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Comment by moritzwarhier | Hacker News Reader

Sorry but this drug really sounds like straight from Margaret Atwood's "Oryx and Crake" dystopia. It has already arrived here, and physicians are eager to offer it (medical insurance covers it from BMI>30 onwards). Long-term "patient relationships", I guess. The physician I went to until recently always employs 10-20 different doctors, most of them straight from university. And the truth is, they do a terribly bad job at treating diseases like Influenza, diabetes, or generally advising people with common health conditions.

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.

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Sorry, but I couldn't disagree more. We have certainly tried the "diet and exercise" mantra for generations at this point, and they simply do not work for society at large (obviously they can work for individuals). I have 0 belief that "educating people more vigorously about food addiction" would do anything to lower obesity rates. Knowledge is not the problem.

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.

I think it's great if we have a treatment for obesity, but can we maybe actually certify & test it for that purpose first instead of this off-label thing it seems to be?

We did. Its called Wegovy.

Many drugs are prescribed in ways that take advantages of their side effects. Indeed, many drugs are designed for one purpose but perform a second purpose much better.

It’s clear that these drugs cause weight loss (in everyone) so I’m not sure what further certification and testing might show

But they have, right? Wegovy works really well. Ozempic is off label for weight loss only in the sense that it is the semaglutide drug that is marketed for diabetes and that it therefore isn't sold at the same high dose as Wegovy.

I don't understand why we're acting like preventing obesity for society at large is an unsolved problem. Looking at Japan with an obesity rate of 3%, it's clearly possible.

prevention is different from treating.

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.

Who's pretending it's unsolvable? The comment was merely pointing out that the current strategy in the US is not working.

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.

Because I don't think it's a realistic solution to say, for example, that in the lifetime of anyone currently alive that we're going to get, say, Dallas, TX to have the built environment and food preferences of Japan.

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.

How is it a solved problem? Did Japan have some sort of campaign that shifted their entire culture from a fat one to a skinny one that we can replicate?

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.

You're presenting a false dichotomy. Endocrine health is just one example of where doctors ought to investigate before more extreme interventions like these weight loss drugs.

The false dichotomy is to believe that these new drugs are the more extreme interventions.

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.

At least we can all agree that knowledge is not the problem. :(

For better or worse. Some of the comments in this thread seem extremely disconnected from reality.

Telling overweight people to eat less or exercise more does not work. There have been countless studies and they all agree. Obesity is clearly a complex subject, but from what I understand some people just experience reality differently in that they're constantly thinking about food. One way it was explained to me is "telling overweight people to eat less is like telling someone to set their thermostat to 40 in the winter to save on their gas bill". It's possible, but extremely uncomfortable and not a realistic solution for most.

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.

Looking at weight gain for immigrants and long-term visitors really shows how hopeless this is to fight individually. It’s not that other countries’ citizens are individually making better choices, it’s that… they don’t live in America.

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)

nah. "what's wrong with our culture" isn't hard to figure out -- sedentary lifestyles, car centric culture that preempts biking, walking and activity, and lots of cheap, fatty foods. we're seeing that happen in other countries, too; the US just got there first.

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.

Well, once we ID the problem there’s still the “fix it” part. The fact that so much of the world is heading the wrong way on this is not reassuring that we have any realistic hope of doing that.

possible, but uncomfortable -- nailed it. life is not supposed to be 100% comfortable. traditional spiritual practices bake in periods of discomfort for a reason.

Baloney. I've been skinny (too skinny for my preference) my whole life. While I used to get a lot more exercise in my youth, I'm (again, unfortunately for my preference) quite sedentary these days.

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.

We can philosophize about what life is suppose to be, but at the end of the day most people do not want to be uncomfortable and will consistently make decisions that reduce their discomfort.

the ability to withstand temporary discomfort for a higher end is trainable. most people do not know any better, and telling them to not even try is rather not charitable.

I'm not saying we should avoid discomfort, but we already encourage lots of forms of discomfort that encourage obesity, such as stress, and discourage the healthy sorts of discomfort like walking to places.

Remember, this is the country that found wearing masks in public for public safety was too onerous a burden and having to inconvenience yourself to help others was met with anger and violence.

