Ozempic and Wegovy are selected for Medicare's price negotiations | Hacker News Reader

Ozempic and Wegovy are selected for Medicare's price negotiations

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188 pointsgeox329 comments

My ACA insurance (because I was unemployed) covered Rybelsus (pill form, which is a much higher dose due to lack of absorption through the stomach), then in like October or November they said "nah" and said "go to Ozempic" I had just completed my first two sets of increases before the final uppage to be on the stable dose, when insurance said "Nah." So my doc RX'd Trulicity to see if they would cover that, which, for some reason they also didn't. I haven't had the time or energy during the holidays to deal with it, so now I'm dealing with increased hunger from going cold turkey off these things all because of bullshit micromanagement from shitty insurance companies on the market place.

If this makes it better and easier for companies to actually pay out for this I am 100% for it, there should not be a constant jerking about for what is or isn't paid. Also - this wasn't for weightloss (which I assume would have been Wegovy approved), this was for diabetes, and it was under control with Rybelsus, and I assume Ozempic, though we were still in the process of building up to it (I was on max dose of Rybelsus and I'm pretty sure I needed the max Ozempic as well). If they had given a reason for the denial it'd be one thing but it was just a blanket denial.

I just hope this makes it easier for folks who need it to be able to obtain it.

Just do keto diet. Assuming T2D. Its the easiest disease it fixes.

Some people cant have it all in life. You gotta sacrifice. The carbs in our case.

Source: I do it for other reasons.

When I last looked up the literature, Keto diet was one of the least effective interventions.

That is, if you follow it, I'm sure it works.

But the vast majority of people drop out of keto diets very quickly. So it's lousy advice and an unsuccessful intervention.

It's a bit like saying to a patient "you gotta sacrifice -- you should doing 3 hours a day of cardio". If they do follow through with it, it will work. But the vast majority of people won't be able to maintain doing that.

There are different keto diets.

The epilepsy version is indeed hard to maintain, but can be life changing (increase life quality in epilepsy, bipolar, schizophrenia etc)

The T2D version is way easier. If you studdy it or get a coach, you will know all the pitfalls. But its like therapy, you need to want it yourself. Cant be forced into it.

Do you have any study or literature to support your claim? Because you answer a factual comment with a random thing on my mind comment

Do any of these work https://www.virtahealth.com/research ?

I started keto in June of 24, lost 50lbs and added a compounded version of Ozempic in November to get through the holiday season with a little extra help. I'm on a fairly low dose, 50mg/week, and it's working tremendously. I've lost another 25lbs up to now and it's about 10x times easier to stick with keto, macro logging, and calorie tracking.

I feel like even with keeping my calories to about 1500/day I'm just fine, and the cravings for sweets and over indulging just aren't in my head.

> "When I last looked up the literature"

Responded to with

> anecdote

I'm happy you have found something that works for you but the diet tribalism on this site is getting old. At least it's good to see the initial Keto comment getting downvoted to oblivion.

I don't think there are any studies yet combining keto and glp inhibitors. At least I can't find them. So yeah, you get personal experiences.

> I'm on a fairly low dose, 50mg/week,

50mg is a huge dose of Ozempic. 2.4mg/week is common.

Apparently I didn't math the math, I'm taking 1.25mg/week. I was measuring in units (.01ml) and the concentration is 2.5mg/ml.

100% agree.

Insurance companies shouldn't get to pick and choose what drugs are in or out.

I was at a company, and Wegovy was covered.

Then randomly I got an email from HR, "Your medication is no longer covered."

The fuck is my insurance company doing telling my HR what medication I'm on? Even if they didn't say it outright, it wouldn't be hard to figure out giving the drugs that came off the list that were paid for that quarter. =P

Going cold turkey on these drugs is hard... like the doctors tell you that once you start taking them, you really aren't supposed to stop taking them. Or if you do, you have to do so gradually.

The drugs mimic the feeling of being satisfied from being full, by overloading your system with a synthetic version of that hormone that makes you feel that way.

Now... imagine going from "my parents used food to control my behavior growing up, and 40 years of bad behavior cemented that conditioning in place, so now it takes a lot of food to make me feel full / content," to "Oh this is nice, thank you drugs! Now I don't have to eat so much!" to "You're on your own, kid! And by the way, now that your body was used to the drugs, virtually no amount of food will make you feel full / content now. Let's see what happens!"

Fucking insurance companies. People are nothing but pre-existing conditions and behavioral patterns. It shouldn't be up to the insurance companies which ones they elect to cover. "Oh, did you think smoking was cool as a kid? Too bad, hope you die from lung cancer!" It just shouldn't be on them to choose.

> Then randomly I got an email from HR, "Your medication is no longer covered."

> The fuck is my insurance company doing telling my HR what medication I'm on?

Isn't this a straightforward HIPAA violation?

No. HIPAA is rarely straightforward, and in any event it’s not uncommon for employers to have some degree of access to claims data. In a case like this I assume the company self-funds the plan.

That's wild; HIPAA mainly exists to protect medical data from employers (among other threat actors) in the first place

I'm 99% sure HIPAA just applies to medical personnel (i.e. nurses, doctors) so they can't outright share private information. Third parties (i.e. your mom or insurance companies) can share it all day without violating HIPAA.

It does not protect your medical data whatsoever.

Insurance companies are absolutely covered by HIPAA. If it’s true that the insurance company (and not some third party service or app) shared the information directly with HR this is definitely a violation.

https://www.hhs.gov/hipaa/for-professionals/covered-entities...

What’s the I stand for in HIPAA?

I know it's a worn-out stereotype to point out, but from an European, I just hope you realize how jarring it sounds that there is a medication that a doctor determined you need, and TWO companies - entities driven by and existing exclusively for profit - are involved in deciding and communicating with each other on whether you will get it or not.

I do think that this should still actively be regarded as scary and abnormal, even if it's the norm for so many people in the US.

IT IS a worn out stereotype. I'm also European and here the doctors are also limited by the national health insurance company on what medication and treatments they can prescribe you due to cost reduction pressure. Their hands are also tied except not by a private corporation but by the government.

Often you'll encounter the infamous "these tests or procedures aren't covered by the national insurance anymore so you'll have to pay out of pocket", or they're covered, but the nearest appointment on the national insurance is 15 months away, at which point you'll either get better or you'll be dead.

My boss recently moved from Germany to the US and was pleasantly surprised how much better the diagnostic, treatment and medication options are for his child who suffers from some rare mental disorder that's basically ignored in Germany by comparison. US seems to always be on the cutting edge of medical research and treatment which of course comes at a cost since research is very expressive.

Your boss is presumably a high-value employee at a prosperous company. They will have good health insurance, but that’s not the norm for most people.

When I worked for Facebook in the US, it was conspicuous how doctors would run extra tests on me because the health insurance was paying for everything and anything. That’s not balanced either because less fortunate people pay for that in their insurance premiums.

Companies negotiate for all employees without tiers for „high value” employees.

What do you consider the norm? 90%+ of Americans have some form of health insurance. I don’t have a bad one, but it’s not as great as some public sector employees do. Am I in the norm? If so, that’s ok

While companies may negotiate for all employees, the percentage of the cost covered can be tiered, and some employees will pay less for better plans.

>Your boss is presumably a high-value employee at a prosperous company.

The company he worked at in Germany was even more prosperous yet had worse healthcare there. What's the deal?

Crazy right? Here in europe they just tell me that my medication isn't covered and I have to pay the whole price for it - if I don't like it, I can switch the government and move somewhere else.

It’s not like you can just switch insurance companies in the US. Most people have healthcare coverage through their employer.

You do realize that Euroean countris also decide what drugs and procedures they will cover on their national health plans too? Because you have a more limited set of options, your doctors will know what is covered and only recomend tose options, but it doesn't mean there aren't things that aren't covered.

At least the set of approved drugs is known. In the US you don’t know until you try to fill the orecription, then it becomes a 4-way game of telephone (patient, MD, pharmacist, and insurance) with each trying to outlast the other.

I concur, it is a pain. The US absolutely needs to improve! The point I was making is that the idea of free, unrestrained, unlimited healthcare in Europe is a myth.

My health insurance plan publishes a formulary.

As does mine, but many drugs require either a prior authorization that insurance companies can fight or an exemption which can also be fought. It's not a guarantee that you'll get coverage for a specific drug just because you have an insurance plan.

Does your country cover ozempic for obesity? In Canada we don't for non diabetics.

Americans get more drugs covered on average is my impression.

Americans get no drugs covered--at all--unless you're over 65, have insurance through your employer, or pay thousands for insurance yourself (and often thousands more to meet your out-of-pocket deductible each year).

I would take the default of "some" coverage over "no" coverage any day.

Over 65, outside drugs delivered in a clinic, hospital or doctors office you don’t get drug coverage UNLESS you pay for it through Part D Medicare, have a Medicare Advantage pan (the privatized version of Medicare that now 50% of the Medicare population has stupidly picked), or a retirement medical policy that acts like a Medicare supplemental policy that many government employees and some company’s offered their retirees.

That said it’s still a good deal and you can switch Part D policies year to year in case there are formulary issues. Plus with the IRA changes the max out of pocket is 2K which before you had no cap on—some new drugs are so crazy expensive that without this even the co-pay would wipe people out. That’s only recent fixed.

In our own case, my wife who 3 years ago our out of pocket for some daily cancer pills went from 15k in 2023, to 8K in 2024, to 2K this year as the IRA fully kicked in.

What the fuck do all these terms mean?

Welcome to "health care" in America!

Of course the overwhelming majority of American do have one of those forms of coverage. You might as well argue American don't have housing or food either since most people need aren't on welfare programs to pay for them.

Over 90 percent of people on ACA plans get subsidies too. Also emergency treatment is guaranteed.

It's certainly a mess of a system, but every time the government does something to "fit" it, the price goes up faster and it becomes a bigger mess.

To be clear you also need a health insurance plan for medication in Canada generally. The difference is that drug prices are regulated by the provinces, so they cost less. However, this also affects which drugs are available.

Some provinces such as Quebec have a public drug insurance plan as well which you pay into via income tax if you haven't got a private plan.

I don't take it but did look into it.

If anything getting it for diabetes got harder now.

Canadian employers sunlife insurance.

If you were prescribed it before the influx(not specific date) it was covered for diabetic purposes and still covered.

Now if you want to apply sunlife says NO, but you can get your doctor to send us these forms with additional info about the diabetes diagnosis and need and may be covered.

On the flip side theres a local diabetic that has been getting multiple high dosage units covered, but doesn't actually need them or take them

Flips them for $200 cad each to people looki g for weightloss.... (230-280cad in a pharmacy with prescription no insurance)

Only for diabetes. Wegovy is authorized for weight loss. There are other GLP agonists that are also authorized for diabetes. I'm not sure if there are other formulations for weight loss.

The US does allow for "off-label" prescriptions. The question then is : will your insurance pay for it. In my case, even though I am diabetic, they wouldn't cover Ozempic, or, apparently even Trulicity, which is just absurd (or Rybelsus which is the oral form of Semaglutide which they DID cover for a full year before putting me on Ozempic for like 2 months, and then denying (after the "new formularies" are approved and I get to be forced and switch to a med they still claimed to cover but not, apparently - I'm assuming they want me to appeal and give a whole run around on that.

But yeah... Technically it's for Diabetes only, but if you have good insurance, they'll probably hand out for any reason (see: "Hottest Celebrity Weight Loss Drug" for example; maybe that's changed now that Wegovy is released/authorized for weight loss)

You think that is jarring? How about a drug company giving kickbacks to doctors to tell patients they need a drug?

