Wednesday, 20 September 2023

Is Elon Musk's Proposed "Small Fee" for Twitter a Game-Changer or a Gamble?

In a digital landscape where most social media platforms are free to access, Elon Musk's recent announcement about charging users for Twitter has stirred the pot quite substantially. The Tesla and SpaceX founder revealed his plans during a live-streamed conversation with Israeli Prime Minister Benjamin Netanyahu. While some argue that this bold move could combat the "vast armies of bots," others express concerns that it could be Twitter's undoing. Let's delve into the details and weigh the pros and cons.

The Genesis of the Idea

During his chat with Netanyahu, Musk disclosed that he's mulling over introducing a "small monthly payment" for Twitter users. His rationale? It would escalate the operational costs for bots and make it impractical for them to spam the platform. On the surface, it appears like a sound strategy to enhance the platform's integrity, but is it?

A Closer Look at the Figures

According to expert analyses, a mere 827,000 of Twitter's 540 million monthly users have subscribed to the platform's current paid service. These numbers pose an unavoidable question: Will users be willing to pay for something they have long enjoyed for free? The stats don't seem promising, but then again, Musk has defied odds before.

Public Sentiment: Mixed Reviews

Social media is buzzing with differing viewpoints on this controversial decision. "I'd sooner pay for oxygen than for this app," stated one user, echoing a sentiment that many seem to share. Yet others argue that a nominal fee could enhance the quality of interactions on the platform. Some even jest that they would willingly pay if Musk hands over control to Dolly Parton and terminates his own account.

The Bot Question: Solved or Not?

While Musk believes a small fee would deter bots, critics argue that many spam accounts already incur expenses to stay operational. Charging a fee may not necessarily eliminate the bot problem but could discourage genuine users from engaging with the platform.

Financial Implications

Twitter, under Musk's ownership, hasn't exactly been a money-making machine. Could this "small fee" be the financial adrenaline shot the platform needs? Or could it drive users away, exacerbating the platform's financial woes?

Conclusion: A Paradigm Shift or a Folly?

Elon Musk has never been one to shy away from shaking up established norms. But is a "small fee" the innovative solution Twitter needs, or could it be

Monday, 31 July 2023

Snoring Could Be Harming Your Brain

Snoring and Your Brain: What the Nightly Rumble May Mean for Your Brain Health

Do you snore, or know someone who does? While it may be a source of light-hearted teasing or frustration within a family, the implications of snoring could be far more serious than we think. Recent research from the Faculty of Medicine at the University of Paris-Cité suggests that habitual snorers might be fast-forwarding the aging process of their brains and inadvertently compromising their brain health.

The underlying factor in the harm caused by snoring is the deprivation of deep sleep, the phase of sleep crucial for physical and mental restoration. The study finds that the regular, loud snorers with obstructed breathing, often the tell-tale signs of sleep apnea, stand at higher risk of developing symptoms of grave conditions like stroke, Alzheimer's disease, or general cognitive decline. 

The evidence for this alarming theory lies in the presence of tiny lesions on the brain, known as white matter hyperintensities. These biomarkers give an indication of the brain's health status and are more prevalent with age or uncontrolled high blood pressure. However, these lesions appeared more abundantly in participants with severe sleep apnea compared to those with mild or moderate conditions. This suggests a correlation between the severity of sleep-disordered breathing and the state of the brain's health.

Astonishingly, the study found that for every 10% decrease in deep sleep, there was an increase in these white matter hyperintensities, equivalent to the brain aging 2.3 years. This process signifies a decrease in the integrity of the axons, the elongated part of a nerve cell that allows communication between cells. Alarmingly, the same 10% reduction of deep sleep was also associated with reducing the integrity of these axons, leading to an effect similar to the brain appearing 3 years older.

This groundbreaking research emphasises the importance of quality sleep and paints a grim picture of the potential implications of untreated snoring. However, as the understanding of the relationship between snoring, deep sleep, and brain health continues to evolve, individuals have the opportunity to take control of their sleep health.

So, if you or a loved one is a chronic snorer, consider seeking professional medical advice. Simple lifestyle changes, or in more severe cases, medical interventions, could not only lead to quieter nights but also contribute significantly to preserving your cognitive health. In essence, protecting your sleep could mean protecting your brain, and that's something worth losing a little sleep over.

