[wonderwonder]

"Diabetes patients think people with obesity are stealing their drug, as it’s currently only approved for the treatment of T2D (though FDA approval for the treatment of obesity may come as soon as this summer.) People with obesity are angry that obesity isn’t recognized as a disease. And users who can’t afford it say they’ve been abandoned by Big Pharma."

Always amazing when an article is verified in real time

[bedast]

It's weird for anyone to "feel abandoned by Big Pharma" when you abused a coupon to get a drug for off-label use, and terms were changed to match its on-label use. Especially when there's versions of these drugs with on-label use for weight loss.

[somehnguy]

Why should anyone need to use a coupon in the first place? Just charge a reasonable price, don’t make people jump through hoops for medicine.

[bedast]

Brand new drugs tend to take a while to get on insurance formularies. I believe Mounjaro is still missing in most formularies. Lilly wants people on their drug, not the competition.

[somehnguy]

So just yet another case of the American healthcare/insurance system being absolutely bottom tier in usability, profits for middlemen over all else.

[bedast]

This is not only an American issue. I've seen people in the UK struggle to get access to treatments and devices through the NHS. Canada tends to follow what the US is doing even though they have their more socialized system. It all tends to be a bit of a mess with brand new drugs and devices. And Mounjaro is new as of last year (approval less than a year ago?).

[spiralx]

No, drug approval takes time everywhere with a health care system. Heck I've been on methylphenidate for my ADHD for almost 15 years now, and it's still off-label when prescribed to an adult in the UK according to the NICE.

[HyperSane]

With very few exceptions obesity is simply the result of eating more calories than needed for a long time. Very obese people eat a LOT of food. 10,000 calories/day for years is not uncommon.

[eyelidlessness]

From high school through nearly all of my adult life I’ve been obese. For the last several years my weight has barely fluctuated, but it’s fluctuated between caution about being underweight and a few pounds “overweight” that barely even count. I’ve eaten almost exactly the same the whole time. The two factors which changed:

- I take ADHD meds, amphetamines, which are appetite suppressants. They haven’t made me eat less, and they’ve reinforced “bad” eating habits I used to have before I lost so much weight, specifically reinforcing my tendency to eat one, large, meal per day.

- I’m much more active than I used to be, because I got a pup who needs the activity and with whom I like to be active.

My caloric intake is about the same as it’s always been. Once I actually paid attention to it I realized it wasn’t even very high. I very seldom reach the recommended 2000 calories diet metrics are based on. I still don’t understand how eating that way made me obese, but I have to assume now I was just absurdly sedentary.

I got lectures like this about caloric intake for years and always found it interesting but confusing! How was I so fat and never eaten much?

I’m not saying this applies to anyone else, but it’s bothered me for decades that I’d been told calories in -> obesity meanwhile my own caloric intake had next to nothing to do with my body mass.

[HyperSane]

People are notorious for underestimating how many calories they are eating. Modern food is so cheap and delicious it isn't hard to eat 1000 calories in a few minutes. I lost weight by only eating food with accurate calorie information available that I could weight to the gram. I then used MyFitnessPal to track it and keep a 1000 calorie/day deficit.

[eyelidlessness]

I’m eating basically the same food, basically the same quantities, and I did start paying attention to the calories. Amusingly I started paying closer attention when I was worried about losing too much weight, and when I found myself frequently craving sweets (which I very seldom have since I was a kid).

[phil21]

The simple act of tracking things - even with no intent to change - typically makes me eat far less, or do the activity far more. Anecdotes with friends makes me believe this is quite common.

There is literally no way to take in more calories than you expend and not gain weight - short of hyper-specific and exceedingly rare medical conditions you'd be quite aware of.

Some people find this easier or harder than others due to a whole host of factors. Physics is physics though, and there is no way to run a calorie deficit and not lose weight. It's why this drug class is so interesting/popular - it lowers the bar for many people, making the effort of taking in less calories than they expend much easier to achieve.

[eyelidlessness]

> The simple act of tracking things - even with no intent to change - typically makes me eat far less, or do the activity far more.

