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- [00:01]
A
This episode of Search Engine is brought to you in part by Zapier. AI has changed so much of the way people work day to day. There's so many little tasks that used to eat up all your time. Organizing notes, moving data between tools, following up on things manually. Now, with AI helping out, a lot of that busy work just happens in the background. And it's much more useful when it's actually connected to the tools you already use. We cover a lot of trends on this show, and over the last few months, everyone's been talking about AI. But let's face it, talking about trends doesn't help you be more efficient at work. For that, you need the right tools. You need Zapier. Zapier is how you break the hype cycle and put AI to work across your company. With Zapier's AI orchestration platform, you can connect top AI models like ChatGPT and Claude to the apps your team already uses. That means AI powered workflows, autonomous agents, customer chatbots, whatever helps your team move faster. Join the millions of businesses transforming how they work with Zapier and AI. Get started for free by visiting zapier.com search that's Z-A P I-E-R.com search. This episode of Search Engine is brought to you in part by Bilt. We can all agree housing is expensive, whether it's rent or a mortgage. It's one of those bills you can't ignore. But Bilt can actually make that monthly payment feel a little more rewarding. Bilt is the membership for where you live. It lets you earn points on your housing payments, whether you rent or own. That means every payment earns you points you can redeem towards travel with partners like United and Hyatt, Lyft rides, Amazon.com purchases and a ton of other options. But what really stands out is the neighborhood concierge. They can help you plan a night out, book a fitness class, or find new places nearby. And you're getting rewarded at over 45,000 partners while you do it. It's such a cool, unexpected perk. It's simple. Being a renter or a homeowner is better. With Bilt. Join the membership for where you live@joinbuilt.com search that's J-O-I-N B I L T.com search make sure to use our URL so they know we sent you. Okay, so here's something. Our show's motto, no question too big, no question too small. But there's some questions that I have on this show avoided. I'll give you an GLP1s search engine has barely acknowledged their existence, which is fine, except I read a lot about them, I think a lot about them, and in my private life, I talk a lot about them. But when they cannonballed into American culture, I had a lot of questions that I didn't want to ask in public. In 2022 and 2023, GLP1s were just, for me, too hot a topic. Going online felt like walking into a crazy shootout at an old western saloon. Except instead of gunslingers, it was all fast draw scolders. There were scolders out there scolding celebrities for taking GLP1s. But then they were getting scolded by other scolders for scolding celebrities. Some people got scolded because they were taking the drugs despite not being fat enough. Scolded for wanting to lose £15. Rich people, of course, were getting scolded all over the place, accused of ripping GLP1s out of the hands of the people who actually needed them. It was scolding mayhem. Meanwhile, offline in real life, 20% of the people I knew just lost 15 to 40 pounds. They seemed happy, and I had questions. What did we really know about these drugs? Were they helping people the way they claimed to? What were the side effects? I had questions, but I hate getting scolded, so I kept my mouth shut. Meanwhile, in 2026, the scolders have moved on to other topics, topics I'll cover in 2029. But today we can finally get some answers on these fascinating drugs, which it turns out, are much weirder than we ever knew. So this week we're going to talk to a doctor who's going to tell us the story of GLP1s from her perspective, which is a very unique one because she's a doctor to a particular patient population that we don't hear from much in the media, almost never. And who were very absent from the entire early discourse around these drugs. Can you say your name and what you do?
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B
Sure. I'm Rachel Bedard. I'm a physician and I'm a writer. I'm a contributing writer to New York Times Opinion. And as a doctor, I am an internist, and my subspecialties are geriatrics and palliative care. But I've had this sort of unusual career where for six years I was a physician on Rikers island, and I now work in a homeless clinic a couple days a week.
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A
Can you tell me about your work at that homeless clinic? Like where's the clinic? What's it like? What's your work like?
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B
So the clinic is. It's a safety net clinic run by the city. The city is a network of these safety net clinics that are embedded in the public hospital system. And so my clinic is at Woodhull Hospital in Brooklyn. So the clinic's in the hospital, but it's an outpatient clinic. It's primary care. We serve people who are either unhoused or sort of in precarious housing situations. They were recently housed or they are staying on friends couches or something like that. But the majority of the people that we take care of are living in shelter or people who are sleeping on the street. So we do sort of all of their primary care. That population has a very high rate of comorbid mental health issues, very high rate of comorbid addiction issues, but also is just very medically sick. So the majority of folks that I take care of have at least one chronic medical comorbidity, like high blood pressure or diabetes or other diseases like that for which they're taking daily medications.
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A
I have a bunch of questions in a bunch of different directions. One is your work puts you, I think, a lot of people who live in New York City. The weird thing about New York, maybe more than other places in America, is that it's both incredibly class stratified. You have very elite, very wealthy people and you have working people and you have very poor people. But the people in those worlds don't always really run into each other. Besides maybe on the subway or literally on the street, you have this unusual life where you're moving between like highly elite worlds like the New York Times, and then working with populations that are so far removed from it. And I just wonder, the thing that I think so many people block out in their minds in order to just live in a city, you've chosen to give yourself a life where you can't. I'm just wondering what that's like.
