overwhelming. Although there’s no set economic form for racism, I think that is closer: a typical fascist approach to labor relations is to put everyone parties at the table -- capital, labor, and government -- and have government play the leading role to assure that the result supports the greatness of our great and glorious, really great awesome nation. Getting people to the table means that only the biggest players get a seat, so you also see a lot of concentration of economic activity. That seems an awful lot like our healthcare system -- medical providers, insurers, drug maker, and so on get forced to the table to negotiate with each other, under the government’s watchful eye and guidance. And the government’s goal is as cloudy as the fascists’ goal in labor relations. But maybe I’m reaching.
You answered your own question. With pets, it's considered acceptable to say, " We can't afford to spend $10k on Fluffy's cancer treatment; we'll have to put him to sleep." with human patients this is not acceptable.
Right.
Because we are unwilling to say, "there is a machine that can keep grandpa alive for another day but it costs $100k per day to use, so we won't use it because (that would not be a good use of his remaining funds) or, even less acceptable (because grandpa doesn't have that much)", we instead are in a situation where literally every other aspect of grandpa's care costs ~10x what it otherwise would.
Don't worry, Canada is working on solving that discrepancy.
https://www.theguardian.com/world/2022/may/11/canada-cases-right-to-die-laws
I would guess that adding obesity related conditions would help with getting insurance to cover it, and this may play a role with how startups are getting insurance coverage: eg, hypertension, sleep apnea, etc.
As long as there is no fraud that seems ok.
Detecting those headed towards, but not yet in, type 2 diabetes seems like a high-ROI use case.
Here's my Ozempic story: So I wanted to get pregnant and had been trying 'the old-fashioned way' for a year. My fertility doctor says I have to lose weight for fertility treatment. In a panic I rush over to my endocrinologist who says 'let's put you on this Ozempic stuff so you can get Clomid.' Okay great. Two weeks in and I'm down 10 lbs. I have to take a pregnancy test before each injection. Okay, about to do infection #3...take my test...and I'm pregnant!! For the next 9 months, I keep hearing jokes about how Ozempic must be a fertility drug....your AMH was WAY too low to get pregnant, etc. Okay, October 2021, I have a beautiful, healthy baby girl. Endocrinologist says I can start my injections as soon as baby's calories are at least 50% from solid food or formula, 50% breastmilk. Okay, okay. I just need to wait and be patient. Well, joke's on me, and my baby girl won't eat and won't drink anything other than breastmilk. She's 12 months old, and in OT to teach her how to chew. And it will be almost 2 years that I will have had 6 months of Ozempic sitting in my fridge. Is it expired? Do I try to sell it?! I don't know...
This article is really useful especially today.
I have a theory about obesity. The mention of the “family” factors — small group - is on the right track. Some people have a condition where they themselves are not overweight but they obsess about the weight of those in their immediate circle. We arrived at the home of this relative last night. This person complains significantly about others’ weight behind their backs. For some reason they had a large tin of cookies & immediately made sure we took it with us to where we were staying (this was not a planned gift). They’re almost a type of poisoner. I resisted the cookies but dang. Someone who hangs around undermining the willpower of others is a common character in the US I think, maybe everywhere, I just happen to be related to this one. Seventy percent odds this person mentions Wegovy before today’s large meal. 99% mentions within 48 hrs. Finding and somehow intervening with the people playing these roles would lead to improved weight control among those in their circles.
Well, they mentioned semaglutide, not Wegovy by name, but I’m calling it accurate.
Your estimate of the proportion of annual healthcare expenses going toward semaglutide in a world without barriers to usage assumes that the obesity rate (or population of obese Americans) stays fixed. If this drug works, there'd be a significant one-time expense and then, presumably, minimal expenses to follow (unless the drug were required for weight maintenance in the formerly obese). Not to mention the knock-on effects of lower expenses for obesity-related disease. As an extreme example, imagine a one-time 50k pill that prevented you from ever getting sick again - I couldn't care less about the proportion of annual spending going toward that drug the first year it was released.
Good article about the drug, the annoying thing is the use of BMI.
It's a bad measure.
1. It's not dimensionless even though people use it like it is. Metric BMI vs. Imperial BMI are not the same number.
2. The (admittedly small) minority of people who have more muscle are unjustly persecuted by their doctors for being "obese".
I admit self-interest here. My (Imperial) BMI is 35, I'm able to deadlift at least 3 times what my doctor does, but I'm the obese one who needs to go on a diet. I did shut him up about it by pointing out that even the US Navy has stopped using it as a measure for their incoming recruits (IIRC they use height/weight/waist/neck plus a chart now - I guess they had too many people able to lift a car but they can't run so they can't be on a ship until they lose weight).
BMI is a simple "ballpark" measure you can do with a scale and a tape measure.
The simplicity has a lot of value. For more serious application, you need better measures.
Yeah it's something the GP can run on a calculator after the nurse has run the measurements before he brings out his prescription pad. Rather than actually looking at me and saying "Does this guy actually need to lose weight?".
Sorry I'm not enamored of the bedside manner of my GP.
35 is enormous, dude. BMI is definitely a flawed measure that can neglect the affect of muscle in extremely large elite strength athletes, but even so. I'm 6'2" 189 right now. I can probably deadlift 3 times what my doctor does, but I imagine I'll never be great at deadlifting because I've got ten screws in my spine, but still, well over double bodyweight at least.
But to get to 30, I'd need to be 234 lbs. That's closing in fast on peak Arnold. That's possible, but it's not possible without steroids, and even most serious bodybuilders are going to admit the size they achieve is not healthy, in spite of being lean. They still end up with elevated resting heart rate, elevated blood pressure, elevated LDL, sleep apnea. Effectively everything you'd associate with being very fat, except diabetes (but still might get that, too, thanks to HGH abuse).
It's great to be strong, but that doesn't make it healthy. By all means, if you've got a shot at being an NFL lineman, a pro sumo wrestler, strongman champion, absolutely go for it anyway. But understand you're sacrificing health to do it. And yeah, military can go overboard with the endurance over strength focus, but there isn't no reason for it. You need to be able to fit into standard sized seats and cockpits. The bulk of jobs involve moving your own body more than they involve moving external heavy objects against resistance. If you become incapacitated, the other people in your unit need to be able to carry you.
5'8", 230 lbs., 58 years old, deadlift of 415 for 3. Normal heart rate, blood pressure and LDL according to tests. No drugs - including no prescriptions at all, which is unusual (all my friends of similar age are on something or other).
I lift 3 times a week for about an hour, almost all triples or 5s. No cardio.
My doctor thinks a deadlift of 135 is a lot - I think that's what he does (admittedly he's likely in his 70s, so there's that).
I'm looking at your stats and thinking that you don't lift, you run. If you get more muscle, the weight will go up a lot faster than your measurement.
I have no experience with being in the armed forces. I suspect that jobs lifting heavy things are more common now that the army is almost all mounted, e.g. loading artillery or tank shells rather than marching off to the trenches.
There's a reason the Army's old fitness test was all endurance and the new one has deadlift and sprint-drag-carry.
I think you're underestimating BMI for natty strength athletes. You can be really fit and 30 BMI natty--I've been there, and I don't have a particularly big frame or anything to suggest I'm an outlier. (Though I'm down to 29 now as I've improved my composition after my last cut.) When I looked at it a while ago, I think 28-30 BMI was typical for elite drug-tested weightlifters (US weightlifters who actually get legit drug tests), many of whom cut weight for competition, so they'd be walking around bigger than that.
Arnold was huge at 240 not because 240 is huge, but because he was well under 10% bf at the time.
If you can, squat two times your body weight, BMI is probably inaccurate for you. But I bet that is less than 5% of the population.
Not quite, but close.
The annoying thing is that there actually is a simple measure that's much better than BMI: waist circumference to height ratio (WHtR).
IIRC Calibrate's pitch to insurers is that by pairing Semaglutide with their behaviour change program (app + coaches) they can eventually wean people off the medication while maintaining the weight loss effects, saving insurers lots of $$ in the long term. So far they've been quite successful convincing insurers (and VCs) of this but I think the evidence shows people need to stay on Semaglutide forever to maintain their weight so I don't think this will hold up.
I would be surprised if Semaglutide was cheaply available as a generic by the mid-2030s unless there are significant reforms made to the patent system or pharma industry rules. Humira and Lantus are good examples of drugs which would be significantly cheaper by now except for repeated patent extension and industry deals maintaining monopolies (although hopefully coming down soon).
