140 million obese Americans x $15,000/year for obesity drugs = . . . uh oh, that can't be right.

Nov 23

The Story So Far

Semaglutide started off as a diabetes medication. Pharma company Novo Nordisk developed it in the early 2010s, and the FDA approved it under the brand names Ozempic® (for the injectable) and Rybelsus® (for the pill).

I think "Ozempic" sounds like one of those unsinkable ocean liners, and "Rybelsus" sounds like a benevolent mythological blacksmith.

Patients reported significant weight loss as a side effect. Semaglutide was a GLP-1 agonist, a type of drug that has good theoretical reasons to affect weight, so Novo Nordisk studied this and found that yes, it definitely caused people to lose a lot of weight. More weight than any safe drug had ever caused people to lose before. In 2021, the FDA approved semaglutide for weight loss under the brand name Wegovy®.

"Wegovy" sounds like either a cooperative governance platform, or some kind of obscure medieval sin.

Weight loss pills have a bad reputation. But Wegovy is a big step up. It doesn’t work for everybody. But it works for 66-84% of people, depending on your threshold.

Of six major weight loss drugs, only two - Wegovy and Qsymia - have a better than 50-50 chance of helping you lose 10% of your weight. Qsymia works partly by making food taste terrible; it can also cause cognitive issues. Wegovy feels more natural; patients just feel full and satisfied after they’ve eaten a healthy amount of food. You can read the gushing anecdotes here (plus some extra anecdotes in the comments). Wegovy patients also lose more weight on average than Qsymia patients - 15% compared to 10%. It’s just a really impressive drug.

Until now, doctors didn’t really use medication to treat obesity; the drugs either didn’t work or had too many side effects. They recommended either diet and exercise (for easier cases) or bariatric surgery (for harder ones). Semaglutide marks the start of a new generation of weight loss drugs that are more clearly worthwhile.

Modeling Semaglutide Accessibility

40% of Americans are obese - that’s 140 million people. Most of them would prefer to be less obese. Suppose that a quarter of them want semaglutide. That’s 35 million prescriptions. Semaglutide costs about $15,000 per year, multiply it out, that’s about $500 billion.

Americans currently spend $300 billion per year total on prescription drugs. So if a quarter of the obese population got semaglutide, that would cost almost twice as much as all other drug spending combined. It would probably bankrupt half the health care industry.

So . . . most people who want semaglutide won’t get it? Unclear. America’s current policy for controlling medical costs is to buy random things at random prices, then send all the bills to an illiterate reindeer-herder named Yagmuk, who burns them for warmth. Anything could happen!

Right now, only about 50,000 Americans take semaglutide for obesity. I’m basing this off this report claiming "20,000 weekly US prescriptions" of Wegovy; since it’s taken once per week, maybe this means there are 20,000 users? Or maybe each prescription contains enough Wegovy to last a month and there are 80,000 users? I’m not sure, but it’s somewhere in the mid five digits, which I’m rounding to 50,000.

That’s only 0.1% of the potential 35 million. The next few sections of this post are about why so few people are on semaglutide, and whether we should expect that to change. I’ll start by going over my model of what determines semaglutide use, then look at a Morgan Stanley projection of what will happen over the next decade.

Step 1: Awareness

I model semaglutide use as interest * awareness * prescription accessibility * affordability. I already randomly guessed interest at 25%, so the next step is awareness. How many people are aware of semaglutide?

The answer is: a lot more now than when I first started writing this article! Novo Nordisk’s Wegovy Gets Surprise Endorsement From Elon Musk, says the headline. And here’s Google Trends:

Semaglutide is now as searched-for on Google as Prozac or Viagra. Even if this is a temporary Musk-related spike, even pre-Musk it was getting a little above half their level. But Google Trends doesn’t exactly track awareness; few people search for Prozac these days precisely because everyone already knows what it is. So all this tells us is that there’s a lot of buzz around semaglutide.

Suppose for the sake of argument that 5% of obese people have heard of this drug.

Step 2: Prescription Accessibility

The FDA says Wegovy is indicated for obesity, defined as BMI ≥ 30, or for people with BMI ≥ 27 and certain medical conditions. Does that mean that if you have that BMI, your doctor will give you a prescription?

I think most doctors will want patients to try diet and exercise first. My experience as a doctor is that most obese people have already considered diet and exercise. Sometimes if you have a very compelling reason and a very well-thought out plan you can get them to try again. But usually they are obese because diet and exercise are hard for them, or don’t work for them, or some other reason besides "they never thought of it".

Still, I hear lots of stories about patient-doctor fights here. I assume this will happen with Wegovy too. Every doctor will have their own threshold for what amount of "already tried diet and exercise" is enough to justify a Wegovy prescription, and sometimes patients won’t meet that threshold.

The history of medicine includes the following story many times: there’s some condition that doctors recommend lifestyle changes for. Then an exciting new medication comes out that treats the condition effectively. Over a generation or so, doctors go from demanding the lifestyle change, to gesturing at the lifestyle change before prescribing the medication, to mostly just prescribing the medication. We saw this with cholesterol and statins, with hypertension and ACE inhibitors, with depression and SSRIs. You can form your own opinion on whether this is good or bad, but we’re probably in the very beginning of this process with obesity. Opinions will be all over the map for a while before the inevitable pharma company victory makes everyone agree that semaglutide is first-line therapy.

…except that this time, Silicon Valley is short-circuiting the process with fly-by-night telemedicine companies that guarantee you’ll get the drugs you want. For example, NextMed charges $138/month ($99 first month only!) for a guaranteed GLP-1 agonist prescription, plus "support and messaging with expert doctors". The DEA sometimes shuts these groups down when they start playing around with controlled substances (eg addictive drugs like Adderall), but Wegovy isn’t controlled, and the government probably doesn’t care that much here. These services guarantee that people with money will be able to circumvent conservative doctors and access a prescription.

Only 75% of Americans have PCPs at all. If we assume half of them will eventually be able to get a Wegovy prescription from their doctor, that’s 37.5%.

Step 3: Affordability

Semaglutide costs $15,000/year. Well-off people like Elon Musk might be able to pay that out-of-pocket, but most people will probably need insurance coverage. Right now this is spotty.

Medicare doesn’t cover obesity drugs. This isn’t a reaction to the threat of semaglutide-related cost explosions - they’re not that smart. I think Medicare laws were just written in the old days when people were less likely to think of obesity as a disease.

Is it time for change? Some Congressmen have proposed a very noble-sounding law telling Medicare and Medicaid to start covering weight loss drugs. I‘m sure this is out of deep compassion for America’s obese population and not because it would make pharma companies one billion zillion dollars.

One of the Congressmen even has the last name "Kind!" Some pharma lobbyist probably got a bonus for that one.

Private insurers mostly have to cover whatever Medicare does, but they can choose whether or not to include extra non-Medicare-covered drugs. Some have chosen to cover semaglutide under some conditions. Others would prefer not to cover it, but can be scared into covering it by the magic words "medical necessity". Overall I don’t understand the laws here beyond that maybe they’ll cover it and maybe they won’t.

Here, too, it might be time for change. The New York Times is publishing articles trying to convince us that private insurances not covering semaglutide is an outrage.

Here in the tiny gray text, I want to take a second to complain about this article. It notes that Wegovy (semaglutide for obesity) costs more per prescription than Ozempic (semaglutide for diabetes), and calls this "a gross inequity", accusing Novo Nordisk of "charg[ing] people more for the same drug because of their obesity". But the obesity prescription is higher dose than the diabetes prescription! Milligram per milligram, Wegovy costs *less* than Ozempic! A steelmanned version of the NYT might object - don’t most of the costs come from the intellectual property and not the manufacturing, so that dose shouldn’t matter? Yes, but if you made the obesity version cost too much less per milligram than the diabetes version, then diabetics would cheat the system by buying the obesity version and splitting it into smaller doses!

Insurances that do cover it may require extra documentation that the patient has tried lots of diet and exercise, maybe including some official diet-and-exercise program like WeightWatchers. They might also want documentation that patients have tried cheaper earlier-generation weight loss drugs without success.

Even when insurances do cover semaglutide, copays may be very high. I have a pretty minimal insurance and it looks like if I got semaglutide my copay would be about $500/month until I reach my out of pocket limit. Harsh. People with better insurances might get hit less hard, but I don’t think anyone will be picking this up for cheap.

Let’s say only 5% of people who clear all previous hurdles can afford the drug.

How Many People Get Semaglutide?

140 million obese Americans * 25% interested * 5% know of semaglutide’s existence * 37.5% can get prescriptions * 5% can afford it = 33,000, which is a pretty good match for the 50,000 estimated prescriptions. I didn’t even fudge the numbers to come out right, it just happened.

The Coming Decade

As a service to pharma investors, Morgan Stanley modeled the economic future of obesity medications over the next decade. Their headline result: semaglutide and various semaglutide-copycat-drugs will be a $30 billion market by 2030. That’s less than the $500 billion disaster I was afraid of! But still almost 10% of all US drug spending!

Here are two core analyses from the report:

The first analysis asks "what if doctors medicalized obesity as comprehensively as they’ve medicalized hypertension and high cholesterol?" That is: what if we put in a society-wide effort to get every obese person to a doctor, and after only a little diet and exercise, the doctor puts them on a medication? They find that the US obesity market would multiply by a factor of 25, to about $87 billion/year.

The second analysis is a more realistic projection for the next decade. Two things stand out. First, the number of patients on Wegovy or related medications goes from an estimated 46,910 now (pretty close to my 50,000 estimate!) to 11.3 million in 2030. Second, the cost per prescription goes from $15,000/year to about $4,000 year. Let’s look at this second change in more detail.

Right now semaglutide is literally in a class of its own for weight loss. But remember, it started as a GLP-1 agonist diabetes drug. And there are other GLP-1 agonists already in use for diabetes. Novo Nordisk’s competitor Eli Lilly owns a closely related molecule, tirzepatide (Mounjaro®). They’ve already done studies showing it also works very well for weight loss - if anything even better than semaglutide - and they’re expected to get FDA approval to market it as a weight loss medication next year. Although capitalism fans might expect the presence of two competing drugs to immediately drive down prices, this is mysteriously not how things work in health care and prices will probably stay the same in the short term. But several other companies are working on semaglutide-like drugs, some will be cheaper to produce than semaglutide, and Morgan Stanley expects that this stronger level of competition will eventually drive costs down to $350/month ($4,000/year) by 2030.

"Mounjaro" sounds like the playful animal sidekick in a Disney movie.

From a purely economic perspective, semaglutide costs the health system money (because it’s expensive) but also saves the health system money (because we don’t have to pay for obesity consequences like diabetes and heart attacks). Which effect wins out? According to the Institute for Clinical and Economic Review, benefits would outweigh costs if semaglutide cost less than about $8,000/year. Since it costs $15,000 year now, it’s not cost effective. But if Morgan Stanley’s model comes true and it costs $4,000/year in 2030, then it will be cost effective. So at some point, Medicare (and so insurance companies) may start covering it more out of self-interest. I can’t tell whether the model takes this into account or not.

(there’s also a third-level effect where it costs the health system money again, because it prevents people from dying of obesity-related complications, and dead people stop needing expensive health care. I think health economists are supposed to ignore this level.)

11.3 million prescriptions at $4,000/year comes to $45 billion, but Morgan Stanley expects that not everyone will fill their prescriptions consistently or stay on the medication the same amount of time, leading to their $31 billion figure.

Towards The Glorious Post-Obesity Transhuman Future

The Morgan Stanley report shows that even the greediest pharma investors, openly plotting to medicalize obesity, can’t bring themselves to believe in more than 11 million US semaglutide patients by 2030. That’s less than 10% of the US obese population.

Isn’t that kind of disappointing? We’ve got > 100 million people dealing with a condition that not only makes them unhealthy, but also causes them psychological distress, and makes lots of people low-grade disappointed in and repulsed by our society. And we’ve got an effective drug that treats the condition. And we’re going to use it on less than 10% of the people involved?

In 2032, semaglutide goes off-patent. It will probably take a few years to sort out legal issues and ramp up generic production, but by the mid-2030s, its price will go way down. I don’t think there are technical barriers to getting it down as low as $10 - $100 per month. By then, maybe there will be even more exciting branded weight loss drugs for wealthy people to choose from. But at the very least, semaglutide itself should become much more widely available even to poor or uninsured patients.

I’m not sure what will happen. Will there be an inflection point, where so many people use semaglutide that obesity becomes unusual again, and then the remaining obese people start using it just to fit in? Will obesity become an optional fashion statement, like shaving your head or getting a tattoo? Or will semaglutide end up disappointing us in some way, like so many promising drugs have before?

I come at semaglutide from a transhumanist perspective. I want to hack genetics and biology until everyone is as tall as they want, as strong as they want, as smart as they want, and whatever gender they want. If you want wings, you should be able to have wings. And yes, part of this vision is everyone having the weight they want.

I’m not sure this will happen, but for the first time I can see a clear path to how it might.

Postscript 1: Should You Take Semaglutide?

I can’t answer this, please ask your doctor.

But I do want to add that there are potential side effects I haven’t mentioned in this post, including nausea, gastrointestinal problems, pancreatitis, and kidney problems.

Semaglutide has been accused of slightly increasing risk of pancreatic and thyroid cancers. Studies have found trends in this direction, but these conditions are so rare that even over thousands of patients over many years, the increase hasn’t yet reached clear statistical significance. The current consensus position is that it may increase thyroid cancer by a tiny amount not relevant to most patients, and that it probably doesn’t increase pancreatic cancer. I think my father has looked over these data more and is less sure than other people about the lack of pancreatic cancer risk, but he can’t get the resources he needs to prove anything, and I can’t remember his exact argument.

More broadly: like all medications, semaglutide has benefits and risks, and you shouldn’t blindly take it after reading one blog article.

Postscript 2: Is There A Way To Cheat The System To Get Semaglutide For Lower Cost?

Health care is much like airline tickets: everyone pays a different price for everything and there’s usually a secret way to get what you want for much less money. Is this true of semaglutide?

Pharma company Novo Nordisk offers a Savings Card that they say brings the price down to as low as $25 per month. I’m a little suspicious of this - pharma company offers are rarely as good as they sound - but I don’t notice any obvious tricks in this one and it should probably be your first bet.

This startup claims that they can get insured people semaglutide for a $25/month copay "after their deductible is met" by negotiating with the insurance company very effectively. I can’t imagine how that works or what they have to negotiate with, but they seem pretty convinced, so I would welcome more information.

Otherwise, you don’t have many great options. Although there are two older forms of semaglutide not FDA-approved for weight loss - Ozempic and Rybelsus - these are both more expensive, milligram per milligram, than Wegovy itself.

Canada is also of no help. The usual Canadian pharmacies don’t seem to carry Wegovy, and charge about the same amount for Ozempic as American pharmacies do.

This article in Drug Discovery Trends says that compounding pharmacies have been selling semaglutide for $300/month, less than a quarter of the sticker price. This is a bit confusing: compounding pharmacies are small local operations permitted to dispense unusual medications by mixing existing ones together in nonstandard ways. They’re arguing that they can legally dispense the semaglutide because they’re mixing it with vitamins, which, fine, but how are they getting it in the first place? Everyone else seems as confused as I am:

"Nobody knows how [compounding pharmacies are] getting it," said Karl Nadolsky, an endocrinologist at Spectrum Health. "Who's making it? [The pharma company that makes it] Novo [Nordisk]'s not giving it to them. They're the ones with the rights to the molecule, so how is anybody getting semaglutide?"

Has nobody asked compounding pharmacists about this? Do they have a conspiracy of silence? Does the FDA sometimes send their goons in to extract the information, but the compounding pharmacists compound sleeping gas / smoke grenades and vanish into the night? Anyway, the usual authorities warn you not to take compounded semaglutide under any circumstances, but they’re the same people who tell you never to buy drugs from a Canadian pharmacy because they might be adulterated. You can decide how much you want to trust them.

Postscript 3: What About Europe And The Rest Of The World?

Countries that are not the US usually negotiate with pharmaceutical companies over price. Because of some combination of "negotiation works" and "they are free-riding off Americans’ hard work", they usually get much lower prices. What does semaglutide cost elsewhere?

This is hard to find out because government health agencies sometimes keep their prices secret, plus Wegovy mostly isn’t available in other countries yet.