Ozempic in Europe seems to be cheap, under $100 in many cases. In the US it costs 10x or more that. So as much as I hate to defend insurance companies, it's not just them.

It is just them. The way insurance works in the US is that insurers negotiate with pharmaceutical companies to get steep rebates so that they are paying far less for the drug than its list price, typically much closer to what you might pay in other countries. If they can't come to an agreement, they won't cover the drug. Sounds reasonable. But in practice, what happens is that if a pharmaceutical company simply cuts the list price to what the rebate would be anyway, the insurance company ends up dropping them from coverage. This seems counter-intuitive, but it happens for two reasons.

First, the middle-men who negotiate and develop the formularies for insurance companies, called pharmacy benefit managers, get a cut of the reduced cost. So they make more money from a drug being $1000 and rebated to $100 than they would from the drug just being $100 all along. The pharma company makes the same amount per unit, $100, but they are much more likely to get onto an insurance plan if they go through the sham of marking it up to $1000 and then cutting it down.

Secondly, extremely inflated list prices that get rebated down simply mean that it becomes that much more critical for patients to pay for an insurance plan, because it is increasingly untenable to be without one.

These "negotiations" that PBMs do have been closely guarded "trade-secrets" but pharma companies have in recent congressional hearings have essentially said this is the situation. This seems to be supported by the fact that in their financial reports for products like insulin, the actual profit per unit has largely kept pace with inflation over the last few decades, despite the listed price of insulin skyrocketing during the same timeframe.

This is pretty much entirely the result of there not being a non-profit seeking government provided insurance option available to all in the US. If there is a reasonable alternative to private insurance that isn't engaging in the insurance cartel, no one is forced to use private insurance and the private insurers are actually forced to compete in a market. Completely socialized medicine isn't required, we simply need a Medicare-for-all option available to destroy the anti-competitive behavior that currently exists in the US insurance market.

We agree on the cause, but not the solution described in your last paragraph.

If it was truly a free market, the federal government wouldn't be involved at all and I could buy insurance from any company in any state. It's because of the government's involvement that I can't buy insurance of my choice and preferred pricing from any insurer in any state.

Four companies. The doctor's office which may be controlled by profit-optimizing administration, the big profit pharma corporation, the for-profit medical insurance company, and the company the insured works for who picks the available insurance plan(s).

Doctor's office won't make money from prescriptions for a drug, and the pharmaceutical company will sell their drug to whoever will buy it. Both those entities also exist in non-US medication transactions as well, so I'm not sure it's relevant. The point is that the insurer and the employer are two extra middlemen.

I get this sounds crazy.

But what’s more crazy is the prospect your doctor is motivated by profit.

Does that mean it’s less likely to be true?

I’ve had some interactions with doctors that would chill your soul.

“Here’s some long acting opiates. Take three a day for a month.”

I’ve had doctors offer me antibiotics for the flu.

I’ve been offered surgeries for conditions that don’t require them.

I’ve seen doctors offer a week in the psych hospital over mild distress.

I mean yes but there is no solution to that problem, but there are many tried and true solutions to the other problem, so this just reads as deflection

I’ve lived abroad and I’ve seen the solution: massive wait times for rationed care.

I never had the problem of doctors pushing treatments I didn’t need in UK, Canada, Italy, or any of the other places I’ve lived.

Seems to be an American thing, but maybe I’m missing something.

Don't forget getting an e-mail about it from HR??

There are these weight loss companies producing the stuff you should buy it from them cost about $350 a month.

https://ro.co/weight-loss/checker-path/

The insurance company is the face, the villain is your company. Most bigger companies are self insured. These drugs are expensive and blow up plan costs when everyone is on them.

A relative has a self-insured Cigna plan that randomly fucks with you. The company hired another company to argue with them on your behalf. End of the day, Cigna is administering the plan they established.

I partly agree with Kennedy. Ozempic will not make America healthy again. You will have to look into lifestyle choices.

This being said, if you want to go the medication route, there are not patents for medications in India. You could try to obtain it from India: https://dir.indiamart.com/impcat/semaglutide-tablet.html

I am not an MD and this is not medical advise.

QUESTION: If I live in the US in state XZ, what is the best, easiest way (zoom?) to get a valid prescription to order drugs from Mark Cuban? https://www.costplusdrugs.com

> Ozempic will not make America healthy again

Will it help a significant net number of Americans be healthier? If so, then it should be made available to those people.

> You will have to look into lifestyle choices

That's not being questioned, is it? Who doesn't understand that exercise and eating well is better than not exercising and eating garbage all day?

You were obviously not able to understand my argument.

Ozempic treats a problems (overweight) and might prevent problems further down the road (diabetes, high blood pressure, heart problems etc.) with trade offs like higher risk for specific cancers.

It does not treat the underlying cause ob obesity. One that might be highly processed food and Kennedy, whatever you think of him, stated this correctly.

Where in my post do you see that I said that Ozempic should not be made available? Please work on your reading abilities.

> It does not treat the underlying cause obesity.

Obesity is caused by compulsive excess calorie intake. That’s precisely what Ozempic treats.

Kennedy is a grifter who profits from quack medicine. Ozempic, because of its effectiveness, threatens the supplements industry which is rife with quack cures for obesity. This is the reason he’s against it.

"Obesity is caused by compulsive excess calorie intake."

OMG. Please don't try to lecture a STEM PhD in Science.

Obesity is caused by many things. Genetics, epigenetics, psychology, bad food (highly processed, addictive taste), social interactions, gut microbiome, hormone balance disruptions (plastics?) possibly even viral infections.

Kennedy may be many things. Maybe even an idiot. With the statement that "Ozempic will not make America healthy again" he is right. If you have a smoking epidemic, better lung cancer treatment is not the right answer. What again does not include that better lung cancer treatments should not be available.

> If you have a smoking epidemic, better lung cancer treatment is not the right answer.

You’re correct, but Ozempic isn’t a lung cancer treatment, it’s a supremely successful smoking cessation aid. I don’t understand how you’re struggling with this metaphor as a Science STEM PhD in Science.

Obesity is a physics problem: you can gain weight on the healthiest food imaginable, and you can lose weight on a diet of marshmallows. Ozempic attacks the lack of control over the calorie input, the only thing that ultimately matters in this equation.

Look, I gave this as a metaphor. Better anti-lung cancer drugs (not Ozempic) are not the right answer to the smoking problem. Neither is Ozempic the right answer to the epidemic. I don't oppose Ozempic, neither would I better anti-lung cancer drugs, and both should be covered by insurance. But both "solutions" would not address the underlying problem? Is this so hard to understand? A 5th grader should understand this.

> Ozempic attacks the lack of control over the calorie input, the only thing that ultimately matters in this equation.

But in fairness, there's a complex etiology behind the lack of control of the calorie input, and attacking causes a bit earlier in the chain could make even more sense, no?

I'm not saying Ozempic is bad-- it's quite a good thing. But to the extent that it lowers our desire to really figure out these causes and deal with them, that's unfortunate.

In this comparison, Ozempic is nicotine patch.

And yeah, it is not a cure, but in the absence of a cure, harm reduction is a worthy goal.

In contrast to "mullingitover", you are able to distinguish between harm reduction and cure. Again, I don't appose harm reduction and it should be covered by insurance. But people are selling the harm reduction as the cure.

I’m not sure what you have a PhD in, but if the degree says you’ve got one in “Science”, I’d try a different cereal box.

Ozempic is nothing like cancer treatment. It’s surprising you don’t understand this. Ozempic would be better compared to medicine that magically removes nicotine cravings, allowing people to quit smoking.

I am not explaining it again. If you don't understand an analogy or if you don't want to understand it, then it is not worth my time.

How convenient. A "Science PhD" who is unable to understand how Ozempic works is also too lazy to explain their point of view when their misinformed view is revealed to them.

Ozempic is only effective with lifestyle changes. The medication makes those changes easier. You should understand the effects of medication before you spout falsehoods.

I had some really bad side effects on those meds... was on for over three years when I realized that was causing my gastroparesis and other issues. I felt like I was starving 24/7 for 8 months coming off. I wouldn't ever go back. Throwing up fermented crap nearly daily isn't fun, let alone the pain and nausea.

Very glad to see this, it's worth noting that the compounded semiglutide pricing (think generic, although it's more complicated than that) has been plummeting ever since it was introduced onto the market. We've seen some pretty incredible results and I really hope they get cheap enough to be prescribed more widely.

It is worth noting that Compounded Semaglutide sold in the US is still more expensive than branded Semaglutide sold in other markets, where national price negotiations occur. For example, it can be under $100/month in several European nations.

The US just has no mechanism to control prices. There isn't really competition for specific drugs.

The research peptide sites are about the only reasonable places to buy this stuff

Nonsetrile compounding, like you'd do from the peptide sites is only safe for immediate use, and semaglutide is not that way. You mix up a vial and use it for a month or so.

Can you do it? Sure. Are you going to get an infection from it? Probably not. Is it riskier than having a compounding pharmacy doing it the right way? Absolutely, and in a meaningful amount of risk. The type of infections you get from contaminated injections are not something you want to deal with

Haven't done it myself but there is a robust DIY community for GLP-1 drugs. No idea if anyone's gotten hurt yet or if it's been pretty okay so far.

Oh sure, there absolutely is. Not only for glp-1s but for all kinds of peptides, especially SARMs.

Doesn't mean it's safe. Lots of people trade off a small risk of harm for immediate benefits. Hell, look at alcohol.

I found a pack of 10 5mg bottles in a Discord group for $90 For me that would be a year's worth. Comes with 3rd party testing. Haven't pulled the trigger on that deal yet but I do have some I got for $50 for a 5mg bottle and that's still a hell of a deal. So far so good.

It comes as lyophilized powder. You reconstitute the drug yourself and follow WHO sterility guidelines (reconstitute with bacteriostatic water, alcohol wipe ampoule top before accessing, keep it in the fridge, and throw it out if you havent finished it within 30 days). I know a dozen people doing this for the last year and none of them have had any sign of even superficial infection.

I think the way it works when you get bacteria into your blood is either you have no noticeable symptoms, or you get a high fever and almost die from sepsis.

People with minimal training drew up billions of doses of covid vaccines from multi-use vials and administered them intramuscularly (deeper and therefore potentially more risky than subcutaneous ozempic/mounjaro) and I never heard of anyone getting an infection from this

Importantly, they weren't the ones mixing the vials. That's the missing piece here. The vials were already sterile.

Those are wise safety procedures, not that's not sterile compounding. EVERYTHING needs to be sterile. The needles used for mixing, the air in the room, the hood you're mixing it in, everything. The room or hood has to be in positive pressure, and the ampule needs to be at a partial vacuum.

What you're describing is a adequate for immediate use. Not use and storage.

Wiping the bottle before use is just standard practice to prevent contamination after compounding.

Everything I said is equivalent to the WHO vaccination programme reconstitution and administration procedures. Vaccine clinics use multidose ampoules for up to a month. These aren’t sterile compounding pharmacies.

Except you have to figure out who is actually selling legit stuff at the real dosage.

From a quick look earlier this week that's not easy, and I've dealt with research peptide sites before. I was hoping to try one of the ones that's newer than Semaglutide for my IBS - that worked really well the later half of the week but not the first few days where it made things worse. I don't need to lose weight but I'd love to get that under control better.

Check out local weight-loss and hormone clinics, which often have connections to reliable compounding pharmacies.

I’ve seen these comparisons a lot, but how is it determined that the actual quality of a name brand medicine is the same in the two different markets…?

i.e. The price difference could be reflecting a real qualitative difference such as being produced in different facilities, slightly less pure ingredients, less stringent QC, etc…

It feels very conspiratorial to suggest multinational pharmaceutical companies are creating low quality versions of their own branded drugs in Europe.