Surely eating less can be translated into paying less for food,, offsetting some of the cost of the drug.
Food is very, very cheap. At least PPP-adjusted in the US.
I have a condition that the NHS doesn't really have a good way of treating (eczema), except for an American drug, called "dupixent" or "dupilumab", that they're extremely reluctant to prescribe because of the cost (about 40k annually).
Should I expect a much more affordable generic, or the cost to go way down, when the patent runs out?
Maybe someone here has some insight, I really would like to know. Apparently it's a type of drug called "biologicals", which are expensive to produce, so maybe even at production cost it would still be prohibitively costly, but surely not 40k costly.
My son uses that drug (dupixent). He contacted the company directly and somehow got it at a huge discount because our insurance company wouldn’t cover it. We are in NYC.
Might be worth a try though.
Similar story here -- I live in the Northeast, my spouse takes it off-label for very serious asthma. There's a ridiculous discount the manufacturer offers via a coupon, I have no idea how the economics of this works, it might as well be Scott's "burn them for warmth" theory.
I will tell you that stuff really works, at least for her type of asthma which is apparently related to eczema. She's been on it for a couple years. She went from regular asthma exacerbations, hospitalizations (for massive IV steroid treatments) about once a year after otherwise minor respiratory infections, and long courses of high-dose oral steroids to ... none of that. At all. For about three years.
In terms of medical costs, the insurance company should be paying for the drug! They'd clearly come out ahead, at least in her case. If it were eczema, I'm not sure the cost/benefit would work out (at least under US health care math), but if it works anywhere near as well for its on-label use as off, I'd try hard to get ahold of it, too.
It works really well for my son, both asthma and eczema. As far as the discount goes, I don’t know, but sometimes I wonder if the company is building a track record for the drug that will force insurance companies to cover it.
As soon as I saw "$500 billion" I thought "That doesn't sound like that much money if it really is a miracle drug." And I think the research about the monetary breakeven point neglects a lot of other potential good side effects. For example, this link from 2012 suggests that Americans waste one billion gallons of gas due to being overweight: https://www.forbes.com/sites/matthewdepaula/2012/10/09/american-obesity-the-biggest-threat-to-fuel-economy/?sh=4acd77c65e92
The same thing applies to overweight people on airplanes. And trains and buses, for that matter.
One thing about the idea of a post-obesity future: if the average responder can reasonably expect to lose 10% of body weight on Semaglutide, that would still leave most of them obese.
AFAIK the standard categorization for 'obese' starts at 30 bmi. Rough napkin math with a BMI calculator makes me think that anyone who starts at about 30-33.5 bmi and then loses 10% of body weight will end up below 30 bmi, but anyone who starts out above ~33.5 and loses 10% will still be obese.
5 minutes of google didn't find me a precise answer to 'what percent of the US population is above '33.5bmi', but it did find some distribution graphs that makes me roughly guess it would still be like 25%-35%.
But maybe the 10% figure comes from a 3-month clinical trial, and if you take it for 5 years you just keep losing until you are at a 'healthy' weight? Or maybe you gain tolerance over 5 years and end up back at your original weight? Seems like a lot is left to be learned about those dynamics.
Yeah, this is the angle I had as well. I know this is a miraculous drug because so few things work at all, but how much do obesity-related risks fall if a 5’8” person goes from 300 to 255 and has to stay on it for life? (My understanding is people regain weight if they stop: it’s not like the drug recalibrates your “set point” permanently or anything.)
Health risks for obesity drop SUBSTANTIALLY with a loss of 10% of body weight. It’s shocking how much difference even that relatively small loss can make.
My father is Canadian, and I was talking about weight loss with him a couple of weeks ago, and he says he has semaglutide. But he doesn't take it because he feels it would be cheating to lose weight that way.
... who does he think is being cheated, exactly?
couldn't tell you.
I came to make the "using a pill to fix all our problems sounds terrible" post. I see others have made the same point above. To take a step back, this feels like more of a me-midlife-crisis problem than a problem with Scott's analyses or arguments.
There are two things recently that have made me think "the modern world is terrible." The first is Britain's new and ongoing reliance on food banks. A rich country in which a significant number of people can't get enough to eat: that's gotta be a sign that something is messed up.
The second is this: rich and resourceful societies around the world that can't get a grip on the deliberate infliction of chronic disease on its citizens by themselves/corporations/society, and instead turn to a pill to solve the problem.
These problems aren't turning me into a conservative, as is often supposed to happen, but they are for the first time ever making me think, at the age of 41, that the world is going to hell in a handbasket. I apply a very low level of credence to this belief, because it's overwhelmingly likely that I'm just thinking it because I'm middle aged. But I definitely do think it now.
In both these cases, it feels like building the right kind of institutions could prevent these things from happening; but something is preventing us from building those institutions. I can't work out what's going wrong. I mean, bloody Tories or whatever, but I don't know if it's really a party political problem.
Would it be 2 of 3 (kind, true and necessary) to ask if Scott owns any stock in the companies making the stuff?
I don't.
I'm not sure if you're asking to see if I have a conflict of interest, or asking to see if I put my money where my mouth is. If the former, I don't. If the latter, I assume I'm late enough that all of this is already priced in.
> I model semaglutide use as interest * awareness * prescription accessibility * affordability.
You are multiplying quantities that are uncertain and the product of multiple distributions is better modeled as a log-normal distribution (and I guess some of your inputs are also already log-normally distributed). And for a product of such quantities the mode is left of the mean by more than one std dev. Did you take that effect into account when estimating the individual numbers?
https://en.wikipedia.org/wiki/Log-normal_distribution
I friend of mine is on Contrave, and has lost *lots* of weight. I tried two of her pills, and somehow forgot to eat most of both days!
She got them through a "fly-by-night telemedicine company" and pays $600/month. The pills themselves cost ~$100/month, and $40 if you get the components separately.
Are there more reasonably priced telemedicine places? I fully expect tons of hidden fees on top of their advertised rates...
I suspect my regular doctors would get me on diet & exercise, which I'm already failing at. But maybe I should give them a try before I go Gray Market?
For what it's worth, Scott, though people may feel it isn't worth the risk due to not exactly being legal, it is fairly trivial to get semaglutide from a grey market lab that just buys bulk chemicals from Chinese raw suppliers to package and resell in western countries. At the one supplier I know for sure is selling tested, real stuff I've seen other people use and get results from, it's currently $120 for a two-month supply. But many, if not most, sellers of research peptides will stock this. You can even get reasonably-priced HGH if you want a little extra lipolysis kick, and in spite of the scare stories from moralizing legislators trying to make examples of pro athletes for cheating, it is extremely safe if you're not doing bodybuilder-level doses. Yet another thing anyone over the age of 40 can get a prescription for by going to any anti-aging clinic, but they're going to charge through the roof and your insurance will definitely not cover it.
Feel free to cry for pharma companies losing some fraction of their precious patent-protected dollars, but $15,000 is utterly absurd. There is no need at all to pay that much.
"PCP" means "personal care physician" in the context that Scott is using it. I only bring it up because the expansion of the acronym wasn't obvious to me and googling it isn't helpful.
"Only 75% of Americans have PCPs at all." Just curious if am I the only one who got confused by this?
*Primary* care physician
Oops, thanks for the correction.
Ugh. I’ve been wanting to take Wegovy ever since I heard of it after Elon Musk’s tweet, then went down a rabbit hole on it. Sounds waaaaay safer than Phentermine, which they give out like cheap candy and is terrible for you, plus doesn’t work for many because of the side effects.
I hope they can reduce the Wegovy price. I can’t justify the payments.
"(there’s also a third-level effect where it costs the health system money again, because it prevents people from dying of obesity-related complications, and dead people stop needing expensive health care. I think health economists are supposed to ignore this level.)"
I am regularly pretty frustrated by arguments that ignore this level, because if we're going to have a discussion specifically on economic grounds, it seems like a glaring omission. There are many versions of "Spend money to prevent this person from dying, because people use a lot of resources when they die, so costs will actually go down." You can still make the argument on moral grounds, but don't use an economic argument that assumes that near-future people will be immortal.
I came to make this comment. This really annoys me so much. People should weigh less because they will live longer and feel better but dying at 60 of a diabetic related infection, heart attack, or stroke, is a lot cheaper than five years in the nursing home at 85 years old. that doesn’t mean we should want people to die early, but it does make the economic argument illiterate. She also: smoking.
