Older Americans Are About to Lose a Lot of Weight | Hacker News Reader

Older Americans Are About to Lose a Lot of Weight

theatlantic.com

17 pointspaulpauper126 comments

I'm still wondering why so many people are so much heavier now than they were fifty years ago and why instead of attempting to medicate our way out of the problem we don't try to attack the actual cause.

We're going to need to medicate our way of the problem while waiting for a public healthy policy that actually works.

It's not like we didn't try, but what we tried didn't work and never really iterated toward something that works.

The reason nothing has worked is because food companies, who pay out massively to regulators, rewire our basic desires to make us buy more of their sugary slop. And now, we have medical companies, who also pay out heavily, trying to cash in even more. I highly suggest reading “ Salt Sugar Fat: How the Food Giants Hooked Us“ by Michael Moss, and “The End of Overeating: Taking Control of the Insatiable American Appetite” by David A. Kessler, former head of the FDA.

Replace obesity with smoking as a simple exercise to understand how absurd these takes sound.

"It's not that I don't want to stop smoking, but the cigarette companies put chemicals in that keep me addicted"

"I live in an environment that pushes me to smoke"

"I wish the policymakers would stop me from smoking"

"I smoke because my genes tell me so"

Life is more complicated than a simple of binary of having responsibility and not having responsibility for a certain affliction such as smoking addiction. Often it's a varying mixture of both.

We should be working to pragmatically solve problems, not playing unhelpful blame game. Doctors don't go around trying to make sure that their patients are first virtuous in their self care. They get on with the business of medicine and do their best.

We now have a powerful drug that help with obesity. Let's make use of that when nothing else accomplish the job as we work on other alternatives such as better regulations, psychological health, etc.

This is actually how we tackle smoking in a large part. There's a lot of regulation on smoking!

> "It's not that I don't want to stop smoking, but the cigarette companies put chemicals in that keep me addicted"

> "I live in an environment that pushes me to smoke"

But those two things are true. The nicotine is addictive and being surrounded by other smokers, smoking materials, smoking in films and on television, all compounded to make smoking more attractive. Plenty of smokers offered me cigarettes when i was in my teens.

This is a very simplified view of the world. You realize humans aren't rational automatons right? Everything you mockingly posted is a real factor in real humans lives regardless of how "dumb" you think it is. When designing policies for society/everyone you have to meet people where they are. Your strategy of claiming everything is personal responsibility has provably not worked so maybe propose a different idea instead of just mocking the things that actually have worked

I’m sorry, what is even your point? Are you trying to claim that obesity is not a problem caused by megacorps by pointing to a health problem that was and is caused by megacorps? Are you trying to say that cigarettes don’t actively contain an addiction chemical, namely nicotine? I actually have had people claim this, as they were tricked by cigarette companies, so it wouldn’t shock me if you thought something so stupid.

It works for me. The secret is simple: Eat food, real food. the trick is to know what real food is (6 main food groups: Beans, whole grains, veg, fruits, nuts/seeds, tubers)

Ignoring the fact that half of those are the same things, science has proven beyond any doubt that a high variety diet of animal and plant-based foods, at a caloric deficit, is best for the body. Choosing one or the other is slowly killing yourself by removing important vitamins and nutrients from your diet.

> secret is simple: Eat food, real food

This is modern voodoo.

I’ve eaten terrifically and exercised regularly. I’ve also been a slob and ordered Uber Eats from bed for a week. I don’t gain much weight either way. When I have, I can lose it within a week. (My figure changes. But not enough that clothes don’t fit.)

This isn’t because I follow some magic (ex post facto obvious in some way) diet. It’s my biology. Other people have different biologies that will save calories irrespective of the source and use; their basal metabolism adjusts to ensure they’re burning less than they eat, all the way to starvation.

In a calorie-deficit environment, or one stricken by plague that disease out digestion while the immune system goes full blast, I die first. In a calorie-rich and vaccinated world, they do. (Even then, mortality is higher amid low BMIs than moderate ones, largely due to disease outcomes.)

Indeed. Around the time that Supersize Me came out I was looking to lose some weight. To prove a point to my friends I did this by going on a fast food diet. Unlike Spurlock, I actually tracked my calorie intake and this affected what I ordered. However, every meal came from one of McDs, BK, or Wendy's as there was one of each in my neighborhood.

I did indeed lose the belly fat I wanted to shed.

I'm sure it wasn't the healthiest thing I ever did, but from the perspective of fat loss it worked AOK

> t’s my biology. Other people have different biologies that will save calories irrespective of the source and use

There is zero scientific evidence about this.

