[mlsu]

My view about obesity has shifted dramatically since Ozempic came out. Before this, I didn't think about it too much (I am not obese myself).

I notice now that there is a LOT of judgement, bias(?), around obesity, that people, obese or not, carry with them [1]. I certainly carried that bias, and the reason I noticed it was because Ozempic is literally an external substance that you take that simply makes obesity go away. So if you believe (like most of us unconsciously do) that obesity is a personal failing or an issue of willpower, an issue of personal merit -- HOW is it possible that a chemical pill, an external chemical process, can SO effectively resolve it? When no amount of hectoring and moralizing and willpower can? My inability to square that circle really changed my thinking about obesity in a fundamental way.

Already there is a reaction to Ozempic -- like people thinking that taking Ozempic is a personal failing, or judging celebrities, for taking it, thinking it's the "easy way out" -- I think the origin of that is this very deep unconscious bias that we all have about what obesity actually is fundamentally.

My view: It is a health condition, that people do not choose. Not unlike diabetes, celiac, or clinical depression. We should be focused on how to improve the lives of people who suffer with that health condition. We all agree insulin is unequivocally a good thing; that it's not a "personal failure" or "cheating" to take insulin; that it really is simple as, diabetes is a health condition and insulin is used to treat it. Ozempic? Same. Exact. Thing.

It's really heartening to hear your experience. Your post really struck me, I felt exactly the same way after getting on a CGM + Insulin Pump for my Type 1 Diabetes. Nobody EVER thought I had a lack of "personal responsibility" or an "issue of willpower" for going low or high on shots of Humilin and NPH.

Thank fucking god for Novo Nordisk.

---

[1] see: this thread!

[seer]

This is a very American way of thinking about it - not invented here vibes all over.

Of course people don’t choose to be obese, but the culture and environment inevitably pushes you to it. A proof of that is that there are places in the world, with similar genes, that don’t have the same problem in the degree that US does.

I don’t think it is a personal failing, more a collective one - the society itself has chosen a set of environmental factors as desirable (car centric, hectic, individualistic, processed cheap food etc) and it just results in more obese people.

Loose the cars (change to walk / cycle / public transport), spend on food as much as the rest of the world do (adjusted to PPP) and suddenly you don’t need ozempic.

It is still weird to me how US choose unironically to develop a drug for reducing addiction, and not putting societal pressure to fix the environmental issues. It’s a democracy, people do choose all of that and can’t really blame it on the government.

[cthalupa]

Obesity is rising rapidly over much of the developed world, both in Europe and Asia, on a trajectory fairly similar to the historical trajectory of it in the US. Obesity in adult men in North Korea more than doubled between 2009 and 2019. The UK is already up to 26% obesity. 36% of adults in Mexico are obese.

America is an unfortunate pioneer in obesity, but it is not even remotely unique to America.

> It is still weird to me how US choose unironically to develop a drug for reducing addiction

Novo Nordisk, the company behind Ozempic, is Danish. (Eli Lilly is American, though, for the tirzepatide drugs.)

I don't disagree with your fundamental premise - a huge amount of the initial conditions for obesity are environmental. But they're incredibly far ranging, incredibly intertwined with modern life in much of the developed world. Unwinding those, even with strong support from the people, would take decades.

We should still do it. But in the mean time, there's a hell of a lot of people that would die earlier than they would if they weren't obese. And a hell of a lot of them can significantly increase their lifespan with the help of these drugs.

[eli_gottlieb]

> Obesity in adult men in North Korea more than doubled between 2009 and 2019.

Ok, someone needs to explain how thoroughly non-Western, undeveloped countries, more known for starvation and malnutrition than overabundance of food, are developing an obesity problem!

[GeorgeTirebiter]

Must be in the air? Seriously, maybe abundant low-quality sources? AI sez:

The diet in North Korea is characterized by a heavy focus on grains, but has changed over time to include more animal protein:

Grains, Rice, wheat, and maize are the main sources of calories in the North Korean diet. In 1961, over 70% of calories came from grains, and that number dropped to 61% five decades later.

Animal protein Before 2000, North Korea's diet was mostly vegetarian, with meat eaten only a few times a year. However, since 2005, the availability of animal protein has increased, with an emphasis on poultry, pigs, rabbits, sheep, goats, and cattle.

