#62: GLP-1s: Life-Changing Results… at What Cost?

A medicine that quiets food noise, trims 15 to 20 percent of body weight, and even lowers the risk of heart events sounds like a fantasy—until you meet GLP-1 drugs. We dig into what makes semaglutide and tirzepatide so different, how they rewire satiety signals, and why their impact extends beyond the scale to blood sugar, blood pressure, and cardiovascular outcomes. Along the way, we get candid about the trade-offs: GI side effects, lean mass loss, and the reality that stopping often means regaining much of the weight.

To go deeper, we’re joined by Dr. David Rind, chief medical officer at the Institute for Clinical and Economic Review (ICER), to decode how “value” gets measured in health care. Together we explore how these medications can be a strong value for individuals at today’s negotiated prices, yet still strain the entire system when millions qualify. You’ll hear why real-world discontinuation is high, why strength training and adequate protein are non-negotiable, and how benefits like fewer heart attacks, fewer joint surgeries, and improved quality of life factor into the equation.

We also tackle the hard question: how do we pay for a breakthrough at population scale without crowding out everything else? From Netflix-style subscription models and dedicated funding to competitive pricing and rethinking our hyperpalatable food environment, we outline pragmatic paths that could expand access while protecting budgets. If you’ve wondered whether GLP-1s are miracle drugs or money pits, this conversation offers a grounded, evidence-based guide to the science, the economics, and the choices ahead.