We know that these drugs cost roughly $10/dose to produce, and most of that is the auto-injector pens. Hardly seems worth ruining their reputation and getting punished be regulators to save a few dollars on something with a 600-6000% markup.

> We know that these drugs cost roughly $10/dose to produce…

Can you link the source?

If it really is a 600% to 6000% markup then it does seem unlikely they would try to save a few dollars.

https://www.cnbc.com/2024/03/27/novo-nordisk-ozempic-can-be-...

I think these calculations are wildly optimistic. As far as I can tell, they basically ignore the cost of development, labor, quality assurance, and regulatory.

It is like estimating the cost of a rocket based on the price of metal.

I think you've lost sight of what the discussion was about.

The person above was claiming they were using substandard versions of their medication in non-US markets where the retail cost is lower. I was pointing out that the manufacturing cost is so low, that doesn't make sense.

Your point now has nothing to do with the discussion being had.

I made a sibling comment agreeing with that point and expanding on why.

However, bad data is bad data. If I said the moon creates waves because it is made of cheese, I think it is completely legitimate to point out out that it is in fact not made of cheese.

Linking a paper with bizarre assumptions, regardless of what the title or abstract claims, simply can’t be productive or helpful.

It can only lower your credibility and the credibility of the associated arguments…

You were claiming non-US markets were:

> less pure ingredients, less stringent QC

Why don't you link to a paper or source showing that to be true? If you want to discuss credibility.

I didn’t claim that…?

You selectively quoted a chunk leaving out “could be reflecting”, implying a probability above 0.

So at most it can be said to imply there will always be a true probability greater than 0.

e.g. Someone could perish from a meteorite hitting them tomorrow. There will always be some non zero probability of that.

It is important to distinguish concepts here.

One concept is a single firm selling a branded product in multiple markets. Novo Nordisk sells at different prices in different markets, but the product is all of equal quality, and usually comes off of the same manufacturing line globally, or one of a few.

The other is usually generics made by entirely different companies. These can vary greatly in quality, from identical to deadly. It is a bit of a stereotype, but you usually see higher quality control and less fraud in US and western European manufacturing than say India, China, or SEA.

Having worked for US drug manufacturers, they deeply desire to move manufacturing to Asia where they can, but dont because of frequent quality issues when they do.

yes, most of the costs are A) development and B) relatively fixed costs of maintaining the manufacturing staff and infrastructure.

The marginal cost of an additional batch is relatively small in comparison.

Developing a cheaper to produce product, even if that was done off-book and you could keep it secret, would need some level of different production methods (different ingredients, different machines or something which makes it cheaper) and some amount of testing which just selling the original product doesn't require.

They do that in China and if you search the net a bit you can get 5mg of Semaglutide for $9 a bottle. Requires a little work as you have to add Bac water and inject yourself but it works great.

Wait until I tell you about the bootleg version I get get from China for $9 for 5mg bottle of Semaglutide. It lasts a month for me and works great. You have to mix it with Bac water yourself so there's a little prep and there isn't a plastic infector. Have to inject yourself with a syringe. These are 3rd party tested so there is some level of safety involved.

Drugs cost what they cost because of R&D, not manufacturing.

Look at how cheap generics are, that's what it costs to actually make and distribute a drug.

The pharma business model is that you spend incredible amounts of money on doing research, identifying promising drugs, doing trials, and overcoming all the regulatory hurdles you need to overcome to get the drugs to market. You then get a 20-year[1] exclusivity deal on your newly-introduced drug through patents, which you use to recoup your costs.

You don't just recoup the costs of inventing this particular drug, but also all the other drugs that seemed promising, had all that money spend on trials, but ended up just a bit too ineffective to ever be sold.

We could abolish the patent system and genericize everything, and that would instantly bring drug prices down massively, but then we wouldn't ever see any new drugs being researched.

I think it is critical to differentiate price controls and purchasing controls.

Most other markets with state insurance have purchasing controls. That is to say, if the price is too high, the government doesn't buy it.

Very few places have price controls e.g. "products cant be sold for more than X".

The US government is the outlier in that it situationally states it will pay the price no matter the cost.

Reasonable government policy needs to start with putting a price on human life (QALY), and purchasing goods and services that come in under that price. This is how it works in other state insurance systems.

We aren't other state insurance systems, though.

Instead, we have a divided and fractured jigsaw and heavy lobbying to keep it that way.

Correct. You have identified a problem

Going to start using this response more frequently.

Although you're right, it's a little misleading.

The point is that governments won't pay any price, they usually negotiate a (good) price given their buying power. As you say they may not buy it, but countries that dictate a price (generally) cannot force a company to supply it.

Ultimately it comes down to market forces, even if the market looks very strange, with essentially one buyer and one seller.

not sure what you find misleading?

> Ultimately it comes down to market forces, even if the market looks very strange, with essentially one buyer and one seller.

That isn't really a market.

Suppose you have a government that requires everyone to pay for public health insurance, effectively eliminating the market for private insurance because hardly anybody buys private insurance when they both already have public insurance and have paid the money they'd have used to buy it in taxes. Then the government insurance declares the maximum price they'll pay. Is there any meaningful way to distinguish this from price controls? The vast majority of customers can't afford the drug without insurance and the government is the insurance company and is setting the price through regulation.

In particular, notice that this has all of the problems of price controls. There is no real market to enable price discovery, no effective way for customers to switch insurers and thereby punish insurers who pay too much and have high premiums or pay too little and have poor coverage, it's just regulators making up a number and saying take it or leave it.

And even at that, you shouldn't have a problem for generic drugs because then the insurance can just put it out for bids and still have price discovery (i.e. a lowest bidder). But here we're talking about brand new drugs that are still under patent, which have one supplier because they're supposed to be expensive because that's the incentive for the drug companies to fund the R&D and cause them to exist to begin with.

> There is no real market to enable price discovery

Note also that this is a feature, not a bug. You don’t want drug companies figuring out what price makes them the most money, because the market for patented drugs is not a competitive market (or a transparent one for the consumer). The price that makes the company the most money is not the same as the one that maximizes welfare.

> You don’t want drug companies figuring out what price makes them the most money, because the market for patented drugs is not a competitive market (or a transparent one for the consumer). The price that makes the company the most money is not the same as the one that maximizes welfare.

It's not supposed to be competitive, that's the entire point of a patent. They're supposed to be able to extract nearly the full value of the drug during the patent term, because that's the value of the drug existing, so that's how much incentive you want there to be to create it. After that the patent expires and it becomes a cheap generic, which is what the public gets out of the deal.

The point is that there’s nothing magical about price discovery under an anti-competitive system. It doesn’t maximize welfare, so there’s no reason to complain about another system that doesn’t allow for price discovery. That’s not a bad thing.

It’s far far more efficient to have an expert guess the price that maximizes public welfare. They won’t get it 100% correct, but they’ll do better than monopoly pricing

> The point is that there’s nothing magical about price discovery under an anti-competitive system.

There is though, because it gives you the price that it's worth to the buyers, which is the amount of benefit the buyers derive from it existing, which is the amount of incentive we want to provide to create it.

For something that wouldn't otherwise exist, the monopoly price for a temporary period of time is a close approximation to what would maximize welfare -- it's proportional to the value of having it exist without being the whole thing, because it becomes a competitive commodity when the patent expires.

> There is though, because it gives you the price that it's worth to the buyers

It does not. It gives you what it’s worth to the last buyer, sure. All of the buyers before that value it higher than that price, and all of the people that don’t buy it value it lower than that price. In the end, all you’ve really found is the price the company expects will maximize profit.

This may tell you a little bit about what the company believes the demand function is, but it doesn’t confirm or deny their correctness.

Romania has state mandated public health insurance (if you're employed or if you make over minimum wage from non employement sources, you have to pay for public health insurance), but the private health insurance market is also thriving.

But, in Romania, Ozempic was negotiated/price controlled by the government to be for around ~100$/month. First year or two supply was enough, so we got it, this year demand in places with more cash is high, so Romanians don't get any more Ozempic (but we still have Rybelsus)

> Romania has state mandated public health insurance (if you're employed or if you make over minimum wage from non employement sources, you have to pay for public health insurance), but the private health insurance market is also thriving.

Where this happens it's basically because the public wants more insurance than the government is providing, e.g. you're required to pay $3000 for $3000 worth of insurance but there are people who want $5000 worth of insurance so they buy another $2000 in private insurance.

But that doesn't really change the problem because the extra insurance covers different stuff. If your coverage from the government covers the drug and your coverage from a private insurer covers longer inpatient stays or hospice care, the latter is unrelated to the former. Meanwhile there are still a lot of people who only have the government insurance and can't switch to a different provider for that coverage because the government plan is required by law. And even if you could get drug coverage from a private insurer, the patient would then be paying for the whole cost of the drug out of the private insurance premiums even though they're still paying for the public insurance, which will deter people from doing that unless the government coverage is not just bad but catastrophically bad.

The way you could make it work is that instead of the government setting the retail price of the drug, they set how much they pay for the drug and the patient pays the rest, which the patient could then have covered by private insurance at their option. Then you actually have price discovery because if the drug is worth more to people than the government is paying, they'll buy the amount of private insurance needed to pay the rest.

> But, in Romania, Ozempic was negotiated/price controlled by the government to be for around ~100$/month. First year or two supply was enough, so we got it, this year demand in places with more cash is high, so Romanians don't get any more Ozempic (but we still have Rybelsus)

Production capacity isn't normally the issue for drugs under patent. The issue is that you need somebody to pay enough to cover the R&D or otherwise you don't get the drug, and drug R&D is crazy expensive because the price has to cover the R&D cost for all the drugs that don't work out.

> Production capacity isn't normally the issue for drugs under patent.

https://www.fiercepharma.com/pharma/ozempic-shortages-contin...

https://www.tga.gov.au/safety/shortages/medicine-shortage-al...

For one of the most popular drugs in recent years, yeah, production might take some time to ramp up.

The issue definitely isn't R&D cost recuperation: in the US Ozempic is much more expensive, but in Romania nobody would pay that much (government or private).

> For one of the most popular drugs in recent years, yeah, production might take some time to ramp up.

Which is why it's an outlier.

> The issue definitely isn't R&D cost recuperation: in the US Ozempic is much more expensive, but in Romania nobody would pay that much (government or private).

This has nothing to do with whether the government sets the price. If people in the US would pay $1000 and people in Romania would pay $200 but the government sets the price at $100 in Romania then there is $100 less incentive for R&D.

Why is it worth noting in this context? It seems like an unrelated observation. The original commenter is clearly in the U.S., so you're telling them something that doesn't help them at all.

Compounded drugs are only legally available when the fda declares there is a shortage. Once novo nordisk shows that they can make enough of it buying compounded versions will be illegal.

Tirzepatide is out of FDA-declared shortage but somehow Semaglutide isn't: https://www.fda.gov/drugs/drug-safety-and-availability/fda-c... But expect it to be soon.

The issue is not with manufacturing costs, Ozempic is €83 in France for example, because there is a single buyer for every drugs (namely the Assurance Maladie, a state apparatus).

Now Mounjaro is out, Ozempic can only really compete on price, which has to be adding downward pressure

It would be easier to squeeze Novo if they included Zepbound from Eli Lilly in the mix - we could argue that if we're going to spend unfathomable amounts on these medications we might as well buy the more effective medication from an American company.

There's no need to spend unfathomable amounts. We just need to establish and enforce the favored nation status if they want to sell their drugs here. No drug (least of all US developed drug) should cost more in the US than it does elsewhere. That's what Trump was proposing in his last term. Because the Congress is corrupt AF, that went nowhere, but maybe we could give it another try now that his mandate is much stronger? As things currently are, we're getting robbed.

