My ACA insurance (because I was unemployed) covered Rybelsus (pill form, which is a much higher dose due to lack of absorption through the stomach), then in like October or November they said "nah" and said "go to Ozempic" I had just completed my first two sets of increases before the final uppage to be on the stable dose, when insurance said "Nah." So my doc RX'd Trulicity to see if they would cover that, which, for some reason they also didn't. I haven't had the time or energy during the holidays to deal with it, so now I'm dealing with increased hunger from going cold turkey off these things all because of bullshit micromanagement from shitty insurance companies on the market place.
If this makes it better and easier for companies to actually pay out for this I am 100% for it, there should not be a constant jerking about for what is or isn't paid. Also - this wasn't for weightloss (which I assume would have been Wegovy approved), this was for diabetes, and it was under control with Rybelsus, and I assume Ozempic, though we were still in the process of building up to it (I was on max dose of Rybelsus and I'm pretty sure I needed the max Ozempic as well). If they had given a reason for the denial it'd be one thing but it was just a blanket denial.
I just hope this makes it easier for folks who need it to be able to obtain it.
Very glad to see this, it's worth noting that the compounded semiglutide pricing (think generic, although it's more complicated than that) has been plummeting ever since it was introduced onto the market. We've seen some pretty incredible results and I really hope they get cheap enough to be prescribed more widely.
It is worth noting that Compounded Semaglutide sold in the US is still more expensive than branded Semaglutide sold in other markets, where national price negotiations occur. For example, it can be under $100/month in several European nations.
The US just has no mechanism to control prices. There isn't really competition for specific drugs.
I think it is critical to differentiate price controls and purchasing controls.
Most other markets with state insurance have purchasing controls. That is to say, if the price is too high, the government doesn't buy it.
Very few places have price controls e.g. "products cant be sold for more than X".
The US government is the outlier in that it situationally states it will pay the price no matter the cost.
Reasonable government policy needs to start with putting a price on human life (QALY), and purchasing goods and services that come in under that price. This is how it works in other state insurance systems.
We aren't other state insurance systems, though.
Instead, we have a divided and fractured jigsaw and heavy lobbying to keep it that way.
Correct. You have identified a problem
Going to start using this response more frequently.
Why is it worth noting in this context? It seems like an unrelated observation. The original commenter is clearly in the U.S., so you're telling them something that doesn't help them at all.
The research peptide sites are about the only reasonable places to buy this stuff
Nonsetrile compounding, like you'd do from the peptide sites is only safe for immediate use, and semaglutide is not that way. You mix up a vial and use it for a month or so.
Can you do it? Sure. Are you going to get an infection from it? Probably not. Is it riskier than having a compounding pharmacy doing it the right way? Absolutely, and in a meaningful amount of risk. The type of infections you get from contaminated injections are not something you want to deal with
Haven't done it myself but there is a robust DIY community for GLP-1 drugs. No idea if anyone's gotten hurt yet or if it's been pretty okay so far.
Oh sure, there absolutely is. Not only for glp-1s but for all kinds of peptides, especially SARMs.
Doesn't mean it's safe. Lots of people trade off a small risk of harm for immediate benefits. Hell, look at alcohol.
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I’ve seen these comparisons a lot, but how is it determined that the actual quality of a name brand medicine is the same in the two different markets…?
i.e. The price difference could be reflecting a real qualitative difference such as being produced in different facilities, slightly less pure ingredients, less stringent QC, etc…
It feels very conspiratorial to suggest multinational pharmaceutical companies are creating low quality versions of their own branded drugs in Europe.
We know that these drugs cost roughly $10/dose to produce, and most of that is the auto-injector pens. Hardly seems worth ruining their reputation and getting punished be regulators to save a few dollars on something with a 600-6000% markup.
> We know that these drugs cost roughly $10/dose to produce…
Can you link the source?
If it really is a 600% to 6000% markup then it does seem unlikely they would try to save a few dollars.
yes, most of the costs are A) development and B) relatively fixed costs of maintaining the manufacturing staff and infrastructure.
The marginal cost of an additional batch is relatively small in comparison.
Developing a cheaper to produce product, even if that was done off-book and you could keep it secret, would need some level of different production methods (different ingredients, different machines or something which makes it cheaper) and some amount of testing which just selling the original product doesn't require.
I think these calculations are wildly optimistic. As far as I can tell, they basically ignore the cost of development, labor, quality assurance, and regulatory.
It is like estimating the cost of a rocket based on the price of metal.
I think you've lost sight of what the discussion was about.
The person above was claiming they were using substandard versions of their medication in non-US markets where the retail cost is lower. I was pointing out that the manufacturing cost is so low, that doesn't make sense.
Your point now has nothing to do with the discussion being had.
I made a sibling comment agreeing with that point and expanding on why.
However, bad data is bad data. If I said the moon creates waves because it is made of cheese, I think it is completely legitimate to point out out that it is in fact not made of cheese.
It would be easier to squeeze Novo if they included Zepbound from Eli Lilly in the mix - we could argue that if we're going to spend unfathomable amounts on these medications we might as well buy the more effective medication from an American company.
There's no need to spend unfathomable amounts. We just need to establish and enforce the favored nation status if they want to sell their drugs here. No drug (least of all US developed drug) should cost more in the US than it does elsewhere. That's what Trump was proposing in his last term. Because the Congress is corrupt AF, that went nowhere, but maybe we could give it another try now that his mandate is much stronger? As things currently are, we're getting robbed.
What about poor countries? If a drug company had to sell drugs for the same price in the US and a country like Sudan, the result would almost certainly be raising the price in Sudan up to US prices rather than lowering the price in the US to Sudan prices.
That would put the drug out of reach of most of the people in those poor countries.
They can do what India and some other countries do, and legislatively ignore pharmaceutical patents when it comes to public health if drug is deemed unaffordable.
I mean, I don't think you're enforcing patent law in South Sudan regardless, but they're also just not capable of manufacturing such drugs. To get a trustworthy drug, they pretty much have to buy it from the patent-holder. India, China, and maybe Brazil are about the only exceptions. Theoretically, I guess you could say we just expect the third-world to rely on black market medicine from India, but uh, that has some risks involved.
Is it really the black market?
It just sounds like it's sourced from somewhere else like any generic would be.
IMO the state should be able to take away monopolies just as easily as it passes them out in the first place.
Or we can offer to take Greenland off the table /s
It's not on the table in the first place. Trump is just forcing fake news MSM to talk about BS to disorient them and make it harder to attack his transition. Expect more of this - he seems to be advised by someone competent this time.
He really is playing 4D chess
There's a reason I put a "/s".
It's commonly used to signify sarcasm or a tongue-in-cheek comment.
/woosh
Not the lifeline for us fatties.
> Medicare enrollees, however, still won’t be able to access the drugs for obesity under a federal law that prohibits the program from paying for weight loss treatments
Also, you have to be severely ill or elderly to get Medicare. This is for their diabetic treatment.
Why is there a specific list? Why don't we just let Medicare negotiate.
Because this isn’t really a “negotiation” as configured by the statute: Medicare doesn’t have a formulary, it doesn’t pay for drugs, the Part D plan providers (some quite large and with their own negotiating heft) do.
It’s a price-setting exercise. Yes, the drug-maker can walk away, but at the cost of massive punitive excise taxes on selling their drug to anyone in the US, not just Medicare Part D plans.
Exactly.
It's like saying taxes are a "negotiation for a contribution to the state government".
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Unfortunately, that's all the Biden administration could get written into law. The Big Pharma lobby is too strong and definitely battled to keep this list as small as possible.
At least the door is cracked open and it's a start.
Of course, Big Pharma will fight to slam it shut again.
That's because it's not really a solution.
It's not a negotiation between two parties with equal power, it's just the government saying "either pay this price or you'll be penalized".
The better solution is to allow parallel trade of pharmaceutical across borders.
It will force countries paying far less to pay more and conversely the US paying less.
Because corruption.
Pat and cynical oversimplifications are bad for discourse, because they suggest that a default angry response is correct and, coincidentally, frees you from having to think harder about anything.
Don't give in!
We can debate the merits of various drug pricing schemes but at the end of the day, prices are set by a small group of interested actors who want the prices to be as high as they possibly can without causing a violet revolt. So call it what you will but let's not pretend there's some deeper, more important meaning to be sussed out here.
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The US is trying to squeeze the Danes to get hold of Greenland.
It is front page news in dk - leaders from major Danish companies have been called in by the government … novo is the biggest exporter to the us and the most obvious squeeze.
Technically this is done by the Biden admin but obviously coordinated with the incoming Trump admin who has made their attention of using trade to squeeze Denmark in order to get full control of Greenland very clear.
Novo is just worth $300B, it's nothing compared to the many trillions of dollars Greenland is worth.
But I guess politicians are much cheaper than that.
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It's not really a "squeeze".
The Danes agreed that Greenland can become independent if supported by a national referendum. Apparently there is a decent amount of interest in that idea.
So the US can come in and say "hey, instead of independent, you could be in a union with the US". There is enough interest in that that it's a serious concern for the Danes.
The Danes aren't concerned because there's enough interest, they're concerned because a violent, hegemonic imperialist superpower run by an unstable authoritarian regime has decided Greenland should be theirs, apparently just because, and historically speaking having something the US wants means your cities get liberated into smoking rubble.
> they're concerned because a violent, hegemonic imperialist superpower
To be fair we learned it from watching Dad (England).