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Transcript

A Big Promise And A Big Price

SPEAKER_01 0:00

What if I told you there's a drug that treats obesity, diabetes, heart disease, sleep apnea, alcohol addiction, and possibly even Alzheimer's? Sounds like snake oil, right? Except it's real. These are GLP1 agonists, and they might be the most powerful class of medications we've developed in decades. There's just one problem. At current prices, using them for all of these conditions would bankrupt our healthcare system. Hi, I'm Dr. Bobby Du Bois, and welcome to Live Long and Well, a podcast where we will talk about what you can do to live as long as possible and with as much energy and vigor that you wish. Together we will explore what practical and evidence-supported steps you can take. Come join me on this very important journey, and I hope that you feel empowered along the way. I'm a physician, Iron Man triathlete, and have published several hundred scientific studies. I'm honored to be your guide. Welcome, my dear listeners, to episode 62, GLP One's, life-changing results at what cost. Advertisements and discussions about Ozempic and Monjaro are everywhere. We all hear stories of 30, 50, 70 pounds or more of weight loss. No more cravings, alcohol desires fall, less smoking, and potentially treatments for sleep apnea, arthritis, and even Alzheimer's. These drugs are injected every week, and when they were released, they cost about$500 to$1,000 a month. In 2023, we spent over$70 billion on them, and about one in eight Americans are on these drugs. Perhaps 18% have tried them. Just last month, the FDA approved an oral form of AZAMPIC. How many more people might start taking them? Are these drugs a miracle for folks who are overweight? What's the evidence? What's the hype? And can we as a society afford them? I hope by the end you will have a firmer understanding of these issues. I have three other weight loss-related episodes that I'll link to in the show notes that you might find of interest. Why now? For years I've been following the clinical trials of these drugs for diabetics, for weight loss, and for a whole slew of new potential uses. In addition to these high-quality evidence data points, I've heard numerous end of one stories. So many friends and colleagues who've had the typical roller coaster dieting experience, losing weight only to gain it back, and having tried every diet known. After losing a few pounds, the craving to eat more just was overwhelming, and most all of the weight came back. Then these same people, after struggling for perhaps decades, start one of the GLP1s, and a lifelong journey of weight struggles takes a new path. Within days, they feel less hungry, had fewer food cravings, and the food noise in their brain had gone away. They lose 20, 30, or 50 pounds. After hearing these studies, after reviewing the evidence, and were about two-thirds of us either obese or overweight, it seemed time to share what I found with you. I've divided the episode into two parts. Part one, I'll review what these drugs are, how they work, how well they work, and their side effects. Then in part two, if these expensive drugs could potentially help so many people, can we as a society afford them? For this discussion, Dr. David Ryan will join me. He's a physician and a health economist. His organization, the Institute for Clinical and Economic Review, recently completed a wonderful analysis of these drugs. As folks may or may not remember, I spent much of my career looking at evidence for what does and doesn't work and whether those treatments are worth the cost. Many of my 180 publications are on this topic. So having David join us brings back lots of fun memories. Let's dive in. Part one. These new drugs are what are called peptides. Now, peptides are mini proteins, like insulin. GLP1s stand for glucagon-like peptide one. GLPs are made in our own body, in our small intestines. They work with the pancreas and our liver to balance our blood sugar. That's why they were created initially for diabetics. They stimulate insulin and inhibit glucagon, also important for diabetics. Most importantly, for weight loss, they slow food from leaving our stomach, giving us a sense of fullness. Second, they affect brain satiety or how hungry we feel, likely through dopamine pathways. Third, these drugs reduce food noise or the constant thoughts about our next meal. The first of the GLP1s to the market was made by NovoNordisk and known as semaglutide or Zempic or Wygopy. Patients self-inject every week. When initially available, these drugs improved blood sugar and also led to weight loss. Then the drugs were tested in obese folks who did not have diabetes. Here's some of the key evidence that got the drugs approved. In the STEP randomized trial, 300 patients who began the study with an average weight of about 220 were followed for two years. Patients lost about 15% of their body weight, or about 35 pounds. In November, an oral version of this drug was approved for weight loss. In the Oasis 4 trial, 200 people who were either overweight or obese lost about 13% of their body weight. As we will talk later, the oral versions work, but perhaps are one-third less powerful for weight loss. The other major drug is terzepatite. In a pretty rare type of study, the company, Lilly, compared its drug, Monjaro, to Novo's drug, Ozempic, in the surmount trial of 750 obese patients. Now, I said this was a risky business move because most companies compare their new drug to placebo. It's easier to beat placebo than your competitor's drug. But Lilly's study turned out to be very important. Ozempic patients lost 14% of their body weight, while Manjaro patients lost 20%. When these drugs were released for overweight and obese folks, there was such a demand that medical societies and insurance companies put out guidelines for who would be good candidates for them. So typical guidelines say you'd be a good candidate if you're obese with a body mass index or BMI greater than 30. Now, what this means is for a man who's 5'10, they weigh about 210 pounds. For a woman who is 5'4, it's about 175 pounds. But these drugs are also approved for folks who are overweight, not just those with a BMI-based obesity. So if you have a BMI of 25 to 30 and also have comorbidities associated with being overweight, like sleep apnea, arthritis, then you might also meet the guidelines. To give you a sense of a BMI of 28, for a man who's 5'10 is around 200 pounds. And for a woman who's 5'4 inches, about 160 pounds. So for the two-thirds of folks who are overweight or obese, are these actually miracle drugs? Well, I can't answer that yet. We need to talk about their side effects. Those side effects are mostly GI, nausea, vomiting, diarrhea constipation. And they usually resolve or get better over time, but not always. There are serious side effects like pancreatitis, gallbladder problems, thyroid cancer, or optic nerve damage. Now, a key and worrisome problem for almost everyone is muscle loss. About a third of the weight folks lose maybe muscle. So if you lose 25 pounds, that might be eight pounds of muscle. Now that's especially problematic in older folks who are already losing muscle. Now, it's unclear if the muscle loss is due to weight loss of any type or whether it's worse because of the drug. And new drugs are being tested that might reduce muscle loss, but we're not there yet. And muscle loss is a big deal. Folks who take these drugs should do strength training and make sure that their protein intake is adequate. These drugs can only help folks if you take them, but many discontinue these drugs because of side effects. They also discontinue because of cost. In the clinical trials, few people stop the drugs because they're free, and patients are seen very regularly and encouraged to continue on them. But in the real world, people stop the drugs because of side effects, the hassle of injecting, and cost. Let's talk costs. When initially released, the list price was around$1,000 a month. Now, Novo and Lilya programs to sell the drugs directly to patients at around$300 to$500 per month. Last month, the government and manufacturers agreed to a big discount. So the drugs would cost about$250 to$350 a month, and even lower for oral versions,$150 per month. Now the companies agreed to lower their prices in exchange for having Medicare and Medicaid pay for their use. So costs are going down. Back to the discontinuation story. It's cost and side effects that determine it. For weight loss, about 65% of folks will quit within a year. Diabetics do better with about 47% quitting, presumably because it's about their disease, not just the weight. Unfortunately, if you stop the drugs, you regain much or most of the weight you lost. About two-thirds of the weight you lost will come back. So if you initially lost 30 to 50 pounds, you might ultimately only have lost 10 to 15 pounds, and perhaps not even that much. Before summing up this part of our discussion, let me share that there are many new uses being tested. Now, some of the new uses likely relate to weight loss. So sleep apnea, arthritis may improve just because patients lose a lot of weight. Other new uses and benefits seem independent of losing weight, like improvements in heart attack risk or liver damage. These drugs may have a direct effect on blood vessels or inflammation. Since these drugs reduce food cravings, they've been tested for other cravings. In the all-Sweden study, the researchers looked at these drugs and whether they reduced hospital admissions for alcohol issues. Turned out that patients on these drugs had 30% fewer alcohol hospitalizations. Not a clinical trial, but very promising. So before ending part one, are these miracle drugs? Well, they provide remarkable benefits for obese patients that no prior drug could do. But they have side effects, and many folks stop taking them. And when they do, almost all the weight comes back. Well, let's shift now to part two. Can we afford these drugs for weight loss and for all of the new potential exciting uses? Let me welcome Dr. David Rind to Live Long and Well. Hello, David. Good to see you.