The only information I could find was from Britain, which is in the process of making Wegovy available to patients. It looks like NHS will "restrict the expensive drug’s availability to very obese people attending specialist weight-loss clinics", but that it might be possible to get it from private clinics for £199/month = £2400/year.

Wegovy has been approved in the EU but doesn’t seem to have made it there yet. I can’t find any information about any other country. Non-weight-loss-indicated versions of semaglutide are available in many countries, but I wouldn’t expect their health care systems to be flexible about redirecting it for weight.

Canadian regulators have approved Wegovy, but it doesn’t seem to be available there yet. I haven’t seen any evidence that Ozempic costs less in Canada than it does in the US, and I’m not sure why. Maybe the pharma companies have figured out that anything that happens in Canada gets imported into the US, and they’re playing hardball this time. I don’t know whether Canadians will be able to get it for cheaper than Americans or not.

Postscript 4: Predictions

(all predictions are conditional on no singularity or global catastrophe)

  1. 10 million Americans on semaglutide (or yet-to-be-approved equally good or superior alternatives) by 2030: 75%

  2. Medicare covers semaglutide (or an alternative) in 2030: 40%

  3. Semaglutide (or an alternative) costs less than $100/month in 2030: 25%

  4. Semaglutide (or an alternative) costs less than $100/month (inflation-adjusted) without insurance in 2040: 66%

  5. US obesity half or less of current rate in 2050: 30%

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P(A|B) = [P(A)*P(B|A)]/P(B), all the rest is commentary.


Isn’t this phentermine? Wasn’t it part of the old phen-phen diet? One "phen" was found to cause heart problems.

No, this isn’t related to phentermine. It’s not any kind of stimulant. It works by making you think you are full and not hungry any more. Source: my better half takes one of the versions for diabetics.

Sorry, I thought I read somewhere that Wegovy is actually phentermine, but on further reading it seems you are correct. It is just a different weight loss medication. And has less long term results and perhaps more side effects.

There are shady weight loss clinics that prescribe and dispense "all natural weight loss supplements" that are actually phentermine. (Getting customers hooked on stimulants is a great way to ensure repeat business!) I wouldn’t be surprised if some of them latched on to the semaglutide hype and started pretending to offer that.

Nov 24·edited Nov 24

I dunno, I don't find that toooo shady — I'd be pleased to get something that actually works, if anything!

And stimulants mostly aren't physically addictive, so "getting hooked" on them because you took some for weight loss and really liked them sounds like complaining that Krispy Kreme got you hooked on food because you really like eating donuts, it seems to me...

Edit: Well, marketing it as "all-natural" *would* be shady — forgot about that part, sorry!

("All-natural" is a stupid term to base purchasing decisions on, though, for many different reasons... so I can't get too worked up about it, heh.)

Phentermine is actually a controlled prescription medication under the same rules and regulations as ADD medications and pain medication. Phentermine is only available by prescription. There are supplements that weight loss specialists use but there is no reason to try to "hook patients" on a medication. Patients actually seek out Phentermine and try to rely on it versus actually changing their diets. Phentermine is highly controlled and should be in a prescription bottle from a pharmacy or a dispensing medical office.

Nov 23·edited Nov 23Author

They're both drugs used to treat obesity, no other connection. Are you asking about something more complicated than that?

Can you extend the cost benefit analysis to include stimulants and other harmful weight loss drugs?

No, GLP-1 drugs work completely differently. Here’s a useful summary by Stephan Guyenet, whom SA has written about approvingly before:

Wegovy is unrelated, but Qysymia, the less-functional diet drug mentioned in passing from the chart, is phentermine + topiramate.

You said, "I have a pretty minimal insurance and it looks like if I got semaglutide my copay would be about $500/month until I reach my deductible." I think you mean out of pocket limit, not deductible, though maybe your plan is odd. Usually, you get zero benefit until you hit the deductible.

Thanks, corrected.

I tried semaglutide and it did nothing to slow rate of weight gain, just produced stomach upset, going up to 2.4mg injectable. I know one other person trying semaglutide and they reported something similar. I wonder if they played some clever games with their choice of patients. My expectation of how the news goes here is a whole lot of people who try semaglutide, maybe after fighting really hard to get on it, and find that it does nothing. That said, I know at least one friend of a friend, if not a friend per se, who claims that semaglutide was their miracle drug. So maybe still worth that hard fight, even if I'm guessing that the real proportion who get nothing out of it will prove to be over 50% in real populations.

Further fun fact: Semaglutide comes heavily recommended with diet and exercise and many stern injunctions about that! The actual insert sheet includes a graph for how much weight people lose with and without "lifestyle interventions" added. The two graphs are roughly the same.

I thought the comments at were impressive, although of course that's a different kind of selection bias.

I hate to be that guy, but I do find all these debates about extremely expensive weight loss cures (Matt Yglesias has a recent article about getting [I forget which] surgery) kind of annoying, where there are literally money-saving ways to lose weight - and more importantly than that, improve your metabolic health (where obesity is a potential symptom).

"semaglutide comes heavily recommended with diet and exercise and many stern injunctions about that!"

I wonder what effect that heavily recommending things that cause weight loss alongside your weight loss drug does.... I also wonder "what" diet and exercise is being recommended, when there is so much (conventional wisdom) diet and exercise advice that will definitely not make you lose weight, or worse, make losing weight so unenjoyable that you don't want to do it.

Nov 24
Comment deleted

Yes, and that's why just waving the magic totem labeled "do diet and exercise" doesn't work. Exercise done right doesn't make you lose weight, but you should still do it. Diet can, but most diet advice doesn't work, or works, but is too difficult to stick to - giving an out to the Puritans who lecture people for being insufficiently pious. And remember "work" isn't defined as "lose weight" it is "be healthier and less likely to have the bad health outcomes that are currently correlated with being overweight"

This works:

Yeah, my first year Behavioural Psych teacher had a great point when he said imagine a problem in the world (I picked AIDS). Then imagine a behavioural change that would 'cure' it. This idea was revitalised with Scot's post along the lines of technology is possible biology (behaviour change) is not (immutable).

Behavior does change, but that doesn't mean anyone can reliably choose to make it change, for themselves, or large groups, or for everyone.

yes. Human behavior is immutable. That's why we still live in tribal societies of no more than a couple hundred people led by hereditary nobles.

>The same can be said about pregnancy and STDs ("Just don't have sex")

Terrible analogy. Not having sex works 100% (alright let's say 99.999% to account for urban legend-tier accidents) for STDs and pregnancy. It's not a problem of effectiveness, it's a problem of "people don't use it". If a medicine cures a disease, it's not a failure when people who decided to not take the medicine suffer from the disease.

"eat less stuff" is a gold star way to lose weight except that people suck ass at it. I have succeeded in the past, but put back on 20 pounds from my ideal body and am failing currently; it's pretty damn hard. I don't know if that's what you mean by money-saving way to lose weight, but if it is then I think it's an incomplete solution--eat less stuff needs a very firm "how," and that seems to vary person-to-person

Why eating less is so difficult and why losing weight at all by any method is so difficult are questions at the very edges of current neuro- and metabolic research. Most of what we tell the obese is unhelpful.

The real reason it's so difficult is that eating too much has simply become too convenient, whereas not doing so apparently doesn't come natural for many people.

I can see it in my wife: when she had the mental strength to account for everything she ate, counting calories and adjusting her diet to get enough protein, she easily lost weight at exactly the expected rate. As soon as she stopped doing that she started to eat too much calories with too little nutritional value again, as those meals are way more convenient to make, more tastier for her and immediately rewarding for the brain (but don't actually make the hunger go away for long). Despite her noticing how a protein rich diet made her feel full for far longer, allowing her to eat only two meals a day easily, she can't maintain such a diet without dedicating substantial mental strength to it; and she can't properly limit her calories with a more convenient diet either.

The difference between her and me is that she absolutely can't tolerate hunger, like at all. Not eating breakfast when starting early into the day to achieve something is simply not an option for her. Neither is skipping meals when eating her usual diet.

I on the other hand would rather sleep in another 15 minutes than to get up early to find the time to eat something. I can easily skip two meals out of three without any issues for days. I feel hunger sometimes, but I can just ignore it for an hour or two, and then it goes away. For me its absolutely no issue to maintain a BMI of 22-23 without ever stepping on a scale, counting calories or diet adjustment. I just stop eating when it's too much. I also don't stuff in left-overs for the sake of finishing them, which makes my wife mad regularly. She just can't get off the idea that this means wasting food.

A drug that would make the feeling of hunger go away would certainly help. But the real message is: convenient diets are unhealthy. We should have more healthy food options which are convenient to consume. If eating healthy requires extra effort, a lot of people will fail to do so ...

And all of that is without even considering people who simply have to eat whatever is the cheapest option available ...

Sorry, but I'm a little miffed here. "Convenient diets are too easy" is certainly a contributing factor, but the rest of your comment reads like someone lecturing a person suffering from chronic pain.

"Well, *I* don't get sensations like my bones are splintering and turning into knives cutting my flesh, so an occasional aspirin handles things for me just fine! Why do *you* need strong pain-killers? Modern pharmaceuticals have made things way too convenient!"

You say you don't get hungry and can easily skip meals without noticing, or ignore any hunger you do feel. Yes, that means it's easier for you not to eat and to stay at a 'normal' weight.

Try imagining you *do* feel hungry. Not even that - do you get thirsty? Do you drink plenty of fluids during the day? Can you easily ignore being thirsty? The next time you are thirsty, try "no you can't have something to drink right now, you had a glass of water this morning, you have to wait a minimum of four hours before you can have your next glass - and only one!" and see how you hold out.

This is probably not how you intended it to sound, but your comment comes off as "my wife is so over-sensitive and has no grit, she can't handle a little bit of pain/hunger, she just needs to toughen up - me, I could have my hand chopped off and not even notice, *that's* normal!" - see what I mean about the comparison to chronic pain?

Nov 24·edited Nov 24

You took my post in exactly the opposite way it was meant. I'm not saying that anyone would be at fault in the way you construed it. Quite the opposite. I was saying that the individual experience of hunger was very different; as is btw. the individual experience of pain.

This makes it extremely difficult for my wife to maintain her weight while consuming exactly the same kind of diet which I eat. Where she needs willpower not to eat something, I just need lazyness to prepare food. While she had to adjust her diet to lose weight to a high protein one, I can live as a skinny fat on a low protein diet just fine without any effort (and then still suffer from much of the issues such a bad diet entails). None of this is my achievement or her failure. It's just a simple fact.

I'm sorry if it came off differently. But I feel as if you were reading my comment almost in bad faith here. How would it even be my wife's fault that she experiences hunger far more severely than I do? And how would it be an achievement of mine that my body reacts far more charitably to not getting any food for an extended period of time? Neither of us chose our bodies or our body experiences. And nowhere did I blame her for her way of experiencing it.

I then proceeded to say that the reason this difference leads to that much obesity is that high calorie diets with low nutritional value are much easier to purchase and consume nowadays than diets which are well balanced. My wife, when trying to lose weight, had to go to great lengths to get all the nutrients she needed, while going cal negative for an extended period of time. IMO this is something we as a society could and should address.

Here again I'm under the impression that you are reading my comment in bad faith, as your example with pain killers works exactly the opposite to what I said. So your comparison doesn't even make sense and IMO only serves to discredit my thought.

And to answer your similar bad faith attempt at thirst: yes, I also experience thirst way less severely than my wife. Again: this isn't her fault or my achievement, it's just a plain fact.

Btw.: I am a chronic pain patient, having shattered my left hip a few years ago. I don't have a single day in my life without pain. And I don't use any medication for it (though I had doctors call me out for it, claiming stupidly that no one should ever need to experience any pain at all). Yet I never told anyone that therefor they shouldn't need any either. That would be simply plain stupid. I did need quite a lot of those the day I shattered my hip ...

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No worries. It's phrases like "a little too convenient" which, if you've had a lifetime's worth of advice about "don't be fat", sound like the same old "just have some WILLPOWER" scolding.

"Eating too much has simply become too convenient" may indeed be true, but there is the whiff of moral judgement about it. If only you, fat tub of lard, would bother to go out and shop for HEALTHY FOODS LIKE VEGETABLES and then put some effort into COOKING A PROPER MEAL, then you wouldn't over-eat and what you ate would be PROPER FOOD. But instead you are too lazy and greedy and want FAST, CONVENIENT, NO-EFFORT CALORIES.

You know, the popular imagery when you search for "overweight" or "obesity":

You know your own home situation better. Is your wife sitting on the couch in front of the TV, cigarette in one hand, bowl of candy on her lap, and sugary soda in the other hand? Does she never cook and eat vegetables?

Or maybe she does that, but still has trouble controlling cravings and habits.

Most of my life, I had no easy access to those sugary snacks or fast food. I grew up eating those healthy veggies and home-cooked meals. And I was a fat kid, a fat teenager, a fat young adult.

"Convenience" is a label that covers a multitude, including accusations, which is why I react badly to it ('you're too LAZY to cook healthy meals!')

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I was specifically talking about the convenience of accessing foods with lots of calories but a lack of protein, not about the easy of access to foods in general.

We noticed this when my wife was actively losing weight. Whenever we were searching food on the go, it was essentially impossible for her to get something which would provide her with enough protein, but not add too many calories. She always had to prepare special meals for herself instead of being able to just eat whatever was available. You can do this for some time, but you can't do this all the time. Which is why she did gain everything back pretty quickly once she lacked the time to painfully account for everything she consumed and to plan ahead everything she consumed for several days.

I'm fully aware that I'm not living healthier than her, as we both eat the same things most of the time. I just have it easier than her to stop at the right amount of calories to maintain my weight. That's all ...

Nov 24·edited Nov 24

I didn't find that your comment at all had that tone, FWIW. Like, it didn't even occur to me to interpret it as dismissive, and I was surprised to see Deiseach reply like that.

A little surprised. It's Deiseach, after all... (Kidding, kidding!)

I too get a bit pissed, sometimes, when people say something is too easy or too convenient or too pleasurable(†) — that's the point of life, as far as I'm concerned: ease and pleasure, mmm! — but in context I thought you clearly meant "too convenient [to easily resist / go with an alternative]", and not any sort of value judgment.


(†) all that said, I totally disagree with your characterization of the doctor's remark! IMO no one *should* ever need experience pain — both in the sense that there's no moral reason, and in the sense that painkillers are great, heh.

Pain has a very useful function though. It's essentially a stop sign issued by your body meant for you to make adjustments to whatever it is you are doing.

Would I like the pain to go away? Of course I'd like that. But would I want to sacrifice the utility it has? Hell no ...

My pain levels are a clear indicator on how well I've done in the past days to regenerate on (replacement) cartilage. They are a clear reminder to train my joints properly and regularly; and to go slowly when my hip joint is fragile ...

"You took my post in exactly the opposite way it was meant."

I read your post exactly the way you meant it :-)

Nov 24·edited Nov 24

I sort of get the convenience complaint, but sort of don’t. I think it is mostly just about the raw hedons. A cucumber is pretty good and super convenient, and you can just eat it like an apple.

But people will make a sandwich or cook something in the microwave instead because that food simply tastes better.

I just don’t think convenience is as much of an issue compared to accessibility and the overlap between caloric density and tastiness. Sugar tastes great.

Maybe I phrased it wrong, but I was trying to convey the convenience of foods actually filling you such that you no longer have any cravings.

My wife eats lots of cucumber btw. ;-), but I wouldn't call them a meal. I could eat ten of them and still be hungry. They might help with alleviating thirst though ;-)

I'd consider accessibility the main part of the convenience btw. A major issue, while trying to lose some weight, for my wife was finding something suitable to eat when not eating at home and not having brought our own food along.

Nov 24·edited Nov 24

No, I totally agree with you and not with Martin Blank. Convenience is the #1 issue for me; if there was anywhere around me that offered quick healthy meals, I'd go there. I don't care too much about how food tastes; I just hate fucking around with it. I end up with fast food mostly because I don't want to take >15min on a meal.

Of course, I'm not obese, so maybe my anecdata doesn't apply to the point Martin was trying to make; but still, I'd certainly be eating *healthier* if it was more convenient, and the same goes for people I know who *are* overweight, I think.

Seriously get some cucumbers then. They are super convenient. Ditto like nuts and berries. Tons of healthy stuff is relatively no fuss.

Cucumbers are great! Water, fiber, and vitamins, all in a portable container. Cucumbers and landjaeger are my go-to travel meal.