Don’t forget that better overall health also means compression of morbidity; you are sick or disabled for a shorter time before that (later) death.
For example, the average smoker lives about 8 years less than the average non-smoker. But also the average smoker is significantly ill or disabled for about 5 years before death, while for the average non-smoker, that period of illness before dying is about 2 years.
Yep:
https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0050029
Nut graf:
"Until age 56 y, annual health expenditure was highest for obese people. At older ages, smokers incurred higher costs. Because of differences in life expectancy, however, lifetime health expenditure was highest among healthy-living people and lowest for smokers. Obese individuals held an intermediate position. Alternative values of epidemiologic parameters and cost definitions did not alter these conclusions."
Basically, lifetime healthcare expenditures seem to be dominated by how long you live.
[Epistemic status: tongue only 33% in cheek]
Obesity should be renamed to crappyprocessedfoodoholism, to highlight the fact that you can avoid it by eliminating all the crappy processed food from the environments where you eat. Obesity was almost nonexistent before we got an industrialized supply of highly refined carbohydrates and oils combined into superstimuli. If you eliminate all the liquid/powdered calories and deriviatives thereof from your food supply, it's really hard to get fat. OTOH 97% of the calories in the supermarket consist of that kind of crap, so it's hard. People don't want to be thin as much as they want to eat processed crap, and there's a lot of bad information out there that derives from rationalizations thereof.
Yep!
I have been taking Wegovy for 14 months. When I began I weighed 275 lbs and my BMI was 39.9. I have hypertension, albeit well controlled by medicines. Diet and exercise phaaahhh. I could eat faster than I could exercise. And no, I eat very little fast food and little candy and soda.
I worked with my doctor to be prescribed Wegovy. It was only approved by the FDA in June 2021. My doctor was reluctant because he was unfamiliar with the class of compounds. He does not like to prescribe off label so he was not willing to to start me on Ozempic. But, the FDA solved that problem.
I knew to ask for the drug because my daughter was pre-diabetic and had been put on Metformin and Ozempic. She lost 100 lbs. in 2019 and 2020.
I started on Wegovy in September 2021. I now weigh 220 and my BMI is 31.5. That represents a 20% reduction in my original weight. 220 was my original goal. To get a BMI under 30 I would have to be under 209. I doubt that I will get there. I am back in 40 in. trousers which I had not been able to wear in 30 years. 220 was my original goal.
I have had no major side effects other than constipation. Even that is a little hard to tease out. I am on 7 Rx drugs and at least 5 of them are constipating. I have been pounding Metamucil and Colace for years.
I have been able to fill my prescriptions using a GoodRx coupon at $1328 for a box with 4 injectors. A year requires 13 boxes. The total cost for 15 boxes has been about $20,000.
I can afford it and it has been worth while. I call it a bargain, the best I've ever had. https://www.youtube.com/watch?v=v6O5slQFFhc
I understand that it still way too expensive for the American health care system to afford. But given the bonanza size of the market. There will be lots of competition starting with the Lilly's tirzepatide. There are several other pharma's with GLP-1 agonists in development. I am sure that the cost will come down.
My doctor tells me that I can expect to stay on semaglutide for the long term. He is proposing that I switch to Ozempic 2 mg for maintenance as I can buy that for less than $1,000 for a four dose pen.
My only sadness is that semaglutide wasn't invented 40 years ago when i would have saved me from a lot of damage. But, I am grateful that it exists now and that it has helped my daughter so much.
"Two-year effects of semaglutide in adults with overweight or obesity: the STEP 5 trial"
| Garvey ae.t.al. and the STEP 5 Study Group*
https://doi.org/10.1038/s41591-022-02026-4
"The STEP 5 trial assessed the efficacy and safety of once-weekly subcutaneous semaglutide 2.4 mg versus placebo (both plus behavioral intervention) for long-term treatment of adults with obesity, or overweight with at least one weight-related comorbidity, without diabetes. The co-primary endpoints were the percentage change in body weight and achievement of weight loss of >=5% at week 104. Efficacy was assessed among all randomized participants regardless of treatment discontinuation or rescue intervention. From 5 October 2018 to 1 February 2019, 304 participants were randomly assigned to semaglutide 2.4 mg (n=152) or placebo (n=152), 92.8% of whom completed the trial (attended the end-of-trial safety visit). Most participants were female (236 (77.6%)) and white (283 (93.1%)), with a mean (s.d.) age of 47.3 (11.0)years, body mass index of 38.5 (6.9) kg/m–2 and weight of 106.0 (22.0) kg. The mean change in body weight from baseline to week 104 was 15.2% in the semaglutide group (n=152) versus 2.6% with placebo (n=152), for an estimated treatment difference of 12.6 %-points (95% confidence interval, 15.3 to 9.8; P<0.0001). More participants in the semaglutide group than in the placebo group achieved weight loss >=5% from baseline at week 104 (77.1% versus 34.4%; P<0.0001). Gastrointestinal adverse events, mostly mild-to-moderate, were reported more often with semaglutide than with placebo (82.2% versus 53.9%). In summary, in adults with overweight (with at least one weight-related comorbidity) or obesity, semaglutide treatment led to substantial, sustained weight loss over 104 weeks versus placebo. NCT03693430"
Health care economic observation. I have read that some health economists believe that declining rates of cigarette smoking have cost the health care system a lot of money because cigarettes killed a lot of people before they got old enough for really expensive sorts of care.
I ma not sure that obesity is like that because it is not a quick or certain killer.
Nope. See my note above about compression of morbidity in non-smokers.
Maybe. I was something I read a while back, and my brother the pulomary doctor thinks it was true. I am too lazy to research the issue. If you have a citation you win.
Is the mechanism of action just suppressing hunger? Wondering how this would interact with a bodybuilding-style cut in terms of preserving lean mass, if at all.
> 10 million Americans on semaglutide (or yet-to-be-approved equally good or superior alternatives) by 2030: 75%
Should this say "at least 10 million..."? (or "at most", or 10±5, or...?)
I am on Mounjaro, and have been for four months. Lost 20 pounds so far, and I'm not yet on full dosage. Occasional mild nausea but real issue for me is....tiredness. Not fatigue or exhaustion. I'm a former insomniac who can now hit the sack at 9:00 and sleep happily to 6 am, which is insanely weird.
I have been trying to lose weight for 6 years, and for most of that time been in a 20 pound range that is 100 pounds over what someone of my height should weigh. I've eaten 1500 calories a day and not lost a pound, have to drop to 1100 to lose weight verrry slowly (that's with intermittent fasting and low carbs, around 50 grams). Last year before Mounjaro I started intermittent fasting and lost 20 pounds very quickly and then stopped cold. I do not have eating issues. I don't binge. I cut out the "four white foods" six years ago because I learned that I do better on meat and cheese and vegetables than I do on pasta or bread or potatoes and vegetables. I put on weight despite walking two and in some cases four miles a day, which I can do easily.
I am ridiculously healthy and do not have an obesity diagnosis. Stone cold normal readings in A1c, glucose, cholestrol. My doctor sent me to an endocrinologist after I lost 20 pounds and then stopped cold despite the same behavior (which I still do today) because she agreed I might be insulin resistant. Endocrinologist shrugged, said it's multifactorial, but agreed that anyone with my numbers, appearance, and obvious good health was clearly doing everything right and put me on Mounjaro with no further questions. Diagnosis: insulin resistance. My insurance pays around $500 but I'm on the $25 coupon.
I didn't change a single thing about my eating habits and lost ten pounds in 2 months on the low dosage. Higher dosages have finally reduced my appetite somewhat, but my endocrinologist and I have decided to stop the increases at 12.5 (15 is the top) and then maybe even reduce, since my appetite is decreasing but the weight loss rate is constant.
Because I lost weight doing the same behavior and no drop, I'm quite convinced that something far different than appetite suppressing is also going on (fwiw, I was on phentarmine back in the day and liked it fine). Mounjaro is supposed to increase insulin production and reduce the liver's sugar production, although what that means I dunno.
I have no idea what's up with obesity but the idea that it's all about cutting intake and exercise is just stupid. I should have been losing weight for all of the past six years and haven't. Plenty of people eat healthily and are still obese. We're probably the descendants of famine survivors.