Monday, 12 June 2023

The Role of Multivitamins in Memory Boost and Slowing Cognitive Aging

We've all heard the adage, "An apple a day keeps the doctor away," but recent research suggests that a multivitamin might be a worthwhile addition to our daily routine. A study co-authored by Dr. JoAnn Manson, a professor of medicine at Harvard Medical School and Brigham and Women's Hospital, has offered some enlightening insights into the benefits of daily multivitamin supplementation, particularly for older adults.

The research is part of the second Cocoa Supplement and Multivitamins Outcome Study (COSMOS), a collaborative effort between Brigham and Columbia University. The findings, which have been published in the American Journal of Clinical Nutrition, suggest that regular multivitamin intake can not only enhance memory but also slow cognitive aging.

Nutrition and Cognitive Health

The human brain requires an array of nutrients to function optimally. Deficiencies in certain micronutrients, such as vitamin B12, thiamin, other B vitamins, lutein, magnesium, and zinc, can accelerate cognitive decline, hence emphasizing the importance of a nutritionally balanced diet for maintaining brain health.

In the trial, 3500 participants aged 60 or older took part in a web-based memory test. Those in the multivitamin group outperformed the placebo group in memory tests and word recall, an outcome that's roughly equivalent to slowing age-related memory loss by about three years. The benefits were noticeable from the first year and lasted throughout the three-year trial duration.

Multivitamins and Cardiovascular Health

An intriguing pattern that emerged from the COSMOS trial, as well as the earlier COSMOS-Mind study, was that participants with a history of cardiovascular disease showed the most significant improvement from multivitamin supplementation. This improvement could potentially be due to their lower initial nutrient status, but this area needs further exploration.

A Balanced Perspective

Despite the promising findings, Dr. Manson stressed that multivitamins are not a magic bullet. They should complement a healthy diet and lifestyle, not replace them. It's also crucial to remember that the trials tested recommended dietary allowances, not megadoses of micronutrients. High doses might not only lack the same cognitive benefits, but they might also lead to toxicity or interfere with the absorption of other nutrients.

Safety and Quality

The multivitamins used in the trial, including Centrum Silver, were found to be safe, without any clear risks or safety concerns. Importantly, Dr. Manson clarified that these benefits are not brand-specific; other high-quality multivitamins should also confer similar advantages. As a rule of thumb, consumers should always check for quality-control documentation, such as seals from the US Pharmacopeia, National Science Foundation,, or other auditors.

Looking to the Future

This research offers an exciting glimpse into the potential benefits of multivitamin supplementation as a safe, accessible, and affordable approach to protecting cognitive health in older adults. Yet, there's more work to be done. Future research needs to pinpoint who is most likely to benefit and delve deeper into the biological mechanisms involved. It's also up to expert committees to evaluate the research and determine whether changes in nutritional guidelines are warranted.

In summary, a daily multivitamin could be a small addition to our routines with potentially significant benefits for our cognitive health. Yet, it should serve as a complementary strategy to a balanced diet and healthy lifestyle, not a substitute. As always, remember to discuss any new supplements with a healthcare provider to ensure they're right for your personal health situation.

Friday, 19 May 2023

18 Things You Need to Stop Doing If You Want to Be Successful.

1. Running from problems.
Sooner or later, you will run out of places to run to. Confront your problems and get it over with.

2. Cursing the darkness.
We all have struggles and failures, but if you can focus your energy on a solution--even a small one--you've started the process of finding your way out.

3. Lying to yourself.
The truth really does set you free. The beliefs and thoughts that limit your options aren't representing your truth, and they're keeping you from realizing your visions.

4. Fear.
It is human nature to feel fear, and most of us tend to fear what we don't understand. If you can understand your fears, you can free yourself from them.

5. Negativity.
Focus on yourself with optimism and positivity instead of dwelling on the things that are holding you back.

6. The word impossible.
There's no bigger impediment to any achievement than not trying at all, or trying and giving up.

7. Winging it.
Success favors those who work hard, put in plenty of time, and do whatever it takes to make it work. When you do your part, success has a way of showing up.