Ah, somebody else who hates fucking around with food! Me too. I hate shopping for it, I hate unloading it and storing it, I hate cooking it and I hate cleaning up the mess that cooking makes. I cannot believe how much time per day other people spend on food prep and related labor. I don't look down on them, just have a hard time understanding why it's worth it to them. Like you, I don't care that much how food tastes. So long as it tastes decent I'm fine with it. I just try to find reasonably healthy things that require little prep, like 5 mins. in the microwave, or can be eaten as is. Fruit, bags of nuts, bags of peeled carrots, Trader Joe's frozen pot stickers . . .

> quick healthy meals

I can buy dried fruit without added sugar at shop. That sounds like a combination of "healthy" and "fast food". But it would be better if I could also buy *vegetables* like that. (And preferably, not too expensive.)

Dried fruit can be hard on my blood sugar. My tolerance for it varies, but it would be a bad idea for me to use it as a staple. It's not health food for me.

Your wife's (and yours!) experience is totally normal. Most people cannot (and shouldn't) abide hunger, and that is a huge part of why normal "eat 20% less calories" diets don't work, even for people (like her) who have the capacity to measure it. Eating 20% less at 3 meals is also far more difficult (and will result in those leftovers) than eating less in discrete chunks by eliminating meals. Obesity (or lack of it) does not come from

But yeah, if you feel HUNGRY, a "diet" isn't gonna work, period. No one can manage long term hunger in a world that has so many easy things to eat.

Not to be internet nutritionist, but the the thing that everyone I've spoken to has worked (for varying quantities of "worked") for is adding replacing carbs with fat/protein (eat as much as you want for dinner, earlier is better) and then just extending the time period until you eat next (breakfast, or lunch, or later lunch, etc...) til whenever you feel hungry. If you feel "kinda" hungry, drink a zero-cal electrolyte drink first and then check if you still wanna eat a meal. Measuring whether you ate 1741 calories or 1787 calories is impossible.

And also, I just want to reiterate: obesity is a symptom of underlying nutritional condition, not a disease. Some people who have it are fat, some are not. It has bad effects even if you aren't fat. Semiglutides (being diabetes treatments) may somewhat treat the underlying thing (I don't know for sure) but if you adopt a diet that you enjoy, and your A1c and other metabolic indicators get better, you are HEALTHIER, and much lower risk for a long laundry list of bad outcomes even if you don't lose any weight, or never had much fat in the first place. Depending on *what/when* you eat, you (with your low BMI) might have less healthy A1c/etc... than your wife, with the potential bad outcomes. This entire thread is far too focused on treating the symptom of obesity and pretending that if we removed that, we'd fix the problem. (it is possible that semiglutides DO partially treat the underlying problem) There are too many skinny 60 year olds who die of things and we go "so sad, what bad luck, they were so healthy!" but if they were fat we'd go "oh man, if only he'd kept in shape" but they died of the same thing for the same reasons.

Well, those diets actually do work. Physics can't be cheated. That's a big part of the problem. Because it puts so much guilt onto people to whom it doesn't come naturally. The problem is that hardly anyone can put up with them for long enough to get into another mindset, where those changes suddenly come naturally.

Btw.: my wife never felt hungry during her time of losing weight, simply because she did ensure to always consume enough protein. The problem is that most foods which are easily available don't come with enough protein to do that. Just eating less doesn't cut it most of the time, as your diet then quickly become protein deficient. You have to adjust your food items a lot to do it. And then convenience goes out the window. That's what made my wife fail eventually as well after nearly making it into perfect BMI territory.

As for "Some people who have it are fat, some are not.": that's exactly what the term skinny fat refers to.

Just for the record: I never pressured my wife into doing any of this and love her just the way she is. I'm merely trying to recount her experience when she tried a few yours ago.

Well, depends what we define as "work." I am defining "work" as "reduce unhealthy outcomes," not necessarily as "lose weight."

"Btw.: my wife never felt hungry during her time of losing weight, simply because she did ensure to always consume enough protein. The problem is that most foods which are easily available don't come with enough protein to do that. Just eating less doesn't cut it most of the time, as your diet then quickly become protein deficient. You have to adjust your food items a lot to do it. And then convenience goes out the window. "

Your wife (and you) are doing great, and what you're saying makes great sense: my only suggestion to you specifically is that while protein is great, the only way to really beat back hunger long term is fat. I guess my other recommendation is to get yearly blood work, and look at those numbers instead of the scale. If your wife is eating healthy and exercising and her numbers look good, extra pounds (which absolutely are going to get harder to keep off as we all get older) can be ignored. I don't want to read into people's thoughts but you are absolutely right about the guilt, and for me at least, having good lab numbers (which are more important than BMI) trumps (and should) what the scale says.

"As for "Some people who have it are fat, some are not.": that's exactly what the term skinny fat refers to."

Yes! It's a great term, especially since it emphasizes that we've mentally replaced the word "unhealthy" with "fat".

I agree about the "lab numbers" > "BMI". My wife was only trying because her parents and her sister really struggle hard with obesity, and their lab numbers have become alarming because of it. Prevention is better than trying to deal with the issues later. We both want to grow old ;-)

That is the same motivation my wife and I have. :) I only mention it because there are times, especially for people like us who are.... on that process of growing older already... when you can do all the Right things with regard to health, diet and exercise, and see good lab numbers but still have "bad" weight/BMI numbers or visible fat, and to not worry as much about that.

> Most people cannot (and shouldn't) abide hunger

This seems an extremely weakminded and degenerate statement to make. Hunger is a natural and healthy state we evolved to cope with. Certainly you SHOULD abide hunger if you are an unhealthy weight

That's fine, and I heartily endorse confronting yourself with things like hunger and overcoming them for all kinds of personal reasons, but within the context of "having a goal of reducing bad health outcomes for hundreds of millions of people with a policy to do every day" then adding a cost (suffering hunger) is something that will detract from that goal.

If hunger (there is also some definition difference here, most Americans have no idea what "hunger" actually is, and use the term to describe the blood sugar low of "it is 4:30 and my tummy says it is time to eat dinner" that is fundamentally not "my body is suffering from lack of vital nutrients and is sending a signal to my brain to acquire sustenance" that comes from different, more extreme situations) were necessary (or the most effective) to become healthier, then I'd agree with you. But it's not. If you eat satiating things for dinner, you won't be "hungry" as soon, making it easier to extend that period. Also, the "hunger" is a real sensation, and if you are feeling hunger, your body is too, and will be doing things (reducing metabolic activity and temperature output) in response to it. For our goals in this case, you want your body to not feel hunger too.

It's not a moral judgement, it's a changing the gear ratio on a machine to reduce friction.

Nov 24·edited Nov 24

Ok, I agree there. I thought you meant we couldn't abide it for moral reasons, which struck me as decadent/degenerate path to take.

Ultimately this doesn't seem all that dissimilar from antidepressants - one one level it probably is possible for many otherwise medicalized people to bootstrap themselves out of depression as well as obesity by personal fortitude, but pharmacological assistance might just lead to the best public health outcome in aggregate.

Pharmaceutical interventions can really help start the bootstrapping, too - A lot of the ruts one can get stuck in are very stable without chemical intervention, but comparatively easy to stay out of once you get out, so taking drugs to get out of the rut doesn't necessarily mean you'll need to keep taking drugs to stay out of it. (though doctors may just keep re-issuing scripts regardless....)

What about, like, peanuts, though? Peanuts are convenient, nutritious, and filling, but eating lots and lots of peanuts isn't very palatable. I don't think we can blame this on convenience, except insofar as convenience is one of several competing, difficult things we're trying to simultaneously optimize for.

Well, good point. What about peanuts? Answer: they are one nutrient, not a meal, and thus lack lots of crucial trace elements. To add insult to injury, opposed to what you said, they aren't convenient at all. Not only don't they solve the issue at hand, but additionally where I live they aren't really readily available. I can easily get french fries, burgers and various other fast food meals on the go. I've never seen peanuts on offer (for obvious reasons). I could go into a super market and buy some; but then again I still wouldn't have a meal, and rather just one ingredient for a meal.

That's the exact opposite of convenient. Rather hard to come by and still lacking all but one ingredients for a meal I still would have to prepare. As opposed to just ordering the Pizza, wait 5 minutes, eat ...

Nuts are kind of weird. I don't know if other people experience this, but when I get a sudden pang of hunger my body completely rejects my suggestions that we eat some nuts. I'll be super hungry, staring into my cupboard, and that bag of peanuts will be completely unpalatable to me. This is in spite of the fact that I love nuts as a snack.

It think it's something where my body doesn't want to deal with a hard and dense fatty food on an empty stomach. Combined with the fact that nuts are quite slow to affect my blood sugar.

In general I think something with starch and fiber is the best remedy when I get that kind of sudden hunger.

I’ve never heard someone else express this. It’s very odd. It’s much easier to eat peanuts with a drink after dinner.

So I am not alone after all!

It's such a pity too, since nuts are so convenient.

I've had a lot more luck with "eat normal portion sizes with fewer calories, and track what you eat." It took me from BMI obese to BMI normal and has kept me there.

Portion control went so disastrously wrong that I'm skeptical of it as dietary advice. It doesn't seem supported by a lot of evidence, either (e.g.

Can you elaborate on the distinction you're drawing here? You said you succeeded with a strategy that sounds to me a lot like "portion control", but then say portion control went disastrously wrong?

Evolutionary mismatch, IMHO. No way to get a 3000 calorie diet 200 years ago unless you were a king.

There's also a lot of calorically dense processed food out there.

> To go with the biscuit, sailors in the RN were issued other food on a standard weekly rotation. On Sunday and Thursday, this was a pound of salt pork and a half-pint of dried peas. Monday was a pint of oatmeal, two ounces of butter, and four of cheese. This was also served on Wednesday and Friday, along with a half-pint of peas. Finally, Tuesday and Saturday usually meant 2 pounds of salt beef. Conventionally, this was washed down with a daily gallon of beer. The total came to approximately 5,000 calories a day, an incredible amount to modern eyes but quite appropriate for sailors at the time.

For comparison, 3000kcal/day is about my current maintenance (180cm 72kg male). And I am _definitely_ way less active (and less muscular) than a sailor or soldier in history (1-2 hours of mostly anaerobic exercise every day).

I think you're right, and the "diet" suggestions tend to be "just eat 10/20% less calories during the day" which isn't gonna work: people don't suck ass at it because they have low discipline, but because it's enormously difficult to measure calories in this scenario, and your behavior/brain/metabolism compensate it. It's not a single-input mechanism black box. Your 20 off, 20 on experience is the absolutely normal failure mode for calorie restriction diets.

Not to be the Weirdo Diet person , but what I mean is: intermittent fasting, cutting out breakfast (and/or lunch) and replacing enough of your daily quick-burn carbs with long-burn fat so you don't feel very hungry while you're doing it. This works because unlike calorie restriction, it doesn't cut against daily Regular American Life behavior (you "fast" every night from after dinner until break-fast, this is just a few more hours) and all the countervailing mechanisms your body has evolved over a billion years to counter generalized calorie restriction.

I don't eat breakfast. I've never felt hungry in the mornings, and when I do eat then, it (ironically) makes me *hungrier*, e.g. at around 11 o'clock I feel like I need a quick snack, whereas without eating breakfast I don't feel that and can even go without lunch.

So all the well-intentioned advice about "skip meals" or "don't skip meals" or "eat more protein" or "eat saturated - I mean unsaturated - I mean polyunsaturated, not monounsaturated - I mean saturated fats" or "just cut out the junk and move more, what's so hard about that?" becomes frustrating.

Human biology is not like a tidy physics experiment. It *should* be "calories in, calories out". It *is* "calories in, calories out* but that is *not* the whole of it, and that is what gets forgotten.

Some people will react beautifully to "I fast X hours a day from this time at night to that time the next morning between meals" but some people will not. Some people will control hunger cravings by eating breakfast, other people will have their appetite stimulated. Some people will tolerate more fat in the diet than others. Potato diet works for one person, packs the pounds on for another.

I think you are right within the realm of the recommendations you are describing, because they're so vague/contradictory. I'm not advocating any of the advice you're mentioning, which you are rightly skeptical about them applying to everyone. Calories in, calories out doesn't "work", as a METHOD of dieting, not as a thermodynamic fact.

But is there any debate at all that replacing carbs with fat/protein in a meal will not result in greater satiety/less hunger later on, and therefore enable one to go longer before their next meal? I think everyone agrees on that, and that it applies to everyone - sure, perhaps in different ways/amounts!

Does it seem acceptable that if you go longer between meals, that your body will spend more time burning energy than storing it? Sort of by definition?

Does it seem acceptable that this would then (regardless of totally weekly calorie consumption) result in storing less energy (fat)?

And again, the goal should not be "weight loss" it should be "reducing the unhealthy outcomes", the likelihood of which can be more accurately measured by metabolic lab values like A1c than at the scale.

If you're someone who's had a good BMI forever and doesn't get their labs done, then you're never gonna notice anything because you aren't measuring anything.

"But is there any debate at all that replacing carbs with fat/protein in a meal will not result in greater satiety/less hunger later on, and therefore enable one to go longer before their next meal?I think everyone agrees on that, and that it applies to everyone - sure, perhaps in different ways/amounts!"

No, not everyone agrees, and it does not apply to everyone. It absolutely does not work for me; restricting carbs triggers middle-of-the-night half-asleep binge eating.

(I'm not normally a binge eater at all; I've only ever had this problem when I've restricted either carbs or eating in the evening.)

"counting calories of every thing one eats, to the gram" is not extremely hard. i know so because I'm doing it, and i do not ever do anything remotely hard.

To do so accurately is hard, because even if you're measuring the weight, you're relying on estimates of calorie density that are potentially many years out of date, wrong in the first place, or that the producer of the food is wrong is assessing.

And ok, that it is easy for you is fine - for millions of other people, it would be A) hard B) sufficiently time-consuming they wouldn't want to do it or C) would result in no measurable effect on their health/weight, so they would stop doing it. Maybe "hard" was the wrong term to use.

The approach you are describing sounds reasonable, but, as with most weight loss approaches, there are a lot of things that will make it hard for people to stick with over the long run:

(1)It is hard to change ones habits, including one's eating habits -- not impossible, of course, but HARD. The effort and attention devoted to that have to come out of the same pot of energy people are using to do all the other hard things in their lives -- do a good job parenting their difficult kid, produce good work in their field, keep their marriage in good shape, budget, ruminate about all the bad stuff in the news. On days when the energy pot's almost empty, most reasonable people are going to choose to reduce their effort to eat in a different way, rather than their effort in other areas which are more clearly crucial

(2) It is a heavy burden to stay continuously aware of something. Take blinking -- if I ask you now to notice your blinks, it's easy as pie, right? But how about if I ask you to stay aware of them continuously for the rest of the day? Very very few could succeed at that, especially while doing all the stuff they need to get done today, and responding to whatever comes at them this evening. Continuously monitoring eating to keep it in compliance with a certain pattern is the same -- easy in the short term, very hard in the longer term.

(3) We are surrounded by highly palatable foods, and our brains are not wired for an environment with that feature. We evolved in settings where it was hard to get enough calories. If you found a honeycomb or were presented with a bunch of roasted animal fat it was desirable to eat as much of that stuff as possible. The parts of our brain that push us to eat the sweet, fatty, salty stuff that is all around us is quite powerful, and the part that understands that it's undesirable to gorge on those things on 2022 cannot reason with the parts that want to gorge. It is possible to simply override them, but it is difficult, and it's probably not possible to override them most of the time if you have other heavy demands on you as well.

1) the goal is not weight loss. That is a side effect. The goal is a healthy diet, and reduction of serious bad outcomes in the future.

2) Yes it is hard to change habits. That's why the method is designed to affect the underlying drives that cause the habits to be hard to change. It IS hard to not eat when you are hungry. It is EASIER to not eat when you have made decisions in the past that mean you are less hungry now. Eating more fat and protein in your past makes you less hungry now.

3) There are immensely palatable foods that are not bad for you, and will provide more satiety so you are not driven to consume more so soon. Animal fat is not (particularly) bad for you. Salt is not bad for you. Replace carbs with them in your meal, eat them, and enjoy not feeling hungry so soon. The goal isn't to override your desire to eat awesome tasty food, it's to hack the system so you eat awesome tasty food that reduces your desire to need to eat ANY food for longer.

