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Scott's most recent post had someone linking to an article in the Atlantic about debunking a study, I went and read it and got sucked into the Atlantic rabbit hole.
Link one: Don't avoid romance says more people are single nowadays and unhappier nowadays because more people have avoidant attachment styles in the past, with some (mostly circumstantial) evidence that the amount of avoidant attachment is increasing. Ends with an exhortation to not be avoidant but doesn't examine the question I would have thought would be of interest, which is why more and more people don't have healthy attachment styles. (Aftereffects of higher divorce rate? Internet usage? Weaker community institutions? Microplastics? I'm just spitballing ideas but wouldn't a marked societal-leve change in people's psychology be something you'd want to investigate the causes of?)
Link two: The Ozempic Flip Flop as someone who gets full very quickly and doesn't have a very strong appetite, I've never really had good mental image of what it's like for normal people with normal appetites let alone obese people with obese appetites. This article in particular presents people who lost weight, noticed immediate massive benefits in their life they're desperate to keep, and yet still can't keep the weight from coming back. It is just the satiety setpoint being set so high it's torture for them to not eat to the point of overeating? I'm trying to match it to my own points of reference for "willpower" struggles but failing. I force myself to go to the gym despite not enjoying exercise, but that's forcing myself to do something, not forcing myself not to do something, so generally speaking once I overcome the activation barrier of inertia the hard part is over. I intermittently (deliberately, as opposed to non-deliberately) fast and can be hungry and craving food but to a pretty easily overcome extent. But what makes someone — who for months now has been eating much less — be unable to maintain the amount they've been eating for months but instead be compelled to keep eating more even though it's actively physically hurting them (and costing them in other ways, like socially). How much stronger incentive can you get? It makes me feel like at some level for some people food is an addictive substance like drugs. (And also still trying to understand how this gets spread — is it really hyperpalatable foods? Something else? We can watch countries become more obese... Whatever the underlying thing that makes someone susceptible to this is, it does appear to be something a country can acquire)
Yes.
The mechanism via which the body "hungers" is somewhat complex, but can be usefully simplified down to the action of ghrelin, a hormone produced in the stomach which makes you hungrier, and leptin, which does the opposite.
Surprisingly, obese people have more adipose tissue, which produces leptin. However, it ceases to have the usual satiety inducing effect, as the body becomes resistant to its action. The way this is perceived is the body interpreting the lack of signal for being full as a sign of starvation.
And starvation sucks. Other than disease, it's probably what's killed the most humans in all of history, and you can imagine that it's a very unpleasant state that the individual feels compelled to rectify. The easiest solution being to eat more, till the pain goes away.
They're also being struck with a double-whammy. In lean people, eating causes suppression of the levels of ghrelin, in obese people, it doesn't. So they feel less full, with the same amount of food, as compared to those at a healthy weight. Hence they feel compelled to not just eat, but eat excessive amounts for the sake of relief.
I can only reiterate that starving sucks, and the body will drive you crazy in order to avoid that feeling. It's too dumb to know or care that you are, objectively, perfectly well fed. Waterboarding feels just as bad as actual drowning despite the ~nil risk of death.
While doctors usually feel compelled to tell their patients to watch their weight and diet, this almost never actually works. I consider myself a pragmatic one, and advice that isn't actioned in practise is about as useless as advice that doesn't work at all. I was on the Ozempic hype-train well before it was cool.
My mother is very obese, and has been for over half her life now. She's diabetic, and has developed fatty liver with hepatic fibrosis. Her own commitments to working out and dieting never held. She's a doctor herself, so she knows, on an intellectual level, what the risks are. She's been driven to tears by the scolding she gets from my grandpa or my dad who genuinely care for her and want her to lose weight, and after gentle suggestions failed, were driven to tough love.
None of it worked. She loved to eat, and reducing her caloric intake was pure agony. For a long time, I was resigned to the seeming inevitability that she'd head into cirrhosis, and I'd have to steel myself up for a liver donation. It's a nasty, nasty surgery, nothing like giving away a kidney. It leaves a grossly disfiguring scar, leaving aside the significant risk of death during and after the procedure. I'd do it for my mom, because I do love her.
Eventually, when Ozempic, or oral formulations of semaglutide, became available in the Indian market, I badgered her into seeing her endocrinologist and getting it prescribed. Despite the initial nausea and diarrhea, she eventually adapted, and lost the lost weight she's ever managed, and kept it that way. Right now, my priority is hounding her into going to that gent again and getting that dose upped, it's well overdue.
Exhortations to exercise failed. Asking her to watch her portion size and not snack failed. Driving her to tears failed.
The pill didn't.
When people get on their high horse and claim that using drugs to solve your problems is a crutch, it takes everything I have to not tell them to go fuck themselves with a rusty pole. It saved my mom, fuck you. Nothing you have to offer, including your empty words, comes close.
