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I am obese, I have been fighting my weight nearly my entire life. At one point I did manage to get down to a "normal" weight and body fat percentage, but it to

I am obese, I have been fighting my weight nearly my entire life. At one point I did manage to get down to a "normal" weight and body fat percentage, but it took more than 7 years of concerted disciplined effort to do so, and it disappeared in less than 6 months by no longer eating as a significant calorie deficit, despite a massive increase in physical activity. For many obese people, for reasons we don't fully understand, our metabolism does not work the same as for people who are not obese. The first time we've had any sort of medical intervention that seems to actually address this is the invention of GLP1 agonists and similar medications. Most insurance providers REFUSE to provide coverage for these medications, even though they are a net positive for the patient and society. Taking a GLP1 agonist while obese can straight-out /prevent/ the development of Type 2 Diabetes, even while you are still obese, and can cure some people of Type 2 Diabetes while they are ungoing further treatment. I am very lucky in that my insurance does cover this treatment. The insurance of several of my friends (who are on ostensibly "better" plans because their premiums are more heavily covered by their employers) does not cover this. If I could make one legal change to the healthcare system in the US, it would be to require insurance providers to cover preventative treatments for obesity. Obesity is the primary cause of chronic health problems in the US, and it's nearly entirely preventable with proper care, but it's almost impossible to get that care /even as a tech worker with employer-provided insurance/. It should be affordable and accessible for nearly anyone in the US to get access to GLP1 agonists and a dietitian. It isn't currently. Lacking this, means that obesity will continue to be a social disease that drives up healthcare costs and drives down productivity, quality of life, and total life outcomes in the US.

dangwhy 4y ago
> For many obese people, for reasons we don't fully understand, our metabolism does not work the same as for people who are not obese. My impression was that obese people first get less insulin sensitive over the years and then become obese as a result. They usually measure insulin sensitivity as a proxy to 'metabolism'. > It should be affordable and accessible for nearly anyone in the US to get access to GLP1 agonists and a dietitian. I thought it was only approved for diabetes not obesity.
- tristor 4y ago
  > I thought it was only approved for diabetes not obesity. Ozempic and Wegovy are the same substance from the same company, Ozempic is approved for diabetes, Wegovy is approved for obesity. Similar situations apply to other competing GLP1 agonists.
  - dangwhy 4y ago
    oh yea i think i have some family on wegovy ( or maybe mounjaro now ), hadn't realized that it was approved for obesity. What i don't understand is that you are saying these are "preventative treatments for obesity" . aren't preventative treatements given before the condition even comes into picture, these drugs are after you get obese so not sure how they are preventative. Doesn't weight just come back instantly once you stop these drugs. Hard time accepting that solution is putting 200million americans on this drug for rest of their lives. "Cardiometabolic improvements seen from week 0 to week 68 with semaglutide reverted towards baseline at week 120 for most variables." https://dom-pubs.onlinelibrary.wiley.com/doi/10.1111/dom.14725 https://dom-pubs.onlinelibrary.wiley.com/doi/10.1111/dom.147...
    - tristor 4y ago
      I didn't say it prevents obesity, I said it prevents Type 2 Diabetes, which is a chronic disease caused by obesity. And it does. It's nearly a miracle drug. Yes, if you stop taking the drugs, after a short time you return exactly how you were prior. You must take these drugs for life, unless something else comes out that improves the situation.
      - dangwhy 4y ago
        > it prevents Type 2 Diabetes Ah I understand now what you meant. I remember looking into while ago( i have like half my extended family on these drugs now lol) but couldn't really find evidence to support this claim. "There is only limited-quality evidence that at-risk patients taking GLP-1 receptor agonists are less likely to progress to diabetes (number needed to treat [NNT] = 23). Serious adverse events were more likely in patients taking GLP-1 receptor agonists than in patients taking placebo (number needed to harm [NNH] = 42). There is insufficient evidence to evaluate the effect of DPP-4 inhibitors on at-risk patients. There is no evidence that either medication class affects the development of diabetes-associated complications.1" https://www.aafp.org/pubs/afp/issues/2018/0401/p437.html https://www.aafp.org/pubs/afp/issues/2018/0401/p437.html
nradov 4y ago
Have you done a resting metabolic rate test to establish a baseline for total daily energy expenditure? The GLP-1 drugs can be a net benefit for some patients but they come with serious side effects. In particular most patients lose significant amounts of lean muscle tissue, which is a risk factor for metabolic diseases and sarcopenia. https://peterattiamd.com/ama45/ https://peterattiamd.com/ama45/
- bumby 4y ago
  It's not clear to me that the risk to lean muscle tissue is unique to GLP-1 drugs. The counter point is that the risk exists in practically any severely calorie restricted plan. In other words, the reason why most treatments work is by reducing calories and if you reduce them too fast, any of those treatments will put lean body mass at risk.
  - nradov 4y ago
    When a patient loses weight, some fraction of that will always be lean muscle mass. The issue with GLP-1 drugs is that fraction tends to be higher than with other approaches to weight loss. See the link I posted above for details which should make the risk clear to you. There are circumstances when those drugs are medically indicated. However, it seems they are being over prescribed without proper consideration of the harmful side effects.
    - bumby 4y ago
      The link doesn’t actually cover all the material listed, only the first 27 minutes. It looks like the relevant stuff came later. Was that higher fraction compared to equally drastic calorie reduction in other methods in a RCT?
      - nradov 4y ago
        Basically yes, but there are nuances too complex to summarize in a brief comment here. If anyone is considering taking one of those drugs then I highly recommend subscribing to watch the entire video and read the show notes (including the linked scientific papers). There is a subscription fee but the it's a fraction of the price of the drugs and the information is top notch.
neuralRiot 4y ago
This a purely anecdotal opinion but most people overestimate their required calorie intake, and according to my long experience in the fitness world you need to keep your desired weight stable for at least 2 years to reach homeostasis and avoid “rebound”. Increased physical activity has a lot of benefits but it has a mild impact in weight loss. Again, this is solely based in my 20+ years of experience.
- tristor 4y ago
  > most people overestimate their required calorie intake It's not something so mechanical as this. For obese people, our /bodies metabolic system/ overestimates our required calorie intake and causes us to feel the pangs of hunger far past when we've consumed a sufficient amount of calories. It's not a conscious choice to overeat, nor is it something that takes effort to do. I ate like a normal person while traveling around the world, walking 10 to 15 miles per day, and going to the gym 3 times a week for an hour, and I still gained back 40 pounds over the course of 18 months (nearly 20 of it in the first 6 months) after going off a monitored, strict calorie restrictive diet. My actual daily caloric intake need was around 1200 kcals, exceeding this isn't hard to do, and keeping to it was a daily struggle that wasn't possible to maintain while traveling when I could no longer strictly control all the food I ate or even know how many calories it was or what its ingredients were. If I was to guestimate, I'd say I was consuming between 2500-3000 kcals daily while traveling, and this was sufficient to gain almost all of the weight I lost over 7 years back in a matter of months. This is the reality of being obese. It's not like you choose to be fat, or you choose to over eat, or even that you're over eating to the point of gluttony, it's merely that your metabolism needs far less calories than it believes it needs, so if you simply eat a normal amount when you are hungry, you will be fat, guaranteed. The reason GLP1 agonists work so well is that they actually change how your body's metabolism reacts, and make it so you no longer feel hungry constantly. In fact, you have to force yourself to eat sometimes or you'll end up having the effects on not eating often enough. While taking a GLP1 agonist, reducing or maintaining weight is not the same struggle as it is without medical intervention. I counted calories and religiously recorded all of my physical activity and food and water intakes using very technological means tied into MyFitnessPal for almost a decade. It was not for lack of effort, dedication, or knowledge that I gained back weight or realized that I was not going to succeed for a lifetime without medical intervention. It's simply not possible to rationally fight your base biological impulses when they are fall into your body's basic survival mechanisms. I effectively "tortured" myself psychologically for almost a decade, and the net result was the moment I stopped I gained all the weight back. GLP1 agonists are basically miraculous.
vallassy 4y ago
Hey mate, as a fellow obese (soon to only be overweight) person, I found something that makes a lot of sense to me: the carbohydrate-insulin model of obesity. The thermodynamic model of calories-in-calories-out doesn't work because we are not a thermodynamic system; it doesn't take into account the hormonal and metabolic changes that occur when calories are chronically restricted.