Or we can offer to take Greenland off the table /s

It's not on the table in the first place. Trump is just forcing fake news MSM to talk about BS to disorient them and make it harder to attack his transition. Expect more of this - he seems to be advised by someone competent this time.

There's a reason I put a "/s".

It's commonly used to signify sarcasm or a tongue-in-cheek comment.

/woosh

He really is playing 4D chess

What about poor countries? If a drug company had to sell drugs for the same price in the US and a country like Sudan, the result would almost certainly be raising the price in Sudan up to US prices rather than lowering the price in the US to Sudan prices.

That would put the drug out of reach of most of the people in those poor countries.

They can do what India and some other countries do, and legislatively ignore pharmaceutical patents when it comes to public health if drug is deemed unaffordable.

I mean, I don't think you're enforcing patent law in South Sudan regardless, but they're also just not capable of manufacturing such drugs. To get a trustworthy drug, they pretty much have to buy it from the patent-holder. India, China, and maybe Brazil are about the only exceptions. Theoretically, I guess you could say we just expect the third-world to rely on black market medicine from India, but uh, that has some risks involved.

Is it really the black market?

It just sounds like it's sourced from somewhere else like any generic would be.

IMO the state should be able to take away monopolies just as easily as it passes them out in the first place.

They could benchmark the price against comparable countries/regions. Pay no more than, say, 110% of the average cost of the drug in Europe.

If it still has to go through congress you still have the same problem.

This will just make it impossible for poor countries to get drugs.

> It would be easier to squeeze Novo

Didn't Novo pretty much tell congress that the only reason why the high price for Ozempic and Wegovy is the US system of middlemen and that lowering it's prices won't necessarily benefit the patients? The CNN reporting from the hearing is pretty interesting[1]. According to Novo Nordisk when they tried lowering the prices of their insulin product, pharmacy benefit managers dropped their products out of coverage, resulting in fewer people having access to the medication overall.

It's not entirely clear that Novo Nordisk is the company that needs to be squeezed.

1) https://edition.cnn.com/2024/09/24/health/ozempic-novo-nordi...

Not the lifeline for us fatties.

> Medicare enrollees, however, still won’t be able to access the drugs for obesity under a federal law that prohibits the program from paying for weight loss treatments

Also, you have to be severely ill or elderly to get Medicare. This is for their diabetic treatment.

That’s because Medicare only covers drugs for approved FDA usage. It’s covered for diabetes but not weight loss. In general this is good policy. It is possible to challenge for some cases but generally that is the rule. It’s a perfectly reasonable way to both control costs and prevent harm.

If the drug manufacturers wanted it to be covered for weight loss there IS a process. File the correct paperwork with the FDA and do the rigorous studies that were don’t for the approved usage.

Wegovy is approved for weight loss (since 2021).

The USA is a racket cubed. https://www.healthsystemtracker.org/brief/prices-of-drugs-fo...

The pharmacies are also in on it https://pmc.ncbi.nlm.nih.gov/articles/PMC11147645/

Don't forget the tariffs that are bound to make it 30% more expensive.

The Pharma chains get product at world wholesale, and in the case of Ozempic = about $100 at the pharmacy where it is picked up = pharmacy pays $75. Same cost base = $500-900 in the USA. 30% tariff will be based on the $75 base import cost = small

Why is there a specific list? Why don't we just let Medicare negotiate.

Unfortunately, that's all the Biden administration could get written into law. The Big Pharma lobby is too strong and definitely battled to keep this list as small as possible.

At least the door is cracked open and it's a start.

Of course, Big Pharma will fight to slam it shut again.

That's because it's not really a solution.

It's not a negotiation between two parties with equal power, it's just the government saying "either pay this price or you'll be penalized".

The better solution is to allow parallel trade of pharmaceutical across borders.

It will force countries paying far less to pay more and conversely the US paying less.

Or simply set our prices to the average or median of something like 5 hand-picked other countries - and make that not only for Medicare/caid but also for everyone else. It's ridiculous that hasn't been done yet.

That doesn’t work because other countries already do that - set price reference to a basket.

You end up with a circular reference that spirals prices down.

At some point that price is lower than the net positive profit point.

> The better solution is to allow parallel trade of pharmaceutical across borders.

No, no it's only a global economy when companies want to manufacture products using slaves in third world countries or they want to outsource programmers and call center employees, but not when consumers want to buy medications or DVDs at the prices they sell for in those same countries or even just want to get higher quality products they refuse to sell you here (https://www.cbsnews.com/news/hershey-sues-shops-importing-br...)

Because corruption.

Pat and cynical oversimplifications are bad for discourse, because they suggest that a default angry response is correct and, coincidentally, frees you from having to think harder about anything.

Don't give in!

We can debate the merits of various drug pricing schemes but at the end of the day, prices are set by a small group of interested actors who want the prices to be as high as they possibly can without causing a violet revolt. So call it what you will but let's not pretend there's some deeper, more important meaning to be sussed out here.

Because this isn’t really a “negotiation” as configured by the statute: Medicare doesn’t have a formulary, it doesn’t pay for drugs, the Part D plan providers (some quite large and with their own negotiating heft) do.

It’s a price-setting exercise. Yes, the drug-maker can walk away, but at the cost of massive punitive excise taxes on selling their drug to anyone in the US, not just Medicare Part D plans.

Exactly.

It's like saying taxes are a "negotiation for a contribution to the state government".

A little more complicated because in some settings drugs are covered by Medicare part B but generally not if administered yourself at home. Then yes it’s part D and the most out of pocket in Part D from 2025 going forward is $2K.

Also, they do negotiate for a very few drugs and the number is climbing. This was part of the IRA. However only drugs that are FDA approved for your issues are covered.

Before the IRA the government was not allowed to negotiate any drug prices by law which was/is crazy.

What, specifically, wasn’t HHS allowed to do? They weren’t purchasing the drugs.

Certainly the VA can and does negotiate prices for the drugs it buys (that’s one input to the HHS Medicare price-fixing formula), but it has a formulary and is buying drugs for its patients directly.

Interesting that they're negotiating semaglutide (Ozempic/Wegovy) but not tirzepatide (Zepbound/Mounjaro). Cynically, maybe a ploy to bolster a US pharma (Lily) as opposed to Danish Novo? I don't know anything about how this program selects drugs to negotiate.

It wouldn't surprise me if they picked who would be included based on which drugs should be relatively price flexible yet cost a lot. I've noticed that ozempic/wegovy prices have dropped in many markets recently, even price controlled ones, especially compared to Mounjaro, as the latter is seen as more effective and in short supply and has fewer generics available still.

In fact, by introducing new multi-dose versions to different regions, I'm starting to see Mounjaro prices reportedly double for some. The real kicker is that for some brands/doses the price doesn't vary whether you get more or less of the drug - so people end up asking to for a prescription to the highest dose off-label and then split the dose themselves.

For example, you can click the auto-injector pen a fewer number of clicks to measure out a smaller dose than what is normally injected by the pen, then relatively safely save it in the fridge for longer than recommended even without preservatives (some pens have and some don't).

It's frustrating when pricing decisions are made assuming insurance benefits and yet insurance isn't always available, e.g. unemployment. This thinking even applies in places that do regulate drug prices. But hey, you can always sign up for the manufacturer's discount program to get it cheaper, so, win-win right?

As others have pointed out, the drugs on this list go into effect in 2027, which is after the EU semaglutide patents expire (2026), so that might be a pretty compelling reason for semaglutide pricing to be more flexible than tirzepatide.

> The real kicker is that for some brands/doses the price doesn't vary whether you get more or less of the drug - so people end up asking to for a prescription to the highest dose off-label and then split the dose themselves.

FWIW, I'm paying cash buying it directly from Lily, and they charge $400/mo for the 2.5mg dose and $550/mo for the 5mg dose. So, some price differentiation between dose sizes, but not linear.

Yeah. I've seen some split between low vs high doses, where the first two doses cost less than the rest - a cynical take is that they want to make it cheaper to get started knowing they will get you hooked possibly for life, or at least the duration of their patent.

But yes, non-linear by design - a 15mg dose provides 6x the medication but cannot be sold for 6x the price or people will stay on lower doses (or discontinue) rather than going to a higher dose.

Meanwhile it provides 6x the medication. One multi-use 4-week pen has enough to provide 12 weeks of doses at 4-week titration if used off-label. Obviously this is only helpful on low doses.

Important note: I am not a doctor, I don't recommend doing this - in fact, I have not done it myself and will probably not do it in future. I have seen YouTube videos of medical professionals explaining how to dose split weight loss drugs though.

I would highly recommend dose splitting the brand name drug over picking some compounding pharmacy's version of the drug, or worse, buying it off the street. It's crazy though, there are even counterfeit medications in the supply chain sometimes, for example: https://www.fda.gov/drugs/drug-safety-and-availability/fda-w...

Would rather have Mounjaro and Zepbound

Or do both, and let them compete with each other for Medicare's business.

That's been so effective so far.

Cheap drugs have massive downward price pressure on alternatives.

The cynic in me thinks they are only going for Semaglutide because the patent expires in several places in 2026, tirzepatide has another ten years.

The patent on the manufacturing process, not the peptide itself.

The US is trying to squeeze the Danes to get hold of Greenland.

It is front page news in dk - leaders from major Danish companies have been called in by the government … novo is the biggest exporter to the us and the most obvious squeeze.

Technically this is done by the Biden admin but obviously coordinated with the incoming Trump admin who has made their attention of using trade to squeeze Denmark in order to get full control of Greenland very clear.

Novo is just worth $300B, it's nothing compared to the many trillions of dollars Greenland is worth.

But I guess politicians are much cheaper than that.

Worth to whom? Greenland has about 44,000 inhabitants over age 17. I would imagine a majority would be willing to sell their citizenship to the US for quite a bit less than a million dollars each....

The natural resources that haven't been exploited

also, taxes on the northwest passage

Now that would be a real tragedy, bunch of common folks largely clueless about finances suddenly becoming millionaires. If anything lottery winners have thought us is mostly just a destructive event.

> it's nothing compared to the many trillions of dollars Greenland is worth.

All of these trillions are imaginary numbers buried in ice

I find it fascinating that Denmark believes Trump isn’t simply lying like he always does?

Why would the Biden administration coordinate with Trump in an attempt to control Greenland? That makes no sense.

This particular thing was always in the works but we should ask the Greenlanders where they’d rather be and pay them if they choose otherwise than us. The land is too strategic and Denmark cannot hold it usefully.

There is no functional difference in likely effectiveness between the present EU, of which Denmark is a member state, or the present US holding Greenland against a Russian attack. The Russian attack would be smashed either way.

That seems unlikely. Peace in Europe exists because the United States threatens its absence with a fist by its heart. America had to save Europe from destroying itself once and now the US has pacified Europe by placing its troops and weapons there lest the nations turn on each other in uncivilized violence again. And then again, when they dragged their feet, the US had to blow up their gas pipelines pour encourager les autres. The continent is incapable of protecting its own shipping lanes without US support and NATO acts as a deterrent solely because the US is in it. Take it out and the Europeans will spend the majority of their time telling everyone how it's not a big deal that Ukraine will fall to Russia, and Poland, and so on.

What you're writing has very little to do with reality.

When we recently made agreements with the US to allow them to store some of their weapons here in case of a crisis we did this, the mutual concern was Russia. The weapons stored are presumably also of types useful for dealing with Russia.

We Europeans have nuclear weapons as well, so there's no possibility of the US preventing any uncivilized violence-- we do in fact have very real autonomy.

