I am curious if this question has come up in company marketing discussions. One of the most common and off-putting things about the weight-loss industry is the vague medicine promise. Have you considered just saying "semaglutide" instead of "a breakthrough medication"? I honestly almost stopped reading because it comes off as so huckster-ish to me.

I think a lot about our framing and I know for sure we haven't nailed it yet.

It's fair to say your avg HN reader is very different to your avg American. For example, you seem already somewhat clued up about Semaglutide. You're likely interested in the biology behind it, and probably aren't afraid to parse the journal article about it.

I really wanna emphasize how different this is to your avg American.

So it's more my bad for not tailoring our language enough for a HN post.

I've never heard the word "Semaglutide" before this moment in my life. However, to me naming the thing sounds like "people that did at least some of the homework, and I could probably look it up and see if it's interesting to me", and calling it anonymous "breakthrough medication" sounds like yet another scam that tries to suppress my rational brain and get money out of me before I had time to think if it's worth it. It literally does nothing to inform me or to make me think I may be interested - everybody who can hire a copywriter has "breakthrough something", and I certainly don't have time to pay attention to dig up real information on all of them.

I understand that the hustle is a part of the marketing. But medicine is not the area where you should lean on it. At least not on it alone. If you don't give me full and verifiable information about what you have, I won't be interested. Too many scams around and too high risk, especially with the new and yet unproven stuff.

Understood. I thought the easiest way to do this would be to link to the articles which talk about this in more detail. Should probably have added a small paragraph which talked about the bio of it.

I assume you've heard the advice that small startups should start in a niche and then expand towards the wider markets? Have you thought about initially focusing on Hacker News types, the types who read up on the technical documentation behind a drug?

You've probably heard the story about Head & Shoulders shampoo? This is taught in a lot of marketing classes. The year it launched there were other shampoos launching that also included selenium disulfide and piroctone olamine and therefore could have sold themselves as anti-dandruff shampoo, but the other shampoos instead went after the general market and they almost all failed. Head & Shoulders started with a niche and eventually became a giant:

"By 1982, it was the "number one brand" of shampoo, and it was noted that "No one hair care brand gets so many ad dollars as Head & Shoulders, a twenty year old brand, and no other brand matches its sales", despite it being a "medicated" shampoo."

https://en.wikipedia.org/wiki/Head_%26_Shoulders

Hadn't heard about H&S.

Will give it more of a think about best early adopters.

As someone who knows nothing about Semaglutide and is an HN type, I can tell you that anecdotally, marketing yourself as a breakthrough medicinal weight loss solution sounds very similar to packaging found on gas station counters.

Ephedrine was also a breakthrough weight loss treatment...until it wasn't...

Helpful to know. Thank you.

Consider hacker mentality. You have a complex system that's not functioning the way it should. Do you drill to the root problem or just patch it temporarily? Weight gain is a problem, and the possible environmental contaminants and other causes behind society-wide weight gain are of interest as a big problem to solve. Workaround hacks like producing more insulin don't drill into the root cause. My first impulse (and probably that of most people here) is to identify what is being sold and then read what's known about the biological pathways it leverages. Not that we wouldn't all mind being fitter. But some argument needs to be made that altering basic cellular biochemistry for up-to 15% weigh loss has a risk/reward profile better than seeking root causes and addressing those, which any coder worth their salt would try to do first.

Noted. For reference, I've very much tried to design Fella to tackle all the root causes of obesity, which vary person to person: metabolic condition, stress, sleep, exercise, food types & volume, and hormone imbalances.

Beyond personal causes like metabolism or diet, there've been some fascinating discussions here in the past few months about why technologically advanced societies seem to have an exponential obesity problem starting around 1980, relative to other cultures that exercise less and take in more calories. I can't find the thread. But it definitely bears consideration. I think the view would be that hacking your way partially out of a problem isn't necessarily bad, but we've seen decades of data used to incorrectly imply one chain of causality or another and there's a larger problem to solve than a drug or a tummy tuck can tackle.

There's also recent evidence that consuming fructose increases your intestine's absorption of nutrients from the food you consume. The rapid integration of fructose into everyday foods (i.e. high fructose corn syrup being put into bread & sauces as a bulking / thickening agent) may be connected to the western world obesity crises.

Didn't know this! Assume it's this study: https://www.nature.com/articles/d41586-021-02195-1

Was posted on HN 4 days ago: https://news.ycombinator.com/item?id=28239113

(in case other people want to check it out)

Yep more research being done on the hormone imbalance side. Nascent area though.

Just to clarify my initial comment... I am actually not particularly interested in the biological pathways, etc. My reaction was 100% because it sounds like the sketchy language of every single other weight loss "breakthrough" that has been touted in my lifetime. If you watch any youtube fitness guru videos (which I do not recommend!) you will see that it is a standard trope: "All you have to do is eat this one amazing super food" and they never tell you what it is. I think you are trying to offer a legitimate service, so please don't sound like those people.

Makes a ton of sense, and really helpful to know. Thank you.

If your cagey about whats in your pill my gut reaction is it either doesnt work or youre overcharging for it.

I am average American.

Not at all trying to be cagey, and also not our pill. The main paper is here for more info about the most notable medication: https://www.nejm.org/doi/full/10.1056/NEJMoa2032183

Important to say this definitely isn't the only medication the doctor will prescribe. That's a decision to make in conjunction with the patient after a full medical history.

And this medication is already approved by the FDA for those of us who are diabetic. At higher doses, even.

They’re just taking the same medication and using it at lower doses for weight loss instead of diabetes control.

And frankly, as a fat diabetic, I strongly suspect it’s doing the exact same thing in both cases, and the reason it works for diabetics is that it helps them lose weight.

It’s definitely on my list to discuss with my endocrinologist.

Good to hear you'll be talking about it your endocrinologist.

Couple things:

Injectable Semaglutide was first FDA approved in 2017 as Ozempic. Wegovy is also injectable Semaglutide. The key difference is the approved dose: Ozempic is 1.0mg, Wegovy is 2.4mg. The FDA approval is also very important for future insurance remibursement.

Semaglutide is a GLP-1 RA. These medications stimulate a receptor in your body which results in three main effects: 1 - Slowing down gastric emptying so food stays in your stomach for longer (this is thought to be why there is sometimes nausea when starting the medication) 2 - Making you feel full by working on your central nervous system 3 - Managing glucose control (which is why it's used for people with diabetes too)

[1] gives you a great summary of the field up to now and how it works.

[1] https://blogs.sciencemag.org/pipeline/archives/2021/02/15/gl...

Or medicines which have really long and strong evidence for weight loss effects like amphetamines?

Or testosterone, which isn’t necessarily great for weight loss, but is fabulous for body composition, which I’m sure many men would be satisfied with. Weighing 200 with 18% body fat is probably more attractive to many tall men than weighing 160 with the same body fat. Muscle also raises basal metabolic rate which is nice for fat loss.

TRT clinics are grossly overpriced, charging $300+ A month for $5 drugs, so there is almost certainly room to disrupt that market. I’d be willing to wager many obese men display hypogonadism too.

And then there’s the fact that obesity is not an individual fault, it is caused by hormone disruptor chemicals in our environment and diet. Of course, higher consumption of more processed foods tends to increase obesity for this very reason: it increases the intake of hormone disruptors.

Definitely an area with compelling evidence. Lot of uncertainty though.

We're starting to do more research into hormone-based treatments. We definitely have hesitancy as hormone treatments are a bigger life decision, and telehealth regulation is murky. We'll look into it more.

The doctors prescribe both GLP-1s & meds like Phentermine, among others. I just didn't wanna list them all out!

Wow. This is really interesting and important. I’m not your target customer and don’t know a ton about health tech, so I’m not sure I can help you, but I wish I could. thank you for taking this on. Someone should. Sometimes the science and medicine is there but branding, marketing, and positioning in a bigger value prop aren’t things that doctors and hospitals are prepared to handle at scale. So, this is cool.

I do know one thing about your space, from pure happenstance. I live in Texas and my wife is a fourth-year medical student here. One of her profs is a bariatric surgeon and she spent time in his clinic. One of the interesting things she learned was the correlation between weight loss for one adult and weight loss of a household. I don’t remember the exact stats, but this doc would have whole families weigh in at his clinic, before and after. The results were astounding. The person who got the surgery would often lose only the plurality of the weight, and sometimes not even that. It’s something to consider messaging around as you target men and try to get through the stigma to persuade them to seek treatment. You are doing something good for your family; this is about more than just you. Texan men in particular are likely to hold more traditional values about being the head of their household, however unfashionable that may be. Help these fellas— and help their families.

Thanks man. Just so I've fully understood here:

> "The person who got the surgery would often lose only the plurality of the weight, and sometimes not even that."

By this you're meaning the whole family lost weight after one individual had bariatric surgery?

Yep, exactly.

Do you help people account for family lifestyles and cooking for more than just themselves? I used to do 2-3 day fasts, but now that I’m married with kids I find it almost impossible to do so since I cook and prep all the meals.

I tried low carb and keto. It works fine for me, but selling my wife on a breakfast that consists of 6 eggs and a pound of bacon is a hard sell. So there’s always bread and pasta in the house, which makes it harder to resist.

My wife is lifelong vegetarian, and I'm a big fan of keto. We've basically adapted to a "I make food for myself, she makes food for herself and we split responsibility for making food for the kids" workflow and it works out pretty well.

It helps a lot that I do the grocery shopping, I try to avoid buying stuff that I'll be too tempted by - like regular carb tortillas or plain tortilla chips.

Keeping food out of the house is a powerful behavioral device. It takes away the "Ability" part from the Fogg Behavior Model if you find that framework helpful.

Yep really good point about the family dynamics - lots of the Fellas talk about how having teenage kids around makes the dietary side really tough.

