The Ozempic Plateau
theatlantic.com
theatlantic.com
I might be wrong, because obesity really is a terrible lethal health problem, from a certain level upwards it's straight up similar to hard drug addiction (e.g. crack).
But if this is the solution.. oh my.
How about offering people rewarding opportunities for exercise that don't cost a fortune (if you live in a traffic-ridden district, who wants to "go for a walk" really?)
How about educating people more vigorously about food addiction?
No fret towards anyone who feels these drugs help them, but for me, it just reminds me how glad I am to have come off SSRIs. The pharmaceutical industry never had any kind of "don't be evil" facade, and they act like it.
At the end of the day heart disease is still the number one killer in this country and reducing obesity is the solution to that problem. With the government paying for the healthcare of a significant portion of the population I think its clear that we need to be pushing these drugs hard, for both the life saving and economic saving aspects.
Something’s just totally fucked about our culture when it comes to food and activity. A few can overcome it, but relying on individual willpower to get us out of this mess is clearly never going to work.
That leaves figuring out what’s wrong with our culture and fixing that (hard, probably multiple generations to achieve) or drugs (available now, doesn’t require coordination to achieve, people who need it can just go get it)
rates of diabetes and obesity are getting pretty high in other countries, too. the UK is pretty fat, and much of Europe is heading that direction. behind the US, but it's trending that way.
The middle east is fat as fuck, but is mitigated by overall poverty and high temperatures -- life in a sauna helps drop weight.
China has seen a surge diabetes, as has several other Asian countries.
And for me to stay skinny, I never have to think about my food intake. I don't diet, I simply never get that hungry. I'm not saying this as some sort of weird internet brag, it's the opposite in fact. I fully recognize that my genetics (and also possibly my childhood upbringing) basically have full control over my weight level and hunger level. This idea that we all should be some sort of Zen ascetics to maintain our weight is horse shit.
Didn't really work with DARE.
By "educating" I meant that a holistic approach is needed, that's why I compared it to drug addiction. Vulnerable and affected people can only be helped by human consultation, with trust and frequent contact.
but that's not going to fix the problem, any more than DARE stopped kids from doing drugs. the war on drugs is over -- the drugs won -- and it's pretty damn clear the war on junk food is also over -- the junk food reigns supreme.
I think what can be hard to understand with disorders of the mind is that you can't really empathize with them if you don't have them. The reality is that there is a lot of documentation that people aren't just suffering from a lack of willpower; they simply don't have it in them to change because of how their brain is wired. Asking people to be less hungry is like asking them to jump over the Empire State Building. You can ask all you want. It's not going to happen. It's literally impossible. The approach for approximately the last 10,000 years of human history is to say "well these people are defective, get them out of here". Only now are we starting to develop treatment options, which can help people live what you and I consider a normal life. I don't think that's some sort of scam from Big Pharma. While they're making a lot of money, people are living measurably better lives. That's the economy. You spend money to get something in return.
Why have people for thousands of years and still in many other countries not had this constant insatiable hunger that you speak of?
The American lifestyle leads to a ~50% morbidly obese rate - not human nature.
Morbidly obese rates throughout all human history were <10% until pretty recently.
What makes you think they didn't? Maybe they just didnt have enough food to satisfy themselves and were constantly uncomfortably hungry.
Europeans can, generally, afford to eat.
The portions at restaraunts are also more reasonable. Not the 1500 calorie abominations (half the calorie budget for an active man) you get in the US
Certainly the wide availability of food, most of it not particularly healthy, isn't helping much. Jobs where you sit in front of a computer all day aren't helping much. But I think it's impossible to give those things up at this point.
I wholeheartedly agree with you that obesity is a modern problem, but if your solution is somehow "we should redesign all American cities so you can bike to work so we can all be like the Netherlands" or "we should all grow our own food", well, that's not really a solution.
if they could have been fat, they would have, but they couldn't get enough to eat to stay alive.
Having been on the other side of these brain problems, I understand your skepticism. I have many apparently-normal friends that, once a month or so, disappear off the face of the planet and eventually they come back and they're like "I thought everyone hated me so I stopped going to work and talking to my friends". My honest thought is "WTF" but I offer them reassurances that that's not true at all and everyone likes them. Then they're OK for another month. Meanwhile behind the scenes, they're seeing a psychiatrist and a therapist every couple weeks, and the fact that they're around at all, ever, is because of this work with their doctors. You have to accept that people's brains are wired differently, often in harmful ways, and that there are treatment options available. It's totally alien to me to be too unhappy to get out of bed. But it does happen to people, the data says it. So I believe the data and try to be supportive.