Other foods Popular foods in North Korea include kimchi, red pepper paste, soybean paste, soup, and rice dishes. A traditional meal might include side dishes, a main course like noodles, porridge, or grilled meat, and rice dishes.

Regional differences People in rural areas and mountain valleys eat more vegetables and herbs, while people in coastal areas have access to seafood.

Healthy options The upper class in North Korea favor healthy, balanced diets, including chicken wraps and tofu rice.

[cthalupa]

Sorry - this was entirely due to me also talking politics with some friends earlier in the day. Switched up SK and NK when I typed this.

Obesity in adult men in South Korea more than doubled between 09 and 19.

[eli_gottlieb]

That makes a lot more sense considering that South Korea is not known for starving its population half to death.

[oblio]

How does obesity increasing correlate with aging? I'd expect that as people age, they start taking less care of their bodies as it's harder to do it.

[cthalupa]

Your expectations are correct - there's a strong correlation between the two.

[oblio]

Then a decent chunk of these simple analyses are useless. All advanced countries are aging.

[cthalupa]

Note: I meant to type South Korea here, not North.

[rootusrootus]

> people thinking that taking Ozempic is a personal failing

I expect that the people who hold this viewpoint are afraid that their lack of being overweight will not be seen as badge of honor, a sign of superior morals and willpower.

To them I say -- GLP-1 agonists are good for anxiety, too!

[scottyah]

The fact that a drug can cause a shortcut is completely normal I think, alcohol can nearly instantly give you the confidence that months of training would take, hallucinogens can give states of mind that monks spend years meditating and breathwork to achieve, steroids give shortcuts to massive gym gains, etc.

I see Ozempic as "taking the easy way out" the same way I see steroids as "taking the easy way out" (except it brings people closer to the norm of a average healthy person and will probably lengthen lifespans).

If you're in it to show mental fortitude for internet/social points, then it is "cheating", but if you're just in it for results it's perfectly acceptable and even recommended.

[kps]

> Not unlike diabetes, celiac, or clinical depression.

The latter is, like obesity, considered a personal failing (being one or more of the Seven Deadly Sins, depending on when you look), and medical treatment elicits similar reactions — both against it being ‘too easy’, and in favour of wholesale societal restructuring instead (“That trick never works!” — Rocky the Flying Squirrel).

[lottin]

It's not just willpower but also lifestyle. It's rare for people who are physically active, and have a balanced diet, to suffer from obesity. I can eat A LOT without putting on a ton of weight, and it's because the types of foods I eat and because I do strength training, which means have a fair amount of muscle mass which acts as metabolic furnace. I'm a little overweight, at the moment, but it'd take a lot of effort on my part to become obese. I think treating obesity as a health condition is the wrong approach.

[barrkel]

It's the other way.

When you eat more than your energy consumption rate, you're less hungry. When you eat less, you're more hungry. You think the activity would stop you getting obese, but it's actually that you aren't hungry enough to overeat, despite high activity.

I'm not overweight, never mind obese. I pay no attention to diet or exercise. If I'm really hungry one day, I can end up overeating something I quickly deep fried from the freezer. And then I barely eat the next day. Not consciously. I'm just not hungry for a long time after I overeat.

Energy homeostasis is the big thing you're not accounting for. Excercise doesn't really do anything much for your weight, just your fitness.

[makeitdouble]

> It's rare for people who are physically active, and have a balanced diet, to suffer from obesity.

Looking at it from the other angle: can obese people be active and have a balanced diet ?

The answer is yes. In particular you can be obese and maintain your BMI at the same level while being fairly active and not overeating, that happens a lot with people gaining weight and reacting to it, but without going down.

From the pool of people physically active and with a balanced diet, what's the split of obesity is a question I don't have the answer to, but the lifestyle part doesn't look like a good differenciator to me if we're solely focusing on current obesity.

PS:if you eat a LOT more without gaining much weight, imagine eating a LOT less and see very little change.

[anon84873628]

It's weird for you to say that "people who have the habits for not being obese aren't obese." What's the real point?