So, I don't think exercise is going to have the effect that people are looking for. I have a BMI of a little less than 30 and exercise an hour every day. Like not an aspiration to exercise, documented evidence of doing an hour every day no matter what. I have lost approximately no weight on this program (but I do enjoy it greatly!). I'm definitely planning on asking my doctor about these drugs, because lowering the internal setpoint for "I need to eat or I'm going to smash something" would be highly valuable to my health.

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.

~50% of Americans are morbidly obese - which is a relatively recent phenomenon.

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.

> Why have people for thousands of years and still in many other countries not had this constant insatiable hunger that you speak of?

What makes you think they didn't? Maybe they just didnt have enough food to satisfy themselves and were constantly uncomfortably hungry.

So ~30% of people in Europe are constantly starving compared to Americans?

Europeans can, generally, afford to eat.

Europeans have better public transit and more walkable/bikable cities.

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

European obesity rates are also on the rise. the US might have gotten there first, but lets not pretend that we're alone on this hill.

Yeah, I mean, we're not resource constrained anymore. It's easy to not gain weight when there are literally no calories available. You also don't contribute much to the economy and you're miserable all the time.

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.

Because for thousands of years people had to worry more about starving than overeating. And America may have gotten their first, but obesity rates are skyrocketing in nearly the entire Western (and many parts of the Eastern) world.

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.

It takes only moment to search on Google to find many, many news articles indicating that obesity is rising quickly in Europe, Asia, and the rest of the world.

until the last ~100 years or so people regularly starved or died of famine & drought.

if they could have been fat, they would have, but they couldn't get enough to eat to stay alive.

270 word comment about trying to lose weight and you didn't mention anything about diet. I know people hate trite phrases like "You can't outrun a bad diet" or "The best weightloss exercise is a fork-putdown", but what do you say to people when they literally don't consider diet as a relevant part of weight management and instead focus entirely on exercise?

Personally I'm not doing too well on the whole diet thing. I'm well aware of the importance and make grand plans. Then I get really hungry and like eat a pound of noodles or something. I literally can't sleep if I'm hungry at bedtime, I will lay awake all night! Given that I have to go to work the next morning or won't be able to afford things like "shelter", I usually opt to try and get some sleep.

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.

Bodybuilders will always say, you lose weight in the kitchen, not the gym. Exercise is for building muscle, and other benefits like cardiovascular health.

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.

We need to go beyond education; the FDA should start demanding reductions in non nutritional and fructose sweetened foods;

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)

Exercise is generally part of a weight loss plan but diet (e.g. cutting out carbs, sugar, not drinking calories, intermittent fasting, etc.) will be the biggest contributor. Running for an hour burns a surprisingly small amount of calories.

Here’s a peer reviewed study that directly compared semaglutide to placebo with additional lifestyle change support. Semaglutide just worked way, way better.

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.

Sorry, the view you're expressing is completely out of touch. You say that obesity is like crack, and then go on to say it just needs more vigorous education. As if going to skid row and starting a DARE problem would all of a sudden stop all addiction.

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?

obesity is the leading cause of deaths in america, and many of the runner ups are a result of obesity.

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

Imagine if a limited course of Ozempic permanently altered your body’s hunger set point. Or if SSRIs permanently altered your mood even after you stopped taking them.

Then you would face a serious risk of overshoot. It would be more like a chemical lobotomy. Sounds worse to me.

> 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?

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

The public health community has been offering diet and exercise as a treatment for decades. At a population level, it simply doesn't work.

It sounds great to me, obesity kills, and humans are hard wired to eat absolute garbage.

It's something called free will about what you choose to consume.

Yet substance abuse and overeating continue to be a common human failing. These people understand their consumption choices are unhealthy but still do them cause of stress, human weakness, and biochemistry.

Honestly absurd premise to think “they just don’t understand junk food makes them fat.”

Honestly - I'm not sure if people actually realise what they eat is bad for them. And this I mean in the sense that the food industry goes out of its way to make sure food is addictive.

I also have the free will to choose Ozempic.

> How about educating people more vigorously about food addiction?

Didn't really work with DARE.

I didn't mean that there is an information deficit.

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.

i mean yeah, we should be teaching kids better, and should take out sugary vending machines from high schools.

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've told this story before, but I'll tell it again.

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.

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