Weighty Matters: The Ethical Challenges of Using Injectables to Fight Obesity and Overweight with Arthur L. Caplan, PhD

Transcript

• 00:00You need to sign, and
• 00:01then we're trying to get
• 00:02more,
• 00:03we're trying to get better
• 00:04at making sure we get
• 00:05the sign on. So there
• 00:05is the sign in sheet.
• 00:06It's right behind that wall
• 00:08on the other side where
• 00:09the vegetarian sandwiches are. We
• 00:11figured that would be a
• 00:11less crowded spot,
• 00:13so you guys can go
• 00:14there and sign up.
• 00:16The way it's gonna work
• 00:17tonight is that as soon
• 00:19as I'm done with just
• 00:20some introductory remarks,
• 00:21professor Kaplan is gonna speak
• 00:23for plus or minus about
• 00:24forty five minutes. And then
• 00:26I'm gonna come back up
• 00:27here, and we'll sit together,
• 00:29and I will,
• 00:30moderate and entertain your questions
• 00:32for doctor Kaplan,
• 00:34who's already told me I'll
• 00:35clue you in because,
• 00:38I think most of you
• 00:38in the audience know that
• 00:39that professor Kaplan is
• 00:41is a is a highly
• 00:43regarded authority on many aspects.
• 00:44Is this yours, Art?
• 00:46This is mine. Okay. Be
• 00:47careful. No problem. I don't
• 00:48wanna spill your water. Alright.
• 00:49So if you if your
• 00:51question is to wander off
• 00:52the topic of the talk,
• 00:53no one's gonna shout at
• 00:54you or shoot you. But
• 00:55the talk itself is actually
• 00:57a fascinating topic, so I'm
• 00:58looking forward actually to hearing
• 01:00the talk as well as
• 01:01our conversation. But let me
• 01:02introduce you to my friend,
• 01:04a man who's been a
• 01:05mentor to bioethicists
• 01:06all over the country as
• 01:07well as the general public,
• 01:09including some of our leadership
• 01:10group here and myself,
• 01:12professor Art Caplan from New
• 01:14York University.
• 01:15Now Art,
• 01:17has, had a prodigious career
• 01:19in bioethics. It started, of
• 01:20course, when it was hardly
• 01:22even a thing.
• 01:23It was just kinda starting
• 01:24to be a thing and
• 01:25certainly within medical centers. We
• 01:27just found out tonight that
• 01:28we actually overlapped at Columbia,
• 01:30just after the civil war.
• 01:32I think Grant was president
• 01:33when we did that. So
• 01:34we were at Columbia together
• 01:36briefly, and and,
• 01:38and since then, he's had
• 01:39an an extraordinary career.
• 01:41He has taught in many
• 01:42places, including at Columbia. He
• 01:44started the bioethics center at,
• 01:45I think, Minnesota,
• 01:47as well as he started
• 01:48the bioethics center at University
• 01:49of Pennsylvania
• 01:50where he was on faculty
• 01:51for many years. He started
• 01:53the bioethics program at NYU,
• 01:56at the medical school there,
• 01:58where he's currently
• 01:59the Walter f and Virginia
• 02:00Connolly Mitty professor,
• 02:03of bioethics and, the director
• 02:05of the program there. He
• 02:07has many of you might
• 02:08recognize him or might have
• 02:10heard his name. He's he's
• 02:11that rarest of individuals who
• 02:13is very highly regarded, not
• 02:15just within academics,
• 02:17but also,
• 02:19within the public at large.
• 02:20So you will hear Art
• 02:22on the radio in New
• 02:23York, in Boston, in Los
• 02:25Angeles. You'll see him from
• 02:26time to time on TV
• 02:27when important bioethics issues are
• 02:29in the news. He's kind
• 02:30of the go to guy,
• 02:32as I say, both for
• 02:33the general public and the
• 02:35media as well as within
• 02:36the academy,
• 02:37which is quite unusual, which
• 02:39in fact, I think within
• 02:40our field, may be close
• 02:41to unique.
• 02:43Art is gonna speak to
• 02:44us tonight on weighty matters,
• 02:46the ethics of using ingest
• 02:48injectable drugs for the treatment
• 02:50of obesity.
• 02:52And so Art's gonna talk
• 02:53for about forty five minutes,
• 02:54and I'll come up, and
• 02:55we'll all have a conversation.
• 02:56So with that, I turn
• 02:57this over to professor Art
• 02:59Caplan.
• 03:01Thank you.
• 03:04Well, it's a real pleasure,
• 03:06to be here with,
• 03:08a lot of former
• 03:09students.
• 03:11Some people I've worked with,
• 03:13as faculty, done research with.
• 03:17Great to see Mark, who
• 03:18I've known for,
• 03:20as he said, longer than
• 03:22we thought. We we didn't
• 03:23realize we we overlapped,
• 03:26way back when at Columbia.
• 03:27He was asking me a
• 03:28little bit about how I
• 03:30got interested in
• 03:31bioethics, and I'll spend a
• 03:33second
• 03:34just telling you about that
• 03:35because it's got
• 03:37a little bit of timeliness
• 03:38to that public side
• 03:40of bioethics things.
• 03:43When he and I were
• 03:44there,
• 03:45I witnessed
• 03:46a very interesting
• 03:47incident
• 03:48in a hallway.
• 03:50Those of you who are
• 03:51medical students or in medicine
• 03:53know that
• 03:54seniority and expertise a little
• 03:56bit is indicated by the
• 03:58length of your coat. Right?
• 04:00So some guy came down
• 04:02the hall with a really
• 04:03short lab coat,
• 04:05getting yelled at by another
• 04:06guy who had, like, a
• 04:07wedding train
• 04:09of a coat. I mean,
• 04:10it was like it was
• 04:11big.
• 04:12And, the first guy was
• 04:14named Landrum Shuttles,
• 04:15and the second guy was
• 04:16named Marie VanderWeele.
• 04:18And the first guy had,
• 04:22been trying for a couple
• 04:23of
• 04:24months
• 04:25to create an embryo
• 04:28in a dish.
• 04:29It was an attempt to
• 04:30do the first IVF experiment.
• 04:33And Ray VanderWeele,
• 04:34who was the head of
• 04:35OB GYN,
• 04:37basically, was a pretty religious
• 04:39Catholic and did not approve
• 04:41of that experiment,
• 04:42didn't know
• 04:43shuttles had been doing it,
• 04:46and had
• 04:47gone in the lab
• 04:49and thrown it down the
• 04:50drain.
• 04:53So that's what they were
• 04:54yelling at each other about
• 04:55in the hall,
• 04:56and I was pinned against
• 04:57the wall just watching this
• 04:59like some nudnik, you know.
• 05:01But I thought,
• 05:02that's pretty interesting.
• 05:04When are we gonna talk
• 05:05about that? That's that's an
• 05:07interesting,
• 05:08issue.
• 05:09And so I went and
• 05:11saw my dean of students
• 05:12at Columbia,
• 05:13another guy that Mark and
• 05:15I knew in common,
• 05:17Bernard Schoenberg, and he said,
• 05:19you just go ask your
• 05:20attending.
• 05:22I don't know what it's
• 05:23like today for med students
• 05:24at Yale. But if I
• 05:26went to ask my attending
• 05:27about the ethics of anything
• 05:29at Columbia at that period
• 05:30of time, I would have
• 05:32been a former medical student
• 05:34at Columbia
• 05:35for sure,
• 05:37like, really getting into their
• 05:38morals. Let's put it that
• 05:39way.
• 05:40But I decided at that
• 05:42point,
• 05:43stimulated by one other event,
• 05:45when I was little, I
• 05:46had polio. That's why you
• 05:47see me running around with
• 05:48these walkers and not so
• 05:50mobile.
• 05:51I was in the last
• 05:52outbreak
• 05:53of polio in Boston where
• 05:55I grew up later to
• 05:57move to Framingham.
• 05:59And,
• 06:01during that period of time,
• 06:02I missed the introduction of
• 06:04the
• 06:05Salk vaccine, I would
• 06:07say, two weeks
• 06:09later it came.
• 06:10And so I got sick
• 06:12right before,
• 06:13that happened.
• 06:14And I spent a lot
• 06:15of time,
• 06:16in the hospital,
• 06:18Boston Children's.
• 06:20And,
• 06:21I can tell you that,
• 06:22nobody knew what to do
• 06:24about polio.
• 06:25Nobody.
• 06:26There was nothing to do.
• 06:27Had no cures. No nothing.
• 06:29Some kids got it in
• 06:30their diaphragm,
• 06:32the muscle that drives your
• 06:33lungs up and down, that
• 06:35became paralyzed. They went into
• 06:36a primitive ventilator known as
• 06:38the iron lung. Some of
• 06:40you may have seen pictures
• 06:41of it. Some of them
• 06:42just died.
• 06:43And,
• 06:45I was paralyzed in the
• 06:46legs and, in the neck,
• 06:49and that got better
• 06:51eventually. In fact, I remember
• 06:52the day it got better.
• 06:53I was getting a bath,
• 06:55and the nurse was bathing
• 06:56me, and I decided,
• 06:58I think I've got some
• 06:59strength back
• 07:01in my little, whatever it
• 07:02was, six year old mind.
• 07:04And I jumped up and
• 07:05tried to climb out of
• 07:06the tub, and it led
• 07:08to, like, a riot. I
• 07:09mean, people were coming in.
• 07:10You can't do this. You
• 07:11can't and I'm slippery.
• 07:15It was sort of an
• 07:16ethics issue.
• 07:18Sorry.
• 07:19But what I wanted to
• 07:20stress to you was I
• 07:22know the power of vaccines.
• 07:24And so
• 07:25part of the reason I
• 07:26got into bioethics
• 07:28was I remember the kids
• 07:29who died.
• 07:30I remember the kids who
• 07:32stayed deformed, paralyzed. You know,
• 07:34you went to PT for
• 07:35a long time
• 07:36after,
• 07:38you got polio.
• 07:39And I sort of told
• 07:41myself I would do something
• 07:43because of those events.
• 07:45So I I can't say
• 07:46I was best friends with
• 07:47a lot of the kids.
• 07:48We moved around a lot.
• 07:51As I say, some of
• 07:52them went down to a
• 07:53different floor for the iron
• 07:54lung. Some of them just
• 07:55died.
• 07:57But when I see the
• 07:59country
• 08:00taking an anti vaccine
• 08:02attitude today,
• 08:03when I listen
• 08:05to the perspective
• 08:06appointment
• 08:07of RFK junior
• 08:10to run anything
• 08:12with an in health, with
• 08:14an anti vaccine
• 08:16stance,
• 08:18it irritates me. And so
• 08:21I'm being kind.
• 08:25So those events,
• 08:26polio,
• 08:27its impact, its aftermath, watching
• 08:30it get fixed,
• 08:32basically, and prevent it later,
• 08:35that drove me into bioethics.
• 08:37And as I said,
• 08:39watching some of the things
• 08:40that were taking place
• 08:42clinically
• 08:43and wondering,
• 08:45how could we get them
• 08:46discussed.
• 08:47So as all of you
• 08:48know in the room, particularly
• 08:50those of you who are
• 08:50minors in bioethics,
• 08:52there are bedside issues.
• 08:54There are really interesting questions
• 08:56that come up
• 08:58about,
• 08:59life and death, about privacy,
• 09:01about relationships
• 09:03between,
• 09:05doctors and patients.
• 09:06And there are many interesting
• 09:08issues that come up on
• 09:09the public,
• 09:10health side.
• 09:11But one of the major
• 09:13ones over the years that
• 09:14just didn't seem to pull
• 09:16much attention
• 09:17was the challenge of obesity.
• 09:20And I'm not sure why
• 09:22it never really hold
• 09:24much attention.
• 09:26In some ways, nutrition, food,
• 09:28eating,
• 09:30even thinking a little bit
• 09:31about lifestyle and prevention,
• 09:33there weren't major pushes
• 09:35within,
• 09:36the way we've structured American
• 09:38health care.
• 09:40We certainly are pretty good
• 09:41at rescue and therapy,
• 09:43and we have a kind
• 09:44of,
• 09:46pulling back from, dead
• 09:48dread disease mentality,
• 09:51that,
• 09:52in many ways is why
• 09:53it's expensive, but it's also,
• 09:55I think, in many ways,
• 09:56an interesting
• 09:58moral commitment.
• 09:59But trying to do something
• 10:01about the cause of many
• 10:03of our ailments with obesity,
• 10:06I would say no. Not
• 10:07on the front burner,
• 10:09not on the back burner,
• 10:11not much in the room.
• 10:14We had a similar phenomenon
• 10:16I'm gonna tell you about
• 10:17at many years ago,
• 10:18and that was sexual dysfunction.
• 10:21And people don't like to
• 10:21talk about that, and you're
• 10:23gonna hear about that
• 10:24a little bit in my
• 10:25talk today
• 10:27because
• 10:27it was embarrassing.
• 10:29They didn't quite know how
• 10:31to
• 10:33discuss it with people
• 10:34for whom there weren't many
• 10:36treatments, reminding me a lot
• 10:38of my experience with polio,
• 10:40which is probably why I
• 10:41was drawn to pay attention
• 10:42to the diseases that don't
• 10:44get attention.
• 10:47And then suddenly,
• 10:50drugs appeared that provided treatment.
• 10:52And actually going back a
• 10:53little further,
• 10:55pills appeared that allowed you
• 10:56to control reproduction.
• 10:58And things changed. And
• 11:01if you will, sex and
• 11:02reproduction began to move into
• 11:04the curriculum, began to get
• 11:06discussed a lot more. Well,
• 11:08that's what's happening a little
• 11:09bit with obesity.
• 11:11I'm saying that knowing
• 11:13that,
• 11:15my friend Sarah Ho was
• 11:16out there. We did try
• 11:17to write at least one
• 11:18article in the American Journal
• 11:19of Cardiology
• 11:20saying eat the vegetarian stuff.