Note that "have a balanced diet" is doing a lot of work here. Our modern environment is saturated with super calorically dense, hyper palatable food. THAT is the cause of the obesity epidemic -- it's not endocrine disruptors or seed oils or office jobs or anything else.

And the ability to refrain from eating cheap processed food, which has been specifically engineered to hack your brain, requires education, discipline, and willpower. As does hitting the gym.

It's not surprising that most people don't innately have this ability, and have ended up sick from it. That sickness is a medical issue regardless of how we got there.

[rixed]

What's the right approach?

Had the right approach better results?

If not, why is it the right approach?

[beezlebroxxxxxx]

My understanding is that more research is pointing to obesity as, in some sense, a precursor/reaction to the onset of type 2 diabetes rather than type 1.

Once you get to quite obese you're dealing with physiological factors that make losing weight medically difficult from behavioral changes alone. It also makes the chances of "yo-yoing" the weight higher as well. At that point the treatment for obesity overlaps with the treatment for type 2 diabetes.

[mlsu]

Yep, it definitely is! I mentioned type 1 because I have it.

As a contrast -- the point was that nobody judges me for having type 1 the way they judge people for having obesity.

As an aside, I notice that sort of "lifestyle/willpower" type framing in discussions about type 2 also.

[DAGdug]

There are varying degrees of control over outcomes. The judgment comes from the correlation between an unobserved variable (effort at controlling or preventing obesity) with the observed variable (actual obesity).

[ElectricSpoon]

> people thinking that taking Ozempic is a personal failing

Considering our society is pushes us toward sedentary highly-caloric lifestyles, I'd say we're set up to fail from the get-go. Therefore the failing is systemic not personal. I wouldn't compare to individual health issues. You can't cure celiac, but you sure could reduce the obesity using policies to drive the food industry toward less-sugar/more-fiber.

[fireflash38]

For some people it is clinical. For others it is mental/willpower. That said... It's exceptionally difficult in the modern world to do everything necessary to be at a healthy weight. Things are shoved at you constantly that are terrible for you. It's so, so much easier to eat poorly and to excess. Combine that with dopamine hits from consuming sugar/fat? No surprise people overeat.

[StefanBatory]

I was obese myself, and I have different thoughts on that.

For me, it was purely an issue of personal falling and willpower issue. I was obese because of a diet I was indulging in; full of unhealthy things and snacks.

It was due to nobody else but myself.

[ripply]

You don’t place any blame on the people that marketed and created that diet? Or the regulators who allowed that to happen? At a certain point people’s well being and health should come before a mega corporation’s profits. The whole world would be better off if unhealthy food was more strictly regulated. Children grow up not learning healthy eating habits that last into adult hood and some never learn them.

[StefanBatory]

No, I do not. It was my decision to keep doing so, it was a bad coping mechanism I developed. My actions are nobody else fault but mine.

[itsoktocry]

For me, personally, it's that we don't really know the long term effects of these drugs ie are you actually "healthier". But we do know that diet and exercise work.

[makeitdouble]

> we do know that diet and exercise work.

Stricly speaking we don't.

This is "common sense" and the official recommendation, but fundamentally we don't have solid long term reproductible experiments[0], and due to the nature of the problem (humans living their life in a complex society) we'll probably never have a good answer.

I've read many many studies spanning a few months and calling it a day (did the subjects rebound ? who knows), other taking a very small and homogenic pathological group, making it follow a strict regimen and end the experiment right after the subjects are let free again. But nothing with an actually rigorous protocol that gives a clear undisputable result.

In a way I feel a lot of researchers are bound to their common sense and think they either don't need to prove the obvious, or it brings them nothing to let the room for controversial results ? (nobody's paying for research that says current policy is dumb)

[0] If you have any double blind study with more than a hundred subjects taken randomly from the general population (including "healthy" subjects), with a control group, spanning more than 3 years of observations I'd be dying to read it..

If you think that's a high bar, obesity is touted to be the worst health crisis the US has to deal with with tremendous impacts, putting at least that much effort into research doesn't seem outlandish.

[CydeWeys]

Everyone who's obese has been prescribed exercise and a better diet. It's the quintessential doctor cliche, and yet it indeed hasn't worked for them. GLP1 agonists do.

[arandomusername]

> Stricly speaking we don't.