I really think not sticking to a diet is the same sort of problem.
Depending on how intense the exercise is and other factors (your weight being a major one) you might burn 300-800 calories for an hour of exercise.
A few cookies/donuts will destroy that in no time.
Ultra filtered milk is an example where we have the means to double protein, convert lactose to sucrose - and has an extensive shelf life; but educating on why one milk is different than the other is extremely difficult.
"Enriched" white bread is an example where wheat bread has less sugar, more protein, more fiber.
Different brands of rice has different fiber contents too; the store brand had 1g of fiber and 1g of protein, but the premium store brand had 5g of fiber and 3g of protein.
And cereal too; Cheerios had 2 fewer carbs, 2g more protein and 2g more fiber than the store brand of whole wheat cereal. (that's a roughly 20% difference)
I wholeheartedly agree that the obesity epidemic is a consequence of modern society: it's easy for the average person to go a whole day with nearly no physical activity, and our foods are calorie dense (not to mention literally designed to addict with fat, sugar and salt) and nutrient poor. But loads of people who have, basically for the first time in their lives, lost weight with semaglutide realistically have no other options.
Do I like that we need to cure one problem with modern society with another drug which has side effects of its own? No. But rather that than condemning people to obesity, which has enormous physical and mental health costs.
It’s clear that these drugs cause weight loss (in everyone) so I’m not sure what further certification and testing might show
What works to keep skinny people skinny won't necessarily make fat people skinny.
That's why some people think things like Ozempic are necessary to deal with obesity in America.
Whatever Japan's strategy is, I can guarantee it is not the type of lifestyle that is convenient in the US, and it's not making pleas for changes away from the current dominant lifestyle.
I can't even get my city to allow basic Japanese style housing, or the type of housing that was commonly built a century ago, with daily needs within convenient walking distance and without threat of massive trucks and SUVs running me over. It's not even legal to build a neighborhood that would fit the Japanese lifestyle in the vast majority of the US.
Perhaps that daily amount of activity is the difference in obesity, perhaps not, but following a typical American diet and the allowed types of transportation is clearly not helping us.
I said directly in my comment "I wholeheartedly agree that the obesity epidemic is a consequence of modern society". And I'm all for making cities more walkable, for example, and making it easier for people to get healthier foods. But I don't think these are realistic options for making a dent in obesity in America any time soon.
If not, are you suggesting you know how to do that? The problem isn't knowing what an individual needs to do. It's knowing how to get an entire country from where we are currently to that point desired point.
Many people who go on semaglutide were on the road to bariatric surgery before these drugs were widely available. Bariatric surgery is a major surgery, with not insignificant rates of complications. I guarantee nearly everyone who gets this surgery considers it a last resort. Yet now, most physicians believe these new drugs will essentially put bariatric surgeons out of business.
I'd be all for any options with fewer side effects, but handwavy "endocrine health" doesn't cut it, again for the society at large.
For better or worse. Some of the comments in this thread seem extremely disconnected from reality.
Then you would face a serious risk of overshoot. It would be more like a chemical lobotomy. Sounds worse to me.
Honestly absurd premise to think “they just don’t understand junk food makes them fat.”
This is also a... dubious... statement... > And the truth is, they do a terribly bad job at treating diseases like Influenza, diabetes, or generally advising people with common health conditions. How would you know they don't treat these issues well? What do you expect the treatment is for influenza, for instance?
replace obesity with the name of any other disease and you see why this is such a bad take.
these drugs have potential to make big impact on quality of life and longevity, and instead were arguing over whether we should instead pursue education, lifestyle and will power
https://www.nejm.org/doi/full/10.1056/NEJMoa2032183
I totally agree that our lifestyles need to change. Unfortunately, as you note, the factors influencing lifestyle are deeply baked into our society. Like sure, I would love to wholesale rearrange our transportation infrastructure towards walking and biking while also somehow (???) changing American food culture to value healthier meals.
That’s not going to happen in our lifetimes though. Sorry.
