Maintenance Phase - Ozempic

00:00:00.000 wait have i ever told you about steakhouse or gay bar hang on i want to look it up just because

00:00:05.540 it's yep is it here we go what does it have uh magic castle oh it's gotta be steakhouse yeah 0.50

00:00:10.740 correct stockyards oh that's a gay bar incorrect steakhouse what excelsior that's either a bad 1.00

00:00:19.920 steakhouse or a bad gay bar oh gay bar fuck yes oh juicy lucy's that's a steakhouse thick cock in 1.00

00:00:25.620 my asshole. Oh, steakhouse. Wow. Charlie Brown's. I'm not touching that. I'm not touching that. 1.00

00:00:32.280 Let's move on. It was a steakhouse. Aubrey, why can't we do a fun episode? Why can't we

00:00:37.020 just do this for an hour instead of talking about Ozempic? Welcome to Maintenance Phase,

00:00:52.080 the podcast that works in the short term but has never been tested for more than two years

00:00:56.360 that's kind of true actually accidentally that is a pretty accurate thing to say about our podcast

00:01:04.560 it hasn't been tested in long term people go back to where they were uh i'm michael hopps i'm aubrey

00:01:10.760 gordon if you would like to support the show you can do that at patreon.com slash maintenance phase

00:01:15.820 or you can subscribe on apple podcasts it's the same audio content michael aubry let's start let's

00:01:22.220 start with your nervousness my nervousness we're gonna talk about it your complicated feelings so

00:01:28.480 today we are talking about ozempic we govi and their active ingredient semaglutide wait i think

00:01:36.900 it was semaglutide i thought it was too and then i heard a million doctors say semaglutide semaglutide

00:01:43.780 Doesn't that seem wrong?

00:01:45.600 Yeah, but sure.

00:01:46.360 I mean, they're made up words anyway.

00:01:47.640 And then on some level, every word is made up.

00:01:49.160 So whatever.

00:01:49.680 Well, listen, from Mr. Denouement, it's a safe space for creative pronunciation. 0.95

00:01:58.500 The thing is, so much of the fucking feedback to this show is about my pronunciations of words. 0.91

00:02:04.580 No one ever wants to give me feedback on the content of the show. 0.98

00:02:10.160 Michael.

00:02:11.320 Aubrey.

00:02:11.720 This episode is actually a little different than how we usually do things.

00:02:15.440 I'm going to walk us through the drug and its origins.

00:02:19.360 You're going to walk us through the clinical trials into this sort of class of drugs.

00:02:26.420 And then we're going to talk about what I think is the thorniest part of all of this,

00:02:31.660 the discourse around those drugs.

00:02:34.160 The discourse.

00:02:35.240 This is a big one.

00:02:37.520 It feels like a really high stakes conversation.

00:02:40.080 So I'm curious about, for you, what are some of the things that you're sort of like bringing

00:02:46.180 to that?

00:02:47.140 I think my weirdness with this episode is the culmination of my weirdness with every

00:02:52.260 episode of the show, where both of us are interested in public health, in the kinds

00:02:58.600 of things that are prescribed, how drugs get approved, what they mean societally.

00:03:03.440 Whereas because Americans have been trained by health media for our entire lives to see

00:03:10.060 everything through an individualistic lens. We are going to be spending basically this entire

00:03:15.840 episode talking about the narratives around Ozempic and Wegovy. We have this new generation 0.99

00:03:23.220 of weight loss drugs that as of now appear to deliver much more weight loss than any previous

00:03:28.480 generation of weight loss drugs. And we've had this immediate huge wave of media being like,

00:03:35.380 is this the end of obesity? Does this invalidate body positivity? And like being a dietician in

00:03:41.980 the age of Ozempic and all this just insufferable kind of end point prediction stuff based on very

00:03:48.900 little information. And what we are interested in and like what we have been talking about

00:03:54.360 behind the scenes nonstop for the last couple of months is like how poisonous these narratives are.

00:04:01.780 but what people tend to hear is like individual health advice mike and aubrey think you shouldn't

00:04:07.340 take ozempic or mike and aubrey think you should take ozempic yeah and like that is just not

00:04:12.360 something that we are interested in we've said on the show before that if you want to lose weight

00:04:16.940 and you want to do keto or a cleanse you can do that we don't we don't have opinions on that yeah

00:04:22.320 totally and if people don't want to do that they also shouldn't be pressured yes to do so and i

00:04:28.360 just know that this is like a big topic for a lot of people, right? For me included, both because

00:04:34.300 I'm engaging with all of this media and fat people writ large are engaging with all this media that

00:04:39.160 is like, could we finally be rid of fat people is like the framing of a lot of this conversation.

00:04:46.300 But like, on top of that, I mean, we've talked about this before on the show that one of my

00:04:52.120 very best friends was diabetic and passed away because she couldn't access treatment.

00:04:56.900 Yeah. Right. That was like facilitated by a lot of things. It was facilitated by capitalism and anti-blackness and transphobia and lots of things. But it was also facilitated by our sort of cultural disregard and disdain for people who have diabetes or any health conditions that we deem as, quote unquote, doing it to yourself.

00:05:16.360 for many folks this is like a matter of body image which is really tender and personal for

00:05:21.860 other folks for people who are on this medication for their diabetes this can very literally be a

00:05:26.940 matter of life and death right right we're talking about like a wide range of big feelings and it's

00:05:35.780 like understandable right this is one of the most intense and sort of widespread moments of body

00:05:41.900 related discourse we've had in quite some time. Right. People who are taking this for weight loss

00:05:47.900 are told that they're sort of taking the easy way out, which they absolutely are not. And which also

00:05:53.040 presumes that people are fat because they don't try hard enough. Right. Right. And when those

00:05:57.540 people are fat, they're often being forced into this kind of weight loss in order to access

00:06:02.140 health care treatments, surgeries, other like super basic needs. Right. Right. This just feels

00:06:07.580 like huge that way. I think a fun bit for the show would be to just do a bunch of table setting

00:06:13.000 and like caveats and then just never get to the topic. Another thing we want to say right off the

00:06:19.060 bat. We have gotten dangerously close to an entire episode of caveats. We're working toward it. So

00:06:25.140 for part one, we're just going to talk about the drug itself. We're going to talk about

00:06:29.060 semaglutide, which is the active ingredient in Ozempic and Wegovi. Ozempic and Wegovi are

00:06:35.780 injections that are produced by Novo Nordisk, which is a big pharmaceutical company. They're

00:06:40.880 part of a group of medications that are called GLP-1 agonists. GLP-1 helps regulate our hunger

00:06:49.500 and satiety signals and production of other hormones like insulin. There are other GLP-1

00:06:57.520 agonists sort of on the market, most of them approved for diabetes treatment. Those are

00:07:03.100 Rebelsis, Manjaro, and there are about another dozen that are sort of coming down the pipeline.

00:07:09.600 Semaglutide has been on the market as a treatment for type 2 diabetes in the U.S. since 2018 under

00:07:14.140 the name Ozempic. When it's prescribed for weight loss, it's prescribed under the name Wegovi.