• 11:24I think that was a
• 11:25couple years. I don't know
• 11:26if it's
• 11:27made a huge impact, but
• 11:29tried.
• 11:30But that was pre the
• 11:31injectable.
• 11:32Now the question comes up,
• 11:34and I won't keep you
• 11:35in suspense, one of the
• 11:36big
• 11:37philosophical
• 11:38deep questions.
• 11:40Are we gonna live a
• 11:41life
• 11:42on drugs
• 11:43to control our weight?
• 11:47Is that a good thing
• 11:48to do? Is that something
• 11:50that can be a lifestyle
• 11:52and
• 11:53append to that,
• 11:55still,
• 11:56more or less, eat what
• 11:57we want,
• 11:59grow the kind of food
• 12:00that we continue to grow
• 12:01that causes great
• 12:03environmental damage,
• 12:05animal suffering, many reasons
• 12:07not to pursue the diet
• 12:09that we do
• 12:11in many many of us,
• 12:12not all of us, but
• 12:13many, and many around the
• 12:15world.
• 12:17There's a real
• 12:18harsh philosophical,
• 12:21challenge.
• 12:22You've got drugs. Right now,
• 12:23they're injectable. I expect them
• 12:25to become pills
• 12:26soon enough,
• 12:28and, therefore, even of more
• 12:30attractiveness
• 12:31to people who don't like
• 12:32needles and don't like taking
• 12:34a needle every week.
• 12:35But let's imagine down the
• 12:37road, what if you could
• 12:38do it once a month
• 12:39and swallow a pill and
• 12:41not do it because you're
• 12:42obese, but do it because
• 12:43you don't wanna become obese?
• 12:47Are we gonna move in
• 12:48that direction?
• 12:49And that's part of where
• 12:51this talk is gonna end
• 12:52on the
• 12:53philosophical question.
• 12:55Is that a good life?
• 12:56Is that a way to
• 12:57be?
• 12:58I will keep you in
• 12:59suspense a little bit about
• 13:01what I think the answer
• 13:02is, but it's whether you
• 13:03wind up agreeing with me
• 13:05or not, it's something I
• 13:06think
• 13:07we have to take seriously
• 13:09and think about,
• 13:10very carefully.
• 13:12Now through the magic of
• 13:14something or other, somebody's out
• 13:15there who's gonna hear me
• 13:16in the next slide.
• 13:18And this is one of
• 13:20the great achievements of bioethics.
• 13:22This is the disclosure slide.
• 13:26People like Jen Miller have
• 13:27carved a career out of
• 13:29this slide.
• 13:31It's a conflict of interest
• 13:32disclosure,
• 13:33and it basically says, you
• 13:35know, what might I be
• 13:37doing
• 13:38that
• 13:38shapes or influences,
• 13:41what I say to you?
• 13:42And I tried to build
• 13:44a website, which you could
• 13:45go Google. If you Google
• 13:47me, there's a web electronic
• 13:49long form that tells you
• 13:51everything I do
• 13:52and tries to explain why
• 13:54I do it and goes
• 13:55past just financial things.
• 13:58The only conflict I have
• 14:00here
• 14:01today is that I really
• 14:03like carbohydrates.
• 14:05Next slide.
• 14:09America,
• 14:10as I think everybody in
• 14:12the room knows,
• 14:13is dangerously
• 14:15fat. And, I use that
• 14:16word deliberately to get your
• 14:19attention.
• 14:19We're among the most obese
• 14:21nations on the planet.
• 14:24Way back in, twenty eighteen,
• 14:26forty two percent
• 14:27of us were obese.
• 14:29Nearly,
• 14:30ten percent of whom were
• 14:31severely obese. It's gotten worse
• 14:34than that number.
• 14:37Obesity increases the risk of
• 14:40lots of diseases. They're listed
• 14:42there. You can look at
• 14:43them.
• 14:45Disturbingly,
• 14:45twenty percent of adolescents are
• 14:47obese,
• 14:48three times as many as
• 14:50were in the mid seventies.
• 14:51If you watch old movies,
• 14:54go back and look at,
• 14:55things that were popular,
• 14:58going to, movie theaters. These
• 15:01were large places where things
• 15:03were displayed on screens.
• 15:08But if you look at
• 15:09the things that were in
• 15:10the movies at that time,
• 15:12everybody's skinny. You just look
• 15:14at the people and it's
• 15:15amazing
• 15:16how much bigger everybody is
• 15:18today
• 15:19than what you would have
• 15:20seen
• 15:22back in the day.
• 15:24So obesity has gotten progressively
• 15:26worse and worse. Next slide.
• 15:29How fat are we? Well,
• 15:30the military in this country
• 15:32is dealing with obesity rates
• 15:34that have been soaring
• 15:36and posing all kinds of
• 15:37challenges,
• 15:39it's harder for them to
• 15:40find people who can serve
• 15:42because they can't meet the
• 15:44physical requirements of weight and
• 15:45fitness for enlistment.
• 15:48Obesity rates among active duty
• 15:51service members doubled in the
• 15:53past decade
• 15:54according to a report that
• 15:55I got a hold of
• 15:56from something called the American
• 15:58Security Project.
• 16:01They jumped from ten point
• 16:02four percent in twenty twelve
• 16:04to twenty one percent in
• 16:06twenty twenty two. That's people
• 16:08not making
• 16:09basic weight
• 16:11requirements
• 16:12to be in the marines,
• 16:13in the army, or the
• 16:14coast guard, or whatever.
• 16:17Sixty eight percent
• 16:19of active duty service members
• 16:21were either overweight or obese.
• 16:23I happen to have family
• 16:26members who are in the
• 16:27military,
• 16:28and they are very concerned
• 16:31about, you know,
• 16:33maintaining physical activity
• 16:35and, trying to pay attention
• 16:37to diet. You forget that
• 16:38this is an important requirement
• 16:40both for recruitment
• 16:42and for staying in the,
• 16:44service
• 16:45and being allowed to get
• 16:47your pay and being allowed
• 16:48to get your benefits
• 16:50and so on. And that's
• 16:51just one
• 16:52profession I wanna point out
• 16:54to you that has to
• 16:56struggle with obesity.
• 16:57Next slide.
• 16:59As I said, it isn't
• 17:00just us.
• 17:02The percent of people obese
• 17:03in some other parts of
• 17:04the world is
• 17:05amazing.
• 17:07American Samoa, seventy five percent.
• 17:09Tonga, seventy one percent with
• 17:11women at eighty one percent.
• 17:13We're down there at forty
• 17:14three. And I put Denmark
• 17:16up there even twenty percent
• 17:18because that is the home
• 17:19of Novo Nordisk,
• 17:21which is the company
• 17:23that makes Wegovy and
• 17:26Cepound, I think, one other
• 17:27injectable,
• 17:29and we'll hear about Denmark
• 17:30a little bit more.
• 17:31But,
• 17:32obesity
• 17:33is a big prob sorry.
• 17:36Large no. Sorry.
• 17:40It's a problem in many
• 17:41countries,
• 17:42many, many parts of the
• 17:43world, Mexico, India. China has
• 17:46growing obesity.
• 17:47So, it isn't just us,
• 17:49but it is us. Next
• 17:51slide.
• 17:53Four billion people are projected
• 17:54to be overweight or obese
• 17:56by twenty thirty five.
• 17:58That would be
• 17:59half the world's population.
• 18:03And here's the said news.
• 18:04Remember I said,
• 18:06we weren't paying much attention
• 18:08to obesity
• 18:09in health care,
• 18:10in teaching about health for
• 18:12a long time,
• 18:14as I've watched the, medical
• 18:16school side of the street.
• 18:18But today,
• 18:19nothing has really slowed this
• 18:21growth in obesity
• 18:23anywhere.
• 18:24And I mean not dieting,
• 18:26and I mean not exercise
• 18:28programs.
• 18:29I mean not,
• 18:31Oprah Winfrey endorsing,
• 18:33you know, different,
• 18:35weight loss companies and strategies,
• 18:37calorie counting, diaries,
• 18:40bariatric surgery.
• 18:42Mm-mm.
• 18:43The trends keep growing. I
• 18:45don't wanna say they fail
• 18:46for every individual. That's not
• 18:48true.
• 18:49But overall,
• 18:51it's just an explosion
• 18:53that nothing today has been
• 18:55able to tempt out, much
• 18:57less reverse.
• 18:59Next slide.
• 19:03Just changed.
• 19:05Here come in the weight
• 19:07loss battle twenty twenty one,
• 19:09first approval by FDA Wegovy,
• 19:12specifically
• 19:13for weight management in adults
• 19:15with obesity and overweight who
• 19:17have at least one
• 19:19medical condition that's associated with
• 19:21overweight,
• 19:22high blood pressure,
• 19:24type two diabetes,
• 19:25or high cholesterol.
• 19:27Other,
• 19:30injectables
• 19:31are coming right behind.
• 19:34There was even an approval
• 19:35for children twelve and over,
• 19:38in December twenty twenty two.
• 19:40And
• 19:41we should remember, in the
• 19:43world that we're in,
• 19:44it's great to have a
• 19:46prescribed injectable for a medical
• 19:48indication,
• 19:49but there are many people
• 19:51who are online
• 19:53getting access to who knows
• 19:55what,
• 19:57touted as equivalents
• 19:59or
• 20:02just as good products,
• 20:04that will lose weight that
• 20:05they get that are cheaper.
• 20:07Sometimes they're brewed up by
• 20:09specialty pharmacies.
• 20:10The FDA just this week
• 20:12has been trying to chase
• 20:13down
• 20:14some of the American specialty
• 20:15pharmacies, but they're all over
• 20:17the Internet, and they're located
• 20:19all over the world.
• 20:20Sketchy wellness clinics
• 20:23make their own stuff and
• 20:24give it to people. It's
• 20:26cheaper. And so for a
• 20:27lot of people, the injectables
• 20:28are too expensive. You'll see
• 20:30in a minute. But for
• 20:31some people, they turn,
• 20:34to often dangerous and risky
• 20:37alternatives
• 20:38that are out there in
• 20:39a big way.
• 20:41But a big change.
• 20:43The proverbial
• 20:45magic bullet
• 20:46appears.
• 20:47Can't do anything, laid out
• 20:49of control.
• 20:50People
• 20:51just don't find it find
• 20:53themselves able to do the
• 20:55lifestyle changes
• 20:56that it might take.
• 20:58And
• 20:59all of a sudden,
• 21:01unexpectedly,
• 21:02except by people who are
• 21:04really tracking
• 21:05work with some of the
• 21:06ingredients of those drugs,
• 21:09they appear. Next slide.
• 21:12And I mentioned their crooks
• 21:14and shysters galore out there
• 21:16selling
• 21:17bad stuff. I just want
• 21:18you to keep that in
• 21:19mind because it's a problem
• 21:20when the injectables appear,
• 21:23so does the underground,
• 21:24so does the black market,
• 21:26and access and insurance
• 21:28drive
• 21:29a lot of ethics questions
• 21:30about
• 21:31are people gonna go elsewhere
• 21:33because they are so desperate
• 21:35to get access to these
• 21:37drugs.
• 21:38Next slide.
• 21:41Well
• 21:42oh, again,
• 21:43I'm going on here about,
• 21:45counterfeits,
• 21:46and and just saying,
• 21:48you don't understand
• 21:50necessarily how desperate people are
• 21:53to take these things. And
• 21:54not just people who are
• 21:56fat, these are people who
• 21:57don't wanna become fat.
• 22:00I believe that describes
• 22:02the world's population.
• 22:04Next slide.
• 22:07So a lot of,
• 22:09more mainstream and legitimate organizations
• 22:11have pronounced
• 22:13that this is the cure.
• 22:14This is the panacea.
• 22:16This is it. The injectables
• 22:18are the start down the
• 22:19road
• 22:21to cure, get rid of
• 22:22obesity.
• 22:23It could spell, says The
• 22:25Economist,
• 22:27very,
• 22:28respected British publication, the end
• 22:30of global obesity.
• 22:32Okay?
• 22:34Bill Hazeltyne, an old buddy
• 22:36of mine, esteemed,
• 22:37geneticist,
• 22:39wrote in Forbes,
• 22:41it's absolutely the, end of
• 22:43obesity.
• 22:44IPVIA, which is a,
• 22:47health
• 22:48consulting,
• 22:49organization that kinda predicts trends
• 22:51in health care,
• 22:53kind of like in a
• 22:54center or being one of
• 22:55those organizations.
• 22:57I just read their report.
• 22:58Just came out recently.
• 23:00The obesity market continues its
• 23:03spectacular
• 23:04ascent.
• 23:05Don't use that kind of
• 23:06language very often about anybody's
• 23:08drug.
• 23:08Twenty twenty five will be
• 23:10another momentous
• 23:11year
• 23:12in this remarkable journey of
• 23:14the,
• 23:16use of the injectables.
• 23:18It will offer a glimpse
• 23:19into the future, pay attention
• 23:21med students,
• 23:22as key trends play out
• 23:23that will shape how obesity
• 23:25is viewed,
• 23:27diagnosed,
• 23:27and treated. When you have
• 23:29a treatment,
• 23:31you are taking away the
• 23:32stigma
• 23:33of the disease, and I'm
• 23:35gonna show you that a
• 23:36little bit.
• 23:39Health care systems are gonna
• 23:40have to grapple with this
• 23:41formidable change in what people
• 23:43are doing.
• 23:44I mean,
• 23:47it looks like a good
• 23:48thing and people losing weight,
• 23:50but there are many reasons
• 23:51to be concerned and a
• 23:53need to monitor,
• 23:55survey, and perhaps even still
• 23:57encourage
• 23:58lifestyle change
• 24:00even with these drugs around.
• 24:02Next slide.
• 24:04What kind of savings? Well,
• 24:06heart disease is costing us,
• 24:08just in the US,
• 24:10hundreds of billions of dollars.
• 24:13Cancer related to obesity
• 24:15is costing us hundreds of
• 24:17billions of dollars.