How the coaching works in the program is that we dive in at the start to really understand the 1-3 key leverage points where we can make the most impact - then focus all our coaching time on these.

I tried Noom twice. I was the only man in the support group both times. It didn’t really speak to me or work for me.

Definitely interested in this!

We've heard this a lot..

I am glad to see this. I was involved in a similar startup that became bogged down due to reasons that had nothing to do with the validity of the approach you are taking.

As I am sure you are aware, obesity is a complex issue and many of the suggestions sufferers get such as eat less, exercise more, try fasting, go keto, etc. are simply not helpful in and of themselves. Neither is just prescribing the latest medications without other forms of support.

I hope your concept of telehealth, medical supervision and personal coaching is one that will get results. Obesity is a serious issue that is robbing society of people and potential.

Agree - I think psychology is everything. It's odd that drinking too much and drugs is always put down to trauma, stress, and psychological treatment is seen as number 1, whereas with food addiction - it's often ignored to the very last.

People can argue until they're blue in the face but if you eat less calories than you burn you will lose weight. The problem is people with trauma plus a food addiction are not able to do this.

Is there any research around where you live and propensity for morbid obesity - especially living by the sea? I could only find one study which did support this theory but it was in the UK. I live in Bondi Beach where socialising is essentially exercising - surfing, swimming, kayaking etc etc and anecdotally I don't think I've ever seen a morbidly obese person in over 30 years (I know this sounds ridiculous and maybe it's because they never leave the house but it's true).

We're definitely a big proponent of a psychological approach for a lot of Fellas. And "food addiction" is a controversial but rapidly growing area of research.

That said, important to state a psychological-only approach sadly isn't sufficient for the majority of people.

I've never looked for research on this, but the environmental & social pressures are definitely believable why they may produce this outcome. I also wonder how important selection effect is here for your Bondi Beach example.

Thank you very much for this. Kind message.

What was the previous startup by the way? Always interested in improving my knowledge of the space!

Great Idea!I checked out the website and it looks like it is targeted towards older men (40+). Was there any particular reasoning for this? I'm in my 20s and I know a lot of men my age who are obese. Was the program developed specifically for older men?

Really good question. In our customer dev, we tended to find the older guys were a more motivated initial audience because health concerns are more top of mind. Plus there's still a lot of hesitancy & stigma around medication for obesity, but the older guys are more ready to take that step.

Fella works just as well for younger guys. Any more questions I can answer?

As somebody who has lost and gained weight a couple times, I can confidently say that losing weight on it’s own is hard. Really hard. I’ve had far more success deliberately changing my entire lifestyle and outlook on life. For me, it had to be a part of a wholistic health regimen. This included therapy, healthy eating, regular exercise, proper sleep, and a good balance of recreational activities (it’s important to have fun!). As somebody with chronic sleep problems, it’s been interesting seeing how unhealthiness in one aspect of life (sleep in my case) can affect other areas of my life (my weight). It’s hard to quantify this line of thinking, because in the end, all I did was eat less and exercise more to lose the weight. That advice isn’t terribly helpful. Then again, it’s very likely that “just be healthier” is just as unhelpful ;)

I will say, don’t be too hard on yourself. My stress eating would spiral (and still does!) when I get too hard on myself. Set small goals and objectives (no eating after dark, be mindful of what you put on your plate, no second helpings, etc) because completing these always feels good.

Well written. These are all core aspects of our coaching program to improve metabolic health: improve sleep, reduce stress, more pleasurable activities, better food choices, sustainable exercise routine, reasonable portion sizes.

The "small goals" is also critical to counter all-or-nothing thinking. We use a mix of behavioral & cognitive approaches to try to cement the improved habits & ways of thinking.

Interesting offering, definitely an important market.

> So we started researching effective, evidence-based treatments for obesity

Fasting has a tremendous amount science supporting it [1], can you articulate why you're pursuing the prescribed semaglutide approach instead?

[1] Fasting: Molecular Mechanisms and Clinical Applications https://www.sciencedirect.com/science/article/pii/S155041311...

Spot on about fasting, and keto has solid evidence as well - https://www.virtahealth.com/ are a great company focused on this.

The issue is we're starting to have a more nuanced understanding of the metabolic resistance people face when they undergo dietary changes - basically the body fights hard against you as you try to lose weight by dieting.

So it's now industry-standard among obesity specialist doctors to see obesity as a "metabolic disease" which, for the vast majority of people, needs a medical approach which doesn't rely on willpower.

> basically the body fights hard against you as you try to lose weight by dieting.

I used to weigh 310lbs, now I'm 215lbs. All I did was count calories to maintain a deficit and the results were essentially the same as predicted by the math. I was a bit hungry sometimes at first as I adjusted to it but that's really it. Prioritizing protein and fat over carbs helps with that.

What ways does the body tend to fight against people?

Unfortunately there are people like me who don't only feel a bit hungry, when I eat at a deficit there are times where I get so hungry my thoughts are completely consumed by the hunger. The only way for me to successfully lose weight was to have days where I simply eat nothing at all.

Sounds counter-intuitive but after getting over the initial extreme hunger I found that the hunger sensations would diminish into a background noise, of sorts. That and the rules are easy to follow: eat nothing. When I'd eat at a deficit I'd frequently justify to myself that eating a little bit more than I was planning on doing was ok because it was only a little. And then I'd do that several times until I felt completely satiated, defeating the purpose.

The complete fasting approach is pretty common among Fellas I've spoken with. Lot of the guys have powerful "all-or-nothing" traits, where it feels easier to have a strict intense rule than a more nuanced approach.

The issue comes when you therefore become so hungry your body drives you to eat a lot of food all at once. But I'm interested that you notice your hunger sensations actually diminish over time.

Isn't it actually well known that you are not hungry when fasting (after a couple of days)?

Yep I've just been reading up on this now actually: ghrelin & leptin changes after day 2 of a fast.

This is what's known as an 'anecdote', and is at the crux of the issues surrounding men's weight loss. This approach, and other very obvious and straightforward ones do indeed work perfectly well for a fair fraction of the population, but they perform poorly for another large fraction, and fail abysmally for yet a third.

While there are no doubt plenty of people that could lose weight fairly readily if they gave it some basic effort, most of the people who are actively trying to do so (enough to pay for a service that supports that, for example) are in the second and third categories. And yet every time anyone posts in a non-dedicated forum anything about systems and plans to help that group solve their problems, there are a dozen people like you popping in to tell us "it's not that hard, just give it a try!"

I regularly make 60 mile bike rides, I can jog 10 miles (though I can't walk the next day when I do), I play tennis about 7 hours a week. I weigh 465 pounds. Trust me, I've tried the approach you're describing here. I once managed to hold onto it for 8 months, during which I lost about thirty pounds and then plateaued, while constantly fighting my body. I was sick twice as often as usual, and I had to carefully micromanage my calorie intake to make sure I had available calories for any physical activity I wanted to engage in, all while constantly battling cravings for dozens of foods _I don't even like_.

It would be a simpler world if all of us fat people were just fat because we're lazy, but the truth is that people vary really a lot, physically and metabolically. Your experience of the world is valid, but not universal.

That's what's known as an anecdote. This is what's known as a counterexample. And one thing is certain: No method has 100% success. To me the more important question isn't what percentage of cases something addresses, but whether it's a self fix where the benefits outweigh the risks. The risks of intermittent fasting are relatively low, and it may have side benefits like prolonged lifespan and slower telomere degradation as shown in animal models. The risks of essentially hacking your own insulin production to upregulate it if you're not diabetic are not nearly as well understood. On an individual basis, whatever gets you to where you're happy is great. Personally I've fasted every day my entire adult life and still have to work to keep weight off. But when someone puts a slick marketing package on fasting or drugs or surgery or anything else, I have to question whether they really have my best interests at heart. And usually the answer is obviously not.

I'm not arguing in favor of any particular approach (in particular the one posed by the original poster, which I have done zero research into). If and when they launch in a meaningful way I'll bother doing that research, but I am also a cynic about people offering to make a difficult thing easy for a recurring fee.

Happy to help with any research if I can. A good starting point for the medication I referred to in my post is here: https://www.nejm.org/doi/full/10.1056/NEJMoa2032183

Sure. And well we should be. Identify what people view as a personal problem, then offer a solution. This is the second YC startup I've seen today that falls under the category of magic baldness cream.

Guess I gotta step in here to protest "magic baldness cream".

We're not offering anything magic. The medication side has a compelling & growing evidence base: https://www.nejm.org/doi/full/10.1056/NEJMoa2032183

For the vast majority obesity doctors, a medication-assisted approach is now the gold standard.

The program side is also no magic. We do tough work, but with a strong evidence base, a powerful support structure and we give ourselves enough time (12-month program). We focus on the root causes of poor metabolic health: stress, sleep, exercise, dietary. From both the behavioral & psychological angles.

No magic here, just evidence-based interventions.

This is what's known as an 'anecdote', and is at the crux of the issues surrounding weight loss.

Virtually every _controlled_ study shows that metabolic differences between adults are within a margin of +/- 15%, with essentially no way to eat the same amount of calories as a 200lb person and stay at 465lbs. Not least of which because your basal metabolic rate is much higher at that weight.

Virtually every study shows that overweight people significantly underestimate their input (whether intentionally deceptive or simply unaware) and overreport their physical activity, like "I can jog 10 miles", or "I play tennis about 7 hours a week", or "I regularly make 60 mile bike rides". If you do, you're the extreme outlier, and it doesn't change the data. Assuming you can do those things, you're almost certainly still in your 20s, and the health effects of your weight haven't really caught up with your body yet.

Very simply, it's far more likely that you miss some of the calories you consume, either because you don't actually weigh your food or you discount the signficance of "small" things. A pound of fat is 3500 calories. That's more complicated inside metabolic processes, but it means that "an apple a day" is 10lbs per year.