00:07:21.080 It's the same thing. They're just different doses. Interestingly, the weight loss one requires a

00:07:26.500 higher dosage of semaglutide. So this drug started to be sort of studied. Its glimmers begin

00:07:35.480 in 1984 with an endocrinologist at the University of Toronto. His name is Dr. Daniel Drucker,

00:07:44.360 and he discovers a new hormone in humans, which is GLP-1. It's called glucagon-like peptide 1.

00:07:53.580 girl glucagon as he and other researchers tried to figure out how glp1 functioned in the human

00:08:00.200 body it starts to show real promise as a treatment for type 2 diabetes but they have this problem

00:08:06.560 glp1 sort of disappears from your system very quickly oh so it makes it really hard to study

00:08:15.200 much less sort of reproduce it so they start looking for alternate sources of glp1 that

00:08:20.920 might last a little longer than the human version right okay and that's when the gila monster

00:08:27.580 comes in oh mike have you ever heard of the gila monster yeah they're like a cute little lizard

00:08:34.720 they're like a kind of like a thick like robust lizard i did not know about them before this

00:08:41.560 episode i didn't know a thing about them they're the largest lizard in north america they're almost

00:08:46.540 two feet i've never seen one in real life but i've seen them in zoo books and they're really cute

00:08:50.020 Well, listen, Dr. Drucker had one shipped to him in Toronto because it goes through long periods

00:08:59.540 without food and it has the ability to slow down its appetite and metabolism. And Drucker wanted

00:09:06.780 to know how they were able to do that. And he discovers that those Gila monsters have genes 1.00

00:09:13.440 for something called Extendin-4, which when sort of synthesized in a lab, eventually became 0.78

00:09:20.600 Ozempic. How ironic that a thick lizard gave us thin women. Interesting. Interesting. So 1.00

00:09:27.100 researchers don't totally know the mechanism for what makes GLP-1 agonists work the way that they

00:09:35.120 do. But we do know that semaglutide sort of mimics that GLP-1 hormone that is, again,

00:09:44.600 released after you eat. It's part of what makes you feel full and it's part of what signals your

00:09:50.420 brain that it's time to stop eating. And so it works by you end up eating less because you just

00:09:55.500 basically feel full after each meal. Yeah. So like it triggers your satiety hormone. So like

00:10:00.600 ordinarily you'd be hungry again two hours after breakfast, but now it's like three or four hours

00:10:04.400 after breakfast. And so over the course of a day, you just end up eating like, I don't know,

00:10:08.780 20, 30% less. Yes. And on top of that, it's holding that food longer in your stomach. So

00:10:14.480 you are physically full for a longer period of time, right? And it's triggering a release of

00:10:21.680 insulin. And also it may help grow pancreatic beta cells, which are the cells that produce

00:10:28.560 and release insulin. So it's not just that it helps you release insulin in the short term.

00:10:34.580 It's also sort of like building up your ability to release insulin in the midterm.

00:10:38.520 Oh, interesting. So it's like flexing a muscle. It's actually like building the muscle that

00:10:41.140 secretes insulin.

00:10:41.900 It seems like it. It seems like it might be.

00:10:43.880 Yeah.

00:10:44.060 The results for people with diabetes in clinical trials are really incredible. So for diabetic

00:10:53.740 people, the most important measure of your blood glucose is your A1c. That's a measure of the

00:11:00.020 amount of hemoglobin in your blood that reflects your blood glucose levels over the last like few

00:11:06.980 months. Most guidance for people with type 2 diabetes suggests that they should keep their

00:11:13.380 A1c below 7 to minimize complications. But people whose blood sugar isn't well managed can have A1c's

00:11:20.820 that are like 10, 11, 12, 13, like really high. It can lead to damage to that person's eyes,

00:11:29.240 including possible blindness, their kidneys, including kidney failure to their nerves and

00:11:34.280 to their heart. With the introduction of these GLP-1 agonists, the results are kind of miraculous.

00:11:42.560 There are stories that are told about the initial presenting of the research on these

00:11:47.900 at the American Diabetes Association conference and people were weeping and gave it a standing

00:11:54.440 ovation.

00:11:55.320 No way.

00:11:56.120 Because what they're talking about is people whose A1Cs went from like 11 to 7, right?

00:12:02.600 From like really heightened urgent risk down to like a pretty safe range just with this

00:12:10.700 one drug, right?

00:12:12.540 I do think one of the fundamental, like difficult things to process about any of these kinds

00:12:17.800 of health conditions is that like we all kind of hate pharmaceutical companies like under a system

00:12:22.800 of capitalism it's like these are big global profit maximizing entities but then on the other

00:12:27.600 hand they deliver a product that is genuinely life-saving yeah we just get kind of weird

00:12:32.740 whenever people like praise pharmaceutical companies i'm like i don't know about that

00:12:36.620 but then whenever people overly criticize pharmaceutical companies i'm also like i don't

00:12:40.160 know either so in the trials for ozempic they start noticing pretty significant weight loss

00:12:47.460 and researchers start going,

00:12:49.620 well, what if we could just use this

00:12:50.660 as a weight loss drug?

00:12:52.340 So they created WeGoV.

00:12:54.300 It's the same drug at a higher dose.

00:12:56.540 It uses more of the active ingredients,

00:12:58.860 semaglutide.

00:13:00.280 And because of that,

00:13:01.580 it costs more.

00:13:03.920 The diabetic version hovers

00:13:05.020 at around $900 a month

00:13:07.740 and it costs more for weight loss.

00:13:09.560 It costs like $1,300 a month out of pocket

00:13:12.480 and most insurers do not cover it.

00:13:14.740 Not that like my main purpose with this show

00:13:16.220 is to like widen the availability of weight loss drugs but like there is something fascinating

00:13:20.720 about how we've gotten all this stuff about like the obesity epidemic is so bad it's like killing

00:13:25.080 our kids and then it's like we get a drug that ostensibly treats it and they're like that's too

00:13:29.560 expensive yeah it is really wild that this is an issue where we like talk out of both sides of our

00:13:35.780 mouths constantly as a culture yeah in a lot of ways the experiences of people who are taking

00:13:41.560 Wegovi for weight loss or Manjaro or Rebelsis or whatever the other ones are that are getting

00:13:46.380 prescribed off label, right? That like a lot of folks are being told that they're like taking the

00:13:51.540 easy way out. Yeah, that's really bizarre. That's the kind of rhetoric that reveals itself to be

00:13:57.880 not about concern, not about your health, just about I want you to suffer for looking the way

00:14:05.780 that you look. We're doing discourse, Aubrey. We're doing discourse and we're not even into

00:14:10.160 the discourse section. I'm keeping my discourse powder dry, but we're discoursing. So Wegovi was

00:14:20.540 approved for weight loss by the FDA in June 2021. Almost as soon as Wegovi was approved for weight

00:14:28.980 loss, both Wegovi and Ozempic went into shortage. That impacts both people seeking the drug for

00:14:37.580 weight loss and the people using it to manage their blood glucose for diabetes. Because what

00:14:42.480 happens is that Wigovi goes into shortage first, right? That's the weight loss one. And then 0.96

00:14:49.280 doctors start prescribing Ozempic, the diabetes medication, off-label to people who want to start

00:14:55.420 to lose weight. Then that goes into shortage too. So as we record this, Wigovi and Ozempic are both

00:15:05.420 in shortage, according to the FDA's sort of drug shortage database. Okay. When a drug goes on the

00:15:12.060 FDA's shortage list, the FDA then allows what are called compounding pharmacies to mix up what is

00:15:19.480 basically their own version of that drug without prior FDA approval or screening. When Ozempic and

00:15:28.600 Wigovi went into shortage, compounding pharmacies across the country started compounding their own

00:15:36.200 versions of semaglutide. Here's the problem. Novo Nordisk has patented the semaglutide molecule

00:15:46.340 and only they can produce it until 2032. So the active ingredient simply isn't available to those

00:15:55.940 compounding pharmacies. These compounding pharmacies are prescribing something. They're

00:16:01.600 calling it semaglutide. Okay. It's not Ozempic and it's not Wegovi. It might be a watered down

00:16:10.320 dose of those things. It could be something called semaglutide sodium. Okay. It's called

00:16:17.080 semaglutide, but it's used in lab animal experiments and is not cleared for use in humans.