I have eaten real food for weeks and yet fast food come back with a vengeance.

There’s been no shortage of proposed solutions and education.

Weight loss is apparently a 90 billion dollar industry.

It’s just that the long term weight loss outcomes are still abysmal.

New approaches are gladly welcomed.

Because we’re genetically engineered to crave stuff that is awful for our bodies in high amounts. Finding sugar in the wild meant foraging for berries for hours or fighting bees for honey. Now you can buy it at the supermarket cheaper than a head of lettuce.

So.. the problem and solution is capitalism? :)

Eating healthy, in the appropriate amounts, and exercising daily is the solution - obviously. Moving the mountains necessary to change America's average diet and lifestyle is much harder than giving out a drug. I agree that the drug isn't the "right" solution. But I'll take a half measure over what we've been getting.

> why instead of attempting to medicate our way out of the problem we don't try to attack the actual cause

Have you noticed that every time this discussion comes up in this forum, simple personal intervention is glossed over as a solution? Causes for obesity, for HN users, are:

- The Environment - The Lack of Walkable Cities - The Policymakers™ - Too Many Cars - The Government Lobbied By Food Corps et cetera.

While none of the above has directly put calories into a person's mouth, and the only responsibility is on the mouth owner, we sometimes forget that the simple solution to the obesity crisis is: caloric restriction. This solution however has a major drawback: it requires being slightly uncomfortable for a tiny amount of time, which is unacceptable to most. So, enter the Magic Pill: No effort is required whatsoever, and we can keep on blaming external factors for what enters our mouth.

Oh were it that easy. While, absolutely, you could not gain weight with a calorie deficit, a targeted calorie deficit alone is not a direct path to loosing weight. If what you eat goes straight to fat (sugar, highly processed foods etc), you’ll still be lacking immediately available sugars to fuel your day. Cue your body slowing down the metabolism while resisting using the fat reserves. What you say is true (and, per personal experience, even the discomfort might not be there) only if the food eaten is of high quality and varied.

Please don’t speak pseudoscience.

Your body doesn’t violate the laws of thermodynamics. Your argumentation is saying if you stop eating you wont lose weight - which is blatantly false.

No one dies of starvation being fat. It’s that simple. You wanna lose weight? Stop eating and drink water. You’ll lose the weight regardless of what nonsense you believe.

Our food is no longer made by people. It is made by companies who make money taking the cheapest ingredients, reconstituting and selling it as 'food'.

I recommend reading this book https://www.amazon.com/Ultra-Processed-People-Science-Behind... (or the audiobook) to learn what makes our 'food' so much worse than 50 years ago.

If you want something more moving, this is good documentary by the same the doctor: https://www.youtube.com/watch?v=5QOTBreQaIk

I am going to guess that its a combination of the prevalence of ultra-processed foods coupled with a steep decline in physical activity.

Because we don't know why. We have many suspects, but no concrete evidence for any of those, and in many cases, not even clear mitigations. (Let's pretend for a moment it's e.g. all about PFAS, what do you actually do about them? And what do you do once there's the inevitable political outcry that it's just spoilsports from the other side trying to ruin your life?)

And so we medicate, because that's the only thing where people can say "my neighbor did it, and look, it worked for them, I'll do it too".

We know exactly why; the average American dietary caloric intake has increased to three thousand and something, which is more than the average person burns, especially if the person is as sedentary as the average American. More calories eaten + less exercise = more weight gained.

This is the technically correct answer and we should try to address it from both ends - eating fewer calories AND being more active. There are a number of issues with "just eat less" because there are reasons people eat more than they should. Part of that is what they eat (what you eat matters for multiple reasons) and also habits or other psychological reasons.

Yes, Most people don't know why. But nutritional researchers like Micheal Gregor (he and his team have read over 20,000 research papers! just for one book - how not to die) know why. The problem is all the people who get the most views on youtube, TV and social media are the people who are best at operating businesses and SEO. they often don't know all the research (and even give bad advice sometimes) and hence we get all this back and forth that we see all over the place. Meanwhile, the real researchers who know what they're talking about and are very knowledgable about nutrition and health don't have time for SEO and running a successful media empire. they're content doesn't get viewed very much.

> Because we don't know why.

Really?

It’s Calories In - Calories Out.

This approach isn't working, has demonstrably failed. Do you actually care about fixing any problems or just happy to shame people you see as less than you?

Simplistically, yes, obviously true.

But how does this theory explain why people lose weight on semaglutide?

Loss of appetite

Not really.