That isn't to say that "prescribe more medication instead of correcting the underlying issue" (trauma, self-medication, dopamine flush, whatever) is the answer, but that diets perform poorly for a large fraction and fail abysmally for another third because we are bad at tracking things, we are bad at being uncomfortable, and we bad at self control, etc. Diets do work. It's sticking to the diet and recognizing when you're off the rails which is difficult.

It's also difficult to acknowledge that this "diet" is not temporary and you can go back to old eating habits once the weight is off. The new caloric consumption is forever, because that's what brought you to the new homeostatis.

Unsure how helpful this slapdown is after the guy is sharing something pretty vulnerable.

Diets don't fail because they're inherently flawed and the system is more complex than we think it is. Diets fail because people fail. "I tried and I failed, but I still do all this physical stuff or could if I wanted to" is dishonesty, whether intended or not.

Asserting that, for some unspecified (but large) fraction of the population, tracking your caloric intake and energy expenditure versus the number on the scale is inherently flawed is dangerous, misleading, and probably false. At least partly because overweight people may lie to themselves.

In this sense, and in the context of Fella, throwing more drugs at the problem isn't a solution any more than throwing additional hardware at an application because the developer insists that database indexes don't work everywhere. It's true, but requires extraordinary evidence, and should not be the baseline assumption.

It does look like Fella is addressing psychological issues which I think are huge. The issue if you deny that calories in v calories burnt is the essential metric is you end up with the problem with bariatric surgery where people literally eat to the point of severe pain and don't lose weight. It's why responsible surgeon always require significant calorie restriction weight loss before surgery.

I'm sorry this isn't clearer. The core part of the coaching program is focused on psychology: we even call it "psychological coaching" internally! That's the stress eating side, then also diving deeper into why we make the food choices & portion size choices we do.

My take: a approach focused only on changing behavior has good parts, but traditionally been way too much reliance on this and not enough on the psychological/cognitive side.

The thing is, if you speak to obesity specialist MDs, they really do come at this in a different way. They have a much more nuanced view of how underlying metabolism / biology interact with CICO.

I know personally because I used to believe a puritan CICO, but had a "viewquake" moment speaking with them and had to change a lot about what I believe!

Importantly they try to focus exclusively on practical solutions for the population: what will actually work in the world. They detach themselves from a lot of the moralizing we see.

Your attitude toward the topic is fairly typical, and pretty harmful. "Diets fail because people fail" is true, of course - my point is that people "failing" is not always (or even usually) a result of intrinsic weakness of willpower, but a result of substantial variation in the real world experience of maintaining a calorie-restricted diet.

As a thought experiment, imagine if, for every 100 calories of deficit in their daily consumption, a random tenth of the population felt substantial and increasing physical pain. Would you describe their inability to consistently lose weight as a 'failure' on their part? As essentially due to a lack of sufficient discipline? What if it were nausea? Exhaustion?

Now picture a world in which that is the actual norm, and those people are subjected to frequent ridicule for their lack of willpower and bombarded with the message that they are inferior because of it. If they'd just man up and stomach the pain for the rest of their lives, they'd have no trouble losing weight, it's simple physics.

This isn't an accurate representation of reality of course. I don't feel physical pain when I run a hundred calorie deficit, I just feel tired most of the time, and I lose the energy to enjoy physical pursuits. I'm confident that if I applied enough effort (again), I'd lose some weight (again), and keep it off for as long as I continued spending that effort. Again.

> Asserting that .. tracking your caloric intake and energy expenditure versus the number on the scale is inherently flawed is dangerous, misleading, and probably false.

That's not what I'm asserting. And I think that's been pretty clear, really! There are millions of fat people who are actively trying to be thinner in various ways and repeatedly "failing". Do you really think that telling all of those people to "just try harder" is a useful thing to do?

I don't personally expect drugs to be the answer to the problem, and I don't have any opinion on the "Fella" business model or likely effectiveness. My position this whole time has just been that fat people are mostly not fat because they don't understand that restricting calories will make them thinner. Understanding the actual reasons is important, and it's far more difficult to do when any real conversation on the topic is inundated with comments to the effect of "have you tried not eating as much? It's really easy, just eat less."

On re-read, this jumped out at me:

> Diets don't fail because they're inherently flawed and the system is more complex than we think it is. Diets fail because people fail.

The system includes the people. If the people "fail", that is relevant information, and should be used to evaluate the 'effectiveness' of the approach. The system is extremely complex, including as it does all of human psychology and physicality, and yet every one of these discussions is dogged by people like you, that think that the problem is just that people don't try hard enough.

Well sure they don't, that's also the reason they can't all bench 400 pounds - "hard enough" is the critical phrase here, and your language and attitude place all of the blame on the individual. It's a lot like explaining that depressed people are responsible for their own emotional state, and should just start exercising and cheer up - it's factually true, and yet also unhelpful, counterproductive, and insulting.

Well written.

> Virtually every _controlled_ study shows that metabolic differences between adults are within a margin of +/- 15%, with essentially no way to eat the same amount of calories as a 200lb person and stay at 465lbs. Not least of which because your basal metabolic rate is much higher at that weight.

That sound a bit wrong to me. Fat needs energy to maintain itself? Isn't it just an energy store? If you're 465lbs with the same muscle percentage as someone 200lbs maybe that's how it works, but no one at 465lbs has less than 15/20% body fat.

It's more that the muscles (assuming same muscle mass) have to do comparatively more work if they are carrying around more weight.

That is true but I don't think that accounts for all the metabolism. There's probably something to say about having to maintain your temperature, but I don't know if it consumes more or less energy in general as fat isolates. Wikipedia (https://en.wikipedia.org/wiki/Basal_metabolic_rate) says that 70% of the metabolism comes from the organs, 20% the muscles and 10% thermogenesis. All probably grow as you gain weight, but I seriously doubt that an obese person weighing 400lbs consumes twice as much energy as someone weighing 200lbs. What I'm trying to say is that the idea that you have to eat enormous quantities of food to maintain a high weight seems wrong to me, and that simply saying that the person must be missing some calories that they consume or lying about their level of activity seems condescending to me.

To change the subject, do you plan on expending Fella to Europe at some point? I really like your approach.

Really nicely put.

Yep we're British founders so would love to expand to Europe in the future. Sadly won't be for a couple of years though - lots of work to be done first in the US!

Thanks, and good luck with the US!

>Fat needs energy to maintain itself?

Yes. Stored fat isn't just inert fat, but fatty tissue. Made of cells that need energy to stay alive.

> overreport their physical activity, like "I can jog 10 miles", or "I play tennis about 7 hours a week", or "I regularly make 60 mile bike rides". If you do, you're the extreme outlier, and it doesn't change the data. Assuming you can do those things, you're almost certainly still in your 20s, and the health effects of your weight haven't really caught up with your body yet

I'm 37, and 6'5". and if you're calling me a liar, you can fuck right off.

>within a margin of +/- 15%, with essentially no way to eat the same amount of calories as a 200lb person and stay at 465lbs. Not least of which because your basal metabolic rate is much higher at that weight.

I was not trying to indicate that the actual metabolic burn rate of humans varies by huge factors, "metabolism" is a colloquial term that encompasses a poorly defined set of features. The physical, psychological, and emotional components of your experience of a calorie deficit are what causes the experiential variance I'm describing.

Of course if I could eat a 2000 calorie diet consistently for a long period of time I would lose weight! I've performed that process numerous times, with various caloric deficits (my basal is a bit past 3k, so 2k is a pretty serious deficit - I wasn't able to hold that one past three weeks). This is when most thin people start rambling about "willpower", but maybe just skip that part this time? It's not useful to any of us actual fat people.

I said that you may be an extreme outlier. You're also larger than every NFL player in history, everyone in World's Strongest Man, etc. A 10 mile jog (let's say 80-100 minutes of uninterrupted running) is the sort of "I could eat 50 eggs" number people pull out.

At 6'5", you are an outlier. 2kcal is too low, much as it's too high for the average woman. This doesn't mean that metabolism is a "colloquial" term. It means that "the physical, psychological, and emotional components" is a long way of saying "it's hard", and "the experiential variance I'm describing" is "the payoff did not seem to be worth the cost".

In general, my post wasn't intended to be an attack on you. It's that "I cut calories and I lost weight" is not anecdotal. It's factual. The anecdote, if any, is "I'm larger than the largest professional athletes and I can still perform". Since it's hard to stick with cutting calories for many people, throwing drugs at it with Fella is not the right answer.

A holistic approach which addresses trauma, reasons for emotional eating, lifestyle replacements, recalibration of palate, satiation even at a deficit, and all the rest should be explored alongside drugs so "I cut calories and I lost weight" is easier to stick with.

> It's that "I cut calories and I lost weight" is not anecdotal. It's factual.

It simplifies the problem though, because for many, that approach has side-effects that seriously affect quality of life, like sleep, concentration, mood swings, depression etc.

Speaking of depression, I often get a similar vibe in those threads, where undoubtedly someone will jump in and say "all you have to do is lift heavy weights and change your diet a bit". It feels like they haven't experienced what other people have, so their advice sounds tone-deaf, a version of "let them eat cake".

> Since it's hard to stick with cutting calories for many people, throwing drugs at it with Fella is not the right answer.

If it works, it's great. Because obviously the "just change your life to be like me and hope for the best" approach doesn't work for most people, or they'd do it.

If calorie restriction is causing those side effects, it is an indicator that the person is "doing it wrong" by either restricting their intake far more than is healthy or more likely their diet is very sub optimal (eg, 100% carbs causing blood sugar to spike and then crash when they "run out" of calories).

These are problems of application which are easy to fix with a food journal and perhaps a bit of research, not really a great argument against calorie restrictions effectiveness.