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B
Yeah. So, you know, one thing I'll say about New York is although the rates of inequality here are astounding, there is, I think, actually more mixing in New York City than there is in a city like la, for example, where people are always in their cars. Right. Like you are sort of interacting on the streets and on the subways, et cetera, you know, and because of the density, people are just on top of each other. Much more. So it doesn't feel. My life certainly feels extremely stratified for lots of reasons, but I think I like living here because it feels as though humanity is in continuity with itself in a way that in some other parts of the country or other very wealthy cities, you can be completely sort of cloistered off. That having been said, yes. My clinical work puts me in not just contact with, but I think just an extremely intimate relationship with people whose lives are really, really difficult in ways that my life has never been and gives me a different sort of level of insight into what it's like to live in those circumstances.
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A
Right. You get this very intimate view into lives that are very different from your own.
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B
Right. Like my patients, their experience of the weather is really different than my experience of the weather because they are exposed to the elements in ways that I am not, with fewer ways to protect themselves, ranging from like, they come to the clinic and they don't have a coat and they don't have gloves and it's really cold outside or it's really hot outside, and they don't necessarily have a place to take cover from that. Right. And so, like, that's a really different way to be in a body in the same spaces that I'm in my body in. If that makes sense.
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A
Completely makes sense. How did you end up working at the homeless clinic?
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B
Well, I. So I had gone into medicine because I wanted to do sort of social medicine, like social justice work through medicine. And it wasn't totally obvious how to do that. And I sort of very luckily by chance, ended up in this job at a fellowship at Rikers, where my job was to take care of older people who were incarcerated in the New York City jail system. And I loved that job so much.
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A
What does it look like day to day to be a doctor at Rikers?
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B
Rikers is a wild place because it is. It's an island, as you know.
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A
I've been once, actually.
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B
Oh, have you?
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A
Yeah. But you should describe it, because I guess the median listener probably has not been.
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B
Yeah. So Rikers island is an island off of Queens. It is connected to Queens via this long bridge. There's security at the front of the bridge, and on the other side, you. You can only drive on the island. You aren't allowed to walk on the island. It's sort of a fortress unto itself that the Department of Corrections for New York City runs. And it is a complex of multiple jails that are all on this island. Bunch of different buildings. The buildings house people sort of in different subspecial populations. There's one for women, there's one for people who are sicker. There are ones for specialized mental health units and Depending on the kind of medicine you practice, your day can look very different. So for the first few years that I worked there, I would basically print a list of everybody in the system who is older than 65, and I would go sort of try to find those people, where they were and call them down to a clinic in that building. There's no freedom of movement in the New York City jail system, which means that every time a guy moves from one place to another, he has to be accompanied by an officer. Like, somebody has to come pick him up and unlock a door and take him out and bring him to you. So things move very slowly. Like, it's like being in the airport all the time. Right. Or the emergency room. It's an incredibly sort of congested system that requires a huge amount of excess human contact. It's hard to have real privacy during clinical encounters because you're not actually sort of behind a truly closed door ever, for safety reasons. But you can imagine that there's, like, a tension there with being able to provide care to people who are ambivalent about revealing themselves in that kind of environment. Right. And so it is a clinical dynamic that's very much constrained by the security concerns of the system. And some of those security concerns are really well justified, and some aren't. One of the first patients I had with advanced cancer, I went to visit him while he was in the hospital, incarcerated. There was a corrections officer sitting outside his room. He had told me he really likes Skittles. The patient I brought skittles. I had to open my bag and show the officer what was in my bag before I was allowed in the room. And I was too sort of junior to know that I should play it cool. And I said, I brought him Skittles. And the guy said, he's not allowed to have those. And I said, why? And he said, well, Skittles aren't on commissary, so he's not allowed to have things that aren't on commissary. That's, like, obviously not a real security concern.
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A
Right?
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B
That's just a rule, and that's not a law. You know, even though the guy saying it to me is in a uniform, and I was like, I'm gonna give him the Skittles. You know, and you can imagine that that's hard to do. And you have to have, like, a fair amount. You have to really feel empowered by the folks who run the healthcare side of things to be able to use your judgment like that. And I was super lucky in who my bosses Were. And I was there for Covid. That was really wild. It made me feel incredibly bonded to a bunch of my colleagues and my supervisors. And then I left at the beginning of 2022, quite burnt out. And a bunch of people who I worked with at Rikers moved on to work at Woodhull. And it was like, you know, like in Mad Men, when they, like, remake the fur. You know what I mean? They're like, season three, we're doing a new one, but it's like, the same guys. That's what it was like. We'd, like, Mad Mend up at Woodhull, which is a bunch of people who I loved working with at Rikers who are super mission driven. And so that's how I ended up there.
- [12:33]
A
And so you're there now. And it sounds like the thing that. I mean, there are many things in common, the people you're working with in common, but the other thing that sounds shared is that I think when a layman thinks about a doctor, it's a person you go to, and they figure out what's wrong with you, and they give you medicine. And your experience of medical care is that oftentimes the job is as much about the social structures around people as just, like, treating their bodies. Because the things that are happening to their bodies and the social structures they're enmeshed in are so inseparable.