When I started tracking things so closely, I was already concerned that I’d been losing weight and feeling very strong cravings for sweets which I don’t usually care for. The effect wasn’t that I ate less: I started making an effort to eat more, again much like I used to eat. The biggest change is that eating enough has been a concerted effort rather than fairly automatic.

[nradov]

Odds are you are consuming more than 2000 kcal/day. Most people underestimate. Have you tried weighing and recording everything you consume for a couple weeks?

Anyone who wants to lose weight should start with a resting metabolic rate test in order to establish a baseline. You just sit in a chair for a few minutes while a machine measures your inhaled and exhaled gasses to calculate energy expenditure. If you consume fewer calories than your RMR then it is impossible to not lose weight.

[eyelidlessness]

This is a confusing response. I do not want to lose weight. I had to pay more attention so I could stop losing weight. Your advice might be good for someone with a different problem, but (1) I don’t have that problem and (2) I addressed the problem I did have by eating more.

[HyperSane]

Have you every reached 600 pounds? 800? If not why do you think that is? It is because you simply didn't eat enough food to do so.

[eyelidlessness]

I reached about 350 lb, and my current weight is just shy of 190. I’m eating almost exactly the same, with some minor adjustments for taste changing over time. What I eat now would still be ill advised for anyone trying to lose weight. The thing that changed is I burn a lot more calories than I used to. Everyone pointing out this basic fact is right, but the focus on calories in is wrong in my case, and I find it pretty odd to totally dismiss the calories burned factor.

[HyperSane]

No one is dismissing calories burned, it is the calories out part of CICO but it is vastly easier to reduce caloric intake than to increase caloric burn. as an example for me it takes an hour of walking to burn 400 - 600 calories.

[wincy]

I agree with you, but have a few qualifiers about it.

I decided I want to lose weight for the third time in my life. A few weeks I was probably eating 5,000 calories a day. I’ve lost 15 pounds in three weeks. Basically before every day I’d eat and eat and never ever feel full. My stomach would hurt, I’d throw up every day, I felt tired and shitty every single day.

Now I can barely managed to eat 1400 calories a day. I’m eating red meat and kimchi, basically. That’s my diet. Once a week I’ll crave a nice big salad with mushrooms and olives and ranch dressing. I feel great. If I try to exceed that calorie amount I’ll feel super satiated (not full, like physically full) and stop mid bite, and save the rest for later. It feels like a long dormant part of my mind that controls calorie intake suddenly has a voice again and that voice has been drowned out for years.

So I mean it’s easy to say “it’s just calories”, but why when I eat a standard American diet am I craving thousands of extra calories per day and that stops when I eat like this? Even stranger, why do I relapse into these habits when I eat even a small amount of food like French fries or ice cream, over and over again? I know precisely why I’m fat, exactly what to do to lose weight, it’s not even difficult, but unless I have a very strong motivation to lose it I just don’t.

Most people don’t even have the requisite knowledge of how to deal with hunger cravings and get themselves in a state where they’re losing at all. They’ll eat chicken breast and a salad with no dressing then wonder why they feel awful because they’re not getting nourishment, then binge on ice cream. So how is the average person supposed to lose weight?

[AdrianB1]

A friend that is a doctor specialized in metabolic problems told me that around 5% of the cases of obesity have some medical cause, not eating too much. 5% is low, but it is a lot more than "very few exceptions". (Disclaimer: the number is for Europe, I have no idea what is in US)

[HyperSane]

All obesity is fundamentally caused by eating too much because fat contains energy that HAS to come from food.

[Dove]

Well, blood sugar contains energy that has to come from somewhere, too, but one would hardly say this means type 2 diabetes is fundamentally caused by eating too much. Shoot, tumors contain energy that has to come from somewhere...

Of course, you could rightly reply that there are a lot of complicated things that happen between the food and the problem, and while those diseases require an energy surplus, that neither causes them, nor does trying to naively eliminate the energy surplus fix them. Contrary to popular wisdom, the same is true of obesity.

The idea that obesity could be avoided or cured with a little bookkeeping and self control is laughable to just about anyone who has tried. Telling obese people to eat less is like telling depressed people to get over it. You'd be astonished by how ultimately impossible that is if you haven't been there.