Yes we do, because it works. Exercise burns more calories. Diet limits your calorie intake.

If you rebound into not doing exercise and overeating, that's on you.

[makeitdouble]

> If you have any double blind study with more than a hundred subjects taken randomly from the general population (including "healthy" subjects), with a control group, spanning more than 3 years of observations I'd be dying to read it

[arandomusername]

Do you also need a blind study to tell you that jumping out of a plane without a parachute will kill you?

[makeitdouble]

I'll bite: yes.

I see a multitude of cases where jumping out of the plane without parachute won't kill me. From the plane being on the ground, to me being equipped with anything other than a parachute that lets me fly enough, jumping from a plane to another etc.

And I'm not just being facetious, that's exactly the issue we have with pathology related diets, there's a myriad of variables and circumstances to take into account, which makes vague common sense dogmas innaplicable.

Think about it: we have very thorough studies of people dying from hitting static surfaces at high velocity. Why don't we have the same level of evidence for long term obesity treatment if it's a obvious as you say it is ?

[bozleh2]

> But we do know that diet and exercise work.

Sure - if you ignore the incredibly poor % of people who comply with a prescription of diet and exercise. If you include compliance then the drugs are way way way ahead.

[cthalupa]

We know for sure that obesity is one of the single biggest increases in all-cause mortality. We know it is directly linked to most of the top disease-related causes of death.

> But we do know that diet and exercise work.

Do you think the ~40% of American adults that are obese don't know that they should eat better and exercise more? That they don't understand that they're cutting decades off their life?

Yes, it is 100% within the power of the overwhelming majority of them to fix things. And I think evolution has kept shame with us for a purpose and that it can be a useful emotion. But I also think it's plainly apparent that neither are causing a real reduction in obesity.

So, should all the people in the world that are obese just continue to fail at losing weight despite knowing what they should, in theory, be doing to resolve it? Because, despite being obese being one of the riskiest things you can do in life for your health and lifespan, we don't know if there might maybe be long term effects from something we know will get them to lose weight?

This room is on fire! I could run out that door over there - I know if I open it and go through I'll leave this room that is currently on fire - but, should I? What if whatever is on the other side of the door is just as bad as being on fire, or worse?!

[mayukh]

Obesity is a side effect of the industrial food production system in advanced economies that is slowly spreading all over the globe.

How about alcohol and smoking ? Is that the same as obesity then

[kps]

> Obesity is a side effect of the industrial food production system in advanced economies that is slowly spreading all over the globe.

Yes, for the first time in the millions of years of existence of humanity and pre-humanity, we consistently have enough to eat.

[beagle3]

Is not just “having enough”. People in New York had enough to eat for more than 60 years now - more like a 100 years. And ywt, up until the 1980s, obesity was a minor problem.

All standards have since changed. I watched the 1st season of the Simpsons again recently. In one of the episodes, Homer weighs himself and is distressed when discovering he weighs 200 lbs. 30 years later, dieters who cross down from 200 lbs to 199 lbs call it “reaching onederland” and it is considered a huge success.

[WalterBright]

The US solved the food problem around 1800, being the first country to end the specter of famine.

[JamesBarney]

Neurologically addiction works very differently than obesity and research says longterm sobriety is far easier to maintain than long term weight loss.

[ekianjo]

The real question is why so many people are obese in 2024 in the US while it was a fraction of the population 50 years ago? And other countries have by far not been affected by the same trend. So effectively something is making people really sick on the US.

[cthalupa]

It's simply not true that this trend isn't impacting other countries. Mexico is only 6% behind the US. The UK is 16%. Obesity is rising rapidly in South Korea - more than doubled in adult males between 2009 and 2019.

America pioneered the obesity epidemic, but a huge chunk of the rest of the developed world is doing their best to catch up.

[slibhb]

> I notice now that there is a LOT of judgement, bias(?), around obesity, that people, obese or not, carry with them [1]. I certainly carried that bias, and the reason I noticed it was because Ozempic is literally an external substance that you take that simply makes obesity go away. So if you believe (like most of us unconsciously do) that obesity is a personal failing or an issue of willpower, an issue of personal merit -- HOW is it possible that a chemical pill, an external chemical process, can SO effectively resolve it? When no amount of hectoring and moralizing and willpower can? My inability to square that circle really changed my thinking about obesity in a fundamental way.

