This is always the struggle for me. Maintaining weight looks exactly the same for me as losing weight because I need less calories now. It’s also shocking how easy it is to gain a few pounds and how hard it is to get them back off because I need to dip down with my calories which feels even more restrictive now that I’m at a healthy weight.
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Sometimes it takes a combo of a little less (and better) food AND a little more exercise.
My story: I lost weight about 20 years ago, when the work fitness center opened (which gave me more exercise as well as healthier bag lunches). When work got busier, the pounds crept back. I procrastinated loosing them again because I did not want to have a lot of yo-yo up/down cycles. Then about 6 years ago I started a walk/run class, which eventually turned me into a runner (a sloooow runner - but I run about 250 miles per year; also some biking and walking.) Because I have a borderline A1C reading (pre-diabetes concerns), I still track food and keep an eye on calories, sugar/carbs etc. All of this got easier to do after I retired 3 years ago, have more time.
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For anyone who was horrified at the cost of Mounjaro, it was just FDA-approved today for treating obesity under a new name: Zepbound.
Cheaper than Wegovy, a bit over $1k for a one-month supply (Wegovy list price is about $1,500). But Lilly has promised a coupon that’ll bring the cost down to $25 for those whose insurance covers weight loss drugs, and $550 for those whose insurance doesn’t.
Supposed to start by year-end.
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My neighbor when I was growing up was disdainful of my mother’s weight struggles. She was, I believe, naturally thin because she really didn’t care for food that much. She said “if I didn’t have to eat to live, I’d never eat and never miss it.” She truly couldn’t understand hunger, the pleasure of eating, or struggle to maintain a healthy weight.
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Yes, people on the far low end of the bell curve of appetite will often experience eating as “a chore.” In rare cases, it gets to the point that people are unable to meet their nutritional needs, and then they qualify for the diagnosis of Avoidant or Restrictive Food Intake Disorder (ARFID) -low or unreliable appetite subtype. These people will often respond Yes to the question “Do you wish you could just take a pill every day to meet your nutritional needs instead of eating?” Of note, to get the diagnosis of ARFID people must NOT be avoiding food out of a desire to stay thin (because people with Anorexia Nervosa will often also answer Yes to the above question because eating is so emotionally fraught for them.) However, to complicate matters, some people who are thin due to ARFID do become very proud of their thinness, and may eventually add on intentional food restriction.
In any case, appetite and satiety have huge genetic influences.
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I’m curious if insurance companies will start to cover weight loss drugs.
They cover meds for issues that are brought on by obesity (eg high blood pressure); some cover bariatric surgery, but many (most?) dont cover these drugs for weight loss.
I wonder 1)why they don’t cover these meds? (taking a med seems so much less invasive than surgery!)
2)if they will start coverage as they are seeing so many good effects from this all.
i get how the premise is that once you start on these meds, you need to stay on forever basically so you dont gain back. But i’ll counter – there are so so so many health benefits from weight loss. Wouldnt those benefits be more than what the costs of these drugs would be?
(have an actuary kid in healthcare. I might ask him about this!)
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@fiftyfifty1 - can you explain what you mean that “appetite and satiety have huge genetic influences?” thanks
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Because insurance considers obesity a cosmetic issue. Also, a law from like 20 years ago prevents Medicare from paying for weight loss drugs. Private insurance companies tend to follow this.
Also because there are MANY obese Americans, and it could have financial consequences - increased rates for all.
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Yes. Hunger (and its flipside satiety) are by no means completely understood by science, but it is clear that gene variations have huge effects. The most striking examples is Congenital Leptin Deficiency which is a gene difference that causes a person to experience constant hunger, so the person keeps eating, rapidly becoming severely obese starting in infancy. Luckily there is now a treatment (leptin shots) that poof! fixes the problem, resulting in normal hunger and satiety and a normal weight.
Congenital Leptin Deficiency is the rare single gene mutation (in this case autosomal recessive) causing obesity. Most variations in hunger and satiety among individuals are not caused by a single gene mutation, but rather by multiple weaker gene mutations working in concert. Food seeking is a drive that is severely redundant. In other words there are multiple genes that drive us to seek food (or tell us to stop eating food.) This is why it can be very hard to “trick” the body into feeling satiety. For example, filling up on water or fiber can trick the body for a few hours or days into feeling full, but then other drivers of hunger will kick in and cause us to eat even though our stomach is distended.
Scientists have identified a number of these gene variants, but by no means all. Looking just at the gene variants we do know, researchers can already make some startlingly accurate predictions about what body size a person is likely to have.