• 24:19So these are estimates
• 24:21of what the obesity
• 24:22burden is,
• 24:25from
• 24:26agencies that I have to
• 24:28throw this politics in. I'm
• 24:29sorry.
• 24:30You may not see numbers
• 24:31like this for a little
• 24:33bit
• 24:34because,
• 24:35the administration just decided they
• 24:37wanted you those outfits to
• 24:39stop publishing
• 24:40their numbers.
• 24:42So there's a pause right
• 24:43now on, some of these
• 24:45outlets. But when they were
• 24:46telling us things,
• 24:48it was pretty clear that
• 24:49there are savings to be
• 24:50had. We could reduce weight.
• 24:52Next slide.
• 24:56Since I live in Ridgefield,
• 24:57Connecticut and you are all
• 24:59here,
• 24:59I couldn't resist
• 25:01a little angle into Connecticut.
• 25:03Local affairs are always interesting.
• 25:06So
• 25:07how much do Ozempic and
• 25:08Mogovy cost the Connecticut taxpayer,
• 25:11projected in the, last half
• 25:14of last year and the
• 25:15first half of this year?
• 25:16Sixty million bucks right now.
• 25:19Like the blockbuster drugs of
• 25:20the past, Ozempic and its
• 25:22cousin
• 25:23that delivers diabetes control
• 25:26and weight loss for,
• 25:28medical indications
• 25:29have become more than just
• 25:30pharmaceuticals.
• 25:31Our state controller, Sean Scanlon,
• 25:33says
• 25:34they're a cultural
• 25:36phenomenon.
• 25:37And what he means is
• 25:40there are all kinds of
• 25:41people showing up at doctor's
• 25:42offices saying,
• 25:44I want this prescribed to
• 25:46me. And the doctor may
• 25:48say, you're diabetic,
• 25:50and you don't have,
• 25:52heart disease,
• 25:53and you don't have hypertension.
• 25:56And the response
• 25:57is, well, I'm going to
• 25:59another doctor until I get
• 26:00it.
• 26:02And that's
• 26:03really out there in a
• 26:04big way. Next slide.
• 26:07The trend matters to Scanlan
• 26:09trying to manage the health
• 26:10care plan for us,
• 26:12state employees,
• 26:13retirees, their dependents, those people.
• 26:17As I said, he expects
• 26:18that sixty million dollars. And
• 26:20then,
• 26:22I said, wow. Sixty million.
• 26:24That's one eighth of the
• 26:25entire pharmaceutical
• 26:27spend
• 26:28for the two hundred and
• 26:28fifty thousand people who are
• 26:30on the Connecticut public plan,
• 26:32those pensioners and state employees.
• 26:35It's expected to hit four
• 26:37hundred and eighty three million
• 26:39by
• 26:40June for the whole
• 26:42thing. So
• 26:43this thing is creeping in
• 26:45and starting to really impact
• 26:47the state budget, and I
• 26:49can assure you that that's
• 26:51going on at the state
• 26:52level
• 26:53everywhere.
• 26:54Next slide.
• 26:57Well, the next question is
• 26:59the injectables. People say they
• 27:00work. Do they work? Yes.
• 27:02They do work. They've been
• 27:03found to decrease obesity
• 27:05twenty to fifty percent in
• 27:07many,
• 27:08patients.
• 27:09It's reasonable to conclude that
• 27:10they will make a significant
• 27:12proportion of people
• 27:13with obesity
• 27:14or who have,
• 27:16obesity related diseases like diabetes,
• 27:19respond. There was a study
• 27:21out that I just got
• 27:22sent to me by former
• 27:23students at, well, Cornell, who
• 27:25know that I'm interested in
• 27:26all this. And what they
• 27:27did is they prescribed,
• 27:30injectables,
• 27:31for their diabetic patients who
• 27:33are about to undergo surgery
• 27:34for various,
• 27:36conditions.
• 27:37And they absolutely found that
• 27:38they reduced
• 27:40pre,
• 27:41get putting them on for,
• 27:43three months before they had
• 27:45their surgery,
• 27:46reduced readmissions,
• 27:48reduced wound complications,
• 27:50and hematomas.
• 27:52It was really it just
• 27:53came out in the annals
• 27:54of surgery.
• 27:55A lot of cases, a
• 27:56lot of numbers, good study,
• 27:58and it really helped,
• 28:01reduce,
• 28:02complications
• 28:03for diabetics
• 28:04who face surgery. So does
• 28:06this work? Yeah. Next slide.
• 28:11Alright.
• 28:12So to recap,
• 28:14couldn't do anything.
• 28:16Stigma.
• 28:17Didn't know how to talk
• 28:18about people who overweight. Remember
• 28:20all those,
• 28:21influencers who are online
• 28:23saying, I'm not fat. I'm
• 28:25just large. I can dance.
• 28:27I'm fit.
• 28:28Do not,
• 28:29stigmatize me. Don't shame me.
• 28:33Don't do anything. Oh, here
• 28:34come the injectables.
• 28:36I'm really fat. Can I
• 28:37get it?
• 28:39I mean, it's just a
• 28:40complete
• 28:41cultural change.
• 28:44I lived through one of
• 28:45these cultural changes.
• 28:47It was with
• 28:48the Agua.
• 28:50And,
• 28:51I can tell you it's
• 28:53somewhat
• 28:54predictive, I believe,
• 28:55of what may happen with
• 28:57our injectables.
• 28:58So in nineteen ninety eight,
• 29:00Pfizer got approval for Viagra.
• 29:04The year before that, nineteen
• 29:07ninety seven,
• 29:08I was,
• 29:10working at Penn,
• 29:12minding my own business, and
• 29:14I got a phone call
• 29:15from a guy at Pfizer.
• 29:17And this guy said,
• 29:19we need an ethicist.
• 29:22I said, you sure do.
• 29:28It didn't actually say that,
• 29:29but I thought it.
• 29:32And he said,
• 29:33we got this new
• 29:35drug.
• 29:36We're testing it to reduce
• 29:38blood pressure. You remember this
• 29:39is a drug that expands
• 29:42blood vessels,
• 29:43allowing blood to flow more
• 29:44easily.
• 29:45He said, it doesn't seem
• 29:47to work as a blood
• 29:48pressure medicine,
• 29:50but it does seem to
• 29:51work in raising something else
• 29:54up.
• 29:56That's his words.
• 29:58And I said,
• 30:00gee,
• 30:01I I don't know what
• 30:02the problem is. You know?
• 30:03Good luck to you.
• 30:05I don't see a big
• 30:06ethics issue here. He said,
• 30:08no. No. No. This is
• 30:09Pfizer. We are not in
• 30:10the reproductive
• 30:11or sexual medicine space.
• 30:14We are terrified that we're
• 30:15going to get into
• 30:17trouble.
• 30:18Religious and conservative backlash will
• 30:21come out against us saying
• 30:22we're promoting
• 30:23irresponsible
• 30:24sex,
• 30:26sex out of marriage,
• 30:28you know,
• 30:30all kinds of people,
• 30:32behaving irresponsibly,
• 30:33gay sex. It's it's gonna
• 30:35put
• 30:36the whole company,
• 30:38perhaps in a bad light,
• 30:39and we'd like you to
• 30:40come and tell us
• 30:41every problem you can think
• 30:43of that we should try
• 30:44to get ready for.
• 30:47So one thing I told
• 30:48them was,
• 30:49well, what's the disease you're
• 30:51treating?
• 30:53And they said, impotence.
• 30:55And I said, boy, I
• 30:56don't know. That may not
• 30:57be
• 30:59precise enough. And
• 31:01they came up with erectile
• 31:03dysfunction.
• 31:05And that got into the
• 31:06diagnostic manual and off they
• 31:08went.
• 31:09So I indirectly
• 31:12am the father of erectile
• 31:13dysfunction.
• 31:17Not only am I that,
• 31:18I am also,
• 31:21the person who said, if
• 31:22you wanna market this thing,
• 31:24you need to have someone
• 31:25who's
• 31:26reputable, trustworthy,
• 31:28and, will appeal to a
• 31:30broad spectrum of people. And
• 31:31that's why Bob Dole was
• 31:32there.
• 31:34I invented Bob Dole,
• 31:37indirectly
• 31:37by saying,
• 31:39you better get spokespeople with
• 31:40the right messaging that it's
• 31:42a medical problem with a
• 31:43medical treatment. You're not trying
• 31:45to promote,
• 31:46sex, and and,
• 31:49you don't have a sex
• 31:50pill, you've got a pill
• 31:51that treats a disease.
• 31:53Bob's saying there may take
• 31:54a little courage to ask
• 31:56your doctor about erectile dysfunction,
• 31:58but everything worthwhile
• 32:00usually does.
• 32:02Bob appeared in a lot
• 32:03of ads. He always appeared
• 32:05with his wife. His wife
• 32:06came out and said, hey.
• 32:08This is a great drive.
• 32:09I'm happy.
• 32:12And later,
• 32:14for those old timers, some
• 32:15of you may remember, every
• 32:16Pfizer ad
• 32:18began with a dancing couple
• 32:20where you could see their
• 32:21wedding ring.
• 32:23So the message was,
• 32:25we're not talking about gay
• 32:26people, and we're not talking
• 32:27about teenagers.
• 32:29Not talking about old guys
• 32:31taking this pill and visiting
• 32:32prostitutes.
• 32:34We're talking about married couples
• 32:35where the guy has a
• 32:37disease.
• 32:38And that's how they marketed
• 32:39it, and off they went.
• 32:41And, that's why,
• 32:43they they,
• 32:45launched it very successfully.
• 32:48By the way, they made
• 32:49a fortune.
• 32:51I, in doing what I
• 32:53believe was the first consultation
• 32:55by a bioethicist
• 32:56to a drug company,
• 32:59got lunch.
• 33:01Next slide.
• 33:03I didn't know what I
• 33:04was doing. It was like,
• 33:04this is so interesting. I
• 33:06guess I should just go
• 33:07and
• 33:08watch them cash their stock
• 33:09out.
• 33:13So that's the magic bullet
• 33:14from decades ago. But what
• 33:16happened to it? We all
• 33:18know.
• 33:19It now is marketed as
• 33:20a lifestyle drug to nervous
• 33:22anybody. I said thirty year
• 33:23olds.
• 33:25But I see it out
• 33:25there for people saying going
• 33:27on a date,
• 33:28maybe you wanna carry some
• 33:29of this with you even
• 33:31if you're nineteen.
• 33:34You can get it online.
• 33:36I decided to test this,
• 33:39and I wanna say I
• 33:40don't need it.
• 33:42But I decided to test
• 33:46going online, and they said
• 33:48doctor approved, consult with a
• 33:50doctor.
• 33:51You will get,
• 33:52Viagra or whatever it is.
• 33:54Tadalafinil
• 33:55sent to you,
• 33:57at your home, by the
• 33:59way, very discreetly,
• 34:01you know, brown wrapper, all
• 34:02that sort of thing.
• 34:04I'm sure the UPS and
• 34:06the Amazon guys are laughing
• 34:07their asses off, but,
• 34:09because they know where they're
• 34:10delivering. They see it all
• 34:11the time.
• 34:13But nonetheless,
• 34:15I had my prescription filled
• 34:18online within fourteen seconds of
• 34:20careful
• 34:21medical consultation.
• 34:24Nobody asked me why I
• 34:25had impotence.
• 34:27Nobody really cared if I
• 34:29had any other troubles, any
• 34:31contraindications,
• 34:32any,
• 34:34risk factors.
• 34:36I got my pills,
• 34:39and and off they went.
• 34:40So
• 34:42pretty easy to acquire.
• 34:44It's got very little medical
• 34:46connection.
• 34:48Most people who are getting
• 34:50treated are not
• 34:52being examined
• 34:53or prescribed anything. What I'm
• 34:55getting at is for the
• 34:56underlying
• 34:57condition.
• 34:58Are they diabetic?
• 34:59Is this an early sign
• 35:01of hypertension?
• 35:02Do they have atherosclerosis?
• 35:04Are they suffering in a
• 35:05bad relationship?
• 35:07Remember what I said before
• 35:09about going on
• 35:11injectables
• 35:11and not looking at the
• 35:13underlying
• 35:14problems?
• 35:16Oh, here is
• 35:18a drug
• 35:19that takes away the symptoms,
• 35:21and nobody examines the underlying
• 35:24problem. And I mean almost
• 35:26nobody. I don't mean nobody,
• 35:27but
• 35:28a lot of people are
• 35:29on these medications
• 35:31with nobody
• 35:33trying to figure out why
• 35:34they have an issue.
• 35:35And a lot of them
• 35:36even show up at doctor's
• 35:37offices and they get a
• 35:39prescription, and
• 35:40they get a small examination
• 35:42of why they might have
• 35:43these issues, but not really
• 35:46because the problem goes away.
• 35:48Next slide.
• 35:50This is the magic bullet.
• 35:51This is the Viagra of
• 35:53today.
• 35:54You got a world with
• 35:55no idea what to do
• 35:56about overweight, including even how
• 35:58to talk about it.
• 36:00Now not just the old
• 36:01obesity control that was the,
• 36:04impotence of Viagra,
• 36:06But now the prospect moves
• 36:08out for expanding the conditions
• 36:10very rapidly
• 36:12to lifestyle
• 36:13use
• 36:15across the board
• 36:16preventatively.
• 36:18If the Connecticut
• 36:21controller thinks he's got a
• 36:22financial problem now,
• 36:25just wait.
• 36:26Just wait.
• 36:28Overweight won't be a source
• 36:29of stigma, shame, or failure.
• 36:32The problem will hopefully
• 36:34greatly,
• 36:35diminish
• 36:36because we have the drug
• 36:37to manage it.
• 36:38Demand will be huge, and
• 36:40you can expect ads
• 36:42stoking more demand.
• 36:45They're already out there. I
• 36:46don't mean to say you
• 36:47don't see an ad for
• 36:49it. You have to be
• 36:50my age and watch the
• 36:51evening news of the network
• 36:53to see these ads.
