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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".
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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