SPEAKER_00 15:44

Hi, Bobby. Good to see you.

SPEAKER_01 15:46

Well, in the uh time between when I recorded the first part and now the second part, David pointed out to me, A, I mispronounced his name, so it's not rind, it's rind, and I apologize for that. And secondly, that he mentioned there was uh an earlier GLP1 before semaglutide called lyroglutide. Came out four or five years beforehand, um, first for diabetes, then for weight loss. And it does work for weight loss, although it's less effective than semaglutide. And uh, as we talked about, uh terzeptide seems to do even better. So let's um uh let me tell you a bit about David's background. He is the chief medical officer of the Institute for Clinical and Economic Review, or ICER. And over the years, he and I were somewhat on different sides of the public policy table. Um, and I hope we brought out the best in each other. Um, and it was great. So I've known David for a long time, even though I miss pronouncing his last name. And it's wonderful to have you back here. At ICER, he leads the teams that analyze the evidence for their assessments of all sorts of medical technology. Obviously, for this episode, they released a report on obesity drugs. Not that they released it for this episode, but that's clearly where I was hoping his expertise might be brought to bear. And David got his bachelor's in chemistry from Yale, his MD from the University of Rochester, and his master's in public health from Harvard. Um, David continues to see patients in primary care working with residents at Beth Israel Deaconess Medical Center, which is in uh Boston. Now, David, I learned from the ICER website that not only did you used to juggle, but you taught juggling. So, what's the story here?

What Is A Fair Price In Health Care

SPEAKER_00 17:59

So I was a camp counselor on Cape Cod, which is interesting mainly because it was the first time I was being in Massachusetts long before I moved here to be a doctor. And I was at this really interesting camp with all these people who had special skills. And one of the counselors juggled and taught a bunch of us to juggle. And a few years later, when I was a counselor, I started teaching other people to juggle. And it was really, really a blast. Um I people are way better jugglers than I am. There's in the age of the internet and social media, there's so much better juggling than when I was doing this. But I can still impress people once in a while.

SPEAKER_01 18:41

That's fantastic. Do you still juggle on a regular basis, or only once after a couple of drinks and somebody grabs you and says, David, do it.

SPEAKER_00 18:51

That or you're hanging out and there are people juggling around and they're like, hey, would you want to try this? And it's like, yeah, I'm willing to give it a try, and then they you show off.

SPEAKER_01 19:03

So that's it. That's great. Well, that's wonderful. So let's begin with what is ICER and what does it do?