• 36:55That means very few of
• 36:57you in this audience have
• 36:58seen them. But trust me,
• 36:59they're out there advertising down
• 37:01to an older,
• 37:03old guard crowd. Next slide.
• 37:06But they're gonna grow.
• 37:08Why? Because we live in
• 37:10a country that worships than
• 37:11this and of course,
• 37:12pathologizes
• 37:13or best ignores fat people.
• 37:15When injectable weight loss drugs
• 37:16become more affordable,
• 37:18weight loss will become perhaps
• 37:20even obligatory.
• 37:22Being thin will no longer
• 37:23be an accident of birth,
• 37:24a perk of wealth,
• 37:26or I should add a
• 37:27reward of, good, self control
• 37:29and lifestyle.
• 37:31It will just become a
• 37:32requirement.
• 37:33I think
• 37:34that opinion in the, Washington
• 37:36Post is right. Next slide.
• 37:39So what ethics issues come
• 37:41out of this
• 37:42prospect
• 37:44of
• 37:45the rapid explosion
• 37:47of what are now medically
• 37:49driven,
• 37:50but still,
• 37:52widely prescribed use of these
• 37:54injectables.
• 37:55They're gonna create, I think,
• 37:56a financial maelstrom
• 37:58that makes the Niagara's history
• 38:00pale, and the Niagara was
• 38:01a blockbuster drug in the
• 38:03billions of dollars.
• 38:06Explosions,
• 38:07you can imagine, in drug
• 38:08use
• 38:09for prevention, not or maintenance,
• 38:11not just for treating something.
• 38:13Marketing, questionable stuffs.
• 38:16Now it's all linked to
• 38:17medical conditions. I don't think
• 38:19it'll stay that way very
• 38:20long. It's gonna follow down
• 38:22the Viagra Road.
• 38:24A failure to really go
• 38:25after the underlying causes,
• 38:27I don't think that's good
• 38:28medicine,
• 38:29but I think it's a
• 38:30real danger that we start,
• 38:32if you will, to see
• 38:34it everywhere. I don't know.
• 38:35It's gonna go in the
• 38:35water supply. Maybe
• 38:37if RFK Junior has his
• 38:39way, it'll replace fluoride.
• 38:42That's a little inside baseball
• 38:43politics joke.
• 38:46But it's gonna be around
• 38:47in a big way.
• 38:49And that raises the question.
• 38:50Maybe I introduced you to
• 38:51those guys in the military.
• 38:55There's gonna be a lot
• 38:56of pressure to make use
• 38:57of this stuff mandatory
• 39:00mandatory.
• 39:01You wanna be in the
• 39:02army?
• 39:03You can't make weight? Why
• 39:04aren't you on this?
• 39:06Safe.
• 39:07Works.
• 39:08Get on
• 39:10it. Airlines,
• 39:12a lot of them have
• 39:12weight requirements for different occupations
• 39:15there. The fashion industry,
• 39:17you can make up your
• 39:18own list
• 39:19of where people are gonna
• 39:20say,
• 39:22you get on this and
• 39:22you maintain your weight, and
• 39:24we don't wanna deal with
• 39:25anybody who's getting
• 39:26overweight. Sports,
• 39:28there are a lot of
• 39:28places where I think the
• 39:30ethical question will become,
• 39:32how far can you go
• 39:34to mandate?
• 39:36Something to really think hard
• 39:37about where now we're thinking,
• 39:39I can't get it. It's
• 39:40a choice. I'm so desperate.
• 39:42Maybe I go offline
• 39:44underground and risk crummy products.
• 39:46That's not the future. The
• 39:48future is plenty of it
• 39:50shifting away from a medicalized
• 39:52prescription
• 39:54and people starting to feel
• 39:56that the shame comes from
• 39:58not using it. Who wouldn't
• 39:59use it
• 40:01and walk around
• 40:03obese in a world where
• 40:04people are getting thin.
• 40:08And I assume that they're
• 40:10gonna be used in children,
• 40:12which raise all manner of
• 40:13questions both about how you
• 40:15teach a child,
• 40:16what's the way to eat,
• 40:17behave, and live, and exercise,
• 40:19and,
• 40:20hopefully, maybe get off your
• 40:21phone or whatever,
• 40:23other lifestyle things might make
• 40:25for a good life for
• 40:26a kid.
• 40:27Adolescent use right now up
• 40:29six hundred percent, and that's
• 40:30in the morbidly obese adolescent.
• 40:35And I mentioned that people
• 40:36are gonna have to,
• 40:38maintain
• 40:39for jobs, appearance,
• 40:41huge issue in this celebrity
• 40:42driven culture, but it is
• 40:44in many other,
• 40:46cultures.
• 40:47So I think who's gonna
• 40:49wanna be on the future
• 40:50of the injectables or their
• 40:52likely
• 40:53pill descendants?
• 40:55I think just about every
• 40:56human being on Earth who's
• 40:57not a newborn or terminally
• 40:59ill.
• 41:01Is that possible? Next slide.
• 41:05Are we gonna live
• 41:06this way with this magic
• 41:08bullet?
• 41:09Are we headed toward a
• 41:10world in which we still
• 41:11eat what we want?
• 41:12Still having those carbs,
• 41:14maybe a little less because
• 41:15it makes us feel less
• 41:16hungry. But, nonetheless,
• 41:18we have our desserts. We
• 41:19have our, you know,
• 41:22chicken fried steak, just maybe
• 41:24smaller portions, but it doesn't
• 41:25make us fat because the
• 41:27injectables
• 41:27counteract that.
• 41:29Maybe we're a little,
• 41:31constipated or maybe
• 41:33we have some other
• 41:34dietary,
• 41:35side effects. But that's okay.
• 41:37You eat what you want.
• 41:39You don't have to exercise
• 41:41really like that anyway.
• 41:44So we're not gonna change
• 41:45much except we'll stay on
• 41:46the pills, and that'll tone
• 41:48down a little bit the
• 41:50weight consequences
• 41:51of maintaining
• 41:53an indulgent
• 41:54lifestyle.
• 41:56Is that even possible? Would
• 41:58we really live that way?
• 41:59Yeah. We do. Where do
• 42:01we? Sex.
• 42:03That's how we all live
• 42:04in our sex lives on
• 42:05drugs.
• 42:07What do we do? We
• 42:08take birth control, contraception.
• 42:11We take abortion drugs.
• 42:13We take erectile dysfunction drugs.
• 42:15We take ovulation boosters if
• 42:17we're,
• 42:18facing infertility.
• 42:20We take menopause hormones.
• 42:22We take retrovirals
• 42:23for sexually transmitted diseases. We
• 42:25use
• 42:26HPV.
• 42:27You live in a medicalized
• 42:29world of sex.
• 42:31It's everywhere.
• 42:33Drugs,
• 42:35vaccines.
• 42:37I think there's every reason
• 42:38to think
• 42:39that the obesity,
• 42:41drugs will move in
• 42:44exactly the same direction,
• 42:46and I fear it will
• 42:47do it without altering or
• 42:49changing
• 42:50the way agriculture,
• 42:52the way animals are used,
• 42:54the way we eat, to
• 42:55put it simply. Next slide.
• 42:59It's also gonna cost us
• 43:00a ton.
• 43:04I said we'd get savings,
• 43:06and we will, but that
• 43:06savings comes in the distance.
• 43:09But if one I'll give
• 43:10you this number. If one
• 43:11third of US obese or
• 43:12weight conscious people
• 43:14use injectables or people who
• 43:15have,
• 43:17obesity related disease,
• 43:18that would be a hundred
• 43:19million people. At current prices
• 43:22and use, that is one
• 43:23point five trillion dollars a
• 43:25year.
• 43:29Pretty good investment, by the
• 43:30way.
• 43:31Just saying.
• 43:32But
• 43:34that's even being a little
• 43:35conservative.
• 43:37We see right now a
• 43:38battle breaking out. Will the
• 43:40new administration
• 43:41overturn the old administration's
• 43:44attempt to put some of
• 43:45the injectables
• 43:46into price negotiation
• 43:48for some of our
• 43:49federal programs? And the answer,
• 43:51I think, is gonna be
• 43:52no. And I think the
• 43:54prices are not gonna drop
• 43:56due to competition.
• 43:58And I don't know if
• 43:58we'll get to one point
• 43:59five trillion, but
• 44:01looming out there are big
• 44:03expenses of the sort
• 44:05that we've never really encountered,
• 44:07and they also,
• 44:10mean worldwide
• 44:11cost because there are plenty
• 44:12of people worldwide
• 44:14who are gonna wanna use
• 44:15these drugs
• 44:16for prevention,
• 44:18maintenance,
• 44:19and treatment.
• 44:20Next slide.
• 44:22How big are the profits?
• 44:23You know what Novo Nordisk
• 44:25is now?
• 44:26It grew Denmark's gross national
• 44:29product by nearly two percent,
• 44:31and the boost is solely
• 44:33due
• 44:35to the sale of injectables.
• 44:38The country's,
• 44:39gross dash gross domestic product
• 44:41would have fallen,
• 44:43a little bit, says the
• 44:44government.
• 44:45Denmark is the first You've
• 44:47heard of the narco state?
• 44:48It's the first pharma state.
• 44:51Next slide.
• 44:54And this is just showing,
• 44:56another
• 44:57approach. Lily, basically, you don't
• 44:59have to read the slide,
• 45:00is setting up its own
• 45:01marketing system
• 45:03with people going online
• 45:04to use Lily products to
• 45:06recommend
• 45:07to people that they start
• 45:08to use the injectables. Again,
• 45:10right now, medically indicated
• 45:12pretty soon, it's gonna be
• 45:13just why don't you take
• 45:14it for prevention and maintenance
• 45:17and meet our
• 45:18online system
• 45:20and funnel that business
• 45:22into our,
• 45:24our version of injectables.
• 45:26Next slide.
• 45:27Oh, excuse me. I forgot
• 45:29one other fact. You don't
• 45:30have to go back. That's
• 45:31just a picture of the
• 45:34Lilly journey
• 45:35toward,
• 45:36starting to take care of
• 45:37your obesity, not your diabetes,
• 45:40by the way, or heart
• 45:41disease.
• 45:42Come meet us online.
• 45:44Lilly has said that in
• 45:46order to meet its demand
• 45:47for its drug,
• 45:49I,
• 45:50think they're Munjaro,
• 45:51I believe.
• 45:52Sorry if I get this
• 45:53mixed up.
• 45:55They have built right now
• 45:57six more factories to make
• 45:59it, and they are going
• 46:00to ultimately build thirteen new
• 46:02factories.
• 46:03Factories cost about a billion.
• 46:07They think there's gonna be
• 46:08demand out there. Next slide.
• 46:12Bernie Sanders did try to,
• 46:14get into a fight trying
• 46:15to use one of the
• 46:16great arguments to drug companies,
• 46:19shame,
• 46:20to try and reduce price.
• 46:22I love shame. I'm a
• 46:23big proponent of it. Doesn't
• 46:25work so well.
• 46:26I feel bad.
• 46:28Price stays the same. Next
• 46:30slide.
• 46:34Oh, and this is what
• 46:35I just told you about,
• 46:37Biden trying to get the
• 46:38drug on the list
• 46:40to make it part of
• 46:41at least some negotiation over
• 46:42price within some part of
• 46:44the
• 46:45federal system that doesn't cover
• 46:47private insurance and many other
• 46:48outlets.
• 46:50Next slide. And I don't
• 46:51think the current administration
• 46:53is, going to go there.
• 46:55So remember, Viagra,
• 46:57I think,
• 46:58the current companies will be
• 46:59pushing
• 47:00telemarketing
• 47:01schemes to really drive demand
• 47:04with their particular injectable.
• 47:06I think you will see
• 47:08messaging that says,
• 47:09this isn't just for people
• 47:10who are diabetic
• 47:12or, who have heart disease.
• 47:14This is for you
• 47:16to maintain your appearance. This
• 47:17is for you to keep
• 47:18your job.
• 47:19This is for you if
• 47:20you wanna look good. This
• 47:22is for you if you
• 47:22wanna keep living a lifestyle
• 47:24that you don't have to
• 47:25change. You're gonna wind up
• 47:26having lower appetite. That's part
• 47:28of what the drug does,
• 47:30But you can still do
• 47:31more or less what you
• 47:33want
• 47:34in terms of, the kitchen
• 47:35and cooking and culture.
• 47:37And if that's true,
• 47:39then we're still stuck with
• 47:40the same wasteful,
• 47:43not environmentally
• 47:44friendly,
• 47:45system
• 47:46of,
• 47:47making food
• 47:49that we have not,
• 47:50fixed. And this gives us,
• 47:52perhaps,
• 47:53even less reason to go
• 47:54fix it. Next slide.
• 47:58There are other ethics concerns
• 48:00out there, and this will
• 48:01be my last slide.
• 48:03I mentioned the mandates. I
• 48:05mentioned
• 48:06pressure
• 48:07to use.
• 48:08I mentioned tipping over our
• 48:10costs
• 48:11if we really expand and
• 48:13we don't drive price
• 48:14in any way that is
• 48:15reasonable. And that would mean
• 48:17taking it from about a
• 48:18thousand dollars a week from
• 48:19an injectable,
• 48:21maybe to something like
• 48:22twenty bucks.
• 48:24Any hands here who think
• 48:25the drug companies are gonna
• 48:27go that route?
• 48:30Thank you.
• 48:32Yeah. I didn't even have
• 48:33to come and talk about
• 48:34it. I already knew.
• 48:36Will the efficacy last? It's
• 48:37possible
• 48:38you take these drugs and
• 48:39maybe after some years, they
• 48:42body adjust to them. I
• 48:43don't know. And they don't
• 48:44work anymore, so we all
• 48:45got excited. But then we're
• 48:47stuck having an outlay, but
• 48:48it doesn't really happen.