Diesel fuel technically has several times as much calories as Cola-Cola. But try drinking diesel fuel for lunch and see what comes about.

This is because the human body doesn't literally burn food like in a calorimeter. Digestion is a very complex chemical reaction with lots of nuance and different nutrient pathways.

...Are you habitually chugging diesel fuel for lunch?

But to address your point: It seems like a disingenious and pedantic argument.

Can you come up with edge cases where my one-liner (Calories In - Calories Out) is not 100% accurate? Yes. Is that the case for the absolutely overwhelming majority of people? No. Over 70% of people in the US are overweight or obese. That's more than 2 in 3. Are we all suffering from some exotic, unknown, mysterious disturbance of the gut microbiome? Or is it more likely that we just move too little while eating too much? I think I know the answer.

what i find fascinating is, you'll see soooo many advertisements about various medications for so many illnesses, all of which are under the umbrella of metabolic syndrome. and then in the background, you'll see people consuming ice cream and pizza, etc. these ads aren't randomly constructed. every short scene is designed to communicate a certain message.

You'd be surprise how much dietary choices and options impact this in America.

Go to Europe and eat home cooked meals there. Your health will improve

As someone who moved to Europe and also lost quite a bit of weight, the bigger factor was eating out is hella more expensive here. Junk food is also more expensive though still relatively cheap, at least in the Netherlands.

But yea, the EU does a lot better job policing what goes into food and it shows. Fruits and vegetables and meat that I buy here spoil within 2-4 days (and 4 is pushing it)! I had to adjust my purchasing habits because it would go bad before I could eat it all.

The public transportation and push to cycle and walk definitely helps, but at least where I live in the south, most families still own at least one car. The difference is that they only use it to drive to work and for trips. Any errands are done on foot or on a bicycle.

Go to Europe where there's public transportation.

Corn subsidies, and what ag subsidies incentivize in general. There is no lobby for a healthy diet, or providing subsidies for it.

People may be heavier than 50y ago, but people are also taller than they were half a century ago.

"...the average height of a man aged 20-74 years increased from just over 5-8 in 1960 to 5-9 ½ in 2002" [1].

Despite the higher weight, life expectancy has increased too [2]. I'm not trying to handwave obesity rates, but pointing out that it's a mixed narrative.

[1] https://www.cdc.gov/nchs/pressroom/04news/americans.htm

[2] https://www.census.gov/content/dam/Census/library/publicatio...

My parents had 4 boys, two of them in the early 70s and two in the early 80s.

Our heights are, in order, from oldest to youngest:

* 5' 7", same as our father

* 5' 9"

* 5' 11"

* 6'

Now obviously the sample size is quite small, but we've always wondered if nutrition had something to do with it.

Nutrition is correlated with childhood growth. Was there a reason why how much they were fed would have changed with each individual, but not across the entire cohort?

There are many causes, one of which that hasn't been mentioned already is the decline in smoking.

I'm not saying we start smoking to lose weight, but it does suppress appetite. Now we have FDA approved medications that can do that.

My step-grandson has taken up boxing at the age of 15. He has lost five percent of his body mass simply by ceasing to drink soft drinks ("pop", in some parts of the USA).

Drink water or black tea or coffee.

You are not alone in this.

https://slimemoldtimemold.com/2021/07/07/a-chemical-hunger-p...

This series of blog posts goes through various theories (and myths) regarding obesity.

A rebuttal to that piece:

https://www.lesswrong.com/posts/7iAABhWpcGeP5e6SB/it-s-proba...

Their thesis doesn't hinge entirely on lithium, but their sloppy work and responses to the rebuttal mean people should take their work with a huge grain of salt.

I believe Yudkowsky has put forth a theory that somewhere in our environment there is a "GLP Supercharger" that's causing the opposite effect of the GLP-1 agonists.

If a lizard bite can make you thinner, maybe there's a metaphorical lizard bite that's making us fatter.

Some people get fat just looking at food, and this may get worse with age. Slow metabolisms, bad genes can play a role. This does not necessarily explain rising rates of obesity over time, but it can explain how some people become obese so easily despite not eating that much or why obesity is so hard to treat or the high failure rates of dieting.

>we don't try to attack the actual cause

It's cars and large houses peripherally connected to amenities by car-only infrastructure.

People love this lifestyle and will fight you very energetically if you try to do anything to nudge city layouts towards the previous level of walkability.

> fight you very energetically

Until they run out of breath, anyway.

While the biking/walkable city is a nice concept, it ignores how it is incompatible with certain lifestyles and hobbies.