SPEAKER_00 19:14

So Icer is a health technology assessment group, and that doesn't really explain anything to anyone because that's not very meaningful to most people in the world. But in most of the developed countries, particularly in Europe, but also Canada and Australia, um, where typically the government is heavily involved either in being the primary insurer or the only insurer, um the government wants to negotiate pricing for drugs and decide whether the prices they're getting are fair. And they turn to organizations that are HTAs, health technology assessors, to say what's a fair price. Uh we don't have anything like that in the US. Um ICER is an independent nonprofit that tries to do that same role that in most places is done by an organization with governmental affiliation and typically governmental authority.

SPEAKER_01 20:13

Well, that makes perfect sense. And ICER does have an impact with the insurance companies throughout the country. So although we don't have a formal HDA process that goes into pricing at the at the national level, your work has always been influential in the discussions that happen between the folks that make the drugs and then the various entities that pay for them. So without getting too nerdy, which of course I love to get nerdy, how do we determine what's a fair amount to spend, both individually and for society or insurance?

Clinical Value: Safety And Outcomes

SPEAKER_00 20:57

Yeah. So it's very hard to answer for a specific individual what a fair price is. And if you're about to die, presumably if you there was a life-saving drug, it's worth all that you have to not die. And that's not a good way to price things. More generally, if you imagine an average person with an average version of whatever condition is being treated, you'd like to know what, if they were valuing this themselves, would feel like a fair price. And health economists have ways of doing this across different diseases, across different treatments, to try to look at the answer to that question. And I often use the analogy to cars. When I'm buying a car, I don't care how much the car costs to build. I don't care how much research went into developing a car. If I'm buying a Toyota Prius, I don't care that Toyota spent lots of money developing the first hybrid. What I care about is what I get out of that car and whether the price I'm paying is worth it to me for that car. And it's not that everybody will have exactly the same set of values I have, but the company is trying to pick an average price that for most people will cause them to go, yeah, that's a fair price for the car. Health is really different to people. And yet, if you don't do something like that, you end up with very distorted ways of figuring out a price. And so what you'd like to know is on average, what value does this drug provide me, the person who needs it? What's it worth in terms of dollars, as best we can figure out, but then not have me pay for it, have the insurer pay that amount. And so that's what we're trying to do.

From Willpower Myth To Brain Signals

SPEAKER_01 22:56

That makes sense. And it obviously sounds a little abstract, but as we get into the GLP1 drugs and we talk a little more specifically, I think it'll become clear to folks, at least I hope so. And as always, my dear listeners, uh, send me questions, comments, or uh feedback whether any of this is um uh makes sense or you need some further clarifications, which I can certainly do. Okay, so ISER recently published an important analysis on GLP1 drugs. What are your thoughts about how effective the GLPs are for weight loss? Now, we'll get into cost issues later, but from a clinical standpoint, how good are they?

SPEAKER_00 23:39

These are, by and large, amazing drugs. I mean, you you were talking to this um in the first part. And I had actually answered some questions on social media five, seven years ago asking what doctors thought of people who were obese. And my answer was when I see patients like that, I'm thinking, I don't have anything good to offer them.

SPEAKER_01 24:04

That's so true.

Valuing Benefits And Offsets

SPEAKER_00 24:08

And it just feels bad. And telling people you really need more willpower and you need to exercise harder and diet more first just blames them. And second, doesn't work. Um, and then these drugs came along, and we were first looking at these drugs five, six years ago, and they're amazing. They cause dramatic weight loss, not as much weight loss as surgery, as bariatric surgery, but much more weight loss than anything we'd had before. And I'm old enough to remember Fenfen, which was this combination of weight loss drugs that we had lots of reasons to worry about the safety of in the early 1990s, and it turned out they weren't safe, that that combination caused heart problems. So, in contrast to all the drugs we've had before where either we weren't sure about safety or we knew they weren't safe, or maybe they were kind of safe, these drugs reduce cardiac events. Symagnetide decreases cardiac events by 20%. That's as much basically as statins do. That means that they have a margin of safety on the most common cause of death in the United States so big that even if they have other side effects we haven't figured out yet, these are great drugs.