• 48:50What are the risks for
• 48:51long term use? Who knows?
• 48:52They haven't been around very
• 48:53long.
• 48:54A lot of kids are
• 48:55already on them. More kids
• 48:57are likely to be there.
• 48:58This is an article
• 49:00that I thought was very
• 49:01prescient,
• 49:02from the MA Journal of
• 49:04Ethics.
• 49:05And the, author, Astrid, said,
• 49:08what are the risks for
• 49:09kids? The risks of continuous
• 49:10pharmaceutical treatment
• 49:12in adolescence in order to
• 49:14stabilize weight are not known.
• 49:16The unknown extent of pharma
• 49:18pharmaco therapeutics
• 49:19risks to adolescents
• 49:21for the benefits of weight
• 49:22loss
• 49:23ethically precludes their prescription.
• 49:26I doubt that despite the
• 49:28scientific consensus to fight obesity
• 49:30by prescribing weight reduction. So
• 49:32we all like weight reduction,
• 49:34but to be
• 49:35frank,
• 49:36a lifetime
• 49:38or many decades on the
• 49:40medication,
• 49:41we better set up surveillance.
• 49:43We better be tracking. I
• 49:44don't know that anybody is.
• 49:46I don't know that the
• 49:47studies
• 49:48in,
• 49:48large numbers are going to
• 49:50get underway,
• 49:52but they have
• 49:53so you can shut the
• 49:54slides up.
• 49:56I'm sorry if I took
• 49:57a little long. I wasn't
• 49:58really watching the time the
• 50:00way I should.
• 50:02New York City, thanks you.
• 50:05The
• 50:07bottom line of all of
• 50:08this is
• 50:10we didn't have a cure,
• 50:11we got a cure.
• 50:13It's a cure that was
• 50:14aimed initially at diseases
• 50:17and the risk of disease.
• 50:19We got a cure like
• 50:20that twenty years ago. I
• 50:21lived through it. I know
• 50:22what it was. It was
• 50:23easy to use.
• 50:25It really
• 50:26destigmatized
• 50:27a condition that no one
• 50:28wanted to talk about and
• 50:29couldn't grapple with and couldn't
• 50:31do much about,
• 50:32really, in any way.
• 50:34What happened there was it
• 50:36exploded.
• 50:37It sold a ton of
• 50:38medicine. It became almost demedicalized.
• 50:42It became a lifestyle choice.
• 50:45That is what I think
• 50:46is the future here unless
• 50:48we start to debate it
• 50:50or decide that it can
• 50:52proceed,
• 50:53but only with
• 50:54adjustments
• 50:56in how we eat, what
• 50:57we eat,
• 50:59to to company. There's still
• 51:01a need for lifestyle alteration.
• 51:04There's still a need to
• 51:05modify
• 51:06how we grow food and
• 51:08burn the environment with polluting
• 51:09our water and,
• 51:11raising,
• 51:12gases into the environment and
• 51:14the whole story that you
• 51:16guys all know, and I
• 51:17wrote recap here. But it
• 51:19looms out as a danger
• 51:21if we don't take seriously
• 51:23the underlying causes
• 51:25of that huge obesity
• 51:27problem.
• 51:29If we just say, oh,
• 51:30yeah.
• 51:30You know, we're from Coca
• 51:32Cola. We're from Pepsi.
• 51:34Keep drinking.
• 51:35Now we get a pill.
• 51:37Enjoy yourselves.
• 51:38Let's see if we could
• 51:39make some more,
• 51:40corn syrup
• 51:42and keep Iowa
• 51:45ninety eight percent corn growing,
• 51:47and that is the monoculture
• 51:50that we'll use
• 51:52out there.
• 51:53So
• 51:54I say this as someone
• 51:56who admits my biggest conflict
• 51:58of interest is
• 51:59I like that lifestyle.
• 52:02I grew up eating
• 52:04cultural foods.
• 52:06Pastrami is not unknown to
• 52:07me.
• 52:09I have some acquaintance
• 52:11with,
• 52:12potato kernel.
• 52:15So I know about,
• 52:17where I speak just in
• 52:18my own battles with,
• 52:21weight and,
• 52:22trying to struggle, if you
• 52:24will, with polio and
• 52:25exercise and all that sort
• 52:27of thing.
• 52:29I'm not saying we shouldn't
• 52:30proceed with the injectables. We
• 52:32have a lot to think
• 52:33about. We're just moving along
• 52:35now almost as a medical
• 52:37thing. I mean, I'll tell
• 52:38you, somebody who's thinking about
• 52:39them is bariatric surgeons.
• 52:41I'm not sure what we're
• 52:42doing with them.
• 52:44Sorry if you are in
• 52:46that space or going there,
• 52:47but I don't think the
• 52:49future's bright,
• 52:50there.
• 52:52And,
• 52:53at the same time, mandated,
• 52:56forced by shame,
• 52:58nobody watching the long term
• 53:00risk,
• 53:01no studies or surveillance set
• 53:03up,
• 53:04to really see what the
• 53:05impact is on
• 53:07kids and younger people.
• 53:09That's where we have to
• 53:10be thinking
• 53:11if we're gonna really take
• 53:12on
• 53:14both the opportunity,
• 53:15but I think many challenges
• 53:18of this pharmaceutical
• 53:20magic bullet. So I'll stop
• 53:22there.
• 53:34That was terrific.
• 53:36I liked it.
• 53:39I
• 53:40amused myself.
• 53:42Fascinating business, this.
• 53:44Alright.
• 53:45So we have some interesting
• 53:47stuff to talk about. I'll
• 53:48take the,
• 53:49the the pleasure of the
• 53:50first question, but I'll let
• 53:52you guys if you have
• 53:53questions, please just line up.
• 53:54There's microphones
• 53:55on either side. Just go
• 53:57there, please, and wait until
• 53:58I call in because I
• 53:59wanna be sure that everybody
• 54:00can hear you, including the
• 54:01folks on Zoom. And by
• 54:02the way, if you're watching
• 54:04this on Zoom, in the
• 54:05chat portion,
• 54:06you can send,
• 54:08is it the the q
• 54:09and a? I think the
• 54:10q and a portion, you
• 54:11can send the questions.
• 54:13And, and then and after
• 54:15a few minutes, those will
• 54:16find their way to me,
• 54:17and I'll address some of
• 54:18those to Art. So first
• 54:20question I have for you,
• 54:21it's,
• 54:24well, actually, it's it's too
• 54:26oh, maybe I see that
• 54:26one a little bit. So
• 54:28here's the first one. The
• 54:29about the saving, the finances
• 54:30of this are actually fascinating.
• 54:32And and first of all,
• 54:33I can congratulate you because
• 54:34I haven't heard anybody talk
• 54:35about this in this manner
• 54:36or in this depth. It's
• 54:37really interesting, and the comparison
• 54:39to Viagra is fascinating as
• 54:40well.
• 54:42But about the financial savings.
• 54:44Next question?
• 54:46No.
• 54:48Is it true that you
• 54:49are the most formidable bioeth?
• 54:51No. That's not the question
• 54:52either.
• 54:53So
• 54:54the the savings, the finances
• 54:55of this are really interesting
• 54:57to me because on the
• 54:58face of it and Jack
• 54:59knows a lot more about
• 55:00this stuff than I do.
• 55:01On the face of it,
• 55:02we could say, well, look.
• 55:03We're gonna spend a ton
• 55:04of money on this stuff,
• 55:05but we're gonna save a
• 55:06ton of money because people
• 55:08aren't gonna get as much
• 55:09cancer. People aren't gonna get
• 55:11as much heart disease.
• 55:12The thing that occurs to
• 55:13me, and I don't know
• 55:14how this thing is, those
• 55:15people
• 55:16are gonna die from something.
• 55:18And, theoretically,
• 55:20if they end up spending
• 55:21three or four years in
• 55:22a nursing home
• 55:24or five years
• 55:25it's possible they die from
• 55:26something that's even more expensive
• 55:28than they would have died
• 55:28of before. So the savings
• 55:31are are a difficult thing
• 55:32to pin down, aren't they?
• 55:33They are. You know, there
• 55:34was a hint
• 55:36in the literature just in
• 55:37the past
• 55:38couple of weeks
• 55:39that this drug might actually
• 55:42be useful in preventing Alzheimer's.
• 55:44Did some of you see
• 55:45that? I don't know if
• 55:46it's true. It's
• 55:48sort of a teeny not
• 55:49a good study.
• 55:51Those,
• 55:52you know, part of your
• 55:53question is what if we
• 55:55wind up in that horrid
• 55:56situation where we are extending
• 55:58the body, but the mind
• 55:59is collapsing and
• 56:01it's expensive?
• 56:03Maybe this thing is a
• 56:04magic bullet for everything in
• 56:05life. I don't know. That
• 56:06Alzheimer's thing caught my eye,
• 56:08but let's presume it doesn't
• 56:10really do that or only
• 56:11delays it. You could have
• 56:13a future where we
• 56:14didn't square the curve.
• 56:16We just had that big
• 56:18tail going out, and now
• 56:20there is a burden on
• 56:21the, social service side, the
• 56:23housing side, the nursing home
• 56:25side, and so on. Entirely
• 56:27possible. Something we really wanna,
• 56:29keep in mind.
• 56:31Also, we're gonna put to
• 56:32the test, I think, something
• 56:33else, which is,
• 56:34was it really the weight
• 56:35that got us sick,
• 56:37or was it the diet
• 56:38that we were eating under
• 56:40it that caused the cancers
• 56:42and the diabetes? In other
• 56:43words, we eat or smaller.
• 56:45We're still eating poorly.
• 56:48So what's the disease reduction
• 56:49gonna be? Something. I have
• 56:51no doubt, but maybe it's
• 56:52not as big as we
• 56:54thought we were gonna get.
• 56:56The last problem is those
• 56:57returns,
• 56:58you know, they're not coming
• 57:00for a while, and that's
• 57:01a lot of expenditure
• 57:03to capture even if you
• 57:05got returns.
• 57:06So,
• 57:09again, I it's almost desperate
• 57:11to drive the price down
• 57:12if you're gonna go in
• 57:13this direction.
• 57:16Thank you. Doctor Ho.
• 57:21Yep.
• 57:22You flip that.
• 57:25Yep. That's right.
• 57:27Now here we go. Okay.
• 57:29Thank you for that wonderful
• 57:31talk.
• 57:32I this is a full
• 57:34disclosure. This is a little
• 57:36bit of the dreaded kind
• 57:37of more of a comment
• 57:38than a question, but I
• 57:39I'd like to hear your
• 57:40your
• 57:41your thoughts on this. You
• 57:43know, it strikes me
• 57:44there are several interesting parallels
• 57:46between the the Viagra example
• 57:48and this injectable example. And
• 57:49one of them is that
• 57:51as you noted a lot
• 57:51of time like, one of
• 57:53the underlying
• 57:54drivers
• 57:56with ED, for example, is
• 57:58atherosclerotic
• 57:59disease and diabetes and hypertension,
• 58:00which in fact are diseases
• 58:02of
• 58:03lifestyle
• 58:04much like,
• 58:05much like obesity is. Although
• 58:07I know that that that
• 58:08in itself is a topic
• 58:09of of some debate. To
• 58:11what extent is obesity a
• 58:12disease versus a manifestation of
• 58:15of dysmetabolism,
• 58:16and and that's besides what
• 58:18I wanna grapple with now,
• 58:20but what what I what
• 58:21I think is interesting is
• 58:22that it's so often
• 58:24when when we talk about
• 58:26lifestyle, it really is still
• 58:27cast. And I I think
• 58:28part of this is because
• 58:29of this American ethos of
• 58:30individualism. It's individual choices. We
• 58:32wanna do that. We wanna
• 58:34have this lifestyle.
• 58:36We're going to choose to
• 58:37to do this when and
• 58:39and,
• 58:39indeed, as you also mentioned,
• 58:41which is true, that that
• 58:43when you do when you
• 58:44go on a
• 58:45a diet or an exercise
• 58:47program, those things don't work.
• 58:49But that's not to say
• 58:50that
• 58:51that those lifestyle
• 58:53interventions aren't actually effective. It's
• 58:55just that they're so
• 58:57nearly impossible to follow in
• 58:59a culture in which we
• 59:01are immersed in an obesogenic
• 59:02environment.
• 59:03And I think that's where
• 59:05really the issue lies because
• 59:06our choices are so constrained
• 59:08by our environment, and all
• 59:09of most of us, except
• 59:11those of us with extreme
• 59:12privilege,
• 59:13both financial,
• 59:15educational, and and otherwise,
• 59:17are are are going to
• 59:18make choices influenced by our
• 59:20environment, and the default choices
• 59:22are all the least healthy
• 59:23choices. And and you made
• 59:23that point yourself that even
• 59:25in your you know, when
• 59:26you grow up eating a
• 59:27certain way, when we live
• 59:28in a culture where convenience
• 59:30is valued, where exercise is
• 59:32almost viewed as an inconvenience,
• 59:33why would you take the
• 59:34stairs when, you know, there
• 59:36you you can't find the
• 59:37stairwell, but there are, like,
• 59:38ten elevator banks right here.
• 59:39And and, you know, when
• 59:41you go to a meeting,
• 59:42the food is all highly
• 59:44processed carbs or ultra processed
• 59:46meat, sugar sweetened beverages.
• 59:48And so it really at
• 59:49at the risk of sounding
• 59:51like RFK Jr, which and
• 59:52I wouldn't be clear. I'm
• 59:53a huge proponent of vaccines
• 59:54as you know because that's
• 59:55what we worked on for
• 59:56my master's thesis when I
• 59:58was a med student.
• 60:00I I I do think
• 01:00:01his his solutions are problematic,
• 01:00:02but I I think there
• 01:00:03is is a point in
• 01:00:04the idea that our food
• 01:00:05systems, as we also wrote
• 01:00:07about in in the paper
• 01:00:08you alluded to, are are
• 01:00:09really, really
• 01:00:11problematic and are driving behaviors.