Anyway, I wrote about it here: https://educationrealist.wordpress.com/2022/10/09/weight-loss-and-mounjaro
Excerpts:
************
My weight is not considered a health issue. This despite the fact that my weight, for my height, is shocking. Fifty pounds below my highest weight would still leave me medically obese. 50 pounds lost moves me at most one or two clothing sizes. I can lose 30 pounds without anyone noticing.
My height and weight suggests a person needing two airplane seats, XXXXL clothing, wheezing, and inability to climb three stairs. In fact I’m in normal clothing sizes, hike and walk frequently, can run a mile if you make me, and only wheeze because of my allergies. I’m not bragging. My weight bothers me. A lot. But I’m grateful that my appearance suggests I need to lose 30-40 pounds, not 100.
My weight history was quite consistent until 2016. I have a big appetite that didn’t make me fat until I was 30. From that point on, I’d have to cut back my intake every five years or so because the same amount of calories wasn’t burning off reliably. I’d ignore my weight gain until something forced me to acknowledge it, then diet to successfully lose weight I’d keep off for five years or more. My methods are a recitation of conventional food wisdom because I always went to doctors to lose weight.
1992: start exercising, cut way back on fat. That rule, I kept as a guideline until 2016. Kept off for five years.
1997: Fenphen, just in time for the fen to be banned. But phentermine by itself kept working until 2008 or so–that is, slow weight gain but no ballooning. Then my doctor told me I couldn’t have phentermine because of my blood pressure, took me off that and put me on hydrochlorothiazide, which I’ve been on ever since (lisinopril and nifedipine added in 2016). Ending phentermine kicked off a ballooning that I ignored because I was worried that cutting calories wouldn’t work.
2010: I bit the bullet, just cut calories, and lost over 50 pounds in eight months. At that time, I vowed to monitor my weight and not ignore weight problems and over that time did pretty well. I didn’t keep all the weight off, but keeping a scale kept me from ignoring it and I’d cut back and minimize weight gains, even lose a few pounds.
In 2015, I started renting with my brother, which operated on my eating like an invasive species. His leftovers were my undoing: fettucine alfredo, fried chicken, fried fucking porkchops, fresh baguettes, and he keeps peanut butter on hand. That was when I learned that 30+ years of being solely in control of food purchases had created strictures I didn’t even know existed–like don’t buy it and you won’t eat it. It only took me a year to regroup but that year was a 30 pound weight gain and I was back to my all-time high. Wah.
2016 is when the history pattern changed. I cut calories and didn’t lose weight past a given limit. However, two things occurred that year. First, I got much better at watching my weight. I could gain ten pounds from the low limit and then lose them instead of ignoring the problem. Of equal importance, I decided to cut both calories and carbs, which focused me on carbs for the first time since the 70s and the Atkins plan.
*****
The endocrinologist is constantly asking me how my behavior changes, am I eating less, and so on, and is skeptical that I’m dropping weight with no other changes.[note--this was written six weeks ago, before recent dosage increases] My internist is much more friendly to my theory that this drug is changing my body chemistry in some way. Various reddit threads have testimonials to how the drug has stopped the taker’s binge-eating and hunger pangs. None of that applies to me. I wasn’t a binger, had no food issues, and my appetite hasn’t changed much.
My own theory is that changing my carb intake in 2016 took me off the Type 2 diabetes path, but that the insulin resistance path is unaffected by diet changes? Keep in mind I have only a vague idea what insulin does. Science is still the one subject I don’t teach. In any event, if this continues to work, my doctor agrees with me I’ll probably have to take it permanently.
**************************
I'm hoping the cost will come down, but I'm pretty sure my insurance will cover a lot of it, and I'm willing to pay quite a bit to keep weight off. It's all tax-deductible, anyway.
I have to ask the stupid, obvious question, but is your weight due to muscle under a layer of fat? Because if you say you need to lose 100lbs but look like you only need to drop 30lbs and you can fit into normal range of clothing, then that doesn't sound like purely fat alone to me.
It does sound like there is *something* going on with your metabolism, but if a qualified endocrinologist doesn't know, I certainly have no idea.
It's not a stupid or obvious question. Yes, I have a lot of muscle mass. I believe you do as well, if I read your posts correctly. I'm only class 2 obesity (under 40 BMI), which given my weight is pretty impressive. But there's plenty of fat to spare on top of the muscle, so it's not the muscle that's failing to disappear.
What are your testosterone levels like?
No clue. Do people test their testosterone levels?
Not sure about people in general but when it comes to weight gain/loss/maintenance it's not unimportant.
Losing 10-15% (at best) of one's body weight honestly wouldn't cut it for a large portion of the obese population (15% of 300 lbs puts you at 255, which is still obese). Hearing "you can solve your huge life-altering problem for $15K/year" would be worth it for a lot of people. But hearing "you can solve half of your problem for $15K and then you'll still need a massive amount of effort to finish it off" sounds way less attractive. These drugs may be better than previous solutions but they'd still need to be improved another doubling or more.
>you can solve half of your problem for $15K and then you'll still need a massive amount of effort to finish it off
This is more less describing bariatric surgery. Though the pills trades less risk for less reward. I wonder how Wegovy compares against lap bands, which are one of the least effective but less obviously invasive versions of bariatric surgery.
Even given that the pharma company that developed it has a monopoly this pricing seems strange. If it's really on the verge of being prescribed so widely and the company can produce it for a relatively low marginal cost the price charged per dose seems wildly above the profit maximizing price.
More generally, why the hell would they price a drug that's likely to have a large market so high while they don't seem to be extracting the maximum profits from other drugs that have fewer applications but are less likely to be denied by insurance?
Should rationalists be more able to lose weight than others? Various people have said something along the lines of, it's obvious that overweight people could lose weight if they stuck with eating less and exercising vigorously. I think that's probably true for most overweight people. Some have health problems that would interfere with their doing vigorous workouts, and a few may have some metabolic quirk that keeps exercise and caloric deficits from taking off the pounds, but I believe that far more than 50% of us could in fact lose weight if we stuck with caloric restriction and increased exercise.
The problem, of course, is that most people fail at sticking to that regimen, including most people posting here today. It seems like most of us must be making simple, obvious errors in our thinking about weight loss regimens when we are on them. Stuff like, today doesn't count -- I deserve a treat -- I'll go back to the regimen tomorrow -- this isn't even going to work, why stick with it?
OK, so it's not motte & baily, but it's simple, obvious errors in reasoning about the situation. Shouldn't rationalists be better than other people at not falling into these thinking errors that lead to abandonment of weight loss regimens?
It sounds like you're asking "should rationalists have more willpower?" I think the first level answer is "no, why would they, low willpower isn't a cognitive error, try kicking a heroin addition, and see how far your being very smart gets you". The second level answer is that reading George Ainslie ( https://www.picoeconomics.org/HTarticles/Bkdn_Precis/Precis2.html ) helped me understand what willpower was in a way that actually did seem to give me slightly more willpower, but I don't want to attribute this to "rationality" specifically because if I knew everything I know now *except* the Ainslie stuff I don't think it would help.
I will read the Ainslie tonight or tomorrow, so I am responding without the benefit of whatever's there. But actually I was not saying that surely rationalists should have more willpower. I was saying that abandoning long term goals because of short term cravings and pain involves various cognitions that clearly do not stand up to close examination, and asking whether we shouldn't expect rationalists to be better than the average person at examining and rejecting these cognitions. So I am not talking here about the sort of thought structures and thinking errors identified in the rationalist canon, but about the kinds of clearly inaccurate ideas that are addressed in cognitive therapy.
Here are some examples of distorted cognitions in someone struggling to break a habit or abstain from use of an addicting substance. They come from my struggles to quit smoking, something I eventually succeeded at 20 years ago. ( I actually have not struggled much with my weight over the years, but I'm sure people struggling to stick with an eating plan have similar thoughts.)
Without cigarettes I will not be able to . . .
-concentrate well enough on my dissertation topic to make any progress
-enjoy talking with friends
-finish eating a meal and feel satisfied
If I do not have a cigarette right now I will . . .
-suffer unbearably intense cravings which continue undiminished for hours, days, and weeks until I eventually give in and have a cigarette.
It's ok to have a cigarette right now because . . .
-I have overcome the addiction enough that one cigarette will not lead to a relapse.
-this is a special occasion and the only way to properly celebrate it is with a cigarette.
