I think it rubs plenty of laymen the wrong way to not make it a bit more explicitly known.

The world could use a bit less nuance in our headlines these days.

It's easy to say "just diet ez" and it's hard to "just diet".

If you can administer a treatment as a simple one and done thing, that's alright. If it's a pill you got to take every day, that's pretty bad. More than once a day? Horrible. Why? Because a lot of patients just don't have it in them to take a pill 3 times a day consistently.

If it's purely an "exercise willpower" thing or a "change your lifestyle" thing? You might as well give up.

The medical establishment wants to do things that work. Telling people "go diet" doesn't work. Semaglutide, evidently, does.

You say force a diet change on a patient. OP certainly meant forcing a diet change in the input of American factories. Sugar can be found in fruits. That's the right place. If you need some, use fruits, maybe alcohol. Everything else can be slashed. No sugar in prepared meals anymore. No sugar in pasta anymore. And most of all, no sugar in water. Sugar input makes more damage than cocaine today.

We can call it the Prohibition II. There will be underground bars with sick people binging on sugar. We can change the shape of sugar to prevent restaurants from adding it to food. We can make it bitter. Absolutely need sugar? Eat that lemon-tasting block. We can call it The War On Sugar.

The medical establishment that I have familiarity with (in the US) pretty much only ever treats symptoms, not causes.

Don't believe me? Next time you go to see your primary care physician, ask them what you should be doing to lower your risk of whatever malady tends to run in your family. (Diabetes, cancer, dementia, etc.) They're going to stare at you in blank confusion for a few seconds before making some vague suggestion about a better diet and more exercise. Guaranteed.

The reasons are many, and detailed enough to write MANY books about, but the low hanging fruit is: we don't have a culture of monitoring and improving our own individual health, physicians are trained almost exclusively to solve problems not prevent them, modern nutrition science is a joke, omnipresent health insurance distorts incentives for everyone, doctors are too overworked to get to know their patients, private equity has captured a large chunk of health care, drugs are positioned as the first line of treatment for almost everything, etc.

There was a fringe that said being overweight was not unhealthy, but the more salient points were the following:

1. BMI was basically just pulled out of a hat, and it turns out that for many health concerns, the overweight class does better than the normal weight class, with the actual “clearly worse” outcomes really coming up as you trend into obesity.

2. Environmental and genetic factors are huge contributors to people being overweight. To some degree moralizing about weight loss is a bit like telling kids with asthma they should live in places with less pollution. Or telling someone with breast cancer to not have the BRCA gene.

3. Doctors would regularly miss health problems because they’d blame them on people being overweight / not exercising enough. Especially for difficult to diagnose issues, it’s easy to just point at the number you have that “looks bad”.

4. We still have no firm reason why people are gaining weight. The popular answer is sugar and processed foods but those very much already existed at scale in the 50s.

The tragedy is that it turned into a morality play where fat people were blamed for it, despite in many ways being as genetic as getting breast cancer.

The reality is people who actually study obesity know that basically GLP-1s are the only health intervention other than bariatric surgery that consistently works. At a population level no intervention has reversed fattening anywhere in the world.

> Everyone knows that eating high sugar diets and being overweight is unhealthy.

There is a lack of evidence that the public understands what healthy and healthy effectively mean to their day to day lives,

aside from “looking better”.

> Fructose can cause fatty liver

It is also a large contributor to rising triglycerides levels and uric acid due to the way it is metabolized. Which in turn contributes to high blood pressure. It also makes Acetyl-CoA, which stimulates lipogenesis.

It is not even true that it is 'blood sugar invisible'. 30-50% of the fructose is converted in glucose and that's visible. The rest won't be available until you start burning fat.

> Yeah, a lot of people have bad diets, but infinitely more pressing is sedentary lifestyles.

No, that's only part of it. And a small part at that. The world didn't suddenly decide to get less active all of a sudden. You can blame some of the sedentary behaviors on societal changes (like suburbs and car dependency in the US), but other countries are getting just as unhealthy, metabolically speaking, and fat.

> The biological reality is that eating a big bowl of frosted flakes is perfectly fine if you follow it up with high amounts of activity.

It has to be really high. We are talking about hours to burn up that bowl of frosted flakes. Spend an hour at a treadmill, calculate the calories you spent. Now check the nearest cereal bar nutritional information. You'll be in for a surprise. You cannot outrun a bad diet.

