[Calavar]

I am a doctor, so let me give you the perspective from the other side.

A friend of mine who works in primary care has a policy of not prescribing semaglutide unless a patient has tried at least three months of diet/exercise first. She now has a long list of patients who decide to screw that and self-refer to a specialist who'd write them the script. I don't work in primary care myself, but this more or less matches my own experience - 95% of people do not want to put in the effort of changing diet, exercise, and other lifestyle habits. They want a quick fix.

In the words of Ronnie Coleman, "Everybody wants to be a bodybuilder, but nobody wants to lift no heavy-ass weights."

So I really do think the popularity of semaglutide is a bottom up phenomenon. There is has been huge consumer demand for a weight loss drug for decades, and pharma is only now meeting that demand.

> doctors having intimate financial relationships with pharma is already a public secret

A small number of elite doctors have intimate relationships with pharma. The other 99% who are prescribing semaglutide do not profit from it. In fact, it's the other way around. You can't bill for the act of prescribing medications, but there are dedicated billing codes for counseling a patient on diet/lifestyle modification.

[CalRobert]

I agree with you, but people shouldn't really have to put in the effort to change diet or exercise or lifestyle habits. But the environment that produces those habits SHOULD change.

I lost a bunch of weight when I moved to Dublin and started walking everywhere. Then I moved to the Netherlands and lost even more, and got stronger. I didn't particularly try, I just lived somewhere where I used my own body to get around and the "normal" portion sizes were actually somewhat sane (a bag of Doritos here is maybe a third the size of one in the US).

I was 280 pounds when I lived in suburban California. I'm 180 pounds now.

Build bike lanes and public transport, put schools where kids can walk to them, and maybe don't sell a thousand calories of chips in a personal-sized and marketed bag, and it should get better.

As an added bonus you get a lot less air pollution (and noise pollution, etc.) and less people being run over!

[stavros]

Sure, but if I'm overweight and unhealthy now, taking medication is a better bet for weight loss than lobbying for rezoning my entire city.

[vincnetas]

why not do both. But yes, after taking a pill it's very easy to forget about the need to improve environment. Until you need to take another pill again, and again...

[philistine]

It's literally the point of Brave New World. The whole populace is hooked on beneficial drugs so they don't want to improve themselves and their society.

[toomuchtodo]

Would you feel differently if instead of being hooked on drugs, we deployed gene therapy at scale to patch the dysfunctional pathways Western society and economies have taken advantage of? What if patching the genome is helping people so that they have capacity to contribute more to improving society? Consider not only the metabolic changes a GLP-1 agonist encourages (a vaccine against Western diet, if you will), but also inhibits addiction.

GLP-1 pharma intervention is breadboarding the human, next step is a permanent fix. Adversarial bioengineering, if you will.

[philistine]

Then you get into Iain Banks' The Culture where every citizen is basically an artificial creation. I have no problem with any specific solution to our societal problems, I take issue with their externalities.

Regarding your proposed gene therapy, would this gene therapy be available to anyone? Could it be refused? Is it reversible? Who would pay for it? The beauty of The Culture is that it is not monolithic, has no border, has godlike AI that takes care of all the problems, and can be abandoned or joined by anyone.

[stavros]

I think the cost of the pill is a pretty strong incentive to want to stop taking it. If the pill is cheap and harmless, then that's just great, there's no need to spend effort improving your environment at all, you've solved the problem already.

[hollerith]

>you get a lot less air pollution

I know what you meant, but according to a comment here once, European city streets actually have worse air pollution than US ones because Europe went hard for diesel engines (to reduce CO2 emissions) for its cars, and diesel produces a lot of very small carbon particles, which turned out to be more harmful than most people suspected back when the diesel decision was made.

[twiss]

Amsterdam has banned most diesel vehicles [1], so at least this is not universally true (anymore).

[1]: https://www.amsterdam.nl/en/traffic-transport/low-emission-z...

[CalRobert]

Indeed, and I’m worried about the same old mistakes being made with EV’s. They produce lots of tyre particulates thanks to being so heavy, which then get in to our brains.

Of course, Volkswagen lying about their diesels and killing people in the aggregate didn’t help.

What we need is car-free or low-car cities, not just different cars.

[bryanlarsen]

Due to it being a common anti-EV talking point, tire longevity has been a strong selling point for EV tires. Longer lasting tires produce less particulates, so this natural pressure should also produce fewer particulates.

Popular EV's aren't significantly heavier than ICE vehicles. A Tesla model 3 and a BMW model 3 are both about 3500 pounds. Range is a huge selling feature for EV's and weight has a significant impact on range, so there is strong evolutionary pressure to lighten EV's. Crappy EV's like the Hummer are heavy; but popular EV's like Tesla's and Hyundai's have weight comparable to normal cars so that they can have impressive ranges without too many expensive and heavy batteries.