To hell with willpower. A world where we can power through our problems with pills is a better one as far as I'm concerned.
I'm a doctor for many reasons, but ranking highly among them is that I have an urge to find solutions to problems that actually work. Telling people to use their will to get over depression or diabetes doesn't, and the same is true for obesity. Claiming the moral high ground and virtue signaling? Doesn't beat adding years of healthy lifespan.
I am very happy that these drugs helped your mother. I do not disparage anything about these drugs or anyone who chooses to take them.
...however.
You, like many others, go too far. Changing your lifestyle does actually work; it's just that many people don't do it. There are a bunch of reasons why they don't do it, and that's okay. They may be perfectly fine using a drug. Nothing wrong with that. But don't tell people that changing their lifestyle doesn't work, because it does.
Let's take something like, I don't know, becoming a doctor. I've heard that this process sucks. I've heard that plenty of folks burn out or fail at some point. I'm sure someone's mother somewhere failed in trying to become a doctor, regardless of how much her family tried to make her do it. Nevertheless, I think there are still fine reasons to say, "Here are the objective things you need to accomplish to become a doctor, and here are a variety of subjective tips to help you pattern your life in a way that is conducive to achieving that goal, if you so choose." Some people won't do it, and that's okay (in fact, the vast majority of people right now don't become doctors). We don't have a pill yet that magically gives people all the required knowledge of a doctor. But even if we did, it wouldn't be a reason to say that the other (true, good) information "doesn't work".
Ah, the good old "all that's needed is just some willpower" argument.
If anything would drive me to be a biological determinist, it's this. Oh, you find it easy to cut down eating, take more exercise, make necessary changes and stick to them?
Do you want a medal for that? Because it's not on you, it's not you making up your mind and applying willpower that does it. It's the genetic luck of the draw of having the fortunate combination of heredity and environment that gave you the physiological and psychological phenotype that means you can eat less, exercise more, and stick to changes.
Both my parents smoked. My father was able to give up smoking and never go back. My mother tried and failed, many times, to give it up and eventually she died of the lung cancer it gave her.
That was not a question of willpower, because my mother was not less strong-willed than my father, or more resistant to change. I don't know why she couldn't stop. She didn't know why she couldn't stop. She wanted to stop, she tried, she failed over and over.
Tell me "all that's needed is just some willpower" about that, and I will spit in your smug face.
Ah, the good old strawman. Actually, very very bad old strawman.
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As much as I hate to intrude on another's discussion, I'm simply going to point at my own experience in terms of weight loss and shrug helplessly.
Like you, I was of a similar attitude. Like you, I felt the majority of weight-gain and weight-loss issues was a matter of people simply not wanting to put in the effort. I still do, to a point - too many people think a diet is like an on-off switch, when I've found it really boils down to actively changing how and what you eat - it's a lifestyle shift, not something you do for a month to fit into your summer bikini. And why not? I did exactly that. I lost 70 pounds from strict CICO and modifying my diet.
However.
I'm not going to go more indepth into my own history of weight loss and weight gain. Instead, I'm going to point to my brother, who has also done the entire weight-loss via keto. And while he was able to lose the weight, there was a plateau, a wall in terms of weight loss he was unable to get past before he simply gave up - the juice wasn't worth the squeeze in terms of the effort he was putting in.
Full disclaimer, he's never been an obese-looking butterball or as heavy as I am, though I'm sure if you put in his BMI stats he'd be labeled as obese.
On semaglutide, he blew through that wall in a few short months and is still loosing weight. He's currently at the weight he was in high school, and hasn't hit a plateau. If things continue as is, both he and I will be at weights we've never been before, ever, and have no idea what we will look like.
I'm no doctor, no medical expert or scientist. I am but a dabbling amateur, stumbling around and trying to piece together a picture of the world. And as time has gone by, I'm becoming more and more convinced that our modern diet has done extreme damage to our bodies, damage that some can adapt to and overcome, and others can't. That we are subject to the cruel tyranny of the flesh that our minds are unable to overcome, even when we fervently wish otherwise. We've learned our lesson, burned our fingers and become wise, but we still carry the scars that we can't fix by ourselves no matter how we wish otherwise.
So we use drugs. Problem solved.
...now, on the gripping hand, I also have experience similar to self_made_human where getting people to loose weight forces you to do the equivalent of making a recalcitrant dog take their medicine, no matter how much they hate it, cause, y'know, they'll die otherwise, but such is life.
I don't think you have accurately captured my attitude. In fact, I think you have gotten it completely wrong.
Perhaps so. Biological processes in general do not seem to be fully-reversible, especially when you include the effects of aging. Nevertheless, that is not an argument against the measurable physiological benefits of certain lifestyle changes.