Diet is most of what needs to be controlled for metabolic health. Resistance training will build muscles, and they are a good buffer since they will eat simple carbs even when you are inactive. Add cardio for cardiovascular health. But, unless you are an athlete or you are active the whole day, you should go easy on the frosted flakes.

They've been used for over 20 years but until they became a weight loss drug recently, almost all of the research was on diabetics which introduces two confounding factors: diabetes and the diets diabetics already have to follow to manage the disease. It's hard to draw any conclusions when the results are muddied by those two factors.

IIRC, mostly used to help with type 2 diabetes... But effects on that cohort may not generalize to the general population.

Could be just because you stopped eating bad food. Things improve dramatically once you limit your intake of industrialized food.

A lot of metabolic stuff is due to insulin and insulin sensitivity. This drives pretty much everything. Insulin sensitization is pretty terrible and it gets more important as you age. Unfortunately natural selection doesn't need to fix this as it doesn't cause issues until after reproduction and often until after your grandkids are born.

Semaglutide and glp1s resensitize it which is why they have these effects.

My opinion

Nah, we’re still too soft on people. It’s really not hard to eat a healthy diet.

They also clearly have some impacts on metabolism. It’s well known that a challenge with dieting isn’t just eating less, it’s metabolic changes that make weight loss harder. GLP-1’s avoid that.

It’s both. That’s why it’s so effective.

What downsides have you experienced?

What is junk food? For example — are cheeseburgers and French fries junk food? What about when you make them at home, or at a fancy restaurant without artificial ingredients? Is it certain additives? If McDonalds makes a happy meal without additives, is it no longer junk food?

What does treat them like cigarettes mean? Tax them? Ban them within 15 feet of a building entrance? Put warning labels? Is giving or selling French fries to children a crime? Does this apply to food made at home?

And have a real conversation around Corn syrup.

Even today, a Soda with 'real sugar', at least for me, is far more satiating for thirst or a 'quick sweet treat' than the same brand/'flavor' using corn syrup, that includes both the big chains as well as the local names.

If I drink a soda with sugar in it, I usually wind up wanting water after. If I drink something with corn syrup, I usually just want more of whatever I just had.

People have tried. Any time the government tries to do anything a substantial portion of the electorate throws a childish hissy fit and tries to make out that the Bolsheviks are coming to make their fries less tasty for no good reason.

Unfortunately in most countries the blocker is politics, not the desire of public health officials to do anything. See the current US admin going after vaccines while declaring open season for peptides.

this is exactly right. We've got this society that readily accepts unpleasantness as what you need to do to get ahead(I'll question that but it's beside the point). People regularly accept suffering of all sorts. However, ask someone to eat a boring meal. that's a hard no. So, you've got large parts of society that won't accept that perhaps they shouldn't eat like children.

> What is interesting about it?

did western society engineer a junkfood-industrial-complex so addicting and so en-sickening that it ultimately required a sort of junk food methadone to wean itself off?

I think you need to read up on why the civil rights act was necessary and the things it fought for. Woman's suffrage was fought for a long time ago, but that does not mean it was universally applied.

Many many times in US history we've said something is true, but put some big asterisks after them. Slavery is over (except it's definitely still permitted in the US), it's illegal to discriminate based on race (except we allowed redlining for generations and arguably are still fighting it), rape is illegal (unless it's your spouse, then it was legal until '93. And a lesser crime still in much of the country).

Voting is no different. Heck, one might argue we still don't have universal suffrage. People who want to vote but because we've put barriers like underfunding stations, long lines, not giving time off to vote, etc. we're clearly preventing some types of people.

No, black woman (among many other minorities) certainly didn't. I guess that part isn't taught in american schools as thoroughly as it should be.

... It can cut both ways, and depends a lot on the 'level' of poverty and specific circumstances, although the calculus has shifted over time.

If people are working crazy hours, sometimes it's a struggle to even get time to properly shop for groceries, let alone cook. There's varying degrees of that too;

i.e. I remember the 3-4$ frozen pizzas that could be used as a dinner and leftovers; And yes, at least back then, We could instead buy some chicken, rice, and a can or two of soup or stock to do something way healthier, at the same overall cost per meal...