Are Current Prices Good Value

SPEAKER_01 25:35

Wow. Um I think the these drugs did two things. One is they bring a lot of help to patients who struggled, struggled, struggled with weight loss. But I think something almost equally important, it taught us as doctors and hopefully more broadly, people in society, that this issue of obesity and what causes it and how you get over it is really complicated. Because I think when we trained, it really was you ate a certain number of calories, you burned another certain amount of calories, you just need to eat less, exercise more, and you'll make it work. And if you don't make it work, then clearly you're not trying hard enough. And I think what these drugs taught me was, you know, person after person after person who had decades of struggle, lose weight, gain weight, lose weight, gain weight. You know, people say, oh, I've lost a thousand pounds, but of course I regained the thousand pounds. You know, not within a year, within like a day or a week, all of a sudden they think about food differently. And that said to me, yes, maybe our food supply isn't helping matters. Maybe there's lots of other factors, but there's something going on in the brain that is really more than just simple willpower. So I was skeptical uh of these drugs initially for weight loss, but now I've, you know, I am understanding of both the side effects and the cost, but they really do have a role for many people. Not everybody, by God's sakes, but for many people.

The Budget Impact Problem

SPEAKER_00 27:18

Yeah, and I think that's exactly right. Um, I've um, you know, for religious reasons, sometimes fast for a day. And by the end of that day, I noticed that every few minutes I'm thinking, oh, I should go get something to eat, and then remember that I shouldn't go get something to eat. And I when your weight is lower than the weight that your brain thinks you should be at, you're constantly getting that signal of, oh, I should go get something to eat. And you have to use your conscious brain to push that down. And I think for many, many people, these drugs cause the weight at which you start getting that signal to be much lower than when you start the drugs. And so yeah. And so instead of having this constant, I need to go eat, you're just happy. And you don't eat, and your weight goes down.

Policy Ideas: Subscriptions And Bonds

SPEAKER_01 28:15

So earlier you had the car analogy of how much is it worth to me? You know, it's like, oh, the ride is nice and the Bose speakers are cool, and I like the fact that it's a hybrid. And yeah, I think it's worth$30,000 or$40,000 or whatever it is. And of course, I'm the one writing the check. So I'm very sensitive about how much I think it's worth. And it may, as you said, it may differ for other people. But with healthcare, um uh we're not paying out of our pocket, by and large. Yes, there are circumstances when that happens. Often, most of the time, somebody else is participating in the payment. Hopefully, your insurance company is paying a whole lot of it. Uh, as I've told my my listeners, Gail uh has uh metastatic cancer, and she's doing great. Um and the drugs were really expensive, and the surgery was really expensive, and the sh insurance paid, which is Medicare and Medigap, everything. So there is a role for insurance companies. But as the insurance companies think about it, they want to understand well, what is a fair price? So I know as you go through this process, you're looking at the disease and what the disease itself costs. You look at, you know, how well does the drug make the disease less serious, and therefore some complications don't occur. So tell us a little bit about the things that go wrong with um patients that are obese, and then how you value what not having some of those complications might be so we can ultimately work our way towards a value-based price.