This is not a moral system. There are not desires to be overcome. There is not decadence to resist. This is not ascetism. There is no willpower. This is a physical system of chemical reactions that we can affect in different ways. We impute no moral significance to a molecule binding to one molecule instead of another, nor should we.

I do think content is certainly as important as portions, if one wants to control obesity. The national health system is pretty good about listing contents on food products. We respond to heat, salt, and sugar, and food manufacturers exploit that. I think if one adheres to a healthy, lean diet, obesity is easier to control. Another important aspect is the consumption of alcohol. Alcohol can provide energy and calories, but can maintain too much weight in an unhealthy body.

I used to be borderline obese when I drank beer or wine, but I lost 75 lbs. when I came down with pancreatitis. Today, after the most recent flare-up, I'm down to 114 lbs. -- but still 6 feet tall. For a time I thought marijuana might help ease the pain, but now my body objects when I try and ingest it, so I've given that up, too. There are certainly no easy answers, but I think the content of one's diet and the consumption of alcohol are important factors. My stomach emptied with this most recent flare-up, which is unusual, so I'm taking the opportunity to curate what I ingest carefully. I'm drinking kefir and Gatorade.

In this case, the problem with "that guy" is not that he’s stating an uncomfortable truth; the problem is that he’s missing the point.

If you think that we should downplay pharma/surgical interventions because dieting and exercise "work," it is incumbent upon you to show how we will overcome the fact that people don’t seem to have the willpower required to use these tools longterm. What’s your plan?

Willpower is a choice. In this study alone, 5% of participants on placebo lost 15% or more of their body weight. The average placebo loss was 2.4%. Granted both of these are hugely less than the treatment group, but they're also hugely less expensive. This is the case in every weight-loss placebo study I'm aware of, just the simple act of taking a pill (sub vitamin or other "healthy" pill they believe could affect weight for placebo in non-lab use) or putting an ab roller in the living room, or anything else that moves diet and exercise slightly closer to the forefront of mind than it was previously can have a significant effect. According to the paper, the lower end fda approved weight loss drugs cause a 4% weight loss, so assuming equal treatment time periods, placebo is 60% as effective on average as some drugs, at 0% of the cost. People are all different, they just need to figure out what best triggers that effect for them, whether it's my examples above (variations of which work for me) or something else.

Again. What’s your plan to get people to actually succeed in exercising willpower?

"just the simple act of taking a pill (sub vitamin or other "healthy" pill they believe could affect weight for placebo in non-lab use) or putting an ab roller in the living room, or anything else that moves diet and exercise slightly closer to the forefront of mind than it was previously can have a significant effect"

Whether you're talking to me or not, the solution is to reduce the thing that is calling on their willpower. It does not take much willpower to not eat if you are not hungry. You achieve being not hungry by increasing the satiety of the food you ate most recently. Food that does that is that which has more fat and protein, and less carbs.

And yet, I was easily overeating and hungry as usual after the first year on a keto diet.

Well, Kenny, just try very hard to try very hard. And if that doesn't work, just try very hard to try very hard to try very hard.

> Granted both of these are hugely less than the treatment group, but they're also hugely less expensive.

Breaking: doing nothing has no effect; is free

> According to the paper, the lower end fda approved weight loss drugs cause a 4% weight loss

Yeah, if you move the goalposts to "the worst drug on the market" the relative effect of the placebo goes up. This doesn’t bear on the article, which is about the best drug on the market.

Nov 24·edited Nov 24

>Breaking: doing nothing has no effect; is free

Breaking: 16% of the improvement of the best drug on the market from taking a sugar pill is not "doing nothing" and is in fact statistically significant. That's why it's included in this paper, and every paper on weight loss drugs.

> This doesn’t bear on the article, which is about the best drug on the market.

No, if you missed it the article is about the best drug on the market and how unattainable it is to most people (and statistically those who would most benefit from it) due to cost. So if we can get 16% of the benefits for almost zero cost that actually a huge deal on its own, and this could likely be improved significantly with other tweaks, as I've now mentioned twice. Less snark, more reading comp next time

What does that even mean? You state that conclusion as if it implies something significant but, I'd argue, it's really just a way to summarize the relation between incentives and behavior. Some things we call choices because they result in different outcomes when you change the incentives (prison for murder decreases murder rater but prison for being short doesn't increase height much). I mean, if you really get down into the details the difference between 'choices' and 'non-choices' isn't that the laws of physics plus initial conditions are any less binding in one than the other or that the biology that happens in the brain obeys some other kind of principle than that in the rest of the body.

But, given that background, saying something is a choice is just a shorthand for describing how responsive it is to incentives. Certainly, choosing not to eat as much is more responsive to incentives than height is but it's a lot less responsive to incentives than many other things.

And once we are made aware of how responsive it is talk of whether it is a choice or not becomes irrelevant. It's like saying something is heavy once you know it weighs 100lbs. It's not adding any information about the thing or helping you figure out what to do with it. Same with weight loss it seems. Absent interventions we aren't willing to make (for good reason) many people don't lose weight but they do on the drug and that's all that's really relevant to deciding policy.

You're exactly right, except that I'm biting the willpower point bullet. Maybe I'm bad at metaphors, sorry.

The plan is this:

1. Forget calorie restriction of the "just eat 20% less calories" form. It requires too much calculation and willpower, and your body will compensate. Forget any diet that stops you from participating in normal social rituals with friends, coworkers or family.

2. Replace carbs in your dinner with fat/protein. Eat as early as possible, eat as much as you want. Don't eat bedtime snacks.

3. Over time, extend the time from ending dinner (your "fast" length) til the next time you eat (breakfast? 12:30 lunch? 2:30 lunch?) as much as possible. Eat the next day when you're hungry, but if you're only feeling kinda hungry try drinking a zero-cal electrolyte drink and see if you still want to eat. Measuring exactly 50/100/150 less calories a day is impossible. Measuring that you ate 10 minutes later is easy. Don't put any sugar or carbs in your morning drinks.

4. Eventually cut out breakfast or lunch, or eat later lunch. Just like dinner, replace carbs with fat/protein as much as possible. Whatever feels okay.

5. Get your yearly blood work done so you can see the improvement in your metabolic indicators. Most importantly: if your numbers get better - whoever you get the labs from will tell you the health ranges - FORGET YOUR WEIGHT, sell your scale.

These are’t terrible recommendations. I do some of the things you list, and it helps me maintain my bodyweight.

But do you seriously think that an epidemic of 70M obese Americans would be fixed if only people would read your five bullet points about intermittent fasting? As per Scott’s math, you are claiming that your tweet-length comment on ACX is worth 500bil. The market disagrees.

"But do you seriously think that an epidemic of 70M obese Americans would be fixed if only people would read your five bullet points about intermittent fasting? As per Scott’s math, you are claiming that your tweet-length comment on ACX is worth 500bil. "


But humbly, my comment is worthless. It's the advertising and execution that matters. Any idiot like me can say "gee, maybe we should build cars in assembly lines with replaceable parts" but it takes Henry Ford to execute. Even tougher, the actual problem here isn't knowing what to do, it's teleporting what to do into the minds and 70M people and then they all have to execute. Which is why I'm babbling my insane, otherwise-worthless ideas in a place run by a person who seems to do a decent job of teleporting ideas into other people's heads.

To elaborate, yes, I really do think it's worth half a trillion, obviously conditional on people actually doing it (though the lack of difficult in doing so is the key feature) and the cost of the advertisement/propaganda to publicize it, and coach people through it. There are companies (look up Virtahealth) that provide physician-led diabetes reversal for a few hundred a year using similar techniques and coaching on it. My only disagreement is you're understating the worth at 500B, because that's only the (estimated) consumer value of "weight loss", because if all 70M people did those 5 things, it would also reduce the downstream occurrence of diabetes, heart disease and cancer as well. (claiming that reducing weight/improving metabolic health reduces those things is a boring conventional medical claim).

Also, re: "the market disagrees", as I pointed out, there are lots of (small) companies providing these services successfully and getting paid for them. Markets can agree in differing amounts, and markets also need information/advertising to match sellers and buyers. If "make cars with assembly lines" was an idea that didn't actually get Ford any money, but rather only gave distributed consumer surplus, he probably wouldn't have executed it.

And while I am a committed free marketeer, markets for services that provide little financial benefits to those who provide them often don't work! I'm not making any money from this. Doctors won't make any money from this - in fact, they will lose money because their gov-mandated quality metrics don't support this type of treatment for obesity or diabetes. Novo Nordisk doesn't make any money recommending this. No supplement or food manufacturer can make money from this. It's not really a product or service to be sold, though some (like Virtahealth) are.

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Nov 25·edited Nov 25

Looked up Virtahealth. Digging in a little it appears to be "we will teach you to eat a keto diet, which will have so few carbs in it that your blood sugar will remain low enough without drugs to call it reversal, except we don't count metformin as a drug because some people like to stay on it".

As someone who took metformin for 3 months and *absolutely could not* tolerate the severe GI side effects, which I never built any tolerance to: lol. lmao, even.

For what it's worth, CoQ`10 settled my stomach (GI tract) when I was starting out with metaformin, but my side effects were never worse than vague queasiness.

They will happily do non-metformin regimes for those who don't want to take metformin, and they will still work.

If your reaction to "this company will, without medication, coach you through reversing your diabetes, which costs millions of Americans billions of dollars a year in insulin, suffering and death" is "lol" then.... what do you want?

I mean, I've been aware of ketogenic diets, and considered trying them, for over half a decade at this point. I know I would not succeed, because like 75% of my favorite foods are incredibly carby and it would be too much of a sacrifice to be sustainable. And I don't have any of the medical conditions that make keto inadvisable for a lot of people.

I also know metformin isn't worth it for me.

I therefore wonder how many of those millions of Americans are in the same spot, and therefore how useful in solving the problem a company whose whole pitch is "keto coaching and maybe keep on metformin" is.

re: Virtahealth, because that's not their "whole pitch." Their method isn't "shove strict keto and metformin down your throat", it's coaching with those as options. If you sign up and say "I don't wanna do those things" they'll work with you. They list those things because they A) do work for many people and B) demonstrate that their goal is metabolic health, rather than counting calories or just losing weight.

"because like 75% of my favorite foods are incredibly carby and it would be too much of a sacrifice to be sustainable."

Which is why I prefer this method to strict, uncoached keto:

1. replace dinner carbs with tasty fat/protein, which are more satiating, therefore you can go longer before being hungry.

2. gradually move back the time you eat your first meal the next day, eventually eliminate breakfast, especially if it's boring crappy cereal. Then push back lunch

3. get your blood work done, if your metabolic indicators (A1c) look good, then you're fine!

Because do you eat those favorite foods at every meal? Maybe you do, congratulations - but most people eat pretty boring and crappy (from a food enjoyment perspective) breakfasts and lunches most of the time. I agree, no diet that says "you can't have your favorite foods at your major dinner time meal with your family" is gonna work. But one that says "maybe you can cut that bland cold cereal in the morning" or "instead of a sugar bomb starbucks latte, get one that just has still-really-awesome-tasting-heavy-cream" or "maybe just push lunch later in the day a bit" can. I'm sure you have favorite foods that have fat and protein instead!

The reason I brought up virtahealth is not "because they force you to do keto/metformin and that is the ONLY WAY" but because they do interactive, working-with-you coaching (that can involve keto or metformin, or intermittent fasting) that provably shows that you can just Talk To People Over Zoom And Get Them To Improve Their Metabolic Health, as a counterpoint to "spend 15k on semiglutide". And I consider the plan above to be an improvement to THAT, because it's something that almost anyone with a messed up metabolism can do even without coaching, in a montessori-sort of "the things that need to be done are simple and intelligible, and you can see for yourself if they are working" way.

I feel like nutrition/metabolism has become very politicized and moralizing. It's just a machine that we can optimize, and I am recommending that we put some oil in the engine to make it run a bit more efficiently. There should be no moral judgements of anyone, except that there is a future where 40% of the nation's GDP goes to insulin and semiglutide and bariatric surgery and.... I judge that as morally inferior to one where we don't?

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This sounds okey if your goal is to go from obese to just chubby.

I don't care how much fat you have, if you get a good diet your body will figure that out on its own. But also, yes, going from obese to just chubby IS correlated (but not causative!) with better health outcomes.

I want you to be healthier, which isn't measured on the scale, but in your blood work and in long term lack of massive health disasters like diabetes, heart disease and cancer. If you're still "chubby" but you don't get those things, well, great!

Nov 25·edited Nov 25

You basically call "healthy" being fat but not sick. Better than being morbidly obese and sick, I guess, but that's not saying much.

That's not good enough, people want to be "fit". You are right by accident with "health isn't measured on the scale" because yes, body fat percentage is what actually matters but it's very hard to measure without (other than doing an autopsy). Unless you are extremely muscular or have great bone density, the scale is a good measure of fitness.

If you want to be fit you can't eat ass much you want for a meal. The usual guides of 2000 kcal a day for the average adult male is probably too much already an puts you on a slight calorie surplus.

Healthy in this case is avoiding bad health outcomes, like diabetes, heart disease or cancer or just death. Good metabolic indicators (A1c) predict that better than weight, (or even body fat, which yes, is better than just weight) which is what I'm talking about.

Yes, sure, some people want to be "fit" by whatever they define that. But "just don't eat as much as you want" isn't helpful advice, and calculating what exactly a "slight" calorie surplus is is really difficult. But if you're trying to improve the health outcomes of 300m different people, you need to measure (at least in a sample population) something more concrete, and you have to have a plan to achieve it that's simple and doable for nearly everyone.

2000 kcal a day is a guide for an average human, male or female. Unless you lay in bed all day or have no muscle mass, as a male you'll be at a deficit at 2000.

As advice, that doesn't work for many people because

- it is very hard to measure calorie intake

- very difficult to measure calorie expenditure

- depending on person, your body will decrease your metabolism in response to getting less calories on average over the day

- also depending on person, your body will send you increasing "hunger" signals if it is getting less average steady stream calories than it did before

- human metabolism is not a calories in, calories out mechanism. It is a goal-seeking mechanism, where one of its goals is to be able to see you through a famine. Even if you think "it would be healthier if you react to this calorie deficit by burning fat/producing less fat" it may think that acquiring excess body fat is healthier so you can avoid a famine, and tweak your hunger/metabolic to achieve that instead.

"Just eat 2000 calories" is the diet advice that most people get, and it doesn't often work, which colors their opinion of simple diet advice in general because it has such scientific consensus and wisdom attached to it. Additionally, it does seem to "work" for lots of people who are already at a "good" weight", but they probably would be so even without the advice, and this also colors their views about what advice "works."

I'm a 71 kg, 181cm, 30 years old man. I can do 13 pull ups, 25ish push ups, toes to the bar abs workout, etc. I'm trying to get some more definition (lower back and abs fat are the most stubborn). I think I hit maintenance at something like 1800 kcal, but need to go south of 1500 to lose any weight for sure.

I think 2000 kcal puts me in that sort of slight surplus that makes people skinny fat over time. I don't know if calorie labels are wrong or consumption guidelines are too high though.

If you are that weight/height/age, doing regular muscle-building work outs, and your metabolic indicators are good, I really don't think you need to worry about counting calories or watching your weight. I wouldn't think you'd get "skinny fat" from 2000 cals and doing that, I'd think you'll probably be gaining muscle weight? I mean, I Am Not A Doctor and skinny fat is Not A Medical Condition, but I think you're good?

Fit, healthy, and lean are not the same things.

This comment is not worth $500bil because, like all comments in this vein, it fails to take into account the complexity of human nutrition. There is no list of 5 points that will work for those 70M obese people. For some, the drug will be the only way. For some it will be a completely different diet. For some, your comment will work, but I expect it to be a decisive minority.

Comments like this are more common than you think, and for me they are just too naive.

2. Literally more than half of my meals are just pasta/rice/bread. Seriously, it's a carb fest down here*.

3. My breakfast is literally chocolate chip cookies. It's one step removed to just shove down my throat spoonfuls of sugar. And it's not even that big of a step.

4. I never skipped a meal. The idea alone of skipping breakfast or lunch is abhorrent to my Italian brain.

And yet, I'm chronically underweight. The only point of yours that I feel to thoroughly endorse without a second thought is the first one.