I feel like this is a pretty bold statement, and I'm not sure how much evidence there is behind this.

Really nicely put.

I've wanted to bring up how physicians treatment of depression has radically changed in the last few decades (to have a much greater appreciation of the medication-assistance), but I didn't want to bring it up myself as I thought it may be too confusion/controversial.

Honestly this is a pretty good description of the Fella program: "A holistic approach which addresses trauma, reasons for emotional eating, lifestyle replacements, recalibration of palate, satiation even at a deficit, and all the rest."

We designed Fella because "throwing drugs at it" is not the best solution for patients.

The crucial difference to your approach is the addition of the medication. Which if you speak to any obesity specialist MD, is exactly what they'd recommend: pharmacotherapy + psychological & behavioral intervention.

Please do not let moral posturing cause you to underrate the importance of a holistic approach which includes medication-assistance.

> Please do not let moral posturing cause you to underrate the importance of a holistic approach which includes medication-assistance.

I get that you're a founder. It would be great to not cast aspersions on people. "I think your approach sucks" is not "moral posturing", and I'd question how many ethical doctors would recommend something insurance will not cover with an unknown end date to the treatment plan as "pharmacotheraphy" out of the gate.

For those who cannot gain muscle mass, injecting testosterone would also work (and would work for weight loss). Messing about with the endocrine system is tricky. Your body is really good at homeostasis. It's also really good at saying "welp, I guess that's covered, so I'm good" when exogenous sources of hormones are introduced.

Is this part of the treatment plan? What about diabetic patients (who appear to be a small part of the studies leading to approval)? How are you going to control for hyperglycemic ketoacidosis?

What's the long term effect of this on alpha cells and pancreatic health? How long is the titration for normal pancreatic function to resume? When exogenous glucagon is removed, what are the hunger levels of patients? Bounceback effect on weight if appetite is increased in the meantime?

Yes, use every tool in your toolbox, but there are a lot of unanswered questions about the medication in question, and a lack of insurance coverage. I've been overweight. Your body is not a formula in the "I calculated CICO, and...", but it does follow basic rules in a "I tracked my calories religiously, and over the last 2 weeks, my average daily intake was X, and the scale change was Y, so I need to modulate intake/activity up/down/stay the same" until you reach your goal.

That's hard for some (many) people. It's also completely sustainable. We want an "easy" way to do things. Sometimes "easy" things have detrimental effects in the long term, which are not apparent during clinical trials or short (let's say 3-5y or less) term, medically speaking.

Doctors would recommend pharmacotheraphy for obese patients because the health effects of being obese are dramatic, and almost certain to be worse than whatever the health effects of the drug are, because they have relationships with the vendors, because they are not sure whether the patient could affect the same change in health without them, etc.

However, if presented with the choice of "Patient X is able to achieve the desired outcome without the addition of medication", that would be the choice every time. You can filter that through the scale to "Patient X is unable to achieve the desired outcome without incurring significant financial burden/hardship by taking a new-to-market drug with unknown long-term consequences and an unpredictable prognosis once pharmaceutical intervention ceases, but the outcomes are so much better that this risk is warranted", which seems to be close to the starting point of the pitch here.

Medical ethics are not moral posturing.

Edit: your cofounder is doing a great job (https://news.ycombinator.com/item?id=28260302) addressing the tradeoffs here.

Not to put too fine a point on it, but this is not the greatest venue for comments like the last one in that chain (yours) (https://news.ycombinator.com/item?id=28261777). People here want to know how it works, why it works, what your pitch is, why we should recommend it, etc.

I am not your target demographic and never would be for a variety of reasons, not least of which being that I've been a competitive athlete in weight-class based sports for almost my entire life (outside of the 5-6 year period where i stopped training and became obese). I am here commenting, though, and you can make a fair guess about who I know based on the demographics of the US and their intersection with the market demographics of software engineers. Lots of overweight people with the kind of income which could afford this.

Like many people on HN, I read a lot. I'd hazard to guess that I come across many more startup ideas and news articles than most people I know, and I do bring them up in conversation. Fella is the sort of thing which I could recommend (well, "here's now insulin/leptin/glucago intersect as part of the HPS axis, and there are GLP-1 analogues, with this startup which may be able to help"), but I'm unlikely to if it leaves a bad taste in my mouth as yet another shill for medicating the symptoms instead of addressing the cause(s).

If I see responses like "this is the sort of stuff our customers talk to their doctors about" and not "this is why you should become our customer", I'm gonna write you off, and that's probably a fair assumption for HN in general. The comments are not the place for elevator pitches, marketing, etc. It reads like "I'm happy to answer your questions once you pay me, but not here".

Understood and good points. Thank you for the candor: I got caught up and quickly typed a throwaway comment. Definitely my bad.

> I cut calories and I lost weight" is not anecdotal. It's factual

I think perhaps you're misunderstanding what "anecdote" means? Anecdotes can certainly be factual - the point is not that it's false, it's that it's not sufficiently representative. In particular, I wasn't challenging his assertion that cutting calories allowed him to lose weight, only the implicit claim that doing so is a universally straightforward and successful approach to effecting actual weight loss.

> and all the rest should be explored alongside drugs

Well yes! That's my position! I don't think "drugs will solve this problem", I think the problem is solvable, and that we need to understand it and its context better in order to do so. I'm a tinkerer, I've been experimenting with my own habits, diet, and activities constantly trying to better understand how I can be healthier and still happy, and there have been some real gains from that process.

I feel like (a) you don't agree with the approach Fella is taking (which is fine, you've clearly looked into it more than I have), and (b) you've decided that my opinions about the effectiveness of diets are somehow "on their side". I think I've been really clear about this, but I have no stake in their game, aside from being excited to see that people are trying to do something other than convince fat people that this diet will totally work (and if it doesn't it's because they were yet again bad people that deserve to be fat.)

> "the physical, psychological, and emotional components" is a long way of saying "it's hard", and "the experiential variance I'm describing" is "the payoff did not seem to be worth the cost".

Not even close. But you seem intelligent, so I'm left wondering if you're intentionally misinterpreting me to score some kind of internet points?

The intent of those phrases is to emphasize that the costs to the humans involved vary. They are different. So yeah, "the payoff did not seem to be worth the cost", in the same sense that a man with a bad knee would evaluate the cost/value of paying for a taxi differently.

Agreed about the willpower rambling and the usefulness. This is the crux for me.

Oh Wow, just wow.

You just explained and expanded on my thoughts and conversations about my ADHD very well.

Interesting parallel.

Really nicely put.

Extreme hunger, like others said. I'd class it as a subset of impulsive behavior, which is basically your primitive brain doing it's caveman shit and not listening to you, the conscious mind.

Apparently some people don't have this problem, which makes me incredibly envious (or would if I could feel anything).

It's this nagging thought of "JESUS CHRIST YOU'RE GONNA DIE IF YOU DON'T EAT A LOT RIGHT NOW!"

I've experienced it after hard days at work (construction), multi hour lifting, cycling 50km. Same shit every time. Surprisingly, unlike what my dumbass brain says, I don't die if I eat only a little and just go to sleep.

Counting calories didn't work btw. It actually made it worse as my primitive brain would know it's "starving".

> I've experienced it after hard days at work (construction), multi hour lifting, cycling 50km. Same shit every time. Surprisingly, unlike what my dumbass brain says, I don't die if I eat only a little and just go to sleep.

I too have experienced this sensation my whole life under such situations. In fact, one of my favorite things to do in life is go for a 6-7 mile run, come home and lift weight for an hour or two... then... wait until I'm hungry (usually about 45 min) and eat an insane amount of food. The food tastes 10x better, and the sensation when eating it is pure bliss.

Always have felt great doing that, and I'm really skinny. We clearly don't have any idea why some people can do that, and others cant. It's probably not until we understand that difference that we'll have any sense what metabolically is happening.

As someone whose weight has been all over the place in my life, I really appreciate hearing this. I've known it is true forever, but it is rare to hear other people saying it. There is much more to weight than calories in/out. Some people can skip a meal without noticing, others count the minutes until the next meal. I always flip it on its head. For some reason it is easy for people to understand that certain people would have trouble gaining 20 pounds, others could do it in a month easily. But when you talk about losing 20 pounds, people start talking about willpower.

I was questioned in high school in the 90s whether I had an eating disorder. I just ignore hunger until it goes away... I simply don't want food. I don't like to eat around other people, either. When I do eat, around 2am every day, I've really looked forward to it so it's pleasurable. But as a functional alcoholic I fully understand counting the minutes to something. This where "eating disorder" self control comes into play. I think of myself drunk just like I think of myself fat with a face covered in food in front of other people, and it's been enough to stop me for 20 years from hitting the bottle until work is over. On the subject of self control, everyone is a hero if you can find any at all.

Thank you for sharing.

I've really never thought about that flip before.

I explain it that way to people all the time and they almost all say that.

> "eat an insane amount of food. The food tastes 10x better, and the sensation when eating it is pure bliss"

This stuck out for me. Especially interesting that taste & eating sensation are both heightened.

Have you heard of Pavlovs Dog, that started salivating when he rang a bell? Normally it's seen as an example of conditioning. But I think it's an illustration of something I noticed in my own life: That the primary cause of hunger feelings is expecting a treat.

When I haven't eaten in a while and know food isn't coming, I don't really feel hungry, I just feel tired.

Interesting to hear!

"hunger" is a simple word for a pretty complex mix of biological, psychological, and environmental factors.

Said like a true Fella. I hear this a lot.

I used to have that problem with sleeping and hunger. For me it just went away eventually.

Interesting. How long is eventually by the way?

