Factually! with Adam Conover - What Does Ozepmic Actually DO? with Dr. Dhruv Khullar

Episode Date: April 3, 2024

There's been a surge in discourse around medications such as Ozempic, prompting understandable skepticism—Is this another weight loss fad, or the beginning of something new? While it is primarily used to treat diabetes and promote weight loss, there's mounting evidence that shows drugs like Ozempic can reduce the risk of heart attacks and strokes, and potentially be instrumental in treating addiction. In this episode, Adam speaks with Dr. Dhruv Khullar, a physician and assistant professor of health policy and economics at Weill Cornell Medical College, exploring the efficacy, risks, and impact these drugs have on our relationship with weight and food.SUPPORT THE SHOW ON PATREON: https://www.patreon.com/adamconoverSEE ADAM ON TOUR: https://www.adamconover.net/tourdates/SUBSCRIBE to and RATE Factually! on:» Apple Podcasts: https://podcasts.apple.com/us/podcast/factually-with-adam-conover/id1463460577» Spotify: https://open.spotify.com/show/0fK8WJw4ffMc2NWydBlDyJAbout Headgum: Headgum is an LA & NY-based podcast network creating premium podcasts with the funniest, most engaging voices in comedy to achieve one goal: Making our audience and ourselves laugh. Listen to our shows at https://www.headgum.com.» SUBSCRIBE to Headgum: https://www.youtube.com/c/HeadGum?sub_confirmation=1» FOLLOW us on Twitter: http://twitter.com/headgum» FOLLOW us on Instagram: https://instagram.com/headgum/» FOLLOW us on TikTok: https://www.tiktok.com/@headgum» Advertise on Factually! via Gumball.fmSee Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

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Hello, and welcome to Factually. I'm Adam Conover. Thank you so much for joining me on the show again. You've probably heard of these drugs that seem to magically help you lose weight. They go by the name brands Wegovi or Ozempic, and they were originally made to help deal with diabetes. But now, celebrities are shelling out thousands for them, losing weight for the red carpet, and then getting made fun of online for having ozempic face. You know, given how every quick fix for weight loss in history has been a total failure,

these drugs often seem to us like just another concerning development in America's long and supremely fucked up relationship with weight and food. I've been skeptical and you have good reason to be as well. But on the other hand, these drugs actually seem to help people lose 15 to 20% of their body weight.

That is better than any drug ever made. And more importantly, they seriously reduce the risk of heart attack and stroke. And even more crazily, these drugs seem to have all sorts of positive impacts on addictive behavior. And that could be nothing short of miraculous. I mean, think about it.

A drug that reduces weight and stops addiction to notoriously difficult and intractable health challenges that affect millions upon millions of people. I mean, we're still in very early days, so we need to tread very carefully. But if this is even partially true, it could be massively transformative for millions, hundreds of millions of people around the world. So a lot of people are asking,

and in fact need to be asking, what the hell is going on with these drugs? How do they work? How well do they work? What are their dangers, their limitations, and their side effects? And how could they transform our society for better and or for worse?

Well, to answer all of your most burning questions about these drugs, we have an incredible guest on the show today. He's a doctor, he's also a writer for The New Yorker, and he has written extensively about these drugs and the most cutting edge research on them. But before we get to this conversation, I just wanna remind you that if you wanna support this show

and all the conversations we bring you week in and week out, please support us on Patreon. Head to patreon.com slash Adam Conover. Five bucks a month gets you every episode of the show, ad free, we also have a community discord, lots of awesome community bonuses. Please come join us at patreon.com slash Adam Conover. And if you love standup comedy,

I hope you'll come see me out on the road from April 18th through 20th. I will be in Indianapolis, Indiana. From April 26th through 28th, I will be in La Jolla, California. And on May 1st, I'll be in San Jose, California. I got a lot of other dates as well. Head to adamconover.net for tickets and tour dates.

And now let's get to today's guest. Dr. Dhruv Kular is a physician and an assistant professor of health policy and economics at Weill Cornell Medical College. And his article for the New Yorker is called The Year of Ozempic. He is absolutely one of the most up-to-date people on these drugs and their effects.

So please welcome Dr. Dhruv Kular. Dhruv, thank you so much for being on the show. Nice for having me. I'm so excited to talk to you about Ozempic and the GLP suite of drugs because it's such a hot topic. And I think that the cultural conversation about them is kind of often missing the medical reality. So let's start with, you know, you're a physician.

What are these drugs actually do physiologically? And then what effect do they have on people in their lives? Sure. You start with, you know, you're a physician. What are these drugs actually do physiologically? And then what effect do they have on people in their lives? Sure. So what a lot of people don't realize, particularly if you're just coming at these drugs through TikTok or Instagram over the past couple of years, is that some version of these drugs

have been around for a long time. And so, you know, the first drug that used GLP-1 was really released in 2005. Now that drug was not something that caused 15 or 20% weight loss. It wasn't something that you could only take once a week. In fact, you had to take it twice a day. It was called Bieta.

But that's all to say that these drugs have been around for a long time and initially they were used for diabetes, specifically type two diabetes. And so the idea would be that they reduce your blood sugar, but they also over time have been found to have a lot of other effects. You know, some of those effects involve changing how quickly food moves through the gut, reducing your sense of appetite, making you feel full more quickly. And increasingly finding there's not just things related to eating and food and diabetes, but some people actually experience changes in their desire for alcohol, for drugs,

for other types of addictive behaviors. So we're really learning a lot about how these drugs work and we're going to learn more in the coming years. Vic. Yeah. A friend of mine was just telling me two days ago that his partner is on one of these drugs and she expressed that she feels less of a desire to use TikTok or other things that she experiences as being, you know, psychologically addictive, maybe small a addictive

and that she's only been on it a week, but she felt that, felt that effect. That is a remarkably like broad set of effects, you know, Like I normally think of a drug as, oh, it works on your brain or it works on your body. I think of those things as separate, which I know is false, but like, I'm like, wow, that is a complicated set of effects. How is it doing these things? So that's an incredibly important observation.