Anyone into machining, high powered rocketry, or shooting or hunting.

YMMV but I doubt you could have a magazine and pass inspection from the BATFE or your state inspection for fireworks or explosives. And dense living near a gun range is impossible unless you got money to build a long range that can catch any stray rounds, when done in a rural area this is done using natural land and hills or building dirt mounds, which a walkable city would not have.

You’re saying this as an either or. Why does everyone need to live a rural area with access to a gun range? Vice versa just because we build more walkable infrastructure doesn’t mean literally everyone everywhere is suddenly walking 15 minutes to work.

Most people doesn't live in such rural area anyway. Machining can be done at a makerspace or you could rent space for your workshop.

Fifty years ago there were like 3-5 TV channels in rural America, no smartphones, and a good bit less automation in rural work. That may have made it more physically involved, and there was a higher proportion of people living rurally vs cities than now too.

People aren’t eating the right foods and not exercising enough. The cause is very simple, the solution is not. It’s hard to get millions of people to make lifestyle changes and that’s even assuming they have access to healthier food in the first place.

So are you wondering? Or you do know the "actual cause"?

The proximate cause is obvious: more calories consumed than are necessary to maintain weight.

I do understand that the causes of over eating are not necessarily so simple.

What I wonder about is that essentially no government has an explicit policy to combat this despite its obvious negative consequences.

More calories means more money being spent. More obesity means more money is spent on all kinds of ways to get rid of the calories.

It’s good for the economy. That’s the answer.

Our diets have gotten worse and we've become even more sedentary.

Why don't we attack that? Because 30+ years of evening news clips showing obese people walking or sitting and handwringing about the obesity crisis have done nothing, and that seems to be the extent of our ability to act.

Activity levels have collapsed.

You can save yourself years of extra health-span standing in any way more than sitting.

Turns out knowledge work is just as dangerous as physical work, you just die in a different way and the coffin is larger.

This is true and contributes to poor health, but I don't think it is the primary factor for weight. It is very hard to excersize yourself out of a high calorie diet.

It's really pretty shocking how much added sugar there is in anything with more than 1 ingredient, and getting more sweetness in is basically a race with every other element of someone's diet. The 1980s had it junk food, but there was still other food.

> It is very hard to excersize yourself out of a high calorie diet.

Is it? Glancing around, it seems to me that the stark difference is between places where nobody walks or bikes anywhere — Tulsa, Little Rock, etc — and places where everyone walks and bikes — NY, DC, SF.

Exercise powerfully contributes to your overall health but it isn't the primary mean by which calories are kept in equilbrium. Worse, your body compensate by reducing basal metabolic rate and other mechanism. So it's an uphill struggle.

Changing your diet will have much greater bang for your bucks and much 'easier' to do.

I'm no expert but don't you have that backwards? Dieting will lower your basal metabolic rate, whereas exercise will increase it. So you burn energy exercising, and you burn more energy when resting, and if you gain muscle that also raises your BML. From my own experience it's just way easier to exercise my way into the shape I want than it is to think about my diet. I get a little fatter in the winter and I lean out again in the spring as I get back on my bike. Just easier to modulate that side of the equation, for me.

I can't see the logic in declaring one side of an equilibrium equation to be secondary. Both sides are obviously of the same importance.

Execise is health hygiene, its not a diet plan. This is obvious when you look at how hard it is to not eat a snickers bar vs how hard it is to burn off a snickers bar worth of calories via exercise. What you are talking about above is maybe a twenty pound seasonal discrepancy, it's not what most fat people are dealing with (also a quarter of that twenty pounds is just excess water you probably shed in the first week of adding back increased activity in the summer)

I don't see the explanatory powers of the irresistible Snickers, since they are universally available and the same price everywhere.

Its easy to not eat a snickers. To burn a snickers off through exercisw you are looking at a half hour to an hours commitment in the gym depending on what you are doing. You can override what most people call a weekly exercise plan with a couple snickers and a few fancy coffee drinks

Ah I see. I had the sense of what you meant backwards.

Yah, sorry, I was also short for time to the point of extreme brevity but not to the point of delaying responses until I had more time for this whole thread. I should have also given the example of t he ideal male BMI being 18-25 so call it 22 and over 30 BMI being obese which, on a 5'10" person (pretty average for a male) corresponds to roughly 154 lbs vs roughly 205 lbs for a 50 lb spread. It's not the 10-20 lb spread that is probably seasonally normal. Trying to reverse that with just exercise is a gargantuan task, it's primarily diet that will reverse something like that (but you definitely should still exercise, it does all sorts of good things for your body on a reasonable schedule with reasonable recovery periods, especially resistance training, which is more true the older you are)

That one large Baskin Robbins Chocolate Oreo Shake has 2600 kcal and to burn that amount of calories, you'll probably need to go for a 3-hour run. And I imagine not a lot of adults have the time to go run for hours to keep up with their high-calorie diets.