> unstable authoritarian regime
How is it unstable?
> apparently just because
Territorial waters and exclusive economic zone claims grant amazing access to the arctic.
> something the US wants
It's really just the moneyed interests inside of it. China and Russia seem to have the same bent for the same reasons. It was recently unusual in Iraq since the federal corruption had risen to such a level, enabled by 9/11, that lackies for these interests somehow found themselves directly employed by government.
I prefer nuance over hyperbole.
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This particular thing was always in the works but we should ask the Greenlanders where they’d rather be and pay them if they choose otherwise than us. The land is too strategic and Denmark cannot hold it usefully.
There is no functional difference in likely effectiveness between the present EU, of which Denmark is a member state, or the present US holding Greenland against a Russian attack. The Russian attack would be smashed either way.
That seems unlikely. Peace in Europe exists because the United States threatens its absence with a fist by its heart. America had to save Europe from destroying itself once and now the US has pacified Europe by placing its troops and weapons there lest the nations turn on each other in uncivilized violence again. And then again, when they dragged their feet, the US had to blow up their gas pipelines pour encourager les autres. The continent is incapable of protecting its own shipping lanes without US support and NATO acts as a deterrent solely because the US is in it. Take it out and the Europeans will spend the majority of their time telling everyone how it's not a big deal that Ukraine will fall to Russia, and Poland, and so on.
What you're writing has very little to do with reality.
When we recently made agreements with the US to allow them to store some of their weapons here in case of a crisis we did this, the mutual concern was Russia. The weapons stored are presumably also of types useful for dealing with Russia.
We Europeans have nuclear weapons as well, so there's no possibility of the US preventing any uncivilized violence-- we do in fact have very real autonomy.
The US probably did blow up Nordstream; but this is very simply that it's easy to make the right choice when you're not paying for it, so this isn't some example of better American morality. Poland has a formal alliance with us and we would have to defend them by all means at our disposal.
But, taking into account the sale of oil fund assets by Azerbaijan and the corresponding increase in military spending I assume more pipelines will soon have to be blown up, only this time it'll be the UK who adds its complaints to those of Germany and the other gas dependent countries. The Armenians might even have to do it themselves, rather than relying on help from others.
Would rather have Mounjaro and Zepbound
Cheap drugs have massive downward price pressure on alternatives.
The cynic in me thinks they are only going for Semaglutide because the patent expires in several places in 2026, tirzepatide has another ten years.
Or do both, and let them compete with each other for Medicare's business.
That's been so effective so far.
Are people who pay for their own prescriptions able to purchase them at these Medicare-negotiated prices?
my favorite part of ozempic is that it settled the debate on calorie reduction.
Ozempic tends to change not just the total number of calories but also the timing and the cravings for shitty food.
Calories in / calories used is NOT a complete model because different foods can have different caloric retention. The most extreme example being corn that comes out entirely undigested. Further, shittier foods that the body craves most are also the least satiating over the longer term.
Reducing calories is three or four steps removed from the actual problem. Like arguing the problem is organ failure when in the first order problem is that you got shot. You have to deal with the wound; and you have to deal with the blood loss. That will, in turn, address the organ failure.
The debate has never been "will consuming less calories than you expend make you lose weight" -- the debate has been "will just telling people to consume less calories, patting yourself on the back and calling it a day make them lose weight."
The latter was settled in a 2023 cohort study that showed doing is completely ineffective. [1]
There's been tons of data on this. The scientific consensus has been pretty clear for a hundred years, but nobody wanted to listen. Probably in part because there was no good solution before.
> The debate has never been "will consuming less calories than you expend make you lose weight"
Maybe the debate amongst actual doctors and researchers. But, the debate amongst dummies on the internet (social media) CERTAINLY had people arguing that it was somehow about more than the number of calories in and out.
We should probably stop treating debates among "dummies on the internet" as anything other than noise that muddies up the conversation.
Edit: to be clear, this also applies to comment sections on HN :-)
Quite true!
I dont think anyone has agued that the follow through is the hard part.
The whole debate seems like people violently agreeing with each other aside from some fringe idiots that dont believe in thermodynamics.
who do you mean by "anyone". it sounds that you mean "nutritionists". There are plenty of laypeople who have supernatural beliefs about calories.
> The debate has never been "will consuming less calories than you expend make you lose weight"
If you missed the whole "calories in, calories out" debate, consider yourself lucky. The comment above isn't helpful, but there really was a period of time where the topic du jour among health influencers was debating that calories didn't explain weight gain or loss. It played into the popular idea that blame for the obesity epidemic rested squarely on the food industry and "chemicals" in our food.
At one point, I had a podcast-obsessed coworker who tried to tell us all that even when he ate 1000 calories per day he couldn't lose weight. He had a long list of influencers and podcasters who supported this claim.
The CICO debate was especially popular among influencers pushing their own diet. Debating CICO was a convenient gateway to selling people your special diet that supposedly avoids the "bad" calories and replaces them with "good" calories, making you lose weight.
Ah, gotcha.
For what it's worth CICO sucks because (1) nobody can stick to it, ever (2) humans are awful at estimating their calories in, studies show only 1/5 of people can properly estimate the calorie content of their food [1] and (3) your metabolism slows down in response to, specifically, caloric restriction diets and your hunger rises which makes it difficult to estimate your calories out without indirect calorimetry.
Yes, CICO works in a lab, and for some weird people. It's a matter of thermodynamics. However you are a far more complex system than a coal powered furnace. And yes certain types of food will be more or less satiating and may influence the amount of total calories you consume. It's really really hard to overeat if you just eat lean protein, for instance.
CICO is, in practice, a tool that is roughly impossible for most people to leverage to lose a meaningful amount of weight and keep it off.
Which brings us back to the difference between maintaining a persistent caloric deficit -- and instructing people to do so.
Actually if you just eat lean protein, you will become ravenous because of the lack of fat. Humans need to consume fat, if there is a lack of carbohydrates in diet. If you eat only lean protein you will die from rabbit starvation. Check out this:
> and (3) your metabolism slows down in response to, specifically, caloric restriction diets and your hunger rises which makes it difficult to estimate your calories out without indirect calorimetry.
This is the critical one that leads people to correctly argue CICO is largely useless for attempting to lose weight: the "CO" part of that is highly variable and is not merely a matter of being active. The body has all sorts of mechanisms that it can adjust to achieve the amount of storage vs burning that it wants to do, regardless of the amount of food consumed or the activity level.
The metabolism slowing down thing is greatly over exaggerated. Everything I’ve read that is evidence based puts it at a nominal difference.
Put simply: starvation mode is a myth for everything but outliers that are uninteresting to discuss.
yes, this. the body decides to become super-duper efficient like a Prius. this is shown by studies in which acts like walking burn less energy . There is a lower threshold in which weight loss must occur, but this can be way lower than predicted by calculators or naive CICO estimates.
Why are people trying to estimate calories blindly? You have to look them up in some sort of system and log it in a food journal for the tracking to be any good at all.
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FYI, GLP1 drugs are CICO - they work because they reduce calories in.
It CICO is physics, not a complete instruction set for life. I dont understand why it makes people so angry.
"you're doing CICO wrong. you can only lose weight in the way I approve of"
who are you quoting? CICO isnt a how to guide
CICO works if you have the patience and discipline to make it work, which few do. At some point it becomes too unpleasant to keep reducing calories or to measure and track everything. Life gets in the way.
It works for everyone.
Full stop.
Even if your metabolism slows down in response to caloric restriction, it does not move the needle to any appreciable degree.
Because it takes energy to do. It just does, you cannot fool physics.
However, measuring calories is incredibly difficult. Both in and out. Also, if you put 5000 calories worth of food inside of you, but then immediately vomit out 4500 of those calories, you've only really consumed 500 calories. You can overwhelm the system.
If you can restrict yourself to consuming at a caloric deficit, you will lose weight.
That's difficult however. Because if you pick a target calorie amount, you will see less progress as you lose weight. Because of math. 1500 is half of 3000, but only a quarter of 2000. People get fixated on 2000, as if we operate based on 2000 calories a day. But if you were previously consuming 3000 calories a day, your weight requires 3000 calories a day. So when you drop to 1500, you are going to lose about a pound every two days for a while. When you get to about 2500 maintenance calories/day, you're going to slow down to a about pound every three days. This is not your metabolism "adjusting". You weigh less, it takes fewer calories to maintain that weight.
And you will be hungry. It will suck. And you have to be meticulous in your record keeping. There are no "free" calories.
And we're not even getting into the mental component of all of this. What's been termed as "food noise". And it's one of the things that people on Ozempic and the like notice the most, they stop thinking about food. And food addiction is one of the absolute worst addictions to have. Hands down. With just about every other addiction, abstinence is an option. Alcohol, gambling, heroin, cocaine, meth, etc, none of that is necessary to live. We need food. We need to eat. You cannot avoid food. You have to actually develop discipline. Teetotalers do not have discipline. They avoid the issue altogether.
So CICO works, but it's incredibly difficult to do for lots of reasons that are not related to the biology or physics of it.
Yup, and where this stall vs. weight occurs is mediated by genes to a large extent. Someone who stalls out at 1.8-2.2 kcal/day while still being obese will need extra help, when cutting more calories is too unpleasant (many such cases). This drug makes that easier. And there is no evidence to suggest it gets easier with time or the body at some point stops trying to put the weight back on. Dieting is 24-7 war on food.