• 01:00:13And to make the right
• 01:00:14choices requires
• 01:00:16such high activation energy
• 01:00:18in in light of our
• 01:00:19culture. And how how how
• 01:00:21do we grapple with that
• 01:00:22realizing that I agree we
• 01:00:24for people who are struggling
• 01:00:25with obesity now,
• 01:00:27we do need to make
• 01:00:28sure that we can treat
• 01:00:29them with all the evidence
• 01:00:30based methods we have. But
• 01:00:31also looking to the future,
• 01:00:33how do we grapple with
• 01:00:34those big drivers, those underlying
• 01:00:36drivers, and and what's the
• 01:00:38right path forward?
• 01:00:39Well,
• 01:00:40I I absolutely appreciate
• 01:00:43the point, and
• 01:00:44I'll just
• 01:00:45reaffirm in a way something
• 01:00:47you said. I was trying
• 01:00:48to hint that even if
• 01:00:49you had a drug that,
• 01:00:52allowed you to
• 01:00:53lose weight
• 01:00:54and,
• 01:00:56still, you have this issue
• 01:00:57of what's the rest of
• 01:00:59the environment
• 01:01:00of food
• 01:01:02gonna do in response? Are
• 01:01:03are we gonna see
• 01:01:05the current huge
• 01:01:07and well entrenched
• 01:01:09obesity
• 01:01:10oriented,
• 01:01:12food industry suddenly change
• 01:01:14and say, oh, you know,
• 01:01:15you're right. Since you're eating
• 01:01:17less, why don't you eat
• 01:01:18healthier?
• 01:01:20No.
• 01:01:21I think they're just gonna
• 01:01:22say, this is the greatest
• 01:01:23thing ever.
• 01:01:24Now we can sell
• 01:01:26continue to sell the stuff
• 01:01:27that we make,
• 01:01:29whether it's, you know,
• 01:01:30fast food or processed food
• 01:01:32or you know more about
• 01:01:33this than I do, but
• 01:01:34whatever it is. And then,
• 01:01:37okay. They're reading a little
• 01:01:38bit less of it, but
• 01:01:40let's just promote it worldwide.
• 01:01:41I mean, actually, what do
• 01:01:42we do to control cigarette
• 01:01:44smoking in the US? A
• 01:01:46big trial.
• 01:01:47Right?
• 01:01:48Cigarette smoking went down,
• 01:01:50sort of. We exported it
• 01:01:51to China.
• 01:01:53In this big world out
• 01:01:54there, you can sell a
• 01:01:55lot of fattening food to
• 01:01:56people,
• 01:01:58drive your markets up. So
• 01:01:59I'm not sure unless we
• 01:02:00have this lifestyle discussion
• 01:02:02and what it means,
• 01:02:04almost in philosophy terms, to
• 01:02:05live a good life,
• 01:02:08that it is
• 01:02:09enough to say we got
• 01:02:10a magic bullet pill,
• 01:02:12and we're not gonna change
• 01:02:13anything else about what's going
• 01:02:14on. It's a big danger.
• 01:02:16But isn't it a point
• 01:02:17you made, Art,
• 01:02:19that the the that the
• 01:02:21the teaching and preaching
• 01:02:23that among other people, our
• 01:02:25profession have done over the
• 01:02:26past, you know, half century
• 01:02:28and more
• 01:02:29has
• 01:02:30actually been quite ineffective in
• 01:02:32terms of, so I mean,
• 01:02:33to me, that's always been
• 01:02:35one of the big lies
• 01:02:36of medicine that, well, here's
• 01:02:37the deal, and this is
• 01:02:37how you're gonna and and
• 01:02:39it just didn't work. Even
• 01:02:40even you mentioned briefly about
• 01:02:42Oprah
• 01:02:42and so, I mean, I
• 01:02:44remember those things they said.
• 01:02:45Well, they did a study
• 01:02:46to to figure out which
• 01:02:47one of those diet plans.
• 01:02:49Remember, there was,
• 01:02:51Weight Watchers. There was others
• 01:02:52like Cameron, Jenny Craig and
• 01:02:53such. And I remember reading
• 01:02:54an article once that said
• 01:02:56specifically about, well, you know,
• 01:02:58actually, we did a study,
• 01:02:59and this one was more
• 01:03:00effective than that. And I
• 01:03:01said, well, that someone did
• 01:03:02a nice study. Then I
• 01:03:04took a look at that,
• 01:03:05and I actually, you know,
• 01:03:07read
• 01:03:08the entire article. And it
• 01:03:09was like, you know, when
• 01:03:10one, you lost six pounds
• 01:03:12and then one, you lost
• 01:03:12five pounds. Yeah. You know,
• 01:03:13and for people who are
• 01:03:14overweight. Six pounds? Yeah. Oh,
• 01:03:16yeah. You know? So it
• 01:03:17was it was clinically
• 01:03:21not a not a significant
• 01:03:22amount of weight. So so
• 01:03:24this gets to your point
• 01:03:25about maybe maybe we need
• 01:03:27to go further upstream. It's
• 01:03:28not just about trying
• 01:03:30to help people,
• 01:03:32in terms of altering their
• 01:03:33lifestyle, but actually
• 01:03:35looking back at this on
• 01:03:36a societal level in terms
• 01:03:38of how we feed our
• 01:03:40population, but this gets into
• 01:03:41control that many people are
• 01:03:42gonna be opposed to. This
• 01:03:44gets into your buddy, RFK
• 01:03:45Junior, who wants to do
• 01:03:46some of this stuff. My
• 01:03:48old buddy,
• 01:03:49RFK Junior, who I'm no
• 01:03:50fan of, as you know,
• 01:03:52is certainly concerned about obesity,
• 01:03:54and he wants to promote
• 01:03:56changes in diet or more
• 01:03:58organic food, more healthy food.
• 01:04:01And a lot of people
• 01:04:02would agree
• 01:04:03and say, you know, okay.
• 01:04:05That's
• 01:04:05a direction we should head
• 01:04:07in.
• 01:04:07But he
• 01:04:08wants also to not use
• 01:04:10the injectable.
• 01:04:11He's very
• 01:04:13anti drug that way. Well,
• 01:04:15anti sub drugs. He likes
• 01:04:16some other drugs, but not
• 01:04:17that drug.
• 01:04:18So
• 01:04:21I'm not sure he's gonna
• 01:04:22get there for the very
• 01:04:23reasons we're talking about. If
• 01:04:24you don't,
• 01:04:25give people the more immediate
• 01:04:27reward of loss of weight,
• 01:04:29saying we're gonna switch to
• 01:04:30organic diets and healthy food,
• 01:04:33where? Against the red states
• 01:04:35that are totally committed
• 01:04:37to an agriculture and a
• 01:04:38food production system,
• 01:04:40and it's not that. They're
• 01:04:41not going organic. You know?
• 01:04:43It's like, I don't see
• 01:04:44it. So I think you
• 01:04:45gotta figure out a strategy
• 01:04:47again.
• 01:04:48I I agree with him.
• 01:04:49We should change diet and
• 01:04:51all that, but it's kinda
• 01:04:52work around lifestyle change, agriculture
• 01:04:55change,
• 01:04:57big cultural shifts. Medicine has
• 01:04:59a role, but as you
• 01:05:00say, it's just a role.
• 01:05:02It's not it's not the
• 01:05:05real engine here
• 01:05:06that I think is gonna
• 01:05:07drive this broader cultural discussion.
• 01:05:10You know, you get a
• 01:05:11president in his first term
• 01:05:13when sports teams went to
• 01:05:14the White House. He served
• 01:05:15them all fast food. Mhmm.
• 01:05:17So he may not be
• 01:05:18the leader to take us
• 01:05:19where I'm thinking we're going,
• 01:05:20but okay.
• 01:05:22You know, it's it's gonna
• 01:05:23be
• 01:05:24at the top in some
• 01:05:26ways if that changes.
• 01:05:27Thank you. Okay. So we've
• 01:05:28got a lot of you.
• 01:05:29I know Sarah's think it's
• 01:05:30I know. So just tell
• 01:05:31us something real quick if
• 01:05:32you Very quick. Just just
• 01:05:33because I think this is
• 01:05:34a really important point to
• 01:05:35impart to the medical students
• 01:05:37based on this is just
• 01:05:38I think too often we
• 01:05:39conflate the questions of does
• 01:05:41lifestyle change work versus can
• 01:05:43people do it? Because it
• 01:05:44often doesn't work when you
• 01:05:45look at the data on
• 01:05:46an individual level, but it
• 01:05:47is a systemic problem that
• 01:05:49requires systemic solutions. Because it
• 01:05:50actually does work when people
• 01:05:52can do it. It's just
• 01:05:53most of the time they
• 01:05:53can't do it. Anyway, thank
• 01:05:55you.
• 01:05:56Okay. Thank you.
• 01:05:58Karen.
• 01:05:59Yeah. So as an emergency
• 01:06:01medicine physician, I tend to
• 01:06:03look at things through the
• 01:06:04lens of disparities.
• 01:06:06And so what I see
• 01:06:07already
• 01:06:08is that many of my
• 01:06:09patients who come to the
• 01:06:10emergency department,
• 01:06:12who would qualify,
• 01:06:15can't get it because they're
• 01:06:16on state or they're they're
• 01:06:17self pay, etcetera.
• 01:06:19And
• 01:06:20but even many of those
• 01:06:21on state, they don't qualify
• 01:06:23because they don't have enough
• 01:06:24conditions. So, yeah, I know
• 01:06:25people who live actually in
• 01:06:26Ridgefield
• 01:06:27with BMIs of twenty three
• 01:06:29point eight
• 01:06:30who got a nurse practitioner
• 01:06:33to prescribe them,
• 01:06:34and their health insurance is
• 01:06:36paying. And, of course, we
• 01:06:38talked about this in professional
• 01:06:39responsibility this year. What happens
• 01:06:41when your patients ask you
• 01:06:42to lie just a little
• 01:06:43bit? Or maybe their BMI
• 01:06:45was, you know, twenty seven
• 01:06:47point five, but there are
• 01:06:48people with BMIs of thirty
• 01:06:49four.
• 01:06:50And then I look at
• 01:06:52the next group of people
• 01:06:53who are even, I think,
• 01:06:54more,
• 01:06:57in,
• 01:06:59you know, disadvantaged, and those
• 01:07:00are people with alcohol use
• 01:07:02disorder.
• 01:07:02And there's evidence that that's
• 01:07:04another condition where we really
• 01:07:06have little
• 01:07:07that works for alcohol use
• 01:07:08disorder, but we're seeing evidence
• 01:07:11in some preliminary data that
• 01:07:12this actually these medications tend
• 01:07:14to work pretty darn good
• 01:07:16for alcohol disorder. But
• 01:07:18are you know, who's gonna
• 01:07:20pay? And these are patients
• 01:07:21who don't have a lot
• 01:07:23of political capital, etcetera. And
• 01:07:25I so I really worry
• 01:07:26about
• 01:07:27this being an awesome
• 01:07:29drug for them,
• 01:07:31but they may not have
• 01:07:32an opportunity because they're gonna
• 01:07:33be competing with the Ridgefield
• 01:07:34people with a BMI of
• 01:07:35twenty three point eight. Certainly
• 01:07:37now and for some years
• 01:07:39to come, that is a
• 01:07:40very fair
• 01:07:42concern. I don't think,
• 01:07:45equitable access is out there.
• 01:07:48You're right. In Ridgefield,
• 01:07:51any party I go to,
• 01:07:52I'm hearing people who I
• 01:07:53know
• 01:07:54got their doctor to prescribe,
• 01:07:57and they're just on it.
• 01:07:58And maybe out of pocket.
• 01:07:59I don't know. But
• 01:08:01they're using and you're right.
• 01:08:03I also see Bellevue, and
• 01:08:04I know
• 01:08:05who comes in there, and,
• 01:08:08they're not on it. And
• 01:08:09we're not putting them on
• 01:08:10it, and they wouldn't have
• 01:08:12coverage
• 01:08:13by any means.
• 01:08:16That's out there now. Now
• 01:08:17I do think that's gonna
• 01:08:18change.
• 01:08:19The pressure in the culture,
• 01:08:21I think, will lead ultimately
• 01:08:23to broader access even at
• 01:08:25high price.
• 01:08:26But at some point, you
• 01:08:28get to that tipping point,
• 01:08:30even if you're looking at
• 01:08:32close to a trillion or
• 01:08:33something like that,
• 01:08:35then everybody's starting to worry
• 01:08:37that
• 01:08:38it's not affordable. So now
• 01:08:40I think the underprivileged,
• 01:08:42the poor, those who have
• 01:08:43access problems
• 01:08:45are not getting benefit. Their
• 01:08:47kids aren't
• 01:08:48the morbidly obese, aren't getting
• 01:08:50benefit. We will fix that,
• 01:08:51I think. But then
• 01:08:53as the demand in the
• 01:08:55market grows to prevention,
• 01:08:57surveillance,
• 01:08:59maintenance, the crisis,
• 01:09:01the cost crisis is gonna
• 01:09:02come.
• 01:09:04So, Art,
• 01:09:05one thing which I think
• 01:09:06you also alluded to, and
• 01:09:08I don't know if you
• 01:09:08have any information on this,
• 01:09:10but one thing that could
• 01:09:11solve a lot of this
• 01:09:12concern would be if the
• 01:09:13price
• 01:09:13fell dramatically, which often happens
• 01:09:15with big drugs. Right? Yep.
• 01:09:17No. I the problem here
• 01:09:19is
• 01:09:20the manufacturers that are making
• 01:09:22it, I don't think you
• 01:09:22have any big incentive to
• 01:09:24drop. They see what each
• 01:09:25other's charging. They see what
• 01:09:27they get away with, and
• 01:09:28off they go. The price
• 01:09:30of Viagra,
• 01:09:31even when,
• 01:09:32its competitors,
• 01:09:33Cialis and so on appeared,
• 01:09:36didn't really drop. It didn't
• 01:09:37really drop
• 01:09:39in any meaningful way until
• 01:09:40the generics came.