In the meantime, tens of millions of people will have hundreds of millions of years cut off their healthy lives by heart disease, diabetes, liver disease, strokes, etc etc etc. Semaglutide will alleviate that. It’s exceptionally distasteful that the only way we get this is by pharma companies extracting as much as possible from us. Nonetheless, I prefer that over having countless lives destroyed while I keep my principles.
I spent the first ~20 years of my life being right on the border of under-weight though no specific actions of my own. Yes I was more active as a youth but to put into context how much food I was eating at the time, I could also eat breakfast, lunch, 3 bowls of afternoon cereal and milk, and then 2 super sized meals from a fast food place. In fact, I did that (or the equivalent) on a relatively regular basis. And the important thing is I NEVER felt consistently full when doing all of that. I was always ready to eat more food. Yes, any individual meal I would hit a point of being physically unable to eat more, but an hour later and I was ready for more.
I then spent the next ~20 years gaining weight and sliding into obesity. Yes I was less active, but I also wasn't eating quite as much food (when you have to buy your own, you stop eating a half a box of cereal a day). I did CICO counting, even had some success with it but could never get it to stick longer than about 3 or 4 months, and was miserably hungry the whole time. It was a daily battle to choose to not eat more for any given meal. I did various attempts at exercise, but mostly that just made me so much hungrier that any calories lost via exercise were quickly replaced by calories gained through eating more.
6 months ago I started a medication for a completely unrelated issue, but one of that medication's side effects is a reduced appetite. For the first time in 20 years, I am actively losing weight and what is enabling that is I'm NOT hungry all the time. When I started this medication and that side effect kicked in, I thought I was sick for the first week because of how not hungry I was. It was only after realizing that I still actually got hungry around meal times, but then was properly satiated by a reasonable amount of food that I realized I've never not been hungry since I was a teenager.
Yes, in the end I'm eating less, CICO and all of that. But the key to this is that I'm not feeling that nagging pull all day every day to eat something more. When 10 AM rolls around and I feel a little hungry, I can look at the time, realize I'll be having lunch in 2 hours and then ... just decide to not go get some food and my mind will go find something else to do. Before this medication, from 10 AM to lunch I would be watching the clock and every 10-15 minutes have to have an internal debate over going to get food. It's probably the closest I've ever gotten to being addicted to something and let me tell you, if you have to fight your own body every single hour of every single day you WILL lose eventually, every single time, forever.
For 6 continuous months I've steadily lost weight. Even through the holidays with all the extra sweets and big meals that almost always meant the end of whatever successes I'd had before, I managed to keep a consistent weight level instead of gaining. It is VASTLY easier to manage your weight when your body is responding to normal levels of food the way we expect a normal body to do so. Before this medicine, I would have told you I was just lazy. That I wasn't putting in enough effort and self control and that I was "making a choice" to be where I was. And to whatever extent that is true, the thing I can also say now is I was "choosing" to keep eating under effectively a threat of constant hunger from my body.
We spend way too much time moralizing about obesity and worrying about other people's self control in a way that is exceedingly out of touch with the reality of the world we live in and the health impacts of the condition. Yes, these medications might mean a lifelong treatment, yes you would need to maintain the new behaviors if you went off the medication or your weight would return. Yes it is possible to do this without medication. And so what? Imagine any other condition that had the same primary and secondary health impacts as being obese does, and then imagine we had a pill that could help someone mitigate that condition, or we could moralize about their poor self control and choices in life and encourage them to instead deal with their condition "naturally". You can deal with diabetes "naturally". You can deal with asthma "naturally". You can deal with gout "naturally". You can deal with poor eyesight "naturally". You can deal with hearing loss "naturally". You can deal with the flu, a cold or COVID-19 "naturally". You can also get many multitudes of modern medical advances to treat any of these, some of which are lifelong continuous treatments, and everyone who can and wants to absolutely should get those treatments because while you can deal with any of these things "naturally", your quality of life and your chances of positive health outcomes are VASTLY improved by the treatments.
It's time we stopped treating obesity as some special class of condition where the only appropriate choice is the "natural" one that the moral scolds provide. Maybe we shouldn't have gotten here in the first place, but now that we are, I'm starting to view people opposed to these treatment options the same way I view fundamentalist religious people who are opposed to various medical drug and addiction treatments for similar moralizing reasons.
> How about educating people more vigorously about food addiction?
Finally, an easy question to answer!
Because these do not work, empirically. They do work in theory, and sometimes work anecdotally, but that's evidently not enough to solve the obesity crisis.