The first thing to say is that there's a tremendous amount of anecdote out there around exactly what you're saying. So people not only have a reduced desire to eat food, but they have all sorts of other potential impacts on their behavior. I think some of the studies on that are still not in. So whether it reduces cravings for smoking or drugs or alcohol or gambling, all these things people have reported unclear is if those are going to bear out in actual studies over time. But certainly

people are reporting these things. One of the reasons is that GLP-1 we think of is primarily located in the gut, the receptors for these molecules. But that's not true. We have GLP-1 receptors in our liver, in our muscles, and importantly, as you pointed out, in our brain. And because of that, the behavioral changes that these drugs manifest go beyond just suppressing our appetite, changing what we wanna eat, or reducing glucose levels in our blood.

There's all these other potential impacts that are wrapped up in our psychology and our behavior. And again, we are still learning exactly how it's producing the behavioral changes that we're seeing. But suffice it to say, it goes a lot further than just the initial indications of diabetes and weight loss. Is the effect primarily behavioral? Are, you know, people are losing weight or it's improving their blood sugar or whatever. Is that primarily because their behavior is changing or is it also doing something physiological that is,

you know, has nothing to do with your conscious choices or things that you do in the world? Yeah, I mean, it's a little hard to disentangle those things completely. Of course. Certainly a lot of the effects are physiological and so there are changes that are occurring in people's bodies and because of those changes and because certain receptors are being activated in the way that they are, that produces behavioral changes

that manifest in the world that. And so, um, it is both the case that we have a clear evidence of physiological changes within the body, but also that those changes inspire a lot of changes in the way that we behave in the real world. I'm just like, I know it's like hard for me to understand this not having gone to med school, but I'm just trying to like get a mental model of like what the fuck is happening in the bot, like what kind of chemical is this and what is it doing?

Is there any sort of 101, I'm a dummy, it's my first year in bio class and human physiology way of explaining like just the literal biology of what's going on. Yeah. I mean, so some of it involves the challenging thing is that these drugs seem to do so many different things. Yeah.

There's not just one drug now. So there is what we think of as GLP one agonist, which is primarily the way people think about it. But there's also now drugs that work on not just one receptor, which is GLP one, but two receptors, GLP-1 and GIP, which is also producing the gut. And there's clinical trials of a third receptor now. So a triple agonist. And the reason that that's important is that it seems at least up until now, every time you hit an additional receptor, you lose more weight. And so was Zempic gives you maybe 15% on average. Monjaro, which hits two receptors, gives you maybe 20%. And then these new trials that are triple receptors, they give you 25% reduction in weight. And so, that's basically on par with bariatric

surgery. So, it's really intense levels of weight loss. It does a number of things. So, it will move sugar from your bloodstream into your muscles and other tissues. And so that's why it's really important for diabetes. It slows how quickly food moves through gut. And so that creates a sense of fullness in your gut. And most importantly, it seems to suppress the appetite. So there's a lot of receptors in the brain that are involved with appetite regulation, the set point at which people feel full, a set point at which people feel like they don't need to eat anymore. And those are all modulated by these GLP-1 agonists and subsequent drugs that are coming

to market now. And so the physiology is all the way from what's happening in your gut, what's happening in your muscles, what's happening in your pancreas, but also what's happening in the brain. You've used the word agonist a couple of times. Can you just tell me what that is? Agonist basically means that you're activating a particular receptor. And so if you're an antagonist, you're blocking it. If you're an agonist, you're activating that receptor.

Okay. So your body produces a certain amount of this already and you're sort of hyper activating a receptor that plays multiple roles in the body, whether in the brain or in the gut or in other places. And we're seeing multiple effects from that. Is that generally right? Totally. And these are important to note,

like supra therapeutic or supra physiologic doses. And so your body produces some of this hormone by itself, but you're really giving it a massive surge in the same way that, you know, certain drugs like cocaine might give you a massive serve of serotonin or dopamine in the same way. You know, this is doing the same thing where it's kind of flooding your body with a particular type of hormone in a way that in nature, you don't necessarily get. Got it. Okay. And you write in your piece about this in the New Yorker that came out a few months ago,

you really frame this as we, there's a lot about it we don't know, but it could be a historic medical breakthrough on some level. Why do you think that? Or did I frame it correctly? I think it will be. And I think I wrote something pretty stark,

which was this could be one of the greatest kind of medications in the annals of chronic disease. And, you know, it's possible that, you know, I'm overstating that and we'll find out that they're not what I kind of suggest they are. But the reason that I say this is that these drugs we're learning are not just good for diabetes and they're not just good for weight loss. Sometimes you know in this kind of cultural conversation people have fixated on maybe the cosmetic aspects of this or the way that people are using them to get in shape for a wedding or go to spring break or something. But what we're seeing is real tangible medical benefits, by which I mean reductions in stroke, reductions in heart attack risk,

slowing of chronic kidney disease, reversal of fat deposition in the liver that is associated with cirrhosis. A lot of people don't realize that we think of cirrhosis kind of classically as due to alcohol use. People are using alcohol over the course of decades and their liver gets shot. No, in a lot of cases now, one of the course of decades and their liver gets shot. Uh, no, in a lot of cases now, one of the greatest reasons that people need a liver transplants is because there's a excess fat deposition that causes inflammation in the liver and ultimately cirrhosis. And so all these things, you know, I'm not saying that, um, we're going to flip the switch and none of these problems are going to be problems in the future. But what I'm saying is that it's not just a cosmetic thing and it's not just for diabetes.