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B
Yes. Although I would say that's truly true for any practice environment, any patient population, really. Yeah. It's just the challenges are really different, and it's more visible, I think, with my patient population. But if you are paying out of pocket to see a concierge doctor, which in New York, there's, like, this incredible stratification and access to primary care. And one, at the high end, people are paying out of pocket to see concierge doctors, which means that they're paying some huge amount of money to have this person basically be on call to see them. And the dynamics of that relationship are totally determined by that payment model, by that person's socioeconomic status, by their access to be able to get care from other kinds of specialists, by their ability to, like, you know, that doctor says, maybe you need a massage for this back pain, and the person can pay for that massage. Right. It's sort of impossible to separate the body from the social.
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A
Yeah, yeah, yeah.
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B
And that's just particularly visible. And the social sort of circumstances for my patients are just so particularly crushing and throwing up obstacles to their being able to take care of their bodies the way that we would want them to that a lot of what the doctor ends up doing is sort of negotiating with the world on behalf of my patients to get them things I think they need. The other thing I would say is that because my patient population, you know, health is socially determined to a large degree. So, like, when you describe, like you go to the doctor, you say something's wrong with you and they give you a medicine, you're picturing going for like strep throat or something, right?
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A
Yeah.
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B
Or I have the flu and I want Tamiflu because that's the experience of people who aren't sick. But my patient population is sick, so they are living with illness all the time. And when they are coming to me, they're not coming necessarily with a new complaint so much as we are in this constant process of trying to modify their experience of illnesses that they live with chronically.
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A
There's nothing about anything you've described where my under informed, stereotypical view of the world you're treating would say like, this is the pop culture sketch I have been given of Ozempic users. Can you tell me the first time you heard about GLP1s? Like, when did they show up on your radar?
- [15:13]
B
Yes, so right, exactly. And this is sort of my whole interest in these medicines to a large degree. So GLP1s have been around for a really long time. Like some version of GLP1s have been around for almost 20 years. There were sort of like first generation GLP1 medications that were only used for diabetics. So I've known about those medicines for a really long time. But the sort of GLP one's class that is like the Ozempic generation and then everything that's followed really came on the radar, like 2021, 2022. And I think the first time I sort of started paying attention to them was when I read about them in mainstream media, not in medical literature, because especially like those very early months, like, they weren't accessible to be prescribed. And so there were sort of these studies that had been done, you know, by Novo Nordisk, suggesting like incredible results for diabetic patients. But there are lots of medicines being invented all the time that are really promising, but that are too expensive and are just like not going to be on formulary for my patients that I don't actually know that much about. I think the way that I personally got really interested in the GLP1s was I actually think that somebody I know who worked at Vogue called me, called me and was like, what's the deal? You know, like, everyone I know wants this medicine. Like, what's the deal with this medicine? And I was like, the diabetes drug, Like, I, you know, it was sort of not on my radar. And then I started to be interested in it as the weight loss effects became clear, well known. And then the drug started to be sought by a patient population that didn't have diabetes, but that wanted to use it for weight loss. And it became sort of this like cultural phenomenon. Like I think 2022, 2023 is really when that happened. Like 2023 is the year to me of the Ozempic first person essay. Yes.
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A
2022 was the year for me of people whispering about it.
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B
Right, yeah. And then 2023 was people being like, all right, I did it, I tried it. Or like, or what does it mean for the body positivity movement that this is happening? Or whatever like that. Right. It was this really interesting thing where this diabetes medicine became this other thing. And at that point, like, really controversial. Right.
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A
Initially it was a medicine that was also a discourse object, right?
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B
Exactly, exactly.
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A
And it like scrambled all these. There were so many relatively set battle lines and ideas about, as you said, like body positivity. And then you had this thing which just, it took this table and just like shook it really, really, really hard.
- [17:39]
B
Totally. And it was so unexpected, frankly. Right. Because one of the sort of truisms up until this class of medicines was we didn't have a magic pill for weight loss. Right. That there had been sort of all of these prior cultural moments like fen phen in the 90s where there had been like a hot discourse object medicine to help people magically shed pounds. Nothing prior to GLP1s had been proven safe in a way that it could be sort of a sustained intervention for people. Nothing really worked that well. Whereas like all of a sudden people were taking Ozempic, it seemed safe, they were tolerating it okay. And they were losing 15 pounds in five weeks. And that it was just so unprecedented in its efficacy. Like, we hadn't had anything like that before. I mean, like these drugs, by the end of 2023, we knew that they had an all cause mortality benefit. Like, that's unbelievable as an outcome. There are very few things in medicine where you can show that it prevents people from dying over a very short period of time of taking the drug. And this did that. And so like, it was really an incredible, from a medical perspective, it was super exciting. And at the same time there was this like weight loss, body image, yada, yada, discourse that was totally divorced from the actual medical impacts of the drugs.
- [18:59]
A
This yada yada discourse Dr. Bedard's referring to. That's what I was referencing in the beginning of this episode, a season which yielded many essays from writers wondering out loud if these new drugs were just morally wrong. To Dr. Bedard, the problem with these pieces is that they rarely seriously engaged with a world beyond the writers, their social circle, and celebrities on Instagram.