-I had one yesterday, after abstaining for 4 weeks, so the whole quit-smoking project is a failure, and I may as well give up and have a cigarette whenever I crave one.
OK, so a few of these are pretty indefensible, and the rest are questionable -- before accepting them as valid you'd want some evidence to support them (are you sure your craving would continue indefinitely? what actually happens when you try not lighting up when you crave a cigarette?). And these statements, if simple accepted as true, lead directly to abstinence violation. They justify it, in a bullshit kind of way, right? So my question is, should we expect rationalists trying to lose weight to do better than others at mistrusting such ideas when they come to mind? It does seem like people who are less likely to just accept these rather silly thoughts as valid predictions would be less likely to be swayed by them, and less likely to relapse.
Thanks, I see more now why you would expect this to work.
I agree it would make sense if good rationalists could also fight distorted cognitions better. My only evidence either way on this is that the LW survey shows readers here have a much higher rate of depression (but lower rate of addictions) than the general population. Since a lot of people say negative cognitions are involved in depression, if you assume people at LW are better rationalists than the average, there doesn't seem to be enough effect to overwhelm whatever else is causing more depression. My guess is that the fewer addictions thing is something else (maybe class?)
Is there a conflation of "distorted cognitions" and "negative cognitions" here? Isn't it possible that an accurate, intelligent, rational assessment of the world produces depression, and that lack of depression is a result of cognitive distortions that most people don't even think of trying to eliminate? And that there's a somewhat benign social rule to lie to each other about this?
As with some other stuff, I don't want this to be the case, and I hope this is not the case, but I don't know of a good argument against it. If you happen to have one ready off the cuff, I'm all ears, but otherwise, please don't feel pressure to come up with one. I mostly just wanted to note the logical possibility.
The strong evidence of the benefits of religion suggests that rationalism would be expected to increase depression.
You could potentially argue from there that reducing addictions increases depression. After all religion is the opiate of the masses.
There's no reason to believe that the universe functions in such a way that understanding it implicitly improves outcomes.
Suppose a world in which humans as raised in matrix like creches by aliens. At the age of puberty they procreate and then are harvested for consumption. Cause they taste delicious when in the stew of puberty chemics. Suppose there was no situation in which humans could rise up and free themselves.
Would you be happier knowing you were being consumed for food and losing ~80 years of your potantial life span? Or would you be happier thinking the angels took away successful procreators into a magical land in the sky?
So I ruminated about this, and actually I do not expect rationalists would be any better than anyone else at challenging the kind of thoughts that people learn to challenge in cognitive therapy. The kinds of bad thinking rationalists have learned to recognize and challenge are much more clever and complex. You have to really apply your mind to see what’s wrong with them. In contrast, the pro-relapse thoughts I was giving as examples are really pretty dumb and easy to spot, especially if they are not the products of your own mind. It doesn’t take no rationalist to shoot them down. For instance say your 15 year old had earnestly shaken hands with you on an agreement not to attend parties where no parents were present, and then you found out he’d been to one. What if he defends his actions by saying “If I hadn’t gone to that party the craving I would have suffered would have been unbearable, and would not have diminished at all over the course of the evening no matter what I did instead.” You’re going to laugh and say “oh, come on,” right? Or how about “it’s a special day, the first day of summer vacation, and going to an unsupervised party was the only appropriate way to celebrate it”? Just silly, right?
Another thing about these “distorted cognitions,” as they’re called in the trade, is that they’re not exactly cognitions — if by cognitions we mean thoughts experienced as factual statements, in the same category as “I’m wearing an overcoat.” They’re more attempts to bridge the gap between one’s craving to smoke and one’s picture of oneself as a reasonable being. If you just go buy a pack and light up all the while thinking of yourself as being in the process of sensibly quitting smoking — you’re kind of fractured & incoherent. We’re not built to endure experiencing ourselves that way. So maybe the lame case in favor of smoking — “if I don’t I won’t be able to focus on my dissertation” — should be thought of almost as the confabulations people with Korsakoff’s or other mental disabilities come up with to reconcile disparities in what they remember.
If there’s any sort of training that would give people an edge in catching thoughts of this kind, it would probably be training simply in catching thoughts. I did a little research on that in grad school, having a roomful of freshman record what they were thinking when I rang a bell, once every 5 minutes or so. Most could do that, though some, like the woman in the Buddhist tale, said they hadn’t been having any thoughts. On some trials I asked people to try to reconstruct the train of thought they had had since the previous bell, and a few seemed to be to be pretty good at doing that. They produced little ramshackle lists of topics, connected by “and then that made me think about . . .” Sounded like the same kind of thing I unearth when I manage to capture a chain of my recent thoughts.
I think believing your own rationalization is a non-trivial part of being stuck, in (mild) addiction and many other forms of modestly dysfunctional behavior. I'm very dubious of the proposition that it's a matter of willpower. When I do see people overcome dysfunctional patterns of behavior, it's not by summoning unusual reserves of willpower. Rather, they stop bullshitting themselves and start making plans that allow them to succeed without the necessity of extra willpower.
They may for example just start playing mind games with themselves -- I can do Y if I first do X, or I'll just do 2 minutes of X and quit if I hate it...OK, 2 minutes down, that wasn't so bad, I'll do just 2 minutes more and then quit if I hate it... Or they'll deliberately put themselves in situations where the temptation is simply impossiible to act on. In any of the times when I've personally had to do stuff I don't want to do, but know I should, that's how it goes. I don't summon herculean reserves of willpower, I just set myself up, so to speak. I may not be happy in the moment that I fall into my own Woozle trap -- damn it, what asshole dug this pit right here?! -- but usually I'm happy enough later with the outcome that I can set the trap up again.
From that point of view, I'd say a rationalist is a priori more and not less likely to have difficulty breaking mildly addictive behavior, because he believes more strongly in the power of reason and is probably better than most at coming up with plausible theories in which to believe.
"they stop bullshitting themselves and start making plans that allow them to succeed"
Sounds like a thing you need willpower for. Bullshitting is part of what failure of willpower looks like.
There's also another part where you recognize the bullshit, make rational plans, then fail to follow them (due to failure of willpower in the moment and/or circumstances beyond your control) and feel like shit about it. Feeling like shit makes it hard to be rational. This is a cycle that lends itself to disordered eating.
"better than most at coming up with plausible theories in which to believe."
This cuts both ways. If someone identifies as a rationalist they probably have pretty high opinions of their own reasoning abilities, and they may even be correct in most cases. This can make it harder to spot one's own bullshit.
I don't think you need willpower especially to recognize bullshit when you see it, even your own. Unless we are going to define "willpower" as merely "what you must have exerted if anything got done," but then I think the concept loses sufficient specificity to be useful.
You do need...something, to be willing to recognize bullshit for bullshit. Personally, I would say an empiricist mind-set does the trick. You have to have greater faith in observations than in theories, and be very willing to doubt theories when seemingly contradictory data comes along.
Honestly, what you've written seems to me an illustration of my point: you sound like you are rationalizating why being a rationalist might actually not be more likely to believe his own bullshit, and it's not a bad rationalization -- much better than someone without the same level of theory-building ability would be able to devise. Which is my point.
Rationalists can be better at choice architecture / environment control so they don't need willpower to eat fewer calories:
* stocking your kitchen with more high-fiber and high-protein solids
* throwing out all the liquid calories and sugar/flour/oil derivatives, no exceptions
* precommit to avoiding any restaurant order with >500 or unknown calories, no exceptions.
It's easy for an occasional "exception" to turn into a habit, so for some people it might make sense to be a teetotaler with respect to some entire categories of food e.g. soda, juice, pastries, ice cream, pizza, and heroin.
Some prescription guidance from Norway. Basically: don't prescribe Wegovy for weight loss yet as we haven't bought the magic injector pens at the right dosage.
I get the need for caution, but does anyone ever make a running tally of the human suffering and mortality caused by bureaucratic foot dragging?
https://relis.no/sporsmal_og_svar/5-6664?source=relisdb
We see many companies doing this in the Nordics already, there is Embla in Denmark: https://www.joinembla.com/ and Yazen in Sweden: https://yazen.se/
In Denmark this costs ~€200/month and in Sweden it's similar, but this includes virtual doctor's appointments and coaching etc. I believe the actual drug is heavily subsidised by the respective government health systems, but also heavily negotiated with Novo Nordisk, since it's the health system that purchases it centrally for the entire country.