There are all these other metabolically oriented disease states that these drugs seem to be helping. There's also the addiction piece of it. I mean, I know that that's the newest piece of it. You say people are reporting it. I'm sure for some people, maybe they're even reporting it as a placebo effect because they heard it could help, you know,

or it's very new it's very new. So we don't want to overstate it. But if we do overstate it and say, well, not a second, do, is it a cure for addiction to some degree, um, or at least a treatment, uh, a treatment for addiction? I mean, addiction is, if we, if we look at it as a medical issue, which it is, it's one of the most devastating medical issues worldwide. And it's one that we have not been able to address via banning the substances.

We tried prohibition a hundred years ago. It didn't work and no one wants to try it again. And yet countless people die of alcoholism or have their lives ruined by alcohol. And so the idea of an actual medical treatment for this for the first time would be obviously a breakthrough if that is what it is. I mean, does it, what is the prospect of that? You know, so this is an area I think we need to tread

a little bit lightly for a couple of reasons. I mean, the first thing to note is that we don't have solid evidence that it's going to diminish people's cravings for certain types of substances yet. I mean, we have a lot of anecdotal reports, which are very encouraging, but we didn't wait till the studies come in. The second point I think is important to make is that we do have some treatments for certain types of addiction. And so, for instance, methadone for people with opioid use disorder or suboxone, there are certain medications that we use for alcohol use disorder. So there are some medications, maybe not as powerful or effective as we might like, but we

do have some. The third thing that I think is most important here is that in the case that these are anti addictive medications. So you get to the point where we feel confident that people who are on these GLP ones actually do have a reduction in alcohol cravings or gambling or whatever it might be. You have to keep taking the drug for it to work. And what we're seeing is that for whatever reason in the real world, a lot of people stop taking these medications over the course of a year or two Oh, you don't know why that is so in clinical trials people do have some side effects

But maybe 5% of people 7% 8% don't end up completing clinical trial because they have nausea vomiting diarrhea a host of side effects the real world evidence is telling a different story, which is that in some cases, a third half two thirds of people who start on these medications are not on them a year later. Again, this is early, this is early evidence, but it's a reason for some caution. When we talk about these medications are going to upend society in a way that's really positive. We have to take that into consideration. We have to keep a close eye on. Why is it that people are coming off these medications in large numbers?

So you're saying that I was, I want to get into side effects. So there are side effects like nausea and, you know, it sounds like gastrointestinal stuff, just uncomfortable things. But maybe people are taking the drug and then after 10 months or so, they're like, oh, I don't feel good. Like I just don't want to go back to the doctor and get more of this. Like I'm not feeling great right now. There's just like a general drop off and we don't really know why yet, but it seems like people are just sort of not continuing to take it. So there are certainly some people who have very severe side effects upfront. That could be constipation, diarrhea, nausea, as you say, mostly gastrointestinal side effects. So that could be part of it.

Part of it is that, you know, some people report that they like eating food and they like certain types of dessert and they want to enjoy these things. It's part of being a human and enjoying life. And for some people it diminishes that part of pleasure that you get from going out to a nice meal and enjoying your birthday cake, whatever these things.

So I can see why. I get it, food is my, I quit smoking, I quit drinking. Food is my last vice. Like that's the thing that I love and I do my best not to overdo it. But sometimes you do want to overdo it, but sometimes you do want to overdo it and eat a whole bunch of barbecue or ice cream or whatever it is. Exactly.

And these are not things that you, you know, you can take one week and then stop it the next week and kind of go back and forth and they're going to work. Like you really have to stay on them if you want the benefits of them. And then the second point I think is important to point out is that these are really expensive medications. And so for some people, they might not be able to afford them over time. Look, some people have good insurance coverage and the insurance might cover a lot of it, but a lot of people will still have copays and deductibles. You know, people on Medicare don't get this covered for weight loss indication. A lot of people on

Medicaid won't have this covered. And so the cost can also build over time and we should talk about the cost here. And so I think some combination, maybe of side effects, excess cost, lifestyle factors, all these things have kind of conspired to make it that the adherence rates aren't as high as I would have expected, but it's still early days. And so these things could change.

The last thing that I point out is that these are still injections, and so people have to, you know, inject themselves once a week. Not the most fun thing to be doing. Well, let's talk about the cost, because I want to get into the issues that you often hear people raise about this,

you know, just water cooler conversation. Oh my God, it was MPEC, and everyone has lots of concerns about this drug. One of them is the cost. I mean, these are fantastically expensive drugs. Why is it that, how expensive are they? And why is it that they cost so much? Well, they cost a lot because the pharmaceutical companies

can charge a lot. And so they do, you know? So let me just put this in perspective. Most of the medications, let's just take Zempic, for instance, Zempic costs around a thousand, the list price is around a thousand dollars a month in the United States. In Canada it's about 150 bucks a month and in the United Kingdom it's less than a hundred bucks.