I'm still sympathetic to those arguments. Humans have, for at least the last several million years, been taught in the evolutionary sense to never let a calorie go uneaten. Too many famines. "Just don't do that thing that every gene in your body screams at you to do, and feel miserable for it" isn't really good advice, and isn't all that insightful. One can't even necessarily make judgements about how many calories they themselves can eat based on what they see other people around them eating. "That other person stays skinny, and I'm eating about the same amount as them" is not an on-the-surface unreasonable assumption... but it doesn't work, even if you could eliminate human misperceptions.
>At one point, I had a podcast-obsessed coworker who tried to tell us all that even when he ate 1000 calories per day he couldn't lose weight. He had a long list of influencers and podcasters who supported this claim.
The week after Thanksgiving, I had a heart attack (age 50). I was in the CICU for nearly a week before they let me go home. On the day I was released, they sent a nutritionist in to tell me that I shouldn't try to eat one meal a day, that I really needed to be eating 3 meals a day, and to eat bread at least for two of those (or other carbs). Don't eat butter, eat margarine though. Yadda yadda. This was what, 8 weeks ago? Not 1962 in any event.
Do you know what 1000 calories looks like spread across 3 meals? Or how long you have to run on a treadmill to make up 300 calories if you bump that up to 1300? Or that, even sitting in an office chair every day, I can't lose weight (of any significance) at caloric intake much above that? I'm willing to concede that any problems I'm having here are in my own head, that I can't change my behavior or habits or whatever (to literally save my own life), but this isn't the sort of problem that can be handled by any but the most godlike of willpowers (which I do not have, if that doesn't go without saying). Right now, I probably need to be eating just one meal every other day, as I'm not really gaining any weight back but I'm not losing much either. My meal, such as it is, is a salad that fits in a small bowl (less than 2 cups of lettuce and uncooked vegetables). None of this is helped by knowing that people who are so-called medical professionals are giving me is absolute horseshit.
The truth of the matter is that we are adapted to eat only once every few days, and for even that meal to be meager and less than appetizing. But we live in a world that has mastered abundance and flavor, and uses marketing science to constantly try to get us to to buy all that. When you tell people "just eat less", really you're just doing the r/fatpeoplehate but in a covert way where you don't have to feel like an asshole. We (all of us, sympathizers, haters, acceptance activists) turn this into a morality tale, and can't think about this rationally. For anyone that cares, I wear 33" jeans, but I probably need to drop another 20-25lbs realistically.
PS Just giggled thinking about what it would mean to the US economy if suddenly every adult over the age of 28 started eating one small meal every 2-3 days... even our stock market is arrayed against us.
My meal, such as it is, is a salad that fits in a small bowl (less than 2 cups of lettuce and uncooked vegetables). None of this is helped by knowing that people who are so-called medical professionals are giving me is absolute horseshit.
Yup welcome to the bad genetics club. Those calculators of TDEE vs weight/height are only an approximation. Many such cases of people who fall well-below those estimates. Many people need far less food than commonly assumed.
PS Just giggled thinking about what it would mean to the US economy if suddenly every adult over the age of 28 started eating one small meal every 2-3 days... even our stock market is arrayed against us.
Not just from less consumption, but also reduced productivity--people being tired all the time, irritable, unable to work as effectively or unable to concentrate. This is why tech companies put so much emphasis on food and having cafeterias stocked with snacks or catering.
there are plenty of obese people who claim that no amount of calorie reduction works. Ozempic has put that to rest. The truth is they were overeating the entire time.
Some people have such bad metabolism that they have to east tiny amounts of food to not gain weight ,way lower than predicted by calculators and controlling for weight. Ozempic makes this easier. Yeah, you're right that overeating is the problem, but this threshold is low for those with crap genetics.
I don't think it was ever really a debate.
"Reduce calories" is about as useful as "exercise more", "sit less", "drink less", etc, etc. All are obviously good, but for various reasons it can be hard for people to achieve them.
GLP-1's basically take the "how" out of the equation. Take this drug, eat less without fighting your own desires.
All of them are essential as an objective to implement or improve the how.
Yes, "eat less" is the answer, but this is harder to do yeah if your metabolism is slow or always being hungry. this drugs makes it easier to eat less and hence lose weight .
there are plenty of people who claim that no amount of calorie reduction results in weight loss. Often it's people who are claiming to eat starvation amounts of food while gaining weight. Of course researchers have known it was delusional, but the belief persisted in pop culture. Ozempic is putting that to rest.
this is a case where more personal / colloquial / folk evidence was needed to convince people.
Did it? The drugs clearly lead to reduced appetite, therefore reduced calories. But do we know that the drugs aren’t also causing other important metabolic changes?
Was it ever really a debate? There’s tons of experimental evidence that shows calorie reduction leads to weight loss, even without pharmaceuticals. The Ozempic data can be explained simply by this factor. There doesn’t seem to be enough data fluctuation between the two sets to indicate a significant set of unknown variables impacting the data.
yeah, but do ozempic et al only rely on calorie reduction? i find it hard to believe that hormones only affect one thing in isolation. it may be doing something like a) suppressing appetite to reduce caloric intake AND b) shielding against a lowered metabolism due to calorie restriction.
If there is predominant evidence of significant calorie reduction leading to weight loss, and no evidence of the metabolic hypothesis , what should be our conclusion?
It's not even appetite per se; GLP-1s regulate blood sugar for more sustained levels, which is upstream of appetite. Safe to say that blood sugar impacts a bunch of other stuff too.
I think it confers some metabolic boost, but more data is needed
Occam's razor
The drugs seem to cause a small increase in resting heart rate. Whether that is due to metabolic or neurologic changes (or something else) isn't completely clear.
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Unfortunately it didn’t. Seems to have actually emboldened the “CICO isn’t a thing” crowd even more.
The amount of woo-woo “science” in laymen communities on the subject is utterly astounding considering the evidence directly in front of them. Check out the various subreddits for a casual glimpse - anyone saying stuff like “the primary method of action is eating less” is downvoted and the woo woo “metabolism” or “hormones” stuff is upvoted and celebrated.
In the end I think there is a lot of weird guilt around overeating I never really understood existed before. I lost 100lbs using Mounjaro but never once thought it was anything other than me eating too much and moving too little while I was obese. It’s just a lot of damn work and willpower for me to change that. Tirzepatide was simply a performance enhancing drug for my diet that finally put me over escape velocity to make lifestyle changes that so far have stuck for a couple years now.
> settled the debate on calorie reduction.
Really? Because GLP1s reduce hunger and food cravings, less of those means less eating, less eating means less calories. The drug just makes people involuntarily fast, it has no thermogenic of lipolysis abilities.
I understand that those drugs are very useful, but in a way it feels for me like ancient Rome with its orgies and vomit inducing so they can eat more. At least looking at USA from Europe. The problem of sugar content, dietary choices and portion sizes remains. It is similar to gas guzzling cars.
Sorry if it seems not empathic enough, that was not my intention. I know that the use of such drugs may be medically necessary.
Edit:
To serious answers: I was wrong, I stay corrected.
> I understand that those drugs are very useful, but in a way it feels for me like ancient Rome with its orgies and vomit inducing so they can eat more.
"Wealthy Ancient Romans did not use rooms called vomitoria to purge food during meals so they could continue eating and vomiting was not a regular part of Roman dining customs. A vomitorium of an amphitheatre or stadium was a passageway allowing quick exit at the end of an event."
"Two of the most notable examples from Ancient Rome
center on the emperors Vitellius and Claudius who were notorious for
their binge eating and purging practices. Historian Suetonius writes
that “Above all, however, he [Vitellius] was … always having at least
three feasts, sometimes four in a day — breakfast, lunch, dinner, and a
drinking party — and easily finding capacity for it all through regular
vomiting” (Suetonius, Vit, 13) [1]. Similarly, the emperor Claudius was
infamous for never leaving a meal until overfed, after which a feather
was placed in his throat to stimulate his gag reflex (Suetonius, Claud, 33) [2].
In his writing, Suetonius takes on a disapproving tone when describing
the eating habits of Claudius and Vitellius, as highlighted by the use of
words such as “luxury,” “cruelty,” and “stuffed”(Crichton, 204). This tone
indicates that although binge eating and purging were accepted, albeit
uncommon in Roman culture, the practices were negatively associated
with gluttony and a lack of self-control. "
> Stories of this kind were part of the common currency of Roman political discourse. Suetonius devotes similar space to the sexual transgressions of Caligula, Nero, and Domitian – such behaviour is to be expected of a tyrant. The remoteness of the emperor’s residence itself must have fuelled the most lurid imaginations back in Rome.
Suetonius was born in 69 AD; Vitellius was emperor in 69 AD and Claudius was emperor from 41-54. They weren't contemporaries.
If you think that's bad just wait until you hear what Hillary was doing in that pizzeria basement!
The Romans were no stranger to just making shit up.
Purely from a cost perspective - imagine a 79 year old grandma.
Heavily overweight. She is already partially immobile. Pre-diabetic. She may have other conditions, further complicated by her weight. She's on a fixed income.
Which is more probable -
1) A dietary intervention that she attends once a week that revamps her entire daily consumption (but remember, she's on a fixed income) along with some intense exercise?
or
2) put her on a single medication that changes her tastes for sugary and starchy foods, reduces her cravings, reduces inflammation, and in turn, will make her lighter and more mobile.
It is a no-brainer for Medicare. This will save so many downstream costs.