- [19:22]
B
I was annoyed on a bunch of different levels. One thing is that it just highlighted how much cultural discourse about bodies, even illness, medicine, people's experience of their bodies really almost never reflects the experience of people who are actually ill. So, you know, type 2 diabetes is, like, one of the most common chronic conditions that Americans live with. It can be really terrible, right? Like, millions of people in this country have had a limb amputated because their diabetes was sufficiently bad that they had vascular complications where they stopped getting blood flow to a limb and they had to lose a leg. That's really terrible. There are half a million people in the US who are on dialysis, which means that three times a week they go for several hours and sit in a recliner in a room full of people in recliners hooked up to huge IV catheters that are exchanging their blood through this, like, blood washing machine, dialysis machine. That's a wild way to live, right? Imagine if you had to do that. And those experiences are never reflected in first person writing about illness in the mainstream media. They're almost never actually described, I think, in the publications that I read, both for news and pleasure. Whereas I'm 43, I think for as long as I can remember, I have been reading an essay a week about what it's like to be a white lady who doesn't feel great about her weight. That is a constant in my life through many changes in the world. And the idea that this breakthrough class of medications that had the potential to revolutionize chronic disease population health in the US Potentially change the expected mortality for Americans like that. It was all sort of being funneled into this same discourse and also processed using the same types of anxieties and neuroses that were sort of the themes that I've been reading about my whole life. Like, was really annoying to me.
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A
TO Dr. Bedard, what was annoying in 2023 was how the conversation about these drugs gave almost all of its oxygen to their cosmetic attributes. What did it mean for everybody's body image that thinness was now much easier to buy than it had been before? I can feel even now saying that sentence, the heat and excitement of all the arguments it provokes. But for Dr. Bedard, those arguments made her want to yell at the screen, forget even for a second, the cosmetic implications. GLP1s were transforming the lives of some of her most vulnerable patients. She thought more of the oxygen in the conversation should have gone there, and that the discourse certainly should not have been so focused on the very particular lives of media elites. We're going to take a short break. When we come back, we're going to move away from discourse, away from the conversations of yesterday's Internet to today, the actual science behind GLP1s and all the weird things doctors have been learning about them in their last three years of widespread deployment. This episode of Search Engine is brought to you in part by Vanguard. To all the financial advisors out there whose job is to help your clients keep more of what they earn, Vanguard is here to help you with that. Vanguard is slashing fees again, this time for more than 50 of its funds. That's on top of big fee cuts they gave last year to investors in 87 of their funds. In an increasingly high priced world, Vanguard is staying true to excellence without expense. With Vanguard, your clients get access to sophisticated active and index bond funds at industry leading low costs, backed by a fixed income team that's truly obsessed with consistent output performance. Lower fees don't just mean savings. They give Vanguard's skilled bond managers more freedom to maneuver as they pursue strong results. And they give you more flexibility to deliver measurable value to your clients because top performance shouldn't come at higher cost. Go see the record for yourself@vanguard.com impact that's vanguard.com impact all investing is subject to risk. Vanguard Marketing Corporation Distributor this episode of Search Engine is brought to you in part by Gusto. Okay, quick question. Have you ever sat down to just check one payroll thing and suddenly it's like two hours later you're buried in forums, googling tax stuff and questioning your life choices. Gusto is here to relieve that problem. Gusto is online payroll and benefits software built for small businesses. It's all in one remote, friendly and incredibly easy to use so you can pay, hire onboard and support your team from anywhere. It handles automatic payroll tax filing, does direct deposits, and even helps with benefits like health insurance and 401ks. Basically, all the stuff that you're used to stressing you out just gets handled. It's one simple monthly price with unlimited payroll runs, no weird fees popping up. Plus, if you ever get stuck, you can actually talk to certified HR experts, which is a lifesaver. Try Gusto today at Gusto.com search and get three months free when you run your first payroll. That's three months of free payroll at Gusto.com search one more time Gusto.com search. This episode of Search Engine is brought to you in part by Framer. Your marketing website sets the tone for your brand and is the one touch point every single one of your customers has. If you still struggle to make small changes and simple updates, you're leaving opportunity on the table. That's why so many companies, from early stage startups to Fortune 500s are turning to Framers, the website builder that turns your.com from a formality into a tool for growth, helping businesses build better websites faster. Framer is an enterprise solution with premium hosting, enterprise grade security and 99.99% uptime SLAs that gives the world's leading brands like Perplexity, Miro and Mixpanel the confidence they need to build their websites in Framer. Learn how you can get more out of your.com from a framer specialist or get started building for free today@Famer.com search for 30% off a Framer Pro annual plan. That's Framer.com search for 30% off Framert.com search rules and restrictions may apply. Welcome back to the show. So can you tell me literally just like what are GLP1s doing inside of your body? Like, what are the mechanics of how these drugs work?
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B
Okay, so when we're talking about GLP1s as a class, we're talking about this class of medications. The first one actually came out in 2005. But like this popular conversation's referring to the ones that have come out in the last couple of years. And the sort of first one is semaglutide, which is Ozempic or Wegovy. Then the second one that's already approved and been on the market for a couple years is Tirzepatide, which is Zepbound or Mounjaro. And then there's this one in the pipeline that I literally cannot pronounce, the one with the R. Retrutide Retatrutide is like the worst possible name. Like, I can't spell it, I can't say it. So semaglutide is this peptide that is a GLP1 agonist. An agonist means that it's a peptide that binds to the GLP1 receptor in the body. And GLP1 in the body does a couple of different things. It Slows gastric emptying. So it makes your stomach stay full longer.