• 01:09:42Now the generics here could
• 01:09:43make a difference, but that's,
• 01:09:45what, Twenty years out at
• 01:09:46crazy expenditure. Depending on patent,
• 01:09:49expirations. Right? So I don't
• 01:09:50see them. It's gonna have
• 01:09:52to be government. The current
• 01:09:54government we've got is not
• 01:09:55really in the mood
• 01:09:57to press or force
• 01:09:59price reduction. They're still
• 01:10:01believers in market forces, but
• 01:10:03I I don't see that
• 01:10:04helping to drive price here.
• 01:10:06So I
• 01:10:08that's an iceberg that's kinda
• 01:10:10just looming out there that
• 01:10:12we're gonna hit costs.
• 01:10:14Thank you. Yes, please.
• 01:10:17Hi. I think it's very
• 01:10:19interesting that you talked about
• 01:10:20how
• 01:10:21Viagra was able to,
• 01:10:23destigmatize
• 01:10:24the condition of erectile dysfunction,
• 01:10:27but I'm not too familiar
• 01:10:28with that. But I think
• 01:10:30that
• 01:10:31right now with the treatment
• 01:10:33of
• 01:10:35the Ozempic,
• 01:10:36I think that
• 01:10:37obesity
• 01:10:39is being more stigmatized.
• 01:10:41Because
• 01:10:41when people see someone who
• 01:10:43is obese, they would
• 01:10:46they would go very straightforward
• 01:10:47and suggest them to use
• 01:10:50the treatment.
• 01:10:51Yep. I I know what
• 01:10:53you're saying. It destigmatizes
• 01:10:55it in the sense in
• 01:10:56which I was trying to
• 01:10:58say you can talk about
• 01:10:59it with your doctor. You
• 01:11:00can,
• 01:11:01admit to people
• 01:11:03that you have a problem.
• 01:11:05But then if you don't
• 01:11:06fix it and you remain
• 01:11:08obese,
• 01:11:09you have a real issue.
• 01:11:11Why aren't you doing something
• 01:11:13about that? So that's where
• 01:11:14I was getting closer to
• 01:11:16both
• 01:11:17mandates
• 01:11:17and cultural pressure.
• 01:11:20You can't go around that
• 01:11:22way. You know? Disability community
• 01:11:24is always worried
• 01:11:26about the wonders of gene
• 01:11:27therapy
• 01:11:28and the glories of personalized
• 01:11:30genetic medicine.
• 01:11:32That if they don't choose
• 01:11:33to use it for whatever
• 01:11:34reason and they have a
• 01:11:35kid with a disability,
• 01:11:37they're gonna be stigmatized. You
• 01:11:39know, how would you not
• 01:11:41prevent sickle cell or cystic
• 01:11:42fibro or you pick whatever
• 01:11:45condition.
• 01:11:45So we do have to
• 01:11:47look forward. You're right.
• 01:11:49How are we gonna protect
• 01:11:51those
• 01:11:52who, for whatever reason,
• 01:11:54don't use it? And I
• 01:11:55didn't say this, but one
• 01:11:56other there's a lot I
• 01:11:57didn't say, but let me
• 01:11:58jump on your question.
• 01:12:00There is some indication that
• 01:12:02like all drugs, there are
• 01:12:03responders and not great responders
• 01:12:06to these drugs.
• 01:12:07Genetic testing is likely to
• 01:12:09become a part of who
• 01:12:11can use this, and that
• 01:12:12means
• 01:12:13that there may be people
• 01:12:15biologically
• 01:12:15who don't respond, and they'll
• 01:12:17become
• 01:12:18subject to stigma that way.
• 01:12:20You know?
• 01:12:21What's wrong with you?
• 01:12:23Oh, you're built so you
• 01:12:24can't take the bill that
• 01:12:26we all take? That's trouble.
• 01:12:28And just one other thing
• 01:12:29I remember from Sarah's comment,
• 01:12:31you know,
• 01:12:32the Lancet this week, I
• 01:12:33didn't put in my talk
• 01:12:34because I haven't really
• 01:12:36read it, but a group
• 01:12:37met
• 01:12:38and defined obesity as a
• 01:12:39disease.
• 01:12:41Well, that's like erectile dysfunction
• 01:12:43one zero one. Here we
• 01:12:44go. Now I got a
• 01:12:45disease, and we're off to
• 01:12:47the races. Now I didn't
• 01:12:48read their
• 01:12:50discussion of this, but I
• 01:12:52know it happened.
• 01:12:55Thank you. This thank you.
• 01:12:56This is fascinating. I'm trying
• 01:12:57to think of as you're
• 01:12:58talking, I'm trying to think
• 01:12:59of other analogies that are
• 01:13:01stigmatized now, and this is
• 01:13:03kind of a loose one.
• 01:13:04But I think that that
• 01:13:06fifty years ago or a
• 01:13:07hundred years ago, most people
• 01:13:09were walking around or a
• 01:13:10lot of people were walking
• 01:13:11around with really crooked teeth.
• 01:13:13And, and and no one
• 01:13:14looked at you and said,
• 01:13:15jeez. Look at your kid's
• 01:13:16teeth. Why don't you do
• 01:13:16something about that? There was
• 01:13:18nothing to be done. But
• 01:13:19now I think largely in
• 01:13:20the middle class United States,
• 01:13:22you don't see so many
• 01:13:23people who have dramatically crooked
• 01:13:25teeth anymore,
• 01:13:26because there's some Yep. A
• 01:13:28treatment available, which is not,
• 01:13:29by the way, financially available
• 01:13:31to everybody.
• 01:13:33But yes. It's interesting to
• 01:13:34think of analogies. Yes, please.
• 01:13:45No. No. You give it
• 01:13:46a try. I think it
• 01:13:46was working a second ago.
• 01:13:49Do you see the switch?
• 01:13:50Oh, thank you, Sarah.
• 01:13:53There
• 01:13:59you go.
• 01:14:00Thank you, Sarah.
• 01:14:01Well, I, like you, also
• 01:14:04don't need Viagra.
• 01:14:05But on a personal note,
• 01:14:08I have hypertension
• 01:14:09and will probably be taking
• 01:14:11medication for the rest of
• 01:14:12my life.
• 01:14:13So if obesity is seen
• 01:14:15as a disease and someone
• 01:14:16is obese
• 01:14:18and the medication does work,
• 01:14:20why can't that person
• 01:14:22to maintain
• 01:14:23their lower weight beyond the
• 01:14:25drug
• 01:14:27forever, like people with diabetes
• 01:14:29or
• 01:14:30any other disease where for
• 01:14:31the rest of your life,
• 01:14:32you're pretty much on medication
• 01:14:34Yeah. And, you know, there
• 01:14:36are certainly women
• 01:14:38who take,
• 01:14:39medicines for osteoporosis
• 01:14:42forever, I guess. And,
• 01:14:44yeah, and there are plenty
• 01:14:46of people out there
• 01:14:47taking their vitamins,
• 01:14:49and god knows what other
• 01:14:51wellness things they take every
• 01:14:53day. I prefer bee pollen,
• 01:14:55but
• 01:14:55whatever.
• 01:14:59With the with the pastrami
• 01:15:01or without the you're awake
• 01:15:02out there. I don't prefer
• 01:15:04bee pollen. I didn't mean
• 01:15:05to suggest that it was
• 01:15:06wrong or unethical to do
• 01:15:08that. I think those are
• 01:15:10the positive benefits
• 01:15:11that will come, and I
• 01:15:13think that that's great. In
• 01:15:14some ways,
• 01:15:16we'll get it. It'll be
• 01:15:17treated.
• 01:15:18You'll be maintained. Presumably, they'll
• 01:15:21do some genetic test to
• 01:15:22see if it's really gonna
• 01:15:24work for you. Maybe it
• 01:15:25won't. We'll be stuck
• 01:15:27with, you know, something else
• 01:15:29to
• 01:15:30to control it, including diet
• 01:15:31maybe and lifestyle.
• 01:15:33But that medical side,
• 01:15:35what I was trying to
• 01:15:37suggest, is going to rapidly
• 01:15:39expand
• 01:15:40just to appearance,
• 01:15:42just to,
• 01:15:44people saying, you know, this
• 01:15:46is what we expect,
• 01:15:48how people look, aesthetics. And
• 01:15:50so there'll be people taking
• 01:15:51it every day,
• 01:15:53not for disease reasons, not
• 01:15:55for disease prevention, just because
• 01:15:57the culture
• 01:15:59values fitness, values,
• 01:16:01appearance.
• 01:16:02So that's expense.
• 01:16:05That gets to be pretty
• 01:16:06expensive.
• 01:16:07To your Viagra point, it
• 01:16:09did help with erectile dysfunction.
• 01:16:11It did. And,
• 01:16:14Bob Dole's marriage was saved.
• 01:16:16No. I don't.
• 01:16:17But it was helped, and
• 01:16:18I'm sure of. And,
• 01:16:21many people would say yes.
• 01:16:23Although, I have to tell
• 01:16:24you two stories about Viagra.
• 01:16:26Settle in settle in now.
• 01:16:28Okay.
• 01:16:29And it and it's appears.
• 01:16:30One was
• 01:16:32there were many
• 01:16:34couples
• 01:16:35where the wife said, I
• 01:16:37am not happy about Viagra.
• 01:16:41I had adjusted my sex
• 01:16:42life, and
• 01:16:44things were fine. And the
• 01:16:45reappearance of this guy is
• 01:16:47not
• 01:16:48my dream lifestyle.
• 01:16:51So that was
• 01:16:52odd. The other was remember
• 01:16:54I hinted about old older
• 01:16:56guys going out and visiting
• 01:16:57prostitutes? Well, they did.
• 01:17:00And v d, venereal disease
• 01:17:02rates
• 01:17:03exploded in different parts of
• 01:17:05the country. They couldn't figure
• 01:17:06out what was going on.
• 01:17:07It was viagra.
• 01:17:09So they had to go
• 01:17:10back to safe sex education
• 01:17:13in groups they weren't worried.
• 01:17:14Actually, this is the third
• 01:17:15problem. Sex broke out in
• 01:17:17nursing homes, and nobody knew
• 01:17:19what to do. There was
• 01:17:20no privacy. There wasn't any
• 01:17:22place to go. And they
• 01:17:23they were like,
• 01:17:24now what?
• 01:17:27That that was just a
• 01:17:28story. It wasn't
• 01:17:29That's a net that's a
• 01:17:30Netflix limited series just waiting
• 01:17:32to happen.
• 01:17:34Yes, sir. Story. So, doctor
• 01:17:36Kaplan, thank you so much.
• 01:17:37Very informative lecture.
• 01:17:39And I think the last
• 01:17:40point sort of covered it.
• 01:17:41But, you know, for patients
• 01:17:42who,
• 01:17:43are obese and have these
• 01:17:45multitude of medical conditions, it's
• 01:17:47getting to be to the
• 01:17:48point of being indefensible
• 01:17:50not to use these incretins.
• 01:17:51So, you know, the nature
• 01:17:52of the this forum, of
• 01:17:54course, is to bring up
• 01:17:55issues, but just for the
• 01:17:56folks who are not familiar
• 01:17:57with it, I mean, there's
• 01:17:58twenty percent reduction in mortality
• 01:18:00if you if you have
• 01:18:01a risk of a cardiovascular
• 01:18:02risk. So, I mean, that's
• 01:18:03one population in which essentially
• 01:18:05it's it's indefensible not to
• 01:18:06use these drugs. I just
• 01:18:07want to sort of make
• 01:18:08that clear, and I'm happy
• 01:18:09to discuss that.
• 01:18:11The other thing is I
• 01:18:12think we fall into a
• 01:18:12little bit of a trap.
• 01:18:14When anybody gets a GLP
• 01:18:15one drug,
• 01:18:17thousands of changes occur inside
• 01:18:18their body, you know, which,
• 01:18:20of course, you know very
• 01:18:21well. And the trap we've
• 01:18:22fallen into is if we
• 01:18:24only speak about things that
• 01:18:25we measure.
• 01:18:27Right? If we could measure
• 01:18:28insulin resistance as easily as
• 01:18:30we can measure weight, we
• 01:18:32would not be speaking about
• 01:18:33weight. Okay? So, I mean,
• 01:18:34I've prescribed these drugs to
• 01:18:36over two thousand individuals. Many
• 01:18:37of them no longer need
• 01:18:38their hypertension medications.
• 01:18:40They are CPAP,
• 01:18:41CPAP machines, etcetera. Mhmm. And,
• 01:18:44you know, as a biologist,
• 01:18:45we need to look at
• 01:18:46them as biologists,
• 01:18:48and thousands of changes take
• 01:18:49place. So forget the weight.
• 01:18:51Throw away the scale and
• 01:18:53just focus on the diseases.
• 01:18:56That's a great point. Thank
• 01:18:57you.
• 01:18:58So it's because you're my
• 01:19:00buddy, Steve. I'm gonna say
• 01:19:01it now while it's your
• 01:19:02turn to talk, which is
• 01:19:03I we've got ten more
• 01:19:05minutes, and I really want
• 01:19:06all three people to get
• 01:19:07a chance to ask their
• 01:19:08questions.
• 01:19:09So no. No. No. No.
• 01:19:10I I want even but
• 01:19:12just to remind all three
• 01:19:13questioners that I'd like to
• 01:19:14I'd like us to get
• 01:19:15all three questions in. I'm
• 01:19:16sorry to just decide that
• 01:19:17on your turn, Steve. Yeah.
• 01:19:19But that's the way it
• 01:19:19goes. No problem. I have
• 01:19:20a backward looking question. I'm
• 01:19:22pretty sure that our problem
• 01:19:23with not being able to
• 01:19:24beat obesity has to do
• 01:19:26with agribusiness and the structure
• 01:19:27of supermarkets and marketing and
• 01:19:30big food and restaurant portion
• 01:19:31sizes and everything else. But
• 01:19:33there's another thing that I
• 01:19:34wonder if you have thought
• 01:19:35about, which is that our
• 01:19:37national health insurance kicks in
• 01:19:38when you're sixty five.