These drugs (mostly) don't allow you to eat more unhealthy food, instead they make it easier to have the self control to avoid over eating / choose healthier foods.
To add, they actually prevent you from eating some bad foods too. At least in the compound versions that i know people on.
If they eat a lot of foods (some even good), their gastro issues are significant. So not only has it had substantial mental shifts around what they desire, but a bunch of foods are just not edible even if they wanted them anyway.
From what I understand these medications make you want to eat less in the first place, so it's not quite the same thing.
Yup. The people i know on this didn't even get it for the weight, but the behavior changes. This isn't letting them eat the same stuff and lose weight, this is changing what they want to eat.
They went from ADHD driven boredom eaters to not even thinking about food.
I have ADHD and the dopamine dysregulation really makes it hard to avoid eating things with sugar in it.
The semaglutide really helps, I'm on a lower dose of it 0.5mg/week and have been on it for over a year. I've lost a fair bit of weight but that has stabilized. It costs me ~$30 per month and I save much more than that on eating less food.
For me it really helps with chronic fatigue which was destroying my life. I think it really is a wonder drug for people with auto-immune issues. I was insanely sensitive to it when I started which I think is common with people with ADHD so I started really low and only very slowly worked my way up.
Sorry if it seems not empathic enough…
You should apologize for making it obvious that you don’t know how the drugs work (as illustrated by sibling comments). If your analogy is “gas-guzzling cars”, I would suggest you revisit your reading on the topic.
My understanding is that the drugs keeps you from wanting to eat as much.
That's just not how these drugs work at all.
If everyone 30+ bmi can get to 30 for “free” (not sure where the subsidizing stops, for me it’s free if I’m over 30 bmi), that’s just too tantalizing to pass up, even if the moral applies.
At least it takes a load off one problem (obesity related diseases). Could it actually exacerbate unethical farming even more or lead to even worse outcomes? Hope not.
This reminds me of my idea to replace EBT with unlimited amounts of soylent
"load off" groan...
I've read that obesity and smoking are net positives for the cost of state-supplied medical care because it causes people to die younger and quicker.
My real concern is what you stated: the by treating some of the symptoms of a toxic food system we will avoid treating the causes (in the USA, we would do well to take soft drinks out of schools and treat adding sugar to foods as an sin to be taxed)
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One of the mechanisms of operation is to reduce your desire to eat.
Taking a step back, obesity actually is an adaptation. When food is scarce, you want your body to extract and store every gram of nutrition it can get. And that would provide a distinct advantage when you're trying to reproduce.
The thing is, GLPs don't only suppress eating. There are plenty of substances out there that can do that...and there are plenty of people who can't lose weight by starving themselves, because your body will try to maintain its weight.
The question should be "why isn't everyone obese, given the huge amount of calories available to humans?"
> The question should be "why isn't everyone obese, given the huge amount of calories available to humans?"
We're close.
According to the CDC, approximately 73.6% of American adults are considered overweight, including those who are obese
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> obesity actually is an adaptation
Obesity is not an adaptation. It's a total aberration. Storing energy in the form of fat is an adaptation. Becoming obese is overloading your entire system.
> why isn't everyone obese
Well... they sure are trying...
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These drugs reprogram the weights in the LLM between the gut and brain, leading to lower calorie intake.
You may be wrong in the specifics of the mechanism of calorie reduction (reducing appetite vs reducing calorific absorption), but not in the general philosophy.
The obesity crisis (specifically in the US, but elsewhere too) has been caused by bad food essentially - food that is not only nutrient deficient, but also engineered to be as cheap as possible and addictive as possible to get you to buy more of it.
As ever, the US is attempting to fix the symptoms, as opposed to the underlying cause, following the general idea of 'if everyone does what they like, things will turn out ok (somehow)'.
Probably negative health implications of these drugs will surface as people become habituated, and we can continue to shake our heads and wonder how it all went so wrong over there.
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I find something really gross and dystopian about the idea of Ozempic. Developing the willpower to resist short-term gratification, and the ability to make long-term decisions about your diet and health are some of the most important ingredients to living a good life. The idea of letting a drug do the thinking for you because you just can't trust yourself really horrifies me.
Respectfully, have you ever had anything in your life that you have struggled desperately with, and needed help? Anything at all that might give you a little empathy on the topic?
I was obese twenty years ago, and lost the weight via diet and exercise. Keeping that weight off is the single hardest thing I have ever done, and a battle I still have to consciously fight every single day. Doing so causes me a great deal of pain and frustration, and I know that I'm someone who is right on the edge of not being able to control my weight. Why should it be that difficult? So that I can pass some kind of purity test?
The fact is that the food we eat has evolved over time, and is too hard to resist overconsuming for a large fraction of our population. If we can create more addictive food, why not create antidotes? If we could easily treat alcohol addiction with a pill, would we tell alcoholics to just apply willpower instead? Why would we want people to suffer like that?
You just don't understand how food addiction works. Going from 34 BMI to 28 (I'm at 26 now) was the hardest thing I ever done, and I had money, great friends, a great family and a doctor that followed me twice a month.
Willpower is not a muscle, it's a well that fill doing what you enjoy, and clear when used. During my diet, my work ethic was at the bottom, and I couldn't force myself to go out meet new people.
Now that I have a healthier weight and stopped dieting hard (I'm still constantly hungry, but now it's my life), I'm a great coworker, I met a lot of people, made life-changing decisions and I have a lot of willpower left to do all the little things right. If I had a drug that helped me control my appetite at the time, i would have taken it.
How have fat people gotten thinner without those meds up until now, then? Was their addiction not as strong as yours, as you seem to imply? They just didn't "understand"? Look, I went from being an absolute fucking fatass to 8% body fat out of willpower alone when I was 17. It took a lot, namely destroying every bad habit I upheld for years regarding food and exercise, but I wanted to do it bad enough, so I did. It was a really extreme and sudden change of mindset, like a flip of a switch, actually, because I had enough of the bullying and lack of self confidence. One day I just got mad enough and changed my whole life.
> You just don't understand how food addiction works.
Would you concede that some foods are more addictive than others? Doesn't this suggest other remedies like food regulations, at the very least, should be deployed in concert with seeming "miracle drugs" like GLP-1 agonists?
Can't speak for the original commenter, but I would not concede that, because experiencing semaglutide has convinced me it's not true. The feeling I can now clearly recognize as something like "food addiction" disappeared uniformly for everything from Brussels sprouts to donuts.
I do make good decisions and put in 10k steps everyday, which according to my stepcounter puts me in the top 5% for people of my age. Truth be told that my body can't effectively lose and maintain weight unless I'm eating a strict 1500 calories and replacing the walking with an hour long run. This isn't to say that the laws of thermodynamics don't apply to me, but my body will fight against them harder than most.
I took compounded Mounjaro for two months. It was like a jolt to the system and got me back on track. I learned how to eat better and alter what I eat plus tracking it. Started walking and going to the gym. Started with 7k steps and now easily over 12k a day on average. I don’t drink soda and if I do it js Coke Zero, Pepsi Zero or Diet Coke. We just don’t buy it. I didn’t know about maximizing my protein and fiber.
It wasn’t short term at all like you say. Something was seriously wrong.
It’s everything though - if it was that easy to just start doing it then people would.
I needed a jolt and impetus to get better. I was depressed, worryful, everything.
I have lost 40 lb. I went from 255 to 229 with the assistance of Mounjaro. I stopped taking it but kept up with the regimen. I am now down to 214.
Some people who take it don’t do it right, they still eat crap and so those are the people who rebound or think they need to go up to 15. I was taking 2.5 then 5 when I stopped.
Yea it is willpower and discipline. Being on the medicine as an assistant along with a lot of research spurred by the community such as maximizing protein, fiber and water intake to become satiated was all that did it with exercise.
Consider the fact that, if a drug can make you skinny, perhaps a drug can also make you fat. Or, even your own body can make you fat. Sometimes, what we think are our choices, have more to do with our biology and environment.
Just like you can't will yourself to be healthy if you are sick with the Flu. Some people can't just will themselves to be skinny. This is why we have drugs and treatments, because our bodies are not perfect machines that work the way we want them to.
> Consider the fact that, if a drug can make you skinny, perhaps a drug can also make you fat.
Yes that would be Prednisone. People call it the devils tic-tac. Its a wonder drug with terrible long term costs to your body especially at higher doses.
> with our biology and environment.
Our biology hasn't changed much in recent years. Our environment has. So has our obesity levels. I mean, it's an "environment" that has "super size," as a default option.
Telling everyone "just get better willpower" is about as useful on a societal level as looking at a disabled person at the bottom of a set of steep stairs and telling them that the struggle is good for them.
Do you object to pencil and paper because people write down reminders because their memory isn't good enough to remember everything?
Just flip it around: what if there were a drug that made people fat? Is it an insufficient willpower issue then? Willpower works for some, but the drugs make it easier.
My ACA insurance (because I was unemployed) covered Rybelsus (pill form, which is a much higher dose due to lack of absorption through the stomach), then in like October or November they said "nah" and said "go to Ozempic" I had just completed my first two sets of increases before the final uppage to be on the stable dose, when insurance said "Nah." So my doc RX'd Trulicity to see if they would cover that, which, for some reason they also didn't. I haven't had the time or energy during the holidays to deal with it, so now I'm dealing with increased hunger from going cold turkey off these things all because of bullshit micromanagement from shitty insurance companies on the market place.