It's hard to say, but probably not more than a month. I think I compensated a bit by saving some calories to eat directly before bed, but there was definitely some time of simply powering through it. If the Fella plan makes things like this easier then that sounds pretty cool.

re: powering through, any tactics you used? Or literally just there in bed promising yourself not to move?

Water helped to an extent. I believe at some point I just lied there for a while and didn't give in. Eating just a little but not enough to not have a deficit anymore also helped. I've done this whole thing very slow and steady in general, and I think that helps with consistency.

Someone here or on reddit once had a problem with their mind keeping them up for either hunger or to check their phone or something, and they started doing pushups every time it happened, and some part of the brain learned the association and cut it out. I never did that but it might be worth trying.

Helpful to know, thanks!

I will use myself as an example: I have Hashimoto disease, and even treated my metabolism can get so slow that I need to eat so little that I start to have nutrient deficits, for example one of the past dieting attempts resulted in hair loss, brittle nails, cracking skin, because I needed so little calories that when I consumed exactly what I needed, I ended with a protein deficit.

Only solution I found that worked was go for pure weightlifting, literally train as if I was aiming to he an Olympic champion, and even then I still ended overweight (I am 1.75m tall, smallest weight I managed, that was then I was training heavily and had a diet that was almost 100% protein, was 98kg)

That's interesting. That weight isn't necessarily unhealthy if it's largely muscle from all the training. Did you end up with a low body fat percentage despite the weight?

i’m in a similar spot as the OP. lifting helps, but i’m still pretty fat. 5’11” 250lbs. worksets are 355lb squat, 225lb bench, 425lb deadlift, 175lb overhead press. it’s hard to tell i’m strong, but i’m slightly more slender at this weight than i was before lifting. it definitely helps with aches and pains i used to have, primarily back pain.

Those are some tasty numbers.

haha, thanks. happy with the strength, not happy being 250lbs.

Really interesting to know, thank you.

Losing weight is essentially a stress on the body, the response of which is to produce a lot of cortisol, which in turn can mess with testosterone and other hormones.

For me the caloric restriction leads to so much cortisol that I can’t really sleep properly no matter how much I try to exhaust myself.

Keto seems to be kinder (in week 3, of trying it for the 3rd time, previous times unsuccessful). But too early to say for sure.

Thanks for pointing out the relationship between caloric restriction and cortisol production. Your statements and anecdotes seem to be well supported by the literature.

> Starvation caused a rise in plasma cortisol [...] but no change in total urinary cortisol metabolites. [1]

> very low calorie diet (VLCD) did not alter plasma cortisol and markedly reduced cortisol metabolite excretion [...]. [1]

> Overall, caloric restriction significantly increased serum cortisol level in 13 studies (357 total participants). Fasting showed a very strong effect in increasing serum cortisol, while VLCD and LCD did not show significant increases. [2]

> The meta-regression analysis showed a negative association between the serum cortisol level and the duration of caloric restriction, indicating serum cortisol is increased in the initial period of caloric restriction but decreased to the baseline level after several weeks. [2]

[1] Influence of short-term dietary weight loss on cortisol secretion and metabolism in obese men https://www.researchgate.net/profile/Alexandra-Johnstone/pub...

[2] Systematic review and meta-analysis reveals acutely elevated plasma cortisol following fasting but not less severe calorie restriction https://www.tandfonline.com/doi/abs/10.3109/10253890.2015.11...

Great links.

Anecdotally: I also used to struggle to sleep when I was dieting. My sensation was intense hunger when I was in bed where I couldn't stop thinking about food in the kitchen.

I used to be able to do that in my twenties. Now, in my thirties, it appears I have lost that ability. Cutting my calories seems to causey body to go into a sort of hibernation where it becomes more efficient and conserves more calories.

In other words, my metabolic burn rate at rest and while active seems to go down significantly.

Important that you bring up the age factor. We're doing more research now with our doctors on how best to adjust treatment based specifically on male hormonal changes with age.

Great to hear you've had success.

[1] is an interesting paper which gives you some hormonal examples. Effectively when you try and lose weight your body responds by increasing the hormones associated with greater satiety and weight regain. And these change may persists for a while — this papers documenting the change lasting past a a year. This will very by person however so if you have something which works for you keep going.

[1] https://pubmed.ncbi.nlm.nih.gov/22029981/

Thanks for your response and taking the time to answer these questions.

> basically the body fights hard against you as you try to lose weight by dieting

Anecdotally I think many folks would agree. Any citations or references you could provide on this point would be greatly appreciated - I'm struggling to find any solid literature with the phrase "metabolic resistance" in the context of dietary changes.

> So it's now industry-standard among obesity specialist doctors to see obesity as a "metabolic disease" which, for the vast majority of people, needs a medical approach which doesn't rely on willpower.

I agree that the current standard of care is largely focused on prescription medication. Is there strong evidence supporting the claim that the majority of people need treatment that doesn't rely on willpower? I'm particularly interested in the well documented association between obesity and mental health [1], and I think Fella would be especially compelling if a holistic approach to treatment was offered.

[1] The High Prevalence of Poor Physical Health and Unhealthy Lifestyle Behaviours in Individuals with Severe Mental Illness https://www.researchgate.net/profile/David-Scott-76/publicat...

(Richie's co-founder here)

You're spot on with the link between mental health and obesity and the need for a holistic approach.

For many of the guys stress and anxiety will play a key part in their food habits. This is something that our coaches actively ask about and help manage if relevant. For other guys it might be sleep [1] or it might be macro-nutrients. The coaching will depend on the person and we make these changes supported by their medical team.

> Anecdotally I think many folks would agree. Any citations or references you could provide on this point would be greatly appreciated - I'm struggling to find any solid literature with the phrase "metabolic resistance" in the context of dietary changes.

"Long-term persistence of hormonal adaptations to weight loss" [2] and [3] are both interesting papers on this. With the summary being that weight loss results in prolonged changes in your hormones associated with increased appetite and thus weight regain. This results in a strong negative feedback cycle.

[1] https://pubmed.ncbi.nlm.nih.gov/28164452/ [2] https://pubmed.ncbi.nlm.nih.gov/22029981/ [3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5764193/

Thank you for the excellent response and citations. I think you and Richie are on to something here - wishing you the best of luck.

Thank you! I enjoyed your great comments too

This has been so true to me. At the beginning of the pandemic I started keto. The first six months the weight fell off then I just hit a wall right around the time I began exercising (a full season of skiing) and weight lifting. For the last month I've been combining keto with IF and I'm getting a tiny bit of headway. My body just seems to be fighting VERY hard to resist my best efforts. And while I'm not checking to see if my body is in ketosis, my diet is significantly more strict compared to when I started keto 1.5 yr ago. I keep doing keto (despite the plateau) because it has helped me in many other ways (sleep, asthma, chronic fatigue, mental health etc.) For reference I am 51 yo.

Interesting to hear this personal experience.

If you're interested in some research behind this:

"Long-term persistence of hormonal adaptations to weight loss" - [1] and [2] are both interesting papers on this. With the summary being that weight loss results in prolonged changes in your hormones associated with increased appetite and thus weight regain. This results in a strong negative feedback cycle.

[1] https://pubmed.ncbi.nlm.nih.gov/22029981/ [2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5764193/

tldr: our bodies make it v difficult for folks!

What’s the connection between stress eating and metabolic disease?

1. Stress causes the adrenal glands to release a hormone called cortisol, and cortisol increases appetite.

2. When stressed, we look for relief - and for a lot of people that relief comes as food, or the act of eating itself.

Both of these often lead to overeating which is a cause of metabolic disease.

I tried fasting and a pure keto diet. While they do work, I felt miserable. This is not sustainable for people like me who has to lose more than 100 pounds.

Now I started losing weight by just balancing macro-nutrients; more protein, more vegetables, less carbs as opposed to absolutes "no" and "only" except for no sugary drinks and beer and deserts except in social occasions. Also big emphasis on weight lifting as opposed to cardio. Cardio helps with its own health benefits but is very poor for muscle growth and fat loss and should be seen as a compliment.

I felt miserable on Keto the first two times I tried it. I’ve found doing fasting in the month prior helped with the adaptation and a large part of the misery was loss of electrolytes.

By using electrolyte powder I only really had one or two really miserable days this time round.

Very interesting. I'll try it out with electrolytes. What did you take as electrolytes supplement?

Interesting. How long have you been doing keto this time?

Only week 3, but finding it pretty great this time round, ketones actively suppressing appetite, eating about 2 meals a day, down about 6kg so far. I still fast a couple of times a week, but being in ketosis already makes it crazy easy. Have enough energy for gym, though power slightly down.

I hear people can hit a wall about 8 weeks in, but also hear that could be down to over-consuming seed oils. Will see how it goes.

Interesting to know, thanks.

Yep spot on about the sustainability. We hear this all the time from the Fellas.

Fasting is a migraine trigger for me. Many other migraineurs agree. Other migraineurs see benefits from fasting.

My point being: there is no "one size fits all" approach to weight loss.

Important to hear this. I'd say there's a huge lack of empathy (understanding that someone can have a very different experience) in this space because of how it's tied in with society's take on individualism & moral responsibility.

As someone who has tried both: semaglutide and smaller diet changes have been a lot easier for me than fasting, which did work but was stressful and extremely difficult to do long term.

Thanks for sharing, important to hear anecdotal evidence.

I have done just about everything over the years to lose weight. I tend to exercise a ton naturally, so it has been more about eating less than exercising more. I would say that my natural weight is slightly overweight but not obese.

I've tried various brands of keto (Atkins/4 Hour Body), Weight Watchers, eating slowly, cutting out sugar and wheat, juice fasts. Everything has worked for a time, but the weight has eventually crept back. I have really good willpower, but I've read the research on willpower being a resource that you use up, and definitely agree with it.