I see no contradiction here. That ozempic works doesn't imply that willpower isn't real or that people can't lose weight via diet and exercise.

> My view: It is a health condition, that people do not choose. Not unlike diabetes, celiac, or clinical depression. We should be focused on how to improve the lives of people who suffer with that health condition. We all agree insulin is unequivocally a good thing; that it's not a "personal failure" or "cheating" to take insulin; that it really is simple as, diabetes is a health condition and insulin is used to treat it. Ozempic? Same. Exact. Thing.

I'm very suspicious of "it's a health condition" applied to obesity, type 2 diabetes, and even depression. I absolutely believe that some people will be able to avoid or cure those "conditions" by changing their behavior. Of course that doesn't imply that there should be a taboo against medication to help people who can't. But my concern is that "it's a health condition" discourages people from examining their choices and making good ones.

[SirMaster]

>My view: It is a health condition, that people do not choose.

If this is true, then why are we so focused on curing it after the fact?

Are we also working on prevention?

If it's not a choice, then what is the cause? And why shouldn't we work on preventing that cause?

I mean it's clean that more people are obese today than in the past right? So what changed to cause that that isn't about people's choice? Why not work on reversing whatever those changes were that caused obesity to increase?

And a separate question:

If it's really not a choice, what would be the approximate rate of obesity among a group or population that all exercised regularly and ate healthy?

I don't think I can be convinced that not exercising regularly and not eating healthy is not a choice.

I just feel like the number of people that would be obese who are regularly exercising and eating healthy would be rather small. And if we agree that exercising regularly and eating healthy is a choice, then it seems at least for many who are obese, it indeed is choice.

I'm not going to say there aren't outliers or other special circumstances, but I still feel like for more people than not, it is indeed a choice.

[buu700]

Personally, I've never seen obesity as a failure of character or willpower, at least as long as I can remember having any particular views on it at all. I see it as a failure of information and choices.

Obesity was rare until the United States officially decided in 1977 that saturated fats were considered harmful. A few years later, it started rising to the current epidemic level. We've come a long way since the American Heart Association was recommending candy and soda as "healthy" alternatives to real food, but the idea that an optimal diet contains low saturated fat and high complex carbohydrates remains firmly entrenched in present-day nutritional and medical orthodoxy.

Imagine a counterfactual where Congress had reached the opposite conclusion, instead recommending a standard diet full of saturated fats, high in salts (both sodium and potassium), moderate in monounsaturated fats, low in polyunsaturated fats, and sparing in carbohydrates. The population and food industry would have moved in an entirely different direction. We'd have a whole different universe of nutritional advice, diet trends, restaurant menu options, and easily available processed foods. A lot would be the same, but large sections of the grocery store would look like lowcarbfoods.com, maybe burger joints would serve mozzarella sticks instead of fries, maybe instead of potato chips and corn chips people would eat pork rinds and kale chips, and maybe instead of rice or potatoes an average dinner would include all manner of delicious fried vegetables. Instead of a low(er)-fat (i.e. high(er)-carb) diet, doctors would tell fat people to try keto. Maybe that timeline's equivalent to trans fat would be sugar alcohols and artificial sweeteners, and governments would ultimately pressure the industry to transition to stevia, monk fruit, and inulin fiber.

In such an alternate universe, I'm sure the food industry would still work overtime to find ways to make many of its products shitty and addictive, and I'm sure the average person would still lean heavily on processed foods and fast food over home cooking and whole foods. I'm sure that would cause its own set of health issues, but what I highly doubt it would cause is an obesity epidemic. It's simply a lot harder to overeat fats than it is carbs. We'd also inherently have less insulin resistance, which means less type 2 diabetes, less dementia, and probably a good amount less of mental/neurological issues like depression and anxiety.

Unfortunately, we live in this universe. And in this universe, I find it really hard to blame individuals for struggling with obesity when we've practically purpose-built an environment to make us fat and keep us that way. In order to not be fat (by pre-1980 standards), you either have to win the genetic lottery, be extraordinarily physically active, put a high amount of effort into controlling your caloric intake, or be willing to go against the grain (no pun intended) on what you've most likely been led to believe for your entire life by everyone and everything around you. It's great to fall into one of those four buckets, but on a population scale it should be obvious that the majority wouldn't.