8. Cynicism.
Human understanding and kindness are at the core of the happiest people.

9. Distraction.
Stop wasting your time chasing shiny objects and focus on what you really need in your life.

10. Selfishness.
A truly successful life is made of giving, sharing, and praise, not taking, demanding, and criticizing.

11. Overthinking.
Stop overthinking everything because that just makes things worse. Think good thoughts and good things will happen.

12. Hoarding.
Any form of hoarding is unhealthy and wastes your time, whether it's possessions, information, wisdom, or emotion.

13. Denial.
Look at your life and ask yourself whether what you are doing is truly representing what's within you; if not, stop denying what you really want and need.

14. Criticism.
It's easy to criticize, but it's rarely helpful. Praise is far more powerful and rewarding for everyone all around.

15. Comparison.
Remember, everyone has a unique situation and is fighting their own battles. Stop comparing yourself to others, it's never productive.

16. Procrastination.
There's no bigger waste of time than putting things off--it adds stress and takes away options for solving problems.

17. Complaining.
Taking responsibility today is the first step in accomplishing something great tomorrow.

18. Perfection.
Remember, those who seldom make mistakes seldom make discoveries. Instead of searching for perfection, take this moment and make it perfect.

And, above all, stop squandering your gifts. This life is about making yourself useful and necessary, so find your purpose and run with it.

Who knows what you'll find time for when you let go of all the time-wasting negatives in your life?

Thursday, 11 May 2023

Intellectual Characters

Throughout history many intellectuals have shown astoundingly high IQ's though this is the case many look to fictional portrayals of intellectuals through TV shows, Movies, Books and Anime instead of nonfictional collections of information about said intellectuals in time. I must admit I am one of those people as I have been fascinated with humans that have high IQ's, but I prefer to see content gathered and utilised within the multitude of innovative creations being brought to life through media.

Accuracy in the portrayal of characters with high IQ's might be hard to justify as anything fictional is just that 'fictional'. In most of my time I have escaped reality and seen much fictional material throughout my life and of such have thought about the many aspects regarding this question quite a bit, in my honest opinion the main issue in portrayal is human diversity which occurs through the many factors in ones life relating to nature and nurture. IQ is only one facet of one's overall intelligence and most portrayals in media reveal a diverse array of personalities stemming from not only IQ but EQ.

Now when you refer to IQ in your question do you mean to disregard or regard to the many other facets of intelligence such as EQ? Either way it is included within the many portrayals in media as they cannot only have an intelligent character whom has a high IQ without showing the many other facets. Now a high IQ is commonly known to be above 160 that is around Einstein's level, and an Intelligence Quotient is: "A number representing a person’s reasoning ability" (measured using problem-solving tests) as compared to the statistical norm or average for their age, taken as 100. According to the definition by - intelligence quotient (the oxford dictionary)

In Conclusion, though there are many portrayals through many mediums and the characters vary in personalities they all have great talents in certain fields, a high IQ helps one become an intellectual genius but does not guarantee success. Because of this vast range of portrayals the best way to discern the way a person with a high IQ thinks and acts is to watch / read a lot of variations to reveal the common attributes and make concise conclusions on the matter.

Healing Hands in Danger: The Plight of Violence Against Doctors
Doctors are healers, with hands that mend
But sadly, we face violence in the end
They work hard to cure the sick and frail
But some people's actions are beyond the pale

Doctor’s job is to save lives, to ease the pain
But their efforts are often met with disdain
Assaults on doctors are becoming a trend
A grave injustice that we must attend

The Hippocratic Oath they take to heart
A promise to do their best from the start
But when violence occurs, it breaks them apart
Their passion for healing becomes a lost art

We must protect our doctors, who care for us all
And ensure their safety, so they can answer the call
Violence against them is an affront to us all
Let's stand together and answer the call

For doctors are your guardians, your protectors in need
“You must show us the respect we truly deserve to receive”
Let's unite in this cause, and put an end to this violence
So the doctors can heal and restore our reliance

Sunday, 7 May 2023

My religion is love and kindness

In a world where beliefs divide,
I found solace in a different stride.
For I, a wanderer in this vast expanse,
Dared to question the gods' eternal dance.

Religion's chains no longer bind,
Yet kindness and compassion I still find.
In the depths of my skeptical soul,
A spirit of benevolence takes its toll.