For the past couple of months I have been on Noom. I have stuck to it, and I'm now thinner than I have been in a long time, but I'm a little bit skeptical that it's going to last long-term. But I'm getting married in less than 2 months, so I only need to stay where I am until the wedding, and then I can gain a few pounds.

> I've read the research on willpower being a resource that you use up, and definitely agree with it

I don't enjoy subjecting you to cognitive dissonance here...but some highly cited research shows this belief may be a self fulfilling prophecy.

> Study 1 found that individual differences in lay theories about willpower moderate ego-depletion effects: People who viewed the capacity for self-control as not limited did not show diminished self-control after a depleting experience. [1]

> Study 2 replicated the effect, manipulating lay theories about willpower. [1]

> Study 3 addressed questions about the mechanism underlying the effect. [1]

> Study 4, a longitudinal field study, found that theories about willpower predict change in eating behavior, procrastination, and self-regulated goal striving in depleting circumstances. [1]

> Taken together, the findings suggest that reduced self-control after a depleting task or during demanding periods may reflect people’s beliefs about the availability of willpower rather than true resource depletion. [1]

[1] Ego Depletion—Is It All in Your Head? Implicit Theories About Willpower Affect Self-Regulation http://icelab.psych.uw.edu.pl/wp-content/uploads/2016/02/job...

[2] Beliefs about willpower determine the impact of glucose on self-control https://www.pnas.org/content/pnas/110/37/14837.full.pdf

Maybe the beliefs come from experiences of different 'types' and the types cause the beliefs?

Really smart to pick this. The econometrician in me smiled.

Interesting! Thanks for sharing.

Interesting, reading this now.

"so I only need to stay where I am until the wedding, and then I can gain a few pounds" - this is interesting

Is it possible that you are at healthy weight for you? Because given lifestyle you described, it is quite possible.

Also agree it's definitely possible, although would need to know more about OP.

Hate to say it but marriage is a sure formula for men’s weight gain.

And any subsequent kids are an exponential... at least during lockdown for me

There's a lot going on in terms of the kids angle: increased stress, sleep deprivation, hormone changes, less time for exercise & healthy eating. Not easy.

It sounds like the medication is an important part of this plan. Is it something that you anticipate someone would take indefinitely, or only to get down to a target weight?

Also, can you give some ELI5 background on how the medication works in the body?

> Semaglutide, sold under the brand name Ozempic among others, is an anti-diabetic medication used for the treatment of type 2 diabetes and chronic weight management. [1]

> Semaglutide acts like human glucagon-like peptide-1 (GLP-1) such that it increases insulin secretion, thereby increasing sugar metabolism. It is distributed as a metered subcutaneous injection in a prefilled pen or as an oral form. One of its advantages over other antidiabetic drugs is that it has a long duration of action, thus, only once-a-week injection is sufficient. [1]

> Side effects including nausea, vomiting, diarrhea, abdominal pain, and constipation may occur. In people with heart problems, it can cause damage to the back of the eye (retinopathy). Side effects include kidney problems, diabetic retinopathy, allergic reactions, low blood sugar, and pancreatitis. [1]

> Warning: Risk of Thyroid C-Cell Tumors - In rodents semaglutide causes dose-dependent and treatment-duration-dependent thyroid C-cell tumors at clinically relevant exposures. It is unknown whether semaglutide causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans as human relevance of semaglutide-induced rodent thyroid C-cell tumors has not been determined. [2]

[1] https://en.wikipedia.org/wiki/Semaglutide

[2] https://www.drugs.com/sfx/semaglutide-side-effects.html

Yep Semaglutide is the key medication. Important to emphasize it appears to be a safe medication.

What is the evidence on safety? The side effects sound potentially pretty serious, and as if the likelihood goes up the longer you take it. If this has only been around for a couple years, I'm not sure I'd jump on this just yet. More details would be useful!

(Richie's co-founder here)

Semaglutide was FDA approved for diabetes in 2018 (3 years ago) and in June this year for weight management. It's part of a class of medication called GLP-1 RAs which operate in a similar way (they all stimulate the same GLP-1 receptor). Liraglutide is another common one that was approved by the FDA in 2010 (11 years ago) for diabetes (by the EU in 2009) and for weight management in 2014. So there is a 3 year of history with this particular medication and an 11 year history for this class of medication.

Here's more about the history of GLP-1s and other weight loss if you'd like: https://blogs.sciencemag.org/pipeline/archives/2021/02/15/gl...

The main side effects that people seem to get are nausea and vomiting when adjusting to the dose, this is likely due to the slowing down of food leaving your stomach. This is documented in the study of nearly two thousand people which lasted for 68 weeks here [1] (where you can also see the other side effects).

It's worth noting that, as with any medication, there is a cost-benefit trade-off. In this case it will depend on someone's current weight, what they've tried in the past, and the risks of other conditions e.g. heart disease, diabetes, and their past medical history. Each person that joins Fella has an in-depth discussion about this with an independent obesity physician and is welcome to speak it through with their own PCP too.

https://www.nejm.org/doi/full/10.1056/NEJMoa2032183

Thanks for your candor. It would be interesting to see what positive effects can be achieved for what types of patients at various different dosing levels.

I'm not at a weight where I'd want to add additional cancer risk in order to lose weight, and unfortunately the data on this sort of incremental risk probably takes decades to be fully realized. Perhaps I'd feel comfortable taking a smaller dose if there were a shorter-than-ideal track record of people taking larger doses without much additional risk.

Agree it's early days in terms of longitudinal follow-up studies. We're looking forward to playing a part in those studies ourselves.

As mid-fifties person, I have a shorter "long term" than many readers on this site. :) For me, there are the very real and immediate risks of being overweight, versus a potential for longer term risks from the medication.

Well said. These are the kinds of nuanced conversations that our Fellas have with their doctor.

(Richie's co-founder here)

> ELI5 for how it works in the body:

GLP-1 RAs such as Semaglutide are increasingly looking like the best class of medication for weight management [1]

GLP-1 RA = Glucagon-like peptide 1 receptor agonist.

These medications stimulates a receptor in your body which results in a reduction in body weight and three main effects: 1 - Slowing down gastric emptying so food stays in your stomach for longer (this is thought to be why there is sometimes nausea when starting the medication) 2 - Making you feel full by working on your central nervous system 3 - Managing glucose control (which is why it's used for people with diabetes too)

[1] gives you a great summary of the field up to now and how it works.

> Is it something that you anticipate someone would take indefinitely, or only to get down to a target weight?

This will depend on the person, whether they are also diabetic and how much weight they have to lose and is decided through a conversation with their obesity doctor. After around 12-months on these medications the weight loss plateaus (at an average of 15% body weight). If one stops the medication then but hasn't made any changes to their lifestyle they'll likely put the weight back on. But during the 12 months of the program we will be tackling the other factors with the coach: sleep, stress, nutrition. And so after the first year it might well make sense to reduce the medication or stop completely.

Let me know if you have any more questions.

[1] https://blogs.sciencemag.org/pipeline/archives/2021/02/15/gl...

It's better to think of the medication as more similar to other medications taken for chronic conditions (e.g. hypertension) than a quick fix magic pill.

The papers show consistent weight loss for ~52 weeks, then plateauing off onto 68 weeks. If you suddenly stop taking the medication, the weight creeps back on. The research therefore suggests you can likely slowly taper off the medication after year 1, but with medical supervision to ensure that doesn't lead to weight gain. This is also why improved mindset & habits are also important.

https://www.nejm.org/doi/full/10.1056/NEJMoa2032183

ELI5: increases satiety, decreases appetite.

Looks like you're using a common and old Diabetes medication to control glucose, changing the regulation of appetite? I'm curious why this works best for men? Does it work in women?

Yep GLP-1 RAs are the gold-standard, if insurance coverage permits (because they are expensive if you have to pay out-of-pocket). The effect is roughly equal in men & women. The big breakthrough was the latest GLP-1 RA called Semaglutide, FDA approved in 2017 for diabetes and June 2021 for weight management. The main paper for that is here if you're interested:

https://www.nejm.org/doi/full/10.1056/NEJMoa2032183

This is really interesting as someone who works as part of a group who takes products similar to this to market! Thank you for sharing.

You mentioned the medication is as effective in women as it is in men. While I understand men are underserved in this space and so I respect the decision to focus on that population on that basis, I'm curious if there are business elements to that decision as well? Would you ever expand to serving women, given that they seem to be a larger potential customer pool?

Sweet what's the group you're part of? Sounds interesting.

It's obviously a great question about the focus on men, and something we think a lot about.

My take: the whole industry is focused on women, and there are already cool companies taking a medication approach with branding clearly focused on women: https://www.joincalibrate.com/, https://joinfound.com/, https://www.formhealth.co/

I'm a fan of what these folks are doing. But you speak to any Fellas (our name for our customers!) and they know those programs aren't aimed at them. Every week we hear something like "I'm fed up of being the only guy in the group".

From a business side, the bet we're taking is that if we manage to crack the messaging/framing/branding for the male audience, that's a great business. Plus how men think about their health is drastically changing as concepts of masculinity change, so the potential customer pool is growing rapidly.

In terms of future expansion: we don't know yet. At least not for the coming few years - there are a lot of bigger guys out there we want to help (35 million men have obesity)!

Thanks very much for answering!

Sorry, if I'd had the foresight to use a throwaway I'd drop a link to our group, but I prefer not to publicly associate my HN account with work. We're a small team of software and data engineers, machine learning scientists, and health policy folks at a large research institution in Canada that take on clients to work on stuff like this (from early stage research to approvals to deployment). I'd be happy to reach out with my contact info privately if you're interested, just let me know.

That makes sense! I wondered if it had something to do with the group component, and I agree that the customer pool is growing.

Congratulations on the launch!

Sounds really interesting. Would love to hear from you: my email is richie@joinfella.com

Do you have any options for people in one of those programs to transfer over?