EV's increased tire wire is due to their massive torque at low range. If you want your tires to last, just don't drive like a hooligan. We got 70,000 km out of our first set of EV tires.

Tire particulates are an "all cars a bad" issue. EV's are not significantly worse than petrol vehicles vis a vis tire particulates. Their lack of exhaust particulates means that an EV produces about ~half the total number of particulates.

[CalRobert]

Well this was interesting to me, thanks for sharing. Looking at https://www.emissionsanalytics.com/news/do-no-harm it looks dependent on what you're optimizing for (and not driving like a hooligan helps, hard acceleration and braking wears tires more).

Even so, I still find that the fewer cars there are, the easier it is for me (and my kids) to walk and bike places safely, helping us be healthier (and not reliant on drugs like Ozempic) which was the real point of my comment.

[bryanlarsen]

That is a very strange article. The Model 3 and Niro are not comparable cars, the Model 3 is much larger and much more powerful.

[thefz]

> but people shouldn't really have to put in the effort to change diet or exercise or lifestyle habits

Everyone is directly responsible for their own health and nobody else is. The insanity of this statement is baffling.

[Earw0rm]

The logic of public health and product design applied to urban/spatial planning basically. And, unsurprisingly, it works wonders.

[CalRobert]

And it’s a happier, less lonely life!

[arkh]

> put in the effort of changing diet

If the genetic / hormonal explanation is right, it would mean the "effort" is not the same for everyone. So expecting people on the wrong side of the equation to not go for a solution to right the scales demonstrate a lack of empathy.

Would you call cochlear implants a quick fix for people who have problem hearing?

[jonahx]

It's not a "lack of empathy". GP is just stating the fact that most people are physically capable of losing weight, but since it is uncomfortable and hard they don't. It's not analogous to being unable to hear.

There's nothing with wanting a quick fix to make it easier and less unpleasant. I'd happily use a provably safe one. The only issue is that currently that fix carries unknown risks.

[pennybanks]

Percent of adults age 20 and older with overweight, including obesity: 73.6%

this is a crisis.

at this point this is like going to a 3rd world country and telling them if you dont want all the problems that come with not having money to just get rich.

like its possible, my brother did it, most my family did it, we all have the capability to do it. it maybe harder for some due to physical limitations or mental ones. so why dont you? dont hate being poor and not getting all the women and luxuries?

74% is sick and its infectious. it curates mental problems that make it even harder to overcome. 74% means there are too many factors that are contributing to this epidemic. if modern technology is able to help get society on the right track i dont know why anyone should be.. for lack of a better word fat shamed haha.

of course we need to be careful and thoughtful. im not even sure though if it will be available for most people anytime soon. i hope so though, iv never been fat per say. maybe a bit more lbs then id like but i do understand how much it helps every part of your life being at a satisfying weight. this could be the greatest cure for depression through medicine ever imo.

i live in one of the fattest cities in america. when i go outside i swear to you sometimes i can go a day without seeing a single person of normal weight. besides the few homeless in my area.

[throw890123128]

Most are capable of losing it, very few are capable of maintaining their achievement for many years.

Rephrasing the famous quote, it's easy to lose weight — I've done it four times already, ranging from 95 kg to 60 kg over the course of the last 15 years. It's much more difficult to maintain healthy weight over the long term — the longest period I managed that was only three years. Even if you have all the information and know which problems obesity leads to, it's difficult to keep yourself from getting back into unhealthy territory unless you're willing to spend your entire life counting calories and tracking weight religiously.

It's something with the brain, it's insatiable and won't leave you alone until you stuff yourself to the point that you physically can't eat any longer. The last time I gained weight (from 68 kg to around 88 kg) I did it eating only healthy food in unhealthy amounts.

If I can get magic fix (like semaglutide) that would allow me not to think about food any longer and maintain healthy weight over the rest of my life, that would be great.

[tasuki]

> it's difficult to keep yourself from getting back into unhealthy territory unless you're willing to spend your entire life counting calories and tracking weight religiously.

It depends on your habits. My habits are generally good enough that I don't need to count calories. Which is mostly luck, not an achievement of mine, btw.

> The last time I gained weight (from 68 kg to around 88 kg) I did it eating only healthy food in unhealthy amounts.

First, there isn't even clear consensus what's healthy and what isn't. But even if there was, I doubt you only ate healthy food. It is very hard to gain much fat eating a lot of vegetables and some fish and eggs.

Of course it's possible your diet is great. My experience with fat people has been that their diet was a whole lot worse than they claimed...

[pjerem]

The whole discussion here is about the environment though.

In absolute, changing diet is not inherently hard : it's pretty easy to eat a balanced diet and get pleasure from it.

But it's not enough to just say "eat better", "do more sports" : people can't change the way the lived their whole life if you don't educate and help them to make the change. The education on this topic is so poor that we are still confusing balanced diet and low-calorie diet.