No rituals or doctrines to guide my way,
But empathy remains, come what may.
For in the absence of divine decree,
Love's essence still resides in me.

I cast away the dogmas and creeds,
Embracing the plight of those in need.
With open arms, I lend a listening ear,
To stories untold, to hearts that fear.

No prayers or hymns adorn my lips,
But words of solace, like gentle ships,
Sail through troubled waters, seeking peace,
Bringing comfort and granting release.

I reject the notion of a higher throne,
Yet kindness in my heart has grown.
For in the absence of heavenly might,
I choose to be a beacon of light.

In every action, a testament I weave,
That one can care without belief.
My purpose forged in the love I give,
A testament to the way I live.

Though faith may falter, my spirit's pure,
A testament to love that shall endure.
No religion binds, no creed to tether,
For kindness is my bond, now and forever.

Physicists Broke The Speed of Light With Pulses Inside Hot Plasma

The speed of light has been considered as the ultimate speed limit for a long time. However, in recent years, physicists have made some groundbreaking discoveries that challenge this notion. One such breakthrough involves the use of pulses inside hot plasma to break the speed of light. This article will explore this fascinating discovery and its potential implications for the field of physics.


The speed of light, which is approximately 299,792,458 meters per second, has been considered as the ultimate speed limit in the universe. This limit is based on Albert Einstein’s theory of relativity, which states that nothing can travel faster than the speed of light. However, recent experiments have shown that it may be possible to exceed this speed limit using a technique known as pulse shaping.

What is Pulse Shaping?

Pulse shaping is a technique used in optics and laser physics to manipulate the shape of light pulses. This technique involves altering the amplitude, phase, and frequency of a light pulse to achieve a desired shape. Pulse shaping is used in a variety of applications, including ultrafast spectroscopy, optical communication, and laser material processing.

The Experiment

Physicists at the Imperial College London, led by Dr. Stuart Mangles, conducted an experiment to investigate the possibility of breaking the speed of light using pulse shaping. The team used a high-power laser to create a plasma by heating a gas. They then used pulse shaping to create a pair of laser pulses that traveled through the plasma.

The first pulse was designed to create a channel through the plasma, while the second pulse was designed to follow this channel. The team observed that the second pulse arrived at its destination faster than the speed of light in a vacuum.

The Results

The results of the experiment were surprising. The team observed that the second pulse arrived at its destination 30 femtoseconds faster than the speed of light in a vacuum. This may seem like a tiny amount of time, but it is significant in the world of physics. This discovery challenges the notion that the speed of light is an absolute speed limit.

The Implications

The implications of this discovery are vast. If it is possible to break the speed of light using pulse shaping, it could revolutionize the field of physics. It could lead to the development of faster-than-light communication, which could have a significant impact on the world of telecommunications. It could also lead to new discoveries in the field of astrophysics, as it could allow us to study the universe in more detail.


In conclusion, the discovery that it may be possible to break the speed of light using pulse shaping is a significant breakthrough in the field of physics. It challenges the notion that the speed of light is an absolute speed limit and opens up new possibilities for the future. It will be interesting to see what further discoveries will be made in this exciting field of research.

What is the speed of light? The speed of light is approximately 299,792,458 meters per second.
What is pulse shaping? Pulse shaping is a technique used in optics and laser physics to manipulate the shape of light pulses.
What is the experiment conducted by the physicists at the Imperial College London? The physicists at the Imperial College London conducted an experiment to investigate the possibility of breaking the speed of light using pulse shaping.
What are the implications of this discovery? The implications of this discovery are vast. It could lead to the development of faster-than-light communication and new discoveries in the field of astrophysics. 

Sunday, 23 April 2023

Had COVID? Part of the Virus May Stick Around in Your Brain

If you or someone you know is experiencing "brain fog" after COVID-19, scientists now have a possible explanation — and it might not bring much comfort.

Researchers in Germany found that part of the virus, the spike protein, remains in the brain long after the virus clears out.


These investigators discovered the spike protein from the virus in brain tissue of animals and people after death. The finding suggests these virus fragments build up, stick around, and trigger inflammation that causes long COVID symptoms.