If this makes it better and easier for companies to actually pay out for this I am 100% for it, there should not be a constant jerking about for what is or isn't paid. Also - this wasn't for weightloss (which I assume would have been Wegovy approved), this was for diabetes, and it was under control with Rybelsus, and I assume Ozempic, though we were still in the process of building up to it (I was on max dose of Rybelsus and I'm pretty sure I needed the max Ozempic as well). If they had given a reason for the denial it'd be one thing but it was just a blanket denial.
I just hope this makes it easier for folks who need it to be able to obtain it.
Very glad to see this, it's worth noting that the compounded semiglutide pricing (think generic, although it's more complicated than that) has been plummeting ever since it was introduced onto the market. We've seen some pretty incredible results and I really hope they get cheap enough to be prescribed more widely.
It is worth noting that Compounded Semaglutide sold in the US is still more expensive than branded Semaglutide sold in other markets, where national price negotiations occur. For example, it can be under $100/month in several European nations.
The US just has no mechanism to control prices. There isn't really competition for specific drugs.
I think it is critical to differentiate price controls and purchasing controls.
Most other markets with state insurance have purchasing controls. That is to say, if the price is too high, the government doesn't buy it.
Very few places have price controls e.g. "products cant be sold for more than X".
The US government is the outlier in that it situationally states it will pay the price no matter the cost.
Reasonable government policy needs to start with putting a price on human life (QALY), and purchasing goods and services that come in under that price. This is how it works in other state insurance systems.
We aren't other state insurance systems, though.
Instead, we have a divided and fractured jigsaw and heavy lobbying to keep it that way.
Correct. You have identified a problem
Going to start using this response more frequently.
Why is it worth noting in this context? It seems like an unrelated observation. The original commenter is clearly in the U.S., so you're telling them something that doesn't help them at all.
The research peptide sites are about the only reasonable places to buy this stuff
Nonsetrile compounding, like you'd do from the peptide sites is only safe for immediate use, and semaglutide is not that way. You mix up a vial and use it for a month or so.
Can you do it? Sure. Are you going to get an infection from it? Probably not. Is it riskier than having a compounding pharmacy doing it the right way? Absolutely, and in a meaningful amount of risk. The type of infections you get from contaminated injections are not something you want to deal with
Haven't done it myself but there is a robust DIY community for GLP-1 drugs. No idea if anyone's gotten hurt yet or if it's been pretty okay so far.
Oh sure, there absolutely is. Not only for glp-1s but for all kinds of peptides, especially SARMs.
Doesn't mean it's safe. Lots of people trade off a small risk of harm for immediate benefits. Hell, look at alcohol.
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I’ve seen these comparisons a lot, but how is it determined that the actual quality of a name brand medicine is the same in the two different markets…?
i.e. The price difference could be reflecting a real qualitative difference such as being produced in different facilities, slightly less pure ingredients, less stringent QC, etc…
It feels very conspiratorial to suggest multinational pharmaceutical companies are creating low quality versions of their own branded drugs in Europe.
We know that these drugs cost roughly $10/dose to produce, and most of that is the auto-injector pens. Hardly seems worth ruining their reputation and getting punished be regulators to save a few dollars on something with a 600-6000% markup.
> We know that these drugs cost roughly $10/dose to produce…
Can you link the source?
If it really is a 600% to 6000% markup then it does seem unlikely they would try to save a few dollars.
yes, most of the costs are A) development and B) relatively fixed costs of maintaining the manufacturing staff and infrastructure.
The marginal cost of an additional batch is relatively small in comparison.
Developing a cheaper to produce product, even if that was done off-book and you could keep it secret, would need some level of different production methods (different ingredients, different machines or something which makes it cheaper) and some amount of testing which just selling the original product doesn't require.
https://www.cnbc.com/2024/03/27/novo-nordisk-ozempic-can-be-...
I think these calculations are wildly optimistic. As far as I can tell, they basically ignore the cost of development, labor, quality assurance, and regulatory.
It is like estimating the cost of a rocket based on the price of metal.
I think you've lost sight of what the discussion was about.
The person above was claiming they were using substandard versions of their medication in non-US markets where the retail cost is lower. I was pointing out that the manufacturing cost is so low, that doesn't make sense.
Your point now has nothing to do with the discussion being had.
I made a sibling comment agreeing with that point and expanding on why.
However, bad data is bad data. If I said the moon creates waves because it is made of cheese, I think it is completely legitimate to point out out that it is in fact not made of cheese.
It would be easier to squeeze Novo if they included Zepbound from Eli Lilly in the mix - we could argue that if we're going to spend unfathomable amounts on these medications we might as well buy the more effective medication from an American company.
There's no need to spend unfathomable amounts. We just need to establish and enforce the favored nation status if they want to sell their drugs here. No drug (least of all US developed drug) should cost more in the US than it does elsewhere. That's what Trump was proposing in his last term. Because the Congress is corrupt AF, that went nowhere, but maybe we could give it another try now that his mandate is much stronger? As things currently are, we're getting robbed.
What about poor countries? If a drug company had to sell drugs for the same price in the US and a country like Sudan, the result would almost certainly be raising the price in Sudan up to US prices rather than lowering the price in the US to Sudan prices.
That would put the drug out of reach of most of the people in those poor countries.
They can do what India and some other countries do, and legislatively ignore pharmaceutical patents when it comes to public health if drug is deemed unaffordable.
I mean, I don't think you're enforcing patent law in South Sudan regardless, but they're also just not capable of manufacturing such drugs. To get a trustworthy drug, they pretty much have to buy it from the patent-holder. India, China, and maybe Brazil are about the only exceptions. Theoretically, I guess you could say we just expect the third-world to rely on black market medicine from India, but uh, that has some risks involved.
Is it really the black market?
It just sounds like it's sourced from somewhere else like any generic would be.
IMO the state should be able to take away monopolies just as easily as it passes them out in the first place.
Or we can offer to take Greenland off the table /s
It's not on the table in the first place. Trump is just forcing fake news MSM to talk about BS to disorient them and make it harder to attack his transition. Expect more of this - he seems to be advised by someone competent this time.
He really is playing 4D chess
There's a reason I put a "/s".
It's commonly used to signify sarcasm or a tongue-in-cheek comment.
/woosh
Not the lifeline for us fatties.
> Medicare enrollees, however, still won’t be able to access the drugs for obesity under a federal law that prohibits the program from paying for weight loss treatments
Also, you have to be severely ill or elderly to get Medicare. This is for their diabetic treatment.
Why is there a specific list? Why don't we just let Medicare negotiate.
Because this isn’t really a “negotiation” as configured by the statute: Medicare doesn’t have a formulary, it doesn’t pay for drugs, the Part D plan providers (some quite large and with their own negotiating heft) do.
It’s a price-setting exercise. Yes, the drug-maker can walk away, but at the cost of massive punitive excise taxes on selling their drug to anyone in the US, not just Medicare Part D plans.
Exactly.
It's like saying taxes are a "negotiation for a contribution to the state government".
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Unfortunately, that's all the Biden administration could get written into law. The Big Pharma lobby is too strong and definitely battled to keep this list as small as possible.
At least the door is cracked open and it's a start.
Of course, Big Pharma will fight to slam it shut again.
That's because it's not really a solution.
It's not a negotiation between two parties with equal power, it's just the government saying "either pay this price or you'll be penalized".
The better solution is to allow parallel trade of pharmaceutical across borders.
It will force countries paying far less to pay more and conversely the US paying less.
Because corruption.
Pat and cynical oversimplifications are bad for discourse, because they suggest that a default angry response is correct and, coincidentally, frees you from having to think harder about anything.
Don't give in!
We can debate the merits of various drug pricing schemes but at the end of the day, prices are set by a small group of interested actors who want the prices to be as high as they possibly can without causing a violet revolt. So call it what you will but let's not pretend there's some deeper, more important meaning to be sussed out here.
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The US is trying to squeeze the Danes to get hold of Greenland.
It is front page news in dk - leaders from major Danish companies have been called in by the government … novo is the biggest exporter to the us and the most obvious squeeze.
Technically this is done by the Biden admin but obviously coordinated with the incoming Trump admin who has made their attention of using trade to squeeze Denmark in order to get full control of Greenland very clear.
Novo is just worth $300B, it's nothing compared to the many trillions of dollars Greenland is worth.
But I guess politicians are much cheaper than that.
It's not really a "squeeze".
The Danes agreed that Greenland can become independent if supported by a national referendum. Apparently there is a decent amount of interest in that idea.
So the US can come in and say "hey, instead of independent, you could be in a union with the US". There is enough interest in that that it's a serious concern for the Danes.
The Danes aren't concerned because there's enough interest, they're concerned because a violent, hegemonic imperialist superpower run by an unstable authoritarian regime has decided Greenland should be theirs, apparently just because, and historically speaking having something the US wants means your cities get liberated into smoking rubble.
> they're concerned because a violent, hegemonic imperialist superpower
To be fair we learned it from watching Dad (England).
> unstable authoritarian regime
How is it unstable?
> apparently just because
Territorial waters and exclusive economic zone claims grant amazing access to the arctic.
> something the US wants
It's really just the moneyed interests inside of it. China and Russia seem to have the same bent for the same reasons. It was recently unusual in Iraq since the federal corruption had risen to such a level, enabled by 9/11, that lackies for these interests somehow found themselves directly employed by government.
I prefer nuance over hyperbole.