I’m curious about its effects on alcohol use disorder.
https://www.insider.com/semaglutide-alcohol-addiction-alcoholism-treatment-weight-loss-drug-2022-10
Purely anecdotal, but I’ve had some success with this. Studies underway. I’m optimistic!
Good luck!
I have a prescription as a diabetic and I cannot get this since it is always on back order at any pharmacy. I’d love it for weight loss but need it for A1C. How do I solve that?
I think there's a temporary manufacturing issue now but it should be solved in a few months.
If semaglutide reduces ad lib caloric intake by 35% (https://doi.org/10.1111/dom.14280), and 10–40% of the U.S. population wants or would benefit from it, then it seems possible that the "ubiquitous cheap semaglutide" scenario could reduce total food demand in the U.S. by 3–10%. (as a first-order effect—there would probably be second-order effects relating to changes in diet composition, food waste patterns, etc.).
Would this be enough to have appreciable effects on global food prices, agricultural emissions, and farmed animal suffering? Presumably the population that might use semaglutide eats more and has more money than the global average, making their consumption patterns particularly impactful. Perhaps EAs focused on farmed animal suffering should be trying to nudge the trajectory towards ubiquitous cheap semaglutide; it's not every day one finds an opportunity to reduce demand for meat by 5% without asking consumers to make any sacrifices!
👍
I use Saxenda for a year now, list price is 500 Canadian dollar per month but with Manulife insurance im payong 100/ per month.
I lost 25 kg in the first 6 months, then I felt "acclimated" to the drug and started eating a lot again. Seeing that the drug is no longer working I stopped. You feel nausea using this drug at first, when the nausea subside the drug is not working anymore for me.
I am a psychiatry resident and am interested in semaglutide as a method of counteracting the metabolic side-effects of second-generation antipsychotics (SGAs), and most prominently the so-called "-pine" drugs: olanzapine, quetiapine, and clozapine. These drugs are fairly effective antipsychotics, but many are hesitant to take them and/or stop taking them due to weight gain. I spoke to an endocrinologist from Columbia University Hospital who said that the psychiatry department there occasionally consults endocrinology to start patient's on semaglutide at the same time as starting an SGA if the patient is already obese. None of my attendings are willing to do this and I have never heard of any other psychiatrists doing it, but I think it is an interesting idea. Scott, have you considered doing this in your practice? Have you seen others doing it? If not, why? A drug that can counteract the metabolic side-effects of SGAs could potentially change psychiatry and would be one of the biggest boosts to compliance in the history of the field.
I am a general internist with a longstanding interest in the medical management of obesity and I think that you are asking an important question. Olanzepine is a highly effective antipsychotic drug and for years, Lilly denied the fact that it caused weight gain and they had to pay one of the highest penalties in pharmaceutical history because they had misrepresented the data!
One of the most common incorrect beliefs about obesity is that it is a psychiatric disorder. There is no convincing evidence to back that up! I often prescribe semaglutide to obese psychiatric patients and they almost invariably do much better, no matter what the psychiatric diagnosis is.
Semaglutide is much less expensive in Canada. I have posted a series of highly evidence based videos on YouTube on the management of obesity. I suspect you would enjoy the one on medically supervised weight loss programs.
Ron Eliosoff md
I agree this could be valuable. I haven't done it yet because I haven't started a lot of patients on antipsychotics recently, but it's something I should keep in mind.
It was my understanding that Yagmuk just can't read english specifically, not that he is fully illiterate. Have I had the lore of this selfless hero wrong this whole time?
My understanding was that this works by causing such intense nausea that patients have difficulty eating enough to stay fat.
I am an internist with a longstanding interest in the medical management of obesity.
Bariatric surgery keeps getting better and better and safer and safer. A Sleeve Gastrectomy in the year 2022 is safer that a gall bladder extraction, a hysterectomy or even a TURP for benign prostate disease.
We now have strong evidence from several high quality prospective studies that obese patients who have bariatric surgery live longer and have much higher quality of lives than carefully matched patients who don’t. If I experienced biliary colic, I would not hesitate to have my gallbladder removed. If I was a woman and I had severe menorrhagia or painful periods, I would not hesitate to have a hysterectomy.
IFSO and the ASMBS, the two largest bariatric surgical associations in the world, recently updated their guideline recommendations for the first time in 30 years. They are now recommending that all patients with a BMI of 35 (except for the occasional weight lifter) should consider bariatric surgery as well as all diabetics with a BMI of 30 (about 90% of diabetics) and that surgery can even be considered in selected patients with no co-morbidities.
I completely support those recommendations. I recently posted a 17 minute highly evidence based discussion on bariatric surgery on YouTube which I think might interest you.
Ronald Eliosoff MD, FRCP
I am a huge fan of semaglutide and here in Canada, it is really not that expensive (about $3,000 /year).
However, for a one-shot payment of $14,000, one could get a Sleeve Gastrectomy by a world class bariatric surgeon. After that the need for meds for diabetes hypertension, arthritis, depression and heart disease all plumet!
From a societal perspective, the cost savings would be incalculable.
I have posted on YouTube a video of a presentation that I gave at an international bariatric surgery conference in which I argued that bariatric surgery pays for itself in less than one year!
Ron Eliosoff MD, FRCP
One-off GLP-1-proximal treatments may be sufficient for significant mitigation of obesity. If this bears out, would significantly alter the cost-benefit calculus. https://twitter.com/DanielJDrucker/status/1591171488002232320?s=20&t=HWuGywdinWSLxCtYDJva2A
One interesting tidbit about Mounjaro's discount program:
Through November, Mounjaro's manufacturer coupon was really generous. You'd bill the primary insurance first and, after getting a rejected claim)/request for a prior authorization, bypass the initial payer and receive a pay amount of $24.99. You didn't need an actual insurance authorization, just proof of insurance to be eligible.
However, it appears this deal is ending. The most recent claim I processed (Monday or Tuesday evening) came back with a patient pay amount over $500 after bypassing the initial payer. Upon calling the pharmacy help desk, the representative informed me that patients with new coupons (anything after mid-november) would have to pay the elevated price sans insurance approval, and that the preexisting $24.99 coupons would be grandfathered in.
Thus, it looks like new patients seeking Mounjaro will need a PA before seeing an affordable price. It's too bad from a pharmacy standpoint, given how much easier it was to bill the drug without getting insurance providers involved.
I predicted back in April that the plethora of obesity-drugs found with A.I. assistance in the next FIVE years would be sufficient to cause a wave of angst against the Pharmafia, such that cheap knock-offs or price-competition finally come into play. We'll see if who's right!
Did you predict competition within 5 years, or only that the drugs would be discovered within 5 years?
Glad to clarify :) 5 years before a wave of AI-tailored drugs have been found which are able to "re-normalize", not just -15% weight. I expect a huge push, with AlphaFold et al. And, with such a plethora, each will be redonkulously priced for its sub-population, which will create a larger *general* public backlash, as opposed to a single drug or maker. We might see price competition happen due to new industry *entrants and small-players* as discovery costs have dropped so much.
Barring an escalating WW3 or robot take-over, etc...
Semaglutide was as far as I know discovered entirely the old-fashioned way, with plenty of natural (human) intelligence and a crapton of high-quality med chem synthesis and characterization. Not a trace of AI in sight. Story is nicely told here:
https://www.frontiersin.org/articles/10.3389/fendo.2019.00155/full
After GLP-1 itself and its role was discovered in the 90s, it became an obvious target for therapy. The principle problem to be solved was extending its life in vivo: native GLP-1 has a half-life of mere minutes, and what was needed was a half-life of at least several days for a reasonable therapy.
The clever bit appears to have been designing semaglutide to have a long fatty-acid tail that causes it to bind to serum albumin, which itself has an unusually long half-life on account of after it gets taken into a cell it promptly binds to a certain receptor that causes it to be ejected before it can be degraded. The ultimate challenge was to find the right length of tail plus attaching spacer that would optimize the combination of lifetime (through binding to albumin) and affinity for the GLP-1 receptor.
Erm, I didn't claim that semaglutide was made by A.I. - try working on reading comprehension.