I've heard that keeping a calorie intake diary is an effective way to lose weight. I also had pretty good results with it personally by setting a calorie target in an app and sticking to it.

Are there more Baskin Robbins in McAllen than in San Jose?

I see people in SF walking around with some Starbucks abomination or another, every day.

A donut is about a half hour of jogging. If a Little Rock breakfast is like the rest of that neighborhood most of the sedentary thin thin state people I know wouldn't be able to keep it down.

Talking about "activity" is like identifying an organism as "a plant". There is huge diversity.

Walk uphill 400 metres altitude gain every day, and you will lose weight, yes. Run uphill 400m every day and you will lose even more. Carry a backpack, and ... you will put on muscle.

Walking or running on the flat, not so much.

But life expectancy is higher now with knowledge work and lower activity levels.

There's been an approx 80% decline in US infant mortality from 1963 to 2023 according to [0]. I know when comparing against pre-industrial society this is a big driver of increased life expectancy. There's another metric that adjusts for this that only looks at the life expectancy of individuals who survive to the age of (iirc) 15, but I don't have time to look it up right now. Perhaps comparing the change in that versus the one that includes the drop in infant mortality would be interesting though.

[0]: https://www.macrotrends.net/global-metrics/countries/USA/uni...

This exists in a system. We have obesity (caused by several factors, diet and activity levels of course and then the factors into those) along with improved medical care. It's like inflating a balloon with a slow leak. The medical care is propping up our life expectancy numbers while our individual behavior is bringing it down. It'll level out or decline at some point as our obese population continues to become a larger percentage and medical improvements stop happening so regularly.

Because we can all afford to go to the doctor regularly. If treated early, you can live with type 2 diabetes and other obesity related diseases for decades.

Infant mortality, smoking levels, alcohol consumption, social acceptance of driving while intoxicated, car collision safety, etc have all changed significantly in that same time frame.

Apparently it's not exercise! [0]

Yes exercise is very healthy, that has been proven, but loosing weight is mostly a matter of eating less, at least according to this (reputable) meta source. Apparently, over eating but not getting fat (which holds true for me), leads to other problems (also true for me, I have an autoimmune disorder).

Eat less to lose weight. Exercise more to be healthy.

(nice, got my first downvotes in less time it takes to watch 1/10th of my source ;))

[0] https://www.youtube.com/watch?v=vSSkDos2hzo

They said activity levels. Activity is more than exercise.

OP was wondering about why we are so much heavier. It seems to be the food. Not much to do with activity levels.

I don't know if OP was strictly on topic or was generalizing to health in general. It’s not like there’s a point to neatly delineate obesity from overall health on this topic since the overall topic is health.

There are a lot of pathological things we do regularly, not just overeat/eat the wrong things. They all contribute. Last I saw less exercise is more caused by obesity than the other way around. And sitting a lot can cause biomechanical maladoptions which makes movement (and in turn exercise) more inconvenient.

Well if you'd watch the movie and read the sources, you'd see that there is not much difference in the amount of calories you burn exercising or sitting at a desk. Consequently you won't loose weight one way or another.

Weight seems to be almost exclusively about the calories you ingest. It has little to do with obesity causing less exercise or the other way around. There is not a swathe of pathological things we do that contribute. We eat too much.

I also found that surprising. You can exercise without changing your diet, but you won't loose (much) weight. You can sit at a desk and start eating less and loose a lot of weight.

> You can exercise without changing your diet, but you won't loose (much) weight.

Exercising without changing your diet is seriously nontrivial for most people, due to compensatory eating - if you burn an extra 400 kCal, you will likely experience commensurate increase in appetite & eat an extra 400 kCal. It takes a lot of vigilance & discipline to avoid that.

IMO that's the 'real' reason diet is a more effective lever for weight loss than exercise. In theory, burning those extra 400 kCal thru exercise is just as effective for creating a caloric deficit as reducing daily consumption by 400 kCal, but in practice it still requires you to eat less than what feels normal/adequate.

So if you’d watch the movie you’d learn that you won’t burn much more calories when you start exercising, perhaps at first but the body rebalances until it’s back on budget. Your body keeps that, they say for some evolutionary reason, very constant.