[HyperSane]

The entire purpose of fat is to store excess energy for future use because over human evolution food supply was unreliable enough for this to create an evolutionary advantage. Getting fat from eating a lot of food is completely predictable.

"The idea that obesity could be avoided or cured with a little bookkeeping and self control"

It absolutely can. Again people just don't want to feel bad about not having enough self control.

[Dove]

>>"The idea that obesity could be avoided or cured with a little bookkeeping and self control"

> It absolutely can.

No it can't. ;)

Well, not always. I've experienced both sides of this: an effortless loss of 60 lbs with easy diet changes and bookkeeping over the course of a year and a half. And a few years later, an abject failure as the same strategy -- a moderate calorie restriction -- resulted in such profound physical distress that I developed psychological problems long before I made any physical progress.

Sometimes it's easy. Sometimes it's impossible.

My story is far from atypical. It's common. Practically universal. Everyone, just about everyone, who tries to lose weight, using any strategy, succeeds over a period of months, and fails over a period of years. The reason is that the underlying control mechanism is in a different condition, in different people who may be the same weight.

> people just don't want to feel bad about not having enough self control.

I know you're really attached to the energy imbalance theory of obesity. People often are. But I'd like to suggest that this comment suggests you may have a different motivation for believing in it than just that you find the evidence persuasive.

I often wonder why people get so attached to a theory that I think is in such obvious evidential crisis. A need to believe a simple solution will be there when they need it? A traumatic dieting experience that they need to believe was necessary and useful and healthy? Maybe it worked for them once and they're universalizing their experience? A desire for moral superiority? The fact that deliberately oversimplifying things makes for slam dunk messages on forums?

I don't know, but diet is one of those weird topics where people are attached to their opinion with the religious fire of a thousand suns. While I know I won't change your mind, it does seem fair to point out that your statements are both hyperbolic and inaccurate, and that's not a good sign.

[Dove]

> The entire purpose of fat is to store excess energy for future use

That isn't true. Though it's a primary use, the opening paragraph of the wikipedia article on fat outlines that it actually has many biological functions (and is properly thought of as an organ!): https://en.wikipedia.org/wiki/Adipose_tissue

> ... because over human evolution food supply was unreliable enough for this to create an evolutionary advantage. Getting fat from eating a lot of food is completely predictable.

Not at all. While fat does have a primary function as an energy reserve, that does not mean that unregulated growth is a simple matter of putting too much energy into the system. After all, just as in nature there are times of famine, there are also times of feast. It would be pretty disadvantageous for animals to have no regulation on their fat growth in times of abundance. Something more has to go wrong to cross the line from "saving for a rainy day" to "killing you". Animals don't eat until they damage their stomachs, do they? Not generally. Why does it make any more sense that they should eat until they damaged their endocrine systems?

An interesting counterpoint: bears hibernate. In preparation for doing so, they become fat by eating a lot. Now, they do this, not just any time of the year when food is abundant, but specifically in the fall as they prepare for the winter. Are they just lucky that food happens to be abundant every fall? Or is something else going on? What happens in years of famine? Do they still manage to get fat so they can hibernate?

Another interesting counterpoint: Pregnant women eat a lot and put on weight. Why do they do that? Is it because more food is available? Or is something else going on?

One last counterpoint. Bodybuilders put on a lot of muscle, which also takes energy, and they eat a ton to support that growth. Why is it that if I eat an extra steak, my flab gets bigger, but when Ahnold eats one, his biceps get bigger?

Obesity is dysregulated growth. While growth does require energy, it is in the failed regulation of that growth that you will find the best explanation for the disease.

[yunwal]

> It absolutely can

It can’t. There are many people who, if they simply scaled down their diet without otherwise modifying their nutrient intake/lifestyle, start having health problems well before they lose weight. Hot flashes, fainting, severe stomach pains, nausea.