00:16:23.940 Oh, that's like when people were taking like horse antibiotics that you could buy on Amazon

00:16:29.420 because they couldn't get like human antibiotics because they're like roughly the same thing.

00:16:33.960 Well, except this is not roughly the same thing and is hazardous to humans' health.

00:16:38.640 So maglutide sodium is not cleared for use in humans because it is bad for humans. 1.00

00:16:43.400 Oh, fuck. 1.00

00:16:44.400 And the third option is that it's something else entirely. 1.00

00:16:47.200 Because this is in shortage and because there is less FDA oversight,

00:16:52.120 Right. These compounding pharmacies are not required to tell anyone what's in the drugs that they are giving people. Right. This may sound niche. These compounding pharmacies may sound niche. This is every web advertisement you see that says Ozempic for $99 a month or $499 a month or whatever.

00:17:13.340 all of these all of the little startups that are like just call and talk to a doctor and you'll

00:17:18.940 have it the next day all of that stuff is powered by compounding pharmacies no way so this got so

00:17:28.420 bad the compounding pharmacy stuff has gotten so bad that the fda has issued a number of official

00:17:33.180 warnings about this and specifically has warned against buying from these startups this is such

00:17:39.740 a bizarre system it's so weird it's like there's a shortage of this drug so we're just gonna like

00:17:46.320 let people buy it from like weird fly-by-night carnival barker ass companies selling whatever 0.87

00:17:52.600 the fuck on the internet we're not gonna regulate it at all there's not an enforcement mechanism 0.91

00:17:57.160 beyond these letters so far right like they're not they're not doing more than that yet at least not 0.99

00:18:03.860 in reporting do you have any sense of like when this could resolve itself like as novo nordis

00:18:08.740 said that they're massively ramping up production? Basically, the goalposts just keep getting moved

00:18:13.660 for when the shortage will end. You know, I checked a couple of months ago, it said it would

00:18:18.440 be over by the fall. I checked again, it said it would be over by the end of the year. Oh,

00:18:22.540 it's like self-driving cars. It's always five years away. Right on the horizon. As we're talking

00:18:28.060 about these compounding pharmacies, big weight loss companies are buying up these startups.

00:18:34.040 oh weight watchers bought one of these and their stock price jumped almost 60 in a day oh from

00:18:40.860 like 12 cents to like 16 cents or something yeah i mean listen it's weight watchers stock was not

00:18:45.820 doing great but the 60 increase is a 60 increase you know they've gone from a limp to a gate and

00:18:51.340 i would say because the discourse around this is all focused on like the real housewives are taking 1.00

00:18:58.380 it and frivolous rich people and celebrities are taking it it makes the issue seem like it isn't

00:19:04.460 incredibly pressing and important right particularly for people with type 2 diabetes particularly for

00:19:11.660 people who can't access health care and other basic needs at their current weight this is the

00:19:16.740 other thing about this discourse that drives me utterly fucking bananas is that there's not

00:19:21.580 meaningful acknowledgement of the straight up income barriers to getting this medication 0.85

00:19:28.000 that this is a shortage that is largely presumably created by people with the disposable income

00:19:35.000 to pay out of pocket for a weight loss medication that almost no insurers are covering right you and

00:19:42.220 i have discussed this until we're blue in the face like neither one of us wants to litigate

00:19:46.020 individual behaviors but like that is one that really doesn't sit right with me my views on this

00:19:52.480 are also very contingent honestly like once we get to a point where these are super duper available 0.98

00:19:57.480 if you want to take one to lose 10 pounds, genuinely, I don't give a shit. In the same 0.88

00:20:01.300 way, I don't give a shit if you want to get a nose job. But like, in time of a shortage. 0.99

00:20:05.400 The same thing. There's an Adderall shortage. If you're not prescribed Adderall, don't take

00:20:09.380 Adderall right now. If you don't need sriracha, I've been doing my part in buying slightly less

00:20:15.880 sriracha than usual. Dude, the sriracha shortage has been a big topic of conversation in our

00:20:21.140 household. Are you still doing it? Can I cancel you for eating sriracha in a time of need?

00:20:24.280 we had a bottle it was about halfway done i got another one hypocrite totally you're hoarding 0.98

00:20:30.940 sriracha one and a half bottles come take them from my cold daddy so michael aubrey this is 0.94

00:20:39.840 unusual for us but this topic was so big and expansive that you and i both actually researched

00:20:48.140 this one and i dug in on sort of the discourse side and the reporting side and you really dug

00:20:53.600 on the research side so can you walk us through just like what do we know from the research this

00:20:59.640 is a weird format break for us because ordinarily like one of us researches and one of us listens

00:21:03.660 but like it would be odd to pretend that we haven't both been following this like obsessively

00:21:08.480 for the last couple months yes i have deliberately avoided the discourse because i find the discourse

00:21:13.160 annoying but i have been following the research and like i have a literal spreadsheet of like

00:21:19.200 the various studies that have been done. And for these drugs, there's actually a quite finite

00:21:24.260 amount of information. And I just, for the love of God, just want to like walk through what we know

00:21:31.940 and what we can expect from these drugs. Yeah. Sounds great. So basically the trials of

00:21:37.320 semaglutide for weight loss are all grouped under this heading of the STEP trials, which is the

00:21:44.000 semaglutide treatment effect in people with obesity, which should be Stepo, but is actually

00:21:49.760 Step. Stepo, what, the fifth Marx brother? Yeah. And these are sort of classic pharmaceutical

00:21:58.780 company randomized control trials. They are global. They comprise 5,000 people. All of them

00:22:05.480 are 68 weeks long. One of them is a little bit longer. We'll get to it. They are funded by Novo

00:22:10.320 Nordisk, of course. And the way that they structure these, they sort of do it like moon

00:22:15.500 missions. You know, there's like Apollo 1 and Apollo 2. These large pharmaceutical trials are

00:22:21.340 like there's step one, step two, step three, and they break them down into like specific things

00:22:25.940 that they want to know. And step one, step two, step three are not different phases in the same

00:22:31.740 study, right? They are separate studies. So step one is like the overall just like we're going to

00:22:38.180 give fat people semaglutide for weight loss. Step two is the same thing, but on people with type 2

00:22:43.980 diabetes. Step three is semaglutide with intensive behavioral therapy. BLTs! And then the rest are

00:22:51.580 kind of like smaller shading. So step four is they put people on semaglutide for a while and

00:22:58.480 then they switch half of them to a placebo. Step five is a two-year trial. Step six and seven are

00:23:04.380 the same thing, but they're done on Japanese, South Korean, and Chinese people. And step eight

00:23:09.400 is testing semaglutide versus one of the other GLP-1s. So it's semaglutide versus liraglutide.