And so we have a system that allows pharmaceutical companies to charge much higher prices in the United States than they do in other countries. Not everyone's going to end up paying a thousand dollars. A lot of insurers will have relationships with pharmaceutical companies that allow them to get rebates and bargain the price down. That being said, they're so very expensive medications that are much more expensive in the United States than they are in other countries. And so that will continue to be a hurdle for a lot of people, a lot of insurers, a lot of government programs. be a hurdle for a lot of people, a lot of insurers, a lot of government programs. I think that as more competitors come to market, you know, right now there's probably like

four main medications, two main companies, Eli Lilly and Nova Nordisk that are really, you know, have the lion's share of the market here. I think over time there will be more competitors and the price will come down. But still, if you multiply, you know, pretty high price times the millions and millions of people that could potentially be on these drugs, it's a colossal budget problem for any country or any insurer. Yeah, I mean, you wrote in your piece that Novo Nordisk,

which is a pharmaceutical company, has been around for a long time. They were the first to market insulin, I have that right? But, you know, not a massive, massive, massive player and is now an enormous part of the economy of Denmark. They're responsible for all of this economic growth and based on this one drug alone, not to mention its future prospects. That's right. So, you know, by some reports last year, Novo Nordis, this one company was responsible for basically all of Denmark's economic growth. And so, you know, in the country, some economists are thinking about breaking out the pharmaceutical sector from

the rest of the economy, just so they can get a sense of what's actually going on in the rest of the economy, because this is such a dominant country, company. And it's, you know, it's one of the most valuable companies in Europe.'s, you know, it's one of the most valuable companies in Europe. So, you know, it's a kind of like a half a trillion dollar market cap. And it's mostly on the back of these medications. You know, this is going to evolve over time. I still think that they're in a very dominant position given that they were first to market and they have a long history. They're basically been a diabetes company for a hundred years now. And so they're an incredible company in some ways. But you're right. I mean, they're profiting

in a really big way in part because the medication is incredibly effective for the indications that's listed. Well, let's talk about, I think everyone's biggest concern about this, not everyone, but the people I talked to, is the use of this cosmetically. As soon as that started happening, people certainly are taking it for purely cosmetic purposes. And that really took over the entire dialogue about this drug because it started interacting with our, here in the US, our societal ideas around weight, body image, both positive and negative.

People started going, oh, which celebrities are on Ozempic? I live here in LA and people will go, oh, she's starting to are on Ozempic? You know, I live here in LA and people will go, oh, you know, she's starting to take an Ozempic. You know, like it's a topic of like rumor and conversation as though there's, you know, there's something a little bit salacious or dirty about doing it, et cetera.

And, you know, I think a lot of that is sort of built in cynicism about any sort of weight loss treatment, you know, just people being mean. But how much of a concern is that? Is that a bad thing medically or pharmaceutical for people to use it for purely cosmetic purposes? So, you know, the short answer is we don't know. And these medications have not been tested

for people of normal weight or who are underweight and or using it for short-term purposes as opposed to long-term Health reasons and so we actually don't know the implications for what's gonna happen as people use these drugs Cosmetically there are some things that people should be aware of I mean there are the side effects We talked about there's also the case that people particularly if they're a little bit older effects we talked about. There's also the case that people, particularly if they're a little bit older, uh, who take these medications lose a lot of muscle too. And, uh, that can be really dangerous if you're losing not just that, but muscle mass and it can cause falls. It can cause, um, you know, uh, various forms of frailty. There's some, uh, evidence that

these medications seem to increase your heart rate, your resting heart rate. Uh, it's not clear exactly why that's the case, but most things, um, that, uh, raise your heart rate, your resting heart rate. It's not clear exactly why that's the case, but most things that raise your heart rate, like fevers and infections and, you know, increased sympathetic tone where you're when you're nervous or you have a fight or fight response is not generally good things. And so, so I don't think these are medications that people should be kind of playing around with or taking in a more recreational way. I think the broader point that you're making is that there still is a tremendous amount of stigma around obesity. It's one of the most stigmatized conditions. People still kind of view it as a choice as opposed to a biological process. And so this medication

is understandably wrapped up in these kind of cultural conversations that we have. You know, as a doctor, I view them first as effective medications for particular conditions that I'm enthusiastic about. But you're right, that we have to be concerned about the ways in which they interact with kind of the cultural ways that we talk about weight and obesity in this country. Yeah, I mean, there's two sides of it.

There's the side of people using it who don't really need to lose the weight. And then there's the side of people who feel, hey, there is a stigma placed on obesity, on being overweight. And so therefore the idea that there would be a medical cure for that, and you know, that they would be somehow compelled to take a drug or thought of as being, you know,

in poor health, that they're not taking such a drug, would itself be an expression of our idea towards weight, which is really a damned if you do damned if you don't. Right? Like, is it bad to want to be skinny and take a drug which is really a damned if you do damned if you don't, right? Like is it bad to want to be skinny and take a drug or is it bad to be happy with who you are and not take a drug? It gets extremely complicated.

And then I add to that, well, are you overweight actually or are you only overweight in your mind? Which is a problem that a lot of people have where they have various forms of dysmorphia about their weight. And then there's the question of, is it under your control? Could you have just exercised? Well, maybe for some people, maybe not for other people. And then there's the fact that as you,

I'm sorry to list all this at once, but as you very aptly put in your piece, obesity is a disease of modernity. That like, it's something that has been done to us by the society that we live in and the food system that we are all forced to eat within. We're not in control of the food that makes its way to our plates fundamentally.