"Citation needed!" okay, here's the result of two seconds of Googling:
https://www.ncbi.nlm.nih.gov/books/NBK221839/
> Apart from the obvious need to increase energy expenditure relative to intake, none of the strategies that have been proposed to promote weight loss or maintenance of weight loss are universally recognized as having any utility in weight management. The efficacy of individual interventions is poor, and evidence regarding the efficacy of combinations of strategies is sparse, with results varying from one study to another and with the individual
> [When you loose weight], your body looks for ways to conserve energy. Your muscles work more efficiently, for example, Ard says, so walking that normally burned 100 calories might now burn only 90. By making you want to eat more and burning fewer calories, your body is eventually able to slow weight loss down to zero.
How exactly is your body able to accomplish the same task with less energy? What are you giving up? Do you become tired more easily, or wear out your muscles more quickly? Or does loosing weight just turn you into a more efficient super-human (albeit perhaps not in a way you would like)?
Would it be desirable for, say, an ultra-marathon runner (who I assume needs to consume as little energy as possible) to spend a year gaining and then loosing a bunch of weight, to make their body more efficient?
Mitochondrial uncoupling proteins [1]. They control how much energy gets converted to ATP in the mitochondria and how much is lost as waste heat. As you enter a caloric deficit, UCP1 is downregulated and the mitochondria adapt to lose less energy to heat.
and oh look here's the protein which controls how much you absorb from it.
CICO is the only actionable advice for an individual (at least in the absence of such drugs) but there are still major questions about things like endocrine disruptors etc. The rise of obesity is far too broad-spectrum (even in feral cat colonies or lab rat populations that shouldn't be affected) to really be attributable to just "people have desk jobs". Lots of people have desk jobs all over the world and obesity is not evenly distributed, and the story has always been that "exercise doesn't matter, what you eat controls your weight" so things like biking vs driving should have a relatively small effect.
But people wanted to turn it into a moral hazard, and they did. Fat people have always been a socially-acceptable target to punch down on. "I'm actually helping them, you see".
Both the CI and CO numbers can have very large error margins, however, the fact that their difference, if leading to a caloric deficit, will cause weight-loss is irrefutable truth.
If you do a diet for 14 days and have no change in weight, it just means you need to reduce consumption more.
CICO isn't unfair because it's incorrect. It's unfair because for some people following CICO comes trivially, while for others it's literally the hardest thing they will ever do in their lives.
And that's why I do sympathize with people who find it hard to lose weight. You are fighting against your most primal instincts (the desire to eat).
But that doesn't mean CICO is incorrect.
Maybe a useful analogy is that my hybrid SUV and a v8 Range Rover sport consume very different amount of gas even for driving the same distance at the same speed.
Having been morbidly obese, i can say that being told to lose weight doesnt work.
You have to want it, be dedicated to it, and have the mental support.
For me it was exercise and changing your food patterns: more small things to keep you full longer. Not denying yourself anything, but everything - and i mean everything- was weighted, added to a calorie tracking app. Your max is your max. Want crisps? Sure, but that comes out of your food budget.
It requires dedication that i find a lot of people are just not willing to put into it, and hence... the popularity of a drug like Ozempic.
I've lost 70kg (154lbs) and it is nearly a decade in still a struggle, having been obese for 20ish years. But the health benefits alone make it worth it.
"5 smaller regular portions during the day" is part of how I went from 100 to over 110kg and struggled to walk longer than 20 minutes. Getting back to walking fit required 10 days being fed minimal amounts to prevent collapse of digestive system with a tube through the nose. I still gained weight ultimately, but combined with exercise it allowed me to walk and even run for short distances.
Spent years just trying to figure out what's wrong with endocrine system - still don't really know. One of the things led to being prescribed ozempic, not just for weight loss, but because of its function of lowering insulin levels.
Why does it matter? Do we worry that asthmatics will start havin asthma attacks again if they stop their medications? Do we worry that diabetics will struggle with insulin problems if they stop theirs? Do we worry that people with vision problems will suffer again if they stop using their eyewear? If someone has to take ozempic every day for the rest of their lives in order to maintain a healthy weight, why the heck do we think that’s worse than being obese every day for the rest of their lives? Why is it more noble that you “nearly a decade in” struggle every single day of your life to maintain a healthy weight? Wouldn’t it be better if you could both maintain a healthy weight and also stop struggling so much?