My set of oversimplified comments will be: never eat sodas, almost never drink alcohol (less than one beer / glass of wine per month), keep a super regular schedule (breakfast lunch, snack, dinner) and never eat out of it (forget chips at parties etc), cook your own meals and eat fast food only occasionally in special circumstances (e.g. you're late for your plane).

Will it work for a "random you" reading? Hell no.

* The hate carbs are getting lately is really puzzling to me. Sure, fat isn't as bad as once thought. But this notion that its ills are solely the product of an evil carb industry that captured the government is ridiculous. I'm sure there is no fat industry that has ever tried to manipulate the public, and, if they do, they only have the public's health interest in mind.

Thank you.

A lot of diets will work for a few people, assuming the only purpose is to lose weight.

Normal people believe that quality of life as reposted by fat people is irrelevant.

Do not adopt diets to lose weight. Adopt a diet to be healthier.

This is the hidden problem* with the semiglutide process: if you take it, lose 20 lbs, fit into your old clothes and declare success, but you're still eating a constant stream of crap 3 times a day, you are still gonna have a higher chance of bad outcomes.

* it's possible that semiglutide is actually affecting your metabolism, in which case it might directly affect your metabolic health, in which case, good for it - it overcomes my "hidden problem" above.

"it fails to take into account the complexity of human nutrition. There is no list of 5 points that will work for those 70M obese people. For some, the drug will be the only way. For some it will be a completely different diet. "

Why do you think human nutrition is only complex on the downside (i.e. losing weight) - in reality, human nutrition is so non-complex that hundreds of millions of people - through diet/lifestyle changes alone - became overweight when before they were not. Nutrition is so non-complex that millions of people were able to gain weight literally without even thinking about it, like breathing.

"And yet, I'm chronically underweight. "

This gets back to my main point: don't focus on weight. Don't think I'm focusing on weight. It's a symptom that does not always present when someone has an underlying issue caused by terrible diet. The key is to increase healthiness (the highly costly downstream effects that we associate with obesity), NOT to lose weight - except that it is often an indicator. I'm not going to judge you, but what you describe yourself consuming does seem to be an unhealthy diet. The key is that unhealthy diets do not always result in obesity for, as you point out, a wide array of reasons, especially age. Would I be wrong in guessing that you're probably under 30?

There is no point whatsoever for you to lose weight, in fact, if you are truly the clinical definition of "chronically underweight" *that itself* is an indicator of even worse health outcomes than being mildly overweight! I am telling you that, in this thread about obsessing over spending 15k a year on weight loss, you could probably stand to gain some pounds. You are not the average American, and to the goal of this post (from Alexander's perspective) you are already cured. But not to my goal, because my goal is "be healthy, avoid really bad health outcomes" and there are people (yourself included) that can (again, going only on your self-report) have unhealthy diets, experience the higher likelihood of bad health outcomes, while not displaying obesity.

I recommend getting some blood work and checking your metabolic indicators. It is possible that you have an unhealthy metabolism without displaying obesity. There are all kinds of people who die of a heart attack at 55 and people go "but he was so skinny!". I

"The idea alone of skipping lunch is abhorrent to my Italian brain."

It's not your Italian brain. It's that for breakfast you consumed a great deal of sugar/carbs, which (short version) burn in your body very fast, (or are stored as fat, which obviously your body is not doing) and your body concludes it needs more quickly, so it tells you are hungry for lunch. The chocolate chip cookies are not unusual. Most cold cereal that anyone actually likes has a similar sugar profile. You are absolutely correct about one thing: people have radically different "energy intake -> how much fat they get" curves, and you have (whatever your age) the "18 year old boy" curve. But the underlying metabolism can be healthy or unhealthy, and one that takes in cookies for breakfast probably isn't.

"The hate carbs are getting lately is really puzzling to me."

From me, it's not hate. It's the simple fact (conventional scientific wisdom) that carbs (especially sugar) are (again, short version) burned faster (some types more than others) in your body that fat or protein, remaining available to be consumed for activity for a shorter period of time, and therefore when they're gone (or converted to storage) your body tells your brain it needs more. It is conventional wisdom that fat and protein create more satiety, which is longer time before hunger. Therefore if you wish to spend more time burning energy (in your case, you want this for good metabolism reasons, rather than weight loss) than consuming energy, and to reduce hunger, carbs are just objectively inferior to fat/protein. It's not some theory that carbs infect your body like poison. Well, except for sugary high fructose corn syrup sodas, those are definitely poison.

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"I recommend getting some blood work and checking your metabolic indicators."

And if his bloodwork comes back with "he's fine, he's healthy", then what, Brian? Your tidy clockwork explanation has failed.

No, I'm not asserting that "if you aren't doing my plan, you can't have good numbers", human variance in history, age, genes, circumstances, mental states, environment and many others mean that there are tons of people who, by my standards, don't eat well but won't have bad indicators. What I am saying is "IF you have bad numbers and you want to improve them, because they are better correlated with bad outcomes than weight, THEN this is a non-15k a year, non-surgical way to do it that I think is easier to follow than most other diet advice."

The fact that there are tons of highly complex factors that could influence where a specific apple is in the universe: the structure of its tree, terrain, climate, soil, growth patterns, it remains that a simple model: if you pluck it from the tree and throw it up in the air, it will go up, and if you throw down to the ground, it will go down - will work to determine its future position.

What you're saying, effectively, is: "you say you have a plan for someone to do X, but what if they don't NEED to do X? Then you have nothing!" to which I say, yep, ok?

About the complexity, I'm unconvinced that people having tried a million things and still being unhealthy is a proof that nutrition is simple. The two doesn't seem to follow.

Anyway, just because you asked, if you were to see a picture of me, you'd think I'm under 30 -- I've got such a baby face, no wrinkles, no grey hair. But I'm 38. And actually I checked, my BMI is 19 (roughly, I don't own a scale) so I was actually wrong about the underweight thing. I'd love to gain a few pounds, but I'd rather them being muscles rather than just fat, this clashes with my couch potato nature unfortunately.

The bit about being Italian is a poor attempt at conveying the memetic nature of eating. Really, the horror of skipping meals has nothing to do with how fast carbs burn (and, again, in the tangent of the carbs, Deiseach writes better than I can the fact that a model that lumps in the same class coca cola and polenta isn't... great?). It's just that meals are a sacred tradition. So my "one neat trick, nutritionists hate him" is: let's just get better memes about food. Italian memes seem to be working well.

This religious aspect colors my opinion, and then I asked myself: if I were to follow your advice, I'd only have one meal at day (dinner) and it should be mostly fat/protein to cover my entire daily calorie intake. Is that even physically possible?

Other than that, in many things we agree, I don't think the pill treatment is the best, since it's unclear whether a taker will then have to be on it for the rest of their life (15k/year, yikes). But if someone there's no other choice, why deny it?

"And actually I checked, my BMI is 19"

That is kind of on the border of where lower BMI starts to be associated with bad outcomes, but with an imprecise calc, and me not being a doctor, I can't really say.

"a model that lumps in the same class coca cola and polenta isn't... great?)"

They are both "carbs" the way they are both "food" or "made of atoms" but no low carb/keto person would consider them in the same quality from a "should I eat this" diet perspective. Full sugar coke is basically the worst. Polenta has (and is often served with) other stuff than carbs in it!

"It's just that meals are a sacred tradition."

Absolutely, that's the primary motivator of my plan: because family dinner meals are a sacred tradition and you shouldn't ever touch them, except to add more tasty fat/protein. I'm talking about cutting out extremely non-sacred meals like your cold sugary cereal in the morning, or the limp sandwich at lunch, or the junk food candy snack at 330.

"if I were to follow your advice, I'd only have one meal at day (dinner) and it should be mostly fat/protein to cover my entire daily calorie intake. Is that even physically possible?"

It is 100% possible, tons of people follow "One Meal A Day", I've done it hundreds of times - and remember, for a long span of humanity's life, we didn't have time for breakfasts or lunches, everyone worked in the fields all day and gathered at the end for that together, family, sacred meal.

But you don't have to go right to that, and probably shouldn't, because if you currently do eat lots of carbs, you will feel super blood-sugar-low-hungry long before you get to dinner! That's another primary motivator of the advice: that it lets you gradually, slowly, measurably ease yourself into it, as far as you want, and only so long as it feels good. If you get migraines from delaying your meal like another commenter then.... don't do it.

Finally, to your specific situation, which is not the "American average person who is considering semiglutide", have you gotten bloodwork done? If all the metabolic stuff looks good, then you're fine!

"But if someone there's no other choice, why deny it?"

On a diff comment, I totally agree that semiglutide has its place for people who want specifically weight loss, and it may just have straight affect-your-metabolism positive effects, which would be great! But the topic at hand is "70 million other people need something like this and they can't all pay 15k" so that's why I'm offering my solution. Also, as Mr. Yudkowsky points out above, semiglutide comes with an emphatic demand to improve your diet and exercise - people should do that (with GOOD diet advice) regardless of being on it or not!

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"The hate carbs are getting lately is really puzzling to me."

Oh, diet recommendations have swung around all over the place. Fats of all kinds are bad for you, replace those fatty foods with (carbs) and (protein). Take the skin off chicken, trim the fat off red meat.

Then it was "not all fats", it was saturated fats, so consume unsaturated fats. Then it was well monounsaturated fats are bad for you, only consume polyunsaturated fats. Omega fats such as found in fish good for you! Well, no, hang on, too much omega-6 is bad for you, you need to up the omega-3 (jury still out on omega-9 for the moment, I suppose).

Dairy bad for you! Dairy good for you! Confused yet?

Then it was red meat is bad for you in excess, so that was (protein) the bad guy. Then smoked meats, because carcinogens.

(Carbs) were still okayish, but then SUGAR - THE PRIME EVILLEST EVIL THAT EVER EVILED. So cut out all the sugary junk (good enough advice). Then that expanded out into other carbs. Simple carbs like potatoes and rice and bread and pasta - bad. Need complex carbs. GI index, so forth and so on.

I think the swinging pendulum of "X is bad, Y is good - now X is good and Y is bad" is down to the complexity of nutrition and metabolism. People are getting fatter and unhealthier, how is this? The simple story of "consuming more calories, and being more sedentary, than past generations" seems not to be the whole picture. So there must be a 'bad' food or class of foods.

Fat makes you fat, right? So fats bad! Cut out fats!

Okay, people still getting fatter - why? how come?

Carbs bad?

Protein bad?

There will be people who eat lots of carbs or fat or protein or whatever, and don't get fat/are chubby but healthy. There will be people who cut out carbs or fat or protein and are fat/unhealthy. There is no simple "one easy fix, just change your portion/plate size and eat six tons of lettuce" cure.

I joke, but it's only half a joke, that the next recommended diet will be "you can only safely consume moss and water".

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There's a similar dance around eggs.

I reserve a special rage for the people who said, "Actually, eggs aren't bad for you. You can have one or two per week."

Oh, the thing about eggs!

First, over on this side of the water, there was a push to market 'eat an egg for breakfast' in the 60s/70s:

But then it was discovered eggs were full of cholesterol and cholesterol is bad for you, so this was dangerous and terrible to eat eggs and you should never eat them.

*Then* it was revised to "well, there is some *good* cholesterol and eggs have that, so you can eat a couple a week".

I don't think eating nothing but eggs would be healthy, but neither do I think eating one egg per day is going to do you in. Again, it's the swinging pendulum around dietary advice that causes more confusion than it solves problems.

"Recent observational studies and meta-analyses have found that eating eggs may not increase your risk of heart disease or its risk factors, like inflammation, stiffening of the arteries, and high cholesterol levels "

Nov 25·edited Nov 25

You know, I gained most of my body weight and reached my fattest point doing exactly that: keto, skipping meals, tons of water and zero calorie drinks. So I'm extremely skeptical of this being useful advice.

My numbers just got worse and worse until I bit the bullet and had them cut out half my stomach and part of my intestines.

Which numbers are we talking about? Weight/BMI? Or ones like A1c?

Weight/BMI, but A1c also got worse. My diabetes had progressed to a point where I couldn't control it with diet and metformin.

Everyone is different. If I could send a letter back to my younger self, the advice I'd put there is to sleep at night and never, ever skip meals.

Nov 26·edited Nov 26

"Get your yearly blood work done so you can see the improvement in your metabolic indicators. Most importantly: if your numbers get better - whoever you get the labs from will tell you the health ranges - FORGET YOUR WEIGHT, sell your scale."

Yes, Brian, but you are forgetting one thing - people in the street can't see your bloodwork numbers, they can see your double chin.

*That's* the metric by which people, including doctors, judge are you 'healthy' or not. I take your point that people confuse "healthy" and "thin", but given all the messaging about "fat is unhealthy", can you expect any different?

About ten to fifteen years back, I had *great* bloodwork numbers. I was still visibly porky. I still had kids yelling at me in the street about being an elephant. I still had at least one doctor visibly and openly furious with anger that he could not punish me for being fat because my blood work didn't back him up.

If you're pudgy, that is the metric society, and you yourself, judge you on. Have you dropped two dress sizes? No? Then it doesn't matter if you can run a mile or have perfect cholesterol levels, you are part of the obesity epidemic that is blighting our healthcare system.

(There's particular irony at work here; I have a sibling who has a thyroid condition and they have to be ultra-careful about their cholesterol levels and fat intake. They are also 'normal weight'. So anyone looking at the two of us together and being asked "who has the high cholesterol?" is going to pick me, the fat hippo. They'll be wrong, but they still won't change their mind - oh that number doesn't matter, we all know being fat is bad for you).

Improving or maintaining your health is worth doing if feasible.

The simplest thing I can think of to solve the prejudice against fat people is a famine, and it isn't worth it. It might not even work.

An expensive preventative for heart disease might work, but that's another version of turning being fat into a status symbol (perhaps an expensive watch is also required). This is better than a famine (do I need to say that?) but way short of excellent.

Continuous blood glucose monitors that displays the numbers on a big LED across your shirt? :)

Yes, I don't know what to do about that, except advertise the fact that bloodwork is a better indicator than weight. The only thing I do know is that, in the case of "good bloodwork, overweight" the answer is NOT "$15k a year semiglutide" or "high mortality-rate surgery."

Nov 24·edited Nov 24

Speaking as a Person Of Amplitude, I think obesity isn't one disease (since we are now calling it that) but a range of factors that have been lumped under the one umbrella of "you're a fat pig".

(1) People who are naturally chunky versus those who are naturally skinny. I think we all know or have seen people who are like twigs, who don't put on weight, who have thin little limbs like sticks. That's not because they're dieting themselves down to that weight, it's natural for them. On the opposite end, I submit that there are people who are naturally going to be chunkier than the median, because that's how their metabolism is set up. They will go a few pounds over what is considered optimum weight, and if they go too far over, their doctor harrumphs at them about "diet and exercise" and they do that and lose the weight. It'll be tougher for them to keep off the weight and they will have to make lifestyle changes like "I can't eat birthday cake ever again", but in the main it will work for them. At the worst, they'll be 'pleasantly plump' or a bit chubby, but not grossly overweight.

An example of someone naturally skinny who is not doing cooking episodes about salads:

This is the good old "willpower" argument: if Joe can lose ten pounds simply by not stuffing his face with rubbish, why can't you?

That brings me on to:

(2) Slowing-down of metabolism. Middle-aged spread. "When I was younger, I could eat what I liked but now I eat the same and put on weight". People get more sedentary, they eat more convenience food, lifestyle changes.

Again, "diet and exercise" will help here. It'll be tougher, but if you were one of the 'naturally' slim types, it helps. Again, you'll probably have to make some lifestyle changes, but you will be able to get off the weight.

(3) Weight gain due to medication. I think we all know about steroids (my late father was put on a course of them and ballooned up, even though he wasn't eating more) and there are other medications with the same side-effects. It's difficult for people who gain weight like this, because they treated like the rest of us greedy lazy porkers, and get the "oh that's only an excuse" response unless they pull out the prescription to prove what they are saying is true, and who wants to have to reveal that *ackshully*, I'm on anti-psychotics which is why I'm stuffing my face with carbs?

Hard case here, since once you don't need to take the meds anymore, you will go back to your natural weight - unless of course you need to constantly be on psych meds, which means increased appetite/weight gain, which gets you the "just have some WILLPOWER" argument from everyone.

(4) And last, the rest of us fat, lazy, greedy slobs with no willpower who just stuff our faces with junk food and never get up off our idle behinds and just go for a walk or something.