dangwhy 4y ago

> For many obese people, for reasons we don't fully understand, our metabolism does not work the same as for people who are not obese. My impression was that obese people first get less insulin sensitive over the years and then become obese as a result. They usually measure insulin sensitivity as a proxy to 'metabolism'. > It should be affordable and accessible for nearly anyone in the US to get access to GLP1 agonists and a dietitian. I thought it was only approved for diabetes not obesity.

tristor 4y ago
> I thought it was only approved for diabetes not obesity. Ozempic and Wegovy are the same substance from the same company, Ozempic is approved for diabetes, Wegovy is approved for obesity. Similar situations apply to other competing GLP1 agonists.
- dangwhy 4y ago
  oh yea i think i have some family on wegovy ( or maybe mounjaro now ), hadn't realized that it was approved for obesity. What i don't understand is that you are saying these are "preventative treatments for obesity" . aren't preventative treatements given before the condition even comes into picture, these drugs are after you get obese so not sure how they are preventative. Doesn't weight just come back instantly once you stop these drugs. Hard time accepting that solution is putting 200million americans on this drug for rest of their lives. "Cardiometabolic improvements seen from week 0 to week 68 with semaglutide reverted towards baseline at week 120 for most variables." https://dom-pubs.onlinelibrary.wiley.com/doi/10.1111/dom.14725 https://dom-pubs.onlinelibrary.wiley.com/doi/10.1111/dom.147...
  - tristor 4y ago
    I didn't say it prevents obesity, I said it prevents Type 2 Diabetes, which is a chronic disease caused by obesity. And it does. It's nearly a miracle drug. Yes, if you stop taking the drugs, after a short time you return exactly how you were prior. You must take these drugs for life, unless something else comes out that improves the situation.
    - dangwhy 4y ago
      > it prevents Type 2 Diabetes Ah I understand now what you meant. I remember looking into while ago( i have like half my extended family on these drugs now lol) but couldn't really find evidence to support this claim. "There is only limited-quality evidence that at-risk patients taking GLP-1 receptor agonists are less likely to progress to diabetes (number needed to treat [NNT] = 23). Serious adverse events were more likely in patients taking GLP-1 receptor agonists than in patients taking placebo (number needed to harm [NNH] = 42). There is insufficient evidence to evaluate the effect of DPP-4 inhibitors on at-risk patients. There is no evidence that either medication class affects the development of diabetes-associated complications.1" https://www.aafp.org/pubs/afp/issues/2018/0401/p437.html https://www.aafp.org/pubs/afp/issues/2018/0401/p437.html