00:23:16.420 So when you say step six and step seven are focusing on East Asian folks, it's worth

00:23:21.980 mentioning that most of these trials for Wegovi in particular are just overwhelmingly white,

00:23:30.580 as many diet studies are. One of the sort of leading meta-analyses of studies involving

00:23:37.960 over 11,000 participants was 80% white, 10% black, and 5% AAPI.

00:23:46.960 Although for diet studies, I mean, we both see diet studies that are like 97% white

00:23:51.840 fairly frequently. So like, it's funny, like 80% white, I'm like, ooh, not bad. 0.99

00:23:56.180 Come on. 0.98

00:23:57.660 The bar is in hell. 1.00

00:23:59.240 Yeah, like by the standards of fucking diet research. 0.99

00:24:02.080 It's like, well, very diverse sample. 0.98

00:24:03.960 The results of these semaglutide trials are like quite consistent, like remarkably consistent.

00:24:10.160 So roughly 80% of people who take semaglutide lose some amount of weight, roughly 5% of their body weight.

00:24:17.400 And roughly half of people who take semaglutide lose 10 to 15% of their body weight.

00:24:23.300 So like a one in two chance of losing like a moderate amount of weight.

00:24:26.820 And then the biggest number and the thing that is like sent the entire like weight loss

00:24:31.660 industry into overdrive on this is that roughly one third of people who take semaglutide lose

00:24:38.320 more than 20% of their body weight, which is roughly on par with like bariatric surgery.

00:24:44.180 And then another thing that is like a pretty big deal about these drugs is that like the

00:24:48.760 results seem to hold up.

00:24:50.160 So there's one trial where people took semaglutide for two years and like by the end of it, 36% of people had lost more than 20% of their body weight.

00:24:59.620 So for about a third of patients, they're losing maybe three times as much weight as previous interventions.

00:25:06.820 We should also note that like there are pretty significant health effects of these drugs.

00:25:11.220 So even in the shorter term trials, people have better blood pressure.

00:25:15.640 They have better cholesterol.

00:25:17.020 overall they have improved a1c levels we also with the longer term trials we've seen modest

00:25:24.000 but also like kind of big deal reduction in heart attacks and strokes so that's really exciting yeah

00:25:31.520 if there is a drug that people can take and they are less likely to die yeah i am pro that drug i

00:25:37.860 actually looked this up that it's it's roughly in line with the effect of statins so this is this

00:25:42.360 is genuinely like a big deal like even if you take the weight loss stuff off the table yeah we should

00:25:46.540 also talk about the side effects the side effects of the drugs seem to be almost universal some

00:25:53.180 studies find i think the lowest one i found was like 60 of people have like gastrointestinal

00:25:57.820 symptoms but then some of them are finding like 93 of people so it's like nausea constipation

00:26:04.560 diarrhea vomiting the sort of tummy stuff that you would associate with like pretty significantly

00:26:10.640 fucking with your like hunger and satiety hormones in addition to all of those side

00:26:16.060 effects. There is sort of this whole class of side effects that get covered mostly in like 0.99

00:26:21.540 beauty media and like gossip blogs, like Ozempic face. Have you heard about Ozempic face?

00:26:29.840 From you like 10 minutes ago, right when we started recording.

00:26:33.160 Some of us were trying to keep the illusion alive, Michael. So it's basically just the

00:26:40.400 appearance of aging okay when taking ozempic and it's just the result of rapid weight loss however

00:26:46.380 you did it it's not unique to ozempic it's just when you lose a lot of weight really quickly you

00:26:51.560 end up with loose skin right and some of that loose skin will be on your face and that is also

00:26:56.580 the same kind of thing that happens when people age so you look older so ozempic face is just like

00:27:01.000 you lost weight face yeah totally these ones just strike me as we were talking about beforehand 0.99

00:27:06.040 like these ones just strike me as so fucking mean it's also so fucked up because it's like 0.99

00:27:10.140 our culture is telling you to lose weight all the fucking time and it's like you finally do 0.99

00:27:13.540 lose weight it's like what's happened to your face yeah totally well and people treat it as 0.99

00:27:17.400 like some kind of like comeuppance right for like taking a drug or daring to lose weight or being

00:27:22.840 too vain or what like whatever like it's just steeped in so much judgment right that i'm like

00:27:28.680 could we just set that one down there's also a bunch of like very rare side effects so there's

00:27:35.840 been some worry about pancreatitis. Some trials find that it like increases, but then there's a

00:27:41.760 trial of liraglutide that finds that it actually decreases. There's concern about thyroid cancer,

00:27:48.860 but that's based on rodent studies. And there haven't been any signs of that in the data,

00:27:54.080 but we don't know kind of any longer than one and a half to two years. There's slightly elevated

00:28:00.340 rates of gallbladder disease, acute kidney injury. There's two cases in Iceland of suicidal ideation

00:28:10.080 and the European Medicines Agency is now looking into that. And just this week, the FDA updated

00:28:17.620 the label on semaglutide to include this thing ileus, which is basically when like digested

00:28:25.080 food builds up in your intestine and backs up. And the only way to deal with it is surgery and

00:28:32.920 it's fatal. So we have 33 cases of this that have been reported to the adverse events database and

00:28:39.260 two deaths. But we don't sort of know what to make of those things because the adverse events

00:28:45.080 database is like, as we've discussed on the show before, is like anyone can submit cases. So it's

00:28:49.340 basically just like a hotline. And so it's something that is like people are looking into

00:28:53.240 more. And there's a study out of China last year that shows that this mechanism exists in mice,

00:29:00.000 where it like basically stops bowel function. And there was some kind of warning in that study of

00:29:04.760 like, oh, this might show up in humans, and it might show up around the sort of 18-month mark,

00:29:10.340 meaning like after these studies would have concluded. But that's also like animal studies,

00:29:14.780 super preliminary. We don't know. It's sort of like people don't really know what to make of

00:29:18.760 this yet? Yeah. And, you know, two people dying is nothing to... That's a huge deal. That's a big

00:29:24.860 deal. That's a big deal. And I think especially in the context of previous diet drugs having sort

00:29:31.320 of gone this way. Yeah. But then one thing that really stood out to me was, you know, we have

00:29:36.620 these like near universal side effects. We have these like much more rare, much more severe side

00:29:41.800 effects. But the dropout rates in these studies are like really low. Yeah. What you find in most

00:29:46.760 of the studies is almost everybody is getting some side effect or another. And they typically

00:29:52.660 happen in the first couple weeks of the study when you're like upping your dose. It actually

00:29:56.160 takes four months to get up to the 2.4 milligrams like weight loss dose. But it typically goes away

00:30:02.240 as people kind of get used to the drugs. And so in the two-year study, there were 150 people who