The gluttons. The "why don't you just have some WILLPOWER?" people. The "diet and exercise, you moron, never heard of that?" folks.

And you know, there is something to that. Yes, we eat too much. Yes, we don't exercise enough. But, like the anecdote related in Dante, when the bishop asked his servant "What do the people say of me?" "Your Grace, that you are always drinking" "Ah yes, but I am always thirsty" - we're always hungry.

Scott mentioned a few years back examples of patients who suffered from unrelenting thirst, who had to be monitored with their fluid intake or else they would literally drink themselves to death, and even when they got enough to drink would still feel thirsty.

Nobody is going to condemn someone who is guzzling pints of water "Just have some WILLPOWER!", because they realise that's not normal and is indicative of a problem.

Now, for the likes of us that are always hungry and never feel full, even when "but I just ate a full meal a couple of hours ago, I shouldn't be feeling hungry", it's hard. Because yeah, you can visibly see we are gross landwhales. And yes, we are leeching the health services normal people should be using with our horrible diseases of obesity that are all our own fault. And yes, calorie-laden tasty modern processed foods, and yes sedentary lifestyles, and yes over-eating and being greedy, and yes diet and exercise work to a degree, and yes "why don't you just have some WILLPOWER?" and get used to feeling pangs all the time. And yes, "I'm big-boned/it's my glands/it's PCOS/it's a response to trauma" do get used as excuses. Yes to all of that, yes I admit we do contribute to our own problems. Having said that:

Do you really think it's a simple problem of NOT ENOUGH MORAL FIBRE once people are desperate enough to have the likes of this done in order to lose weight?

"Roux-en-Y (roo-en-wy) gastric bypass. This procedure is the most common method of gastric bypass. This surgery is typically not reversible. It works by decreasing the amount of food you can eat at one sitting and reducing absorption of nutrients.

The surgeon cuts across the top of the stomach, sealing it off from the rest of the stomach. The resulting pouch is about the size of a walnut and can hold only about an ounce of food. Typically, the stomach can hold about 3 pints of food.

Then, the surgeon cuts the small intestine and sews part of it directly onto the pouch. Food then goes into this small pouch of stomach and then directly into the small intestine sewn to it. Food bypasses most of the stomach and the first section of the small intestine, and instead enters directly into the middle part of the small intestine.

Sleeve gastrectomy. With sleeve gastrectomy, about 80% of the stomach is removed, leaving a long, tube-like pouch. This smaller stomach can't hold as much food. It also produces less of the appetite-regulating hormone ghrelin, which may lessen the desire to eat.

Advantages to this procedure include significant weight loss and no rerouting of the intestines. Sleeve gastrectomy also requires a shorter hospital stay than do most other procedures.

Biliopancreatic diversion with duodenal switch. This is a two-part surgery in which the first step involves performing a procedure similar to a sleeve gastrectomy. The second surgery involves connecting the end portion of the intestine to the duodenum near the stomach (duodenal switch and biliopancreatic diversion), bypassing the majority of the intestine.

This surgery both limits how much you can eat and reduces the absorption of nutrients. While it is extremely effective, it has greater risk, including malnutrition and vitamin deficiencies."

Reading those comments, they resonate with me. Constantly eating, never feeling 'full', eating until so stuffed I might throw up, And I've tried diets and they've worked - for a time. Then I plateau at a certain weight, and something happens (the last, most successful diet, I got swine flu then the weather was so unseasonably bad I couldn't go out for exercise) and I fall off the wagon and put all the weight back on.

So yeah, maybe all I need is some WILLPOWER, can you tell me where I can obtain a shot of that, because I don't manufacture enough myself? And that's where the "moral failing" angle of the condemnation of the overweight comes in - if we just gritted our teeth and scrunched up our eyes and *willed* hard enough, we could do it!

I don't know if this new drug *is* a miracle cure for weight loss, I think like all new treatments it is being hyped out of enthusiasm. Once it settles down, I think it's more likely to be at the 60% end of the successful treatments scale. And this is something you have to take forever, or else you will put the weight back on. And there probably will be some people for whom it doesn't work - I've had at least two medications prescribed where I was told that a side-effect was weight loss so that would help me, and no, it didn't happen at all.

So yeah, "CICO" - but that's simple. Why people consume a heck of a lot more CI than expend CO is the hard part to solve.

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This doesn't respond to most of your very valid points, and it's definitely not meant as a "just exercise more" response, nor to suggest it will solve all your weight problems, but I think it is likely to be more effective and metabolically helpful than most forms of workouts: have you looked into Zone 2 exercise? Peter Attia has a number of podcasts and videos on it, and it's the central plank in his treatment of patients with metabolic disorders.

Briefly, zone 2 exercise is low intensity exertion which stays just within the energy regime at which the mitochondria in muscle cells can burn fat to supply the fuel they need. By training within that zone, not only are you specifically burning fat, but you are also training your mitochondria to be more effective at utilizing fat and less dependent on glucose, thus improving your overall metabolic health.

A simple way to try it is to get a cheap used rowing machine or exercise bike, set it up in front of the TV or computer, and ride them for 45 minutes to an hour at the intensity level that lets you still just barely breathe through your nose or maintain a conversation. Aim for at least 3 hours a week; more is better.

I'm surprised that you, usually a defender of religion and traditionalism, would have such a view on willpower. This isn't a criticism--when people are too predictable in their views, I tend to wonder if they ever think for themselves.

Isn't gluttony one of the seven deadly sins? Sin is part of the human condition, and the seven deadly sins are remarkable for their mundaneness: probably every person who ever lived has been guilty of all of them on a regular basis. But that doesn't mean societies (and not just Christian ones!) don't or shouldn't blame people for being lazy, angry, greedy, arrogant, or gluttonous. The purpose of the blaming and shaming is to discourage the sin by imposing a social cost. Just willpower alone may not be enough for someone to not have bursts of rage or to not eat to excess, but the combined effect of willpower and social disincentives might be enough to make people relatively healthy and well behaved. And so, in moderation, fat shaming is good in the same way that small amounts of sloth-shaming and wrath-shaming are good.

"I'm surprised that you, usually a defender of religion and traditionalism, would have such a view on willpower."

Oh ho, friend! What do you think I am, a Pelagian heretic?

We can do nothing of our own will to be freed from sin, we need the help of grace. Gluttony is a sin, but willpower alone won't free you from that sin.

I haven't enough willpower natively, I need the injection of it from outside to help me . Shaming people and blaming people is not that help.

What works?

God alone knows. If I were a totally different person with a totally different personality, maybe I would love exercise, or be able to muster willpower to only eat three slices of carrot and six heads of steamed unbuttered unoiled unsauced* broccoli for every meal.

*I mean white sauces like bread sauce, parsley sauce, cheese sauce, onion sauce, etc . The ones made with flour and butter and hence Bad For You.

I was asking about what works for you as an injection of willpower from the outside.

Support and encouragement. Seeing visible beneficial effects.

All the nagging, shaming, bullying and so forth as recommended in comments here has never done anything but driven me to emulate a bear getting ready for hibernation: hole up in my cave and eat eat eat.

"I was asking about what works for you as an injection of willpower from the outside."

I have found that having (a) a schedule and (b) a workout partner helps for exercising. There is a SCHEDULE that means that working out is a default for a given place/time and you have a partner to not let down. Neither of you may want to go for any given session, but neither of you wants to be the one to call off the (obviously good or you wouldn't have schedule it!) session.

I have no idea how to make this work for diet modifications.

And I exercise and think it helps with general health, but I'm not convinced that it is terribly useful (long term) for weight loss.

"We can do nothing of our own will to be freed from sin, we need the help of grace. Gluttony is a sin, but willpower alone won't free you from that sin."

My theology is rusty, so forgive me if I'm wrong, but aren't we supposed to at least try? No Christian I've met has ever said "don't worry about it and sin as much as you want, because God will forgive you". At the very least they stress repentance, which doesn't sound very different from accepting blame--and when done publicly, it's not very different from shame.

> there are literally money-saving ways to lose weight

Too bad you didn't mention them.

Eat less, cook instead of ordering takeout, walk instead of bus, bike instead of car, etc.

Nov 24·edited Nov 24

"Eat less, cook instead of ordering takeout, walk instead of bus, bike instead of car, etc."

Excuse me while I rock in my chair, laughing.

In my 30s-40s I was one of the fittest fat people you'd ever meet. I can't drive, and there isn't a bus service in my town, so I walked everywhere I needed to go. Sometimes I'd cycle. That was my entire life, pretty much (if I needed to go somewhere further than my local town, I'd get the intercity bus or a lift from a family member with a car).

I had tree-trunk calves from about the age of twelve from all that cycling and walking and carrying things while I walked. Did it make me lose weight? No, I was still podgy of body and pudgy of face. But I was *fit*.

So yeah, "just exercise more and it'll drop off" was always a source of amusement to me. I once, due to a screw-up in getting paid, while living away from home spent an entire week living on soup once a day and (of course) walking everywhere. I was at the point of fainting into bed at night, but the one bright spot was that surely I'd lose *some* weight.

Guess what? No. Maybe a pound or two, but nothing significant. My body was grimly hanging on to the fat reserves come hell or high water. The biggest disappointment of my life, but the reality of what the hell my metabolism is and I don't know why. I keep being told my thyroid levels are fine, but I don't know.

I have a theory people vary in their ability to take fat out of storage and use it for energy.

Yeah, I think the actual pill we need is: "convince the fat cells to release their energy into the bloodstream".

It needs more sophistication than just taking fat out of storage. Even very lean people are at least 5% fat.

In ideal case, the pill should allow you to choose the parts of your body where you want that 5% to remain. (Anecdotally, it seems to be a problem for some women, that when they diet, they start losing fat from the wrong body parts.)

Anyone else remember the heyday of brown fat? Brown fat was the healthy body fat and was the response to cold, so we should all expose ourselves to cold temperatures and that would encourage conversion of body fat to brown fat which would be then be burned off to heat us up and we'd get thin.

I remember sitting in cold rooms until I literally turned blue with the cold. Never started any of that miraculous burning away all your body fat for heat.

They do that already, and indeed that's how one loses (fat) weight. The problem is however that the combustible form of fat (fatty acids) bears no biochemical resemblance to the glucose which apparently is the main component of "have you eaten enough?" signaling pathways to/from the brain. Thus the irony that we can feel "starving" while at the same time having a complete sufficiency of energy available through fatty acid metabolism (and gluconeogenesis).

That is, the problem is not the energy pathways themselves, but the signaling pathways to and from the brain.

So basically keto?

Actually, a pill that instantly throws you into ketosis sounds amazing.

[speculation] In men it's mostly testosterone levels. It signals the body to both repair+increase the muscle mass AND not to burn muscle for energy when on a calorie deficit. Some people will never be lean as their bodies prefer shedding muscle before burning fat.

There's also probably some other factor regulating this behavior. IIRC there's a yet unexplained effect of anabolic steroids that makes fat burning more predominant even beyond what would be accounted by the muscle gain. It could be that steroids activate what naturally lean people have going.

Did you grow up food-insecure? Because this sounds pretty in line with the 'thrifty phenotype/epigenotype' hypothesis: your body is hanging on to those fat reserves because experience has told it that reliable access to food is not something it can take for granted. Maybe the hunter gatherer lifestyle that it's adapted for needed all that fat when it was living on raw tubers and bugs for months on end, and it doesn't think a week on soup is an emergency worth burning more than two pounds of fat for.

I wouldn't say that, but there is obesity on one side of the family, so you tell me if it's genetics or what at work.

Also Irish, so... descendant of the people who *didn't* die in the Famine?

Some of it is environmental/genetics, but some of it must be bad habits and no willpower, since I have a sibling who has the opposite problem (they get stressed and stop eating and over-exercise and are always skinny; I get stressed and comfort-eat).

Tangential to your main point (that one can't really lose weight by pure exercise), which so far as I know is quite accurate, I thought it might be worth mentioning that a pound or two is a pretty significant weight loss for a week.

1 lb = 3500 kcal, so if you actually lost 2 lb = 7000 kcal that implies a deficit of 1000 kcal/day, which would be very noticeable indeed. The basal metabolism demands for a 5'4" female age 35 at 135 lb is ~1400 kcal, and walking tends to burn ~200-350 kcal/hour, so to run a 1000 kcal deficit daily one would have to cut the usual ration by two thirds, walk 3-5 hours a day, or some combination of both -- pretty harsh.

I think Gary Taubes in one of his many diatribes against calories in/calories out points to some empirical evidence that if people exercise they almost always boost their intake more than enough to compensate for the calories burned, because exercise makes you hungrier of course.

No, the first weight you lose is water weight. It's easy to 'lose' weight like that, but it's not shifting fat. I was disabused of that the first time I had stuck to a diet (as advised by my doctor to go on a diet), lost a stone, and went back to report all pleased with myself.

Doctor told me that was just water weight, I hadn't really lost fat, and I would have to continue on a lot longer to really start losing weight.

So living on a bowl of soup and lots of water per day for a week got rid of some of that water weight, but didn't kick off the fat-burning. And of course once I got my money sorted out and could buy food, I went back to eating normally so naturally no weight loss. If I stuck to "one bowl of soup a day" for a month, then maybe real fat-burning weight loss would have happened.

Yes, that is also true. Water makes it difficult to assess genuine weight loss over anything less than a few weeks. As a weird illustration, I am in the habit of 72-hour fasts on certain regular occasions, and one thing that is interesting is that, although I am obviously missing ~6000 kcal, so probably have lost ~1.5lb of fat, whether I will actually weigh more, less, or the same afterwards is impossible to predict -- depends too much on what changes may have occured in my state of hydration.

I was just pointing out that if you *had* actually lost "a pound or two" over a week, that would be pretty sizeable.

The amount of water (and of (literal) shit) in your body can fluctuate by more than a pound or two -- you're better off treating the last digit of your weight as a random number generator. See _The Hacker's Diet_.

I don't even have a car or a bike, and since covid I also started avoiding buses. I walk to my work for 40 minutes.

I admit I could work harder about the eating less part.

The meta-point about the traditional advice is that either you need to do it 100% right and mere 90% gets you nowhere (possible, but then it would be nice to admit that following the advice is harder than it seems), or just one part of it is the real advice and the rest is bullshit (also possible, but then please stop telling the bullshit parts).

Let me fix that failure here:

<< reposted from other comment >>

1. Forget calorie restriction of the "just eat 20% less calories" form. It requires too much calculation and willpower, and your body will compensate. Forget any diet that stops you from participating in normal social rituals with friends, coworkers or family.

2. Replace carbs in your dinner with fat/protein. Eat as early as possible, eat as much as you want. Don't eat bedtime snacks.

3. Over time, extend the time from ending dinner (your "fast" length) til the next time you eat (breakfast? 12:30 lunch? 2:30 lunch?) as much as possible. Eat the next day when you're hungry, but if you're only feeling kinda hungry try drinking a zero-cal electrolyte drink and see if you still want to eat. Measuring exactly 50/100/150 less calories a day is impossible. Measuring that you ate 10 minutes later is easy. Don't put any sugar or carbs in your morning drinks.

4. Eventually cut out breakfast or lunch, or eat later lunch. Just like dinner, replace carbs with fat/protein as much as possible. Whatever feels okay.

5. Get your yearly blood work done so you can see the improvement in your metabolic indicators. Most importantly: if your numbers get better - whoever you get the labs from will tell you the health ranges - FORGET YOUR WEIGHT, sell your scale.

Hey you have described your weight loss system multiple times here. I think readers get it. You sound like you think the reason we're not all converts is that we do not understand your system, and need to hear it explained again. In fact, people are telling you multiple reasons why things along these lines have not worked for them, and/or multiple reasons why they believe such things generally do not work for many people over the long run. Are you giving any thought to all this testimony and all these ideas?

"Are you giving any thought to all this testimony and all these ideas?"

Absolutely, previous people's testimony and experience (of which all of the versions given in this thread are a subset - not as a critical judgment of them, just that diet advice almost always fails in relatively predictable ways) is the reason this is my plan, instead of being traditional stuff like weight watchers calorie restriction.

"Hey you have described your weight loss system multiple times here. "

Well, not to be rude, but if you're describing it as a weight loss system, then I haven't explained it well, because it's not a weight loss system, it's a "increase healthiness system" and I posted it here because I think focus on specifically weight loss via semiglutides or surgery is part of the problem.