The US probably did blow up Nordstream; but this is very simply that it's easy to make the right choice when you're not paying for it, so this isn't some example of better American morality. Poland has a formal alliance with us and we would have to defend them by all means at our disposal.

But, taking into account the sale of oil fund assets by Azerbaijan and the corresponding increase in military spending I assume more pipelines will soon have to be blown up, only this time it'll be the UK who adds its complaints to those of Germany and the other gas dependent countries. The Armenians might even have to do it themselves, rather than relying on help from others.

It actually appears that Ukraine blew up Nordstream.

https://www.washingtonpost.com/national-security/2023/06/06/...

It's very possible that they did, it's very feasible and to some degree a simple matter. However, I still believe that it's more likely that the US did than that the Ukrainians did. My initial assumption, right after it happened was Ukrainians or the US, but I have always leaned to that the US is more likely, and there's at lot of reasons for that.

However, I mostly think you did it because you said you would, and I kind of trust you when you do things like that. When your leaders try to communicate their intentions, they usually mean what they say and it's not terribly complicated.

The US talk about agreement with the EU view that this is somehow a brazen and dangerous sabotage is pretty funny though, because this kind of thing is absolutely legal-- completely, not like 'Oh, this is disputable', but completely. The useless German arrest warrant that was issued was funny too. Neither of these two mean anything, but I get the impression that everybody knows it's legal and wish it weren't. They know that the Armenians can blow up Turkstream and the Georgian pipelines, even with the slightest provocation, since there's no ceasefire agreement and all their big investments can be destroyed in an instant with unhappy Brits as a likely result.

You don't even need an order. If your country is occupied by another country or at war, and you can damage infrastructure useful for the enemy war effort, whether in export of energy or the electrical grid or anything like that, you don't need an order, you should just do it. Attacks on things in international waters is obviously permitted. If it belongs the enemy and you can attack it, you probably should. It's more complicated if it's in a neutral country, and then it might actually be illegal, but otherwise-- do the work and put on some distinctive marking for the attack itself, and there's nothing to complain about.

It's something that anyone who has lived in a smaller country with a neighbour that could possibly make war upon them drills into their own heads when they first read their grandparent's old 1950s military manuals.

Of course, if the US really did warn, then it may be as you say-- after all, why warn of what one would oneself plan to do, but people can be tricky, so there isn't a guarantee there either, especially if the explosives are pre-planted.

I'm reminded of the weird US accusations against Russia right after the event though, now that I read the article again, and that's another reason to suspect the US. Imagine that you're in an Agatha Christie novel and somebody says stupid things to you. There's only one conclusion-- he wants you to think stupid things. The article also contains some of this kind of stupid about 1/3 in and it's right when it starts discussing this kind of thing, so, no it's 100% the US. You don't talk like this, or reason like this, unless you did it. It even has one of those 'how did you know the parts you weren't there for' problems.

Maybe we should start asking very single tribe/minority across the world if they want to be independent. We would very quickly find that current states are rather fragile conglomerates sometimes holding together by surprisingly weak forces.

I can see few parts in US for example wanting independence under certain conditions. Or US could have given kurds Kurdistan in the middle east with all that crap it caused in past 2 decades, largely stabilizing (big part of) the region. Clearly not policy US cares about much, so lets stop pretending actual wants or needs of Greenland population are anybody's concern here.

It's not really a "squeeze".

The Danes agreed that Greenland can become independent if supported by a national referendum. Apparently there is a decent amount of interest in that idea.

So the US can come in and say "hey, instead of independent, you could be in a union with the US". There is enough interest in that that it's a serious concern for the Danes.

The Danes aren't concerned because there's enough interest, they're concerned because a violent, hegemonic imperialist superpower run by an unstable authoritarian regime has decided Greenland should be theirs, apparently just because, and historically speaking having something the US wants means your cities get liberated into smoking rubble.

> they're concerned because a violent, hegemonic imperialist superpower

To be fair we learned it from watching Dad (England).

> unstable authoritarian regime

How is it unstable?

> apparently just because

Territorial waters and exclusive economic zone claims grant amazing access to the arctic.

> something the US wants

It's really just the moneyed interests inside of it. China and Russia seem to have the same bent for the same reasons. It was recently unusual in Iraq since the federal corruption had risen to such a level, enabled by 9/11, that lackies for these interests somehow found themselves directly employed by government.

I prefer nuance over hyperbole.

> How is it unstable?

I'll bite - the guy taking office soon recently attempted a coup and his party backs him no matter what action he takes despite his rampant criminality.

There have been at least 2 assassination attempts on this individual recently (by folks who ostensibly supported him previously) and had one been successful who knows what his remaining supporters would have done in response.

The USA is teetering.

> recently attempted a coup

This is just more hyperbole and relies on a highly subjective interpretation of a single tweet and blithe expansion of the accepted definition of coup. The least generous but realistic interpretation of those actions is that through poor word choices he incited a riot. You can credibly debate that this was criminal and intentional but to call it an example of a "coup" is flatly absurd.

> his party backs him no matter what

There is astounding and readily available evidence to the contrary. I'm not sure why you think there hasn't been or isn't currently Republican Party members that despise him and openly attempt to undermine him. They're not particularly difficult to find.

> despite his rampant criminality.

It seems like the majority of his actions are within the law. I understand you disagree with his administrative prerogatives but this lens is extremely distorted.

> at least 2 assassination attempts on this individual recently

How that implicates "stability" of a nation is beyond me. Are you prepared to label all prior presidents with successful or unsuccessful assassination attempts as being "unstable?" Is that your bar? Do you not see any connection between your widely held extreme points of view and these extreme actions?

Finally.. what is the source of this instability? That he won an election? That's an odd understanding of politics. One that I think is projected by lazy "news" channels that find it easier to market outrage than they do facts.

> and had one been successful who knows what his remaining supporters would have done in response.

From hyperbole into historically detached flights of fancy.

> The USA is teetering.

All actual available evidence is to the contrary. The economy is strong and the social order isn't. Qui bono? Perhaps you shouldn't focus so much on domestic politics.

> You can credibly debate that this was criminal and intentional but to call it an example of a "coup" is flatly absurd.

The Jan 6 committee laid it out in detail but if not for Mike Pence having a shred of integrity trump's plan would have led to the state delegations in the House selecting the "winner" of the 2020 election. That's a coup attempt. It was well documented.

If you were a drug company how much money would you spend on developing an Ozempic/Wegovy follow on drug?

Price controls like this are popular because the benefits are easy to see and the costs are distributed and nebulous. Excepting things like the fires in LA which are distributed and obvious.

Are people who pay for their own prescriptions able to purchase them at these Medicare-negotiated prices?

A lot if times yes. Almost always cash buyers pay the least, even less than those with insurance.

  https://www.vox.com/22553793/gila-monster-lizard-venom-inspired-obesity-drug-semaglutide

The fact that it's up to the insurance provider to choose what medication they cover is so absurd. Your doctor can prescribe medication, and the insurance company can say, "Nah, we choose not to cover that. And we don't cover the generic versions either!"

It's so shitty when you have to change insurance plans, and then get stuck holding the bill for medication that you were taking, but is no longer covered under your new plan -- especially for weight loss drugs that don't seem to be even like 80% covered under any plan you can get on your own.

Insurance should cover everything. Period. Full stop. Just because you change jobs doesn't mean you should ever have to change medications.

Anyway, Free Luigi! =P

my favorite part of ozempic is that it settled the debate on calorie reduction.

Did it? The drugs clearly lead to reduced appetite, therefore reduced calories. But do we know that the drugs aren’t also causing other important metabolic changes?

The drugs seem to cause a small increase in resting heart rate. Whether that is due to metabolic or neurologic changes (or something else) isn't completely clear.

Was it ever really a debate? There’s tons of experimental evidence that shows calorie reduction leads to weight loss, even without pharmaceuticals. The Ozempic data can be explained simply by this factor. There doesn’t seem to be enough data fluctuation between the two sets to indicate a significant set of unknown variables impacting the data.

yeah, but do ozempic et al only rely on calorie reduction? i find it hard to believe that hormones only affect one thing in isolation. it may be doing something like a) suppressing appetite to reduce caloric intake AND b) shielding against a lowered metabolism due to calorie restriction.

If there is predominant evidence of significant calorie reduction leading to weight loss, and no evidence of the metabolic hypothesis , what should be our conclusion?

It's not even appetite per se; GLP-1s regulate blood sugar for more sustained levels, which is upstream of appetite. Safe to say that blood sugar impacts a bunch of other stuff too.

Occam's razor

I think it confers some metabolic boost, but more data is needed

The debate has never been "will consuming less calories than you expend make you lose weight" -- the debate has been "will just telling people to consume less calories, patting yourself on the back and calling it a day make them lose weight."

The latter was settled in a 2023 cohort study that showed doing is completely ineffective. [1]

There's been tons of data on this. The scientific consensus has been pretty clear for a hundred years, but nobody wanted to listen. Probably in part because there was no good solution before.

[1] https://pmc.ncbi.nlm.nih.gov/articles/PMC10407685/

> The debate has never been "will consuming less calories than you expend make you lose weight"

If you missed the whole "calories in, calories out" debate, consider yourself lucky. The comment above isn't helpful, but there really was a period of time where the topic du jour among health influencers was debating that calories didn't explain weight gain or loss. It played into the popular idea that blame for the obesity epidemic rested squarely on the food industry and "chemicals" in our food.

At one point, I had a podcast-obsessed coworker who tried to tell us all that even when he ate 1000 calories per day he couldn't lose weight. He had a long list of influencers and podcasters who supported this claim.

The CICO debate was especially popular among influencers pushing their own diet. Debating CICO was a convenient gateway to selling people your special diet that supposedly avoids the "bad" calories and replaces them with "good" calories, making you lose weight.

Ah, gotcha.

For what it's worth CICO sucks because (1) nobody can stick to it, ever (2) humans are awful at estimating their calories in, studies show only 1/5 of people can properly estimate the calorie content of their food [1] and (3) your metabolism slows down in response to, specifically, caloric restriction diets and your hunger rises which makes it difficult to estimate your calories out without indirect calorimetry.

Yes, CICO works in a lab, and for some weird people. It's a matter of thermodynamics. However you are a far more complex system than a coal powered furnace. And yes certain types of food will be more or less satiating and may influence the amount of total calories you consume. It's really really hard to overeat if you just eat lean protein, for instance.

CICO is, in practice, a tool that is roughly impossible for most people to leverage to lose a meaningful amount of weight and keep it off.

Which brings us back to the difference between maintaining a persistent caloric deficit -- and instructing people to do so.

[1] https://pmc.ncbi.nlm.nih.gov/articles/PMC3719184/

Why are people trying to estimate calories blindly? You have to look them up in some sort of system and log it in a food journal for the tracking to be any good at all.

It works for everyone.

Full stop.

Even if your metabolism slows down in response to caloric restriction, it does not move the needle to any appreciable degree.

Because it takes energy to do. It just does, you cannot fool physics.

However, measuring calories is incredibly difficult. Both in and out. Also, if you put 5000 calories worth of food inside of you, but then immediately vomit out 4500 of those calories, you've only really consumed 500 calories. You can overwhelm the system.

If you can restrict yourself to consuming at a caloric deficit, you will lose weight.

That's difficult however. Because if you pick a target calorie amount, you will see less progress as you lose weight. Because of math. 1500 is half of 3000, but only a quarter of 2000. People get fixated on 2000, as if we operate based on 2000 calories a day. But if you were previously consuming 3000 calories a day, your weight requires 3000 calories a day. So when you drop to 1500, you are going to lose about a pound every two days for a while. When you get to about 2500 maintenance calories/day, you're going to slow down to a about pound every three days. This is not your metabolism "adjusting". You weigh less, it takes fewer calories to maintain that weight.