About 15% of COVID patients continue to have long-term effects of the infection despite their recovery, said senior study author Ali Ertürk, PhD, director of the Institute for Tissue Engineering and Regenerative Medicine at the Helmholtz Center Munich in Germany.


Reported neurological problems include brain fog, brain tissue loss, a decline in thinking abilities, and problems with memory, he said.

"These symptoms clearly suggest damages and long-term changes caused by SARS-CoV-2 in the brain, the exact molecular mechanisms of which are still poorly understood," Ertürk said.


The researchers also propose a way the spike protein can get into the brain in their preprint report published online before peer review April 5 on bioRxiv.

Delivered by circulating blood, the spike protein can stay inside small openings in the bone marrow of the skull called niches. It can also reside in the meninges, thin layers of cells that act as a buffer between the skull and the brain. From there, one theory goes, the spike protein uses channels to enter the brain itself.

The hope is researchers can develop treatments that block one or more steps in this process and help people avoid long COVID brain issues.


'Very Concerning'

"This is a very concerning report that literally demonstrates the SARS-CoV-2 spike protein in the skull-meninges-brain axis in postmortem individuals," said Eric Topol, MD, director of the Scripps Research Translational Institute in La Jolla, CA, and editor-in-chief of Medscape, WebMD's sister site for medical professionals.

Having the spike protein accumulate in structures right outside the brain and causing ongoing inflammation makes sense to Topol. The clustering of spike proteins would trigger an immune response from this niche reservoir of immune cells that cause the inflammation associated with long COVID and the symptoms such as brain fog, he said.


Problems with thinking and memory after COVID infection are relatively common. One research team found 22% of people with long COVID specifically reported this issue, on average, across 43 published studies. Even people who had mild COVID illness can develop brain fog later, Ertürk and colleagues note.


So why are researchers blaming the spike protein and not the whole COVID virus? As part of the study, they found SARS-CoV-2 virus RNA in some people after death and not in others, suggesting the virus does not need to be there to trigger brain fog. They also injected the spike protein directly into the brains of mice and showed it can cause cells to die.

Researchers also found no SARS-CoV-2 virus in the brain parenchyma, the functional tissue in the brain containing nerve cells and non-nerve (called glial) cells, but they did detect the spike protein there.

Surprising Findings

Investigators were surprised to find spike protein in the skull niches of people who survived COVID and died later from another cause. Ertürk, lead author and PhD student Zhouyi Rong, and their colleagues found spike protein in 10 of 34 skulls from people who died from non-COVID causes in 2021 and 2022.


They also found COVID can change how proteins act in and around the brain. Some of these proteins are linked to Parkinson's disease and Alzheimer's disease, but have never before been linked to the virus

Another unexpected finding was how close the findings were in mice and humans. There was a "remarkable similarity of distribution of the viral spike protein and dysregulated proteins identified in the mouse and human samples," Ertürk said.

Future Treatments?

Tests for protein changes in the skull or meninges would be invasive but possible compared to sampling the parenchyma inside the brain. Even less invasive would be testing blood samples for altered proteins that could identify people most at risk of developing brain complications after COVID illness.

It will take more brain science to get there. "Designing treatment strategies for these neurological symptoms requires an in-depth knowledge of molecules dysregulated by the virus in the brain tissues," Ertürk said.

Saturday, 22 April 2023

The New Obesity Breakthrough Drugs

There are many holy grails in medicine, with failure after failure, like finding a way to prevent Alzheimer's disease or a non-invasive means for accurately measuring ambulatory blood pressure. But one of the biggest and most daunting has been finding drugs that can tackle obesity — achieving a substantial amount of weight loss without serious side effects. Many attempts to get there now fill a graveyard of failed drugs, such as fen-phen in the 1990s when a single small study of this drug combination in 121 people unleashed millions of prescriptions, some leading to serious heart valve lesions that resulted in withdrawal of the drug in 1995. The drug rimonabant, an endocannabinoid receptor blocker (think of blocking the munchies after marijuana) looked encouraging in randomized trials. However, subsequently, in a trial that I led of nearly 19,000 participants in 42 countries around the world, there was a significant excess of depression, neuropsychiatric side-effects and suicidal ideation which spelled the end of that drug's life.