Many of these exact same genes are found in other animals. For example, researchers created “thin” and “fat” lines of mice and rats decades ago just by selective breeding. And now that we have the ability to sequence their genes, we find that the “fat mice” have many of the same gene variations that people prone to obesity have. Are “fat mice” always fat no matter what? No, when you expose them to conditions of tightly restricted food, they can become “normal weight”, but they act extremely hungry the entire time, and as soon as food conditions are returned to normal they quickly become fat again.
This is why I don’t think that obesity is a matter of “willpower” as most of society seems to believe. If it were willpower, how would a leptin shot (or a semaglutide shot) fix that?
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Thank you so much for your insights. Those of us who’ve struggled all our lives with weight have always suspected there was something “wrong” with us, yet have been told over and over again “just eat less and exercise more,” as if we hadn’t tried that already. It’s not that simple a solution for many people.
Does that mean I always ate the right things, no, of course not. Binge eating, anorexia, bulimia are all characterized by unhealthy choices. There was always something in my mind, chattering away in the background, a low hum of “eat eat eat” that I truly was not aware of. But it drove the way I felt about and responded to food. To find out that genetics influences these habits is such a relief, honestLy. Yes, there’s still a difficult road, but there are answers now, and science to back up the landscape of obesity.
@bgbg4us - the main reason why insurance companies don’t cover these medications is cost. Yes, they can greatly reduce the health impacts down the road, but insurance companies have calculated that when those impacts are most likely to cost money, the patient will not be on their roster anymore. It won’t be their problem, so they don’t see any cost benefit to paying for a medication that will have benefits for a different insurer (likely Medicare).
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Damage to the ventromedial hypothalamus also causes constant hunger (ie no sensation of satiety)
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Yes, although I will note that these conditions also have significant genetic influences as shown by studies such as ANGI (Anorexia Nervosa Genetics Initiative.)
Also of note, binge eating is a normal and actually desirable biological behavior in essentially all mammals (from rats to wolves to monkeys) in response to food shortage. Many people with genetics that predispose them to an obese body build restrict food during the day in public due to social pressures, which the body can perceive as threatened famine. This biologically predisposes them to binge eating, with binges often occurring late in the day. If this happens frequently enough it can reach the level of clinical Binge Eating Disorder.
Exactly. The recommendation to “just eat less and exercise more” is especially pernicious because it contains a truth mixed with a falsehood. It is true that eating less and/or exercising more will absolutely result in weight loss. The false part is the word “just.” “Just” implies that doing so is simple and attainable when the reality is that it involves resisting extremely strong (and redundant) biological imperatives to eat. Eating is an activity like breathing or blinking that technically you can control, but that is strongly influenced by biological drives that originate in parts of our brains NOT under conscious control. Sure I can make myself breathe less or blink less; anybody can. But how long can I keep it up?
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Meanwhile I have a relative by marriage visiting for Thanksgiving. He is morbidly obese - not sure of his weight now, as I haven’t seen him since April, but he was easily 350lbs then, about 5’11’. He was on a liquid diet then. I do not know his diet since then. He’s in a eating disorder support group, goes to therapy, I don’t know what all else.
His wife is at her wits’ end. She thought he was doing well or at least maintaining, but he has apparently revealed to her that he had another binge episode two weeks ago, which stunned her. They’re in their early 30s, she wants another kid, but she is really, really worried that he won’t be around if this doesn’t get resolved.
I strenuously urged him to try Mounjaro in the spring, but he said he had tried it. It did nothing for him, he said.
Now, mind you, he lives in a country that does not have access to Mounjaro (did not at the time), so I don’t know what he was on - maybe ozempic, maybe saxenda, all of them not nearly as powerful - but his attitude is, been there, doesn’t work, leave me alone.
He was very dismissive (this was by email, via his wife) so I couldn’t really get more details or add information to possibly change his mind.
I want to try again at Thanksgiving. Because while Mounjaro is not 100% effective, the percentage that it does not work for is vanishingly small, and I think the research and the results warrant him giving it another go.
Any advice on how I’d go about advocating for this when I see him?
Because continuing on as he is - it’s simply not working.
My advice: Don’t.
He knows that he’s obese. He doesn’t need you explaining anything to him. This doesn’t really feel like it’s your business.
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Contrave is a different type of drug that helps specifically with binge eating (among other things).
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Seems that the trend among insurance companies and employers is to consider dropping coverage of those drugs (if currently covered) due to the cost.
Remember that the cost is short term, while the reduced cost of obesity reduction is long term. For privately insured people, the long term is likely to be under some other insurance company or employer as people change employment over time. So the incentive for insurance companies and employers favors the short term over the long term.
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I think one factor would be how long the meds are needed. One story I read (can’t know if really true) is that continued meds are needed to keep the weight off. If so, that would be really expensive.
It’s a lifetime commitment. The dosage can be adjusted , but most people gain the majority of the weight back within a year of stopping.
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But isn’t that true of almost all diets?
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