[nradov]

Type 2 diabetes is fundamentally caused by eating too much of carbohydrates. Most type 2 diabetics can put the condition into remission by changing their diet.

https://www.virtahealth.com/research

There are many people who have cured their obesity with a little bookkeeping and self control. Sue Reynolds and David Goggins are a couple of prominent examples, but there are many others. It's not easy, but it's certainly possible.

https://suereynolds.net/book/ https://davidgoggins.com/book/

[Dove]

> Type 2 diabetes is fundamentally caused by eating too much of carbohydrates. (Emphasis mine)

Fructose, specifically, is the going theory. And I'm a big fan of Virtahealth specifically, and Dr. Fung's approach for treating type 2 diabetes generally. :)

However, I'd disagree that we know that that's what causes it. We know that treats it. Cancer is not caused by a lack of chemotherapy, and I think chemotherapy is a good analogy for the fasting and low carb approach in this situation. It is a treatment, not a generally normative lifestyle.

But my point is actually more limited, and you actually sort of made it for me by adding the detail about carbohydrates. To wit: just because sugar requires energy, does not mean that you got too much sugar by bringing in too much energy. It's not that simple. You won't get the disease by eating too much protein, for example (you'll get protein poisoning ;) ). You get the disease as a result of liver dysfunction, which you exacerbate and possibly cause by eating too much fructose. It's a control mechanism problem and an injury problem -- the fact that energy is involved (even required!) does not make that the central issue.

Cancer requires energy for growth, but that doesn't make energy the central problem. Blood sugar requires energy for dysregulated high levels, but that doesn't make energy the central problem. Fat requires energy for dysregulated growth, but that doesn't make energy the central problem. That's something you have to demonstrate, and rigorous attempts to demonstrate it fail.

> There are many people who have cured their obesity with a little bookkeeping and self control ... David Goggins

Citing David Goggins as an example of "a little bookkeeping and self control" is hilarious to me. I've read his book. I love his talks. But the guy is about as heroic and extreme as it is possible to get, and that is far from the only thing he did.

[unmole]

> but one would hardly say this means type 2 diabetes is fundamentally caused by eating too much.

Eating too much is literally what causes type 2 diabetes.

[swatcoder]

Technically right is the most reliable kind of right, but in this case “too much” means that someone’s body responds differently than expected to the same amount of food.

It’s true that the extra stored fat might must come from calories not used or excreted elsewhere, but that might be because their body is very poor at making immediate use of the calories as energy or is unusually efficient at storing energy that might otherwise be used. To put a number to it, a 2000 calorie diet as normally recommended may leave them depleted of energy and increasingly fat.

It can take years to discover that kind of “outside the norm” issue, and obesity can easily set in before its recognized let alone addressed. And of course, once obesity does become a part of someone’s life, there’s a whole spiral of challenges that make it hard to overcome. Even moreso when your body doesn’t work normally.

[perfecthjrjth]

Calories In Calories Out (CICO) doesn't explain obesity. You are dealing with biochemical machines (humans). CI enters this biochemical machine; here, the signal system should be effective to 'equalize'. Otherwise, you get all kinds of problems: obesity, t2d, cardiovascular events, etc.

These new generation of drugs (semaglutide, tirzapatide) deal with the signaling system (endocrine signaling, that is).

[HyperSane]

"Calories In Calories Out (CICO) doesn't explain obesity."

Yes it does, because it is basically just repeating basic laws of thermodynamics. Obesity is actually just the body working as intended by storing the excess energy for future use during a famine. CICO is why obesity used to be very rare in past when calories were expensive and is now common when calories are very cheap and artificially delicious.

[perfecthjrjth]

Well, two conceptions of human beings are in conflict: (a) humans are controlled by their own "will" (b) signaling system (biochemical interactions) control stuff. (a) is a cultural intuition. Now many life sciences researchers sell us a hybrid version: both (a) and (b) are true.

[kilgnad]

No. Absorption rates are different. Liquefied fat of the same calories translates to more fat then plant with the same calories.

That's just an extreme example. The real culprit is processed foods.

[HyperSane]

The difference should not be enough to be the difference from a body fat percentage of 15% to 80%.

[kilgnad]

https://www.theatlantic.com/health/archive/2015/09/why-it-wa...

You don't know that.

[galangalalgol]

Thermodynamics obviously holds, but I'm unsure what you implication is. If it is that the obese should simply eat less, that doesn't seem terribly useful though it is completely true.