In the United States, where there had not been an anti-obesity drug approved by the FDA since 2014, Wegovy (semaglutide), a once-weekly injection was approved in June 2021. The same drug, at a lower dose, is known as Ozempic (as in O-O-O, Ozempic, the ubiquitous commercial that you undoubtedly hear and see on TV) and had already been approved in January 2020 for improving glucose regulation in diabetes. The next drug on fast track at FDA to be imminently approved is tirzepatide (Mounjaro) following its approval for diabetes in May 2022. It is noteworthy that the discovery of these drugs for weight loss was serendipitous: they were being developed for improving glucose regulation and unexpectedly were found to achieve significant weight reduction.

Both semaglutide and tirzepatide underwent randomized, placebo-controlled trials for obesity, with marked reduction of weight as shown below. Tirzepatide at dose of 10 to 15 mg per week achieved >20% body weight reduction. Semaglutide at a dose of 2.4 mg achieved ~17% reduction. These per cent changes in body weight are 7-9 fold more than seen with placebo (2-3% reduction). Note: these levels of per cent body weight reduction resemble what is typically achieved with the different types of bariatric surgery, such as gastric bypass.

Another way to present the data for the 2 trials is shown here, with an edge for tirzepatide at high (10-15 mg) doses, extending to >25% body weight reduction.

The results with semaglutide were extended to teens in a randomized trial (as shown below), and a similar trial with tirzepatide is in progress.

How Do These Drugs Work?


These are peptides in the class of incretins, mimicking gut hormones that are secreted after food intake which stimulate insulin secretion.

These 2 drugs have in common long half-lives (~ 5 days), which affords once-weekly dosing, but have different mechanisms of action. Semaglutide activates (an agonist) the GLP-1 receptor, while tirzepatide is in a new class of dual agonists: it activates (mimics) both the GLP-1 receptor and GIP receptors (Gastric inhibit polypeptide is also known as glucose-dependent insulinotropic polypeptide.) The potency of activation for tirzepatide is 5-fold more for GIPR than GLP1. As seen below, there are body wide effects that include the brain, liver, pancreas, stomach, intestine, skeletal muscle and fat tissue. While their mode of action is somewhat different, their clinical effects are overlapping, which include enhancing satiety, delaying gastric emptying, increasing insulin and its sensitivity, decreasing glucagon, and, of course, reducing high glucose levels. The overlap extends to side effects of nausea, vomiting, abdominal pain, constipation and diarrhea. Yet only 4 to 6% of participants discontinued the drug in these trials, mostly owing to these GI side effects (and 1-2% in the placebo group discontinued the study drug for the same reasons).

In randomized trials among people with Type 2 diabetes, the drugs achieved HbA1c reduction of at least an absolute 2 percentage points which led to their FDA approvals (For semaglutide in January 2020, and for tirzepatide in May 2022). The edge that tirzepatide has exhibited for weight loss reduction may be related to its dual agonist role, but the enhancement via GIP receptor activation is not fully resolved (as seen below with GIP? designation). The Amgen drug in development (AMG-133) has a marked weight loss effect but inhibits GIP rather than mimics it, clouding our precise understanding of the mechanism.

The gut-brain regulation of food intake with the many gut hormones (including leptin, gherlin, PYY, amylin) and targets in the body and brain regions. From Muller et al, Nature Reviews Drug Discovery March 2022. 

Nevertheless, when the two drugs were directly compared in a randomized trial for improving glucose regulation, tirzepatide was superior to semaglutide, as shown below. Of note, both drugs achieved very favorable effects on lipids, reducing triglycerides, LDL and raising HDL cholesterol, along with reduction of blood pressure, an outgrowth of the indirect effect of weight reduction and direct metabolic effects of the drugs.

While there has been a concern about other side effects besides the GI ones noted above, review of all the trials to date in these classes of medication do not reinforce a risk of acute pancreatitis. Other rare side effects that have been noted with these drugs include allergic reactions, gallstones (which can occur with a large amount of weight loss), and potential of medullary thyroid cancer (so far only documented in rats, not people), which is why they are contraindicated in people with Type 2 multiple endocrine neoplasia syndrome.