We're at the end of that system. We don't have direct control over it. And so yeah, there's a lot of complicated concerns. We could talk for three hours about this in every direction. Where do you, when you are at a dinner party and the Ozempic conversation starts, how do you try to encourage people to think about it just to tease apart this conversation?

Yeah, I think one thing that you mentioned was this is a disease of modernity. And I think that's so true. And I think it's something that gets lost. It wasn't as if everyone just lost their willpower in the 1970s and all of a sudden we put on, you know, all this weight. Like there were structural things that happened in our society that made it such that in 1920 or 1940 or 1950, we did not have 70% of this country that was considered overweight and 40% of the country obese these are things that have happened over time most notably the food supply has changed we have a lot of ultra processed food we subsidize fats sugars.

Are there scientists that figure out the exact right proportions of those things to make food hyper palatable and kind of irresistible in some ways. to make food hyper palatable and kind of irresistible in some ways. You know, our jobs are different. You know, you and I are talking, you know, sitting at our desks as opposed to doing things out in the world. We have very sedentary kind of jobs. You know, our a lot of our neighborhoods are not walkable neighborhoods anymore. They're places. There's not a lot of green space. We're often our cars. There's all these things's not a lot of green space. We're off in our cars. There's all these things that have happened over the past five or six decades that have made it difficult for people,

if not impossible, to lose weight. And we've tried everything. One of the things that I think is so important to point out is that it's not like people haven't been working on this problem for decades. You know, there are weight loss programs, there's movements to cap the size of sodas in New York City, and there's movements to get vending machines out of schools and people have tried to change the subsidies for food. And really nothing has really worked. You

know, if you look at the the the year on year increase in rates of obesity in this country, it's pretty much a straight line upward. Finally, we have something that may start to bend the curve, I think, you know, and so, you know, I want to, I think that suggests, or should make clear that this is a biological process. Of course, there's interactions with your genetics. Of course course there's interactions with your genetics. Of course there's interactions with, uh, your behavior and environment. But, um, but is your biology that creates a new set point after, uh, people have been inundated with these types of foods and makes it very difficult, uh, not just to lose weight, but to keep that weight off over time.

And we may have a start of a solution to that problem. Uh, it's so fascinating. I want to talk about obesity as a health issue first, cause I think you have a pretty balanced opinion of it in the writing of yours that I've read because. You know, there is a stigma against being overweight, that being overweight equals being unhealthy. Um, and that is not the case. And yet for some people, obesity can still be a health issue.

Can you just tell me about that a little bit, how you think of it as a physician? Yeah, so I think there's a couple points to point out. The first is that we use BMI, which is body mass index, which is a very crude measure of someone's metabolic health. So it's not the case that just because you have a BMI, anyone over 25, BMI of 25 is considered overweight, over 30 it's considered obese and so on up the scale.

And it's not just the case, just because your BMI is a certain number, you're going to have negative health effects. And so I think there are people who are considered overweight or obese who have normal blood glucose levels and have normal blood pressure and, you know, don't have heart disease. And so it's not a one-to-one correlation. That being said, you know, obesity, the reason that it has been medicalized over time is

because it is associated with a lot of negative consequences for our health. Higher rates of stroke, higher rates of heart attacks, higher rates of stroke, higher rates of heart attacks, higher rates of arthritis, higher rates of infertility, higher rates of cancer. So, so it's not just that people are unfairly stigmatizing this as a health condition, it is a health condition. It is something that's linked to a lot of negative outcomes. We need to treat it, I think, as a health condition, a medical problem, as opposed to attaching certain views of, you know, is it someone's fault? Should we blame them? You know, what's the ideal body shape? What's how should people look? No, those are not the conversations that I think are most helpful or important. It's, this is a biological problem and it impacts people's

ability to live a long and healthy life. And that's ultimately what we're here to do. Well, and it can be hard in a medical context to even, you know, a doctor who's doing their best job to detach cultural stereotypes and, and presuppositions from actually treating someone. If you, if you know, you've really someone if you have really internalized that idea that there's a moral dimension to weight, which a lot of people have,

that if you are overweight, you have done something wrong, that can change how a doctor treats, I have friends who have been treated that way by doctors themselves, but we should still be doing our best to separate those things. And there are conditions, as you point out,

that are not just linked to obesity, but are caused by obesity, sleep apnea, and things like that, that can actually lead to even worse health outcomes. So, but then, like, okay, let's talk about the disease and modernity piece of it. Because on the one hand, I think, oh my God, what a horrible thing.

If we've invented a drug to cure this disease that modernity itself has caused, then the cause is also offering us the solution. The same capitalist, techno-scientific, you know, machine that caused all these problems to begin with, that, you know, the Green Revolution and the mass produced food and all that is now mass producing a drug

that's gonna cure the same problem it solved. What a horrible thing. We should just reform those systems in the first place. And I think that and I believe it. And on the other hand, I think, so you're telling me that we need to reform our entire society before we can help people treat a difficult condition. you know, that in,

and again, we've been trying to do so for decades. People have been saying these things for a long time and it hasn't been working. And my God, what if we just had a pill that actually, you know, could result in a better life for millions of people? Shouldn't we use it? I feel both of those things simultaneously. I'm curious how you feel about it. Yeah, I think it's a really important discussion to have. And, you know, I'm someone who has been long skeptical of magic pills and technological solutions that are going to solve everything. And it seems too easy. It does. And it's and in a way, it feels like we're putting a bandaid on a larger problem, which is that we have

