Semaglutide

My Weight Loss History

About ten years ago, I lost 30lb on Slimming World, a UK program similar to Weight Watchers. Every week, I went to meetings, diligently meal prepped, made sure I was eating at least 50% fruit and vegetables, I counted my “syns”, and carefully analyzed restaurant menus before going out to eat. It probably helped that I essentially did intermittent fasting the day before the weekly weigh in.

I was pleased with my success, but it was not easy. Planning and executing my diet and exercise regime felt like a part-time job.

A year or so later, I moved cities. I wanted to make new friends, so I started organizing and attending lots of social events. It was great fun, but my carefully crafted “healthy lifestyle” went out the window. Then my mum got sick, and suddenly nothing else mattered.

The weight crept back, and I put on more than I’d lost.

Since then, I’ve tried various strategies: calorie counting, macro counting, fasting, high-protein diets, plant-based diets, even Slimming World again. Often these will work briefly, while I’m wholly focused and can put in the energy of a part-time job into them, but as soon as I drop the ball, or have to travel (which disrupts my routine), or something unexpected happens, it all falls apart and the weight creeps back.

My Lifestyle

It might be tempting to assume that all overweight people have an unhealthy lifestyle. There was perhaps some truth to this for me in the past, but these days I think I do a lot of things right:

• Exercise: I workout with a personal trainer twice a week, doing a mix of HIIT and strength training. I’ve done this for the past ~4 years. I don’t naturally enjoy exercise, but I do have a lot of active pastimes that I engage in with varying frequency: hiking, dancing, roller skating, powerlifting, etc. My cardiovascular fitness took a hit from getting covid 3 times in the space of 9 months, but I am weirdly strong and flexible.

• Diet: I love cooking. I eat a flexitarian diet with lots of whole foods, and I try to keep an eye on my protein. Because I don’t eat much meat, I eat cottage cheese, greek yogurt, high-welfare eggs, and supplement with protein shakes. I sneak leafy greens, onions, tomatoes and other veg into most stuff I cook. I’m not a big fan of sweet stuff, so dessert is usually a square of dark chocolate or some greek yogurt and berries. I love bread and I do eat out a few times a week, but overall I think my diet is a far cry from what most people picture when they think of what an overweight person in America eats.

• General health: I currently have no chronic conditions (weight related or otherwise) that impact my life (though I’m aware this could change as I could get older, which is part of my motivation for solving this problem).

So What’s the Problem?

It’s simple: I love food and I have a big appetite.

Even though I eat mostly healthy-ish food, I eat a lot of it. I get great pleasure from food, it takes a lot to make me feel full, and I hate feeling unsatisfied. I also love novelty; I find it very hard to resist trying new and exciting or delicious looking things. I once met someone who told me they don’t particularly enjoy food (they are quite happy just drinking Soylent for every meal) and I was baffled, this is just such a foreign idea to me. It’s one of life’s great joys!

Lots of people have various theories about why people are more overweight today (“Seed oils!”, “Lithium!” etc), and have quirky ideas about how to solve it (“Eat 2 tbsp of olive oil everyday!”). For me, it’s always been quite clear: I eat too much, and if I try to eat a normal amount, I am in a state of constant non-functionality, obsessed with food, always hungry, never satisfied. It’s not sustainable, and unsurprisingly, it doesn’t last.

Getting Semaglutide

I first heard about semaglutide via Scott Alexander, and after doing some research decided it would be worth a shot.

I spoke to my absolutely wonderful primary care doctor who was incredibly supportive and nonjudgmental and not patronizing. I love her. We discussed my other attempts to lose weight, and the benefits and risks of the medication. She sent me for some tests, which showed I had slightly high blood pressure and cholesterol, which semaglutide can help with. She gave me a prescription for Wegovy.

Next I had to wait for my insurance to authorize it. It took about a week, but it came through. I would pay $25 for 4 shots (a one month supply). I would start on 0.25mg, and then each month the dose would increase until I hit the full dose of 2.4mg. This titration period is to help with side effects.

My Experience so Far

After getting my prescription, I plunged into the r/semaglutide subreddit and read amazing stories. I tried to manage my expectations, aware that it doesn’t work well on everyone, and that the side effects can be bad.

Four weeks in, and I am blown away. I’ve had minimal side effects (just some slight nausea in the first week), I’ve lost 8lb, and it has completely changed my attitude to food and my appetite:

• I no longer get shaky and nonfunctional when I’m hungry - it seems to regulate my blood sugar much better.