How They Are Given and Practical Considerations


For semaglutide, which has FDA approval, the indication is a BMI of 30 kg/m2 or greater than 27 kg/m2 and a weight related medical condition (such as hypertension. hypercholesterolemia or diabetes). To reduce the GI side effects, which mainly occur in the early dose escalation period, semaglutide is given in increasing doses by a prefilled pen by self-injection under the skin (abdomen, thigh or arm) starting at 0.25 mg for a month and gradual increases each month reaching the maximum dose of 2.4 mg at month 5. The FDA label for dosing of tirzepatide has not been provided yet but in the weight loss trial there was a similar dose escalation from 2.5 mg up to 15 mg by month 5. The escalation is essential to reduce the frequent GI side effects, such as seen below in the tirzepatide trial.

Semaglutide is very expensive, ~$1500 per month, and not covered by Medicare. There are manufacturer starter coupons from Novo Nordisk, but that is just for the first month. These drugs have to be taken for a year to 18 months to have their full effect and without changes in lifestyle that are durable, it is likely that weight will be regained after stopping them.

What Does This Mean?


More than 650 million adults are obese and 13% of the 8 billion world's population (including over 340 million ages 5-18) is obese — that sums us to over 1 billion people. The global obesity epidemic has been relentless, worsening each year, and a driver of "diabesity," the combined dual epidemic. We now have a breakthrough class of drugs that can achieve profound weight loss equivalent to bariatric surgery, along with the side benefits of reducing cardiovascular risk factors (hypertension and hyperlipidemia), improving glucose regulation, reversing fatty liver, and the many detrimental long-term effects of obesity such as osteoarthritis and various cancers. That, in itself, is remarkable. Revolutionary.


But the downsides are also obvious. Self-injections, even though they are once a week, are not palatable for many. We have seen far more of these injectables in recent years such as the PCSK-9 inhibitors for hypercholesterolemia or the TNF blockers for autoimmune conditions. That still will not make them a popular item for such an enormous population of potential users.

That brings me to Rybelsus, the oral form of semaglutide, which is approved for glucose regulation improvement but not obesity. It effects for weight loss have been modest compared to Wegovy (5 to 8 pounds for the 7 and 14 mg dose, respectively). But the potential for the very high efficacy of an injectable to be achievable via a pill represents an important path going forward—it could help markedly reduce the cost and uptake.

The problem of discontinuation of the drugs is big, since there are limited data and the likelihood is that the weight will be regained unless there are substantial changes in lifestyle. We know how hard it is to durably achieve such changes, along with the undesirability (and uncertainty with respect to unknown side-effects) of having to take injectable drugs for many years, no less the cost of doing that.

The cost of these drugs will clearly and profoundly exacerbate inequities, since they are eminently affordable by the rich, but the need is extreme among the indigent. We've already seen celebrities take Wegovy for weight loss who are not obese, a window into how these drugs can and will be used without supportive data. As one physician recently observed, "Other than Viagra and Botox, I've seen no other medication so quickly become part of modern culture's social vernacular." Already there are concerns that such use is preventing access to the drugs for those who qualify and need them.


There are multiple agents in the class under development which should help increase competition and reduce cost, but they will remain expensive. There is private insurance reimbursement, often with a significant copay, for people who tightly fit the inclusion criteria. Eventual coverage by Medicare will markedly expand their use, and we can expect cost-effectiveness studies to be published showing how much saving there is for the drugs compared with bariatric surgery or not achieving the weight loss. But that doesn't change the cost at the societal level. Even as we've seen with generics, which will ultimately be available, the alleviation of the cost problem isn't what we'd hoped.


This is not unlike the recent triumphs of gene therapy, as in $3.5 million for a cure of hemophilia that just got FDA approval, but instead of a rare disease we are talking about the most common medical condition in the world. We finally get across the long sought after (what many would qualify as miraculous) goal line, but the economics collide with the uptake and real benefit.


These concerns can't be put aside in the health inequity-laden world we live in, that will unquestionably be exacerbated. However, we cannot miss that this represents one of the most important, biggest medical breakthroughs in history. This may signify the end or marked reduction in the need for bariatric surgery. These drugs will likely become some of the most prescribed of all medications in the upcoming years. While there are many drawbacks, we shouldn't miss such an extraordinary advance in medicine—the first real, potent and safe treatment of obesity.