a certain structure, a certain set of incentives in society that have created this problem. On the other hand, as you point out, I mean, it's the case that we're not gonna, you know, overhaul society in a night. And we've tried a lot of different remedies. And this is something that actually seems to work and is giving people hope and giving patients hope giving clinicians hope and to change

direction of this epidemic basically that has developed over the course of decades and so you know I I sometimes go you know have conversations with people who say kind of hinted at some of the things that you were talking about earlier, which is, you know, are people taking the easy way out? Uh, you know, should they, uh, should they have to work for, uh, you know, uh, weight loss and so on. And I kind of reject that, um, uh, view, which is, um, you know, a lot of these things are not strictly in people's control. Um um these are very difficult things to do uh if there is a medical intervention um for this problem we should use it when it's appropriate we do that for all other uh conditions if you have uh you know a heart attack if you have diabetes if

you have uh uh you know you need a hip replacement we don't you know make people uh work for it or uh it think of them as culpable for further conditions. So I think we should have the same kind of approach to this problem. Well, and the idea that you can, you know, if someone has, you know, is really struggling with obesity, that you can work that off is to me, just ludicrous. I mean, I, you know, because I put a lot of time and effort into it. I eat well, I exercise a shitload. It's a change that I've made in my life over the last 10 years.

In doing so, yes, I look better, I feel better. I've lost maybe five pounds, maybe 10 pounds on a good week, you know, total compared to what I weighed, you know, 10 years ago or so. All the benefits are otherwise health benefits, you know, of exercise and eating while quitting, drinking, stuff like that. The idea that someone who benefits, you know, of exercise and eating while quitting drinking, stuff like that.

The idea that someone who weighs, you know, a hundred pounds more than I would, would get to a, you know, standard weight simply by exercising and sweating is just ludicrous. And the people who do, who go on, I've covered this on my show, Adam Ruins Everything, who went on, you know, the Biggest Loser and did that sort of crash dieting,

it's been proven they all gain it back very quickly because they're like fucking with their metabolisms on such a deep level that, but yet we believe somehow that, as you say, that there's a moral dimension that, oh, it's the easy way. For this one problem, you must work it off. Yeah, and you know, there's this phenomenon

called yo-yo dieting, which is exactly what you're getting at, which is people diet, they're able to lose weight, but then they end up gaining it all back. And that happens with these drugs too. If you stop taking the drugs, they're not going to stay in your system. You're not going to have these enormous levels of GLP-1 floating around and you're going to put the weight back on. And so I think it's the same kind of thing. And the other thing that I'm sure your experience bears out is

that you also just feel better on a day to day basis. I mean, it's hard to carry extra weight either psychologically. You don't feel as good as you might or physically, you know, you're eating better foods, exercise is certainly, you know, the best thing that you can basically do that for your body, for your mental health, for your physical health. And so it's not just kind of trying to, in the longterm, feel better, look better, be healthier, but it has real tangible effects in your day-to-day life today,

which I think is really important. Let's talk about the thing that I think I hear people say that most often about this drug, which is, and you've said it yourself, you have to keep taking it forever. Um, as being, oh, what? I mean, it's horrible. You have to keep taking the drug forever. Like, what are you going to do? And that kind of makes me go, well, there's a lot of drugs people take forever.

Like I'm not on any, on any forever drugs right now. I expect by the time I'm 60, I'm going to have one of those little, you know, pill canisters going to be taking one of those things every day until I die. People take insulin every day. That's Novonordisk's other drug. And look, if this is going to cure addiction, you said people have to take it every day. Well, you know what? They were taking whatever they were addicted to every day before. So you can take one thing every day or another. How much of that is a concern,

whether you're talking about this treating diabetes or treating obesity or any other addiction, is that a real problem that you need to take it for the rest of your life? Or is that, I don't know, not that big an issue. Yeah, I mean, you're exactly right. I mean, there's a lot of medications, aspirin or a statin or insulin,

that people take every day for their whole life once they develop a chronic disease. It's a little bit tricky in this situation, in part because of the very high costs of the medication. And so maybe that'll come down over time, in part because of the regular injections that people might not want to subject themselves to.

Although again, maybe we'll have great pill formulations. The other thing that you mentioned is that, you know, maybe by the time you're 60 or 70, you are on a medication every day. But a lot of these medications are now being targeted or at least explored in very young people, you know, adolescents, teenagers. So it's one thing to say to tell, you know, a 65 year old, you're gonna have to take a statin until you die. It's another thing to take a 13 year old side who is struggling with their weight and is obese and look, childhood and adolescent obesity is predictive of adult

obesity. And so we do need to pay attention to that issue. But you're kind of telling this 15 year old kid that they need to be on those epic for the next 70 years, potentially. Right. And so that is just a, not a reason necessarily not to use the medications, but something that we need to be aware of as we're kind of committing people to a certain path. Look, I think it's possible that we will either buy additional changes to the medications or certain types of biological, you know, remedies or associated exercise programs or something, be able to get people off these medications so they don't have to take them for their whole life. But, but as of now, um, you know, if you want the benefits of these

medications, you need to be on these medications. Yeah. And if they are so expensive and you have to take them for your entire life, a, you can imagine that's a huge amount of money for the pharmaceutical industry. Um, that this is like, I don't know if it's a magical magic pill for obesity, certainly a magic pill for their profits. Um, this is like the ultimate oil fields to find. Um, I have to imagine the financial impact on the rest of the healthcare.