00:30:08.560 completed the two-year trial and only 10 of them dropped out due to adverse effects, which is only

00:30:13.520 6%. So like what this indicates is that like people are getting side effects, but most like

00:30:20.160 the vast majority of people are willing to like push through the side effects and like complete

00:30:24.200 these trials. Yeah. So what you're saying is folks are more likely to stay in these studies than

00:30:29.500 other studies into sort of like how folks can lose weight. Yes. So, so far I've kind of been

00:30:36.100 presenting like the case for semaglutide, like the way that you read about it in these clinical

00:30:42.720 trials. I've been reading a lot of things from like, you know, people in like the weight loss

00:30:47.180 world. And like, this is how they talk about the drug, right? Is that it's delivering very

00:30:52.420 significant weight loss. The dropout rates are relatively low. And before we get to like

00:30:57.880 complicating that picture a little bit, I think it's important to first of all, just like

00:31:01.840 acknowledge that like, that is the data that we have. And like, I think this new generation of

00:31:06.620 weight loss drugs is like genuinely just a big deal. At the same time, to me, like the most

00:31:11.380 bizarre thing about the discourse especially recently but you know since the results of

00:31:15.660 these trials started coming out is like the weird victory lap that people have been doing it's like

00:31:21.620 okay we know we have something now that works for weight loss right we finally have an effective

00:31:26.020 weight loss drug and then there's this weird sort of second order thing where they're like what are

00:31:30.440 the fat activists gonna do now yeah like this ruins body positivity and there's all this weird 0.85

00:31:35.840 shit of like, well, now we have a cure for obesity, right? And I feel like just to sort of 0.98

00:31:42.260 take these results as we've been presented with them, right? Like the quote unquote best possible

00:31:48.220 version of these events, right? All of the weight loss, all of the benefits, everything.

00:31:52.360 It's like, we're talking about a drug that 50% of people who take it will lose 15% of their body

00:32:02.360 weight and like that is not a world without fat people this is like the aspect of the drug that

00:32:07.860 drives me absolutely fucking nuts it's not going to end the quote-unquote obesity epidemic it just 0.63

00:32:13.080 isn't yeah we still as a society need to work on like stigma against fat people improving medical 0.98

00:32:19.340 care for fat people all of the things we say on this show right are still fucking true if every 0.74

00:32:24.900 single person in america loses 15 of their body weight and that is a dramatic overestimation of 0.94

00:32:30.940 what's even about to happen right yeah even if as you say even if they work exactly as they are

00:32:35.720 projected to even if the data doesn't change one bit with future trials yeah someone my size

00:32:43.460 goes from being 330 pounds to being 280 pounds that would take me from uh being an a person with

00:32:53.240 an obese bmi to being a person with an obese bmi yeah this whole thing about like you know is this

00:33:01.760 the end of the obesity epidemic like a no it's not as you've pointed out but b that is the meanest 1.00

00:33:10.100 fucking thing to say we currently have this fucking nightmare bullshit which is like the 1.00

00:33:14.180 whole fucking show is dedicated to this where it's like a fat person goes into the doctor for a 1.00

00:33:17.680 migraine and they're like i have a migraine and the doctor's like you should go on a diet yeah 0.99

00:33:21.100 And then it's like, you haven't asked me what I do.

00:33:22.820 You haven't asked me if I eat fast food. 0.99

00:33:24.160 You haven't asked me fucking anything. 1.00

00:33:25.960 You're giving me this bullshit ass advice when all I want is fucking advice for my migraine, 1.00

00:33:28.840 right? 1.00

00:33:29.240 Yeah.

00:33:29.480 We're now going into a scenario where you go into the doctor with a migraine.

00:33:32.900 They're like, you should go on Ozempic.

00:33:34.040 Yeah.

00:33:34.340 And you're like, well, I've already been on Ozempic three times.

00:33:36.300 And I was one of the half of people who lost less than 10% of my body weight. 0.99

00:33:41.300 It was costing me more than my fucking rent. 0.97

00:33:43.420 I was having weird side effects. 0.98

00:33:44.860 People report like not enjoying food anymore, which is like really sad to think about.

00:33:48.440 Yeah. 0.98

00:33:48.560 And then the minute I went off of it, I gained all the fucking weight back. 0.98

00:33:51.100 And I've done that four times. 1.00

00:33:52.980 And when I'm going in, you're giving this generic bullshit fucking advice to go on Ozempic. 0.99

00:33:56.440 You haven't asked me whether I've been on it before. 0.99

00:33:58.460 You haven't asked me about weight cycling.

00:33:59.500 You haven't asked me whether I tolerate the drug or if it intersects with some antidepressant

00:34:02.740 that I'm taking. 0.98

00:34:03.680 We're just redoing the same fucking thing, except instead of go on a diet, it's go on 0.99

00:34:07.820 Ozempic. 0.99

00:34:08.340 Yeah. 0.97

00:34:08.820 And like, in the same way that it's not possible for everyone to go on a fucking diet or they've 0.98

00:34:12.740 been on a million already, it's not possible for everyone to go on fucking Ozempic and 0.97

00:34:15.540 it's not going to work for everybody.

00:34:16.500 I mean, I told listen, I told you this off mic, but I think this is the darkest episode that I have researched for us.

00:34:24.880 Yeah, it's really bad.

00:34:25.700 It is really upsetting.

00:34:27.800 And I will say like not just on an individual level, but also like systemically, like I stopped seeing doctors for like eight years.

00:34:38.820 I've written about this a bunch of times and that was at the height of like the bariatric surgery craze.

00:34:45.800 And that really fucking fueled how doctors would talk to me and what treatments they would offer me. And it was like a very frequent conversation of me being like, hey, I'm 24 and I have an entry level position at a nonprofit where I feel fortunate to have health coverage at all. No, I don't have 25 grand for a weight loss.

00:35:07.220 right yeah but that still became a thing right amongst uh health care providers who we already

00:35:13.700 know are more likely to think of fat patients as non-compliant as slovenly as unattractive as

00:35:19.920 weak-willed as all of these things right like this becomes another reason for that group of people

00:35:26.660 also to stop listening to fat people like it's going to get harder for me to get health care

00:35:32.180 right that's part of what's about to happen this is this is why i wanted to go out of my way

00:35:37.120 to, like, insufferably present the results of these trials as if they will hold up.

00:35:43.280 Because even in a world in which that happens, that doesn't call anything into question about

00:35:49.660 the need for equal treatment.

00:35:51.300 And at the same time, the results of these trials are extremely unlikely to pan out in

00:35:58.340 the real world.

00:35:59.180 Yeah, totally.

00:35:59.700 So I have three reasons why these drugs are very unlikely to pan out and deliver, like,

00:36:06.160 the end of obesity or all the stuff that the insufferable discourse has been telling us.

00:36:10.500 We're tucking into the debunk bed.

00:36:12.240 Yeah, this is much more comfortable space for us.

00:36:14.780 The first is that the populations that are being studied in these trials are actually

00:36:19.140 relatively narrow.

00:36:21.300 So step one, which is the trial that's kind of the overall, like just normal weight loss

00:36:26.500 drugs being given to people.

00:36:28.460 I'm going to read you the exclusion criteria.