"In fact, people are telling you multiple reasons why things along these lines have not worked for them, and/or multiple reasons why they believe such things generally do not work for many people over the long run."

To be very specific, no one I've seen so far (maybe I missed it) is saying they have tried something like this and failed, (whereas I personally have succeeded, and know dozens of other real live people whose testimony is that it works) and the "such things" they present are often critically different in major ways that are also exactly the reason I present this strategy as an antidote to them. You're essentially saying "well, all these other people have tried such things like, leeches and balancing bodily humors, why do we expect your plan to take antibiotics to work?" Maybe I'm arrogantly assuming my method is superior, but it was created (not by me!) precisely to incorporate what you're saying - the testimony of millions of people saying that previously recommended "diet" advice didn't work. The key is in the "what" is being recommended, and whether it goes against the grain of how we understand humans and their metabolisms to function.

Additionally, when people are saying "diet advice X didn't work for me" in this thread, in every case they have cited weight. This is the part I want to repeat more than my strategy: don't measure success on the scale. You can't timetravel to see if you get diabetes 25 years from now, you have to get bloodwork done, or you have to read all the papers describing the other markers you can see to detect a healthier metabolism, or get a continuous glucose monitor, or you have to take my word for it. (This cost of this measuring indeed a major failure point of my plan, which you should critique)

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Nov 25·edited Nov 25

OK, Brian, I have tried it and failed, and by failed I mean not simply that I did not lose weight, but that I did not stick with the plan. I had been reading about carbs, and how processed carbs and sugar do not really satisfy and you make you crave more of them. So I planned to follow a regimen of eating nothing sweet except fruit, not much refined flour & the like, and lots of protein, fruits and veggies. I did not avoid animal fat. I am a vegetarian, but ate lots of sharp cheddar, an animal fat favorite of mine. I did not count calories. I was not solely focused on losing the 20 pounds I wish I were not carrying, but of course that was on my mind. It is simply impossible not to care about that. And I did deviate from the approach you describe in that I did not make insanely delicious meals that gave me deep satisfaction. I absolutely hate cooking, and am simply not willing to take much time away from activities I value in order to do awesome cooking.

I have stuck with the no-sugar part for several years now, and find that cookies etc. are no longer calling my name when I'm in a bakery. However, I have not stayed with lots of fruits and veggies, I have slid back into eating simple carbs, things like slices of white bread, because I like them and they're easy to grab . And I never did do the part of preparing wonderfully palatable meals. The things that have kept me from sticking to my plan are things like this:

-Most vegetables are not pleasant to eat unless you chop them up and put a nice dressing on them, or cook them. I hate doing food prep. If I'm busy, tired, or preoccupied with something else important to me cooking is the first thing to go.

-I default to eating lots of cheddar cheese and little else -- because I'm out of fruit, and the veggies I have need prep to be bearable. I got busy and did not shop.

-I get busy doing something important to me, miss a meal, then am so hungry I grab whatever's handy that I can stand -- cans of cashews, lumps of cheese, fried stuff from Uber eats.

Obviously I *could* have done other things at those times. I could have made a salad or cooked the veggies or made an awesome delicious meal. I could have shopped more often so there was more healthy stuff in the house. I could have not let myself get so hungry. But it is an illusion that knowing that makes it likely that in the future one will act differently. The same factors that led to suboptimal eating in the recent past are all going to be there in the near future. Habits are hard to break, and the breaking of them draws on the same limited pool of energy and self-monitoring capacity as all the other things we need to accomplish. Eating is a simple pleasure and doing it provides a break from life's demands. Turning it into something that must be done a certain way both reduces the amount of simple pleasure in the day and also adds a new demand. That's a hard sell. There may exist some heaven of healthy eating, zero minutes per day of craving things that are unhealthy, and amazingly delicious meals that satisfy the living daylights out of a person, but then again there may not, for all of us. And even if it does exist, getting there is no easier than accomplishing lots of other goals we have for our careers and relationships, and far more dispensable.

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That's.... not my plan? What you're describing is keto, and yeah, while it does work, people have trouble sticking to it, for exactly the reasons you point out. That's.... the entire point of my plan, that things like keto are sometimes hard to do.

I apologize, sometimes on substack it is hard to see which previous comment someone is replying, which makes me think maybe the "plan" we are debating is not the same one. This is my plan:

Short version:

1. add tasty fat and protein to your dinner. This increases satiety, and therefore the amount of time til you're hungry. Reduce the carbs if convenient/easy, you will likely be forced to, because if you add fat/protein to a meal, you won't have room for the carbs.

2. Over time, extend the time from ending dinner until the next time you eat as much as possible, eventually cutting out breakfast and delaying lunch.

3. Get bloodwork done yearly, and use the metabolic indicators in that to inform your success, rather than weight.

The reason this is the plan is precisely because of the experiences you (and many others) had with a keto diet (or many others). Hunger is powerful. Cravings are powerful. Eating tasty food is enjoyable. People have increasingly little time to select/prepare foods. A diet that works must accept that, which is why "my" plan explicitly caters to those limitations in daily life.

No, I wasn't doing keto. I don't think you read carefully. I said I ate nothing sweet except fruit (should have said fruit and vegs), and nothing with much refined flour. That's a far cry from keto. I ate potatoes, sweet potatoes, grapes, starchy vegs like peas and corn, whole wheat bread, brown rice, oatmeal -- lotsa carby things, just not white-flour based things and nothing with added sugar, corn syrup etc. and I did not limit how much of them I ate. My daily carb count would have been way far out of the keto range. It was not, though, terribly high I think, because I really liked cheese, full fat cheese, by the way, better than most of these things. A typical dinner for me might have been a potato with a LOT of cheese melted on it, and a piece of fruit, maybe a coupla raw carrots. As I mentioned, I do not cook. This meal may sound sort of drab to some people, but I truly enjoyed it. I did not limit quantities. No matter how much I eat in the evening, I need to eat fairly early after waking up the next day. First of all, I wake up hungry. But the big problem is that if I get very far into the day without eating I get a headache, and sometimes that turns into a migraine. Have a couple of my migraines, and you too will lose your enthusiasm for trying to go as long as possible before eating the first meal of the day. (And yes, it happens even if I drink a lot of water to rehydrate for the day.)

Okay, was just trying to slot it based on a few key words.

If you have migraines with triggers based on deviation from your routine, then yeah, this (and many other things that involve changing routines) are going to be difficult. If the migraine trigger is low blood sugar, as it is for some, then it might be possible (no way for me to tell!) to affect it (like the sensation of hunger) based on the blood-sugar-affecting quality of the food you eat. I don't have frequent migraines, but I have had a few that I think are triggered by over-consumption of very specific foods.

While you were doing this, did you happen to get A1c or other indicators taken? There might not be anything that needs fixing!

Oh, now carbs are the new sin, and you were a terrible sinner. Professor. Fung would be so disappointed in you!

""They are so high in carbohydrates that they are more like grains than greens. It makes more sense to put them in the same category as breads, rice, or pasta," says dietitian Teresa Fung, adjunct professor in the nutrition department at the Harvard T.H. Chan School of Public Health.

When you eat mashed potatoes you're probably adding butter and other unhealthy ingredients. Or maybe you top a baked potato with sour cream and bacon bits. And it's quite easy to overeat, and you end up eating a lot of calories that aren't so satiating," Fung says.

Fung says that, if you're healthy, you can probably eat one serving of root vegetables every day. "Just make sure it's a side dish or part of another dish, and that it's the only starch on your plate," she advises. In other words, don't have a serving of rice and a serving of sweet potatoes."

So for the ideal diet, you could have had one cup of mashed turnips per day. Or one slice of bread. Or - well, you can figure it out

isn't the way that semaglutide works is by making you feel full and satiated after eating? of course you need to be changing your diet -- if you continued eating the same way, you wouldn't be able to lose any weight. the hard thing about losing weight is that your body will do anything it can to make you eat the calories you're trying to avoid (and will hold on to the fat it already has, although that can usually be overcome with enough time). the brilliance of this drug is that it basically helps you stick to a diet.

IMO exercise doesn't actually help you lose weight anyway except insofar as it helps you build muscle, which makes your metabolism higher, but it's a good thing that people should do regardless.

You're spot on, on both diet and exercise.

re: diet, I think semiglutide might being affecting your metablism too - hence its use as diabetes drug, but I'm not educated enough to know for sure.

re: exercise, yes, it may not make you lose weight (in fact I think you should gain weight, if you're doing strength training) but it makes you healthier.

And to dovetail both: we want to be healthier metabolically, that is the goal. Weight is just a symptom that we only care about as potential signal.

This jives with my experience on the drug earlier this year. I was on living primarily on pre-made keto meals and after starting on semaglutide I felt like it was too much food for a setting, switched to a lower cal option. When shortages of the drug caused me to miss a few weeks, the lighter meals were quickly noticed as not-satiating.

While this is technically true, there are a *lot* of things that would be unnecessary if everyone in the world always made good decisions and showed perfect discipline at all times and experienced no akrasia at all. That world would look extremely alien to the one we actually live in.

Given that we live in a world of imperfect willpower and decision making, finding ways to mitigate the consequences of those failures is both important and valuable.

I will say, though, this is one of the areas where I feel like government intervention may be warranted, or at least could have good outcomes. I don't think people would suffer if there was a tax on fat and sugar above a certain point on all foods such that all their food choices were healthier.

My quality of life drops sharply if I don't eat a fair amount of fat, possibly more than some theory of health would permit.

Nov 24·edited Nov 25

Wait, I've got an idea. Let's put everyone on the diet-that-can't-fail. Then, we can piggyback all the other things people have trouble sticking to onto it, like ornaments onto a Christmas tree: Every time you have a proteiny meal, write down a work goal for the next few hours -- productivity solved! Every time you lose a pound, pay any unpaid bills -- budgeting solved! Every time you lose 5 pounds, spend an afternoon working on that great idea you had that you've been procrastinating on fleshing out -- getting rich and famous solved!

Nope. It is the semaglutide. See my comment below for details. I lost 20% of my weight (55 lbs) in 14 months. I did not change what I ate (good fresh home prepared food) or how much I exercise (mostly an hour a day of walking). I just ate less of the same stuff.

Meh, I recommend weight loss to my diabetic patients until I’m blue in the face and for years nothing changes, but when I put them on GLP-1 agonists they generally do. Same for SGLT2 inhibitors. Some times it’s so dramatic that I get worried they have some kind of occult cancer until I hold the offending medication and the weight loss plateaus.

Does the weight return once treatment is ceased? Or is this a situation where one would take the medication for the rest of their life?

From the description of its mechanism (feeling sated with less in the stomach), I would think so.

Additional anecdata - I'm only on the 1mg dose for diabetes, but I've lost 8kg over 8 months with only minor stomach upset.

I'm 6 foot and was 235, took it and I'm now at 180. Uncle took a different glp-1 same thing happened. These are miracle drugs for most people. I also got upset stomach, and bad heartburn but that went away with the weight loss.

It’s quite disturbing how pills have become the answer to everything these days. The opioid crisis in rural America is a good example of what happens when pills are handed out like crazy. Nowadays any hyperactive kid is given what is essentially meth, anyone who is depressed is given SSRIs, etc. Big Pharma is swimming in money from America’s pill culture.

Edit: Okay, I’ll explain. You state that you hope semaglutide can be part of a transhumanist culture where all problems can be solved via taking pills. In this world, all of society’s ills can be solved via medication. We could also get rid of any disease, of anxiety, of depression, etc. Now, this does sound like a utopia… expect that it ensures that pharmaceutical companies will maintain an iron grip on society, like in Huxley’s Brave New World where Soma "solved" everyone’s problems. But we’ve seen from Big Pharma the failures of this method, most recently Purdue Pharmaceuticals being responsible for thousands of opioid overdoses a year. And you mention that semaglutide increases the chance of certain cancers. Who knows if there are more long-term side effects that may occur while taking it, just like with Oxycontin? That was supposed to be a miracle drug too, and look what happened.

Also, in a perfect transhumanist fully-automated-luxury-space-communism world, would obesity really exist? Everyone would have perfect GMO food engineered to be as delicious and nutritious as possible. No one would even be fat to begin with unless they want to be. In that case semaglutide would not be necessary at all.

Also, the promotion of semaglutide would divert attention from the current problems of food deserts. Instead of making sure communities have access to cheap and healthy food, it lets food companies put out as much junk as possible and hope the pill fixes everything. In addition, semaglutide would increase America's problem of instant gratification without facing the consequences, which many members of Red Tribe see as a problem (bootstrap theory/no holdouts ethos).

And then there's the whole other can of worms about transhumanism and designer babies and what it means to be human. But let's not even get into that.

Nov 23·edited Nov 23Author

Trivial warning (1% of ban) - please try to justify your opinions instead of just asserting them hyperbolically. If there's a controversial question (like whether the current amount of these medications is good or bad), explain your position such that someone on the other side could understand where you're coming from.

I really don't like these trivial warnings. Just the word "ban", even preceded by "trivial" and "1% of", has a chilling effect on free speech. Nothing that isn't worth more than a 1/3 ban should have a warning, in my opinion. If it's really a "trivial warning", why do you need it at all? Why not just state your point directly?

I disagree. Free speech is an important value, but it need not be the paramount value in all situations. A moderation policy that has a "chilling effect" on posting unsupported hyperbolic assertions should be seen as a good thing. If people want to make bold unconventional claims with strong moral implications, it is perfectly reasonable to expect them to explain their positions. The use of words like "warning" and "ban" sends a clear signal that low-quality comments that do not contribute substantially to the discussion should be avoided at all costs.

Thanks for pushing back on this. I'll think about it more, but two reasons I'm doing it this way now:

- I like to have these in my List Of Warnings I've Given so I can interpret people's future offenses in the context of past offenses. I suppose I could do this quietly, but it seems less transparent.

- I like to have separation between my role as moderator and my role as a commenter just like everyone else who sometimes disagrees with you guys and gets angry. Otherwise I worry that everyone I disagreed with would interpret my disagreement as "the moderator doesn't like you and is gearing up to ban you", whereas in most cases I appreciate your feedback but still disagree with it.

- I really do feel like King Canute turning back a tide of bad commenters, and I'm more worried about not doing this enough than about accidentally banning an innocent person. If chilling effects cause one warning to chill five people, that's a victory in my book (even though it sounds kind of offensive to say it that way)

- I do feel like this conversation went well and that speaks well of Sheluyang, but a lot of people respond with "@#$% you, I'm leaving", and for those people, that is a good outcome.

Thanks for taking my concerns seriously! I really appreciate that you took the time to read my comment and give a detailed response.

My opinion is that "doing this quietly" is the better option, even though it is slightly less transparent. Everyone already knows that their offenses will be judged in the context of their previous words. That's as true in real life as it is on the Internet. A "trivial warning" presumably won't shift the balance that much in favor of a ban anyways, and that's the way it should be.

I don't know how to turn back a tide of bad commenters, but I doubt banning and scaring people is the answer. We already have plenty of heavily moderated (I would say "censored") online platforms. The more open you can keep your platform, the more valuable and distinctive of a public service it is.

Nov 23·edited Nov 23Author

Thanks for the explanation:

> Expect that it ensures that pharmaceutical companies will maintain an iron grip on society, like in Huxley’s Brave New World where Soma "solved" everyone’s problems. But we’ve seen from Big Pharma the failures of this method, most recently Purdue Pharmaceuticals being responsible for thousands of opioid overdoses a year.

How is this different from the fact that we abandoned subsistence farming, but now agricultural companies have an iron grip on society because we can't get food without them? How is it different from using electricity for warmth but now utility companies have an iron grip on society?

The problem with opioids is that they're addictive and potentially deadly. Semaglutide doesn't have either of these problems. I agree you can think about this on a very broad level where drugs are inherently scary and even if we don't think they have side effects they probably do. But I think that level is the wrong level, and if used consistently would have you avoid stoves because eg fire is bad.

> Also, in a perfect transhumanist fully automated luxury space communism world, would obesity really exist? Everyone would have perfect GMO food and no one would even get fat to begin with. So the idea of using semaglutide to cure obesity is self-defeating.

In a perfect transhumanist world, obesity wouldn't exist because we would have some powerful technology that could eliminate it. I think medication is the most likely such technology. Maybe in the far far future we will have even easier and better technologies, but I don't think we should skip the first just because there might be other ones decades down the line.