[HyperSane]

The implication is that obesity is not a disease, it is actually the human body working as intended by storing the excess energy as fat for future use.

[Clubber]

Do you think depression is a disease? I would argue obesity is certainly a symptom of depression in some people.

[kilgnad]

1 in 3 people in the US are obese. It is not just about eating more calories than needed for a long time. The story is much much more complicated then that given that 1 in 3 people are obese.

It's like saying an overdose on heroin is simply someone doing too much heroin at a time.

[HyperSane]

"It is not just about eating more calories than needed for a long time."

Yes it is. It really is as simple as that, people just don't want to hear it. Historically food was scarce that it was nearly impossible to sustain a calorie surplus long enough to get fat. But some people did, that is why the rich used to be called "fat cats" but now calories are so cheap and delicious and lifestyles are so sedentary that it is very easy for almost anyone to sustain the caloric surplus needed to become very fat. I had a cousin who reached 650 pounds and then died. He would spend hours every day eating and almost as long shitting.

[kilgnad]

>Yes it is. It really is as simple as that, people just don't want to hear it. Historically food was scarce that it was nearly impossible to sustain a calorie surplus long enough to get fat. But some people did, that is why the rich used to be called "fat cats" but now calories are so cheap and delicious and lifestyles are so sedentary that it is very easy for almost anyone to sustain the caloric surplus needed to become very fat.

I'm skinny so I'm unbiased. There is nothing I "don't" want to hear because I'm literally not affected by it. Thus, I assure you I have more information than you. Read below:

https://www.theatlantic.com/health/archive/2015/09/why-it-wa...

Your reasoning is on anthropological timescales, which while technically true, doesn't explain why people were still skinny in the 80s and before. There was an actual turning point AFTER the 80s... A huge shift in weight gain where MODERN and well-fed people suddenly got heavier. Something happened with the food supply starting with the US.

We only have correlative studies that match a number of things with the sudden change in weight. Thus no causative confirmation on the exact source. Our educated guess says that it has to do with processed foods. Processed foods streamline calorie absorption to unnatural levels leading to unnatural weight gain.

The article above mentions a number of other factors that I think are possible.

[HyperSane]

Self-reported calorie consumption is worthless.

But a reader questions the methodology of the researchers: “My main concern is that the calories are almost assuredly self-reported, which is notoriously unreliable.” Another reader agrees:

    In the 1980s, we weren’t walking around with a computer in our pockets to look up accurate calorie counts for everything that allowed us to store an accurate list of everything we’ve eaten and compute the calories based on that database. It was 100% self-reporting and calorie lookups “from memory” or done manually (complete with calculations) long after the fact. So the reports based on that old data might be suspect.

But another reader notes:

    The study authors addressed that point somewhat:

    Whether self-reported dietary intake accurately reflects an individual’s true dietary intake has been questioned. Indeed, doubly-labelled water studies typically show that individuals underreport their energy intake, and that the magnitude of the underreporting may be larger in people who are obese.

[kilgnad]

Lots of stretching of the imagination here in attempt to fill in the gaps in your bias. I mean you had to dig for this stuff in order to support your stance. Why not let the facts change your conclusions as an unbiased person should?

The fact of the matter is, people weighed less in the 80s then they do today. No amount of stretching can change this quantitative measurement. So something must've changed. What changed?

You can continue to talk about calories in and calories out just like we can blame the overdose problem on people doing too much heroin. Again, while YOU can do that, it's not a very useful position.

[anonuser123456]

Great. Now answer why they eat that much.

[HyperSane]

Addiction to the dopamine rush it gives them.

[DangitBobby]

Did we read the same comment?

> If you want a GLP-1 RA (this drug class) for weight loss, go get Wegovy or Saxenda, which are a version of these drugs approved for weight loss for those with a BMI over 30, or wait for the tirzepatide version. Leave the diabetes drugs alone.

Definitely think it's forgiveable and even rational to be upset that droves of people are creating shortages of a medicine you need with off-label use, however legitimate.

[wonderwonder]

I'm not saying that the feelings are unjustified. I just thought it was interesting to see the article confirmed so quickly. If I needed a medication intendeded for my illness and couldn't get it I would feel the same way.