- [27:23]
A
Like not the feeling, not just the feeling of being full, but literally, like if I eat a salad, it stays there.
- [27:28]
B
Exactly. That does absolutely increase your fullness and gets you to fullness faster.
- [27:33]
A
Yeah.
- [27:34]
B
It also does increase your sense of fullness by working on like hormone receptors in the brain. And it decreases hunger and increases satiety. And then it. And this is why it's really important and works in diabetes. It works on glucose balance. And so it provokes the pancreas to release insulin in response to high glucose levels. So it doesn't cause your pancreas to just like willy nilly release insulin all the time, but it augments the insulin response to high glucose levels in your body.
- [28:05]
A
And what's the relationship between, like, glucose enters my body when I eat, like sugar or bread or something like that. What's the relationship between glucose and insulin?
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B
So when you eat anything that has carbohydrates in it, it gets broken down to release glucose, which is like sugar in your blood. In response to glucose in the blood, the pancreas, which is like an organ in the back of your belly, releases insulin, which is a hormone. Insulin helps your muscles take the glucose out of your blood into the muscle and use it for energy. What happens in people of type 2 diabetes or people with pre diabetes, is they develop insulin resistance, which means that they have decreased response to insulin, which means they are less effective at taking the glucose out of your blood. And that means that your body needs to release more insulin in order to take that glucose out of your blood.
- [28:55]
A
Yeah.
- [28:56]
B
So for diabetics, who often have very high levels of glucose, just like circulating in the blood, high levels of glucose, called hyperglycemia, it causes all sorts of downstream effects. It hurts your eyes, it hurts your kidneys, eventually it contributes to plaque buildup in your arteries, which can cause heart attacks and strokes. So what you want to do in diabetics is get their glucose levels, their average circulating glucose levels down. And GLP1 agonists help do that by signaling to your pancreas when you have a glucose spike to release insulin so that the glucose spike doesn't spike too high. Basically it helps sort of maintain your glucose levels within a range that your body can handle. And GLP1 agonists, through that sort of combination of effects, the semaglutide, like wegoviosympics lead to like 10 to 15% body weight loss over the course of a year in the studies. But the thing that I think is really interesting about these drugs and one of the reasons that they've been sponsored, inspired so much excitement is because they've had effects that we sort of anticipated that were like targeted effects in the initial trials, improved blood sugar control and weight loss. And then they've had a bunch of unexpected downstream effects, probably related to weight loss and better blood sugar control. Like they prevent heart attacks, they prevent strokes, they prevent people from progressing to diabetic kidney disease. They seem to improve people's knee arthritis, which, like, was really unexpected. They seem to improve heart failure. And then they also have this potential effect around addiction. And that's interesting because you really can't attribute that impact to weight loss. So, like, there's no reason to think
- [30:44]
A
that if I'm £225 or £180 I should want to drink more or less, right?
- [30:50]
B
Exactly. Other than maybe there's some psychological impact, et cetera, et cetera. But what we're sort of interested in is it's revealed that there are GLP1 receptors in places where I think we didn't totally recognize they were there didn't fully recognize their potential role in things that we weren't thinking about. So there are GLP1 receptors in like the dopamine reward circuitry in your brain. And one sort of hypothesis around the addiction stuff, or the sort of strongest Hypothesis, is that GLP1 agonist binding there is interrupting reward circuitry pathway stuff in a way that for people who have strong reward pathways built around addictive behaviors, like, it interrupts that.
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A
And is it like these sort of unexpected positive effects, the ones that are sort of surplus effects that go beyond what you would have modeled as likely benefits of just like losing weight? Does it suggest that maybe being like a certain amount of overweight can be more dangerous to our health than we understood? Or is it more like these things are just doing things in places that we don't understand?
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B
I think it's the first. I think that one of the things that's really interesting about the diverse array of effects that the GLP1 drugs seem to have is that it's suggestive of the fact that obesity, and what people who study obesity have long asserted is a pathological condition that has consequences way beyond just being overweight and moving around the world in a bigger body. Having a lot of excess fat tissue on your body changes all sorts of hormone signaling and homeostasis mechanisms in your body. So losing that adipose tissue, that fat tissue makes a huge difference in changing how your body self regulates. And that Seems to improve a whole bunch of things that we maybe didn't totally anticipate. There's this sort of hand wavy thing that the GLP1s decrease inflammation, which is true. We sort of do know that, that they decrease inflammatory markers in the body. And just seeing all the different ways in which decreasing inflammation seems to help people is really fascinating.
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A
Yeah. You've described the known benefits. You described that there's some like, sort of, I don't wanna say unknown possible benefits, but like question marky things that
- [33:13]
B
look good, a million things that are like question marky things that look good. Like I should just list some of them because it's so exciting. Cancer prevention. So we know this is another one where like on the one hand we know that there are a bunch of cancers for which obesity is a risk factor. Breast cancer is like that, colon cancer is like that. GLP1s seem to help with those. There are a bunch of cancers where we don't think of obesity as being a risk factor, where GLP1s because of this anti inflammatory sort of impact, we're not totally sure may also play a role. So there are trials to look at cancer prevention. There are trials to look at Alzheimer's prevention. The first Alzheimer's prevention trial was negative, which means the drug didn't make a difference. But I don't think it's conclusively negative that it doesn't help with Alzheimer's prevention or treatment necessarily. There are sort of more trials to be done there. There are trials happening in Parkinson's disease. Like these are big, extremely common conditions that either lead to death or that totally derail people's lives. And so the potential benefits that are still under characterized or unproven are super exciting.