But it would take an hour or so to properly prepare instead of just tossing that 3-4$ frozen pizza into the oven and letting it do it's thing.

Then throw into the mix where both partners due to work and/or school aren't even home till 8PM, and one of them has to wake up by 7AM to get to work the next morning [0]

I've lived that situation, although thankfully that wasn't every night and we could balance between the healthy self cooked option and the junkish-food-pizza.

But I've also lived the situation where both parties are working late, or the commute is so bad, you're glad you advanced enough you could afford the more expensive, but at least then managable 'taco bell' option.

But then there's the sort of 'generational passing on' where we now have multiple generations raised on carry out, fast food, or microwaved meals. Sometimes where they were never given the teaching or responsibility of cooking because (for reasons similar to above, including more affluent cases) the general concept of 'a home cooked meal' becomes the exception case rather than the norm [1]

[0] - You don't want to eat too late for other health reasons of course...

[1] - And yes, that group really does tend to be less healthy overall from my personal experiences, even if their dining tastes are 'expensive'.

> Pleasing your customers is how profit is maximized.

If you ignore everything like, including but not limited to, market capture, addictive products, lock-in, information asymmetry, planned obsolescence, dark patterns, captive markets, artificial scarcity, seldom-lucrative-yet-important services and any externality, very true!

Where are you getting a steak and potato for 2 for less than a bag of Doritos? Is it a 50 lb bag of Doritos?

You are missing the protein.

I'm using reta myself, but honestly it's because sema/tirz isn't allowed for me either. If you have medical tirz available, you should have some serious reasons to jump into the unregulated shark tank.

My protocol was to take semaglutide

As a consequence I ate less. Weirdly, I think I eat more sugar now but my total calorie intake is lower. I eat more sugar because sometimes it's the only thing that seems palatable or I'm trying to counteract the hypoglycemia feelings.

Yes the medicine does it. It's attacking T2D via several pathways, but in the case of Reta the glucagon is doing the heavy lifting of clearing liver fat.

This extra receptor is why Reta is a triple agonist unlike semaglutide (single glp1) or tirzepatide (glp1+gip double agonist).

Going back to my endurance days, I think people bonk because they aren't adapted. After a year or so of pushing through the bonk, and growing up with hypoglycemia if I didn't eat frequently, I got to where I could start out at 5am on an empty stomach and not eat until noon or later. If I did bonk, I'd sip V-8(yeah, really) and instantly recover.

Being a competitive athlete is probably why you have no idea what I'm talking about (and maybe you're not in your 50s). You have a reason to keep your momentum and you are likely more regularly active than I was. Sure I lifted weights, but it was only 2-3 days a week for maybe 6 hours total.

People who eat well below their maintenance calories tend to have lower energy levels. That's the most likely explanation.

True, but sugar can be converted to fat in the body. If you eat too much sugar before/during a ride, the extra sugar becomes fat.

You’re on too high a dose. The highest dose made me a vegetable, with no energy, and so on. That is not the way.

Lower the dose (with your doctor, of course). For me, the “middle” dose was the sweet spot of positive effects with minimal side effects.

You are likely a “hyper-responder” to GLP-1s.

Also, tirzepatide had far fewer side effects for me, fwiw.

YMMV, of course.

To "actshully" you (because there are no absolutes in biology) pro-triathlete Lionel Sanders got his hba1c up to prediabetic range (5.9)

https://www.tri247.com/triathlon-news/elite/lionel-sanders-t...

Also age plays a pretty significant role. I know older asians who regularly walk who still got T2D. You could argue that walking isn't physically active enough... but they'd argue otherwise. It's all relative.

Doubt you can eat just pure fructose for 30 years and ”move” and avoid diabetes.

> It shrinks visceral fat, it's been shown to clear liver fat

The brain is 60% fat, so I'm not running to the pharmacy yet.

It is well known that forcing a sudden drop in chronically high average blood glucose (like, from 200+ to a normal ish range) with insulin can cause vision loss. I wonder if it's the same mechanism?

It's also true that having a crowded optical disc is pretty much a required precursor condition to suffering NAION.

Which you can get checked for via a $50 optical scan.

No crowded disc, very little risk.

(Cup to Disc ratio of 0.2ish or less starts to present risk)