If you're an insurer, you're thinking, oh my God, people are going to be, this is a thing that we're going to be paying out for people forever. Um, and so what are some of the other macro? Oh my God, people are going to be, this is a thing that we're going to be paying out for people forever. And so what are some of the other macro, I can't imagine a new treatment that could have a bigger macro economic effect on, you know, healthcare, which is already one, I think the largest sector of the U S economy or one of the largest. So what are we talking about there? Yeah. So, you know, there's one study that came out that basically suggested that if Medicare covered these medications for all Medicare adults who are obese and who end up taking these, they would spend more on just these medications than all the other drugs that they pay for combined.

And so you can imagine the economic and budgetary impact of the same thing. This is one of the central problems, because any insurer that covers these medications for the population that is eligible for them and can potentially benefit is going to have challenges. And so I think what we're going to see is that there's going to be a lot of hurdles that are placed in people's way to get these medications. Some of that might be telling people to try different medications first, try six months or a year of some exercise program, only allowing the medication to be available at extremely high BMIs as opposed

to kind of overweight or lower levels of obesity. And so there will be all these kind of changes that are put into place to kind of modulate who can have these medications. The issue becomes I think, when we start to realize that these medications may be helpful or are helpful actually, for not just obesity and diabetes, but they have actual tangible health consequences that are beneficial beyond that. And so you're not saying to people look I don't want to pay for you to lose weight you're saying I don't want to pay for you to lose weight and by the way this also will prevent heart attacks and strokes and that's a different

proposition for an insurer to to talk about so you know I think this is going to be kind of one of the central issues is how do we give it there there's very few conditions that affect you know 40 to 70% of the population and so the addressable market is enormous and how do we figure out how to make sure the people who really need these medications get them. This brings us to one other issue I think which is that we just had tremendous shortages of these medications and people are turning to kind of less reputable places to get their hands on GLP-1s and that can cause all sorts of issues as well. I mean, are these drugs actually difficult or expensive to manufacture? Well, they haven't been able to manufacture them to the in the numbers they need, but

it's not just the drug itself. It's also the at least in Nova Nordicis case, the pen that is needed to inject the medication is a specialized kind of pen. You've probably heard of, you know, Epi pens, epinephrine pens, a different kind of pen that they haven't been able to produce in high enough quantities. Because of that, the FDA allows what are called compound pharmacies, which are pharmacies that usually make medications for people, either if there's a shortage of medication, which is the case now, or for people who can't tolerate particular medicine for some reason. Let's say you're allergic to a certain active, a certain ingredient in a vaccine,

or, you know, you're not able to swallow pills. And so they'll put it in a, you know, liquid form and you can take like that. So they're allowed to do that. And in this case, the, so they, so many of these compound pharmacies are now turning their attention to Zepic and other similar medications. In some cases that's helped people get access to the medication when they otherwise couldn't. But there's also been a lot of reporting on, you know, some sketchy behavior on the part of compound pharmacies, either in terms of whether these are the right, you know, versions of semi glutide, which is the active ingredient of ozempic or if they're pure formulations, if there's potentially contaminants in there,

the shipping of these is not always shipped in the way that they should be. And so I think people should be aware that there are risks of turning to these types of pharmacies and you should make sure that first of all, a clinician prescribes the medication for you, but secondly, that the pharmacy that you get it from is kind of state licensed and an approved pharmacy.

Yeah. I mean, it seems like this drug has a lot of the ingredients you need to, to cause a lot of weird gray market issues, you know, that you have, you have a demand that's born, you know, there's the cosmetic demand, which is sort of separate from the medical demands. So you're going to have people who are like, I want this drug, but I can't necessarily get a, you know, my regular doctor to give it to me. So I gotta go to Dr. Good Vibes.

I gotta go to Dr. Skinny, right? And then you've got a shortage. You know, how much of a concern is that? Because, I mean, that was my first thought when I heard about the drug. I was like, oh, this sounds like, and again, this is a little bit ignorant of me, but, Oh, this sounds a little bit like Botox designed for one thing. It turns out it's good for something else ends up being used cosmetically.

And you know, it's going to be, you're going to have clinics springing up everywhere. Hey, come in and get a quick jab. And then you'll have all of the, you know, weird side effects, except unlike Botox where you got a droopy eyebrow, maybe you got a droopy colon or something. I don't know. Yeah. Yeah. Is that worrisome?

I don't think it's a bad analogy. I mean, I, you know, I walked down the streets of New York and you go to subway and the other billboards for Ozempic and Munjaro, you walk out and you walk past any, you know, on any avenue or a street. And there are advertisements for these things. And so it is the case that these were initially kind of developed for a particular indication. And as they have

become a phenomenon, a lot of people want them, many people who need them and some people who don't, but also a lot of businesses see an opportunity to make a profit from, um, from procuring and then selling them to people. Um, and, um, and we need to be careful and thoughtful about that. You know, I think one of the things that gives me, um, a little bit of confidence in these medications is that GLP ones, unlike say, you know, fen-fen, uh, in the 1990s, um, uh, they've been around for a long time, you know, almost 20 years now versions of the drug. You know, they were initially given twice a day or once a day, now they're given once a week. So they're more powerful now they're different. But it gives me some

confidence in the safety profile of these medications that we're not going to wake up tomorrow and find out that they're causing, you know, all sorts of cancers or, um, you know, negative, uh, uh, health effects. And so I think we can feel, um, a little bit confident that, uh, it's, it's, it's going to be mostly a good thing for people. Um, but, uh, at the same time, uh, we need to make sure that the right people are, are taking them, uh, people who actually need them can, can get them and so on. Yeah. I mean, my first thought honestly was, I'll be honest.