So educate me, then. Because the phrase 'Changing your lifestyle does actually work; it's just that many people don't do it.' falls pretty well in line with what my attitude would have been a year or more ago.
It isn't meant to be. My point isn't 'lifestyle changes don't work' it's that 'lifestyle changes can sometimes only work to a point'.
You went wrong a single sentence later:
Possibly so. I'd need to see some high quality research on this question to know much either way, where those points might be, whether they can be predicted, etc.
...do you not equate the phrase 'it's just that many people don't do it.' to 'not wanting to put in the effort'? I would think them rather similar.
Compare what I wrote:
I don't know to what extent a clustering can be identified that can be simply labeled "not wanting to put in the effort".
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I'm not denying that lifestyle changes work! If they didn't, why would doctors feel obligated to recommend them?
What I'm saying is that advising lifestyle changes rarely works. I don't have firm figures at hand, but I suspect that the number of people I've recommended such eminently sensible things like losing weight, stopping smoking and going to gym grossly outweigh (pun not intended) the number who actually did anything about it.
If there was a magic pill that did nothing else but make people go to the gym, it would be one of the most revolutionary advances in medicine of all time! It would be Nobel Prize worthy. We now, thankfully, have a pill that, if not literally magical, meets the "sufficiently advanced technology" threshold when it comes to obesity. It certainly beats even the most sage advice in terms of practical utility.
This is much more circumspect than your original comment. The problem of advice-giving is significantly different in nature, and it has significant dependency on a wide variety of external, contingent factors that are not-necessarily related to the typical time-independent, mechanistic processes that the biological and medical sciences study. If you would please kindly continue to be this circumspect in future comments, that would be appreciated.
I'm not being circumspect. I am merely elaborating on a point I've made, which was interpreted in a sense I didn't intend (I'm not accusing you of an intentional, bad faith claim, misinterpretations happen). I don't see any additional hedging, or caveats at play.
I would like to think I'm usually quite clear in what I mean via what I say, not that this is any guarantee of people interpreting it exactly as intended. Even legal documents and contracts, intended to maximize clarity and leave no room for error, often end up in the courts. They also make for riveting reading.
Then by all means, please elaborate on how you intended the following sentence to be interpreted:
That telling people to make lifestyle changes is highly ineffective? That implies nothing about whether or not the changes themselves don't work. I consider it clear enough, in the context of the comment. In fact, the very next sentence is:
The only reason we even bother trying is that telling people to do things is rather cheap and low-effort. In rare cases, they might even listen. It also makes us feel good, and ticks boxes.
So, in this sentence, what is the "problem" that is in need of a solution? Is it, like, "the problem of trying to decide what to tell people"? Or what?
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The tricky part is actually achieving it. I do not have this specific problem (eating so much that I cannot move under own power) but I have some other problems with obvious solutions that I have failed to do so far.
For example winning war can be obviously done by destroying enemy warfighting capacity. It can be done, was done multiple times and it works. But telling this to Russia/Ukraine/Hamas/Israel and telling them that they are stupid failures because they have not achieved it so far despite trying to win a war is not going to be an useful advise.
Sorry, what? You're just off the mark. Aside from the inherent differences between adversarial processes and other dynamic processes.
Maybe "But don't tell people that utterly destroying enemy doesn't work, because it does." would be better?
trying to not overeat vs extreme marketing of hyperpalatable foods is an adversarial process
I don't know how this analogy is supposed to work. The point of the development of military doctrine is to build up a body of professional knowledge, generally to the purpose of, indeed, destroying the enemy (though there are sometimes tweaks for political constraints or other political objectives). This is, indeed, intended to be "what works".
Is the point of your analogy that the endeavor of developing military doctrine is simply fallacious from the get-go? This has other implications that I can think of. For example, rather than moving TRADOC, as Trump did, I think this point of view says that he should have simply eliminated it altogether. Of course, I think you can tell that I don't think that this is the point of the analogy, but I'm kind of struggling to see what the point is.
Maybe, on the other end, it's something along the lines of, "It's not terribly helpful to be a 400lb guy in a bed who just writes somewhere on the internet, 'Hurr durr, have you tried killing the bad guys?'"? I mean, sure? Yeah, I just don't get what you're going for, and I don't get how it's relevant to what I've said.
Mathematically speaking, I would distinguish the two. This may be a complicated and difficult environment, but it is not an adversarial one. There are deep mathematical differences between the two.
no, it is that obvious solution like "just eat less" or "just militarily destroy enemy" are both true, and often not sufficient in practice as achieving them may be hard/nearly impossible
Oh, well then this is just the standard, all-too-common, strawman. You're responding to a figment of your imagination, not anything I've written.
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