00:36:31.740 People were not able to participate in step one if they have a history of major depressive disorder, they have a diagnosis of a severe psychiatric disorder, they fill out the patient health questionnaire with a score of over 15.

00:36:48.980 This is one of those questionnaires that has like, you know, I have feelings of hopelessness, like rank from like every day to like never.

00:36:55.720 Yeah, yeah, yeah.

00:36:56.180 It's basically a measure of like how depressed you are.

00:36:58.820 It's like, are you feeling tired?

00:37:00.300 One of them is, do you have poor appetite or overeating, which is like a funny exclusion

00:37:05.080 criteria to include in this.

00:37:06.920 They're also excluding people with a lifetime history of a suicide attempt, any history

00:37:13.080 of myocardial infarction, stroke, hospitalization, any kind of existing cardiovascular stuff,

00:37:19.180 known or suspected abuse of alcohol or recreational drugs, and female who is pregnant, breastfeeding,

00:37:25.860 intends to become pregnant or is of childbearing age and not using a highly effective contraceptive

00:37:31.520 method. Holy shit that cuts out so many people Michael. Well the thing is I mean with these 0.99

00:37:36.700 studies like I sort of get why people who design studies do this stuff because they want to start

00:37:41.640 with a kind of baseline of like quote-unquote normal people without a bunch of like pre-existing

00:37:46.780 conditions which I get for the purpose of a trial. I get why you want to have like a clean

00:37:52.220 sample. However, once these drugs get out into the real world, they're going to be taken by people

00:37:59.100 with depression. When you're designing a trial like this, I imagine you're walking a real line,

00:38:04.780 right? You want the trial itself to be safe for the people who participate in it. So you want to

00:38:09.140 eliminate things like existing heart conditions, like anything, existing pancreatic conditions,

00:38:15.280 anything sort of related to the mechanisms involved in this drug. I totally get that,

00:38:19.540 right? And you don't want it to make anything worse for anybody, like just like a human level,

00:38:24.800 that totally makes sense to me. The trick is, all of that gets translated into an assumption

00:38:33.420 that this is how it will play out for all people who are not being monitored in a study and

00:38:38.580 provided the drug for free. Yeah. And all people who have all of these other conditions that are

00:38:44.600 extremely prevalent in the US, right? Yes. And also, I mean, I probably should have started

00:38:50.120 with this, but the second reason why it's unlikely that these are going to deliver on

00:38:55.700 the results that we're seeing in the trials is because there are real world studies of

00:39:00.520 semaglutide and they don't find the same results. So there's a study in the US that followed like

00:39:07.600 people who went to weight loss clinics and got these drugs for one year. If you remember in the

00:39:12.940 trials of these drugs, the average weight loss was around 15%. In the real world trial, people

00:39:19.280 are losing 7.5% of their body weight. And there are other real world trials, it's quite remarkable

00:39:25.380 actually, that find almost the same thing that like the weight loss, you know, 80% of people

00:39:29.360 lose 5% of their body weight or more. In the real world, that tends to be around 40%. So almost all

00:39:35.020 of the numbers that we're seeing in these randomized controlled trials are half once we

00:39:39.640 get to the real world. They're not zero, right? So this still is going to be, again, a big deal,

00:39:44.340 but we're not seeing in the real world those results continue to show up.

00:39:49.460 Yeah.

00:39:49.640 It's not totally clear why this is happening. One of them appears to be that in the randomized

00:39:56.820 controlled trials, people aren't just taking the drug. They're also getting like dietary counseling.

00:40:03.360 So one of the trials is like super intensive behavioral therapy where they're like meeting

00:40:07.840 with dieticians once a week. But in all of the other trials, they're doing monthly check-ins

00:40:13.300 with counselors. And they're having all of these biomarkers taken. And I think there's something

00:40:18.780 about people just being in a study. You really want to finish because you're like, oh, I'm part

00:40:23.100 of this project. And it's experimental and super cool. And the adherence rates for these randomized

00:40:30.100 controlled trials are significantly higher than we have in the real world. When you look at the

00:40:35.300 real world trials, even among people who have type 2 diabetes and who like really need these drugs,

00:40:41.240 a lot of them are finding like 50% dropout rates after two years. And some of them,

00:40:46.280 one of them finds 70% dropout rate. You can already see as we're sort of like walking

00:40:51.220 through this research, the gap between the popular claims that are being made about these

00:40:56.600 drugs and what the research actually says. That's where we got to with Fen Fen. That's where we got

00:41:02.920 to with ally that's where we got to with like this is sort of a pattern with weight loss drugs

00:41:08.100 is that we get out over our skis culturally with like this kind of magical thinking excitement

00:41:15.540 stuff yeah we then make a bunch of policy decisions based on the excitement and not the data

00:41:22.100 and then we're kind of stuck with these sort of adjusted systems that were again changed based on

00:41:29.740 what we thought was possible, not what we were actually seeing.

00:41:33.960 Exactly. And the other thing that, again, we have very good data on is that people tend to

00:41:41.980 regain all of the weight the second they stop taking these drugs. So one of the step studies

00:41:47.640 switched people from semaglutide to a placebo at 20 weeks. There's also a trial of another GLP-1

00:41:54.720 tier zepatide these fucking tides that did the same thing after 36 weeks they switch people to 0.87

00:42:01.000 a placebo and basically it's like people start regaining the weight very quickly and like within 0.98

00:42:06.520 a year they've regained almost all of the weight these drugs seem to put people in the same cycle

00:42:12.760 as fad diets but just with like more dramatic and like longer results well and the people that i

00:42:19.340 have heard talk about taking these drugs are like i'm just going to take it until i get down to x

00:42:23.340 weight and then I'm going to stop. Yeah. Yeah. Right. And that is people's plan for how this

00:42:27.880 is going to happen. And that's not how these drugs work. I'm seeing this discourse among

00:42:33.220 like weight loss clinicians too, where they're like, well, ultimately it comes down to diet

00:42:37.320 and exercise. And so we need to get people on these drugs and then teach them the diet and

00:42:40.780 exercise stuff. And then once they know that we can take them off the drugs. But this trial of

00:42:46.640 carizepatide the other drug had people on an intensive behavioral therapy program when they

00:42:54.620 went off the drug so people took it for a while then they switched to a placebo while still doing 0.98

00:42:59.820 like exercise and like cooking classes and all this stuff that everybody says is so fucking

00:43:03.740 effective and they gained all the weight back this is another case of pump the brakes and ask 0.64

00:43:08.740 a fat person yeah has anybody tried to teach you how to cook has anybody offered you a gym

00:43:12.920 membership has anybody told you that your form was wrong while you were working out right this

00:43:17.320 is every day the reason that people think that in part is that it reinforces our existing beliefs

00:43:24.300 about fat people right right which is just that they're too lazy or they're too unintelligent or

00:43:30.620 they're too uninformed to just do it for themselves so they need a thin person to teach them how this 0.63

00:43:36.240 is going on my Aubrey Gordon soundboard yeah step back ask a fat person I mean genuinely that's

00:43:41.740 gonna be my advice like 80 of the time is like have you even talked to a fat person about this 0.92

00:43:47.860 this is another like super fucking familiar pattern where it's like okay everyone should 0.70