• 01:19:40And most people who are
• 01:19:42insured are insured by their
• 01:19:43employers, and that means
• 01:19:45the employer, the insurance company,
• 01:19:47and the physicians who see
• 01:19:48that person have no incentive
• 01:19:49to try to keep their
• 01:19:51weight down because all the
• 01:19:51stuff's gonna come home to
• 01:19:53roost when they're on the
• 01:19:54feds.
• 01:19:55Do you think that's a
• 01:19:56cause here?
• 01:19:58Well, it
• 01:19:59makes people less risk sensitive
• 01:20:03knowing that that safety
• 01:20:05net is out there. I
• 01:20:06do have people tell me
• 01:20:08sometimes when we're talking about
• 01:20:09some of these, questions in
• 01:20:11adult groups or church group
• 01:20:13or something,
• 01:20:15you know,
• 01:20:16I I still am gonna
• 01:20:17take my chances because that
• 01:20:18care at the end will
• 01:20:19rescue me.
• 01:20:21Comes up. People mention it.
• 01:20:22So yeah.
• 01:20:24Yeah. Little bit. Little bit.
• 01:20:25I was thinking more that
• 01:20:27your doctor is not gonna
• 01:20:28get paid to give you
• 01:20:29this Well, there's that. Weight.
• 01:20:30Yes. Because when you're sixty
• 01:20:32five, you'll be someone else's.
• 01:20:33Yeah. So, Steve, you got
• 01:20:35two points there. One of
• 01:20:37which you didn't make,
• 01:20:38but,
• 01:20:39I did, which is
• 01:20:41there are people who
• 01:20:42say, I have a safety
• 01:20:44net at the end of
• 01:20:44the road,
• 01:20:45so I'll indulge myself more
• 01:20:47now.
• 01:20:48And
• 01:20:50there are doctors who would
• 01:20:51say, look. The payout is
• 01:20:52not
• 01:20:53there for me to,
• 01:20:55you know,
• 01:20:57it's the incentives are out
• 01:20:58of whack. Let's put it
• 01:20:59that way. They're not lined
• 01:21:01up properly. I I would
• 01:21:02agree with that. And there's
• 01:21:04one other thing we have
• 01:21:05to confess.
• 01:21:06I I hate to bring
• 01:21:07it into the church of
• 01:21:08health like at Yale here
• 01:21:10at the med school, but
• 01:21:12not not everybody has health
• 01:21:13as their number one value.
• 01:21:15Right? They like risk. They
• 01:21:17like gambling. They like
• 01:21:19whatever they like. They like
• 01:21:21a lot of bad stuff.
• 01:21:23If
• 01:21:24if sin wasn't so much
• 01:21:25fun, they wouldn't do it.
• 01:21:26It's like
• 01:21:28so those are realities.
• 01:21:30And even if you took
• 01:21:31this pill, that's what I
• 01:21:33was trying to hint to
• 01:21:33you. Sorta not
• 01:21:35the incentives aren't just to
• 01:21:36stay healthy. They are in
• 01:21:38our culture,
• 01:21:39the evil can evil. Get
• 01:21:40on a bike and drive
• 01:21:41it over a canyon.
• 01:21:44Well, that's not what I
• 01:21:45would call public health oriented.
• 01:21:48Right? I mean, there are
• 01:21:49plenty of it. You know?
• 01:21:50You injure yourself in sports,
• 01:21:51keep playing.
• 01:21:54The gymnast broke her ankle,
• 01:21:56Jump again. It's the olymp
• 01:21:57I mean, these these messages
• 01:21:59are pretty
• 01:22:00common in this society.
• 01:22:04Yes, please.
• 01:22:05Hi.
• 01:22:07Speaking towards what the gentleman
• 01:22:09before me said, several changes
• 01:22:11happen with GLP one drugs,
• 01:22:12and I apparently,
• 01:22:14some of that happen are
• 01:22:15in taste sensitivity.
• 01:22:17So people say that when
• 01:22:19they take GLP one drugs,
• 01:22:20our taste buds change, and
• 01:22:21they actually have less sensitivity
• 01:22:22to,
• 01:22:24sweets or salty foods.
• 01:22:27And so I wonder
• 01:22:28if we have a large
• 01:22:30proportion of our population who
• 01:22:31are taking GLP one drugs,
• 01:22:33might that actually change our
• 01:22:34food industry?
• 01:22:35Well, that's good. Good question.
• 01:22:37I don't know.
• 01:22:38I don't know. I think
• 01:22:40it's,
• 01:22:42as as been pointed up
• 01:22:43by you and others,
• 01:22:45a lot of changes when
• 01:22:46you take things,
• 01:22:47and
• 01:22:48they may impact not just,
• 01:22:52let's say, obsessive behavior,
• 01:22:54compulsive behavior. I think that's
• 01:22:55part of the alcohol thing
• 01:22:56is I understand what the
• 01:22:58mechanisms are, and I'm not
• 01:22:59sure anybody's got it.
• 01:23:03It could be. It could
• 01:23:05actually wind up changing. But
• 01:23:06if it doesn't,
• 01:23:08then we still got a
• 01:23:09lot to address.
• 01:23:12Thank you. Wait. Give me
• 01:23:14one second, Ben. Ben, you're
• 01:23:15gonna ask the final question
• 01:23:16of the night, so make
• 01:23:17sure it's really good. But
• 01:23:18before you do that, I
• 01:23:19wanna just get one Zoom
• 01:23:21question in, if I could,
• 01:23:22please.
• 01:23:23They,
• 01:23:25this program is fabulous.
• 01:23:27What an engaging and bright
• 01:23:28speaker.
• 01:23:30No no mention whatsoever of
• 01:23:31the moderator, but that's
• 01:23:34should we try to push
• 01:23:35patients into GLP treatments
• 01:23:37knowing they may not be
• 01:23:39supported financially
• 01:23:40or with necessary follow-up more
• 01:23:42services?
• 01:23:43You know, I think you
• 01:23:44gotta do it in terms
• 01:23:46of at least offer.
• 01:23:48People have a right to
• 01:23:49know that something would really
• 01:23:51benefit them and help them
• 01:23:52and control
• 01:23:54a particular problem. I don't
• 01:23:55care what it is in
• 01:23:56health care. They may then
• 01:23:57go out and get a
• 01:23:58loan from their cousin. They
• 01:24:00may run a fundraiser.
• 01:24:02I see it
• 01:24:03not commonly, but I see
• 01:24:04it.
• 01:24:05Things they think, you think,
• 01:24:07they'll never be able to
• 01:24:08get there.
• 01:24:09Once in a while, they
• 01:24:10do. So I think part
• 01:24:11of informed consent is to
• 01:24:13say,
• 01:24:14here's this medication, and it
• 01:24:16really would help you.
• 01:24:18Right now, it's not covered
• 01:24:19by your insurance plan and
• 01:24:21so on.
• 01:24:22Nonetheless,
• 01:24:23if you could find a
• 01:24:24way to pay for it,
• 01:24:26here's you know, it's out
• 01:24:28there. The other thing it
• 01:24:29does, it generates political pressure
• 01:24:31to cover. So if they
• 01:24:32don't know that it's there,
• 01:24:33then they don't go nag
• 01:24:34their
• 01:24:35legislator
• 01:24:36to pay for it. You
• 01:24:37know? They they didn't know.
• 01:24:39So I think you do
• 01:24:40have to bring it up
• 01:24:41to offer it to say
• 01:24:42what it could be even
• 01:24:43though it's frustrating. You're just
• 01:24:44gonna say, well, gonna dangle
• 01:24:46this before you and but
• 01:24:47you can't reach it.
• 01:24:50Nonetheless, I think that's the
• 01:24:51right thing to do. I
• 01:24:52mean, that's treating people, like
• 01:24:55adults. I mean, it's being
• 01:24:56fair to let them let
• 01:24:57them know what's what is
• 01:24:58available,
• 01:24:59what the possibilities might be.
• 01:25:01It seems but it's a
• 01:25:01difference. It was interesting. The
• 01:25:03the questioner talked about pushing
• 01:25:05patients in a certain direction,
• 01:25:06whereas I think you emphasized
• 01:25:07more, you know, in full
• 01:25:09disclosure, making patients aware that
• 01:25:10this is an option Mhmm.
• 01:25:12Potentially, and here's what it
• 01:25:13might cost, etcetera. Thank you.
• 01:25:15Doctor Tolchin with the final
• 01:25:17question, please.
• 01:25:18So so I think I
• 01:25:18I just wanna
• 01:25:20put a plug in
• 01:25:22support of the GLP
• 01:25:24medications. As a clinician,
• 01:25:26you know, I think you
• 01:25:27alluded to several of the
• 01:25:28speakers have, several of the
• 01:25:29the questioners have alluded to
• 01:25:31some of the the really
• 01:25:32incredible benefits that we're seeing
• 01:25:35in really unexpected areas. I
• 01:25:36mean, not almost neurologist
• 01:25:38stroke is changing radically, like,
• 01:25:41as we speak,
• 01:25:42but so is obstructive sleep
• 01:25:45apnea. So is osteoarthritis.
• 01:25:46Well, you know, every place
• 01:25:49we're doing studies
• 01:25:50like your colleagues in in
• 01:25:52surgery, we're finding
• 01:25:54unanticipated
• 01:25:55benefits of these GLP medications.
• 01:25:57Yeah. And it's happening now,
• 01:25:59you know, with the patients
• 01:26:00that we're seeing now.
• 01:26:01And so, you know, I
• 01:26:03think this this this
• 01:26:05split of,
• 01:26:07well, wouldn't it be better
• 01:26:09if we
• 01:26:11recreated our society
• 01:26:12to focus more on health
• 01:26:14and got rid of agribusiness?
• 01:26:17Like,
• 01:26:18yes. Of course. Those would
• 01:26:19be wonderful things, and you
• 01:26:21can support those things and
• 01:26:23also at the same time
• 01:26:24use GLP one medications
• 01:26:27to to provide benefits to
• 01:26:28patients now because those things
• 01:26:30are not gonna happen in
• 01:26:30our patients' lifetime. I'm not
• 01:26:33against that conclusion.
• 01:26:35I absolutely
• 01:26:36wanna see people get access.
• 01:26:38I know the benefits
• 01:26:40are out there.
• 01:26:42I want us to think
• 01:26:43about, at the same time,
• 01:26:44it's just
• 01:26:45the deeper
• 01:26:47whether it's mandated,
• 01:26:49whether somebody feels guilt if
• 01:26:51they don't use it, the
• 01:26:52broad use that's coming for
• 01:26:54prevention
• 01:26:55and maintenance, and it's coming
• 01:26:57outside of the medical interventions
• 01:27:00that really do help, you
• 01:27:01know, people with conditions or
• 01:27:03preconditions
• 01:27:04and so on. So I
• 01:27:05don't mean to say
• 01:27:06there's no benefit. There's big
• 01:27:08benefit.
• 01:27:09This carries along with it
• 01:27:11as many things do
• 01:27:13a bunch of other
• 01:27:14sort of sideline ethical things
• 01:27:16to think about. Like you,
• 01:27:17I you know,
• 01:27:18I'm a little sneering about
• 01:27:20the fact that we're gonna
• 01:27:21reform our food system and
• 01:27:22agriculture and all is gonna
• 01:27:24go away. I I think
• 01:27:26that's not very likely.
• 01:27:28Doesn't mean we shouldn't think
• 01:27:29about it on the march,
• 01:27:30but tough.
• 01:27:32Tough, tough, tough.
• 01:27:35Thank you. Thank you very
• 01:27:36much.
• 01:27:37So
• 01:27:38I wanna thank you folks
• 01:27:39for coming out on such
• 01:27:40a cold night.
• 01:27:42And I wanna thank you,
• 01:27:43Art. Something I didn't mention
• 01:27:44at the beginning, which I
• 01:27:45should mention now, is that
• 01:27:46Art has actually been a
• 01:27:47friend of this program
• 01:27:49since we started. I can
• 01:27:50remember, and we I talked
• 01:27:51about this briefly with Art
• 01:27:52when he came. And I
• 01:27:53don't think we were friends
• 01:27:54then. I think this is
• 01:27:55the maybe the first time
• 01:27:56we actually met was he
• 01:27:57was kind enough to come
• 01:27:58up here when this program
• 01:27:59was just getting going. And
• 01:28:01we sat in my office
• 01:28:02and talked for a couple
• 01:28:03hours about and Art was
• 01:28:04already,
• 01:28:05you know, a a leader
• 01:28:06in the field, was running
• 01:28:08the program at Penn at
• 01:28:09the time, which he had
• 01:28:10founded also,
• 01:28:11and was just proved to
• 01:28:12be a source of guidance
• 01:28:13and support. Like, by the
• 01:28:14way, he's been for,
• 01:28:16so many people all over
• 01:28:17the country. So you've been
• 01:28:18a great friend, to so
• 01:28:20many of us, myself included,
• 01:28:22and to this program. We
• 01:28:23appreciate that. We appreciate this
• 01:28:25very interesting and insightful talk
• 01:28:26today. Thank you so much.
• 01:28:28Please join. Thank you.
• 01:28:37And, of course,
• 01:28:39you don't wanna leave
• 01:28:41without some Yale stuff, Art.
• 01:28:43Oh.
• 01:28:45Look at all the writing
• 01:28:46we got on that cap.
• 01:28:47Yale program
• 01:28:48or biomedical ethics. There you
• 01:28:49go. We said make Yale
• 01:28:51great again. Make Yale great
• 01:28:53again.
• 01:29:00Thanks, man.
• 01:29:01Good. Good.
• 01:29:03That's really interesting.
• 01:29:07I'm sure that, you know,