Food Environment, Taxes, And Hope

Final Takeaways And Resources

SPEAKER_00 30:12

Yeah, so uh just sticking with the car analogy for one second, um, one of the things you might think about if you're buying a car is I don't have to pay as much for the train to commute, or I don't need to get as many Uber or Lyft rides. And so there are cost offsets when you buy a car. They don't pay for the price of the car, and you don't expect them to because you're getting a lot out of the car. But you are getting some cost offsets, and you want to count that when you're thinking about things. Uh, and you want to think about how much it makes your life better to have that car in different ways. Maybe your commute is faster, and so you don't, or you like listening to your Bose speakers as you go in or whatever. Um, when you take medications for weight loss, you lose weight, and there's benefit to people just in terms of how they feel about themselves for losing weight. And that's a gain that we want to figure out how much that's worth. They have see their blood pressure come down and their um lipids come down, and so they don't need to take statins as much, and they don't need to take blood pressure drugs as much. So those are cost offsets. And then they develop less diabetes, and they develop fewer heart attacks and fewer strokes, and they live longer. And that's worth a lot. You know, not having a stroke, not having a heart attack, living longer is worth a lot of money. And there are all sorts of different ways of valuing that. Um, but uh one way that we think about this is that various studies have suggested that in the U.S. it's reasonable to pay for an extra year of really healthy life, somewhere in the range of$100,000 to$150,000 a year. So now again, we're averaging across a lot of people. Not everybody who gets put on these drugs is living an extra year, but that's a that's in the range of what we might be willing to pay for these things. Um, other benefits of these drugs are your knees may hurt less. You may be able to not get knee surgery or hip surgery that you were thinking you were going to get. So both cost offsets and you're not needing an operation. So there's a whole bunch of things that go into the price that you might be willing to pay for this. And part of the reason I'm stressing it this way is the number of times I've talked about this that people have thought, well, a drug is only worth it if it overall saves money, is not right. We don't want to only pay for drugs that save the system money overall. We want to pay for drugs even if they cost the system money, but they buy an appropriate amount of health. And that's what we looked at when we looked at these drugs.

SPEAKER_01 33:13

And what'd you find? Was the the price being charged commensurate with the value? And to remind our listeners that you know, when these drugs came out, they were about$500 to$1,000 a month. Um, and that was sort of the cash price. And and then everything got negotiated down, and now actually they're quite a bit lower. And as I mentioned, there's ways of buying it directly from Novo, Nordisk, or Lily that's really quite a bit lower. So what did you find uh uh and what prices did you plug into your equations? And would things be a lot different because the prices appear to be falling?

SPEAKER_00 33:55

Yeah, so the prices do seem to be falling, and we found that even at the prices when we started the report, which were higher than they seem to be now, these drugs are a great value. You're getting uh a great amount of health for the cost of these drugs. Um in ranges that we don't usually see for new drugs on the market in the United States. Now, both of these drugs have been on for a little bit of time, but even then, when we go and look at drug therapies, most of them are overpriced in the U.S. These drugs are not overpriced at the real prices that people are paying, not the list price that may be published somewhere, but what the insurers are really paying or what you can get directly from the companies. And if you look at the prices that have been negotiated supposedly by the government, and we're not totally sure what government will really be paying, um, it's possible that terzepatide, Munjaro, Zepp bound, all three ways of saying the same drug, may in fact actually be cost saving over a lifetime. It's incredible. At that price, it may actually be cost saving, which we almost never see.

SPEAKER_01 35:10

Almost never see. I I can't, I'm having a hard time figuring out what they might be. Maybe generic penicillin um might be uh cost savings by and large, if used for serious illnesses. But uh it is very, very, very rare. So there is a disconnect here, I suspect, for listeners, because if their insurance company isn't paying, and many insurance companies are quite severe or strict about who gets, and I talked earlier, you had to either be obese with a BMI of 30 or more, or have complications of the problem and have a BMI of 25 or 28 or so. Um, so many people are having to pay out of pocket. And even though it is, quote, a good value, it is tough for some people. Now, uh, with the government stepping in for Medicare Medicaid, there will be more people where the insurance company will pay for this. But let's let's shift our perspective. Here we've said, you know, actually these drugs are reasonably priced, which of course will make the manufacturers very happy that two smart people, or at least I hope we're two smart people, are saying the prices are reasonable. But Icer also analyzes not just what the price is for an individual, but the price for society. So it's a math equation, you know, the price may be fine for one person, but when, you know, 40 million people end up on the same drug, it can bankrupt the system. So tell us the listeners a little bit about what budget impact analysis is, why we care when on an individual basis we're saying it's it's a good bargain. And shouldn't we just say, well, it's a good bargain for John? So therefore it's a good bargain for Sally and Jane and the other 40 million people who might need it.

