rich-cartwright

Bigger spend is definitely important. Drug approval, decentralized decision making, consumer norms all also important.

Yep exactly - the prescription drug element requires state-by-state medicine licenses.

Well written. These are all core aspects of our coaching program to improve metabolic health: improve sleep, reduce stress, more pleasurable activities, better food choices, sustainable exercise routine, reasonable portion sizes.

The "small goals" is also critical to counter all-or-nothing thinking. We use a mix of behavioral & cognitive approaches to try to cement the improved habits & ways of thinking.

If you had a bigger family member who had tried everything, what would you recommend to them?

The sustainability of approaches is what we hear most from the Fellas. Most diets work in the short run but aren't sustainable long-term, especially when you're already battling against your metabolism.

"calories in" (too much or wrong things) is for sure important - but focusing solely on this when we're looking for practical solutions is not the most helpful framework for people who are fighting obesity.

It is interesting how divisive conversations around weight can be. For a lot of people, it represents a broader theme of we view individualism & morality.

Interesting references.

UK market is tricky for a few reasons. Very centralized decision-making for healthcare funding, and the timelines are too long for a startup to survive. Plus us Brits are definitely more hesitant of medication approaches in general, although that is changing.

Both my parents, my sister and my brother-in-law work in the NHS - so lots of interesting family conversations about this!

Perfect! Working our hardest to get live in WA in the coming quarters.

Sounds really interesting. Would love to hear from you: my email is richie@joinfella.com

Keeping food out of the house is a powerful behavioral device. It takes away the "Ability" part from the Fogg Behavior Model if you find that framework helpful.

Interesting. How long have you been doing keto this time?

Yep CBT (and third wave cognitive therapies in general) are very effective against emotion-based overeating (e.g. stress eating). Stress eating is widespread and addressing it is a core part of our coaching.

Important to say not everyone struggles with stress eating, which is why our coaching program goes much broader than that.

The metabolic medication aspect is also really helpful, which is why we combine the two for Fella.

1. Stress causes the adrenal glands to release a hormone called cortisol, and cortisol increases appetite.

2. When stressed, we look for relief - and for a lot of people that relief comes as food, or the act of eating itself.

Both of these often lead to overeating which is a cause of metabolic disease.

haha Luke beat me to it

This is probably a bug in our infra! We're on it now to fix. If you email richie@joinfella.com I'll sort you.

Yep really good point about the family dynamics - lots of the Fellas talk about how having teenage kids around makes the dietary side really tough.

How the coaching works in the program is that we dive in at the start to really understand the 1-3 key leverage points where we can make the most impact - then focus all our coaching time on these.

Yep spot on about the sustainability. We hear this all the time from the Fellas.

15% average body weight loss was the breakthrough study: https://www.nejm.org/doi/full/10.1056/NEJMoa2032183

Important to emphasize that diet & exercise are only two parts of broader metabolic health. Sleep also very important.

And something our program focuses a lot on is stress eating. Very prevalent and a big factor, but normally overlooked.

We've heard this a lot..

Really good question. In our customer dev, we tended to find the older guys were a more motivated initial audience because health concerns are more top of mind. Plus there's still a lot of hesitancy & stigma around medication for obesity, but the older guys are more ready to take that step.

Fella works just as well for younger guys. Any more questions I can answer?

Emailed you!

It's a possibility. There's already another YC co doing great things in the addiction space: https://www.quitgenius.com/

We'll have to see. We have a long way to go in the coming years reaching the 35 million men in the US who are fighting obesity.

Not for the coming year. We'd love to as soon as we have capacity!

Our focus is the US for the coming year or two. The state-by-state expansion is tricky for telehealth companies. But we're British founders so we recognize that this is needed in many other countries in the coming years!

Eloquently written.

It's important you've written this. We need to have frank conversations about obesity. It affects a lot of people and a lot of people have very strong views on the best solution.

I'll focus on one area of your post: "They will have developed no good habits at all. They will not have a clue as to how to manage stress. They sure as fuck are not going to understand that exercise is important and necessary. They are not going to become discerning about what they eat...They will pop your pills as they suck-in a two liter drink with insane amounts of sugar and inhale cheap carbohydrates in their burritos, burgers, pizza, etc."

I want to emphasize how wrong you are here.

Fella is a 12-month program, with continued support for the rest of your life after that first year. The program is focused on:

- building resilience to stress & other testing emotions

- building a sustainable exercise habit which is enjoyable and sustainable

- building healthier eating habits which are realistic & sustainable

- building sleep habits which help improve metabolic health

In terms of the medication, it's really important to listen to obesity specialists here. They are trying to find practical solutions to help people. It's clear that moral indignation isn't working so far.

These are all legitimate concerns you raise. Know that I have researched this deeply, and genuinely believe this is the best practical solution to help the most amount of people.

Please let me know your thoughts.

Spot on about fasting, and keto has solid evidence as well - https://www.virtahealth.com/ are a great company focused on this.

The issue is we're starting to have a more nuanced understanding of the metabolic resistance people face when they undergo dietary changes - basically the body fights hard against you as you try to lose weight by dieting.

So it's now industry-standard among obesity specialist doctors to see obesity as a "metabolic disease" which, for the vast majority of people, needs a medical approach which doesn't rely on willpower.

Haha fancing seeing you here