I did, I was at a gala event and it was sponsored by Novo Nordisk and the CEO Novo Nordisk gets up and goes, we're so committed to health and curing diabetes and stuff. And I was looking at the guy going like, you invented the weight loss drug. That's what you actually did. And you're, that's why you're going to be, be a trillionaire now. And you know, this is a drug that you invented for diabetes, but you know, that people are going to mainly use it cosmetically and that's what it's for.

Now I, and that made me a little mad. Now talking to you and reading your work, since I'm realizing what a great medical breakthrough it could be. In addition to the cosmet, that the, that the cosmetic piece of it might still be a small part of the story because it is so huge. And yet on top of that, the potential for abuse by people who are taking who shouldn't,

unscrupulous doctors, et cetera, it just seems very large and worrisome. But I also, I don't know, I don't have like a thing of here's what I think should be done differently because we live in the world that we live in and and it is a it is a fascinating and Potentially super impactful discovery for so many lives Yeah, I do think that things are gonna settle into somewhat of a steady state in the next couple years Obviously these drugs have been around for a while

But but them as a phenomenon that like is all over the internet and is kind of recognized as a medication that you know millions of people want to get their hands on. You're still in the first year or two of this version of the medication and so I do think that you know three four years down the line I hope that we're a steady state where. that, you know, three, four years down the line, I hope that we're in a steady state where we figure out the financing of this medication, we figure out who for whom it's most beneficial and appropriate. And we don't have this kind of, you know, mad rush that we do right now. We have a steady state where things are sorted out. We know both the medical consequences and also some of the potential psychiatric consequences of these, how they may interact with people who are struggling with addiction and so on. And so I think we're still kind of early days in this

and you know, if we're having this conversation a year or two or three years from now, I think it'll be a different conversation. I mean, I can't imagine how many people are doing studies on this and how much more there'll be to talk about in a couple of years. So we should have you back for a check-in at some point. But for folks who are thinking about it right now,

I mean, I literally had lunch with a friend who I said, you know, said his partner had been using it and he was like, I don't know, maybe I should, I'm not really sure, you know, she's been it for a week, it seems like it's been nice. He's, you know, my friends had plenty of struggles throughout his life, I don't wanna tell his story, but you know, I could imagine being in that position, right? Going like, I've had issues my entire life,

could this really be a magic pill, but we don't know that much about it, what should I do? And so do you have advice for folks in that position? Well, you know, as a doctor, I'm gonna say talk to a doctor about it. You know, it's one of those things where these are conversations that need to be had with a trained professional.

And also is the case that there's not a one size fits all solution. Some people who do have extras, you know, excess weight, they won't be the right candidate for this either for side effects or other things. And other people, it could be one of the most transformative things that they've done in their lives. And so it's an individualized discussion, but it also needs to be done under the care of a trained professional who knows what they're doing. It was the right dose should be on.

It was how to escalate that dose. Knows what to look out for in terms of concerning side effects. Like, um, you know, uh, my view is that we need, we need to have these conversations with people, understand their goals and values and then move from there. I think that's really helpful. Um, I will say, I, I so often have said in my own work, talk to your doctor and then eventually you realize

not everybody has a doctor because not everybody has health insurance in this country, but that's its own, I think, episode of this show. I also think we're gonna learn so much as, right now people have been taking this drug for a year and they're like, oh my God, it feels great, but is it something, as you say, that they're gonna still be taking in five years or will they say? Oh, yeah, I did that for a couple years and then I didn't really work out and and what is the cultural conversation gonna be?

At that point. I remember 10 15 years ago you know I take I I at the time was taking Adderall for ADHD and There was a new drug I forget what time was taking Adderall for ADHD and there was a new drug, I forget what it was called, but it was a narcolepsy drug and people were building, there were trend pieces about like, will this drug cure sleep? Like, will it be the magic bullet for ADHD? And that's a drug nobody talks about because I don't know,

I guess the side effects were not great. I'm sure some people use it, but it did not end up transforming our society. Is there a chance that this happens with this or do we just have to wait and see, I suppose? Yeah, part of it is wait and see. I do think that this is gonna have staying power. I don't know how broad ranging the impact is going to be

in the sense of how many billions of people end up taking the medication, what the knock-on effects are for the economy. People have speculated that airlines are gonna to be more efficient cuz keep passengers way less and people say Chris is gonna go out of business. Yes soda and snacks stocks like when you down or something in the last couple months and I think that is again some of this we're not in a steady state yet people don't know what the ultimate impact is going to be. I would be surprised if there's a broadly positive impact, but I think it's too early to say, the casinos are gonna close and Krispy Kreme

is out of business and airlines are gonna be 10% faster because of this medication. So I think that part of things we still need to wait and see. Well, I got, I can't thank you enough for coming on the show and giving us like the actual truth, uh, as best we know it today and being really clear about what we don't know. It's been incredibly valuable to have you here, given all the frenzy about this topic.

And uh, I hope we can have you back in the future to talk about this and some of your other work. Where can, where can people find your work and find you on the internet? Yeah. So I'm, I'm a writer at the New Yorker and And so that's probably the best place to find some of my work. I'm also a physician and a health policy researcher at Wild Cornell in New York. Dhruv, thank you so much for being here. It's been incredible. Thanks for having me.

Well, thank you once again to Dr. Dhruv Kular for coming on the show. I hope you loved that conversation as much as I did. Once again, if you want to support this show, you can do so on Patreon. Head to patreon.com slash Adam Conover. Five bucks a month gets you access to every single one of our community features and gets you every one of these podcast episodes without ads.

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