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A
And what are the current unknown or questionable possible harms that you're tracking?
- [34:28]
B
I mean one that's sort of been studied some, but I think not in a way that's super, super conclusive is for some people it does seem to provoke a depression. There's been this concern about increased suicidality that has not borne out in studies thus far. But like is on the radar as a thing that people are concerned about. But these psychiatric neurologic complications I'm interested in and paying attention to. The most common side effects with these drugs are the GI side effects. So like bad nausea and vomiting and constipation. And so I'm really interested in both increased clarity around what standard of care looks like for prescribing them to minimize those side effects and whether these future like GLP1 2.0, 3.0, 4.0s are going to improve that side effect profile because that would actually make a very big difference.
- [35:22]
A
Right. Because there's people that can't tolerate the side effects.
- [35:24]
B
Yeah. I mean, some people are really nauseous and vulnerable at the beginning because they just haven't figured out how to eat on the drugs. Like, they're still eating too much. But some people have like constipation that they just can't tolerate. Some people are persistently nauseous in a way that doesn't get better. For most people, it gets better, but that's a real, like, rate limiting step.
- [35:44]
A
So there's a world of discourse and media which I belong to, which bungled this story for at least a year. In the world of the patient populations who you treat, like, what was actually happening far away from the discourse. Can you just tell me stories, like from early on, like, what type of patient was taking these medicines at your clinic and how was it affecting them?
- [36:08]
B
Sure. So I work in New York City. New York State has generous Medicaid. New York City's public hospital system has its own pharmacies. And they did some amazing job, I don't totally understand, in which they were able to provide access to the GLP1s even during the period when it was very, very hard to get them at sort of regular community pharmacies. And so between both that sort of generous insurance and that access in our hospital pharmacy, I have had this incredible good fortune of being able to prescribe Ozempic for diabetic patients since like 2020 or 2024 who are poor and otherwise would not have access to it. Right. And this is like a huge issue is that like, for most patients, like my patient population, they aren't on it yet because their insurance doesn't cover it. Or if their insurance covers it, it covers it only for a very narrow set of indications and they have trouble getting it or whatever it is. My patients have been able to get it the whole time. And I do think it's sort of like a miracle breakthrough in primary care for underserved populations that have the morbidity burden that my patients have. So most of my patients have diabetes and high blood pressure and high cholesterol and some degree of kidney disease and maybe some degree of other complications of diabetes, like retinal disease in their eyes and fatty liver disease. Most of my patients also have some addiction history in my homeless clinic, so alcohol or other substances. And it's been my experience that for the patients for whom I'VE been able to prescribe Ozempic, which is the one that I've been able to get paid for. It really does help with all of those things. Like, their diabetes improves, they lose weight, their chronic pain improves, their blood pressure improves, their cholesterol markers improve, and patients really like it.
- [38:07]
A
I mean, what did they say?
- [38:08]
B
Like, I had this great paranoid schizophrenic lady who was on it. She was the first patient I ever prescribed it to in primary care, and she was in my office, and she's sort of, like a little bit psychotic at baseline, but she takes her medicines. So she's telling me some story, like, I kind of can't follow about, like, some people who have been, like, tapping her phone. And then I said, oh, wow, you lost, like, 12 pounds or something. Because I'm looking at her chart and she pauses and she, like, locks in, and she goes, I haven't weighed this much since 1996 and I died. Like, I was like, you go, girl. Like, amazing. So happy for you. And that's, like. That's been true for a bunch of my patients, that they feel better in their bodies, both psychologically and physically, and they don't work for everybody. There are Certainly, you know, 5 to 10% of people who don't tolerate them because the side effects are too much. Like, some people just get much more nauseous than the average person. And then they're just like, I can't do this. I don't like it. A few people have said more in my personal life than in my practice, that they thought that they felt low on them, that made them feel a little bit depressed. I haven't had that happen in my practice. But that's just to say that there are a bunch of reasons why some people don't tolerate them. But for people who tolerate them and for whom they work, they're an incredible intervention. Most of my patients are on eight to 10 medicines a day. And for them to be able to take one shot a week, lose weight, improve their diabetes, improve their high blood pressure, improve their high cholesterol, you know, carrying less weight, and also have less inflammation in their body, so their pain is better, their depression is better, like, that's an extraordinary thing to be able to offer them. It's not everybody's experience. But for people for whom it works like, it works better than any other single intervention I've ever given someone other than curative ones. And so, like, I'm unbelievably grateful for them and I'm incredibly excited about them you know, like, I think as there's this arms race in developing better, more effective, more targeted GLP1s and as we get more and more studies about how to dose them correctly for different conditions, et cetera, et cetera, like, you know, I mean, it already has, but it will absolutely revolutionize primary care practice.