• I’m not constantly thinking about food and planning what I will eat.

• I crave vegetables and protein instead of bread and cheese.

• I can easily leave stuff on my plate when I notice I’m full.

• I get full and satisfied much more easily - normally I’m eyeing up everyone’s leftovers, now I’m the one with leftovers!

• I seem to just have more general mental clarity.

Even if I wasn’t losing weight, I think I might still take it just for all these other benefits. Of course, I’m only a few weeks in, so I don’t know how things will go long term.

Reflections

I knew I had a big appetite compared to others, but I don’t think I realized quite how much of a disadvantage this was. Now that I know what it feels like to have “normal” appetite, I think people who have that naturally just don’t don’t understand how much suffering is involved for people who have to constantly artificially restrict their intake below what makes them feel satisfied in order to maintain a healthy weight.

I’ve been trying to think of an analogy. Maybe it’s like: Imagine if every time you watched TV (or a movie, or read a book), you had to stop 2/3 of the way through. Remember, it doesn’t just stop playing on its own, you have to have the strength of will to turn it off yourself, for some hard to quantify, very small, intangible future benefit. And you have to make this decision consistently, multiple times a day, forever. And you keep seeing trailers for all these tantalizing shows with dramatic twists that you will never get to experience in full.

Most people who are overweight have tried diet and exercise, among many other things. It does not surprise me at all that the vast majority of people who successfully lose weight end up gaining it all back and more.

People say: “Diet and exercise is the only sustainable solution for weight loss!”

I say: “Diet and exercise alone is not a sustainable solution for weight loss!”

People taking semaglutide generally are in fact changing their lifestyle. They eat less and they eat healthier food, out of choice. It allows them to do so without the suffering involved in doing it unaided, and is therefore much more sustainable. Semaglutide generally helps people lose 1-2lb per week over a long period of time - it is not a “quick fix”.

Yet many people are derisive towards it. I suspect this is in part due to the naturalistic fallacy, and in part due to some misplaced notion that things are only virtuous if they are difficult. The evidence is quite clear that diet and exercise alone is not enough to help most people lose weight and keep it off, no amount of hammering on about it and shaming overweight people for not being virtuous enough is going to change that. I am overjoyed that there now seems to be a solution that actually works!

Faq

I am answering these from my personal perspective, YMMV!

Q: How did you get Wegovy?

I spoke to my wonderful primary care doctor.

Q. How do you pay for it?

It’s covered by my insurance.

Q: What benefits have you experienced?

Aside from the weight loss:

• I no longer get shaky and nonfunctional when I’m hungry - it seems to regulate my blood sugar much better.

• I’m not constantly thinking about food and planning what I will eat.

• I crave vegetables and protein instead of bread and cheese.

• I can easily leave stuff on my plate when I notice I’m full.

• I get full and satisfied much more easily - normally I’m eyeing up everyone’s leftovers, now I’m the one with leftovers!

• I seem to just have more general mental clarity.

Q: How long will you take it for?

Honestly, I would happily take it for life if these benefits continue. The inconvenience is minor (an easy, painless injection once a week, way less annoying than e.g. having to brush my teeth twice a day), and the mental and physical health effects have so far been great. However, I may try coming off it if I have maintained a healthy weight for a while to see how it goes, but would want to go back on it if I lose the benefits.

Q: Why not just do diet and exercise?

Most people who struggle with their weight, including me, have tried diet and exercise alone and found it to be unsustainable. Semaglutide does change your lifestyle and improve your diet, the help it gives makes it sustainable.

Q: What side effects have you had?

A slight amount of nausea in the first week, pretty much nothing since then.

Q: How does semaglutide work?

I don’t really know, something to do with insulin and hunger hormones? As well as changing your appetite, I think it has some beneficial metabolic effects.

Q: Why did you choose this instead of bariatric surgery?

• I don’t qualify for it

• It seems to me to be way more invasive and inconvenient than a weekly painless injection (even if I had to do them for life)

• Surgery can have major complications

• Wegovy is easier to try and is revocable if I decide it’s not for me

• There is limited evidence that the results of bariatric surgery are durable - a solution that doesn’t address my appetite and the mental aspects probably wouldn’t work for me long term

• AFAICT surgery results in much quicker weight loss, whereas slower weightless is generally thought to be safer (and reduces the chance of loose skin)