This particular thing was always in the works but we should ask the Greenlanders where they’d rather be and pay them if they choose otherwise than us. The land is too strategic and Denmark cannot hold it usefully.
There is no functional difference in likely effectiveness between the present EU, of which Denmark is a member state, or the present US holding Greenland against a Russian attack. The Russian attack would be smashed either way.
That seems unlikely. Peace in Europe exists because the United States threatens its absence with a fist by its heart. America had to save Europe from destroying itself once and now the US has pacified Europe by placing its troops and weapons there lest the nations turn on each other in uncivilized violence again. And then again, when they dragged their feet, the US had to blow up their gas pipelines pour encourager les autres. The continent is incapable of protecting its own shipping lanes without US support and NATO acts as a deterrent solely because the US is in it. Take it out and the Europeans will spend the majority of their time telling everyone how it's not a big deal that Ukraine will fall to Russia, and Poland, and so on.
What you're writing has very little to do with reality.
When we recently made agreements with the US to allow them to store some of their weapons here in case of a crisis we did this, the mutual concern was Russia. The weapons stored are presumably also of types useful for dealing with Russia.
We Europeans have nuclear weapons as well, so there's no possibility of the US preventing any uncivilized violence-- we do in fact have very real autonomy.
The US probably did blow up Nordstream; but this is very simply that it's easy to make the right choice when you're not paying for it, so this isn't some example of better American morality. Poland has a formal alliance with us and we would have to defend them by all means at our disposal.
But, taking into account the sale of oil fund assets by Azerbaijan and the corresponding increase in military spending I assume more pipelines will soon have to be blown up, only this time it'll be the UK who adds its complaints to those of Germany and the other gas dependent countries. The Armenians might even have to do it themselves, rather than relying on help from others.
Would rather have Mounjaro and Zepbound
Cheap drugs have massive downward price pressure on alternatives.
The cynic in me thinks they are only going for Semaglutide because the patent expires in several places in 2026, tirzepatide has another ten years.
Or do both, and let them compete with each other for Medicare's business.
That's been so effective so far.
Are people who pay for their own prescriptions able to purchase them at these Medicare-negotiated prices?
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The USA is a racket cubed. https://www.healthsystemtracker.org/brief/prices-of-drugs-fo...
The pharmacies are also in on it https://pmc.ncbi.nlm.nih.gov/articles/PMC11147645/
my favorite part of ozempic is that it settled the debate on calorie reduction.
Ozempic tends to change not just the total number of calories but also the timing and the cravings for shitty food.
Calories in / calories used is NOT a complete model because different foods can have different caloric retention. The most extreme example being corn that comes out entirely undigested. Further, shittier foods that the body craves most are also the least satiating over the longer term.
Reducing calories is three or four steps removed from the actual problem. Like arguing the problem is organ failure when in the first order problem is that you got shot. You have to deal with the wound; and you have to deal with the blood loss. That will, in turn, address the organ failure.
The debate has never been "will consuming less calories than you expend make you lose weight" -- the debate has been "will just telling people to consume less calories, patting yourself on the back and calling it a day make them lose weight."
The latter was settled in a 2023 cohort study that showed doing is completely ineffective. [1]
There's been tons of data on this. The scientific consensus has been pretty clear for a hundred years, but nobody wanted to listen. Probably in part because there was no good solution before.
[1] https://pmc.ncbi.nlm.nih.gov/articles/PMC10407685/
> The debate has never been "will consuming less calories than you expend make you lose weight"
Maybe the debate amongst actual doctors and researchers. But, the debate amongst dummies on the internet (social media) CERTAINLY had people arguing that it was somehow about more than the number of calories in and out.
We should probably stop treating debates among "dummies on the internet" as anything other than noise that muddies up the conversation.
Edit: to be clear, this also applies to comment sections on HN :-)
Quite true!
I dont think anyone has agued that the follow through is the hard part.
The whole debate seems like people violently agreeing with each other aside from some fringe idiots that dont believe in thermodynamics.
who do you mean by "anyone". it sounds that you mean "nutritionists". There are plenty of laypeople who have supernatural beliefs about calories.
> The debate has never been "will consuming less calories than you expend make you lose weight"
If you missed the whole "calories in, calories out" debate, consider yourself lucky. The comment above isn't helpful, but there really was a period of time where the topic du jour among health influencers was debating that calories didn't explain weight gain or loss. It played into the popular idea that blame for the obesity epidemic rested squarely on the food industry and "chemicals" in our food.
At one point, I had a podcast-obsessed coworker who tried to tell us all that even when he ate 1000 calories per day he couldn't lose weight. He had a long list of influencers and podcasters who supported this claim.
The CICO debate was especially popular among influencers pushing their own diet. Debating CICO was a convenient gateway to selling people your special diet that supposedly avoids the "bad" calories and replaces them with "good" calories, making you lose weight.
Ah, gotcha.
For what it's worth CICO sucks because (1) nobody can stick to it, ever (2) humans are awful at estimating their calories in, studies show only 1/5 of people can properly estimate the calorie content of their food [1] and (3) your metabolism slows down in response to, specifically, caloric restriction diets and your hunger rises which makes it difficult to estimate your calories out without indirect calorimetry.
Yes, CICO works in a lab, and for some weird people. It's a matter of thermodynamics. However you are a far more complex system than a coal powered furnace. And yes certain types of food will be more or less satiating and may influence the amount of total calories you consume. It's really really hard to overeat if you just eat lean protein, for instance.
CICO is, in practice, a tool that is roughly impossible for most people to leverage to lose a meaningful amount of weight and keep it off.
Which brings us back to the difference between maintaining a persistent caloric deficit -- and instructing people to do so.
[1] https://pmc.ncbi.nlm.nih.gov/articles/PMC3719184/
Actually if you just eat lean protein, you will become ravenous because of the lack of fat. Humans need to consume fat, if there is a lack of carbohydrates in diet. If you eat only lean protein you will die from rabbit starvation. Check out this:
https://www.thecanadianencyclopedia.ca/en/article/rabbit-sta....
> and (3) your metabolism slows down in response to, specifically, caloric restriction diets and your hunger rises which makes it difficult to estimate your calories out without indirect calorimetry.
This is the critical one that leads people to correctly argue CICO is largely useless for attempting to lose weight: the "CO" part of that is highly variable and is not merely a matter of being active. The body has all sorts of mechanisms that it can adjust to achieve the amount of storage vs burning that it wants to do, regardless of the amount of food consumed or the activity level.
The metabolism slowing down thing is greatly over exaggerated. Everything I’ve read that is evidence based puts it at a nominal difference.
Put simply: starvation mode is a myth for everything but outliers that are uninteresting to discuss.
yes, this. the body decides to become super-duper efficient like a Prius. this is shown by studies in which acts like walking burn less energy . There is a lower threshold in which weight loss must occur, but this can be way lower than predicted by calculators or naive CICO estimates.
Why are people trying to estimate calories blindly? You have to look them up in some sort of system and log it in a food journal for the tracking to be any good at all.
FYI, GLP1 drugs are CICO - they work because they reduce calories in.
It CICO is physics, not a complete instruction set for life. I dont understand why it makes people so angry.
"you're doing CICO wrong. you can only lose weight in the way I approve of"
who are you quoting? CICO isnt a how to guide
CICO works if you have the patience and discipline to make it work, which few do. At some point it becomes too unpleasant to keep reducing calories or to measure and track everything. Life gets in the way.
It works for everyone.
Full stop.
Even if your metabolism slows down in response to caloric restriction, it does not move the needle to any appreciable degree.
Because it takes energy to do. It just does, you cannot fool physics.
However, measuring calories is incredibly difficult. Both in and out. Also, if you put 5000 calories worth of food inside of you, but then immediately vomit out 4500 of those calories, you've only really consumed 500 calories. You can overwhelm the system.
If you can restrict yourself to consuming at a caloric deficit, you will lose weight.
That's difficult however. Because if you pick a target calorie amount, you will see less progress as you lose weight. Because of math. 1500 is half of 3000, but only a quarter of 2000. People get fixated on 2000, as if we operate based on 2000 calories a day. But if you were previously consuming 3000 calories a day, your weight requires 3000 calories a day. So when you drop to 1500, you are going to lose about a pound every two days for a while. When you get to about 2500 maintenance calories/day, you're going to slow down to a about pound every three days. This is not your metabolism "adjusting". You weigh less, it takes fewer calories to maintain that weight.
And you will be hungry. It will suck. And you have to be meticulous in your record keeping. There are no "free" calories.
And we're not even getting into the mental component of all of this. What's been termed as "food noise". And it's one of the things that people on Ozempic and the like notice the most, they stop thinking about food. And food addiction is one of the absolute worst addictions to have. Hands down. With just about every other addiction, abstinence is an option. Alcohol, gambling, heroin, cocaine, meth, etc, none of that is necessary to live. We need food. We need to eat. You cannot avoid food. You have to actually develop discipline. Teetotalers do not have discipline. They avoid the issue altogether.
So CICO works, but it's incredibly difficult to do for lots of reasons that are not related to the biology or physics of it.
Yup, and where this stall vs. weight occurs is mediated by genes to a large extent. Someone who stalls out at 1.8-2.2 kcal/day while still being obese will need extra help, when cutting more calories is too unpleasant (many such cases). This drug makes that easier. And there is no evidence to suggest it gets easier with time or the body at some point stops trying to put the weight back on. Dieting is 24-7 war on food.