Yep we've actually had that happen already. Happy to help if you'd like.

To reiterate thought: I have nothing against these programs, from the outside they look really solid & I overall really support the direction of treatment.

Over the last 4 years, I've brought my weight down from nearly 310lb to under 240lb using an approach that seems to resemble closely what you're describing here (Liraglutide / Semaglutide, combined with nutritional and psychological coaching).

At 50+, I had more or less given up on losing a significant amount of weight, but due to increasing mobility issues and a diabetes risk, I wanted to give it another shot, and I'm glad I did.

I think the right kind of coaching makes a lot of difference: I describe the clinic I'm going to (dazz.ch) as "Weight Loss for Rich Old People": Everybody is non-judgmental, it's accepted as a given that behavioral change is hard and that setbacks occur, and the focus is on motivating people to keep trying.

So I could see your approach having a good chance of working for people like me. I suspect that one important and tricky element will be to build a personal rapport between your clients and the coaching staff — important, because it adds an element of accountability to the weight loss (I've always felt I didn't want to disappoint my dietician); tricky, because ultimately you want your clients to be loyal to your company and not to the employees.

Really interesting, thanks for sharing.

My wife is a doctor specialized in obesity management and works in a hospital daily where patients come in with BMIs well over 40. Besides semaglutide, which isn’t availble in this part of the world yet, they also prescribe liraglutide.

I’d say that if someone is extremely obese, it’s unlikely they’ll be able to bring their weight down just through medication and counseling because most people lack the motivation or self-awareness to turn it into a lifestyle, which is KEY to keeping the weight off. In most cases, bariatric surgery would be their only option. It’s also very easy for folks to fall off the bandwagon while going on a weight loss journey - I’ve always had periods of being overweight to the point of obese since I was young and it’s been a yo-yo of getting fit and then slowly slumping back into being unhealthy over the years until I had the mental shift that it’s a lifestyle change. Getting people to this state through telemedicine may be difficult. It’s a hard space to be in but definitely one that will have an unending supply of patients due to the way the world eats these days. Let me know if I can help in any way. Best of luck!

Semaglutide makes it a lot easier to eat healthy though, at least for me. When you aren't super hungry all the time it's easier to make healthier choices or just not eat at all.

Spot on.

Thank you for the support! Where in the world are you based btw? Always interested to follow the approvals of Semaglutide.

Singapore

The catch with this "wonder drug" semaglutide is: It has to be taken _life-long_, not just during a diet!

So when you are 30 now, you will be on medication for the next 40+ years. This is a long time.

=> Long term side effects are not known yet. In animal studies, semaglutide caused thyroid tumors or thyroid cancer. It is not known whether these effects would occur in people using regular doses.

(Richie's co-founder here)

> The catch with this "wonder drug" semaglutide is: It has to be taken _life-long_, not just during a diet!

This is why the coaching part of the program is so important.

Whether it's taken for a while or just for the first year will depend on the person, whether they are also diabetic and how much weight they have to lose. It's a personalized decision based on a conversation with their obesity doctor.

After around 12-months on these medications the weight loss plateaus (at an average of 15% body weight). If one stops the medication then but hasn't made any changes to their lifestyle they'll likely put the weight back on. But during the 12 months of the program we will be tackling the other factors with the coach: sleep, stress, nutrition. And so after the first year it might well make sense to reduce the medication or stop completely.

It's also likely we'll continue to see new medications and improvements with our understanding of obesity that makes being on this particular medication for 40+ years very unlikely.

> Long term side effects are not known yet. In animal studies, semaglutide caused thyroid tumors or thyroid cancer. It is not known whether these effects would occur in people using regular doses.

Semaglutide was FDA approved for diabetes in 2018 (3 years ago) and in June this year for weight management. It's part of a class of medication called GLP-1 RAs which operate in a similar way (they all stimulate the same GLP-1 receptor). Liraglutide is another common one that was approved by the FDA in 2010 (11 years ago) for diabetes (by the EU in 2009) and for weight management in 2014. So there is a 3 year of history with this particular medication and an 11 year history for this class of medication.

Here's more about the history of GLP-1s and other weight loss if you'd like: https://blogs.sciencemag.org/pipeline/archives/2021/02/15/gl...

It's worth noting that, as with any medication, there is a cost-benefit trade-off. In this case it will depend on someone's current weight, what they've tried in the past, and the risks of other conditions e.g. heart disease, diabetes, and their past medical history. Each person that joins Fella has an in-depth discussion about this with an independent obesity physician and is welcome to speak it through with their own PCP too.

https://www.nejm.org/doi/full/10.1056/NEJMoa2032183

Would have loved to know you're only live in Texas before I went through the ~10 page survey about all my personal information.

Really sorry about this. We tried to make this clear in the post, but you're right we can definitely make this clearer on our website.

Before launching on HN we haven't had an non-Texas traffic so there are some bits we need to change to our infra!

What are your plans for the information that got filled out on the form, though?

We plan to store it until we expand to more states. If you'd like us to delete it, send me an email on richie@joinfella.com & I'll sort it.

I'm currently working on losing weight and having a fair bit of success, largely because my wife is also extremely serious about it now. I'm basically feeding off her success, and supporting her is making it easier for me to make changes in my diet.

Over the last 2 months she's lost almost 30lbs, and I'm at over 20. Largely this has been serious changes in diet: Little to no carbs, basically a lot of grilled veggies, Soylent, protein drinks, yogurts, fruits... A little more exercise.

Really, the trick has been: She got a sleeve surgery a week ago, and for around 6 weeks before that she was basically on the reverse after-surgery diet to get used to it. And I've been kind of following her diet, though she encourages some tweaks to make sure I'm getting what I need. And this week when she's been just having a cup of broth a day, I've not been anywhere near that.

Short story long, She's on this path enforced by surgery. I want to support her, but I also want to use her journey to help me with my own. I'm fairly healthy, but want to make some activities easier, and I've been having some arthritis in my hips that make me want to ease their burden.

Fella sounds interesting as a way of further supporting my journey. Sounds like it's not available outside of TX, which I assume is related to "board certified". Also a little hard to tell what the final cost is going to be, $450/quarter plus whatever the drug is? I saw one of the other similar drugs on goodrx at $1K (a month? a quarter? Not sure), but looks like my insurance might cover it to the tune of ~$100. Boy, sure hope there's no tie to pancreatic cancer though. :-)

On the one hand, extra support might be nice. On the other hand, we've been going for 2 months and I'm about 20% of the way to my goal, and it hasn't been so hard, but I could also see it getting harder. I've previously lost almost double what I've lost so far, and then plateaued and gained it back over ~5 years. But now I have my wife going through it as well, so maybe it'll be different? Or maybe not...

At $250/mo for the program and drugs, it seems worth trying, but doesn't sound like it's even an option outside of Texas. Thoughts?

Okay all important context, thanks for this. Which state are you in?

If you drop me an email on richie@joinfella.com, we'll talk it through

The only thing you need to beat obesity is exercise and reduced caloric intake.

The idea that entire companies can be started to wrap that fact in a neat little package for people makes me depressed.

> It leads to an average 15% decrease in body weight, efficacy close to bariatric surgery [3]. However, medication-assisted treatment for obesity is still stigmatized by family doctors and therefore hard to access.

This won’t lead to a healthier society, it will lead to a more wasteful and consumeristic one.

This is the same ineffective trope said repeatedly without grounding in practical solutions which help real people get to a healthier weight.

How is the drug different than victoza or any of the other weight management drugs that are currently under investigation for causing pancreatic cancer?

(Richie's co-founder here)

Victoza is the brand name for Liraglutide. The drug we are primarily interested in is Semaglutide. Both Semaglutide and Liraglutide are GLP-1 receptor agonists.

It's worth doing your own research and consulting a doctor but the experts I've spoken to (academics and clinicians) along with the studies state that: "GLP-1 analogues did not increase the risk for pancreatic cancer when compared to other treatments" (from a Nature Scientific Reports meta-analysis paper published in 2019) [1].

Here is the postmarket FDA safety information on Victoza if you are interested: https://www.fda.gov/drugs/postmarket-drug-safety-information...

[1] https://www.nature.com/articles/s41598-019-38956-2

I get how when compared to other treatments for diabetes it may not increase your risk but when we are comparing with other treatments for weight management or just no treatment at all, I find it hard to believe that it doesn't significantly increase the risk for pancan. I understand it's FDA approved but so have been all other drugs in its class that are allegedly linked to pancreatic cancer.

We're definitely watching this closely.

It's worth noting that, as with any medication, there is a cost-benefit trade-off. In this case it will depend on someone's current weight, what they've tried in the past, and the risks of other conditions e.g. heart disease, diabetes, and their past medical history. Each person that joins Fella has an in-depth discussion about this with an independent obesity physician and is welcome to speak it through with their own PCP too.

I'm non-binary, assigned male at birth. I totally agree that having a program aimed at men and building supportive communities for men is important, as they are often under served by existing support infrastructures.

I'm curious if you'd consider non-binary folks as well? Should I not sign up if I'm nonbinary? Or even anyone who is ok with a 'primarily for men' atmosphere?

You're 100% welcome here. Would love it if you wanted to sign up.

Or if easier, you can drop me an email on richie@joinfella.com and we'll sort you!

Hi folks, congratulations on the launch.

Are you considering expanding services for other chronic eating disorders? For example, chronic under eating.

Interesting question. We're no longer coming at this from an ED angle - I could & should write a whole blog about this at some point! Quick take: tackling obesity from a wider health angle (metabolic health, psychological health, behavioral health) is more needed than a narrower focus.

A impressive co focused on serious, udner-eating EDs is https://equip.health/ if you're interested

Ever think of branching into addiction? That's another place where evidence based care is sorely lacking.