It sounds paradoxical but I know people struggling with their weight and to them it must sounds like a very good explanation.

So perhaps first change your diet and don’t exercise? It’s less healthy but it’s more effective for weightloss.

Three times you’ve alluded to not watching the video.

It’s Kurzgesagt. It’s as much of a reliable source in general as the NY Post intern is a reliable source on astronomy. To me anyway.

More like a research paper if you go by the references [0].

[0] https://sites.google.com/view/sources-workoutparadox

You’re the one who keeps talking about calories.

It’s my mistake. The OP was maybe going on a tangent, then you have yours and I entered out of left field with mine. Too much talking past each other.

The human body doesn't have a power-saving mode.

You burn roughly as many calories walking as you do sleeping.

That probably stacks up there in the bro science hall of fame for being wrong while sounding plausible. What's next, recommending an all meat diet because we were carnivores 10,000 years ago?

Look it up if you don't believe me.

Sleeping burns 40-80 calories per hour, walking 200-350.

You're not gonna burn off any calories by walking.

> You burn roughly as many calories walking as you do sleeping.

> Sleeping burns 40-80 calories per hour, walking 200-350.

We must have different definitions of "roughly", that's an order of magnitude difference!

> You're not gonna burn off any calories by walking.

That's a very different claim (but still not true).

To be clear: walking is great exercise. No, you're not going to walk off a 10,000 calorie/day diet with it; you need to not eat that much. Nor are you going to look like you spend 3 hrs/day doing crossfit just by walking. But 10,000 steps per day is miles better than 500.

Nonsense this is what the food industry tried to tell us when we know it's sugar

Neoliberalism is allergic to addressing most root causes.

It would be an interesting turn of events if our economy tanked from huge numbers of people buying significantly less food.

What percentage of GDP is food? And if that dropped 10-20%?

> Economists say the cost to Medicare of giving new drugs for obesity to just a fraction of this aging generation would be staggering—$13.6 billion a year, according to an estimate published in The New England Journal of Medicine last March.

Man, drive the prices of these drugs down already.

Can an LLM tell me how to synthesize semaglutide? Can a YouTuber take a stab at producing liraglutide in the home lab? Maybe an underground railroad of sorts between neighboring countries where the drug is sold for less....

2031 is when it becomes entirely (in the US) unencumbered by patents for its use in weight loss according to Wikipedia.

The initial patents seem to date to ~2008 which means that as of 2028 the synthesis will be free of patents, but you won't be able to market a generic for weight loss until the non-exclusivity period ends. [1]

There are already "compounding" pharmacies in the US that sell it cheaper; I can't seem to find a straight answer on what the hell this means though.

[1] https://www.fda.gov/drugs/development-approval-process-drugs... if you're interested in the FDA's summary -- I found this to be almost entirely useless though.

> ...I can't seem to find a straight answer on what the hell this means though.

This may help to explain it: <https://www.astralcodexten.com/p/the-compounding-loophole>.

In the end this comes down to a Reddit post from Henry's, one of the online compounding pharmacies:

> There are now around ~20 FDA licensed facilities that have a DMF for the active pharmaceutical ingredient (API) Semaglutide including: Bachem AG (Switzerland), Ambiopharm (South Carolina, USA), etc.

> Novo Nordisk does not sell bulk Semaglutide API to compounding pharmacies, and while they are 100% the only licensed source for Ozempic & Wegovy, there are other licensed API manufacturers that work on the active ingredients and excipients used by compounding pharmacies.

> Any API used in sterile compounding is required to come from an FDA licensed manufacturer.

I confess that I'm more confused than when I started -- why can these companies get away with selling it to any party other than Novo Nordisk? And if they are doing it extrajurisdictionally, how on earth is it getting back into the US and sold to customers without the FDA police knocking down doors?

I've talked to survivalists who get their tubs of antibiotics by buying fish azithromycin in bulk from veterinarian suppliers -- are we going to be buying horse Ozempic next?

> I confess that I'm more confused than when I started -- why can these companies get away with selling it to any party other than Novo Nordisk

I don’t think (many? Most? All?) of the drugs in this class are patent-encumbered. They’ve been around for a while.

… application as a weight loss drug is patented. That’s new. You can’t package and sell them to fill a weight loss prescription if you’re not allowed to by the patent holder.

So it stands to reason that the factories that make the chemical can sell it to whoever they want, as long as the buyer is permitted to receive drugs and such in the first place. The drugs themselves, the actual chemical, isn’t what’s covered by the patent.