00:43:52.680 go on atkins because low fat diets work and then like or low carb diets work and then of course 0.91

00:43:57.000 after like six months everyone gains the weight you know and then it's like it's like well if you

00:44:00.660 stayed on it you would have kept the weight off which is true fine if you can stay on it but no

00:44:04.240 one can fucking stay on it yeah right we know in the real world no one can stay on these extreme 0.95

00:44:08.020 low carb diets for very long so let's move forward on that basis that no one can fucking stay on them 0.98

00:44:12.160 right and with this it's going to be the same thing of like well ozempic does work if you can

00:44:16.580 stay on it yeah okay but people aren't staying on it we know from real world data that even when

00:44:20.460 it's fucking free people are not staying on it well and if you do stay on it people characterize 0.98

00:44:24.660 it as the easy way out yeah and then you have this bullshit right like oprah was just saying 0.99

00:44:29.280 the other day like it's the easy way out so i'm not gonna do it and i'm like oprah you were in 0.96

00:44:34.600 your 60s how hard do you think you need to have appeared to have tried yeah and then like listen

00:44:41.120 the discourse makes it worse because in the discourse is like a bunch of the reporting is

00:44:46.100 like we really need to tamp down on the stigma facing people who take ozempic and i'm like yeah

00:44:51.420 is that the stigma that we need to clamp down on well it's so fucking annoying to me about this

00:44:57.640 discourse you have like successfully radicalized me on this in like the last 72 hours oh hey as i've 0.83

00:45:02.580 been as i've been reading this it's like this shows up everywhere like what about the stigma 0.99

00:45:06.860 of taking the drugs but the stigma of taking ozempic is fat phobia it's the same fucking 0.98

00:45:13.420 stigma that fat people are facing but just like yes yes you're taking the easy way out by using 0.97

00:45:17.740 a weight loss drug that's the connection between fatness and virtue you should lose weight in the 0.99

00:45:22.900 virtuous way take the stairs yeah take the fucking stairs it's like well you might look thin but 0.99

00:45:28.400 you're really a fat person yeah you cannot muster any fucking gumption from anybody to like give a 0.99

00:45:35.700 shit about stigma against fat people but they're super chill to invoke fat phobia against people 1.00

00:45:41.440 who stop being fat and they still do the fucking stigma against fat people and they still do it 0.99

00:45:45.640 it's all also been fascinating i'll say on the discourse end that like there have been all of 0.97

00:45:51.600 these bizarre hand-wringing pieces from thin people being like, was body positivity for nothing?

00:45:58.760 I know. It was all a lie. The vast majority of fat people were under no illusions about broader

00:46:04.540 social acceptance. At best, people said fewer unwanted things about our bodies. It never

00:46:12.480 stopped. We were never lifted up. We were never centered. We got one Lizzo out of it.

00:46:18.920 and we don't even have that anymore and we don't even have that anymore like right like

00:46:24.840 the degree to which this discourse is thin people telling themselves stories that they want to hear

00:46:33.460 it's funny to me that like we we like meticulously like outline this and plan that out but neither

00:46:38.500 one of us can resist talking about the discourse i hate it so much like fast forwarding

00:46:44.160 Okay, Michael, we've talked about the drug. Let's talk about the manufacturer

00:46:50.980 of the drug. Yeah. Ozempic and Wegovy are both made by Novo Nordisk. It's a big pharmaceutical

00:46:57.860 company from Denmark. From Denmark. And their marketing practices have really set the template

00:47:04.260 for all the discourse we've been seeing since. Okay. Wait, are there ads for Wegovy and Ozempic?

00:47:10.060 you haven't seen the oh oh oh oh zampic that's like the cover songs that are in all the fucking 0.78

00:47:14.920 trailers now the very slow brooding cover of like i whip my hair back and forth 0.89

00:47:19.760 i'm blue bodu dee da do die but it's like super dark yeah no as we've discussed many times we're

00:47:30.380 on very different like instagram experiences and like algorithms and like i've never seen

00:47:36.260 an ad for weight loss anything i'll tell you what mike i might give you homework at one point and

00:47:41.580 be like don't watch a half an hour of tv and tell me what you notice about the dude no 0.85

00:47:45.140 absolutely not i watch terrestrial tv like once a fucking year when i'm like visiting my grandma 0.98

00:47:53.000 and i'm like this is like this is like actively making me stupider it's like shocking how bad it 0.96

00:47:57.360 is so we're going to talk a little bit about the marketing practices at novo nordisk okay there is 0.66

00:48:02.760 a lot here that leaves me feeling icky. A very good example of this is a campaign called It's

00:48:09.900 Bigger Than Me. Have you seen this campaign at all? Is it like billboards? There are ads,

00:48:15.520 there are billboards, there are branded segments on TV shows, there are so many things. The slogan

00:48:20.940 is obesity, it's bigger than me. Okay. The idea behind the campaign is it's not your fault you're

00:48:27.760 fat, followed immediately by, it's because you have a disease, and that disease requires medical

00:48:34.640 treatment. And that medical treatment can only be provided by one company. It's bigger than me.

00:48:39.700 It's $15,000 per year. Yeah, that's right. That's right. As part of this campaign,

00:48:45.060 Novo Nordisk has specifically courted Black public figures, and particularly Black women,

00:48:51.080 as spokespeople their first spokesperson was queen latifah their next was yvette nicole brown

00:48:58.220 who was on community their third was roland martin from cnn okay who ran an hour-long segment

00:49:07.600 on fatness in black communities that was listed as quote-unquote powered by novo nordisk that's

00:49:14.420 like when influencers say like i've partnered with nike or whatever it's like yeah it's just

00:49:19.580 them paying you to say words. Well, and on top of that, the reporting around the quote unquote,

00:49:26.100 it's bigger than me campaign is just rife with like the most garbage messages about fatness and 0.97

00:49:34.020 body positivity and all kinds of stuff. So I read an interview with Yvette Nicole Brown with the 0.97

00:49:40.400 Griot. In that interview, she said, quote, being focused on your health does not mean that you're

00:49:46.060 not body positive. I think it's actually the most exemplary way that you can be body positive

00:49:52.080 because you need your body to continue to live. Aubrey, were you just like losing your mind?

00:49:57.300 You hate this body positivity stuff already. This is like, this is reifying everything you've said

00:50:03.420 about the whole body positivity thing that it's all just like they're repackaging the same shit 0.99

00:50:08.100 and selling it back to you. The article goes on to say that quote, Brown said somewhere down the 0.99

00:50:13.200 line society at large developed the idea that if you're body positive you can't care about physical 0.98

00:50:19.180 health in my notes i wrote in all caps who is saying this who fucking said this oh my god who 0.91

00:50:27.060 is saying this and it's like trolls right it's like it's seeding a bad faith argument right to 0.97

00:50:33.420 be like we don't think that's true look at what all those nutty people are saying they're wrong

00:50:39.100 This is like when conservatives are like, feminists don't even want you to get married 1.00

00:50:43.020 and have kids. 1.00

00:50:44.220 It's the phenomenon that has built Michael Hobbes' Twitter feed.

00:50:48.100 Hey!

00:50:49.080 Hey!

00:50:49.940 You're familiar with my work.