I remember a piece you did some years back. It's one of my favorite works of political commentary. The one about how rightist/leftist is basically a survive mindset versus a thrive mindset, that conservatives focus on survival in a primitive world, and liberals focus on building an egalitarian utopia.

The idea of transhumanism and a drug-induced utopia is essentially the thrive mindset fulfilled. It assures no problems will ever happen in the world and there will be no zombie apocalypse.

Yes, we live in a world where our needs are all tendered for us. We have all the food and energy our ancestors could only dream of. But one day, the improbable could happen. Agricultural companies and utility companies may not last. Maybe it's zombies, maybe it's Covid-666, maybe it's the Seattle Mariners winning the World Series. And in that world, transhumanist theories will vanish in the blink of an eye.

Don't get me wrong, I appreciate modern medicine. I know many adults with type 1 diabetes that would all have died as kids without insulin. But if the insulin supply chain is disturbed, that's all gone.

So maybe we can't see eye to eye because you are thrive-brained and I am survive-brained. But I'd rather solve obesity via getting rid of food deserts and returning to a diet like those of our ancestors. That way the risk is minimized for if the economy collapses, or pharma companies can't get the ingredients needed anymore, etc. I am all about minimizing risk. I would love to live in a transhumanist utopia, but I'd rather focus on the practical now.

>So maybe we can't see eye to eye because you are thrive-brained and I am survive-brained. But I'd rather solve obesity via getting rid of food deserts and returning to a diet like those of our ancestors.

I'd also rather do that, but we've spent ~30 years trying really hard and it's gone terribly and obesity rates have actually kept going up the whole time. See also

I guess a good thing about this example is that if society collapses so much we can't produce semaglutide, we'll probably go back to agrarian living without processed foods and the obesity crisis will solve itself.

>I'd also rather do that, but we've spent ~30 years trying really hard and it's gone terribly and obesity rates have actually kept going up the whole time.

Have you (I'm assuming that "we" refer to the American society), tho? Have the US -and that's a totally genuine question, not a rethorical one- implemented many policies to promote weight loss, healthy diet & exercise? Some countries have increased taxes on unhealthy food, some have mandatory labels, some, I heard, even toyed with litteraly taxing the fat. Some even forbid free soda refills. I think US health insurance providers offer discount for practicing sport, but beyond that? I haven't heard of much. Then there's plenty of weird, attention-grabbing stories ("school consider pizza as a vegetable" was a very popular one back in the days), aspects of the food culture leaking into pop culture (I learned of "lunchables" from watching "fresh of the boat").

I'm not claiming that the policies cited works, or are even well thought of or well implemented (nutriscore is pretty shitty to judge food with small serving size, for instance, and is apparently lackluster on plenty of metrics), but they're attempts. Compared to the rest of the developped world, the American society at large don't seem to be trying "very hard" to crack down on obesity. Which can be explained by multiple factors, and considered as a negative side effect to an overall positive culture of personal responsability (and, it just occured to me, any policy to crack down on obesity is probably going to make the obese unhappy. Which, once you reach a large enough share of the population, may become a political suicide). But you probably shouldn't think "oh well everything that was possible to do has been done, let's pop some pills".

And, sure, I was thinking of "society-is-fixed-biology-is-mutable", society is hard to change and all that. But is it harder to change than 15k/y/40% of the population?

I believe Japan has laws penalizing being fat, including penalizing employers for having fat employees. I don't know how it's worked out.

Perhaps mixed use neighborhoods would encourage walking.

> But is it harder to change than 15k/y/40% of the population?


Also, outside of the US, it's nowhere near 15K/y. And medical patents ensure monopoly - but only for a very limited time. Few years after it becomes really widespread, it'll be sold as generic drug.

Nov 25·edited Nov 25

The question "How are pharma companies different from agricultural and electricity ones?" seems to be key here. I think the general consensus in US and many other countries is that pharma companies are quite different. This can be seen from the fact that agriculture and electricity are not subject to such a draconian regulation, with every new version of the product required to pass multiple year + $billion approval. Also, I do not think that any shareholders of a farm or a power station were ever at risk of proceedings such as ones against the Sacklers. Of course, existence of this consensus does not prove that it is correct, but, I think, it shifts the burden somewhat to demonstrating that pharma companies are, indeed not different from agri or utility ones.

I could speculate on why the consensus could be such as it is and what is so different about pharma. There are probably several reasons for that. The simple one is that it is harder for a consumer to form an good opinion on product benefits, even if the consumer is a professional doctor. This explains the first consensus observation (on FDA), but does not really explain the Sacklers. Another reason as that pharma companies rely on state enforcement of temporary monopoly power in a way few other industries do.

The third reason is a bit more involved. Many usual economic and public policy arguments involving utility functions assume that these functions are unmutable. This assumption is probably ok in many cases, but is obviously broken with many medicines. Addiction, in a general sense, is when consumption of a good radically increases future subjective utility of further consumption of the same good. It was, obviously, an important factor in the opioid/Purdue/Sacklers saga. It may be also at play with the obesity drugs, although in a subtler way. Of course, there is no reason to believe that these drugs lead to an addiction similar in medical sense to an opioid addiction. However, people using these drugs to successfully control their weight, will find themselves at the mercy of 2-3 large companies in a way they are not at a mercy of their baker or their electricity supplier. Stopping eating any kind of white bread or moving to an area supplied by a completely different set of electricity companies is a much more palatable lifestyle choice than having one's weight increase back 20% because one goes off a particular drug. So once one becomes a client of such a company, it is very hard and expensive, in utility loss sense, to go back, quite unlike any agricultural or electricity companies.

Definitely. As long as the pharma company's patent is still active, which for semaglutide will be for over a decade, all consumers will be beholden to the company, and depend on it for weight loss. They are getting people hooked on pills to fix obesity, something that barely existed 100 years ago.

I note that Agriculture and Pharma in fact share the same regulator, it's the *Food* and Drug Administration, after all. Agriculture just comes up with entirely new products far far more rarely, but new GMO crops go through similarly massive hurdles to new drugs.

Actually, the same level of regulation for food, would be something like "any change in a bagel recipe that substantially changes its chemical composition and nutritional properties, such as adding raisins and increasing baking temperature by 20F is illegal until you spend 2 years and $1e9 on approvals". Luckily, food regulation is not like that.

For a slightly different take on this, I find it disconcerting that we're using pills to solve a very new problem that our ancestors definitely didn't solve with semaglutide. We're not making progress, we're abandoning the very interesting and likely very important question of "why are people fat now and what can we do to avert the cause of people being fat now" and just slapping a medical band-aid on top of it.

Are we ever going to figure it out? What happens if the underlying issue gets worse and worse, and we medicate and medicate instead of solving the issue, and the medicine runs out?

I agree this is concerning. I think the main reason people are gaining weight is the rise of hyperprocessed foods; I stopped all of these for a while and lost ~20% body weight, but it was tough and unpleasant because there were lots of processed foods available that would have been very easy to take in a moment of poor willpower (though I know other people say they've tried the same experiment and it didn't work for them). I feel like this solves the mystery and I don't really have a good solution to the existence of processed food (beyond extreme authoritarianism) so I will grudgingly accept the transhumanist solution.

When I moved out of my Orthodox Jewish home to Atlanta, I started eating a lot more processed food and promptly lost 50 pounds. Later on, I tried many diets with no processed food, paleo and others; of course none of those worked at all. I am reasonably sure that this, too, does not solve the mystery.

Based on our previous conversations, my understanding is you've eliminated almost every possible bad thing from your diet without significant change. Either you have some kind of extremely weird condition that would have made you the one obese person in your village in 1850, or it's a ratchet effect where some factor causes weight gain when present, but doesn't (always) remove weight gain when absent. Compare to how eg everybody will be unhappy when tragedies are happening, but some genetically unlucky people will stay unhappy even after the tragedy ends (PTSD, depression, etc).

I believe Eliezer has an extremely weird metabolism. As I recall, missing a meal or two makes him lose the ability to think. (From memory and possibly old news.)

This is not how most people react to missing a meal or two-- they may be miserable and/or hungry, but the effect isn't that extreme.

In the middle ages, a person like Eliezer would simply seem to be not particularly bright.

Maybe, but that sounds a lot like how many people react to *hunger*. At least for me, it causes a hyperfocus on food until I resolve the cause. The effect is similar to being horny, but what the body craves isn't an orgasm but a sandwich.

When you moved out of your orthodox jewish home you may? have let up on the shul kiddushes, simchas which involve large meals, shabbat dinner which is often a pretty elaborate multi-course meal etc. which might have helped you out there.

Serious question: if you rate your awareness of your food patterns high, what probability would you assign to having one or more significant psychological blind spots interfering? Would you assign roughly the same probability to other people who rate themselves highly food pattern aware?

If you don't rate your awareness of food patterns high, do you have some speculations about what's standing in the way?

Asking as the sometimes heavy, sometimes thin child of an endocrinologist and a biochemist dietician person, having observed really enormous variability in awareness levels, even among people who thought they were careful.

Did you eat a lot of fruit? says a big problem is fructose, which signals the body it's autumn: time to prepare for winter and get fat. That's not all there is to it, I'm sure (the book mentions salt, too, for one), but cutting out all sugar and artificial sweeteners (some of which get converted to fructose in the body) and reducing the amount of fruit I eat has definitely made me less hungry.

> artificial sweeteners (some of which get converted to fructose in the body)

Which artificial sweeteners get converted to fructose?

I looked it up, and it's really only one of them, but some of the others have other problems:

"Despite having minimal calories, some artificial sugars still activate the survival switch. For example, sorbitol, which is often used in sugar-free syrups, is part of the polyol pathway and is actually converted to fructose in the body.

Absorption of sorbitol is variable, but it can be significant. Tagatose is another artificial sugar that can substitute for fructose and directly activates the survival switch because it, like fructose, is metabolized by fructokinase. While saccharin does not activate the survival switch, it has been reported to cause insulin resistance in animals, likely through an effect on gut bacteria. Excess intake of saccharin in mice has also led to bladder tumors. My recommendation is to avoid these three sweeteners."

(The "survival switch" is the process that shifts your body towards fat-saving mode.)

I avoid *all* sweeteners myself, because I've read that other types are bad for your intestinal flora, and I don't like the taste of most of them anyway.

Fair enough. I think I have very very far from baseline food preferences/requirements in a few ways so I am not a very good judge of what diets most people would consider reasonable.

Is processed foods messing with the lipostat still the best supported theory? And if so, has anybody discovered whether/how it's possible to undo the damage?

Nov 24·edited Nov 24

Can you unpack the words "processed" and "hyperprocessed"? They seem to be used more as virtue labels than anything objective about the ingredients and process. At least, I've never seen anyone say what they mean by the words. All cooking is "processing", but hopefully something more specific is intended.

And "junk food", for that matter. I suspect that with my eating habits and preferences, and affluence, I never see any "junk food" from one year to another, so I am unsure what is being talked about.

It's a gradient, and not really that complex. Compare carrots and steamed carrots. Cabbage and steamed cabbage. The processing makes digestion a lot easier, makes the calories a lot more available.

The thing that make it a bit complex are things like unflavored yogurt, which *are* hyperprocessed, but are still good food choices. Some foods are "hyperprocessed" to improve their durability. But this doesn't always mean that the calories are more available.

It's really slightly the wrong dimension, but there's a very strong correlation with "hyperprocessed" and "no fiber, lots of starch and sugar".

Processing (including cooking) tends to make foods easier to digest. This means that your GI system doesn't burn as many calories, that more of the calories in the food are actually absorbed (rather than pooped out) and that you get hungry again sooner. Some processed foods are also designed to act as a superstimulus, making you want to eat more of them even when you're not hungry.

How odd. I never want to eat when I'm not hungry. I mean...why?

Boredom. Where's Amy?

It varies. There are times when eating remains interesting even if I'm not hungry.

The worst was when I'd get irritated when I was full because I didn't want to eat more. Fortunately, I didn't have a bad case of that one.

Have you never found yourself eating more potato chips than intended because they're more-ish? I very rarely eat the kind of food that triggers this effect in me - I have chronic health issues and am exceptionally conscious of what I eat as a result - but I'm aware it exists.

For me, there are no "moreish" foods. I am quite capable of eating a single raisin.

"Moreish" is something food companies research, so find the combination of taste, texture, mouth feel, etc., which makes people enjoy a food without getting satiated.

I've eaten junk food and still eat it occasionally, but I don't like it enough for it to be a major part on my diet. I'm apparently not the person the food companies are aiming at. I don't think it's a sort of moral superiority on my part.

Basically all food is "Processed" to some extent, unless it's literally raw fruit and veg I guess, but "processed" and "hyperprocessed" are basically shorthand for "comes in a packet and is high in salt, fat and/or sugar". It would say that its more about the incentives behind the design of most processed food than the fact of processing itself.

That's more or less how I understand it. Basically, foodstuffs in a style/composition similar to mid-to-late 20th century mass-produced convenience foods, which is used as a heuristic for foods with a particular cluster of characteristics that makes a diet that relies on such foods as staples to be particularly apt for overeating.

The representative features of "processed" foods is that they're designed for cheap and easy mass production and distribution in a 1950-ish environment, and for palatability across a wide range of local food cultures. White flour, corn syrup, and vegetable shortening were and are cheap and conducive to making stuff that doesn't need to be refrigerated and has very long shelf lives. Starchy and fatty foods tend to keep longer at room temperature as well: starchy stuff with appropriate preservatives doesn't really spoil the way most fruity or protein-based foods tend to, shortening doesn't go rancid like many cooking fats, and presence of fats helps the foods not feel dry even if they're very low moisture (low moisture being one of the keys to minimizing spoilage), and both lots of fat and minimal moisture both help prevent the starches retrograding (i.e. going stale). And to appeal to a wide range of palates, much of it is pretty bland and inoffensive, relying on various combos of fat, sweetness, and saltiness for palatability. Heavily sweetening or salting also helps shelf life, since lots of salt or sugar with little moisture helps make it inhospitable to bacteria and molds.

Nutritionally, such foods tend to high glycemic indices (from white flour and sugar), lots of omega-6 fats (from the shortening and a little from the flour), and to generally be calorie dense relative to satiation.

Guyenet's formulation of it is actually "hyperpalatable", and based on some very limited exchanges I've had with him, I don't think he can nail down precisely what it means. I think he's working honestly with the empirical data we have available, but it's a bit undertheorized.

> I don't really have a good solution to the existence of processed food

Many people buy their food online. I could imagine a software solution that would support automatic filtering or blocklists.

Imagine that you are a vegetarian, so you go to the application settings and check "do not show me products that contain meat", and from that moment (until you change the settings again in the future), the application will pretend that products containing meat simply do not exist. Not just showing you the message "4 out of 15 products were hidden because of your filter settings", but simply there would only be the 11 products displayed, with no indication that anything else exists. Categories that only contain hidden items would themselves also become hidden, so instead of seeing an empty category for "bacon", there would be no such category in the menu. Unless someone makes a soy bacon, in which case the category would appear again.

In other words, shopping at a normal supermarket with this setting turned on should feel indistinguishable from shopping at a vegetarian supermarket. (Which removes the need to actually build a separate vegetarian supermarket.) Out of sight, out of mind. Willpower is no longer necessary when the temptations are removed.

You would be able to create your own blocklist (for example, you may decide to boycott Nestlé), or subscribe to other people's blocklists. Maybe even write your own algorithm in some scripting language, using the available metadata, such as "hide everything that contains more carbs than proteins". This of course assumes that the web application would contain the metadata.

I would love to have such application available, because every time I regret buying and eating something, I could simply add it to my personal blocklist and never see it again.

There is probably an economical incentive against creating an application like this; maybe the problematic products are the most profitable ones, and if you allow your customers to remove them too effectively, you hurt your profits. Maybe this application would have to be created by a third party. (In which case, it could perhaps integrate products from multiple supermarkets, that would be even better.)

This actually seems like a really valuable idea! I worry that the metadata wouldn't be available to a third party though (I give it 50/50 odds that some of the metadata you would really want isn't available internally either)

Yeah when I switched to a fruit and veggies and yogurt and other simple foods diet, I just ate a lot more of those foods. Didn’t really help at all.

It’s all CICO, and when I actually stick to say a 1700/day budget, the weight flies off because I am fairly active. When I don’t stick to that budget I quickly balloon up because I suspect my bodies generic desire for food is something like 3500/day or some other unhealthy level. Probably learned at teenage years when I was an athlete.