SPEAKER_00 37:10

Yeah, apart from the thing I already said, which almost never happens, which is cost saving potentially for one of these drugs over a lifetime, the other thing is when you have a hundred million plus people in the United States with a BMI of 40 or greater, it's really hard to find a price that you could be paying year after year that doesn't have huge budget problems for the country as a whole. So if you just do a trivial calculation and say, well, okay, I can buy these drugs for about$3,600 a year right now, if I'm buying directly. If I multiply that by 100 million people, that's$360 billion a year that we need to start spending on these drugs. And our health system doesn't have$360 billion a year to start spending on these drugs. The cost savings are over a lifetime, some of them down the road. But even if some of them were sooner, I'm a primary care doctor. I need visiting nurses to go in and take care of patients in their homes. I need to be able to hospitalize people and get them operations. I need other drugs to get people.$360 billion added to the system isn't there. And that's why you see all these insurance companies that at some level should be going, these drugs are a great deal. They're they're appropriately priced. We never see that. They their patients want them, they're wonderful drugs, are instead going, we have to figure out how to get fewer people to take them because otherwise premiums are going to skyrocket.

SPEAKER_01 38:58

So, okay. Now you are the czar of healthcare, and you've been called to Washington to solve this dilemma. Um and we all agree the price per patient is okay, but the price for society is really high and will take away what we also otherwise might do with some money. What's the solution here? And I don't think it's we take the patent away from the drug company and you know, some government lab manufactures it and gives it away. So, how how do you solve this dilemma?

SPEAKER_00 39:34

Yeah, I mean, I I think I have not heard a single answer to this that everybody hearing that answer goes, oh, that would work. We should all just do that. But let me give a couple of possibilities. One is um people talk about a subscription model where maybe you could go to these two manufacturers and say, we're willing to guarantee you.$50 billion a year each. And we're you won't have to do prior off negotiations. You won't have to spend lots of money on salespeople and whatever else. We're going to give you$50 billion a year. You have to give us as many doses as we have people we want to treat with these drugs. And that would make life easier for doctors. It would make life easier for patients. It would make life easier in some ways for the manufacturers. And they'd be getting$50 billion a year, which to me seems like a lot of money. I'm not a CEO of a major pharmaceutical company, but$50 billion seems like real dollars. So that's a way that I could imagine doing that.

SPEAKER_01 40:48

That's a creative way.

SPEAKER_00 40:50

Sorry.

SPEAKER_01 40:51

That's a creative way.

SPEAKER_00 40:52

Yeah. Another thing you could imagine is what we do anytime that there's a something that is a huge expense, but the benefits accrue over a long time, is to imagine the government having bonds almost, or saying, you know, we will raise money for this so that we can treat people, recognizing that over the long term this is a good deal, but we need a separate revenue source to pay for it. So that's another thing that could happen. I think the third thing, the one based on hope, is that as more and more of these drugs come on the market, some of them that aren't quite as good will drop in price and competition will get us out of this mess. And maybe that will happen. But I think there'll be a lot of people who could benefit from the drugs who won't get them over the next five to ten years if that's what we wait for.

SPEAKER_01 41:52

All of those make sense. And uh since government generally doesn't make sense, we probably won't see any of those. But with with my optimistic hat, I will hope that uh one of those or all of those are part of the solution. So, okay, so I'm gonna ask this admittedly stupid question. And I know it's stupid from the moment I came up with the question. Um should we add these drugs to the water supply? Okay, now the understanding is the injectable drugs you can't add to the water supply. It's not gonna work. But the oral drugs you could potentially add to the water supply. And yes, I know that for an individual patient, they might need more, they might need less, they might have some side effects. I mean, I know you cannot do this. But when you think about adding fluoride to the water, it's helping kiddos prevent cavities. So 100% of people are drinking water when only, I don't know, 10, 20% of the people are going to get some benefit. Now, are there harms to the other people? You know, people could argue on both sides of this. And I'm not I'm not endorsing fluoride in the water or not endorsing it, or you know, fortified wheat with vitamin D or other things. And I'm not really endorsing that. But for fluorate, 10 to 20% of people benefit. For these drugs, 70% of the U.S. population is either obese or overweight. So we could help 70%. Now, of course, you know, how do we pay for this? That's a whole separate thing. So this is a kind of a straw man exercise. So anything, any darts you would like to throw at this stupid idea?