I'm still sympathetic to those arguments. Humans have, for at least the last several million years, been taught in the evolutionary sense to never let a calorie go uneaten. Too many famines. "Just don't do that thing that every gene in your body screams at you to do, and feel miserable for it" isn't really good advice, and isn't all that insightful. One can't even necessarily make judgements about how many calories they themselves can eat based on what they see other people around them eating. "That other person stays skinny, and I'm eating about the same amount as them" is not an on-the-surface unreasonable assumption... but it doesn't work, even if you could eliminate human misperceptions.
>At one point, I had a podcast-obsessed coworker who tried to tell us all that even when he ate 1000 calories per day he couldn't lose weight. He had a long list of influencers and podcasters who supported this claim.
The week after Thanksgiving, I had a heart attack (age 50). I was in the CICU for nearly a week before they let me go home. On the day I was released, they sent a nutritionist in to tell me that I shouldn't try to eat one meal a day, that I really needed to be eating 3 meals a day, and to eat bread at least for two of those (or other carbs). Don't eat butter, eat margarine though. Yadda yadda. This was what, 8 weeks ago? Not 1962 in any event.
Do you know what 1000 calories looks like spread across 3 meals? Or how long you have to run on a treadmill to make up 300 calories if you bump that up to 1300? Or that, even sitting in an office chair every day, I can't lose weight (of any significance) at caloric intake much above that? I'm willing to concede that any problems I'm having here are in my own head, that I can't change my behavior or habits or whatever (to literally save my own life), but this isn't the sort of problem that can be handled by any but the most godlike of willpowers (which I do not have, if that doesn't go without saying). Right now, I probably need to be eating just one meal every other day, as I'm not really gaining any weight back but I'm not losing much either. My meal, such as it is, is a salad that fits in a small bowl (less than 2 cups of lettuce and uncooked vegetables). None of this is helped by knowing that people who are so-called medical professionals are giving me is absolute horseshit.
The truth of the matter is that we are adapted to eat only once every few days, and for even that meal to be meager and less than appetizing. But we live in a world that has mastered abundance and flavor, and uses marketing science to constantly try to get us to to buy all that. When you tell people "just eat less", really you're just doing the r/fatpeoplehate but in a covert way where you don't have to feel like an asshole. We (all of us, sympathizers, haters, acceptance activists) turn this into a morality tale, and can't think about this rationally. For anyone that cares, I wear 33" jeans, but I probably need to drop another 20-25lbs realistically.
PS Just giggled thinking about what it would mean to the US economy if suddenly every adult over the age of 28 started eating one small meal every 2-3 days... even our stock market is arrayed against us.
My meal, such as it is, is a salad that fits in a small bowl (less than 2 cups of lettuce and uncooked vegetables). None of this is helped by knowing that people who are so-called medical professionals are giving me is absolute horseshit.
Yup welcome to the bad genetics club. Those calculators of TDEE vs weight/height are only an approximation. Many such cases of people who fall well-below those estimates. Many people need far less food than commonly assumed.
PS Just giggled thinking about what it would mean to the US economy if suddenly every adult over the age of 28 started eating one small meal every 2-3 days... even our stock market is arrayed against us.
Not just from less consumption, but also reduced productivity--people being tired all the time, irritable, unable to work as effectively or unable to concentrate. This is why tech companies put so much emphasis on food and having cafeterias stocked with snacks or catering.
there are plenty of obese people who claim that no amount of calorie reduction works. Ozempic has put that to rest. The truth is they were overeating the entire time.
Some people have such bad metabolism that they have to east tiny amounts of food to not gain weight ,way lower than predicted by calculators and controlling for weight. Ozempic makes this easier. Yeah, you're right that overeating is the problem, but this threshold is low for those with crap genetics.
I don't think it was ever really a debate.
"Reduce calories" is about as useful as "exercise more", "sit less", "drink less", etc, etc. All are obviously good, but for various reasons it can be hard for people to achieve them.
GLP-1's basically take the "how" out of the equation. Take this drug, eat less without fighting your own desires.
All of them are essential as an objective to implement or improve the how.
Yes, "eat less" is the answer, but this is harder to do yeah if your metabolism is slow or always being hungry. this drugs makes it easier to eat less and hence lose weight .
there are plenty of people who claim that no amount of calorie reduction results in weight loss. Often it's people who are claiming to eat starvation amounts of food while gaining weight. Of course researchers have known it was delusional, but the belief persisted in pop culture. Ozempic is putting that to rest.
this is a case where more personal / colloquial / folk evidence was needed to convince people.
Did it? The drugs clearly lead to reduced appetite, therefore reduced calories. But do we know that the drugs aren’t also causing other important metabolic changes?
Was it ever really a debate? There’s tons of experimental evidence that shows calorie reduction leads to weight loss, even without pharmaceuticals. The Ozempic data can be explained simply by this factor. There doesn’t seem to be enough data fluctuation between the two sets to indicate a significant set of unknown variables impacting the data.
yeah, but do ozempic et al only rely on calorie reduction? i find it hard to believe that hormones only affect one thing in isolation. it may be doing something like a) suppressing appetite to reduce caloric intake AND b) shielding against a lowered metabolism due to calorie restriction.
If there is predominant evidence of significant calorie reduction leading to weight loss, and no evidence of the metabolic hypothesis , what should be our conclusion?
It's not even appetite per se; GLP-1s regulate blood sugar for more sustained levels, which is upstream of appetite. Safe to say that blood sugar impacts a bunch of other stuff too.
I think it confers some metabolic boost, but more data is needed
Occam's razor
The drugs seem to cause a small increase in resting heart rate. Whether that is due to metabolic or neurologic changes (or something else) isn't completely clear.
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Unfortunately it didn’t. Seems to have actually emboldened the “CICO isn’t a thing” crowd even more.
The amount of woo-woo “science” in laymen communities on the subject is utterly astounding considering the evidence directly in front of them. Check out the various subreddits for a casual glimpse - anyone saying stuff like “the primary method of action is eating less” is downvoted and the woo woo “metabolism” or “hormones” stuff is upvoted and celebrated.
In the end I think there is a lot of weird guilt around overeating I never really understood existed before. I lost 100lbs using Mounjaro but never once thought it was anything other than me eating too much and moving too little while I was obese. It’s just a lot of damn work and willpower for me to change that. Tirzepatide was simply a performance enhancing drug for my diet that finally put me over escape velocity to make lifestyle changes that so far have stuck for a couple years now.
> settled the debate on calorie reduction.
Really? Because GLP1s reduce hunger and food cravings, less of those means less eating, less eating means less calories. The drug just makes people involuntarily fast, it has no thermogenic of lipolysis abilities.
I understand that those drugs are very useful, but in a way it feels for me like ancient Rome with its orgies and vomit inducing so they can eat more. At least looking at USA from Europe. The problem of sugar content, dietary choices and portion sizes remains. It is similar to gas guzzling cars.
Sorry if it seems not empathic enough, that was not my intention. I know that the use of such drugs may be medically necessary.
Edit: To serious answers: I was wrong, I stay corrected.
> I understand that those drugs are very useful, but in a way it feels for me like ancient Rome with its orgies and vomit inducing so they can eat more.
https://en.wikipedia.org/wiki/List_of_common_misconceptions
"Wealthy Ancient Romans did not use rooms called vomitoria to purge food during meals so they could continue eating and vomiting was not a regular part of Roman dining customs. A vomitorium of an amphitheatre or stadium was a passageway allowing quick exit at the end of an event."
"Two of the most notable examples from Ancient Rome center on the emperors Vitellius and Claudius who were notorious for their binge eating and purging practices. Historian Suetonius writes that “Above all, however, he [Vitellius] was … always having at least three feasts, sometimes four in a day — breakfast, lunch, dinner, and a drinking party — and easily finding capacity for it all through regular vomiting” (Suetonius, Vit, 13) [1]. Similarly, the emperor Claudius was infamous for never leaving a meal until overfed, after which a feather was placed in his throat to stimulate his gag reflex (Suetonius, Claud, 33) [2]. In his writing, Suetonius takes on a disapproving tone when describing the eating habits of Claudius and Vitellius, as highlighted by the use of words such as “luxury,” “cruelty,” and “stuffed”(Crichton, 204). This tone indicates that although binge eating and purging were accepted, albeit uncommon in Roman culture, the practices were negatively associated with gluttony and a lack of self-control. "
~ Ancient Hunger, Modern World by Solia Valentine
Via: https://escholarship.org/content/qt2594j40t/qt2594j40t_noSpl...
[1]: https://www.perseus.tufts.edu/hopper/text?doc=Perseus%3Atext... [2]: https://www.perseus.tufts.edu/hopper/text?doc=Perseus:abo:ph...
Hit pieces aren't a modern invention.
https://blog.oup.com/2014/11/roman-emperor-tiberius-capri-su...
> Stories of this kind were part of the common currency of Roman political discourse. Suetonius devotes similar space to the sexual transgressions of Caligula, Nero, and Domitian – such behaviour is to be expected of a tyrant. The remoteness of the emperor’s residence itself must have fuelled the most lurid imaginations back in Rome.
Suetonius was born in 69 AD; Vitellius was emperor in 69 AD and Claudius was emperor from 41-54. They weren't contemporaries.
If you think that's bad just wait until you hear what Hillary was doing in that pizzeria basement!
The Romans were no stranger to just making shit up.
Purely from a cost perspective - imagine a 79 year old grandma.