And you will be hungry. It will suck. And you have to be meticulous in your record keeping. There are no "free" calories.

And we're not even getting into the mental component of all of this. What's been termed as "food noise". And it's one of the things that people on Ozempic and the like notice the most, they stop thinking about food. And food addiction is one of the absolute worst addictions to have. Hands down. With just about every other addiction, abstinence is an option. Alcohol, gambling, heroin, cocaine, meth, etc, none of that is necessary to live. We need food. We need to eat. You cannot avoid food. You have to actually develop discipline. Teetotalers do not have discipline. They avoid the issue altogether.

So CICO works, but it's incredibly difficult to do for lots of reasons that are not related to the biology or physics of it.

Yup, and where this stall vs. weight occurs is mediated by genes to a large extent. Someone who stalls out at 1.8-2.2 kcal/day while still being obese will need extra help, when cutting more calories is too unpleasant (many such cases). This drug makes that easier. And there is no evidence to suggest it gets easier with time or the body at some point stops trying to put the weight back on. Dieting is 24-7 war on food.

It is easier if you couple this with exercise. Many people successfully lose weight with exercise and managed diet. You have to want to do it to a certain extent. I think the solution for people who lack willpower for this isn’t ozempic, its therapy for the underlying depression that probably bleeds into all other aspects of life.

medication makes things easier. I think it's better to use technology to make life easier than to be resistant to it and make life unnecessarily hard.

CICO also wants you to collect your poo, so you can check the CO of it in a bomb calorimeter

> and (3) your metabolism slows down in response to, specifically, caloric restriction diets and your hunger rises which makes it difficult to estimate your calories out without indirect calorimetry.

This is the critical one that leads people to correctly argue CICO is largely useless for attempting to lose weight: the "CO" part of that is highly variable and is not merely a matter of being active. The body has all sorts of mechanisms that it can adjust to achieve the amount of storage vs burning that it wants to do, regardless of the amount of food consumed or the activity level.

The metabolism slowing down thing is greatly over exaggerated. Everything I’ve read that is evidence based puts it at a nominal difference.

Put simply: starvation mode is a myth for everything but outliers that are uninteresting to discuss.

yes, this. the body decides to become super-duper efficient like a Prius. this is shown by studies in which acts like walking burn less energy . There is a lower threshold in which weight loss must occur, but this can be way lower than predicted by calculators or naive CICO estimates.

FYI, GLP1 drugs are CICO - they work because they reduce calories in.

It CICO is physics, not a complete instruction set for life. I dont understand why it makes people so angry.

"you're doing CICO wrong. you can only lose weight in the way I approve of"

who are you quoting? CICO isnt a how to guide

CICO works if you have the patience and discipline to make it work, which few do. At some point it becomes too unpleasant to keep reducing calories or to measure and track everything. Life gets in the way.

Actually if you just eat lean protein, you will become ravenous because of the lack of fat. Humans need to consume fat, if there is a lack of carbohydrates in diet. If you eat only lean protein you will die from rabbit starvation. Check out this:

https://www.thecanadianencyclopedia.ca/en/article/rabbit-sta....

People not being serious about diet and exercise doesn’t mean it doesn’t work. Look at reality tv where there is calorie restriction, like Alone or “Survivor” and everyone loses weight. On the former in particular people have lost like 40 pounds in as many days before and have lost so much weight so fast that medical teams have pulled them from the show.

This is like saying most people barely use 5lb dumbbells when told to work out, so working out must not work. Like, of course major lifestyle changes take willpower!

I'm still sympathetic to those arguments. Humans have, for at least the last several million years, been taught in the evolutionary sense to never let a calorie go uneaten. Too many famines. "Just don't do that thing that every gene in your body screams at you to do, and feel miserable for it" isn't really good advice, and isn't all that insightful. One can't even necessarily make judgements about how many calories they themselves can eat based on what they see other people around them eating. "That other person stays skinny, and I'm eating about the same amount as them" is not an on-the-surface unreasonable assumption... but it doesn't work, even if you could eliminate human misperceptions.

>At one point, I had a podcast-obsessed coworker who tried to tell us all that even when he ate 1000 calories per day he couldn't lose weight. He had a long list of influencers and podcasters who supported this claim.

The week after Thanksgiving, I had a heart attack (age 50). I was in the CICU for nearly a week before they let me go home. On the day I was released, they sent a nutritionist in to tell me that I shouldn't try to eat one meal a day, that I really needed to be eating 3 meals a day, and to eat bread at least for two of those (or other carbs). Don't eat butter, eat margarine though. Yadda yadda. This was what, 8 weeks ago? Not 1962 in any event.

Do you know what 1000 calories looks like spread across 3 meals? Or how long you have to run on a treadmill to make up 300 calories if you bump that up to 1300? Or that, even sitting in an office chair every day, I can't lose weight (of any significance) at caloric intake much above that? I'm willing to concede that any problems I'm having here are in my own head, that I can't change my behavior or habits or whatever (to literally save my own life), but this isn't the sort of problem that can be handled by any but the most godlike of willpowers (which I do not have, if that doesn't go without saying). Right now, I probably need to be eating just one meal every other day, as I'm not really gaining any weight back but I'm not losing much either. My meal, such as it is, is a salad that fits in a small bowl (less than 2 cups of lettuce and uncooked vegetables). None of this is helped by knowing that people who are so-called medical professionals are giving me is absolute horseshit.

The truth of the matter is that we are adapted to eat only once every few days, and for even that meal to be meager and less than appetizing. But we live in a world that has mastered abundance and flavor, and uses marketing science to constantly try to get us to to buy all that. When you tell people "just eat less", really you're just doing the r/fatpeoplehate but in a covert way where you don't have to feel like an asshole. We (all of us, sympathizers, haters, acceptance activists) turn this into a morality tale, and can't think about this rationally. For anyone that cares, I wear 33" jeans, but I probably need to drop another 20-25lbs realistically.

PS Just giggled thinking about what it would mean to the US economy if suddenly every adult over the age of 28 started eating one small meal every 2-3 days... even our stock market is arrayed against us.

My meal, such as it is, is a salad that fits in a small bowl (less than 2 cups of lettuce and uncooked vegetables). None of this is helped by knowing that people who are so-called medical professionals are giving me is absolute horseshit.

Yup welcome to the bad genetics club. Those calculators of TDEE vs weight/height are only an approximation. Many such cases of people who fall well-below those estimates. Many people need far less food than commonly assumed.

Not just from less consumption, but also reduced productivity--people being tired all the time, irritable, unable to work as effectively or unable to concentrate. This is why tech companies put so much emphasis on food and having cafeterias stocked with snacks or catering.

It makes no sense that a mammal that needs to keep 150 pounds of tissue at 98.6 degrees could do so on so many fewer calories than dogs and chimps. I think you're restricting to the point your body is cutting its calorie expenditure, not finding an equilibrium for a healthy human.

> The debate has never been "will consuming less calories than you expend make you lose weight"

Maybe the debate amongst actual doctors and researchers. But, the debate amongst dummies on the internet (social media) CERTAINLY had people arguing that it was somehow about more than the number of calories in and out.

We should probably stop treating debates among "dummies on the internet" as anything other than noise that muddies up the conversation.

Edit: to be clear, this also applies to comment sections on HN :-)

Quite true!

Internet dummies, and you occasionally get crank doctors espousing these points of view too. Most doctors are smart, but, you know, there are a lot of doctors.

So the debate of the flatness of earth is also not settled based on your measurements of internet sentiment?

I mean, it's certainly settled for me. At the same time, I think it would dishonest to insinuate that there are NOT people claiming the Earth is flat on the internet (Honestly, I don't believe that flat-earthers actually believe that--I think they're all trolling).

So, I don't know. I guess I just wanted to chime in to note that I have seen people repeat this crap about calories.

I dont think anyone has agued that the follow through is the hard part.

The whole debate seems like people violently agreeing with each other aside from some fringe idiots that dont believe in thermodynamics.

who do you mean by "anyone". it sounds that you mean "nutritionists". There are plenty of laypeople who have supernatural beliefs about calories.

there are plenty of obese people who claim that no amount of calorie reduction works. Ozempic has put that to rest. The truth is they were overeating the entire time.

Some people have such bad metabolism that they have to east tiny amounts of food to not gain weight ,way lower than predicted by calculators and controlling for weight. Ozempic makes this easier. Yeah, you're right that overeating is the problem, but this threshold is low for those with crap genetics.

yeah that's not true. every study has shown over reporting activity and under reporting calories

I believe that, but also a lot of online calculators give insane numbers in part because they don't guide people to the right activity level. E.g. if you work an office job, you're almost guaranteed to be sedentary, but people often think they're still "active" because they go to the gym every day.

They're not.

If you account for that, a lot of the calculators make more sense, and a lot of people would be shocked at how little they should be eating.

No, there are definitely lots of people that straight up claim that CICO is a myth, some magic force makes some calories turn into fat or not turn into fat. Totally aside from the "'eat less' is hard advice to take" crowd (which is true). That former group has been proven incorrect.

Unfortunately it didn’t. Seems to have actually emboldened the “CICO isn’t a thing” crowd even more.

The amount of woo-woo “science” in laymen communities on the subject is utterly astounding considering the evidence directly in front of them. Check out the various subreddits for a casual glimpse - anyone saying stuff like “the primary method of action is eating less” is downvoted and the woo woo “metabolism” or “hormones” stuff is upvoted and celebrated.

In the end I think there is a lot of weird guilt around overeating I never really understood existed before. I lost 100lbs using Mounjaro but never once thought it was anything other than me eating too much and moving too little while I was obese. It’s just a lot of damn work and willpower for me to change that. Tirzepatide was simply a performance enhancing drug for my diet that finally put me over escape velocity to make lifestyle changes that so far have stuck for a couple years now.

I’ve been flamed here on HN for asserting CICO is valid. In truth there are few scientists among us.

I don't think it was ever really a debate.

"Reduce calories" is about as useful as "exercise more", "sit less", "drink less", etc, etc. All are obviously good, but for various reasons it can be hard for people to achieve them.

GLP-1's basically take the "how" out of the equation. Take this drug, eat less without fighting your own desires.

All of them are essential as an objective to implement or improve the how.

there are plenty of people who claim that no amount of calorie reduction results in weight loss. Often it's people who are claiming to eat starvation amounts of food while gaining weight. Of course researchers have known it was delusional, but the belief persisted in pop culture. Ozempic is putting that to rest.

this is a case where more personal / colloquial / folk evidence was needed to convince people.

I doubt that the people who believe that obese people somehow violate the first law of thermodynamics will be convinced to change their mind now, just because Ozempic became a thing. They will probably just misunderstand how the drug works.

Yes, "eat less" is the answer, but this is harder to do yeah if your metabolism is slow or always being hungry. this drugs makes it easier to eat less and hence lose weight .

> settled the debate on calorie reduction.

Really? Because GLP1s reduce hunger and food cravings, less of those means less eating, less eating means less calories. The drug just makes people involuntarily fast, it has no thermogenic of lipolysis abilities.

Ozempic tends to change not just the total number of calories but also the timing and the cravings for shitty food.

Calories in / calories used is NOT a complete model because different foods can have different caloric retention. The most extreme example being corn that comes out entirely undigested. Further, shittier foods that the body craves most are also the least satiating over the longer term.

Reducing calories is three or four steps removed from the actual problem. Like arguing the problem is organ failure when in the first order problem is that you got shot. You have to deal with the wound; and you have to deal with the blood loss. That will, in turn, address the organ failure.