nradov 4y ago

Have you done a resting metabolic rate test to establish a baseline for total daily energy expenditure? The GLP-1 drugs can be a net benefit for some patients but they come with serious side effects. In particular most patients lose significant amounts of lean muscle tissue, which is a risk factor for metabolic diseases and sarcopenia. https://peterattiamd.com/ama45/ https://peterattiamd.com/ama45/

bumby 4y ago
It's not clear to me that the risk to lean muscle tissue is unique to GLP-1 drugs. The counter point is that the risk exists in practically any severely calorie restricted plan. In other words, the reason why most treatments work is by reducing calories and if you reduce them too fast, any of those treatments will put lean body mass at risk.
- nradov 4y ago
  When a patient loses weight, some fraction of that will always be lean muscle mass. The issue with GLP-1 drugs is that fraction tends to be higher than with other approaches to weight loss. See the link I posted above for details which should make the risk clear to you. There are circumstances when those drugs are medically indicated. However, it seems they are being over prescribed without proper consideration of the harmful side effects.
  - bumby 4y ago
    The link doesn’t actually cover all the material listed, only the first 27 minutes. It looks like the relevant stuff came later. Was that higher fraction compared to equally drastic calorie reduction in other methods in a RCT?
    - nradov 4y ago
      Basically yes, but there are nuances too complex to summarize in a brief comment here. If anyone is considering taking one of those drugs then I highly recommend subscribing to watch the entire video and read the show notes (including the linked scientific papers). There is a subscription fee but the it's a fraction of the price of the drugs and the information is top notch.

neuralRiot 4y ago

This a purely anecdotal opinion but most people overestimate their required calorie intake, and according to my long experience in the fitness world you need to keep your desired weight stable for at least 2 years to reach homeostasis and avoid “rebound”. Increased physical activity has a lot of benefits but it has a mild impact in weight loss. Again, this is solely based in my 20+ years of experience.

tristor 4y ago
> most people overestimate their required calorie intake It's not something so mechanical as this. For obese people, our /bodies metabolic system/ overestimates our required calorie intake and causes us to feel the pangs of hunger far past when we've consumed a sufficient amount of calories. It's not a conscious choice to overeat, nor is it something that takes effort to do. I ate like a normal person while traveling around the world, walking 10 to 15 miles per day, and going to the gym 3 times a week for an hour, and I still gained back 40 pounds over the course of 18 months (nearly 20 of it in the first 6 months) after going off a monitored, strict calorie restrictive diet. My actual daily caloric intake need was around 1200 kcals, exceeding this isn't hard to do, and keeping to it was a daily struggle that wasn't possible to maintain while traveling when I could no longer strictly control all the food I ate or even know how many calories it was or what its ingredients were. If I was to guestimate, I'd say I was consuming between 2500-3000 kcals daily while traveling, and this was sufficient to gain almost all of the weight I lost over 7 years back in a matter of months. This is the reality of being obese. It's not like you choose to be fat, or you choose to over eat, or even that you're over eating to the point of gluttony, it's merely that your metabolism needs far less calories than it believes it needs, so if you simply eat a normal amount when you are hungry, you will be fat, guaranteed. The reason GLP1 agonists work so well is that they actually change how your body's metabolism reacts, and make it so you no longer feel hungry constantly. In fact, you have to force yourself to eat sometimes or you'll end up having the effects on not eating often enough. While taking a GLP1 agonist, reducing or maintaining weight is not the same struggle as it is without medical intervention. I counted calories and religiously recorded all of my physical activity and food and water intakes using very technological means tied into MyFitnessPal for almost a decade. It was not for lack of effort, dedication, or knowledge that I gained back weight or realized that I was not going to succeed for a lifetime without medical intervention. It's simply not possible to rationally fight your base biological impulses when they are fall into your body's basic survival mechanisms. I effectively "tortured" myself psychologically for almost a decade, and the net result was the moment I stopped I gained all the weight back. GLP1 agonists are basically miraculous.

vallassy 4y ago

Hey mate, as a fellow obese (soon to only be overweight) person, I found something that makes a lot of sense to me: the carbohydrate-insulin model of obesity. The thermodynamic model of calories-in-calories-out doesn't work because we are not a thermodynamic system; it doesn't take into account the hormonal and metabolic changes that occur when calories are chronically restricted.