Heavily overweight. She is already partially immobile. Pre-diabetic. She may have other conditions, further complicated by her weight. She's on a fixed income.
Which is more probable -
1) A dietary intervention that she attends once a week that revamps her entire daily consumption (but remember, she's on a fixed income) along with some intense exercise?
or
2) put her on a single medication that changes her tastes for sugary and starchy foods, reduces her cravings, reduces inflammation, and in turn, will make her lighter and more mobile.
It is a no-brainer for Medicare. This will save so many downstream costs.
These drugs (mostly) don't allow you to eat more unhealthy food, instead they make it easier to have the self control to avoid over eating / choose healthier foods.
To add, they actually prevent you from eating some bad foods too. At least in the compound versions that i know people on.
If they eat a lot of foods (some even good), their gastro issues are significant. So not only has it had substantial mental shifts around what they desire, but a bunch of foods are just not edible even if they wanted them anyway.
From what I understand these medications make you want to eat less in the first place, so it's not quite the same thing.
Yup. The people i know on this didn't even get it for the weight, but the behavior changes. This isn't letting them eat the same stuff and lose weight, this is changing what they want to eat.
They went from ADHD driven boredom eaters to not even thinking about food.
I have ADHD and the dopamine dysregulation really makes it hard to avoid eating things with sugar in it.
The semaglutide really helps, I'm on a lower dose of it 0.5mg/week and have been on it for over a year. I've lost a fair bit of weight but that has stabilized. It costs me ~$30 per month and I save much more than that on eating less food.
For me it really helps with chronic fatigue which was destroying my life. I think it really is a wonder drug for people with auto-immune issues. I was insanely sensitive to it when I started which I think is common with people with ADHD so I started really low and only very slowly worked my way up.
Sorry if it seems not empathic enough…
You should apologize for making it obvious that you don’t know how the drugs work (as illustrated by sibling comments). If your analogy is “gas-guzzling cars”, I would suggest you revisit your reading on the topic.
The ancient Rome vomiting thing is a myth. https://en.m.wikipedia.org/wiki/Vomitorium
My understanding is that the drugs keeps you from wanting to eat as much.
That's just not how these drugs work at all.
If everyone 30+ bmi can get to 30 for “free” (not sure where the subsidizing stops, for me it’s free if I’m over 30 bmi), that’s just too tantalizing to pass up, even if the moral applies.
At least it takes a load off one problem (obesity related diseases). Could it actually exacerbate unethical farming even more or lead to even worse outcomes? Hope not.
This reminds me of my idea to replace EBT with unlimited amounts of soylent
"load off" groan...
I've read that obesity and smoking are net positives for the cost of state-supplied medical care because it causes people to die younger and quicker.
My real concern is what you stated: the by treating some of the symptoms of a toxic food system we will avoid treating the causes (in the USA, we would do well to take soft drinks out of schools and treat adding sugar to foods as an sin to be taxed)
One of the mechanisms of operation is to reduce your desire to eat.
Taking a step back, obesity actually is an adaptation. When food is scarce, you want your body to extract and store every gram of nutrition it can get. And that would provide a distinct advantage when you're trying to reproduce.
The thing is, GLPs don't only suppress eating. There are plenty of substances out there that can do that...and there are plenty of people who can't lose weight by starving themselves, because your body will try to maintain its weight.
The question should be "why isn't everyone obese, given the huge amount of calories available to humans?"
> The question should be "why isn't everyone obese, given the huge amount of calories available to humans?"
We're close.
According to the CDC, approximately 73.6% of American adults are considered overweight, including those who are obese
> obesity actually is an adaptation
Obesity is not an adaptation. It's a total aberration. Storing energy in the form of fat is an adaptation. Becoming obese is overloading your entire system.
> why isn't everyone obese
Well... they sure are trying...
These drugs reprogram the weights in the LLM between the gut and brain, leading to lower calorie intake.
You may be wrong in the specifics of the mechanism of calorie reduction (reducing appetite vs reducing calorific absorption), but not in the general philosophy.
The obesity crisis (specifically in the US, but elsewhere too) has been caused by bad food essentially - food that is not only nutrient deficient, but also engineered to be as cheap as possible and addictive as possible to get you to buy more of it.
As ever, the US is attempting to fix the symptoms, as opposed to the underlying cause, following the general idea of 'if everyone does what they like, things will turn out ok (somehow)'.
Probably negative health implications of these drugs will surface as people become habituated, and we can continue to shake our heads and wonder how it all went so wrong over there.
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I find something really gross and dystopian about the idea of Ozempic. Developing the willpower to resist short-term gratification, and the ability to make long-term decisions about your diet and health are some of the most important ingredients to living a good life. The idea of letting a drug do the thinking for you because you just can't trust yourself really horrifies me.
Respectfully, have you ever had anything in your life that you have struggled desperately with, and needed help? Anything at all that might give you a little empathy on the topic?
I was obese twenty years ago, and lost the weight via diet and exercise. Keeping that weight off is the single hardest thing I have ever done, and a battle I still have to consciously fight every single day. Doing so causes me a great deal of pain and frustration, and I know that I'm someone who is right on the edge of not being able to control my weight. Why should it be that difficult? So that I can pass some kind of purity test?
The fact is that the food we eat has evolved over time, and is too hard to resist overconsuming for a large fraction of our population. If we can create more addictive food, why not create antidotes? If we could easily treat alcohol addiction with a pill, would we tell alcoholics to just apply willpower instead? Why would we want people to suffer like that?
You just don't understand how food addiction works. Going from 34 BMI to 28 (I'm at 26 now) was the hardest thing I ever done, and I had money, great friends, a great family and a doctor that followed me twice a month.
Willpower is not a muscle, it's a well that fill doing what you enjoy, and clear when used. During my diet, my work ethic was at the bottom, and I couldn't force myself to go out meet new people.
Now that I have a healthier weight and stopped dieting hard (I'm still constantly hungry, but now it's my life), I'm a great coworker, I met a lot of people, made life-changing decisions and I have a lot of willpower left to do all the little things right. If I had a drug that helped me control my appetite at the time, i would have taken it.
How have fat people gotten thinner without those meds up until now, then? Was their addiction not as strong as yours, as you seem to imply? They just didn't "understand"? Look, I went from being an absolute fucking fatass to 8% body fat out of willpower alone when I was 17. It took a lot, namely destroying every bad habit I upheld for years regarding food and exercise, but I wanted to do it bad enough, so I did. It was a really extreme and sudden change of mindset, like a flip of a switch, actually, because I had enough of the bullying and lack of self confidence. One day I just got mad enough and changed my whole life.
> You just don't understand how food addiction works.
Would you concede that some foods are more addictive than others? Doesn't this suggest other remedies like food regulations, at the very least, should be deployed in concert with seeming "miracle drugs" like GLP-1 agonists?
Can't speak for the original commenter, but I would not concede that, because experiencing semaglutide has convinced me it's not true. The feeling I can now clearly recognize as something like "food addiction" disappeared uniformly for everything from Brussels sprouts to donuts.
I do make good decisions and put in 10k steps everyday, which according to my stepcounter puts me in the top 5% for people of my age. Truth be told that my body can't effectively lose and maintain weight unless I'm eating a strict 1500 calories and replacing the walking with an hour long run. This isn't to say that the laws of thermodynamics don't apply to me, but my body will fight against them harder than most.
I took compounded Mounjaro for two months. It was like a jolt to the system and got me back on track. I learned how to eat better and alter what I eat plus tracking it. Started walking and going to the gym. Started with 7k steps and now easily over 12k a day on average. I don’t drink soda and if I do it js Coke Zero, Pepsi Zero or Diet Coke. We just don’t buy it. I didn’t know about maximizing my protein and fiber.
It wasn’t short term at all like you say. Something was seriously wrong.
It’s everything though - if it was that easy to just start doing it then people would.
I needed a jolt and impetus to get better. I was depressed, worryful, everything.
I have lost 40 lb. I went from 255 to 229 with the assistance of Mounjaro. I stopped taking it but kept up with the regimen. I am now down to 214.
Some people who take it don’t do it right, they still eat crap and so those are the people who rebound or think they need to go up to 15. I was taking 2.5 then 5 when I stopped.
Yea it is willpower and discipline. Being on the medicine as an assistant along with a lot of research spurred by the community such as maximizing protein, fiber and water intake to become satiated was all that did it with exercise.
Consider the fact that, if a drug can make you skinny, perhaps a drug can also make you fat. Or, even your own body can make you fat. Sometimes, what we think are our choices, have more to do with our biology and environment.
Just like you can't will yourself to be healthy if you are sick with the Flu. Some people can't just will themselves to be skinny. This is why we have drugs and treatments, because our bodies are not perfect machines that work the way we want them to.
> Consider the fact that, if a drug can make you skinny, perhaps a drug can also make you fat.
Yes that would be Prednisone. People call it the devils tic-tac. Its a wonder drug with terrible long term costs to your body especially at higher doses.
> with our biology and environment.
Our biology hasn't changed much in recent years. Our environment has. So has our obesity levels. I mean, it's an "environment" that has "super size," as a default option.
Telling everyone "just get better willpower" is about as useful on a societal level as looking at a disabled person at the bottom of a set of steep stairs and telling them that the struggle is good for them.
Do you object to pencil and paper because people write down reminders because their memory isn't good enough to remember everything?
Just flip it around: what if there were a drug that made people fat? Is it an insufficient willpower issue then? Willpower works for some, but the drugs make it easier.