- [40:30]
A
Doctor Bedard says that part of this revolution has come because maybe surprisingly, maybe not. One side effect of the huge demand surge for these drugs in 2023 and 2024 is that the price has been driven down. When the manufacturers of drugs like Ozempic couldn't meet demand, compounding pharmacies entered the marketplace selling compounded versions at a much lower price that ended up pushing prices further down, even on the name brand GLP1s. So now semaglutide, which not so long ago cost $1200 a month without insurance, can be found online for as low as 150 bucks a month. A healthcare market that for once seems to have kind of sort of worked. Eventually we're going to take one more break and when we come back, Dr. Bedard gives us her take on people who are taking these drugs for decidedly off label use. This episode of Search Engine is brought to you in part by Dell PCs. Dell PCs with Intel inside are built for the moments that matter. From the moments you plan and the ones you don't. Built for the busy days that turn into all night study sessions. The moment you're working from a cafe and realize every outlet's taken. The moments you're deep in flow and the absolute last thing you need is an auto update throwing off your momentum. That's why Dell builds tech that adapts to the way you actually work. Built with long lasting batteries so you're not scrambling for the closest outlet. And built in intelligence that makes updates around your schedule, not in the middle of it. They don't build tech for tech's sake. They build it for you. Find technology built for the way you work@dell.com DellPCS built for you. This episode of Search Engine is brought to you in part by Vuori. You know that feeling when you put on something and can't stop reaching for it? That is genuinely what happened to me with Fiore. The first time I put on their black sweatshirt, I was struck by how soft the fabric is, how perfectly it fits without being restrictive, and how it moves with me. People have also complimented me on it, which doesn't always happen with my clothes. I've worn it on a morning walk running errands. Lounging on the couch, even out for coffee with friends. It looks like a human adult outfit every time. Fiori is an investment in your happiness. And for our listeners, they're offering 20% off your your first purchase. Get yourself some of the most comfortable and versatile clothing on the planet@vuori.com search that's V U O-R-I.com search exclusions apply. Visit the website for full terms and conditions. Not only will you receive 20% off your first purchase, but enjoy free shipping on any US orders over $75 and free returns. Go to Vuori.com search and discover the versatility of Vuori. Clothing exclusions apply. Visit the website for full terms and conditions.
- [43:14]
B
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- [43:53]
A
Welcome back to the show. Do you just in your social life, do you have non patient people, friends, family members, still asking about the drugs?
- [44:02]
B
Constantly, constantly, constantly. I take an unofficial assumption. Consult a D. What do you tell people right now? I mean, I am very GLP1 supportive. So, you know, it's case to case. Like it's not for everybody. But I will give you sort of examples of like the kinds of things like, you know, I have lots of women in my life who are struggling with postpartum weight gain or like pregnancy weight gain and not being postpartum, feeling overweight, or people who one of their real anxieties about getting pregnant again is that they gained a huge amount of weight and they don't feel like they're back in their own bodies and they don't want to gain more. I'm really supportive of people using a GLP1 for a period of time to help them lose weight that they gained really suddenly and are having a hard time losing. There are obviously some people who have long histories of eating disorders in their lives and where you think, I think if you do this, this is not gonna be great for you. Actually, I think that this is reigniting a series of obsessions that you've done a lot of work to try to get past. For those folks, I don't think that they should, you know, entertain the idea of a GLP1, but for lots of people, I think it's a fine thing to do.
- [45:11]
A
Do you talk to people who are talking about using it, I guess off label to manage addictions?
- [45:17]
B
I have. So I don't. I know one guy who was taking it so that he would post on Twitter less.
- [45:26]
A
Really?
- [45:27]
B
Yeah.
- [45:27]
A
Did it work?
- [45:28]
B
He said so. And then he's posting a lot recently, so maybe he's off. I don't know.
- [45:32]
A
You know, if I really thought it was a cure for Twitter use, there's people I would. No, I stand outside other people's houses with like a blow gun and just like.
- [45:42]
B
I mean, you know, I think, yes, I absolutely have people who. I have a close friend whose primary motivation in trying it was that he wanted to drink less. He also probably wanted to lose 10 or 15 pounds. But, like, probably wouldn't have taken it just for that alone.
- [45:56]
A
Yeah.
- [45:57]
B
Asked and I said, yeah, try it. See how you tolerate. You know, the other thing is that they just are quite safe. That doesn't mean that they're safe for everybody to take for 60 years week after week. You know, like, we don't totally have exactly that data, but we have 20 years of data about this class of medicines and we have a pretty good sense of there is a very narrow slice of the population who they're totally inappropriate for. If you've had a family history of certain rare cancers, for the majority of people, giving them a shot and seeing how you tolerate is totally appropriate and fine. And so this friend, like, took them. He didn't identify as an alcoholic, but he identified as someone who wanted to drink less and who drank daily. And for this friend, he took them for six months or something, or four months. Totally changed his relationship to drinking. I think he's been off now for a little while and he said he's not back to drinking the way that he was. He feels that relationship feels altered for him, even if he's not as suppressed in his desire as he maybe was when he was like, on the medicine week after week.
- [47:02]
A
I had one last question for Dr. Bedard. I wanted to know if she had a perspective on a class of drugs that are adjacent to, but in my view, Fairly different from GLP1s Internet peptides, the wilder west of molecules. Many people are now using drugs. We've covered elsewhere on the show.