00:50:52.440 So our third section, Michael, is the part that I have realized is most troubling to

00:50:59.980 me, and that is the discourse.

00:51:02.760 There's been a lot of like garbage media about this in the last like year. 0.98

00:51:06.460 here are three actual fucking headlines from coverage of this one will ozempic change how we 0.99

00:51:15.180 think of being fat and thin question mark okay life after food question mark yeah and ozempic 0.99

00:51:23.240 settles the obesity debate oh it is just bad faith proclamations and bullshit question mark 0.98

00:51:31.860 headlines, like as far as the eye can see. Yeah, yeah. What I am worried about is that 0.97

00:51:37.800 when we see a wave of media like we have seen around Ozempic, we also tend to see a wave of

00:51:44.880 increased anti-fat bias, right? Right, right. And the reporting that I have seen so far,

00:51:50.160 the think pieces that I have seen so far, none of them are grappling with that. Right. Very few

00:51:56.420 people are asking fat people what they need in this moment. And nobody is asking diabetic people

00:52:02.860 what they need in this moment. Like a thing that I experientially know in every bone in my body

00:52:10.040 is that when people I know start to lose weight, the vast majority of them start to see themselves

00:52:17.720 as more virtuous. Yeah. Whether they want to or not, whether they mean to or not,

00:52:24.120 whether or not they would say it out loud. It's very common for people to expect social

00:52:29.020 reinforcement for weight loss. And I would say now, as I have said for years now, which is

00:52:35.720 you have got to get people's consent to do that. The best case scenario is that you're sending a

00:52:42.200 message that you're like not a very good friend to a fat person, right? And the worst case scenario

00:52:48.440 is that you're increasing the stigma that they face and potentially also like triggering people's 0.99

00:52:52.820 eating disorders yeah like this shit is not un thorny and the fact that you're hearing it 0.93

00:52:58.540 everywhere doesn't make it less urgent i would argue it makes it more urgent to like double up 0.99

00:53:03.780 on those boundaries like you have got to give fat people an out for this conversation and we've got

00:53:10.200 to stop presuming that this is like a good and exciting conversation for everybody i i'm like

00:53:16.380 not all that invested in like the drugs themselves the drugs are the drugs i don't know i mean same

00:53:22.140 maybe there'll be effective weight loss drugs maybe they won't i don't know but like given

00:53:26.980 what we know now the most likely scenario is that like they're going to be prescribed to millions

00:53:32.840 potentially tens of millions of people and like what you said to me the other day is that like 0.60

00:53:38.000 you can see the number of people who lost like 15 fucking pounds and then all of a sudden are like 0.85

00:53:44.180 really mean to fat people just like exponentially increasing the other thing that i will say about 0.96

00:53:48.840 the discourse around this is that every like celebratory story about Ozempic that comes out

00:53:55.600 now, that's all going to be mirrored by future panicky think pieces on the rising costs of

00:54:02.740 obesity and how fat people are bankrupting us once again, right? This is an unbelievably expensive

00:54:09.200 medication. And all of that is going to come back to scapegoating fat people once again, right?

00:54:16.280 That like right now we're saying it's frivolous housewives and whatever.

00:54:20.060 When we get into the insurance conversations, we're not going to be scapegoating rich people.

00:54:24.200 We generally don't do that. 1.00

00:54:25.920 We scapegoat poor people, BIPOC, fat people, queer people. 1.00

00:54:30.060 You know what I mean? 1.00

00:54:30.420 Like we've got a list of people we scapegoat.

00:54:32.360 We're also setting ourselves up for another round of excruciating discourse in another

00:54:36.340 couple of years when people look around and they're like, wait a minute, there's still

00:54:39.460 fat people.

00:54:40.600 Yeah.

00:54:40.700 All the magazines told me a couple of years ago that this was the end of obesity.

00:54:44.960 And yet people are still fat. 0.99

00:54:47.560 We should also say, like, listen, you will face serious, serious fucking stigma as a 0.99

00:54:53.120 person who stays fat. 0.98

00:54:54.640 Trust me, a person who has stayed fat through all the interventions, right?

00:54:59.580 Like, yeah, I've already like sort of started shifting socially.

00:55:04.920 You know, I'm already a very homebody indoorsy kind of lady.

00:55:07.980 and I'm already restricting who I socialize with pretty dramatically because of this kind of talk 0.99

00:55:16.000 and because I'm unwilling to be in spaces where this shit will come up. Yeah. Right. And for me, 0.99

00:55:21.480 that means functionally like a vast majority of people I know who are not fat and some people I

00:55:27.360 know who are. Right. Right. So I just want people to understand like the stakes of this as a fat

00:55:31.820 person are I feel like I don't belong in the world. Right. When people talk about how great

00:55:37.320 it's going to be when I'm not around. It's that's not me being too sensitive. That's not fat people

00:55:42.420 taking it too hard. That's you saying plainly, right? Everything will be better when you're

00:55:46.900 gone. Right. And then fat people like taking that message. That's horrible. The fact that you have

00:55:53.320 been through so many rounds of this, it's like, why aren't you on Fen Fen? Why aren't you on

00:55:57.100 bariatric surgery? Why aren't you clean eating? Why aren't like all this is, is just new packaging

00:56:02.400 for like, why aren't you thin? And like, that is worth listening to. This isn't like a paranoid

00:56:08.000 fantasy on the part of fat people. This is something that they've been through numerous

00:56:12.380 times over the course of their lifetimes now. We're just doing the same thing again, even when

00:56:18.020 the data does not remotely indicate that we're not going to have fat people anymore. It never

00:56:22.700 has. We're always going to have fat people. And there's always going to be people, whatever the 0.97

00:56:26.760 medical intervention is, that can't use it, or it doesn't work for them, or they've tried it

00:56:31.560 already that's always gonna be the case yeah the the fact that people are so obsessed with asking

00:56:38.480 the question is this the end of obesity like really early yeah like oh is this gonna be the 0.62

00:56:42.900 reason we don't have fat people around anymore it's like it's so fucking telling so moving forward

00:56:47.480 we're gonna continue to get these drugs we're gonna continue to get this sort of quote-unquote 0.92

00:56:52.280 gold rush and in that time i think it is worth being extra skeptical and returning to

00:57:01.180 the voices of fat people and diabetic people when media isn't doing that for us right to like

00:57:08.480 actually return to the people who are most impacted by this debate and to spend way the

00:57:13.800 fuck less time speculating about elon musk and courtney kardashian and making celebrities defend

00:57:21.220 themselves yeah and like trying to think through how do we get these drugs to people who need them 0.99

00:57:27.240 how do we design a better discourse that isn't so wildly dehumanizing to fat people and again

00:57:34.320 to diabetic people right and like how do we just show up for people a little bit more around this

00:57:40.400 stuff and interrupt some of this like dancing in the street kind of energy that is like really

00:57:46.060 upsetting to see as a fat person okay we've done enough table setting uh let's start the episode

00:57:51.700 Are you ready? 0.59

00:57:53.620 It's been two hours and 45 minutes.

00:57:55.920 I think we're ready.

00:57:56.720 We can dive in.

00:58:21.700 You

Maintenance Phase - October 10, 2023

Ozempic

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