And then there is the elephant in the room which is the refined sugar : for some dubious reason, most scientists agree that refined sugar acts like a hard drug but nobody officially wants to call it a drug. Recent research are saying that the addictive effects of refined sugar are akin to heroin. That's a serious issue then. What it means is that a doctor asking his patient to eat less sugar / eat a balanced diet without further guidance or help is just like saying to an heroin addict that he should stop.

I'm relatively overweight and pretty self educated on the topic but I still decided to work with a nutritionist to change my diet and we are talking about months if not years of follow-up. Eating habits are largely automated by our biology : willpower and education are nothing against an hypoglycemia induced sugar craving.

Like drugs, most people need help and guidance on the long term to change those habits. But what's even worse is that unlike drugs, unhealthy products are basically everywhere in your supermarket, your TV ads, your billboards, your friends lifestyle, and even worse, profoundly ingrained in the culture. You have to fight the "drug" but also the whole capitalist world around you.

[arkh]

> In absolute, changing diet is not inherently hard : it's pretty easy to eat a balanced diet and get pleasure from it.

But even a balanced diet can let you put weight if you eat too much.

We know genetics disorder like Prader-Willis can cause insatiable appetite. Even with a "balanced diet" those affected by it will end-up obese.

Now the current research on GLP-1 hint at many people having a harder time feeling satiated, not to the Prader-Willis point but still worse than what is considered normal. For people who don't have the problem it is easy to think they just have more discipline / willpower and that's why they're thin. I'd like them to imagine what would happen if after eating 2 or 3 pizza slices they'd still feel like their stomach is empty. What if it's not a one time occurrence but all day every day from the moment they develop a conscience to their death bed. A little like drug addiction but you need some drug to live so it is legal and you can buy it everywhere. Still think you'd have the discipline to not go for the whole pizza?

[pjerem]

I totally agree with you but "being obese" is just a data point. Being obese is defined by your ICM, which means nothing else than being heavier than the norm.

Being obese with a balanced diet is absolutely not the same thing than being obese because you eat too much "bad" calories. Obese or not, a balanced diet gives you everything your body needs to function properly, be able to move and for your mind to be clear.

The thing is, obesity is a really, really recent trend in humanity history, so recent that a lot of countries are still not concerned by the phenomena (but it's changing). It's pretty certain that _something_ in the environment changed recently and made the humans obese.

People who blames other people willpower just don't understand that if obesity is in an uptrend, it means that people who were previously healthy are becoming obese for some reason. Something new pressurizes humans to become obese and the only question is not if you are concerned but when will the pressure be high enough.

I think it's refined sugar. Plus a bonus of sedentary lifestyles.

[vinhcognito]

> I'd like them to imagine what would happen if after eating 2 or 3 pizza slices they'd still feel like their stomach is empty

Even that is the generous interpretation. Imagine instead of just their regular (or lack of) hunger signals, people had an alarm constantly ringing in the head telling them to eat all the time, that was only ever silenced if they over ate. The persistence of it pushes it in the direction of mental torture.

Yes, technically it can be overcome, but it is a huge tax on your life.

The truth is we can never really know what someone else's inner experience is.

[torginus]

I'm glad you mentioned bodybuilding, since its known to even laymen that taking anabolic steroids gives you an edge that is impossible to replicate just with diet and exercise.

This ozempic study seems to suggest something similar.

Self-discipline is a noble concept, and probably important in the grand scheme of things, but sometimes medicine and technology outpaces what is naturally possible, which inevitably results in a moral backlash.

[latentcall]

> 95% of people do not want to put in the effort of changing diet, exercise, and other lifestyle habits. They want a quick fix.

Well yes obviously that is difficult to do. Our society (American society, that is) is about “me” and convenience.

Nobody seems to want to say what is obvious to me: ban junk food. Sugary white bread, Cheez Its, Oreos, candy, ice cream, highly processed frozen burritos, frozen pizza, Little Debbie’s, potato chips , all of it.

It is crazy to me the C levels of poison food companies do not rot in jail for the rest of their lives for knowingly selling poison and lying about it. It is crazy to me how a group of people can conspire to harm the citizens of a nation in the name of profit and not receive any consequences. It’s crazy to me the governments of that nation actually enjoy it and don’t care.

[paulpauper]

A friend of mine who works in primary care has a policy of not prescribing semaglutide unless a patient has tried at least three months of diet/exercise first. She now has a long list of patients who decide to screw that and self-refer to a specialist who'd write them the script. I don't work in primary care myself, but this more or less matches my own experience - 95% of people do not want to put in the effort of changing diet, exercise, and other lifestyle habits. They want a quick fix.

The data however shows that diet and exercise fails for most people though. I don't see it as entirely irrational to go strait to the more effective drugs.

[ddorian43]

What most people don't know is that patients are terrible. I'm not a doctor but I know some doctors and patients.

Many are unlucky to have unforgiving disorders.

This is easily seen in T2D which is mostly diet related and fixable.