The compounding’s legality is covered by the Codex post: compounding pharmacies are allowed to package and sell drugs that are on the FDA’s shortage list, regardless of patents that would ordinarily prevent selling them. These drugs (various glp-1 agonists) are on the shortage list. So, that part’s fine too.

The initial patent for semaglutide specifically was issued in 2008 and is under protection for 20 years -- while liraglutide has been around for much longer, semaglutide is relatively new in patent terms.

So presumably the licensed DMF facilities are operating under a license from Novo Nordisk, because otherwise they'd be shut down. But why do the terms of the license allow them to sell to anyone else?

You are correct that the use specifically for weight loss is newer and the FDA's labyrinthine procedures give Novo Nordisk exclusivity for a significant amount of time after that.

> In the end this comes down to a Reddit post from Henry's, one of the online compounding pharmacies

I disagree. Alexander mentions several other compounding pharmacies that will sell you the same medication if you present a subscription, so it's not just one place that's selling this stuff:

> HenryMeds is $297/month, Eden is $296, Mochi is $254...

You probably do not know this, but the fellow has been a psychiatrist for a decade or more. He's also aware of the business and regulatory side of the medical profession, so I expect the assertion that "But the law says that compounding pharmacies are allowed to step in and compete with Big Pharma during a shortage." is true and accurate.

The Reddit post claims a source for the chemicals, but the explanation about what compounding pharmacies are doing during times of medication supply shortage and how they can legally do it come from industry knowledge.

> But why do the terms of the license allow them to sell to anyone else?

Likely because the FDA permits compounding pharmacies to sell Big Pharma drugs when there's a shortage of them. If compounding pharmacies can get reliable access to the same chemicals that Big Pharma is selling, then the bottleneck is somewhere in Big Pharma's side of the machine (rather than the chemical "feedstock" production side), and the FDA has a strong interest in permitting entities that can take up the slack to do so.

I can't imagine the FDA has any interest at all in undermining its ability to solve drug shortages by enlisting secondary drug manufacturers, so I expect any "feedstock" production agreements must not restrict the ability for the "feedstock" producer to sell to secondary drug manufacturers when the FDA deems it necessary to permit them to sell products from that "feedstock".

1) Drugs in medicare need to be cheaper, absolutely, but that's regulatory/legal issue, not something that can be solved by tech.

2) $13.6 billion sounds like a lot. But what is it costing the entire economy by not "curing" obesity with these drugs? How much is spent on health care, how much lost utility and lost quality of life is there for older Americans who are obese?

Article is from February. Paywall-free archive: https://archive.is/n9Ots

Last year I decided to give a try to semaglutides, at the time I was exercising pretty heavy, both weight lifting and long distance running.

And then I went to vacation to Maldives for a couple of weeks. Not much chance to exercise when you are locked on a tiny island.

I surely lost some fat during these 2 weeks, but the amount of muscles I lost? Jeeez! I think it offset my training goals by 2 months.

I realized how unhealthy it was, you are literally starving and not feeling it, and I kept myself on a low dose!

When you consume food it's not just calories, it's also nutrients, if you eat a lot less you are body is missing out on all the essentials!

So it might be a magic pill in some sense, but in other it's extremely unhealthy.

Later that year I have actually lost more weight by doing more long-distance running, that motherfucker burns calories big time and in a healthier way.

Can you talk more about the muscle loss? I've read that, but is it any different from the loss of strength when dieting "naturally"? Like, I've lost significant amounts of weight before and my bench press/etc. all went down just due to loss of body mass. Are you saying it's somehow worse than that in terms of muscle loss?

It's good to have a tool like GLP-1 in the quiver. But we really need to start focusing on childhood weight stats/obesity. School lunches are often disgusting, if offered at all. "Lunch food" served at grocery stores is often more like candy. Whole cohorts of kids enter and leave the public school system with poor diet and nutrition habits that will persist for life, with the high likelihood of corresponding lifelong health problems as well. I feel it is a social and moral imperative for everyone to take a hard look at the future many of these kids will have.

This is not even mentioning the growing sedentariness of many young people's lives. This stat explodes as people enter the workforce. Simply going for a 30min to 1hr walk once a day can give you more exercise than enormous swathes of the population.

> School lunches are often disgusting, if offered at all.

Are there any instances where school lunches are not offered at all? I believe it's a requirement for public schools across the US, but I'm not sure if that requirement would extend to private schools.

It is a requirement to offer lunch in public schools in the US. Very few states are free. Some kids qualify for "reduced" cost depending on the district and their parent's income. The variance in the quality can be huge depending on the district.