I should get more karma for this sub thread

Just coming here to say that most of the world (outside the USA) does not need Ozempic at all to be healthy. So maybe this medication is really a luxury.

I'm not in the US and know plenty of people that use it. It's also maybe a 1/5 of the US cost, even accounting for the exchange rate.

In France it's reimbursed but only if you are diabetic. I'm not sure people talking about it here are diabetic.

This isn't true at all.

The obesity epidemic is international.

https://en.wikipedia.org/wiki/List_of_countries_by_obesity_r...

Self inflicted epidemic...

A disease is a disease regardless..

Telling people to eat less or move more doesn't work and hasn't worked.

It's more like "environmental," eg food deserts, and advertising.

I understand that those drugs are very useful, but in a way it feels for me like ancient Rome with its orgies and vomit inducing so they can eat more. At least looking at USA from Europe. The problem of sugar content, dietary choices and portion sizes remains. It is similar to gas guzzling cars.

Sorry if it seems not empathic enough, that was not my intention. I know that the use of such drugs may be medically necessary.

Edit: To serious answers: I was wrong, I stay corrected.

These drugs (mostly) don't allow you to eat more unhealthy food, instead they make it easier to have the self control to avoid over eating / choose healthier foods.

To add, they actually prevent you from eating some bad foods too. At least in the compound versions that i know people on.

If they eat a lot of foods (some even good), their gastro issues are significant. So not only has it had substantial mental shifts around what they desire, but a bunch of foods are just not edible even if they wanted them anyway.

From what I understand these medications make you want to eat less in the first place, so it's not quite the same thing.

Yup. The people i know on this didn't even get it for the weight, but the behavior changes. This isn't letting them eat the same stuff and lose weight, this is changing what they want to eat.

They went from ADHD driven boredom eaters to not even thinking about food.

I have ADHD and the dopamine dysregulation really makes it hard to avoid eating things with sugar in it.

The semaglutide really helps, I'm on a lower dose of it 0.5mg/week and have been on it for over a year. I've lost a fair bit of weight but that has stabilized. It costs me ~$30 per month and I save much more than that on eating less food.

For me it really helps with chronic fatigue which was destroying my life. I think it really is a wonder drug for people with auto-immune issues. I was insanely sensitive to it when I started which I think is common with people with ADHD so I started really low and only very slowly worked my way up.

My understanding is that the drugs keeps you from wanting to eat as much.

That's just not how these drugs work at all.

If everyone 30+ bmi can get to 30 for “free” (not sure where the subsidizing stops, for me it’s free if I’m over 30 bmi), that’s just too tantalizing to pass up, even if the moral applies.

At least it takes a load off one problem (obesity related diseases). Could it actually exacerbate unethical farming even more or lead to even worse outcomes? Hope not.

This reminds me of my idea to replace EBT with unlimited amounts of soylent

"load off" groan...

I've read that obesity and smoking are net positives for the cost of state-supplied medical care because it causes people to die younger and quicker.

My real concern is what you stated: the by treating some of the symptoms of a toxic food system we will avoid treating the causes (in the USA, we would do well to take soft drinks out of schools and treat adding sugar to foods as an sin to be taxed)

The ancient Rome vomiting thing is a myth. https://en.m.wikipedia.org/wiki/Vomitorium

These drugs reprogram the weights in the LLM between the gut and brain, leading to lower calorie intake.

Sorry if it seems not empathic enough…

You should apologize for making it obvious that you don’t know how the drugs work (as illustrated by sibling comments). If your analogy is “gas-guzzling cars”, I would suggest you revisit your reading on the topic.

One of the mechanisms of operation is to reduce your desire to eat.

Taking a step back, obesity actually is an adaptation. When food is scarce, you want your body to extract and store every gram of nutrition it can get. And that would provide a distinct advantage when you're trying to reproduce.

The thing is, GLPs don't only suppress eating. There are plenty of substances out there that can do that...and there are plenty of people who can't lose weight by starving themselves, because your body will try to maintain its weight.

The question should be "why isn't everyone obese, given the huge amount of calories available to humans?"

> The question should be "why isn't everyone obese, given the huge amount of calories available to humans?"

We're close.

According to the CDC, approximately 73.6% of American adults are considered overweight, including those who are obese

> obesity actually is an adaptation

Obesity is not an adaptation. It's a total aberration. Storing energy in the form of fat is an adaptation. Becoming obese is overloading your entire system.

> why isn't everyone obese

Well... they sure are trying...

> I understand that those drugs are very useful, but in a way it feels for me like ancient Rome with its orgies and vomit inducing so they can eat more.

https://en.wikipedia.org/wiki/List_of_common_misconceptions

"Wealthy Ancient Romans did not use rooms called vomitoria to purge food during meals so they could continue eating and vomiting was not a regular part of Roman dining customs. A vomitorium of an amphitheatre or stadium was a passageway allowing quick exit at the end of an event."

"Two of the most notable examples from Ancient Rome center on the emperors Vitellius and Claudius who were notorious for their binge eating and purging practices. Historian Suetonius writes that “Above all, however, he [Vitellius] was … always having at least three feasts, sometimes four in a day — breakfast, lunch, dinner, and a drinking party — and easily finding capacity for it all through regular vomiting” (Suetonius, Vit, 13) [1]. Similarly, the emperor Claudius was infamous for never leaving a meal until overfed, after which a feather was placed in his throat to stimulate his gag reflex (Suetonius, Claud, 33) [2]. In his writing, Suetonius takes on a disapproving tone when describing the eating habits of Claudius and Vitellius, as highlighted by the use of words such as “luxury,” “cruelty,” and “stuffed”(Crichton, 204). This tone indicates that although binge eating and purging were accepted, albeit uncommon in Roman culture, the practices were negatively associated with gluttony and a lack of self-control. "

~ Ancient Hunger, Modern World by Solia Valentine

Via: https://escholarship.org/content/qt2594j40t/qt2594j40t_noSpl...

[1]: https://www.perseus.tufts.edu/hopper/text?doc=Perseus%3Atext... [2]: https://www.perseus.tufts.edu/hopper/text?doc=Perseus:abo:ph...

Hit pieces aren't a modern invention.

https://blog.oup.com/2014/11/roman-emperor-tiberius-capri-su...

> Stories of this kind were part of the common currency of Roman political discourse. Suetonius devotes similar space to the sexual transgressions of Caligula, Nero, and Domitian – such behaviour is to be expected of a tyrant. The remoteness of the emperor’s residence itself must have fuelled the most lurid imaginations back in Rome.

Suetonius was born in 69 AD; Vitellius was emperor in 69 AD and Claudius was emperor from 41-54. They weren't contemporaries.

If you think that's bad just wait until you hear what Hillary was doing in that pizzeria basement!

The Romans were no stranger to just making shit up.

Purely from a cost perspective - imagine a 79 year old grandma.

Heavily overweight. She is already partially immobile. Pre-diabetic. She may have other conditions, further complicated by her weight. She's on a fixed income.

Which is more probable -

1) A dietary intervention that she attends once a week that revamps her entire daily consumption (but remember, she's on a fixed income) along with some intense exercise?

2) put her on a single medication that changes her tastes for sugary and starchy foods, reduces her cravings, reduces inflammation, and in turn, will make her lighter and more mobile.

It is a no-brainer for Medicare. This will save so many downstream costs.

You may be wrong in the specifics of the mechanism of calorie reduction (reducing appetite vs reducing calorific absorption), but not in the general philosophy.

The obesity crisis (specifically in the US, but elsewhere too) has been caused by bad food essentially - food that is not only nutrient deficient, but also engineered to be as cheap as possible and addictive as possible to get you to buy more of it.

As ever, the US is attempting to fix the symptoms, as opposed to the underlying cause, following the general idea of 'if everyone does what they like, things will turn out ok (somehow)'.

Probably negative health implications of these drugs will surface as people become habituated, and we can continue to shake our heads and wonder how it all went so wrong over there.

It's unclear what the exact cause of the obesity epidemic is. Ultra processed foods are one theory, but not the only one. The US has been down the path before of making public policy from unsettled science, and it led to probably worse food.

Anecdotally, I can say that you absolutely can get quite fat on a diet of abundant "quality", minimally-processed food. It's just a little more expensive. I don't know how the food supply arguments about obesity can land anywhere other than "we should make calories more expensive" or "we should make it illegal to make food taste good", neither of which are remotely politically viable or morally justifiable.

I wonder how much the smoking habit of the greatest generation kept the obesity at bay?

I think it's just a case of our ape bodies not being prepared for a modern world where calories are abundant - which is a good thing! It means people don't starve in developed countries.

We wear clothes because we evolved to not have hair. We wear glasses because we spend more time focusing on nearby objects. Some people need GLP-1 agonists because their body makes them consume food it doesn't need, and there's no scarcity to stop them. It's okay to use technology to adapt our bodies to a different world.

The tradeoff with these price controls is that they make current medications cheaper, but make future medications substantially less profitable, making them less likely to be developed.

It's rare to see this mentioned, so I'm trying to build awareness.

You believe in a lie, most of the insane margins go towards sharholders of private laboratories or insurance companies and other parasites. Very little of it goes toward actual R&D, and the foundational part of it is done by public labs anyway, that are payed for by taxes.

Developing an approved drug costs 1-2 billion dollars.

If you can't recoup that by selling the drug, developing drugs is not sustainable and will not happen. And the US is really the only country where you can sell for substantially more than manufacturing cost.

Ozempic manufacturers do make huge profits now, but that's quite rare. This is a tough industry to make money in.

I find something really gross and dystopian about the idea of Ozempic. Developing the willpower to resist short-term gratification, and the ability to make long-term decisions about your diet and health are some of the most important ingredients to living a good life. The idea of letting a drug do the thinking for you because you just can't trust yourself really horrifies me.

I took compounded Mounjaro for two months. It was like a jolt to the system and got me back on track. I learned how to eat better and alter what I eat plus tracking it. Started walking and going to the gym. Started with 7k steps and now easily over 12k a day on average. I don’t drink soda and if I do it js Coke Zero, Pepsi Zero or Diet Coke. We just don’t buy it. I didn’t know about maximizing my protein and fiber.

It wasn’t short term at all like you say. Something was seriously wrong.

It’s everything though - if it was that easy to just start doing it then people would.

I needed a jolt and impetus to get better. I was depressed, worryful, everything.

I have lost 40 lb. I went from 255 to 229 with the assistance of Mounjaro. I stopped taking it but kept up with the regimen. I am now down to 214.

Some people who take it don’t do it right, they still eat crap and so those are the people who rebound or think they need to go up to 15. I was taking 2.5 then 5 when I stopped.

Yea it is willpower and discipline. Being on the medicine as an assistant along with a lot of research spurred by the community such as maximizing protein, fiber and water intake to become satiated was all that did it with exercise.

Consider the fact that, if a drug can make you skinny, perhaps a drug can also make you fat. Or, even your own body can make you fat. Sometimes, what we think are our choices, have more to do with our biology and environment.

Just like you can't will yourself to be healthy if you are sick with the Flu. Some people can't just will themselves to be skinny. This is why we have drugs and treatments, because our bodies are not perfect machines that work the way we want them to.

> Consider the fact that, if a drug can make you skinny, perhaps a drug can also make you fat.

Yes that would be Prednisone. People call it the devils tic-tac. Its a wonder drug with terrible long term costs to your body especially at higher doses.

Olanzapine, too. Gained 50 pounds on that stuff.

Insulin injections as well. Also, just about every anti-depressant.

> with our biology and environment.