[fortran77]

Do you view a chronic smoker as a failure of character or willpower?

[buu700]

I wouldn't say inherently. Trying and failing to quit is plainly a failure of willpower on some level, albeit an understandable one given varying levels of nicotine addiction. Perhaps it could also be a failure of information (helpful techniques, etc.), although I'm not familiar enough to comment in detail on what quitting smoking is like.

On the other hand, is picking up the habit in the first place, or choosing not to attempt to quit, a failure of character? I'm not sure that's for anyone other than the individual to decide. I personally feel it's unwise given that in 2024 smoking tobacco is pretty much universally known and accepted to be wildly unhealthy, but if someone weighs the tradeoffs and decides that maybe it has social and/or professional and/or mental benefits for them that outweigh the downsides, I wouldn't call that a character flaw so much as a decision that I'd highly disagree with. I'd say the same whether we were discussing tobacco or meth.

---

Edit: More to the point I now see you were probably getting at, there's a pretty big difference in the knowledge and time/resource investment required to stop buying cigarettes (which costs nothing) and to adopt a low-carb or ketogenic diet that a particular individual would be happy with long-term. I've been keto for over 12 years, and I have a routine that I enjoy, know my way around a kitchen, know what foods I like, and know all the right ingredients and recipes to use to create any food I might want to eat in a keto-friendly form that's as good as or better than what I could otherwise buy at a store or restaurant. For example, I make some of the best ice cream I've had anywhere (sometimes in flavors that I've never seen commercially available), and the one time I cheated for a New York slice I was disappointed because it didn't hold up to the pizza I'd already been making at home.

Maintaining my diet takes zero willpower, because I enjoy it even more than my diet from when I was fat, and I never had to starve myself or give up my sweet tooth. The problem is that for that to work it required not just the inclination to research and adopt keto in the first place (a major hurdle in itself), but turning it into a dedicated hobby with development of knowledge and skills that I wouldn't expect the average person to casually pick up. That may work for me, but isn't a scalable solution for the population at large. On the other hand, if I could magically reformulate every food product in the world based on what I know from experience works, no one would struggle to eat a high-fat diet because that would just be the default instead of high-carb.

[j-a-a-p]

The willpower frame actually works pretty well for a lot of people. If not than in our society almost everybody would be obese. This pill will make things worse for the group that hangs out in the treadmills and drinks green and disgusting smoothies.

On topic, very happy this medicine exists, but let's pray god will keep the prescription only for BMI > 35.

[autoexec]

> The willpower frame actually works pretty well for a lot of people. If not than in our society almost everybody would be obese.

In the US nearly 75% of the population is overweight and almost half are clinically obese. Sounds like "willpower" isn't working for the vast majority of people.

[j-a-a-p]

That is not logical. If willpower fails, how could a pill be a solution? That is like suggesting to give everybody methadon, because the substance dependency issues are just too overwhelming. Or even better, give certain kids from 12 to 6 years old a gun to solve the school shootings issue.

If we give up on willpower, we have no plan b.

[Ygg2]

> If not than in our society almost everybody would be obese.

Isn't that already the case. I'm of belief, the failing isn't individual but societal. You have obese toddlers and wild animals in the US.

I don't think this is a failure of willpower, it's a failure to investigate the actual causes of the obesity epidemic. Maybe it's sugar, perhaps it's highly processed oils, etc. Whatever it is, people aren't investigating it thoroughly enough.

[j-a-a-p]

I live in lala land. Obese children are rare, however overweight is 11% and declining from 15% post covid.

The school where my kids go to has zero obese and zero overweight kids (n = 300).

We have Starbucks, McDonalds, Dunkin' Donuts and the same brands like Heinz and Coca Cola. Pizza.

So, I am optimistic willpower can prevent us from a new Ozempic disorder. I suggest to go for willpower and not pills. If willpowers falls short, in my country when a child becomes obese, child welfare steps in. So let the government intervene (yep, you will lose your parental power) with a lifestyle program.