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Comment by fiftyfifty | Hacker News Reader

The biggest problem with semaglutide is once you stop taking it things like blood sugar and body weight start to go back to where they were before. On average people gain back 70% of the weight they lost on the drug within the first year when they stop taking it. It seems likely this is going to be true with other addictions as well such as alcohol. While the effects are impressive, without addressing the underlying causes such as psychological factors that cause people to overeat or abuse other substances like alcohol it seems like we are just replacing one form of chemical dependance with another, albeit a healthier one.

https://www.healthline.com/health/semaglutide-withdrawal-sym...

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While this is oft repeated, it’s not very relevant. First of all, some weight is kept off, which is a huge win. Secondly, the drug can be taken again. Thirdly, it will be a second chance for millions at a heather lifestyle. Once you get so fat, it becomes a doom spiral of low physical activity and low body image. Personal willpower and choice can have a huge impact but its very hard to start exercising when you can barely walk down the street.

It's not just that the weight is gained back but the rate that it's gained back. Imagine someone loosing 100 pounds on semaglutide and then gaining 70 pounds of it back in 1 year when they stop taking it. That's over 1 pound a week of weight gain, likely much faster than that individual gained the 100 pounds originally. That type of rapid weight gain is associated with even worse health effects than carrying the extra 100 pounds probably was, and that's just at 1 year, where will this individual be in 2 years, 3 years etc? Will they really keep that other 30% weight off? We don't have the data yet, but it doesn't seem likely they will. I'm not saying we shouldn't use these drugs, just that we need to understand that they are only the first step to a much longer strategy to improved health.

This is literally a straw man argument.

> That type of rapid weight gain is associated with even worse health effects than carrying the extra 100 pounds probably was

Source?

And are the people losing 100 lbs regaining 70 of it? These statistics are provided in the aggregate [1]. I wouldn't assume the re-feeding of someone who lost 20 lbs will mirror someone who lost 100 lbs.

Also, conventional methods resulted in "more than half of the lost weight was regained within two years, and by five years more than 80% of lost weight was regained" [2]. So our baseline is the 100 lb person regaining 50 lbs following diet and exercise or whatever.

[1] https://pubmed.ncbi.nlm.nih.gov/35441470/

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5764193/

> it seems likely this is going to be true with other addictions as well such as alcohol

Why? We need to eat. We don't need to drink.

Removing alcohol for a year or more could allow both the body and environment to be adapted to a point where it is no longer presented in the same way.

i’m not sure whether there’s any physiological basis for this, but subjectively having an addiction feels a lot like having an additional need in the same vein as hunger and thirst. The addict’s mind is convinced it does “need” the substance.

It’s worse than that for e.g. alcohol and opiates. The organism lets the addict know in no uncertain terms it needs the substance. It’s not a choice the mind does unless you’re a zen master or something.

Agreed, speaking from experience taking a long break from alcohol does wonders to reset the brain’s idea of what’s “normal” plus the simple act of just disrupting an engrained habit.

Won’t be the case for everyone but I think even taking it for a limited amount of time could do a lot for a certain type of excessive drinker.

How is this any different than treatments for high blood pressure and other chronic illnesses? I hear this refrain often, which diminishes the incredible achievement and benefit of these new drugs.

I think there are two kinds of people, those for whom taking medications for the rest of their lives is unthinkable, and those for whom it's completely normal. I'm definitely in the latter camp but the cultures colliding can be a real surprise.

Just... keep taking it then? What's the downside of taking a drug that has a number of beneficial effects, especially the reduction of addictions (food, alcohol) that have high fatality rates?

I'm not on Ozempic, but I am on plenty of medications that I'll be taking for the rest of my life.

Yes, this is how medicine usually works

Well then maybe we shouldn't use it unless the consequences are severe enough to warrant them. In particular we shouldn't use them without trying behavior modification first.

Behavior modification has been failing for decades. It had its shot.

Skinny foreigners move here and gain weight. That’s a pretty strong indication that individual willpower doesn’t have much to do with why skinny countries are skinny. Why would we expect that to work here?

Our options that have any hope of actually working are a huge overhaul of probably a lot of things, including our food culture, zoning and city layouts, farm policy, and social safety net, to name a few—or, a miracle drug.

Realistically, if we want results this century, that leaves only the latter option.

> Behavior modification has been failing for decades.

What are you basing this assertion on?

> Skinny foreigners move here and gain weight.

Do you have any data to back this up?

> including our food culture, zoning and city layouts, farm policy, and social safety net, to name a few—or, a miracle drug.

Why do you think that only extreme solutions are available?

> Realistically, if we want results this century

I don't think there's anything realistic in what you've proposed.

Google either of those first two things. The answers are in the first page, no need to provide a citation and open up “well I don’t like that citation” cans of worms, pick your source, there will be a mountain of them. Dig a little on any of them and you’ll be on actual meta-studies and such. Neither is a controversial claim, or even close to it.

“Why only extreme solutions?” 1) because zero non-extreme ones have worked, 2) because the root cause appears to be deeply embedded in a complex web of systems, which means addressing the root cause within a human lifespan is necessarily extreme, 3) the drugs arguably aren’t really extreme, and 4) supporting #3, the alternatives we’re currently reaching for are drugs to treat the outcome of the pattern of failures in behavior modification / willpower approaches, so this is really what we’re already doing just applied before things get extremely bad.

[edit] here, a couple examples, why not:

https://pubmed.ncbi.nlm.nih.gov/19538440/

Maybe it’s just me, but the last sentence of the abstract reads like a punch line:

“Future research is needed to identify the specific mechanisms through which living in the USA may adversely affect health outcomes.”

I chuckled. “Uh well we know it’s real bad but as for why, look, it’s fuckin’ complicated and probably gets political way faster than you’d expect”

(The paper appears to recommend weight gain prevention intervention programs for immigrants, because what else are you gonna do?)

https://www.nature.com/articles/s41366-024-01525-3

Paywalled but the summary provides some good info. Between this and others (also appearing on the first page of my ddg searches for this) one puts together a consistent picture

1) thanks to a ton of research and spending we’re getting better behavior modification programs! Hooray!

2) the ones that kinda work are a lot higher-touch than you probably expect. I.e. expensive and not accessible to lots of folks, for a variety of reasons.

3) despite all that the expensive state-of-the-art isn’t good enough to tackle the obesity crisis. It helps, but not enough, even if we could provide that help to everyone who needs it.

4) comically (again) this particular summary ends on a “… but now that we have really good weight loss drugs, maybe it’ll work!” note.

(“Just do a diet” without ongoing professional support is basically not effective at all for long term weight loss, on a population level)

GP is victim blaming, a perennial favourite with a certain type of person. The fundamental attribution error[1].

1. https://en.wikipedia.org/wiki/Fundamental_attribution_error

Why? What is the evidence base?

You sound like the people who say that trans people should try psychological interventions (conversion therapy) before medically transitioning (which is also a lifelong medical commitment in many cases). Psychological interventions don't work, while medical transition does. It's the same here. Ozempic works while telling people to eat less does not.

> In particular we shouldn't use them without trying behavior modification first.

As someone who is diabetic and who has lost a lot of weight on semaglutide I can assure you that several genuine and difficult attempts to modify behavior were attempted before getting on the drug.

I guarantee you that I'm not the only one - I'd expect the vast majority (75%+) of people using semaglutide to have attempted behavior modification before starting the drug.

Nah… there is also the type of medicine where you take the pills and the disease is gone, and then you won’t need those pills no more.

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