Our biology hasn't changed much in recent years. Our environment has. So has our obesity levels. I mean, it's an "environment" that has "super size," as a default option.

Also, smoking levels have decreased.

Edit: In addition, anti-depressant prescription has sky rocketed.

This is the kind of comment that can change a person's life. Really thoughtful. I'm going to quote it in future. Thanks.

Do you object to pencil and paper because people write down reminders because their memory isn't good enough to remember everything?

Just flip it around: what if there were a drug that made people fat? Is it an insufficient willpower issue then? Willpower works for some, but the drugs make it easier.

Telling everyone "just get better willpower" is about as useful on a societal level as looking at a disabled person at the bottom of a set of steep stairs and telling them that the struggle is good for them.

You just don't understand how food addiction works. Going from 34 BMI to 28 (I'm at 26 now) was the hardest thing I ever done, and I had money, great friends, a great family and a doctor that followed me twice a month.

Willpower is not a muscle, it's a well that fill doing what you enjoy, and clear when used. During my diet, my work ethic was at the bottom, and I couldn't force myself to go out meet new people.

Now that I have a healthier weight and stopped dieting hard (I'm still constantly hungry, but now it's my life), I'm a great coworker, I met a lot of people, made life-changing decisions and I have a lot of willpower left to do all the little things right. If I had a drug that helped me control my appetite at the time, i would have taken it.

> You just don't understand how food addiction works.

Would you concede that some foods are more addictive than others? Doesn't this suggest other remedies like food regulations, at the very least, should be deployed in concert with seeming "miracle drugs" like GLP-1 agonists?

Can't speak for the original commenter, but I would not concede that, because experiencing semaglutide has convinced me it's not true. The feeling I can now clearly recognize as something like "food addiction" disappeared uniformly for everything from Brussels sprouts to donuts.

Yeah, my fridge has been virtually empty of ultra-processed foods for years. Mounjaro silenced the little voice saying "hey, why not go dig into the leftovers?", and when I do find myself grabbing a late-night snack (because my glucose monitor says I need one), I find it much easier to eat a little scoop of yogurt rather than wiping out most of the chicken I cooked for my lunches that week. I have to remind myself to finish things off before they go bad, now.

You have multiple type of food addiction. Most are hormones dependent. For some people, it's linked with insulin, and they will crave carbs, and probably modern diet doesn't help.

Mine is linked to grahlin, I'm just always hungry. Painfully so too (at least it used to be). Do you have a friend who doesn't like to eat, sometimes forget to, and only do so to avoid hypoglycemia? I'm the opposite, I produce too much grahlin, too fast. The weird part is that the more you eat/fatten, the more your hormone production increase.

My solution was regular, multiple days fast. Not calorie reduction (which was slightly painful, and very hard to follow), but full on fast, where the first two days are impossibly painful, but then your body start to ignore grahlin, and the last 3-5 are pretty much OK (hypoglycemia is an issue though, I did it with a doctor). And of course, more fibers in the diet (reducing milk-based products and meat helped).

How have fat people gotten thinner without those meds up until now, then? Was their addiction not as strong as yours, as you seem to imply? They just didn't "understand"? Look, I went from being an absolute fucking fatass to 8% body fat out of willpower alone when I was 17. It took a lot, namely destroying every bad habit I upheld for years regarding food and exercise, but I wanted to do it bad enough, so I did. It was a really extreme and sudden change of mindset, like a flip of a switch, actually, because I had enough of the bullying and lack of self confidence. One day I just got mad enough and changed my whole life.

> How have fat people gotten thinner without those meds up until now, then?

Mostly, they haven't. You and I are outliers.

The population-level data tells us that overweight people are mostly unable to control their weight in the face of modern food. That being the case, it doesn't seem unreasonable to look for alternative solutions to the failed option of just telling people to eat less.

edit: regarding strength of addiction - I mean, of course, isn't it profoundly obvious that different people will have different strengths of addiction? I can drink without the slightest inclination to excess, while others are broken alcoholics. My grandfather didn't have the slightest interest in food beyond the calories needed to survive, while I have to fight every day to eat well.

Exactly, regarding strengths of addiction. I don't feel morally superior about not being an alcoholic... it's pretty clear that my experience of alcohol is just wildly different from some of my friends. I enjoy alcohol fine, but I never feel like I'm exercising willpower when I choose to stop after 1-2 drinks.

>edit: regarding strength of addiction...

It's profoundly obvious you're missing the point, and conflating somehow having a low degree of addiction to something with not being addicted at all to it. Your example about alcohol clumsily compares people addicted to it with people who obviously don't have a problem with it. We were talking, instead, about people, like myself, who had some degree of addiction to food, and still found it in themselves to overcome that shit. So it's two groups of people: addicts who beat their addiction, and addicts that didn't; not addicts and non-addicts, like you explained. Your examples, as you can see, are totally irrelevant and miss the point completely.

You also seem to imply that the degree to which you're addicted to something is the sole factor determining whether you will overcome your addiction or not, leaving your own will out of the equation. It should be logically self-evident that the fact that somebody beat their addiction says close to nothing about its "strength". One could have many physiological and psychological predispositions to food adiction and still beat it, while somebody with just a fraction of such problems could live a miserable life and never do away with it.

Me> different people will have different strengths of addiction

You> It's profoundly obvious you're missing the point, and conflating somehow having a low degree of addiction to something with not being addicted at all to it

Suggest applying some of that willpower towards paying attention to what you're reading.

> You also seem to imply that the degree to which you're addicted to something is the sole factor determining whether you will overcome your addiction or not

I don't imply anything of the sort. Willpower is one variable, level of addiction is another. What I do imply is that without deeper observation of a person's life, and the other areas in which they might demonstrate willpower, you can't make strong conclusions about their lacking willpower based simply on their weight.

Based on all I know about you (or you about me), we could each be people of tremendous willpower who overcame titanic odds to beat our food addiction, or we could simply be people who really quite like food who tried hard and overcame our mild predisposition.

the guy you're replying to also lost weight without the drugs... he says he would have taken them if they'd been available.

> Willpower is not a muscle, it's a well that fill doing what you enjoy, and clear when used.

I won't negate your experience, since this is such a personal thing, and it's not like we have a rigorous scientific understanding of these things. But to me, willpower does feel like a trainable thing. Doing hard things seems to make me better at doing other hard things. Limiting my TV makes me less likely to compulsively eat later. Working out hard makes me less likely to lie in bed scrolling on my phone. Doing hard coursework makes me more focused at work.

The caveat is that these changes seem to happen pretty gradually, and the gains can be lost pretty easily, just like with muscle.

But being in a perpetual caloric deficit can be pretty rough and can definitely sap your energy. Glad you found your way to a healthier weight.

It's different per thing. Yes, working out gives me energy (even though I hate it and am bored out of my mind doing it), but going hungry or resisting food isn't the same kind of thing. If I had a bad day at work, I'll usually go "fuck it" and eat a pizza. If I've gone hungry all day because I'm eating what I should, I'll be cranky and not as much fun.

I can definitely relate with the GP, even though your comment is relatable too. They're just different mechanisms, or they apply differently to different people.

Tangential to the discussion, but I'd encourage you to not give up trying to find a form of exercise that you don't find boring. It makes it much easier to get adequate exercise. Also, not having to spend time doing things you hate is nice.

For example, personally I find lifting in the gym or running on the treadmill to be quite boring. I like biking and running outside, especially on trails. A lot of people enjoy group classes like crossfit or yoga, since the social reinforcement can make it psychologically a lot easier.

Καλή τύχη.

Yeah, I (try to) cycle and play tennis, but due to some circumstances both are less frequent than I'd like. You need to lift weights too, though, to build and maintain muscle, so there's no getting out of that. I'll definitely need to do more cardio, though.

Thanks!

I do make good decisions and put in 10k steps everyday, which according to my stepcounter puts me in the top 5% for people my age. I've managed to slow my progression into the abyss; but I'm still going there.

Truth be told, my body can't effectively lose and maintain weight unless I'm eating a strict 1500 calories and replacing the walking with an hour long run each day. I know this because I've tried it and managed to maintain it for 6-months. It was a herculean effort and despite the results I paid a toll both physically and mentally. This isn't to say that the laws of thermodynamics don't apply to me; but my body will fight against them harder than most.

(I believe I would be a good candidate for these drugs. The only thing stopping me is the thought of having to be on them indefinitely.)

Respectfully, have you ever had anything in your life that you have struggled desperately with, and needed help? Anything at all that might give you a little empathy on the topic?

I was obese twenty years ago, and lost the weight via diet and exercise. Keeping that weight off is the single hardest thing I have ever done, and a battle I still have to consciously fight every single day. Doing so causes me a great deal of pain and frustration, and I know that I'm someone who is right on the edge of not being able to control my weight. Why should it be that difficult? So that I can pass some kind of purity test?

The fact is that the food we eat has evolved over time, and is too hard to resist overconsuming for a large fraction of our population. If we can create more addictive food, why not create antidotes? If we could easily treat alcohol addiction with a pill, would we tell alcoholics to just apply willpower instead? Why would we want people to suffer like that?

There is multiple effects fighting against people who want to lose weight:

* habits. often times, obese people use food as a stress response, as a reward, etc. this then makes them relapse.

* "target weight" of the body. there is a memory effect where once you have built up fat tissue, your body wants you to return to that weight. In other words, it's not just the first step that's hard, but all the steps thereafter. Relapse is easy.

* fat tissue makes you more hungry.

* environmental issues, like unwalkable cities, an entire industry putting chemicals into foods that make you addicted to them, its excessive marketing, missing availability of non-processed foods (large percentage of US population lives in food deserts), etc.

It's not just discipline of the individual holding them back.

It's also unlike most addictions, you have to eat few times a day if you don't want to die... alcohol, drugs, gambling are not required to survive, eating is.

I don’t understand why the USA doesn’t just ban processed foods? I know USA only cares about profit but come on. Other countries don’t eat like we do.

Obesity is not just a USA problem.

Because there's no coherent regulatory framework to "ban processed foods", no country has ever done such a thing, and it would be political suicide to be the party that banned cheeseburgers, french fries, and Coca-Cola.

Ozempic helps many people make better long-term decisions about their diet than they would otherwise. Do you think no one without extraordinary willpower should be able to "live a good life?" The drug doesn't "do the thinking for you."

Would you be horrified at drug that made heroin addicts not want to do heroin anymore?

I know it's an unpopular opinion, but I agree, at least partially. I think you're underestimating the "developing willpower" part, but I do think that helping people lose weight the themselves should be the solution, not chemicals.

These weight loss drugs are conditioning people to feel satisfied with less food in their stomachs, but only while they take the medication. If you don't put the same serious effort into improving your lifestyle, you're going to end up overeating again, gaining all that weight back, and probably going back on weight loss pills. Instead of solving the unhealthy dependency on food that most seriously overweight people struggle with, you're adding a dependency on medication.

Where I live, these drugs haven't even passed medical review for weight loss yet, they're purely prescribed for diabetics. That doesn't stop the illegal second hand market (taking drugs out of the hands of diabetics that are much better served with them) unfortunately.

In general, I do think weight loss drugs are better for society as a whole, as they save people from the ticking time bomb that is obesity, but I wish we could come up with a better solution.

The best way to change your lifestyle is to change it, and GLP-1 agonists make it easier to change your lifestyle. In fact, they don't work at all if you don't. Someone who's unable to change their diet and exercise routines while taking a GLP-1 agonist wasn't going to be able to do it without the medication, either.

And this talk of "dependency on medication" is ridiculous. Lots of people take medication every day to live a better life, or they use medical devices like eyeglasses and hearing aids, etc. That's one of the blessings of modern society.

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