SPEAKER_00 43:37

So, first thing I'd say is uh this has come up, you know, people have said this about statins in the past. Exactly. Um, it's sort of the same thing, which is these drugs do great stuff for lots of people. You know, I I don't think like you, nobody's really serious about putting them in the water supply. But how do we get them to all the many people who could benefit from them? Unlike statins, these drugs um many people wouldn't want them because if you're at an appropriate weight, there are people who don't want to lose weight. And these drugs cause some nausea, they make you less interested in eating. I've actually had patients who went on these drugs and lost all interest in food and came back and said, I for socially I want to eat with people, I can't stay on this drug because I have no interest in eating anymore. So, you know, there are people who really wouldn't want these drugs, even if they seem appropriate for them. Right, right.

SPEAKER_01 44:47

Now you're gonna though.

SPEAKER_00 44:48

There are people, I would say, like me, who, by BMI, I have a perfectly good BMI. I also have high blood pressure and high cholesterol. Almost certainly I have some degree of metabolic syndrome, which probably means I have too much visceral fat. And we haven't yet shown that these drugs are good for people like me. But if you ask me to bet what the data will show over the next five to ten years, I bet they show that if somebody like me takes these drugs, I reduce my risk of heart attack, I reduce my risk of stroke, I have less arthritis, and I don't need blood pressure medication and lipid medication anymore. So we probably, at that level, we almost should have them in the water because there are probably a whole bunch of other people who we haven't figured out yet could benefit from these drugs, who it is going to turn out would benefit from these drugs. So more broadly, uh, we know that there is um an entire Asian population that on our BMI measurements looks thin and fit and has metabolic syndrome, and that these drugs work in that population too. There's been studies specifically in Asian populations, I think because of the interest in that. So apart from anything else, when you say 70% are overweight, that's using measurements that actually don't capture everybody who's probably really able to benefit from these drugs. Yeah. I didn't give so for one more answer for how you could pay for these, if you believe, and I actually do believe this, that a big part of the problem is that um in our competitive food market, people have figured out how to make high-calorie foods almost addictive. I don't love the number of things we call addictive, but you know, the number of foods that call to you. I I have some pastries sitting out there in another room that are calling to me. Um if we were taxing calories in some way to help pay for the drugs that we only need because we've created these high-calorie addictive foods, uh, you could imagine a system like that working. Um, I'm not sure either of us thinks that very many governments could pull that off very well, but but it is a thing to think about.

SPEAKER_01 47:26

That's wonderful. David, your insights are great as always. This has been uh fascinating and fun. And you didn't shoot my idea about adding it to the water too crazily. Look, again, don't get me wrong. I'm not suggesting we do this. Understood. So, okay, so let's wrap up. So, from part one, these drugs help diabetics. And for those who are overweight or obese, they truly help them in ways that were really never possible before. Folks with a lifelong struggle to lose weight and the roller coaster of ups and downs, these drugs can lead to 30, 50, or 70 pounds of weight loss. But they have important short-term and potentially long-term side effects. And many people stop the drugs and almost all of the weight comes back on. So for most people, they're making a lifelong commitment. Now, from part two, the prices of these drugs have fallen a lot, but the prices actually seem to be reasonably fair with more and more folks taking them. Who knows how much higher our current$70 billion spending on these drugs will go. With one in eight Americans on them now, could we see a time when half of all Americans take drugs like this? David taught us to think not just about how much it costs for these drugs for an individual patient, but to think broadly about societal expenditure. Now, I have various episodes about weight loss that folks might want to listen to. I have one on nutrition in general, which is number four. I have one on weight loss, episode number 15, and what you eat affects how much you eat, which is episode 49. I'm convinced that for many folks, these drugs can be life-changing. Does that make them a miracle drug? Well, for some, yes, for others, perhaps not. Let me know what you think, whether David and I gave a fair and balanced review. And as always, I hope that you live long and well, and that these drugs are an important and growing part of our toolbox for health. Thanks so much for listening to Live Long and Well with Dr. Bobby. If you like this episode, please provide a review on Apple or Spotify or wherever you listen. If you want to continue this journey or want to receive my newsletter on practical and scientific ways to improve your health and longevity, please visit me at Dr. Bobby Livelong and Well dot com. That's doctor as a D R Bobbi Livelong and Well.com.