I was in school in the 2000s. My school's food was almost always more like fast food than actual meals. Fruits and vegetables were not a big component, or weren't available at all, and the food never seemed "fresh". A lot of kids were kind of embarrassed to be seen eating the food. I know some kids that often skipped meals to just eat candy or went to cheaper vending machine fare.

Had same experience, and was in a well funded upper middle class school district so have to imagine it's even worse in other places

Batsis said. But even when a weight-loss treatment benefits an older patient, what happens when it ends? People tend to regain fat, but they don’t recover bone and muscle,

This is false. People can regain muscle, such as after an injury or paralysis. Resistance training works at all ages.

Also one must take into the marginal utility of these drugs, which may not justify the cost if the result is only a little extra life expectancy.

Obesity does lower life expectancy by a lot, that is not 'the narrative'. The marginal utility of an anti-obesity drug goes beyond extending life expectancy into a huge number of areas that come together to increase quality of life, mobility, memory, and ability to live independently. With fewer young people to care for the rapidly aging population, making these people require less care overall is a necessity if we are going to ensure they live with dignity.

After the age of 50, there's a marked and steady yearly loss of muscle mass. This is a huge driver of morbidity in older folks. This has been studied extensively and isn't particularly controversial. [1]

I would expect the proportion of people > 50 that perform resistance based weight training to be small. Adding a drug that diminishes your muscle mass when you can least afford to lose it sounds like it could be terrible for that aging population.

1: https://generic.wordpress.soton.ac.uk/mrclec/research/muscul...

> I would expect the proportion of people > 50 that perform resistance based weight training to be small. Adding a drug that diminishes your muscle mass when you can least afford to lose it sounds like it could be terrible for that aging population.

Then prescribe weight training in addition to it. This isn't rocket science. Older folks should be doing exercise to offset the potential loss in muscle and bone mass anyway. It works. We've proven it works. We've proven it improves health outcomes and quality of life long-term going into old age. This isn't just something that should be waved away with "ah, well, we've proven people lose muscle mass, nothing we can do about it".

At 63, I have gained about 4 kilos of muscle mass and lost about two kilos of abdominal fat in three months by doing more rucking (backpacking, up hills).

Older people need a high protein diet, but muscle gain isn't impossible, nor is muscle loss inevitable.

Absolutely. That’s my plan as well. I never said this was inevitable, but it is a well established pattern. Even with weight training, it’s harder than it would be when you’re younger to pack on the pounds of muscle.

hell yeah man get after it

It’s much harder to regain muscle, though. Especially as you’re older. And if weight loss drugs are done without regard for diet (ie you just eat chips… but fewer chips), then muscle loss would be expected.

The problem for old people is that it's hard to get bone and muscle, as most of them simple will not exercise.

Also stomach acid drops a lot in old people which makes protein digestion even harder.

In the ideal world, assuming GLP1 is not toxic long-term and that they can keep the weight off, people would exercise to regain muscle.

But if those people got obese in the 1st place, do you really think many of them will suddenly uptake exercise for more than a New Years resolution week or two?

Yes.

People can also lose weight through discipline. Yet here we are.

It works on short timescales but discipline has almost zero correlation with long term (5+ years) weight loss.

Drugs, bariatric surgery, and even techniques / lifestyle change make a difference. Discipline alone gets eroded by various hormonal systems aiming to return lost weight.

Exactly, "here we are" meaning we're in a place where we can admit that the "discipline" approach has completely failed and we need another idea?

You've cut the quote out of context and as such missed what is being said. It might help to rephrase the quoted sentence: when an older patient stops weight-loss treatment, on average they regained the fat, but didn't recover the bone and muscle. The point isn't about what's possible, it's about real outcomes that happened. The older you get, the less your body responds to resistance training.

As someone who’s been 150kg and 75kg, fat, fit and everything in between I can guarantee you fat and muscle/bone do not build or atrophy at the same rate, both volumetrically and temporally

Bones and joints are especially slow to adapt (in both directions). Even losing ~0.25kg/w for a year is sufficient to cause my shoulders to frequently sublux if I attempt to raise my arm above shoulder height

And trivially, gaining weight without proper training or too quickly can result in insufficient time for your bones and joints to adapt, placing them under potentially dangerous stress

The time scale the article is talking about does not follow the same trends as recovery from sudden and complete mobility cessation (injury/paralysis)

Resistance training does work at all ages, but the degree to which it is effective varies greatly, and its recommendation is potentially dangerous if applied bluntly to all people

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