Keeping people on this medication for life seems like a really bad thing - atleast until we clearly know what the long term effects are. Those are unknown.
The other medication you mention is known, studied, affordable. Comparing insulin to Ozempic is .. well, a non-comparison in my book.
Generally speaking - definitely for something that you can treat with a life style change and some inconvenience in the beginning - a life where you can live without a drug is better than one where you keep being dependent on it.
Unless you're the pharma industry, that is.
Ozempic is literally a drug for diabetes. We're already prescribing this to people with the expectation they will be on it for life.
>something that you can treat with a life style change and some inconvenience in the beginning
We have people in this very discussion who are also morally opposed to Ozempic describing how keeping their weight is a decades long daily struggle. That doesn't sound like "some inconvenience in the beginning". We also have decades of research (and the reality of the world we live in) suggesting to us that "lifestyle change and some inconvenience" is not working as a treatment.
I exercise at a minimum of 35-45 minutes a day, and when I can get out in the warmer months sometimes as much as 90 minutes a day. While it does have its health benefits, it can just make me hungrier.
And sure, I’ve tried eating less. But I find that leads to me being foggy headed, tired, and irritable. Which the leads to more stress too. And let me tell you as remote developer that is not a great way to live your life.
And in the past when I’ve done all that I still plateau around fifteen pounds lost. And if I slip up any, well, I have to work that much harder to get back again.
I’m not sure I’m ready to resort to medication yet, but I can definitely see the appeal.
If that were the case, it doesn't seem to apply to me.
When I was on a fat-loss journey, I had gone from ~102 kg down to 72.5 kg, which I stayed around for several years. That's a difference in 29.5 kg.
29.5 * 90 = 2,655 kCal
Not that I didn't get very hungry at times, but I'm failing to wrap my head around what this guy was saying. If it's true, then either my daily energy expenditure would be more than twice what it currently is (which I've measured through respiratory gas analysis), or I'm hungrier than I know and I'm just shitting out all those extra "calories" that I'm not turning into fat mass.
> Ard says, so walking that normally burned 100 calories might now burn only 90. By making you want to eat more and burning fewer calories, your body is eventually able to slow weight loss down to zero.
The problem here is in believing that the level of perceived hunger has a linear relation to "calories" burned which, if we are going to be accurate, describes a unit of heat. The body doesn't directly delegate heat because photons have no mass. All the body cares about having different kinds of mass in the optimal places at the current time. Just because you feel more hungry than usual doesn't mean that your body demands to burn X number of calories. Because there's more in play than just energy-in-energy-out, in order to overcome those plateaus, you have to either alter the fuel mixture to optimize for hormone levels, or you have to eat such little mass that it can't make up for all of the mass that your body loses otherwise. This isn't even counting the psychology behind hunger, and how people can think they are hungry with relatively low ghrelin levels because they are relying on food for psychological comfort.
I’ve lost about 100lbs in the past 15 months and my appetite hasn’t really changed at all. I do get hungrier on gym days, but that’s to be expected since I’m expending more energy.
In fact, I recently discussed calorie intake with my trainer, who is extremely fit and about the same height as me - our BMR is nearly identical.
But, I'm also frustrated at the US food choices; Fast food, even sit down food is often devoid of fiber. Store brand cereals, grains are devoid of fiber unless you pay a premium. Ultra filtering milk doubles protein and halves sugar (by converting lactose to glucose) -- but it costs 8x as much. Why do we even sell "enriched" white bread when whole grain wheat bread has lower sugar, more protein, and more fiber? Margarine - with partially hydrogenated oils - but sold in stores and often at restaurants (waffle house).
On the other hand, pharmaceutical companies only care about money and the chemistry is pretty straight-forward. They will continue making new drugs, and they will certainly release a "newer and better" version when their patents run out.
But, there will certainly be unintended consequences, and we still don't have a good understanding of the cause of the obesity epidemic.
yes, we do. it's not rocket science. sedentary lifestyle + huge amounts of cheap calories, esp. cheap carbohydrates. the Japanese are much skinnier than the US because the eat ~1000 calories less than the US. much of Asia and the ME are skinnier due to poverty and climate -- easy to be thin when you live in a sauna. and they're rapidly catching up to the US; America just got there first, and hard.
2. magic pill
3. ???
4. profit!