- [47:19]
B
I think that. I think that it is both GLP1s and peptides to some degree are part of a larger shift in health, wellness medicine, which is this, like, paradigm shift between thinking of medicines as things that we use to treat illness to thinking of pharmaceutical products as something that we offer people to help them feel the way they want to feel.
- [47:48]
A
Is that a bad shift? Is that a neutral shift?
- [47:51]
B
It's a complicated shift, I think so. You know, the, the better example to me peptides is like the use of hormone supplementation for a million different indications. Right. Like that's another huge discourse. It's like, you know, women taking estrogen supplementation in their early 40s when they start to feel what they self diagnose as perimenopausal symptoms. Women on testosterone, there's been a bunch of essays about that. Men on test, you know, like it's a very different way of conceptualizing the role of healthcare then. It's not why I went into healthcare. And it's also different from the sort of paradigm I trained in. But I'm also a little bit trying to remain neutral about this in thinking about the changing relationship between patients and providers to one that's a more sort of shared goal setting, shared decision making model. Which doesn't quite answer your peptides question, but I kind of see all of like the peptides, the GLP1s, the cosmetic procedure stuff, it's like all part of a thing of like I don't feel the way I want to feel in my body, I don't look the way that I want to look in my body, et cetera, et cetera. I'm going to seek medical intervention to help me become the thing that I want to become. I have really complicated reactions to it, but I don't yet have a definitive opinion about it. I'm really trying to think it through.
- [49:10]
A
I can't tell if what you're describing is that interventions that we just would have understood as cosmetic before are becoming much more socially acceptable or if it's more complicated, which is that like interventions like we thought of as cosmetic, we're now in our own minds labeling as medical.
- [49:26]
B
I think it's the second one. So I think that we have in a weird way medicalized a lot of the experience of being like in the human life cycle, you know.
- [49:37]
A
Yeah.
- [49:37]
B
And that's complicated, you know, and again like these are all sort of questions and discourse topics, etc. So they're so far afield from my medical practice and my patients lives and my patients bodies and they're so far afield from sort of what are the things that sick people actually live with, what are the things that actually kill people, et cetera, et cetera. So with this sort of large caveat that all of my initial anxieties about the GLP1 discourse apply to this other sort of wider discourse around other interventions that are for self fulfillment but are sort of being medicalized. I'm trying to be like a little bit thoughtful before. I just sort of react to them as a knee jerk moral panic around those.
- [50:18]
A
But it's like you feel uneasy, but you feel uncertain about your uneasiness.
- [50:21]
B
Yeah, I'm like really working through it.
- [50:23]
A
I think that's an intellectually honest position.
- [50:26]
B
Thank you.
- [50:28]
A
Thank you for talking about this.
- [50:29]
B
My pleasure. Thank you for having me.
- [50:37]
A
Doctor Rachel Bedard. She's a doctor and a writer. We'll have a link to her story about the rise of Ozempic in the show Notes. Also, I have to say there was one more part of this conversation which it was the part I found myself talking the most about with friends the week afterwards, but it was on a slightly adjacent topic. So we got more into this idea of cause medicine, like the place where cosmetic interventions and medical interventions kind of meld together and about how there are middle aged people who are thinking about interventions like taking testosterone or estrogen or going to the dermatologist for lasers to try to look more the way they think Anne Hathaway looks, or men going to Turkey to get a new hairline. I don't know how we're supposed to think about this era where looking older seems to be becoming more optional, where many people on the Internet seem forever 35 and talking to Dr. Bedard who is also working this stuff out. It really helped me. These ideas have already been swirling around my brain. It settled them a little bit. If you want to hear that conversation, we're going to publish it as an extra small feature on Incognito Mode. You can sign up for that at Search Engine Show. If you're already signed up, it is in your feed now. Search Engine is a presentation of Odyssey. It was Created by me, P.J. vogt and Shruthi Pimaneni. Garrett Graham is our senior producer. Emily Moltaira is our associate producer. Theme, original composition and mixing by Armin Bazarian. Our production intern is Piper Dumont. Piper also fact checks this episode. Our executive producer is Leah Rees Dennis. Thanks to the rest of the team at Odyssey, Rob Mirandi, Craig Cox, Eric Donnelly, Colin Gaynor, Maura Curran, Josephina Francis, Kirk Courtney and Hilary Schuff. Also, if you have a business which you would like to advertise on our show, please email us at. Email address is pjvote85mail.com subject line advertising. If you'd like to support our show, get ad free episodes, zero reruns and bonus audio including this week. Please consider signing up for Incognito Mode at Search Engine Show. Thanks for listening. We'll see you next week.
- [53:32]
B
Nerds.
- [53:32]
A
Today's episode is sponsored by NerdWallet's Smart Money podcast. Ever Google a money question and end up 12 tabs deep with 12 different answers? This podcast is your shortcut back to clarity. NerdWallet's Smart Money podcast breaks down financial decisions with a team of trusted journalists. They explain the why behind decisions like investing, home buying and choosing credit cards with clear research backed insights. No jargon, no misinformation. Make your next financial move with confidence. Follow NerdWallet's Smart Money podcast on your favorite podcast. Apparently.