I don't recall saying you did. But I don't see that it matters. My point is a strong rebuttal to your assumption beause for an obesity drug "found with AI assistance" to be approved -- or even submitted for approval -- in the next five years, it would already have to be in very late stage development, probably at least in animals studies, if not Phase I trials. And if the use of "AI assistance" were common enough in the past 5-10 years of research on obesity therapies that there were already drugs in late-stage development that had been developed that way, it would certainly have played a role in the development of semaglutide. Which it did not.
Also, being a smartass doesn't really help your argument, you just sound immature.
No, you did not provide a rebuttal; the case of industry over the last ten years is clearly *not* indicative of its progress in the next 5 years; they didn't have AlphaFold. Due to A.I. a researcher can now fold a protein that acts as a receptor site, and then *ask* A.I. to design a protein that will target that receptor. That was previously impossible, just a few years ago. Already "Whether in preclinical stages or in the commercialization of a drug, AI-enabled drug development is now used by an estimated 400 companies and has reached a $50 billion market" according to MIT Technology Review.
[[https://www.technologyreview.com/2022/10/06/1060590/ai-and-data-fuel-innovation-in-clinical-trials-and-beyond/]]
"Several biotech companies have recently announced drugs discovered or developed using AI that have progressed to clinical trials, including Exscientia, Evotec and Insilico Medicine." from Financial Times, talking about funding round for one of those companies, merged under Eli Lily, so you know it's serious.
[[https://www.ft.com/content/0006ae3f-7064-4aa6-98cd-8912f544acc5]]
You're behind the state of the art, making an argument that is out of date. I specifically said that we would *find* such treatments in 5 years, and that the delays which are normal for FDA would cause a public backlash, potentially accelerating access. I didn't say "access in 5 years."
[[Details - that Financial Times company, as they mentioned, is already going into human trials - this is clearly accelerated. Further, robotic labs are beginning to work! And, those articles I linked were both written in the last few weeks; acceleration is here.]]
> “Where are the compounding pharmacies getting it?”
There are peptide synthesis companies a compounding pharmacy could contract with. The sequence is known. I figure this is what they’re doing, since…
> ways to get it cheaper
Some of these peptide companies are selling (cheaper but still expensive) semaglutide to consumers for “research purposes only”.
In this context, the transhumanist argument is not very convincing. The technology to lose weight already exists. It's called "healthy food". It's widely available and not patented.
The magical weight-loss pill is meant for people who do not want to use healthy food as a weight loss method. Instead of eating healthy, they want to consume psychoactive drugs which contain also lots of calories. Those are called "junk food".
The primary problem is dealing with the addiction to junk food. That's a serious mental health problem.
Maybe the transhumanist solution would be the development of new psychoactive drugs that won't cause enormous health problems to the users. People could add them to healthy food in order to consume it instead of junk food.
There’s already a lot of literature on the topic, but it’s a lot more complicated than “healthy or junk”. Brief summary here (brief compared to the lit):
1.) All food is unhealthy past a certain threshold, so creating lower calorie foods that provide any type of nutrients or macros that are more addicting than junk food would still be pretty detrimental to health, and sometimes it turns out they’re also less healthy at smaller volumes (this has been tried multiple times on a national scale already- see trans fats). Another option: one would have to balance zero macro addictive foods with non addictive macros--which is already a popular diet form that is complicated & also has a lot of barriers. I know one person that has succeeded at this and two dozen that have failed.
2.) For a long time, snack food and fast food were significantly cheaper than any “better “ foods aside from a handful of staples (flour, rice, beans) so anyone struggling with money or trying to save on costs for any reason (like paying for education!) were highly incentivized to get poor quality food. This dynamic is a lot weaker now but still prevalent + folks that developed habits under previous conditions will have to actively break those habits, which is much more difficult than starting the habit because a.) still addicting b.) your entire social circle eats unhealthy snack foods c.) busy busy busy busy d.) YOU ARE ACTIVELY BEING TARGETED BY MARKETING CAMPAIGNS.
3.) Underlying health problems. 3.5) Underlying health problems that previously would’ve caused moderate weight gain on a healthy diet now cause severe weight gain on a diet-thats-not-that-unhealthy-but maybe allows chips and soda once every five days. (“My gym bros have a cheat day fridays and they’re still ripped? WTF?”) 3.55) Underlying health problems that previously would’ve caused severe weight gain and high mortality, but now only cause severe weight gain.
4.) Education! Lots of folks go out of their way to avoid food they think is unhealthy, and DO only eat food they think is healthy, but it doesn’t work! I’m sure it has nothing to do with the “””health””” industry being whole magnitudes larger than health education... or that whole scandal from the 70s where suppliers told the government to tell everyone “our food is the healthiest”, and the government did it. RIP Food Pyramid.
5.) Did I mention how busy and disconnected people are? Everyone is expected to work overtime (maybe even raise kids with two parents working overtime or a single parent household.) On top of that, many people have used the mobility of the modern era to leave their traditional family communities (for very good reasons) but failed to find new, better ones that could support them.
Aside from number three, there are better solutions to many of these problems than simply “take pills” yes, but they’re incredibly difficult to solve on the macro scale, and unless we see folks that have figured out how to fast-track all these problems, we desperately need an interim solution- perhaps something that’s as simple as a visit to the pharmacy. (On the individual scale, if anyone reading this post is considering pursuing weight loss or general lowered disease risk, I definitely recommend at least attempting the community-building option and freeing-up-time-for-self-care option. Even if you end up failing to lose weight, there are many other benefits to reap here, so it’s a much better investment of time than a fad diet.)
Do you suppose there’s a pill that would cure people suffering from the delusion that things that come easily to them would come easily to everyone else too if only they weren’t a bunch of lazy, whining assholes?
Just as a point of information, my Medicare Advantage plan covers Ozempic with a 20% copay which was $94 for the first prescription and $47 thereafter at CVS so I think the $1,000 price is not correct. I think uptake will be very fast among those of us over 65.
I don't think you'd need more than 10% or whatever of people to take the drug to have a large effect on obesity in general.
Very smart people in the comments have noticed that obesity is caused by eating too much food, and that the permanent cure to it is to eat less food. This has the great advantage of being true, but is incredibly unhelpful to the people who actually are obsese. That's really hard, and it's hard for a lot of psychological reasons and social reasons and structural reasons that have a lot less to do with personal willpower and a lot more to do with what everyone else is doing around you. You don't eat because you're hungry, you eat because it's there/you're tired/everyone else is doing it/you're used to it. Exercising and increasing activity suffers from the same problem: it's not that you don't want to exercise, it's that it's hard and nobody else is doing it so there's no immediate profit to doing so.
However, if the hype is real and semaglutide really works like that, it sounds like it removes a lot of the social/psychological pressures and lets your body's metabolism figure out how much you need to eat without all the extra noise. It's a lifestyle drug, not a weight-loss drug. If you had a drug that, say, can make people walk around the block every day after dinner, you'd get a similar result. (At least, in my limited understanding of the actual mechanics here).
Obese people tend to travel in the same circles as other obese people for obvious social and economic reasons. If you could take 10% of those people and cause them to magically change their lifestyles (say, by giving them a drug or something), you'd have spillover effects within their social circles. This isn't just that the family goes to a salad bar instead of the fried cheese palace for dinner (although that will probably help on the margins), it's dumb but important stuff like how they see themselves and what they think is possible and even guilt about losing weight because you'll be making yourself "better than" your friends/family. (I've heard this from several obese and formerly obese people, including my mother, this sentiment is *shockingly* common). If your friend or family member is losing weight and you can see them feeling better and they're less likely to indulge in behaviors like overeating when they're around you, you have a model for instigating those same lifestyle changes and the motivation to do so.
You don't need everyone to take the drug, you just need a small population to change their lifestyles enough that their social circles can follow suit. Does the snowball effect eliminate obesity in burgerstan? Probably not, but it could be a serious factor and reduce obesity rates much more than the 10% of semaglutide users would indicate.
How does this compare to the bodybuilding drug Clenbuterol aka Clen? "Eat Clen tren hard" is a meme for a reason.
For what it's worth, I use a similar savings card for a far more expensive medication, and it basically does what it says on the tin, no weird gotchas. In fact, mine's better, it brings the out-of-pocket cost down to $5 and has no limit on monthly rebates.
It's basically a dance where the medication company says "we'll sell you this drug for *a million bajillion dollars* and not a cent less! but your patient needs it, so you must pay!" and the insurance company says "well, we'll cover $4,000 dollars, the patient can pay the rest" and the medication company says "the *patient*? have you no *pride* in the health of our citizens? why, out of the goodness of our hearts, *we* will altruistically cover the rest! also thanks for the four grand".