It's a possibility. There's already another YC co doing great things in the addiction space: https://www.quitgenius.com/

We'll have to see. We have a long way to go in the coming years reaching the 35 million men in the US who are fighting obesity.

Isn't obesity a result of food addiction?

It's one important cause - although "food addiction" is interestingly quite controversial in the research space, and the literature is fast growing here.

It's certainly something we tackle head on in our program.

But food addiction is not representative of everyone's struggles.

Only available in Texas currently. When's the nationwide rollout? Any more precise than "soon"?

Not affiliated, but I believe with every telemedicine company, the care providers need a medical license in each and every state they have patients in. So it will likely be a long time before they have “nationwide” coverage. This is why many telemedicine startups are only in a select handful of states.

Exactly this! Got there before me.

Hey Richie we can help with that :) https://medallion.co/

Emailed you!

It's tough with the state-by-state regulation. CA & NY are in the coming month or two. Then the plan is the next 5-10 states by end of Q1 2022. We'll be sprinting to go fully nationwide by end of 2022.

Is this just because of the prescription drug element of your program? If there weren't any medications involved, would you need any state certifications?

Yep exactly - the prescription drug element requires state-by-state medicine licenses.

Congratulations on the launch! I’m on one of your waitlists. Do you work with any T1 diabetics? My understanding is I wouldn’t qualify for Victoza since I haven’t demonstrated sufficient ineffectiveness of Metformin. Does the weight loss prescription bypass that whole line of questioning?

We do work with T1 diabetics, and the weight loss prescription does bypass that line of questioning.

BUT. Cards on the table about qualifying for GLP-1 RAs: most insurance policies still don't include weight management medication, and if they do it is difficult to know how your insurance will react until the doctor writes the prescription. I know people smarter than me are working on changing this about the US healthcare system!

So we'd have to see exactly which medication was a fit after a conversation with the doctor.

Which state are you in by the way?

Makes sense. I’m in IL and my doctor would be quite willing to have that conversation. :)

Nice. Working hard to get to you as soon as we can!

I tried going through your sign up process to see if I could just get notified if you start in the U.K. but it seems you assume anyone coming to the site is in the US. I for one would welcome something like this.

British founder here so I'm genuinely sorry about this! Thought I'd fixed it the day before we launched on HN. Our infra will be updated by end of this week.

If you'd like to be on our waitlist, just drop me a quick email on richie@joinfella.com and I'll make sure you're in our system.

You mentioned stress eating, how does the coaching help stress and sleep management? As our self-regulatory cognitive defenses drop across a long stressful day, how to help encourage sleep not eating?

The stress eating side takes inspiration from a CBT-based approach. Lots of aspects to CBT, but an important part is to recognize what we're use the tool (relieve stress) & when we're using the tool (late evening) - then to find a better tool to replicate that stress relief.

I had been very, very excited to start semaglutide, but about eight weeks ago I picked up a CBT-based eating book called The Beck Diet Solution and I’ve so far found it very very effective

Not to suggest anything about your personal experience, but note that in general pretty much anyone can follow pretty much any diet for two months and lose weight if they try. The seriously hard bit - and the way you know you've found the right diet for you - is if you can follow it for the third month (and then all the months thereafter). Two months is roughly the upper limit for the "any diet will work for anyone" effect.

Well said. My take from research: structures from a CBT-based approach are really helpful and should be more widespread - but for most people are not sufficient in staying at a healthier weight long-term.

Yep CBT (and third wave cognitive therapies in general) are very effective against emotion-based overeating (e.g. stress eating). Stress eating is widespread and addressing it is a core part of our coaching.

Important to say not everyone struggles with stress eating, which is why our coaching program goes much broader than that.

The metabolic medication aspect is also really helpful, which is why we combine the two for Fella.

A lot of docs I know are prescribing GLP1s already for weight loss, off label. When they get RCT data, get coverage, you guys will be way ahead. Congrats, amazing concept.

I remember reading studies of 30-36 lbs in a year, IF they maintain diet and exercise. I see this adherence as your competitive advantage.

15% average body weight loss was the breakthrough study: https://www.nejm.org/doi/full/10.1056/NEJMoa2032183

Important to emphasize that diet & exercise are only two parts of broader metabolic health. Sleep also very important.

And something our program focuses a lot on is stress eating. Very prevalent and a big factor, but normally overlooked.

Where is Washington state in your rollout plan? 2021? 2022?

(Richie's co-founder here) We are aiming for Washington by the end of 2021. If you'd like me to let you know when we launch there feel free to fill in the "Am I Eligible" quiz and join the waitlist or send an email to luke@joinfella.com and I'll add you manually

Already filled it out, thank you!

Perfect! Working our hardest to get live in WA in the coming quarters.

How long before there's a generic version of these drugs, Semaglutide and Liraglutide? I assume Medicare doesn't cover these yet.

These are relatively new medications, so I think roughly a decade for Liraglutide and more for Semaglutide but I'd have to check. Medicare doesn't cover them yet sadly.

There is another promising obesity medication in Phase 3 trials at the moment so it's fair to expect increased competition & decreased prices in the coming years - although it's obviously hard to predict.

I'm really sorry - I honestly thought we'd added that in yesterday in prep for having more exposure via HN. Very much my bad.

If you still want to go down on our waitlist, please do drop me a line on richie@joinfella.com

Do you plan to open in Europe at some point?

100%. We're actually British founders so it's been a baptism of fire learning about the nuances of US healthcare! That said, the US is the focus for the moment, so we're not planning to expand to Europe for quite a while.

What was the reason for going after the US market instead of the UK market?

I'm in the UK and would love to try Fella, especially if I could get it on the NHS with a GP referral.

UK market is tricky for a few reasons. Very centralized decision-making for healthcare funding, and the timelines are too long for a startup to survive. Plus us Brits are definitely more hesitant of medication approaches in general, although that is changing.

Both my parents, my sister and my brother-in-law work in the NHS - so lots of interesting family conversations about this!

> What was the reason for going after the US market instead of the UK market?

Might have something to do with exorbitant amount of money in the US healthcare.

Bigger spend is definitely important. Drug approval, decentralized decision making, consumer norms all also important.

Canada?

Not for the coming year. We'd love to as soon as we have capacity!

Kudos on launch! (I know the founders personally) — amazing mission and the team is a great fit to solve this problem.

Thank you Brian! Appreciate your support.

Congratulations on the launch fella team!

What would you say the biggest learning is you’ve had since starting this journey?

Thanks Matt!

Few things:

1. As we said in the post, men represent only ~10% of those using weight management services in the US, despite representing ~50% of those with obesity. Pretty fascinating to reflect on the reasons why.

2. There are only ~5000 board-certified obesity doctors in the US, roughly one for every 70000 Americans.

3. Binge Eating Disorder is the most common eating disorder, and has above 20% clinical prevalence in those above 40 BMI.

Maybe most importantly: the bias towards willpower and the stigma against medical treatment for obesity (medication or surgery) is very real, especially among family doctors. This will change over the coming decade, but it's deeply routed.

You apparently don't let people sign-up who are willing to pay out of pocket. Shame.

It should be possible — select "Uninsured" when you try and sign up (although I realize now that we can make that clearer). Email me at luke@joinfella.com if you have any issues

haha Luke beat me to it

This is probably a bug in our infra! We're on it now to fix. If you email richie@joinfella.com I'll sort you.

Intermittent fasting offers a great alternative that is completely free! The problem Fe Business perspective is of course that there's nothing to sell. No pills no magic nutrition plan or foods or exercise regime. And best of all...no calorie counting!

If you're fasting and feel hungry while carrying body fat it means your metabolism is broken. Insulins levels are high and thus prevent the use of stored body fat for energy. It's possible to reverse this condition but it can take time up to 6 months approx.

I really recommend to watch a pod cast with Dr. Benjamin Bikman.

https://www.youtube.com/watch?v=TfSJFPu50_A

It's incredible how fasting just works. I've lost 10kg of bf and 10cm from my waistline without counting a single calorie or feeling hungry at all over the course of 6 months. And I haven't lost strength either and my workouts are as intense as before. After i started fasting it took me a about 6 weeks to start seeing visible changes.

(Richie's co-founder here) Great to hear that intermittent fasting has been working well for you! There's also interesting research about the longevity benefits even if you're not looking for weight loss.

The best approach for getting to a healthier weight will vary by person. If you've put on a few pounds over the holidays but are otherwise fine then Fella is not for you. We're focusing on guys with a higher BMI (30+), they've tried everything including intermittent fasting, keto, Weight Watchers, etc. Normally they will have had short term results (even losing 60lbs+) but then put the weight back on. This is often the case for the guys that have been at a higher weight for a longer period of time as their metabolism is in a different place.

I sincerely hope regardless of methods you're able to help people and of course manage a to build a successful business well. Best of luck.

Thank you! You too

Im genuinely curious: how much different is obesity in women?

Biologically: mostly similar, although some important hormonal differences. More research coming on this.

Psychologically & socially: very different.

Any plan for Canada?

Our focus is the US for the coming year or two. The state-by-state expansion is tricky for telehealth companies. But we're British founders so we recognize that this is needed in many other countries in the coming years!

One thing that helps is to not buy candy from Costco.

Just don't. If you have it at home, it's going to get eaten even if you have it on another floor.

Better to buy smaller candy from elsewhere. It'll still get eaten, but at least there'll be no more, and you aren't going to go out again that night to get more candy.

This is one solid behavioral tactic. Good to have in the toolbox for most people. Lot more to it than this!

Hey folks, Richie here, co-founder of Fella. I'll be responding to comments all day, or feel free to shoot me an email at richie@joinfella.com.

If you'd like to check out the site: https://www.joinfella.com/

Best intern we ever had ;)