Compounding pharmacist here:
1) I’m not certain where other folks are getting semaglutide, but I would imagine Chinese pharma companies. You may have heard of the pharmacy in SLC, UT that attempted to compound hcq for COVID and sell it to the state of Utah? He bought it from a Chinese pharma company and what he eventually got busted for was false shipping manifests, not the blatant violation of the FDCA. I imagine something similar happened here.
2) while I can’t speak to the legality of sourcing the active ingredient, preparing the compound is probably legally fine. Wegovy and Ozempic has been in a shortage state for nearly 2 years now. In cases of shortages, I CAN legally compound products, including those protected by a patent or otherwise theoretically available. Patient access comes first- if I can’t source a finished product due to the manufacturer not having adequate supply, I’m good. I have to maintain documentation of my inability to source the patented products or the otherwise available product, but this is accepted practice. See, for example, this week’s FDA GFI re: compounding amoxicillin suspension for kids.
Also a couple other points:
1) wegovy is sold in monthly dose paks, not weekly doses.
2) no, we don’t compound semaglutide in my pharmacy, and no I don’t intend to. The legal risks of compounding sterile products (ie injectables like this one) are intense enough for me to not do sterile products, let alone involving possible patent claims.
3) the savings card thing is “if your insurance pays something, we’ll cover most of your copay.” In the case of wegovy, they’ll pay up to $200/28 days for commercially insured prescriptions and up to $500/28 days for prescriptions paid out of pocket. The basis of these programs is that there is solid evidence that when prescriptions are >$50/month, people pick them up way less frequently. Coupons like these ShOULD be illegal, imo, as they basically invalidate the whole concept of copays and therefore allow pharma companies to Jack their prices into the stratosphere because the end user has no concept of the actual price. Without these cards, they would lower their prices so that people’s copays would typically hit a price of ~$50/month or less, out of pure profit maximization. (There’s also the fact that pharma pays rebates to PBMs to lower their prices are NOT used by those PBMs/insurers to set patient copays lower, ever, which is manifestly unfair and results in situations where people pay more for their insulin than their insurer has landed on with their rebates- ie the insurer collects a rebate so large that the patient is effectively subsidizing their insurer, rather than the other way around- I call this “reverse insurance”).
Also also, among small business pharmacists, there is a substantial fear of dispensing ozempic or Mounjaro for anything other than very obvious diabetes, due to the fact that
1) I typically make <$10 per branded prescription like these.
2) insurers and their PBMs routinely audit pharmacies for documentation to substantiate the insurance claim. In the case that an insurer finds anything they don’t like (missing information, unclear directions from the physician, a diagnosis of weight loss, a LACK of diagnosis of diabetes, etc), the insurer recoups the full amount of the claim, not just the pharmacy’s profit. In this case, that would mean that if I dispensed ozempic and billed your insurance for it, and they later audited and recouped the full amount, I would lose ~$1000. That means I would have to dispense >100 prescriptions at that same <$10 profit in order to break even on this drug.
The reimbursement for branded drugs to small pharmacies has gotten SO bad that it’s literally impossible to source product at the price the PBM is willing to pay (outside of stupid programs like the 340b drug pricing program, or counterfeiting). This has predictable results: https://benjaminjolley.substack.com/p/pbms-3-counterfeit-drugs
Can you refuse to fill a valid prescription in the US? It looks to me like the insurance companies expect you to somehow give a second opinion on the prescribing physicians diagnosis and otherwise carry the risk the insurer is supposed to carry.
I know that there is some law around moral objection for things like Plan-B or whatever. But not generally for branded drugs. I suppose that they could just stop carrying branded drugs, though the PBMs would probably be delighted in that - they trying to push everybody to use their in-house mail-order pharmacies in the first place.
Really enjoyed this article, didn’t know much about these drugs post-Elon mentioning he uses them.
As someone who eats healthy, works out a lot and still struggles to lose weight, seems like a really great option for millions of people in the same camp trying to live their best lives.
I'm on it (have been for the past 1.5 mo) and have taken two prior "cycles" going a few years back. The effects described on the Reddit screenshots are pretty much what I've felt. On the side-effect side, on a previous attempt at starting the current cycle (maybe 3mo ago) I've had such an upset stomach that it felt just like it feels when I'm extremely anxious (say, before giving a talk or starting an Ironman)... in a very bad way, so bad that the feeling reminded be of my worst days of depression. Anyway, I started on a higher dose (.5mg) straight away; on this current attempt, I started at .1mg, and increased dosage *very* slowly, so that I'm only now reaching .5mg.
When I was working at an outpatient hospital pharmacy briefly in Bakersfield we had tons of medical residents writing Ozempic prescriptions for themselves so they could get it for cash cheap with a huge 340B discount (I want to say it was something ridiculous like $400ish per month). We had to constantly reprimand them not because they were outrageously abusing 340B but because almost all of them were doing it incorrectly by not having their attending document an office visit and then writing the prescription for them.
The pancreatitis thing worries me with semaglutide. There's already a huge spike in that going on that is poorly understood, and as someone who got hit with it last year, it appears to have permanently effed my digestion, even as mild an episode as it was (no walled necrosis or multisystem organ failure). Ironically, I did lose a ton of weight (who knew permanent exocrine damage was so good for the waist line?). Anyways, I'm probably overly sensitive to that risk, given personal trauma, but at the same time, given the already rising tide of pancreatic issues, it would seem that putting 10s of millions of people on this drug might be a tough situation. But maybe the risk is small enough its ok. I've not seen any hard number put to it anywhere so I don't really know how to judge it.
In Portugal the price of the drugs is available publicly on Infarmed's website (the Portuguese counterpart for the DA part of the FDA).
Wegovy is not yet being sold here, but the price for Ozempic is 120€/month. The government supports 90% of that, and the patient the other 10%. I believe that for Wegovy, the patients will have to pay the whole amount (or have some health insurance pay it, but I think that's unlikely).
https://extranet.infarmed.pt/INFOMED-fo/detalhes-medicamento.xhtml?med_guid=255e52d08c2411e8897bb0491981aaed
Edit: I've seen a chinese pharma that seems legit enough selling it for 50$/month (considering the weekly dosage of 2.4mg, while Novo Nordisk is selling in Portugal for 120€/month the 1mg dosage)
Ozempic 1g /week one year. 5'10". From 285 lb to 265lb.
Stopped because of hepatic pains getting consistently relatable post injections.
Worked by aversion mechanism to fat , permanent bloated uncomfortable feel, and making sugary things very unappealing ( which are to me anyway).
After being miserable and ( more ) depressed , I stopped it.
Next week I finally enjoyed my favourite cheeses and sourdough.
Never ever eating fast food, greasy spoon , buffet. Gourmandly hedonistic ( lived all over the world ( Europe mostly) and that's actually a curse.
I gained 16 back ( within two month). Now I'm shedding 2 lb/ month just doing portion control ( inflation and scarcity ) helps . At this pace , in 3 yrs will be overweight ( BMI 29.5) . In 6 yrs within normal ( BMI 24). Then retirement and ensuing poverty will potentially be contributing factors to go at the 20-21 BMI . If I won't die until then, that's my plan.
Why take drugs to lose weight?
(Taking drugs means to eat more - whereas losing weight means to eat less.)
There's gut bacteria that result in increased GLP-1 production in response to food intake.
I suspect some people just have a lot of these. Something happened in environmental factors to kill a lot of these in people. Semaglutide works by replacing the lost endogenous GLP-1.
https://www.nature.com/articles/s41598-020-61112-0
Rybelsus is much cheaper here in Brazil. A box of 30 pills 3mg (with manufacturer coupon) cost like U$ 50. 7 mg would be around U$ 110 and 14mg about U$ 200.
RE: What About Europe And The Rest Of The World?
In Denmark, the home country of Novo Nordisk, Wegovy litterally just arrived on the market the other day. The price is around DKK 1,500 (~$200) per month.
The Danish health authorities have denied the application for public subsidies for the drug, citing that the price is too high, lack of evidence of the long-term effects, and lack of evidence of effectiveness against cardiovascular disease.
lol i've been on it for over 14 months and it costs me a little over $40 per week (NO INSURANCE). This article is ridiculous
Are the percentages following the predictions in postscript four some sort of confidence estimate?